John Nicholls

Consensus conference on the stapled transanal rectal resection (STARR) for disordered defaecation

An international working party was convened in Rome, Italy on 16–17 June, 2005, with the purpose of developing a consensus on the application of the circular stapling instrument to the treatment of certain rectal conditions, the so‐called Stapled Transanal Rectal Resection (STARR). Since the procedure has been submitted to only limited objective analysis it was felt prudent to hold a meeting of interested individuals for the purpose of evaluating the current status and to make conclusions and recommendations concerning the applicability of this new approach.

Stump cancer following gastric surgery

This paper reviews the literature regarding the development of gastric cancer in the stomach remnant following gastric resection. Although there is as yet little supporting experimental evidence, clinical studies suggest that the risk of developing gastric cancer is increased, perhaps as much as 6-fold, following partial gastrectomy for benign lesions. It also appears that the risk of developing cancer is greatest if the lesion for which the gastrectomy was originally performed was a gastric ulcer rather than a duodenal ulcer. The type of gastrectomy does not seem to influence this increased risk. Hypotheses are reviewed concerning the role of changes in gastric morphology following partial gastrectomy in the development of cancer. Revue de la littérature concernant le développement dun cancer dans le moignon gastrique après gastrectomie subtotale. Malgré labsence de preuve expérimentale, les études cliniques suggèrent que le risque dapparition dun cancer est accru, peutêtre jusquà 6 fois, après gastrectomie pour lésion bénigne. Le risque semble être également plus élevé après gastrectomie pour ulcère gastrique que pour ulcère duodénal. Le type de résection gastrique na aucune influence. Diverses hypothèses ont été émises concernant les altérations postopératoires de la morphologie gastrique et leur rôle possible dans le développement du cancer: ces hypothèses sont revues.This paper reviews the literature regarding the development of gastric cancer in the stomach remnant following gastric resection. Although there is as yet little supporting experimental evidence, clinical studies suggest that the risk of developing gastric cancer is increased, perhaps as much as 6-fold, following partial gastrectomy for benign lesions. It also appears that the risk of developing cancer is greatest if the lesion for which the gastrectomy was originally performed was a gastric ulcer rather than a duodenal ulcer. The type of gastrectomy does not seem to influence this increased risk. Hypotheses are reviewed concerning the role of changes in gastric morphology following partial gastrectomy in the development of cancer.RésuméRevue de la littérature concernant le développement dun cancer dans le moignon gastrique après gastrectomie subtotale. Malgré labsence de preuve expérimentale, les études cliniques suggèrent que le risque dapparition dun cancer est accru, peutêtre jusquà 6 fois, après gastrectomie pour lésion bénigne. Le risque semble être également plus élevé après gastrectomie pour ulcère gastrique que pour ulcère duodénal. Le type de résection gastrique na aucune influence. Diverses hypothèses ont été émises concernant les altérations postopératoires de la morphologie gastrique et leur rôle possible dans le développement du cancer: ces hypothèses sont revues.

Restorative proctocolectomy in patients with ulcerative colitis: a cross‐sectional Danish population study on function and quality of life

The study evaluated function and quality of life (QoL) in all patients having restorative proctocolectomy (RPC) in Denmark for ulcerative colitis (UC) from 1980 to 2010. Inclusion of all patients in one country has never previously been achieved.

No more 'standard' abdominoperineal excision.

