Prevention of surgical morbidity/ mortality Optimal oncological clearance



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  • Prevention of surgical morbidity/ mortality

  • Optimal oncological clearance

    • Cancer and Lymph Node clearance > 12 LN
  • Prevention of local recurrence – TME, radioRx

  • Quality of life

  • Laparoscopic Surgery still needs to uphold these objectives.





1826: Lisfranc 1st report of local excision

  • 1826: Lisfranc 1st report of local excision

  • 1884: Czerny

  • 1886: Kraske

  • 1907: Miles

  • 1917: Bevan

  • 1970: York-Mason

  • 1979: Heald introduces TME Total Mesorectal Excision

  • 1984: Buess introduces TEM Transanal Endoscopic Microsurgery



Patient factors:

  • Patient factors:

    • Elderly, frail and high anesthetic risk
    • Patient refusal of a stoma/ radical treatment


Location: <10 cm from the anal verge

  • Location: <10 cm from the anal verge

  • Size & circumference of lesion:

    • No evidence to predict local recurrence
    • <4cm & <40% of circumference
  • Mobility: -Fixed tumours not appropriate

  • T staging:

    • LN involvement: T1(6-12%) T2(17-22%) T3(66%)
    • Local recurrence: T1(5%) T2(18%) T3(22%)
  • Tumour grade:

    • LN mets: well-mod diff(11%) poor diff(33%)
    • Local recurrence: well-mod diff(14%) poor diff(30%)


Lymphovascular & perineural invasion:

  • Lymphovascular & perineural invasion:

    • Greater likelihood of LN mets and local recurrence
    • LN mets: 33% vs 14-17%
  • Mucinour tumours:

    • Greater likelihood of LN mets and local recurrence
  • Nodal status:

    • Not appropriate for local excision


PR/ sigmoidoscopy

  • PR/ sigmoidoscopy

  • Tissue biopsy: - May miss area of poor differentiation

  • ERUS

    • Quoted accuracy T staging(67-93%) N staging(61-88%)
    • Recent study found the accuracy in picking T1(50.8%) and T2(58.6%), understaging tumours(12.8%) Marusch et al., Endoscopy 2002
  • MRI

    • Best for evaluating nodal status, accuracy at 82%
  • Colonoscopy, CT AP, PET-CT



Recommended criteria:

  • Recommended criteria:

    • <10 cm from anal verge
    • Tumour < 4cm and <40% of circumference
    • Favourable T1 stage
      • Well- moderate differentiation
      • No lymphovascular or perineural invasion
      • Non-mucinous tumours
    • No nodal disease


Trans-sacral resection

  • Trans-sacral resection

    • Kraske procedure
    • Coccyx and lower 2 segments of sacrum excised
    • Sphincter complex preserved
    • Mid-rectal lesions
    • Cx: faecal fistula
  • Trans-sphincteric resection

    • York-Mason procedure
    • Similar approach to Kraske, however the sphincter complex is completely divided and sacrectomy not performed
    • Lower and mid rectal lesions
    • Cx: Incontinence and faecal fistula




Transanal excision

  • Transanal excision

    • Full thickness excision with 1cm margin
    • Rectal defect closed transversely
    • Varying results in the lit, small retrospective series
    • Local recurrence high
      • T1(18%) T2(47%)
    • Survival
      • T1(72-90%) T2(55-78%)


Transanal Endoscopic Microsurgery (TEM)

  • Transanal Endoscopic Microsurgery (TEM)

    • Developed for lesions out of reach from transanal approach
    • Can be used for benign lesions above the peritoneal reflection
    • Favourable T1 lesions have equivalent local recurrence and 5yr survival cf radical surgery
    • Unfavourable T1 lesions have higher local recurrence (10-15%)
    • TEM + XRT on T2 have local recurrence (25-46%)


Electrocoagulation

  • Electrocoagulation

    • Used as palliative & curative Rx
    • Disadv: no tissue spec, 1/3 conversion to radical surgery, 20% secondary haemorrhage
    • Poor outcomes
  • Endocavitatory radiation

    • Direct contact radiation 10-12000 cGy
    • Useful in palliative setting
    • In select pts 5yr survival & local control of 76-90%


Splenic flexure mobilization

  • Splenic flexure mobilization

  • Sigmoid colon resected

    • Quality of circulation is poor
    • Functional outcomes as neo-rectum poor
  • High ligation of IMA

