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326
D. A. Kleiman and S. A. Lee-Kong
cases. Having a senior-level trainee or partner available may help reduce frustration
and operative time.
Conversion from a minimally invasive to open approach should not be considered failure. The goal of the operation is successful reversal of the colostomy, and
the operation should only be considered a failure if the rectal stump cannot be salvaged and reversal is not possible. Oftentimes, this decision to convert to open is
made relatively early in the course of the operation. Dense intra-abdominal or pelvic
adhesions may preclude adequate visualization. If the surgeon is comfortable with
laparoscopic or robotic adhesiolysis, this can be attempted once adequate port
placement has been achieved. Hasson entry in the supraumbilical midline or initial
colostomy takedown and port placement via this aperture are both reasonable strategies for safe abdominal entry.
Minimally invasive Hartmann’s reversal operations can be complicated by nuisance bleeding caused by management of intra-abdominal or pelvic adhesions. The
use of a laparoscopic suction irrigator can help evacuate blood, which may obscure
your view of the operative eld. Alternatively, introduction of a sponge or laparotomy pad into the abdomen can be helpful for the evacuation of blood or clot. This
can also be used to clean the laparoscope should the lens become soiled during the
operation.
Should splenic exure mobilization become necessary, a medial to lateral
approach can be performed. Incising the peritoneum beneath the IMV and entering
the retromesenteric plane at this location may allow for easier exure takedown.
Peritonitis from perforation and prior surgery may make lateral to medial mobilization of the left colon and splenic exure difcult. Taking advantage of the “virginal”
retromesenteric plane may facilitate exure mobilization and avoid potential injury
to the colon conduit.
Even with complete mobilization of the splenic exure, sufcient reach may not
be achieved in all cases. This can happen if a signicant portion of the left colon had
been resected at the index operation or if the remaining left colon is diseased, ischemic, or otherwise unusable. In such scenarios, the transverse mesocolon may not
be long enough to allow a tension-free anastomosis between the distal transverse
colon and the rectum. While one option would be to abort the procedure and remature the end colostomy, one can consider mobilization and counterclockwise
rotation of the right colon with anastomosis of the right or proximal transverse
colon to the rectum (Deloyers procedure). The transverse colon is sacriced during
this procedure to allow for right colon to rectum anastomosis. The blood supply to
the right colon must, obviously, be carefully preserved. A variation of this is the
Turnbull procedure, in which a window is created in an avascular portion of the
terminal ileal mesentery allowing the proximal colon to be passed in a retroileal
fashion to the colorectal anastomosis.
Dense pelvic inammation may hamper attempts at mobilization of the rectal
stump. At times, the stump can become completely retroperitonealized, making
initial identication difcult. Having an assistant pass an EEA sizer or large bougie
transanally may help in identication of the top of the stump and may help dene
the course of the rectum in the pelvis. Once identied, entering the presacral space,
21 Laparoscopic andRobotic Hartmann’s Reversal: Strategies toAvoid Complications
327
which is seldom violated at the original operation, may allow for easier mobilization of the rectum. This dissection is usually begun at the sacral promontory.
Ureteral catheters can be helpful in identication of the ureters at this level.
Resection of the brotic proximal rectal stump is often required, to allow anastomosis to soft, pliable rectum.
Outcomes
The literature outlining the clinical outcomes of minimally invasive Hartmann’s
reversal continues to evolve. While the proportion of patients who never undergo
colostomy closure remains high, it appears that more reversal surgeries are being
performed using minimally invasive techniques.
Several studies have examined outcomes of laparoscopic Hartmann’s reversal,
which are summarized in Table21.1. Pei and colleagues examined national trends
and outcomes in laparoscopic colostomy reversal using the American College of
Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) [9]. By
2014, up to 74% of reversal surgeries were performed laparoscopically, with an
annual increase of 2.87% per year during the study period. Laparoscopic reversal
was associated with shorter hospital length of stay and lower overall complication
rates when compared to open surgery.
Table 21.2 summarizes several studies that compared outcomes of laparoscopic
and open Hartmann’s reversal. Most studies demonstrated slightly shorter operative
times and shorter length of stay in the laparoscopic group compared to open.
However, since these studies were not randomized, selection bias likely skewed the
laparoscopic group toward less challenging cases.
