Surgical management of Low Rectal Cancer

It describes the surgical options of low rectal cancer, along with it's recent updates and complications

1. Surgical Managements of Low Rectal Tumors Dr Nilanjan Ghosh

2. Things that to be discussed: Low rectal cancer Role of mechanical bowel preparation and pre-op sphincter evaluation Margins, CRM TME, LAR, ULAR, ISR, PELM, APR, ELAPE, TATME, Pelvic exenteration, TEMS, TAMIS High vs low ligation Why to save autonomic nerve plexus PLND, Inguinal LND Lap and Robot Complications: AL, sexual and urinary complications, LARS

3. Low Rectal Cancer What does it mean?

4. How to identify? Lower rectum corresponds to the first 2 cm of rectum above the upper edge of the sphincter or the first 5 cm above the anal margin The upper edge of the sphincter is easily palpable on DRE corresponding to the muscular bundles of the puborectalis sling and levator ani musculature The internal sphincter, external sphincter, and levator ani are hypo intense and separated by the hyper intense intersphincteric space in MRI In T1 images with Gadolinium contrast, the internal sphincter is easily visible because the signal intensity is increased relative to that of the external sphincter

5. Gina Brown classification

6. Rullier et al classification

7. Standard procedure acc. to Rullier classification

8. Role of Mechanical Bowel Prep +/- Antibiotic prophylaxis

9. Any advantage? Reduces stool burden – facilitates insertion of stapling devices and reduces surgical field soiling Reduces septic complications, But AL not reduced (Scarborough et al, Koller et al, Roos et al, Morris et al, GRECCAR III) Antibiotics covering aerobic and anerobic bacteria – reduces SSI 39% to 13% Cephalosporin + Metronidazole (oral 1 day before and IV 1 hour before surgery) Without Antibiotics, MBP alone has no clinical advantage.

10. Pre-op sphincter assessment

11. Methods DRE – The basal sphincter tone is determined by the internal anal sphincter, whereas the squeezing tone is determined by the external anal sphincter. Water holding procedure – 100 ml water for 20 min EUS and MRI – To look for sphincter muscles morphology Anal manometry – The manometry probe is inserted and positioned with the tip in the ampulla of the rectum. Can objectively check resting and squeeze pressure. Also useful in treatment monitoring

12. Normal result:

13. Margins

14. Concept of field of spread – Miles vs Heald

15. Recommended margins - Heald described a zone of downward spread within the mesorectum, up to 4 cm beyond distal mucosal edge Intramural spread beyond 1 cm is rarely seen ; 4-7% beyond 1 cm in T3-T4 but 0% beyond 2 cm As a result, tumors as low as 2 cm above the dentate line are suitable for sphincter preservation; Resection of part of internal sphincter (tumors at <1 cm) may allow LAR without much sphincter function compromise. Recommended distal margin – 1 cm for T1-T2 well differentiated tumors, 2 cm for T3-T4 DRM of less than 1 cm does not seem to adversely affect survival and recurrence rates ( Bujko et al)

16. CRM

17. Definitions Distance (in mm) between the deepest point of tumor invasion in the primary cancer whether contiguous or not and the (non-serosal) margin of resection – mesorectum or seromuscular layers and sphincter muscles A CRM of ≤ 1 mm is considered to be invaded LRR: CRM <1mm – 20%, CRM >1mm – 6% Factors related to the risk of radial margin invasion include the response to CRT, palpable tumor fixation, and height of the tumor above the dentate line on DRE MRI can predict CRM in 90% cases pre-operatively (MRI>EUS)

18. Effect of CRT on CRM MRI as well as EUS fails to correctly predict CRM after CRT. These errors are mainly overestimates, because MRI distinguishes poorly between residual tumor and post-radiation fibrosis Despite gross tumor reduction post-CRT, microscopic peritumoral disease persists near the edges of the tumor. Intramural tumor extensions still remain within 1 cm of the tumor post-CRT Several studies that adapted the surgical procedure depending on the response to CRT treatment have good oncologic results with rates of CRM invasion and local recurrence varying respectively from 3 to 10% and 0—10% After pre-op CRT more sphincters can be saved (Sauer et al)

