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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 -
Surgery Mar 2021Surgery for low rectal cancer can be associated with severe bowel dysfunction and impaired quality of life. It is important to determine how patients value the trade-off...
BACKGROUND
Surgery for low rectal cancer can be associated with severe bowel dysfunction and impaired quality of life. It is important to determine how patients value the trade-off between anorectal dysfunction versus abdominoperineal resection. Therefore, the objective was to determine patients' preferences for treatment for low rectal cancer.
METHODS
Ambulatory patients without colorectal cancer at a single high-volume academic colorectal referral center from September 2019 to March 2020 were included. Patients with prior stoma or malignancy were excluded. Participants were presented with a hypothetic scenario describing a low rectal cancer. A threshold task identified preferences for functional and oncologic outcomes for sphincter preservation versus abdominoperineal resection.
RESULTS
A total of 123 patients were recruited. Patients preferred abdominoperineal resection over sphincter preservation if there were more than a mean of 6.7 (standard deviation 4.0) daily bowel movements, 1.9 (standard deviation 2.6) daily episodes of stool incontinence, and 6.5 (standard deviation 3.2) gas incontinence. Abdominoperineal resection was preferred over sphincter preservation in 38% if daily activities were altered owing to fecal urgency. Patients were willing to accept a 10% (interquartile range, 5-25) absolute increase in risk of margin involvement with sphincter preservation to avoid abdominoperineal resection. Abdominoperineal resection was the preferred option overall for 18% of patients.
CONCLUSION
An important proportion of patients would prefer abdominoperineal resection over sphincter preservation owing to the impairments in anorectal function associated with sphincter preservation. The decision to perform sphincter preservation or abdominoperineal resection should consider how the patients' value functional outcomes with a low anastomosis.
Topics: Adult; Aged; Anal Canal; Fecal Incontinence; Female; Humans; Male; Middle Aged; Organ Sparing Treatments; Patient Preference; Proctectomy; Rectal Neoplasms
PubMed: 32854970
DOI: 10.1016/j.surg.2020.07.020 -
Diseases of the Colon and Rectum Jun 2023
Topics: Humans; Robotic Surgical Procedures; Robotics; Rectum; Proctectomy; Laparoscopy
PubMed: 36876981
DOI: 10.1097/DCR.0000000000002614 -
Colorectal Disease : the Official... Nov 2021This study aimed to quantify displacement of urogenital organs after abdominoperineal resection (APR), and to explore patient and treatment characteristics associated...
AIM
This study aimed to quantify displacement of urogenital organs after abdominoperineal resection (APR), and to explore patient and treatment characteristics associated with displacement.
METHOD
Patients from 16 centres who underwent APR for primary or recurrent rectal cancer (2001-2018) with evaluable preoperative and 6-18 months postoperative radiological imaging were included in the study. Anatomical landmarks on sagittal images were related to a coordinate system based on reference lines between fixed bony structures and absolute displacements were calculated using the Pythagorean theorem. Rotation of landmarks was measured relative to a pubic-S5 reference line.
RESULTS
There were 248 patients included of which 171 were men and 77 women. The median displacement of the internal urethral orifice was 25 mm in men (maximum 65), and 17 mm in women (maximum 50). Rotation of the internal urethral orifice was in a caudal direction in 160/170 (94%) of men and 65/73 (89%) of women, with a median of 32 degrees (maximum 85) and 33 degrees (maximum 83), respectively. Displacements of the posterior bladder wall, distal end of prostatic urethra and cervix were significantly correlated with the internal urethral orifice. In linear regression analysis, biological mesh reconstruction of the pelvic floor and visceral interposition were significantly associated with increased displacement of the internal urethral orifice, and female gender and any filling of the presacral space with decreased displacement.
CONCLUSIONS
Substantial absolute displacement and rotation of urogenital organs after APR for rectal cancer were observed, but with high variability among both men and women, and being significantly associated with reconstructive interventions.
