Colorectal Cancer Surgery Mr Zeev Duieb GP Dinner presentation 06 Au gust 2013 @6.30pm Clover Cottage Duieb Colorectal Suite 9, 1st Floor, 50 Kangan Drive Berwick Ph 9709 6666 St J of G Suite 4 Gibb St Berwick 3806 Ph 9768 9331 Colorectal Surgeon Monash Health

Objectives in Colorectal cancer surgery Prevention of surgical morbidity/ mortality Optimal oncological clearance Cancer and Lymph Node clearance > 12 LN Prevention of local recurrence – TME, radioRx Quality of life Laparoscopic Surgery still needs to uphold these objectives.

Colorectal Major Resections B C D E F G H A-B right hemicolectomy A-C extd right hemicolectomy B-C transverse colectomy C-E left hemicolectomy D-E sigmoid colectomy D-F anterior rection D-G (ultra) low anterior resection 32025 Anastomosis <10cm from anal verge 32026 Anastomosis <6cm from anal verge D-H abdomino-perineal resection A-D subtotal colectomy A-E total colectomy A-H total procto-colectomy © CCrISP Australasia 3rd Edition

Historical vignettes 1826: Lisfranc 1st report of local excision 1884: Czerny 1886: Kraske 1907: Miles 1917: Bevan 1970: York-Mason 1979: Heald introduces TME Total Mesorectal Excision 1984: Buess introduces TEM Transanal Endoscopic Microsurgery

Rectal Ca Local excision - Patient selection Patient factors: Elderly, frail and high anesthetic risk Patient refusal of a stoma/ radical treatment

Rectal Ca Local excision - Tumour factors Location: <10 cm from the anal verge Size & circumference of lesion: No evidence to predict local recurrence <4cm & <40% of circumference Mobility: -Fixed tumours not appropriate T staging: LN involvement: T1(6-12%) T2(17-22%) T3(66%) Local recurrence: T1(5%) T2(18%) T3(22%) Tumour grade: LN mets: well-mod diff(11%) poor diff(33%) Local recurrence: well-mod diff(14%) poor diff(30%)

Rectal Ca Local excision - Tumour factors Lymphovascular & perineural invasion: Greater likelihood of LN mets and local recurrence LN mets: 33% vs 14-17% Mucinour tumours: Nodal status: Not appropriate for local excision

Rectal Ca Local excision - Patient evaluation PR/ sigmoidoscopy Tissue biopsy: - May miss area of poor differentiation ERUS Quoted accuracy T staging(67-93%) N staging(61-88%) Recent study found the accuracy in picking T1(50.8%) and T2(58.6%), understaging tumours(12.8%) Marusch et al., Endoscopy 2002 MRI Best for evaluating nodal status, accuracy at 82% Colonoscopy, CT AP, PET-CT

Rectal Ca Local excision - Patient evaluation Recommended criteria: <10 cm from anal verge Tumour < 4cm and <40% of circumference Favourable T1 stage Well- moderate differentiation No lymphovascular or perineural invasion Non-mucinous tumours No nodal disease

Rectal Ca Local excision – Old Fashioned Posterior approaches Trans-sacral resection Kraske procedure Coccyx and lower 2 segments of sacrum excised Sphincter complex preserved Mid-rectal lesions Cx: faecal fistula Trans-sphincteric resection York-Mason procedure Similar approach to Kraske, however the sphincter complex is completely divided and sacrectomy not performed Lower and mid rectal lesions Cx: Incontinence and faecal fistula

Kraske posterior proctotomy

Rectal Ca Local excision – New Fashion Transanal approaches Transanal excision Full thickness excision with 1cm margin Rectal defect closed transversely Varying results in the lit, small retrospective series Local recurrence high T1(18%) T2(47%) Survival T1(72-90%) T2(55-78%)

Rectal Ca Local excision – Latest Fashion Transanal approaches Transanal Endoscopic Microsurgery (TEM) Developed for lesions out of reach from transanal approach Can be used for benign lesions above the peritoneal reflection Favourable T1 lesions have equivalent local recurrence and 5yr survival cf radical surgery Unfavourable T1 lesions have higher local recurrence (10-15%) TEM + XRT on T2 have local recurrence (25-46%)

Rectal Ca Local excision - Ablative procedures Electrocoagulation Used as palliative & curative Rx Disadv: no tissue spec, 1/3 conversion to radical surgery, 20% secondary haemorrhage Poor outcomes Endocavitatory radiation Direct contact radiation 10-12000 cGy Useful in palliative setting In select pts 5yr survival & local control of 76-90%

Rectal Ca Radical excision - Left colon mobilization Splenic flexure mobilization Sigmoid colon resected Quality of circulation is poor Functional outcomes as neo-rectum poor High ligation of IMA Allows mobilization of descending colon Ligation of main trunk of left colic

Left colon mobilization

Left colon mobilization

Left colon mobilization

Radical excision-Total Mesorectal Excision(TME) Introduced by RJ Heald in 1979 Use of sharp dissection under vision to mobilize the rectum rather than the conventional blunt finger dissection First series of 112 pts: 5yr LR 2.9% and survival 87.5% Local recurrence: Conventional surgery: 11.7 - 37.4% TME surgery: 1.6 - 17.8% Higher leaks rates reported possibly due to: Devascularisation of distal rectal stump Lower anastamosis Other factors: stomas, drains

TME - Trials Multi-institutional r/w of conventional to TME surgery found large difference in LR (4-9 vs 32-35%) and 5yr survival (62-75 vs 42-44%) Havenga et al., Eur J Surg Oncol 25, 1999 Norwegian Rectal Cancer Grp: Experiencing LR 25+% 1794 pts enrolled (1395 TME vs 229 conventional) LR of 6 vs 12% (30m) and 4yr survival of 73 vs 60% No difference in anastamotic leak rate (10%) & mortality (3%) Dutch trial the largest prospective trial of 1861 pts demonstrated 2yr LR of 5.3% (TME 8.2% vs TME+XRT 2.4%) Operative mortality (3.5 vs 2.6%) and anastamotic leak (11 vs 12%)

TME - Technique Peritoneal incision around rectum Rectosigmoid reflected ant and posterior avascular plane developed using sharp scissor or diathermy dissection under vision Blobbed lipoma should be demonstrated Posterior dissection first, then lateral and finally anterior dissection Do not ‘finger hook’ or clamp the lateral ‘ligaments’ Partial TME to a distance 5cm distal to tumour Anterior dissection incorporates Denonvilliars fascia?

