Joint Hospital Surgical Grand Round

Tsui Tsun MiuNDH

Type Histologic Diagnosis

Neoplastic Adenoma

    Tubular adenoma (adenomatous polyp)

    Tubulovillous adenoma (villoglandular adenoma)

    Villous adenoma (villous papilloma)

  Carcinoma

Hamartomas Juvenile polyp

  Peutz-Jeghers polyp

Inflammatory Inflammatory polyp (pseudopolyp)

  Benign lymphoid polyp

Unclassified Hyperplastic polyp

Miscellaneous Lipoma, leiomyoma, carcinoid, lymphoma

Chang George J, Shelton Andrew A, Welton Mark L, "Chapter 30. Large Intestine" (Chapter). Doherty Gerard M.: CURRENT Diagnosis & Treatment: Surgery, 13th Edition: http://www.accesssurgery.com.easyaccess1.lib.cuhk.edu.hk/content.aspx?aID=5309393.

Treatment Rectal Tumour

Benign Malignant

Local Treatment:1.Colonoscopic polypectomy2.Endoscopic Mucosal Rescion3.Endoscopic Submucosal Dissection4.Transanal local excision:

• Parks’ method• Transanal Endoscopic Microsurgery

5.Desiccation Procedure:• Nd-Yag Laser• Argon Plasma Coagulation

Radical Surgery:1.Anterior Resection2.Low Anterior Resection3.Abdominal Perineal Resection

Early Cancer?

Transanal local excision:• Parks’ method• Transanal Endoscopic Microsurgery

Fit for Surgery

Review of 53 prospective cohort studies + 45 RCTs (36,315 patients with 24,845 patients had an anastomosis)

Anastomotic leak rate – 11% Pelvic sepsis rate – 12% Postoperative death rate – 2% Fecal incontinence rates – 7%

Prevalence of Sexual dysfunction Men – 69% Women – 62%

Hendren SK, O'Connor BI, Liu M, et al. Prevalence of male and female sexual dysfunction is high following surgery for rectal cancer. Ann Surg. 2005;242:212–223.

Postoperative complications following surgery for rectal cancer. Paun BC. Cassie S. MacLean AR. Dixon E. Buie WD. Annals of Surgery. 251(5):807-18, 2010 May.

Avoidance of Stoma

Avoidance of Major Post-op Complications

Morbidity Oncological Control

Cannot Clear Lymph Node Metastasis

Chance of nodal metastases T1 disease 0-12% T2 disease 12-28% T3 disease 36-79%

Local excision as curative intent only limited to T1 lesion

Taylor RH, Hay JH, Larsson SN: Transanal local excision of selected low rectal cancers. Am J Surg 1998; 175: 360–363Bleday R, Breen E, Jessup M, et al.: Prospective evaluation of local excision for small rectal cancers. Dis Colon Rectum 1997; 40: 388–392Saclarides TJ, Bhattacharyya AK, Britton-Kuzel C, et al.: Predicting lymph node metastases in rectal cancer. Dis Colon Rectum 1994; 37: 52–57

Endorectal Ultrasound T1N0 lesion Moderately to well differentiated

carcinomas No evidence of perineural or

lymphovascular invasion No mucinous component Size no strict criteria

First reported by Parks Excision of rectal polyps of any dimension <6 cm from the anal verge Anal retractors

i.e. Park’s Retractor Use of snare

Limited to small pedunculated lesion Use of resectoscope

Piecemeal resection Difficult for complete excision

Parks AG, Rob C, Smith R, Morgan CN. Benign tumours of the rectum. In: Rob C, Smith R, Morgan CN, eds. Clinical Surgery. Vol 10. England, London: Butterworths, 1966: 541

Retrospective Comparative study 149 Local excision vs 169 Radical

Surgery 5 year local recurrence rateTrananal Local

ExcisionRadical Surgery

Chi-Square

T1 Tumors

18% 0% p=0.03

T2 Tumors

47% 6% p=0.001

Mellgren A, Sirivongs P, Rothenberger DA, Madoff RD, García-Aguilar J. Is local excision adequate therapy for early rectal cancer? Dis Colon Rectum 2000; 43: 1064–74.

