Monday, February 14, 2011

Surgeons Pioneer Sphincter-Sparing Treatment for Rectal Cancer - Helping Reduce Recurrence Rates

While sphincter-sparing surgery is fairly common for upper rectal and mid-rectal cancers, it is less common for low rectal cancers, which are more difficult to resect due to anatomical challenges and their proximity to important structures in the pelvis. Yet gastrointestinal surgeons at the Massachusetts General Hospital Digestive Healthcare Center regularly offer this procedure to patients with mid-rectal and low rectal cancers. Many times, these patients have been told by other physicians that they will lose their sphincters, which will result in fecal incontinence.

In 2009, the Mass General Digestive Healthcare Center performed 75 rectal cancer surgeries. Of these, 55 were performed using sphincter-sparing approaches—half were done laparoscopically. The remaining rectal surgeries were done via abdominoperineal resection (APR). Most patients presented with mid-rectal and low rectal cancers.

Expertise in Surgical Approaches

Images illustrating preoperative staging of rectal cancer by endorectal ultrasound (ERUS) and pelvic magnetic resonance imaging (MRI).

Surgeons at the Digestive Healthcare Center have advanced several sphincter-sparing procedures for patients with rectal cancer. The standard of care for curative rectal resection is the total mesorectal excision (TME) procedure, which involves removal of the rectum together with the surrounding envelope of lymph nodes.

Research shows that recurrence rates are highly dependent on the quality of the surgical resection. The recurrence rate for a TME is 3 to 6 percent, compared with 5 to 11 percent for an intramesorectal excision and 8 to 21 percent for a muscularis propria excision. At the Digestive Healthcare Center, colorectal surgeons follow a rigid TME protocol during which all final specimens undergo a pathological assessment for quality control. During the assessment, the pathologist will confirm if the surgeon has left an intact mesorectum with the specimen and achieved negative distal and radial circumferential margins of 1 centimeter. By following this protocol, surgeons can help reduce the patient’s rate of recurrence significantly.

For tumors that are very low in the rectum and possibly involve the internal sphincter but have not broken through to the external sphincter, surgeons at the Digestive Healthcare Center offer intersphincteric resection (ISR) with a coloanal anastomosis. This procedure is an option for patients who have been told by other hospitals they will lose their sphincters. In an ISR, the dissection is performed between the internal and external sphincter. The internal sphincter is removed, but the external sphincter that controls the voluntary ability to squeeze and hold stool remains intact. A hand-sewn anastomosis is performed between the neorectum and the anus. By performing this difficult procedure, surgeons can help preserve a patient’s continence after surgery, even for tough-to-treat low rectal cancers that are 2 to 4 centimeters from the anal verge.

A Completely Transanal Approach

For several years, gastrointestinal surgeons have performed transanal endoscopic microsurgery (TEM), which involves the use of magnification and laparoscopic tools to remove the tumors. This approach is for precancerous lesions of the rectum and carefully selected patients with early T1 tumors of the rectum that only invade the mucosa. In TEM, the tumor is removed along with a 1 centimeter margin. If the tumor has not spread to the lymph nodes, the patient may be treated without losing the rectum.

This internal sphincter resection (ISR) illustration shows the sphincters labeled. IS = internal sphincter.

TEM requires a skilled, fellowship trained gastrointestinal surgeon as well as a TEM surgical platform. This platform, which uses a specially designed protoscope and CO2 system that creates working space in the rectum, has been available at Mass General since 2008. The Digestive Healthcare Center has the TEM platform and the surgical expertise to perform this advanced surgery.

A completely transanal approach is being investigated for select patients at the Digestive Healthcare Center. It involves removing the tumor as well as the surrounding lymph nodes without major abdominal incisions. The surgery builds on concepts in natural orifice translumenal endoscopic surgery (NOTES). Gastrointestinal surgeon Patricia Sylla, MD, and her team performed the first transanal NOTES rectal cancer resection with total mesorectal excision (TME) using transanal endoscopic microsurgery (TEM) last year in Spain.

Combined Expertise for Pretreatment of Patients

Preoperative staging and adequate patient selection is critical for successful rectal cancer surgery. Physicians at the Massachusetts General Hospital Cancer Center and the Digestive Healthcare Center host weekly multidisciplinary conferences to review colorectal cancer cases and develop an individualized care plan for each patient. The team includes gastrointestinal radiologists, pathologists, radiation oncologists, medical oncologists, and surgeons. Their combined input on the patient’s pelvic MRIs, CT scans, and other factors can determine if he or she is a candidate for sphincter-sparing surgery.

