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Cornelis van de Velde Professor of Surgery 29th april 2008 Developments in rectal cancer surgery L EIDEN U NIVERSITY M EDICAL C ENTER.

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Presentation on theme: "Cornelis van de Velde Professor of Surgery 29th april 2008 Developments in rectal cancer surgery L EIDEN U NIVERSITY M EDICAL C ENTER."— Presentation transcript:

1 Cornelis van de Velde Professor of Surgery 29th april 2008 Developments in rectal cancer surgery L EIDEN U NIVERSITY M EDICAL C ENTER

2 Content Perineal sacral and abdominal resectionAbdominoperineal resectionSphincter saving resectionTotal mesorectal excisionLateral lymph node dissectionNerve sparing resectionMinimal invassive resectionCurrent developments

3 Content Perineal sacral and abdominal resectionAbdominoperineal resectionSphincter saving resectionTotal mesorectal excisionLateral lymph node dissectionNerve sparing resectionMinimal invassive resectionCurrent 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 resectionAbdominoperineal resectionSphincter saving resectionTotal mesorectal excisionLateral lymph node dissectionNerve sparing resectionMinimal invassive resectionCurrent developments

11 1st Abdominoperineal resection 1895 Quénu

12 William Ernest Miles : 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 1.An abdominal anus is necessary 2.The whole of the pelvic colon must be removed 3.The whole of the pelvic mesocolon must be removed 4.The group of lymph nodes situated over the bifurcation of the common iliac artery must be removed 5.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 resectionAbdominoperineal resectionSphincter saving resectionTotal mesorectal excisionLateral lymph node dissectionNerve sparing resectionMinimal invassive resectionCurrent developments

18 Anterior resection 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 +/ 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 Results Evans RA J Amer Coll Surg 1994

24 Content Perineal sacral and abdominal resectionAbdominoperineal resectionSphincter saving resectionTotal mesorectal excisionLateral lymph node dissectionNerve sparing resectionMinimal invassive resectionCurrent 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: 1.Inadequate circumferential margins of resection are responsible for local recurrence 2.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 1.Meticulous sharp dissection along known anatomic planes 2.En bloc resection of the primary tumour and its possible direct extention to adjacent organs 3.En bloc resection of potential lymph node spread 4.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 resectionAbdominoperineal resectionSphincter saving resectionTotal mesorectal excisionLateral lymph node dissectionNerve sparing resectionMinimal invassive resectionCurrent developments

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

33 Lateral lymph nodes Dukes C Rectal Cancer below the peritoneal reflection three or less LN metatases 10% four or more LN metastases 25% Lateral node negative 8.5% Lateral node positive 33% Rate of local recurrence 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 resectionAbdominoperineal resectionSphincter saving resectionTotal mesorectal excisionLateral lymph node dissectionNerve sparing resectionMinimal invassive resectionCurrent 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 recurrences5% Preservation of potency86.7% Ejaculation87.9% Failed initial voiding5% 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 Maas CP, Moriya Y et al. Lancet 1999;354:772-3 ‘We only see what we look for and we only look for what we know’ Walsh Autonomic nerve preservation

42 Content Perineal sacral and abdominal resectionAbdominoperineal resectionSphincter saving resectionTotal mesorectal excisionLateral lymph node dissectionNerve sparing resectionMinimal invassive resectionCurrent developments

43 Minimal invasive surgery 1913 Strauss electrocoagulation-technique 1983 Buess TEM, local excision T0-T 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. Lap 1,3 1. Quah HM Br J Surg Lindsey I Br J Surg 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 Lindsey I Br J Surg 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 resectionAbdominoperineal resectionSphincter saving resectionTotal mesorectal excisionLateral lymph node dissectionNerve sparing resectionMinimal invassive resectionCurrent developments

48 Unsatisfactory results APR CRM+ LAR10.7% P=0.002 APR30.4% 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 Holm T Br J Surg 2007

52 Neoadjuvant chemoradiotherapy Tumour down- sizing and staging↑ sphincter preservationLocal excisionNo 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 Cornelis van de Velde, Professor of Surgery Marilyne Lange, Research fellow Thank you for your attention Department of Surgery Leiden University Medical Center The Netherlands


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