Download The importance of mesorectal excision in preventing

Kaiser Permanente
4th Annual National Surgical Symposium
April 2008
Ojai, California
Technical Pearls
for Rectal and Pelvic Surgery
Julio Garcia-Aguilar
Professor of Surgery
Chief, Section of Colon and Rectal Surgery
Department of Surgery
University of California, San Francisco
Important Issues
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know the anatomy
stage the tumors appropriately
develop a "game" plan
have proper instrumentation
get adequate help
Simple instrumentation….
Or not so simple….
Anatomy
• rectum and mesorectum
• pelvis
• pelvic floor muscles
Mesorectum
• Visceral mesentery surrounding the rectum
• Derived from the dorsal mesentery of the hindgut
• Covered by the fascia propria of the rectum
• Contains:
– branches of the superior rectal vessels
– perirectal lymph nodes
Mesorectum
Axial MRI View
Mesorectum
Fascia
Propria
of the
Rectum
Mesorectum
• Connected to pelvic sidewall by the lateral stalks –
a condensation of the endopelvic fascia
• The lateral stalks may contain accessory middle
rectal vessels; the middle rectal artery runs
immediately above the levators
• The mesorectum tapers distally toward the hiatus
of the puborectalis
• The very distal portion of the rectum – the
anorectal ring – is devoided of mesosrectal fat
Mesorectum
• Thinner in the front, compared to sides and the
back
• Separated from urogenital organs by Denonvillier’s
fascia – a remnant of the embryological cull de sac
• The fascia propria of the rectum not very clearly
visualized anteriorly
Sagital view
Mesorectum
Bladder
Pubis
Prostate
Levator
Sphincter
Coronal View
fascia
propria
levator
Some facts…
• The holy plane is the “only” plane
to perform an anatomical excision
of the rectum
• Any other plane makes surgery
technically more difficult and
increases the risk of bleeding,
injuring other organs, and tumor
recurrence
• Total mesorectal excision can be
safely done by an open,
laparoscopic or robotic approach
• Use sharp dissection –
electrocautery works well
Principles
• Best way to identify the right plane is to get
behind the superior rectal vessels above the
promontory
• It is important to pay attention to the hypogastric
plexsus that runs in front of the bifurcation of
the aorta
• Pulling the superior rectal vessels forward
stretches the areolar tissue that connects the
fascia propria of the rectum to the promontory
and opens the entrance to the “holy plane”
Best way to identify the right plane is to get behind
the superior rectal vessels above the promontory
It is important to pay attention to the
hypogastric plexus that runs in front of the
bifurcation of the aorta
Pulling the superior rectal vessels forward stretches the
areolar tissue that connects the fascia propria of the rectum
the promontory and open the entrance to the “holy plane”
Presacral Areolar Plane
Start the dissection posteriorly and continue as far
as you can
Visualize and preserve the hypogastric nerves as
they course laterally and distally
Work from posterior to anterior opening the
peritoneum in both sides of the mesorectum all the
way to the cull-de-sac.
Divide the lateral stalk keeping in mind the pelvic
plexus – they usually contain accessory branches of
the middle rectal
In cancer patients continue the anterior dissection
in front of Denonvillier’s
Surgical
Specimen
TME and Sphincter Preservation
Division of the Rectum
I use a TA 30 with 4.5 mm staples (green load)
If I have enough length, I fire twice and divide the
rectum between the staple lines
Special Circumstances…
• The high tumor
• The very distal tumor
• The anterior tumor
The Cancer of the Upper Rectum
Do we need to excise the entire
mesorectum in every rectal cancer?