Arkenbosch and colleagues examined the same database, identifying patients
undergoing Hartmann’s reversal between 2005 and 2012 [12]. Only 17.6% of
patients underwent a laparoscopic procedure. Patients in this group tended to have
a lower BMI, shorter operations, and a lower overall morbidity. Rates of
Table 21.1 Outcomes of laparoscopic Hartmann’s reversal
Author Data source
Year
2018 Park [8] Single
2018 Pei [9] ACS-NSQIP N/A % of laparoscopic reversal increased
2017 Brathwaite [10] ACS-NSQIP N/A Less SSI, shorter LOS
2017 Horesh [11] Multi-
2015 Arkenbosch [12] ACS-NSQIP N/A Lower morbidity, shorter LOS
2014 Richards [13] Multi-
2013 Lin [7] Single
institution
institution
institution
institution
Conversion
rate (%)
49 Lower morbidity, shorter LOS
27.2 N/A
64 N/A
47 Lower morbidity
Major ndings in laparoscopic reversal
over open reversal
over time
328
Table 21.2 Comparison of laparoscopic vs. open Hartmann’s reversal
Year Author
2018 Horesh [14] 56 204 NR NR 10.9 11.8 46 47 36 38
2018 Kwak [6] 17 12 212.5 251.8 11.7 14.8 29.4 41.7 24 17
2015 Arkenbosch
[12]
2014 Yang [15] 43 64 276 242 6.7 10.8 19 38 7 5
2013 de’Angelis
[16]
Number of
patients
Lap Open Lap Open Lap Open Lap Open Lap Open
732 3416 187.6 190.4 5 6 18.4 27 14 19
28 28 171.1 235.8 6.7 11.2 10.7 27.8 0 33.3
Operative
time (min)
Length of
stay (days)
D. A. Kleiman and S. A. Lee-Kong
Surgical site
Complication
rate (%)
of infection
(%)
reoperation, incisional and organ space surgical site infection, and sepsis were also
lower in the laparoscopic group. A similar study by Brathwaite and colleagues demonstrated identical results [10].
Despite increased experience and comfort with minimally invasive techniques
including robotic surgery, conversion rates of Hartmann’s reversal remain high, and
they have not yet been consistently demonstrated to have decreased over time. It is
not yet clear what impact the introduction of robotics will have on conversion rates
since very limited data are currently available on this.
Conclusion
Minimally invasive Hartmann’s reversal is often a challenging operation, requiring
careful patient selection and preoperative planning. Advanced training in minimally
invasive colorectal surgery is essential in achieving acceptable outcomes and limiting complications. Rates of conversion to open surgery remain high but should not
be interpreted as a failure. Successful completion of minimally invasive surgery is
associated with lower postoperative morbidity and shorter length of hospital stay.
Surgeons should be comfortable with the various minimally invasive techniques
available, applying them as applicable. A signicant learning curve for minimally
invasive colorectal surgery exists, and this should be kept in mind prior to attempting laparoscopic or robotic Hartmann’s reversal surgery.
References
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of life in uncomplicated symptomatic diverticular disease: is it another good reason for treatment? Dig Dis. 2007;25(3):252–9.
2. Feingold D, Steele SR, Lee S, Kaiser A, Boushey R, Buie WD, etal. Practice parameters for
the treatment of sigmoid diverticulitis. Dis Colon Rectum. 2014;57(3):284–94.
3. Bailey MB, Davenport DL, Procter L, McKenzie S, Vargas HD.Morbid obesity and diverticu-
litis: results from the ACS NSQIP dataset. J Am Coll Surg. 2013;217(5):874–80 e1.
4. Steinemann DC, Stierle T, Zerz A, Lamm SH, Limani P, Nocito A.Hartmann’s procedure and
laparoscopic reversal versus primary anastomosis and ileostomy closure for left colonic perforation. Langenbecks Arch Surg. 2015;400(5):609–16.
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5. Royo-Aznar A, Moro-Valdezate D, Martín-Arévalo J, Pla-Martí V, García-Botello S, Espín-
Basany E, etal. Reversal of Hartmann’s procedure: a single-centre experience of 533 consecutive cases. Colorectal Dis. 2018;20(7):631–8.
