Abdominosacral Amputation of the Rectum for Low Rectal Cancers: Ten Years of Experience (original) (raw)
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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
Survival and locations of recurrence following abdomino-perineal resection for rectal cancer
Journal of Surgical Oncology, 1986
Records of 134 patients treated by abdomino-perineal resection (1971)(1972)(1973)(1974)(1975)(1976)(1977)(1978)(1979) were reviewed. One hundred and thirteen had curative operations. Mortality was 2.6% and morbidity was 51 %. Ninety-three were evaluable and were followed for 5 to 8 years; they were evaluated for survival and pattern of recurrence. Five-year survival for Dukes' A,B,C, and D lesions was 86,62,31, and 0%, respectively. Thirty-seven had recurrence: Four pelvic, nine pelvic and distant, and 24 only distant lesions. The overall incidence of failures was 47 % , failure rates by stage were 11 % for stage A, 27% for B, 48% for C, and 70% for D. Incidence of local recurrence was significantly higher in stage C compared to stage B. Irrespective of stage, after detection of local or distant recurrence, survival did not differ. Furthermore, radiotherapy for local recurrence and chemotherapy for distant lesions did not improve survival time.
European Journal of Cancer, 2009
The aim of this study is to identify factors associated with the decision to perform an abdominoperineal resection (APR) and to assess if these factors or the surgical procedure itself is associated with circumferential resection margin (CRM) involvement, local recurrence (LR), overall survival (OS) and cancer-specific survival (CSS). The Swedish Rectal Cancer Trial (SRCT), TME trial, CAO/ARO/AIO-94 trial, EORTC 22921 trial and Polish Rectal Cancer Trial (PRCT) were pooled. A propensity score was calculated, which indicated the predicted probability of undergoing an APR given gender, age and distance, and used in the multivariate analyses. An APR procedure was associated with an increased risk of CRM involvement [odd ratio (OR) 2.52, p<0.001], increased LR rate [hazard ratio (HR) 1.53, p=0.001] and decreased CSS rate (HR 1.31, p=0.002), whereas the propensity score was not. The results suggest that the APR procedure itself is a significant predictor for non-radical resections and increased risk of LR and death due to cancer for patients with advanced rectal cancer.
Extended Abdominoperineal Resection
Seminars in Colon and Rectal Surgery, 2005
Several retrospective case series have shown that in patients with colorectal cancer fixed to adjacent organs, en block resection of the primary tumor and the surrounding organs resulted in lower recurrence and better survival compared to separating the tumor from the adjacent organ. These differences in long-term survival between patients undergoing multivisceral versus standard resection were significant despite the higher surgical mortality associated with multivisceral resection. Based on these early reports, radical en block resection of the primary tumor and surrounding organs has become the standard operation for locally advanced colorectal cancer adherent to adjacent structures. Treatment often requires a multidisciplinary surgical and medical team that in addition to the colorectal surgeon should include a medical oncologist, a radiation oncologist, and urologist, and often a plastic surgeon. Advances in the imaging studies that made it possible to identify patients with locally advanced disease preoperatively, to select the patients who are candidates for curative surgery, and to plan the extent of the resection. Many of these patients may be candidates to preoperative adjuvant therapy. Organs adherent to the tumor at the time of the surgery should be removed in continuity with the rectum. Every effort should be made to achieve a negative resection margin, because the type of resection, along with the nodal status, are the main predictors of long term survival in patients with locally advanced rectal cancer.
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.
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.
Annals of medicine and surgery (2012), 2018
The use of abdominoperineal resection (APR) in the management of low rectal cancer has received criticism over high rates of incomplete resection due to tumour involvement at the circumferential resection margin. Extralevator abdominoperineal resection has been advocated as a means of improving complete resection. However, Extralevator abdominoperineal resection can result in increased cost, morbidity and reduced quality of life.This study aims to assess the histological features and long-term outcomes of patients undergoing standard abdominoperineal resection and discusses the potential role of Extralevator abdominoperineal resection in this cohort. A retrospective review of a prospectively maintained database of rectal cancer patients at a single centre. Patients undergoing standard APR were included from 01/06/2007 to 31/05/2012 to allow a minimum 2-year follow-up. Data was collected on age, gender, co-morbidity, pre-operative stage, neo-adjuvant therapy, histology, recurrence an...
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.