Surgery for Rectal CancerSurgery for Rectal Cancer

Mr Darren TonkinMr Darren Tonkin

Colorectal SurgeonColorectal Surgeon

Calvary North Calvary North AdelaideAdelaide

Rectal CancerRectal Cancer

Colorectal cancer = commonest Colorectal cancer = commonest internal malignancy in Australiainternal malignancy in Australia

1 in 12 risk up to age 851 in 12 risk up to age 85 Rectum is commonest site for Rectum is commonest site for

CRC CRC M>FM>F Overall 5yr survival >50%Overall 5yr survival >50%

Rectal CancerRectal Cancer

Local recurrence rates 25-35% in Local recurrence rates 25-35% in pastpast

Modern techniques => LR <10%Modern techniques => LR <10% NIH consensus:NIH consensus:

Adjuvant chemotherapy and Adjuvant chemotherapy and radiotherapy for T3 and N1 rectal radiotherapy for T3 and N1 rectal adenocarcinomaadenocarcinoma

Wide surgeon variability for local Wide surgeon variability for local recurrence and survivalrecurrence and survival

Surgical considerationsSurgical considerations“What is a surgeon “What is a surgeon

thinking?”thinking?” The patientThe patient The tumourThe tumour Preoperative chemoradiotherapyPreoperative chemoradiotherapy The operation (TME)The operation (TME) Postoperative treatmentPostoperative treatment Postoperative dysfunctionPostoperative dysfunction

The PatientThe Patient

AgeAge SexSex Build (BMI)Build (BMI) Co-morbiditiesCo-morbidities CognitionCognition Ability to manage a Ability to manage a

stomastoma ContinenceContinence

The TumourThe Tumour

Height from anal vergeHeight from anal verge Circumferential relationshipsCircumferential relationships SizeSize Tumour depth (T stage)Tumour depth (T stage) Distant metastasesDistant metastases Rectal examinationRectal examination Imaging - CT, MRI, ERUSImaging - CT, MRI, ERUS ? Other tumours (colonoscopy)? Other tumours (colonoscopy)

Rectal AnatomyRectal Anatomy1

5 c

m

High Anterior Resection

Low Anterior Resection

Ultra-low Anterior Resection

Abdominoperineal Resection (APR)

Endorectal UltrasoundEndorectal Ultrasound

EndorectalEndorectal UltrasoundUltrasound

MRIMRI

Circumferential ResectionMargin (CRM)

Pre-operative Pre-operative ChemoradiotherapyChemoradiotherapy

BeforeBefore AfterAfter

Pre-operative Pre-operative ChemoradiotherapyChemoradiotherapy

T3 / T4 or N1 TumoursT3 / T4 or N1 Tumours Down stage tumourDown stage tumour Long course (5-6 Long course (5-6

weeks)weeks) Short course (1 week)Short course (1 week) Reduced local Reduced local

recurrencerecurrence ? Improved survival? Improved survival

Total Mesorectal Total Mesorectal ExcisionExcision

An operation for Rectal CancerAn operation for Rectal Cancer Low rate of Local Recurrence Low rate of Local Recurrence

after “curative” resectionafter “curative” resection The term initially introduced The term initially introduced

by Bill Heald (UK) in 1982by Bill Heald (UK) in 1982 Many surgeons had practised Many surgeons had practised

this concept of surgery prior this concept of surgery prior to the introduction of the term to the introduction of the term “TME”“TME”

Bill HealdBill Heald

Archives of Surgery 1998Archives of Surgery 1998 405 curative resections405 curative resections No radiotherapyNo radiotherapy Local Recurrence 3% at 5 yearsLocal Recurrence 3% at 5 years Local Recurrence 4% at 10 yearsLocal Recurrence 4% at 10 years Disease free survival 80% at 5 Disease free survival 80% at 5

yearsyears Disease free survival 78% at 10 Disease free survival 78% at 10

yearsyears

Local RecurrenceLocal RecurrenceWhat is Important?What is Important?

