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Proctectomy and Anastomosis for Low Rectal Cancer

Johns Hopkins Surgery
July 23, 2015

A specialized camera shows an anastomosis after injecting fluorescent dye. It helps confirm that the connection has adequate blood supply.

When a business executive was diagnosed with a cancerous tumor just 3 centimeters away from his anus, he was told that his only option was a colostomy. He sought a second opinion, however, from surgeon Bashar Safar at The Johns Hopkins Hospital, where he would ultimately undergo treatment—thousands of miles from his home in China.

“The majority of my low rectal cancer surgeries don’t result in colostomy,” says Safar. The key, he says, is in the way that the cancer is removed. Frequently, Safar uses a surgical robot for a proctectomy and stoma-sparing anal anastomosis.

“It’s a confined space, and access is difficult. When you go really low in the pelvis,” he says, “it’s hard to see and get a clean surgery plane, but the robot can facilitate this approach to rectal dissection.”

Ports in the abdomen provide access for the robot’s instruments to the rectum. A camera on one of the instruments allows a clear view of the pelvic structures and planes so Safar can decide precisely where to cut. The goal, he says, is a complete excision of the rectum and surrounding tissue; the specimen is removed in one piece without cutting into it or nearby tissue or bone. “If the operation is compromised,” he says, “the disease can come back again.”

Surgery for the recurrent cases can be particularly challenging due to scar tissue that obscures the normal anatomical landmarks. For these and more advanced cancers, Safar mobilizes a team from multiple disciplines, including urology, gynecology, plastic surgery and radiation oncology. The urologist can reconstruct the urinary system or remove the bladder or prostate if needed. A gynecologist can perform a hysterectomy if needed and a plastic surgeon can reconstruct the pelvis.

When the margins are close to tissue or the pelvic bones, Safar works with radiation oncologists to deliver intraoperative radiation to the area for about an hour, which can help reduce the risk of disease recurrence.
Thanks to Safar’s extensive experience with cancer that occurs low in the rectum, he was able to remove the executive’s cancer without a colostomy. “We do a lot of these procedures,” says Safar, “and we get good results.”

To refer a patient: 443-997-1508  


Colorectal surgeons use their best judgment when performing an anastomosis. If the tissue is dark in color, they stay away. If it is pinker, they proceed. Looking for a better way to identify healthy tissue, Bashar Safar is taking part in a clinical trial using fluorescence imaging to reveal blood flow.

During a low anterior resection, Safar will inject a fluorescent dye and then use a special camera to see where the tissue lights up. Within seconds, the area with healthy blood flow brightens. After surgery, he will follow the patients to see if they experience any anastomotic leaks.  

“If this can tell us that an anastomosis is going to be fine, we could avoid the temporary stoma that some patients have,” says Safar. “It could potentially augment clinical decision-making.”

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