It is better to wait for ten to twelve weeks for Neoadjuvant radiotherapy for cancer resection - Prof. Panis

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Colorectal Surgery week at JPMC-II
It is better to wait for ten to twelve weeks
for Neoadjuvant radiotherapy for cancer
resection - Prof. Panis
In low rectal cancer, perineal approach 
should be the first choice

KARACHI: Changing Practice in Rectal Cancer was the topic of first presentation by Prof. Yves Panis noted Colorectal Surgeon from France during the 14th Colorectal Week for Colorectal Surgery organized by Jinnah Postgraduate Medical Centre Karachi held from 14-17th October 2019. He discussed in detail what to do in case of suspicion of compelte tumour response, when to evaluate and which evaluation to be performed. He also talked about whether rectal preservation was possible and if the answer was in Yes, should one Watch and wait or go for local excision.

In the preoperative management he talked about TME and Neoadjuvant radiotherapy for rectal cancer and pointed out that it is better to wait for ten to twelve weeks for Neoadjuvant radiotherapy for cancer resection. It helps in better diagnosis and intra operative management. There is a high chance to have CTR on TME specimen. It offers better prognosis. He further stated that all the protocols of organ preservation are linked with long delay after RCT. Organ preservation can be very interesting in high-risk patients or indication of APR. It will result in better post-operative recovery and also lower mortality rate. It has the same oncologic outcomes in higher risk of bad TME specimen. Some studies have suggested different surgical approaches. Robots use for TME does not offer better results. Hence it is better not to go for Robot TME.

Continuing Prof. Panis remarked that a minimally invasive surgical approach should be used whenever the expertise is available. Strong recommendation is based on high quality evidence. In low and Mid Rectal Cancer, total Mesorectal excision should leave 1cm margin, go for very low anastomosis, it could be stapled low colorectal or manual. He then discussed as to which was best anastomosis is and what is the best technique? He then referred to the 2016 French Guidelines on Rectal Cancer. It states that the preservation of the anal sphincter should be considered if a distal margin of at least 1cm below the tumour can be achieved. It is recommended that the decision whether or not to perform conservative surgery should be taken preoperatively after Neoadjuvant therapy. Using a preoperative MRI classification of low rectal cancer allows assessment of the possibility of sphincter preservation. Careful selection of the patient is very important. Studies have showed that there is no difference in outcome in immediate surgery compared with watch and wait strategy. As such now we do not wait and have changed our strategy. He also shared the results of multiple RCT trials results related to organ preservation of rectal cancer.

Coloanal anastomosis and intersphincteric resection, Prof. Panis stated, is a very good option. Bad selection of patients will give you bad results and higher mortality. Partiers prefer avoiding definitive stoma. If it fails, reoperation with definitive stoma is always possible but it is not possible if APR is the first operation. Speaking about the best strategy for Lap TME with Coloanal manual anastomosis, he described the two options. Laparoscopy first up to the very low rectum. It should be checked by several rectal examinations during operations be sure that enough dissection have been made. The other is perineal approach first which is now a standard technique for low rectal cancer is now. The risks of TATME include too lateral dissection, nerves injury, too posterior dissection with bleeding, inadequate posterior dissection wit incomplete mesorectum. Too anterior dissection could result in prostate, urethra and bladder injury. Inadequate anterior dissection will result in rectal perforation. The expected benefits include easier dissection in male with narrow pelvis, Lower rate of nerve injury and lower rate of R1 resection. He concluded his presentation by stating that use oral antibiotics for ten to twelve weeks for bowel preparation, wait for Neoadjuvant radio chemotherapy, and ensure organ preservation. Robot surgery offers no benefits. TATME needs more evidence as there is a high risk for local recurrence. In low rectal cancer, perineal approach should be the first choice. Rectal preservation is not validated which can be proposed in selected cases but always ensure strict follow up.

Responding to questions during the discussion, Prof. Panis said that colorectal surgeons must have good experience and anyone who is doing just one or two cases in a year is not good enough.

Prof. Ronan O’Connell from UK was the next speaker who talked about anastomotic leakage. It is described as automatic site leading to communication between intra and extra luminal compartments. In Grade-A, he said there is no change in management. In B-Grade, it does require intervention but does not need re-laparotomy. Anastomotic leak in colorectal surgery is reported between 5-19%. Speaking about the causes of leakage he mentioned the surgical technique, blood supply, tension, traction, local sepsis, inflammation, presence of faecal matter besides deficiencies in bacterial load. Anastomosis is a wound healing level in four stages. It includes sutures appropriate tissue until collagen is laid down. It requires meticulous attention to details. It minimizes tissue trauma, avoids tension and one should be aware of local sepsis. Always ensure good blood supply. Do not do anastomosis in infected bed. He also discussed the microloid pathogenesis of anastomotic leak. In case of large tumours, dissection is difficult as there is a blood loss. There is a prolonged operation time because of prior abdominal surgery. In lower anal rectal surgery lately I was not happy using too many staples, it is difficult compared to surgery, he remarked. His advice was do not use three or four staples.

It was followed by a live surgery by Prof. Yves Panis on a forty one years old male having low rectal cancer who already had chemo radiotherapy.

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