1. The history of colorectal cancer
surgery
Theo Wiggers & Klaas Havenga
Cascais, Portugal
Sunday February 13th,2011
Department of Surgery, University Medical Center Groningen

2. Historic overview of the treatment of colorectal cancer
Introduction Old times Before TME TME Conclusions
This lecture
• Treatment of rectal cancer in the past
• Before TME =during my residency
• The Total Mesorectal Excision era:
results from the Dutch TME study
Department of Surgery, University Medical Center Groningen

3. Historic overview of the treatment of colorectal cancer
Introduction Old times Before TME TME Conclusions
First description of
rectal cancer
No surgery because:
•Sacrifice of sphincter
•Bleeding
•Faces intraperitoneal
Department of Surgery, University Medical Center Groningen

4. Historic overview of the treatment of colorectal cancer
Introduction Old times Before TME TME Conclusions
Alfred Armand Velpeau 1795 - 1867
• The first perineal resection
:1739 Faget
• Series of 6 perineal
resections
• 3 patients died after operation
"La suppression de la douleur en
chirurgie est une chimère. Il est absurde de
continuer à chercher à y parvenir."
Velpeau AA. Nouveaux élémènts de médecine opératoire. Deuxième
édition. Paris, JB Baillière 1839, pp808-14
Department of Surgery, University Medical Center Groningen

5. Historic overview of the treatment of colorectal cancer
Introduction Old times Before TME TME Conclusions
•Chief surgeon Hôpital de la Pitié
•First series perineal resections
•9 patients between 1826-1830
•3 patients died due to sepsis
•Secondary wound healing
•No severe incontinence
Department of Surgery, University Medical Center Groningen

6. Historic overview of the treatment of colorectal cancer
Introduction Old times Before TME TME Conclusions
Department of Surgery, University Medical Center Groningen

7. Historic overview of the treatment of colorectal cancer
Introduction Old times Before TME TME Conclusions
William Morton 1819-1868
•1846 Ether anesthesia
•Same period:
•Chloroform
•Nitrous oxide: laughing gas
Department of Surgery, University Medical Center Groningen

8. Historic overview of the treatment of colorectal cancer
Introduction Old times Before TME TME Conclusions
Joseph Lister, 1827-1912
Antisepsis carbolspray
since 1869
Department of Surgery, University Medical Center Groningen

9. Historic overview of the treatment of colorectal cancer
Introduction Old times Before TME TME Conclusions
Theodor Kocher 1841-1917
•Resection of os coccyx in
combination with perianal phase
•Better exposure ,less blood loss
–Better lymph node dissection
–Less wound infections
Kocher T. Die Extirpatio recti nach vorhehiger Excision des Steissbeins.
Centralblatt für Chirurgie 1874, 1: 145-147
Department of Surgery, University Medical Center Groningen

10. Historic overview of the treatment of colorectal cancer
Introduction Old times Before TME TME Conclusions
Paul Kraske, 1851-1930
•Resection coccyx and distal
sacrum
•resection proximal rectum
possible
•low tumors: sacral colostomy
•high tumors: anastomosis
Kraske P. Zur extirpation hochsitzender Mastdarmkrebse.
Verh dt Ges Chir 1885, 14: 464-474
Department of Surgery, University Medical Center Groningen

11. Historic overview of the treatment of colorectal cancer
Introduction Old times Before TME TME Conclusions
Ernest Miles 1869-1947
• From 1899 to 1906 57
perineal resections
• 95% early recurrences
• 1923 recurrence rate 29.5%
Department of Surgery, University Medical Center Groningen

12. Historic overview of the treatment of colorectal cancer
Introduction Old times Before TME TME Conclusions
Principles of Miles
Based on anatomy and
biological behavior
1. Abdominal anus in stead of
sacral
2. Resection in the zone of the
upward spread
3. Resection of the mesorectum
4. Resection of the iliac nodes
5. Wide perineal resection
Department of Surgery, University Medical Center Groningen

