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Surgery for Rectal Cancer
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Surgery for Rectal Cancer

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  • 1. Surgery for Rectal Cancer Mr Darren Tonkin Colorectal Surgeon Calvary North Adelaide
  • 2. Rectal Cancer
    • Colorectal cancer = commonest internal malignancy in Australia
    • 1 in 12 risk up to age 85
    • Rectum is commonest site for CRC
    • M>F
    • Overall 5yr survival >50%
  • 3. Rectal Cancer
    • Local recurrence rates 25-35% in past
    • Modern techniques => LR <10%
    • NIH consensus:
      • Adjuvant chemotherapy and radiotherapy for T3 and N1 rectal adenocarcinoma
    • Wide surgeon variability for local recurrence and survival
  • 4. Surgical considerations “What is a surgeon thinking?”
    • The patient
    • The tumour
    • Preoperative chemoradiotherapy
    • The operation (TME)
    • Postoperative treatment
    • Postoperative dysfunction
  • 5. The Patient
    • Age
    • Sex
    • Build (BMI)
    • Co-morbidities
    • Cognition
    • Ability to manage a stoma
    • Continence
  • 6. The Tumour
    • Height from anal verge
    • Circumferential relationships
    • Size
    • Tumour depth (T stage)
    • Distant metastases
    • Rectal examination
    • Imaging - CT, MRI, ERUS
    • ? Other tumours (colonoscopy)
  • 7. Rectal Anatomy 15 cm High Anterior Resection Low Anterior Resection Ultra-low Anterior Resection Abdominoperineal Resection (APR)
  • 8. Endorectal Ultrasound
  • 9. Endorectal Ultrasound
  • 10. MRI Circumferential Resection Margin (CRM)
  • 11. Pre-operative Chemoradiotherapy Before After
  • 12. Pre-operative Chemoradiotherapy
    • T3 / T4 or N1 Tumours
    • Down stage tumour
    • Long course (5-6 weeks)
    • Short course (1 week)
    • Reduced local recurrence
    • ? Improved survival
  • 13. Total Mesorectal Excision
    • An operation for Rectal Cancer
    • Low rate of Local Recurrence after “curative” resection
    • The term initially introduced by Bill Heald (UK) in 1982
    • Many surgeons had practised this concept of surgery prior to the introduction of the term “TME”
  • 14. Bill Heald
    • Archives of Surgery 1998
    • 405 curative resections
    • No radiotherapy
    • Local Recurrence 3% at 5 years
    • Local Recurrence 4% at 10 years
    • Disease free survival 80% at 5 years
    • Disease free survival 78% at 10 years
  • 15. Local Recurrence What is Important?
    • Circumferential margins
    • Distal margin
    • Removal mesorectal envelope containing all the lymph nodes
    • Cytocidal rectal washout
    • Radiotherapy - pre or post operative
    • YOUR SURGEON
  • 16. TME
    • Rectal cancer spreads to lymph nodes in the mesorectum
    • This may be in nodes below the inferior margin of the cancer
    • Particularly relevant in cancers of the middle and lower thirds of the rectum
  • 17. TME
  • 18. TME
  • 19. TME Leak Rate
    • Karanjia, Heald et al BJS 1994
    • 219 LAR with TME
    • Major leak (abscess or peritonitis) 11%
    • Minor leak (contrast enema) 6.4%
  • 20. TME
    • Nerve preservation (sexual and bladder function)
    • Low anastomosis - Reduced APR
    • Low anastomosis - Colonic pouch
    • Higher anastomotic leak rate
    • Higher rate covering stoma
    • ? Negates the need for routine use of radiotherapy
  • 21. Modified TME
    • Distal spread of adenocarcinoma in the rectal wall or mesorectum for more than 2-3 cm is rare
    • When it occurs it is with advanced tumours and associated with a poor prognosis
    • The need to remove the mesorectum more than 5 cm below the tumour is not proven and unnecessary and will increase the rate of anastomotic leakage (devascularised rectal stump)
  • 22. Modified TME 5 cm 5 cm
  • 23. The Technique Pre-operative
    • Consent
    • Optimize comorbidities
    • Bowel preparation
    • Stomal therapy and siting for stoma
    • DVT prophylaxis
    • Antibiotics
    • Urinary catheter
  • 24. The Technique Set-up
    • Extended Lloyd-Davies position
    • Good assistance
    • Long midline incision
    • Wide retraction
    • Small bowel packed out of the way
    • Full laparotomy (liver etc)
  • 25. Operative Position
  • 26. The Technique Colonic Mobilisation
    • Transverse, splenic flexure and descending colon mobilised
    • High ligation of inferior mesenteric artery on the aorta
    • High ligation of inferior mesenteric vein at the lower border of the pancreas
    • Preservation of ureter, gonadal vessels, and hypogastric nerves
  • 27. Sigmoid Mobilisation “Ureter” Ureter
  • 28. Splenic Flexure Mobilised
  • 29. High Ligation of Inferior Mesenteric Artery
  • 30. Ligation of Inferior Mesenteric Vein
  • 31. Full Bowel Mobilisation
  • 32. The Technique Posterior Rectal Dissection
    • Develop the plane at the pelvic brim anterior to the hypogastric nerves and posterior to the superior rectal artery.
