Oslo University Hospital Dept. Gastrointestinal Surgery CoE-Cancer Biomedicine Colorectal Cancer Research Centre
Kirurgiske teknikker ved rectum cancer
NFAR seminar – Gardermoen
02- mai 2016
Arild Nesbakken
Avd Gastrokirurgi og Barn
OUS – Ullevål
Oslo University Hospital Dept. Gastrointestinal Surgery CoE-Cancer Biomedicine Colorectal Cancer Research Centre
Rectum – anatomi / definisjoner Norge Japan
Flex rectosigmoid Øvre rektum Midtre rectum Nedre rectum
Analåpning
20
6
10
15
0
Sigmoideum
Oslo University Hospital Dept. Gastrointestinal Surgery CoE-Cancer Biomedicine Colorectal Cancer Research Centre
Endoskopisk nivå-diagnostikk; Houston’s folder; fint supplement v fleksibel skopi Houston’s 2 fold : Nivå 10 cm Peritoneale omslagsfold
2. fold
1. fold
3. fold
Fasit: Målt på stivt skop
Oslo University Hospital Dept. Gastrointestinal Surgery CoE-Cancer Biomedicine Colorectal Cancer Research Centre
Oslo University Hospital Dept. Gastrointestinal Surgery CoE-Cancer Biomedicine Colorectal Cancer Research Centre
Oslo University Hospital Dept. Gastrointestinal Surgery CoE-Cancer Biomedicine Colorectal Cancer Research Centre
PREOPEATIV DIAGNOSTIKK: Endoskopi
Oslo University Hospital Dept. Gastrointestinal Surgery CoE-Cancer Biomedicine Colorectal Cancer Research Centre
• Kvinne 75 år
• Konkl. Preop
• Sannsynlig premalign
Oslo University Hospital Dept. Gastrointestinal Surgery CoE-Cancer Biomedicine Colorectal Cancer Research Centre
Oslo University Hospital Dept. Gastrointestinal Surgery CoE-Cancer Biomedicine Colorectal Cancer Research Centre
Rektal ultralyd
Oslo University Hospital Dept. Gastrointestinal Surgery CoE-Cancer Biomedicine Colorectal Cancer Research Centre
Oslo University Hospital Dept. Gastrointestinal Surgery CoE-Cancer Biomedicine Colorectal Cancer Research Centre
MR bekken
Veileder vedr
forbehandling
Veikart for
kirurgen
Oslo University Hospital Dept. Gastrointestinal Surgery CoE-Cancer Biomedicine Colorectal Cancer Research Centre
Behandling ca recti: Oppgaven
• Kurere sykdommen
– Preoperativ stadievurdering
• Metastaser
• Lokal dybdevekst
• Forbehandling ?? Neoadjuv radiokjemo
• Unngå komplikasjoner
– Anastomose-lekkasjer ved lav fremre res
– Infeksjoner / Blødning ++
– Funksjonelle plager pga nerveskader
Oslo University Hospital Dept. Gastrointestinal Surgery CoE-Cancer Biomedicine Colorectal Cancer Research Centre
Prinsipper for kurativ kirurgi:
Total mesorektal eksisjon
Nøyaktig disseksjon i anatomiske plan
Bekken anatomi
• Rektum-rør
• Mesorektale fettpute
• Mesorektal fascie
• Parietal bekken-fascie
Oslo University Hospital Dept. Gastrointestinal Surgery CoE-Cancer Biomedicine Colorectal Cancer Research Centre
• Kurere sykdommen
– Nøyaktig preoperativ stadievurdering
• Er det fjernspredning (Metastaser) ?
• Hvor dypt vokser svulsten
• Er det spredning til lymfeknuter utenfor tarmen
• Unngå komplikasjoner
Oslo University Hospital Dept. Gastrointestinal Surgery CoE-Cancer Biomedicine Colorectal Cancer Research Centre
• Sylindrisk rektum - amputasjon
Oslo University Hospital Dept. Gastrointestinal Surgery CoE-Cancer Biomedicine Colorectal Cancer Research Centre
Sympaticus
Inferior hypogastric
plexus
Hypogastric nerves
Ejakulasjons-forstyrrelser
Retrograd ejakulasjon
Redusert ejakulasjon
Nerveskader v disseksjon utenfor korrekt plan
Oslo University Hospital Dept. Gastrointestinal Surgery CoE-Cancer Biomedicine Colorectal Cancer Research Centre
Parasympaticus
Pelvic nerves S2- S5
(nervi erigentes)
Plexus hypog. Inf
Nevrovascular bundles
Nerver til blære og genitalia
Urinretensjon
Redusert potens / impotens
