Low rectal tumor surgical options - LAR vs. APR

[rickker20]

I received Topo Radition it only targets the tumor and not the surrounding area. My doctor told me if he had to remove interior or cut into the sphincter I would get a APR because you would have no control. I'm not worry about the getting my reversal surgery in May.

[CaliforniaBagMan]

Wombat,

Clearly the overriding issue here is "what choice gives the maximum chance of cure and minimal chance of recurrence?" In my opinion, that is APR due to the surgical techniques and getting proper margins.

Check the UOAA site-- specifically the Irrigation section. I had an APR for a low rectal tumor, maybe a year after surgery I started doing irrigation. Life today if very very close to identical to my post-cancer life, except I spend a bit more time in the bathroom each morning. With a low rectal tumor, you lose minimal colon length and that makes a big difference on your future success with irrigation.

Good luck to you.

[James65]

All,
I would add too that you should be careful about how much faith you put into recurrence rates. I have not read this study and it may be a very good one, but whenever I have seen rates like this or similar ones there are a few variables that don't seem to be taken into account such as age, aggressiveness of treatment, exact stage (IIa,b,c, etc) and a few other issues.

I would be interested in why recurrence rates are about the same for both procedures and wonder if they are comparing patients with cancers in nearly the exact same locations, stage, age, and so on.

Just a thought.

Best,
James

[dschreffler]

Hi James,

You're right on about these studies - a lot of variables and although some are showing reoccurrence rates differences between types of surgeries narrowing, there are a lot of factors. I found similar study flaws in the quality of life comparisons between LAR and APR. Initially studies showed LAR vastly better outcomes then APR. But once you looked at age, stage, and responsiveness of patient to chemo/rad, you see "apples and oranges" in terms of the patients.

I found this on interesting as was a 5 year study on quality of life ..... http://www.lowrectalcancer.com/PDF%20Files/Cons%207.pdf

"In conclusion our study demonstrated that half of the patients undergoing sphinctersaving
resection for rectal cancer have a poor long-term functional outcome and that
the height of the anastomosis, i.e. the length of the residual rectal stump, is the only
predictive factor of good functional results. It is thus advisable to preserve as much of
the non-devascularized rectal stump is oncologically feasible."

In my case, it would appear that given the location of my tumor, I can expect more issues:
"when the anastomosis is below 3 cm from the anal margin, i.e. when all of the rectum has
been resected, the majority of the patients have poor functional outcome."

[James65]

D --
When I met with the surgeon prior to surgery he said quite clearly that it may be in my best interests to go with the bag even if there was a chance to keep what would clinically be enough of the rectal stump/anal sphincter to avoid a colostomy. The main reason is that I would have continence issues the rest of my life and be tied to a bathroom and more.

There are a lot of people on this board that were able to avoid a bag and have managed to adapt to their new situation quite well, but I think that a millimeter or two can make a very big difference as to how well that goes.

I would also add that if anything I am saying feels like I am pushing you toward one decision or another, please know that I very much believe that this choice--to the degree that it is a choice--is very much up to you. I just want to share my experience and thoughts.

Best,
James

[dschreffler]

Thanks james - I appreciate the input.. this is the very reason I asked - to have the great folk here weigh in as to how they arrived at their decisons. This way I won't dope slap myself after the fact - err, well as little as possible anyway

Anything the ups the percentage against recurrence is definitely the main driver with functional outcome avery close next consideration.

[wombat]

Saw my surgeon today to see what was left of my tumor after chemo/radiation. Turns out not much! In the words of my surgeon, the tumor is "substantially" reduced in size and there's "very little" left. However, part of the tumor is still in the anal canal. He says I'm a candidate for an intersphincteric resection procedure called TATA (transanal abdominal transanal proctosigmoidectomy with coloanal anastomosis). This involves removing the internal sphincter muscle, but leaving the external sphincter muscle in place. I haven't heard of this procedure (I think it's also called intersphincteric resection), but will be reading up on it. My surgeon said there's "not a huge difference" between the recurrence rates between this procedure and APR, but I'm not so sure what "not a huge difference" really means. He says there's no study out there directly comparing the two procedures, so I realize that there's some "apples and oranges" comparisons going on. Not surprising as I don't think many people would want a computer to make the LAR vs. APR decision as part of a double blind randomized clinical trial. I sure wouldn't.

Anyways, my gut is still telling me to go with the APR. It just seems a more conservative approach in terms of local recurrence, and offers a "known" outcome in terms of pooping. I don't want to have to go through 12, 18 or 24 months with little bowel control only to find out that the best things are ever going will not allow me to have the lifestyle I want, and then wind up getting a bag later anyways. I go long cycling rides, backpacking trips, etc. and I don't want to be kept away from those activities from a leaky bottom - even for a year or two.

Lots to read up on in the next few weeks, but that's where my thinking is at the moment.

