so what I'm going to do today is as I
got at least some of the advances in the
management of rectal cancer I'm going to
emphasize the importance of surgical
technique because at the end of the day
most patients are going to need to cut
the rectum remove I want to talk about
the evidence supporting the use of
laparoscopic surgery I'm going to touch
a little bit upon the use of Robotics in
retinal cancer surgery and and also in
some new techniques something that is
now called transana
DME I'm a surgeon and I had to emphasize
a surgical technique matters this is all
data but it just emphasized the
variation in local recurrence among
surgeons an institution that has been
known for many many years
these differences are far greater that
the difference that we can achieve with
neoadjuvant therapy with adjuvant
therapy has a great impact for patients
outcomes I think we have to credit em
bill Hill by helping us understand why
there was such a wide variability in
outcomes in Beijing with rattle cancer
he introduced the concept total
mesorectal excision because probably
surgeons were not following the fine
anatomical planes when they were
removing the rectum that combined with
the work of pathology such as field work
helped us tremendously to identify the
flaws that we had in the surgery for
rectal cancer in the 80's and 90's and
to introduce new educational sessions
for surgeons to improve our surgical
technique but even today M there are
significant variation in outcomes among
surgeons and institutions throughout the
world again this has been emphasized by
studies like the Dutch trial who really
proved that the completeness of the
mesorectal excision the quality of the
surgery had a tremendous impact on the
outcomes for the patients so I think dr.
Brown give us a very good overview of
the use of MRI in identified risk
different risk groups among patient with
rectal cancer that helped us select a
new adjuvant therapy I think in Europe
we now identify three groups and these
groups are treated with different
protocols again according to the
can local run laps of Easter metastases
but I think what is most important from
the surgical point of view MRI helped us
select the operation that every patient
requires I think in this day and age
with the imaging that we have at our
disposal
patients should go to the operating room
understanding and knowing exactly what
type of procedures are they going to
have and I'm going to give you some
examples at what do we do today so this
is a typical meal rectal cancer it will
call it law intermediaries with which is
not threatening the circumference or
sexual margin and that is far enough
from the pelvic floor and the filter
complex to allow us to perform a total
mesorectal exist excision with a double
staple anastomosis distal to the tumor
we will have enough margin to transect
the rectum with a stapling device and
not open in the rectum and then using
the standard step-in devices that we use
today to perform an end-to-end across
anastomosis that will rest ablis the
Bible continuity we have seen also from
dr. abdur
the functional of Congolese patients
that for the most part they are
manageable and patients are willing to
put up with to avoid a permanent stone
now a different story is a tumor that is
located very low in the rectum but it's
not involved in the pelvic floor is not
involved in the sphincter complex and
you know as I mentioned based on the MRI
images obtained before or after as you
can therapy guide us on what type of
surgery we can perform to the patient so
we can counsel the patient about the
procedures that we can do and in this
case it will be ultra low anastomosis
ultra low resection with a coronal
anastomosis some surgeons will go as far
as removing the entire internal
sphincter and perform an interest
interest resection
again knowing the anatomy of the pelvis
and the location of the tumor in
relation to all the important structures
we can dissect from the abdomen we can
dissect through the annals do a
transitional extraction and then perform
a hands-on coronal anastomosis
we shouldn't be doing or attempting and
stable anastomosis in this patient
because probably we are going
transected two more and ruin the
possibility of a swinter saving
procedure I'm not advocating that these
operations should be performed in
everyone I think it's safe are longer we
have a negative circumference of
resection margin as explained by Magina
before and as long as we can get just
about a centimeter distal to the tumor
that's all we need from the oncological
point of view unfortunately there is one
morbidity associate with these
operations there is a large body of
literature they just summarize the
morbidity associated with it there is
also some functional outcomes that they
are worse than the outcomes that we will
achieve with a double staple technique
but again many patients prefer him all
these myriad of bowel problems to a
permanent colostomy and also we know
that oncological is probably safe as
long as we can achieve negative feel
confidential sexual margin and a distal
margin of approximately one centimeter
or more the quality of life is debatable
but as I mentioned even though it's
worse than standard low anterior
resection with the stable anastomosis
some patients still prefer this approach
to a abdominal analysis another rectum
and this is an important issue that
surgeons need to discuss with the
patient before offering one or the other
procedure again going back to the
imaging the imaging is very accurate and
in this case it will show that there is
involvement of the elevator or the
sphincter complex and in this case as
filter saving procedure won't be
feasible the patients should know that
before it goes to the operating room and
so we should be appropriately counseled
for that these patients are gonna
require an abdominal analysis another
rectum and it was also mentioned by dr.
