Ultra low lap anterior resection, pull through & coloanal anastomosis : 5yr experience
Ultra low laparoscopic anterior resection, trans anal
pull through with colon pouch-anal anastomoses: a 5yr experience.
D Glancey, B Chaudhary, A
Badrek*, AR Dixon
Examine the efficacy of restorative ultra-low laparoscopic resection in
patients with low rectal cancer.
Over the 5yrs to December 2011, 22 patients (14 men) aged 49-78yrs
underwent laparoscopic excision of rectal carcinomas located >1.5 cm of the
dentate line. 10 received preoperative
radiotherapy; 7 long-course. Surgery comprised total-mesorectal excision with
intersphincteric resection; pull through, trans-anal colo-anal anastomosis with
colopouch and loop ileostomy.
There were no conversions. The median length of stay was 4 days (3-7). Immediate
morbidity included ileus (2), ischaemic colopouch and AF with one return to
theatre. There were three readmissions: obstructed ileostomy, ischaemic
colo-pouch and pelvic sepsis.
Histology comprised - T2 (13), T3 (9) disease; 21 were R0 resections.
The R1 related to vascular invasion <1mm from the distal margin. All circumferential
resection margins were clear. All patients remain disease free at a median
follow-up of 2 years (3-48 months). Median-term sphincter preservation was
achieved in 19. Sexual function was preserved in 11 men, two requiring Cialis,
and seven women. All but one covering stomas were closed. 5 patients required additional surgery: end
stoma (2), anastomotic dilatation, pouch advancement and incisional hernia
CONCLUSION: A laparoscopic approach can
be considered in most patients with low rectal cancer. Laparoscopic ultralow intersphincteric
resection and pull through is a difficult technique. The potential for
complications is significant and in 14%of cases these can lead to an end stoma.
What this adds
cancer surgery is now well established1-3. However, concerns still exist regarding its use in rectal cancer.
Whilst no randomised trial (RCT) has specifically addressed this topic, CLASSIC
did include 85 total mesorectal excisions (TMEs) 4; 3yr follow-up data have shown no differences in cancer outcomes 5. A 2006 Cochrane review concluded
that laparoscopic TME may have short-term advantages over open with respect to
blood loss, early diet and post-operative pain, and without any significant
differences in leaks, lymph node harvest, resection margin positivity,
morbidity or mortality; although with longer operation times and higher costs. However, small numbers and duration of
follow-up, precluded any conclusions regarding longe-term cancer outcome 6.
Three larger TME series
have since been reported: anastomotic leakage (9.6-16.8%), conversion
(6.1-12.7%), 30-day morbidity (31.8-39.3%), R1 resection (2.6-6.7%) and local
recurrence (4.78-5.79%) 14-16. We have recently examined
the medium-term results of 150 TMEs in patients with mid to low rectal cancer; 6 (4%) conversions, 13
(8.6%) leaks, 5 (3.3%) R1, and one R2 resection with four (2.7%) local
recurrences. Whilst these results
are encouraging, laparoscopic TME however, is a demanding procedure that
involves a long learning curve.
In the absence of adverse
tumour features (un-differentiation, tumour budding, vascular invasion (Ueno H
et al]) which allow for smaller (1cm), yet safe distal resection margins and
the development of intersphincteric dissection, it is now possible to consider
sphincter-preserving surgery in many patients who would otherwise traditionally
have had an abdominoperineal excision (Velez et al). Moreover, an intersphincteric dissection allows the
possibility of employing trananal extraction of smaller, less bulkier tumours
and then performing a hand sutured colo-anal anastomoses. It was in 2000 that this concept was first
applied to laparoscopic surgery (Watanabe et al 2000)
2006 to December 2011, 22 highly selected patients attending our institution
with lower 1/3 rectal cancer >1.5cm from the dentate line, and were referred
by the MDT to a single-surgeon. Long-course pre-operative chemo radiotherapy
(CRT) was offered to patients with advanced T3 / T4 disease who were predicted
to have a threatened CRM. Short-course
radiotherapy (RT) was offered to patients with T2/early T3 disease and adverse
prognostic features. Patients were
counselled preoperatively about potential adverse functional outcomes. During the same time period 30 patients
underwent a laparoscopic abdominoperineal resection with end colostomy.
