The best method for distal rectal resection -...

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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?