EPIDEMOLOGY 2015 Estimates New cases: 96,830 (colon); 40,000 (rectal) Deaths: 50,310 (colon and rectal combined) Death rate over last 20 years declining Screening and improvements in treatment

1. ΚΑΡΚΙΝΟΣ ΟΡΘΟΥ
ΧΕΙΡΟΥΡΓΙΚΗ ΕΠΕΜΒΑΣΗ
ΔΥΝΑΤΟΤΗΤΕΣ ΚΑΙ ΠΕΡΙΟΡΙΣΜΟΙ
ΔΗΜΗΤΡΗΣ Π. ΚΟΡΚΟΛΗΣ
ΧΕΙΡΟΥΡΓΟΣ
ΔΙΔΑΚΤΩΡ ΠΑΝΕΠΙΣΤΗΜΙΟΥ ΑΘΗΝΩΝ
Α.Ο.Ν.Α. «Ο ΑΓΙΟΣ ΣΑΒΒΑΣ»

2. EPIDEMIOLOGY
2015 Estimates
• New cases: 96,830 (colon); 40,000 (rectal)
• Deaths: 50,310 (colon and rectal combined)
• Death rate over last 20 years declining
• Screening and improvements in treatment

5. Anatomic Location of CRC
 Cecum 14 %
 Ascending colon 10 %
 Transverse colon 12 %
 Descending colon 7 %
 Sigmoid colon 25 %
 Rectosigmoid junct.9 %
 Rectum 23 %
30%

6. Rectal Cancer
 Surgery is the mainstay of treatment of RC
 After surgical resection, local failure is common
 Local recurrence after conventional surgery:
 15%-45% (average of 28%)
 Radiotherapy significantly reduces the number
of local recurrences

7. Predicting risk of recurrence in RC
 Surgery-related
-Low anterior resection
-APR
-Excision of the mesorectum
-Extend of lymphadenectomy
-Postoperative anastomotic
leakage
-Tumor perforation
 Tumor-related
-Anatomic location
-Histologic type
-Tumor grade
-Pathologic stage
-radial resection margin
-neural, venous, lymphatic
invasion

8. Incidence of local failure in RC
 T1-2,No,Mo <10%
 T3,No,Mo 15-35%
 T1,N1,Mo 15-35%
 T3-4,N1-2,Mo 45-65%

20. The

22. Radical excision
Total Mesorectal Excision(TME)
 Introduced by RJ Heald in 1979
 Use of sharp dissection under vision to mobilize the rectum rather than the
conventional blunt finger dissection
 First series of 112 pts: 5yr LR 2.9% and survival 87.5%
 Local recurrence:
 Conventional surgery: 11.7 - 37.4%
 TME surgery: 1.6 - 17.8%
 Higher leak rates reported possibly due to:
 Devascularization of distal rectal stump
 Lower anastomosis
 Other factors: stomas, drains

23. TME - Trials
 Multi-institutional r/w of conventional to TME surgery found large difference in
LR (4-9 vs 32-35%) and 5yr survival (62-75 vs 42-44%)
Eur J Surg Oncol 25, 1999
 Norwegian Rectal Cancer Grp:
 Experiencing LR 25+%
 1794 pts enrolled (1395 TME vs 229 conventional)
 LR of 6 vs 12% (30m) and 4yr survival of 73 vs 60%
 No difference in anastomotic leak rate (10%) & mortality (3%)
 Dutch trial the largest prospective trial of 1861 pts demonstrated 2yr LR of 5.3%
(TME 8.2% vs TME+XRT 2.4%)
 Operative mortality (3.5 vs 2.6%) and anastomotic leak (11 vs 12%)

30. Circumferential resection margin

31. TME - CRM

32. TME Specimen

33. 5–10%
Blunt dissection TME
LR 20–40%

34. ADEQUACY OF CIRCUMFERENTIAL RESECTION
MARGINS

35. Fascial plane In mesorectum In/on muscularis
Dataset for colorectal cancer (2° edition), RCOP, 2007

36. SURGERY QUALITY:
EFFECT OF THE PLANE OF SURGERY ON LOCAL
RECURRENCE

37. Copyright © American Society of Clinical Oncology
Nagtegaal, I. D. et al. J Clin Oncol; 26:303-312 2008
LOCAL RECURRENCE AND CRM

