1 00:00:05,069 --> 00:00:07,990 so what I'm going to do today is as I 2 00:00:07,990 --> 00:00:10,420 got at least some of the advances in the 3 00:00:10,420 --> 00:00:12,580 management of rectal cancer I'm going to 4 00:00:12,580 --> 00:00:14,199 emphasize the importance of surgical 5 00:00:14,199 --> 00:00:15,639 technique because at the end of the day 6 00:00:15,639 --> 00:00:17,110 most patients are going to need to cut 7 00:00:17,110 --> 00:00:19,600 the rectum remove I want to talk about 8 00:00:19,600 --> 00:00:20,980 the evidence supporting the use of 9 00:00:20,980 --> 00:00:22,990 laparoscopic surgery I'm going to touch 10 00:00:22,990 --> 00:00:25,570 a little bit upon the use of Robotics in 11 00:00:25,570 --> 00:00:27,970 retinal cancer surgery and and also in 12 00:00:27,970 --> 00:00:30,220 some new techniques something that is 13 00:00:30,220 --> 00:00:31,360 now called transana 14 00:00:31,360 --> 00:00:37,090 DME I'm a surgeon and I had to emphasize 15 00:00:37,090 --> 00:00:40,329 a surgical technique matters this is all 16 00:00:40,329 --> 00:00:42,430 data but it just emphasized the 17 00:00:42,430 --> 00:00:44,710 variation in local recurrence among 18 00:00:44,710 --> 00:00:46,570 surgeons an institution that has been 19 00:00:46,570 --> 00:00:47,920 known for many many years 20 00:00:47,920 --> 00:00:49,870 these differences are far greater that 21 00:00:49,870 --> 00:00:51,910 the difference that we can achieve with 22 00:00:51,910 --> 00:00:53,410 neoadjuvant therapy with adjuvant 23 00:00:53,410 --> 00:00:55,690 therapy has a great impact for patients 24 00:00:55,690 --> 00:00:58,480 outcomes I think we have to credit em 25 00:00:58,480 --> 00:01:02,140 bill Hill by helping us understand why 26 00:01:02,140 --> 00:01:04,059 there was such a wide variability in 27 00:01:04,059 --> 00:01:06,040 outcomes in Beijing with rattle cancer 28 00:01:06,040 --> 00:01:07,840 he introduced the concept total 29 00:01:07,840 --> 00:01:09,670 mesorectal excision because probably 30 00:01:09,670 --> 00:01:11,649 surgeons were not following the fine 31 00:01:11,649 --> 00:01:13,179 anatomical planes when they were 32 00:01:13,179 --> 00:01:15,880 removing the rectum that combined with 33 00:01:15,880 --> 00:01:18,249 the work of pathology such as field work 34 00:01:18,249 --> 00:01:20,799 helped us tremendously to identify the 35 00:01:20,799 --> 00:01:23,409 flaws that we had in the surgery for 36 00:01:23,409 --> 00:01:25,810 rectal cancer in the 80's and 90's and 37 00:01:25,810 --> 00:01:29,380 to introduce new educational sessions 38 00:01:29,380 --> 00:01:32,229 for surgeons to improve our surgical 39 00:01:32,229 --> 00:01:35,049 technique but even today M there are 40 00:01:35,049 --> 00:01:37,149 significant variation in outcomes among 41 00:01:37,149 --> 00:01:38,829 surgeons and institutions throughout the 42 00:01:38,829 --> 00:01:42,369 world again this has been emphasized by 43 00:01:42,369 --> 00:01:45,069 studies like the Dutch trial who really 44 00:01:45,069 --> 00:01:47,499 proved that the completeness of the 45 00:01:47,499 --> 00:01:49,209 mesorectal excision the quality of the 46 00:01:49,209 --> 00:01:51,849 surgery had a tremendous impact on the 47 00:01:51,849 --> 00:01:56,709 outcomes for the patients so I think dr. 48 00:01:56,709 --> 00:01:59,049 Brown give us a very good overview of 49 00:01:59,049 --> 00:02:02,919 the use of MRI in identified risk 50 00:02:02,919 --> 00:02:04,959 different risk groups among patient with 51 00:02:04,959 --> 00:02:07,749 rectal cancer that helped us select a 52 00:02:07,749 --> 00:02:09,550 new adjuvant therapy I think in Europe 53 00:02:09,550 --> 00:02:12,460 we now identify three groups and these 54 00:02:12,460 --> 00:02:14,710 groups are treated with different 55 00:02:14,710 --> 00:02:16,620 protocols again according to the 56 00:02:16,620 --> 00:02:18,450 can local run laps of Easter metastases 57 00:02:18,450 --> 00:02:20,610 but I think what is most important from 58 00:02:20,610 --> 00:02:23,400 the surgical point of view MRI helped us 59 00:02:23,400 --> 00:02:27,120 select the operation that every patient 60 00:02:27,120 --> 00:02:29,340 requires I think in this day and age 61 00:02:29,340 --> 00:02:31,680 with the imaging that we have at our 62 00:02:31,680 --> 00:02:32,549 disposal 63 00:02:32,549 --> 00:02:34,790 