6. Kwak HD, Kim J, Kang DW, Baek SJ, Kwak JM, Kim SH.Hartmann’s reversal: a comparative
study between laparoscopic and open approaches. ANZ J Surg. 2018;88(5):450–4.
7. Lin F, Boutros M, Da Silva GM, Weiss EG, Lu XR, Wexner SD.Hartmann reversal: obesity
adversely impacts outcome. Dis Colon Rectum. 2013;56:83–90.
8. Park W, Park WC, Kim KY, Lee SY.Efcacy and safety of laparoscopic Hartmann colostomy
reversal. Ann Coloproctol. 2018;34(6):306–11.
9. Pei KY, Davis KA, Zhang Y.Assessing trends in laparoscopic colostomy reversal and evaluat-
ing outcomes when compared to open procedures. Surg Endosc. 2018;32:695–701.
10. Brathwaite S, Latchana N, Esemuede I, Harzman A, Husain S.Risk factors for surgical site
infection in open and laparoscopic Hartmann closure: a multivariate analysis. Surg Laparosc
Percutan Tech. 2017;27(1):51–3.
11. Horesh N, Lessing Y, Rudnicki Y, Kent I, Kammar H, Ben-Yaacov A, etal. Considerations for
Hartmann’s reversal and Hartmann’s reversal outcomes-a multicenter study. Int J Colorectal
Dis. 2017;32(11):1577–82.
12. Arkenbosch J, Miyagaki H, Kumara HM, Yan X, Cekic V, Whelan RL.Efcacy of laparoscopic-
assisted approach for reversal of Hartmann’s procedure: results from the American College
of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Surg
Endosc. 2015;29:2109–14.
13. Richards CH, Roxburgh CS, Scottish Surgical Research Group (SSRG). Surgical outcome in
patients undergoing reversal of Hartmann’s procedures: a multicentre study. Colorectal Dis.
2015;17(3):242–9.
14. Horesh N, Lessing Y, Rudnicki Y, Kent I, Kammar H, Ben-Yaacov A, etal. Comparison
between laparoscopic and open Hartmann's reversal: results of a decade-long multicenter retrospective study. Surg Endosc. 2018;32:4780–7.
15. Yang PF, Morgan MJ.Laparoscopic versus open reversal of Hartmann’s procedure: a retro-
spective review. ANZ J Surg. 2014;84:965–9.
16. de’Angelis N, Brunetti F, Memeo R, Batista da Costa J, Schneck AS, Carra MC, et al.
Comparison between open and laparoscopic reversal of Hartmann’s procedure for diverticulitis. World J Gastrointest Surg. 2013;5(8):245–51.
329
Principles ofRectal Cancer Management:
Preoperative Staging, Neoadjuvant
22
Treatment, Basic Principles ofTME,
andAdjuvant Treatment
EmmanouilPappou andMartinR.Weiser
Introduction andRationale
Rectal cancer was considered incurable up until the eighteenth century, when techniques to remove the rectum were developed. With innovations in anesthesia and the
advent of aseptic technique, proctectomy became more radical and aggressive. In
1908, William Ernest Miles described his technique of a combined abdominal and
perineal resection (APR) with en bloc removal of all associated lymph nodes in
upward, lateral, and downward directions (cylindrical concept), introducing the
basis for curative rectal cancer surgery. The widespread acceptance of Miles’ APR
represented anacknowledgment that cancer surgery should be based on anatomical
and biological principles. In 1910, the American surgeon Donald Balfour described
a technique of anterior resection with construction of a primary end-to-end anastomosis, which didn’t gain acceptance, as it was thought that this operation was not
radical enough. However, Miles’ concept concerning the spread and recurrence of
rectal cancer was subsequently proven wrong when Cuthbert Dukes, an English
pathologist at St. Mark’s Hospital, demonstrated that downward and lateral spread
from rectal cancer was overestimated by Miles, as the majority of metastaticlymph
nodes were either parallel to or proximal to the level of the primary tumor. This
observation initiated the historical shift to sphincter-saving procedures. Claude
Dixon, surgical chair at the Mayo Clinic, reported in 1948 a mortality rate of 2.6%
E. Pappou
Department of Surgery, Memorial Sloan Kettering Cancer Center, Cornell University,
New York, NY, USA
e-mail: pappoue@mskcc.org
M. R. Weiser (
Department of Surgery, Stuart H.Q.Quan Chair in Colorectal Surgery, Vice Chair for
Education and Faculty Development, Memorial Sloan Kettering Cancer Center, Cornell
University, New York, NY, USA
e-mail: Weiser1@mskcc.org
© Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2020
