1. Oncological and functional outcome of ultra low colo – anal anastomosis with and without intersphincteric resection for low rectal cancer R.Ruppert Städt. Klinikum München GmbH Klinikum – NEUPERLACH Klinik für Allgemein und Viszeralchirurgie endokrine Chirurgie und Coloproktologie Teaching hospital of the Ludwigs Maximilians University Heads of Departement: Prof. N. Nüssler / Dr. R.Ruppert

2. 40 % of all colorectal carcinomas are located in the rectum Rectum is defined as 16 cm upwards from anocutaneus line Rectal cancer Surgical Technique Sphincter saving procedures Abdominoperineal Resection (APR) Low anterior resection (LAR) Intersphincteric resection (ISR) Sphincter sacrificing procedure

3. Total mesorectal Exzision (TME) Sharp dissection under direct vision “plane” between visceral und parietale pelvic fascia Stelzner 1962 Heald 1982 Stelzner F (1962) Die gegenwärtige Beurteilung der Rectumresektion und Rectumamputation beim Mastdarmkrebs. Bruns Beitr 204:41 Heald RJ, Husband EM, Ryall RDH (1982) The mesorectum in rectal cancer surgery—the clue to pelvic recurrence? Br J Surg 69:613–616

4. Surgical options for rectal cancer in the lower third of the rectum Low anterior resection (LAR) / ISR abdominoperineal Resection (APR) Expected number : 80 -85 % Expected number : 10 -15 %

5. The Status of radical proctectomy and sphincter-sparing surgery in the United States Ricciardi, irnig,Madoff,Rothenberger,Baxter DCR 8, 2007:1119-1127

6. Oncological Outcomes after Mesorectal Excision For Cure for Cancer of the Lower Rectum: Anterior vs Abdominoperineal Resection Wibe et al., Trondheim, DCR 2004, 48-58 2136 konsecutive patients between 1993-1999 in 47 Hospitals in Norway Multivariate analyses of prognostic factors: APR (risc 1,3), age over 20y (3,1), UICC,

7. Julius von Hohenegg (1859 – 1940) „pull through procedure“ Wien klin.Wzschr.1888 1:272-354 Schematischer Sagittalschnitt durch ein männliches Becken nach ausgeführter Durchziehmethode

8. Straight coloanal anastomosis Established by Sir Alan Parks 1974 Circular stapler / hand sewn TME Covering stoma

10. History of „intramural spread“ 1910: Hanley 1913: Cole case reports Large intramural tumor spread 5 cm rule for distal resection margin was establlished for avoiding local recurrence

11. 1 cm rule ? 1995: Shirouzu –610 Pat. DIS: overall 10%, all cases less < 1cm –3,8% were curative cases –40% were palliativ cases (distant metastases) Pat. with DIS have an advanced cancer stage They have a worse overall survival but no increased local recurrence Conclusion : 1cm distal resection margin is adequat

12. CRM involvement APR versus AR APRAR Mercury < 6cm tumours n=282 33%13% Classic trial curative n= 400 21%10% Dutch TME trial curative n= 1586 29%13% Norwegian audit 12%5% Trent pelican Basingstoke 21%10% CR 07 n=1350 17%8% The CRM is the most pognostic factor ( independent) not the distal resection margin (DIS)

13. Japanese Experience Saito N et al. Dis Colon Rectum 2006 1995 - 2004 7 hospitals 228 low rectal cancers < 5 cm from anal verge T 1 n=46, T 2 n= 78, T 3 n= 104 Neoadjuvant Radiotherapy 57 Local recurrence at 5 years: 7 % Disease free survival (DFS): 83 % at 5 years Good continence (Kirwan I –II): 68 %

14. French Experience – Eric Rullier, ESCP 2008 Nantes Results n = 300 CAAPartial ISRTotal ISRAPR Age67656365ns Tumour stage T1/T2 22 %13 %10 %6 %0,001 T372 %76 %81 %51 % T46 %11 %9 %43 % Preop RT67 %86 %88 %79 %0,007 Distance to anal ring (cm) 21- 0,5- 10,001 Hand sewn37 %96 %100 %0,001 Level of anastomosis 3 cm2 cm1 cm0,001 Colonic pouch 62 %72 %83 %0,01

15. Oncological feasibility French experience - Eric Rullier, ESCP, Nantes 2008 n = 300 CAAp ISRt ISRAPR CRM (mm) 75460,07 R o resection 87 %88 %81 % ns Tumor stage I 43 %45 %46 %16 %0,005 II 22 %24 %26 %39 % III 35 %29 %30 %45 % ns

16. Oncological outcome French experience - Eric Rullier, ESCP 2008, Nantes n = 300 CAAP ISRT ISRAPR Follow up (month) 37395536ns Local recurrence 5559ns Overall recurrence 20 % 21 %36 %P = 0,07 Delay of recurrence (month) 17181115ns

17. 5 year overall and DFS

18. Meta analysis of ISR Tilney & Tekkis Colorectal Disease 2008 21 series from 13 units 612 patients Mortality 1,6 % Leakage 10,5 % Local recurrence 9,5 % (0 – 31) 5y survival 81 % Radiotherapy: oncological benefit but worse functional outcome

19. Summary For oncological reasons, intersphincteric resection is safe and should be offered to all patients as often it is possible.

20. Functional outcome ? How is continence influenced by intersphincteric resection ? Quality of life ?

21. Sphincter function 1. Internal anal sphincter – resting pressure 2. External anal sphincter - squeeze pressure

22. Intersphincteric resection Physiology 1.Loss of internal sphincter (innervation) 2. Loss of anal transitional zone 3. loss of rectal compliance

23. Own Results 1978 – 1992 low anterior resections n = 2707 coloanal anastomosis n = 103 (3,8 %) Male = 75, female = 28 Age 58,6 ( m = 59,8, f = 57,4) Rectal cancer n =88 Large adenomas n =9 Rectovaginal fistula after radiotherapy n = 6

26. summary Final evaluation for functional outcome makes sense only after 2 years. Subjective outcome in our series –80,6 % satisfied – 5,8 % not satisfied

27. Functional outcome CAAP ISR T ISR normal continence 73 %52 %51 % Incontinence for gas 6 %7 %3 % Minor incontinence 6 %26 %24 % Major incontinence 13 %11 %16 % colostomy2 %4 %5 % Good continence 79 %59 %54 % P = 0,02ns Bretagnol Dis Colon Rectum 2004

28. Summary functional outcome after ISR is acceptable Be aware of minor and major problems of incontinence in one third of the patients. Preoperative information about these problems are absolutely necessary Younger patients are more suitable for ISR. No good results will be achieved in older women Patient selection is the key to good functional results Avoid Creation of a perineal stoma

29. "Advance means progress to something better and not progress to something new." Sir Heneage Ogilivie (1887-1948 Guy's Hospital London)

30. Thank you for your attention