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Plastic and Reconstructive Surgery Nov 2019Flap reconstruction is recommended for select patients undergoing abdominoperineal resection to mitigate complications. However, the clinical effectiveness and financial... (Comparative Study)
Comparative Study
BACKGROUND
Flap reconstruction is recommended for select patients undergoing abdominoperineal resection to mitigate complications. However, the clinical effectiveness and financial implications of flap reconstruction remain unknown. The authors aim to compare the costs and complications for patients undergoing abdominoperineal resection with and without flap reconstruction.
METHODS
The Truven MarketScan Databases (2009 to 2016) were used to perform retrospective population-based analysis of colorectal carcinoma patients who underwent abdominoperineal resection with and without flap reconstruction. Univariate and multivariable logistic regressions were used to study effective cost (cumulative cost/number of healthy days) and complications.
RESULTS
Of 2557 total abdominoperineal resection patients, 194 patients underwent flap reconstruction. Patients undergoing flap reconstruction had a higher Elixhauser Comorbidity Index (p = 0.004) and were more likely to have local invasion (p < 0.001). At 6 months postoperatively, there were no differences in complications between the two groups (p = 0.116). Flap reconstruction was protective against intraabdominal infections (OR, 0.4; 95 percent CI, 0.2 to 0.9; p = 0.033) but conferred an increased risk of wound complications (OR, 1.5; 95 percent CI, 1.0 to 2.3; p = 0.039). Total median cost of care was similar (abdominoperineal resection alone, $40,050; abdominoperineal resection with flap, $41,380; p = 0.456). Effective cost was greater for abdominoperineal resection alone ($259/healthy day) than abdominoperineal resection with flap ($186/healthy day) but was not statistically significant (p = 0.17).
CONCLUSIONS
Patients with flap reconstruction displayed a higher comorbidity score and more extensive disease, but these unfavorable factors did not result in a higher complication rate, total cost, or effective cost. Therefore, flap reconstruction for complex perineal defects confers a benefit in select patients and is a judicious use of health care resources.
CLINICAL QUESTION/LEVEL OF EVIDENCE
Therapeutic, III.
Topics: Adenocarcinoma; Adult; Aged; Anus Neoplasms; Carcinoma, Squamous Cell; Cohort Studies; Cost-Benefit Analysis; Databases, Factual; Female; Humans; Male; Middle Aged; Proctectomy; Plastic Surgery Procedures; Rectal Neoplasms; Retrospective Studies; Risk Assessment; Statistics, Nonparametric; Surgical Flaps; Treatment Outcome; Wound Closure Techniques; Wound Healing
PubMed: 31688766
DOI: 10.1097/PRS.0000000000006158 -
Current Oncology Reports Aug 2021This review aims to clarify the current role of minimally invasive surgery in the treatment of rectal cancer, highlighting short- and long-term outcomes from the latest... (Review)
Review
PURPOSE OF REVIEW
This review aims to clarify the current role of minimally invasive surgery in the treatment of rectal cancer, highlighting short- and long-term outcomes from the latest trials and studies.
RECENT FINDINGS
Data from previous trials has been conflicting, with some failing to demonstrate non-inferiority of laparoscopic surgical resection of rectal cancer compared to an open approach and others demonstrating similar clinical outcomes. Robot-assisted surgery was thought to be a promising solution to the challenges faced by laparoscopic surgery, and even though the only randomized controlled trial to date comparing these two techniques did not show superiority of robot-assisted surgery over laparoscopy, more recent retrospective data suggests a statistically significant higher negative circumferential resection margin rate, decreased frequency of conversion to open, and less sexual and urinary complications. Minimally invasive surgery techniques for resection of rectal cancer, particularly robot-assisted, offer clear short-term peri-operative benefits over an open approach; however, current data has yet to display non-inferiority in terms of oncological outcomes.
Topics: Humans; Laparoscopy; Margins of Excision; Minimally Invasive Surgical Procedures; Postoperative Complications; Proctectomy; Quality of Life; Rectal Neoplasms; Robotic Surgical Procedures; Treatment Outcome
PubMed: 34342706
DOI: 10.1007/s11912-021-01110-1 -
Surgical Oncology Jun 2021Given the lack of consensus in the surgical treatment of anal adenocarcinoma, practice-patterns demonstrate utilization of organ-preserving techniques. The adequacy of...