P. Sylla et al. (eds.), The SAGES Manual of Colorectal Surgery,
https://doi.org/10.1007/978-3-030-24812-3_22
*)
331
332
E. Pappou and M. R. Weiser
and a 5-year survival of 64% with anterior resection, establishing the technique as
an accepted treatment for upper and middle rectal cancers. The understanding in the
1970s that a distal margin of 1–2cm did not compromise survival or local control
initiated the shift from APR to anterior resection even for low-rectal tumors. Circular
stapling devices, rst conceived in Russia and introduced in the United States by
Steichen and Ravitch, revolutionized rectal surgery by facilitating the creation of
low colorectal anastomoses in a safe and expeditious manner while reducing the
risk of anastomotic leakage. Interest in lateral tumor spread was renewed when
Quirke and Dixon found that there was a high predictive value of the involvement
of the circumferential resection margin (CRM) for the subsequent development of
local recurrence and poor survival. Bill Heald popularized a low anterior resection
technique he termed “total mesorectal excision” (TME), which involves en bloc
resection of the tumor and mesorectum using sharp dissection under direct vision
and along embryologically dened surgical planes, resulting in decreased rates of
positive lateral margins and lower rates of local recurrence. This approach became
the gold standard in rectal cancer surgery, along with the principle of autonomic
nerve preservation (hypogastric nerves, inferior hypogastric plexus, and pelvic
splanchnic nerves), which was initiated in Japan by Hojo and Moriya and promoted
in the United States by Warren Enker.
Although at present the primary treatment of rectal cancer is centered on surgical
resection, chemotherapy and radiation have become increasingly important. The
concept of neoadjuvant therapy for rectal cancer was rst introduced in the 1920s,
when signicant tumor response was notedfollowing implantation of radon seeds
directly into rectal tumors. As surgery became safer and the limitations of contact
radiation (the only radiation treatment modality at that time) became apparent, the
use of radiation as a primary treatment declined. After it became apparent that the
outcomes of radical surgery were suboptimal, investigators in Europe and the United
States explored utilizing neoadjuvant radiotherapy and chemoradiotherapy, and
eventually the benets of administering radiotherapy in the preoperative period in
reducing local recurrence rates were demonstrated. Subsequent studies suggested
that the oncologic benets of neoadjuvant radiotherapy and good surgical technique
were additive, not compensatory, with regard to pelvic control. Several large trials
have since shown the benet of preoperative radiotherapy combined with chemotherapy, and consensus guidelines since the 1990s have established trimodal therapy– chemotherapy, radiation, and surgery– as the standard of care for locally
advanced rectal cancer.
Preoperative Staging
Assessment of the extent of disease at the time of diagnosis is important because
clinical stage dictates treatment decisions. The preoperative staging of rectal cancer
follows the clinical TNM system, based on the depth of tumor penetration in the
rectal wall, presence of involved regional lymph nodes, and presence of distant
22 Principles ofRectal Cancer Management: Preoperative Staging, Neoadjuvant…
333
metastatic disease. However, the preoperative assessment of rectal cancer goes
beyond determination of clinical tumor stage; it includes the distance of the tumor
from the anal verge, its relationship to the sphincter complex and the levator muscles, the proximity of the tumor to the mesorectal fascia, the involvement of surrounding structures (e.g., prostate, bladder, vagina), and the presence of extramural
venous invasion.
A complete history and physical examination are essential components of the
initial preoperative evaluation. The physician should inquire about changes in bowel
habits, rectal bleeding, control of atus and stool, obstructive symptoms, recent
weight loss or anorexia, and sacral or sciatic pain. A detailed family history should
also be taken to rule out the possibility of a hereditary cancer syndrome.