13. Historic overview of the treatment of colorectal cancer
Introduction Old times Before TME TME Conclusions
Cuthbert Dukes 1890–1977
Pathologist St
Mark’s Hospital
Classification of
rectal cancer A,B,C
1967 Turnbull D
The classification of cancer of the rectum.
The Journal of Pathology and Bacteriology, London, 1932, 35: 323-32 .
Department of Surgery, University Medical Center Groningen

14. Historic overview of the treatment of colorectal cancer
Introduction Old times Before TME TME Conclusions
Balfour
Balfour DC. A method of anastomosis between sigmoid and rectum.
Ann Surg 1910, 51: 239-241
Department of Surgery, University Medical Center Groningen

15. Historic overview of the treatment of colorectal cancer
Introduction Old times Before TME TME Conclusions
Henri A Hartmann 1860-1952
Rectosigmoid resection
closure of the rectal stump and
colostomy
Colon cancer and diverticulitis
Hartmann, H.: 30th Congress Francais de Chirurgie-Process,
Verheaux, Memoires, et Discussions, 30:411, 1921
Department of Surgery, University Medical Center Groningen

16. Historic overview of the treatment of colorectal cancer
Introduction Old times Before TME TME Conclusions
Sir Alexander Fleming (1881-1955)
1928 Penicillin
1940 Isolation of drug
1944 Large scale
Production
From 1950 Large scale availability
of blood transfusion
Department of Surgery, University Medical Center Groningen

17. Historic overview of the treatment of colorectal cancer
Introduction Old times Before TME TME Conclusions
Claude F Dixon 1893-1968
•Low anterior resection
•Mayo clinic from 1930
•Hand sewn anastomosis
•Mobilization of rectum by manual
evaluation of the gland bearing tissue from
the hollow of the sacrum
Department of Surgery, University Medical Center Groningen

18. Historic overview of the treatment of colorectal cancer
Introduction Old times Before TME TME Conclusions
Rubert Turnbull jr 1913-1981
Surgeon Cleveland clinics
No-touch isolation tecnnique
Cancer of the colon: the influence of the no-touch isolation technic on survival rates.
Ann Surg. 1967 ; 166: 420–427.
Department of Surgery, University Medical Center Groningen

19. Historic overview of the treatment of colorectal cancer
Introduction Old times Before TME TME Conclusions
Moscow Proctologic Institute 1967
Russian circular stapler
Department of Surgery, University Medical Center Groningen

20. Historic overview of the treatment of colorectal cancer
Introduction Old times Before TME TME Conclusions
During residency
Blunt dissection
“Coning”
“Shake Hands”
Department of Surgery, University Medical Center Groningen

21. Historic overview of the treatment of colorectal cancer
Introduction Old times Before TME TME Conclusions
How bad was it
50%
40%
Local recurrence %
30%
Norway
20% Netherlands
Enker
10% Moriya
Heald
0%
0 1 2 3 4 5
Years
Havenga, Eur J Surg Oncol 1999
Department of Surgery, University Medical Center Groningen

22. Historic overview of the treatment of colorectal cancer
Introduction Old times Before TME TME Conclusions
Introduction of preoperative radiotherapy
• March 1987 till February 1990 1168
patients
• Randomization: preoperative 40%
radiotherapy (5x5 Gray) directly
followed by surgery
• Local recurrence rate:
– surgery alone: 27% 10%
– surgery and radiotherapy: 11%
• Difference in 5-year survival: 10 %
Swedish Rectal Cancer Trial N Engl J Med,1997
Department of Surgery, University Medical Center Groningen