Distal Mesorectal Spread
in TME Specimens
• 50 rectal cancer patients treated by TME
• No mesorectal tumor deposits in 6 T2 tumors
• Mesorectal/nodal deposits in 28 of 44 (64%) T3 tumors
– 12 with mesorectal deposits distal to tumor
– 5 with mesorectal deposits more than 2 cm distal to
tumor
– 1 with mesorectal deposits more than 5 cm distal to
tumor
Reynolds et al, BJS 1996
Distal Mesorectal Spread
Increases with Tumor Penetration
• 20% mesorectal tumor deposits distal to tumor
– 12% for T3 tumors
– 25% for T4 tumors
• No tumor deposits beyond 5 cm from tumor
Hida et al, JACS 1996
Total vs. Partial Excision of the
Mesorectum
• Evidence: retrospective analysis
• Cancers of the upper rectum treated by partial excision of
the mesorectum have the same local recurrence rate than
rectosigmoid cancers
» Lopez-Kostner et al, Surgery 1998
• No difference in local recurrence between upper rectal
tumors treated by partial mesorectal excision and mid and
lower rectal tumors treated by total mesorectal excision
» Bokey et al, Br J Surg 1999
“Tumor Specific” Mesorectal Excision
• Sharp excision
• Complete excision of the mesorectum for cancers
of the mid and distal rectum
• Transection of the mesorectum 5 cm below the
lower margin of the tumor for cancers of the
upper rectum
• No conning to the distal resection margin
Low rectal tumors
For “very” low tumors…
• Anterior tumors that do not infiltrate the
prostate or vagina, levators or anal sphincter
• Have responded to neoadjuvant chemoradiation
• You are uncertain about being able to place the TA
stapler and ensure adequate margin
• Do a transanal – transabdominal resection with
direct vision of the distal margin
Transanal – Transabdominal Approach
• Star with the patient prone
• Make a full-thickness circumferential incision in
the bowel wall at or slightly above the dentate line
– you should see the lower margin of the tumor
(leave 1 cm margin)
• Dissect the rectal wall from the surrounding
tissues – prostate anteriorly, puborectalis
laterally, and levator posteriorly
• Carrie the dissection several centimeter
proximally
• Close the lumen of the rectum with interrupted
sutures
Transanal dissection
Transanal – Transabdominal Approach
(cont)
• Transfer the patient to the lithotomy position
• Do your total mesorectal excision until you reach
the dissected area down in the pelvis
• If you do it laparoscopically you could remove the
specimen through the anus, and avoid an abdominal
incision
• Do your hand-sewn colo-anal anastomosis
• Loop ileostomy
Transanal removal of specimen
Transanal
Intersphincteric
If the tumor infiltrates the levator or the sphincter
before neoadjuvant therapy, the patient should
probably have an APR
Low tumors that infiltrate the levators …
Low tumors that infiltrate the levators …
Abdominoperineal Excision
APR Specimens - No conning!!
From Marr et al, Ann Surg 242, 2005
Anterior (distal) Tumors
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Mesorectum thinner in the front
Prognosis worse in anterior tumors
Stay anterior to Denonvillier’s
Consider extended resection if fat plane not seen
Males less likely to have an “extended” resection
Up to 12% of rectal cancers
extend beyond the structures that
are normally removed with a total
mesorectal excision
Postoperative chemoradiation does not
prevent recurrence if the
circumferential resection margin
is involved by tumor
Organs Involved
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Urinary System
Male genital system
Female genital system
Small bowel
Sacrum
Pelvic side walls
Fixation to Adjacent Organs
• Direct tumor infiltration in ~ 50% of cases
• Due to inflammatory adhesions in ~ 50% of cases
• Impossible to distinguish tumor infiltration from
inflammatory adhesions
Facts
• Separating tumor from adjacent organs associated
with high tumor recurrence rates
• En block resection associated with less recurrence
and better survival, in spite of higher operative
morbidity
Avoid facing a multivisceral
resection when the surgeon and
the patient are unprepared
Diagnosis
• Suspect from H & P
– Urogenital symptoms predictors of involvement in
93% of cases
– Digital exam not very accurate in identifying
colorectal cancer invasion to adjacent organs
• Confirm diagnosis by endoscopy
• Determine extension by imaging studies
Efficacy in Assessing Invasion of
Adjacent Organs
• Ultrasound
• CT