Brown the importance of performing this
operation well the imaging studies is
going to guide us about the location of
the tumor and we need to tailor our
operation properly we should do an
accelerator APR removing the elevator
Mars muscles along with the rectum and
the mess of rectum to avoid the waste in
the surgical specimen that has been the
source or record
and worse outcomes impatient with
digital rectal cancer having abdominal
perennial decision of the rectum this
has been again shown elegantly in many
different studies standard APR with
without removing the levator muscle
leads to more perforation and a greater
risk of the confidential or sexual
management there are other tumors that
they're going to go even beyond what we
remove in a total mesorectal excision
and it was mentioned before that this
will help us guide the operation and do
a standard procedure whether it is a
complete pelvic centration sometimes it
will be on a pelvic ascent aeration so
this is one of the main advances that is
helping us to a tailor the surgical
procedure to the tumor now one of the
main areas in in general surgery in
general and in colorectal cancer in
particular in the last few decades has
been the introduction of the minimally
invasive surgery there are a number of
prospective randomized trials in in
colon cancer they have proven that the
minimally invasive approach is superior
to the standard open approach in terms
of patient recovery and reduce in length
of stay in patients with colon cancer in
particularly places that do do not need
that conversion so patient that they are
straight laparoscopic procedure they
require less narcotics they have less
pain they are discharged home faster and
they return to work earlier than
patients who have open surgery and this
has been achieved without compromising
the oncological outcomes in rectal
cancer the story's not quite the same
they have been so far five major
prospective randomized trials two of
them in Europe one in Korean to one in
the United States and another one in
Australia different designs radically
different patient population but the
message is that the compression rate is
not insignificant at least 10% that the
completeness of the mass of rectal
excision is a little bit inferior at
least in the last two trials compared to
opened tme and that they were not a
dramatic difference in terms of the
length of a stage
your patient recovery so they has put a
little bit of a cloud in the end - she
asked for minimally invasive surgery in
patients with rectal cancer M
oncological outcomes are equivalent the
two of the studies they have reported
already mature data in terms of
long-term survival
surgery doesn't seem to compromise his
laparoscopic surgery doesn't seem to
compromise long-term outcomes in rectal
cancer but what they have failed to
deliver is the improvements in outcomes
that we have seen with colon cancer so
again similar length of the stay mixed
results about completeness of the
mesorectal excision and the survival
probably equivalent the fact of the
matter is that a laparoscopy is rarely
used in rectal cancer today this is data
from the United States I don't know how
it will be in Europe but probably not
that different less than 10% of rectal
cancer such we did with laparoscopic in
the United States today and why is
laparoscopy not widely adopted
I think the rectal cancer surgery is
challenging is more challenging than
colon cancer particularly in a obese
patient with a narrow pelvis that has a
victim two more the resection of that
that that type of patient and tumor is
quite difficult laparoscopically
laparoscopic stenick le challenging we
work with long instrument rigid that did
not articulate the surgical limited
control only can have two instruments is
very difficult to triangulate economics
is very poor and the plataform usually
has two-dimensional visualization you
need to have a very good help to do
minimally invasive surgery and more
important and I think this stands not
only - laparoscopy but all the aspects
of the treatment of rectal cancer most
rectal cancer surgeries are performed by
surgeons who do very few cases here and
an institution that they are considered
to be low volume so what are the
alternatives what are we now trying to
do to extend the minimally invasive
surgery to rectal cancer patients one of
the things that we have done is the
introduction of the robotic platform and
I think there would be a large
presentation tomorrow the other one is
something that you might have be
starting to hear about which is the
trans Amal DME instead of going from top
down going from bottom up to do the mess
of rectal dissection so the robot Y the
robot M there are many advantage of this
platform allow us to see in three
dimensional we have articulating
instruments that they can scale motion
and eliminate the tremor enhance the
precision I think the surgeon has more
control we can control the camera and at
least three instruments at the same time
and I think is much better from the
ergonomical point of view for the
surgeon performing the operation there
are some disadvantages you have to dock
and undock the device which we time is
is something that we do quite rapid a
they argue about the lack of tactile
sensation which is very interesting but
we somehow
replace with some haptic sensation just
by looking at the tissues and the most
important one is the course this is a
spensive machine that is expensive to
maintain and has this possible that they
also cost fair amount of money robotics
have come a long way from the day that I
started using this system and almost a
decade ago on today we have gone through
four different platforms the technology
has improved and so has improved the
flow of the operation we have figured
out now how to do this operation with
one set of instruments and at the speed
that probably is parallel to what we do
in open surgery there is there is a lot
of literature about robotic surgery most
of them they are retrospective case
series there is only one prospective
trial comparing laparoscopic and robotic
but the data is not mature yet the only
thing that we can say is that with the
robotic platform we are able to complete
the minimally invasive approach in more
