Surgical Treatment of theLow (Distal Third) Rectal Cancer

Feza H. Remzi FACS, FASCRS, FTSS ( Hon )Feza H. Remzi FACS, FASCRS, FTSS ( Hon ) Chairman Chairman

Department of Colorectal SurgeryDepartment of Colorectal SurgeryProfessor of SurgeryProfessor of Surgery

Rupert B Turnbull Jr,. MD Chair Rupert B Turnbull Jr,. MD Chair Digestive Disease InstituteDigestive Disease Institute

Cleveland Clinic, Cleveland, OHCleveland Clinic, Cleveland, OH

Disclosure

• None

Conclusion• Oncological clearance is the priority

• Radical excision with TME is the preferred technique

• Neoadjuvant chemo –X-rt is the preferred adjuvant therapy and it does not alter the decision for sphincter preservation

• Optimal bowel function and quality of life can be improved by colonic reservoirs

• Do not hesitate to divert

• Observation after neoadjuvant therapy can be dome under trial

• Local therapy can be alternative in selected- high morbid patient

• Maximize likelihood of cure

• Minimize risk of complications

• Sphincter preservation

• Optimal bowel function and quality of life

Treatment Goals

• Surgeon

• Radiologist

• Oncologist

• Radiation Therapist

• Enterostomal therapist

Team Approach

• Mainstay of therapy is surgery

• TME: Total mesorectal excision

• Surgical technique: refined to an anatomic dissection to include the fascia propria of the rectum

Surgery

• Negative radial margins

• Distal margin�At least 5 cm of margin when there is a

distance of 5 cm distal resection

�At least 1 cm or more when there is no distance for 5 cm of distal dissection

Margin

• Colon mobilization and high ligation of the mesenteric vessels

• TME

• APR versus reconnection with reconstruction

Surgery

TME

Anastomosis

Issues

• Blood Supply

• Reach

• Reconstruction

• Anastomosis

• Blood Supply

• Reach

Issues

If onclogocally feasible,

double stapled anastomosis

is the preferred technique

of anastomosis

Handsewn Anastomosis

Technique

• Start in Kraske position; especially anterior lesions

• Put everting stay sutures and dissect circumferentially till you reach the plane above the levator muscles

• Use injectable epinephrine solution where mucosectomy is required

• Leave one location intact so the rectum doesn't retract

• Be careful not to do keyhole injury during the posterior dissection

• Release your stay sutures when you are ready to flip patient back to Lyodd –Davis position

Intersphincteric Proctectomy

Pros

• N=92 , R0 89%, Local recurrence 2%

• 5 yr overall and disease-free survival was 81 and 71 %

Cons

• 11 % radial margin positive

• Morbidity was N=25 (27 %) where, there was 14 patients with anastomotic complications

• Only 58 patients had minimum of two years of F/U

• Minimal information on functional outcome and final stoma status

Rullier et all Ann Surg 2005

Sphincter Preservation and QOL

• Increased associated morbidity

• Impact on QOL ?

• 30 Studies, 11 were non randomized, N= 1412 patients

• Six trials showed APR did not have poorer QOL than LAR

• Four trials showed APR had significantly poorer QOL than LAR

• Due to heterogeneity, meta-analysis was not possible

Cochrane Review 2005Cochrane Review 2005

Selection• No compromise in the oncologic clearance

• Patient must consent for the possibility of APR

• Motivated patient

• Lack of associated co-morbidity

• Good preoperative sphincter function

• If all above conditions are met, try to reconnect with diverting temporary stoma and have patient decide for himself or herself whether to live as they are or go back to stoma

1990 National Institute of Health consensus conference:

Recommends adjuvant postoperative radiotherapy and fluorouracil based chemotherapy for patients with B2-C rectal adenocarcinomas (JAMA 1990)

Pelvic Radiation and Rectal Cancer

• Pre or post op?