Topics: Female; Humans; Male; Neoplasm Recurrence, Local; Pelvic Floor; Perineum; Proctectomy; Rectal Neoplasms; Urethra
PubMed: 34427972
DOI: 10.1111/codi.15885 -
Polski Przeglad Chirurgiczny Apr 2022<b>Introduction:</b> Perineal hernia (PH), also termed pelvic floor hernia, is a protrusion of intraabdominal viscera into the perineum through a defect in...
<b>Introduction:</b> Perineal hernia (PH), also termed pelvic floor hernia, is a protrusion of intraabdominal viscera into the perineum through a defect in the pelvic floor. </br></br> <b>Aim:</b> The study was conducted to evaluate the cases of perineal hernia resulting as a complication of abdominoperineal resection (APR) of rectal cancer. </br></br> <b> Material and methods:</b> 30 cases from 24 articles published in reputable peer reviewed journals were evaluated for eight variables including [I] patient age, [II] gender, [III] time since APR, [IV] clinical presentation, [V] approach to repair, [VI] type of repair, [VII] presence/absence of pelvic adhesions [VIII] complications. </br></br> <b>Results:</b> There was a total of 30 cases (18 males and 12 females) with a mean age of 71.5 years. The time of onset of symptoms ranged from 6 days to 12 years. Perineal lump with pain was the chief presenting feature followed by intestinal obstruction. Different approaches were adopted to repair by various methods. </br></br> <b>Conclusions:</b> Perineal hernia as a complication of abdominoperineal resection is reported increasingly nowadays, as the approach to management of rectal cancer has gradually got shifted from open to minimally invasive in recent years. There is a need to spread awareness about this condition, so that it is actively looked for, during the postoperative follow-up. Management is surgical repair; the approach and type of repair should be individualized.
Topics: Female; Male; Humans; Aged; Proctectomy; Rectal Neoplasms; Intestinal Obstruction; Abdominal Cavity; Hernia
PubMed: 36468514
DOI: 10.5604/01.3001.0015.7677 -
Diseases of the Colon and Rectum Dec 2022A robotic approach to total colectomy/proctectomy and ileal pouch reconstruction would seem to be a sensible use of the platform's enhanced reach, visualization, and...
BACKGROUND
A robotic approach to total colectomy/proctectomy and ileal pouch reconstruction would seem to be a sensible use of the platform's enhanced reach, visualization, and dexterity.
OBJECTIVE
The study aimed to discuss current published data for robotic ileal pouch surgery.
STUDY SELECTION
The study selection included a paucity of published data to date, representing early learning curves and case series with small numbers.
CONCLUSIONS
Current robotic platforms may offer advantages, particularly in the low pelvis beyond what is found with a laparoscopic approach.
Topics: Humans; Robotic Surgical Procedures; Colitis, Ulcerative; Colonic Pouches; Colectomy; Proctectomy; Laparoscopy; Proctocolectomy, Restorative; Treatment Outcome
PubMed: 35867639
DOI: 10.1097/DCR.0000000000002549 -
The International Journal of Medical... Apr 2020Laparoscopic abdominoperineal resection (APR) for low rectal cancers is technically demanding. Robotic assistance may be of help and can be hybrid (HAPR) or totally... (Comparative Study)
Comparative Study
INTRODUCTION
Laparoscopic abdominoperineal resection (APR) for low rectal cancers is technically demanding. Robotic assistance may be of help and can be hybrid (HAPR) or totally robotic (RAPR). The present study describes outcomes of robotic APR and compares both approaches.
MATERIAL AND METHODS
A multicentric retrospective analysis of rectal cancer patients undergoing either HAPR or RAPR was conducted. Patients' demographics, surgeons' experience, oncologic results, and intraoperative and postoperative outcomes were collected.
RESULTS
One hundred twenty-five patients were included, 48 in HAPR group and 77 in RAPR group. Demographics and comorbidities were comparable. Operative time was reduced in RAPR group (266.9 ± 107.8 min vs 318.9 ± 75.1 min, P = .001). RAPR patients were discharged home more frequently (91.18% vs 66.67%, P = .001), and experienced fewer parastomal hernias (3.71% vs 9.86%, P = .001).
CONCLUSION
RAPR is safe and feasible with appropriate oncologic outcomes. Totally robotic approach reduces operative time and may improve functional outcomes.
