Anthony Antoniou - The Royal Marsden

The Royal Marsden 

Colorectal cancer surgery 

and subsequent quality of 

life post resection 

Mr Anthony Antoniou 

Senior Clinical Lecturer/ Honorary 

Consultant Colorectal Surgeon 

Upper and lower GI cancers - 16.07.2010

The Royal Marsden Upper and lower GI cancers - 16.07.2010 

The surgical team 

Professor Lord Darzi, Professor of Surgery 

Mr Paris Tekkis, Reader in Surgery/ Honorary 

Consultant Surgeon 

Mr Anthony Antoniou, Senior Clinical Lecturer/ 

Honorary Consultant Surgeon


Why choose The Royal Marsden 

Early cancers 

– TEMs 

Colorectal carcinomas 

– traditional open 

– laparoscopic resections 

– ultra low resections and colo-anal anastamosis 

Synchronous colonic resections 

– HPB 

Recurrent cancer surgery



Early cancers 

– TEMs 






– HPB 



Trans Anal Endoscopic Microsurgery


Indications for TEMs 

– Any benign rectal lesion above the dentate line 

within reach of the operating proctoscope 

– Selected T1 lesions 

– Selected T2 lesions with combined therapy


Rectal cancer treatment options 

Local excision 

TME 

Disc excision of rectal wall 

Removal of all node bearing tissue 

Higher local recurrence rates 

Lower local recurrence rates 

Decreased operative morbidity 

Increased operative morbidity 

No functional disturbance 

Functional disturbance


TEM for benign disease 

Year Patients (N) Local 

Recurrence 

Rates (%) 

Menteges et al 1996 236 2 

Morshel et al 1998 226 3.6 

Nagy et al 1999 80 2.5 

Buess et al 2001 362 1.7 

Lloyd et al 2002 68 5.9 

Langer et l 2003 57 8.8 

Palma et al 2004 71 5 

Platell et al 2004 62 2.4 

Endreseth et al 2005 64 13 

Whitehouse et al 2006 146 4.8


TEM for T1 cancer 

Year Patient (N) Local Recurrence 

Rates (%) 

Buess et al 1988 12 0 

Buess et al 1992 25 4 

Winde et al 1996 24 4.2 

Smith et al 1996 30 10 

Langer et al 2001 16 12.5 

Demartines et al 2001 9 8.3 

Lee et al 2003 52 4.1 

Stipa et al 2006 23 8.6 

Floyd et al 2006 53 7.5 

Baatrup et al 2008 72 6


TEMs vs TME for T2 cancer 

• 70 patients with T2 

rectal cancer 

– 35 TEMs 

– 35 Laparoscopic 

resection 

• All received neoadjuvant 

treatment 

• Median follow up 84 

(72-96) months 

TEMs (%) TME (%) 

Local failure 5.7 2.8 

Distant 

metastases 

Local or 

Distant Failure 

2.8 2.8 

9 9 

Survival 94 94 

Lezoche et al Surg Endosc. 2008


Recommended treatment plan



Early cancers 

– TEMs 






– HPB 




Early cancers 

– TEMs 






– HPB 



Potential advantages of laparoscopic 

resection 

– Quicker return to 

function 

– Shorter stay 

– Decreased 

complications 

– Decreased pain


Laparoscopic colon resection 

Positioning and ports


Laparoscopic surgical resection


Laparoscopy vs open surgery (colon cancer) 

Proven benefits 

– Quicker recovery from surgery 

– Lower wound infections 

– Lower respiratory problems 

– Huge benefit in elderly patient 40% less morbidity 

– Shorter length of Hospital Stay average 3-5 days 

– Quicker return to normal activity 

– Community nursing requirements 80% 

reduction 

– Lower hernia rates 

– Lower blood loss 

– Lower blood transfusion rate 

Conclusion of Trials 

N > 3000 patients


Laparoscopic colorectal surgery 

Rectal cancer (survival RTC + CTs) 

