Transcript Oncological and functional outcome of ultra low colo

Oncological and functional outcome of ultra low
colo – anal anastomosis with and without
intersphincteric resection for low rectal cancer
R.Ruppert
Städt. Klinikum München GmbH
Klinikum – NEUPERLACH
Klinik für Allgemein und Viszeralchirurgie
endokrine Chirurgie und Coloproktologie
Teaching hospital of the Ludwigs Maximilians
University
Heads of Departement:
Prof. N. Nüssler / Dr. R.Ruppert
Rectal cancer
40 % of all colorectal carcinomas are located in the rectum
Rectum is defined as 16 cm upwards from anocutaneus line
Surgical Technique
Sphincter saving
procedures
Low anterior
resection
(LAR)
Intersphincteric
resection
(ISR)
Sphincter sacrificing
procedure
Abdominoperineal
Resection
(APR)
Total mesorectal Exzision (TME)
•Sharp dissection under direct vision
•“plane” between visceral und
parietale pelvic fascia
•Stelzner 1962
•Heald 1982
Stelzner F (1962) Die gegenwärtige Beurteilung der Rectumresektion und Rectumamputation beim Mastdarmkrebs. Bruns Beitr
204:41
Heald RJ, Husband EM, Ryall RDH (1982) The mesorectum in rectal cancer surgery—the clue to pelvic recurrence? Br J Surg
69:613–616
Surgical options for rectal cancer in the lower third of
the rectum
Low anterior resection
(LAR) / ISR
Expected
number :
80 -85 %
abdominoperineal
Resection
(APR)
Expected
number :
10 -15 %
The Status of radical proctectomy and
sphincter-sparing surgery in the United States
Ricciardi, irnig,Madoff,Rothenberger,Baxter
DCR 8, 2007:1119-1127
Oncological Outcomes after Mesorectal Excision
For Cure for Cancer of the Lower Rectum:
Anterior vs Abdominoperineal Resection
Wibe et al., Trondheim , DCR 2004, 48-58
2136 konsecutive patients between 1993-1999 in 47 Hospitals in Norway
Multivariate analyses of prognostic factors:
APR (risc 1,3), age over 20y (3,1), UICC,
Julius von Hohenegg (1859 – 1940)
„pull through procedure“
Wien klin.Wzschr.1888 1:272-354
Schematischer Sagittalschnitt durch ein
männliches Becken nach ausgeführter
Durchziehmethode
Straight coloanal anastomosis
Established by Sir Alan Parks 1974
Circular stapler / hand sewn
TME
Covering stoma
History of „intramural spread“
1910: Hanley
1913: Cole
case reports
Large intramural tumor spread
5 cm rule for distal resection margin
was establlished
for avoiding local recurrence
1 cm rule ?
• 1995: Shirouzu
– 610 Pat.