patients should go to the operating room 64 00:02:34,790 --> 00:02:36,989 understanding and knowing exactly what 65 00:02:36,989 --> 00:02:38,459 type of procedures are they going to 66 00:02:38,459 --> 00:02:39,599 have and I'm going to give you some 67 00:02:39,599 --> 00:02:43,470 examples at what do we do today so this 68 00:02:43,470 --> 00:02:45,269 is a typical meal rectal cancer it will 69 00:02:45,269 --> 00:02:48,000 call it law intermediaries with which is 70 00:02:48,000 --> 00:02:49,829 not threatening the circumference or 71 00:02:49,829 --> 00:02:51,870 sexual margin and that is far enough 72 00:02:51,870 --> 00:02:53,609 from the pelvic floor and the filter 73 00:02:53,609 --> 00:02:56,340 complex to allow us to perform a total 74 00:02:56,340 --> 00:02:59,040 mesorectal exist excision with a double 75 00:02:59,040 --> 00:03:01,890 staple anastomosis distal to the tumor 76 00:03:01,890 --> 00:03:03,780 we will have enough margin to transect 77 00:03:03,780 --> 00:03:05,640 the rectum with a stapling device and 78 00:03:05,640 --> 00:03:07,950 not open in the rectum and then using 79 00:03:07,950 --> 00:03:10,140 the standard step-in devices that we use 80 00:03:10,140 --> 00:03:13,170 today to perform an end-to-end across 81 00:03:13,170 --> 00:03:15,480 anastomosis that will rest ablis the 82 00:03:15,480 --> 00:03:18,599 Bible continuity we have seen also from 83 00:03:18,599 --> 00:03:20,000 dr. abdur 84 00:03:20,000 --> 00:03:22,709 the functional of Congolese patients 85 00:03:22,709 --> 00:03:24,030 that for the most part they are 86 00:03:24,030 --> 00:03:27,060 manageable and patients are willing to 87 00:03:27,060 --> 00:03:29,900 put up with to avoid a permanent stone 88 00:03:29,900 --> 00:03:32,910 now a different story is a tumor that is 89 00:03:32,910 --> 00:03:36,299 located very low in the rectum but it's 90 00:03:36,299 --> 00:03:37,799 not involved in the pelvic floor is not 91 00:03:37,799 --> 00:03:39,419 involved in the sphincter complex and 92 00:03:39,419 --> 00:03:41,519 you know as I mentioned based on the MRI 93 00:03:41,519 --> 00:03:44,220 images obtained before or after as you 94 00:03:44,220 --> 00:03:47,010 can therapy guide us on what type of 95 00:03:47,010 --> 00:03:48,959 surgery we can perform to the patient so 96 00:03:48,959 --> 00:03:51,120 we can counsel the patient about the 97 00:03:51,120 --> 00:03:52,590 procedures that we can do and in this 98 00:03:52,590 --> 00:03:55,489 case it will be ultra low anastomosis 99 00:03:55,489 --> 00:03:57,959 ultra low resection with a coronal 100 00:03:57,959 --> 00:04:01,410 anastomosis some surgeons will go as far 101 00:04:01,410 --> 00:04:03,150 as removing the entire internal 102 00:04:03,150 --> 00:04:04,739 sphincter and perform an interest 103 00:04:04,739 --> 00:04:06,379 interest resection 104 00:04:06,379 --> 00:04:10,799 again knowing the anatomy of the pelvis 105 00:04:10,799 --> 00:04:11,910 and the location of the tumor in 106 00:04:11,910 --> 00:04:13,829 relation to all the important structures 107 00:04:13,829 --> 00:04:16,349 we can dissect from the abdomen we can 108 00:04:16,349 --> 00:04:17,940 dissect through the annals do a 109 00:04:17,940 --> 00:04:20,250 transitional extraction and then perform 110 00:04:20,250 --> 00:04:22,380 a hands-on coronal anastomosis 111 00:04:22,380 --> 00:04:26,070 we shouldn't be doing or attempting and 112 00:04:26,070 --> 00:04:28,530 stable anastomosis in this patient 113 00:04:28,530 --> 00:04:29,710 because probably we are going 114 00:04:29,710 --> 00:04:32,710 transected two more and ruin the 115 00:04:32,710 --> 00:04:34,360 possibility of a swinter saving 116 00:04:34,360 --> 00:04:36,760 procedure I'm not advocating that these 117 00:04:36,760 --> 00:04:38,410 operations should be performed in 118 00:04:38,410 --> 00:04:41,020 everyone I think it's safe are longer we 119 00:04:41,020 --> 00:04:42,970 have a negative circumference of 120 00:04:42,970 --> 00:04:45,520 resection margin as explained by Magina 121 00:04:45,520 --> 00:04:48,490 before and as long as we can get just 122 00:04:48,490 --> 00:04:50,950 about a centimeter distal to the tumor 123 00:04:50,950 --> 00:04:52,960 that's all we need from the oncological 124 00:04:52,960 --> 00:04:57,490 point of view unfortunately there is one 125 00:04:57,490 --> 00:04:58,750 