TME - Technique

TME - Nerve injury Preaortic sympathetics during high ligation Sympathetics at the pelvic brim during rectal mobilization Parasymp(nervi erigentes) and sympathetics during posterolateral dissection No clear lateral ligaments Do not hook or clamp these tissues, avoid excessive traction Higher rates exp by Japanese with extended lateral LN dissection Anterior lateral dissection off the prostatic capsule The most likely area of damage, reflected by higher rates of sexual dysfunction in APR(14-51%) vs AR(9-29%) The role of denonvilliars fascia

TME - Denonvilliars fascia Charles Denonvillier described in 1836 Fusion of rectovesical cul-de-sac Glistening white trapezoid apron Anterior mesorectal envelope Laterally close to neurovasc bundle Visible on MRI Heald et al recommend dissection in front

TME - Fascial envelope

TME - Denonvilliars fascia Mortensen et al., recommends dissection behind the fascia as it is the natural continuation of lateral dissection Also notes that there is a theoretical higher risk of nerve damage Notes that there may be a role for dissection anterior to the fascia for anterior tumours

TME - Distal resection margin Not clear in the literature 5cm preop will expand to 7-8cm on rectal mobilization This will shrink to 2-3cm with specimen removal and formalin fixation Rare for tumour to spread beyond 1.5cm Rare reports of poorly diff tumours having spread 4.5cm distally Recommend: 5cm ideally however 2cm is adequate

Reconstruction of Neorectum Hand sewn sutured anastamosis 1982: Parks and Percy performed the coloanal sutured anastamosis ‘Pulled through’ coloanal anastamosis (Turnbull & Cuthbertson) Stapled anastamosis Circular stapled technique Double staple technique For low and coloanal anastamosis

Reconstruction of Neorectum Straight end to end Low AR or Coloanal end-to-end anastamosis cause tenesmus, urgency and incontinence (Anterior resection syndrome) Colonic J Pouch Increases volume of neorectum 5 vs 10cm pouches have smaller reservoirs but better evacuation (Hida et al., Ds Colon Rectum 1996) Size is critical to functional outcome, recommend 5-8 cm Sigmoid colon should not be used Better short term functional results and possible lower anastamotic leaks compared to end-to-end anastamosis Coloplasty New technique introduced in 1999 (Z’graggen et al., Dig Surgery 1999) Better in narrow pelvis and limited length of colon Long incision closed transversely Randomized trial underway comparing to J-pouch

Abdominoperineal Resection Described by Sir Ernest Miles 1908 1-2 surgeons TME rectal dissection Anus sutured closed Wide perineal dissection, starting from posterior to lateral then anterior Anterior dissection can proceed cranio-caudal or vice versa SB exclusion - omentum or absorbable mesh Drain the pelvic space Reduced rates of APR Coloanal anastamosis Acceptance of smaller margins Downsizing by chemoradiotherapy

Abdominoperineal Resection

Complications of Colorectal Surgery Anastomotic leak Intraabdominal abscess, stoma retraction, haemorrhage, Dvt, wound infection, & other general

Principals - Locally advanced tumours T3 and/or N1 Rectal lesions should have neoadjuvant (preoperative) chemoradiotherapy Select T4 lesions could be down staged prior to pelvic exenteration Role of CRT downsizing and rates of sphincter preservation. Rouanet et al., performed sphincter preservation in 21/27 pts after CRT downsizing. At 2 yrs only 2 LR (Ann Surg 1995) Grann et al., performed sphincter preservation in 17/20 T3 lesions (Ds Colon Rectum 1997)

Factors Of Possible Prognostic Significance (Surgeon Related) Extent of margins of resection - Intraluminally (2cms) - Extraluminally (M.E. 5cms) - Contiguous Organs Extent of lymphatic resection Timing and level of vascular ligation Anastomotic technique Intraluminal cytotoxic solutions

Conclusions Beaware of the inaccuracies of preop staging Local excision in favourable T1 lesions TME should be standard practice in rectal dissection Nerve preservation surgery Role of distal margins Neoadjuvant chemoradiotherapy

Laparoscopic Resection

Sacro-coccygectomy with APR

Colorectal Cancer Surgery Questions? Dr Zeev Duieb Dr Zeev Duieb is a Colorectal Surgeon. Melbourne born Dr Duieb studied at Monash University and completed his Medical and Surgical training in Melbourne (FRACS). Prior to establishing his own private practice in Berwick & Knox, Dr Duieb completed a Colorectal Fellowship with Southern Healthcare Network (Monash Health) where he has current Clinical Appointments to Dandenong (Colorectal Unit) and Casey Hospital (General Surgery Dept). Duieb Colorectal Suite 9, 1st Floor, 50 Kangan Drive Berwick Ph 9709 6666 St J of G Suite 4 Gibb St Berwick 3806 Ph 9768 9331 Colorectal Surgeon Monash Health