19. Quality assessment of CRM – College of American Pathologists (CAP)

20. Quality assessment of CRM – College of American Pathologists (CAP)

21. TME

22. A technique to achieve negative CRM Excision of rectum along with its blood vessels & surrounding lymph nodes within an intact visceral fascial envelope If a 5-cm distal mesorectal margin can be achieved, can go ahead with partial mesorectal excision Key elements to prevent pelvic recurrence – preserving integrity of mesorectal fascial envelope and obtaining negative CRM Macroscopic assessment of quality and completeness of excision of the mesorectum and the state of the fascia propria should be reported

23. Holy Plane TME removes the rectal cancer with its primary lympho-vascular drainage as an intact package Preserves the autonomic nerves required for the maintenance of urinary and sexual function Holy plane – An avascular interface between the mesorectum and the surrounding somatic structures An avascular, areolar tissue plane lies between the mesorectal fascia and the parietal pelvic fascia Anteriorly, the mesorectum is thin and bordered by Denonvilliers ’ fascia, a tough fibrous, double- layered tissue that separates the extraperitoneal rectum anteriorly from Prostate/ Seminal vesicle/ Vaginal wall

24. Fascial coverings

25. Fascial coverings

26. Fascial coverings

27. 6 steps of TME + LAR Left retroperitoneum dissection Inferior mesenteric vessels and superior rectal vessels dissection Upper mesorectum dissection Lateral stalk dissection Anterior dissection Distal mesorectum and anorectal junction dissection

28. Technique of TME Circumferential holy plane sharp dissection to remove tumor en bloc with intact surrounding mesorectum with preservation of ANP. Bilobed due to anococcygeal raphe and concavities of levator ani. Pelvic dissection continues anterior to the presacral fascia and outside the fascia propria Lateral dissection should be carried out as close to the mesorectal envelop as possible, so as to avoid the nervi erigentes Denonvillier fascia lies between the anterior rectal wall and the prostate. Routinely its not included in specimen unless the patient has an anteriorly based tumor, and it is oncologically necessary to achieve negative margins A rectosacral or anosacral ligament can prevent complete posterior mobilization of the rectum down to the levator muscles. If necessary, this should be divided

29. Customized DVR – A way to preserve NV bundle For anteriorly based tumor to get a clear CRM. Dissection progresses posteriorly to DVF at the level of the seminal vesicles, and transecting DVF at the prostate level changing dissection to the anterior plane between DVF and the prostate capsule, excising the distal portion of DVF and including it on the specimen.

30. LAR

31. Is it for lower rectum? LAR is performed for tumors in the middle and upper third of the rectum and occasionally for lesions in the lower third, generally located > 5 cm from the DL Surgical options for lower rectal cancer mainly starts with uLAR

32. Major surgeries for lower rectum

33. ULAR

34. What is it? The uLAR represents the complete resection of the rectum and mesorectum (total proctectomy) The uLAR removes the rectum en bloc near the attachment point at the puborectalis for tumors located 1 to 2 cm above the DL For low- lying tumors, 1 to 2 cm near the DL, a perianal stage of the procedure is done to expose the anal canal with self-retaining retractors A hand-sewn CAA is required after an uLAR , if possible a DST can also be used for eg in LAR

35. Anastomosis technique Stapled colo -anal anastomosis. A circular stapler, even when introduced from above downward, is too large to allow anastomosis at the dentate line. Stapled coloanal anastomosis therefore leaves from 1—2 cm of rectal mucosa in place Hand-sewn colo -anal anastomosis(CAA). Endo-anal dissection of the mucosa from below upward beginning at the dentate line allows resection of the entire rectal mucosa and obtains an additional 1—2 cm of distal margin compared to stapled colo -anal anastomosis. The CAA is hand sewn and preserves the external and internal sphincter The anastomosis techniques (DST or CAA) do not show any difference in disease-free and disease-specific survivals and the frequency and location of recurrence

36. ISR

37. Idea of it  Described initially by Schiessel et al Transanal division of the rectum, with removal of part or the entire internal anal sphincter (IAS) after TME with restoration of bowel continuity achieved by a hand-sewn coloanal anastomosis. ISR and coloanal anastomosis are performed as both abdominal and perineal approach. Abdominal part of the operation is performed either as open or laparoscopic technique.