morbidity associate with these 126 00:04:58,750 --> 00:05:00,310 operations there is a large body of 127 00:05:00,310 --> 00:05:02,050 literature they just summarize the 128 00:05:02,050 --> 00:05:04,360 morbidity associated with it there is 129 00:05:04,360 --> 00:05:07,480 also some functional outcomes that they 130 00:05:07,480 --> 00:05:09,340 are worse than the outcomes that we will 131 00:05:09,340 --> 00:05:12,790 achieve with a double staple technique 132 00:05:12,790 --> 00:05:15,460 but again many patients prefer him all 133 00:05:15,460 --> 00:05:19,030 these myriad of bowel problems to a 134 00:05:19,030 --> 00:05:21,550 permanent colostomy and also we know 135 00:05:21,550 --> 00:05:23,800 that oncological is probably safe as 136 00:05:23,800 --> 00:05:26,230 long as we can achieve negative feel 137 00:05:26,230 --> 00:05:28,480 confidential sexual margin and a distal 138 00:05:28,480 --> 00:05:30,310 margin of approximately one centimeter 139 00:05:30,310 --> 00:05:34,120 or more the quality of life is debatable 140 00:05:34,120 --> 00:05:36,190 but as I mentioned even though it's 141 00:05:36,190 --> 00:05:38,410 worse than standard low anterior 142 00:05:38,410 --> 00:05:40,110 resection with the stable anastomosis 143 00:05:40,110 --> 00:05:42,610 some patients still prefer this approach 144 00:05:42,610 --> 00:05:46,270 to a abdominal analysis another rectum 145 00:05:46,270 --> 00:05:47,680 and this is an important issue that 146 00:05:47,680 --> 00:05:49,330 surgeons need to discuss with the 147 00:05:49,330 --> 00:05:51,700 patient before offering one or the other 148 00:05:51,700 --> 00:05:54,370 procedure again going back to the 149 00:05:54,370 --> 00:05:56,470 imaging the imaging is very accurate and 150 00:05:56,470 --> 00:05:58,480 in this case it will show that there is 151 00:05:58,480 --> 00:06:00,160 involvement of the elevator or the 152 00:06:00,160 --> 00:06:02,290 sphincter complex and in this case as 153 00:06:02,290 --> 00:06:04,330 filter saving procedure won't be 154 00:06:04,330 --> 00:06:06,370 feasible the patients should know that 155 00:06:06,370 --> 00:06:08,320 before it goes to the operating room and 156 00:06:08,320 --> 00:06:10,360 so we should be appropriately counseled 157 00:06:10,360 --> 00:06:12,190 for that these patients are gonna 158 00:06:12,190 --> 00:06:13,960 require an abdominal analysis another 159 00:06:13,960 --> 00:06:17,710 rectum and it was also mentioned by dr. 160 00:06:17,710 --> 00:06:19,870 Brown the importance of performing this 161 00:06:19,870 --> 00:06:23,650 operation well the imaging studies is 162 00:06:23,650 --> 00:06:25,210 going to guide us about the location of 163 00:06:25,210 --> 00:06:27,070 the tumor and we need to tailor our 164 00:06:27,070 --> 00:06:29,890 operation properly we should do an 165 00:06:29,890 --> 00:06:33,490 accelerator APR removing the elevator 166 00:06:33,490 --> 00:06:36,310 Mars muscles along with the rectum and 167 00:06:36,310 --> 00:06:38,980 the mess of rectum to avoid the waste in 168 00:06:38,980 --> 00:06:40,750 the surgical specimen that has been the 169 00:06:40,750 --> 00:06:41,710 source or record 170 00:06:41,710 --> 00:06:43,930 and worse outcomes impatient with 171 00:06:43,930 --> 00:06:46,060 digital rectal cancer having abdominal 172 00:06:46,060 --> 00:06:48,640 perennial decision of the rectum this 173 00:06:48,640 --> 00:06:52,060 has been again shown elegantly in many 174 00:06:52,060 --> 00:06:56,220 different studies standard APR with 175 00:06:56,220 --> 00:06:58,270 without removing the levator muscle 176 00:06:58,270 --> 00:07:00,580 leads to more perforation and a greater 177 00:07:00,580 --> 00:07:02,140 risk of the confidential or sexual 178 00:07:02,140 --> 00:07:05,020 management there are other tumors that 179 00:07:05,020 --> 00:07:06,820 they're going to go even beyond what we 180 00:07:06,820 --> 00:07:08,320 remove in a total mesorectal excision 181 00:07:08,320 --> 00:07:10,540 and it was mentioned before that this 182 00:07:10,540 --> 00:07:13,750 will help us guide the operation and do 183 00:07:13,750 --> 00:07:15,730 a standard procedure whether it is a 184 00:07:15,730 --> 00:07:17,860 complete pelvic centration sometimes it 185 00:07:17,860 --> 00:07:20,140 will be on a pelvic ascent aeration so 186 00:07:20,140 --> 00:07:22,030 this is one of the