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Developments in rectal cancer surgery

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Presentation on theme: "Developments in rectal cancer surgery"— Presentation transcript:

1 Developments in rectal cancer surgery
Leiden University Medical Center Developments in rectal cancer surgery Cornelis van de Velde Professor of Surgery 29th april 2008

2 Content Perineal sacral and abdominal resection
Abdominoperineal resection Sphincter saving resection Total mesorectal excision Lateral lymph node dissection Nerve sparing resection Minimal invassive resection Current developments

3 Content Perineal sacral and abdominal resection
Abdominoperineal resection Sphincter saving resection Total mesorectal excision Lateral lymph node dissection Nerve sparing resection Minimal invassive resection Current developments

4 Rectal cancer treatment in the 18th century
Policy of abstinence In some cases defunctioning stoma 1739 Jean Faget: 1st perineal resection, removing only a few cm of the distal rectum

5 Transsacral resection with coccygectomie
1874 Theodor Kocher

6 Extention sacral resection
1885 Paul Kraske Resection up to S4 Improved sight Resection higher tumours possible

7 Problems perineal and sacral resection
Limited view Inadequate resection Sacral anus Poor hygiene

8 Abdominal resection Combined spinal and gas anaesthesia
muscle relaxation Joseph Lister: antipsepsis reduced risk of peritonitis

9 1st Abdominal resection
1879 Carl Gussenbauer Closure terminal rectum Colostoma Hartmann-procedure Nowadays palliative procedure

10 Content Perineal sacral and abdominal resection
Abdominoperineal resection Sphincter saving resection Total mesorectal excision Lateral lymph node dissection Nerve sparing resection Minimal invassive resection Current developments

11 1st Abdominoperineal resection
1895 Quénu

12 William Ernest Miles 1899-1906: 57 perineal resections → 54 recurrence
Post mortem examination location of recurrence: Pelvic peritoneum Pelvic mesocolon Lymph nodes over the bifurcation of left common illiac artery “recurrence appeared … beyond the scope of a removel from the perineum”

13 Miles’ cylindrical concept
Spread occurs particularly in the lymphatics and in all directions

14 Miles’ principles An abdominal anus is necessary The whole of the pelvic colon must be removed The whole of the pelvic mesocolon must be removed The group of lymph nodes situated over the bifurcation of the common iliac artery must be removed The perineal part of the operation should be carried out as widely as possible (lateral and downward zones of spread)

15 1908 Miles’ abdominoperineal resection
En bloc resection and associated lymph nodes R2 → R0 resection 1st curative and anatomical correct resection Recurrence: 29.5% Miles Lancet 1908

16 Problems abdominoperineal resection
Permanent colostoma 100% impotence

17 Content Perineal sacral and abdominal resection
Abdominoperineal resection Sphincter saving resection Total mesorectal excision Lateral lymph node dissection Nerve sparing resection Minimal invassive resection Current developments

18 1st anterior resection with construction of an anastomosis
1910 Donald Balfour: 1st anterior resection with construction of an anastomosis 1948 Claude Dixon: 400 patients mortality 2.6% 5-year survival 64%

19 Blunt pre-sacral dissection in anterior resection

20 Further developments +/- 1980
Distal margin of 2 cm is adequate: low anterior resection Circular stapler: reduced risk of anastomotic leakage Anterior resection golden standard

21 Problems sphincter saving resection
Faecal incontinence Anastomotic leakage

22 1986 Colonic J-pouch ↓ anastomotic leakage and faecal incontinence (Hallböök O Ann Surg 1996)

23 Sphincter saving resection 45%1 Erectile dysfunction 50-85%
Results 5-year survival ~50% Local recurrence 30-40% Distant recurrence 60-65% Sphincter saving resection 45%1 Erectile dysfunction 50-85% 1Evans RA J Amer Coll Surg 1994

24 Content Perineal sacral and abdominal resection
Abdominoperineal resection Sphincter saving resection Total mesorectal excision Lateral lymph node dissection Nerve sparing resection Minimal invassive resection Current developments

25 Local failure after convential/blunt dissection
52 surgical specimens of “curative” operations 14 of the 52 (27%) unsuspected involvement of circumferetial margin and violation of the mesorectum 12 of the 14 (85%) pelvic recurrences Conclusion: Inadequate circumferential margins of resection are responsible for local recurrence CRM is essential to an R0 resection Quirke P Lancet 1986

26 Total mesorectal excision
Heald Br J Surg 1982 The mesorectum in rectal cancer surgery—the clue to pelvic recurrence?

27 Total mesorectal excision
Meticulous sharp dissection along known anatomic planes En bloc resection of the primary tumour and its possible direct extention to adjacent organs En bloc resection of potential lymph node spread Reproducible specimen with negative or uninvolved surgical margins = an anatomically and pathologically reproducible specimen, predictable clinical outcomes, and an emphasis on function and organ preservation wherever possible

28 Outdated surgical techniques
No blunt dissection No “coning” No “shake hands”

29 Results total mesorectal excision
23-35% overall recurrence 15-25% metastatic disease 5-8% local recurrence TME golden standard Enker Arch Surg 1992 MacFarlane Lancet 1993 Enker J Amer Coll Surg 1995

