advances in surgical treatment of colon and rectal cancers
26
ADVANCES IN SURGICAL TREATMENT OF COLON AND RECTAL CANCERS Slawomir Marecik, MD, FACS Advocate Lutheran General Hospital, Park Ridge, IL Clinical Assistant Professor University of Illinois, Chicago, USA
description
S l awomir Marecik, MD, FACS Advocate Lutheran General Hospital, Park Ridge, IL Clinical Assistant Professor University of Illinois, Chicago, USA. advances in surgical treatment of colon and rectal cancers. The advantages of robotic low anterior resection. Robots. Are here to stay - PowerPoint PPT Presentation
Transcript of advances in surgical treatment of colon and rectal cancers
ADVANCES IN SURGICAL TREATMENT OF COLON AND RECTAL CANCERS
Slawomir Marecik, MD, FACSAdvocate Lutheran General Hospital, Park Ridge, ILClinical Assistant ProfessorUniversity of Illinois, Chicago, USA
THE ADVANTAGES OF ROBOTIC LOW ANTERIOR
RESECTION
Robots Are here to stay One of the available tools in our
armamentarium Powerful tool Massive potential
Laparoscopic TME Technically challenging
Tumor location Anatomic structures Difficult retraction Unstable camera Poor ergonomics for surgeon
UK MRC CLASICC
Advanced lesion
Obese, low (male)
APROPEN
LAPAROSCOP
Y
Major Robotic Advantages
1 Quality Of Dissection
2 Minimally Invasive
3 Comfort For Surgeon
Quality Of Dissection
Robotic n=56
Mesorectal grade
Complete 52
Nearly complete 4
Incomplete 0
Laparoscopic n=57
Mesorectal Grade
Complete 43
Nearly complete 12
Incomplete 2
p=0.033
Baik SH. Robotic versus laparoscopic low anterior resection of rectal cancer: short-term outcome of prospective comparative study.
Ann Surg Oncol. 2009
Quality Of Dissection
Robotic vs. Lap Rectal Dissection
Quality Of Dissection Pigazzi, Baek O.7 % CRM 143 pts Kim 1.6 % CRM 59 pts Prasad, Marecik 1 % CRM 82 pts
ROLLAR ACOSOG
Can we reduce preoperative radiation? Improved urogenital function?
Randomized Studies To Compare Laparoscopic vs.
Robotic Resection
Minimally Invasive Aspect The robot is more useful in certain areas
Laparoscopy is more useful in other
areasA Hybrid Approach Is
The Most Practical Solution At This Time
Comfort For The Surgeon Laparoscopic TME challenging Difficulties with advanced disease An increase in obese patient population
Source: Behavioral Risk Factor Surveillance System, CDC.
2000
Obesity Trends* Among U.S. AdultsBRFSS, 1990, 2000, 2010
(*BMI 30, or about 30 lbs. overweight for 5’4” person)
2010
1990
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
Robotic LAR randomized data is lacking
ACOSOG, ROLARR pending
difficulties in adoption of Korean experience BMI height splenic flexure mobilization radiation
DCR 2010
Comparison Robotic vs. Open TME
Open/HALS (=46) Robotic (n= 36) P valueMid and low rectal tumors
47.8% 80.5% .006
OR time (min) 273.8 337.9 .003EBL (mL) 273.8 187.5 .036Postoperativecomplications, n (%)
15 (32.6) 11 (30.6) .84
Length of stay (days)
7.3 7.0 .74
Distal margin positive, n (%)
0 (0) 1 (2.8) .44
Radial margin positive, n (%)
3 (6.5) 0 NS
Lymph nodes 16.8 15 .26deSouza AL, Prasad LM , Marecik SJ et al. Comparison of Open and Robotic Total Mesorectal Excision for Rectal Adenocarcinoma; Dis Colon Rectum, 2011
Author No. of Pts Conversion rate
Mean BMI Laparoscopic
Mean BMI Converted
P value
Yamamoto SJapan (2009)
1073(Lap)
7.3% 22.7(13.7-36.7)
24.6(16.6-34.8)
<0.0001
Agha AGermany (2008)
300(Lap)
8.6% 26.2(16.7-37.5)
29.0(22.6-43.9)
0.002
Rottoli MItaly (2009)
173(Lap)
15% 24.9 ±3.2 27.3±2.9 <0.001
deSouza2010*
44(Robotic)
4.5% 28.2(17.6-43)
41.5 -
Laparoscopy for rectal cancer – conversion rates
Robotic TME
MRC CLASSIC trial conversion rate – 34% (2005)
Colorectal Dis 2011
APR (abdomino-perineal resections)cylindrical intraabdominal levator transection
Robotic Cylindrical Abdominoperineal Resection with Intraabdominal Levator Transection Marecik SJ, Zawadzki M, deSouza AL, Park JJ, Abcarian H, Prasad L
Dis Colon Rectum, Oct 2011
RILT
Distal pursestring
Prasad LM, deSouza AL, Marecik SJ, Park JJ, Abcarian H. Robotic pursestring technique in low anterior resection. Dis Colon Rectum. 2010 Feb;53(2):230-4.
Natural orifice extraction
Robotic LAR
upper rectumeasy, thin patient
Laparoscopic TMEMini-laparotomy
lower rectumdifficult, obese
patientRobotic
???
Conclusion Robotic assistance in low anterior resection
decreases conversion rates when compared to laparoscopy
Mesorectal quality grade is higher in robotic technique, which may translate into better oncological outcomes
Robotic system allows for a very precise work in deep pelvis making intersphincteric dissection easier, distal pursestring application possible and transanal specimen extraction more common
Conclusion Robotic assistance has potential to
improve outcomes in obese patients and in patients with advanced disease
