oncological and functional outcome of ultra low colo – anal anastomosis with and without...
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Oncological and functional outcome of ultra low colo – anal anastomosis with and without
intersphincteric resection for low rectal cancer
R.Ruppert
Städt. Klinikum München GmbHKlinikum – NEUPERLACH
Klinik für Allgemein und Viszeralchirurgie endokrine Chirurgie und Coloproktologie
Teaching hospital of the Ludwigs Maximilians University
Heads of Departement:Prof. N. Nüssler / Dr. R.Ruppert
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40 % of all colorectal carcinomas are located in the rectum
Rectum is defined as 16 cm upwards from anocutaneus line
Rectal cancer
Surgical Technique
Sphincter saving procedures
Abdominoperineal Resection
(APR)
Low anterior resection
(LAR)
Intersphincteric resection
(ISR)
Sphincter sacrificingprocedure
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Total mesorectal Exzision (TME)
•Sharp dissection under direct vision•“plane” between visceral und parietale pelvic fascia •Stelzner 1962•Heald 1982
Stelzner F (1962) Die gegenwärtige Beurteilung der Rectumresektion und Rectumamputation beim Mastdarmkrebs. Bruns Beitr 204:41
Heald RJ, Husband EM, Ryall RDH (1982) The mesorectum in rectal cancer surgery—the clue to pelvic recurrence? Br J Surg 69:613–616
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Surgical options for rectal cancer in the lower third of the rectum
Low anterior resection(LAR) / ISR
abdominoperineal Resection
(APR)
Expected number : 80 -85 %
Expected number : 10 -15 %
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The Status of radical proctectomy and sphincter-sparing surgery in the United StatesRicciardi, irnig,Madoff,Rothenberger,Baxter
DCR 8, 2007:1119-1127
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Oncological Outcomes after Mesorectal ExcisionFor Cure for Cancer of the Lower Rectum:Anterior vs Abdominoperineal Resection
Wibe et al., Trondheim , DCR 2004, 48-58
2136 konsecutive patients between 1993-1999 in 47 Hospitals in Norway
Multivariate analyses of prognostic factors:
APR (risc 1,3), age over 20y (3,1), UICC,
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Julius von Hohenegg (1859 – 1940)„pull through procedure“
Wien klin.Wzschr.1888 1:272-354
Schematischer Sagittalschnitt durch ein männliches Becken nach ausgeführter Durchziehmethode
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Straight coloanal anastomosis
Established by Sir Alan Parks 1974
Circular stapler / hand sewnTMECovering stoma
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History of „intramural spread“
1910: Hanley1913: Cole
case reports
Large intramural tumor spread
5 cm rule for distal resection marginwas establlished
for avoiding local recurrence
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1 cm rule ?
• 1995: Shirouzu– 610 Pat.