    • Allows mobilization of descending colon
  • Ligation of main trunk of left colic









Introduced by RJ Heald in 1979

  • 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 leaks rates reported possibly due to:

    • Devascularisation of distal rectal stump
    • Lower anastamosis
    • Other factors: stomas, drains


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%)

  • 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%)

  • Havenga et al., 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 anastamotic 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 anastamotic leak (11 vs 12%)


Peritoneal incision around rectum

  • Peritoneal incision around rectum

  • Rectosigmoid reflected ant and posterior avascular plane developed using sharp scissor or diathermy dissection under vision

  • Blobbed lipoma should be demonstrated

  • Posterior dissection first, then lateral and finally anterior dissection

  • Do not ‘finger hook’ or clamp the lateral ‘ligaments’

  • Partial TME to a distance 5cm distal to tumour

  • Anterior dissection incorporates Denonvilliars fascia?





Preaortic sympathetics during high ligation

  • Preaortic 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 exp by Japanese 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 denonvilliars fascia


Charles Denonvillier described in 1836

  • Charles Denonvillier described in 1836

  • Fusion of rectovesical cul-de-sac

  • Glistening white trapezoid apron

  • Anterior mesorectal envelope

  • Laterally close to neurovasc bundle

  • Visible on MRI

  • Heald et al recommend dissection in front





Mortensen et al., recommends dissection behind the fascia as it is the natural continuation of lateral dissection

  • Mortensen et al., recommends dissection behind the fascia as it is the natural continuation of lateral dissection

  • Also notes that there is a theoretical higher risk of nerve damage

  • Notes that there may be a role for dissection anterior to the fascia for anterior tumours



Not clear in the literature

  • 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



Hand sewn sutured anastamosis

  • Hand sewn sutured anastamosis

    • 1982: Parks and Percy performed the coloanal sutured anastamosis
    • ‘Pulled through’ coloanal anastamosis (Turnbull & Cuthbertson)
  • Stapled anastamosis

    • Circular stapled technique
    • Double staple technique
      • For low and coloanal anastamosis


Straight end to end

  • Straight end to end

    • Low AR or Coloanal end-to-end anastamosis cause tenesmus, urgency and incontinence (Anterior resection syndrome)
  • Colonic J Pouch

    • Increases volume of neorectum
    • 5 vs 10cm pouches have smaller reservoirs but better evacuation (Hida et al., Ds Colon Rectum 1996)
    • Size is critical to functional outcome, recommend 5-8 cm
    • Sigmoid colon should not be used
    • Better short term functional results and possible lower anastamotic leaks compared to end-to-end anastamosis
  • Coloplasty

    • New technique introduced in 1999 (Z’graggen et al., Dig Surgery 1999)
    • Better in narrow pelvis and limited length of colon
    • Long incision closed transversely
    • Randomized trial underway comparing to J-pouch


Described by Sir Ernest Miles 1908

  • 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





ANASTOMOTIC LEAK

  • ANASTOMOTIC LEAK

  • INTRAABDOMINAL ABSCESS, STOMA RETRACTION, HAEMORRHAGE,

  • DVT, WOUND INFECTION, & OTHER GENERAL



T3 and/or N1 Rectal lesions should have neoadjuvant (preoperative) chemoradiotherapy

  • T3 and/or N1 Rectal lesions should have neoadjuvant (preoperative) chemoradiotherapy

  • Select T4 lesions could be down staged prior to pelvic exenteration

  • Role of CRT downsizing and rates of sphincter preservation.

  • Rouanet et al., performed sphincter preservation in 21/27 pts after CRT downsizing. At 2 yrs only 2 LR (Ann Surg 1995)

  • Grann et al., performed sphincter preservation in 17/20 T3 lesions (Ds Colon Rectum 1997)



Extent of margins of resection

  • Extent of margins of resection

  • - Intraluminally (2cms)

  • - Extraluminally (M.E. 5cms)

  • - Contiguous Organs

  • Extent of lymphatic resection

  • Timing and level of vascular ligation

  • Anastomotic technique

  • Intraluminal cytotoxic solutions



Beaware of the inaccuracies of preop staging

  • Beaware of the inaccuracies of preop staging

  • Local excision in favourable T1 lesions

  • TME should be standard practice in rectal dissection

  • Nerve preservation surgery

  • Role of distal margins

  • Neoadjuvant chemoradiotherapy


























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