1. Local Treatment of Rectal Tumour
Joint Hospital Surgical Grand Round
Tsui Tsun Miu
NDH

2. Rectum

3. Rectum

4. Rectal tumour Type Histologic Diagnosis Neoplastic Adenoma
  Tubular adenoma (adenomatous polyp)
  Tubulovillous adenoma (villoglandular adenoma)
  Villous adenoma (villous papilloma)
Carcinoma
Hamartomas
Juvenile polyp
Peutz-Jeghers polyp
Inflammatory
Inflammatory polyp (pseudopolyp)
Benign lymphoid polyp
Unclassified
Hyperplastic polyp
Miscellaneous
Lipoma, leiomyoma, carcinoid, lymphoma
Chang George J, Shelton Andrew A, Welton Mark L, "Chapter 30. Large Intestine" (Chapter). Doherty Gerard M.: CURRENT Diagnosis & Treatment: Surgery, 13th Edition:

5. Transanal local excision: Parks’ method
Treatment Rectal Tumour
Benign
Malignant
Early Cancer?
Fit for Surgery
Local Treatment:
Colonoscopic polypectomy
Endoscopic Mucosal Rescion
Endoscopic Submucosal Dissection
Transanal local excision:
Parks’ method
Transanal Endoscopic Microsurgery
Desiccation Procedure:
Nd-Yag Laser
Argon Plasma Coagulation
Radical Surgery:
Anterior Resection
Low Anterior Resection
Abdominal Perineal Resection
Transanal local excision:
Parks’ method
Transanal Endoscopic Microsurgery

6. Why do we need local treatment?

7. Morbidity of Radical Rectal Surgery
Review of 53 prospective cohort studies + 45 RCTs (36,315 patients with 24,845 patients had an anastomosis)
Anastomotic leak rate – 11%
Pelvic sepsis rate – 12%
Postoperative death rate – 2%
Fecal incontinence rates – 7%
Prevalence of Sexual dysfunction
Men – 69%
Women – 62%
Postoperative complications following surgery for rectal cancer.
Paun BC. Cassie S. MacLean AR. Dixon E. Buie WD.
Annals of Surgery. 251(5):807-18, 2010 May.
Hendren SK, O'Connor BI, Liu M, et al. Prevalence of male and female sexual dysfunction is high following surgery for rectal cancer. Ann Surg. 2005;242:212–223.

8. Development of Local Treatment of Rectal Tumour
Avoidance of Stoma
Avoidance of Major Post-op Complications

9. Morbidity
Oncological Control

10. Limitation of Local Treatment
Cannot Clear Lymph Node Metastasis

11. T-stage and N-stage Chance of nodal metastases
T1 disease  0-12%
T2 disease  12-28%
T3 disease  36-79%
Local excision as curative intent only limited to T1 lesion
Taylor RH, Hay JH, Larsson SN: Transanal local excision of selected low rectal cancers. Am J Surg 1998; 175: 360–363
Bleday R, Breen E, Jessup M, et al.: Prospective evaluation of local excision for small rectal cancers. Dis Colon Rectum 1997; 40: 388–392
Saclarides TJ, Bhattacharyya AK, Britton-Kuzel C, et al.: Predicting lymph node metastases in rectal cancer. Dis Colon Rectum 1994; 37: 52–57
Pre-op / post-op investigation for ?lymph node metastasis

12. Indication of Curative Local Excision
Endorectal Ultrasound T1N0 lesion
Moderately to well differentiated carcinomas
No evidence of perineural or lymphovascular invasion
No mucinous component
Size  no strict criteria

13. Transanal Excision

14. Conventioanl Transanal Excision (TAE)
First reported by Parks
Excision of rectal polyps of any dimension
<6 cm from the anal verge
Anal retractors
i.e. Park’s Retractor
Use of snare
Limited to small pedunculated lesion
Use of resectoscope
Piecemeal resection
Difficult for complete excision
Add Lone start retractor
Parks AG, Rob C, Smith R, Morgan CN. Benign tumours of the rectum. In: Rob C, Smith R, Morgan CN, eds. Clinical Surgery. Vol 10. England, London: Butterworths, 1966: 541

