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Surgery Mar 2023Prior studies evaluating the safety and efficacy of local excision relative to surgical resection in early-stage rectal adenocarcinoma have primarily included low rectal...
BACKGROUND
Prior studies evaluating the safety and efficacy of local excision relative to surgical resection in early-stage rectal adenocarcinoma have primarily included low rectal cancers treated with abdominoperineal resection as control comparison cohorts. The role of local excision in early-stage rectal adenocarcinoma is incompletely defined.
METHODS
We queried the National Cancer Database to identify patients with cT1 N0 M0 rectal adenocarcinoma between 2004 and 2019. Patients undergoing abdominoperineal resection were excluded. Multivariable regression was used to identify factors associated with use of local excision instead of low anterior resection. Patients undergoing local excision were propensity score matched for age, sex, demographic characteristics, Charlson-Deyo comorbidity class score, and tumor grade and size to those undergoing low anterior resection. Short-term clinical outcomes and 5-year overall survival for matched cohorts were compared by standard methods.
RESULTS
A total of 5,693 patients met inclusion criteria; 1,973 patients underwent local excision and 3,720 low anterior resection. Age (adjusted odds ratio 1.26; 95% confidence interval, 1.17-1.37), tumor histology (poorly differentiated histology: adjusted odds ratio 0.66; 95% confidence interval, 0.51-0.86), and size (>4 cm: adjusted odds ratio 0.20; 95% confidence interval, 0.16-0.25) were associated with choice of intervention. On comparison of matched cohorts, patients undergoing LE demonstrated shorter hospital stay (2.4 ±9.8 vs 5.6 ±8.1 days; P < .001) and lower readmission rate (4% vs 7%; P = .002) but higher margin-positive resection rates (8% vs 2%; P < .001). Overall survival profiles for patients undergoing local excision were comparable with those for low anterior resection.
CONCLUSION
In patients with cT1 N0 M0 rectal adenocarcinoma, local excision is associated with a higher margin-positive resection rate than low anterior resection but affords accelerated postprocedure recovery and comparable rates of overall survival.
Topics: Humans; Treatment Outcome; Adenocarcinoma; Rectal Neoplasms; Digestive System Surgical Procedures; Proctectomy; Retrospective Studies; Neoplasm Staging
PubMed: 36273975
DOI: 10.1016/j.surg.2022.08.040 -
ANZ Journal of Surgery Nov 2022Perineal wound morbidity following abdominoperineal resection (APR) is a significant challenge. Myocutaneous flap-based techniques have been developed to overcome...
BACKGROUND
Perineal wound morbidity following abdominoperineal resection (APR) is a significant challenge. Myocutaneous flap-based techniques have been developed to overcome morbidity associated with perineal reconstruction. We reviewed outcomes for patients undergoing APR in a hospital that performs inferior gluteal artery myocutaneous (IGAM) island transposition flaps and primary closure (PC) for perineal reconstruction.
METHODS
A retrospective study of patients who underwent APR for malignancy between January 2012 and March 2020 was performed and outcomes between IGAM reconstruction and PC compared. Primary outcomes were wound infection and dehiscence. Secondary outcomes included return to theatre, operative time, length of stay, flap loss and perineal hernia incidence.
RESULTS
One-hundred and two patients underwent APR, with 50 (49%) who had PC and 52 (51%) had IGAM flap reconstructions. There were no differences between each group with regards to wound infection (23 vs. 22%, P = 0.55) or wound dehiscence (25 vs. 24%, P = 0.92). Thirteen (25%) IGAM patients required a return to theatre compared to three PC patients (6%) (P = 0.008). IGAM procedures required twice the overall operative time (506 vs. 240 min, P = 0.001) with no differences between groups when comparing the APR component (250 vs. 240 min, P = 0.225). The IGAM group had a longer length of stay (median 13 days vs. 9 days, P = 0.001). Only one IGAM flap was lost and no symptomatic hernias were identified.
CONCLUSION
Perineal closure technique did not affect the incidence of wound infection or dehiscence. Closure technique should be tailored to underlying patient characteristics and surgical pathology.
Topics: Humans; Arteries; Myocutaneous Flap; Perineum; Postoperative Complications; Proctectomy; Plastic Surgery Procedures; Rectal Neoplasms; Retrospective Studies; Wound Infection
PubMed: 35604223
DOI: 10.1111/ans.17769 -
Gan To Kagaku Ryoho. Cancer &... Dec 2022Perineal wound complications(PWCs)are common after abdominoperineal resection(APR). We examined the incidence of PWCs after APR for anorectal lesions and their risk...
BACKGROUND
Perineal wound complications(PWCs)are common after abdominoperineal resection(APR). We examined the incidence of PWCs after APR for anorectal lesions and their risk factors.
