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Surgery for Colorectal Cancer

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					Surgery for Colorectal Cancer




                 Edinburgh Oncology Symposium May 2010
      Age distribution of CRC incidence
                     (Scottish 1995 annual i id
                     (S    ih                                    )
                                         l incidence - 3251 cases)

700

600

500

400

300

200

100

  0
      25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+
      25 29 30 34 35 39 40 44 45 49 50 54 55 59 60 64 65 69 70 74 75 79 80 84 85

                                                    Edinburgh Oncology Symposium May 2010
Influence of the surgeon on
         outcome
•   Decision to operate
•   Perioperative morbidity & mortality
•   Local recurrence rates
•   Quality of life




                         Edinburgh Oncology Symposium May 2010
     Decision to operate
• Stage of disease
  – Local stage (T stage)
  – Metastases
     • Potentially operable
     • Inoperable
  Fitness of the patient
• Fit      f th    ti t
• Use of pre-operative radiotherapy
• Risk : benefit analysis

                              Edinburgh Oncology Symposium May 2010
 Perioperative morbidity &
         mortality
                 y
• Anaesthesia
• Perioperative care
     g
• Surgeon related factors
  – anastomotic leakage




                          Edinburgh Oncology Symposium May 2010
        Correct Operation
•   Site of the tumour
•   Size of tumour
•            g
    Other organs involved
•   Technical expertise of surgeon
•   Patient related factors




                         Edinburgh Oncology Symposium May 2010
  Local Recurrence Rates
• Primary tumour disrupted
• Inadequate local excision
    p
• Implantation of viable cells




                        Edinburgh Oncology Symposium May 2010
    Maximising perioperative
            survival
•   Survival varies across units
         • USA          >80        97.5%
                                   97 5% 30 day mortality
         • Edinburgh    >80        94%    30 day mortality
         • ACPGBI       >80        85% 30 day mortality
    –   Pre-optimisation
    –   Peri-operative anaesthesia
    –   Quality of surgery
    –   HDU / ward management




                                     Edinburgh Oncology Symposium May 2010
     Quality of life issues
• Survival
• Stoma
  – physical problems
  – psychological problems
• Bowel function
  – coloanal anastomosis
  – colonic j pouch
• Radiation related side effects

                           Edinburgh Oncology Symposium May 2010
     p                      g
Pre-operative Decision Making
      Colorectal Cancer




                 Edinburgh Oncology Symposium May 2010
Major Difference Colon /
   Rectum:- Access




 Colon                         Rectum
             Edinburgh Oncology Symposium May 2010
 Major Differences Colon &
          Rectum
• Colon                     • Rectum
  –   DXT - no                –   DXT - yes
  –   Morbidity - low         –   Morbidity - higher
  –   Mortality - low         –   Mortality - higher
  –   Stoma rate - low        –   Stoma rate - higher
  –   Function - good         –   Function - poorer
  –   Collateral damage -     –   Collateral damage -
      low                         high




                              Edinburgh Oncology Symposium May 2010
                   Treatment Options
           Colon                           Rectum

Curative      Palliate     Curative               DXT               Palliative




Lap           Lap / open   Lap                    Pre-op SC         Stent
Open          Stent        TEMS                   Preop LC +/- CT   Transanal rebore
              Watch        Local Excision         Post-op           Resect
                           Anterior resection     Stoma             Stoma
                           Coloanal anastomosis
                           C                  i                     DXT
                           AP resection                             Laser ablation
                           Stoma



                                         Edinburgh Oncology Symposium May 2010
 Three cardinal features of
     colorectal cancer
• Location
  – is it in the rectum
• Location
  – is it in the rectum
• Location
  – is it in the rectum




                          Edinburgh Oncology Symposium May 2010
Rectal Centres




             Colon Centre


                 Edinburgh Oncology Symposium May 2010
Planning For Colon Cancer
• Site
     • colonoscopy
     • X-sectional imaging
• T stage
     • CT scanning
     t
• N stage
     • CT scanning
     t
• M stage
     • CT scanning / PET CT


                              Edinburgh Oncology Symposium May 2010
              Surgical Principles in
           Colon Cancer M
           C l C         Management  t

Cancer clearance   Radical colorectal excision
                   Mesocolonic excision
                   Maximal Lymphadenectomy
                   en bloc resection (R0)

Nerve preservation Not relevant

Reconstruction     Ileo-colic/colo-colic anastomosis
                   Complex visceral reconstruction

