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1、The The typetype of of operationoperation and the and the surgeonsurgeon asas factorsfactors affectingaffecting oncologicaloncological outcomeoutcomein in rectalrectal cancercancer surgerysurgeryDepartment of Surgery and Anaesthesia Policlinico S.Orsola-Malpighi University of Bologna ITALYS.FARELLAE
2、PIDEMIOLOGYCOLORECTAL CANCER CRC CRC is is one of the one of the mostmost importantimportant reasonreason of of deathdeath in in EuropeEurope and U.S. and U.S. 300000 new 300000 new casescases and 200000 and 200000 deathsdeaths per per yearyear 53.5/100.000 53.5/100.000 malesmales 37.6/100.000 37.6/
3、100.000 femalesfemales In In ItalyItaly 16.000 new 16.000 new casescases in 1970, 37.000 in 1990 in 1970, 37.000 in 1990e, in 1998, 50.000 in 2000. e, in 1998, 50.000 in 2000. In In EnglandEngland 10.000 10.000 nwnw casescases of RC per of RC per yearyear withwith 6.000 6.000 deathsdeaths In USA, in
4、1995, 39.000 In USA, in1995, 39.000 casescases of RC of RC withwith 8.000 8.000 deathsdeathsEff. Health Care 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; 43:1606-1627RECTAL CANCE
5、R The The technicaltechnical success success of of rectalrectal cancercancer resectionresection is is usuallyusually measuredmeasured byby permanentpermanent stoma stoma rate, rate, incidenceincidence of of locallocal recurrencerecurrence and 5-year and 5-year survivalsurvival J.H. Scholefield J. Ga
6、stroenterol 2000; 35:126-129Evolving concepts in surgical strategy The goal The goal hashas alwaysalways beenbeen toto achieveachieve anan optimaloptimal oncologiconcologic resectionresectionwithwith goodgood qualityquality of life. of life. Abdomino-perineal resection has been considered for long t
7、he best Abdomino-perineal resection has been considered for long the bestway to achieve way to achieve thatthat goal. goal. Recent advances in colorectal surgery (stapling devices, TME, Recent advances in colorectal surgery (stapling devices, TME,coloanal anastomoses) and a better understanding of c
8、oloanal anastomoses) and a better understanding of distaldistal and andlaterallateral spreadspread of the rectal cancer have dramatically of the rectal cancer have dramatically decreaseddecreasedthe the indicationindication toto the the abdomino-perinealabdomino-perineal resectionresection, , whichw
9、hich is is nownowindicatedindicated in in aboutabout 10% of 10% of casescases. . JMD Wheeler et al, Br J Surg 1999; 86: 1108-1120 SD Wexner, NA Rotholtz, Dis Colon Rectum 2000; 43:1606-1627RECTAL CANCERVariability in results The The incidenceincidence of of locallocal recurrencerecurrence is is 3% 3
10、% toto 32%. 32%. Ten year-survival after curative surgery is 20% Ten year-survival after curative surgery is 20% toto 63%. 63%. Two-year survival after palliative surgery is 7% Two-year survival after palliative surgery is 7% toto 32%. 32%.C S Mc Ardle, D Hole, BMJ 1991; 302:1501-1505 JMD Wheeler et
11、 al, Br J Surg 1999; 86:1108-1120 SD Wexner, NA Rotholtz, Dis Colon Rectum 2000; 43:1606-1627RECTAL CANCERMain factors affecting variability in resultsTumor biologyStage of diseaseTherapeutic planType of operationSurgeonRECTAL CANCERThe The typetype of of operationoperation asas factorfactoraffectin
12、gaffecting oncological outcome oncological outcomeRECTAL CANCERSurgical optionsTraditionalTraditional resectionresection withwith stapledstapled or or suturedsutured anastomosisanastomosisTraditionalTraditional resectionresection withwith lowlow stapledstapled or or suturedsutured anastomosisanastom
13、osisProctectomyProctectomy + TME + TME withwith direct direct or pouch colo-anal or pouch colo-anal anastomosisanastomosisAPRAPRAPR + APR + graciloplastygraciloplasty / / artificialartificial sphinctersphincterProctectomyProctectomy + TME + TME withwith direct or direct or pouchpouch colo-analcolo-a
14、nal anastomosisanastomosisLocalLocal treatment ( treatment (transanaltransanal techniquestechniques) )RECTAL CANCERTrans-anal techniquesSD Wexner, NA Rotholtz, Dis Colon Rectum 2000; 43:1606-1627RECTAL CANCERTrans-analTrans-anal proceduresprocedures include include methodsmethods of of ExcisionExcis
15、ion ( (locallocal excisionexcision, TEM), TEM) AblationAblation (laser, (laser, cryotherapycryotherapy, , electrocauteryelectrocautery, ,endocavitaryendocavitary irradiationirradiation) )AdvantagesAdvantages: : lowlow morbiditymorbidity and and lowlow mortalitymortality ratesratesDisadvantagesDisadvantages: : inabilityinability toto assessassess the the lymphlymph nodesnodes and (and (ablationablation) ) toto permitpermit stagingstaging of the of the tumortumor itselfitself. .Trans-anal techniques Trans-anal techniques can result in cure rates equivalent to those obtained afte
