Ultralow resections Emmanuel Tiret Hôpital Saint-Antoine, AP-HP Université Pierre et Marie Curie, Paris VI
Introduction <ul><li>Tumor above the pelvic floor : </li></ul><ul><li>total mesorectal excision </li></ul><ul><li>distal m...
Introduction <ul><li>Tumour  at 1-2 cm from the upper extent of the sphincter : </li></ul><ul><ul><li>Abdominoperineal res...
Surgical technique <ul><li>abdominal approach </li></ul><ul><li>- tumour exclusion before sectioning the bowel </li></ul><...
Circumferential incision of the  anal mucosa with special attention to preserve a sufficient length  of anoderm. After cir...
A coloanal anastomosis is performed  with single sutures taking the anus and  parts of the external anal sphincter Surgica...
Exclusion <ul><li>Clinical and endoanal ultrasound assessment </li></ul><ul><li>Contraindications : </li></ul><ul><li>inva...
Preoperative radiotherapy or radiochemotherapy Rouanet et al. Ann Surg 1995; 221: 67-73 Rullier et al. Ann Surg 2001; 234:...
Patients 1992-2004 <ul><li>90 patients (59 men) median age : 58.9 (27-82) </li></ul><ul><li>Tumour : </li></ul><ul><ul><li...
Intersphincteric resections 1992-2004 : 6% of 1319 rectal adenocarcinoma
Patients <ul><li>Tumour :  ypT0 = 7 (8%) </li></ul><ul><ul><ul><ul><li>pT1= 12 (13%)  </li></ul></ul></ul></ul><ul><ul><ul...
upper third : upper half or > : 63 (70%)   27 (30%) Level of internal sphincter excision T Median distal resection margin ...
Postoperative complications   Mortality :  0 Morbidity :  18.8% (17) Stenosis : 8.4% (8) <ul><li>Anastomotic leakage </li>...
<ul><li>R0 resection : 94.4% (85) </li></ul><ul><li>circumferential margin + : 4  positive distal margin : 1 </li></ul><ul...
<ul><li>Median follow-up : 56,2 months (13-168) </li></ul><ul><li>Overall recurrence :  17% (16) </li></ul><ul><li>Local :...
Characteristics of 6 patients with local recurrence and 2 patients with combined recurrence Ann Surg 2007; 246: 916-22
Survival Five-years overall survival  82%   IC 95% [80-97] Five-years disease free survival  75% IC 95%[64-86] Death from ...
Recurrence and survival Author n Stage Follow-up (months) Local recurrence Distant recurrence Survival Schiessel  121 T1-4...
Functional results at follow-up (55 months) 83 patients (colonic J-pouch)  2 patients lost of FU and 5  APR Stool frequenc...
Functional results  Continence at follow-up <ul><li>Continence status was assessed by the Wexner score </li></ul><ul><ul><...
Relationship between level of coloanal anastomosis and complete continence <ul><li>Subtotal resection : </li></ul><ul><ul>...
Manometry Schiessel et al. Dis Colon Rectum 2005; 48: 1858–1867 n = 117 IRS Relationship between level of coloanal anastom...
Factors influencing functional outcome   Univariate analysis Chamlou R et al. Ann Surg 2007; 246: 916-22
Factors influencing functional outcome Multivariate analysis OR [IC 95%] p Age 1,032 [0,984;1,084] ns Sex 1,139 [0,369;3,5...
Functional result Author n  Stool frequency n/24h Normal  continence Major incontinence  Colostomy Schiessel 117  3 86.3% ...
Conclusion <ul><li>Intersphincteric resection is currently the limit of safe sphincter preservation. </li></ul><ul><li>Com...
