surgery of rectal cancer : potentials and limitations - dimitris p. korkolis
TRANSCRIPT
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ΚΑΡΚΙΝΟΣ ΟΡΘΟΥ
ΧΕΙΡΟΥΡΓΙΚΗ ΕΠΕΜΒΑΣΗ
ΔΥΝΑΤΟΤΗΤΕΣ ΚΑΙ ΠΕΡΙΟΡΙΣΜΟΙ
ΔΗΜΗΤΡΗΣ Π. ΚΟΡΚΟΛΗΣ
ΧΕΙΡΟΥΡΓΟΣ
ΔΙΔΑΚΤΩΡ ΠΑΝΕΠΙΣΤΗΜΙΟΥ ΑΘΗΝΩΝ
Α.Ο.Ν.Α. «Ο ΑΓΙΟΣ ΣΑΒΒΑΣ»
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EPIDEMIOLOGY
2015 Estimates
• New cases: 96,830 (colon); 40,000 (rectal)• Deaths: 50,310 (colon and rectal combined)
• Death rate over last 20 years declining• Screening and improvements in treatment
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Anatomic Location of CRC
Cecum 14 %
Ascending colon 10 %
Transverse colon 12 %
Descending colon 7 %
Sigmoid colon 25 %
Rectosigmoid junct.9 %
Rectum 23
%
30%
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Rectal Cancer
Surgery is the mainstay of treatment of RC After surgical resection, local failure is
common Local recurrence after conventional surgery:
15%-45% (average of 28%)
Radiotherapy significantly reduces the number of local recurrences
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Predicting risk of recurrence in RC
Surgery-related
-Low anterior resection
-APR
-Excision of the
mesorectum
-Extend of
lymphadenectomy
-Postoperative anastomoticleakage
-Tumor perforation
Tumor-related-Anatomic location
-Histologic type
-Tumor grade
-Pathologic stage
-radial resection margin
-neural, venous, lymphatic invasion
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Incidence of local failure in RC
T1-2,No,Mo <10% T3,No,Mo 15-35% T1,N1,Mo 15-35% T3-4,N1-2,Mo 45-65%
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The
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Radical excisionTotal Mesorectal Excision(TME)
Introduced by RJ Heald in 1979 Use of sharp dissection under vision to mobilize the rectum rather than the
conventional blunt finger dissection First series of 112 pts: 5yr LR 2.9% and survival 87.5%
Local recurrence: Conventional surgery: 11.7 - 37.4% TME surgery: 1.6 - 17.8%
Higher leak rates reported possibly due to: Devascularization of distal rectal stump Lower anastomosis Other factors: stomas, drains
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TME - Trials
Multi-institutional r/w of conventional to TME surgery found large difference in LR (4-9 vs 32-35%) and 5yr survival (62-75 vs 42-44%)
Eur J Surg Oncol 25, 1999
Norwegian Rectal Cancer Grp: Experiencing LR 25+% 1794 pts enrolled (1395 TME vs 229 conventional) LR of 6 vs 12% (30m) and 4yr survival of 73 vs 60% No difference in anastomotic leak rate (10%) & mortality (3%)
Dutch trial the largest prospective trial of 1861 pts demonstrated 2yr LR of 5.3% (TME 8.2% vs TME+XRT 2.4%) Operative mortality (3.5 vs 2.6%) and anastomotic leak (11 vs 12%)
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Circumferential resection margin
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TME - CRM
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TME Specimen
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5–10%5–10%
Blunt dissection Blunt dissection TME TME
LR 20–40%LR 20–40%
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ADEQUACY OF CIRCUMFERENTIAL RESECTION MARGINS
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Fascial plane In mesorectum In/on muscularis
Dataset for colorectal cancer (2° edition), RCOP, 2007
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SURGERY QUALITY:EFFECT OF THE PLANE OF SURGERY ON LOCAL
RECURRENCE
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Copyright © American Society of Clinical Oncology
Nagtegaal, I. D. et al. J Clin Oncol; 26:303-312 2008
LOCAL RECURRENCE AND CRM
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JH012804
• Cure
• Local control
• Sphincter preservation
• Preservation of sexual
and urinary function
• Cure
• Local control
• Sphincter preservation
• Preservation of sexual
and urinary function
GoalsGoals
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TME - Distal resection margin
Not clear in the literature 5cm preop will expand to 7-8cm on
rectal mobilization This will shrink to 2-3cm with
specimen removal and formalin fixation
Rare for tumour to spread beyond 1.5cm
Rare reports of poorly diff tumours having spread 4.5cm distally
Recommend: 5cm ideally however 2cm is adequate
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RECTAL CANCER OPERATIONS
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JH012804
JH012804
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SURGICAL TECHNIQUE - LAR
