Laparoscopic Resection for Rectal Cancer

4,003 views

Published on

Published in: Health & Medicine
  • Be the first to comment

Laparoscopic Resection for Rectal Cancer

  1. 2. <ul><li>Laparoscopic colectomy 1 st attempted in early 90’s </li></ul><ul><li>Slow to gain acceptance unlike rapid take-up of lap cholecystectomy </li></ul><ul><li>Reasons for this include: </li></ul><ul><ul><li>Steep learning curve </li></ul></ul><ul><ul><li>Cost </li></ul></ul><ul><ul><li>Time </li></ul></ul><ul><ul><li>Concern re oncological soundness </li></ul></ul><ul><ul><li>Possible port site metastases </li></ul></ul>
  2. 3. <ul><li>Sharp dissection between the parietal and visceral layers of the endopelvic fascia </li></ul><ul><li>Complete excision of rectum & draining lymphatics with intact visceral envelope </li></ul><ul><li>Preservation of pelvic autonomics </li></ul><ul><li>Low local recurrence rates (4% @ 10yrs) </li></ul>Heald 1986
  3. 5. <ul><li>Less blood loss </li></ul><ul><li>Faster recovery </li></ul><ul><li>Earlier return of gut function </li></ul><ul><li>Lower morbidity </li></ul><ul><li>Magnified view allows precise dissection (pelvic autonomics) </li></ul>
  4. 6. <ul><li>Reduced pain </li></ul><ul><li>Improved cosmesis </li></ul><ul><li>Decreased adhesions </li></ul><ul><li>Decreased wound infection rate </li></ul><ul><li>Reduced immune effect of surgery </li></ul>
  5. 7. <ul><li>Steep learning curve </li></ul><ul><li>Longer operating times (+30% to 50%) </li></ul><ul><li>Cost </li></ul><ul><ul><li>Instruments / equipment </li></ul></ul><ul><li>Port-site recurrence? </li></ul><ul><li>Oncological soundness compared with open TME? </li></ul>
  6. 8. <ul><li>Practical and technical limitations </li></ul><ul><ul><li>Crowding of instruments in the pelvis </li></ul></ul><ul><ul><li>Plume can obscure vision </li></ul></ul><ul><ul><li>Retraction of the rectum can be very difficult </li></ul></ul><ul><ul><li>Division of the rectum can be difficult </li></ul></ul><ul><ul><li>Identification of tumour site can be difficult </li></ul></ul><ul><ul><li>Pneumoperitoneum </li></ul></ul><ul><ul><ul><li>Gas embolism / decreased venous return </li></ul></ul></ul>
  7. 9. <ul><li>Purely Laparoscopic </li></ul><ul><ul><li>Specimen extraction through natural orifice (ie anus) </li></ul></ul><ul><ul><li>Hand-sewn colo-anal anastomosis </li></ul></ul><ul><ul><li>No abdominal incision apart from port sites </li></ul></ul><ul><li>Laparoscopically Assisted </li></ul><ul><ul><li>Small incision for specimen retrieval </li></ul></ul><ul><li>Hybrid </li></ul><ul><ul><li>Incision to allow rectal dissection , vessel ligation or anastomosis to be performed in an open fashion </li></ul></ul><ul><li>Hand-assisted Laparoscopy </li></ul><ul><ul><li>Combination of both open and laparoscopic techniques through a hand port </li></ul></ul>
  8. 10. <ul><li>Optics / image Processing </li></ul><ul><li>Energy devices (e.g. harmonic scalpel, bipolar energy) </li></ul><ul><li>New staplers </li></ul><ul><li>Wound protectors / retractors </li></ul><ul><li>Hand assist devices </li></ul><ul><li>Robotics? </li></ul>
  9. 11. <ul><li>Smaller, better optical properties </li></ul><ul><li>Magnification 15-20X </li></ul><ul><li>Flexible </li></ul>
  10. 13. <ul><li>Modified lithotomy (adjustable stirrups) </li></ul><ul><li>Bean bag or soft mouldable mattress to allow maximum tilt </li></ul><ul><li>4-5 cannulas (1/quadrant) </li></ul><ul><li>CO 2 insufflation (12-15mmHg) </li></ul><ul><li>30 degree or flexible laparoscope </li></ul><ul><li>Laparoscope lens cleaner </li></ul><ul><li>Plume extractor </li></ul>
  11. 18. Incision
  12. 19. May expedite the mid and upper abdominal steps
