大腸直腸外科的過去、現在與未來

1. 大腸直腸外科的過去、現在與未來 王正儀 教授 2008/12/14

3. 九十四年台灣十大癌症統計 每10萬人口(不含原位癌)計, 依年齡標準化率22000年世界標準人口為標準人口排序 註：年齡標準化率11976年世界標準人口 資料來源：行政院衛生署國民健康局癌症統計年報

4. Advances in Colo-Rectal Surgery • CCRT • Sphincter Saving procedures • Laparoscopic Surgery • PPH in hemorrhoid • Chemotherapy in metastatic Colo-Rectal Cnacer

5. Preoperative Radiotherapy for Locally Advanced Rectal Cancer

6. Local recurrent rate – 1970 – 80s Level II or I evidences

7. Randomized trials – Post - OP Level I evidences

8. 1990 NIH consensus statement Combined postoperative chemotherapy and radiation therapy improves local control and survival in Stage II and III patients and is recommended. At the present time, the most effective combined modality regimen appears to be 5-FU plus methyl-CCNU, and high-dose pelvic irradiation (45 to 55 Gy) but chronic toxicity considerations of methyl-CCNU mitigate against using this regimen outside ongoing clinical trials

9. Pre-Operative Radiotherapy More easily to achieve complete tumor resection because of the shrinkage of tumor after pre-OP RT The injury to the bowels might be less since the irradiated bowel loop will be removed if the RT is delivered pre-operatively The sphincter preservation rate might be increased for low-lying rectal tumor after pre-OP CCRT.

10. Randomized trials – Pre - OP Level Ib evidence

11. Meta-analysis JAMA 2000; 284:1008 Lancet 2001; 358: 1291 Level Ia evidence

12. Long course vs Short course Pre-OP RT

13. Randomized trials – Pre-OP Level Ib evidence

14. Total mesorectal resection – since 1971

15. The Dutch Trial -continued

16. Long course - Results Level II or I evidences

17. Long course vs Short course RT The effects of tumor control is similar In order to improve the likelihood of sphincter preservation, long course of RT (5000 cGy) is likely to be optimal. Radiotherapy & Oncology 72(1); 15-24: 2004

18. ASCO news – 2006 June

19. Rationale of using FOLFOX regimen In a large international multicenter cooperative trial (MOSAIC), the addition of oxaliplatin to adjuvant chemotherapy with 5-FU and LV is associated with a significant better disease-free survival at 3-year in 2246 patients with stage II or III colon cancer (N Eng J Med 350:2343-51, 2004) In several phase I-II studies, oxaliplatin also shows activities in patients with rectal cancer (Br J Cancer 93:993-8, 2005, Ann Oncol, 16:1898-905, 2005, Br J Cancer 92:655-61, 2005) Level Ib or II evidence

21. XELOX phase II trials

22. Ongoing Phase III trials

23. Intersphincteric Resection (ISR) for lower rectal cancer

24. If a distal clearance of 1 cm can be achieved, a low rectal cancer should be suitable for anterior resection ~ a recommendation in the ‘Guidelines for the Management of Colorectal Cancer’ from the Royal College of Surgeons of England and the Association of Coloproctology of Great Britain and Ireland ~ Association of Coloproctology of Great Britain and Ireland.(1996) Guidelines for the management of colorectal cancer. The Royal College of Surgeons of England, London.

25. Transanal technique in low rectal anastomosis. (CAA) • Parks AG. • In 1972,Proc R Soc Med. • for benign disease Intersphincteric excision of the rectum • Lyttle JA, Parks AG. • In 1977, Br J Surg • for inflammatory bowel disease

26. Resection and sutured colo-anal anastomosis for rectal carcinoma • Parks AG. and Percy JP. • In 1982, Br J Surg • Described the technique of rectal excision with peranal anastomosis • Denude the mucosa from anal canal

29. Resection and colo-anal anastomosis with colonic reservoir for rectal carcinoma • R. Parc, et al. • In 1986, Br J Surg • 31 patients, • Technique of excision as method of Parks • AG., use a J-shaped reservoir of 8 cm

32. Results of Intersphincteric Resection of the Rectum With Direct Coloanal Anastomosis for Rectal Carcinoma • Joseph Braun, et al. • In 1992, Am J Surg • 63 patients underwent ISR • Evaluate the oncologic results • (comparing with APR) and continence

33. Intersphincteric resection for low rectal tumours • R. Schiessel, et al. • In 1994, Br J Surg • Complete or partial excision of the internal • sphincter • 38 patients , reported the oncological follow-up, • continence and bowel habit

35. Intersphincteric Resection in Patients with Very Low Rectal Cancer: A Review of the Japanese Experience • Norio Saito et al. • In 2006, Dis Colon Rectum • ISR, PESR • (partial external sphincter resection)

37. Laparoscopic colorectal surgery

38. History Laparoscopic surgery was developed by gynecologists in the 1960s as a diagnostic tool. The procedure was gradually extended to allow minor surgical interventions. In 1984 Reddick first applied the technique to laparoscopic cholecystectomy. By 1991 more than 10,000 laparoscopic cholecystectomy cases were reported. In the last decades laparoscopic surgery has been extended to surgery of the appendix, colon , stomach , kidney ,and liver.