Mode               Minimally invasive

                                  Edinburgh Oncology Symposium May 2010
   Resections for colorectal cancer




   Right
   Ri ht        Extended right       Left
                                     L f              Anterior resection
hemicolectomy   hemicolectomy    hemicolectomy


                                    Edinburgh Oncology Symposium May 2010
T4 colonic tumours




           Edinburgh Oncology Symposium May 2010
T4 Colonic tumours




           Edinburgh Oncology Symposium May 2010
Edinburgh Oncology Symposium May 2010
Rationale for Laparoscopic
    Colorectal Surgery
Laparoscopic surgery is less of an
insult than open surgery

A decrease in the trauma of surgery is
of benefit

Valuable to
   patients
   healthcare systems
   doctors
                        Edinburgh Oncology Symposium May 2010
                Summary
Laparoscopic surgery is consistently associated
with:-
Decreased • Morbidity
          • Intra-operative blood loss
            Intra operative
          • Post operative analgesia
          • Post-operative ileus
          • Length of stay

Increased • O
I              ti ti
        d Operating time


                            Edinburgh Oncology Symposium May 2010
              Cochrane review
Short Term-benefits of Laparoscopic Colorectal Resection
(25 RCTs)

Under traditional perioperative treatment, laparoscopic colonic
                          y                  g
resections show clinically relevant advantages in selected
patients. If the long-term oncological results of laparoscopic
and conventional resection of colonic carcinoma show
equivalent results, the laparoscopic approach should be
preferred in patients suitable for this approach to colectomy.

Schwenk et all 2005


                                    Edinburgh Oncology Symposium May 2010
              Cochrane Review

   g                   p      p
Long-term Results of Laparoscopic Colorectal Cancer
Resection (33 RCTs)

Laparoscopic resection of carcinoma of the colon is
associated with a long term outcome no different from that
         colectomy
of open colectomy. Further studies are required to determine
whether the incidence of incisional hernias and adhesions is
           y            pp           p       p     g y
affected by method of approach. Laparoscopic surgery for
cancer of the upper rectum is feasible, but more randomised
trials need to be conducted to assess long term outcome.

Kurhy et all 2008                   Edinburgh Oncology Symposium May 2010
Edinburgh Oncology Symposium May 2010
                                    Length of stay
          18
          16
          14
          12
Num ber




          10                                                                               lap
  m




           8                                                                               open
           6
           4
           2
           0
               1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

                                              Days       Edinburgh Oncology Symposium May 2010
         Length of stay
• Home by 4th day
• laparoscopic 36% open 9%

• Home by 6th day
• laparoscopic 59% open34%




                     Edinburgh Oncology Symposium May 2010
Edinburgh Oncology Symposium May 2010
           Grey areas
• BMI > 30
• Transverse colon (middle colic +
  adjacent organs
• Rectum - middle and lower third




                       Edinburgh Oncology Symposium May 2010
Patient selection




           Edinburgh Oncology Symposium May 2010
            Summary
• Laparoscopic surgery is becoming
    ld t d d f        l
  gold-standard for colon cancer
• Role in rectum not yet established
• Not for transverse colon tumours




                       Edinburgh Oncology Symposium May 2010
Surgical Treatment of Rectal
           Cancer




                Edinburgh Oncology Symposium May 2010
Surgical Anatomy
of the Rectum




                   Edinburgh Oncology Symposium May 2010
      Surgical principles
• Upper 5cm
  clearance
• Middle TME
• Lower - TME + 1cm
• AP prone
  (cylindrical)




                      Edinburgh Oncology Symposium May 2010
Edinburgh Oncology Symposium May 2010
Edinburgh Oncology Symposium May 2010
   Total mesorectal
   excision




Edinburgh Oncology Symposium May 2010
Mercury Study Group




            Edinburgh Oncology Symposium May 2010
MDT




      Edinburgh Oncology Symposium May 2010
Edinburgh Oncology Symposium May 2010
Edinburgh Oncology Symposium May 2010
Edinburgh Oncology Symposium May 2010
Edinburgh Oncology Symposium May 2010
Edinburgh Oncology Symposium May 2010
Edinburgh Oncology Symposium May 2010
             Surgical Options

                 Size of    Stage of   Nodes   Morbidity Function
                 T
                 Tumour     Tumour
                            T                            D fi i
                                                         Deficit

