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Surgical Treatment of the Low (Distal Third) Rectal Cancer Feza H. Remzi FACS, FASCRS, FTSS ( Hon ) Chairman Department of Colorectal Surgery Professor.

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Presentation on theme: "Surgical Treatment of the Low (Distal Third) Rectal Cancer Feza H. Remzi FACS, FASCRS, FTSS ( Hon ) Chairman Department of Colorectal Surgery Professor."— Presentation transcript:

1 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 Rupert B Turnbull Jr,. MD Chair Digestive Disease Institute Cleveland Clinic, Cleveland, OH

2 Disclosure None

3 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

4 Maximize likelihood of cure Minimize risk of complications Sphincter preservation Optimal bowel function and quality of life Treatment Goals

5 Surgeon Radiologist Oncologist Radiation Therapist Enterostomal therapist Team Approach

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

7 Negative radial margins 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 Margin

8 Colon mobilization and high ligation of the mesenteric vessels TME APR versus reconnection with reconstruction Surgery

9 TME

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15 Anastomosis

16 Issues Blood Supply Reach Reconstruction Anastomosis

17 Blood Supply Reach Issues

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

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31 Handsewn Anastomosis

32 Technique 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

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

37 Sphincter Preservation and QOL 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

38 Selection 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 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

39 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

40 Pre or post op? Dose if preoperative Timing of surgery if given pre-op Which patients benefit ? If needed with TME Decision for APR versus reconnection, when ? Pelvic Radiation and Rectal Cancer: Current Dilemma

41 Dutch TME study 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 Pelvic Radiation Preop and TME Kapitenijn et al NEJM 2001

42 Summary 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

43 Function and QOL after Radical Resection and Sphincter Preservation Inadvertent and uncontrollable passage of flatus to frank fecal incontinence Urgency Frequency Anterior resection syndrome Cost?

44 Radical Resection of Rectal Cancer End-to-end coloanal anastomosisEnd-to-end coloanal anastomosis Side-to end colonic J-pouch-anal anastomosisSide-to end colonic J-pouch-anal anastomosis End-to-end coloplasty-anal anastomosisEnd-to-end coloplasty-anal anastomosis Side-to-end coloanal anastomosisSide-to-end coloanal anastomosis

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47 End-to-end versus J-pouch

48 Prospective randomized trials Seow-Choen, Goh. Br J Surg 1995;82:608Seow-Choen, Goh. Br J Surg 1995;82:608 Ortiz, et al. Dis Colon Rectum 1995;38:375Ortiz, et al. Dis Colon Rectum 1995;38:375 Hallböök, et al. Ann Surg 1996;224:58.Hallböök, et al. Ann Surg 1996;224:58. Lazorthes, et al. Br J Surg 1997;84:1449Lazorthes, et al. Br J Surg 1997;84:1449 Fürst, et al. Dis Colon Rectum 2002;45:660Fürst, et al. Dis Colon Rectum 2002;45:660 Sailer, et al. Br J Surg 2002;89:1108Sailer, et al. Br J Surg 2002;89:1108

49 End-to-end versus J-pouch Technical reasons for failure to create J- pouch Narrow pelvis (12%)Narrow pelvis (12%) Bulky sphincters or mucosectomy (9%)Bulky sphincters or mucosectomy (9%) Extensive diverticulosis (3%)Extensive diverticulosis (3%) Insufficient length (2%)Insufficient length (2%) Harris, et al. Dis Colon Rectum 2002;45:1304

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53 J-pouch versus Coloplasty

54 Prospective randomized trials Ho, et al. Ann Surg 2002;236:49Ho, et al. Ann Surg 2002;236:49 Fürst, et al. Dis Colon Rectum 2003;46:1161Fürst, et al. Dis Colon Rectum 2003;46:1161 Pimentel, et al. Colorect Dis 2003;5:465Pimentel, et al. Colorect Dis 2003;5:465

55 N Pouch size Follow-up Ho88 6 cm/7 cm 12 months Fürst 40 5 cm/8 cm 6 months Pimentel30 5 cm/8 cm 12 months J-pouch versus Coloplasty

56 FrequencyUrgencyConstipation Ho Fürst - Pimentel J-pouch J-pouch Coloplasty Coloplasty J-pouch versus Coloplasty

57 Fazio et al 2007 Ann Surg N=364 Mortality N= % 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

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60 J-pouch versus Side-to-end

61 Prospective randomized trials Huber, et al. Dis Colon Rectum 1999;42:896Huber, et al. Dis Colon Rectum 1999;42:896 Machado, et al. Ann Surg 2003;238:214Machado, et al. Ann Surg 2003;238:214 J-pouch versus Side-to-end

62 N Pouch size Follow-up Huber59 6 cm/4 cm 6 months Machado100 8 cm/4 cm 12 months J-pouch versus Side-to-end

63 FrequencyUrgencyConstipation Huber J-pouch J-pouch Machado J-pouch versus Side-to-end

64 Local Excision Abdominoperineal resection or low anterior resection for rectal cancer Complete tumor excision Clearance of regional lymph nodes Operative mortality, morbidity × Urinary and sexual dysfunction % × Anastomotic complications 5-10 % × Mortality of 1- 6 % after APR × Necessity of permanent or temporary diversion

65 Surgical Approaches Local excision alone Local excision followed by adjuvant therapy Local excision after neoadjuvant therapy Limited surgical morbidity 0-22 %

66 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)

67 When Should We Consider It with Curative Intent? PreferredAcceptable Stage 1 T1N0M0 FavorableLE Radical featuresChemo / X-rt ? resection UnfavorableRadicalLE + resection chemo / X-rt Stage 1 T2N0M0RadicalLE + resection chemo / X-rt

68 Future of Local Excision It is here to stay Better predictive factors ̶ Kikuchi classification ̶ Better preoperative staging ̶ Markers Telomerase, p53, COX,MIB-1, BCL-1, BCL-X, MLH-1, MSH-2 and MSH-6 The necessity of multicenteric and controlled trials Kikuchi 1995, Ramalingam 2002 SSAT

69 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

70 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 Conclusion

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72 Jagelman / Turnbull International Colorectal Disease Symposium REGISTER NOW Feb 11-16, th Anniversary 35 th Anniversary

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