Effective Treatment for Rectal Cancer
Sphincter Preservation Procedure Effective Treatment for Rectal Cancer
“J-Pouch” restores normal bowel function, quality of life following surgery
By Lisa Schwartz
For GBMC Greater Oncology Today
Colorectal cancer, the third most common cancer in men and women is also the most preventable and treatable form of the disease when detected in its earliest stages. Regular screening*, including rectal exams and colonoscopy, can altogether prevent the development of the majority of colorectal cancer. Recent medical advances and breakthroughs in treatment modalities have increased survival rates and the quality of life for patients diagnosed with rectal cancer, in particular.
Minimally Invasive Treatment Option – It’s All About Preservation
Sphincter preservation is the latest treatment option for rectal cancer, according to George Apostolides, MD, Division Head of Colon and Rectal Surgery at GBMC. “In the past, patients diagnosed with rectal cancer, especially males found to have tumors in the mid or lower third of the rectum, had their rectums removed completely and were given a permanent colostomy,” he explains. “Sphincter preservation surgery allows us to save all or part of the rectum in many cases, with good results and improved quality of life for our patients.”
The laparoscopic procedure, once considered experimental, is now as effective in treating most rectal cancers as more traditional, open surgery. The best candidates for the newer, restorative procedures, also known as a “J-pouch” or coloplasty, are those whose cancer has not spread through the bowel wall.
The minimally invasive technique involves removal of the rectum to a safe margin below the tumor. The lower portion of the colon (approximately 2 to 4 inches) is connected to the anal canal and formed into a J-shaped pouch, restoring the function of the resected portion of the rectum. This pouch stores stool until it can be eliminated.
“Essentially, we are creating a new rectum,” adds Dr. Apostolides, stressing that the procedure saves the sphincter muscles and re-establishes the storage function of the rectum so that patients can move their bowels normally (although some patients may require a temporary colostomy bag) following surgery.
Accurate Diagnosis, Staging is Critical for Preservation
If cancer is detected in the rectum, accurate diagnosis and staging of the cancer is vital to the preservation of the rectum and sphincter during treatment. Specialized equipment – endorectal ultrasound – provides physicians with a 360-degree view of the rectum and is ideally suited for the pre-surgical work-up of rectal lesions. Endorectal ultrasound can determine how deep the cancer has penetrated the rectal wall and if it has spread to nearby lymph nodes and the pelvis. Additional staging by CT scan of the abdomen is also part of the work-up.
Chemoradiation for Improved Outcomes
Radiation therapy pre-operatively can offer certain advantages for rectal cancer patients. “With pre-operative radiation therapy, a patient can be treated with less toxicity, providing them with an increased chance for sphincter preservation,” explains Eva Zinreich, MD, Radiation Oncologist at GBMC. Radiation treatment prior to surgery can shrink the size of the tumor, thereby making surgery more effective. Depending on the stage of the cancer and/or if the cancer has spread through the bowel wall, post-operative chemotherapy or chemo-radiation therapy may also be recommended.
The new advances in restorative rectal surgery have dramatically improved long-term outcomes for patients undergoing surgical procedures. “Preservation surgery certainly gives patients hope for optimal medical outcomes and a better quality of life,” concluded Dr. Apostolides.
A 69-year-old male presented with blood in his stool. A colonoscopy showed multiple polyps in the lower rectum, which were removed. Following a biopsy of the polyps, the patient was diagnosed with lower rectal cancer. A digital exam showed normal sphincter muscle tone and a 4 cm tumor in the posterior rectum.
A thorough work-up of the patient was ordered including endorectal ultrasound and CT scans to access whether or not the cancer had spread through the bowel wall. The ultrasound showed an early stage 2 (T2) of the mid portion of the rectal wall with one small lymph node involvement.
A course of pre-operative chemoradiation was initiated to shrink the tumor and the patient underwent treatment for five weeks, five days per week. Four weeks after the last chemoradiation treatment, the patient underwent a 4-½ hour
laparoscopic lower resection of the rectum. A colo-anal J-pouch was constructed and connected to the anus and the patient received a temporary ileostomy following surgery, which was performed in September 2006. Of note, patients previously diagnosed with mid rectal tumors would have had complete removal of the rectum and permanent colostomy. Preservation surgery saved the majority of the patient’s rectum for optimal results and improved quality of life.
The ileostomy was closed and removed in November 2006 and the patient was able to move his bowels normally, with successful sphincter muscle preservation. Regular follow-up has been initiated and full re-evaluation is planned one year from date of surgery.