23. Historic overview of the treatment of colorectal cancer
Introduction Old times Before TME TME Conclusions
• Preoperative radiotherapy 14 trials,
6633 patients
• Postoperative radiotherapy 8 trials,
2157 patients
• Risk reduction of local recurrence pre
44%, post 33%
• Survival with radiotherapy 63.3%,
without 62.2%
• Positive effect of radiotherapy
counterbalanced by death from other
courses
• Preoperative radiotherapy: shorter
treatment period, higher compliance,
less complications
Lancet 2001;358:1291-304
Department of Surgery, University Medical Center Groningen

24. Historic overview of the treatment of colorectal cancer
Introduction Old times Before TME TME Conclusions
Bill Heald
Skills based on anatomy and biological behaviour
Department of Surgery, University Medical Center Groningen

25. Historic overview of the treatment of colorectal cancer
Introduction Old times Before TME TME Conclusions
Waldeyer: Das Becken 1899
Department of Surgery, University Medical Center Groningen

26. Historic overview of the treatment of colorectal cancer
Introduction Old times Before TME TME Conclusions
Gray’s anatomy 1860
Department of Surgery, University Medical Center Groningen

27. Historic overview of the treatment of colorectal cancer
Introduction Old times Before TME TME Conclusions
Phil Quirke
• Local recurrence of rectal adenocarcinoma
due to inadequate surgical resection
Department of Surgery, University Medical Center Groningen

28. Historic overview of the treatment of colorectal cancer
Introduction Old times Before TME TME Conclusions
Lateral lymph node dissection
• Promoted since 1950
• Technique revived and
improved in Japan
• Same results as TME +
radiotherapy
• However: more blood loss ,
longer operation time, more
autonomic dysfunction
Department of Surgery, University Medical Center Groningen

29. Historic overview of the treatment of colorectal cancer
Introduction Old times Before TME TME Conclusions
Nerve preserving
• Damage to the pelvic autonomic
nerve system inevitable
• Initiated in Japan: Hojo and
Moriya
• Enker: nerve preservation and
TME
• Still a major problem
Department of Surgery, University Medical Center Groningen

30. Historic overview of the treatment of colorectal cancer
Introduction Old times Before TME TME Conclusions
Transanal Endoscopic Microsurgery
• 1985 Buess
Department of Surgery, University Medical Center Groningen

31. Historic overview of the treatment of colorectal cancer
Introduction Old times Before TME TME Conclusions
Study Design
RECTAL CANCER Eligibility criteria:
stage I, II, III
no upper age limit
Randomization
Statistics:
5 x 5 Gy 5% LR in R0,
RT+TME group
10% LR in R0,
TME TME
TME alone group
α = 0.05
R0 R1 or R2 R0 R1 or R2 power=0.90
N = 1026
Observe 28 x 1,8 Gy Observe Observe
and / or CT or CT
R1/R2 + ineligible
N = 1400
Department of Surgery, University Medical Center Groningen

32. Historic overview of the treatment of colorectal cancer
Introduction Old times Before TME TME Conclusions
Infrastructure
Local Local Local
datamanager surgeon pathologist
Central Datacenter
Datamanagers
Instructor Surgery coordinator Pathology
surgeon Radiotherapy coordinator Review
Pathology coordinator Committee
QOL/CE coordinator
Local Monitor Patient
Radiotherapist Committee
Department of Surgery, University Medical Center Groningen

33. Historic overview of the treatment of colorectal cancer
Introduction Old times Before TME TME Conclusions
0,20
Local recurrence rate
Median follow-up 5.2 years(1.2-8.1)
0,15
10.5%
0,10
5.9%
0,05
0,00
0,0 2,0 4,0 6,0 8,0
Department of Surgery, University Medical Center Groningen

34. Historic overview of the treatment of colorectal cancer
Introduction Old times Before TME TME Conclusions
0,4
Distance recurrence risk
Median follow-up 5.2 years(1.2-8.1)
28.7%
0,3
25.9 %
0,2
0,1
0,0
0,0 2,0 4,0 6,0 8,0
Department of Surgery, University Medical Center Groningen