38. JH012804
• Cure
• Local control
• Sphincter preservation
• Preservation of sexual
and urinary function
Goals

40. TME - Distal resection margin
 Not clear in the literature
 5cm preop will expand to 7-8cm on
rectal mobilization
 This will shrink to 2-3cm with
specimen removal and formalin
fixation
 Rare for tumour to spread beyond
1.5cm
 Rare reports of poorly diff tumours
having spread 4.5cm distally
 Recommend: 5cm ideally however 2cm
is adequate

41. RECTAL CANCER OPERATIONS

42. JH012804
JH012804

43. SURGICAL TECHNIQUE - LAR

44. JH012804
Splenic vein
Inferior
mesenteric
vein
Duodenum
Inferior
mesenteric
artery
JH012804
N > 12 LNs

45. SURGICAL TECHNIQUE - LAR

46. SURGICAL TECHNIQUE - LAR

47. TME - Nerve injury
 Pre-aortic sympathetics during high ligation
 Sympathetics at the pelvic brim during rectal
mobilization
 Parasymp(nervi erigentes) and sympathetics during
posterolateral dissection
 No clear lateral ligaments
 Do not hook or clamp these tissues, avoid excessive traction
 Higher rates with extended lateral LN dissection
 Anterior lateral dissection off the prostatic capsule
 The most likely area of damage, reflected by higher rates of
sexual dysfunction in APR(14-51%) vs AR(9-29%)
 The role of Denonvilliers’ fascia

48. Hypogastric Nerve Plexus

49. Reconstruction of Neorectum
 Hand sewn sutured anastomosis
 1982: Parks and Percy performed the colo-anal sutured anastomosis
 ‘Pulled through’ coloanal anastomosis (Turnbull & Cuthbertson)
 Stapled anastomosis
 Circular stapled technique
 Double staple technique
 For low and coloanal anastomosis

50. JH012804
Roticulator
A B
C D E
JH012804
Knight and Griffen, 1980

51. JH012804
Endo Anal vs Stapled anastomosis
• Better function with stapler but preferable to
do endo- anal anastomosis :
1. Intersphincteric dissection
2. Very narrow pelvis
3. Enlarged prostate
4. Prior radiation for prostate cancer
5. Short margin !

52. JH012804
Colo-anal anastomosis

53. JH012804
JH012804

54. Reconstruction of Neorectum
 Straight end to end
 Low AR or Colo-anal end-to-end anastomosis cause tenesmus, urgency
and incontinence (Anterior resection or “post-proctectomy” syndrome)
 Colonic J - Pouch
 Increases volume of neorectum
 5 vs 10cm pouches have smaller reservoirs but better evacuation
 Size is critical to functional outcome, recommend 5-8 cm
 Sigmoid colon should not be used
 Better short term functional results and possible lower anastomotic
leaks compared to end-to-end anastomosis
 Transverse Coloplasty
 Better in narrow pelvis and limited length of colon
 Long incision closed transversely
 Randomized trial underway comparing to J-pouch

55. COLORECTAL – COLOANALANASTOMOSIS
“Straight” End to End Anastomosis
Transverse Coloplasty

56. COLONIC NEORECTUM
Colonic J - Pouch

57. COLONIC NEORECTUM

58. JH012804
JH012804

59. JH012804
JH012804

60. INTERSPHINCTERIC RESECTION

61. INTERSPHINCTERIC RESECTION – COLOANAL
ANASTOMOSIS

62. INTERSPHINCTERIC RESECTION

63. TRANSABDOMINAL – TRANSANAL
INTERSPHINCTERIC RESECTION

64. Intersphincteric Resection versus Stapled Coloanal
Anastomosis for Low Rectal Cancer
J Korean Soc Coloproctol. 2008 Apr;24(2):113-120

65. Intersphincteric Resection versus Stapled Coloanal
Anastomosis for Low Rectal Cancer
J Korean Soc Coloproctol. 2008 Apr;24(2):113-120

66. JH012804
Indications for APR
• Inadequate sphincter : low Hartmann?
• Sphincter invasion
• Inadequate margin
• Fecal Incontinence
• Patient wishes !