• Dose if preoperative

• Timing of surgery if given pre-op

• Which patients benefit

• ? If needed with TME

• Decision for APR versus reconnection, when ?

Pelvic Radiation and Rectal Cancer: Current Dilemma

• Dutch TME study

• Conclusion

�Even with good surgery, radiation improves local control for stage II and III low rectal cancers

�Patients with T3N0 tumors > 10 cm from the verge probably do not need XRT

Pelvic Radiation Preop and TME

Kapitenijn et al NEJM 2001

Summary

• Not all rectal cancers need preoperative radiation therapy

• Stage I rectal cancers probably do not need adjuvant treatment

• Predicting which stage II and III lesions require adjuvant tx not currently possible�ELUS is good, MRI is high likely the better

• Avoid the need for postoperative X-rt

• Better staging modalities in the future

Function and QOL after Radical Resection and Sphincter Preservation

• Inadvertent and uncontrollable passage of flatus to frank fecal incontinence

• Urgency

• Frequency

• “Anterior resection syndrome”

Cost?

Radical Resection of Rectal Cancer

• End-to-end coloanal anastomosisEnd-to-end coloanal anastomosis

• Side-to end colonic J-pouch-anal Side-to end colonic J-pouch-anal anastomosisanastomosis

• End-to-end coloplasty-anal End-to-end coloplasty-anal anastomosisanastomosis

• Side-to-end coloanal anastomosisSide-to-end coloanal anastomosis

End-to-end End-to-end versusversus J-pouch J-pouch

End-to-end End-to-end versusversus J-pouch J-pouchProspective randomized trials Prospective randomized trials

• Seow-Choen, Goh. Seow-Choen, Goh. Br J SurgBr J Surg 1995;82:608 1995;82:608

• Ortiz, Ortiz, et alet al. . Dis Colon RectumDis Colon Rectum 1995;38:375 1995;38:375

• HallbHallböööök, k, et alet al. . Ann SurgAnn Surg 1996;224:58. 1996;224:58.

• Lazorthes, Lazorthes, et alet al. . Br J SurgBr J Surg 1997;84:1449 1997;84:1449

• FFüürst, rst, et alet al.. Dis Colon Rectum Dis Colon Rectum 2002;45:660 2002;45:660

• Sailer, Sailer, et alet al. Br . Br J SurgJ Surg 2002;89:1108 2002;89:1108

End-to-end End-to-end versusversus J-pouch J-pouch

Technical reasons for failure to create Technical reasons for failure to create J-pouchJ-pouch

• Narrow pelvis (12%)Narrow pelvis (12%)

• Bulky sphincters or mucosectomy (9%)Bulky sphincters or mucosectomy (9%)

• Extensive diverticulosis (3%)Extensive diverticulosis (3%)

• Insufficient length (2%)Insufficient length (2%)

Harris, Harris, et alet al. . Dis Colon RectumDis Colon Rectum 2002;45:1304 2002;45:1304

J-pouch J-pouch versusversus Coloplasty Coloplasty

J-pouch J-pouch versusversus Coloplasty Coloplasty

Prospective randomized trialsProspective randomized trials

• Ho, Ho, et alet al. . Ann SurgAnn Surg 2002;236:49 2002;236:49

• FFüürst, rst, et alet al. . Dis Colon RectumDis Colon Rectum 2003;46:1161 2003;46:1161

• Pimentel, Pimentel, et alet al. . Colorect DisColorect Dis 2003;5:465 2003;5:465

