Transcript Surgical Options in Rectal Cancer

Colorectal Cancer Surgery
MR ZEEV DUIEB
GP DINNER PRESENTATION
06 AU GUST 2013 @6.30PM
CLOVER COTTAGE
Duieb
Colorectal
Suite 9, 1st Floor, 50 Kangan Drive Berwick Ph 9709 6666
St J of G Suite 4 Gibb St Berwick 3806
Colorectal Surgeon Monash Health
Ph 9768 9331
Objectives in Colorectal cancer surgery
 Prevention of surgical morbidity/ mortality
 Optimal oncological clearance

Cancer and Lymph Node clearance > 12 LN
 Prevention of local recurrence – TME, radioRx
 Quality of life
 Laparoscopic Surgery still needs to uphold these objectives.
Colorectal Major Resections
B
C
A-B right hemicolectomy
A-C extd right hemicolectomy
B-C transverse colectomy
C-E left hemicolectomy
D-E sigmoid colectomy
D
A
D-F anterior rection
D-G (ultra) low anterior resection
32025 Anastomosis <10cm from anal verge
32026 Anastomosis <6cm from anal verge
E
D-H abdomino-perineal resection
A-D subtotal colectomy
A-E total colectomy
F
G
H
A-H total procto-colectomy
© CCrISP Australasia 3rd Edition
Historical vignettes
 1826: Lisfranc 1st report of local excision
 1884: Czerny
 1886: Kraske
 1907: Miles
 1917: Bevan
 1970: York-Mason
 1979: Heald introduces TME
Total Mesorectal Excision
 1984: Buess introduces TEM
Transanal Endoscopic Microsurgery
Rectal Ca Local excision - Patient selection
 Patient factors:
 Elderly, frail and high anesthetic risk
 Patient refusal of a stoma/ radical treatment
Rectal Ca Local excision - Tumour factors
 Location: <10 cm from the anal verge
 Size & circumference of lesion:
 No evidence to predict local recurrence
 <4cm & <40% of circumference
 Mobility: -Fixed tumours not appropriate
 T staging:
 LN involvement: T1(6-12%) T2(17-22%) T3(66%)
 Local recurrence: T1(5%) T2(18%) T3(22%)
 Tumour grade:
 LN mets: well-mod diff(11%) poor diff(33%)
 Local recurrence: well-mod diff(14%) poor diff(30%)
Rectal Ca Local excision - Tumour factors
 Lymphovascular & perineural invasion:
 Greater likelihood of LN mets and local recurrence
 LN mets: 33% vs 14-17%
 Mucinour tumours:
 Greater likelihood of LN mets and local recurrence
 Nodal status:
 Not appropriate for local excision
Rectal Ca Local excision - Patient evaluation
 PR/ sigmoidoscopy
 Tissue biopsy: - May miss area of poor differentiation
 ERUS
 Quoted accuracy T staging(67-93%) N staging(61-88%)
 Recent study found the accuracy in picking T1(50.8%) and
T2(58.6%), understaging tumours(12.8%) Marusch et al., Endoscopy 2002
 MRI
 Best for evaluating nodal status, accuracy at 82%
 Colonoscopy, CT AP, PET-CT
Rectal Ca Local excision - Patient evaluation
 Recommended criteria:
 <10 cm from anal verge
 Tumour < 4cm and <40% of circumference
 Favourable T1 stage
Well- moderate differentiation
 No lymphovascular or perineural invasion
 Non-mucinous tumours
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No nodal disease
Rectal Ca Local excision – Old Fashioned Posterior
approaches
 Trans-sacral resection
 Kraske procedure
 Coccyx and lower 2 segments of sacrum excised
 Sphincter complex preserved
 Mid-rectal lesions
 Cx: faecal fistula
 Trans-sphincteric resection
 York-Mason procedure
 Similar approach to Kraske, however the sphincter complex is
completely divided and sacrectomy not performed
 Lower and mid rectal lesions
 Cx: Incontinence and faecal fistula
Kraske posterior proctotomy
Rectal Ca Local excision – New Fashion Transanal
approaches
 Transanal excision
 Full thickness excision with 1cm margin
 Rectal defect closed transversely
 Varying results in the lit, small retrospective series
 Local recurrence high
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T1(18%) T2(47%)
Survival
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T1(72-90%) T2(55-78%)
Rectal Ca Local excision – Latest Fashion Transanal
approaches
 Transanal Endoscopic Microsurgery (TEM)
 Developed for lesions out of reach from transanal approach
 Can be used for benign lesions above the peritoneal reflection
 Favourable T1 lesions have equivalent local recurrence and 5yr
survival cf radical surgery
 Unfavourable T1 lesions have higher local recurrence (10-15%)
 TEM + XRT on T2 have local recurrence (25-46%)
Rectal Ca Local excision - Ablative procedures
 Electrocoagulation
 Used as palliative & curative Rx
 Disadv: no tissue spec, 1/3 conversion to radical surgery, 20%
secondary haemorrhage
 Poor outcomes
 Endocavitatory radiation
 Direct contact radiation 10-12000 cGy
 Useful in palliative setting
 In select pts 5yr survival & local control of 76-90%
Rectal Ca Radical excision - Left colon mobilization
 Splenic flexure mobilization
 Sigmoid colon resected
 Quality of circulation is poor
 Functional outcomes as neo-rectum poor
 High ligation of IMA
 Allows mobilization of descending colon
 Ligation of main trunk of left colic
Left colon mobilization
Left colon mobilization
Left colon mobilization
Radical excision-Total 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:
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Conventional surgery: 11.7 - 37.4%
TME surgery: 1.6 - 17.8%
 Higher leaks rates reported possibly due to:
 Devascularisation of distal rectal stump
 Lower anastamosis
 Other factors: stomas, drains
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%)
Havenga et al., Eur J Surg Oncol 25, 1999
 Norwegian Rectal Cancer Grp:
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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 anastamotic 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 anastamotic leak (11 vs 12%)
TME - Technique
 Peritoneal incision around rectum
 Rectosigmoid reflected ant and posterior avascular plane
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developed using sharp scissor or diathermy dissection
under vision
Blobbed lipoma should be demonstrated
Posterior dissection first, then lateral and finally anterior
dissection
Do not ‘finger hook’ or clamp the lateral ‘ligaments’
Partial TME to a distance 5cm distal to tumour
Anterior dissection incorporates Denonvilliars fascia?