• DIS: overall 10%, all cases less < 1cm
– 3,8% were curative cases
– 40% were palliativ cases (distant metastases)
Pat. with DIS have an advanced cancer stage
They have a worse overall survival but no increased
local recurrence
Conclusion : 1cm distal resection margin is adequat
CRM involvement APR versus AR
APR
AR
Mercury < 6cm tumours
n=282
33%
13%
Classic trial curative
n= 400
21%
10%
The CRM is the most pognostic factor ( independent)
Dutch TME trial curativenot the distal resection margin (DIS)
29%
13%
n= 1586
Norwegian audit
12%
5%
Trent pelican Basingstoke
21%
10%
CR 07 n=1350
17%
8%
Japanese Experience
Saito N et al. Dis Colon Rectum 2006
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1995 - 2004 7 hospitals
228 low rectal cancers < 5 cm from anal verge
T 1 n=46, T 2 n= 78, T 3 n= 104
Neoadjuvant Radiotherapy 57
Local recurrence at 5 years: 7 %
Disease free survival (DFS): 83 % at 5 years
Good continence (Kirwan I –II): 68 %
French Experience – Eric Rullier, ESCP 2008 Nantes
Results
n = 300
CAA
Partial ISR
Total ISR
APR
Age
67
65
63
65
ns
Tumour stage
T1/T2
22 %
13 %
10 %
6%
0,001
T3
72 %
76 %
81 %
51 %
T4
6%
11 %
9%
43 %
Preop RT
67 %
86 %
88 %
79 %
0,007
Distance to
anal ring (cm)
2
1
- 0,5
-1
0,001
Hand sewn
37 %
96 %
100 %
0,001
Level of
anastomosis
3 cm
2 cm
1 cm
0,001
Colonic
pouch
62 %
72 %
83 %
0,01
Oncological feasibility
French experience - Eric Rullier, ESCP, Nantes 2008
n = 300
CRM (mm)
Ro
resection
Tumor stage
I
II
III
CAA
p ISR
t ISR
APR
7
5
4
6
0,07
87 %
88 %
81 %
81 %
ns
43 %
45 %
46 %
16 %
0,005
22 %
24 %
26 %
39 %
35 %
29 %
30 %
45 %
ns
Oncological outcome
French experience - Eric Rullier, ESCP 2008, Nantes
n = 300
CAA
P ISR
T ISR
APR
Follow up
(month)
37
39
55
36
ns
Local
recurrence
5
5
5
9
ns
Overall
recurrence
20 %
20 %
21 %
36 %
P = 0,07
Delay of
recurrence
(month)
17
18
11
15
ns
5 year overall and DFS
Meta analysis of ISR
Tilney & Tekkis Colorectal Disease 2008
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21 series from 13 units
612 patients
Mortality 1,6 %
Leakage 10,5 %
Local recurrence 9,5 % (0 – 31)
5y survival 81 %
Radiotherapy: oncological benefit but worse
functional outcome
Summary
For oncological reasons, intersphincteric resection is safe
and should be offered to all patients as often it is possible.
Functional outcome ?
How is continence influenced by intersphincteric resection ?
Quality of life ?
Sphincter function
1. Internal anal sphincter – resting pressure
2. External anal sphincter - squeeze pressure
Intersphincteric resection
Physiology
1. Loss of internal sphincter
(innervation)
2. Loss of anal transitional zone
3. loss of rectal compliance
Own Results 1978 – 1992
low anterior resections n = 2707
coloanal anastomosis n = 103 (3,8 %)
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Male = 75, female = 28
Age 58,6 ( m = 59,8, f = 57,4)
Rectal cancer n =88
Large adenomas n =9
Rectovaginal fistula after radiotherapy n = 6
incontinence first postoperative year (%)
grade III (solid); 9,7
normal continence;
40,8
grade II (liquid); 31,1
grade I (gas); 18,4
incontinence after the first postoperative
year (%)
grade III (solid); 3,9
grade II (liquid); 11,7
grade I (gas); 16,5
normal continence;
67,9
summary
• Final evaluation for functional outcome makes sense
only after 2 years.
• Subjective outcome in our series
– 80,6 % satisfied
– 5,8 % not satisfied
Functional outcome
CAA
P ISR
T ISR
normal
continence
73 %
52 %
51 %
Incontinence
for gas
6%
7%
3%
Minor
incontinence
6%
26 %
24 %
Major
incontinence
13 %
11 %
16 %
colostomy
2%
4%
5%
Good
continence
79 %
59 %
54 %
P = 0,02
ns
Bretagnol Dis Colon Rectum 2004
Summary
• functional outcome after ISR is acceptable
• Be aware of minor and major problems of incontinence in one third
of the patients.
• Preoperative information about these problems are absolutely
necessary
• Younger patients are more suitable for ISR.
• No good results will be achieved in older women
• Patient selection is the key to good functional results
Avoid
Creation of a perineal stoma
"Advance means progress to something
better and not progress to something new."
Sir Heneage Ogilivie (1887-1948
Guy's Hospital London)
Thank you for your
attention