dr richard downey. hs, 61 yr old male no significant medical history 18 month hx of perianal...
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Cylindrical Abdominoperineal Resection
Dr Richard Downey
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HS, 61 yr old male No significant medical history 18 month hx of perianal pain, pruritus ani
and occasional PR bleeding EUA Deep posterior anal fissure surrounded by
area of induration and thickening◦ Biopsies-chronically inflamed and fibrotic
squamocolumnar anal mucosa◦ Consistent with fissure in ano
Background
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Symptoms unresponsive to topical Rx o/e Large posterior fissure and associated
skin tag, BRBPR Crohn’s Disease suspected Scheduled for EUA Rectum in urgently and
SBFT
Background
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Biopsies at colonoscopy in EUA-Low Rectal Tumour extending into anus◦ Histology-Anal gland vs Rectal cancer◦ Moderately differentiated Adenocarcinoma
MRI pelvis◦ Increased soft tissue thickening posterior to
superficial perianal area◦ Number of mesorectal lymph nodes seen◦ Does not extend above internal sphincter◦ T4N1M0 Rectal Adenocarcinoma
Work Up
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MRI image
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Number of palpable hard satellite lesions up to 3cm from anal verge along perianal skin
Neoadjuvant treatment◦ Chemotherapy-5FU◦ Radiotherapy encompassing perianal skin,
inguinal nodes and external iliac nodes EUA Tumour at 3cm, bulky, friable perianal skin Scheduled for APR and VRAM flap
reconstruction
Oncology
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APR◦ Lower midline laparotomy◦ Left colon and rectum mobilised◦ Total mesorectum excision◦ Sigmoid colon dived and proximal end brought
out as colostomy ◦ Wide perineal resection performed◦ Rectum delived through anus and resected in full◦ Haemostasis achieved
Surgery
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photo
Perineal defect
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Reconstruction perineal defect with right VRAM Flap◦ VRAM raised through lateral incision◦ Ant rectus sheath opened and muscle dissected
from post rectus sheath◦ Inferior deep epigastric artery pedicle preserved◦ Deepithelialisation of skin over muscle◦ Muscle mobilised to cover defect◦ Abdominal closure with prolene mesh, sutures◦ Perineum closure with sutures
Surgery
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Unremarkable Wounds clean and healthy Satisfactory stoma care Discharged day 16 post op Histology
◦ For discussion Oncology
◦ For adjuvant chemotherapy in Letterkenny
Post op
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Pre neoadjuvant biopsy
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Resected specimen
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Immunohistochemistry
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Colorectal cancer surgery
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Right Hemicolectomy
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Left Hemicolectomy
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Anterior Resection
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Indicated for rectal cancer in the lower third of rectum
APRs involves removal of the anus, the rectum, part of the sigmoid colon and ther associated lymph nodes
Incisions are made in the abdomen and perineum
Remaining sigmoid colon brought out as a colostomy
Abdominoperineal Resection
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Abdominoperineal Resection (APR)
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Abdominoperineal Resection (APR)
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First described by Ernest Miles in 1908 By the 1920s, recurrence rates were down to 30%-gold
standard at that time Several modifications were proposed to promote
locoregional control and survival, with little success Better suture material and devices enabling low
anastomoses heralded a shift toward sphincter-saving approaches with respect to cancer of the rectum
Anterior resection replaced APR as the mainstay of therapy in the 1950s
There was concern that sphincter-saving surgery might increase local recurrence
It was in this setting that total mesorectal excision (TME) was first described in 1982 by Heald and colleagues
Abdominoperineal Resection
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The TME concept is based on the locoregional recurrence preference of rectal carcinoma
Therefore adequate en bloc clearance of the rectal mesentry, including its blood supply and lymphatic drainage, would minimize possible disease relapse
TME is now considered the Gold Standard adjunctive therapy for colorectal cancer
Total Mesorectal Excision
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Improved surgical techniques (eg total mesorectal excision and autonomic nerve preservation) have shown a corresponding decrease in local recurrence rates and increase in overall survival of patients with rectal cancer
However local recurrence and survival after an APR have not improved to the same degree as that seen after an anterior resection
This difference has been attributed to relative smaller tissue volumes around the tumour and higher rates of cancer at circumferential resection margins (CRM) after an APR compared with an anterior resection
APR
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As tumour-free lateral margins have been demonstrated to be an important prognostic factor for local recurrence and survival, an extensive resection is frequently required
In an attempt to improve healing, several techniques for perineal closure have been described◦ Epiploplasty◦ Gracilis Flap◦ Vertical Myocutaneus Flap◦ Gluteus Maximus Flap
Cylindrical APR
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They facilitate closure of the perineal defect with healthy and well-vascularized tissue without placing the tissue under undue tension
The vertical rectus abdominis myocutaneous (VRAM) flap is also useful in creating a neo-vagina after posterior colpectomy
There is a lack of information in the literature concerning the efficacy of VRAM flap reconstruction after APR
Cylindrical APR
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Lefevre et at evaluated the results of a VRAM flap after APR for anal cancer
95 patients underwent APR, including 43 patients who subsequently received a VRAM flap
Survival in the 2 groups was equivalent despite the presence of more advanced cancers in the VRAM flap cohort
They concluded VRAM is an effective technique for reducing both the perineal complication rate and wound-healing delay in patients undergoing APR for AC that does not increase abdominal wall morbidity
Annals of Surgery, Oct 09
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Long term treatment of fissures in ano-Could their be an underlying malignacy??
Advancements in treating rectal cancers Cylindrical APR and VRAM flaps
STUDENTS◦ Different colorectal cancer operations
Thank You
Discussion Points