39. Procedures for Laparoscopic Colorectal Surgery High anterior Resection Right hemicolectomy Left hemicolectomy Abdomino-perineal Resection Lower anterior Resection Subtotal colectomy Total proctocolectomy Almost No Limitation!!

40. The rationales for laparoscopic surgery Advantages over conventional techniques - reduced postoperative pain - earlier recovery of bowel function - shorter length of hospital stay - a decreased risk of peritoneal tumor growth with laparoscopic as compared with open procedures

41. Challenge in Laparoscopic colorectal surgery It requires dissection in multiple parts of the abdomen. Need to isolate and ligate major arteries and veins. Need to divide of colonic attachments Identification and preservation of critical retroperitonealstructures Intestinal division, and reconstruction of bowel continuity. Different Training course and Technique

42. Important Issues in Laparoscopic Surgery for Colorectal Cancer

43. Issue (1) Dose the laparoscopic colorectal surgery increase the Port-site (wound) recurrence ?

44. Laparoscopic surgery of colon and rectum : Port-site recurrence remains a leading concern. World J Surg 1999 Apr 23;(4) 397-405 • Port-site recurrence rate : 0.5%~1.1% Dis colon rectum 2000 Jan /Am Surg 2000 Mar 66(3) 245~8 • Results of a multicenter study of 1,057 cases of rectal cancer treated by laparoscopic surgery. No port-site metastases Surg Endosc. 2008 Sep 19. • A cochrane systematic review of randomised controlled trials. Port-site metastases were rare and no differences in occurrence after laparoscopic and open surgery Cancer Treat Rev. 2008 Oct;34(6):498-504

45. Issue (2) Could minimally invasive surgery achieve a proper oncologic resection, with the same extent of exploration and information about lymph-node staging provided by a standard open resection ?

46. Prospective comparison of laparoscopic vs. open resections for colorectal cancer over a ten-year period. (III)Dis Colon Rectum. 2003 May;46(5):601-11 Stage-for-stage overall five-year survival rates were similar in the two groups. The statistical analysis performed for colonic vs. rectal primary adenocarcinoma confirmed that TNM stage for stage-overall survival was similar in the laparoscopic and open-resection groups.

47. A Comparison of Laparoscopically Assisted and Open Colectomy for Colon Cancer (Ib) NEJM 2004 May 350(20) 2050-2059 A multicenter trial (48 institutions) Randomly assigned 872 patients with adenocarcinoma of the colon to undergo open or laparoscopically assisted colectomy performed by credentialed surgeons. The median follow-up was 4.4 years. For patients with any stage of cancer, NO difference in the • time to recurrence, • disease-free survival, • overall survival

48. Issue (3) Dose laparoscopic surgery increase the Morbidity or Mortality ?

49. A Comparison of Laparoscopically Assisted and Open Colectomy for Colon CancerNEJM 2004 May 350(20) 2050-2059 A multicenter trial (48 institutions) Randomized control trial (872 patients) There were no significant differences between the groups in the rates of : - Intraoperative complications 30-day postoperative mortality (P=0.40), - Rates and severity of postoperative complications at discharge (P=0.98) and at 60 days (P=0.73), - Rates of readmission (10 percent and 12 percent, respectively; P=0.27), - Rates of reoperation (less than 2 percent in each group, P=1.0)

50. What is the learning curve for laparoscopic colorectal surgery ? • The gap in laparoscopic colorectal experience between colon and rectal and general surgery residency training programs • Dis Colon Rectum. 2007 Dec;50(12):2023-31; • Learning curves for laparoscopic colectomy are reported in the range of 20 to 60 cases. • Does the laparoscopic colorectal surgery learning curve adversely affect the results of colorectal cancer resection? A 3-year prospective study in a district general hospital. • Colorectal Dis. 2008 May;10(4):363-9. • Changing from open to laparoscopic dissection for colorectal cancer is safe even during the initial learning curve. • Estabilish training Program!