Laparoscopic colorectal surgery

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					Minimally invasive colorectal
         surgery
      Joe Ragg, RMH yr III
Minimally invasive colorectal
         surgery
   Laparoscopic colorectal surgery
  Local therapy for rectal carcinoma
 Laparoscopic colorectal surgery
• First described 1991
  – cf. Laparoscopic Cholecystectomy 1987
  – ie. not progressed into common use as yet
 Laparoscopic colorectal surgery
• Indications
  – Cancer
  – Stoma formation
  – Other
     • IBD resections
     • Diverticular resections
     • Dysmotility resections
 Laparoscopic colorectal surgery
• Technical issues (Same principals as Open
  procedures)
  – Mobilisation
     • Atraumatic bowell grasping forceps eg Babcocks
     • Diathermy, Harmonic shears
     • Tilt table
  – Division of vascular pedicle
     • Linear stapler
 Laparoscopic colorectal surgery
• Technical issues (Same principals as Open
  procedures)
  – Resection of bowel (extra-corporeal)
     • Over site of intended anastomosis
     • Size of wound according to tumor size
     • “Totally laparoscopic” approaches have been
       described including delivery of specimen
       transanally.
             - Only common one is APR.
 Laparoscopic colorectal surgery
• Technical issues (Same principals as Open
  procedures)
  – Restoration of continuity or formation of stoma
 Laparoscopic colorectal surgery
• Clinical outcome
  – 5 RCT only
     • 2 immunological outcome / 1 perioperative data
       onlywith outcome data to follow
  – 60 reports of prospective and retrospective
    audits
 Laparoscopic colorectal surgery
• Clinical outcome: currently running studies
   – CLASSICC
      • Conventional V Lap Assisted Surgery In Colorectal Cancer
      • UK, 1000 cases
   – COST
      • Clinical Outcome from Surgical Therapy
      • North American, NCI funded, Started 1994, 1200 cases
   – COLOR
      • Colon carcinoma Lap or Open Resection
      • Northern Europe, 1200, started 1997
 Laparoscopic colorectal surgery
• Clinical outcome
  – Duration of procedure
     • Uniformly longer
     • Does reduce with experience
     • Nil to suggest that times will be faster than open
       technique
 Laparoscopic colorectal surgery
• Clinical outcome
  – Conversion
     • 1.5 – 48%; Mean for collated series around 17.5%
     • Suggested difficulties
        –   Obesity
        –   Adhesions
        –   Exposure / Anatomy
        –   Size of tumor
        –   Difficulty in ascertaining degree of fixity or local invasion
 Laparoscopic colorectal surgery
• Clinical outcome
  – Complications
     • Specifically laparoscopic
        – Open technique to introduce pneumoperitoneum /
          Remainder ports under vision
        – Meticulous closure of port sites >= 10mm
        – Thrombo-embolic complications < 2%
 Laparoscopic colorectal surgery
• Clinical outcome
  – Complications
     • Morbidity / Mortality comparable to Open
       Technique in nature and incidence; Major 0 – 12%
        – Leak: < 10% and proportional to L sided work
        – Major haemorrhage, inadavertent enterotomy, ureteral
          injury, Iliac vessel inury
 Laparoscopic colorectal surgery
• Clinical outcome
  – Patient recovery and well being
     • Theoretically less wound -> less trauma
        – ie. reduced pain and ileus, quicker mobility and a return to
          usual function
        – NOT consistently borne out in studies
     • COST study has reported on Quality of Life (QOL)
        – n=429; Only difference was Lap having a better global
          rating score at 2 weeks. Lap did require less analgesia in
          hospital.
