Surgery for Rectal Cancer

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Surgery for Rectal Cancer

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

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