• DIS: overall 10%, all cases less < 1cm– 3,8% were curative cases
– 40% were palliativ cases (distant metastases)
Pat. with DIS have an advanced cancer stageThey have a worse overall survival but no increased
local recurrenceConclusion : 1cm distal resection margin is adequat
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CRM involvement APR versus AR
APR ARMercury < 6cm tumours n=282 33% 13%Classic trial curative
n= 400 21% 10%
Dutch TME trial curative n= 1586 29% 13%
Norwegian audit 12% 5%
Trent pelican Basingstoke 21% 10%
CR 07 n=1350 17% 8%
The CRM is the most pognostic factor ( independent) not the distal resection margin (DIS)
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Japanese Experience
Saito N et al. Dis Colon Rectum 2006
• 1995 - 2004 7 hospitals• 228 low rectal cancers < 5 cm from anal verge• T 1 n=46, T 2 n= 78, T 3 n= 104• Neoadjuvant Radiotherapy 57• Local recurrence at 5 years: 7 %• Disease free survival (DFS): 83 % at 5 years• Good continence (Kirwan I –II): 68 %
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French Experience – Eric Rullier, ESCP 2008 Nantes
Resultsn = 300
CAA Partial ISR Total ISR APR
Age 67 65 63 65 ns
Tumour stage T1/T2
22 % 13 % 10 % 6 % 0,001
T3 72 % 76 % 81 % 51 %
T4 6 % 11 % 9 % 43 %
Preop RT 67 % 86 % 88 % 79 % 0,007
Distance to anal ring (cm)
2 1 - 0,5 - 1 0,001
Hand sewn 37 % 96 % 100 % 0,001
Level of anastomosis
3 cm 2 cm 1 cm 0,001
Colonic pouch
62 % 72 % 83 % 0,01
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Oncological feasibility French experience - Eric Rullier, ESCP, Nantes 2008
n = 300
CAA p ISR t ISR APR
CRM (mm)7 5 4 6 0,07
R o resection 87 % 88 % 81 % 81 % ns
Tumor stage
I43 % 45 % 46 % 16 % 0,005
II 22 % 24 % 26 % 39 %
III 35 % 29 % 30 % 45 %
ns
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Oncological outcome
French experience - Eric Rullier, ESCP 2008, Nantes
n = 300
CAA P ISR T ISR APR
Follow up (month) 37 39 55 36 ns
Local recurrence 5 5 5 9 ns
Overall recurrence 20 % 20 % 21 % 36 % P = 0,07
Delay of recurrence (month)
17 18 11 15 ns
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5 year overall and DFS
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Meta analysis of ISRTilney & Tekkis Colorectal Disease 2008
• 21 series from 13 units• 612 patients• Mortality 1,6 %• Leakage 10,5 %• Local recurrence 9,5 % (0 – 31)• 5y survival 81 %• Radiotherapy: oncological benefit but worse
functional outcome
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Summary
For oncological reasons, intersphincteric resection is safe and should be offered to all patients as often it is possible.
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Functional outcome ?
How is continence influenced by intersphincteric resection ?
Quality of life ?
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Sphincter function
1. Internal anal sphincter – resting pressure
2. External anal sphincter - squeeze pressure
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Intersphincteric resectionPhysiology
1. Loss of internal sphincter (innervation)2. Loss of anal transitional zone3. loss of rectal compliance
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Own Results 1978 – 1992
low anterior resections n = 2707coloanal anastomosis n = 103 (3,8 %)
• Male = 75, female = 28• Age 58,6 ( m = 59,8, f = 57,4)• Rectal cancer n =88• Large adenomas n =9• Rectovaginal fistula after radiotherapy n = 6
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incontinence first postoperative year (%)
normal continence;
40,8
grade I (gas); 18,4
grade III (solid); 9,7
grade II (liquid); 31,1
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incontinence after the first postoperative year (%)
normal continence;
67,9
grade I (gas); 16,5
grade III (solid); 3,9grade II (liquid); 11,7
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summary
• Final evaluation for functional outcome makes sense only after 2 years.
• Subjective outcome in our series– 80,6 % satisfied– 5,8 % not satisfied
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Functional outcome
CAA P ISR T ISR
normal continence
73 % 52 % 51 %
Incontinence for gas
6 % 7 % 3 %
Minor incontinence
6 % 26 % 24 %
Major incontinence
13 % 11 % 16 %
colostomy 2 % 4 % 5 %
Good continence
79 % 59 % 54 %
P = 0,02 ns
Bretagnol Dis Colon Rectum 2004
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Summary
• functional outcome after ISR is acceptable• Be aware of minor and major problems of incontinence in one third
of the patients.• Preoperative information about these problems are absolutely
necessary• Younger patients are more suitable for ISR.• No good results will be achieved in older women• Patient selection is the key to good functional results
Avoid
Creation of a perineal stoma
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"Advance means progress to something
better and not progress to something new."
Sir Heneage Ogilivie (1887-1948Guy's Hospital London)
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Thank you for your attention