[weisssoccermom]

Wombat,

I've heard of the TATA procedure. If memory serves me correctly, Dr. Marks of Philly was one of the first ones to perform this procedure and (I did find something on it as I had told Sheilap about Dr. Marks a year or so back) he and his dad perfected it. Here's a link to a small article about it. Dr. Marks (both Sr and Jr) are considered top of the line experts in the field of colorectal surgery. Somewhere on the web is a video of the procedure as well. I would contact Dr. Marks for any information about it. Sheilap may have some contact info for him.

http://www.mainlinehealth.org/wtn/Page. ... =WTN000140

Jaynee

[weisssoccermom]

Wombat,

I knew I had seen the video somewhere. I gave this link to Sheilap when I first told her about Dr. Marks.

http://www.markscolorectal.com/site/MCSA%20Procs.htm
http://www.suzanne.tv/show.aspx?sid=470

[rickker20]

Wombat

I would check about Pull thru surgery. It could save you from a bag for life. I don't know in what part of the USA you live. Please check out my doctors they are located in Houston Texas and they are some the best in the USA. Good luck


http://www.crchouston.com/

[dschreffler]

I would check about Pull thru surgery. It could save you from a bag for life. I don't know in what part of the USA you live. Please check out my doctors they are located in Houston Texas and they are some the best in the USA. Good luck
/

Wondering what your Dr's said about any potential downside of the pull thru surgery was - what is average recover time, what are potential complications, and what is long term frequency of incontinence, pain, etc in contrast to a colostomy?

[Terry]

My tumor was about 2 cm away from the anal verge. My first surgeon said I had to have a permanent colostomy. I then saw a board certified colorectal surgeon and he said he could do a transanal excision. I haven't had any sphincter trouble unless I get diarhea.

Good luck to you. Prayers are with you!
\Terry

[dschreffler]

My tumor was about 2 cm away from the anal verge. My first surgeon said I had to have a permanent colostomy. I then saw a board certified colorectal surgeon and he said he could do a transanal excision. I haven't had any sphincter trouble unless I get diarhea.

Good luck to you. Prayers are with you!
\Terry

Excellent Terry - good to hear!!!
If you don't mind me asking, were you treated with radiation for rectal cancer, what was tumor stage (Tx) and when did you have the transanal surgery performed?

[Staci's team]

Doug, just another data point....you're doing a great job of considering options and thoughtfully listening to others' stories, so I thought I'd put this out there for you.

My wife's rectal tumor was "just inside the internal sphincter," to use the surgeon's terms, and "fixed to the muscles around the anus," so from the beginning he was talking APR and permanent colostomy. Subsequent opinions came to the same conclusion, so that remained the plan. She had the standard 28 sessions of chemoradiation, delay of 8 weeks to let the radiation continue to work, and had APR surgery on 11/20. We did end up having to take her back to the hospital due to a blockage caused by adhesions, so she had another surgery to get rid of the those and has been fully functional since.

In her case, from the time the surgeon first examined her, she did not have any concerns or hang-ups about the colostomy. As she puts it, "It's a bag or my life. I'll take the bag to keep my life." She has had no trouble with her ostomy since she came home in early December, and although I know it's only been a short time in the grand scheme of things, she's able to do everything she did before surgery -- moderate bicycling, swimming, and chasing after one who's just hit the "terrible two's."

She does still have constant muscle pain, from her "Barbie butt" rear end down through the outside of her quads, that both her surgeon and her oncologist attribute to the healing process. I won't lie -- some days she looks like she's 83 instead of 33 the way she walks. Every doc and nurse who have checked her behind since the surgery,though, have commented on what a great job the surgeon did, and a pic was even used in one of their tumor board presentations to demonstrate "this is what it should look like," so the healing process hasn't been compromised by a lackluster surgical job. She doesn't like hearing that it's a 6-12 month healing process, but accepts that yes, it was a major surgery, so it will indeed take time. Combine that with low blood counts because of the chemo and it just takes longer for stuff to heal.

OK, enough of a book for now. If you have any other questions about her experiences, feel free to PM me.


Chris

[weisssoccermom]

Like Terry I also had a transanal excision. To answer your questions, I was dxd as a T3 but there has been some discrepancy about that - late T2 or potential T3??? To this day, the opinions still differ. I also had neoadjuvant chemoradiation. Just 'celebrated' three years since my last treatment. I am ecstatic about my quality of life issues - there are none. No 'accidents', perfectly normal BMs, etc. but.......everyone is different and to be truthfully honest, even with me being on the cusp of a stage I/II (because of the T2/T3 thing), a full thickness transanal excision isn't for everyone or every situation.

After reading all the different posts, I don't know what I would do in your case. Honestly, I do feel, in my opinion, that the two surgeries - LAR v APR - are probably equal in 'risk' but if your tumor truly is that low, then you may want to seriously think about the quality of life aspect. One of my biggest questions would have to be with the LAR ...just how likely is it that there wouldn't be bowel issues??? That was a HUGE factor for me and my tumor wasn't located as close to the sphincter as yours is. Certainly none of this is what any of us expected or wanted but it's the hand we are dealt. I also am not sure just how realistic the surgeon can be about a patient's quality of life afterwards because I truly don't think they know when...even when the tumor is located higher up. Let's face it....you take out the majority of all of the rectum and your life is bound to be different. This truly is a tough decision and only you can decide what factors are important for you.

Good luck.
Jaynee