Innovations in rectal cancer surgery TAMIS and transanal TME

Transcription

1 Innovations in rectal cancer surgery TAMIS and transanal TME A.D Hoore MD PhD, EBSQ CR Chair Departement of Abdominal Surgery University Hospitals Leuven, Belgium Actual treatment in rectal Early rectal cancer (T1,T2,N0) cancer Advanced rectal cancer T3, TxN1 T1sm1,(sm2) good MRI poor Neoadjuvant chemoradiotherapy TAE/TEM TAMIS Radical Surgery TME +/ proctectomy open laparoscopic transanal organ preservation wait and see protocol 1

2 Development of laparoscopic surgery major disruptive change first CCD camera Evolution in Surgery Open surgery Laparoscopic surgery Robotic surgery new evidence invasiveness MISS surgery NOSE TAMIS NOTES time EMR Endoscopic polypectomy Endoscopic biopsy Diagnostic endoscopy 2

3 accumulating evidence for a laparoscopic approach in rectal cancer Lancet Oncol 2013 New Engl J Med 2015 COLOR II trial (non inferiority phase III) patients randomised (2:1) 699 in laparoscopic surgery group 345 in open surgery group Locoregional recurrence rate at 3 years : 5.0% in both groups DFS: 74.8% (laparoscopic) and 70.8% (open) OS : 86.7% (laparoscopic) and 83.6% (open) N Engl J Med

4 Disease free survival Overall survival CRM positivity (%) Robotic versus laparosocpic TME (non published data) Laparoscopic versus open TME Laparoscopic versus open colon and rectum 4

5 Color II trial : short term laparosocpy open Duration of surgery 240 ( ) 188 ( ) < Conversions 17% Blood loss 200 ( ) 400 ( ) < day mortality 1% 2% ns Overall morbidity 40% 37% ns Leak rate 13% 10% ns Hospital stay 8.0 ( ) 9.0 ( ) <0.36 Lancet Oncol 2013 Conversion to laparotomy (%) remains substantial 5

6 Adoption of lap TME for mid + low rectal cancer in surgical practice over 6 years 38 % 12% conversions 22 % distal rectal transection : not perpendicular to pelvic floor blind distal margin prone to leak? > 2 firings : increased risk for leak Ito M Int J Colorectal Dis 2008; 23(7)

7 Independent predictors for conversion and morbidity in laparoscopic TME Odds ratio P Conversion sex (M:F) 3.01 ( ) % vs 11.1% stapled anastomosis 2.42 ( ).042 rectal fixity ( ) <.001 Morbidity sex (M:F) 6.25 ( ) <.001 stapled anastomosis 3.74 ( ).010 Laurent C, Br J Surg 2008 Factors affecting suitability for lap TME BMI Pelvic anatomy Previous surgery Co morbidity Preference Experience Quality Assurance T size, fixity, level Anastomotic level Colorectal Disease2006; 8 (s3):

8 Full laparoscopic dissection and transanal specimen extraction (TATA) a laparoscopic transanal abdominal transanal radical proctosigmoidectomy and a descending coloanal handsewn anastomosis (TATA). This technique, developed in 1984 by Dr. Gerald Marks at Thomas Jefferson University Hospital to avoid a permanent colostomy 8

9 Totally laparoscopic restorative proctectomy with transperineal handsewn colonic J pouch J. Marks et al. Surg Endoscopy 2010; 24: F. Prete et al. Surg Endoscopy 2007; 21:1679 B Person et al. Surg Endoscopy 2006; 20 : Transanal specimen extraction does not compromise oncologic outcome Denost, Ann Surg

10 TEM: the first NOTES platform Cost Technique Learning curve Training Limited indication T1 sm1,sm2 good mod diff Buess G Endoscopy 1985, Endoscopic surgery of the rectum Intraluminal 10

11 Endoluminal TAMIS Differences: TEM TAMIS TEM TAMIS Patient position ~ tumor localization lithotomy Equipment Rigid TEM proctoscope Gelpoint Path port 12 or 20 cm floppy Equipment Special insufflator Standard insufflator insufflation High flow, <15 mmhg Airseal Equipment Special 30 TEM scope 5 or 10 mm 30 laparoscope camera (cameraholder) Instruments Bended instruments Lap instruments Surgeon Single surgeon Two surgeons reduced learning curve 11

12 Insuflation Devices 1. Stable pneumoperitoneum 2. Continuous smoke evacuation 3. Valve free access Transanal NOTES : extra luminal TAMIS rectosigmoidresection Porcine and human cadavers Whiteford Surg Endoscopy 2007 Denk GI End 2008 Sylla Surg End

13 first ta TME (hybrid) using TEM Sylla P. et al. Surg Endoscopy 2013 No Scar Transanal Total Mesorectal Excision The Last Step to Pure NOTES for Colorectal Surgery Joël Leroy, MD, FRCS TEM technology (stable transanal platform) JAMA Surgery

14 Transanal natural orifice transluminal endoscopic surgery (NOTES) rectal resection: down to up total mesorectal excision (TME) short term outcomes in the first 20 cases Antonio M. Lacy et al. Surg Endoscopy 2013 ta TME (transanal TME or reversed TME) line of dissection pursestring Tumor transmural incision 14

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16 posterior mesorectum 16

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18 S3 R hypogastric nerve 18

19 ) Ta TME : hybrid laparoscopic mesenteric pedicle and splenic flexure transanal retrievement of the specimen 19

20 Conceptual advantage tatme visual control of the distal margin Tailored level of anastomosis in distal rectal cancer Supra anal low stapled Juxta anal (< 1cm) colo anal (sleeve mucosectomy) partial ISR Rullier E et al. Dis Colon Rectum

21 Partial and complete ISR, mucosal sleeve Stapling Mucosal sleeve anastomosis Laparoscopic TME Transanal TME p n = 37 n=37 Surgical time 252 ± ±60 <0.01 Colo anal 43% 16% <0.01 Distal margin 1.8 ± ±1.7 =0.05 Early morbidity equal readmission 22% 6% =

22 Transanal endoscopic proctectomy innovative procedure for difficult resection of rectal tumors in men with narrow pelvis (n=30, jan 2009 june 2011) Laparoscopic assisted (splenic flexure) Main causes for TAEP narrow pelvis fatty mesorectum large anterior tumor Morbidity urethral Injuries (n=2, reoperation (n=2, 7%) 7%) Hospitalization 14d (19 25) Rouanet Ph et al. Dis Colon and Rectum 2013 Shift from double stapled to single stapled low colorectal anastomosis Ann Surg

23 Dog ear formation as a risk factor for anastomotic disruption Single stapled Double stapled Circular (n=35) Dog Ear (n=32) median bursting pressure 90 mmhg 60 mmhg p<.001 Roumen R et al. Dis Colon Rectum 2000; 43: ta TME : a technique in evolution 1. Learning curve to be defined lesions to the urethra, NVB of concern! 1. Reduces the need for conversions to lapartomy 2. Technology will follow different new transanal platforms robotic adaptations 23

24 The future of surgery will not be like the past not the strongest but the most adaptive to change will survive. Innovation in surgery is not to pave the something new but for something better way for and there is only one stakeholder : our patient 24