38. Total ISR has poor continence. Good continence when anastomosis is at least 2 cm above anal verge or 1 cm above ano -rectal ring

39. Types of ISR:

40. Case selection INDICATION: 1 cm from anorectal ring Tumors located 30 mm from anal verge 15mm from dentate line Local spread restricted to the rectal wall or the lAS Adequate preoperative sphincter function and continence CONTRA-INDICATION: Presence of faecal incontinence Puborectalis and external anal sphincter invasion T4 lesions Undifferentiated tumors

41. PELM

42. Aka. Hemi Levalor Excision (HLE) The dissection continues between the internal and external anal sphincter to the level about 0.5–1 cm below the tumor like an ISR The direction of the dissection turned transversally here to include the deep part of the external sphincter until the ischiorectal fossa fat could be visualized. The dissection continued in a cephalic direction to include the levator ani muscle, from where the pelvic cavity is entered.

43. APR

44. APR Basics For tumors reaching below the anorectal junction, invading beyond IAS, but not involving the levator . 2 team approach Topographic landmarks for perineal dissection: medial edges of the ischial tuberosities laterally coccyx dorsally perineal body level ventrally

45. Planes where we go: Extrasphincteric plane - his is the conventional APR technique, which removes less tissue at the level of the tumor ("coning in") Extra- levator plane (ELAPE) - For those cases in which levators are not involved, ELAPE cannot be recommended over conventional APR because of a potential for higher perineal wound morbidities  Intersphincteric plane - This plane is reserved for resection of inflammatory bowel disease-related dysplasia or malignancy, or a very low rectal cancer that does not involve the anal sphincter complex. Ischio -anal plane - Dissection outside the fat pad of ischioanal fossa and along fascia of obturator internus muscle for tumors involving perianal skin, ischioanal fat, levator muscles with direct tumor invasion, perforation, abscess, fistula

46. ELAPE

47. Risk vs benefit ELAPE was associated with a reduction in the rate of intraoperative perforation and local recurrence, without any increase in the CRM positivity and postoperative perineal wound complication rate when compared with traditional APR Wound dehiscence is less likely to occur after ELAPE, because the ELAPE procedure has a better field of view and more precise homeostasis than APR ( Habr -Gama et al) This technique might result in a significant perineal defect which needs reconstruction by a flap or biological mesh with increased perineal morbidity. Delayed healing of the perineal wound (>4 weeks) occurred more frequently after ELAPE than after conventional APR

48. TATME

49. An approach to attain a better TME TATME merges 3 established rectal surgery techniques: TME, transanal transabdominal ISR, and TAMIS Recent studies showed that this “bottom-to-up” approach could reduce a positive rate of CRM, get an adequate DRM, and get a better complete TME specimen Experts recommended TATME in patients with the following characteristics: male, narrow and deep pelvis, obese, tumor less than 4 cm from anal verge, prostate enlargement, and distorted planes caused by irradiation Incorrect anterior dissection plane near the prostate urethra results in urethral injury.

50. COLOR III ongoing trial exploring TATME vs LapTME COLOR III trial, which aims to compare TaTME with LapTME , exclusion criteria for TaTME were cT3 with margin of < 1 mm from the endopelvic fascia, tumors with ingrowth in the internal sphincter or the levator ani muscle, and all cT4

51. Pelvic Exenteration

52. Concept of morphogenetic units Embryologic studies by Hockel identified urinary, genital, and digestive tract components to have a common origin in the "morphogenetic unit" of the pelvis The rectum, anus, and mesorectum originate from the hindgut. The Mullerian morphogenetic unit forms the Fallopian tubes, mesosalpinx, uterine corpus and cervix, mesometrium , proximal vagina, and mesocolpium . The distal ureters, urinary bladder, urethra, and distal vagina arise from the urogenital sinus and Wolf ducts. En-bloc resection of the unit with affected viscera for e.g. removal of 2 or more morphogenetic units represents an ultraradical compartmentalized surgery or pelvic exenteration

53. 5 types of Pelvic exenteration Anterior pelvic exenterations, which in addition to the resection of central pelvic organs include removal of the bladder and distal ureters bilaterally Posterior pelvic exenteration (PPE), which involve removal of the central organs together with the rectosigmoid (with or without the anal canal) Total pelvic exenterations, a combination of both anterior and PPE Extended exenterations, which include abdomino -sacral resection; Individualized approaches, such as rectal excision with concomitant radical prostatectomy with preservation of the bladder

54. Extensions Current radical surgery expands the posterior compartment to include the sacrum with the rectum when necessary to achieve R0 The extension of an anterior compartment neoplasm might incorporate the pubic bone. The lateral extension of a pelvic neoplasm can require excision of the lateral compartment involving the vascular, neurologic, and muscular structures of the pelvic sidewall.

