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26 Management ofLow Rectal Cancer After Complete Clinical Response
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45. Maas M, Nelemans PJ, Valentini V, Das P, Rodel C, Kuo LJ, etal. Long-term outcome in
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299
Optimizing Function forVery Low Rectal
Tumors: Intersphincteric Resection
27
orAPR?
SrikanthParsi, JeanSalem, andJohnH.Marks
Introduction
Rectal cancer is a challenging entity posing technical problems of operating in the
connes of the bony pelvis with proximity to the anal sphincter.
Traditionally rectal cancer was managed by abdominoperineal resection (APR)
which was rst described by Miles in 1908 [1]. APR was the only surgical option
until Dixon performed anterior resection for upper rectal carcinoma in 1948. It took
a while for surgeons to adopt the technique of anterior resection as an alternative to
APR as it was associated with signicant morbidity from anastomotic leak and
mortality. In 1986, Heald described total mesorectal excision (TME) which dramatically improved local recurrence rate for rectal carcinoma [2]. The introduction
of surgical staples in 1980s allowed ultralow anterior resection for mid-rectal
tumors.
However, for low rectal cancers, APR remained the only surgical option until the
transanal abdominal transanal (TATA) proctectomy and transanal endoscopic
microsurgery (TEM) options emerged in the 1980s [3]. These techniques evolved
with the introduction of chemoradiation in the management of rectal carcinoma
which revolutionized sphincter-preserving surgery (SPS) for low rectal tumors. As
part of a long-standing rectal cancer management program, we were the rst to
perform full-thickness local excision (FTLE) after preoperative radiation therapy in
1984 [4].
SPS in the lower pelvis has deterred surgeons because of the challenge of obtaining
adequate distal and circumferential margins as well as the difculty in performing a
low anastomosis. This is due to the connes of the bony pelvis as well as the tapering
S. Parsi • J. Salem • J.H. Marks (*)
Marks Colorectal Surgical Associates, Lankenau Institute for Medical Research,
Wynnewood, PA, USA
Division of Colorectal Surgery, Lankenau Medical Center, Wynnewood, PA 19096, USA
e-mail: parsis@mlhs.org; salemj@mlhs.org; marksj@mlhs.org
© Springer International Publishing AG 2018
C.M. Schlachta, P. Sylla (eds.), Current Common Dilemmas in Colorectal Surgery,
https://doi.org/10.1007/978-3-319-70117-2_27
301
302
of the mesorectum. Historically, resections in this area have been prone to local recurrence (LR) and have posed signicant incontinence and poor quality of life.
To address these issues, Gerard Marks in 1984 described the transanal abdominal
transanal proctectomy (TATA) with descending coloanal anastomosis for low rectal
tumors following high-dose preoperative radiation [5]. The main advantage of TATA
is avoidance of a permanent colostomy with preservation of the anal sphincter as this
obviates the need for placement of a stapler from above. In the last few years, a modication of TATA emerged in the form of taTME (bottom-up TATA) using single- port
laparoscopy to extend the dissection from below. This has even been extended to
natural orice transluminal endoscopic surgery (NOTES) where the entire procedure
including splenic exure mobilization is performed transanally [6].
S. Parsi et al.
Treatment Strategies forLow Rectal Cancer
Management of low rectal cancer involves a multidisciplinary team and is based on
TNM staging of the disease. As part of our multidisciplinary rectal cancer management program, we offer neoadjuvant chemoradiation therapy for all tumors in the
distal third of the rectum and unfavorable cancers at all levels of the rectum (i.e.,
≥T3 or N+). The hallmark to extending sphincter preservation and optimizing the
benet of the downstaging effect of chemoradiation is that nal decisions regarding
surgical treatment are made after completion of the neoadjuvant therapy. TEM can
be offered for tumors <4cm in size, <40% of circumference, mobile, and which
have regressed to within the rectal wall (≤T2).
For >T2 low rectal tumors, intersphincteric resection (ISR) should be considered
along with APR. Sphincter-preserving surgery (SPS) is offered for all patients,
except those whose cancer remains xed at or below the 3cm level.
Our standard practice is to wait 8–12weeks and reassess clinically to decide
upon the nal surgical plan.
APR Vs Sphincter-Preserving Surgery
Neoadjuvant chemoradiotherapy has led to an increase in the rate of SPS by downstaging the tumor and, coupled with improved surgical technique, a decrease in the
locoregional recurrence [7].