Circumferential marginsCircumferential margins Distal marginDistal margin Removal mesorectal envelope Removal mesorectal envelope

containing all the lymph nodescontaining all the lymph nodes Cytocidal rectal washoutCytocidal rectal washout Radiotherapy - pre or post Radiotherapy - pre or post

operativeoperative YOUR SURGEONYOUR SURGEON

TMETME

Rectal cancer spreads to lymph Rectal cancer spreads to lymph nodes in the mesorectumnodes in the mesorectum

This may be in nodes below the This may be in nodes below the inferior margin of the cancerinferior margin of the cancer

Particularly relevant in cancers of Particularly relevant in cancers of the middle and lower thirds of the middle and lower thirds of the rectumthe rectum

TMETME

TMETME

TME Leak RateTME Leak Rate

Karanjia, Heald et al Karanjia, Heald et al BJS 1994BJS 1994

219 LAR with TME219 LAR with TME Major leak (abscess or Major leak (abscess or

peritonitis) 11%peritonitis) 11% Minor leak (contrast Minor leak (contrast

enema) 6.4%enema) 6.4%

TMETME

Nerve preservation (sexual and Nerve preservation (sexual and bladder function)bladder function)

Low anastomosis - Reduced APRLow anastomosis - Reduced APR Low anastomosis - Colonic pouchLow anastomosis - Colonic pouch Higher anastomotic leak rateHigher anastomotic leak rate Higher rate covering stomaHigher rate covering stoma ? Negates the need for routine use ? Negates the need for routine use

of radiotherapyof radiotherapy

Modified TMEModified TME

Distal spread of adenocarcinoma in the rectal Distal spread of adenocarcinoma in the rectal wall or mesorectum for more than 2-3 cm is wall or mesorectum for more than 2-3 cm is rarerare

When it occurs it is with advanced tumours and When it occurs it is with advanced tumours and associated with a poor prognosisassociated with a poor prognosis

The need to remove the mesorectum more The need to remove the mesorectum more than 5 cm below the tumour is not proven and than 5 cm below the tumour is not proven and unnecessary and will increase the rate of unnecessary and will increase the rate of anastomotic leakage (devascularised rectal anastomotic leakage (devascularised rectal stump)stump)

Modified TMEModified TME

5 cm

5 cm

The TechniqueThe TechniquePre-operativePre-operative

ConsentConsent Optimize comorbiditiesOptimize comorbidities Bowel preparationBowel preparation Stomal therapy and siting for Stomal therapy and siting for

stomastoma DVT prophylaxisDVT prophylaxis AntibioticsAntibiotics Urinary catheterUrinary catheter

The TechniqueThe TechniqueSet-upSet-up

Extended Lloyd-Davies positionExtended Lloyd-Davies position Good assistanceGood assistance Long midline incisionLong midline incision Wide retractionWide retraction Small bowel packed out of the Small bowel packed out of the

wayway Full laparotomy (liver etc)Full laparotomy (liver etc)

Operative PositionOperative Position

The TechniqueThe TechniqueColonic MobilisationColonic Mobilisation

Transverse, splenic flexure and Transverse, splenic flexure and descending colon mobiliseddescending colon mobilised

High ligation of inferior mesenteric High ligation of inferior mesenteric artery on the aortaartery on the aorta

High ligation of inferior mesenteric High ligation of inferior mesenteric vein at the lower border of the vein at the lower border of the pancreaspancreas

Preservation of ureter, gonadal Preservation of ureter, gonadal vessels, and hypogastric nerves vessels, and hypogastric nerves

Sigmoid MobilisationSigmoid Mobilisation“Ureter”“Ureter”

Ureter

Splenic Flexure MobilisedSplenic Flexure Mobilised

High Ligation of Inferior High Ligation of Inferior Mesenteric ArteryMesenteric Artery

Ligation of Inferior Ligation of Inferior Mesenteric VeinMesenteric Vein

Full Bowel MobilisationFull Bowel Mobilisation

The TechniqueThe TechniquePosterior Rectal DissectionPosterior Rectal Dissection

Develop the plane at the pelvic brim anterior to the hypogastric nerves and Develop the plane at the pelvic brim anterior to the hypogastric nerves and posterior to the superior rectal artery. posterior to the superior rectal artery.

Enter the areolar space between the mesorectal fascia and the sacral fascia.Enter the areolar space between the mesorectal fascia and the sacral fascia. St Marks retractorSt Marks retractor Sharp dissection or diathermy Sharp dissection or diathermy Do not Do not “cone in”“cone in” on the mesorectum on the mesorectum Avoid blunt dissectionAvoid blunt dissection

St Mark’s RetractorSt Mark’s Retractor

The TechniqueThe TechniquePosterior Rectal DissectionPosterior Rectal Dissection

The TechniqueThe TechniquePosterior Rectal Posterior Rectal

DissectionDissection

The TechniqueThe TechniqueAnterior Rectal Anterior Rectal

DissectionDissection Divide the anterior peritoneum of Divide the anterior peritoneum of

rectovesical or rectouterine rectovesical or rectouterine pouch above and anterior to its pouch above and anterior to its apexapex