Oslo University Hospital Dept. Gastrointestinal Surgery CoE-Cancer Biomedicine Colorectal Cancer Research Centre
Suboptimal kirurgi
Disseksjon innenfor korrekt plan
• Skade av den viscerale fascie i pelvis
– Disseksjon inn i mesorektale fettpute
• Øker risiko for lokalt recidiv
Oslo University Hospital Dept. Gastrointestinal Surgery CoE-Cancer Biomedicine Colorectal Cancer Research Centre Avdeling for kreftbehandling
Preoperativ strålebehandling Brukes i økende grad -- siste år 44 %
50 Gy vanligvis med 5FU eller kapecitabin
2014: 44 %
Oslo University Hospital Dept. Gastrointestinal Surgery CoE-Cancer Biomedicine Colorectal Cancer Research Centre Avdeling for kreftbehandling
Ulike operasjons-typer ved ca recti
Andeler
1993-1997 1998-2000 2001-2003 2004-2006 2007-2010 p
Lav fremre res 59 56 56 58 57 ns
Amputasjon 29 28 28 26 26 0.02
Hartmann 5 9 9 8 8 0.009
Lokal excisjon 7 6 6 6 5 0.02
Oslo University Hospital Dept. Gastrointestinal Surgery CoE-Cancer Biomedicine Colorectal Cancer Research Centre
Lav fremre rectum-reseksjon
Høy cancer Distal res margin: 5 cm
Lav cancer: Distal margin : 1 cm
Oslo University Hospital Dept. Gastrointestinal Surgery CoE-Cancer Biomedicine Colorectal Cancer Research Centre
Lav cancer Distal margin i tarmveggen : 1 cm Distal margin i mesorektum : Hele mesorektum tas med, Opp til 5 cm distalt for tumor
Oslo University Hospital Dept. Gastrointestinal Surgery CoE-Cancer Biomedicine Colorectal Cancer Research Centre
Lymfedrenasje fra rektum
Oslo University Hospital Dept. Gastrointestinal Surgery CoE-Cancer Biomedicine Colorectal Cancer Research Centre
Lymfeknuter regionalt
Oslo University Hospital Dept. Gastrointestinal Surgery CoE-Cancer Biomedicine Colorectal Cancer Research Centre
Regionale lymfeknuter / krøs-reseksjon
Høy cancer
Midtre / lav cancer
Oslo University Hospital Dept. Gastrointestinal Surgery CoE-Cancer Biomedicine Colorectal Cancer Research Centre
Løse mesosigmoid – sigmoid fra laterale og bakre
bukvegg
• Start lateralt
• Identifiser og
behold korrekt
plan på
mesosigmoideums
laterale / bakre
flate
Oslo University Hospital Dept. Gastrointestinal Surgery CoE-Cancer Biomedicine Colorectal Cancer Research Centre
• Medialt
• Incisjon peritoneum
bakre bukvegg
• Identifiser og behold
korrekt plan på
mesosigmoideums
mediale / bakre flate
• Sett av karene
– Art. / v mesent inf
Oslo University Hospital Dept. Gastrointestinal Surgery CoE-Cancer Biomedicine Colorectal Cancer Research Centre
Oslo University Hospital Dept. Gastrointestinal Surgery CoE-Cancer Biomedicine Colorectal Cancer Research Centre
Peritoneum incideres nedover langs rectumrøret
Deles foran og over (1 cm) omslagsfolden
Oslo University Hospital Dept. Gastrointestinal Surgery CoE-Cancer Biomedicine Colorectal Cancer Research Centre
omslagsfold Når dere sier innvekst i omslagsfold : Presiser eksakt
Oslo University Hospital Dept. Gastrointestinal Surgery CoE-Cancer Biomedicine Colorectal Cancer Research Centre
Tett på vesicula seminalis / bakre vaginalvegg
Oslo University Hospital Dept. Gastrointestinal Surgery CoE-Cancer Biomedicine Colorectal Cancer Research Centre
Oslo University Hospital Dept. Gastrointestinal Surgery CoE-Cancer Biomedicine Colorectal Cancer Research Centre
Oslo University Hospital Dept. Gastrointestinal Surgery CoE-Cancer Biomedicine Colorectal Cancer Research Centre
Hvor skal vi dele Denonvillier ved lav cancer ??
Oslo University Hospital Dept. Gastrointestinal Surgery CoE-Cancer Biomedicine Colorectal Cancer Research Centre
Hvor skal vi dele Denonvilliers fascie
• Heald – Ca midt på prostata
• Nå diskuteres – Individualisere ??
– Ingen tumor fortil: Gå bak Denonv. ?
– Avansert tumor fortil: Gå inn i prostata ?
