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.
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