TME - Technique
TME - Nerve injury
 Preaortic sympathetics during high ligation
 Sympathetics at the pelvic brim during rectal mobilization
 Parasymp(nervi erigentes) and sympathetics during
posterolateral dissection
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No clear lateral ligaments
Do not hook or clamp these tissues, avoid excessive traction
Higher rates exp by Japanese 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 denonvilliars fascia
TME - Denonvilliars fascia
 Charles Denonvillier described in
1836
 Fusion of rectovesical cul-de-sac
 Glistening white trapezoid apron
 Anterior mesorectal envelope
 Laterally close to neurovasc
bundle
 Visible on MRI
 Heald et al recommend dissection
in front
TME - Fascial envelope
TME - Denonvilliars fascia
 Mortensen et al., recommends
dissection behind the fascia as it is the
natural continuation of lateral
dissection
 Also notes that there is a theoretical
higher risk of nerve damage
 Notes that there may be a role for
dissection anterior to the fascia for
anterior tumours
TME - Distal resection margin
 Not clear in the literature
 5cm preop will expand to 7-8cm on
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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
Reconstruction of Neorectum
 Hand sewn sutured anastamosis
 1982: Parks and Percy performed the coloanal sutured anastamosis
 ‘Pulled through’ coloanal anastamosis (Turnbull & Cuthbertson)
 Stapled anastamosis
 Circular stapled technique
 Double staple technique
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For low and coloanal anastamosis
Reconstruction of Neorectum
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Straight end to end
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Colonic J Pouch
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Low AR or Coloanal end-to-end anastamosis cause tenesmus, urgency and incontinence (Anterior
resection syndrome)
Increases volume of neorectum
5 vs 10cm pouches have smaller reservoirs but better evacuation
(Hida et al., Ds Colon Rectum 1996)
Size is critical to functional outcome, recommend 5-8 cm
Sigmoid colon should not be used
Better short term functional results and possible lower anastamotic leaks compared to end-to-end
anastamosis
Coloplasty
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New technique introduced in 1999 (Z’graggen et al., Dig Surgery 1999)
Better in narrow pelvis and limited length of colon
Long incision closed transversely
Randomized trial underway comparing to J-pouch
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
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anterior
Anterior dissection can proceed cranio-caudal or vice versa
SB exclusion - omentum or absorbable mesh
Drain the pelvic space
Reduced rates of APR
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Coloanal anastamosis
Acceptance of smaller margins
Downsizing by chemoradiotherapy
Abdominoperineal Resection
Complications of Colorectal
Surgery
ANASTOMOTIC LEAK
INTRAABDOMINAL ABSCESS, STOMA
RETRACTION, HAEMORRHAGE,
DVT, WOUND INFECTION, & OTHER GENERAL
Principals - Locally advanced tumours
 T3 and/or N1 Rectal lesions should have neoadjuvant
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(preoperative) chemoradiotherapy
Select T4 lesions could be down staged prior to pelvic
exenteration
Role of CRT downsizing and rates of sphincter
preservation.
Rouanet et al., performed sphincter preservation in 21/27
pts after CRT downsizing. At 2 yrs only 2 LR (Ann Surg 1995)
Grann et al., performed sphincter preservation in 17/20 T3
lesions (Ds Colon Rectum 1997)
Factors Of Possible Prognostic Significance
(Surgeon Related)
1)
Extent of margins of resection
- Intraluminally (2cms)
- Extraluminally (M.E. 5cms)
- Contiguous Organs
2)
Extent of lymphatic resection
3)
Timing and level of vascular ligation
4)
Anastomotic technique
5)
Intraluminal cytotoxic solutions
Conclusions
 Beaware of the inaccuracies of preop staging
 Local excision in favourable T1 lesions
 TME should be standard practice in rectal dissection
 Nerve preservation surgery
 Role of distal margins
 Neoadjuvant chemoradiotherapy
Laparoscopic Resection
Sacro-coccygectomy with APR
Colorectal Cancer Surgery Questions?
Dr Zeev Duieb
Dr Zeev Duieb is a Colorectal Surgeon. Melbourne born Dr Duieb studied at Monash
University and completed his Medical and Surgical training in Melbourne (FRACS).
Prior to establishing his own private practice in Berwick & Knox, Dr Duieb completed
a Colorectal Fellowship with Southern Healthcare Network (Monash Health)
where he has current Clinical Appointments to Dandenong (Colorectal Unit) and
Casey Hospital (General Surgery Dept).
Duieb
Colorectal
Suite 9, 1st Floor, 50 Kangan Drive Berwick Ph 9709 6666
St J of G Suite 4 Gibb St Berwick 3806
Colorectal Surgeon Monash Health
Ph 9768 9331