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TAUNTON SPR TRAINING DAY 7 TH DECEMBER 2012 EARLY RECTAL CANCER Tom Edwards Consultant Colorectal Surgeon.

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Presentation on theme: "TAUNTON SPR TRAINING DAY 7 TH DECEMBER 2012 EARLY RECTAL CANCER Tom Edwards Consultant Colorectal Surgeon."— Presentation transcript:

1 TAUNTON SPR TRAINING DAY 7 TH DECEMBER 2012 EARLY RECTAL CANCER Tom Edwards Consultant Colorectal Surgeon

2 Introduction Emergency/ complication Symptomatic presentation Screening for asymptomatic disease

3 Staging for Rectal Cancer

4

5 More History APER AR TME DXT CR07: T1 disease 1.8 (2.9)% LR // OS 94%

6 The early rectal cancer dilemma  Stage 1 rectal cancer is a curable disease with radical surgery But…

7 The cost for cure  Total mesorectal excision associated with  Long hospital stay and convalescence  Death (young 2% : >85 20%)  Leak rate (16%)  Urinary dysfunction  Sexual dysfunction  Defaecatory dysfunction  Permanent stoma rate (10-40%)

8 Bowel Dysfunction Radical surgery for rectal cancer Temple et al, DCR 2005

9 Sexual Dysfunction Radical surgery for rectal cancer Activity: Pre Op Post Op Loss Spont Embarrassed APR 91% 55% 53% 44% LAR 94% 74% 27% 24% TART 80% 87% 13% 0% Hendren et al, Ann Surg 2005

10 ?

11 So, what about trans anal, full thickness local excision?

12 Local Excision is Appealing  Low morbidity  Quick recovery  Minimal effect on long term bowel function  Organ sparing technique  Genitourinary dysfunction avoided

13 BUT………………Lymph nodes!!!!  Blumberg, et al, Dis Colon Rectum 1999 T 1/2 = 20% +LN T 3 = 40% +LN

14 Local Excision: In an Ideal World  We would know that the lymph nodes are clear  Technically a FTLE is possible  the surgery should be curative!  But equally, if there is a recurrence …  Salvage surgery does not worsen the oncological result

15 Trans Anal Resection of Tumour (TART) Unfortunately... the oncologic results have been disappointing

16 Favorable T1 Cancers Trans Anal Excision (TAE) Mellgren (2000) n=TAE 69 OS 30 Paty (2002) n=TAE 74 Nascimbeni (2004) n=TAE 70 OS 74 Madbouly (2005) n=52 Local Recurrence TAE 18% Rsxn 4% (TME) TAE 14% TAE 7% Rsxn 3% (TME) TAE 17% Survival (CSS/Overall) TAE 72% Rsxn 80% TAE 92% TAE 92% TAE 89% (72%) Rsxn 90% TAE 89% (75%) TAE 89% (75%) “Transanal excision equals total mesorectal neglect” - David Rothenberger

17 Favorable T1 Cancers Local Recurrence Survival (CSS/Overall) Mellgren (2000) n=TAE 69 OS 30 TART 18% 4 %(TME) TART 72% 80%(TME) Paty (2002) n=TAE 74 TART 14% TART 92% Nascimbeni (2004) n=TAE 70 OS 74 TART 7% 3%(TME) TART 89% (72%) 90%(TME) Madbouly (2005) n=52 TAE 17% TAE 89% (75%) “Transanal excision equals total mesorectal neglect”

18 But, don’t worry, we can perform salvage radical surgery!

19 Salvage Surgery for Recurrence  Recurrent stages (n=29)  Mean time to recurrence = 26 months  23/29 underwent curative surgery  Mean follow up = 39 months  Friel, et al. Dis Colon Rectum 2002

20 Salvage Surgery for Recurrence FTLE Patients DFS Overall 2912(59%) T110 7(70%) T21910(53%) Good histol2215(68%) Bad histol 7 2(29%)  Friel, et al. Dis Colon Rectum 2002

21 Salvage Surgery for Recurrence  Weiser, et al. Dis Colon Rectum 2005  49/50 patients underwent curative surgery  27 (55%) multivisceral resections  47/49 underwent R0 resection

22 Salvage Surgery for Recurrence FTLE Weiser, et al. Dis Colon Rectum year Survival 53%

23 Why the high local recurrence rates?  Progression of occult lymphatic tumor  Better histologic predictors  ‘Are all polyps made equal?’ TART technically limiting

24 Are all polyps equal? NO

25 Polyp morphology Pedunculated Sessile

26 7 Adverse features 1. Morphology 2. Differentiation 3. Mucinous 4. LV infiltation 5. Peri neural invaision 6. Margin 7. Exophytic vs ulcerating

27 The Difficult TART: Origins of TEMS Standard transanal excision:  Limited to lesions:  distal rectum  small tumors (<3 cm)  However…  lighting and exposure is poor  surgical field collapses “short reach, poor visibility”

28 Professor Gerhard Buess Origins of TEMS

29 Transanal Endoscopic Microsurgery 4 cm x cm proctoscope, airtight faceplate, insufflation, telescope, and laparoscopic instruments

30 Karl Storz (TEO)

31 Other techniques are available ESDContact DXT

32 Operative Techique

33 pT1 Rectal Cancer: TEM case series  , single surgeon, n=53 (75)  Age 65 y (31-89) (65y)  Average 7 cm (0-13) from verge (7cm)  F/U: 2.8 y  7.5% (4/53) recurrence(9%)  No cancer related deaths(0%) Floyd and Saclarides DCR 2006 (Abarca and Saclarides ASCRS 2010)

34 uT1N0 Rectal Cancer: RCT: TEM vs Low Anterior Rsxn Patients: Age (y): LocationL/M/U: Follow-up (m): Complications: Local Recur: Survival: TEM /12/ % 1 (4%) 96% LAR /11/ % 0 96% Winde et al, DCR 1996

35 Patients: Local Recur: Distant Recur: Prob of any Recur: DFS: TEM 35 2 (5.7%) 9% 94% LAC-TME 35 1 (2.8%) 2 (5.7%) 6% 94% Lezoche et al Surg Endosc 2007 uT2N0 Low Rectal Cancer RCT: ChemoXRT followed by TEM vs Laparoscopic TME minimum 5 year follow-up

36  So how should we manage early rectal cancer?

37 Clinical Evaluation 1. History Family history Continence history Evaluation of operative risk 2. Physical Abdomen Digital Rectal Examination Rigid proctoscopy

38 Rectal Cancer Work Up 1. Biopsy 2. Colonoscopy/ full bowel imaging 3. CEA 4. CT Scan Abdomen / Pelvis 5. Chest imaging (CXR or CT) 6. Endoscopic Ultrasound /MRI

39 Bulky lesion MR/USS T1/2 Biopsy benign TEMS Young fit patient Biopsy proven Ca Bad T1 T2 TME/ APER Good T1 Op/ Stoma averse Elderly/ comorbidity Biopsy proven Ca

40 Thanks For Listening!


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