METHODS
Patients who underwent APR for anorectal lesions at our hospital from January 2011 to December 2021 were included. Complications of Clavien-Dindo Grade Ⅱ or higher were considered as PWCs.
RESULTS
Eighty-one patients were included; PWCs were observed in 24 patients (29.6%), and associated with a history of Crohn's disease(p=0.018), longer operation time(p=0.040), higher blood loss (p=0.011), extensive perineal resection(p=0.003), and closure with a skin flap(p=0.003). Forty-one patients underwent APR for initial rectal cancer without extended perineal resection, and PWCs were observed in 9 patients(22.0%). Prognostic nutritional index(PNI)<45(p=0.049), smoking(p=0.034), and alcohol consumption(p=0.021)were associated with PWCs.
CONCLUSION
We examined the incidence of PWCs after APR for anorectal lesions and their risk factors. Appropriate intervention in nutrition, smoking, and alcohol consumption may prevent PWCs.
Topics: Humans; Surgical Flaps; Rectal Neoplasms; Plastic Surgery Procedures; Crohn Disease; Proctectomy; Perineum; Postoperative Complications; Retrospective Studies
PubMed: 36733046
DOI: No ID Found -
Asian Journal of Endoscopic Surgery Apr 2020Needlescopic surgery (NS) is a minimally invasive operation beyond traditional laparoscopic surgery. This study aimed to describe NS for intersphincteric resection (ISR)...
INTRODUCTION
Needlescopic surgery (NS) is a minimally invasive operation beyond traditional laparoscopic surgery. This study aimed to describe NS for intersphincteric resection (ISR) and abdominoperineal resection (APR) for low rectal cancer without a small abdominal skin incision for extracting the specimen and to evaluate the safety and feasibility of the operation.
METHODS
From January 2011 to April 2016, 36 patients underwent NS for either ISR or APR. By definition, NS for ISR or APR at our institution uses three 3-mm ports and two 5-mm ports at the umbilicus and in the right lower quadrant. The specimen was extracted through the anus or the perineal wound. The feasibility of this operation was determined based on short-term outcomes and pathological findings.
RESULTS
No patients required conversion to open surgery. The mean operation time was 299 minutes, and the mean estimated blood loss was 30 mL. Postoperative complications higher than Clavien-Dindo grade III occurred in 2.8% of patients (n = 1). The median number of harvested lymph nodes was 16 (range, 0-30), and in no case was there a positive circumferential resection margin.
CONCLUSIONS
Needlescopic surgery for ISR or APR is technically safe and feasible for low rectal cancer based on the short-term outcomes and the oncological quality, particularly when compared to conventional laparoscopic surgery as described in previous reports.
Topics: Adult; Aged; Aged, 80 and over; Feasibility Studies; Female; Humans; Laparoscopy; Length of Stay; Male; Middle Aged; Operative Time; Postoperative Complications; Proctectomy; Rectal Neoplasms; Retrospective Studies; Treatment Outcome
PubMed: 31282070
DOI: 10.1111/ases.12730 -
Annales de Chirurgie Plastique Et... Sep 2022Abdominoperineal resection (APR) of low rectal and anal tumors are performed for optimal oncological outcome but results in large defects in the perineum. Although... (Review)
Review
INTRODUCTION
Abdominoperineal resection (APR) of low rectal and anal tumors are performed for optimal oncological outcome but results in large defects in the perineum. Although vertical rectus abdominus (VRAM) flap is commonly employed for extensive perineal reconstruction, donor site morbidity remains problematic. The fascio-cutaneous "lotus petal" flap is an appealing option for reconstructing perineal defects as it may benefit from less donor site morbidity than other techniques. The purpose of this study is to demonstrate that the lotus flap should not only be limited to small and moderate sized defects, but can also be applied to extensive APR.
MATERIAL AND METHODS
A systematic review of the literature on the outcomes and dimensions of the lotus flap was performed. Articles with clear anatomical landmarks and internal pudendal artery flaps dimensions were identified. Afterwards, the lotus flap technique was applied on a series of patients with extensive perineal defects following APR treated in our center.
RESULTS
Four articles on internal pudendal artery perforator flap were selected. The average reported size of this flap was 13cm×6cm. In our center, reconstruction of the perineum with oversized lotus flaps was performed on 10 consecutive patients. None had partial/complete flap loss or donor-site morbidity. The use of a Jack-Knife surgical position, indocyanide green fluorescence imaging, and preservation of a proximal skin bridge can extend the size of a secure flap to up to 20cm in length.
CONCLUSION
The oversized lotus flap is a reliable option for reconstruction after extensive APR.