NN Pouch sizePouch size Follow-upFollow-up

HoHo 8888 6 cm/7 cm6 cm/7 cm 12 months12 months

FFüürstrst 4040 5 cm/8 cm5 cm/8 cm 6 months6 months

PimentelPimentel 3030 5 cm/8 cm5 cm/8 cm 12 months12 months

J-pouch J-pouch versusversus Coloplasty Coloplasty

FrequencyFrequency UrgencyUrgency ConstipationConstipation

HoHo ↔↔ ↔↔ ↔↔

FFüürstrst ↔↔ ↔↔ --

PimentelPimentel ↓ ↓ J-pouchJ-pouch ↔↔ ↓ ↓ ColoplastyColoplasty

J-pouch J-pouch versusversus Coloplasty Coloplasty

Fazio et al 2007 Fazio et al 2007 Ann SurgAnn Surg

• N=364

• Mortality N=23 7.4 %

• No difference between the groups in complications

• N=297 were available for functional and QOL assessment

• Straight versus coloplasty same

• Colonic J pouch was superior to others

J-pouch J-pouch versusversus Side-to-end Side-to-end

Prospective randomized trialsProspective randomized trials

• Huber, Huber, et alet al. . Dis Colon RectumDis Colon Rectum 1999;42:896 1999;42:896

• Machado, Machado, et alet al. . Ann SurgAnn Surg 2003;238:214 2003;238:214

J-pouch J-pouch versusversus Side-to-end Side-to-end

NN Pouch sizePouch size Follow-upFollow-up

HuberHuber 5959 6 cm/4 cm6 cm/4 cm 6 months6 months

MachadoMachado 100100 8 cm/4 cm8 cm/4 cm 12 months12 months

J-pouch J-pouch versusversus Side-to-end Side-to-end

FrequencyFrequency UrgencyUrgency ConstipationConstipation

HuberHuber ↓ ↓ J-pouchJ-pouch ↔↔ ↔↔

MachadoMachado ↔↔ ↔↔ ↔↔

J-pouch J-pouch versusversus Side-to-end Side-to-end

Local Excision Abdominoperineal resection or low anterior

resection for rectal cancerComplete tumor excisionClearance of regional lymph nodes

Operative mortality, morbidity

× Urinary and sexual dysfunction 30-40 %

× Anastomotic complications 5-10 %

× Mortality of 1- 6 % after APR

× Necessity of permanent or temporary diversion

Surgical Approaches

• Local excision alone

• Local excision followed by adjuvant therapy

• Local excision after neoadjuvant therapy

• Limited surgical morbidity 0-22 %

RecurrenceLocal recurrence N=9 17 % (site 8%,pelvic 9%)

Distant metastasis N=2 4%

Distant and local N=4 6%

Unknown N=1 2%

Total N=15 29%

Average time to diagnose recurrence was 28.5± 22.1 months (range 1-72 months)

When Should We Consider It with Curative Intent?

Preferred Acceptable

Stage 1 T1N0M0

Favorable LE Radicalfeatures Chemo / X-rt ?

resection

Unfavorable Radical LE +resection chemo / X-rt

Stage 1 T2N0M0 Radical LE + resection chemo / X-rt

Future of Local Excision• It is here to stay

• Better predictive factors�Kikuchi classification

�Better preoperative staging

�Markers• Telomerase, p53, COX ,MIB-1, BCL-1, BCL-X,

MLH-1, MSH-2 and MSH-6

• The necessity of multicenteric and controlled trials

Kikuchi 1995, Kikuchi 1995, RamalingamRamalingam 2002 SSAT 2002 SSAT

Conclusion

• Oncological clearance is the priority

• Radical excision with TME is the preferred technique

• Neoadjuvant chemo –X-rt is the preferred adjuvant therapy and it does not alter the decision for sphincter preservation

• Optimal bowel function and quality of life can be improved by colonic reservoirs

• Do not hesitate to divert

• Local therapy can be alternative in selected- high morbid patient

• Oncological clearance is the priority

• Radical excision with TME is the preferred technique

• Neoadjuvant chemo –X-rt is the preferred adjuvant therapy and it does not alter the decision for sphincter preservation

• Optimal bowel function and quality of life can be improved by colonic reservoirs

• Do not hesitate to divert

• Observation after neoadjuvant therapy can be dome under trial

• Local therapy can be alternative in selected- high morbid patient

Conclusion

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