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CHAPTER 1 Introduction & Outline of the Thesis University of Groningen Risk estimation in colorectal cancer surgery van der Sluis, Frederik Jan DOI: 10.33612/diss.131466807 IMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite from it. Please check the document version below. Document Version Publisher's PDF, also known as Version of record Publication date: 2020 Link to publication in University of Groningen/UMCG research database Citation for published version (APA): van der Sluis, F. J. (2020). Risk estimation in colorectal cancer surgery. Rijksuniversiteit Groningen. https://doi.org/10.33612/diss.131466807 Copyright Other than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons). The publication may also be distributed here under the terms of Article 25fa of the Dutch Copyright Act, indicated by the “Taverne” license. More information can be found on the University of Groningen website: https://www.rug.nl/library/open-access/self-archiving-pure/taverne- amendment. Take-down policy If you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediately and investigate your claim. Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons the number of authors shown on this cover page is limited to 10 maximum. Download date: 29-09-2021 FabianvanderSluis_BNW.indd 6 04/06/2020 14:49:14 CHAPTER 1 Introduction & outline of the thesis FabianvanderSluis_BNW.indd 7 04/06/2020 14:49:14 SURGICAL TREATMENT OF COLORECTAL CANCER; A HISTORICAL PERSPECTIVE The Antiquity Colorectal diseases and its surgical treatment have been described since ancient times. The first written records of colorectal surgery date back to pharaonic Egypt1. Probably the most relevant papyrus text with regard to colorectal diseases, is the Chester Beatty Papyrus VI. This text was written around 1,200 BC during the New Kingdom and contains a description of 41 treatments for different anal diseases (pruritus ani, perianal abscess, hemorrhoids and prolapse). In these times, all diseases were thought to arise in the bowel. In a geographic area where intestinal parasitosis was and is very common2, this philosophy appears to be quite intuitive. Until now, most of the diseases in Egypt still arise in the abdomen (bacterial diarrhea, hepatitis A, typhoid fever and schistosomiasis)3. During antiquity, the focus of causative thinking with regard to the development of diseases remained to be the abdomen. One of the famous quote’s attributed to Hippocrates; “All disease begins in the gut” nicely illustrates this continuation of ancient Egyptian philosophy. Up to this point, few of the surgical procedures that were performed, were actually documented in detail. This changed during the Roman era. From this period onwards, we have some excellent textbooks and journals on anatomy and surgical procedures. Around 47 AD, “de Medicina” was published by Aulus Cornelius Celsus. De Medicina is a medical treatise that consists of eight books of which the seventh book deals with ”the art that cures by the hand”. Detailed descriptions are given on the surgical treatment of traumatic bowel injury, perianal fistula, hemorrhoids and fissura. Middle Ages and Renaissance During the Middle Ages, the focus of colorectal surgery remained primarily on hemorrhoids, abscesses and fistula (a common disease among knights). Although, in 1376 John of Arderne wrote a very clear treatise on his perspective on rectal cancer. John of Arderne (1307-1392) was a famous English barber surgeon with a special interest in proctology. This treatise contains a clear 8 FabianvanderSluis_BNW.indd 8 04/06/2020 14:49:14 description of the clinical presentation, findings of physical examination and prognosis of rectal cancer. “I will first say that the ulceration of it is nothing other than a concealed cancer, that may not in the beginning be recognized by inspection, for it is completely hidden within the anus, and is therefore called bubo for just as bubo (owl) is a beast dwelling in hiding places” 1 “It is recognized as follows: the doctor should put his finger into the anus of his patient and if he finds within the anus something as hard as stone, sometimes it’s just on the side, sometimes on both, so that it hinders the patient from passing excrement, then this is certainly a bubo.” “so that it may never be cured with human treatment, unless it pleases god to help” Futhermore, Arderne describes in his treatise the principles of treatment for tumor obstruction (recipes for enema’s) and palliative care that are currently still being applied in medical practice. The Renaissance did not offer many developments with regard to the techniques used in colorectal surgery. However, in this period important advances were made in anatomical knowledge. In “De Humani Corporis Fabrica”, the results of Vesalius studies on human anatomy were published. In great detail, the anatomy of the abdomen is being described. The 18th and 19th centuries The