  13. 20. <ul><li>Pre-operative assessment </li></ul><ul><ul><li>Can / should it be done laparoscopically? </li></ul></ul><ul><li>Lateral to medial dissection </li></ul><ul><li>Full mobilisation of splenic flexure </li></ul><ul><li>High vascular division </li></ul><ul><li>Rectal dissection / division / anastomosis </li></ul>
  14. 32. <ul><li>Evidence is mainly from comparative non randomised trials </li></ul><ul><li>Many with small numbers & short follow-up </li></ul><ul><li>Two randomised trials in the literature looking at lap TME (restorative) </li></ul><ul><ul><li>(Zhou 2004) </li></ul></ul><ul><ul><li>MRC CLASICC (Guillou 2005) </li></ul></ul><ul><li>One RCT on Lap APR </li></ul><ul><ul><li>(Araujo 2003) </li></ul></ul>
  15. 33. <ul><li>Zhou et al (China) </li></ul><ul><li>Extraperitoneal rectal cancer </li></ul><ul><li>Lap : open = 82:89 </li></ul><ul><li>No defunctioning ileostomy </li></ul><ul><li>Short term results only </li></ul><ul><li>No conversion rate reported </li></ul>
  16. 34. <ul><ul><ul><ul><ul><li> Lap Open </li></ul></ul></ul></ul></ul><ul><li>Mortality (%) 0 0 </li></ul><ul><li>Morbidity (%) 6.1 12.4 </li></ul><ul><li>Leak (%) 1.2 3.4 </li></ul><ul><li>Operation time (min) 120 106 </li></ul><ul><li>Blood loss (ml) 20 106 </li></ul><ul><li>Pain (days) 3.9 4.1 </li></ul><ul><li>First bowel action (days) 4.3 4.5 </li></ul><ul><li>LOS (days) 8.1 13.3 (p=0.001) </li></ul>
  17. 35. <ul><li>Guillou et al (UK) </li></ul><ul><li>Multicentre RCT </li></ul><ul><li>Colon & rectal cancer </li></ul><ul><li>All surgeons had performed at least 20 laparoscopic resections </li></ul><ul><li>794 patients randomized 2:1 for laparoscopic : open surgery </li></ul><ul><li>381 patients with rectal cancer (253:128) </li></ul>Lancet 2005 365:1718-26
  18. 36. <ul><li>Conversion 34% (overall fall in conversion rate during the trial) </li></ul><ul><li>Mortality - all patients (colon and rectal) </li></ul><ul><ul><li>Intention to treat </li></ul></ul><ul><ul><ul><li>Open 5% Lap 4% </li></ul></ul></ul><ul><ul><li>Actual treatment </li></ul></ul><ul><ul><ul><li>Open 5% Lap 1% Conversion 9% </li></ul></ul></ul>Lancet 2005 365:1718-26
  19. 37. <ul><li>Complications – rectal cancer </li></ul><ul><ul><li>Intention to treat </li></ul></ul><ul><ul><ul><li>Open 37% Lap 40% </li></ul></ul></ul><ul><ul><li>Actual treatment </li></ul></ul><ul><ul><ul><li>Open 37% Lap 32% Conversion 59% (p=0.002) </li></ul></ul></ul>
  20. 38. <ul><li> </li></ul><ul><li>Open Lap Conv </li></ul><ul><li>Anaesthetic time* 135 180 180 mins </li></ul><ul><li>1 st BM 6 5 6 days </li></ul><ul><li>Normal diet 7 6 7 days </li></ul><ul><li>LOS 13 10 13 days </li></ul><ul><ul><li>*Rectal and colonic resection </li></ul></ul>
  21. 39. <ul><li>Cost – intention to treat (mean) </li></ul><ul><li>Open Lap </li></ul><ul><li>Theatre £ 1448 £ 1816 </li></ul><ul><li>Hospital £ 3713 £ 3359 </li></ul><ul><li>Others £ 2659 £ 3085 </li></ul><ul><li>Total £ 7820 £ 8260 </li></ul>Br J Cancer 2006 95:6-12
  22. 40. <ul><li>Quality of Life </li></ul><ul><ul><li>no difference at 2 or 3 months </li></ul></ul><ul><li>Good quality pathological specimens were received in both groups </li></ul><ul><ul><li>(nodes and length to vascular tie) </li></ul></ul><ul><li>Positive CRM rate (anterior resections) </li></ul><ul><ul><li>Laparoscopic 12% (16/129) </li></ul></ul><ul><ul><li>Open 6% (4/64) </li></ul></ul>
  23. 41. <ul><li>CLASSIC group suggest that laparoscopic anterior resection is not justified as a routinue approach due to concerns over: </li></ul><ul><ul><li>Increased positive CRM rate </li></ul></ul><ul><ul><li>High morbidity with conversion </li></ul></ul><ul><li>Learning curve underestimated at the 20 cases used in the trial </li></ul>