30 TME: increased rate of sphincter saving surgery

31 Content Perineal sacral and abdominal resection
Abdominoperineal resection Sphincter saving resection Total mesorectal excision Lateral lymph node dissection Nerve sparing resection Minimal invassive resection Current developments

32 History of rectal cancer surgery in Japan
1970 Extended surgery 1978 Komatubara initially reported NSS 1980 1984 Nerve Sparing Surgery 1990 Based on better understanding of pelvic neuro-anatomy Optimize function without compromising local control 2000

33 Dukes C Rectal Cancer below the peritoneal reflection
Lateral lymph nodes Dukes C Rectal Cancer below the peritoneal reflection Rate of local recurrence three or less LN metatases % four or more LN metastases % Lateral node negative % Lateral node positive % P=0.031 P=0.008

34 Extended resection with lateral lymph node dissection
Improved survival and local control But: Similar results with PRT + TME ↑ blood loss, ↑ operation time, ↑ nerve damage (urogenital dysfunction) Low incidence of positive lateral nodes

35 Trial in Japan without RT
Randomised trial TME versus D3 dissection T2-3 tumours No RT

36 Content Perineal sacral and abdominal resection
Abdominoperineal resection Sphincter saving resection Total mesorectal excision Lateral lymph node dissection Nerve sparing resection Minimal invassive resection Current developments

37 Autonomic nerves and rectal cancer surgery
Walsh and Tsuchiya described the autonomic nerve- preserving radical pelvic operations for prostate and rectal cancers

38 TME with autonomic nerve preservation
Retrospective study of 42 male patients Local recurrences 5% Preservation of potency 86.7% Ejaculation % Failed initial voiding 5% Enker WE Arch Surg 1992

39 TME with autonomic nerve preservation
Prospective study urogenital function Yoshihiro Moriya 50 Dutch patients No urinary dysfunction 19 male patients complete nerve preservation: no sexual dysfunction Maas CP Lancet 1999

40 Autonomic nerve preservation
Direct association between specific nerve damage and dysfunction Autonomic nerve preservation is achievable However, excellent results of experts have not been reproduced in large trials

41 Autonomic nerve preservation
‘We only see what we look for and we only look for what we know’ Walsh Maas CP, Moriya Y et al. Lancet ;354:772-3

42 Content Perineal sacral and abdominal resection
Abdominoperineal resection Sphincter saving resection Total mesorectal excision Lateral lymph node dissection Nerve sparing resection Minimal invassive resection Current developments

43 Minimal invasive surgery
1913 Strauss electrocoagulation-technique 1983 Buess TEM, local excision T0-T1 1991 Jacobs laparoscopic resection

44 Laparoscopic versus open TME
The SINGAPORE trial Sexual dysfunction: Laparoscopic 47% vs. Open 5%.1 Probably due to distal anterior dissection.2 Bladder Function: No overall differences Open vs. Lap1,3 1. Quah HM Br J Surg 2002 2. Lindsey I Br J Surg 2002 3. Jayne DG Br J Surg 2005

45 Laparoscopic versus open TME
The CLASSIC trial Men: 43% severe changes in sexual function vs. 23% in open cases. Factors associated with erectile dysfunction: 1. Open conversion (technique or tumor-related factors?) 2. TME vs. PME (extent of distal dissection?) Women: Unexplained 50% decrease in sexual activity. Vaginal dryness. 1. Quah HM Br J Surg 2002 2. Lindsey I Br J Surg 2002 3. Jayne DG Br J Surg 2005

46 Laparoscopic versus open TME
Cochrance review Until now know long-term differences in long-term oncologic and functional outcome The long-term value of laparoscopy is still evolving Breukink S Cochrane Database Syst Rev 2006

47 Content Perineal sacral and abdominal resection
Abdominoperineal resection Sphincter saving resection Total mesorectal excision Lateral lymph node dissection Nerve sparing resection Minimal invassive resection Current developments

48 Unsatisfactory results APR
CRM+ LAR 10.7% P=0.002 APR 30.4% Wider excision needed?

49 Extended APR with gluteus maximus flap
Mesorectum is not dissected off the levator muscles Perineal dissection is done in prone position En bloc resection levator muscles with the anus and lower rectum Holm T Br J Surg 2007

50 Extended APR with gluteus maximus flap
Holm T Br J Surg 2007

51 Extended APR with gluteus maximus flap
ypT0 (n = 2) ypT3 (n=20) ypT4 (n=6) Preoperative treatment Radiotherapy 25Gy 6 Radiotherapy 50Gy 1 11 4 Radiochemotherapy 3 2 Bowel perforation CRM involvement Intraoperative radiotherapy Local recurrence Holm T Br J Surg 2007

52 Neoadjuvant chemoradiotherapy
Tumour down- sizing and staging ↑ sphincter preservation Local excision No surgery at all Crane CH Cancer 2003 Szynglarewicz World J Gastr 2007 Habr-Gama J Gastrointes Surg 2006

53 Further current developments
Improved imaging Identification predictive biomarkers Individual treatment: patient selection for neoadjuvant therapy, LAR/APR, local excision Finetuning TME with respect to nerve damage, anastomotic leakage, quality of APR

54 Department of Surgery Leiden University Medical Center The Netherlands
Cornelis van de Velde, Professor of Surgery Marilyne Lange, Research fellow Thank you for your attention


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