Extended Abdominoperineal Resection (original) (raw)
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Colorectal Disease, 2014
The conventional, synchronous combined, abdomino-perineal excision (APE) for low rectal cancer is associated with intra-operative tumour perforation and tumour involved circumferential resection margins (CRM+). Several studies have demonstrated worse rates of local recurrence and survival after APE than after low anterior resection (LAR). Extra-levator APE (ELAPE) in the prone position may reduce the risk of perforation and involved resection margins and may therefore improve outcome. The aim of this study was to report the outcome after the introduction of ELAPE in a prospective study of consecutive patients from a single colorectal unit.
Abdominoperineal Resections for Rectal Cancer: Reducing the Risk of Local Recurrence
Seminars in Colon and Rectal Surgery, 2010
Treatment of patients with distal and locally advanced rectal cancer is challenging. In many series, abdominoperineal resection for distal rectal cancer is related to a high percentage of local recurrences. Some authors relate this high percentage of local recurrence to the abdominoperineal resection itself, considering it to be a poor operation for distal rectal cancer, while other authors relate it to technically inadequate resections: a high incidence of positive circumferential resection margins is seen because of coning of the specimen when the mesorectal fascia is followed or because of inadvertent perforation of the rectal wall. In many other series an acceptable low percentage of local recurrence after abdominoperineal resection is reported. These authors have consistently advocated a wide perineal resection, resecting the levator ani muscle en bloc with the specimen. These enhanced perineal resections are not standardized in the surgical world. We reviewed the literature and describe technical considerations for performing the perineal phase in abdominoperineal resection to reduce circumferential resection margin positivity and local recurrence rates. Semin Colon Rectal Surg 21:81-86
International Journal of Colorectal Disease, 2018
Background Extralevator abdominoperineal excision (ELAPE) probably improves the oncological quality of low rectal cancer surgery, as compared to standard abdominoperineal excision (SAPE), possibly due to lower rates of accidental perioperative bowel perforations and lower rates of circumferential resection margin (CRM) positivity. The procedure may however, increase post-operative morbidity. The aim of this paper was to compare outcomes of SAPE and ELAPE for carcinoma of the lower rectum. Methods This is a retrospective study of patients operated on at a single colorectal unit, in a provincial hospital in Denmark. Consecutive patients undergoing abdominoperineal excision (APE) between 2006 and 2012 were included. During this period, a gradual paradigm shift occurred towards adopting ELAPE, although both procedures were performed without a clear selection strategy. We reviewed medical records, including the pathological and radiological data. Patients were divided into two groups, SAPE and ELAPE. Main endpoints were rates of positive CRM, intraoperative bowel perforations, local recurrence rate, length of hospital stay, operative time, and perineal woundrelated complications. Results One hundred and seven patients were included (median age 68 years, range 42-88 years; men = 72). The SAPE group included 39 patients and the ELAPE group 68 patients. Intraoperative bowel perforation was significantly lower in the ELAPE group (20.5 % SAPE vs 7.4 % EL-APE, p = 0.045). The rate of positive CRM was not significantly different (2.6 % SAPE vs 7.4 % ELAPE, p = 0.413). The local recurrence rate was not statistically significant (17.9 % SAPE vs 13.2 % ELAPE, p = 0.513). In the ELAPE group, operative time and hospital stay were significantly longer than the SAPE group (p = 0.001 and p = 0.021, respectively). Conclusions We found low rates of positive CRM after APE compared with the literature. ELAPE did not reduce these rates, and although the local recurrence rate was lower, this did not reach statistical significance. ELAPE has significantly reduced the rate of intraoperative bowel perforation and can optimize low rectal cancer surgery in selected patients. We found no significant differences between the two procedures regarding wound-related complications. A tailored approach and a larger trial with longer follow-up are needed to evaluate long-term results.