Since the description of extralevator abdominoperineal excision of the rectum by Holm of the Karolinska Institute, Stockholm [1], there has been some confusion regarding terminology. We forget that the Miles’ operation, which was described in 1908 [2], took many years to enter routine clinical practice. The operative mortality in those early days approached 50%, and the posterior approach to the rectum, which was used by most surgeons at the time because it was less traumatic, continued to be the main procedure for rectal cancer for some time. However, by the 1930s, abdominoperineal excision (APE) had become commonly adopted for most tumours of the rectum, including many that were in the upper third. At about this time major sphincter-preserving surgery was coming into practice. The name ‘anterior resection’ (through the abdomen) distinguished it from posterior resection (parasacral), which gradually died out as the better oncological results of APE and anterior resection were demonstrated. By the 1950s onwards, to surgeons trained by the generation of surgeons who followed Miles, the perineal part of the operation involved removal of the entire pelvic floor by dividing the levator at its insertion into the bony pelvis. This was how Miles described it in his publication in The Lancet in 1908. He used the term ‘cylinder’ to emphasize the need to avoid coning and described the removal of all the levator plate. This was an extralevator removal and many older surgeons found it difficult to understand why the operation had to be reinvented 100 years later. Part of the answer was that APE and anterior resection were not understood by many surgeons to be different procedures with regard to the mode of dissection of the lower rectum. In the latter procedure, dissection was carried out downwards in the presacral plane to the level of the pelvic floor where it was then continued further between the upper surface of the levator ani muscle and the fascia propria of the rectum. This was, of course, essential in the case of a rectal carcinoma in the middle or lower third of the rectum as it was the only means of achieving adequate distal clearance whilst allowing for an anastomosis. Were this mode of rectal mobilization to be applied to APE, there would be a danger of entering the tumour when dissecting the levator off the lower rectum because this is just where the tumour is located. There are several reasons why local recurrence after APE may be more likely than after anterior resection, and failure to achieve R0 removal through using the wrong mode of dissection is one of them. The results of studies performed in the 1990s and 2000s, which showed more local recurrence after APE than after anterior resection, and higher rates of circumferential resection margin positivity and rectal perforation, were the factors that led to the description of total removal of the levator ani in the operation promulgated by Holm. The pathological aim of cancer surgery for any tumour is to achieve an R0 resection. Holm produced data to indicate that this was more likely where the perineal dissection involved removal of the entire levator ani muscle. The operation was given the title ‘extralevator abdominoperineal excision’ (or ELAPE) to distinguish it from so-called ‘standard’ APE, which was said to be the operation performed by many surgeons at the time. Holm’s was a contribution to surgery similar to that made by Heald, for anterior resection, 20 years previously. Both showed that surgical technique mattered and that it influenced cancer-specific end-points. ELAPE and total mesorectal excision (TME) are each based on anatomical definitions and their intention is to optimize the chance of R0 resection. Owing to the different levels of the carcinoma in the rectum pertaining to the two operations, dissection of the lower rectum suitable for one is not suitable for the other. ELAPE would be supported by surgeons brought up on the oncological principles included in the doctrine of Miles, but to distinguish it from other forms of perineal dissection, a name had to be found. The adjective ‘standard’ began to be applied to APE, but it had no meaning because it was not possible to describe it anatomically. ‘Standard’ is, in effect, any operation other than intersphincteric APE that is not an ELAPE. The confusion arising from this term should now be over through the statement made by Dr Anna Martling of the Karolinska Institute, Stockholm, at the recent meeting of the European Society of Coloproctology (ESCP) in Belgrade. In a lecture entitled ‘Tailored abdominoperineal resection for rectal cancer’, only two forms of total rectal excision were recognized. These included APE with intersphincteric removal of the anal canal and APE of the rectum with a perineal dissection in which all the levator was removed, or in today’s parlance, ELAPE. Technical points related to the position of the patient, prone or supine, and the need or not for some form of plastic procedure or mesh insertion to facilitate closure of the perineal wound, are details that can be discussed in parallel but they are secondary to the major