55. Saccrectomy (A) Low sacrectomy involves sacral transection in the axial plane below the S2 foraminae . (B) High sacrectomy involves sacral transection at or above the S2 foraminae and involves disarticulation from sacroiliac joints. (C) Hemisacrectomy involves tumours not crossing the midline of the sacrum, thus, leaving the contralateral side intact. (D) High subcortical sacrectomy (HISS) or anterior table sacrectomy is reserved for tumours adherent to the median sacral plane but not involving the sacral foraminae laterally, and the anterior sacral cortex only is removed.

56. For Gynec-onco , types are different Type I: supralevator Type II: infralevator Type III: infralevator with vulvectomy or ­ vulvoanusectomy

57. Flaps for large perineal defect

58. Fill in the gap In patients with large perineal defects, reinforcement with a biological absorbable mesh anchored to the coccyx, coccygeus muscle and pelvic sidewall is done to prevent wound dehiscence and perineal hernia Other options: VRAM flap B/L V-Y advancement gluteal flaps  Gracilis muscle flap Free ALT flap

59. Choice of flaps

60. High vs Low ligation of IMA

61. Lay low High ligation - IMA division less than 2cm from aorta. Low ligation - IMA division immediately distal to LCA origin. High IMA ligation can injure the sympathetic fibers of superior hypogastric plexus – may affect bladder compliance with urgency and incontinence and impaired ejaculation in male, also higher rate of AL Low Ligation of IMA reduces Genitourinary Dysfunction (HIGHLOW Trial). IMA LN which is the principal LN for rectum not dissected LL can achieve equivalent lymph node yield to HL

62. Why to save ANP?

63. The sympathetic nerves come from the L2 and L3 spinal nerve roots and travel through the pelvis as the lumbar splanchnic nerve and superior hypogastric nerve; they facilitate bladder smooth muscle relaxation, internal urethral sphincter contraction, and ejaculation. Damage to the sympathetic nerves during ligation of the IMA or during mesorectal mobilization, can lead to urinary incontinence and retrograde ejaculation. The parasympathetic nerves come from the S2–S4 nerve roots and travel through the pelvic splanchnic nerve and pelvic nerve plexus to cause bladder smooth muscle contraction, internal sphincter relaxation, lubrication and erection. Damage during the lateral or anterior dissection can lead to difficulty with erection, urinary retention, and issues with sexual lubrication.

64. PLND

65. When to do? According to the Japanese guidelines, PLND is mandatory when the lower border of the tumor is located distal to the peritoneal reflection, and the tumor has invaded beyond the muscularis propria In most Western centers, abnormal LPLNs were initially treated with standard NCRT and assumed to be sterilized by radiotherapy to include the lateral LNs (LLNs) basins, followed by TME without PLND TME after NCRT may be insufficient in patients with enlarged LPLN and that selective PLND may reduce local recurrence Size criteria > 5 mm in short axis after CRT, > 7 mm in primary imaging These nodes are collectively referred to as the LPLNs and include the common iliac, internal iliac, external iliac, and obturator artery lymph nodes

66. Which nodes? PLND when added wih CRT: Improves local control No change in DFS and OS RT dose escalation to nonresected suspicious PLND during NCRT was well tolerated and associated with a high rate of the short-term local control in 12 months without increasing risk of intraoperative complications. ( Hartvigson et al.)

67. Risk of LPLN disease

68. Inguinal LND

69. Necessary? Shiratori et al. suggested that DL involvement and ILN of > 8 mm predicted the development of ILN metastases in patients with low-lying rectal cancer Inguinal irradiation without ILN dissection may be advised in patients with high suspicious ILN metastases, given that inguinal radiation seems more effective than surgical resection in controlling inguinal micrometastases . If salvage surgery is needed, ILN resection can also be performed after inguinal irradiation if residual or recurrent. Routine elective inguinal radiation is not necessary for low rectal cancers with anal canal involvement

70. Lap

71. Trials COlorectal cancer Laparoscopic or Open Resection (COLOR) II trial Improved short-term outcomes Similar long-term outcomes after laparoscopic resection of rectal cancer, compared with open resection. CLASICC II trial : "Long-term results continue to support use of laparoscopic surgery for colonic and rectal cancer." COREAN II trial : "Laparoscopic surgery after NACRT for mid or low rectal cancer is safe and has short-term benefits compared with open surgery; the quality of oncological resection was equivalent."