Topics: Aged; Equipment Design; Female; Humans; Intraoperative Period; Laparoscopy; Male; Middle Aged; Operative Time; Postoperative Complications; Postoperative Period; Proctectomy; Rectal Neoplasms; Retrospective Studies; Robotic Surgical Procedures; Treatment Outcome; United States
PubMed: 31876089
DOI: 10.1002/rcs.2073 -
Colorectal Disease : the Official... Jun 2024There is ongoing controversy regarding the extent to which Hartmann's procedure (HP) should be used in rectal cancer treatment. This study was designed to investigate... (Comparative Study)
Comparative Study
AIM
There is ongoing controversy regarding the extent to which Hartmann's procedure (HP) should be used in rectal cancer treatment. This study was designed to investigate 30-day postoperative morbidity and mortality following HP, anterior resection (AR) and abdominoperineal resection (APR) for rectal cancer using a national registry.
METHODS
All patients operated for rectal cancer, tumour height 5-15 cm, between the years 2010 and 2017, were identified through the Swedish colorectal cancer registry.
RESULTS
A total of 8476 patients were included: 1210 (14%) undergoing HP, 5406 (64%) AR and 1860 (22%) APR. HP was associated with an increased risk of intra-abdominal infection (OR 1.7, CI 1.26-2.28, P = 0.0004) compared to AR and APR, while APR was related to an increased risk of overall complications (OR 1.18, CI 1.01-1.40, P = 0.040). No significant difference was observed in the rate of reoperations and readmissions between HP, AR and APR, and type of surgical procedure was not a risk factor for 30-day mortality. Findings from a subgroup analysis of patients with a tumour 5-7 cm from the anal verge revealed that HP was not associated with increased risk for complications or 30-day mortality.
CONCLUSIONS
For patients where AR is not appropriate HP is a valid alternative with a favourable outcome. APR was associated with the highest overall 30-day complication rate.
Topics: Humans; Rectal Neoplasms; Male; Female; Aged; Proctectomy; Postoperative Complications; Middle Aged; Sweden; Registries; Reoperation; Risk Factors; Colostomy; Aged, 80 and over; Patient Readmission; Intraabdominal Infections
PubMed: 38802985
DOI: 10.1111/codi.17033 -
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 -
Surgical Endoscopy Apr 2022Sphincter-saving operation is the treatment of choice in patients with lower rectal cancer, although abdominoperineal resection (APR) is necessary in some cases for...
BACKGROUND
Sphincter-saving operation is the treatment of choice in patients with lower rectal cancer, although abdominoperineal resection (APR) is necessary in some cases for adequate oncological outcomes. This study compared the oncologic outcomes of patients with low rectal cancer undergoing APR and intersphincteric resection (ISR) after neoadjuvant chemoradiotherapy (nCRT).
METHODS
We compared 104 patients who underwent ISR for lower rectal cancer between 2008 and 2014 with 79 patients who underwent APR during the same period. Cases in which tumors involved the levator ani muscle or the external anal sphincter, as well as those in which surgeons were unable to obtain a negative distal margin via sphincter-saving operation were excluded. Fifty-two patients who underwent ISR were matched via propensity scoring with 52 patients who underwent APR. The analyzed variables included patient and tumor characteristics and long-term outcomes before and after 1:1 propensity score matching (PSM).
RESULTS
After matching, there were no significant differences between the two groups in clinical stage and tumor distance from anal verge. Short- and long-term outcomes were similar between the two groups. The 5-year disease-free survival rate was 76.3% in the ISR group and 57.8% in the APR group (p = 0.080). The 5-year cancer-specific survival rate was 89.5% in the ISR group and 85.4% in the APR group (p = 0.383).
CONCLUSIONS
This reveals that ISR and APR have similar oncologic outcomes following nCRT in patients with advanced low rectal cancer adjusted for background variables.
Topics: Anal Canal; Humans; Neoadjuvant Therapy; Proctectomy; Propensity Score; Rectal Neoplasms; Treatment Outcome
PubMed: 34008108
DOI: 10.1007/s00464-021-08558-z