patients that we can use in a
laparoscopy and that the circumferential
sexual knowledge in the surrogate for
the quality of the surgery is very much
equivalent to you can do with a
laparoscopy or open surgery at our own
institution we have adopted robotic kind
of enthusiastically because we have
equipment and we have
move towards the robotic tme we are now
probably doing 500 cases a year and we
have recently revealed our experience
comparing the cases done in the last few
years
open laparoscopic assisting and robotic
the only difference in this patient
preparation is our increase use of
induction chemotherapy in the new age of
onset in inpatient with rectal cancer
all the other characteristics who are
the same the circumferential sexual
margin in our hands you know very
different the number of live nodes
probably is different but I don't know
if is clinically meaningful it takes a
little bit longer to do robotics this
includes our learning curve what we have
found is that the complication rates
particularly when it comes to
superficial surgical site infection and
some other complications are less we
have been able to reduce the length of
stay probably in two days of course at a
significant cost we don't know if the
cost incurred by the patient who
developed complications because after
this charge will offset the cost of the
in hospital charges for the use of the
robot we don't know yet we are working
on that in multivariate analysis the
robot didn't have an impact in the total
number of complications but was
significant in the surgical site
infection in the length of stay and of
course in the cost using the robot is
more expensive we have also looked at
the APR and even though the numbers are
less because we don't do as many a peers
or with early years the trend is the
same the complication rate seems to be
less patient seems to recover faster and
the length of a stay is less that would
need to be proven in a larger cohorts
and probably one day in a prospective
trial now what about the alternative for
places for a surgeon who don't have
access to the robotic platform they have
introduced the transitional DME just
trying to do the dissection starting at
the rectum and moving up upwards from
the anal canal up so we use one of the
single port devices to use laparoscopic
instruments get through the bowel wall
try to find a measure of rectal plane
and started a section through the annals
up to
the pelvis needless to say that today
they needs to be another team working in
the abdomen to control the vessels
mobilize the colon to be able to
complete the operation and perform the
anastomosis why the Tata t me as I say
for surgeons who don't have access to
the robotic platform or not have the
expertise or don't believe in it
the rationale is because this posture in
the distal rectum is quite difficult
when we go from the abdomen following
the plane that we used to follow in open
surgery particularly anteriorly in very
distal tumors is very difficult to
visualise from above that area and it's
easier when you go through the annals
for very distant tumors as I mentioned
before is difficult to transect the
rectum using a stapling device you don't
have an office space in another pelvis
in a male for a very Beast of rectal
tumor and the idea was to avoid the
compression rate and make the
laparoscopy more accessible to patients
there is a lot of data this data has
come out in the last couple years there
is a systematic review that was
published earlier this year with a total
of 500 and temptations and what this
preliminary experience tell us is that
this is probably technically feasible in
that this technique to keep in the
surgical armamentarium I see some
problems because the transitional tme do
not eliminate the need for an access
through the abdomen so you need to have
two set of equipments working from above
and from below one set of instruments to
do the mobilization of the colon and
another one to water from the rectum I
don't know the impact on cost that
hasn't been analyzed yet and requires
opening the rectum to the pelvis with
the possibility of contamination and in
some cases spillage of cancer cells I
don't know Aquila will lead to any
problems in the future in addition it
makes the surgeon in general to try to
perform a lower than astonishes compared
to when you do the double stapling
technique and that probably has been
view as a problem because the lower the
anastomosis the higher the risk of
having a low anterior resection syndrome
and probably warrants a blood count and
there are some technical issues just
working through the anus
you had the instruments in parallel and
is not that simple I think is not
something that it will be accessible to
a surgeon who does one or two or these
procedures every year I think we need to
in this approach identify the
neurovascular bundle in the area what is
more exposed and I'm worried that we're
gonna see more problem with the sexual
and urinary dysfunction but I think all
this thing needs to be improvement in
larger studies there is already a
prospective trial going on in Europe
that we'll be able to answer some of
these questions again in my opinion is
not needed for most cancers for more
cancers we can do is steal the traps
abdominal approach from a bob transfer
the rectum with a stapler and do the
double stapling but I think is something
that should be in the surgical
armamentarium for some patients in whom
as winter preservation might be
difficult even when using the robot just
from about
so in summary these are some of the
advances that I see today in the
surgical treatment of rectal cancer I
think the selection a base on the MRI
imaging is critical as I said before no
patients should go to the operating room
without knowing what type of procedure
you can have I think medically minimally
invasive is decidable patient recover
faster patients get less complications
and return to work easier but I think
it's technically challenging I think the
robotic plataform my help we hope that
the cost of this instrument will be
reduced in the future and I think that
data tme is also a useful tool that
needs sometimes to find a place in our
surgical armamentarium thank you