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JH012804
Splenic veinSplenic vein
Inferiormesentericvein
Inferiormesentericvein
DuodenumDuodenum
Inferiormesenteric
artery
Inferiormesenteric
artery
JH012804
N > 12 LNs
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SURGICAL TECHNIQUE - LAR
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SURGICAL TECHNIQUE - LAR
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TME - Nerve injury
Pre-aortic sympathetics during high ligationSympathetics at the pelvic brim during rectal
mobilizationParasymp(nervi erigentes) and sympathetics during
posterolateral dissection No clear lateral ligaments Do not hook or clamp these tissues, avoid excessive traction Higher rates with extended lateral LN dissection
Anterior lateral dissection off the prostatic capsule The most likely area of damage, reflected by higher rates of
sexual dysfunction in APR(14-51%) vs AR(9-29%) The role of Denonvilliers’ fascia
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Hypogastric Nerve Plexus
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Reconstruction of Neorectum
Hand sewn sutured anastomosis 1982: Parks and Percy performed the colo-anal sutured anastomosis ‘Pulled through’ coloanal anastomosis (Turnbull & Cuthbertson)
Stapled anastomosis Circular stapled technique Double staple technique
For low and coloanal anastomosis
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JH012804
RoticulatorRoticulator
AA B
CC DD EE
JH012804
Knight and Griffen, 1980Knight and Griffen, 1980
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JH012804
Endo Anal vs Stapled anastomosisEndo Anal vs Stapled anastomosis
• Better function with stapler but preferable to
do endo- anal anastomosis :
1. Intersphincteric dissection
2. Very narrow pelvis
3. Enlarged prostate
4. Prior radiation for prostate cancer
5. Short margin !
• Better function with stapler but preferable to
do endo- anal anastomosis :
1. Intersphincteric dissection
2. Very narrow pelvis
3. Enlarged prostate
4. Prior radiation for prostate cancer
5. Short margin !
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JH012804
Colo-anal anastomosisColo-anal anastomosis
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JH012804
JH012804
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Reconstruction of Neorectum
Straight end to end Low AR or Colo-anal end-to-end anastomosis cause tenesmus, urgency
and incontinence (Anterior resection or “post-proctectomy” syndrome)
Colonic J - Pouch Increases volume of neorectum 5 vs 10cm pouches have smaller reservoirs but better evacuation Size is critical to functional outcome, recommend 5-8 cm Sigmoid colon should not be used Better short term functional results and possible lower anastomotic
leaks compared to end-to-end anastomosis
Transverse Coloplasty Better in narrow pelvis and limited length of colon Long incision closed transversely Randomized trial underway comparing to J-pouch
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COLORECTAL – COLOANAL ANASTOMOSIS
“Straight” End to End Anastomosis
Transverse Coloplasty
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COLONIC NEORECTUM
Colonic J - Pouch
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COLONIC NEORECTUM
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JH012804
JH012804
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JH012804
JH012804
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INTERSPHINCTERIC RESECTION
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INTERSPHINCTERIC RESECTION – COLOANAL ANASTOMOSIS
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INTERSPHINCTERIC RESECTION
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TRANSABDOMINAL – TRANSANAL INTERSPHINCTERIC RESECTION
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Intersphincteric Resection versus Stapled Coloanal Anastomosis for Low Rectal
CancerJ Korean Soc Coloproctol. 2008 Apr;24(2):113-120
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Intersphincteric Resection versus Stapled Coloanal
Anastomosis for Low Rectal CancerJ Korean Soc Coloproctol. 2008 Apr;24(2):113-120
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JH012804
Indications for APRIndications for APR
• Inadequate sphincter : low Hartmann? • Sphincter invasion• Inadequate margin• Fecal Incontinence• Patient wishes !
• Inadequate sphincter : low Hartmann? • Sphincter invasion• Inadequate margin• Fecal Incontinence• Patient wishes !
