the surgery for rectal cancer
DESCRIPTION
Nick RiegerAssociate ProfessorUniversity of AdelaideSouth AustraliaTRANSCRIPT
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The Surgery for Rectal Cancer
Nick RiegerAssociate Professor
University of Adelaide
South Australia
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Surgical considerations“What is a surgeon thinking”
• The patient
• The tumour
• Preoperative chemoradiotherapy
• The Operation (TME)
• Postoperative dysfunction
• Postoperative chemoradiotherapy
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The Patient
• Age
• Sex Male vs Female
• Build (BMI)
• Co-morbidities
• Cognition
• Ability to manage a Stoma
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The Tumour
• Height from anal verge• Circumferential relationships• Size• Tumour depth (T stage)• Distant metastasis• Rectal examination• Imaging
CT, MRI, ENUS
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Rectal Anatomy15
cm
High Anterior Resection
Low Anterior Resection
Ultralow Anterior Resection
Abdominoperineal Resection
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Endorectal Ultrasound
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MRI
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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.
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Pre-operative Chemoradiotherapy
Before After
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Pre-operative Chemoradiotherapy
• T3 / T4 Tumours
• Down stage tumour
• Long course (5-6 weeks)
• Short course (1 week)
• Reduced local recurrence
• Improved survival
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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”
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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
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Local RecurrenceWhat is Important?
• Circumferential margins
• Distal margin
• Removal mesorectal envelope containing all the lymph nodes
• Cytocidal rectal washout
• Radiotherapy - pre and post operative
• YOUR SURGEON
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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
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TME
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TME
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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%
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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
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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)
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Modified TME
5 cm
5 cm
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Rectal Ultrasound
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The TechniquePre-operative
• Consent
• Bowel preparation
• Stomal therapy and siting for stoma
• DVT prophylaxis
• Antibiotics
• Urinary catheter
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The TechniqueSet-up
• Extended Lloyd-Davies position
• Good assistance
• Long midline incision
• Wide retraction
• Small bowel packed out of the way
• Full laparotomy (liver etc)
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Operative Position
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The TechniqueColonic 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
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Mobilisation Sigmoid Colon“Ureter”
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Splenic Flexure Mobilised
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High Ligation Inferior Mesenteric Artery
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Ligation Inferior Mesenteric Vein and Exposure of the Spleen
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Full Bowel Mobilisation
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The TechniquePosterior 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
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St Mark’s Retractor
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The TechniquePosterior Rectal Dissection
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The TechniquePosterior Rectal Dissection
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The TechniqueAnterior 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
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The TechniqueAnterior Rectal Dissection
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The TechniqueTransection 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
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Transverse Staple Line Rectal Stump
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The TechniquePreparation 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
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The TechniquePreparation Proximal Bowel
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The TechniquePreparation Proximal Bowel
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The TechniquePreparation Proximal Bowel
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Transected Bowel
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Staple Gun Head
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The TechniqueAnastomosis
• Ensure colon not twisted
• Ensure vagina excluded
• Double staple anastomosis
• Check donuts and Air test
• Haemostasis
• Drain pelvis
• Loop ileostomy
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Mid-rectal AnastomosisInserting the Staple Gun
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Midrectal Anastomosis
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Resected Specimen
Low anterior resection Abdominoperineal resection
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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.
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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
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Laparoscopy
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Postoperative Adjuvant Therapy
• Multi-disciplinary meeting
• Chemotherapy
• Radiotherapy
• Age and well-being of the patient
• Tumour factors
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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
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Conclusions
• Results of surgery operator dependent
• “Good” surgery must account for the nuances of the patient and the tumour
• Multidisciplinary approach