REVIEW Scandinavian Journal of Surgery 92: 53–56, 2003
SURGERY FOR RECTAL CANCER T. Wiggers Division of Surgical Oncology, Groningen University Hospital, Groningen, The Netherlands Key words: Rectal cancer; total mesorectal exicision; transanal endoscopic
INTRODUCTION Since the pioneers, work of Miles in the beginning of the twentieth century, surgery with a combined abdominal and perineal approach is the mainstay for the treatment of rectal cancer. During the first 50 years, the perineal route for removal of the rectal cancer without anastomosis was advocated but starting in the fifties, the anterior approach with restoration of continuity became increasingly popular (1) . With the knowledge of limited intramural spread of the tumor the number of sphincter saving procedures increased. However, results varied enormously among surgeons with different local recurrence rates and corresponding survival figures (2) . Increasingly it became clear that the local recurrence rate after resection of a rectal carcinoma is directly related to the surgical technique, the radicality of the resection and the optimal use of (preoperative) radiotherapy (3) . The surgeon became the most important prognostic factor. This makes him responsible for the end result. Every attempt should be made to achieve a R0 resection, which means complete macroscopic and microscopic removal of the tumor including its lateral and caudal lymphatic spread in the mesorectum. Besides low local recurrence rates modern surgery should be associated with minimal short term (leakage rates, wound infections) and long term morbidity (impaired sexual and urological functions and sphincter saving procedures). In this paper, we shall describe the relevance of preoperative imaging, the use of the Total Mesorectal Excision (TME) as the golden standard, the alternatives for surgery and the maintenance of quality control in rectal cancer surgery.
Correspondence: Theo Wiggers, M.D. Division of Surgical Oncology Groningen University Hospital P.O. Box 30.001 NL - 9700 RB Groningen The Netherlands Email:
[email protected]
RELEVANCE OF IMAGING FOR THE CHOICE OF A SURGICAL PROCEDURE After establishing of the diagnosis of a rectal cancer, preoperative imaging should focus on the presence of distant metastases and the extent of the local tumor growth relevant for the surgical procedure. The classical clinical pretreatment TNM staging is not sufficient for this purpose since surgical decisions are not based on the outcome of this classification. Terms as “tethered” or “fixed” have no uniform description and should not be used any longer. The crucial step in imaging is not the discrepancy between T2 and T3 tumors but the relation of the primary tumor to the endopelvic fascia (4) . Tumors with a distance of less then two millimeters to the fascia have a high local recurrence rate even with the use of the total mesorectal excision and the use of short term preoperative radiotherapy (5). A MRI with a phase array coil (6) or a multislice CT scan can help in the prediction of a free circumferential margin. Based on this outcome one may proceed with direct surgery in patients with small tumors (T1, T2, limited T3) or with neo-adjuvant (chemo) radiation in patients with locally advanced tumors (extensive T3 or T4) in order to achieve downsizing and even downstaging. Comorbidity or disseminated disease is relevant each in its own way. Age by itself is not a contraindication for surgery (7) . However severe pulmonary or cardiac comorbidity with an expected high mortality due to the abdominal part of the procedure may influence the choice in favor of a more limited procedure such as a local excision. If the life expectancy is very short due to extensive disseminated disease, other treatment modalities for local symptom control may be appropriate. Laser therapy or radiation can control bleeding and placement of a stent or local ablative techniques obstruction (8). Even the construction of a colostomy only can be adequate palliation. A CT scan is the best option for examining lung, liver and the remaining abdomen with only one investigation (so called “one stop shop”) with the highest sensitivity and specificity. The use of endoluminal ultrasound is important if local procedures are anticipated. It is the best modal-
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ity to distinguish between infiltration of the tumor beyond the mucosa in the muscularis propria or even into the mesorectal fat (9). Positron Emission Tomography (PET) is in general not advisable in primary cases because of false positive results caused by inflammatory changes in the tumor. THE “GOLD STANDARD”: TOTAL MESORECTAL EXCISION (TME) The aim of surgery is to achieve a tumor free margin in all directions and removal of the lymphatic spread close to the tumor. This procedure should have limited morbidity and mortality with an acceptable quality of life. Since the pioneer work of Heald, Morya and Enker it has become clear that with a sharp dissection technique, following the anatomical planes, radical resections with a low recurrence rate of a less than 10 % are possible (10–12). Other positive effects are an increased number of sphincter-saving procedures and preservation of the neural structures resulting in less sexual and bladder dysfunction. STAGING
At the start of the laparotomy, the abdomen is carefully checked for liver, nodal, or peritoneal metastases (optional intraoperative ultrasound for the liver). In case of an unanticipated locally advanced tumor this laparotomy can used as a staging procedure only. Nevertheless, if known on forehand it is often part of the preoperative workup to prepare the patient for preoperative radiotherapy by clipping the cranial level of the tumor, using the distal rectosigmoid as a spacer and construction of a stoma. This spacer is essential to remove small bowels as much as possible from the small pelvis (13). Only if a complete distal obstruction is present construction of a mucous fistula is necessary. Surgical exploration follows 4–6 weeks after completion of the radiotherapy. In case of a T1, T2 or limited T3 tumor a standard TME procedure has to be performed: The operation itself begins with the opening of the avascular plane between the mesentery and the surrounding parietal structures. In general, the inferior mesenteric artery will not be divided flush with the aorta, but 1–2 cm below it, to preserve the autonomic nerves around its origin. At the lower border of the pancreas, the inferior mesenteric vein is divided to create better mobility of the splenic flexure. The avascular aeriolar tissue plane, the ‘holy plane’, surrounds the mesorectum, forming a buttock-like bilobar lipoma. Under direct vision and sharp dissection, this plane is followed. There are two important nerve structures to be preserved. The hypogastric plexus, curving anteriorly around the mesorectal surface, and the nervi erigentes. They leave the sacral foramina, and join the presacral nerves to form neurovascular bundle on the lateral edges of the seminal vesicles. From the posterior dissection plane the lateral attachments are carefully cut under direct vision of the sidewalls of the pelvis. Occasionally one or two middle rectal ves-