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MCC 2011 - Slide 14

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MCC 2011 - Slide 14

  1. 1. Ultralow resections Emmanuel Tiret Hôpital Saint-Antoine, AP-HP Université Pierre et Marie Curie, Paris VI
  2. 2. Introduction <ul><li>Tumor above the pelvic floor : </li></ul><ul><li>total mesorectal excision </li></ul><ul><li>distal margin > 1cm </li></ul><ul><li>low colorectal or coloanal anastomosis </li></ul>
  3. 3. Introduction <ul><li>Tumour at 1-2 cm from the upper extent of the sphincter : </li></ul><ul><ul><li>Abdominoperineal resection </li></ul></ul><ul><ul><li>Intersphincteric resection : distal margin > 1 cm can be obtained by partial internal sphincteric resection allowing a sphincter preserving surgery. </li></ul></ul>
  4. 4. Surgical technique <ul><li>abdominal approach </li></ul><ul><li>- tumour exclusion before sectioning the bowel </li></ul><ul><li>- technical challenge (obese, narrow pelvis) </li></ul><ul><li>transanal approach </li></ul><ul><li>- easier </li></ul><ul><li>- risk of tumour dissemination? </li></ul><ul><li>similar local recurrence rates </li></ul>T
  5. 5. Circumferential incision of the anal mucosa with special attention to preserve a sufficient length of anoderm. After circumferential preparation the rectum is mobile and the external sphincter has been completely preserved. Surgical technique Schiessel et al. Dis Colon Rectum 2005; 48: 1858–1867
  6. 6. A coloanal anastomosis is performed with single sutures taking the anus and parts of the external anal sphincter Surgical technique
  7. 7. Exclusion <ul><li>Clinical and endoanal ultrasound assessment </li></ul><ul><li>Contraindications : </li></ul><ul><li>invasion of the external sphincter or pelvic floor (levator ani) </li></ul><ul><li>T4 except in anterior extension (vagina) </li></ul><ul><li>histologic : poorly differentiated or mucinous tumours </li></ul>
  8. 8. Preoperative radiotherapy or radiochemotherapy Rouanet et al. Ann Surg 1995; 221: 67-73 Rullier et al. Ann Surg 2001; 234: 633-40 <ul><li>Conservative resection for low rectal cancer after high dose </li></ul><ul><li>of radiation </li></ul><ul><li>T3 tumours </li></ul><ul><li>level of transection of the internal sphincter decided </li></ul><ul><li>prior to treatment </li></ul><ul><li>downstaging : 42%, associated with a greater radial margin </li></ul>
  9. 9. Patients 1992-2004 <ul><li>90 patients (59 men) median age : 58.9 (27-82) </li></ul><ul><li>Tumour : </li></ul><ul><ul><li>mean distance from the anal verge : 35mm (2.2 - 5.25) </li></ul></ul><ul><li> from the anorectal ring : 12 mm (0 - 2.5) </li></ul><ul><li>Previous transanal resection : 9 </li></ul><ul><li>Preoperative radiotherapy : 37 (41%) </li></ul><ul><ul><ul><ul><ul><li>long course (45 Gy) : 24 </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>short course (25Gy) : 13 </li></ul></ul></ul></ul></ul>Ann Surg 2007; 246: 916-22
  10. 10. Intersphincteric resections 1992-2004 : 6% of 1319 rectal adenocarcinoma
  11. 11. Patients <ul><li>Tumour : ypT0 = 7 (8%) </li></ul><ul><ul><ul><ul><li>pT1= 12 (13%) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>pT2 = 35 (39%) (9N+) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>pT3= 32 ( 36%) (12N+) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>pT4N+ = 4 (vagina=3, prostate=1) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>pN0 = 69% </li></ul></ul></ul></ul><ul><ul><ul><ul><li>pN1 = 20% </li></ul></ul></ul></ul><ul><ul><ul><ul><li>pN2 = 11% </li></ul></ul></ul></ul><ul><li>Stage : I : 41%, II : 18% </li></ul><ul><li>III : 28%, IV : 6% </li></ul>
  12. 12. upper third : upper half or > : 63 (70%) 27 (30%) Level of internal sphincter excision T Median distal resection margin : 12mm (5-35)
  13. 13. Postoperative complications Mortality : 0 Morbidity : 18.8% (17) Stenosis : 8.4% (8) <ul><li>Anastomotic leakage </li></ul>8 <ul><li>Pelvic haematoma </li></ul>1 <ul><li>Partial wound dehiscence </li></ul>1 <ul><li>Small Bowel obstruction </li></ul>2 <ul><li>Upper GI bleeding </li></ul>1 <ul><li>Septicaemia </li></ul>1 <ul><li>Pouch necrosis </li></ul>1 <ul><li>Acute pancreatitis </li></ul>1 <ul><li>Pulmonary embolism </li></ul>1
