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The best method for distal rectal resection
Francis Seow-ChoenSeow-Choen
Colorectal Centre
Singapore
Rectal Cancer Rectal Cancer is a
surgical disease Surgical technique
is one of the most important factor to reduce local recurrence.
Meticulous attention in performing rectal resection is of the utmost importance
La muse
Real old methods William Allingham
claimed in 1882 that much relief could be obtained by tearing out the rectum with his fingers!
By 1947, Synchronized APR was in fashion with operability at 86% and operative mortality at 8.2%
Granshaw L. St Marks Hospital, London A social history of a specialist Hospital
Open Surgery: The modern era:Blunt methods
Anterior resection often removed by forceful tearing away from the pre-sacral fascia
Results in excessive bleeding and a substantial local recurrence rates of up to 55%
However this technique may still be useful in a very small number of cases even today.
New understanding: The Mesorectum
First known description of the mesorectum was by the Romanian surgeon and anatomist Thomas Jonnesco.
Jonnesco was the first to observe that the rectum was encapsulated within a thin fibrous sheath, which partitions it from the other pelvic organs, and he also described how proper respect for this fibrous sheath allowed the rectum to be mobilized from the sacrum without damage to the presacral vessels.
The mesorectum and TME
Heald gave TME widespread attention in 1979
He emphasized direct vision and sharp dissection of the mesorectum by dividing between the visceral and parietal pelvic fascia during rectal mobilization.
Open Surgery: Sharp disssection
Heald, in fact, reported the lowest recurrence rates for rectal cancer at that time, with his first series of 112 patients showing a cumulative 5-year local recurrence rate of 2.7% and an overall corrected 5-year survival of 87.5%.
Heald et al Lancet 1986:1:1479-82
Good indications for Open TME Surgery
Very large bulky cancer in the low rectum
Lack of minimally invasive facilities or training
Locally advanced in a fat male patient
The minimally invasive era: Laparoscopic TME
Three randomized controlled trials evaluated feasibility and oncologic safety of laparoscopic TME
Clasicc-5 year results No differences were found
between laparoscopicallyassisted and open surgery in terms of overall survival, disease-free survival, and local and distant recurrence at 5 yrs. Wound/port-site recurrence rates in the laparoscopic arm remained stable at 2.4 per cent.
The use of laparoscopic surgery to maximize short-term outcomes does not compromise the long-term oncological results
Br J Surg. 2010 Nov;97(11):1638-45 Jayne et al Leeds UK
Color II Short term results 1103 patients were randomly
assigned to the laparoscopic (n=739) and open surgery groups (n=364), and 1044 were eligible for analyses (699 and 345, respectively).
Patients with rectal cancer treated by skilled surgeons, laparoscopic surgery resulted in similar safety, resection margins, and completeness of resection to that of open surgery, and recovery was improved after laparoscopic surgery.
Lancet Oncol. 2013 Mar;14(3):210-8. Laparoscopic versus open surgery for rectal cancer (COLOR II): short-term outcomes of a randomised, phase 3 trial. van der Pas MH
http://www.ncbi.nlm.nih.gov/pubmed/23395398http://www.ncbi.nlm.nih.gov/pubmed?term=van%20der%20Pas%20MH%5BAuthor%5D&cauthor=true&cauthor_uid=23395398
Corean TrialOpen versus laparoscopic surgery for mid or low REctalcancer After Neoadjuvantchemoradiotherapy 340 patients randomized
open surgery (n=170) or laparoscopic surgery (n=170). Both groups with similar outcomes for disease-free survival as open resection, thus justifying its use.
Lancet Oncol. 2014 Jun;15(7):767-74. Open versus laparoscopic surgery for mid-rectal or low-rectal cancer after neoadjuvant chemoradiotherapy (COREAN trial): survival outcomes of an open-label, non-inferiority, randomised controlled trial. Jeong SY
http://www.ncbi.nlm.nih.gov/pubmed/24837215http://www.ncbi.nlm.nih.gov/pubmed?term=Jeong%20SY%5BAuthor%5D&cauthor=true&cauthor_uid=24837215
Good indications for Laparoscopic Surgery
Smaller rectal cancer especially in a thin female with wide pelvis
No evidence of extensive pelvic disease
Experienced laparoscopic surgeon
Robotic Rectal Resection Robotic surgery is an
emerging minimally invasive technique. The optical system provides a high definition, three-dimensional vision, and surgical instruments are provided for seven degrees of freedom and for a range of motion greater than the human wrist; this enables extremely fine and precise manual dexterity.
Robotic-assisted versus laparoscopic colorectal surgery: a meta-analysis of four randomized controlled trials
4 out of 71 studies were found to meet the inclusion criteria .
110 patients underwent RCS, and 116 patients underwent LCS.
