Surgical Treatment of the Low (Distal Third) Rectal Cancer Feza H. Remzi FACS, FASCRS, FTSS ( Hon ) Chairman Department of Colorectal Surgery Professor of Surgery Rupert B Turnbull Jr,. MD Chair Digestive Disease Institute Cleveland Clinic, Cleveland, OH

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None Disclosure

Conclusion

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Oncological clearance is the priority Radical excision with TME is the preferred technique Neoadjuvant chemo –X-rt is the preferred adjuvant therapy and it does not alter the decision for sphincter preservation Optimal bowel function and quality of life can be improved by colonic reservoirs Do not hesitate to divert Observation after neoadjuvant therapy can be dome under trial Local therapy can be alternative in selected- high morbid patient

Treatment Goals

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Maximize likelihood of cure

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Minimize risk of complications

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Sphincter preservation

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Optimal bowel function and quality of life

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Surgeon Team Approach

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Radiologist

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Oncologist

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Radiation Therapist

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Enterostomal therapist

Surgery

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Mainstay of therapy is surgery TME: Total mesorectal excision Surgical technique: refined to an anatomic dissection to include the fascia propria of the rectum

Margin

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Negative radial margins

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Distal margin At least 5 cm of margin when there is a distance of 5 cm distal resection At least 1 cm or more when there is no distance for 5 cm of distal dissection

Surgery

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Colon mobilization and high ligation of the mesenteric vessels

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TME

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APR versus reconnection with reconstruction

TME

Anastomosis

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Blood Supply

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Reach

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Reconstruction

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Anastomosis Issues

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Blood Supply

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Reach Issues

If onclogocally feasible, double stapled anastomosis is the preferred technique of anastomosis

Handsewn Anastomosis

Technique

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Start in Kraske position; especially anterior lesions Put everting stay sutures and dissect circumferentially till you reach the plane above the levator muscles Use injectable epinephrine solution where mucosectomy is required Leave one location intact so the rectum doesn't retract Be careful not to do keyhole injury during the posterior dissection Release your stay sutures when you are ready to flip patient back to Lyodd –Davis position

Intersphincteric Proctectomy

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Pros N=92 , R0 89%, Local recurrence 2% 5 yr overall and disease-free survival was 81 and 71 %

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Cons 11 % radial margin positive Morbidity was N=25 (27 %) where, there was 14 patients with anastomotic complications Only 58 patients had minimum of two years of F/U Minimal information on functional outcome and final stoma status Rullier et all Ann Surg 2005

Sphincter Preservation and QOL

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Increased associated morbidity Impact on QOL ?

30 Studies, 11 were non randomized, N= 1412 patients Six trials showed APR did not have poorer QOL than LAR Four trials showed APR had significantly poorer QOL than LAR Due to heterogeneity, meta-analysis was not possible Cochrane Review 2005

Selection

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No compromise in the oncologic clearance Patient must consent for the possibility of APR Motivated patient Lack of associated co-morbidity Good preoperative sphincter function

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If all above conditions are met, try to reconnect with diverting temporary stoma and have patient decide for himself or herself whether to live as they are or go back to stoma

Pelvic Radiation and Rectal Cancer 1990 National Institute of Health consensus conference: Recommends adjuvant postoperative radiotherapy and fluorouracil based chemotherapy for patients with B2-C rectal adenocarcinomas (JAMA 1990)

Pelvic Radiation and Rectal Cancer: Current Dilemma

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Pre or post op?

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Dose if preoperative

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Timing of surgery if given pre-op

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Which patients benefit

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? If needed with TME

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Decision for APR versus reconnection, when ?

Pelvic Radiation Preop and TME

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Dutch TME study

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Conclusion Even with good surgery, radiation improves local control for stage II and III low rectal cancers Patients with T3N0 tumors > 10 cm from the verge probably do not need XRT Kapitenijn et al NEJM 2001

Summary

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Not all rectal cancers need preoperative radiation therapy Stage I rectal cancers probably do not need adjuvant treatment Predicting which stage II and III lesions require adjuvant tx not currently possible ELUS is good, MRI is high likely the better Avoid the need for postoperative X-rt Better staging modalities in the future

Function and QOL after Radical Resection and Sphincter Preservation Cost?

