Ein Leben nach tiefer Rektumresektion: Was erwartet unsere Patienten im Langzeitverlauf? Dieter Hahnloser Klinik für Viszeral- und Transplantationschirurgie UniverstätsSpital Zürich
Low Rectal Resection -1980 5cm 1983 2cm Williams NS. BJS 1983 Pollett WG. Ann Surg 1983 2005 <1cm Rullier E. Ann Surg 2005
Low Rectal Resection Coloanal Anastomosis
Low Rectal Resection Abdominoperineal Amputation
Low Rectal Resection VASOG II 1975-80 94% EORTC 1976-81 81% Stockholm I 1980-87 63% GITSG 1981-85 59% Swedish 1987-90 56% NCCTG-7951 1980-86 51% NCCTG 1986-90 47% NSABP-R02 1987-92 43% Dutch 1996-99 27% German 1995-02 25% Oncological efficiency Pre vs. Post Radiochemo 39% vs. 19% sphincter preserving German Rectal Cancer Study Group NEJM 2004 Technical advances
Low Rectal Resection Intersphincteric Resection Total Subtotal Partial
Long-term outcome
Long-term outcome Oncologic
Long-term outcome Oncologic Bowel movements Continence Sexual and urinary function Quality of life
Function, Continence
Function, Continence J-Pouch eligible J-Pouch ineligible n=364, multicenter PRT, all 48 month FU Fazio V. Ann Surg 2007
Function, Continence n=364, multicenter PRT, all 48 month FU Fazio V. Ann Surg 2007
Function, Continence n=364, multicenter PRT, all 48 month FU Fazio V. Ann Surg 2007
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
Function, Continence Bowel/24h 1.7-5 Urgency 19-58% Leakage day 15% Leakage night 20% Wexner Score 6-12 Review, n=612, 13 studies Tilney HS. Colorectal Dis 2007
Function, Continence n=96, median margin 15mm, median FU 37 month Ito M. DCR 2009
Function, Continence n=96, median margin 15mm, median FU 37 month Ito M. DCR 2009
Function, Continence n=90, median margin 12mm, median FU 56 month Chamlou R. Ann Surg 2007
Function, Continence Retrospective, n=37 and n=40, median FU 56 month Bretagnol F. DCR 2004
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
Function, Continence oder n=192, median FU 65 month Hassan I, Hahnloser D. DCR 2007
Function, Continence Change/Empty bags 2-4x/day Change appliance every 2-3 days 5 339 / 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
Sexual and urinary function
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 )
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 )
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
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
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
Quality of Life + + graciloplasty + worse Symptoms Subjective Prospective, n=197 Anterior Resection, n=65, n=15 Williams score Renner K. Dis Colon Rectum 1999
Quality of Life n=47 laparoscopic resections, 10cm from AV 90 80 70 60 50 40 30 20 Preop Ileostomie 6 mt 12 mt 24 mt Global Health Role functioning Social functioning QLQ CR-38 and C30
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 30 20 10 Preop 6 mt 12 mt 24 mt
Ein Leben nach tiefer Rektumresektion: Was erwartet unsere Patienten im Langzeitverlauf? Sphincter preserving <5 6-23 >24 /year Probability of 3.2x 2.1x 1x p=0.003 InterGroup 0114 Study (n=1330) J Clin Oncol 2004
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
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
Klinik für Viszeral- und Transplantationschirurgie 6. Proktologie Kurs Zürich, 3.-6. November 2009 Programm: www.proktokurs.eu