main advances that is 187 00:07:22,030 --> 00:07:24,700 helping us to a tailor the surgical 188 00:07:24,700 --> 00:07:28,000 procedure to the tumor now one of the 189 00:07:28,000 --> 00:07:33,760 main areas in in general surgery in 190 00:07:33,760 --> 00:07:35,410 general and in colorectal cancer in 191 00:07:35,410 --> 00:07:39,370 particular in the last few decades has 192 00:07:39,370 --> 00:07:40,750 been the introduction of the minimally 193 00:07:40,750 --> 00:07:43,750 invasive surgery there are a number of 194 00:07:43,750 --> 00:07:45,850 prospective randomized trials in in 195 00:07:45,850 --> 00:07:48,400 colon cancer they have proven that the 196 00:07:48,400 --> 00:07:50,650 minimally invasive approach is superior 197 00:07:50,650 --> 00:07:54,100 to the standard open approach in terms 198 00:07:54,100 --> 00:07:56,470 of patient recovery and reduce in length 199 00:07:56,470 --> 00:08:00,010 of stay in patients with colon cancer in 200 00:08:00,010 --> 00:08:04,120 particularly places that do do not need 201 00:08:04,120 --> 00:08:05,920 that conversion so patient that they are 202 00:08:05,920 --> 00:08:08,110 straight laparoscopic procedure they 203 00:08:08,110 --> 00:08:09,820 require less narcotics they have less 204 00:08:09,820 --> 00:08:12,550 pain they are discharged home faster and 205 00:08:12,550 --> 00:08:14,050 they return to work earlier than 206 00:08:14,050 --> 00:08:16,420 patients who have open surgery and this 207 00:08:16,420 --> 00:08:18,160 has been achieved without compromising 208 00:08:18,160 --> 00:08:20,800 the oncological outcomes in rectal 209 00:08:20,800 --> 00:08:22,630 cancer the story's not quite the same 210 00:08:22,630 --> 00:08:24,970 they have been so far five major 211 00:08:24,970 --> 00:08:27,250 prospective randomized trials two of 212 00:08:27,250 --> 00:08:29,920 them in Europe one in Korean to one in 213 00:08:29,920 --> 00:08:31,270 the United States and another one in 214 00:08:31,270 --> 00:08:34,809 Australia different designs radically 215 00:08:34,809 --> 00:08:36,280 different patient population but the 216 00:08:36,280 --> 00:08:38,110 message is that the compression rate is 217 00:08:38,110 --> 00:08:42,309 not insignificant at least 10% that the 218 00:08:42,309 --> 00:08:43,510 completeness of the mass of rectal 219 00:08:43,510 --> 00:08:46,060 excision is a little bit inferior at 220 00:08:46,060 --> 00:08:48,730 least in the last two trials compared to 221 00:08:48,730 --> 00:08:51,880 opened tme and that they were not a 222 00:08:51,880 --> 00:08:53,800 dramatic difference in terms of the 223 00:08:53,800 --> 00:08:54,529 length of a stage 224 00:08:54,529 --> 00:08:56,480 your patient recovery so they has put a 225 00:08:56,480 --> 00:08:59,089 little bit of a cloud in the end - she 226 00:08:59,089 --> 00:09:01,519 asked for minimally invasive surgery in 227 00:09:01,519 --> 00:09:03,939 patients with rectal cancer M 228 00:09:03,939 --> 00:09:06,709 oncological outcomes are equivalent the 229 00:09:06,709 --> 00:09:08,569 two of the studies they have reported 230 00:09:08,569 --> 00:09:10,279 already mature data in terms of 231 00:09:10,279 --> 00:09:11,689 long-term survival 232 00:09:11,689 --> 00:09:14,600 surgery doesn't seem to compromise his 233 00:09:14,600 --> 00:09:16,160 laparoscopic surgery doesn't seem to 234 00:09:16,160 --> 00:09:18,170 compromise long-term outcomes in rectal 235 00:09:18,170 --> 00:09:20,300 cancer but what they have failed to 236 00:09:20,300 --> 00:09:23,480 deliver is the improvements in outcomes 237 00:09:23,480 --> 00:09:28,339 that we have seen with colon cancer so 238 00:09:28,339 --> 00:09:30,829 again similar length of the stay mixed 239 00:09:30,829 --> 00:09:32,240 results about completeness of the 240 00:09:32,240 --> 00:09:34,009 mesorectal excision and the survival 241 00:09:34,009 --> 00:09:36,379 probably equivalent the fact of the 242 00:09:36,379 --> 00:09:39,350 matter is that a laparoscopy is rarely 243 00:09:39,350 --> 00:09:41,959 used in rectal cancer today this is data 244 00:09:41,959 --> 00:09:43,519 from the United States I don't know how 245 00:09:43,519 --> 00:09:45,499 it will be in Europe but probably not 246 00:09:45,499 --> 00:09:48,110 that different less than 10% of rectal 247 00:09:48,110 --> 00:09:50,420 cancer such we did with laparoscopic in 