 Laparoscopic colorectal surgery
• Clinical outcome
  – Oncologic outcome
     • Technical ability for oncologic operation
        – Equivalence of mesenteric / longitudinal margins of
          clearance,and of no. of harvested lymh nodes all resection
          types
            » nb. High rather than low IMA ligation has never been
               shown to have oncologic benefit
            » nb. No study has shown number of harvested lymph
               nodes to correlate with oncologic outcome
 Laparoscopic colorectal surgery
• Clinical outcome
  – Oncologic outcome
     • Technical ability for oncologic operation (cont.)
        – Anterior resection; no facility for a trial dissection (no
          tactile information). Some have said there are
          inappropriately high rates of APRs.
 Laparoscopic colorectal surgery
• Clinical outcome
  – Oncologic outcome
     • Pattern of recurrence
         – Port site metastase; possibly significant
             » Over 30 cases reported including some after Dukes A
                resections
             » Conflicting results re. incidence in animal models
             » Known free cells at laparotomy for CRC which can adhere
                to instruments; repeated passes of instruments could aid
                implantation, local ischaemia at trocar sites (pressure),
                pneumo-peritoneum aiding dissemination (?)
             » No difference in systemic immune markers Lap Vs Open
 Laparoscopic colorectal surgery
• Clinical outcome
  – Oncologic outcome
     • Long Term Survival
        – Relatively short follow up to date. Of RCTs:
        – Lacy 1998 Surg Endosc
            » N=91: recurrence 16% Lap and 15% Open at median
              21.4 mths (range13-41mths)
        – Milsom 1998 J Am Coll Surg
            » N=109, 80 Cx / 29 large adenoma: At median 1.5 yr ,
              3/55 Lap cases had cancer related death cf. 4/54 at
              median 1.7yrs in Open group
 Laparoscopic colorectal surgery
• Clinical outcome
  – Oncologic outcome
     • Long Term Survival
        – Series seem to point to equivelence in terms of disease
          specific recurrence and survivial
 Laparoscopic colorectal surgery
• Conclusion
  – Currently running trials should establish role in
    cancer surgery. Seems feasable / appropriate /
    safe at present.
  – Presently clustered in particular institutions (eg
    Brisbane) – training, attitude
Local therapy for rectal cancer
  Local therapy for rectal cancer
• History
  –   Lisfranc 1826
  –   Kraske 1886
  –   Bevan 1917 / York Mason 1970
  –   Increasing interest recently with more accurate
      investigative staging of tumor
  Local therapy for rectal cancer
• Why ?
  – Sphincter preservation, Avoidance of radical
    surgery
• Limitations
  – Accessible (within 6-8cm of anal verge, higher
    with TEMS)
  – Less than 1/3 of circumference
  – Not fixed (T4) or tethered (T3)
  Local therapy for rectal cancer
• Considerations pre-operatively
  – Staging
     • Endorectal ultrasound (ERUS)
        – T: 81-94% accuracy (sf for MRI)
        – N: 58-80% accuracy, NPV 70-95% (MRI with endorectal
          coil may be better)
     • A significant number of nodal disease are
       micrometastes
     • Around 18% of biopsy underestimate degree of
       anaplasia (cf operative specimen)
  Local therapy for rectal cancer
• Considerations pre-operatively
  – Staging
     • Predicting nodal status
        T Stage: T1: 6-12%, T2: 17-22%, T3: up to 66%
        Tumor size: NOT a good predictor o f N stage (or of T stage
          or outcome):
        Of T1 and T2 tumors:
            Differentiation: Well-Moderate 14% cf poor 30%
            Lymphovascular or perineural invasion:
                     Not present 14-17% cf Present 33%
        Of T1 – T4 tumors
            Mucinous content: Not present: 30% cf 52% Present
 Local therapy for rectal cancer
• Outcome
  – APR for early rectal cancers (T1 T2)
     • 85 - 98% cancer-specific survival
     • 5 – 10% local recurrence
     • Mortality for radical resecional surgery (AR, APR)
        – 1 – 5%
        – Markedly higher in the aged
            7%      70 - 79 yo
            17%     >80 yo
  Local Excision
    1% mortality, 5-18% morbidity
 Local therapy for rectal cancer
• Techniques
  – Carcinoma: full thickness excision with a 1cm
    margin
     • ie unsuitable if above the pertioneal reflection –
       faecal spillage
  – Adenomata: full thickness excision with a
    0.5cm margin, or dissection in the submocosal
    plane if above the peritoneal reflection
 Local therapy for rectal cancer
• Techniques
  – Transanal excision
     • Full thickness rectal wall excision down to perirectal
       fat, closed transversely with interupted sutures
 Local therapy for rectal cancer
• Techniques
  – Transanal endoscopic microsurgery (TEM)
    • Buess, Germany (Tubingen)
    • CO2 insufflation / 40mm operating rectoscope
      Binocular stereoscopic eyepiece
      Instruments inserted in parallel through 4 ports
            tissue grasper, cautery device, scissors, needle
            holder, suction catheter
    • Introduced initially as an alternative for lesions
      middle and upper 1/3 rectum
 Local therapy for rectal cancer
• Techniques
  – Transanal endoscopic microsurgery (TEM) –
    cont.