Related to high chance of positive margins and piecemeal resection of specimen

Transanal endoscopic microsurgery versus conventional transanal excision for patients with early rectal cancer. Christoforidis D. Cho HM. Dixon MR. Mellgren AF. Madoff RD. Finne CO. Annals of Surgery. 249(5):776-82, 2009 May.

• Originally designed by Buess et al. in 1980s

– 40-mm operating proctoscopy Insufflation of the rectum Magnified three-dimensional image

Facilitates an extremely precise dissection

– Full thickness excisions– 20cm from anal verge posteriorly– 12cm from anal verge anteriorly

– Primary closure– Remove submucosal tumours (i.e. leiomyoma,

carcinoid tumour) by full thickness excisionBuss G, Theiss R, Gunther M, et al. Endoscopic surgery in the rectum. Endoscopy. 1985;17:31-5

csite.clevelandclinic.org

tropicalgastro.com

5mm margin of normal appearing mucosa for adenomas

1cm margin for cancers Full thickness

Extrarectal fat as a landmark to signify transmural penetration

Wound closed transversely with running sutures

Residual adenoma in the Surgical Margin 11%

Recurrence Rate 6.3%

Surgical resection of rectal adenoma: a rapid review. Casadesus D. World Journal of Gastroenterology. 15(31):3851-4, 2009 Aug 21

For pathology T1 lesions: Recurrence rates from 0% - 12.5%

Saclarides TJ. TEM/local excision: indications, techniques, outcomes, and the future. J Surg Oncol. 2007;96:644–650.

Significant increase in local recurrence rate in T2 and T3 rectal cancer

Tsai BM, Finne CO, Nordenstam JF, et al. Transanal endoscopic microsurgery resection of rectal tumors: outcomes and recommendations. Dis Colon Rectum 2010; 53:16–23

If TEM specimen showed unfavourable histologic characteristics

T2 or above Poor differentiated Lymphovascular invasion Mucinous component

Baron PL, EnkerWE, Zakowski MF, Urmacher C.Immediate vs salvage resection after local treatment for early rectal cancer. Dis Colon Rectum 1995; 38: 177–181.

Disease-free survival rate

Immediate APR for adverse pathological features

94%

Salvage APR for local recurrence 56%

Entry into peritoneal cavity Conversion to laparoscopy /

laparotomy Bleeding Faecal Soilage Rectal Stenoses Wound dehiscence Urinary dysfunction Rectovaginal fistula

Inadvertent opening of the peritoneum (4.3%)

80% can be treated with direct suturing without conversion to major surgery

Other post-op complications: Bleeding (3.7%) Suture dehiscence (1.7%) Rectovagina fistula (1.3%)Transanal endoscopic microsurgery for rectal neoplasms: experience of 300 consecutive cases.

Allaix ME. Arezzo A. Caldart M. Festa F. Morino M. Diseases of the Colon & Rectum. 52(11):1831-6, 2009 Nov.

Risk factor for Post-op bleeding: Localization of the tumour on the lateral

wall of the rectum Tumour diameter > 2cm

Kreissler-Haag D, Schuld J, Lindemann W, Konig J, Hildebrandt U, Schilling M. Complications after transanal endoscopic microsurgical resection correlate with location of rectal neoplasms.Surg Endosc 2008; 22: 612–6.

• Retrospective study• 42 TEM vs 126 TAE• TEM over TAE by:

– Increased likelihood of clear margins– Less specimen fragmentation– Lower recurrence rates– More proximal tumours can be accessed

Moore JS, Cataldo PA, Osler T, Hyman NH. Transanal endoscopic microsurgery is more effective than traditional transanal excision for resection of rectal masses. Dis Colon Rectum. 2008;51:1026–31

Possible reasons: Carbon dioxide insufflation and

distension of the rectum Superior optics that provide a magnified

image Simultaneously evacuate smoke, blood,

and liquid while cutting and sewing

Randomized controlled trial Rectal adenocarcinoma (GI/II) + ERUS

uT1 N0 Transanal endoscopic microsurgery (TEM; n=24) Anterior resection (AR; n=26)

Local recurrence and five-year survival rates similar

Early postoperative mortality was zero Significant differences in

Time of hospitalization Loss of blood Operation time Opiate analgesia

Surgical cure for early rectal carcinomas (T1). Transanal endoscopic microsurgery vs. anterior resection. Winde G. Nottberg H. Keller R. Schmid KW. Bunte H. Diseases of the Colon & Rectum. 39(9):969-76, 1996 Sep.

