MCC 2011 - Slide 1

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MCC 2011 - Slide 1

  1. 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. 2. Historic overview of the treatment of colorectal cancerIntroduction 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. 3. Historic overview of the treatment of colorectal cancerIntroduction 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. 4. Historic overview of the treatment of colorectal cancerIntroduction 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. 5. Historic overview of the treatment of colorectal cancerIntroduction 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. 6. Historic overview of the treatment of colorectal cancerIntroduction Old times Before TME TME Conclusions Department of Surgery, University Medical Center Groningen
  7. 7. Historic overview of the treatment of colorectal cancerIntroduction 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. 8. Historic overview of the treatment of colorectal cancerIntroduction Old times Before TME TME Conclusions Joseph Lister, 1827-1912 Antisepsis carbolspray since 1869 Department of Surgery, University Medical Center Groningen
  9. 9. Historic overview of the treatment of colorectal cancerIntroduction 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. 10. Historic overview of the treatment of colorectal cancerIntroduction 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. 11. Historic overview of the treatment of colorectal cancerIntroduction 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. 12. Historic overview of the treatment of colorectal cancerIntroduction 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. 13. Historic overview of the treatment of colorectal cancerIntroduction 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. 14. Historic overview of the treatment of colorectal cancerIntroduction 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. 15. Historic overview of the treatment of colorectal cancerIntroduction 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. 16. Historic overview of the treatment of colorectal cancerIntroduction 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. 17. Historic overview of the treatment of colorectal cancerIntroduction 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. 18. Historic overview of the treatment of colorectal cancerIntroduction 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. 19. Historic overview of the treatment of colorectal cancerIntroduction Old times Before TME TME Conclusions Moscow Proctologic Institute 1967 Russian circular stapler Department of Surgery, University Medical Center Groningen
  20. 20. Historic overview of the treatment of colorectal cancerIntroduction Old times Before TME TME Conclusions During residency Blunt dissection “Coning” “Shake Hands” Department of Surgery, University Medical Center Groningen
  21. 21. Historic overview of the treatment of colorectal cancerIntroduction 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. 22. Historic overview of the treatment of colorectal cancerIntroduction Old times Before TME TME ConclusionsIntroduction 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. 23. Historic overview of the treatment of colorectal cancerIntroduction 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. 24. Historic overview of the treatment of colorectal cancerIntroduction Old times Before TME TME Conclusions Bill Heald Skills based on anatomy and biological behaviour Department of Surgery, University Medical Center Groningen
  25. 25. Historic overview of the treatment of colorectal cancerIntroduction Old times Before TME TME Conclusions Waldeyer: Das Becken 1899 Department of Surgery, University Medical Center Groningen
  26. 26. Historic overview of the treatment of colorectal cancerIntroduction Old times Before TME TME Conclusions Gray’s anatomy 1860 Department of Surgery, University Medical Center Groningen
  27. 27. Historic overview of the treatment of colorectal cancerIntroduction 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. 28. Historic overview of the treatment of colorectal cancerIntroduction 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. 29. Historic overview of the treatment of colorectal cancerIntroduction 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. 30. Historic overview of the treatment of colorectal cancerIntroduction Old times Before TME TME Conclusions Transanal Endoscopic Microsurgery • 1985 Buess Department of Surgery, University Medical Center Groningen
  31. 31. Historic overview of the treatment of colorectal cancerIntroduction 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. 32. Historic overview of the treatment of colorectal cancerIntroduction 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. 33. Historic overview of the treatment of colorectal cancerIntroduction 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. 34. Historic overview of the treatment of colorectal cancerIntroduction 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. 35. Historic overview of the treatment of colorectal cancerIntroduction 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. 36. Historic overview of the treatment of colorectal cancerIntroduction 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. 37. Historic overview of the treatment of colorectal cancerIntroduction 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 onlyabdominal dehiscence perineal dehiscence APR only 5 10 15 20 25 30 TOTAL Department of Surgery, University Medical Center Groningen
  38. 38. Historic overview of the treatment of colorectal cancerIntroduction 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. 39. Historic overview of the treatment of colorectal cancerIntroduction 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. 40. Historic overview of the treatment of colorectal cancerIntroduction 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. 41. Historic overview of the treatment of colorectal cancerIntroduction 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. 42. Historic overview of the treatment of colorectal cancerIntroduction 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. 43. Historic overview of the treatment of colorectal cancerIntroduction 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. 44. Historic overview of the treatment of colorectal cancerIntroduction Old times Before TME TME Conclusions Thank you for your attention Happy to answer questions Department of Surgery, University Medical Center Groningen

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