248 00:09:50,420 --> 00:09:53,559 the United States today and why is 249 00:09:53,559 --> 00:09:55,639 laparoscopy not widely adopted 250 00:09:55,639 --> 00:09:58,249 I think the rectal cancer surgery is 251 00:09:58,249 --> 00:09:59,720 challenging is more challenging than 252 00:09:59,720 --> 00:10:02,240 colon cancer particularly in a obese 253 00:10:02,240 --> 00:10:04,759 patient with a narrow pelvis that has a 254 00:10:04,759 --> 00:10:07,009 victim two more the resection of that 255 00:10:07,009 --> 00:10:09,170 that that type of patient and tumor is 256 00:10:09,170 --> 00:10:10,839 quite difficult laparoscopically 257 00:10:10,839 --> 00:10:13,339 laparoscopic stenick le challenging we 258 00:10:13,339 --> 00:10:15,319 work with long instrument rigid that did 259 00:10:15,319 --> 00:10:18,170 not articulate the surgical limited 260 00:10:18,170 --> 00:10:20,149 control only can have two instruments is 261 00:10:20,149 --> 00:10:22,490 very difficult to triangulate economics 262 00:10:22,490 --> 00:10:25,459 is very poor and the plataform usually 263 00:10:25,459 --> 00:10:27,769 has two-dimensional visualization you 264 00:10:27,769 --> 00:10:30,129 need to have a very good help to do 265 00:10:30,129 --> 00:10:34,009 minimally invasive surgery and more 266 00:10:34,009 --> 00:10:36,649 important and I think this stands not 267 00:10:36,649 --> 00:10:38,660 only - laparoscopy but all the aspects 268 00:10:38,660 --> 00:10:40,370 of the treatment of rectal cancer most 269 00:10:40,370 --> 00:10:42,620 rectal cancer surgeries are performed by 270 00:10:42,620 --> 00:10:45,589 surgeons who do very few cases here and 271 00:10:45,589 --> 00:10:47,689 an institution that they are considered 272 00:10:47,689 --> 00:10:50,420 to be low volume so what are the 273 00:10:50,420 --> 00:10:52,279 alternatives what are we now trying to 274 00:10:52,279 --> 00:10:54,439 do to extend the minimally invasive 275 00:10:54,439 --> 00:10:57,170 surgery to rectal cancer patients one of 276 00:10:57,170 --> 00:10:59,149 the things that we have done is the 277 00:10:59,149 --> 00:11:00,949 introduction of the robotic platform and 278 00:11:00,949 --> 00:11:02,620 I think there would be a large 279 00:11:02,620 --> 00:11:05,059 presentation tomorrow the other one is 280 00:11:05,059 --> 00:11:06,379 something that you might have be 281 00:11:06,379 --> 00:11:08,209 starting to hear about which is the 282 00:11:08,209 --> 00:11:10,879 trans Amal DME instead of going from top 283 00:11:10,879 --> 00:11:14,089 down going from bottom up to do the mess 284 00:11:14,089 --> 00:11:18,379 of rectal dissection so the robot Y the 285 00:11:18,379 --> 00:11:21,559 robot M there are many advantage of this 286 00:11:21,559 --> 00:11:23,689 platform allow us to see in three 287 00:11:23,689 --> 00:11:25,339 dimensional we have articulating 288 00:11:25,339 --> 00:11:27,319 instruments that they can scale motion 289 00:11:27,319 --> 00:11:31,459 and eliminate the tremor enhance the 290 00:11:31,459 --> 00:11:33,559 precision I think the surgeon has more 291 00:11:33,559 --> 00:11:35,389 control we can control the camera and at 292 00:11:35,389 --> 00:11:36,889 least three instruments at the same time 293 00:11:36,889 --> 00:11:39,019 and I think is much better from the 294 00:11:39,019 --> 00:11:40,370 ergonomical point of view for the 295 00:11:40,370 --> 00:11:44,720 surgeon performing the operation there 296 00:11:44,720 --> 00:11:46,339 are some disadvantages you have to dock 297 00:11:46,339 --> 00:11:48,980 and undock the device which we time is 298 00:11:48,980 --> 00:11:51,589 is something that we do quite rapid a 299 00:11:51,589 --> 00:11:53,629 they argue about the lack of tactile 300 00:11:53,629 --> 00:11:55,759 sensation which is very interesting but 301 00:11:55,759 --> 00:11:57,079 we somehow 302 00:11:57,079 --> 00:12:00,079 replace with some haptic sensation just 303 00:12:00,079 --> 00:12:02,000 by looking at the tissues and the most 304 00:12:02,000 --> 00:12:03,679 important one is the course this is a 305 00:12:03,679 --> 00:12:05,750 spensive machine that is expensive to 306 00:12:05,750 --> 00:12:07,879 maintain and has this possible that they 307 00:12:07,879 --> 00:12:10,879 also cost fair amount of money robotics 308 00:12:10,879 --> 00:12:13,250 have come a long way from the day that I 309 00:12:13,250 --> 00:12:15,620 started using this system and almost a 310 00:12:15,620 --> 00:12:18,049 decade ago on today we have gone through 311 00:12:18,049 --> 00:12:21,199 four different platforms the technology 312 00:12:21,199 --> 00:12:23,750 has improved and so has improved the 313 00:12:23,750 --> 00:12:26,420 flow of the operation we have figured 314 00:12:26,420 --> 00:12:29,149 out now how to do this operation with 315 00:12:29,149 --> 00:12:31,730 one set of instruments and at the speed 316 00:12:31,730 --> 00:12:34,069 that probably is parallel to what we do 317 00:12:34,069 --> 00:12:37,549 in open surgery there is there is a lot 318 00:12:37,549 --> 00:12:39,379 of literature about robotic surgery most 319 00:12:39,379 --> 00:12:40,759 of them they are retrospective case 320 00:12:40,759 --> 00:12:42,769 series there is only one prospective 321 00:12:42,769 --> 00:12:44,569 trial comparing laparoscopic and robotic 322 00:12:44,569 --> 00:12:47,329 but the data is not mature yet the only 323 00:12:47,329 --> 00:12:49,600 thing that we can say is that with the 324 00:12:49,600 --> 00:12:52,759 robotic platform we are able to complete 325 00:12:52,759 --> 00:12:54,559 the minimally invasive approach in more 326 00:12:54,559 --> 00:12:57,339 patients that we can use in a 327 00:12:57,339 --> 00:13:00,049 laparoscopy and that the circumferential 328 00:13:00,049 --> 00:13:01,939 sexual knowledge in the surrogate for 329 00:13:01,939 --> 00:13:04,040 the quality of the surgery is very much 330 00:13:04,040 --> 00:13:07,429 equivalent to you can do with a 331 00:13:07,429 --> 00:13:10,100 laparoscopy or open surgery at our own 332 00:13:10,100 --> 00:13:12,019 institution we have adopted robotic kind 333 00:13:12,019 --> 00:13:13,429 of enthusiastically because we have 334 00:13:13,429 --> 00:13:15,680 equipment and we have 335 00:13:15,680 --> 00:13:20,240 move towards the robotic tme we are now 336 00:13:20,240 --> 00:13:23,899 probably doing 500 cases a year and we 337 00:13:23,899 --> 00:13:25,850 have recently revealed our experience 338 00:13:25,850 --> 00:13:28,190 comparing the cases done in the last few 339 00:13:28,190 --> 00:13:28,520 years 340 00:13:28,520 --> 00:13:30,529 open laparoscopic assisting and robotic 341 00:13:30,529 --> 00:13:32,330 the only difference in this patient 342 00:13:32,330 --> 00:13:34,430 preparation is our increase use of 343 00:13:34,430 --> 00:13:37,820 induction chemotherapy in the new age of 344 00:13:37,820 --> 00:13:39,170 onset in inpatient with rectal cancer 345 00:13:39,170 --> 00:13:41,060 all the other characteristics who are 346 00:13:41,060 --> 00:13:43,940 the same the circumferential sexual 347 00:13:43,940 --> 00:13:45,410 margin in our hands you know very 348 00:13:45,410 --> 00:13:46,910 different the number of live nodes 349 00:13:46,910 --> 00:13:48,410 probably is different but I don't know 350 00:13:48,410 --> 00:13:50,899 if is clinically meaningful it takes a 351 00:13:50,899 --> 00:13:53,510 little bit longer to do robotics this 352 00:13:53,510 --> 00:13:56,149 includes our learning curve what we have 353 00:13:56,149 --> 00:13:57,740 found is that the complication rates 354 00:13:57,740 --> 00:13:59,330 particularly when it comes to 355 00:13:59,330 --> 00:14:01,399 superficial surgical site infection and 356 00:14:01,399 --> 00:14:04,190 some other complications are less we 357 00:14:04,190 --> 00:14:05,750 have been able to reduce the length of 358 00:14:05,750 --> 00:14:08,510 stay probably in two days of course at a 359 00:14:08,510 --> 00:14:11,240 significant cost we don't know if the 360 00:14:11,240 --> 00:14:14,450 cost incurred by the patient who 361 00:14:14,450 --> 00:14:16,910 developed complications because after 362 00:14:16,910 --> 00:14:19,100 this charge will offset the cost of the 363 00:14:19,100 --> 00:14:23,510 in hospital charges for the use of the 364 00:14:23,510 --> 00:14:25,279 robot we don't know yet we are working 365 00:14:25,279 --> 00:14:28,700 on that in multivariate analysis the 366 00:14:28,700 --> 00:14:31,130 robot didn't have an impact in the total 367 00:14:31,130 --> 00:14:33,140 number of complications but was 368 00:14:33,140 --> 00:14:34,940 significant in the surgical site 369 00:14:34,940 --> 00:14:36,800 infection in the length of stay and of 370 00:14:36,800 --> 00:14:38,959 course