Can we extend the indication of local excision?

Randomized controlled trial T2 tumour neoadjuvant

chemoradiation TEM vs Laparoscopic Resection (35 vs

35) Median follow-up period : 84 months

(range, 72–96 )

TEMLaparoscopic

Resection

Local recurrence 5.7% 2.9%

Distant metastasis 2.9% 2.9%

5-year Disease-Free Survival

94% 94%

Lezoche G, Baldarelli M, Guerrieri M, Paganini AM, De Sanctis A, Bartolacci S, et al. A prospective randomized study with a 5-year minimum follow-up evaluation of transanal endoscopic microsurgery versus laparoscopic total mesorectal excision after neoadjuvant therapy. Surg Endosc 2008;22:352-8

570 patients : the rate of lymph node involvement was

5%.

Kundel Y; Brenner R; Purim O; Peled N; Idelevich E; Fenig E; Sulkes A; Brenner BIs local excision after complete pathological response to neoadjuvant chemoradiation for rectal cancer an acceptable treatment option?.Diseases of the Colon & Rectum. 53(12):1624-31, 2010 Dec.

Retrospective comparative study Subjects:

clinical stage T3 to 4Nx, TxN+ Neoadjuvant chemoradiation Radical Surgery or Local Excision Final Pathology – pT0

Radical Surgery (n=37)

Local excision (n=14)

5 year disease free survival

88% 100%

Pelvic recurrence free survival

92% 100%

Overall survival 97% 100%

Kundel Y; Brenner R; Purim O; Peled N; Idelevich E; Fenig E; Sulkes A; Brenner BIs local excision after complete pathological response to neoadjuvant chemoradiation for rectal cancer an acceptable treatment option?.Diseases of the Colon & Rectum. 53(12):1624-31, 2010 Dec.

We can spare this particular group of patients from Radical Surgery!• Pathology T0 after neoadjuvant chemoradiation

Post-excision pathology T2 disease Not fit for Salvage Radical Surgery

A Case Series: Significantly lower disease recurrence in

T2 disease with radiotherapy 18% (with adj. RT) vs 66% (without adj. RT)

Han SL. Zeng QQ. Shen X. Zheng XF. Guo SC. Yan JY. The indication and surgical results of local excision following radiotherapy for low rectal cancer. Colorectal Disease. 12(11):1094-8, 2010 Nov

Colonoscopic polypectomy Suitable in 90% of rectal polyps Complete resection difficult if tumour in

submucosal area i.e. carcinoid tumors / malignant rectal tumour

Suitable for pedunculated polyp Endoscopic mucosal resection

Removal of mucosal lesion of < 1cm Special device needed if tumour suspected

to be in submucosal area i.e. 2 channel EMR

Indicated when one−piece resection by conventional procedures is impossible: Large−sized lesions Lesions with biopsy−induced scars Lesions on haustra

Rate of one-piece resection with ESD: 70-88% Rate of perforation: 5% Mean size :

26.2 mm (8 ± 60) 32.8 mm (9 - 91)

Onozato Y, Kakizaki S, Ishihara H, et al. Endoscopic submucosal dissection for rectal tumors. Endoscopy. 2007;39:423– 427

Fujishiro M, Yahagi N, Nakamura M et al. Endoscopic submucosal dissection for rectal epithelial neoplasia. Endoscopy 2006; 38: 493±497

Colorectal endoscopic submucosal dissection: present status and future perspective, including its differentiation from endoscopic mucosal resection. [Review] [47 refs] Tanaka S. Oka S. Chayama K. Journal of Gastroenterology. 43(9):641-51, 2008

