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Diseases of the Colon and Rectum Jun 2020Previous studies have reported that 30% to 40% of patients with squamous cell carcinoma of the anus will require salvage abdominoperineal resection after... (Observational Study)
Observational Study
BACKGROUND
Previous studies have reported that 30% to 40% of patients with squamous cell carcinoma of the anus will require salvage abdominoperineal resection after chemoradiotherapy.
OBJECTIVE
The purpose of this study was to identify the use, risk factors, and impact on survival of salvage abdominal perineal resection for squamous cell carcinoma of the anus.
DESIGN
This was a retrospective, population-based cohort study.
SETTINGS
Patients treated in Ontario, Canada through a single-payer universal healthcare system, were included.
PATIENTS
Patients included all incident cases of squamous cell anal cancer who underwent curative intent radiotherapy from 2007 to 2015.
MAIN OUTCOME MEASURES
Risk of salvage abdominoperineal resection, factors associated with salvage abdominoperineal resection, and survival were measured.
RESULTS
A total of 1125 patients were treated with curative intent radiotherapy for squamous cell cancer of the anus. Within this cohort, salvage surgery was performed in 8% (93/1125), whereas 14% (156/1125) required a permanent colostomy. In log-binomial regression, younger age was associated with salvage surgery, whereas sex, cancer stage, socioeconomic status, and HIV were not. There was a suggested lower risk of salvage surgery in those who completed chemoradiation (relative risk = 0.67 (95% CI, 0.43-1.03)). Crude 5-year overall survival rate was 73% (95% CI, 70%-76%) in those not requiring salvage surgery and 48% (95% CI, 37%-58%) in those who did. In Cox models, mortality was higher in patients requiring salvage surgery compared with those who did not (adjusted HR = 2.20 (95% CI, 1.65-2.94), whereas improved survival was seen in those who completed chemoradiation (HR = 0.65 (95% CI, 0.42-0.82)) LIMITATIONS:: The study was limited by its potential residual confounding by indication for salvage surgery.
CONCLUSIONS
In this large, contemporary cohort of patients with squamous cell carcinoma of the anus, the proportion of patients undergoing salvage surgery was considerably lower than previous reports. Younger age was associated with salvage surgery, and there was a suggestion of lower risk of salvage surgery with completion of chemoradiation. Patients requiring salvage surgery had poor 5-year overall survival. See Video Abstract at http://links.lww.com/DCR/B205. RAP DE RESCATE PARA EL CARCINOMA ANAL DE CéLULAS ESCAMOSAS: USO, FACTORES DE RIESGO Y RESULTADOS EN UNA POBLACIóN CANADIENSE: Estudios anteriores han reportado que 30-40% de los pacientes con carcinoma de células escamosas del ano requerirán una resección abdominoperineal de rescate después de la quimiorradioterapia.Identificar la utilización, los factores de riesgo y el impacto en la supervivencia de la resección abdominoperineal de rescate para el carcinoma de células escamosas del ano.Estudio de cohorte retrospectivo, basado en la población.Todos los casos incidentes de cáncer anal de células escamosas que se sometieron a radioterapia con fines curativos de 2007 a 2015.Pacientes tratados en Ontario, Canadá, un sistema de salud universal de un solo pagador.Riesgo de resección abdominoperineal de rescate, factores asociados con la resección abdominoperineal de rescate y la supervivencia.1125 pacientes fueron tratados con radioterapia de intención curativa para el cáncer de células escamosas del ano. Dentro de esta cohorte, la cirugía de rescate se realizó en el 8% (93/1125), mientras que el 14% (156/1125) requirió una colostomía permanente. En la regresión log-binomial, la edad más joven se asoció con la cirugía de rescate, mientras que el sexo, la etapa del cáncer, el estado socioeconómico y el VIH no. Se sugirió un menor riesgo de cirugía de rescate en aquellos que completaron la quimiorradiación (RR 0,67; IC del 95%: 0,43 a 1,03). La tasa de supervivencia global bruta a 5 años fue del 73% (IC del 95%: 70-76%) en aquellos que no requirieron cirugía de rescate y del 48% (IC del 95%: 37-58%) en los que sí lo requirieron. En los modelos de Cox, la mortalidad fue mayor en los pacientes que requirieron cirugía de rescate en comparación con aquellos que no lo requirieron (HR ajustado 2.20, IC 95%: 1.65 - 2.94), mientras que se observó una mejor supervivencia en aquellos que completaron la quimiorradiación (HR 0.65, IC 95% 0.42 - 0,82).Posible confusión residual por indicación de cirugía de rescate.En esta gran cohorte contemporánea de pacientes con carcinoma de células escamosas del ano, la proporción de pacientes sometidos a cirugía de rescate fue considerablemente menor que los informes anteriores. La edad más temprana se asoció con la cirugía de rescate, y se sugirió un menor riesgo de cirugía de rescate con la finalización de la quimiorradiación. Los pacientes que requirieron cirugía de rescate tuvieron una deficiente supervivencia general de 5 años. Consulte Video Resumen en http://links.lww.com/DCR/B205. (Traducción-Dr Gonzalo Hagerman).