15. Conventional Transanal Excision Outcome
Retrospective Comparative study
149 Local excision vs 169 Radical Surgery
5 year local recurrence rate
Trananal Local Excision
Radical Surgery
Chi-Square
T1 Tumors
18% 0%
p=0.03
T2 Tumors
47% 6%
p=0.001
Mellgren A, Sirivongs P, Rothenberger DA, Madoff RD, García-Aguilar J. Is local excision adequate therapy for early rectal cancer?
Dis Colon Rectum 2000; 43: 1064–74.

16. TAE – High local recurrence rate?
Related to high chance of positive margins and piecemeal resection of specimen
Transanal endoscopic microsurgery versus conventional transanal excision for patients with early rectal cancer.
Christoforidis D. Cho HM. Dixon MR. Mellgren AF. Madoff RD. Finne CO.
Annals of Surgery. 249(5):776-82, 2009 May.

17. Can We Do Better?

18. Transanal Endoscopic Microsurgery (TEM)
Originally designed by Buess et al. in 1980s
40-mm operating proctoscopy
Insufflation of the rectum
Magnified three-dimensional image
Facilitates an extremely precise dissection
Full thickness excisions
20cm from anal verge posteriorly
12cm from anal verge anteriorly
Primary closure
Remove submucosal tumours (i.e. leiomyoma, carcinoid tumour) by full thickness excision
Add photo
Buss G, Theiss R, Gunther M, et al. Endoscopic surgery in the rectum. Endoscopy. 1985;17:31-5

19. csite.clevelandclinic.org
tropicalgastro.com

20. TEM technique 5mm margin of normal appearing mucosa for adenomas
1cm margin for cancers
Full thickness
Extrarectal fat as a landmark to signify transmural penetration
Wound closed transversely with running sutures

21. TEM outcome – Rectal Adenoma
Residual adenoma in the Surgical Margin
11%
Recurrence Rate
6.3%
Surgical resection of rectal adenoma: a rapid review. Casadesus D. World Journal of Gastroenterology. 15(31):3851-4, 2009 Aug 21

22. TEM outcome – Rectal T1 Cancer
For pathology T1 lesions:
Recurrence rates from 0% %
Saclarides TJ. TEM/local excision: indications, techniques, outcomes, and the future. J Surg Oncol. 2007;96:644–650.

23. Outcome of TEM
Significant increase in local recurrence rate in T2 and T3 rectal cancer
Tsai BM, Finne CO, Nordenstam JF, et al.
Transanal endoscopic microsurgery resection of rectal tumors: outcomes and recommendations.
Dis Colon Rectum 2010; 53:16–23

24. Failed Local Excision, What should we do?

25. Immediate Salvage Surgery vs Delay Radical Surgery
If TEM specimen showed unfavourable histologic characteristics
T2 or above
Poor differentiated
Lymphovascular invasion
Mucinous component
Disease-free survival rate
Immediate APR for adverse pathological features
94%
Salvage APR for local recurrence
56%
Baron PL, EnkerWE, Zakowski MF, Urmacher C.
Immediate vs salvage resection after local treatment for early rectal cancer.
Dis Colon Rectum 1995; 38: 177–181.

26. TEM complication Entry into peritoneal cavity
Conversion to laparoscopy / laparotomy
Bleeding
Faecal Soilage
Rectal Stenoses
Wound dehiscence
Urinary dysfunction
Rectovaginal fistula

27. TEM Complications Inadvertent opening of the peritoneum (4.3%)
80% can be treated with direct suturing without conversion to major surgery
Other post-op complications:
Bleeding (3.7%)
Suture dehiscence (1.7%)
Rectovagina fistula (1.3%)
Transanal endoscopic microsurgery for rectal neoplasms: experience of 300 consecutive cases.
Allaix ME. Arezzo A. Caldart M. Festa F. Morino M.
Diseases of the Colon & Rectum. 52(11):1831-6, 2009 Nov.