The physical exam should focus on the presence of abdominal masses, inguinal
lymphadenopathy, and palpable rectal masses. A careful digital rectal exam should
be performed, noting the resting anal tone, anal squeeze, and length of the surgical
anal canal. If a mass is encountered, its orientation, quality (hard vs. soft, mobile vs.
xed), and distance both from the anal verge and more importantly from the sphincter complex (anorectal ring) should be noted. A hard mass in the pouch of Douglas
felt on digital rectal exam may indicate peritoneal carcinomatosis.
The lumen of the rectum should be examined with either a rigid proctoscope or
exible sigmoidoscopy, although tumor location is most accurately measured by
rigid proctoscopy. This allows for accurate assessment of tumor orientation, location in relation to the rectal folds (proximal, middle, and distal Houston’s valves),
circumferential involvement, proximal and distal extent of the tumor, and whether
the tumor is obstructing or near-obstructing. If the diagnosis of invasive cancer has
not yet been conrmed, additional biopsies should be taken.
Laboratory studies including complete blood count, coagulation parameters,
chemistry panel, and carcinoembryonic antigen (CEA) level are generally obtained
prior to start of treatment.
Whenever possible, the patient should have a full colonoscopy because synchronous polyps and synchronous colorectal cancers are present in up to 30% and up to
5.3% of rectal cancer patients, respectively. If a full colonoscopy is not possible at
the outset, it can be attempted after tumor downsizing by neoadjuvant therapy.
Alternatives include CT colonography (virtual colonoscopy) and intraoperative palpation of the colon. In cases where a complete colonoscopy is not feasible prior to
an operation, a short-interval surveillance colonoscopy should be performed
3–6months after surgery.
Accurate pretreatment locoregional staging is needed to assess the depth of
tumor penetration through the rectal wall as well as the presence of suspiciously
enlarged regional lymph nodes. The two most commonly utilized imaging modalities for locoregional staging are endorectal ultrasound (ERUS) and magnetic resonance imaging (MRI).
ERUS is used to evaluate the depth of tumor invasion through the rectal wall and
to detect any enlarged adjacent mesorectal lymph nodes; it is most useful for staging
early-stage, T1–T2 rectal cancers. The main advantages of ERUS are its low cost
334
E. Pappou and M. R. Weiser
and ability to distinguish between Tis, T1, and T2 tumors (Fig.22.1a–d). However,
it has a relatively short focal range, is inferior at evaluating the mesorectal fascia,
and cannot assess pelvic lymph nodes that are remote from the rectum. It is also
limited by operator skill and is associated with a substantial learning curve.
Rectal MRI (specicallyhigh-resolution T2-weighted images including a narrow eld of view of the rectum) provides the best assessment of the rectal wall and
perirectal fat and is considered the best modality for distinguishing T2–T4 tumors
(Fig.22.2a, b). It provides hightissue resolution and excellent anatomical depiction
of the rectum, the mesorectum, the mesorectal fascia, the levator muscles, other
pelvic structures adjacentto the tumor, and possible extramural venous invasion.
Advanced functional sequences such as diffusion-weighted imaging permit the
quantication of tumor biologic processes such as microcirculation, vascular
b
a
b
c
Fig. 22.1 (a–d) Endorectal ultrasound in rectal cancer staging. The sonographic 5-layer structure
of the rectal wall consists of 3 hyperechoic layers (interfacebetween the balloon and mucosa,
submucosa, andperirectal fat/serosa) separated by 2 hypoechoic layers (muscularis mucosa and
muscularis propria). Lesions are T staged as uT0/uTis when the mass is within the hypoechoic M.
mucosa layer, as uT1 when invading the hyperechoic submucosal layer, and as uT2 if they cause a
distinct break in the submucosal layer and invade into the hypoechoic muscularis propria layer.
(All imagesused with permission of Springer Nature from Valinluck Lao and Fichera [53].)