All our surgery
(3-port [5mm x2, 10mm] technique with a 30o laparoscope) (Glancey
paper) takes place within an enhanced recovery protocol 17. The first step is to
mobilise the rectum posteriorly/right lateral margin down to the pelvic floor
and puborectalis, followed by the left pelvic sidewall. The endopelvic fascia is then incised
and this opens up the intersphincteric plane, which facilitates the perineal
phase of the procedure. Toldt’s
fascia is then dissected (medial to lateral), followed by high division of the
inferior mesenteric vessels at their origins. The splenic flexure is fully mobilised up to the middle colic
vessels and the omentum detached from the left part of the transverse colon;
allows for maximal mobility of the descending colon. It is important not to
damage the venous arcade distal to the origin of the inferior mesenteric vein. The pneumo-peritoneum is then released.
The patient is
then placed in lithotomy and the anal canal exposed with insertion/fixation of
a PPH CAD (circular anal dilator) device ( Baber paper). A cytocidal swab is inserted into the lower
rectum. Using cutting diathermy a full thickness incision is made at the
dentate line. The rectal tube is
then closed off with a running suture to avoid any rectal spillage. The dissection proceeds in the intersphincteric
plane until entry into the peritoneal cavity. If oncological concerns allow it is better to preserve part
of the internal anal sphincter by creating a mucosal sleeve and then incising
the internal sphincter at a more proximal level.
The CAD is
removed and the rectum, sigmoid and descending colon delivered, carefully
ensuring that no rotation or mesenteric tearing takes place, through the anal
canal. This aspect of the
operation is carried out under laparoscopic vision. The mesocolon is transected at the level of the upper lympadenectomy. The proximal descending colon is then divided
with a linear cutter and a 6cm colonic J pouch created. The pouch is then reduced back
into the pelvis, the CAD reinserted and an easy hand sutured colon-pouch-anal
anastomoses completed. A suction
drain is placed deep in the presacral space and a loop ileostomy created. All
patients underwent a period of intense pelvic floor physiotherapy/biofeedback
instruction before stoma closure.
22 selected patients underwent ultralow anterior resection, trans anal
pull-through with colo pouch-anal anastomoses over a five-year period. The
median tumor distance from the dentate line was 2cm (range 1.5 – 2.5). There were no conversions, abandonment
of any of the planned procedures or mortality. The median length of stay was 4
days (range 3-7 days). Immediate morbidities included small bowel ileus (2),
new onset AF and pouch ischaemia.
The latter was heralded by a post-operative tachycardia and
pyrexia. The patient returned to
theatre at 36hrs, was re-laparoscoped, the ischaemic segment (thought to be
venous) excised per-anally and an end colostomy created and the ileostomy
closed. The patient was discharged
3 days later.
There were three readmissions: high output stoma secondary to an obstructed
ileostomy (required early closure) and cases of 1) an ischaemic colo-pouch and 2).
pelvic sepsis secondary to a presumed infected haematoma (no drain used). The slough of the colo-pouch was removed
per-anally and an end colostomy fashioned. The pelvic abscess was drained extra-sphincterally. Eventually this patient required pouch
advancement to close the internal defect; the sinus has since healed and the
covering ileostomy closed. A final
patient (who had received long course radiotherapy) had an anastomotic
disruption when seen in clinic at 6 weeks. Although the anastomosis has since strictured, the patient
declined further intervention. A further anastomotic stricture responded to
simple dilatation. There were thus a total of four (18%) surgical interventions
outside the 21 ileostomy closures. One patient has had a laparoscopic repair of
an incisional hernia post stoma closure.
Final histology comprised - T2 (13), T3 (9) disease; 21 were R0
resections with an intact fascia propria. The R1 was accounted by a single
focus of vascular invasion seen <1mm from the distal resection margin. This patient has been followed up with
3/12 examinations of the anastomosis and MRI scans at 12 and 18 months.
Circumferential resection margins were otherwise all clear. All 22 patients remain disease free at a
median follow-up of 2 years (range 3-48 months).
Full potency was preserved in 11 of 12 preoperative potent men, two requiring
Cialis (manufact details), and seven women, none of who complained of dyspareunia. There has been no case of urinary
dysfunction. Five patients report
some degree of minor urge incontinence (median Cleveland clinic score 4, range
2-7) at a median of 2 years. All
improved with medical therapy and biofeedback. Median-term sphincter
preservation was thus achieved in 19 (86%).
Whilst laparoscopic rectal cancer surgery is something rather new and
has not gained the same international acceptance as laparoscopic colon surgery,
pull-through procedures with rectal stump eversion and colonic anal anastomosis
have been around for almost 60 years (Bacon). Parks et al reporting that long-term survival and local
recurrence rates after intersphincteric resection were similar to those after
APER. It wasn’t until the introduction
of stapling devices that they became obsolete. Proponents of the technique
reported good oncological and functional results; zero local recurrence and 88%
continence at 28/12 (Velez JP). Others have demonstrated a learning curve with 5yr local
recurrence rates falling from 12% in the first three years to zero over the
subsequent 5yrs (Chihn-Chien).