In choosing the right procedure in surgical treatment of low rectal carcinoma,
one has to take into account several important factors. Patient baseline sphincter
function is of course important as are tumor size and involvement of sphincter complex, response to neoadjuvant chemoradiation, level of surgeon’s experience in
intersphincteric surgery, and lastly patient preference after discussing pros and cons
of each procedure. However, it must be emphasized that nal decisions regarding
sphincter preservation should be held until the 8–12-week interval to maximize the
benet of chemoradiation.
27 Optimizing Function forVery Low Rectal Tumors: Intersphincteric Resection…
Despite this, APR rates in the literature remain as high as 32–67% [8]. We advocate that all cancers of the distal 3cm of the rectum that are not xed 8–12weeks
after neoadjuvant chemoradiotherapy are managed either by taTME, laparoscopic
TATA, ultralow LAR, or TEM.
303
Preoperative Planning
Preoperative work-up includes complete blood count, metabolic prole, coagulation
prole, liver function test, and baseline carcinoembryonic antigen (CEA). Digital
rectal examination (DRE) along with exible sigmoidoscopy and biopsy is performed in the ofce during the initial visit. Colonoscopy to rule-out synchronous
lesions is performed if not done recently. Tumors are evaluated for extent of invasion
by computed tomography (CT), magnetic resonance imaging (MRI), or endorectal
ultrasound.
Metastatic disease is evaluated with a CT of the abdomen, pelvis, and chest.
Positron-emission tomography CT is not routinely performed unless CT or MRI is
equivocal for metastasis.
Patients who undergo neoadjuvant chemoradiation are initially evaluated by
DRE and exible endoscopy. Size, xity, position, degree of ulceration, shape, clinical T stage, and level in the rectum relative to the anorectal ring are noted originally
and at 8–10 weeks post-radiation therapy. At 8–12 weeks after completion of
chemoradiation, nal assessment is performed to determine whether ISR or APR is
indicated [9]. All patients with adequate sphincter function, except those cancers
that remained xed on examination after completion of their neoadjuvant chemoradiation, undergo sphincter-preserving surgery. The TATA is utilized for patients
whose cancer resides in the distal 3cm of the rectum.
Every patient undergoing an APR is seen by an ostomy specialist for ostomy
teaching. A very high level of preoperative education and expectation from either
surgery are discussed in detail prior to surgery.
TATA Procedure
This operation is offered to patients with non-xed cancers in the distal 3cm of the
rectum. Patients are positioned in extreme lithotomy position with Yellons®
Stirrups (Allen Medical Systems, Acton, MA) for adequate perianal exposure
(Fig.27.1). It is therefore essential that patients are secured rmly to the operating
table. Preoperative antibiotic is given along with alvimopan for faster gastrointestinal recovery in the postoperative period. The abdomen and anus are prepped with
povidone-iodine and drapes secured to the anus with 2-0 nylon suture. We use
lighted suction device that is very helpful during the procedure (VitalVue™,
Medtronic Minimally Invasive Therapies, New Haven, CT).
To start, the perineum is injected with lidocaine and epinephrine for hemostasis
and to facilitate dissection.
304
Fig. 27.1 Patient positioning and operating room setup
S. Parsi et al.
Allis-Adair clamps are used to evert the anal canal and to identify the dentate line
(Fig.27.2). The hallmark of the TATA is starting the operation transanally by performing a full-thickness circumferential incision at or just above the dentate line,
followed by an intersphincteric dissection (Fig.27.3). The dissection is carried out
in the intersphincteric plane between the puborectalis and the internal sphincter
circumferentially (Fig.27.4). The TATA is classically performed by making an incision at the dentate line, therefore excising the upper half of the internal sphincter,
while preserving the external sphincter, puborectalis, and levator ani. When the
tumor invades the upper anal canal, at times a complete resection of the internal
sphincter is carried out, but the functional outcome is likely impaired in this situation. The rectum is mobilized transanally to the level of the cervix in female subjects
and the seminal vesicles in male subjects. This allows for a known distal margin
while sparing the external sphincter and the distal half of the internal sphincter
muscles. The rectum is then oversewn in a watertight fashion followed by placement of a transanal access platform (GelPOINT Path, Applied Medical, Rancho
Santa Margarita, CA) and a exible-tip Olympus videoscope (Fig.27.5). Driving
the camera is a signicant challenge because of the infrequent use of exible-tip
cameras and the constant need to avoid collision with the surgeon instruments in a
narrow working space. We continue the dissection with the help of a LigaSure™
(Medtronic Minimally Invasive Therapies, New Haven, CT) bipolar energy device,
transanally as proximal as possible, including opening the peritoneal cavity, mobilization of the left colon and the splenic exure, and ligation of the inferior mesenteric artery and vein, when possible.