28. TEM Complications Risk factor for Post-op bleeding:
Localization of the tumour on the lateral wall of the rectum
Tumour diameter > 2cm
Kreissler-Haag D, Schuld J, Lindemann W, Konig J, Hildebrandt U, Schilling M.
Complications after transanal endoscopic microsurgical resection correlate with location of rectal neoplasms.
Surg Endosc 2008; 22: 612–6.

29. How good is TEM comparing other treatment modalities?

30. TEM vs Park’s Transanal Excision
Retrospective study
42 TEM vs 126 TAE
TEM over TAE by:
Increased likelihood of clear margins
Less specimen fragmentation
Lower recurrence rates
More proximal tumours can be accessed
Moore JS, Cataldo PA, Osler T, Hyman NH. Transanal endoscopic microsurgery is more effective than traditional transanal excision for resection of rectal masses. Dis Colon Rectum. 2008;51:1026–31

31. TEM vs Park’s Transanal Excision
Possible reasons:
Carbon dioxide insufflation and distension of the rectum
Superior optics that provide a magnified image
Simultaneously evacuate smoke, blood, and liquid while cutting and sewing
Complete resection specimen photo of TEM
Can orientate much better

32. Comparison of TEM with Radical Surgery
Randomized controlled trial
Rectal adenocarcinoma (GI/II) + ERUS uT1 N0
Transanal endoscopic microsurgery (TEM; n=24)
Anterior resection (AR; n=26)
Local recurrence and five-year survival rates similar
Early postoperative mortality was zero
Significant differences in
Time of hospitalization
Loss of blood
Operation time
Opiate analgesia
Surgical cure for early rectal carcinomas (T1). Transanal endoscopic microsurgery vs. anterior resection.
Winde G. Nottberg H. Keller R. Schmid KW. Bunte H.
Diseases of the Colon & Rectum. 39(9):969-76, 1996 Sep.

33. Can we extend the indication of local excision?
Combined therapy

34. Can we extend the Indication?
Randomized controlled trial
T2 tumour  neoadjuvant chemoradiation
TEM vs Laparoscopic Resection (35 vs 35)
Median follow-up period : 84 months (range, 72–96 )
TEM
Laparoscopic Resection
Local recurrence
5.7%
2.9%
Distant metastasis
5-year Disease-Free Survival
94%
Lezoche G, Baldarelli M, Guerrieri M, Paganini AM, De Sanctis A, Bartolacci S, et al.
A prospective randomized study with a 5-year minimum follow-up evaluation of transanal endoscopic microsurgery versus laparoscopic total mesorectal excision after neoadjuvant therapy.
Surg Endosc 2008;22:352-8

35. Pathological T0 after neoadjuvant chemoradiation
570 patients :
the rate of lymph node involvement was 5%.
Kundel Y; Brenner R; Purim O; Peled N; Idelevich E; Fenig E; Sulkes A; Brenner B
Is local excision after complete pathological response to neoadjuvant chemoradiation for rectal cancer an acceptable treatment option?.
Diseases of the Colon & Rectum. 53(12): , 2010 Dec.

36. Local exicison on pT0 after neoadjuvant therapy
Retrospective comparative study
Subjects:
clinical stage T3 to 4Nx, TxN+
Neoadjuvant chemoradiation
Radical Surgery or Local Excision
Final Pathology – pT0
Radical Surgery (n=37)
Local excision (n=14)
5 year disease free survival
88%
100%
Pelvic recurrence free survival
92%
Overall survival
97%
Kundel Y; Brenner R; Purim O; Peled N; Idelevich E; Fenig E; Sulkes A; Brenner B
Is local excision after complete pathological response to neoadjuvant chemoradiation for rectal cancer an acceptable treatment option?.
Diseases of the Colon & Rectum. 53(12): , 2010 Dec.