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Inadvertent and uncontrollable passage of flatus to frank fecal incontinence

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Urgency

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Frequency

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“Anterior resection syndrome”

Radical Resection of Rectal Cancer

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End-to-end coloanal anastomosis

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Side-to end colonic J-pouch-anal anastomosis

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End-to-end coloplasty-anal anastomosis

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Side-to-end coloanal anastomosis

End-to-end versus J-pouch

End-to-end versus J-pouch Prospective randomized trials

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Seow-Choen, Goh. Br J Surg 1995;82:608

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Ortiz, et al. Dis Colon Rectum 1995;38:375

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Hallb öök, et al. Ann Surg 1996;224:58.

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Lazorthes, et al. Br J Surg 1997;84:1449

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F ürst, et al. Dis Colon Rectum 2002;45:660

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Sailer, et al. Br J Surg 2002;89:1108

End-to-end versus J-pouch Technical reasons for failure to create J pouch

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Narrow pelvis (12%)

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Bulky sphincters or mucosectomy (9%)

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Extensive diverticulosis (3%)

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Insufficient length (2%) Harris, et al. Dis Colon Rectum 2002;45:1304

J-pouch versus Coloplasty

J-pouch versus Coloplasty Prospective randomized trials

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Ho, et al. Ann Surg 2002;236:49

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F ürst, et al. Dis Colon Rectum 2003;46:1161

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Pimentel, et al. Colorect Dis 2003;5:465

J-pouch versus Coloplasty Ho F ürst Pimentel N 88 40 30 Pouch size 6 cm/7 cm 5 cm/8 cm 5 cm/8 cm Follow-up 12 months 6 months 12 months

J-pouch versus Coloplasty Ho F ürst Pimentel Frequency Urgency Constipation ↔ ↔ ↓ J-pouch ↔ ↔ ↔ ↔ ↓ Coloplasty

Fazio et al 2007 Ann Surg

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N=364 Mortality N=23 7.4 % No difference between the groups in complications N=297 were available for functional and QOL assessment Straight versus coloplasty same Colonic J pouch was superior to others

J-pouch versus Side-to-end

J-pouch versus Side-to-end Prospective randomized trials

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Huber, et al. Dis Colon Rectum 1999;42:896

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Machado, et al. Ann Surg 2003;238:214

J-pouch versus Side-to-end Huber Machado N 59 100 Pouch size Follow-up 6 cm/4 cm 8 cm/4 cm 6 months 12 months

J-pouch versus Side-to-end Huber Machado Frequency Urgency Constipation ↓ J-pouch ↔ ↔ ↔ ↔ ↔

Local Excision Abdominoperineal resection or low anterior resection for rectal cancer

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Complete tumor excision

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Clearance of regional lymph nodes

× × × ×

Operative mortality, morbidity Urinary and sexual dysfunction 30-40 % Anastomotic complications 5-10 % Mortality of 1- 6 % after APR Necessity of permanent or temporary diversion

Surgical Approaches

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Local excision alone

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Local excision followed by adjuvant therapy

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Local excision after neoadjuvant therapy

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Limited surgical morbidity 0-22 %

Recurrence Local recurrence N=9 17 % (site 8%,pelvic 9%) Distant metastasis N=2 4% Distant and local N=4 6% Unknown N=1 2% Total N=15 29% Average time to diagnose recurrence was 28.5

± 22.1 months (range 1-72 months)

When Should We Consider It with Curative Intent?

Preferred Acceptable Stage 1 T1N0M0 Favorable LE

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features Radical Chemo / X-rt ?

resection Unfavorable Stage 1 T2N0M0 Radical resection Radical resection LE + chemo / X-rt LE + chemo / X-rt

Future of Local Excision

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It is here to stay

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Better predictive factors Kikuchi classification Better preoperative staging Markers

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Telomerase, p53, COX ,MIB-1, BCL-1, BCL-X, MLH-1, MSH-2 and MSH-6

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The necessity of multicenteric and controlled trials Kikuchi 1995, Ramalingam 2002 SSAT

Conclusion

• • • • • •

Oncological clearance is the priority Radical excision with TME is the preferred technique Neoadjuvant chemo –X-rt is the preferred adjuvant therapy and it does not alter the decision for sphincter preservation Optimal bowel function and quality of life can be improved by colonic reservoirs Do not hesitate to divert Local therapy can be alternative in selected- high morbid patient

Conclusion

• • • • • • •

Oncological clearance is the priority Radical excision with TME is the preferred technique Neoadjuvant chemo –X-rt is the preferred adjuvant therapy and it does not alter the decision for sphincter preservation Optimal bowel function and quality of life can be improved by colonic reservoirs Do not hesitate to divert Observation after neoadjuvant therapy can be dome under trial Local therapy can be alternative in selected- high morbid patient

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