Develop the plane between the Develop the plane between the seminal vesicle or vagina anterior seminal vesicle or vagina anterior to Denonvilliers fasciato Denonvilliers fascia

Continue dissection to pelvic floorContinue dissection to pelvic floor

The TechniqueThe TechniqueAnterior Rectal DissectionAnterior Rectal Dissection

The TechniqueThe TechniqueTransection of RectumTransection of Rectum

Mesorectum at least 5 cm below Mesorectum at least 5 cm below tumour (modified TME) or at pelvic tumour (modified TME) or at pelvic floor.floor.

Cross clamp or staple below Cross clamp or staple below tumourtumour

Rectal cytocidal washoutRectal cytocidal washout 30 mm stapler at least 2 cm below 30 mm stapler at least 2 cm below

the tumourthe tumour Haemostasis Haemostasis

Transverse Staple Line Transverse Staple Line Rectal StumpRectal Stump

The TechniqueThe TechniquePreparation of Proximal Preparation of Proximal

BowelBowel Ligation of mesenteric vessels Ligation of mesenteric vessels

preserving the marginal arterypreserving the marginal artery Avoid using the sigmoid colon Avoid using the sigmoid colon Use the descending colonUse the descending colon Fashion colonic pouch if ULARFashion colonic pouch if ULAR Insert purse-string suture and head Insert purse-string suture and head

of circular staple gunof circular staple gun

The TechniqueThe TechniquePreparation of Proximal Preparation of Proximal

BowelBowel

The TechniqueThe TechniquePreparation of Proximal Preparation of Proximal

BowelBowel

The TechniqueThe TechniquePreparation of Proximal Preparation of Proximal

BowelBowel

Transected BowelTransected Bowel

Pedicle

Staple Gun HeadStaple Gun Head

The TechniqueThe TechniqueAnastomosisAnastomosis

Ensure colon not twistedEnsure colon not twisted Ensure vagina excludedEnsure vagina excluded Double staple anastomosisDouble staple anastomosis Check donuts and air testCheck donuts and air test HaemostasisHaemostasis Drain pelvisDrain pelvis Loop ileostomyLoop ileostomy

Mid-rectal AnastomosisMid-rectal AnastomosisInserting the Staple GunInserting the Staple Gun

Midrectal AnastomosisMidrectal Anastomosis

Resected SpecimenResected Specimen

Low anterior resectionAbdominoperineal resection

SummarySummary

TME associated with low rate of TME associated with low rate of local recurrencelocal recurrence

Requires meticulous technique Requires meticulous technique and a surgeon familiar with and a surgeon familiar with operating in the pelvisoperating in the pelvis

Modified TME acceptable for high Modified TME acceptable for high and mid rectal tumours.and mid rectal tumours.

StomasStomas

Temporary Loop IleostomyTemporary Loop Ileostomy Dependent on:Dependent on:

Height of anastomosisHeight of anastomosis Ease and technical success of Ease and technical success of

operationoperation Well being of the patient (co-Well being of the patient (co-

morbidities)morbidities) Surgical conservatismSurgical conservatism RadiationRadiation

StomasStomas

Permanent End ColostomyPermanent End Colostomy Dependent on:Dependent on:

Height of tumour from anal canalHeight of tumour from anal canal Likelihood of continenceLikelihood of continence

Postoperative Adjuvant Postoperative Adjuvant TherapyTherapy

Multi-disciplinary meetingMulti-disciplinary meeting Chemotherapy Chemotherapy RadiotherapyRadiotherapy Age and well-being of the patientAge and well-being of the patient Tumour factorsTumour factors

Postoperative Bowel Postoperative Bowel FunctionFunction

Rectum acts as a reservoirRectum acts as a reservoir Removal leads to replacement Removal leads to replacement

with a colonic conduit with a colonic conduit (neorectum) (neorectum)

““Anterior resection syndrome”Anterior resection syndrome” Frequent loose stool, stool Frequent loose stool, stool

clustering, urgency, occasional clustering, urgency, occasional incontinenceincontinence

Colonic “J” PouchColonic “J” Pouch

ConclusionsConclusions

Results of surgery are operator Results of surgery are operator dependentdependent

““Good” surgery must account for the Good” surgery must account for the nuances of the patient and the nuances of the patient and the tumourtumour

Multidisciplinary approachMultidisciplinary approach