increased insight in the anatomy of the abdomen proved to be extremely useful in the 18th century. During this era, many wars were fought (French revolution, Napoleonic Wars, American Revolutionary War). Because of this, battle-field surgeons were able to obtain a lot of experience with the surgical treatment of sharp abdominal injury. Techniques to suture bowel, to create a 9 FabianvanderSluis_BNW.indd 9 04/06/2020 14:49:14 fistula or to construct a stoma were developed4. In light of these new techniques many attempts were undertaken at surgical bowel resection with the creation of an anastomosis (most with poor result from a patient point of view). From the beginning of the 19th century, colorectal surgery started to evolve rapidly. At first, the only surgical procedure that was performed for rectal cancer was the creation of a defunctioning stoma. This procedure was promoted largely by Jean Zulema Amussat5. Soon attempts at local, perineal, tumor resection were performed. The first “successful” perineal resection was performed by Jaques Lisfranc in 1826. During this period, several techniques were developed for local tumor resection through a perineal (local) approach6. These procedures invariably coincided with high perioperative mortality and morbidity. One of the surgeons experimenting with perineal resection was William Ernest Miles. In a series of patients Miles operated on, he observed a 95 percent recurrence rate within 2 years after surgery. Based on postmortem studies in this group he found that local recurrence occurred in the mesocolon and adjacent lymph nodes. He concluded that in order to gain local tumor control, a wide cylindrical resection of the tumor with associated lymph nodes was required. At the same time new techniques were being developed regarding anesthesiology and antisepsis. Because of these developments it became possible to perform a laparotomy and resect proximal tumors under relatively safe circumstances. In 1879 Carl Gussenbauer introduced a procedure for proximal rectal tumors which the distal rectum was left closed in the abdomen and a colostomy was constructed after resection of the tumor7. Later on this procedure was propagated by the French surgeon Henri Hartmann and became known as the so called Hartmann procedure. The 20th century and onwards Miles combined the transabdominal resection method with his insights in tumor spread and recurrence and developed a technique in which the tumor is resected through a combined transabdominal and perineal approach. The abdominoperineal resection (APR) was created. Because of the combined approach it was possible to resect more proximally situated tumors and gain a larger resection margin. Furthermore, the technique allows for a proximal lymph 10 FabianvanderSluis_BNW.indd 10 04/06/2020 14:49:14 node dissection. With the introduction of this method, a drastic decrease in local recurrence was achieved (from approximately 100% to 29.5%)8. Although an enormous improvement in recurrence rate was obtained, the procedure related mortality remained high (around 30%)7. After its introduction by Miles in 1908, the APR remained to be the gold standard for both low and upper rectal cancers during the first part of the 20th century. In 1 this period new insights were gained with regard to tumor spread. Studies done by Cuthbert Dukes (known for the Dukes classification for colorectal cancer) and John Goligher demonstrated that lymphatic tumor spread rarely occurred distal to the primary tumor9. This indicated that “below” the primary tumor a smaller resection margin could safely be accepted. The previously accepted distal resection shifted from a 5 cm margin to a minimum of 2 cm margin. In the past, several techniques had been described to excise the primary tumor and create a primary anastomosis (1888 Hochenegg; Durchzug procedure, 1910 Donald Balfour; anterior resection). None of these became generally accepted because of high mortality rates. However, improved surgical techniques in combination with the acceptance of a smaller distal resection margin led to improved results of sphincter preservation through anterior resection. In 1948, Claude Dixon published his results on sphincter preserving treatment of upper rectal cancer10. In this study of 400 patients he observed a perioperative mortality rate of 2.6% and a 5 year survival rate of 64%. Because of these favorable results, sphincter preservation for cancers of the upper rectum became a generally accepted treatment option. During the early 20th century an important technical development took place that simplified the creation of a “low“ anastomosis and increased its safety. After its development by the Russians, the surgical stapling device evolved from a 4kg impractical instrument to a widely available and reliable surgical instrument. In 1973 the first circular stapler was created by the United States Surgical Corporation.
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