BACKGROUND
Given the lack of consensus in the surgical treatment of anal adenocarcinoma, practice-patterns demonstrate utilization of organ-preserving techniques. The adequacy of local excision compared to abdominoperineal resection (APR) as a surgical approach for stage II disease is unknown. Our study examines the utilization of local excision in the treatment of stage II anal adenocarcinoma, rates of R0 resection, and differences in overall survival compared to APR.
MATERIALS AND METHODS
Using the National Cancer Database (2004-2016), we retrospectively analyzed patients diagnosed with clinical stage II anal adenocarcinoma who received chemoradiation and surgery. Patient cohorts were assigned based on the surgical procedure they received. Propensity score matching was used to offset selection bias and confounding factors. Treatment approach, pathologic margin status, and overall survival were assessed.
RESULTS
Overall, 359 patients underwent resection of clinical stage II anal adenocarcinoma and received chemoradiation therapy. Of these patients, 87 (24%) underwent local excision, whereas 272 (76%) received an abdominoperineal resection. In a propensity score-matched cohort, patients who underwent local excision were less likely to achieve an R0 resection (40% vs 90%), and more likely to receive adjuvant instead of neoadjuvant chemoradiation. Overall survival was not significantly different between the propensity-matched groups. Surgical approach and pathologic margin status were not independently associated with overall survival.
CONCLUSIONS
Among patients with clinical stage II anal adenocarcinoma who received chemotherapy and radiation, complete resection was significantly less likely with local excision compared to abdominoperineal resection, however, overall survival was not affected. Prospective studies of neoadjuvant chemoradiation followed by local excision are warranted.
Topics: Adenocarcinoma; Adult; Aged; Aged, 80 and over; Anus Neoplasms; Chemoradiotherapy; Cohort Studies; Female; Humans; Male; Margins of Excision; Middle Aged; Neoplasm Staging; Proctectomy; Propensity Score; Survival Rate; Treatment Outcome
PubMed: 33819849
DOI: 10.1016/j.suronc.2021.101551 -
Hernia : the Journal of Hernias and... Oct 2022Perineal hernia (PH) following abdominoperineal resection (APR) is a rare but challenging problem. Although different techniques have been described in literature, the...
PURPOSE
Perineal hernia (PH) following abdominoperineal resection (APR) is a rare but challenging problem. Although different techniques have been described in literature, the recurrence rate is still remarkable, and there is no consensus regarding the optimal repair approach. In the present study, we reported our experience based on a consecutive series of ten cases.
METHODS
Ten symptomatic large perineal hernias were repaired exclusively with the same laparoscopic-perineal dual fixation technique. Key steps consist laparoscopic adhesiolysis, hernia contents reduction, open excess perineal hernia sac resection, and mesh placement and dual fixation. Frist, a coated mesh was fixed to the sacrum and pelvic sidewalls with the metallic tacks in the laparoscopic step, second, the mesh was fixed anteriorly to urogenital diaphragm and laterally to the sacrotuberous ligament with permanent sutures in the perineal step.
RESULTS
Ten symptomatic PHs were repaired by the same laparoscopic-perineal dual fixation technique, 6 males and 4 females, median age at the time of repair was 69.5 years (range 66-77 years), the BMI was 24 ± 1. Four concomitant procedures were performed, including bilateral inguinal hernia repair with the transabdominal preperitoneal repair (TAPP) in one case, and laparoscopic parastomal hernia repair in two patients. The average operative time was 171 ± 45 min; the postoperative average hospital stay was 14 ± 4 days. There was no perineal hernia recurrence during the follow-up period (the median follow-up was 42 months; range 1-63 months).
CONCLUSION
Perineal hernia after APR is a rare and challenging postoperative complication, although many different approaches have been described, the recurrence is still high and the best method cannot be drawn. The present laparoscopic-perineal dual fixation approach proved to be a reproducible, effective and durable technique, and gave excellent results during the medium-long-term follow-up.