Rectal cancer seen over 30 years

This is my last year as Editor-in-Chief of Colorectal Disease. I have one more editorial to go, which will be published in the last issue of 2014. It has been difficult to select the topic owing to the huge number of possibilities, but when I look back on the last 30 years, the progress in the understanding and treatment of rectal cancer has perhaps been the most interesting for the professional and important for the patient. Thirty years ago, general rectal cancer was almost entirely the province of the general surgeon, and local recurrence was not regarded as the end-point by which surgery should be judged until the 1970s. Up to that time, survival was the statistic that everybody understood. Reliable local recurrence data were difficult to obtain. There was still a large variance in the rates of local failure between surgeons. Published figures of over 30% were commonplace, and almost all patients with local recurrence died of the disease. The most important changes in the last 30 years have been the reduction of local recurrence to 5% or less and a steady increase in survival. These have been achieved by improved surgery and combined modality treatment underpinned by the clear thinking of histopathologists and radiologists. The importance of anatomical dissection has been established for major restorative resection and total anorectal excision, resulting in a degree of standardized surgery that did not exist previously. Mesorectal dissection can be defined anatomically and unless the tumour has broken out beyond the fascia propria of the rectum, an R0 resection is likely to result. Anatomical surgery was practiced by many surgeons during the previous decades, but lack of standardization meant that some were less concerned than others about finding the tissue planes that would allow complete removal of the organ, taking the entire locoregional pathology with it. Improved surgery must account for much of the fall in the rate of local recurrence, but radiotherapy and then radiotherapy combined with chemotherapy have made an enormous contribution in achieving improved locoregional tumour control. Our present knowledge of the effects of these treatments has come from formal systematic prospective clinical trials based on ever more refined preoperative staging and changes in management strategies. Preoperative staging by cross-sectional imaging has achieved a high degree of accuracy that can predict the histopathological examination of the excised specimen in most cases. This has allowed selection of patients for chemoradiotherapy integrated with surgery, either major or local. A long-standing difference in opinion regarding the use of preoperative or postoperative radiotherapy has been settled in favour of the former by prospective randomized clinical trial. Treatment has been further transformed dramatically through the application of chemoradiotherapy as a primary treatment: patients experiencing a complete response are followed without surgery or undergo local excision at the site of the primary tumour. This approach still needs validation and several prospective follow-up studies are now examining this question. Unfortunately, low anterior resection is followed by poor anorectal function in 30-50% of patients, especially if chemoradiotherapy has also been given. This consideration and the diagnosis of tumours at an earlier pathological stage through population screening have encouraged the strategy of organ preservation, which minimizes the amount of rectum removed, thereby preserving its reservoir function and causing less surgical trauma and mortality. Organ preservation can only be acceptable provided cancer-specific end-points are not degraded. There are current prospective randomized clinical trials aiming to answer this question. Genetic analysis has demonstrated that large bowel cancer is at least three diseases. The blank genetic picture of 30 years ago is gradually being filled in by an extraordinary amount of new information, which is already influencing the choice of treatment, as discussed in multidisciplinary team (MDT) meetings. The management of pelvic recurrence and metastatic disease is becoming more standardized. These developments have occurred during one professional lifetime. It is impossible to say how the picture will look even in 5 or 10 years, but we can expect an expansion in knowledge of the molecular biology of rectal cancer, assisting management decisions and prediction of response to nonsurgical treatment. Manipulation of the tumour biology may make it possible to increase its sensitivity to treatment. New agents will be developed and major surgery is likely to continue its current decline. Screening methods will improve and become easier to apply to large populations, perhaps through proteomics for example. For a doctor starting now, the state of rectal cancer at the end of his or her career is as unimaginable as it was 30 years ago.