72. Trials Two other trials, ACOSOG Z6051 and ALaCaRT , have reported pathologic outcomes Z6051 , the primary endpoint was a composite of CRM greater than 1 mm, negative distal margin, and TME completeness. ALaCaRT , the primary endpoint was also a composite of resection quality measures. The criteria for non-inferiority of the laparoscopic approach were not met BUT DFS, LRR and OS were similar

73. Conclusions Laparoscopic vs open Similar disease-free and overall survival Similar tumor recurrences No difference in AL rate Increased operating time in lap

74. Robot

75. Trials Robotic versus Laparoscopic Resection for Rectal Cancer (ROLARR) study First multicenter RCT comparing RALS versus CLS for rectal cancer Among 471 randomized, 466 (98.9%) completed the study. Showed no significant differences between RALS and CLS, did not support the superiority of RALS over CLS. Among patients with rectal carcinoma suitable for curative resection, RALS, as compared with conventional laparoscopic surgery, did not significantly reduce the risk of conversion to open laparotomy.

76. TAE Upto 8 cm from anal verge

77. Indication T1, N0 early- stage cancers Small ( <3 cm ), well to moderately differentiated tumors Within 8 cm of the anal verge Limited to less than 30% of the rectal circumference Negative (>3 mm) deep and mucosal margins are required, and tumor fragmentation should be avoided. If pathologic examination reveals adverse features such as – positive margins, LVI, poor differentiation, or sm3 , a more radical resection is recommended.

78. TEMS Upto 15 - 20 cm from anal verge

79. Patient positioning is based on tumor location

80. How it looks

81. The setup Rectoscope is - Diameter 40 mm Length 12 or 20 cm Rectoscope with facepiece and capped rubber sleeves through which the instruments and optics can be inserted This has 4 ports - 1 for the magnifying stereoscopic optic 3 for instruments - Tissue graspers; Cautery knife; Suction device

82. Pros and Cons Advantage: Minimal morbidity ( eg , a sphincter-sparing procedure) and mortality Rapid postoperative recovery Limitations: Absence of pathologic staging of nodal involvement

83. TAMIS Upto 15 cm from anal verge

84. GelPOINT TAMIS Port - Camera is free

85. TAE vs TEMS vs TAMIS

86. Complications: AL

87. Risk factors Male gender, age > 60, co-morbidities, advanced stage, deeper depth of tumor invasion, larger tumor circumference > 3cm, longer operation time, and early postoperative diarrhea were associated with AL Modifiable – central obesity, alcohol intake, smoking, immunosuppression, malnutrition Serum CRP as strong predictor of anastomotic leak Lower CRP levels <180 mg/L on POD 4 may indicate the absence of AL

88. Decision to divert? Ultralow rectal anastomosis Incomplete donuts Positive leak test Tension on anastomosis Radiated More than one stapler fire for distal end.

89. Sexual and urinary complications

90. Fecal incontinence

91. Due to loss of internal sphincter The sacrifice of the internal sphincter alters continence by reducing resting anal pressure After ISR, the average number of stools per day is three, and half of the patients have good continence The main risk factors for poor continence are neo-adjuvant CRT, ultra-low anastomosis, complete resection of the internal sphincter, and pre-existing impairment of continence prior to treatment. Impact of internal and external sphincter sacrifice with reconstruction as a perineal colostomy was similar to total ISR

92. LARS – Defecatory dysfunction after proctectomy LARS is due to a combination of Preoperative function, including underlying continence, number of bowel movements, and rectal compliance Postoperative neurologic changes, as well as mechanical changes to the rectum, and stretching of the sphincters. Treatments include – Adequate fiber ingestion, Loperamide, anorectal biofeedback, pelvic floor rehabilitation, sacral nerve stimulation (SNS), and permanent stoma construction, intermittent rectal irrigation

93. THANK YOU