in the cost using the robot is 371 00:14:38,959 --> 00:14:41,690 more expensive we have also looked at 372 00:14:41,690 --> 00:14:43,310 the APR and even though the numbers are 373 00:14:43,310 --> 00:14:45,050 less because we don't do as many a peers 374 00:14:45,050 --> 00:14:47,029 or with early years the trend is the 375 00:14:47,029 --> 00:14:49,220 same the complication rate seems to be 376 00:14:49,220 --> 00:14:51,470 less patient seems to recover faster and 377 00:14:51,470 --> 00:14:53,510 the length of a stay is less that would 378 00:14:53,510 --> 00:14:55,940 need to be proven in a larger cohorts 379 00:14:55,940 --> 00:14:58,130 and probably one day in a prospective 380 00:14:58,130 --> 00:15:01,339 trial now what about the alternative for 381 00:15:01,339 --> 00:15:03,529 places for a surgeon who don't have 382 00:15:03,529 --> 00:15:07,130 access to the robotic platform they have 383 00:15:07,130 --> 00:15:09,320 introduced the transitional DME just 384 00:15:09,320 --> 00:15:11,240 trying to do the dissection starting at 385 00:15:11,240 --> 00:15:13,310 the rectum and moving up upwards from 386 00:15:13,310 --> 00:15:17,209 the anal canal up so we use one of the 387 00:15:17,209 --> 00:15:19,820 single port devices to use laparoscopic 388 00:15:19,820 --> 00:15:22,130 instruments get through the bowel wall 389 00:15:22,130 --> 00:15:24,140 try to find a measure of rectal plane 390 00:15:24,140 --> 00:15:26,150 and started a section through the annals 391 00:15:26,150 --> 00:15:27,020 up to 392 00:15:27,020 --> 00:15:29,420 the pelvis needless to say that today 393 00:15:29,420 --> 00:15:31,640 they needs to be another team working in 394 00:15:31,640 --> 00:15:33,290 the abdomen to control the vessels 395 00:15:33,290 --> 00:15:35,540 mobilize the colon to be able to 396 00:15:35,540 --> 00:15:37,580 complete the operation and perform the 397 00:15:37,580 --> 00:15:41,300 anastomosis why the Tata t me as I say 398 00:15:41,300 --> 00:15:43,820 for surgeons who don't have access to 399 00:15:43,820 --> 00:15:45,410 the robotic platform or not have the 400 00:15:45,410 --> 00:15:47,050 expertise or don't believe in it 401 00:15:47,050 --> 00:15:50,480 the rationale is because this posture in 402 00:15:50,480 --> 00:15:51,950 the distal rectum is quite difficult 403 00:15:51,950 --> 00:15:54,410 when we go from the abdomen following 404 00:15:54,410 --> 00:15:56,090 the plane that we used to follow in open 405 00:15:56,090 --> 00:15:59,180 surgery particularly anteriorly in very 406 00:15:59,180 --> 00:16:01,550 distal tumors is very difficult to 407 00:16:01,550 --> 00:16:04,010 visualise from above that area and it's 408 00:16:04,010 --> 00:16:06,310 easier when you go through the annals 409 00:16:06,310 --> 00:16:08,630 for very distant tumors as I mentioned 410 00:16:08,630 --> 00:16:10,190 before is difficult to transect the 411 00:16:10,190 --> 00:16:12,080 rectum using a stapling device you don't 412 00:16:12,080 --> 00:16:14,120 have an office space in another pelvis 413 00:16:14,120 --> 00:16:16,160 in a male for a very Beast of rectal 414 00:16:16,160 --> 00:16:18,680 tumor and the idea was to avoid the 415 00:16:18,680 --> 00:16:20,780 compression rate and make the 416 00:16:20,780 --> 00:16:23,590 laparoscopy more accessible to patients 417 00:16:23,590 --> 00:16:26,480 there is a lot of data this data has 418 00:16:26,480 --> 00:16:28,220 come out in the last couple years there 419 00:16:28,220 --> 00:16:29,780 is a systematic review that was 420 00:16:29,780 --> 00:16:31,910 published earlier this year with a total 421 00:16:31,910 --> 00:16:34,790 of 500 and temptations and what this 422 00:16:34,790 --> 00:16:37,130 preliminary experience tell us is that 423 00:16:37,130 --> 00:16:39,650 this is probably technically feasible in 424 00:16:39,650 --> 00:16:41,570 that this technique to keep in the 425 00:16:41,570 --> 00:16:44,210 surgical armamentarium I see some 426 00:16:44,210 --> 00:16:49,010 problems because the transitional tme do 427 00:16:49,010 --> 00:16:51,020 not eliminate the need for an access 428 00:16:51,020 --> 00:16:52,940 through the abdomen so you need to have 429 00:16:52,940 --> 00:16:54,860 two set of equipments working from above 430 00:16:54,860 --> 00:16:57,290 and from below one set of instruments to 431 00:16:57,290 --> 00:16:59,510 do