Anthony P D’andrea, MD, MPH, Jordan M Cuevas, BS, Deepika Bhasin, MPH, Antoinette Bonaccorso, MD, Daniel A Popowich, MD, Patricia Sylla, MD. Division of Colorectal Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai
Background: Lateral pelvic lymph node dissection (LPLND) is routinely performed in Japan during total mesorectal excision for rectal cancer, but this practice has not been adopted in the United States except in selected patients with suspected lateral pelvic metastases. We present a laparoscopic-assisted transanal total mesorectal excision (taTME) with LPLND for the treatment of a locally invasive rectal cancer clinically downstaged with chemoradiation.
Methods: A 41-year-old male presented with a 1-year history of constipation and 50-pound weight loss. At colonoscopy, a bulky rectal mass was identified 12 cm from the anal verge. Pathology confirmed a moderately differentiated adenocarcinoma. CT and pelvic MRI demonstrated a cT4N1M0 with a positive circumferential resection margin (CRM), bulky mesorectal nodes, and a 3cm left external iliac lymph node. He underwent full-course neoadjuvant chemoradiation. Though the tumor downstaged to cT3N1M0 on repeat imaging, the CRM remained threatened with a persistently suspicious left external iliac lymph node. He underwent consolidation chemotherapy for 3 months followed by laparoscopic-assisted taTME with LPLND.
Results: Bilateral ureteral stents were placed and laparoscopic-assisted taTME commenced using a 2-team approach. The abdominal team performed high-ligation of the inferior mesenteric vessels followed by rectosigmoid mobilization and splenic flexure takedown. Meanwhile, the transanal team performed endoscopic pursestring closure of the rectum 6 cm from the anal verge followed by full-thickness dissection of the rectum and mesorectum according to principles of TME. Posteriorly, the plane between the mesorectal and endopelvic fasciae was dissected sharply. Anteriorly, the plane between the rectum and posterior prostate was identified and dissected. Upon dividing the peritoneal reflection anteriorly and entering the abdominal cavity from below, transanal and abdominal dissections combined to complete the TME. The TME specimen was extracted through a lower midline incision. The distal rectal stump was closed endoscopically with a pursestring suture. LPLND was performed laparoscopically with sharp dissection of all lymphatic tissue between the left psoas, the left external iliac vessels, and in the obturator and femoral canals. A stapled end-end colorectal anastomosis was performed followed by creation of a diverting loop ileostomy. The patient was discharged 6 days postoperatively without complications. Final pathology was ypT3N1a with negative margins and 1/16 lymph nodes positive. The TME specimen was complete. The patient completed 6 cycles of adjuvant therapy and is scheduled for ileostomy closure.
Conclusion: Laparoscopic-assisted taTME with LPLND for locally invasive rectal cancer with pelvic lymphadenopathy is safe and feasible, especially when performed as a 2-team approach.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 94578
Program Number: V118
Presentation Session: Colorectal III
Presentation Type: Video