Surgical Treatment of the Low (Distal Third) Rectal Cancer

1. Surgical Treatment of theLow (Distal Third) Rectal Cancer Feza H. Remzi FACS, FASCRS, FTSS ( Hon ) Chairman Department of Colorectal Surgery Professor of Surgery Rupert B Turnbull Jr,. MD Chair Digestive Disease Institute Cleveland Clinic, Cleveland, OH

2. Disclosure • None

3. 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

4. Treatment Goals Maximize likelihood of cure Minimize risk of complications Sphincter preservation Optimal bowel function and quality of life

5. Team Approach • Surgeon • Radiologist • Oncologist • Radiation Therapist • Enterostomal therapist

6. Surgery • Mainstay of therapy is surgery • TME: Total mesorectal excision • Surgical technique: refined to an anatomic dissection to include the fascia propria of the rectum

7. Margin • 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

8. Surgery Colon mobilization and high ligation of the mesenteric vessels TME APR versus reconnection with reconstruction

9. TME

15. Anastomosis

16. Issues • Blood Supply • Reach • Reconstruction • Anastomosis

17. Issues • Blood Supply • Reach

25. If onclogocally feasible, double stapled anastomosis is the preferred technique of anastomosis

31. Handsewn Anastomosis

32. 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

36. 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

37. 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 2005

38. 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

39. Pelvic Radiation and Rectal Cancer 1990 National Institute of Health consensus conference: Recommends adjuvant postoperative radiotherapy and fluorouracil based chemotherapy for patients with B2-C rectal adenocarcinomas (JAMA 1990)

40. Pelvic Radiation and Rectal Cancer: Current Dilemma 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 ?

41. Pelvic Radiation Preop and TME 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 Kapitenijn et al NEJM 2001

42. 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

43. Function and QOL after Radical Resection and Sphincter Preservation Cost? • Inadvertent and uncontrollable passage of flatus to frank fecal incontinence • Urgency • Frequency • “Anterior resection syndrome”

44. Radical Resection of Rectal Cancer • End-to-end coloanal anastomosis • Side-to end colonic J-pouch-anal anastomosis • End-to-end coloplasty-anal anastomosis • Side-to-end coloanal anastomosis

47. End-to-end versus J-pouch

48. End-to-end versus J-pouch Prospective randomized trials • Seow-Choen, Goh. Br J Surg 1995;82:608 • Ortiz, et al. Dis Colon Rectum 1995;38:375 • Hallböök, et al. Ann Surg 1996;224:58. • Lazorthes, et al. Br J Surg 1997;84:1449 • Fürst, et al. Dis Colon Rectum 2002;45:660 • Sailer, et al. Br J Surg 2002;89:1108

49. End-to-end versus J-pouch Technical reasons for failure to create J-pouch • Narrow pelvis (12%) • Bulky sphincters or mucosectomy (9%) • Extensive diverticulosis (3%) • Insufficient length (2%) Harris, et al. Dis Colon Rectum 2002;45:1304