d
ab
22 Principles ofRectal Cancer Management: Preoperative Staging, Neoadjuvant…
Fig. 22.2 (a, b) Magnetic resonance imaging in rectal cancer staging. Routine use of rectal MRI
in the context of a multidisciplinary assessment of rectal cancer has been used to plan neoadjuvant
therapy and surgery and has been shown to reduce the incidence of positive circumferential margins. Axial and sagittal views of a locally advanced rectal cancer are shown, depicting extramural
venous invasion and enlarged obturator lymph nodes
permeability, and tissue cellularity and are useful in the assessment of response to
neoadjuvant therapy. However, it is often difcult to distinguish the submucosa
from the muscularis propria on MRI, and therefore differentiating T1 and T2 tumors
can be difcult, and overstaging can occur. Tumor distance from the mesorectal
fascia is highly predictive of achieving a negative CRM; it has prognostic implications for local recurrence and patient survival and has become one of the most
important parameters in the preoperative evaluation. The excellent accuracy of MRI
in delineating the mesorectal fascia– producing results comparable to those of histological analysis– was demonstrated by a large European multicenter trial known
as the MERCURY study, in which 349 patients underwent preoperative MRI assessment, followed by TME surgery. MRI was found to be accurate within 0.5mm, with
a specicity of 92%, in predicting a clear CRM [1]. MRI with a rectal cancer protocol has become more widely available and has replaced ERUS as the primary imaging modality used for the locoregional staging of rectal cancer, although ERUS
remains useful for staging of early T1–T2 tumors.
The National Accreditation Program for Rectal Cancer (NAPRC) that was developed through a collaboration with the Commission on Cancer (CoC), a quality program of the American College of Surgeons, considers rectal MRI the standard for
the pretreatment staging of rectal cancer. ERUS can be used in addition to rectal
MRI for small rectal lesions (T1/T2) to improve accuracy of T staging.
A CT scan of the chest, abdomen, and pelvis with oral and intravenous contrast
should be obtained to exclude distant metastases, which are present in up to 20% of
patients at the time of diagnosis. PET-CT is not routinely used for initial staging.
335
Indications and Contraindications
One of the difculties in constructing algorithms and guidelines for treatment of
rectal cancer is that treatment decisions must take into account multiple variables,
336
E. Pappou and M. R. Weiser
Patients with rectal cancer
Low risk: “The Good”
T1-T3 (< 5 mm) mid/upper rectum
T1-T3 (superficial) lower rectum
NO
Extramural vascular invasion: no
MRF clear
Risk of LR < 10%
TME
lntermediate risk: “ The Bad”
T3 (> 5 mm)
T4 (posterior vaginal wall only)
or
N1/2
or
Extramural vascular invasion: yes
MRF clear (> 1 mm)
Risk of LR 10-20%
Preoperative
short-course radiation
TME
Adjuvant chemotherapy
High risk: “The Ugly”
T4 (other than posterior
vaginal wall)
N0/1/2
MRF involved
Risk of LR > 20%
Preoperative
chemoradiation
TME
Adjuvant chemotherapy
Fig. 22.3 European model of stratication for patients with rectal cancer based on magnetic reso-
nance imaging. Abbreviations: MRF, mesorectal fascia; LR, local recurrence; TME, total mesorectal excision. (Source: Ferrari and Fichera [54]. Published under the terms of the Creative Commons
CC License.)
including tumor location, xation, circumferential involvement of the rectum, the
tumor’s relation to the pelvic oor muscles, pelvic morphology, clinical stage, presence of symptoms and degree of obstruction, presence and location of metastases,
continence status, prior treatments, and patient preferences. It is virtually impossible to create straightforward guidelines that account for all of these factors. At present, the clinician caring for patients with rectal cancer must be able to tailor
recommendations for therapy based on the characteristics of the tumor, and the
patient, and have a rm grasp of the rationale and the existing data supporting any
proposed treatment plan.
In a number of European countries, treatment decisions are based on MRI ndings of tumor aggressiveness including the proximity of the primary tumor to the
mesorectal fascia, the depth of tumor invasion, the presence of metastatic lymph
nodes, and the presence of venous invasion (Fig.22.3). While this algorithm is intuitive, its utility has not been yet evaluated in prospective trials [2]. A simplied version of the National Comprehensive Cancer Network guidelines for locally advanced
rectal cancer is also shown (Fig.22.4).
Local Excision forEarly-Stage Rectal Cancer
Transanal endoscopic surgery for rectal cancer is covered in Chap. 39 in more detail.
Historically, local excision was associated with high recurrence rates; however, the
advent of accurate preoperative staging, tumor downstaging following neoadjuvant
therapy, and the development of new surgical techniques such as transanal endoscopic microsurgery and transanal minimally invasive surgery have resulted in
increased interest inlocal excision. Currently, the National Comprehensive Cancer