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1、The type of operation and the surgeon as factors affecting oncological outcomein 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 a
2、nd U.S. 300000 new cases and 200000 deaths per year 53.5/100.000 males 37.6/100.000 femalesIn Italy 16.000 new cases in 1970, 37.000 in 1990e, 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 Ed
3、. 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 of
4、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 resectionwith good quality of life.Abdomino-perineal resection has been considered for long the bestway to achieve
5、that goal.Recent advances in colorectal surgery (stapling devices, TME,coloanal anastomoses) and a better understanding of distal andlateral spread of the rectal cancer have dramatically decreasedthe indication to the abdomino-perineal resection, which is nowindicated in about 10% of cases.,JMD Whee
6、ler 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% to 32%.,C
7、 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,RECTAL CANCER
8、,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 anastomosisProctectomy + TME with direct or pouch colo-anal anastomosis,APR,APR + graciloplasty /
9、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 excision, TE
10、M)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 cure rates equ
11、ivalent 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,Selection cri
12、teria for curative trans-anal treatment,SD Wexner, NA Rotholtz, Dis Colon Rectum 2000; 43:1606-1627,RECTAL CANCER,Tumor stage and risk of nodal involvement,Poorly differentiated, mucinous tumors with lymphovascular involvement carry a much higher risk of nodal metastatic involvement.,AK Banerjee et
13、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 Abel et al,
14、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 surgical opti
15、ons 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 in pts with 2
16、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) aftercurative 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.,RECTAL CANCER,Variations in distal margin according to specimen setting,cm,Intra-abd. specimen,Resected specimen,Fixed specimen,4,2,2,9,
