Colorectal (Pelvic) Surgery
Introduction
More than 6 years have past since July 1992, when the National Cancer Center Hospital East (NCCHE) was launched. The number of major operations in our group has constantly increased year by year. Our chief event in 1998 was the addition of a new urologist to our staff last June in order to advance our clinical activity from colorectal to pelvic surgery. The concept of pelvic surgery, which is the integration of surgical activities for colorectal, urogenital and gynecological malignancies, was initially proposed by Dr. Ebihara, the Director of NCCHE, several years ago. Since then, we have discussed what we could do and what perspective to have on this new field of surgical oncology at the conference, The Next Ten Year-strategy of NCCHE. Finally, we came to an understanding that this new approach to pelvic malignancies is worth carrying out as a challenge to the conventional treating systems, because it promises to bring many clinical implications into full play even for a small staff. We think that the cooperative treatment of pelvic disease will enhance not only the development of surgical procedures but also the establishment of a disease-oriented strategy. Of course, the concept of pelvic surgery has to develop with the input of medical staff including nurses over time. Also, the medical support of the Urology Division of NCCH will continue to be necessary for the time being.
Routine Activities
1) Outpatient activities:
The outpatient clinic is open 5 days a week and about 250 new patients consulted the clinic during 1998. The doctors in charge employ various diagnostic modalities to screen for early recurrence with surveillance of almost all patients who underwent curative colorectal surgery. Every Friday the function care clinic is open to evaluate objectively postoperative patients with lower rectal cancer by urodynamic scanner or rigiscan. In addition, the urological outpatient clinic is also open on Tuesday and Thursday, mainly to consult with inpatients of NCCHE.
2) Treatment system
Our pelvic surgery group consists of five consultants (4 general surgeons and 1 urologist) and two to three residents, and carries out five to seven operations a week under general anesthesia. We have three conferences a week concerning GI malignancies as follows: l) image diagnosis conference with radiologists and endoscopists on Monday, 2) case conference on Friday and 3) the integral clinical conference on gastroenterology patients on Wednesday, where we make therapeutic decisions on all new cases with GI malignancies through discussion with medical oncologists, endoscopists and surgeons. The surgical pathology conference is held monthly with attending surgeons and pathologists. Concerning intrapelvic malignancy, we now consult with our new urologist each time.
3) Treatment modalities
In early cancer cases, many modalities have been introduced such as endoscopic mucosal resection (EMR) or transanal endoscopic microsurgery (TEM). In addition, the laparoscopy-assisted operation (Lap-Op) was introduced in 1994, and since then, it has been used as a minimally invasive surgical technique. Until December 1997, patients who had early cancers with submucosal invasion histologically confirmed after EMR, or those who had unresectable and/or metastatic lesions had been indicated for Lap-Op in our group. Since January 1998, however, we have utilized the technique of wider lymph node dissection up to D2. As a result, the indications for Lap-op have been extended (see research activities).
Research Activities
1) IORT for rectal cancer patients: To clarify the efficacy of limited surgery for advanced lower rectal cancer, a one arm prospective study on nerve sparing operation + IORT (intraoperative radiotherapy) is now ongoing.
2) Adjuvant chemotherapy (a N-SAS-CC trial): To clarify the efficacy of adjuvant chemotherapy using oral 5-FU derivatives (UFT: Tegafur+uracil), a randomized controlled trial is now ongoing for those with Dukes' C colorectal cancer.
3) The extension of indications for Lap-Op: A prospective trial for extending indications of Lap-Op is ongoing. The subjects are patients who fulfill the following diagnostic criteria: 1) tumor size within 5 cm in diameter, 2) no mass lesion more than 7 mm in diameter around the main tumor in CT image diagnosis, and 3) combining no histological component of poorly differentiated adenocarcinoma. The above criteria were based on the results of a retrospective analysis on preoperative diagnosis in patients operated on at NCCHE, and the noncurative risk in those who fulfill the criteria can be estimated as less than 1%. About 40% of operable colon cancer patients could be operated on by this method in 1998.
4) Concerning the pelvic oncology: Dysfunction of the pelvic region after surgery is an inevitable and important postoperative problem in patients with intrapelvic malignancies, particularly for those who have damage caused by intrapelvic autonomic nerve injury during the operation. Objective evaluation for degree of dysfunction, however, is difficult to make and stable data has not been available, though many methods have been reported. To evaluate the efficacy of objective measurement for urinary or sexual functions, we started to accumulate objective and subjective data prospectively.
5) The reconstruction of anus after Milesﾕ Op: The perineal artificial anus with functional reconstruction using skeletal muscle is planned as a cooperative project with the Division of Plastic Surgery, NCCHE.
Statistics
| Year | Total cases | Colorectal cases | Stomach cases |
||
| Colon | Rectum | Total | |||
| 1993 | 196 | 63 | 38 | 101 | 77 |
| 1994 | 238 | 66 | 41 | 107 | 105 |
| 1995 | 270 | 75 | 61 | 136 | 88 |
| 1996 | 295 | 84 | 68 | 152 | 122 |
| 1997 | 318 | 120 | 75 | 195 | 115 |
| 1998 | 346 | 109 | 77 | 186 | 109 |
| Total | 1663 | 517 | 360 | 877 | 616 |
| Stage | 1-yr | 2-yr | 3-yr | 4-yr | 5-yr |
| I | 99 | 99 | 97 | 97 | 97 |
| II | 98 | 96 | 92 | 92 | 88 |
| IIIa | 95 | 91 | 91 | 91 | 83 |
| IIIb | 84 | 73 | 73 | 47 | 47 |
| IV | 64 | 38 | 38 | 38 | 28 |
(M. Ono)