37. We can spare this particular group of patients from Radical Surgery!
Pathology T0 after neoadjuvant chemoradiation

38. Local exicison + Post-op radiotherapy
Post-excision pathology T2 disease
Not fit for Salvage Radical Surgery
A Case Series:
Significantly lower disease recurrence in T2 disease with radiotherapy
18% (with adj. RT) vs 66% (without adj. RT)
Han SL. Zeng QQ. Shen X. Zheng XF. Guo SC. Yan JY.
The indication and surgical results of local excision following radiotherapy for low rectal cancer.
Colorectal Disease. 12(11):1094-8, 2010 Nov

39. Endoscopic local treatment
Colonoscopic polypectomy
Suitable in 90% of rectal polyps
Complete resection difficult if tumour in submucosal area
i.e. carcinoid tumors / malignant rectal tumour
Suitable for pedunculated polyp
Endoscopic mucosal resection
Removal of mucosal lesion of < 1cm
Special device needed if tumour suspected to be in submucosal area i.e. 2 channel EMR

40. Endoscopic Submucosal Dissection
Indicated when one−piece resection by conventional procedures is impossible:
Large−sized lesions
Lesions with biopsy−induced scars
Lesions on haustra
Rate of one-piece resection with ESD: 70-88%
Rate of perforation: 5%
Mean size :
26.2 mm (8 ± 60)
32.8 mm (9 - 91)
Colorectal endoscopic submucosal dissection: present status and future perspective, including its differentiation from endoscopic mucosal resection. [Review] [47 refs]
Tanaka S. Oka S. Chayama K.
Journal of Gastroenterology. 43(9):641-51, 2008
Onozato Y, Kakizaki S, Ishihara H, et al.
Endoscopic submucosal dissection for rectal tumors.
Endoscopy. 2007;39:423– 427
Fujishiro M, Yahagi N, Nakamura M et al.
Endoscopic submucosal dissection for rectal epithelial neoplasia.
Endoscopy 2006; 38: 493±497

41. Other Local Treatment Modalities
Endoscopic Nd-Yag Laser Ablation
Palliate bleeding, mucinous discharge, impending obstruction
Success in 8 out of 11 patients
Argon Plasma Coagulation
Palliate tumour bleeding
Debulking
Endoscopic laser ablation of advanced rectal carcinoma--a DGH experience.
Rao VS. Al-Mukhtar A. Rayan F. Stojkovic S. Moore PJ. Ahmad SM.
Colorectal Disease. 7(1):58-60, 2005 Jan
Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction: effectiveness of the new pulsed APC versus forced APC.
Eickhoff A. Jakobs R. Schilling D. Hartmann D. Weickert U. Enderle MD. Eickhoff JC. Riemann JF.
Endoscopy. 39(7):637-42, 2007 Jul.

42. Local Recurrences (range%)
Discussion
Radical Surgery Outcome:
Multicenter Dutch study:
for T1-T2,N0 lesions, the local recurrence rate in 244 total mesorectal excisions = 0.7%
Local Excision Outcome
968 patients in 22 studies
Kapitejn E, Marijnen C, Nagtegaal ID, et al.
Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer.
N Engl J Med 2001;345:638–46.
T-staging
Local Recurrences (range%) T1
9.7% (0-24%) T2
25% (0-50%)
Overall
13.7%
Sengupta S, Tjandra JJ.
Local excision of rectal cancer: What is the evidence?
Dis Colon Rectum 2001;44:1345–61.

