Farella-結(jié)直腸癌外科進展.ppt

1、The type of operation and the surgeon as factors affecting oncological outcome in rectal cancer surgery,Department of Surgery and Anaesthesia Policlinico S.Orsola-Malpighi University of Bologna ITALY,S.FARELLA,EPIDEMIOLOGY,COLORECTAL CANCER,CRC is one of the most important reason of death in Europe

2、and U.S. 300000 new cases and 200000 deaths per year 53.5/100.000 males 37.6/100.000 females In Italy 16.000 new cases in 1970, 37.000 in 1990 e, in 1998, 50.000 in 2000. In England 10.000 nw cases of RC per year with 6.000 deaths In USA, in1995, 39.000 cases of RC with 8.000 deaths,Eff. Health Care

3、 Ed. it, vol 2 n 5; Sett.ott. 1998 C Camm et al, JAMA 2000; 284:1008-1015 JM Wheeler et al, Br J Surg 1999; 86:1108-1120 SD Wexner, NA Rotholtz, Dis Colon Rectum 2000; 43:1606-1627,RECTAL CANCER, The technical success of rectal cancer resection is usually measured by permanent stoma rate, incidence

4、of local recurrence and 5-year survival ,J.H. Scholefield J. Gastroenterol 2000; 35:126-129,Evolving concepts in surgical strategy,The goal has always been to achieve an optimal oncologic resection with good quality of life. Abdomino-perineal resection has been considered for long the best way to ac

5、hieve that goal. Recent advances in colorectal surgery (stapling devices, TME, coloanal anastomoses) and a better understanding of distal and lateral spread of the rectal cancer have dramatically decreased the indication to the abdomino-perineal resection, which is now indicated in about 10% of case

6、s.,JMD Wheeler et al, Br J Surg 1999; 86: 1108-1120 SD Wexner, NA Rotholtz, Dis Colon Rectum 2000; 43:1606-1627,RECTAL CANCER,Variability in results,The incidence of local recurrence is 3% to 32%. Ten year-survival after curative surgery is 20% to 63%. Two-year survival after palliative surgery is 7

7、% to 32%.,C S Mc Ardle, D Hole, BMJ 1991; 302:1501-1505 JMD Wheeler et al, Br J Surg 1999; 86:1108-1120 SD Wexner, NA Rotholtz, Dis Colon Rectum 2000; 43:1606-1627,RECTAL CANCER,Main factors affecting variability in results,Tumor biology Stage of disease Therapeutic plan Type of operation Surgeon,RE

8、CTAL CANCER,The type of operation as factor affecting oncological outcome,RECTAL CANCER,Surgical options,Traditional resection with stapled or sutured anastomosis,Traditional resection with low stapled or sutured anastomosis Proctectomy + TME with direct or pouch colo-anal anastomosis,APR,APR + grac

9、iloplasty / artificial sphincter,Proctectomy + TME with direct or pouch colo-anal anastomosis,Local treatment (transanal techniques),RECTAL CANCER,Trans-anal techniques,SD Wexner, NA Rotholtz, Dis Colon Rectum 2000; 43:1606-1627,RECTAL CANCER,Trans-anal procedures include methods of,Excision (local

10、excision, TEM) Ablation (laser, cryotherapy, electrocautery, endocavitary irradiation),Advantages: low morbidity and low mortality rates,Disadvantages: inability to assess the lymph nodes and (ablation) to permit staging of the tumor itself.,Trans-anal techniques,Trans-anal techniques can result in

11、cure rates equivalent to those obtained after abdominal procedures. Appropriate patient selection is mandatory. If strict criteria are used, 3-8% of patients with rectal cancer are candidates to curative trans-anal procedures.,SD Wexner, NA Rotholtz, Dis Colon Rectum 2000; 43:1606-1627,RECTAL CANCER

12、,Selection criteria for curative trans-anal treatment,SD Wexner, NA Rotholtz, Dis Colon Rectum 2000; 43:1606-1627,RECTAL CANCER,Tumor stage andrisk of nodal involvement,Poorly differentiated, mucinous tumors with lymphovascular involvement carry a much higher risk of nodal metastatic involvement.,AK

13、 Banerjee et al, Br J Surg 1995; 82:1165-73 MJ Killingback, World J Surg 1992; 16:437-446 DG Kim, RD Madoff, Semin Surg Oncol 1998; 15:101-113,RECTAL CANCER,Curative trans-anal treatment: results,Ablation: 47 82 %,Excision: 80 90 %,Survival,Ablation : 8 (50) 21 (85) %,Recurrence,Excision : 0 27 %,ME

14、 Abel et al, Dis Colon Rectum 1993; 36:991-1006 TL Hull et al, Dis Colon Rectum 1994; 37:1266-1270 HR Bailey et al, Surgery 1992; 111:555-561 B Mentges et al, Dis Colon Rectum 1996; 39:886-892,RECTAL CANCER,RECTAL CANCER TREATED BY TRANSANAL EXCISION,RECTAL CANCER,Rectal cancer,If we consider other

15、surgical options We should take care of: Distal margin Lateral margins Mesorectum,Distal margin,WG Pollet, RJ Nicholls, Ann Surg 1983; 198:159-163,Distal margin 2 cm does not adversely affect recurrence and survival.,N Wolmark, B Fischer, Ann Surg 1986; 204:480-487,Comparable disease-free survival i

16、n pts with 2 vs 3 cm distal margin.,K Shirouzu et al, Cancer 1995;76:388-392,Distal intramural spread present in only 3,8% of cases (19/505) after curative resection.,S Andreola et al, Dis Colon Rectum 1997;40:25-29,Distal intramural spread related to stage, size, depth of invasion and nodal status.