Author Patients Follow-up Outcome 

Dulucq C 

Surg End 2005 

Morino M 

Surg Endo 2005 

Feliciotti F 

Surg Endo 2003 

Lezoche E 

Hepatogastro 2002 

Barlehner E 

Surg Endos 2005 

Delgado S, Lacy A 


Poulin EC 


218 5 years Same as open 





220


Laparoscopy versus open surgery 

• Results the same as open surgery for colon cancer 

– Cancer survival 

– Lymph node harvest 

– Wound metastases 

– Anastomotic leak rate 

– Operative complication rate



Early cancers 

– TEMs 






– HPB 




Early cancers 

– TEMs 






– HPB 



Ultra low anterior resection 

• 30% of cancers located in 

rectal area 

• patients with mid to low 

rectal cancers 

• sphincter preserving 

techniques 

– advent of stapling 

devices 

– improved surgical 

technique 

• acceptable oncological 

results and preserved 

sphincter function


Ultra low anterior resection 

– increased rates of stool 

frequency, urgency, and 

incontinence due to the 

loss of the rectal reservoir 

– colonic reservoirs are 

superior in terms of 

functionality compared 

with SCAA at least within 

the first 2 years 

postoperatively


Rectal cancer resections 2008 - 2010 

• Total 91 cases 

– 12 (13%) ultra low restoration of bowel continuity 

– 21 (23%) laparoscopic resection



Early cancers 

– TEMs 






– HPB 




Early cancers 

– TEMs 






– HPB 



Presentation 

• within 2 years 

• depends on site 

• pain 

– perineum 

– buttock 

– leg 

• raised CEA 

• CT / MRI scan 

• colonoscopy


Localised - perianastomotic


Localised – connective tissue


Localised – perineal recurrence


Abdomino-perineal excision with sacrectomy


Total pelvic exenteration with sacrectomy


The Royal Marsden – pelvic exenterations 

– 2006 - 2010 

– referrals - 96 

– n=58 (n=48 recurrent rectal cancer) 

– R0: 64% 

– R1: 16% 

– R2: 20% 

– sacrectomy: 40% 

– exenteration: 60% 

– EL: 35% 

– perineal flap: 35% 

– blood loss: 1500mls (250mls - 17l)


Mortality and morbidity (n = 58) 

– any complications 50% 

– minor complications 57% 

– major complications 23% 

– intraoperative complications 9.1% 

– readmissions (90-day) 39% 

– Mortality 1.7% 

– length of stay (median; range) 14 days (3 – 86)


ICL – pelvic exenterations 

overall survival n=50 disease free survival n=40 

– overall survival – 46.8% 4 years 

– disease-free survival – 60% 4 years


Years N= R0 Morbidity Mortality Survival 

Japan 

1983-2001 57 84% 58% 3.5% 23% 5yr 

Vienna 1987-2004 12 -- 42% 0% 17% 3yr 

Dutch 1994-1999 37 52% 82% 0% 41% 3yr 

Denver 1983- 45 73% 56% 4% 31% 5y 

Mayo 1990-1994 16 87% 50% 0% 48% 2y 

MSK 1987-2004 29 62% 59% 3% 47% 5yr 

Leeds 

(ASR) 1996-2006 40 62% 48% 2.5% 44% 3yr 

Imperial 2006-2010 58 65% 50% 1.7% 47% 4yr


Multi-disciplinary team approach 

• oncologist / radiotherapist 

• surgeons: 

– colorectal, plastic, orthopaedic, urology, 

gynaecology 

• radiologist: diagnostic, interventional 

• anaesthetist: pain specialist, intensivist 

• nurses: stoma, nutrition, tissue viability 

• physiotherapy 

• pathologist


Quality of life following 

colorectal surgery


Quality of life following colorectal surgery 

Factors evaluated 

– bowel function 

– urinary function 

– sexual function 

– need for stoma 

Cornish et al. Ann Surg Oncol. 2007 Jul;14(7):2056-68


QoL APER vs AR 

– Avoiding a permanent stoma following rectal cancer 

excision is believed to improve quality of life (QoL) 

– meta-analysis of studies published between 1966 

and 2006 

– Quality of life outcomes measured by EORTC QLQ 

C30, CR38 and SF-36 for APER vs AR 

– outcomes for 1,443 patients from 11 studies, of 

whom 486 (33%) underwent APER 

– QoL assessments were made at periods of up to 2 

years following surgery


No Diff. 

AR 

AR 

APER


Sexual and urinary outcomes after rectal 

cancer excision 

• assessment 

– at pre-op, 4mths, 8mths, then yearly for up to 5 

yr 

• Primary end points in sexual function 

– sexual activity 

– frequency of sexual intercourse per month 

– ability to achieve arousal 

– ability to attain orgasm 

– presence of dyspareunia 

Tekkis et al. Dis Colon Rectum. 2009 Jan;52(1):46-54


Sexual and urinary outcomes after rectal 

cancer excision 

• Primary end points in urinary function 

– urinary urgency 

– urinary incontinence 

– nocturia 

– poor urinary stream 

– straining to pass urine 

– urinary retention 

– use of urinary catheter


Study population 

AR APR p 

value (n=222) (n=73) 

mean age (yrs) 59.3 65.5 0.001 

median follow up (yrs) 3.28 2.95 NS 

radiotherapy 33.8% 60.3%


Summary – sexual function 

• APR 

– less sexually active 

– intercourse 

– dyspareunia 

• radiotherapy dyspareunia 

• age ≥ 65 years sexual dysfunction across ALL 

domains


Summary – urinary function 

• APR 

– urinary urgency 

– urinary incontinence 

– poor stream 

– urinary retention


Conclusion 

– no differences in general QoL following APER vs AR 

– sexual and urinary outcomes should be considered 

when planning operative management 

– appropriate patient selection 

– individualization of care


Why The Royal Marsden 

We have 

• Word leading Oncology Department 

• Surgical expertise 

– Trans- anal surgery 

– Laparoscopic surgery 

– Low rectal cancer surgery 

– Synchronous liver/ colorectal surgery 

– Recurrent cancer surgery 

• Excellence in endoscopy 

• Imaging resources 

• Nurse practitioner 

• Dedicated junior staff

Anthony Antoniou - The Royal Marsden

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