Endoscopic Nd-Yag Laser Ablation Palliate bleeding, mucinous discharge,

impending obstruction Success in 8 out of 11 patients

Argon Plasma Coagulation Palliate tumour bleeding Debulking

Endoscopic laser ablation of advanced rectal carcinoma--a DGH experience. Rao VS. Al-Mukhtar A. Rayan F. Stojkovic S. Moore PJ. Ahmad SM. Colorectal Disease. 7(1):58-60, 2005 Jan

Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction: effectiveness of the new pulsed APC versus forced APC. Eickhoff A. Jakobs R. Schilling D. Hartmann D. Weickert U. Enderle MD. Eickhoff JC. Riemann JF. Endoscopy. 39(7):637-42, 2007 Jul.

Radical Surgery Outcome: Multicenter Dutch study:

for T1-T2,N0 lesions, the local recurrence rate in 244 total mesorectal excisions = 0.7%

Local Excision Outcome 968 patients in 22 studies

Kapitejn E, Marijnen C, Nagtegaal ID, et al. Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. N Engl J Med 2001;345:638–46.

T-stagingLocal Recurrences

(range%)

T1 9.7% (0-24%)

T2 25% (0-50%)

Overall 13.7%

Sengupta S, Tjandra JJ. Local excision of rectal cancer: What is the evidence? Dis Colon Rectum 2001;44:1345–61.

Pedunculated polyp

Endorectal Ultrasound Assessment

Rectal Tumour

Colonoscopic Polypectomy

• EMR• ESD• Parks TAE• TEM (level 1b)

Neoadjuvant ChemoRT+TEM (level 1b)

Complete polypectomy not feasible, i.e. broad base

uT1N0 uT2N0

Immediate Radical Surgery (level 3b)

If Unfavourable factor present

Neoadjuvant ChemoRT+TEM (level 3b)

uT3/4Nx

Cure (level 3b)

if final pathology T0

Mucosal tumour Submucosal tumour

• EMR• ESD• Parks TAE• TEM

~10% to 17% of all carcinoid tumors Middle-aged adults Small, solitary, submucosal nodules Midrectum between 4 and 8 cm from

the anorectal junction Tendency for metastasis:

Low if tumour size < 1cm Local excision is adequate if tumour size

< 1cmOnozato Y. Kakizaki S. Iizuka H. Sohara N. Mori M. Itoh HEndoscopic Treatment of Rectal Carcinoid TumorsDiseases of the Colon & Rectum. 53(2):169-76, 2010 Feb

Located in submucosal layer To be removed by

Endoscopic submucosal resection with a ligation device

2 channel EMR Endoscopic submucosal dissection

Ono A, Fujii T, Saito Y, Matsuda T et al. Endoscopic submucosal resection of rectal carcinoid tumors with a ligation device. Gastrointest Endosc 2003; 57: 583±587

Overall MobilePartially

fixedFixed P 

Number of patients

271 103(38%) 51(19%) 92(34%) –

Complete response

(CR)80(30%) 50(49%) 11(22%) 8(9%) <0.01

Local relapse after CR

62(78%) 36(72%) 8(73%) 8(100%) <0.05

5 year survival

27% 48% 26% 6% <0.01

Wang Y, Cummings B, Catton P, Dawson L, Kim J, Ringash J, Wong R, Yi QL, Brierley J.Primary radical external beam radiotherapy of rectal adenocarcinoma: long term outcome of 271 patients. Radiother Oncol 77:126–132

•Complete Response (no tumour clinically)•Median progression-free survival = 65 months

•Partial Response (shrunken tumour)•Median progression-free survival = 15 months

•T1/2 group •Median PFS = 64 months

•T3 •Median PFS = 28 months

Lim L, Chao M, Shapiro J, et al. Long-term outcomes of patients with localized rectal cancer treated with chemoradiation or radiotherapy alone because of medical inoperability or patient refusal. Dis Colon Rectum 2007;50:2032-9.