35. Historic overview of the treatment of colorectal cancer
Introduction Old times Before TME TME Conclusions
1,0 Overal suvival
Median follow-up 5.2 years(1.2-8.1)
0,8
0,6
0,4
0,2
0,0 2,0 4,0 6,0 8,0
Department of Surgery, University Medical Center Groningen

36. Historic overview of the treatment of colorectal cancer
Introduction Old times Before TME TME Conclusions
• Clinical nature and prognosis of locally recurrent rectal
cancer after total mesorectal excision with or without
preoperative radiotherapy. J Clin Oncol. 2004
•Survival after local recurrence is shorter in the TME + XRT than
in the TME group(6.1 versus 15.9 months)
•Patients with a local recurrence in the TME + XRT had more
distant metastases than in the TME group (74 versus 40%)
•Patients with a local recurrence in the TME + XRY group
underwent less surgical resections of the local recurrence (17
versus 34%)
Department of Surgery, University Medical Center Groningen

37. Historic overview of the treatment of colorectal cancer
Introduction Old times Before TME TME Conclusions
• Acute side effects and complications after short-term
preoperative radiotherapy combined with total mesorectal
excision in primary rectal cancer: report of a multicenter
randomized trial. J Clin Oncol. 2002
TME
ileus RT+TME
bleeding
stoma
leakage LAR only
abdominal dehiscence
perineal dehiscence APR only
5 10 15 20 25 30
TOTAL
Department of Surgery, University Medical Center Groningen

38. Historic overview of the treatment of colorectal cancer
Introduction Old times Before TME TME Conclusions
• Late side effects of short-course preoperative radiotherapy combined
with total mesorectal excision for rectal cancer: increased bowel
dysfunction in irradiated patients--a Dutch colorectal cancer group
study. J Clin Oncol. 2005
70
60
50
40
RT+TME
30 TME
20
10
0
Incontinence at Incontinence at Anal mucus loss Anal blood loss Use of pads
day night
Department of Surgery, University Medical Center Groningen

39. Historic overview of the treatment of colorectal cancer
Introduction Old times Before TME TME Conclusions
• Impact of short-term preoperative radiotherapy on health-
related quality of life and sexual functioning in primary rectal
cancer: report of a multicenter randomized trial.
J Clin Oncol. 2005
Short term preoperative radiotherapy leads to more
sexual dysfunction, slower recovery of bowel function
and impaired daily activity
Patients with an APR scored better on physical and
psychological dimension than LAR but worse on voiding
Department of Surgery, University Medical Center Groningen

40. Historic overview of the treatment of colorectal cancer
Introduction Old times Before TME TME Conclusions
Summarizing the TME study
• Less local recurrence
• Importance of preoperative radiotherapy
• Similar overall survival
• Many (late) side effects
• Enormous boost in standardization of
diagnosis and treatment of rectal cancer
in the Netherlands
• New studies
Department of Surgery, University Medical Center Groningen

41. Historic overview of the treatment of colorectal cancer
Introduction Old times Before TME TME Conclusions
from experience to evidence
Pathology
Chemotherapy Radiology
Radiotherapy Evidence
Surgery
1900 1950 2000
Department of Surgery, University Medical Center Groningen

42. Historic overview of the treatment of colorectal cancer
Introduction Old times Before TME TME Conclusions
Survival rate has increased
Local recurrence rate has decreased
Percentage of APR diminished
Department of Surgery, University Medical Center Groningen

43. Historic overview of the treatment of colorectal cancer
Introduction Old times Before TME TME Conclusions
From clinical to imaging=fusing of disciplines
Medical oncologists, Radiation oncologists,
Pathologists, Radiologists, Surgeons
are speaking the same language!
Department of Surgery, University Medical Center Groningen

44. Historic overview of the treatment of colorectal cancer
Introduction Old times Before TME TME Conclusions
Thank
you for
your
attention
Happy to
answer
questions
Department of Surgery, University Medical Center Groningen