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First report of APR technique at MayoFirst report of APR technique at Mayo
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Abdominoperineal Resection
Described by Sir Ernest Miles 1908 1-2 surgeons TME rectal dissection Anus sutured closed Wide perineal dissection, starting from posterior to lateral
then anterior Anterior dissection can proceed cranio-caudal or vice versa SB exclusion - omentum or absorbable mesh Drain the pelvic space Reduced rates of APR
Coloanal anastomosis Acceptance of smaller margins Downsizing by chemoradiotherapy
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Abdominoperineal Resection
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SURGICAL ANATOMY OF THE RECTUM
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Abdominoperineal Resection
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APR – Cylindrical Resection
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TEM
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TRANSANAL ENDOSCOPIC MICROSURGERY
TEM Full thickness excision with 1cm margin including mesorectal fat Rectal defect closed transversely T1 and/or T2 Rectal Tumors Occult Locoregional Metastases (20% to 33%) Local Recurrence Rate is still High and more than double compared to
radical surgery. T1(15%) T2(47%)
Overall Survival is NOT significantly different T1(72-90%) T2(55-78%)
Heafner TA, Glascow SC. A critical review of the role of local excision in the treatment of early (T1 and T2) rectal tumors. J Gastrointest Oncol 2014
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TRANSANAL ENDOSCOPIC MICROSURGERY
Transanal Endoscopic Microsurgery (TEM) Developed for lesions out of reach from transanal approach Favourable T1 lesions have equivalent local recurrence and 5yr
survival comparable to radical surgery Unfavourable T1 lesions have higher local recurrence (10-15%) TEM + XRT on T2 have local recurrence (25-46%) Neoadjuvant CRT in T1-2 lesions may achieve CR (50%)
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TRANSANAL ENDOSCOPIC MICROSURGERY
Indications:
1. Well – moderately differentiated tumors
2. No lymphovascular invasion
3. No perineural invasion
4. No mucinous components
5. < 3 cm in size
6. Clear margin of resection
7. < 3 cm of bowel circumference
8. Mobile / nonfixed
9. Early T1 and T2 rectal tumors
10. No nodal disease
11. < 10 cm from the anal verge
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LOCALLY ADVANCED RECTAL CANCER
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Laparoscopic Resection for Rectal Cancer
Should we do it?
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LAPAROSCOPIC TME
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Potential Advantages of Lap TME
• Less blood loss• Faster recovery• Earlier return of gut function• Lower morbidity• Magnified view allows precise dissection
(pelvic autonomics)
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Potential Advantages of Lap TME
• Reduced pain• Improved cosmesis• Decreased adhesions• Decreased wound infection rate• Reduced immune effect of surgery
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Potential Disadvantages
• Steep learning curve• Longer operating times (+30% to 50%)• Cost
– Instruments / equipment
• Port-site recurrence?• Oncological soundness compared with open
TME?
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Potential Disadvantages
• Practical and technical limitations – Crowding of instruments in the pelvis– Plume can obscure vision– Retraction of the rectum can be very difficult– Division of the rectum can be difficult– Identification of tumour site can be difficult– Pneumoperitoneum
• Gas embolism / decreased venous return
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Laparoscopic Resection for Rectal Cancer: What is the Evidence?
Dedrick Kok HC, et al. Biomed Res Int 2014
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Long – Term Results in Rectal Cancer
Lai JH, et al. Br Med Bull 2012
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Laparoscopic Resection for Rectal Cancer: What is the Evidence?
Dedrick Kok HC, et al. Biomed Res Int 2014
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Open versus Laparoscopic surgery for mid-rectal or low-rectal cancer after
neoadjuvant chemoradiotherapy (COREAN trial): Survival Outcomes.
Findings:
We randomly assigned 340 patients with rectal cancer to receive either open surgery (n=170) or laparoscopic surgery (n=170), after neoadjuvant chemoradiotherapy
3 year disease-free survival was 72·5% (95% CI 65·0–78·6) for the open surgery group and 79·2% (72·3–84·6) for the laparoscopic surgery group
Jeong SY, et al. Gastrointestinal Cancer 2014
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Factors Of Prognostic Significance (Surgeon Related)
1) Extent of margins of resection
2) Extent of lymphatic resection
3) Timing and level of vascular ligation
4) TME Technique
5) Anastomotic technique
6) Intraluminal cytotoxic solutions
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Conclusions
TEM in favorable T1 lesions
TME the standard practice in rectal dissection
High vascular ligation
Nerve preservation surgery
Role of distal margins
Sphincter – preserving surgery
Laparoscopic TME feasible and oncologically acceptable
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Rectal cancerRectal cancer
SURGEON
MEDICAL ONCOLOGIST
RADIOTHERAPIST
CUREQOL
PATHOLOGIST
STOMA THERAPIST NURSE
RADIOLOGIST