Local Excision   2 cm       T1/T2      No      Minimal     Minimal


TEMS             2cm        T1/T2      No      Minimal     Minimal


Transabdominal   Any size   T1-T4      Yes     Significant Significant
Surgery




                                        Edinburgh Oncology Symposium May 2010
Local excision of rectal
        cancer




              Edinburgh Oncology Symposium May 2010
                  TEMS
• Indications
  –   Polyp or T1 tumour
  –   < 2cm in diameter
  –   good histology
  –   >6 but < 15 cm from verge

  but technically difficult




                              Edinburgh Oncology Symposium May 2010
Transanal Endoscopic
Microsurgery (
        g y (TEMS) )




            Edinburgh Oncology Symposium May 2010
       Problems with Local
            Excision
•   Limitations of access (men)
•   Accuracy of staging
•                     (       ,      )
    Recurrence rates (T1- 15%, T2 40%)
•   No nodal status
•   Patient selection




                         Edinburgh Oncology Symposium May 2010
              Surgical Principles in
           Rectal Cancer M
           R t lC         Management t

Cancer clearance   Radical colorectal excision
                   Mesocolonic excision
                   Maximal Lymphadenectomy
                   en bloc resection (R0)

Nerve preservation Pelvic autonomic nerves / plexuses

Reconstruction     Colorectal anastomosis
                   Coloanal anastomosis
                   Coloperineal anastomosis
                   Complex visceral reconstruction

                                Edinburgh Oncology Symposium May 2010
            Principles
• Determine which operations feasible
• Do not compromise oncological
  clearance
• Avoid permanent stomas where
  p
  possible
• Maximise post-operative function




                       Edinburgh Oncology Symposium May 2010
      Surgical principles
• Upper 5cm
  clearance
• Middle TME
• Lower - TME + 1cm
• AP prone
  (cylindrical)




                      Edinburgh Oncology Symposium May 2010
Edinburgh Oncology Symposium May 2010
           Rectal Cancer
•   Historically majority AP resection
•   Advent of stapling techniques
•      g
    Surgical advances
•   Reconstruction often possible (?
    advisable)




                          Edinburgh Oncology Symposium May 2010
Low anterior resection




             Edinburgh Oncology Symposium May 2010
Coloanal anastomosis




            Edinburgh Oncology Symposium May 2010
Impact of training on rectal cancer outcome
             Local recurrence




                         Edinburgh Oncology Symposium May 2010
Impact of training on rectal cancer outcome
          Cancer specific survival




                         Edinburgh Oncology Symposium May 2010
Impact of caseload on rectal cancer outcome
          Swedish TME surgeons

                      High volume Low volume HR                   P
Mean ops/yr               >12          0-12
Curative ops           245 (78%)    277 (82%)
Follow-up (mths)       41 (24-59)   43 (24-59)
Local recurrence         9 (4%)      27 (10%)        2.4         0.02
Distant mets            39 (16%)     54 (19%)        1.2        0.33
Rectal cancer death     26 (11%)     51 (18%)        1.9        0.007




                                    Edinburgh Oncology Symposium May 2010
                                                   Martling et al BJS 2002
 Impact of caseload on colorectal cancer outcome
        SEER data and surgeon volume


      I-III            cancer,
Stage I III colorectal cancer n=5935
Endpoint readout – post-operative procedural interventions
     p
Time period 1992-97

                        v low   low     medium        high        v high
Mean ops/yr              1-2    3-5      6-12         13-19        >20
Proportion surgeons (%) 54.3    27.1     13.7          3.5          1.5
Complications            5.9    5.9       5.5          6.2          3.0



                                                      al
                                       Billingsley et al. J Am Coll Surg 2007

                                       Edinburgh Oncology Symposium May 2010
      Anastomotic Leak
• Leaks will happen
• Colon SIGN < 5% (ECR <2%)
•                    (
  Rectum SIGN <20% (ECR 7%)   )
• Need to know AP rate (SIGN 40% /
  ECR <10%)
• Ideal measure of quality would be
  permanent stoma rate
• 1/3 temp stomas never closed

                       Edinburgh Oncology Symposium May 2010
Anastomotic leak and colorectal cancer outcome
Anastomotic leak rate    Overall - 3.8%, Colon - 2.4%,      All rectal - 6.4%
30-day mortality         Overall - 4.3%, Leak – 16%,        No leak – 3.9%