With regard to function after intersphicteric dissection, comparative
studies have shown that at least 50% of patients have good spontaneous continence
(Bretagnol). Medical therapy and biofeedback are said to improve continence in
a further 25% (Laurent/Benjahad). Functional results at 4yrs are better after partial than
after total intersphincteric excision: 73% versus 50% (Gamagami). Surprisingly, patient
characteristics have not been shown to influence function (Denost).
In 2000 the concept of
per-anal “pull through” for low rectal cancer was starting to be applied in
laparoscopic surgery (Watanabe).
There technique as used in seven patients started with a perineal
dissection and isolation of the intersphincteric plane, which was then
continued into the lowermost part of the mesorectal dissection. They then returned to the perineum for specimen
extraction, colo-pouch formation after completion of the laparoscopic phase.
Rullier modified this
approach by reconstructing 32 patients with a coloplasty; three cases were converted. Postoperative morbidity occurred in ten patients, relating mainly to the
coloplasty and neo-rectum. In view of these problems the
Bordeaux group discontinued with their “pull through” method preferring to remove
the specimen and fashion the coloplasty via a small laparotomy. A modification
that lead to a reduction in morbidity when the case series was extended to 50
patients (Bretagnol et al) Macroscopic evaluation demonstrated an intact mesorectum in 29 of 32
specimens; microscopically, 30 of the 32 resections were R0. Sphincter preservation was achieved in
31 patients. The hypogastric nerves and pelvic plexuses were identified and
preserved in 24 of the 32 patients. Sexual function was preserved in ten of 18
Two reports employing a
similar technique were soon added to the literature (Prete, Wexner), both
reporting neither mortality or early local relapse; 1/3 of patients reported
minor incontinence at 18 months. Like
the French series before, (Rullier) and ours, Prete also experienced problems
of colonic pouch ischaemia (10%).
Whilst there has been no
RCT and probably never will be, a small comparative study of 40 patients compared
laparoscopic stapled ultra low versus
pull-through hand sutured colonic-anal anastomoses; there were no differences
in early morbidity, function or cancer outcome. Anastomotic strictures were seen to be more common (p=0.42)
following hand-sutured cases. (Hiranyakas). A larger retrospective comparative study from Rullier’s
group (Laurent) comparing 65 open against 110 laparoscopic intersphincteric
dissections demonstrated no differences in morbidity, 5yr local recurrence and
disease free survival rates. A
recent report of a similarly sized study has confirmed these same endpoints.
(Park JS 2011)
Using the same surgical principles, a Korean group have developed a
robotic approach, again following an initial perineal dissection; 47 cancers at
a median of 4cm from the anal verge (range 1-6) cm. There were no conversions.
The mean operation time was protracted at 6hrs with transanal extraction
utilised in only 49%. Disappointingly,
use of the robot did not improve cancer outcomes or complications; circumferential
resection margins were positive in 3 cases (6.4%), and there were 10 (21%)
early complications [3 anastomotic leaks (6.4%) and 5 pelvic abscesses (10.6%)].
There were two local recurrences
at a median follow-up of 21 months.
These reports like ours, have demonstrated that it is possible in
selected patients (low, non bulky mobile rectal cancers suitable for a
laparoscopic approach) to restore bowel continuity using this hybrid approach,
which maintains all the perceived advantages of laparoscopic surgery and good oncological
outcome. The technique is clearly
reproducible. The learning curve
for laparoscopic TME is higher than commonly stated for other laparoscopic
procedures (Park JS). As we have demonstrated the technique demands “high end”
laparoscopic skills. Complications
specific to the technique, namely colo-pouch/coloplasty ischaemia are not
insignificant and lead to surgical re-intervention and end colostomy. If ischaemia is suspected (tachycardia,
temperature, pain) early intervention can as we have shown lead to a
laparoscopic solution and quick recovery.
Delayed recognition will herald readmission and more invasive
surgery. Whilst others believe
that it develops in response to prolonged ischaemia of the exteriorized segment
(Rollier, Prete), it is our opinion that the likely cause is venous ischaemia
arising from damaging the venous arcade nearest to the high ligation of the
inferior mesenteric vein in construction of the colopouch. A simple end-to-end anastomosis will almost
certainly avoid this risk, all be it at the expense of functional outcome (Tiret
E)(Park JG). A colonic j pouch also requires a full mobilization of the distal
transverse colon up to the middle colic vessels. Conversely, as demonstrated in
a recent RCT (Ho YH), the high morbidity in the French series could be due to
the coloplasty itself.
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