Journal of Turkish Association of Colorectal Surgeons, 2011
Background After introduction of total mesorectal excision (TME) as the gold standard for rectal cancer surgery, oncologic results appeared to be inferior for abdominoperineal excision (APE) as compared to anterior resection. This has been attributed to the technique of standard APE creating a waist at the level of the tumor-bearing segment. This systematic review investigates outcome of both standard and extended techniques of APE regarding inadvertent bowel perforation, circumferential margin (CRM) involvement, and local recurrence. Methods A literature search was performed to identify all articles reporting on APE after the introduction of TME using Medline, Ovid, and Embase. Extended APE was defined as operations that resected the levator ani muscle close to its origin. All other techniques were taken to be standard. Studies so identified were evaluated using a validated instrument for assessing nonrandomized studies. Rates for perforation, CRM involvement, and local recurrence were compared using chi-square statistics. Results In the extended group, 1,097 patients, and in the standard group, 4,147 patients could be pooled for statistical analysis. The rate of inadvertent bowel perforation and the rate of CRM involvement for extended vs. standard APE was 4.1% vs. 10.4% (relative risk reduction 60.6%, p=0.004) and 9.6% vs. 15.4% (relative risk reduction 37.7%, p=0.022), respectively. The local recurrence rate was 6.6% vs. 11.9% (relative risk reduction 44.5%, p<0.001) for the two groups. Conclusion This systematic review suggests that extended techniques of APE result in superior oncologic outcome as compared to standard techniques.
Journal of the Egyptian National Cancer Institute, 2013
Introduction: This study aimed to investigate local control and survival rates following abdominoperineal resection (APR) compared with low anterior resection (LAR) in lower and middle rectal cancer. Methods: In this retrospective study, 153 patients with newly histologically proven rectal adenocarcinoma located at low and middle third that were treated between 2004 and 2010 at a tertiary hospital. The tumors were pathologically staged according to the 7th edition of the American Joint Committee on Cancer (AJCC) staging system. Surgery was applied for 138 (90%) of the patients, of which 96 (70%) underwent LAR and 42 were (30%) treated with APR. Total mesorectal excision was performed for all patients. In addition, 125 patients (82%) received concurrent (neoadjuvant, adjuvant or palliative) pelvic chemoradiation, and 134 patients (88%) received neoadjuvant, adjuvant or concurrent chemotherapy. Patients' follow-up ranged from 4 to 156 (median 37) months. Results: Of 153 patients, 89 were men and 64 were women with a median age of 57 years. One
Diseases of The Colon & Rectum, 2004
PURPOSE: This study was designed to examine the outcome of cancer of the lower rectum, particularly the rates of local recurrence and survival for tumors located in this area that have been treated by anterior or abdominoperineal resections. METHODS: A prospective, observational, national, cohort study which is part of the Norwegian Rectal Cancer Project. The present cohort includes all patients undergoing total mesorectal excision in 47 hospitals during the period November 1993 to December 1999. A total of 2,136 patients with rectal cancer within 12 cm of the anal verge were analyzed; there were 1,315 (62 percent) anterior resections and 821 (38 percent) abdominoperineal resections. The lower edge of the tumor was located 0 to 5 cm from the anal verge in 791 patients, 6 to 8 cm in 558 patients, and 9 to 12 cm in 787 patients. According to the TNM classification, there were 33 percent Stage I, 35 percent Stage II, and 32 percent Stage III. RESULTS: Univariate analyses: The five-year local recurrence rate was 15 percent in the lower level, 13 percent in the intermediate level, and 9 percent in the upper level (P = 0.014). It was 10 percent local recurrence after anterior resection and 15 percent after abdominoperineal resection (P = 0.008). The five-year survival rate was 59 percent in the lower level, 62 percent in the intermediate level, and 69 percent in the upper level (P < 0.001), respectively, and it was 68 percent in the anterior-resection group and 55 percent in the abdominoperineal-resection group (P < 0.001). Multivariate analyses: The level of the tumor influenced the risk of local recurrence (hazard ratio, 1.8; 95 percent confidence interval, 1.1–2.3), but the operative procedure, anterior resection vs. abdominoperineal resection, did not (hazard ratio, 1.2; 95 percent confidence interval, 0.7–1.8). On the contrary, operative procedure influenced survival (hazard ratio, 1.3; 95 percent confidence interval, 1–1.6), but tumor level did not (hazard ratio, 1.1; 95 percent confidence interval, 0.9–1.5). In addition to patient and tumor characteristics (T4 tumors), intraoperative bowel perforation and tumor involvement of the circumferential margin were identified as significant prognostic factors, which were more common in the lower rectum, explaining the inferior prognosis for tumors in this region. CONCLUSIONS: T4 tumors, R1 resections, and/or intraoperative perforation of the tumor or bowel wall are main features of low rectal cancers, causing inferior oncologic outcomes for tumors in this area. If surgery is optimized, preventing intraoperative perforation and involvement of the circumferential resection margin, the prognosis for cancers of the lower rectum seems not to be inherently different from that for tumors at higher levels. In that case, the level of the tumor or the type of resection will not be indicators for selecting patients for radiotherapy.
