MCC 2011 - Slide 9

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MCC 2011 - Slide 9

  1. 1. Positioning and technique of a wide perineal resection ESO-ESSO Master Class in Colorectal Cancer Surgery 12 – 17 February 2011 Cascais, Portugal Torbjörn Holm MD PhD Section of Coloproctology Department of Surgery Karolinska University Hospital Stockholm, Sweden
  2. 2. Outline <ul><li>Problems associated with conventional APR </li></ul><ul><li>Changing concept of APR </li></ul><ul><ul><li>Inter-sphincteric APR </li></ul></ul><ul><ul><li>Extra-levator APR </li></ul></ul><ul><ul><li>Ischio-anal APR </li></ul></ul><ul><li>Indications for APR in rectal cancer </li></ul><ul><ul><li>Patient unsuitable for bowel reconstruction </li></ul></ul><ul><ul><li>Tumour extending less than 1 cm from dentate line </li></ul></ul><ul><ul><li>Tumour threatening CRM </li></ul></ul><ul><ul><li>Locally advanced cancer </li></ul></ul>
  3. 3. APR in rectal cancer Sir Ernest Miles (1869-1947) Lancet 1908
  4. 4. Miles’ Perineal Dissection
  5. 5. APER (Miles)
  6. 6. Copyright ©2008 BMJ Publishing Group Ltd. Morris, E et al. Gut 2008;57:1690-1697 Problems associated with conventional APR Variation in the use of rectal operations by English NHS hospital trust
  7. 7. <ul><li>APR performed in 75-80 % in Sweden 1995 - 2008 </li></ul>APR in low rectal cancer (0-6 cm above anal verge) LAR APR Hartmann
  8. 9. Conventional APR - synchronous combined
  9. 10. Problems associated with conventional APR <ul><li>Synchronous combined APR is not a standardised operation </li></ul><ul><li>Results are variable and suboptimal </li></ul><ul><li>Results poorer than after anterior resection </li></ul><ul><ul><li>Perforations </li></ul></ul><ul><ul><li>Involved margins </li></ul></ul>
  10. 11. Problems associated with conventional APR <ul><li>Inadvertent bowel perforation </li></ul><ul><li>significantly more common </li></ul><ul><li>after APR </li></ul><ul><li>AR APR </li></ul><ul><li>Norway 4% 15% </li></ul><ul><li>Sweden 3% 14% </li></ul><ul><li>Holland 3% 14% </li></ul>
  11. 12. Norwegian Rectal Cancer Group Br J Surg 2004; 91: 210-16
  12. 13. Problems associated with conventional APR <ul><li>Tumour involved circumferential resection margin significantly more common after APR (CRM +ve) </li></ul><ul><li>AR APR </li></ul><ul><li>Dutch TME Trial 12% 29% </li></ul><ul><li>MERCURY Trial 12% 33% </li></ul>
  13. 14. Problems associated with conventional APR Data from the Dutch TME Trial Local recurrence Survival APR CRM + 30 % 38 % CRM - 9 % 72 % Nagtegaal et al. J Clin Oncol 23; 9257 – 9264, 2005
  14. 15. Abdominoperineal Resection Conventional APR Abandon Redrawn from Gordon & Nivatvongs QMP 1999 by A.Tøttrup, Aarhus
  15. 16. Changing concept of APR <ul><li>Three different APR procedures </li></ul><ul><li>Related to defined anatomical structures </li></ul><ul><ul><li>Inter-sphincteric </li></ul></ul><ul><ul><li>Extra-levator </li></ul></ul><ul><ul><li>Ischio-anal </li></ul></ul><ul><li>Each procedure should be standardised </li></ul><ul><li>Indications should be defined for each procedure </li></ul><ul><li>Based on appropriate staging – MRI, ultrasonography and clinical examination </li></ul>
  16. 17. Inter-sphincteric APR Redrawn from Gordon & Nivatvongs QMP 1999 by A.Tøttrup, Aarhus
  17. 18. Extra levator APR Redrawn from Gordon & Nivatvongs QMP 1999 by A.Tøttrup, Aarhus
  18. 19. Ischio-anal APR Redrawn from Gordon & Nivatvongs QMP 1999 by A.Tøttrup, Aarhus
  19. 20. Indications for APR in rectal cancer Inter-sphincteric APR <ul><li>Patient unsuitable for bowel reconstruction </li></ul><ul><ul><li>Preoperative history of incontinence </li></ul></ul><ul><ul><li>High risk of anastomotic leak </li></ul></ul><ul><ul><li>Co-morbidity – crucial to prevent leakage + fatal outcome </li></ul></ul><ul><ul><li>Patients preference </li></ul></ul><ul><ul><li>Options </li></ul></ul><ul><ul><li>Hartmann’s procedure </li></ul></ul><ul><ul><li>Inter-sphincteric APR </li></ul></ul>
  20. 21. Problems associated with Hartmann's procedure <ul><li>Pelvic sepsis –abscess </li></ul><ul><li>New tumour in remnant rectal stump </li></ul><ul><li>Soiling, (bleeding, pain) </li></ul><ul><li>Proctoscopy may be difficult and painful </li></ul>