Topics: Aged; Anus Neoplasms; Carcinoma, Squamous Cell; Case-Control Studies; Chemoradiotherapy; Colostomy; Female; Humans; Male; Middle Aged; Neoplasm Staging; Ontario; Proctectomy; Retrospective Studies; Risk Factors; Salvage Therapy; Survival Analysis; Treatment Outcome
PubMed: 32384405
DOI: 10.1097/DCR.0000000000001630 -
The Journal of Surgical Research Nov 2018Abdominoperineal resection (APR) is primarily used for rectal cancer and is associated with a high rate of complications. Though the majority of APRs are performed as...
BACKGROUND
Abdominoperineal resection (APR) is primarily used for rectal cancer and is associated with a high rate of complications. Though the majority of APRs are performed as open procedures, laparoscopic APRs have become more popular. The differences in short-term complications between open and laparoscopic APR are poorly characterized.
METHODS
We conducted a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program database to determine the frequency and timing of onset of 30-d postoperative complications after APR and identify differences between open and laparoscopic APR.
RESULTS
A total of 7681 patients undergoing laparoscopic or open APR between 2011 and 2015 were identified. The total complication rate for APR was high (45.4%). APRs were commonly complicated by blood transfusion (20.1%), surgical site infection (19.3%), and readmission (12.3%). Laparoscopic APR was associated with a 14% lower total complication rate compared to open APR (36.0% versus 50.1%, P < 0.001). This was primarily driven by a decreased rate of transfusion (10.7% versus 24.9%, P < 0.001) and surgical site infection (15.5% versus 21.2%, P < 0.001). Laparoscopic APR had shorter length of stay and decreased reoperation rate but similar rates of readmission and death. Cardiopulmonary complications occurred earlier in the postoperative period after APR, whereas infectious complications occurred later.
CONCLUSIONS
Short-term complications following APR are common and occur more frequently in patients who undergo open APR. This, along with factors such as risk of positive pathologic margins, surgeon skill set, and patient characteristics, should contribute to the decision-making process when planning rectal cancer surgery.
Topics: Aged; Female; Humans; Laparoscopy; Male; Middle Aged; Postoperative Complications; Proctectomy; Retrospective Studies; Time Factors; United States
PubMed: 30278971
DOI: 10.1016/j.jss.2018.05.009 -
Langenbeck's Archives of Surgery May 2021Abdominoperineal resection of the rectum has evolved over the last century, with few modifications until 2007, when extralevator abdominoperineal resection was...
PURPOSE
Abdominoperineal resection of the rectum has evolved over the last century, with few modifications until 2007, when extralevator abdominoperineal resection was introduced, which improved local disease control but resulted in a significant rise in perineal complications. We adopted a modified approach in which dissection was tailored according to magnetic resonance-defined tumour involvement. The aim of this study was to assess short-term and long-term oncological outcomes following a tailored abdominoperineal resection (APR) approach.
METHODS
This study was a retrospective review of prospectively maintained databases at three centres: Portsmouth NHS Trust (UK), Poole General Hospital (UK) and Champalimaud's Cancer Foundation, Portugal. The study included consecutive patients who underwent abdominoperineal resection from October 2008 until April 2018 under the supervision of the senior author. Oncological outcomes, including overall survival and disease-free survival, were used as the main outcome measures.
RESULTS
A total of 584 patients underwent rectal cancer surgery during the study period. The APR ratio was 65/584 (11%). The median age was 66 years. Neoadjuvant treatment was administered to 74% of patients. Of the patients, 91% underwent surgery via a minimally invasive approach. The median hospital stay was 7 days. Patients were followed up for a median of 41 months. Only four patients had positive resection margins. The 5-year overall and disease-free survival rates were 64% and 62%, respectively.
CONCLUSION
Our data suggest that tailored APR has similar short-term and long-term oncological outcomes compared with extralevator abdominoperineal resection but reduced perineal wound complications. We believe this approach could be a safe alternative but recommend a larger sample size to accurately assess its effectiveness.
Topics: Abdomen; Aged; Humans; Perineum; Proctectomy; Rectal Neoplasms; Retrospective Studies; Treatment Outcome
PubMed: 33638682
DOI: 10.1007/s00423-021-02122-y -
Plastic and Reconstructive Surgery Jan 2022Reconstruction following abdominoperineal resection improves outcomes by reducing wound-related complications, particularly in irradiated patients. Little is known...
BACKGROUND
Reconstruction following abdominoperineal resection improves outcomes by reducing wound-related complications, particularly in irradiated patients. Little is known regarding system-level factors that impact patients' access to reconstructive surgery following abdominoperineal resection. This study aimed to identify barriers to undergoing reconstruction following abdominoperineal resection.
METHODS
Using the National Inpatient Sample database from 2012 to 2014, all encounters with colorectal or anorectal carcinoma patients who underwent abdominoperineal resection were extracted based on International Classification of Disease, Ninth Revision, diagnosis and procedure codes. Multivariable logistic regression analyzed the outcome of undergoing reconstruction.
RESULTS
The weighted sample included encounters with 19,205 abdominoperineal resection patients, of whom 1243 (6.5 percent) received a flap. Notable patient-level predictors of receiving a flap included age younger than 55 years (OR, 1.82; 95 percent CI, 1.23 to 2.74; p = 0.003) and neoadjuvant chemoradiation therapy (OR, 1.37; 95 percent CI, 1.01 to 1.88; p = 0.041). Race, sex, income level, insurance type, and Elixhauser Comorbidity Index were not associated with increased odds of receiving a flap. For facility-level factors, urban teaching hospitals (OR, 23.6; 95 percent CI, 3.29 to 169.4; p = 0.002) and larger hospital bedsize (OR, 2.64; 95 percent CI, 1.53 to 4.56; p = 0.000) were associated with higher odds of reconstruction. Plastic surgery facility volume was not found to be a significant predictor of undergoing flap reconstruction (p > 0.05).
CONCLUSIONS
Patients undergoing abdominoperineal resection at academic centers were over 23 times more likely to undergo reconstruction, after adjusting for available confounders. Patients undergoing abdominoperineal resection at smaller, nonacademic centers may not have equitable access to reconstruction despite being appropriate candidates. Given the morbidity of abdominoperineal resection, patients should be referred to large, academic centers to have access to flap reconstruction.
CLINICAL QUESTION/LEVEL OF EVIDENCE
Risk, III.
Topics: Academic Medical Centers; Adolescent; Adult; Age Factors; Aged; Cohort Studies; Female; Health Services Accessibility; Humans; Male; Middle Aged; Neoadjuvant Therapy; Postoperative Complications; Proctectomy; Plastic Surgery Procedures; Rectal Neoplasms; Surgical Flaps; United States; Young Adult
PubMed: 34813526
DOI: 10.1097/PRS.0000000000008661 -
Langenbeck's Archives of Surgery May 2023Conformal sphincter preservation operation (CSPO) procedure is a sphincter preservation procedure for preserving the anal canal function for very low rectal cancers....
Comparison of functional and oncological outcome of conformal sphincter preservation operation, low anterior resection, and abdominoperineal resection in very low rectal cancer: a retrospective comparative cohort study with propensity score matching.
PURPOSE
Conformal sphincter preservation operation (CSPO) procedure is a sphincter preservation procedure for preserving the anal canal function for very low rectal cancers. This study investigated the functional and oncological outcome of conformal sphincter preservation operation by comparing with low anterior resection (LAR) and abdominoperineal resection (APR).
METHODS
This is a retrospective comparative study. Patients who received conformal sphincter preservation operation (n = 52), low anterior resection (n = 54), or abdominoperineal resection (n = 69) were included between 2011 and 2016 in a tertiary referral hospital. Propensity score matching was applied to adjust the baseline characteristics which may influence the choice of the surgical procedure.
RESULTS
Twenty-one pairs of conformal sphincter preservation operation vs. low anterior resection and 29 pairs of conformal sphincter preservation operation vs. abdominoperineal resection were selected. The first group had a higher tumor location than the second group. Compared with the low anterior resection group, the conformal sphincter preservation operation group had shorter distal resection margins; however, no significant differences were identified in daily stool frequency, Wexner incontinence score, local recurrence, distant metastasis, overall survival, and disease-free survival between both groups. Compared with the abdominoperineal resection group, the conformal sphincter preservation operation group had shorter operative time and shorter postoperative hospital stay. No significant differences were identified in local recurrence, distant metastasis, overall survival, and disease-free survival.
CONCLUSION
Conformal sphincter preservation operation is oncologically safe compared to APR and LAR, and has similar functional findings to LAR. Studies comparing CSPO with intersphincteric resection should be performed.
Topics: Humans; Cohort Studies; Propensity Score; Retrospective Studies; Proctectomy; Anal Canal; Neoplasms
PubMed: 37222797
DOI: 10.1007/s00423-023-02925-1 -
International Journal of Surgery... Nov 2019This study was performed to compare the short- and long-term outcomes of laparoscopic extralevator abdominoperineal resection (LELAPR) versus laparoscopic... (Comparative Study)
Comparative Study
BACKGROUND
This study was performed to compare the short- and long-term outcomes of laparoscopic extralevator abdominoperineal resection (LELAPR) versus laparoscopic abdominoperineal resection (LAPR) in patients with lower rectal cancer.
METHODS
Consecutive patients who underwent LELAPR or LAPR in our unit from September 2009 to December 2015 were retrospectively reviewed. The patients' clinicopathological data and short- and long-term outcomes were compared and analyzed.
RESULTS
Of the 111 patients included in this study, 58 (52%) patients underwent LAPR and 53 (48%) LELAPR. A negative circumferential resection margin was achieved in all the two groups of patients. The LELAPR group had a longer operation time (P = 0.049), more intraoperative blood loss (P = 0.037), shorter hospitalization after surgery (P = 0.002), fewer lymph nodes harvested (P = 0.001), fewer positive lymph nodes (P = 0.002), and a shorter maximum tumor diameter (P < 0.001) compared with the LAPR group. There were also lower rates of intraoperative perforation (P = 0.039) and death (P = 0.013) in the LELAPR group. However, there were no significant differences in the rates of local recurrence (P = 0.144), metastasis (P = 0.111), overall survival (P = 0.404), disease-free survival (P = 0.515), or progression-free survival (P = 0.210) between the two groups. There were no significant differences in postoperative complications including postoperative hernia (P = 0.918), urinary retention (P = 0.579), intestinal obstruction (P = 1.0), and perineal wound complications (P = 0.252).
CONCLUSIONS
Compared with LAPR, the LELAPR approach significantly reduced the rate of intraoperative perforation and postoperative death without increasing postoperative complications. LELAPR was beneficial to patients with ulcerative, anterior and advanced lower rectal cancer.
Topics: Abdomen; Adult; Aged; Blood Loss, Surgical; China; Disease-Free Survival; Female; Humans; Laparoscopy; Male; Margins of Excision; Middle Aged; Operative Time; Perineum; Postoperative Complications; Proctectomy; Rectal Neoplasms; Rectum; Retrospective Studies; Treatment Outcome
PubMed: 31526895
DOI: 10.1016/j.ijsu.2019.09.010 -
Journal of Surgical Oncology Jun 2019This study is a systematic review with meta-analysis designed to compare the perioperative and oncological outcomes of the abdominoperineal resection (APR) carried out... (Meta-Analysis)
Meta-Analysis
BACKGROUND AND OBJECTIVES
This study is a systematic review with meta-analysis designed to compare the perioperative and oncological outcomes of the abdominoperineal resection (APR) carried out in the prone jack-knife position (P-APR) vs the classic lithotomy position (C-APR).
METHODS
We conducted an electronic search through PubMed utilizing the PRISMA guidelines. We included all randomized and nonrandomized studies which allowed for comparative analysis between the two groups. Research that focused on and analyzed the extralevator abdominal excision were excluded. Pooled variables and number of events were analyzed using the random-effect model.
RESULTS
The final analysis included seven nonrandomized retrospective cohorts encompassing 1663 patients. P-APR was associated with decreased operative time (OT) (DM, -43.8 minutes; P < 0.01) and estimated blood loss (EBL) (DM, 86.9 mL; P < 0.01). There were no observed differences regarding perineal wound infections (PWI) (odds ratio [OR], 0.36; P = 0.18), intraoperative perforation of rectum (IOP) (OR, 0.98; P = 0.97), circumferential resection margin (CRM) positivity (OR, 1.02; P = 0.98) or 5-year LR (OR, 1.00; P = 0.99).
CONCLUSION
The prone approach for APR is associated with decreased EBL and OT, although not with any change in the incidence of PWI or IOP. Moreover, surgical positioning per se does not appear to affect the CRM positivity rates or LR rate.
Topics: Humans; Margins of Excision; Patient Positioning; Proctectomy; Prone Position; Randomized Controlled Trials as Topic; Rectal Neoplasms; Retrospective Studies; Treatment Outcome
PubMed: 30729542
DOI: 10.1002/jso.25402 -
Colorectal Disease : the Official... Dec 2020
Topics: Abdomen; Colpotomy; Female; Humans; Pregnancy; Proctectomy; Rectal Neoplasms; Robotic Surgical Procedures
PubMed: 32780504
DOI: 10.1111/codi.15303 -
Surgical Endoscopy Oct 2020In abdominoperineal resection (APR) in male patients with rectal cancer, high margin involvement and urethral injury have been reported to result from difficulty in...
BACKGROUND
In abdominoperineal resection (APR) in male patients with rectal cancer, high margin involvement and urethral injury have been reported to result from difficulty in dissecting the anterior anorectum. Recently, the efficacy of an endoscopic down-to-up rectal dissection was reported. Here, we present a safe and simple technique for anterior dissection using a simultaneous laparoscopic and transperineal endoscopic approach.
METHODS
We perform transperineal APR (TpAPR) using both the laparoscopic and transperineal approach (a 2-team approach). Anterior dissection commences just behind the superficial transverse perineal muscle. Next, the striated muscle complex surrounding the rectum (levator ani and puborectalis muscle) is divided. At this point, it is difficult to identify the dissection plane between the membranous urethra and anterior rectum; thus, dissection along the lateral aspect of neurovascular bundle from the lateral to anterior side with the assistance of the laparoscopic team is helpful in identifying the posterior surface of the prostate. Once the prostate is identified, it is relatively easy to divide the rectourethralis muscles. The key steps of our procedure are shown in the video.
RESULTS
Between April 2016 and July 2019, we performed 14 TpAPR procedures in male patients with rectal cancer without distant metastasis. Extended surgery was performed in 8 patients, including pelvic sidewall dissection and combined resection of adjacent organs. Median operative time was 453 min and median blood loss was 46 g. There was 1 (7.1%) circumferential-positive case, but no cases of urethral injury or rectal perforation.
CONCLUSIONS
The 2-team TpAPR procedure is beneficial for appropriate dissection of the anterior side during APR surgery.
Topics: Aged; Aged, 80 and over; Anus Neoplasms; Humans; Laparoscopy; Male; Proctectomy; Rectal Neoplasms; Rectum; Urethra
PubMed: 32430530
DOI: 10.1007/s00464-020-07655-9 -
Colorectal Disease : the Official... Mar 2022Intraoperative rectal washout is performed to eliminate exfoliated intraluminal cancer cells and thereby decrease the risk of local recurrence. Rectal washout in...
AIM
Intraoperative rectal washout is performed to eliminate exfoliated intraluminal cancer cells and thereby decrease the risk of local recurrence. Rectal washout in abdominoperineal resection has not been studied. The aim of this study was to assess the oncological outcome after rectal washout in abdominoperineal resection for rectal cancer and to find evidence as to whether rectal washout should be performed or not.
METHOD
Data for all patients registered in the Swedish Colorectal Cancer Registry who underwent elective surgery with abdominoperineal resection for rectal cancer (TNM Stages I-III) between 2007 and 2013 were analysed using multivariable analysis.
RESULTS
No significant differences were shown between the rectal washout group and the no rectal washout group for local recurrence [10/265 (3.8%) vs. 87/2160 (4.0%), p = 0.84], distant metastasis [51/265 (19.2%) vs. 476/2160 (22.0%), p = 0.29] or overall recurrence [53/265 (20.0%) vs. 505/2160 (23.4%), p = 0.21]. In multivariable analysis, rectal washout did not significantly affect the oncological outcome in terms of local recurrence, distant metastasis, overall recurrence or 5-year overall or relative survival.
CONCLUSION
Our results do not support routine rectal washout during abdominoperineal resection in order to improve the oncological outcome.
Topics: Elective Surgical Procedures; Humans; Neoplasm Recurrence, Local; Proctectomy; Rectal Neoplasms; Therapeutic Irrigation; Treatment Outcome
PubMed: 34726339
DOI: 10.1111/codi.15977