This document discusses surgical considerations for rectal cancer, including: 1. The total mesorectal excision (TME) technique aims to remove the mesorectum containing all lymph nodes, leading to low local recurrence rates of 3-4% after 5-10 years. 2. Pre-operative chemoradiotherapy can downstage tumours and improve survival, especially for T3/T4 tumours. 3. A modified TME removing the mesorectum at least 5cm below the tumour is acceptable for high and mid rectal cancers, as distal spread beyond this is rare. 4. Good surgical outcomes depend on meticulous technique, surgeon experience operating in the pelvis, and multidis

1. The Surgery for Rectal Cancer Nick Rieger Associate Professor University of Adelaide South Australia

2. Surgical considerations “What is a surgeon thinking” The patient The tumour Preoperative chemoradiotherapy The Operation (TME) Postoperative dysfunction Postoperative chemoradiotherapy

3. The Patient Age Sex Male vs Female Build (BMI) Co-morbidities Cognition Ability to manage a Stoma

4. The Tumour Height from anal verge Circumferential relationships Size Tumour depth (T stage) Distant metastasis Rectal examination Imaging CT, MRI, ENUS

5. Rectal Anatomy 15 cm High Anterior Resection Low Anterior Resection Ultralow Anterior Resection Abdominoperineal Resection

6. Endorectal Ultrasound

7. MRI

8. Rectal cancer Cooperative trials Local recurrence rates 25-35% NIH consensus adjuvant chemotherapy and radiotherapy for T3 and N1 rectal adenocarcinoma Wide surgeon variability for Local Recurrence and Survival.

9. Pre-operative Chemoradiotherapy Before After

10. Pre-operative Chemoradiotherapy T3 / T4 Tumours Down stage tumour Long course (5-6 weeks) Short course (1 week) Reduced local recurrence Improved survival

11. Total Mesorectal Excision An operation for Rectal Cancer Low rate of Local Recurrence after “curative” resection. The term initially introduced by Bill Heald (UK) in 1982 Many surgeons had practised this concept of surgery prior to the introduction of the term “TME”

12. Bill Heald Archives of Surgery 1998 405 curative resections / No radiotherapy Local Recurrence 3% at 5 years Local Recurrence 4% at 10 years Disease free survival 80% at 5 years Disease free survival 78% at 10 years

13. Local Recurrence What is Important? Circumferential margins Distal margin Removal mesorectal envelope containing all the lymph nodes Cytocidal rectal washout Radiotherapy - pre and post operative YOUR SURGEON

14. TME Rectal cancer spreads to lymph nodes in the mesorectum This may be in nodes below the inferior margin of the cancer Particularly relevant in cancers of the middle and lower thirds of the rectum

15. TME

16. TME

17. TME Leak Rate Karanjia, Heald et al BJS 1994 219 LAR with TME Major leak (abscess or peritonitis) 11% Minor leak (contrast enema) 6.4%

18. TME Nerve preservation (sexual and bladder function) Low anastomosis - Reduced APR Low anastomosis - Colonic pouch Higher anastomotic leak rate Higher rate covering stoma ? Negates the need for routine use of radiotherapy

19. Modified TME Distal spread of adenocarcinoma either in the rectal wall or mesorectum greater than 2-3 cm is rare. When it occurs it is with advanced tumours and associated with a poor prognosis. 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)

20. Modified TME 5 cm 5 cm

21. Rectal Ultrasound

22. The Technique Pre-operative Consent Bowel preparation Stomal therapy and siting for stoma DVT prophylaxis Antibiotics Urinary catheter

23. The Technique Set-up Extended Lloyd-Davies position Good assistance Long midline incision Wide retraction Small bowel packed out of the way Full laparotomy (liver etc)

24. Operative Position

25. The Technique Colonic Mobilisation Transverse, Splenic flexure and Descending colon mobilised High ligation inferior mesenteric artery on the aorta High ligation inferior mesenteric vein at the lower border of the pancreas Preservation of ureter, gonadal vessels, and hypogastric nerves

26. Mobilisation Sigmoid Colon “Ureter”

27. Splenic Flexure Mobilised

28. High Ligation Inferior Mesenteric Artery

29. Ligation Inferior Mesenteric Vein and Exposure of the Spleen

30. Full Bowel Mobilisation

31. The Technique Posterior Rectal Dissection Develop the plane at the pelvic brim anterior to the hypogastric nerves and posterior to the superior rectal artery. Enter the areolar space between the mesorectal fascia and the sacral fascia. Do not “cone in” on the mesorectum Sharp dissection or diathermy Avoid blunt dissection St Marks retractor

32. St Mark’s Retractor

33. The Technique Posterior Rectal Dissection

34. The Technique Posterior Rectal Dissection

35. The Technique Anterior Rectal Dissection Divide the anterior peritoneum of rectovesical or rectouterine pouch above and anterior to its apex Develop the plane between the seminal vesical or vagina anterior to Denonvilliers fascia Continue dissection to pelvic floor

36. The Technique Anterior Rectal Dissection

37. The Technique Transection of Rectum Mesorectum at least 5 cm below tumour (modified TME) or at pelvic floor. Cross clamp or staple below tumour Rectal cytocidal washout 30 mm stapler at least 2 cm below the tumour Haemostasis

38. Transverse Staple Line Rectal Stump

39. The Technique Preparation Proximal Bowel Ligation mesocolon vessels preserving the marginal artery Avoid using the sigmoid colon Use the descending colon Fashion colonic pouch if ULAR Insert purse-string suture and head of circular staple gun

40. The Technique Preparation Proximal Bowel

41. The Technique Preparation Proximal Bowel

42. The Technique Preparation Proximal Bowel

43. Transected Bowel

44. Staple Gun Head

45. The Technique Anastomosis Ensure colon not twisted Ensure vagina excluded Double staple anastomosis Check donuts and Air test Haemostasis Drain pelvis Loop ileostomy

46. Mid-rectal Anastomosis Inserting the Staple Gun

47. Midrectal Anastomosis

48. Resected Specimen Low anterior resection Abdominoperineal resection

49. Summary TME associated with low rate of local recurrence Requires meticulous technique and a surgeon familiar with operating in the pelvis Modified TME acceptable for high and mid rectal tumours.

50. TEMPORARY STOMA (Ileostomy) Dependant on: Height of anastomosis Ease and technical success of operation Well being of the patient (co-morbidities) Surgical conservatism Radiation PERMANENT STOMA (Colostomy) Dependant on: Height of tumour from anal canal Likelihood of continence

51. Laparoscopy

52. Postoperative Adjuvant Therapy Multi-disciplinary meeting Chemotherapy Radiotherapy Age and well-being of the patient Tumour factors

53. Postoperative Bowel Function Rectum acts as a reservoir Removal leads to replacement with a colonic conduit (neorectum) “ Anterior resection syndrome” Frequent loose stool, stool clustering, urgency, occasional incontinence Colonic “J” Pouch

54. Conclusions Results of surgery operator dependent “ Good” surgery must account for the nuances of the patient and the tumour Multidisciplinary approach