  21. 22. <ul><li>Overall rate of pelvic abscess 31/163 19% </li></ul><ul><li>Transsection < 2cm Transsection > 2cm </li></ul><ul><li>above pelvic floor above pelvic floor </li></ul><ul><li>Pelvic 24/73 33% 7/90 8% </li></ul><ul><li>abscess </li></ul>Dis. Colon Rectum 2005; 48: 251–255
  22. 23. CONCLUSION : Surgical alternatives to Hartmann’s procedure should be considered when the level of transsection is <2 cm above the pelvic floor, particularly in males.
  23. 24. Swedish experience Ersta Hospital 1995 – 2004 (M. Machado) <ul><li>82 patients had a Hartmann’s procedure </li></ul><ul><li>Overall rate of pelvic abscess 21% (17/82) </li></ul><ul><li>High transsection 0% (0/19) </li></ul><ul><li>Low transsection (TME) 27% (17/63) </li></ul>
  24. 25. Inter-sphincteric APR - probably better than low Hartmann’s <ul><li>Potential benefits </li></ul><ul><ul><li>Reduced rate of pelvic sepsis </li></ul></ul><ul><ul><li>Eliminates the risk of metachronous cancer </li></ul></ul><ul><ul><li>No disabling symptoms from rectal stump </li></ul></ul><ul><ul><li>No need for surveillance of rectal stump </li></ul></ul><ul><li>Drawbacks </li></ul><ul><ul><li>Prolongs operation time </li></ul></ul><ul><ul><li>Perineal wound infection </li></ul></ul>
  25. 26. Indications for APR in rectal cancer Extra-levator APR <ul><li>Tumour extending less than 1 cm from dentate line </li></ul><ul><ul><li>Inter-sphincteric APR (adenomas, T1 cancer) </li></ul></ul><ul><ul><li>Extra-levator APR (T2 – T4 cancer) </li></ul></ul><ul><li>Tumour threatening CRM </li></ul><ul><ul><li>Extra-levator APR </li></ul></ul>
  26. 27. Tumour threatening CRM Threatened CRM
  27. 34. Indications for APR in rectal cancer Ischio-anal APR <ul><li>Locally advanced cancer infiltrating </li></ul><ul><ul><li>Levator muscles </li></ul></ul><ul><ul><li>Ischio-anal fat </li></ul></ul><ul><ul><li>Perianal skin </li></ul></ul><ul><li>Perforated cancer with </li></ul><ul><li>abscess or fistula in </li></ul><ul><li>ischio-anal fossa </li></ul>
  28. 35. Tumour perforating into ischio-anal fossa
  29. 36. Supine or prone approach <ul><li>Inter-sphincteric APR: Supine </li></ul><ul><li>Extra-levator APR: Prone preferable, Supine possible </li></ul><ul><li>Ischio-anal APR: Prone </li></ul>
  30. 37. Supine versus prone? Risk of inadvertent perforation West et al. BJS 2010; 97: 588–599
  31. 38. Phase 1 <ul><li>Supine position </li></ul><ul><li>Warm cloud mattress </li></ul><ul><li>Split legs </li></ul><ul><li>Trendelenburgs position </li></ul><ul><li>Support for the shoulders </li></ul><ul><li>Catheterisation of the bladder (closed) </li></ul>
  32. 39. Operating table
  33. 40. Warmcloud mattress
  34. 41. Patient in the supine position <ul><li>Planned incision and position of the stoma </li></ul>
  35. 42. Stoma, drain and catheter (suprapubic)
  36. 43. Phase 2 <ul><li>Turning session </li></ul><ul><li>Mobilizer </li></ul><ul><li>Jack-knife position </li></ul><ul><li>Leg support devices </li></ul><ul><li>Special pillow for the face </li></ul>
  37. 44. Mobilizer
  38. 45. Moving the patient to the prone Jack-knife position with a mobilizer
  39. 46. Operating table for prone position Chest and abdomen cushions from TEMPUR company
  40. 47. Facepillow From the MIZUHOSI company; 7” gentle touch pillow
  41. 49. Patient in the Jack-knife position
  42. 50. When is APR the correct choice? Conclusion <ul><li>Assess patient and tumour </li></ul><ul><ul><li>Anal function, co-morbidity, patient preference </li></ul></ul><ul><ul><li>Very low or threatened CRM </li></ul></ul><ul><li>If APR the correct choice – what type of APR? </li></ul><ul><ul><li>Inter-sphincteric </li></ul></ul><ul><ul><li>Extra-levator </li></ul></ul><ul><ul><li>Ischio-anal </li></ul></ul><ul><li>Extent of procedure must be planned preoperatively </li></ul><ul><li>Avoid changing approach during surgery </li></ul>
  43. 51. Colorectal surgery at Karolinska Institutet Workshop and Symposium May 4-6, 2011 Stockholm, Sweden Welcome

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