Rectal cancer: “It facilitates the resection of the rectum without automatically having to remove the anus”

Surgery is intended to be less and less invasive, less painful, with the least possible scarring and the fastest recovery for the patient. It is in this sense that in 2005, “NOTES” surgery (Natural Orifice Transluminal Endoscopic Surgery) was introduced worldwide, which allowed surgeons to access the internal cavities of the body through orifices such as: the mouth, anus, vagina, without any external incision. Everything happens inside the body. Thus leaving almost no wounds, limiting the risk of infection and a reduced convalescence time.

Heir to this minimally invasive technique, Dr Patricia Sylla has seen further: resecting deep cancers of the rectum or lower colon using surgery called “transanal“. There is no shame in going through the anus to remove lesions, polyps or cancerous tumors to avoid the large abdominal incision and thus preserve your rectal functions and the surrounding organs, taking into account the high precision of this minimally invasive technique. Let’s get to the interview!

Why Doctor: Why can we call you an expert in minimally invasive colorectal cancer surgery?

Dr Patricia Sylla: I did two specializations in colorectal surgery in New York and then in surgery ““minimally invasive”where I developed my repertoire a little bit with bariatric and esophageal, the upper part. I moved with my family to Boston where I practiced for almost nine years. It was a very special time because I was completely immersed in natural route surgery, I was part of the first attempts at natural minimally invasive access to reflux through the vagina. My interest was in doing it from the rectum. I was really intrigued by that route because we had always had pain issues with traditional colorectal surgery, because even if it’s laparoscopic or robotic, there are still incisions. There’s always an extraction site with a risk of infection and therefore recovery difficulties. And so, I was really intrigued by the idea of ​​being able to access the rectum through the transanal route.

“We did the first case in the world in Spain in 2009”

Were you one of the first to bring this rectal ablation technique to the USA?

Yes, we did the first case in the world in Spain in 2009. I spent almost 9 years training surgeons around the world. And so, Ircad was a huge collaborator in the process because they were very involved. Then, I brought this technique to New York and I continued. We did a multicenter clinical study that was just published last year. We demonstrated the efficacy and safety of the procedure on patients across eleven centers in the United States. It had already been validated in Europe and Asia, but in the United States it was more complex.

When did Ircad come into your life and what were your points of convergence?

At the very beginning, I had an incredible chance when I was still training in my specialty. I received a Travel Fellowship Awardthey were offering a course at Ircad, and so I chose to come at the end of my training. I was already in the laboratory developing the experimental method focused on anal access, and Jacques Marescaux and his team were very interested. They were working a little more on the transgastric oral route and a lot on the transvaginal. They did the first case of course, but the rectal… they weren’t too involved in that, so we started working a little bit together on that. It was the first time I tested the concept of transanal surgery and they were the first people in the world who saw it and encouraged me to develop this procedure.

This is the magic part of this procedure! For the patient, especially for the cancer which is very low.

What is the advantage of the transanal technique in the context of rectal cancer, for example?

The most important benefit, especially for rectal cancer, is the fact that this technique facilitates the resection of the rectum without having to automatically and systematically remove the anus. This is the magic part of this procedure! Especially for cancer that is very low. Traditionally: the lower the cancer, the more difficult the surgery is because you really have to go down deep into the anatomy, especially in men who have a very narrow pelvis and obese people. This makes the surgery much more complex and because of this, we see a lot of conversions.open“, that is, surgeons start with the laparoscopic or robotic route in a safe way. And, because of the difficulty of accessing the tumor, end up giving up. In this case, they finish their intervention with the classic abdominal incision. Or in the worst case, when the cancer is really very low, that is, when you can feel it with your finger and they cannot go down, they tell the patient: “I cannot save the muscle of the anus, I have to remove everything.” This is the “APR (Abdominoperineal Resection in English)”, and that is catastrophic.

Why is abdominoperineal resection (APR) a disaster scenario?

Because the anus which is shaped like a tube is removed, and the rectum as well. The colon, which is higher up, is cut, then taken out through the skin to make a pouch. Instead of having an anus, there is nothing left! They call this colloquially the “barbie butt“, that’s to say “barbie buttocks”. And when we look at the details, usually it’s because the tumors were 4 or 5 centimeters from the anus. So when the cancers are very, very low, it becomes more and more complicated to resect the whole thing without compromising the quality of the surgery. Especially since it’s cancer, we can’t take any risks. We can’t damage the rectum because otherwise the cancer will come back. So most surgeons are traditional: “I don’t take any risks, I remove everything, so we are sure that we cure the patient permanently.”

We can begin the dissection very precisely, we are no longer in the realm of suppositions.

And finally, what does the transanal procedure change?

With the transanal procedure, the biggest advantage is that for the lowest cancers, we start from the bottom, we see the cancer, it’s in front of us, everything is enlarged because we are on 5K or 4K HD screens and we can start the dissection very precisely, we are no longer in the suppositions. The resection will be done at the site of the cancer with perhaps some tissues around. We start the dissection, then we go through the muscle, we go back up and we join the part above. So in fact we combine the dissection from above and from below but it facilitates the dissection, it makes it easier because I do the most complex part while the other surgeon from above stops when it becomes hard, I go in from below and when we are finished, we bring the colon from above to reconnect it to the anus. So everything is done internally and we take the rectum out from below. And the connection is made by the stapler or with sutures in the traditional way. A suture and then the tissues are sewn together. This is the concept of transanal.

What drives you in your specialty? What motivates you on a daily basis in this discipline which is not easy? ?

The most satisfying part is the gratitude of the patients. Of course there are always complications, and we have to re-educate them regarding the changes in defecatory function.. NOTWe monitor them for 5 years for oncological reasons and we end up becoming very close with these patients. I am a surgeon, I love operating but I really like the relationship with my patients especially cancer patients. These are very special relationships that keep me going. I encourage my patients to use groups on social networks to support cancer patients with defecatory dysfunctions which have more than a hundred members around the world who connect with each other, exchange their experiences, their solutions to live better.

And the second thing that motivates me is seeing all this technological development, the endoluminal techniques, the advanced endoscopies, and the innovative instruments that allow us to avoid complex and disfiguring abdominal surgery.