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Surgical Mgmt of Rectal Cancer
1. Surgical management of Rectal
Cancer: Are we there yet?
OTHON WILTZ, MD, FACS, FASCRS
MEDICAL DIRECTOR, COLON AND RECTAL SURGERY
MEMORIAL HEALTHCARE SYSTEM, HOLLYWOOD, FLORIDA
2. Surgery in Rectal Cancer
Where have we been?
Early 20th century-Miles procedure
1980s-concept of TME
1980s-XRT trials
1990-2000s- MDT approach to Rectal cancer
1990’s-Swedish trial and Dutch TME trial
2000’s-Minimally invasive surgery applied to rectal cancer
3. Surgery in Rectal Cancer
Where are we now?
Outcome of rectal cancer surgery
Survival
Local recurrence
Long term quality of life
Quality of surgery- readily measurable
TME grade
Resection margins
Lymph node yield
Permanent stoma rate
4. Surgery in Rectal Cancer
How are we doing nationally?
What type of operations are we doing?
Who is doing them?
Where is it being done?
Is treatment evidence based?
5. Surgery in Rectal Cancer
University of Minnesota study 2007
60.3% of patients are having permanent colostomy done
Higher in males, elderly, black and low income zip codes
DCR 2007; 50:1119-1127
6. Surgery in Rectal Cancer
Colostomy rates compared world wide:
Norwegian rectal Cancer project- 38%
Dutch trial- 32%
German trial- 25%
Trans-Tasman- 33%
AHRQ and OSHPD-USA- 50%
7. Surgery in Rectal Cancer
Where are these cases being done?
72% of hospitals with low volume-(<30/year)
30% treated at high volume hospitals-(>60/year)
Higher rates of mortality, LOS and colostomy rates in low volume hospitals
8. Surgery in Rectal Cancer
How about evidence based treatment?
Significant variation based on hospital volume
Only 74% of patients with stage II/III receiving neo-adjuvant therapy
Variation with geography- Midwest-78% vs South-70%
9. Surgery in Rectal Cancer
Quality of Surgery?
Suboptimal lymph node yieald-35.5%
CRM positivity-17.2%
10. Surgery in Rectal Cancer
US Rectal cancer care?
Suboptimal adherence to evidence based protocols
Suboptimal Surgery
High rates of CRM+, surrogate marker for poor oncologic outcomes
US outcomes are worse compared to European countries which have instituted
National programs to improve rectal cancer care,
11. Surgery in Rectal Cancer
How do we fix the problem?
Follow example of Norway , Sweden, Denmark, UK etc.
Establish a National rectal cancer program based on European models:
“OSTRiCh Consortium”-> “NAPRC”
Train and accredit MDTs in all hospitals motivated
Establish standards in protocols of patient care
Prospective data collection
Administered by ACS and CoC
12. Surgery in Rectal Cancer
NAPRC
Inclusive
Proposed standards in radiology, pathology, radiation and surgery
Quality improvements:
APR rate
Anastomotic leak rate
Reoperation and readmission rate
CRM+ and distal margin
TME grade and lymph node yield
Mortality
Recurrence rate
3 year disease free survival
13. Surgery in Rectal Cancer
What is the future?
Training at national center for radiology, pathology and surgery
TME- surgical technique
Pathology assessment
MRI protocol and reading
Administration and teamwork
