1. Surgical Treatment of the Low (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
Lazorthes 1986 Br J Surg (Toulouse, France)

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
Seow-Chen: Singapore
Ortiz: Pamplona, Spain
Hallbook: Sweden
Lazorthes: Toulouse, France
Furst: Regensburg, Germany
Sailer: Wurzburg, Germany

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

53. J-pouch versus Coloplasty
Kaspar Z’graggen; University of Bern (Switzerland); Digestive Surgery 1999

54. J-pouch versus Coloplasty
Prospective randomized trials
Ho, et al. Ann Surg 2002;236:49
Fürst, et al. Dis Colon Rectum 2003;46:1161
Pimentel, et al. Colorect Dis 2003;5:465
Ho: Singapore
Furst: Regensburg, Germany
Pimentel: Portugal

55. J-pouch versus ColoplastyN
Pouch size
Follow-up Ho 88
6 cm/7 cm
12 months
Fürst 40
5 cm/8 cm
6 months
Pimentel 30

56. J-pouch versus Coloplasty
Frequency
Urgency
Constipation Ho ↔
Fürst -
Pimentel
↓ J-pouch
↓ Coloplasty
Stool frequency: 2.1 versus 2.8 at 12 months
Stool fragmentation: 7% versus 14 % at 12 months
Constipation: 14% versus 0% at 12 months

57. Fazio et al 2007 Ann 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
Stool frequency: 2.1 versus 2.8 at 12 months
Stool fragmentation: 7% versus 14 % at 12 months
Constipation: 14% versus 0% at 12 months

60. J-pouch versus Side-to-end

61. J-pouch versus Side-to-end
Prospective randomized trials
Huber, et al. Dis Colon Rectum 1999;42:896
Machado, et al. Ann Surg 2003;238:214
Huber: Munich, Germany
Machado: Stockholm

62. J-pouch versus Side-to-end
Pouch size
Follow-up
Huber 59
6 cm/4 cm
6 months
Machado
100
8 cm/4 cm
12 months

63. J-pouch versus Side-to-end
Frequency
Urgency
Constipation
Huber
↓ J-pouch ↔
Machado
Huber: Stool frequency: 2.1 versus 3.1 at 6 months; Constipation: 7% versus 0% at 6 months
Machado: Stool frequency: 2.1 versus 2.8 at 12 months; Stool fragmentation: 7% versus 14 % at 12 months; Constipation: 14% versus 0% at 12 months

64. Local Excision Abdominoperineal resection or low anterior
resection for rectal cancer
Complete tumor excision
Clearance of regional lymph nodes
Operative mortality, morbidity
Urinary and sexual dysfunction %
Anastomotic complications %
Mortality of 1- 6 % after APR
Necessity of permanent or temporary diversion

65. Surgical Approaches Local excision alone
Local excision followed by adjuvant therapy
Local excision after neoadjuvant therapy
Limited surgical morbidity 0-22 %

66. Recurrence Local 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 ± 22.1 months (range 1-72 months)

67. When Should We Consider It with Curative Intent?
Preferred Acceptable
Stage 1 T1N0M0
Favorable LE  Radical features Chemo / X-rt ? resection
Unfavorable Radical LE + resection chemo / X-rt
Stage 1 T2N0M0 Radical LE + resection chemo / X-rt

68. 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, Ramalingam 2002 SSAT

69. 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

70. 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

72. Jagelman / Turnbull International Colorectal Disease Symposium
25th Anniversary th Anniversary
Jagelman / Turnbull International Colorectal Disease Symposium
Feb 11-16, 2014
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