Advanced and recurrent rectal cancer

The management of recurrent pelvic malignancy and primary advanced rectal cancer is an area of growing interest. Major surgery to deal with advanced pelvic malignancy goes back to case reports by Bowers (1948) and Heys (1953) who reported visceral removal with sacrectomy for this terrible affliction. Over the next twenty years the literature is studded with reports from surgeons who applied themselves seriously to this form of surgery such as Polk, Brunschwig, Ceurlemans and Wanebo. These surgeons made the subdivision between pelvic compartments and pioneered techniques which only few at the time were in a position to take up. Either they did not have the clinical material or they were unwilling to carry out such high risk surgery. Many of the patients reported in the literature had sarcomas and others had pelvic recurrence of gynaecological or rectal malignancy. The medical developments that have occurred over the last thirty years have changed this to some extent. Surgery has become safer, largely owing to better conduct of the operations but probably as much to improved anaesthesia and postoperative critical care. In the 1980s and 1990s the concept of multidisciplinary treatment began to take shape. Not only did this involve oncologists and specialist surgeons, but also intensive care physicians, specialist nurses and physiotherapists. Psychological support and physical rehabilitation were regarded as important parts of the treatment. One of the earliest units for the multidisciplinary management of extensive pelvic malignancy was established at the Mayo Clinic where in the Department of Colon and Rectal Surgery oncologists and surgeons of various specialties were brought together to deal with all aspects of the care of such patients. This approach was adopted increasingly in the 1980s in many units in the USA, Europe, Australasia and Asia. Local recurrence rates after primary surgery have fallen owing to the emphasis on surgery aimed to achieve a clear circumferential and distal margin. They have also been reduced by preoperative radiotherapy. Despite these advances, however, local recurrence still occurs in about 5–10% of patients. Thus for a total number of 10 000 patients treated by primary surgery for rectal cancer 500–1000 will develop local recurrence. Although it usually occurs within the first two years of primary treatment, its presentation may be delayed for many years. Surgery is the only hope for the patient, but it is a formidable and costly undertaking with a mortality of around 5% and a high morbidity. The most important part of case selection is the preoperative prediction of a complete or R0 resection. The reported proportion of patients who achieve this ranges from about 40% to 65%. Patients in this category can expect to have a 3 year survival of around 30–50%. This means that for the remainder, survival is less and the patient will die of the tumour. Often treatment failure is manifest by the appearance of metastatic disease, but local recurrence after major pelvic surgery is also a major cause of death. The increasing accuracy of pretreatment imaging by computerized tomography for metastatic disease and magnetic resonance for the precise anatomical relationship of the pelvic tumour to surrounding organs has allowed the oncologist and the colorectal surgeon to identify preoperatively patients who may have a real prospect of complete removal of the tumour with increasing accuracy and to plan treatment with a reasonable expectation of survival at least over a few years. In the current issue of Colorectal Disease Bhangu and colleagues [1] report a series of 107 patients of whom 70 underwent an attempt at surgical clearance. Of these about two thirds had an R0 resection. They confirmed that survival was related to R stage, but importantly it was also dependent on the number of pelvic compartments involved by the tumour. Thus the hazard ratio for survival of R0 patients with one or more than one compartment involved was 2.6. In addition survival after an R2 resection was no longer than for patients who were inoperable. These observations emphasise still more the need for focussed case selection since failed surgery is a disaster for the patient and his or her family and very costly. Discussion by the multidisciplinary team is obligatory. The question of operability is considered in the other relevant article in this issue. Harji and colleagues [2] review the literature on even more extensive resection for pelvic malignancy, aiming to examine the present anatomical frontiers beyond which the tumour becomes inoperable. Sacrectomy has been used for years, but extending this to the upper sacral segments is relatively new. Lateral pelvic wall involvement or invasion through the greater sciatic notch has been regarded as a contra-indication to operability, but under certain circumstances this is no longer true. In some cases hind quarter amputation has been used and resection of recurrence taking the sciatic nerve is reported with reasonable preservation of function. This extreme form of ultra radical surgery can only be carried out in a specialized unit. For a population yielding a few hundred

Session 3: Beyond TME and radiotherapy MRI evaluation of rectal cancer treatment response

Magnetic resonance imaging plays an increasingly important role in evaluating the effect of cancer treatment. Imaging alone cannot predict pathological complete response and imaging interpretation should be combined with clinical information and endoscopy findings to predict complete response. Professor Blomqvist reviews current and future imaging techniques and whether the quantitative can add significant or important prognostic information over the current qualitative techniques.

Session 3: Intra-operative radiotherapy - creating new surgical boundaries

In patients with advanced and recurrent colorectal cancer, surgical resection with clear margins is the greatest challenge and is limited by known anatomical constraints. Preoperative or intra‐operative assessment of the limits of surgical dissection may help to explore the possibility of improving resectability through either targeted external beam radiotherapy or intra‐operative radiotherapy. Professor Chang reviews the evidence base and potential advantages and disadvantages of this approach, whilst the expert panel agree a consensus on the evidence for assessment and therapy of such patients.

Session 3: Many ways to organ preserve the rectum but which is correct?

From the patients perspective, cancer cure with full preservation of function is a crucial goal. There are many advances that have emerged which may make this possible in a greater proportion of patients without compromising oncological outcomes. Professor Tekkis reviews the options and evidence to date for ‘organ preservation’ and the expert panel discuss the implications for current and future patient care.

Session 3: Beyond the boundaries of Total Mesorectal Excision - where surgeons fear to tread

Approximately 10–15% of patients present with an advanced rectal cancer that extends beyond the conventional total mesorectal excision (TME) planes. In such cases extending the surgery to ensure resection with clear margins (R0 resection) is essential in order to achieve long‐term cure. Professor Holm describes the techniques of beyond‐TME exenterative surgery, the methods of patient selection and outcomes.