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

Oncological and functional outcome of ultra low colo – anal anastomosis with and without intersphincteric resection for low rectal cancer. R.Ruppert. Städt. Klinikum München GmbH Klinikum – NEUPERLACH Klinik für Allgemein und Viszeralchirurgie endokrine Chirurgie und Coloproktologie

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

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  1. Oncological and functional outcome of ultra low colo – anal anastomosis with and without intersphincteric resection for low rectal cancer R.Ruppert Städt. Klinikum München GmbH Klinikum – 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

  2. Rectal cancer 40 % of all colorectal carcinomas are located in the rectum Rectum is defined as 16 cm upwards from anocutaneus line Surgical Technique Sphincter saving procedures Sphincter sacrificing procedure Low anterior resection (LAR) Intersphincteric resection (ISR) Abdominoperineal Resection (APR)

  3. 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

  4. Surgical options for rectal cancer in the lower third of the rectum Low anterior resection (LAR) / ISR Expected number : 80 -85 % abdominoperineal Resection (APR) Expected number : 10 -15 %

  5. The Status of radical proctectomy and sphincter-sparing surgery in the United States Ricciardi, irnig,Madoff,Rothenberger,Baxter DCR 8, 2007:1119-1127

  6. Oncological Outcomes after Mesorectal Excision For 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,

  7. Julius von Hohenegg (1859 – 1940)„pull through procedure“Wien klin.Wzschr.1888 1:272-354 Schematischer Sagittalschnitt durch ein männliches Becken nach ausgeführter Durchziehmethode

  8. Straight coloanal anastomosis Established by Sir Alan Parks 1974 Circular stapler / hand sewn TME Covering stoma

  9. History of „intramural spread“ 1910: Hanley 1913: Cole case reports Large intramural tumor spread 5 cm rule for distal resection margin was establlished for avoiding local recurrence

  10. 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 stage They have a worse overall survival but no increased local recurrence Conclusion : 1cm distal resection margin is adequat

  11. CRM involvement APR versus AR The CRM is the most pognostic factor ( independent) not the distal resection margin (DIS)

  12. Japanese ExperienceSaito 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 %

  13. French Experience – Eric Rullier, ESCP 2008 NantesResultsn = 300

  14. Oncological feasibilityFrench experience - Eric Rullier, ESCP, Nantes 2008 n = 300 ns

  15. Oncological outcome French experience - Eric Rullier, ESCP 2008, Nantesn = 300

  16. 5 year overall and DFS

  17. 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

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

  19. Functional outcome ? How is continence influenced by intersphincteric resection ? Quality of life ?

  20. Sphincter function 1. Internal anal sphincter – resting pressure 2. External anal sphincter - squeeze pressure

  21. Intersphincteric resectionPhysiology • Loss of internal sphincter • (innervation) • 2. Loss of anal transitional zone • 3. loss of rectal compliance

  22. Own Results 1978 – 1992low 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

  23. summary • Final evaluation for functional outcome makes sense only after 2 years. • Subjective outcome in our series • 80,6 % satisfied • 5,8 % not satisfied

  24. Functional outcome P = 0,02 ns Bretagnol Dis Colon Rectum 2004

  25. 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

  26. "Advance means progress to something better and not progress to something new." Sir Heneage Ogilivie (1887-1948 Guy's Hospital London)

  27. Thank you for your attention

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