1. T4 Colon Cancer and Laparoscopic Approach Gustavo Plasencia MD FACS, FASCRS Clinical Professor of Surgery Gustavo Plasencia MD FACS, FASCRS Clinical Professor of Surgery Florida International University College of Medicine Florida International University College of Medicine MISS, Salt Lake City, 2011 MISS, Salt Lake City, 2011

2. Guidelines for Laparoscopic Resection of Curable Colon and Rectal Cancer Best available approach Best available approach Systematic review of available data and expert opinion Systematic review of available data and expert opinion Not necessarily the best approach Not necessarily the best approach Complex health care environment Complex health care environment Flexible Flexible Periodically updated Periodically updated

3. Oncologic Principles Proximal ligation of the primary arterial supply Proximal ligation of the primary arterial supply Adequate proximal and distal margins Adequate proximal and distal margins Appropriate lymphadenectomy (level 1 evidence) Appropriate lymphadenectomy (level 1 evidence) Minimum of 12 lymph nodes Minimum of 12 lymph nodes Inability to follow the oncologic principles should lead to conversion to open surgery Inability to follow the oncologic principles should lead to conversion to open surgery

4. Recent Guidelines The European Association of Endoscopic Surgery (Veldkamp et al 2004) and French Society of Digestive Surgery (Peschaud et al 2006) both recommend open resection for preoperatively suspected T4 colorectal cancers. The European Association of Endoscopic Surgery (Veldkamp et al 2004) and French Society of Digestive Surgery (Peschaud et al 2006) both recommend open resection for preoperatively suspected T4 colorectal cancers.

5. Laparoscopic en-bloc Resection for a T4 Lesion En bloc resection with negative margins is curative En bloc resection with negative margins is curative Depends on: Depends on: structure tumor is adherent structure tumor is adherent surgeons skill surgeons skill surgeons experience surgeons experience avoid perforation of the tumor avoid perforation of the tumor conversion is an option conversion is an option

6. T4 Colorectal Cancer: Is Laparoscopic Resection Contraindicated? 39 patients with suspected T4 lesion 39 patients with suspected T4 lesion Organ involved: Organ involved: abdominal or pelvic side wall 21 abdominal or pelvic side wall 21 bladder 4 bladder 4 small bowel colon 6 small bowel colon 6 vagina and ovary 3 vagina and ovary 3 prostate and seminal vesicles 3 prostate and seminal vesicles 3 duodenum 2 duodenum 2 F Bretagnol etal 2010 F Bretagnol etal 2010

7. T4 Colorectal Cancer: Is Laparoscopic Resection Contraindicated? 39 patients, 20 men and 19 women 39 patients, 20 men and 19 women Median age 73 years (49 – 90 years) Median age 73 years (49 – 90 years) Right colon 18 Right colon 18 Left colon 9 Left colon 9 Rectum 12 Rectum 12 Diagnosis made by endorectal ultrasound, abdominal CT scan and pelvic MRI Diagnosis made by endorectal ultrasound, abdominal CT scan and pelvic MRI F Bretagnol etal 2010

8. Combined Resection of a Preoperatively Invaded Organ Abdominal wall and pelvic lateral side wall 21 Abdominal wall and pelvic lateral side wall 21 Partial cystectomy 4 Partial cystectomy 4 Posterior vaginal wall 2 Posterior vaginal wall 2 Small bowel resection 4, segmented colectomy 2 Small bowel resection 4, segmented colectomy 2 Partial prostatectomy 1, seminal vesicles 3 Partial prostatectomy 1, seminal vesicles 3 Partial duodenal resection 1 Partial duodenal resection 1 Bilateral oophrectomy 1 Bilateral oophrectomy 1 F Bretagnol etal 2010 F Bretagnol etal 2010

9. Conversion Rate/Morbidity and Mortality Rate 7 out of 39 patients (18%) 7 out of 39 patients (18%) Tumor fixity 3 Tumor fixity 3 Difficult in performing a bloc resection 3 Difficult in performing a bloc resection 3 Intra-abdominal bleeding 1 Intra-abdominal bleeding 1 Morbidity rate 33% Morbidity rate 33% Mortality rate 2.5% Mortality rate 2.5% F Bretagnol etal 2010 F Bretagnol etal 2010

10. Histopathology/Survival T4 tumor in 30 of 39 patients (77%) T4 tumor in 30 of 39 patients (77%) Right colectomy 17 of 18 (94%) Right colectomy 17 of 18 (94%) Left colectomy 6 of 9 (67%) Left colectomy 6 of 9 (67%) Rectum 7 of 12 (58%) Rectum 7 of 12 (58%) Overall R1 resection rate was 13% Overall R1 resection rate was 13% Survival at 19 months median f/u 94% (3 pt’s with metastatic disease no local recurrence Survival at 19 months median f/u 94% (3 pt’s with metastatic disease no local recurrence FBretagnol etal 2010

11. Patient U.C. 57 y/o male 57 y/o male Colon tumor found in colonoscopy Colon tumor found in colonoscopy CT scan 04/02/10 showed a sigmoid mass with involvement of the bladder, air in the bladder. CT scan 04/02/10 showed a sigmoid mass with involvement of the bladder, air in the bladder. Follow up 09/23/10, on chemo now. Follow up 09/23/10, on chemo now. PET CT planned for February 2011. PET CT planned for February 2011.

12. Patient U.C. Laparoscopic sigmoid colectomy with resection of colovesical fistula performed on 05/13/10 Laparoscopic sigmoid colectomy with resection of colovesical fistula performed on 05/13/10 Clear Margins Clear Margins Pathology T4N0 Pathology T4N0

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16. Conclusion Not enough data today Not enough data today Never compromise oncological principle Never compromise oncological principle If specimen requires a long incision (>8 cm) procedure should be done open If specimen requires a long incision (>8 cm) procedure should be done open Common sense may be better than medical evidence in some situation Common sense may be better than medical evidence in some situation Be honest with our own skills and experience Be honest with our own skills and experience