Endoscopic Nd-Yag Laser Ablation Palliate bleeding, mucinous discharge,

impending obstruction Success in 8 out of 11 patients

Argon Plasma Coagulation Palliate tumour bleeding Debulking

Endoscopic laser ablation of advanced rectal carcinoma--a DGH experience. Rao VS. Al-Mukhtar A. Rayan F. Stojkovic S. Moore PJ. Ahmad SM. Colorectal Disease. 7(1):58-60, 2005 Jan

Prospective nonrandomized comparison of two modes of argon beamer (APC) tumor desobstruction: effectiveness of the new pulsed APC versus forced APC. Eickhoff A. Jakobs R. Schilling D. Hartmann D. Weickert U. Enderle MD. Eickhoff JC. Riemann JF. Endoscopy. 39(7):637-42, 2007 Jul.

Bianchi PP, Ceriani C, Rottoli M, et al.: Endoscopic ultrasonography and magnetic resonance in preoperative staging of rectal cancer: Comparison with histologic findings. J Gastrointest Surg 2005; 9: 1222–1228

Ramirez et al.22 concluded from a randomized trial that intraoperative results and outcome were not affected according to whether or not the defect was sutured.

The defect was left open in the majority of patients in the present study (72·0 per cent) to minimize the risk of rectal stenosis, although it was closed in patients with a high tumour.

Colonoscopy Snare Submucosal dissection

Transanal excision Parks (Direct transanal approach) Transanal Endoscopic Microsurgery

Others Radiotherapy Laser / Argon Plasma Coagulation

Colonoscopic polypectomy Suitable in 90% of rectal polyps Complete resection difficult if tumour in

submucosal area i.e. carcinoid tumors / malignant rectal tumour

Suitable for pedunculated polyp Endoscopic mucosal resection

Removal of mucosal lesion of < 1cm Special device needed if tumour suspected

to be in submucosal area i.e. 2 channel EMR

Ono A, Fujii T, Saito Y, Matsuda T et al. Endoscopic submucosal resection of rectal carcinoid tumors with a ligation device. Gastrointest Endosc 2003; 57: 583±587

Indicated when one−piece resection by conventional procedures is impossible: Large−sized lesions Lesions with biopsy−induced scars Lesions on haustra

Rate of one-piece resection with ESD: 70-88% Rate of perforation: 5% Mean size :

26.2 mm (8 ± 60) 32.8 mm (9 - 91)

Onozato Y, Kakizaki S, Ishihara H, et al. Endoscopic submucosal dissection for rectal tumors. Endoscopy. 2007;39:423– 427

Fujishiro M, Yahagi N, Nakamura M et al. Endoscopic submucosal dissection for rectal epithelial neoplasia. Endoscopy 2006; 38: 493±497

Colorectal endoscopic submucosal dissection: present status and future perspective, including its differentiation from endoscopic mucosal resection. [Review] [47 refs] Tanaka S. Oka S. Chayama K. Journal of Gastroenterology. 43(9):641-51, 2008

Ono A, Fujii T, Saito Y, Matsuda T et al. Endoscopic submucosal resection of rectal carcinoid tumors with a ligation device. Gastrointest Endosc 2003; 57: 583±587

Limited to: Involvement only to SM1 or less

Kikuchi Classification of Adenocarcinoma in Sessile Polyp

The junction between the sigmoid colon and the rectum has been variously described:

A point opposite the left sacroiliac joint Level of the 3rd sacral vertebra Level at which the sigmoid mesentery disappears Level at which sacculations and epiploic appendages

disappear and taeniae broaden to form a complete muscle layer (long transition)

Level at which the superior rectal artery divides into right and left branches

Construction with anterior angulation (proctoscopy) Level of superior rectal fold (inconstant) Transition between rugose mucosa of colon and smooth

mucosa of rectum (cadaver)Skandalakis John E, Colborn Gene L, Weidman Thomas A, Kingsnorth Andrew N, Skandalakis Lee J, Skandalakis Panajiotis N, Shafik Followed b, "Chapter 18. Large Intestine and Anorectum" (Chapter). Skandalakis JE, Colburn GL, Weidman TA, Foster RS Jr, Kingsworth AN, Skandalakis LJ, Skandalakis PN, Mirilas PS: Skandalakis' Surgical Anatomy: http://www.accesssurgery.com.easyaccess1.lib.cuhk.edu.hk/content.aspx?aID=74406.