27 Optimizing Function forVery Low Rectal Tumors: Intersphincteric Resection…
Fig. 27.2 Allis-Adair clamps are used to evert the anal canal and identify the dentate line.
Dissection is started by doing a full-thickness circumferential incision at the dentate line
305
Fig. 27.3 Intersphincteric dissection carried circumferentially
The abdominal dissection is completed by open, laparoscopic, or robotic techniques. In our early experience, the abdominal portion was completed in an open
fashion. Over the last decade, we began using minimally invasive transanal and
transabdominal platforms for the completion of the dissection. The abdominal portion is completed laparoscopically either with a single-port or multiport technique.
The rectum and sigmoid colon are then delivered transanally and transected at the
sigmoid-colic junction (Fig.27.6). A hand-sewn coloanal anastomosis is performed
306
Fig. 27.4 Intersphincteric dissection landmarks: dissection carried out in the intersphincteric
plane between the puborectalis and the internal sphincter. The upper portion of the internal sphincter is resected en bloc with the rectal specimen
S. Parsi et al.
Fig. 27.5 Placement of a transanal access platform
transanally with 0 Vicryl sutures (Ethicon. Cincinnati, OH). Different options of
anastomosis exist: straight coloanal, colonic J-pouch-anal, side-to-end anastomosis.
A temporary diverting stoma is made to protect the coloanal anastomosis. In case of
SILS abdominal approach, we use the same site for the diverting ileostomy in the
right lower abdomen [10].
27 Optimizing Function forVery Low Rectal Tumors: Intersphincteric Resection…
Fig. 27.6 Delivery of the
specimen transanally
307
Complications
Early complications pertaining to TATA include anastomotic dehiscence/leak
(5–48%), pelvic abscess (0–9%), intra-abdominal bleeding (0–3.8%), small bowel
obstruction (0–16%), and internal hernia [11, 12]. Delayed complications include
anastomotic stricture (2% to 16%) and neorectal prolapse (0.8–3.7%) [12].
Postoperative Management
Postoperatively, intravenous doxycycline is provided while the patient is hospitalized; this is continued orally for 10days after discharge for all patients. Our postoperative pain regime includes IV ketorolac and intramuscular meperidine. Very
rarely, patients need patient-controlled analgesia (PCA). A clear liquid diet is initiated immediately postoperatively. Patients are assessed at follow-up at 2weeks after
surgery, every 3months for the rst 2years, every 4 months for the next 2years,
every 6months for the fth year, and yearly thereafter.
308
S. Parsi et al.
Clinical and digital examinations are performed at each postoperative visit.
Flexible sigmoidoscopy is performed at 6-month intervals for the rst 2years. Full
colonoscopy is performed at 1year followed by every 3years. CEA is measured at
each visit, and CT of the abdomen and pelvis is performed at 6months, 1year, and
then annually. PET scan is performed selectively if recurrence is suspected.
Results
Between 1984 and 2015, we have performed 373 TATA procedures. The mean
tumor level from the anorectal ring was 1.7cm. About 97.7% of patients received
neoadjuvant radiation with a mean dose of 5405 cGy. Seventy-seven percent of
patients received concurrent chemotherapy with infusional 5FU or capecitabine.
Mean time from completion of neoadjuvant therapy was 11weeks.
The TME was initiated transanally in all cases with the abdominal portion completed in an open fashion in 48% (n = 180) and laparoscopic approach in 52%
(n=193) of cases. Of patients who underwent laparoscopic surgery, the abdominal
portion was carried out by multiport access in 147 patients, SILS in 34 patients, and
robotic access in 13 patients. In 38 patients, the transanal TME dissection was continued further using a single-port platform into the peritoneal cavity as in the taTME
fashion. A hand-sewn coloanal anastomosis was performed via a colonic J-pouch,
side-to-end , or straight coloanal anastomosis depending on the length of the remaining colon. A temporary diverting loop stoma was made in all patients. Overall mean
blood loss was 550mL and incidence of transfusion was 12.6%. Mean length of
stay was 6.2days.