      McArdle et al BJS 2005              Edinburgh Oncology Symposium May 2010
                     pre op
Surgical thoughts on pre-op
            DXT




                Edinburgh Oncology Symposium May 2010
              y            p
     Meta-Analysis of Pre-operative XRT
Overall mortality                                       HR 0.93 (0.87-1.0)
  (non significant
  (non-significant 2% absolute difference)

Local recurrence significantly reduced                  HR 0.71 (0.64-0.78)
  (effect heterogeneous across trials)

No benefit in sphincter sparing procedure               OR 0.94 (0.85-1.04)

Increased pelvic or perineal wound infection,

Rectal and sexual dysfunction                           40%

CRT provides incremental benefit for local control compared with PRT

No difference in outcome between 2 and 8 wk interval from RT to surgery

        g                                 y
     Wong et al. Cochrane Collab meta-analysis

                                                 Edinburgh Oncology Symposium May 2010
       Summary of DXT
• Pre-op > post-op
• Positive margin is bad
•              g
  Positive margin - DXT is terrible
• Surgical decisions made prior to DXT
• Uncertain management of complete
  response
  Considerable morbidity with DXT
• C    id   bl      bidit   ith


                       Edinburgh Oncology Symposium May 2010
                  pre op
  Who should have pre-op
          DXT
• Where mesorectal clearance is
  th   t   d 1
  threatened <1mm
  –   big tumour / small mesorectum
  –   anterior tumours
  –   poorly differentiated ?
  –   lower third tumours ?
• T4 tumours



                           Edinburgh Oncology Symposium May 2010
Prophylactic Oophrectomy ?
• Why
  – Potentially  rates of ovarian cancer
  – Preferential site of metastases
  – Relatively chemoresistant


• Why not
    p        p
  – premenopausal
  –  operative morbidity


                            Edinburgh Oncology Symposium May 2010
Modern Treatment of Large
   Bowel Obstruction
• Prove the colon is obstructed
• Stage the disease
                y prognosis
• Consider likely p g
  – primary histology
      etastat c oad
  – metastatic load
  – co-morbidity




                        Edinburgh Oncology Symposium May 2010
Edinburgh Oncology Symposium May 2010
Cross sectional imaging




              Edinburgh Oncology Symposium May 2010
    Potential advantages of
             stents
•   Relief of obstruction
•   No operation
•               y       p      y
    No ICU delayed hospital stay
•   Cost benefits




                         Edinburgh Oncology Symposium May 2010
            Indications
• Patient unfit for surgery
• Instead of surgery
         g          g y
• As bridge to surgery




                         Edinburgh Oncology Symposium May 2010
Bridge to surgery




           Edinburgh Oncology Symposium May 2010
Technique 1 - Find the
       tumour




             Edinburgh Oncology Symposium May 2010
Stent Insertion




          Edinburgh Oncology Symposium May 2010
Edinburgh Oncology Symposium May 2010
       y
     Systematic review of
     efficacy and safety of
             stents
• 598 attempts
• Technical success 92%
• Clinical success in 88%
  – Palliation in 90%
  – Bridge 85% (95% one stage procedure)

  Br J Surg 2002



                         Edinburgh Oncology Symposium May 2010
           Complications
•   Mortality (1%)
•   Perforation rate 4%
•           g
    Stent Migration 10%
•   Re-obstruction rate 10%




                        Edinburgh Oncology Symposium May 2010
      Current uncertainties
•   Timing of palliative stents
•   Longevity of stents
•    y p                  g
    Symptoms warranting stenting g
•   Need for continuous laxatives
•   Surveillance of luminal patency




                         Edinburgh Oncology Symposium May 2010
          Conclusions
• Colon easy / rectum complex
• Laparoscopic colonic surgery is
  good
• Anastomotic leaks bad
• Rectal cancer surgery should be in
  high volume centre
• DXT stratergy should be considered
• reconstruction is desirable but not
  only consideration
                       Edinburgh Oncology Symposium May 2010
               Judgement
• “Poor judgement is responsible for much
      surgery
  bad surgery, including the withholding of
  operations that are necessary or advisable,
      p                           y
  the performance of unnecessary and
  superfluous operations and the
  performance of inefficient, imperfect and
  wrongly chosen ones”
  Charles Saint 1886-1973




                            Edinburgh Oncology Symposium May 2010
Edinburgh Oncology Symposium May 2010

				
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