European Journal of Surgical Oncology (EJSO), 2005
Aims. The surgical management of rectal cancer is not uniform. Both abdominoperineal (APR) and anterior resection (AR) are used in potentially curative surgery but there is no definitive evidence regarding comparative survival outcomes and no randomised controlled trials. We sought to determine if any differences in survival existed between patients who received AR or APR. In addition, we sought to determine how variations in surgical management relate to the degree of specialisation and caseload of the managing consultant. Patients and methods. A retrospective study of population-based data collected by the Northern and Yorkshire Cancer Registry and Information Service was undertaken. All patients (3521) diagnosed with rectal cancer in the former Yorkshire Regional Health Authority (population 3.6 million) between 1986 and 1994 who received either an APR or AR were included. Survival was assessed in relation to the surgical methods adopted. In addition, we determined whether the extent of specialisation of the managing consultant influenced the type of operation adopted. Results. A Log Rank test, stratified for sex and age, showed a statistically significant 6.7% 5-year survival advantage for patients receiving AR (pZ0.0064). AR was more likely to be performed by more specialist colorectal cancer surgeons (p! 0.001). Conclusions. This evidence suggests that the outcomes of the two main surgical procedures used in curative surgery for rectal cancer are different and that, when possible, AR should be the operation of choice. Our results show no indication of excess risk associated with this procedure compared with APR.
Treatment of advanced rectal cancers: Cylindrical abdominoperineal excision of rectum
Journal of Society of Surgeons of Nepal, 2018
Introduction: Treatment for patients with locally advanced low lying rectal cancer differs significantly from patients with rectal cancer restricted to the mesorectum. They require multimodality treatment, including preoperative chemo-radiation and extended surgical resection. Cylindrical abdominoperineal excision of rectum (C-APER) along with possible composite pelvic organ resection is a surgical method to remove an adequate circumferential margin. Method: Patients with the diagnosis of advanced rectal cancers over a period of 9 months are included in this study. Therapeutic approach of C-APER is taken for these patients with focus on multimodality treatment protocols to downstage the tumours and extended resections to enable complete removal of all tumour tissue with clear surgical margins. Consecutive review of cases of advanced rectal cancer to their immediate surgical outcome were done. Results: Five patients with compromised CRM in MRI of rectum, 4 were treated with Neoadjuva...
Extended resection in the treatment of colorectal cancer
International Journal of Colorectal Disease, 1991
Between 1975 and 1990, 525 patients underwent resection of colorectal cancer in our unit. Of these, 38 had turnout invading adjacent structures and underwent an extended resection. Overall, there were 67 cases treated palliatively. Of these, three were in the group of 38 having an extended resection. When the groups of radical not extended (n = 423) and radical extended resections (n = 35) were compared, respective values for mortality (1.9% vs 0) and morbidity (12.8% vs 11.3%) were not different. Respective local recurrence rates (13% vs 26%) were significantly greater after extended resection. Five-year survival after extended resection was 30%, no different from the general survival rate for standard resections for T z_ 3 node-positive turnouts. Extended resection is thus a safe and important approach for locally advanced tumours. R~sum~. Entre 1975 et 1990 525 ont subi une r6section pour cancer colo-rectal dans notre unit& Parmi ceux ci 38 avaient une tumeur envahissant les structures adjacentes et ont dfi subir une r6section &endue. 67 cas furent trait6s palliativement. De ceux-ci trois appartenaient au groupe des 38 qui eurent une r6section 6tendue. Comparant le groupe des r6sections radicales non 6tendues (n=423) et des r+sections radicales +tendues (n = 35), les valeurs respectives pour la mortalit6 (1,9% vs 0) et la morbidit6 (12,8% vs 11,3%) n'6taient pas diff+rents. Le taux respectif de r~currence locale (13~ vs 26%) ~tait significativement plus grand apr+s 6tendue. La survie/t 5 ans apr6s r6section 6tendue +tait de 30% ne cliff+rant pas du taux de survie g6n6ral pour une r~section standard pour des tumeurs Tz-T 3 ganglions positifs. La r+section ~tendue est done une m6thode sure et importante pour traiter les tumeurs localement 6volu6es.