Benefits of RCS include a reduced conversion rate, reduced blood loss and reduced time to recovery of bowel function. There were no significant differences in operation time, complication rate and LOS between the two groups. However, RCS was associated with a significant increase in total costs relative to LCSLiao et al: World Journal of Surgical Oncology 2014, 12:122 Park JS, Choi GS, Park SY, Kim HJ, Ryuk JP: Randomized clinical trial of robot-assisted versus standard laparoscopic
right colectomy. Br J Surg 2012, 99:1219-1226. Patriti A, Ceccarelli G, Bartoli A, Spaziani A, Biancafarina A, Casciola L: Short- and medium-term outcome of robot-
assisted and traditional laparoscopic rectal resection. JSLS 2009, 13:176-183. Baik SH, Ko YT, Kang CM, Lee WJ, Kim NK, Sohn SK, Chi HS, Cho CH: Robotic tumor-specific mesorectal excision of
rectal cancer: short-term outcome of a pilot randomized trial. Surg Endosc 2008, 22:1601-1608. Jimenez RR, Diaz PJ, de La Portilla DJF, Prendes SE, Hisnard CDJ, Padillo J: Prospective randomised study: robotic-
assisted versus conventional laparoscopic surgery in colorectal cancer resection. Cir Esp 2011, 89:432-438.
Good indications for robotic rectal surgery
Very low rectal cancer
Sexual function important
Male obese patients
Pre-operative chemoradiation
Large tumours
The next big thing From June 2012 until July 2013, 25
consecutive patients underwent transanal TME.
Within the transanal TME group, 96 % of the specimens had a complete mesorectum, while in the traditional laparoscopic group, 72 % was deemed complete (p < 0.05). Other pathological characteristics were comparable between the two groups.
Transanal TME appears associated with a significant higher rate of completeness of the mesorectum.
Surg Endosc. 2014 Jun 28. Transanal versus traditional laparoscopic total mesorectal excision for rectal carcinoma. Velthuis S et al
http://www.ncbi.nlm.nih.gov/pubmed/24972923http://www.ncbi.nlm.nih.gov/pubmed?term=Velthuis%20S%5BAuthor%5D&cauthor=true&cauthor_uid=24972923
Advantageous Twenty selected patients with
rectal cancer had transanalNOTES and minilaparoscopytechnique.
Thirty-five percent of tumorswere in the distal rectum, 50% in midrectum, and 15% in proximal rectum. There were no procedure-related complications. The mesorectalfascia was intact in all the specimens.
Reverse TME may offer advantages over pure laparoscopic approaches for visualizing and dissecting out the distal mesorectum.
Surg Endosc. 2013 Sep;27(9):3165-72. Transanal natural orifice transluminal endoscopic surgery (NOTES) rectal resection: "down-to-up" total mesorectal excision (TME)--short-term outcomes in the first 20 cases. de Lacy AM
http://www.ncbi.nlm.nih.gov/pubmed/23519489http://www.ncbi.nlm.nih.gov/pubmed?term=de%20Lacy%20AM%5BAuthor%5D&cauthor=true&cauthor_uid=23519489
Data from Gerald Marks 2009 Laparoscopic Rectal
Cancer Operations TATA N=106 Surgical approach can
be confirmed before surgery
Local recurrence rate 2.6% (oncologic goal)
Sphincter preservation can be achieved in >90% of patients
Start with Laparoscopy
Then insert the TEO set
Insert the purse string
Reverse TME
Easy 1 man job
Connect to the Laparoscopic wound
Prolapse the rectum and cancer
Transect and insert stapler head
Insert the distal purse string
Anastomosis done!
Reverse TME wounds
Resected cancer
Why Reverse TME?
Minimally Invasive Technique maintained Low Rectal Cancer in a difficult position Distal margin assured at start of surgery Perfect TME possible by combination
technique if required Decreased wound sites!
Technologies and Techniques are getting more advanced but the most important
question is not whether we are using latest technology or technique!
The more important question is: are we becoming better humans?
The best method for distal rectal resectionRectal CancerReal old methodsOpen Surgery: The modern era:Blunt methodsNew understanding: The MesorectumThe mesorectum and TMEOpen Surgery: Sharp disssectionSlide Number 8Good indications for Open TME SurgeryThe minimally invasive era: Laparoscopic TMEClasicc-5 year resultsColor II Short term resultsCorean TrialSlide Number 14Good indications for Laparoscopic SurgeryRobotic Rectal ResectionRobotic-assisted versus laparoscopic colorectal surgery: a meta-analysis of four randomized controlled trialsSlide Number 18Slide Number 19The next big thingAdvantageousData from Gerald Marks 2009Start with LaparoscopyThen insert the TEO setInsert the purse stringSlide Number 26Reverse TMEEasy 1 man jobConnect to the Laparoscopic woundProlapse the rectum and cancerTransect and insert stapler headInsert the distal purse stringAnastomosis done!Reverse TME woundsResected cancerWhy Reverse TME?Technologies and Techniques are getting more advanced but the most important question is not whether we are using latest technology or technique!The more important question is: are we becoming better humans?