Ein Leben nach tiefer Rektumresektion: Was erwartet unsere Patienten im Langzeitverlauf?
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1 Ein Leben nach tiefer Rektumresektion: Was erwartet unsere Patienten im Langzeitverlauf? Dieter Hahnloser Klinik für Viszeral- und Transplantationschirurgie UniverstätsSpital Zürich
2 Low Rectal Resection cm cm Williams NS. BJS 1983 Pollett WG. Ann Surg <1cm Rullier E. Ann Surg 2005
3 Low Rectal Resection Coloanal Anastomosis
4 Low Rectal Resection Abdominoperineal Amputation
5 Low Rectal Resection VASOG II % EORTC % Stockholm I % GITSG % Swedish % NCCTG % NCCTG % NSABP-R % Dutch % German % Oncological efficiency Pre vs. Post Radiochemo 39% vs. 19% sphincter preserving German Rectal Cancer Study Group NEJM 2004 Technical advances
6 Low Rectal Resection Intersphincteric Resection Total Subtotal Partial
7
8 Long-term outcome
9 Long-term outcome Oncologic
10 Long-term outcome Oncologic Bowel movements Continence Sexual and urinary function Quality of life
11 Function, Continence
12 Function, Continence J-Pouch eligible J-Pouch ineligible n=364, multicenter PRT, all 48 month FU Fazio V. Ann Surg 2007
13 Function, Continence n=364, multicenter PRT, all 48 month FU Fazio V. Ann Surg 2007
14 Function, Continence n=364, multicenter PRT, all 48 month FU Fazio V. Ann Surg 2007
15 Function, Continence Bowel/24h day ~2, night ~1 Urgency 70-93% Pad usage 55-70% Antidiarrheal use 44-70% Clustering daily 20-39% n=364, multicenter PRT, all 48 month FU Fazio V. Ann Surg 2007
16 Function, Continence Bowel/24h Urgency 19-58% Leakage day 15% Leakage night 20% Wexner Score 6-12 Review, n=612, 13 studies Tilney HS. Colorectal Dis 2007
17 Function, Continence n=96, median margin 15mm, median FU 37 month Ito M. DCR 2009
18 Function, Continence n=96, median margin 15mm, median FU 37 month Ito M. DCR 2009
19 Function, Continence n=90, median margin 12mm, median FU 56 month Chamlou R. Ann Surg 2007
20 Function, Continence Retrospective, n=37 and n=40, median FU 56 month Bretagnol F. DCR 2004
21 Function, Continence oder Permanent Stoma 24% 61% anorectal dysfunction (incontinence, fistula, abscess) 9% bowel obstruction 9% patient-related 22% recurrence n=192, median FU 65 month Hassan I, Hahnloser D. DCR 2007
22 Function, Continence oder n=192, median FU 65 month Hassan I, Hahnloser D. DCR 2007
23 Function, Continence Change/Empty bags 2-4x/day Change appliance every 2-3 days / year Parastomal hernia up to 45% Skin Problems 20% Prolapse 2-5% Carne P. BJS 2003 Adang EM. DCR 1998 Salvadalena G. J Wound Ostomy Continence Nurs 2008
24 Sexual and urinary function
25 Sexual and urinary function Anterior Resection Sexual active AR 50% 25% n=292 women, mean FU 3.2 yrs Tekkis PP. DCR 2009 (n=222 AR and n=73 )
26 Sexual and urinary function Anterior Resection Urgency OR 8.5 Incontinence OR 2.4 Poor stream OR 5.6 Catheter use OR 3.9 Age >65 yrs 69% urinary retention No risk factors: Radiotherapy,sepsis n=292 women, mean FU 3.2 yrs Tekkis PP. DCR 2009 (n=222 AR and n=73 )
27 Sexual and urinary function 6 month Bladder function: 72% 23% 5% Ejaculation: 56% 19% 25% Potency: 63% 16% 21% Female sexual 53% 14% 32% Liang JT Ann Surg Oncol 2007
28 Quality of Life Physical functioning Role functioning Global health status Body image Sexual functioning Better without stoma 5yrs tumor free, 30 and 32 resection without permanent stoma QLQ-C30 and C38 Fucini C. Ann Surg Oncol 2008
29 Quality of Life worse only in embarassment score Same partial vs. Subtotal Retrospective, n=37 and n=40, median FU 56 month Bretagnol F. DCR 2003
30 Quality of Life + + graciloplasty + worse Symptoms Subjective Prospective, n=197 Anterior Resection, n=65, n=15 Williams score Renner K. Dis Colon Rectum 1999
31 Quality of Life n=47 laparoscopic resections, 10cm from AV Preop Ileostomie 6 mt 12 mt 24 mt Global Health Role functioning Social functioning QLQ CR-38 and C30
32 Quality of Life n=47 laparoscopic resections, 10cm from AV 6 mt 24 mt Nocturnal defecation 38% 75% Stool evacuation problems 60% 75% 40 Defecation problems perception score Preop 6 mt 12 mt 24 mt
33 Ein Leben nach tiefer Rektumresektion: Was erwartet unsere Patienten im Langzeitverlauf? Sphincter preserving < >24 /year Probability of 3.2x 2.1x 1x p=0.003 InterGroup 0114 Study (n=1330) J Clin Oncol 2004
34 Ein Leben nach tiefer Rektumresektion: Was erwartet unsere Patienten im Langzeitverlauf? Dutch Trial Sphincter preserving (TME + Radiotherapie vs. TME) Good Fecal Function, incontinence acceptable (62% vs 38%)* continence Important Factors: Nerve preserving Mucus loss (27% vs. 15%)* surgery and radiotherapy Pad wearing (56% vs 33%)* Anal blood loss (11% vs 3%)* Lower satisfaction with bowel function with greater impact on daily activities Peeters KC. J Clin Oncol 2005;23:6199 * p<0.05
35 Ein Leben nach tiefer Rektumresektion: Was erwartet unsere Patienten im Langzeitverlauf? Sphincter preserving Good Function, acceptable continence Important Factors: Nerve preserving surgery and radiotherapy QoL excellent Good functioning stoma is better than a very unhappy patient
36 Klinik für Viszeral- und Transplantationschirurgie 6. Proktologie Kurs Zürich, November 2009 Programm:
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