apr technique of a wide perineal resection

Torbjörn Holm MD PhD

Section of Coloproctology

Department of Surgery

Karolinska University Hospital

Stockholm, Sweden

APRTechnique of a wide perineal resection

Advanced Course on Rectal Cancer 8-10 September 2008

The Hague, The Netherlands

Abdominoperineal resectionin rectal cancer

• Indications for APR in rectal cancer– Development of surgical perspectives

• Problems associated with conventional APR– Bowel perforation– Involved circumferential margin– Perineal wound infection - dehiscence

• Optimised technique in APR

Indications for APR in rectal cancer

Sir Ernest Miles (1869-1947)

Lancet 1908

• Rates of APR varies significantly (<10% - 50%)

• Local recurrence rates higher after APR than AR

• Local recurrence rates after APR varies (5-30%)

• Higher local recurrence rates with low APR rates– Selection of distal, advanced tumours for APR?


• Present indications – specialised centres(tumours 0-5 cm above dentate line)

– Distal resection margin < 1 cm ?– Invaded external sphincter or levator ani– Impaired anal function

• < 10% APR overall ( RJ Heald)


• Reality (tumours 0-6 cm above anal verge)

• APR performed in 75% in Sweden 2006

• APR performed in 82% in Norway 1993-99(Wibe et al.)


Conventional APR- synchronous combined

Dissection planes in conventional APR

Problems associated with APR

• Inadvertent bowel perforationsignificantly more commonafter APR

AR APR

Norway 4% 15%

Sweden 3% 14%

Holland 3% 14%

Norwegian Rectal Cancer GroupBr J Surg 2004; 91: 210-16

Problems associated with APR

• Tumour involved circumferential resection margin significantly more common after APR (CRM +ve)

AR APR

• Dutch TME Trial 12% 29%

• MERCURY Trial 12% 33%

Local recurrence Survival

APR

CRM + 30 % 38 %

CRM - 9 % 72 %

Data from the Dutch TME Trial

Nagtegaal et al. J Clin Oncol 23; 9257 – 9264, 2005

Optimised technique in APR-posterior perineal approach

• Aim– Reduced rate of perforation– Reduced rate of CRM+– Reduced rate of perineal wound infection

• Improved oncological results

APR – Posterior perineal approach

• Patient in prone jack-knife position • Surgeon between legs• Assistants on each side• Good exposure• Sacral resection may be performed• m. Gluteus maximus may be used as flap

The CRM is not formedby the sphincter muscles.The levator is resecteden bloc the anal canal

Dissection planes in extended APR

• Abdominal dissection stops above levator muscles

• Leaving levator muscles attached to the mesorectum

Posterior approach- good exposure in large, bulky tumours

The final part of a pelvic exenteration in locally advanced low rectal cancer may be performed by

the posterior approach

Gluteus maximus flapGood postoperative cosmetic result

Data from Leeds and Stockholm

“Conventional” “Cylindrical”APR APRn= 101 n= 27 p

Mean cross sectionaltissue area/slice (mm2) 1411 2550 0.0001around tumour

Involved CRM 40.6% 14.8% p=0.013

Bowel perforation 22.8% 3.7% p=0.025

Histo-pathological stage

y p T0 3 (5 %)y p T1 3 (5 %)y p T2 12 (20 %)y p T3 26 (43 %)y p T4 16 (27%)

Extended APRKarolinska experience 2001-2007

60 patientsMedian follow-up 19 months (3-86)


60 patients

Neoadjuvant treatment

ypT0 ypT1 ypT2 ypT3 ypT4 Totaln=3 n=3 n=12 n=26 n=16 n=60

No treatment 0 1 0 1 1 3 (5 %)

RT only 3 0 9 18 7 37 (62 %)

RT – chemo 0 2 3 7 8 20 (33 %)


60 patients Outcome

ypT0 ypT1 ypT2 ypT3 ypT4 Totaln=3 n=3 n=12 n=26 n=16 n=60

Bowel perforation 0 0 0 3 2 5 (8%)

CRM involvement 0 0 0 3 7 10 (17%)

R1 resection 0 0 0 1 7 8 (13%)

Local recurrence 0 0 0 0 2 2 (3%)(median 19 months)

Death (any cause) 0 0 0 7 9 16 (27%)

Karolinska HospitalCurrent treatment intention

• T1 – T2 tumours above anal canal

Preoperative radiotherapy +

ultra low anterior resection

with inter-sphincteric dissection

• T3 – T4 tumours 0-5 cm above anal canal

or fixed to pelvic floor, coccyx - sacrum

Preoperative radio-chemotherapy +

Abdominoperineal resection

with posterior perineal approach

Karolinska HospitalCurrent treatment intention

Conclusions

“Cylindrical” APR in the prone position

removes more tissue around the

tumour, leading to

• Reduced rates of:

– Bowel perforations

– Tumour positive resection margins

• This probably improves local control and survival

apr technique of a wide perineal resection

Documents