Transcript Surgery for Rectal Cancer – Difficulties and Challenges

TME: to divert or not?
Dr. Jimmy Li Chak Man
Department of Surgery
Prince of Wales Hospital
The mesorectum in rectal cancer:
the clue to pelvic recurrence
Heald et al. Br J Surg 1982; 69: 613-616.
Line of
transection in
conventional
rectal surgery
• Isolated tumour deposits
can be found within the
mesorectum up to 3-4 cm
distal to the main tumour
The Basingstoke experience of TME,
1978-1997
Heald et al. Arch Surg 1998; 133: 894-898.
 TME: the new ‘gold standard’ in rectal cancer surgery
• 519 patients with rectal cancer with operation
• 405 ‘curative’ resections, the local recurrence rate was 3% at 5
years and 4% at 10 years
• Disease-free survival in this group was 80% at 5 years and 78%
at 10 years
• Anastomotic leak rate: 6.5% clinical and 5.5% radiological
• Temporary stomas were constructed in 73%
Leakage rate after TME
Major leak
Minor leak
20%
17.7%
N=219
15%
10%
P=0.03
8.2% 8.9%
5%
0.0%
0%
Stoma
No stoma
• Karanjia et al. Br J Surg 1994; 81:1224-26.
• Defunctioning colostomy group has significantly lower risk of
major leakage (p=0.03)
• The overall leakage rate was the same between the two groups
Concerns and controversies
•
Leakage rate?
•
Consequences of leakage?
•
Does protective stoma prevent major complication?
•
What are the risk factors for leakage?
•
Which type of stoma is better?
•
Does protective stoma affect survival?
•
What should be the timing of stoma closure?
•
Is stoma cost effective?
•
How many patients will end up with permanent stoma?
Stoma or no stoma: results from RCTs
• 2 RCTs identified:
•
Graffner at el. Dis Colon Rectum 1983; 26: 87-90.
• 50 patients included, with overall leakage rate 8%
• No significant difference in all parameters including leakage rate
• Pakkasite at el. Eur J Surg 1997; 163: 929-33.
• 38 patients included, with overall leakage rate 24%
• No significant difference in major and overall leakage rate
• No stoma group has significantly higher reoperatively rate for
leakage
Covering stoma does not reduce anastomotic leakage rate but can
reduce most of the severe infective consequences of leakage
Risk factors
Year
Number of
patients (stoma
rate%)
1998
N=219
(71%)
Rullier
1998
N=272
(41%)
18%
8%
Male sex
Level of anastomosis
Obesity
Law
2000
176 TME
(52%)
4.8%
16.1%
No stoma
Men
Marusch
2002
75 hosp
N=482
(30.7%)
2%
6.9%
No stoma
Pakkastie
1994
134
(7%)
11%
10%
Level of anastomosis
Author
Karanjia
Leakage rate
in stoma gp.
6.5%
Leakage rate
in no stoma
gp
Risk factors for leakage
11%
No stoma
Sigmoid for
anastomosis
Risk factors
•
Makela at el. Dis Colon Rectum 2003;46: 653-60.
•
Case-control study
•
44 patients were identified with anastomotic leakage that required
surgery
Risk factors of anastomotic leakage identified:
Malnutrition
Hypoabluminaemia
Wt loss> 5 kg
Medical illness
Use of alcohol
Bowel preparation
ASA
Contamination
Level of anastomosis
Incomplete donuts
Blood transfusion
OT time >120 mins
Type of defunctioning system
• Loop ileostomy (LI)
• Loop transverse
colostomy (LTC)
• Caecostomy
• Transanal tube/
intracolonic device
Loop ileostomy vs. loop colostomy
Author
Year
No. of patient
LI/LTC (total)
Results
Khoury
1986
32/29(61)
LI functions faster
Rullier
2001
107/60 (167)
LI Stoma related morbidity and risk of reoperation lower
Willaims
1986
23/24(47)
Wound infection after closure more common
in TLC
Edwards
2001
34/36(70)
Overall cx rate increases in TLC.
Gooszen
1998
37/39(76)
Overall cx more common in LI
Law
2002
42/38(80)
More IO and prolonged ileus in LI
Tube caecostomy vs. loop transverse
colostomy
Tschmelitsch et al. Arch Surg 1999; 134: 1385-88.
Loop colostomy
Tube caecostomy
P value
No. of patients
19
30
Leakage rate
16%
17%
>0.05
Re-operation rate
0%
10%
>0.05
Overall hospital
stay
28
15
<0.05
Transanal tube/intracolonic device
Coloshield
• Patrascu at el. 2004
• Ravo at el. 1984
(coloshield)
• 38 patients and 10
patients respectively
• No major complication
reported
Long term survival:
affects by diversion stoma and early closure?
 Experimental carcinogenesis is enhanced at colorectal anastomosis
 Inhibited by proximal faecal diversion
 Promoted by the closure of a defunctioning stoma
Dukes’ B
Meleagros et al. BJS 1995; 82: 21-25.
5-yrs. DFS
5-yr. DFS
100%
80%
P<0.01
66.8%
80%
60%
50.4%
60%
40%
40%
20%
20%
0%
0%
Stoma
No stoma
Early closure Late closure
No stoma
Timing of closure
Early closure is possible
But how many patient can have early closure?
Advantage and disadvantage?
Any logistic problem in our hospital?
Author
year
Stoma
No.
complication
Mortality
Lewis
1982
Transverse
colostomy
60
4 leak
1 IO
6 wound
1(MI)
Bakx
2003
Loop
ileostomy
27
1 IO
2 wound
1 line sepsis
0
Techniques and complications of
ileostomy closure
Phang et al. Am J Surg 1999; 177, 463-6.
339 patient with LI closure
65%: enterotomy suture
20%: resection with handsewn anastomosis
15%: stapled anastomosis
IO rate significantly lower in
enterotomy suture group
Leakage rate no significant
difference between groups
Cost-effectiveness of defunctioning stomas
Koperna Arch Surg 2003; 138: 1334-1338
Cost analysis study
Cost drivers:
Cost
LAR no stoma
Overall n=51
€10391
LAR no stoma no
leak
€8400
LAR with stoma
n= 19
€13985
LAR with leakage
€42250
Anastomotic leak and Defunctioning
stomas
Leakage rate of 16.5% necessary to balance
the overall cost of stoma
Conclusion:
should keep low stoma rate and low
leakage rate for LAR :
10% stoma rate and 10% leakage rate
Incidence and causes of permanent
stoma after anterior resection
Some patient had no stoma closed
•
General health
•
Age
•
Complications
•
•
Anastomotic stricture
Disease factors
•
Local
•
Systemic recurrence
Bailey et al. Colorectal disease 2003; 5: 331-334.
•
59 with defunctioning stoma
•
5/59 not closed (8%)
•
2 metastatic disease, 2 anastomotic stricture, 1 patient choice
Summary
•
Clinical leakage rate?
3-17%
•
Consequences of leakage?
Re-operation 3-16%
•
Does protective stoma prevent major complication?
Yes
•
Which type of stoma is better?
Depends on surgeon preferences
•
Is stoma cost effective?
Stoma is expensive if leakage rate is low
•
How many patients will end up with permanent stoma?
???