    • Similar results / indications as for transanal excision
    • Slow to popularise
       – Expense
       – Utilistation (very specific equipment)
  Local therapy for rectal cancer
• Other techniques
  – Trans-sacral (Kraske procedure)
     • mid rectum
     • Posterior vertical incision, transverse incision anococcygeal
       raphe, S4 S5 coccyx resection, midline division Waldeyers
       fascia
     • Significant morbidity including faecal fistula
  – Trans-sphicteric (York Mason procedure)
     • Low / mid rectum
     • Similar approach to Kraske proced. (but without sacrectomy)
       to then divide entire sphincteric complex in posterior midline,
       then posterior proctotomy
  Local therapy for rectal cancer
• Other techniques
  – Ablative procedures
     • Elecrocoagulation
         –   Cautery / debridement until normal tissue encountered
         –   No pathologic specimen for definitive staging
         –   Below peritoneal reflection
         –   Significant conversion rate to APR
         –   Results inferior to resection; role mainly palliative
     • Endocavitay radiation
         – Direct contact, possibly with implant for boost to deeper layers
         – Results near to resection although procedure should be
           abandoned if less than 80% response rate at 2/52 (of 6/52 Rx)
 Local therapy for rectal cancer
• Outcome
  – Mostly small retrospective series of
    heterogeneous patients
     • ie. interpretation of results difficult
 Local therapy for rectal cancer
• Outcome
   Local excision alone
    • Local recurrence   T1     5 – 18%
                         T2     To 47%
     Survival     T1     72 – 90%
                  T2     55 – 78%
   Local excision with adjuvant radiation +/-
   chemotherapy
     Local recurrence    T1    0-11%
                         T2    0 – 24%
  Local therapy for rectal cancer
• Survival
  – No RCT Local excision Vs Radical resection
  – A retrospective comparative trial indicated
    equivalent results to radical surgery only for
    favourable histopathologic results (Willet CG,
    Cancer 1994)
  – Local failure : Reports exist of reasonable salvage
    with APR or LAR (Approx half are candidates for
    such)
  – Unexpectadly unfavourable histopathology:
    Better to salvage immediately than after local failure
    (Baron CL, Dis Colon Rectum 1995)
  Local therapy for rectal cancer
• Survival
  – Follow-up
     • Finger, Proctoscope, ERUS (including with
       Doppler)
     • Important: Curative salvage operations are possible
  Local therapy for rectal cancer
• Conclusion
  – Curative: Needs accurate pre-operative staging (T1,
    N0) with the understanding of radical resection
    immediately if an unfavorable histopathological report
    arises. Close follow-up monitoring given the possibility
    of curative salvage procedure. Most would give
    adjuvant radiotherapy.
  – Other: A consideration for high co-morbidities and / or
    very elderly. An option in a palliative setting.