    • Enter the areolar space between the mesorectal fascia and the sacral fascia.
    • St Marks retractor
    • Sharp dissection or diathermy
    • Do not “cone in” on the mesorectum
    • Avoid blunt dissection
  • 33. St Mark’s Retractor
  • 34. The Technique Posterior Rectal Dissection
  • 35. The Technique Posterior Rectal Dissection
  • 36. The Technique Anterior Rectal Dissection
    • Divide the anterior peritoneum of rectovesical or rectouterine pouch above and anterior to its apex
    • Develop the plane between the seminal vesicle or vagina anterior to Denonvilliers fascia
    • Continue dissection to pelvic floor
  • 37. The Technique Anterior Rectal Dissection
  • 38. The Technique Transection of Rectum
    • Mesorectum at least 5 cm below tumour (modified TME) or at pelvic floor.
    • Cross clamp or staple below tumour
    • Rectal cytocidal washout
    • 30 mm stapler at least 2 cm below the tumour
    • Haemostasis
  • 39. Transverse Staple Line Rectal Stump
  • 40. The Technique Preparation of Proximal Bowel
    • Ligation of mesenteric vessels preserving the marginal artery
    • Avoid using the sigmoid colon
    • Use the descending colon
    • Fashion colonic pouch if ULAR
    • Insert purse-string suture and head of circular staple gun
  • 41. The Technique Preparation of Proximal Bowel
  • 42. The Technique Preparation of Proximal Bowel
  • 43. The Technique Preparation of Proximal Bowel
  • 44. Transected Bowel Pedicle
  • 45. Staple Gun Head
  • 46. The Technique Anastomosis
    • Ensure colon not twisted
    • Ensure vagina excluded
    • Double staple anastomosis
    • Check donuts and air test
    • Haemostasis
    • Drain pelvis
    • Loop ileostomy
  • 47. Mid-rectal Anastomosis Inserting the Staple Gun
  • 48. Midrectal Anastomosis
  • 49. Resected Specimen Low anterior resection Abdominoperineal resection
  • 50. Summary
    • TME associated with low rate of local recurrence
    • Requires meticulous technique and a surgeon familiar with operating in the pelvis
    • Modified TME acceptable for high and mid rectal tumours.
  • 51. Stomas
    • Temporary Loop Ileostomy
      • Dependent on:
        • Height of anastomosis
        • Ease and technical success of operation
        • Well being of the patient (co-morbidities)
        • Surgical conservatism
        • Radiation
  • 52. Stomas
    • Permanent End Colostomy
      • Dependent on:
        • Height of tumour from anal canal
        • Likelihood of continence
  • 53. Postoperative Adjuvant Therapy
    • Multi-disciplinary meeting
    • Chemotherapy
    • Radiotherapy
    • Age and well-being of the patient
    • Tumour factors
  • 54. Postoperative Bowel Function
    • Rectum acts as a reservoir
    • Removal leads to replacement with a colonic conduit (neorectum)
    • “ Anterior resection syndrome”
    • Frequent loose stool, stool clustering, urgency, occasional incontinence
    • Colonic “J” Pouch
  • 55. Conclusions
    • Results of surgery are operator dependent
    • “ Good” surgery must account for the nuances of the patient and the tumour
    • Multidisciplinary approach