67. JH012804
First report of APR technique at Mayo

68. Abdominoperineal Resection
 Described by Sir Ernest Miles 1908
 1-2 surgeons
 TME rectal dissection
 Anus sutured closed
 Wide perineal dissection, starting from posterior to lateral then
anterior
 Anterior dissection can proceed cranio-caudal or vice versa
 SB exclusion - omentum or absorbable mesh
 Drain the pelvic space
 Reduced rates of APR
 Coloanal anastomosis
 Acceptance of smaller margins
 Downsizing by chemoradiotherapy

70. Abdominoperineal Resection

71. SURGICALANATOMY OF THE RECTUM

72. Abdominoperineal Resection

74. APR – Cylindrical Resection

82. TEM

84. TRANSANAL ENDOSCOPIC MICROSURGERY
 TEM
 Full thickness excision with 1cm margin including mesorectal fat
 Rectal defect closed transversely
 T1 and/or T2 Rectal Tumors
 Occult Locoregional Metastases (20% to 33%)
 Local Recurrence Rate is still High and more than double compared to
radical surgery.
 T1(15%) T2(47%)
 Overall Survival is NOT significantly different
 T1(72-90%) T2(55-78%)
Heafner TA, Glascow SC. A critical review of the role of local excision in the treatment of
early (T1 and T2) rectal tumors. J Gastrointest Oncol 2014

85. TRANSANAL ENDOSCOPIC MICROSURGERY
 Transanal Endoscopic Microsurgery (TEM)
 Developed for lesions out of reach from transanal approach
 Favourable T1 lesions have equivalent local recurrence and 5yr
survival comparable to radical surgery
 Unfavourable T1 lesions have higher local recurrence (10-15%)
 TEM + XRT on T2 have local recurrence (25-46%)
 Neoadjuvant CRT in T1-2 lesions may achieve CR (50%)

86. TRANSANAL ENDOSCOPIC MICROSURGERY
Indications:
1. Well – moderately differentiated tumors
2. No lymphovascular invasion
3. No perineural invasion
4. No mucinous components
5. < 3 cm in size
6. Clear margin of resection
7. < 3 cm of bowel circumference
8. Mobile / nonfixed
9. Early T1 and T2 rectal tumors
10. No nodal disease
11. < 10 cm from the anal verge

87. LOCALLY ADVANCED RECTAL CANCER

96. Laparoscopic Resection
for Rectal Cancer
Should we do it?

97. LAPAROSCOPIC TME

98. Potential Advantages of Lap TME
• Less blood loss
• Faster recovery
• Earlier return of gut function
• Lower morbidity
• Magnified view allows precise dissection
(pelvic autonomics)

99. Potential Advantages of Lap TME
• Reduced pain
• Improved cosmesis
• Decreased adhesions
• Decreased wound infection rate
• Reduced immune effect of surgery

100. Potential Disadvantages
• Steep learning curve
• Longer operating times (+30% to 50%)
• Cost
– Instruments / equipment
• Port-site recurrence?
• Oncological soundness compared with open
TME?

101. Potential Disadvantages
• Practical and technical limitations
– Crowding of instruments in the pelvis
– Plume can obscure vision
– Retraction of the rectum can be very difficult
– Division of the rectum can be difficult
– Identification of tumour site can be difficult
– Pneumoperitoneum
• Gas embolism / decreased venous return

102. Laparoscopic Resection for Rectal Cancer: What is
the Evidence?
Dedrick Kok HC, et al. Biomed Res Int 2014

103. Long – Term Results in Rectal Cancer
Lai JH, et al. Br Med Bull 2012

104. Laparoscopic Resection for Rectal Cancer: What is
the Evidence?
Dedrick Kok HC, et al. Biomed Res Int 2014

105. Open versus Laparoscopic surgery for mid-rectal or low-
rectal cancer after neoadjuvant chemoradiotherapy
(COREAN trial): Survival Outcomes.
Findings:
We randomly assigned 340 patients with rectal cancer to receive either open
surgery (n=170) or laparoscopic surgery (n=170), after neoadjuvant
chemoradiotherapy
3 year disease-free survival was 72·5% (95% CI 65·0–78·6) for the open
surgery group and 79·2% (72·3–84·6) for the laparoscopic surgery group
Jeong SY, et al. Gastrointestinal Cancer 2014

106. Factors Of Prognostic Significance
(Surgeon Related)
1) Extent of margins of resection
2) Extent of lymphatic resection
3) Timing and level of vascular ligation
4) TME Technique
5) Anastomotic technique
6) Intraluminal cytotoxic solutions

107. Conclusions
 TEM in favorable T1 lesions
 TME the standard practice in rectal dissection
 High vascular ligation
 Nerve preservation surgery
 Role of distal margins
 Sphincter – preserving surgery
 Laparoscopic TME feasible and oncologically acceptable

108. Rectal cancer
SURGEON
MEDICAL ONCOLOGIST
RADIOTHERAPIST
CURE
QOL
PATHOLOGIST
STOMA THERAPIST
NURSE
RADIOLOGIST