Desto lengre nedover vi går foran Denonvillier - jo større risiko for impotens
Oslo University Hospital Dept. Gastrointestinal Surgery CoE-Cancer Biomedicine Colorectal Cancer Research Centre
Kvinner
Oslo University Hospital Dept. Gastrointestinal Surgery CoE-Cancer Biomedicine Colorectal Cancer Research Centre
Deling av rektum-røret distalt
Oslo University Hospital Dept. Gastrointestinal Surgery CoE-Cancer Biomedicine Colorectal Cancer Research Centre
Oslo University Hospital Dept. Gastrointestinal Surgery CoE-Cancer Biomedicine Colorectal Cancer Research Centre
Anastomose ved rectum reseksjon
Oslo University Hospital Dept. Gastrointestinal Surgery CoE-Cancer Biomedicine Colorectal Cancer Research Centre
Rekonstruksjon med EEA suturmaskin
Oslo University Hospital Dept. Gastrointestinal Surgery CoE-Cancer Biomedicine Colorectal Cancer Research Centre
Oslo University Hospital Dept. Gastrointestinal Surgery CoE-Cancer Biomedicine Colorectal Cancer Research Centre
Neorektal funksjon:
Avhengig av rekonstruksjon
Anastomose-lekkasje : Ca 10 %
Obs tolkning av CT m rektal kontrast
Oslo University Hospital Dept. Gastrointestinal Surgery CoE-Cancer Biomedicine Colorectal Cancer Research Centre
Avlastende ileostomi for å unngå lekkasje fra tarmskjøt
Legges alltid ved lav tarmskjøt (< 6 cm fra analåpningen)
x x 1/3 ut - 2 cm ned
Oslo University Hospital Dept. Gastrointestinal Surgery CoE-Cancer Biomedicine Colorectal Cancer Research Centre
Oslo University Hospital Dept. Gastrointestinal Surgery CoE-Cancer Biomedicine Colorectal Cancer Research Centre
Oslo University Hospital Dept. Gastrointestinal Surgery CoE-Cancer Biomedicine Colorectal Cancer Research Centre
Rectum-amputasjon med
permanent stomi
Oslo University Hospital Dept. Gastrointestinal Surgery CoE-Cancer Biomedicine Colorectal Cancer Research Centre
Conventional APR
- synchronous combined
Oslo University Hospital Dept. Gastrointestinal Surgery CoE-Cancer Biomedicine Colorectal Cancer Research Centre
Oslo University Hospital Dept. Gastrointestinal Surgery CoE-Cancer Biomedicine Colorectal Cancer Research Centre
Konvensjonell Sylindrisk
Oslo University Hospital Dept. Gastrointestinal Surgery CoE-Cancer Biomedicine Colorectal Cancer Research Centre
I praksis ikke mulig å
adaptere muskulatur så
godt
Vi legger aldri dren
Oslo University Hospital Dept. Gastrointestinal Surgery CoE-Cancer Biomedicine Colorectal Cancer Research Centre
Ofte problemer med sårtilheling,
Spesielt hos de som har fått strålebeh før op
Oslo University Hospital Dept. Gastrointestinal Surgery CoE-Cancer Biomedicine Colorectal Cancer Research Centre
Oslo University Hospital Dept. Gastrointestinal Surgery CoE-Cancer Biomedicine Colorectal Cancer Research Centre
Oslo University Hospital Dept. Gastrointestinal Surgery CoE-Cancer Biomedicine Colorectal Cancer Research Centre
Lokal eksisjon med TEM
Kurativ setting: T1 sm 1 – 2
Kompromiss: T2
Oslo University Hospital Dept. Gastrointestinal Surgery CoE-Cancer Biomedicine Colorectal Cancer Research Centre
TEM for lokal excisjon av tidlig cancer
Oslo University Hospital Dept. Gastrointestinal Surgery CoE-Cancer Biomedicine Colorectal Cancer Research Centre
Oslo University Hospital Dept. Gastrointestinal Surgery CoE-Cancer Biomedicine Colorectal Cancer Research Centre Avdeling for kreftbehandling
Resultater
5-års relativ overlevelse alle pasienter
63 %
54 %
Oslo University Hospital Dept. Gastrointestinal Surgery CoE-Cancer Biomedicine Colorectal Cancer Research Centre Dept. of Oncology
5- års Relativ overlevelse -- stadium I-III
Bedret fra 71 % to 81 %
Oslo University Hospital Dept. Gastrointestinal Surgery CoE-Cancer Biomedicine Colorectal Cancer Research Centre Dept. of Oncology
Reduksjon lokale residiv
14.5 %
5 %
Redusert
Historisk 28 %
Guren MG et al, Acta Onc 2015
Oslo University Hospital Dept. Gastrointestinal Surgery CoE-Cancer Biomedicine Colorectal Cancer Research Centre Dept. of Oncology
Ingen endring i forekomst fjernmetastaser
Uendret
Oslo University Hospital Dept. Gastrointestinal Surgery CoE-Cancer Biomedicine Colorectal Cancer Research Centre
Oslo University Hospital Dept. Gastrointestinal Surgery CoE-Cancer Biomedicine Colorectal Cancer Research Centre
Hva vil jeg vite av MR - radiologen i MDT
• Tumors nedre nivå = relasjon til puborektalis ikke til analåpning
• Tumors lengde
• Tumors utbredelse rundt circumferens (kl)
• Dypeste infiltrasjon – hvor rundt circumferens ?
• Hvor dypt
• Minste avstand mrf
• Hvis T4b – beskriv nærmere
• Er det metastase-suspekte lymfeknuter i mesorektum
• Hvis nei -- ikke si noe mer om lymfeknutene
• Hvis ja - hvor og hva er avstand til mrf
• Er det karinnvekst
• Hvis ja - lokalisasjon -- avstand karinnvekst til mrf
• Er det sannsynlige lymfeknute-metastaser på bekkenveggen
• Hvis ja - lokalisasjon
Oslo University Hospital Dept. Gastrointestinal Surgery CoE-Cancer Biomedicine Colorectal Cancer Research Centre