• MRI
44% to 94%
64%
75%
Limitations of Imaging Studies
in Advanced Rectal Cancer
• Most patients with an advanced rectal cancer receive
preoperative chemoradiation
• Preoperative images not comparable to pathology
• Imaging studies unable to distinguish post-treatment
fibrosis from residual tumor
Decisions regarding
the extent of resection
in patients with
locally advanced rectal cancer must
be based on
the pre-treatment images
Tumor Infiltrating Bladder
CT Scan
MRI
Patient Selection
• Patient related issues
– Performance status
– Co-morbid conditions
• Extension of the disease
– Local extension
– Metastasis
Resection Margins
Three Anatomical Planes
Anterior:
the urogenital organs
Lateral:
ureters, iliac vessels, side wall
Posterior:
sacrum, piriformis, sacral plexus
Anterior and Posterior Margins
Lateral Margins
Involved
Free
The plane beyond the mesorectum
Lateral Pelvic Wall Involvement
only 17 (31%) of 55 patients with T4 rectal cancer
Curative Resection
Involved
Non-involved
Survival
6%
13 months
92%
49 months
Yiu et al, DCR 2001
Preoperative Considerations
• Plan de operation
• Multidisciplinary approach
Urology
Intraoperative Radiation
Plastic surgeon
• Prepare OR team
Operative Decisions
• Exclude intra-abdominal spread
• Assess resectability; if you think you cannot remove the
tumor, don't try
• Start your dissection in planes that you think should be
normal based on proeperative imaging
• Work around the tumor
• Avoid open anatomical planes potentially involved by
tumor
Operative Decisions
• En-block (total or partial ) resection of adjacent organs
• Take frozen sections
• Identify potential positive margins
• Don't think about the reconstruction; leave it to the
urologist and plastic surgeon
Results of Surgery for Locally
Advanced Rectal Cancer
• Recurrence
7% to 33%
• Survival
31% to 80%
• Complications
11% to 79%
Multivisceral Resection
No Adjuvant Therapy
Moriya et al, Colorectal Dis 2003
• 128 patients with T4 rectal cancer
• 23% required pelvic exenteration
• 1.6% operative mortality
• 27% morbidity
• 33% recurrence
• 57% survival
Multivisceral Resection
And Neoadjuvant Therapy
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Sanfilipo et al, IJRBP 2001
45 patients with T4 tumors by CT or ERUS
5-FU based chemoradiation
13 never had surgery
14 of 32 (41%) had invasion of adjacent organs
20% local recurrence
69% survival
Management of the Urinary System
• Extensive resections often requires complex
reconstruction and permanent urinary diversion
• Partial excision my compromise cure without reducing
morbidity
• Urinary leaks common after chemoradiation
Management of the Urinary System
• 101 patients with locally advanced or recurrent
colorectal cancer
• complete cystectomy or prostatectomy better
results than partial resection
• ureteral invasion was an ominous sign
Stief, European Urol 2002
Gender Differences in Treatment?
• 282 patients undergoing APR at MSKCC
– 15% of females had vaginectomy
– 4% of males had prostatectomy
• Are we less aggressive in males?
• Can this explain gender differences in local
recurrence?
Complications
after Multivisceral Resections
• Probably higher than after simple resection
• Survival similar if resection RO in both groups
• Most common complications:
– sepsis
– delayed wound healing
– fistulas
Perineal Wound Complications
• Infection/separation in 13% to 79%
• Rate increases if:
– preoperative radiation
– total pelvic exenteration
– sacrectomy
• Musculocutaneous flaps reduce the rate of
complications (79% to 46%, Ko et al surgery 2001)
– Rectus muscle
– Gluteus
– Gracilis
Summary
• Identify patients before start treatment
• Treatment decisions based on initial imaging
studies
• Multidisciplinary approach
• Initial surgery provides the best opportunity for
cure
• Cure is possible if the tumor can be totally
removed
Conclusions
• A sharp excision following the areolar space outside the
fascia propria of the rectum is the optimal surgical
technique to perform a radical proctectomy.
• This procedure can be now be equally performed by open,
laparoscopic, or robotic approach.
• A total mesorectal excision should be the standard surgical
procedure for cancers of the mid and distal rectum that
require a radical operation.
• Transection of the mesorectum 5 cm distal to the lower
mural margin of the tumor is acceptable for cancers of the
upper rectum.