Oncological and functional outcome of ultra low colo – anal anastomosis with and without

intersphincteric resection for low rectal cancer

R.Ruppert

Städt. Klinikum München GmbHKlinikum – NEUPERLACH

Klinik für Allgemein und Viszeralchirurgie endokrine Chirurgie und Coloproktologie

Teaching hospital of the Ludwigs Maximilians University

Heads of Departement:Prof. N. Nüssler / Dr. R.Ruppert

40 % of all colorectal carcinomas are located in the rectum

Rectum is defined as 16 cm upwards from anocutaneus line

Rectal cancer

Surgical Technique

Sphincter saving procedures

Abdominoperineal Resection

(APR)

Low anterior resection

(LAR)

Intersphincteric resection

(ISR)

Sphincter sacrificingprocedure

Total mesorectal Exzision (TME)

•Sharp dissection under direct vision•“plane” between visceral und parietale pelvic fascia •Stelzner 1962•Heald 1982

Stelzner F (1962) Die gegenwärtige Beurteilung der Rectumresektion und Rectumamputation beim Mastdarmkrebs. Bruns Beitr 204:41

Heald RJ, Husband EM, Ryall RDH (1982) The mesorectum in rectal cancer surgery—the clue to pelvic recurrence? Br J Surg 69:613–616

Surgical options for rectal cancer in the lower third of the rectum

Low anterior resection(LAR) / ISR

abdominoperineal Resection

(APR)

Expected number : 80 -85 %

Expected number : 10 -15 %

The Status of radical proctectomy and sphincter-sparing surgery in the United StatesRicciardi, irnig,Madoff,Rothenberger,Baxter

DCR 8, 2007:1119-1127

Oncological Outcomes after Mesorectal ExcisionFor Cure for Cancer of the Lower Rectum:Anterior vs Abdominoperineal Resection

Wibe et al., Trondheim , DCR 2004, 48-58

2136 konsecutive patients between 1993-1999 in 47 Hospitals in Norway

Multivariate analyses of prognostic factors:

APR (risc 1,3), age over 20y (3,1), UICC,

Julius von Hohenegg (1859 – 1940)„pull through procedure“

Wien klin.Wzschr.1888 1:272-354

Schematischer Sagittalschnitt durch ein männliches Becken nach ausgeführter Durchziehmethode

Straight coloanal anastomosis

Established by Sir Alan Parks 1974

Circular stapler / hand sewnTMECovering stoma

History of „intramural spread“

1910: Hanley1913: Cole

case reports

Large intramural tumor spread

5 cm rule for distal resection marginwas establlished

for avoiding local recurrence

1 cm rule ?

• 1995: Shirouzu– 610 Pat.

• DIS: overall 10%, all cases less < 1cm– 3,8% were curative cases

– 40% were palliativ cases (distant metastases)

Pat. with DIS have an advanced cancer stageThey have a worse overall survival but no increased

local recurrenceConclusion : 1cm distal resection margin is adequat

CRM involvement APR versus AR

APR ARMercury < 6cm tumours n=282 33% 13%Classic trial curative

n= 400 21% 10%

Dutch TME trial curative n= 1586 29% 13%

Norwegian audit 12% 5%

Trent pelican Basingstoke 21% 10%

CR 07 n=1350 17% 8%

The CRM is the most pognostic factor ( independent) not the distal resection margin (DIS)

Japanese Experience

Saito N et al. Dis Colon Rectum 2006

• 1995 - 2004 7 hospitals• 228 low rectal cancers < 5 cm from anal verge• T 1 n=46, T 2 n= 78, T 3 n= 104• Neoadjuvant Radiotherapy 57• Local recurrence at 5 years: 7 %• Disease free survival (DFS): 83 % at 5 years• Good continence (Kirwan I –II): 68 %

French Experience – Eric Rullier, ESCP 2008 Nantes

Resultsn = 300

CAA Partial ISR Total ISR APR

Age 67 65 63 65 ns

Tumour stage T1/T2

22 % 13 % 10 % 6 % 0,001

T3 72 % 76 % 81 % 51 %

T4 6 % 11 % 9 % 43 %

Preop RT 67 % 86 % 88 % 79 % 0,007

Distance to anal ring (cm)

2 1 - 0,5 - 1 0,001

Hand sewn 37 % 96 % 100 % 0,001

Level of anastomosis

3 cm 2 cm 1 cm 0,001

Colonic pouch

62 % 72 % 83 % 0,01

Oncological feasibility French experience - Eric Rullier, ESCP, Nantes 2008

n = 300

CAA p ISR t ISR APR

CRM (mm)7 5 4 6 0,07

R o resection 87 % 88 % 81 % 81 % ns

Tumor stage

I43 % 45 % 46 % 16 % 0,005

II 22 % 24 % 26 % 39 %

III 35 % 29 % 30 % 45 %

ns

Oncological outcome

French experience - Eric Rullier, ESCP 2008, Nantes

n = 300

CAA P ISR T ISR APR

Follow up (month) 37 39 55 36 ns

Local recurrence 5 5 5 9 ns

Overall recurrence 20 % 20 % 21 % 36 % P = 0,07

Delay of recurrence (month)

17 18 11 15 ns

5 year overall and DFS

Meta analysis of ISRTilney & Tekkis Colorectal Disease 2008

• 21 series from 13 units• 612 patients• Mortality 1,6 %• Leakage 10,5 %• Local recurrence 9,5 % (0 – 31)• 5y survival 81 %• Radiotherapy: oncological benefit but worse

functional outcome

Summary

For oncological reasons, intersphincteric resection is safe and should be offered to all patients as often it is possible.

Functional outcome ?

How is continence influenced by intersphincteric resection ?

Quality of life ?

Sphincter function

1. Internal anal sphincter – resting pressure

2. External anal sphincter - squeeze pressure

Intersphincteric resectionPhysiology

1. Loss of internal sphincter (innervation)2. Loss of anal transitional zone3. loss of rectal compliance

Own Results 1978 – 1992

low anterior resections n = 2707coloanal anastomosis n = 103 (3,8 %)

• Male = 75, female = 28• Age 58,6 ( m = 59,8, f = 57,4)• Rectal cancer n =88• Large adenomas n =9• Rectovaginal fistula after radiotherapy n = 6

incontinence first postoperative year (%)

normal continence;

40,8

grade I (gas); 18,4

grade III (solid); 9,7

grade II (liquid); 31,1

incontinence after the first postoperative year (%)

normal continence;

67,9

grade I (gas); 16,5

grade III (solid); 3,9grade II (liquid); 11,7

summary

• Final evaluation for functional outcome makes sense only after 2 years.

• Subjective outcome in our series– 80,6 % satisfied– 5,8 % not satisfied

Functional outcome

CAA P ISR T ISR

normal continence

73 % 52 % 51 %

Incontinence for gas

6 % 7 % 3 %

Minor incontinence

6 % 26 % 24 %

Major incontinence

13 % 11 % 16 %

colostomy 2 % 4 % 5 %

Good continence

79 % 59 % 54 %

P = 0,02 ns

Bretagnol Dis Colon Rectum 2004

Summary

• functional outcome after ISR is acceptable• Be aware of minor and major problems of incontinence in one third

of the patients.• Preoperative information about these problems are absolutely

necessary• Younger patients are more suitable for ISR.• No good results will be achieved in older women• Patient selection is the key to good functional results

Avoid

Creation of a perineal stoma

"Advance means progress to something

better and not progress to something new."

Sir Heneage Ogilivie (1887-1948Guy's Hospital London)

Thank you for your attention