Pretreatment with chemoradiation of locally advanced rectal cancers increases the likelihood that a patient will qualify for sphincter-sparing surgery. About 40 to 60 percent of rectal tumors show down-staging at the end of a course of radiation. As many as 15 to 30 percent of patients experience a complete recession of tumors. This allows for easier mobilization of the rectum during surgery.

Comprehensive Postoperative Care

Postoperative care is critical for patients who receive sphincter-sparing surgery. Large randomized controlled studies have unfortunately shown that up to 40 to 60 percent of patients who have sphincter-sparing surgery and lose their rectum develop low anterior syndrome, which includes symptoms of fecal incontinence—and the rates are in large part dependent upon the extent of rectal resection and whether patients received radiotherapy. For these patients, the Digestive Healthcare Center offers its Pelvic Floor Disorders Service, established by Liliana G. Bordeianou, MD, MPH. The service draws patients who seek advanced solutions for fecal incontinence, often as a result of sphincter-sparing surgery.

Coordinated by a dedicated nurse practitioner, the service provides postsurgical patients with a treatment plan that involves diet, biofeedback, medication, and sometimes surgery to manage their symptoms. The center performs more artificial bowel sphincter surgeries than most other programs in New England. The artificial bowel sphincter device is placed around the neorectum so that patients have better control of their bowel movements.

With preoperative surgical planning to advanced surgical techniques to comprehensive postoperative care, the Mass General Digestive Healthcare Center can offer solutions to patients with the most difficult-to-treat rectal cancers. In the near future, the center hopes to make more of its expertise available to patients with protocols designed to study TEM and other less invasive sphincter-sparing procedures.

Selected References

  • Fleshman J, Sargent D, Green E, Anvari M, Stryker S, Beart R, Hellinger M, Flanagan R, Peters W, Nelson H for the Clinical Outcomes of Surgical Therapy Study Group. (2007). Laparoscopic colectomy for cancer is not inferior to open surgery based on 5-year data from the COST Study Group trial. Ann Surg, 246(4): 655-62.
  • Kapiteijn E, Marijnen CA, Nagtegaal I, Putter H, Steup W, Wiggers T, Rutten H, Pahlman L, Glimelius B, van Krieken J, Leer J, van de Velde C, Dutch Colorectal Cancer Group. (2001). Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. N Engl J Med, 345: 638-46.
  • Moore JS, Cataldo PA, Osler T, Hyman NH. (2008). Transanal endoscopic microsurgery is more effective than traditional transanal excision for resection of rectal masses. Dis Colon Rectum, 51(7): 1026-30.
  • Quirke P, Steele R, Monson J, Grieve R, Khanna S, Couture J, O’Callaghan C, Myint AS, Bessell E, Thompson LC, Parmar M, Stephens RJ, Sebag-Montefiore D, MRC CR07/NCIC-CTG CO16 Trial Investigators, NCRI Colorectal Cancer Study Group. (2009). Effect of the plane of surgery achieved on local recurrence in patients with operable rectal cancer: A prospective study using data from the MRC CR07 and NCIC-CTG CO16 randomised clinical trial. Lancet, 373(9666): 821-28.
  • Ricciardi R, Virnig BA, Madoff RD, Rothenberger DA, Baxter NN. (2007). The status of radical proctectomy and sphincter-sparing surgery in the United States. Dis Colon Rectum, 50(8): 1119-27.
  • Sauer R, Becker H, Hohenberger W, Rodel C, Wittekind C, Fietkau R, Martus P, Tschmelitsch J, Hager E, Hess CF, Karstens J, Liersch T, Schmidberger H, Raab R, German Rectal Cancer Study Group. (2004). Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med, 351(17): 1731-40.
  • Sylla P, Rattner D, Delgado S, Lacy A. (2010). NOTES transanal rectal cancer resection using transanal endoscopic microsurgery and laparoscopic assistance. Surg Endosc, 24(5): 1205-10.

Massachusetts General Hospital Digestive Healthcare Center

The Massachusetts General Hospital Digestive Healthcare Center is a collaborative practice of gastroenterologists, endoscopists, surgeons, radiologists, pathologists, hepatologists, oncologists, and radiation oncologists dedicated to the prevention, diagnosis, treatment, and management of digestive diseases.

The Digestive Healthcare Center offers a full range of medical and surgical treatments for digestive diseases, including conditions of the esophagus, stomach, small and large intestines, liver, gallbladder, pancreas, and colon.

The Digestive Healthcare Center is organized into six disease areas dedicated to the diagnosis and management of digestive health issues. For more information about these services, visit the Digestive Healthcare Center website

Other Articles in This Issue

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  • New Trial Explores Two Sides of Deep Vein Thrombosis Treatment
  • Genetic Profiling Uncovers New Therapeutic Approaches to Ovarian Cancer

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