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Ultra low lap anterior resection, pull through & coloanal anastomosis : 5yr experience

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11/12/2011

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


Abstract

AIMS:

Examine the efficacy of restorative ultra-low laparoscopic resection in patients with low rectal cancer.

METHODS:

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.

RESULTS:

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 repair.

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

 


Introduction

Laparoscopic colonic 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)


Patients and methods

From January 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.  

 

 


Results

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%).


Discussion

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 evaluable men.

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.

  

 

 

References

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