43. Summary Rectal Tumour Endorectal Ultrasound Assessment
Pedunculated polyp
Complete polypectomy not feasible, i.e. broad base
Endorectal Ultrasound Assessment
Colonoscopic Polypectomy
Submucosal
tumour
Mucosal tumour
uT1N0
uT2N0
uT3/4Nx
EMR
ESD
Parks TAE
TEM (level 1b)
Neoadjuvant ChemoRT +
TEM (level 1b)
Neoadjuvant ChemoRT +
TEM (level 3b)
if final pathology T0
If Unfavourable factor present
Cure (level 3b)
Immediate Radical Surgery (level 3b)
EMR
ESD
Parks TAE
TEM

44. Thank You

45. Rectal Carcinoid ~10% to 17% of all carcinoid tumors
Middle-aged adults
Small, solitary, submucosal nodules
Midrectum between 4 and 8 cm from the anorectal junction
Tendency for metastasis:
Low if tumour size < 1cm
Local excision is adequate if tumour size < 1cm
Onozato Y. Kakizaki S. Iizuka H. Sohara N. Mori M. Itoh H
Endoscopic Treatment of Rectal Carcinoid Tumors
Diseases of the Colon & Rectum. 53(2):169-76, 2010 Feb

46. Rectal Carcinoid Located in submucosal layer To be removed by
Endoscopic submucosal resection with a ligation device
2 channel EMR
Endoscopic submucosal dissection
Ono A, Fujii T, Saito Y, Matsuda T et al.
Endoscopic submucosal resection of rectal carcinoid tumors with a ligation device.
Gastrointest Endosc 2003; 57: 583±587

47. Palliative local treamtent

48. Palliative Radiotherapy
Overall
Mobile
Partially fixed
Fixed P 
Number of patients
271
103(38%)
51(19%)
92(34%) –
Complete response (CR)
80(30%)
50(49%)
11(22%)
8(9%)
<0.01
Local relapse after CR
62(78%)
36(72%)
8(73%)
8(100%)
<0.05
5 year survival
27%
48%
26% 6%
Five (1.8%) patients developed grade 3 or 4 acute toxicity. Four patients had acute bowel toxicity and one patient had acute skin toxicity. All patients with acute toxicity
recovered after treatment with intravenous rehydration or medications. Another four patients (1.5%) developed grade 3 or higher late toxicity. Three patients developed skin ulcers. One recovered after treatment with topical medication, the second patient was treated with rotation flap surgery, and the third patient died of osteomyelitis and sepsis secondary to skin ulcer infection. One patient developed ureteric stenosis, and recovered after ureteric stenting.
Wang Y, Cummings B, Catton P, Dawson L, Kim J, Ringash J, Wong R, Yi QL, Brierley J.
Primary radical external beam radiotherapy of rectal adenocarcinoma: long term outcome of 271 patients.
Radiother Oncol 77:126–132

49. Palliative chemoradiation
Complete Response (no tumour clinically)
Median progression-free survival = 65 months
Partial Response (shrunken tumour)
Median progression-free survival = 15 months
T1/2 group
Median PFS = 64 months T3
Median PFS = 28 months
Lim L, Chao M, Shapiro J, et al.
Long-term outcomes of patients with localized rectal cancer treated with chemoradiation or radiotherapy alone because of medical inoperability or patient refusal.
Dis Colon Rectum 2007;50:

50. Other Local Treatment Modalities
Endoscopic Nd-Yag Laser Ablation
Palliate bleeding, mucinous discharge, impending obstruction
Success in 8 out of 11 patients
Argon Plasma Coagulation
Palliate tumour bleeding
Debulking
Endoscopic laser ablation of advanced rectal carcinoma--a DGH experience.
Rao VS. Al-Mukhtar A. Rayan F. Stojkovic S. Moore PJ. Ahmad SM.
Colorectal Disease. 7(1):58-60, 2005 Jan
Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction: effectiveness of the new pulsed APC versus forced APC.
Eickhoff A. Jakobs R. Schilling D. Hartmann D. Weickert U. Enderle MD. Eickhoff JC. Riemann JF.
Endoscopy. 39(7):637-42, 2007 Jul.