  24. 42. <ul><li>Araujo et al (Brazil) </li></ul><ul><li>28 patients – laparoscopic vs open APR </li></ul><ul><li>Results </li></ul><ul><ul><li>No conversions </li></ul></ul><ul><ul><li>Operating time faster in laparoscopic group ! </li></ul></ul><ul><ul><ul><li>228 vs 284 mins (p=0.04) </li></ul></ul></ul><ul><ul><li>At mean 4yr follow up </li></ul></ul><ul><ul><ul><li>0 recurrences in laparoscopic group </li></ul></ul></ul><ul><ul><ul><li>2 local recurrences in open group </li></ul></ul></ul>Rev Hosp Clin Fac Med Sao Paulo 2003 58:133-40
  25. 43. <ul><li>Breukink et al (2006) </li></ul><ul><li>48 studies, 4244 patients </li></ul><ul><li>Poor study methodologies, only 3 RCT’s </li></ul><ul><li>No strong conclusions possible </li></ul>
  26. 44. <ul><li>5-year disease free survival </li></ul><ul><ul><li>No apparent difference </li></ul></ul><ul><li>Local Recurrence </li></ul><ul><ul><li>Most studies found no significant difference </li></ul></ul><ul><ul><li>Overall <10% (variable follow up) </li></ul></ul><ul><ul><li>Higher for APR (0% - 25%) </li></ul></ul><ul><ul><li>0% to 6% for sphincter-saving lap TME </li></ul></ul><ul><ul><li>Comparable to open situation (Heald showed 33% LR after APR) </li></ul></ul>
  27. 45. <ul><li>Perioperative mortality </li></ul><ul><ul><li>No significant difference </li></ul></ul><ul><li>Morbidity </li></ul><ul><ul><li>No apparent difference </li></ul></ul><ul><ul><li>Trend towards lower complications in lap groups </li></ul></ul><ul><li>Anastomotic leak </li></ul><ul><ul><li>No difference </li></ul></ul>
  28. 46. <ul><li>Blood loss </li></ul><ul><ul><li>Reduced with lap TME </li></ul></ul><ul><li>Operative Time </li></ul><ul><ul><li>Significantly longer with lap TME </li></ul></ul><ul><li>Conversion Rate </li></ul><ul><ul><li>Highly variable (0 to 33%) </li></ul></ul><ul><ul><li>Surgeon experience crucial </li></ul></ul><ul><li>Surgical margins </li></ul><ul><ul><li>No difference </li></ul></ul>
  29. 47. <ul><li>Lymph node harvest </li></ul><ul><ul><li>No difference </li></ul></ul><ul><li>Postoperative recovery </li></ul><ul><ul><li>Improved with lap TME </li></ul></ul><ul><li>Quality of life </li></ul><ul><ul><li>Insufficient data </li></ul></ul>
  30. 48. <ul><li>Cost </li></ul><ul><ul><li>Probably increased for lap TME </li></ul></ul><ul><ul><li>Poor data </li></ul></ul><ul><li>Immune response to surgery </li></ul><ul><ul><li>Appears reduced with lap TME </li></ul></ul>
  31. 49. <ul><li>No firm conclusions </li></ul><ul><li>Laparoscopic TME appears to have short term benefits </li></ul><ul><li>Long term oncological safety requires further randomized trials </li></ul>
  32. 50. <ul><li>Port-site herniae </li></ul><ul><ul><li>Rare at 0.3% </li></ul></ul><ul><ul><li>Attention to port site closure </li></ul></ul><ul><li>Port site metastases </li></ul><ul><ul><li>First reported 1993 </li></ul></ul><ul><ul><li>Rare at 0.1% overall </li></ul></ul><ul><ul><li>Comparable to wound recurrence in open surgery </li></ul></ul>
  33. 51. <ul><li>Bladder and sexual function </li></ul><ul><ul><li>Quah (Singapore) </li></ul></ul><ul><ul><ul><li>80 patients randomised to open or laparoscopic assisted resection </li></ul></ul></ul><ul><ul><ul><li>Of sexually active males 46% (7/15) decreased function in laparoscopic group vs 6% (1/15) open </li></ul></ul></ul><ul><ul><li>CLASICC </li></ul></ul><ul><ul><ul><li>Erectile dysfunction in 41% of laparoscopic vs 23% open (NS) </li></ul></ul></ul>Br J Surg 2002: 89:1551–6 Br J Surg 2005 : 92:1124-32
  34. 52. <ul><li>Laparoscopic TME is technically challenging </li></ul><ul><li>In experienced hands, lap TME can be performed safely and confers short term post-operative benefits in terms of recovery </li></ul><ul><li>Cost and quality of life data are lacking </li></ul><ul><li>Long term oncological outcomes are unknown, but should be theoretically no worse if TME principles are followed </li></ul><ul><li>The 3 and 5-year results from the CLASSIC trial are awaited ! </li></ul>

×