  14. 14. <ul><li>R0 resection : 94.4% (85) </li></ul><ul><li>circumferential margin + : 4 positive distal margin : 1 </li></ul><ul><li>Abdominoperineal excision : 2 </li></ul><ul><ul><ul><li>pouch necrosis : 1 </li></ul></ul></ul>Results
  15. 15. <ul><li>Median follow-up : 56,2 months (13-168) </li></ul><ul><li>Overall recurrence : 17% (16) </li></ul><ul><li>Local : 6,6% (6) </li></ul><ul><ul><ul><li>median disease free interval : 13 months (6-44) </li></ul></ul></ul><ul><ul><li>median distal resection margin : 6 mm (5-30) </li></ul></ul><ul><ul><li>(included 1 cancer cells implant on hemorrhoid) </li></ul></ul><ul><li>Distant : 8.8% (8) </li></ul><ul><li>liver metastasis : 5.5% (5) </li></ul><ul><li>lung mestastasis : 7% (7) </li></ul><ul><li>Combined : 2 </li></ul>Oncological results
  16. 16. Characteristics of 6 patients with local recurrence and 2 patients with combined recurrence Ann Surg 2007; 246: 916-22
  17. 17. Survival Five-years overall survival 82% IC 95% [80-97] Five-years disease free survival 75% IC 95%[64-86] Death from cancer : 14.4% (13)
  18. 18. Recurrence and survival Author n Stage Follow-up (months) Local recurrence Distant recurrence Survival Schiessel 121 T1-4 94 5.3% Köhler 31 T1-3 82 10% 10% 79% Rullier 92 T1-4 44 2% 19% 81% Saito 225 T1-3 41 6.7%   91.9% Braun 63 T1-3 80 11% 33% 62% * Hohenberger St Antoine 53 90 T1-4 56.2 25.1% 6.6% 8.8% 85% 82%
  19. 19. Functional results at follow-up (55 months) 83 patients (colonic J-pouch) 2 patients lost of FU and 5 APR Stool frequency (per 24 hours) 2.3 ± 1.3 <ul><ul><li>≤ 2 </li></ul></ul>50 (60%) <ul><ul><li>3 to 5 </li></ul></ul>30 (36%) <ul><ul><li>> 5 </li></ul></ul>3 (4%) Nocturnal defaecation 24 (29%) Urgency 16 (19%) Pad wear 38 (46%) Intestinal transit regulators 22 (26,5%) Feces-flatus discrimination 21 (25,3%) Stool fragmentation 40 (41%) Alimentary restriction 30 (36%)
  20. 20. Functional results Continence at follow-up <ul><li>Continence status was assessed by the Wexner score </li></ul><ul><ul><li>Perfect (score =0) 34 (41%) </li></ul></ul><ul><ul><li>Minor problems (mean score : 3.7) 29 (35%) </li></ul></ul><ul><ul><li>Incontinence (mean score : 15) 20 (24%) </li></ul></ul><ul><li>major incontinence 2 </li></ul><ul><li>Subjective satisfaction : 76% </li></ul>
  21. 21. Relationship between level of coloanal anastomosis and complete continence <ul><li>Subtotal resection : </li></ul><ul><ul><ul><li>normal continence in > 50% </li></ul></ul></ul><ul><ul><ul><li>lower resting anal pressure </li></ul></ul></ul>Schiessel et al. Dis Colon Rectum 2005; 48: 1858–1867
  22. 22. Manometry Schiessel et al. Dis Colon Rectum 2005; 48: 1858–1867 n = 117 IRS Relationship between level of coloanal anastomosis and complete continence
  23. 23. Factors influencing functional outcome Univariate analysis Chamlou R et al. Ann Surg 2007; 246: 916-22
  24. 24. Factors influencing functional outcome Multivariate analysis OR [IC 95%] p Age 1,032 [0,984;1,084] ns Sex 1,139 [0,369;3,516] ns pT stage <ul><ul><li>0-1-2 </li></ul></ul>1 ns <ul><ul><li>3-4 </li></ul></ul>1,311 [0,436;3,948] ns Preoperative radiotherapy <ul><ul><li>no </li></ul></ul>1 <ul><ul><li>yes </li></ul></ul>3,1 [1,051;8,982] 0,04
  25. 25. Functional result Author n Stool frequency n/24h Normal continence Major incontinence Colostomy Schiessel 117 3 86.3% 0% 0 Köhler 26 3-4 29.6% 3.7% 1 Bretagnol 40 2.5 15% 12% 0 Saito 181 3-4 68%   7% 0 Braun 41 2.2 80% 3% 0 St Antoine 83 2.3 41% 2% 0
  26. 26. Conclusion <ul><li>Intersphincteric resection is currently the limit of safe sphincter preservation. </li></ul><ul><li>Compared to abdominoperineal resection, recurrence and survival are not compromised. </li></ul><ul><li>Good function may be achieved in 75% of the patients. </li></ul><ul><li>Function is significantly altered by preoperative radiotherapy </li></ul><ul><li>It should be considered in selected patients with rectal tumours 2.5 to 5.5 cm from the anal verge, provided the external sphincter and levator ani are spared. </li></ul>

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