51. Ultrasound Staging
Bianchi PP, Ceriani C, Rottoli M, et al.: Endoscopic ultrasonography and magnetic resonance in preoperative staging of rectal cancer: Comparison with histologic findings. J Gastrointest Surg 2005; 9: 1222–1228

52. Deal with Complication
Ramirez et al.22 concluded from a randomized trial that intraoperative results and outcome were not affected according to whether or not the defect was sutured.
The defect was left open in the majority of patients in the present study (72·0 per cent) to minimize the risk of rectal stenosis, although it was closed in patients with a high tumour.
Ramirez JM, Aguilella V, Arribas D, Martinez M. Transanal
full-thickness excision of rectal tumours: should the defect be
sutured? A randomized controlled study. Colorectal Dis 2002;
4: 51–55.

53. Local treatment modalities
Colonoscopy
Snare
Submucosal dissection
Transanal excision
Parks (Direct transanal approach)
Transanal Endoscopic Microsurgery
Others
Radiotherapy
Laser / Argon Plasma Coagulation

54. Colonoscopic procedures

55. Endoscopic local treatment
Colonoscopic polypectomy
Suitable in 90% of rectal polyps
Complete resection difficult if tumour in submucosal area
i.e. carcinoid tumors / malignant rectal tumour
Suitable for pedunculated polyp
Endoscopic mucosal resection
Removal of mucosal lesion of < 1cm
Special device needed if tumour suspected to be in submucosal area i.e. 2 channel EMR

56. 2 channel EMR Ono A, Fujii T, Saito Y, Matsuda T et al.
Endoscopic submucosal resection of rectal carcinoid tumors with a ligation device.
Gastrointest Endosc 2003; 57: 583±587

57. Endoscopic Submucosal Dissection
Indicated when one−piece resection by conventional procedures is impossible:
Large−sized lesions
Lesions with biopsy−induced scars
Lesions on haustra
Rate of one-piece resection with ESD: 70-88%
Rate of perforation: 5%
Mean size :
26.2 mm (8 ± 60)
32.8 mm (9 - 91)
Colorectal endoscopic submucosal dissection: present status and future perspective, including its differentiation from endoscopic mucosal resection. [Review] [47 refs]
Tanaka S. Oka S. Chayama K.
Journal of Gastroenterology. 43(9):641-51, 2008
Onozato Y, Kakizaki S, Ishihara H, et al.
Endoscopic submucosal dissection for rectal tumors.
Endoscopy. 2007;39:423– 427
Fujishiro M, Yahagi N, Nakamura M et al.
Endoscopic submucosal dissection for rectal epithelial neoplasia.
Endoscopy 2006; 38: 493±497

58. ESD Ono A, Fujii T, Saito Y, Matsuda T et al.
Endoscopic submucosal resection of rectal carcinoid tumors with a ligation device.
Gastrointest Endosc 2003; 57: 583±587

59. ESD in Rectal Cancer Limited to: Involvement only to SM1 or less
Kikuchi Classification of Adenocarcinoma in Sessile Polyp

61. Rectum
The junction between the sigmoid colon and the rectum has been variously described:
A point opposite the left sacroiliac joint
Level of the 3rd sacral vertebra
Level at which the sigmoid mesentery disappears
Level at which sacculations and epiploic appendages disappear and taeniae broaden to form a complete muscle layer (long transition)
Level at which the superior rectal artery divides into right and left branches
Construction with anterior angulation (proctoscopy)
Level of superior rectal fold (inconstant)
Transition between rugose mucosa of colon and smooth mucosa of rectum (cadaver)
Skandalakis John E, Colborn Gene L, Weidman Thomas A, Kingsnorth Andrew N, Skandalakis Lee J, Skandalakis Panajiotis N, Shafik Followed b, "Chapter 18. Large Intestine and Anorectum" (Chapter). Skandalakis JE, Colburn GL, Weidman TA, Foster RS Jr, Kingsworth AN, Skandalakis LJ, Skandalakis PN, Mirilas PS: Skandalakis' Surgical Anatomy: