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European Journal of Surgical Oncology :... Dec 2023Patients who develop a perineal hernia after abdominoperineal resection may experience discomfort during daily activities and urogenital dysfunction, but the impact on...
INTRODUCTION
Patients who develop a perineal hernia after abdominoperineal resection may experience discomfort during daily activities and urogenital dysfunction, but the impact on quality of life has never been formally assessed.
MATERIALS AND METHODS
Patients who underwent abdominoperineal resection for rectal cancer between 2014 and 2022 in two prospective multicenter trials were included. Primary outcome was defined as median overall scores or scores on functional and symptom scales of the following quality of life questionnaires: 5-level version of the 5-dimensional EuroQol, Short Form-36, and European Organization for Research and Treatment of Cancer QoL Questionnaire Colorectal cancer 29 and 30, Urogenital Distress Inventory-6, Incontinence Impact Questionnaire-7.
RESULTS
Questionnaires were available in 27 patients with a perineal hernia and 62 patients without a perineal hernia. The 5-dimensional EuroQol score was significantly lower in patients with a perineal hernia (83 vs 87, p = 0.048), which implies a reduced level of functioning. The median scores of pain-specific domains were significantly worse in patients with a perineal hernia as measured by the SF-36 (78 vs. 90, p = 0.006), the EORTC-CR29 (17 vs. 11, p=<0.001) and EORTC-C30 (17 vs. 0, p = 0.019). Also, significantly worse physical (73 vs. 100, p = 0.049) and emotional (83 vs. 100, p = 0.048) functioning based on EORTC-C30 was observed among those patients. Minimally important differences were found for role, physical and social functioning of the SF-36 and EORTC-C30. The urological function did not differ between the groups.
CONCLUSION
A symptomatic perineal hernia can significantly worsen quality of life on several domains, indicating the severity of this complication.
Topics: Humans; Quality of Life; Prospective Studies; Rectal Neoplasms; Proctectomy; Hernia; Surveys and Questionnaires
PubMed: 37839295
DOI: 10.1016/j.ejso.2023.107114 -
Journal of Plastic, Reconstructive &... Nov 2020Abdominoperineal resection (APR) in patients with anorectal carcinomas may involve flap-based perineal reconstruction techniques, such as rectus abdominis, myocutaneous,... (Review)
Review
Abdominoperineal resection (APR) in patients with anorectal carcinomas may involve flap-based perineal reconstruction techniques, such as rectus abdominis, myocutaneous, gracilis, and gluteal flaps. There is no consensus on the optimal approach. We evaluated the outcomes of perineal reconstruction following APR in the literature and identified a predominance of abdominal-based approaches, though overall outcomes were similar compared with thigh or perineal-based options. Statistical power to detect small differences in outcomes is limited, however, due to the retrospective design, relatively short-term follow-up, and potential selection bias based on morbidities associated with reconstructive techniques. Lacking randomized studies to define optimum approaches to perineal reconstruction, clinicians should individualize surgical strategy.
Topics: Anus Neoplasms; Humans; Patient Selection; Postoperative Complications; Proctectomy; Plastic Surgery Procedures; Rectal Neoplasms; Surgical Flaps
PubMed: 32958425
DOI: 10.1016/j.bjps.2020.08.090 -
Journal of Reconstructive Microsurgery Feb 2022Pelvic reconstruction with a muscle flap significantly improves postoperative outcomes following abdominoperineal resection (APR). Despite it being the gold standard,...
BACKGROUND
Pelvic reconstruction with a muscle flap significantly improves postoperative outcomes following abdominoperineal resection (APR). Despite it being the gold standard, significant surgeon-selection bias remains with respect to the necessity of pelvic obliteration, flap choice, and ostomy placement. The objective of the study was to characterize management practices among colorectal surgeons (CSs) and plastic surgeons (PSs).
METHODS
Specialty-specific surveys were distributed electronically to CSs and PSs via surgical societies. Surveys were designed to illustrate geographic and specialty-specific differences in management.
RESULTS
Of 106 (54 CSs and 52 PSs) respondents (58% Canada, 21% Europe, 14% the United States, and 6% Asia/Africa), significant interdisciplinary differences in practices were observed. Most respondents indicated that multidisciplinary meetings were not performed (74% of CSs and 78% of PSs). For a nonradiated pelvic dead space with small perineal defect, 91% of CSs and 56% of PSs indicated that flap reconstruction was not required. For a radiated pelvic dead space with small perineal defect, only 54% of CSs and 6% of PSs indicated that there was no need for flap reconstruction. With respect to ostomy placement, 87% of CSs and 21% of PSs indicated that stoma placement through the rectus was superior. When two ostomies were required, most CSs preferred exteriorizing ostomies through bilateral recti and requesting thigh-based reconstruction. PSs favored the vertical rectus abdominis muscle (VRAM; 52%) over the gracilis (23%) and inferior gluteal artery perforator (IGAP; 23%) flaps. Among PSs, North Americans favor abdominally based flaps (VRAM 60%), while Europeans favor gluteal-based flaps (IGAP 78%).
CONCLUSION
A lack of standardization continues to exist with respect to the reconstruction of pelvic defects following APR and pelvic exenteration. Geographic and interdisciplinary biases with respect to ostomy placement, flap choice, and role for pelvic obliteration continues to influence reconstructive practices. These cases should continue to be approached on a case by case basis, driven by pathology, presence of radiation, comorbidities, and the size of the pelvic and perineal defect.
Topics: Colorectal Neoplasms; Humans; Pelvic Exenteration; Perineum; Proctectomy; Plastic Surgery Procedures; Surgeons; Surgical Flaps
PubMed: 34187060
DOI: 10.1055/s-0041-1729750 -
International Journal of Colorectal... Aug 2023Abdominoperineal resection (APR) remains a key procedure for the treatment of low rectal/anorectal cancers. However, perineal wound closure remains challenging,...
PURPOSE
Abdominoperineal resection (APR) remains a key procedure for the treatment of low rectal/anorectal cancers. However, perineal wound closure remains challenging, particularly in extralevator abdominoperineal resection (ELAPR) due to gapped tissue planes. Different approaches have been attempted to improve perineal wound repair. The aim of this study is to report our 6-year experience in perineal wound closure utilising biological mesh.
METHODS
We conducted a retrospective study using data from our prospectively maintained database, including patients who underwent APR with perineal mesh closure between 2016 and 2021.
RESULTS
49 patients underwent APR with perineal mesh reconstruction for low rectal cancer during the 6-year period. Of these, 63% were males, with a mean age of 68 (± 11), and a mean BMI of 27.9 (± 13.7). 49% (24) of patients received neoadjuvant therapy. 88% (43) of patients underwent standard "S-APR" and only 12% (6) underwent ELAPR. Majority of procedures were laparoscopic (87.8%) with conversion rate of 6.9%. Mean length of stay was 11.7 (± 11.6). The perineal wound infection rate was 30% and only two patient required mesh removal due to entero-cutaneous perineal fistula and pelvic abscess. Perineal hernia was found in only two patients (4.1%). CRM was negative in 81.6% of the patients. Mean follow-up period was 29.2 (± 16.5) months, and disease recurrence occurred in 9 (18.3%) patients with average number of months for recurrence of 21 (± 7). Overall survival during the follow-up period was 91%.
CONCLUSION
Our series shows a favourable short- and medium-term outcome with routine insertion of mesh for perineal wound closure.
Topics: Male; Humans; Aged; Female; Retrospective Studies; Surgical Mesh; Neoplasm Recurrence, Local; Proctectomy; Neoadjuvant Therapy; Cutaneous Fistula
PubMed: 37606697
DOI: 10.1007/s00384-023-04507-5 -
Zhonghua Wei Chang Wai Ke Za Zhi =... May 2020Presacral recurrent rectal cancer (PRRC) which involves the presacral fascia or/and sacral bone is one of the classification of locally recurrent rectal cancer.... (Review)
Review
Presacral recurrent rectal cancer (PRRC) which involves the presacral fascia or/and sacral bone is one of the classification of locally recurrent rectal cancer. Presacral fascia or/and sacral bone involvement and posterior fixation make treatment difficult. In recent years, there are many researches on the diagnosis, surgical treatment and surgical methods of PRRC. The major therapeutic principle of PRRC is to perform radical resection with combined therapy under the evaluation of the multidisciplinary team (MDT). Among the surgical methods, abdominal resection or abdominoperineal resection, sacrectomy and abdominosacral resection are the common surgical methods for the treatment of PRRC. Recent articles revealed that limited sacrectomy could also result in good efficacy, provided strict indications for this procedure. With the development of minimally invasive technology, the application of laparoscopic technology in PRRC has been increasingly emphasized. In summary, the surgical principle of PRRC has shifted from solely pursuring radical resection to obtaining good efficacy as well as reduced morbidity with individualized management. In this article, the research progress of surgical methods of presacral recurrent rectal cancer in recent years are reviewed in order to provide reference to clinical diagnosis and treatment.
Topics: Humans; Neoplasm Recurrence, Local; Proctectomy; Rectal Neoplasms; Rectum; Sacrum; Treatment Outcome
PubMed: 32842422
DOI: 10.3760/cma.j.cn.441530-20200303-00108 -
Romanian Journal of Morphology and... 2020Perineal eventration (PE) is a rare complication after the lower rectal cancer resection surgery, affecting the quality of life of the patient. In 5.5 years of...
Perineal eventration (PE) is a rare complication after the lower rectal cancer resection surgery, affecting the quality of life of the patient. In 5.5 years of evolution, out of 620 patients with rectal cancer treated by curative surgery, 176 patients with lower ampullary rectal cancer treated by abdominoperineal resection (APR) with the closure of the defect by direct suture of the perineal floor were selected. Ten (5.6%) of them were diagnosed with PE. This paper shows the results of a retrospective study, which compares the clinico-pathological and therapeutic aspects of a subgroup of 166 patients (subgroup I) with APR without PE and a subgroup of 10 patients (subgroup II) with PE. Starting from the question of whether aspects can influence the evolution of PE, we aimed to investigate the similarities and differences between these two groups, from the histological, clinical and therapeutic points of view. Regarding the tumor, node, metastasis (TNM) staging, we encountered the following aspects: for the subgroup II with PE, pT3 predominated, stages N0 and N1 were equal (50%) and the absence of metastases (M0) was found in all cases; in subgroup I, pT3 and N0 also predominated, followed by N1 and N2, and for stage M, M0 is predominant, followed by M1. For the clinical profile of the PE group, the symptoms were characteristic, with the presence of the usual triggering factors [hysterectomy, radiochemotherapy and wide resection surgery - extralevatorial APR]. The therapeutic approach revealed various aspects, including plastic surgery procedures (direct closure, meshes, flaps) used in pelvic reconstruction. The accurate surgical technique applied in order to achieve oncological safety allowed for a longer survival, which favored the appearance of PE in addition to the other favoring factors. Our results underlined the clinico-pathological profile of the two subgroups, without being able to establish a correlation with the appearance and evolution of PE. However, the clinico-pathological risk factors for this condition are not yet fully defined. Therefore, reports based on the experience in the diagnosis and treatment of PE should bring valuable data, aiming to create the knowledge framework for prevention.
Topics: Female; Humans; Perineum; Proctectomy; Quality of Life; Rectal Neoplasms; Retrospective Studies
PubMed: 34171060
DOI: 10.47162/RJME.61.4.13 -
Surgery Today Apr 2022Although robotic surgery for rectal cancer can overcome the shortcomings of laparoscopic surgery, studies focusing on abdominoperineal resection are limited. The aim of...
PURPOSE
Although robotic surgery for rectal cancer can overcome the shortcomings of laparoscopic surgery, studies focusing on abdominoperineal resection are limited. The aim of this study was to compare the operative outcomes between robotic and laparoscopic abdominoperineal resection.
METHODS
This retrospective cohort study was conducted from April 2010 to March 2020. Patients with rectal cancer who underwent robotic or laparoscopic abdominoperineal resection without lateral lymph node dissection were enrolled. The perioperative and oncological outcomes were compared.
RESULTS
We evaluated 33 and 20 patients in the robotic and laparoscopic groups, respectively. The median operative time and blood loss were comparable between the two groups. No significant differences in the overall complication rates were noted, whereas the rates of urinary dysfunction (3% vs. 26%, p = 0.02) and perineal wound infection (9% vs. 35%, p = 0.03) in the robotic group were significantly lower in comparison to the laparoscopic group. The median postoperative hospital stay was significantly shorter in the robotic group (8 days vs. 11 days, p < 0.01). The positive resection margin rates were comparable between the two groups.
CONCLUSION
Robotic abdominoperineal resection demonstrated better short-term outcomes than laparoscopic surgery, suggesting that it could be a useful approach.
Topics: Humans; Laparoscopy; Proctectomy; Rectal Neoplasms; Retrospective Studies; Robotic Surgical Procedures; Treatment Outcome
PubMed: 34417866
DOI: 10.1007/s00595-021-02359-6 -
Journal of Gastrointestinal Cancer Jun 2022Locally advanced rectal cancer (LARC) can involve surrounding pelvic organs requiring multivisceral resection. Extended total mesorectal excision (e-TME) or...
BACKGROUND
Locally advanced rectal cancer (LARC) can involve surrounding pelvic organs requiring multivisceral resection. Extended total mesorectal excision (e-TME) or multivisceral resection is a complex procedure associated with high morbidity, mortality, and R1 resection rates. However, e-TME in LARC with surrounding organ involvement is the only potential option for cure. The study aims to assess the clinical outcome of patients requiring e-TME for LARC.
METHODS
The study is a retrospective review of all patients with LARC requiring multivisceral resection (2013 to 2019). The database includes clinic-demographic profile, pelvic organ involved, operative details, resection margin status, morbidity, mortality, and survival.
RESULTS
Seven consecutive patients (9.2%) out of 76 LARC (median age 46 years; 5 females) required multivisceral resection. The organs involved were bladder (4); posterior wall of vagina (2); and uterus (1). The en bloc resection included total cystoprostatectomy - 1; partial cystectomy - 3; posterior vaginectomy - 2; and hysterectomy - 1. Additionally, four required abdominoperineal resection. All were adenocarcinoma: stage III, with R0 resection - 76%. The overall complications were seen in 60% of patients, majority being wound related. There was no operative mortality. The median survival was 32.2 months in the entire series, while one died with the disease at a 28-month follow-up.
CONCLUSION
e-TME with curative intent, though a complex procedure, is associated with high wound-related morbidity, R1 resection, but improved median survival benefit.
Topics: Female; Humans; Margins of Excision; Middle Aged; Neoplasm Recurrence, Local; Proctectomy; Rectal Neoplasms; Rectum; Retrospective Studies; Treatment Outcome
PubMed: 33417198
DOI: 10.1007/s12029-020-00562-1 -
Journal of Reconstructive Microsurgery Jan 2020Abdominoperineal resection (APR), which involves resection of the rectum, anal canal, and perianal skin, results in a large dead space in the pelvis, devascularized...
BACKGROUND
Abdominoperineal resection (APR), which involves resection of the rectum, anal canal, and perianal skin, results in a large dead space in the pelvis, devascularized tissues, and high bacterial loads. This predisposes to wound complications, especially in the setting of neoadjuvant chemoradiotherapy. Additional sacral resection further compounds these effects. We aimed to assess perineal wound outcomes and complications in patients who underwent flap reconstruction for APR with sacrectomy (APRS) at our institution.
METHODS
We reviewed the charts of all patients who underwent flap reconstruction for APRS over a 20-year period (1999-2018). Medical comorbidities, details of the surgical procedure, and major and minor wound complications were recorded and analyzed.
RESULTS
Forty-six patients underwent flap reconstruction following APRS-28 (60%) for colorectal cancer, 8 (17%) for sacral chordoma, and 10 diagnosed with other malignant histologies. Rectus abdominis myocutaneous (RAM) flap reconstruction was used in 42 patients (91%). The median time to the first major perineal complication was 111 days (interquartile range: 22-660 days). Half of our cohort ( = 23) experienced a major perineal complication. No significant differences were found in major or minor perineal or abdominal wall complications between RAM flap and other flaps. APR with high sacrectomy was performed in 27 patients (59%) and was associated with significantly increased full-thickness dehiscence in the perineal region when compared with APR with low sacrectomy, 33 versus 0%, respectively ( = 0.0076). Complete flap loss occurred in one patient.
CONCLUSION
The RAM flap was the workhorse flap for pelvic reconstruction following APRS in our cohort. Wound complications are common following APRS. High sacrectomy is associated with higher incidence of complications compared with low sacrectomy. Optimal surgical planning and patient counseling is fundamental to improve current surgical outcomes.
Topics: Humans; Perineum; Proctectomy; Plastic Surgery Procedures; Rectal Neoplasms; Rectus Abdominis; Sacrum; Surgical Flaps; Treatment Outcome; Wounds and Injuries
PubMed: 31537019
DOI: 10.1055/s-0039-1697629 -
International Journal of Surgery... Apr 2024The efficacy of intersphincteric resection (ISR) surgery for patients with lower rectal cancer remains unclear compared to abdominoperineal resection (APR). The aim of... (Meta-Analysis)
Meta-Analysis Comparative Study
BACKGROUND
The efficacy of intersphincteric resection (ISR) surgery for patients with lower rectal cancer remains unclear compared to abdominoperineal resection (APR). The aim of this study is to compare the oncologic outcomes for lower rectal cancer patients after ISR and APR through a systematic review and meta-analysis.
MATERIALS AND METHODS
A systematic electronic search of the Cochrane Library, PubMed, EMBASE, and MEDLINE was performed through January 12, 2022. The primary outcomes included 5-year disease-free survival (5y-DFS) and 5-year overall survival. Secondary outcomes included circumferential resection margin involvement, local recurrence, perioperative outcomes, and other long-term outcomes. The pooled odds ratios, mean difference, or hazard ratios (HRs) of each outcome measurement and their 95% CIs were calculated.
RESULTS
A total of 20 nonrandomized controlled studies were included in the qualitative analysis, with 1217 patients who underwent ISR and 1135 patients who underwent APR. There was no significant difference in 5y-DFS (HR: 0.84, 95% CI: 0.55-1.29; P =0.43) and 5-year overall survival (HR: 0.93, 95% CI: 0.60-1.46; P =0.76) between the two groups. Using the results of five studies that reported matched T stage and tumor distance, we performed another pooled analysis. Compared to APR, the ISR group had equal 5y-DFS (HR: 0.76, 95% CI: 0.45-1.30; P =0.31) and 5y-LRFS (local recurrence-free survival) (HR: 0.72, 95% CI: 0.29-1.78; P =0.48). Meanwhile, ISR had equivalent local control as well as perioperative outcomes while significantly reducing the operative time (mean difference: -24.89, 95% CI: -45.21 to -4.57; P =0.02) compared to APR.
CONCLUSIONS
Our results show that the long-term survival and safety of patients is not affected by ISR surgery, although this result needs to be carefully considered and requires further study due to the risk of bias and limited data.
Topics: Humans; Rectal Neoplasms; Proctectomy; Anal Canal; Treatment Outcome; Disease-Free Survival; Neoplasm Recurrence, Local
PubMed: 36928167
DOI: 10.1097/JS9.0000000000000205