In regard to complications, there was one perioperative mortality due to myocardial infarction (0.3%).
The overall morbidity rate was 25.7%. Early morbidity was 13.4% with 4 anastomotic dehiscences, 3 pelvic abscesses, and 3 small bowel obstructions. Reoperation
was performed in two patients, one for internal hernia and the other for intraabdominal bleeding. Delayed morbidity rate was 12.3% with 10 pelvic abscesses,
10 anastomotic strictures, and 10 patients with neorectal prolapse.
Overall 25.3% had complete pathological response. Tumor’s nal pathological
stages were as follows: 9.6% were ypT1, 33.1% ypT2, 31.7% ypT3, and 0.34%
ypT4. About 4.8% had positive circumferential resection margin of <1mm.
Mean follow-up was 65.7 months. The overall 5-year survival was 90%
(KM5YAS) and was better in patients who underwent a laparoscopic abdominal
completion of transanally initiated TME rather than open abdominal approach (93
vs 87%, p=0.03). Overall local recurrence rate was 7.4%. LR was also less in laparoscopic group when compared to open group (4.3 vs 10.85%, p=0.02).
Distance metastasis was observed in 19.5%. Only four patients required salvage APR.
27 Optimizing Function forVery Low Rectal Tumors: Intersphincteric Resection…
309
Functional Outcomes: ISR Vs APR
Surgical resection represents the mainstay treatment of rectal cancer. However, for
patients with very low rectal cancer, this usually entails removing the anal sphincter
and committing the patient to a permanent colostomy. Although APR offers the
chance of cure, it is correlated with a worse quality of life (QoL) and an increased
prevalence of depression because of the permanent colostomy [12].
Around one-quarter of stoma patients experience clinically signicant psychological symptoms postoperatively. The most common symptoms are those of an
anxiety disorder and major depressive episode. Twenty-nine percent of the patients
improve psychologically after surgery, 23% deteriorate, and 48% of patients experience no change in psychological symptoms [13].
Studies suggest that patients with a stoma have also a poorer QoL than those
without a stoma, and although many patients accept a colostomy without issue,
many patients consider life with a permanent colostomy to be unacceptable [14, 15].
Stoma patients seem to report similar concerns. These can be broadly categorized
into concerns about changed body image and attractiveness, noise, odor, and leakage. To tackle these psychological and QoL issues, we were the rst to describe the
TATA proctosigmoidectomy, a sphincter-preserving surgery designed to simultaneously cure the rectal cancer and avoid a permanent colostomy [16]. Although this
approach has been well described, for a variety of reasons, its adoption in the surgical community has been limited. A major concern voiced has been, ironically, concerns over the QoL of patients in terms of continence and functional status. Indeed,
a common refrain from many surgeons reluctant to the approach of expanded
sphincter preservation has been either “The patient would be better off with a colostomy” or “Why give the patient a perineal colostomy?”.
To address these concerns, we have recently published our data on QoL after
TATA [17]. It is one of the largest studies in the literature with 90 patients included,
and it adds signicantly to the understanding of QoL of patients in the United States
after ISR and TATA.Patients were surveyed using the FIQLS, EORTC QLQ-C30,
CR38, and the Marks Metric for Effect of Continence on QoL.We concluded that
patient’s QoL was not signicantly different after surgery. However, in subgroup
analysis, we found that patients with more proximal tumors had better lifestyle and
physical and emotional scores and that older patients performed better on multiple
levels; this is perhaps related to the fact that older patients coped better and had
more realistic expectations than younger ones [8]. When we compared our results
with those published in the literature for APR using standardized questionnaires,
patients who underwent TATA scored better in all of the functional scales, including
general QoL, physical, role, emotional, cognitive, and social [17].
Konanz etal. compared the QoL of patients after low anterior resection, ISR, and
APR using the EORTC QLQ-C30, CR38, and the Wexner score [18]. They found
that global QoL was comparable between the groups. However, physical and sexual
functions were signicantly better after ISR compared with APR, but diarrhea and
constipation were higher after ISR [18].