the mobilization of the colon and 432 00:16:59,510 --> 00:17:02,240 another one to water from the rectum I 433 00:17:02,240 --> 00:17:03,620 don't know the impact on cost that 434 00:17:03,620 --> 00:17:06,140 hasn't been analyzed yet and requires 435 00:17:06,140 --> 00:17:08,720 opening the rectum to the pelvis with 436 00:17:08,720 --> 00:17:10,640 the possibility of contamination and in 437 00:17:10,640 --> 00:17:12,980 some cases spillage of cancer cells I 438 00:17:12,980 --> 00:17:14,569 don't know Aquila will lead to any 439 00:17:14,569 --> 00:17:17,720 problems in the future in addition it 440 00:17:17,720 --> 00:17:20,000 makes the surgeon in general to try to 441 00:17:20,000 --> 00:17:23,089 perform a lower than astonishes compared 442 00:17:23,089 --> 00:17:24,410 to when you do the double stapling 443 00:17:24,410 --> 00:17:26,180 technique and that probably has been 444 00:17:26,180 --> 00:17:28,160 view as a problem because the lower the 445 00:17:28,160 --> 00:17:31,340 anastomosis the higher the risk of 446 00:17:31,340 --> 00:17:33,140 having a low anterior resection syndrome 447 00:17:33,140 --> 00:17:36,190 and probably warrants a blood count and 448 00:17:36,190 --> 00:17:38,540 there are some technical issues just 449 00:17:38,540 --> 00:17:40,290 working through the anus 450 00:17:40,290 --> 00:17:41,850 you had the instruments in parallel and 451 00:17:41,850 --> 00:17:43,740 is not that simple I think is not 452 00:17:43,740 --> 00:17:46,200 something that it will be accessible to 453 00:17:46,200 --> 00:17:48,510 a surgeon who does one or two or these 454 00:17:48,510 --> 00:17:51,030 procedures every year I think we need to 455 00:17:51,030 --> 00:17:53,010 in this approach identify the 456 00:17:53,010 --> 00:17:56,430 neurovascular bundle in the area what is 457 00:17:56,430 --> 00:17:59,340 more exposed and I'm worried that we're 458 00:17:59,340 --> 00:18:01,140 gonna see more problem with the sexual 459 00:18:01,140 --> 00:18:03,990 and urinary dysfunction but I think all 460 00:18:03,990 --> 00:18:07,100 this thing needs to be improvement in 461 00:18:07,100 --> 00:18:09,570 larger studies there is already a 462 00:18:09,570 --> 00:18:11,190 prospective trial going on in Europe 463 00:18:11,190 --> 00:18:12,450 that we'll be able to answer some of 464 00:18:12,450 --> 00:18:15,210 these questions again in my opinion is 465 00:18:15,210 --> 00:18:16,680 not needed for most cancers for more 466 00:18:16,680 --> 00:18:18,780 cancers we can do is steal the traps 467 00:18:18,780 --> 00:18:21,450 abdominal approach from a bob transfer 468 00:18:21,450 --> 00:18:22,830 the rectum with a stapler and do the 469 00:18:22,830 --> 00:18:24,990 double stapling but I think is something 470 00:18:24,990 --> 00:18:26,580 that should be in the surgical 471 00:18:26,580 --> 00:18:29,520 armamentarium for some patients in whom 472 00:18:29,520 --> 00:18:31,590 as winter preservation might be 473 00:18:31,590 --> 00:18:34,230 difficult even when using the robot just 474 00:18:34,230 --> 00:18:35,160 from about 475 00:18:35,160 --> 00:18:38,030 so in summary these are some of the 476 00:18:38,030 --> 00:18:40,410 advances that I see today in the 477 00:18:40,410 --> 00:18:42,060 surgical treatment of rectal cancer I 478 00:18:42,060 --> 00:18:44,610 think the selection a base on the MRI 479 00:18:44,610 --> 00:18:47,100 imaging is critical as I said before no 480 00:18:47,100 --> 00:18:48,660 patients should go to the operating room 481 00:18:48,660 --> 00:18:50,280 without knowing what type of procedure 482 00:18:50,280 --> 00:18:53,400 you can have I think medically minimally 483 00:18:53,400 --> 00:18:55,290 invasive is decidable patient recover 484 00:18:55,290 --> 00:18:57,660 faster patients get less complications 485 00:18:57,660 --> 00:19:01,650 and return to work easier but I think 486 00:19:01,650 --> 00:19:03,510 it's technically challenging I think the 487 00:19:03,510 --> 00:19:06,840 robotic plataform my help we hope that 488 00:19:06,840 --> 00:19:08,570 the cost of this instrument will be 489 00:19:08,570 --> 00:19:11,160 reduced in the future and I think that 490 00:19:11,160 --> 00:19:14,360 data tme is also a useful tool that 491 00:19:14,360 --> 00:19:17,400 needs sometimes to find a place in our 492 00:19:17,400 --> 00:19:21,440 surgical armamentarium thank you