sels have to be divided. At the anterior side, the peritoneum is incised anterior to the peritoneal reflection. Dissection is continued behind the vesicles and in front of Denonvilliers fascia. Where the fascia joins with the posterior prostatic capsule, it is incised onto the anterior rectal wall. At this level, the decision has to be made to continue with either a low anterior resection with direct anastomosis usually with the aid of stapler apparatus or to continue with the perineal part of the operation completing it as an abdominoperineal resection. Turning the patient to a prone position makes the distal dissection between the rectal wall and the prostate easier due to the direct vision and the ability to control the bleeding more efficient. In cases of T4 tumors the above mentioned procedure is extended with an en-bloc resection of the involved organs. For restoration of continuity, an end to side or a small pelvic J-pouch is advocated because of the short-term functional results (significant less bowel movement daily) (14) . FILLING THE GAP
At the end of the operation, after an abdominoperineal resection an omentoplasty may be constructed to fill the empty pelvic space both for controlling diffuse bleeding and promoting perineal healing (15). Other possibilities especially in cases after total exenteration are myo(cutaneous) flaps such as the rectus abdominis flap, the (bilateral)gracilis or even a free latisimus dorsi flap based on the inferior epigastric vascular pedicle in the groin. A strong and safe pelvic floor reconstruction after extensive abdominoperineal resections is obtained by a “sandwich” procedure consisting of a prosthetic mesh covered on one side by the omentum and on the other side by the gracilis. DIVERTING STOMA
The construction of a diverting stoma either ileo- or colostomy after a low anterior resection is still controversial (16). Most surgeons prefer to be liberal in the use if there is any doubt about the safety of the anastomosis. The results of prospective randomized studies about the advantage of an ileostomy or colostomy are contradictory Although there are at least five prospective randomized studies on the choice for a diverting colostomy or ileostomy for temporary diversion of the fecal flow the conclusion is different since it is based on different endpoints used (17, 18). LAPAROSCOPIC SURGERY
Laparoscopic resection of colorectal malignancies is still controversial, mainly due to initial reports on port-site metastases. Several retrospective studies with large numbers of patients now suggest that the outcome is comparable to open surgery. It is also clear that Total Mesorectal Excision is technically possible with the use of the laparoscope. First longterm results of a randomized trial comparing laparoscopic versus open colectomy for colonic cancer
Surgery for rectal cancer
showed an improved 3-year survival following laparoscopic resection (19). A prospective randomized study in rectal cancer is necessary if this approach is at least equal to the open procedure in a cost-effective way. TRANSANAL ENDOSCOPIC MICROSURGERY In selected cases, a local excision is advocated with the TEM (transanal endoscopic microsurgery) procedure (20). This may be attractive an alternative for old patients with a high comorbidity but data reporting on local recurrence per T level are always higher than with radical resections (21). Only for T1 cases with well-differentiated tumors this may be considered as standard treatment. The combination with neo-adjuvant treatment consisting of chemoradiation before resection is even in T2 cases more promising with a local recurrence rate of 2.9 % (22). After induction radiochemotherapy up to 20 % of the cases have a complete pathological response. Refraining of operation is no option in cases with a negative biopsy since the local recurrence rate in those cases is very high. Sufficient data from literature are lacking to consider local excision even after induction therapy as standard treatment. Large number of patients in a prospective study are necessary to prove if a local recurrence rate below 5 % is possible since this is the standard in modern treatment of rectal cancer. VOLUME, TRAINING AND QUALITY CONTROL After the first description of McArdle (23) in 1991 there has been a continuos flow of manuscripts about the relation between volume and outcome and training and outcome (24) from many countries all over the world. In the Dutch TME study training and specialization of the individual surgeon was directly related to the local recurrence rate without a strong relationship between hospital volume and outcome (25). The intactness of the mesorectum proved to be an independent variable in predicting the local recurrence rate (26). This quality control tool, which can be determined together with the pathologist, is combined with the percentage R0 resections and leakage rate a strong instrument for a from day to day monitoring of the quality of rectal cancer treatment. With the introduction of the circumferential margin as the key to optimal treatment of rectal cancer, all disciplines, both diagnostic and therapeutic involved in rectal cancer share the same interest and talk the same language (27). THE FUTURE ROLE OF SURGERY After a century of rectal cancer surgery, the total mesorectal excision is to be considered as the golden standard. Since the systematic introduction of this technique reproducible figures both on local recurrence rates of around ten percent and survival fig-
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ures of 70 % have been reported (28). This technique is presently the “golden standard” in combination with preoperative radiotherapy. It is unlikely that in primary resectable cases surgery that is more extensive will occur. The Japanese data with resection outside the mesorectal envelope have no better local recurrence data. In the coming years there will be promising developments for less mutilating effects of the surgery (sphincter preservation and avoidance of sexual and urological complications). On the one hand, improvement of nerve sparing surgery and the introduction of laparoscopic (assisted) rectal cancer surgery will minimize morbidity (especially in the elderly patient). On the other hand more effective neo-adjuvant radiochemotherapy and availability of pathologic markers in predicting both the presence of lymph node metastases and effect of radiotherapy will raise the number of local excisions. Both predictive and prognostic markers will have an influence on a more individualized treatment plan and tailor the extent of surgery and the use of adjuvant therapy.
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Received: January 31, 2003