Topics: Aged; Female; Hernia; Hernia, Abdominal; Herniorrhaphy; Humans; Laparoscopy; Male; Proctectomy; Surgical Mesh
PubMed: 35652965
DOI: 10.1007/s10029-022-02632-8 -
World Journal of Gastroenterology Aug 2019Rectal cancer constitutes a major public health issue. Total mesorectal excision has remained the gold standard treatment for mid and low rectal tumors since its... (Review)
Review
Rectal cancer constitutes a major public health issue. Total mesorectal excision has remained the gold standard treatment for mid and low rectal tumors since its introduction in the late 1980s. Removal of all lymph nodes located in the mesorectum has indeed improved pathological and oncological outcomes. However, when cancer spreads to the lateral lymph nodes (located along the iliac and obturator arteries) Western and Japanese practices differ. Where the Western guidelines consider this condition as an advanced form of the disease and use neoadjuvant radiochemotherapy liberally, the Japanese guidelines define it as a local disease and proceed to lateral lymph node dissection with or without neoadjuvant treatment. Herein, we review the current literature regarding both therapeutic strategies, with the aim of contributing to potential improvements in treatment and outcome for patients with low and mid rectal cancer.
Topics: Chemoradiotherapy; Gastroenterology; Humans; Iliac Artery; Japan; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Medical Oncology; Neoadjuvant Therapy; Practice Guidelines as Topic; Proctectomy; Rectal Neoplasms; Treatment Outcome
PubMed: 31496614
DOI: 10.3748/wjg.v25.i31.4294 -
Annali Italiani Di Chirurgia 2021The improvement of surgical procedures and oncological outcomes in the treatment of low-ultralow rectal cancer, made important the evaluation of functional results. The...
INTRODUCTION
The improvement of surgical procedures and oncological outcomes in the treatment of low-ultralow rectal cancer, made important the evaluation of functional results. The aim of this study is to evaluate the functional results after open and laparoscopic approach.
PATIENTS AND METHODS
From our global experience, over the period 2000/2018, within the patients surgically treated for rectal cancer, we have gathered and studied 37 patients with low-ultralow site of lesion, submitted to sphincterpreserving surgery, subdivided based on the approach: 20 open, 17 laparoscopic, of which 8 robotic . For each type of procedure, as low and ultralow anterior resection, intersphinteric resection, abdominoperineal resection, were investigated functional outcomes, as bowel continence, urinary functions, male and female sexual functions, based on the following tests: Wexner Incontinence Score, International Prostatic Symptom Score, International Index of Erectile Function- 5, Female Sexual Function Index. The controls were performed before surgery and 3-6-12 months postoperatively. Statistical analisis: X2-test, impaired and paired t-test two tailed, Bonferroni post-hoctest.
RESULTS
The immediate surgical results and pathological features of the tumor are reported and evaluated. The evaluation of fecal continence in all patients submitted to rectal resection and primary anastomosis showed function compromission without differences statistically significant between the laparo and open approach. In the comparison between specific surgical procedures, the damage of continence function were more severe after intersphinteric resection mached with low-ultralow rectal resection. The rehabilitation therapies continued for several months after surgery showed clear improvement. The urinary continence, in male and female patients, did not show statistically significant alterations in the pre and postoperative comparison in relation to the approach and the type of resective intervention. The sexual function in male patients has had impairment after all type of surgical resection but the damage was more severe after intersphinteric resection. The female sexual function had not significant changes between pre and postoperative evaluation.
CONCLUSION
Bowel continence damage, urinary and sexual dysfunctions after surgical treatment for low-ultralow rectal cancer are frequent and form the low anterior resection syndrome. The severity of the syndrome is connected with the site of anastomosis. The rehabilitation therapies can play an important role in achieving the appreciable improvements of the functional alterations.
KEY WORDS
Laparoscopic surgery, Rectal cancer.
Topics: Female; Humans; Laparoscopy; Male; Postoperative Complications; Proctectomy; Rectal Neoplasms; Syndrome; Treatment Outcome
PubMed: 34548426
DOI: No ID Found -
International Journal of Colorectal... Oct 2022This study aimed to establish the functional impact of displacement of urogenital organs after abdominoperineal resection (APR) using validated questionnaires.