17、,RECTAL CANCER,Variations in distal margin according to specimen setting,cm,Intra-abd. specimen,Resected specimen,Fixed specimen,4,2,2,9,2,3,SP Kwok et al, Br J Surg 1996; 83:969-972,RECTAL CANCER,Lateral margins,P Quirke et al, Lancet 1986; 332:969-972,52 pts, with 14 (27%) having positive lateral

18、margins (follow-up 23 months). Local recurrence: 85% in pts with positive lateral margins vs 3% in those with negative margins.,DF de Haas Kock et al, Br J Surg 1996; 83:781-785,253 pts with 31 (12%) having positive lateral margins. Local recurrence: 29% in pts with positive lateral margins vs 8% in

19、 those with negative margins (p0.01).,RECTAL CANCER,RJ Heald et al, Br J Surg 1982; 69:613-616,Rectum and mesorectum must be resected “en bloc” (TME) because of possible distal mesorectal neoplastic diffusion. Extensive use of TME = 3.6% local recurrence and 86% 9-year survival.,Mesorectum,RECTAL CA

20、NCER,TME and local recurrence,SD Wexner, NA Rotholtz, Dis Colon Rectum 2000; 43:1606-1627,RECTAL CANCER,TOTAL MESORECTAL EXCISION,RECTAL CANCER,Rectal Cancer,Guidelines 2000 for colon and rectal cancer surgery,Society for Surgery of the Alimentary Tract,American Society of Colon and Rectal Surgeons,

21、Society of Surgical Oncology,National Cancer Institute,“ Experts Panel” (21 members),H Nelson et al. J Natl Cancer Inst 2001; 93: 583-96,Rectal Cancer,Level of evidence,Grade of raccomandation,Tumor-free distal margin 2 cm. Tumor-free radial margin “En bloc” resection of adherent lesions R0 resectio

22、n (no residual tumor) Total mesorectal excision Lymphovascular ligation at IMA origin Extended lateral lymph node dissection,III-IV III III IV III II-III IV,B B B B C C C,Optimal rectal cancer surgery: technical factors positively affecting oncological outcome.,H Nelson et al. J Natl Cancer Inst 200

23、1; 93: 583-96,Rectal Cancer,Optimal surgery and tumors at initial stage,Optimal surgery allows an adequate control of the disease both in terms of local recurrence and survival for stage I tumors (T1-T2 N0). These tumors do not need adjuvant therapies to improve control of the disease.,Level of evid

24、ence: V Grade of raccomandation: B,Guidelines for colorectal cancer, ASSR, Roma 2002,Rectal Cancer,Tumors at stage II (T3-T4 N0) and III (T1-4 N+) require a combined treatment based on surgery, radiotherapy and chemotherapy.,Optimal surgery and locally advanced tumors,Level of evidence: I Grade of r

25、accomandation: A,Guidelines for colorectal cancer, ASSR, Roma 2002,The surgeon as factor affecting oncological outcome,RECTAL CANCER,The surgeon as prognostic factor,“. surgeon is an independent prognostic factor that needs to be considered pari passu with Dukes staging.”,RK Phillips et al Br J Surg

26、 1984; 71:12-16,RECTAL CANCER,Improved results can be obtaineed through:,Proper training in colorectal surgery Practice of colorectal surgery as “special interest” in the context of a general surgery practice Both modalities,RECTAL CANCER,The surgeon as prognostic factor,Surgical volume and results,

27、The volume of activity required to reach the “plateau” in mortality is 10 50 colorectal operations per year.,H Dorrance, J ODwyer Br J Surg 1997; 84: 84-16 (absr),RECTAL CANCER,The surgeon as prognostic factor,Comparison* between general surgery and colorectal surgery residents activity,* Average of

28、 three studies based on Am. Board of Colorectal Surg. and Am. Board of Surgery database.,S Galandiuk, Arch Surg 1995; 130: 1136-1138 ET Goldstein, Dis Colon Rectum 1996; 39: 1193-1198 DJ Schoetz Jr, Dis Colon Rectum 1998; 41: 1-10,RECTAL CANCER,The surgeon as prognostic factor,General Surgeon vs. Co

29、lorectal Surgeon,Mortality in patients with co-morbidity of any level of severity,General Surg.: 7.3 %,Colorectal Surg.: 1.4 %,Mortality in severity level 2 and 3 patients,General Surg.: 3.8 % - 16.4,Colorectal Surg.: 0.8 % - 5.7%,Hospitalization in severity level 2 and 3 patients,General Surg.: 16.