PURPOSE
This study aimed to establish the functional impact of displacement of urogenital organs after abdominoperineal resection (APR) using validated questionnaires.
METHODS
Patients who underwent APR for primary or recurrent rectal cancer (2001-2018) with evaluable pre- and postoperative radiological imaging and completed urinary (UDI-6, IIQ-7) and sexual questionnaires (male, IIEF; female, FSFI, FSDS-R) were included from 16 centers. Absolute displacement of the internal urethral orifice, posterior bladder wall, distal end of the prostatic urethra, and cervix were correlated to urogenital function by calculating Spearman's Rho (ρ). Median function scores were compared between minimal or substantial displacement using median split.
RESULTS
There were 89 male and 36 female patients included, of whom 45 and 19 were sexually active after surgery. Absolute displacement of the internal urethral orifice and posterior bladder wall was not correlated with UDI-6 in men (ρ = 0.119 and ρ = 0.022) nor in women (ρ = - 0.098 and ρ = - 0.154). In men with minimal and substantial displacement of the internal urethral orifice, median UDI-6 scores were 10 (IQR 0-22) and 17 (IQR 5-21), respectively, with corresponding scores of 25 (IQR 10-46) and 21 (IQR 16-36) in women. Displacement of the cervix and FSDS-R were correlated (ρ = 0.433) in sexually active patients.
CONCLUSION
This first analysis on functional impact of urogenital organ displacement after APR suggests that more displacement of the cervix might be associated with worse sexual function, while the data does not indicate any potential functional impact of bladder displacement. Studies are needed to further explore this underexposed topic.
Topics: Female; Humans; Male; Neoplasm Recurrence, Local; Proctectomy; Quality of Life; Sexual Behavior; Surveys and Questionnaires
PubMed: 36044045
DOI: 10.1007/s00384-022-04234-3 -
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 -
International Journal of Colorectal... May 2022Abdominoperineal resection (APR) has been considered to have a higher risk of local recurrence and poorer survival outcome than sphincter-saving operation (SSO) in...
Comparative survival risks in patients undergoing abdominoperineal resection and sphincter-saving operation for rectal cancer: a 10-year cohort analysis using propensity score matching.
PURPOSE
Abdominoperineal resection (APR) has been considered to have a higher risk of local recurrence and poorer survival outcome than sphincter-saving operation (SSO) in patients with rectal cancer. This study compared long-term oncologic outcomes and prognostic parameters in propensity score-matched patients who underwent APR and SSO.
METHODS
This study analyzed 958 consecutive patients with lower rectal cancer who underwent preoperative chemoradiotherapy followed by APR or SSO between 2005 and 2015. Propensity score matching analysis was performed to adjust baseline characteristics, including clinical stage, tumor distance from the anal verge, and tumor size.
RESULTS
In the entire cohort, the APR group had larger and lower tumors and showed significantly shorter 5-year disease-free survival (DFS) than the SSO group (64.5% vs. 75.8%, p = 0.01). After propensity score matching, there were no significant between-group differences in local (9.5% vs. 8.0%, p = 0.59) and systemic (27.9% vs. 23.4%, p = 0.3) recurrence rates, and 5-year DFS (67.5% vs. 69.9%, p = 0.49) and overall survival (80.8% vs. 82.9%, p = 0.65) rates. A lower number of lymph nodes retrieved was independently associated with recurrence and survival outcomes in the APR group, whereas poorly differentiated histology was an independent associated parameter in the SSO group. Advanced stage and perineural invasion were identified as independent prognostic parameters in both groups.
CONCLUSIONS
This study indicated that the long-term oncologic outcomes of APR were comparable to those of SSO. Because prognostic parameters associated with oncologic outcomes differed between the respective procedures, correctable parameters could be ameliorated through complete total mesorectal excision and personalized systemic treatment.
Topics: Cohort Studies; Humans; Neoplasm Recurrence, Local; Proctectomy; Propensity Score; Rectal Neoplasms; Retrospective Studies; Treatment Outcome
PubMed: 35378615
DOI: 10.1007/s00384-022-04138-2 -
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