30、1 g - 21.2 g,Colorectal Surg.: 12.3 g - 17.0 g,L Rosen et al Dis Colon Rectum 1996; 39: 129-135,RECTAL CANCER,The surgeon as prognostic factor,P Hermanek, W Hohenberger, Eur J Surg Oncol 1996; 22:213-215,Analysis of 600 curative rectal resections (GSGCRC). Surgeons enrolling 15 rectal resections in

31、the study expose patients to an increased risk of local recurrence. One or two resections per month are held as a threshold to warrant an optimal local recurrence rate.,RECTAL CANCER,The surgeon as prognostic factor,683 cases of rectal cancer operated by “CRT surg.” and “NCRT surg.” in 8 years. Low

32、rectal anastomoses much more frequent for “CRT surg.” (p0.001). APR much more frequent for “NCRT surg.”(p0.001). Local recurrence much more frequent for “NCRT surg.” (p=0.001). Better survival for “CRT surg.” (p=0.005). Surgeons performing 21 operations in the considered period had better results th

33、an those performing 21 (p=0.001). “CRT surg.” with 21 operations in the considered period had the best results (p=0.005).,GA Porter, Ann Surg 1998; 227:157-167,RECTAL CANCER,The surgeon as prognostic factor,9793 operations for colorectal cancer performed by 812 surgeons in 50 hospitals. Year volume/

34、surgeon: low (10). Year volume/hospital: low (70). Surgeons with higher volume obtained better results in terms of mortality, hospitalization and costs. Surgeons with “middle volume” obtained results close to “high volume” colleagues if working in “high volume” hospitals.,JW Harmon, Ann Surg 1999; 2

35、30:404-413,RECTAL CANCER,The surgeon as prognostic factor,378 cases of rectal cancer operated during a 3 years-period by vascular, transplant, general and colorectal surgeons (median follow-up: 45 months). Local recurrence: the only 2 factors associated with a significant reduction were the length o

36、f the resected specimen and the “colorectal specialty” (p=0.004). Metastases: factors with positive influence are early stage of disease, absence of vascular invasion and the “colorectal specialty” (p=0.025).,HR Dorrance et al, Dis Colon Rectum 2000; 43:492-498,RECTAL CANCER,The surgeon as prognosti

37、c factor,Rectal Cancer,Personal experience (October 1995 April 2003),Total CRC 568 pts,RC 154,150,Upper rectum 33 (21.4%) Mid rectum 37 (24.1%) Lower rectum 84 (54.5%),(Oct. 1995 Apr. 2002) 118 Surgery alone or surgery + adjuvant therapies,(May 2002 Apr. 2003) 32 Candidates to pre-op. radio-chemothe

38、rapy,Operative mortality 4 (2.6%),Clin Chir III Univ. BO 2003,Rectal Cancer,Personal experience (October 1995 April 2002),118 pts,Surgery alone,Post-op. adjuvant ther.,59 (50%),59 (50%),loc. recurrence 3.9% (2/51) dist. metastases 11.8% (6/51) both 5.9% (3/51),loc. recurrence 6.0% (3/50) dist. metas

39、tases 28.0% (14/50) both 8.0% (4/5),50 (stage IV excl.),51 (stage IV excl.),Clin Chir III Univ. BO 2003,Rectal Cancer,Personal experience (October 1995 April 2002),Overall survival curve,surgery alone,adjuvant terapies,months,% survivors,Clin Chir III Univ. BO 2003,(stage IV excl.),Rectal Cancer,Per

40、sonal experience (October 1995 April 2003),Total CRC 568 pts,RC 154,150,Upper rectum 33 (21.4%) Mid rectum 37 (24.1%) Lower rectum 84 (54.5%),(Oct. 1995 Apr. 2002) 118 Surgery alone or surgery + adjuvant therapies,(May 2002 Apr. 2003) 32 Candidates to pre-op. radio-chemotherapy,Operative mortality 4

41、 (2.6%),Clin Chir III Univ. BO 2003,Rectal Cancer,Personal experience (May 2002 April 2003),32 pts,Neo-adjuvant programme,Standard treatments,6,26,3 direct coloanal anast. 1 J-pouch coloanal anast. 2 APR,17 (stage 0, I, II) 4 (stage IV with no curable metastases) 5 (age),Clin Chir III Univ. BO 2003,

42、(candidates to APR : 5),Type of operation as factor affecting oncological results: final considerations,Relatively small, mobile tumors, located not more than 8-10 cm from anal verge, uT1N0, well differentiated and without signs of vascular and lymphatic invasion may be treated with trans- anal proc

43、edures. Any other rectal tumor requires an abdominal approach. At present the abdomino-perineal resection may be limited to 10% of cases. To guarantee the chance of an oncologically safe anastomosis, tumor-free distal (2 cm on the fresh specimen) and lateral margins are required. If the anastomosis can be performed 10 cm or more above the anal verge, an anterior resection must be held as fully reliable. If the anastomosis must be performed less than 10 cm from the anal verge, the procedure of choice should be a proctectomy with TME and J-Pouch colo-a