Topics: Anus Neoplasms; Humans; Myocutaneous Flap; Perforator Flap; Perineum; Proctectomy; Plastic Surgery Procedures
PubMed: 35773115
DOI: 10.1016/j.anplas.2022.06.001 -
Digestive Diseases (Basel, Switzerland) 2021Despite new medical and surgical strategies, 5-year local recurrence of rectal adenocarcinoma was reported in up to 25% of cases. Therefore, we aimed to review surgical... (Review)
Review
BACKGROUND
Despite new medical and surgical strategies, 5-year local recurrence of rectal adenocarcinoma was reported in up to 25% of cases. Therefore, we aimed to review surgical strategies for the prevention of local recurrences in rectal cancer.
SUMMARY
After implementation of the total mesorectal excision (TME), surgical resection of rectal adenocarcinoma with anterior resection or abdominoperineal excision (APE) allowed decrease in local recurrence (3% at 5 years). More recently, extralevator APE was described as an alternative to APE, decreasing specimen perforation and recurrence rate. Moreover, technique modifications were developed to optimize rectal resection, such as the laparoscopic or robotic approach, and transanal TME. However, the technical advantages conferred by these techniques did not translate into a decreased recurrence rate. Lateral lymph node dissection is another technique, which aimed at improving the long-term outcomes; nevertheless, there is currently no evidence to recommend its routine use. Strategies to preserve the rectum are also emerging, such as local excision, and may be beneficial for subgroups of patients. Key Messages: Rectal cancer management requires a multidisciplinary approach, and surgical strategy should be tailored to patient factors: general health, previous perineal intervention, anatomy, preference, and tumor characteristics such as stage and localization.
Topics: Adenocarcinoma; Aged; Female; Humans; Laparoscopy; Lymph Node Excision; Male; Middle Aged; Neoplasm Recurrence, Local; Proctectomy; Rectal Neoplasms; Risk Factors; Robotic Surgical Procedures; Treatment Outcome
PubMed: 33011726
DOI: 10.1159/000511959 -
Surgical Endoscopy Sep 2020Transanal total mesorectal excision (taTME) is a novel approach to surgery for rectal cancer. The technique has gained significant popularity in the surgical community...
INTRODUCTION
Transanal total mesorectal excision (taTME) is a novel approach to surgery for rectal cancer. The technique has gained significant popularity in the surgical community due to the promising ability to overcome technical difficulties related to the access of the distal pelvis. Recently, Norwegian surgeons issued a local moratorium related to potential issues with the safety of the procedure. Early adopters of taTME in Canada have recognized the need to create guidelines for its adoption and supervision. The objective of the statement is to provide expert opinion based on the best available evidence and authors' experience.
METHODS
The procedure has been performed in Canada since 2014 at different institutions. In 2016, the first Canadian taTME congress was held in the city of Toronto, organized by two of the authors. In early 2019, a multicentric collaborative was established [The Canadian taTME expert Collaboration] which aimed at ensuring safe performance and adoption of taTME in Canada. Recently surgeons from 8 major Canadian rectal cancer centers met in the city of Toronto on December 7 of 2019, to discuss and develop a position statement. There in person, meeting was followed by 4 rounds of Delphi methodology.
RESULTS
The generated document focused on the need to ensure a unified approach among rectal cancer surgeons across the country considering its technical complexity and potential morbidity. The position statement addressed four domains: surgical setting, surgeons' requirements, patient selection, and quality assurance.
CONCLUSIONS
Authors agree transanal total mesorectal excision is technically demanding and has a significant risk for morbidity. As of now, there is uncertainty for some of the outcomes. We consider it is possible to safely adopt this operation and obtain adequate results, however for this purpose it is necessary to meet specific requirements in different domains.
Topics: Canada; Consensus; Humans; Laparoscopy; Proctectomy; Rectal Neoplasms; Rectum; Surgeons; Transanal Endoscopic Surgery
PubMed: 32504263
DOI: 10.1007/s00464-020-07680-8 -
Diseases of the Colon and Rectum Nov 2022Flap-based reconstruction following abdominoperineal resection has been used to address the resultant soft tissue defect and reduce postoperative wound complications....
BACKGROUND
Flap-based reconstruction following abdominoperineal resection has been used to address the resultant soft tissue defect and reduce postoperative wound complications. Vertical rectus abdominis myocutaneous flaps have been the traditional choice, but locoregional flaps have attracted attention in minimally invasive resection because they avoid additional abdominal dissection. However, few data exist comparing flap types.
OBJECTIVE
To compare outcomes for different types of perineal reconstruction in patients undergoing abdominoperineal resection exclusively for anorectal pathology.
DESIGN
This was a retrospective comparative study.
SETTING
This study was conducted at a large, tertiary referral institution.
PATIENTS
Following Institutional Review Board approval, prospectively maintained clinical and financial databases were interrogated and cross-referenced for patients undergoing proctectomy or abdominoperineal resection with flap reconstruction from 2007 to 2018. Patients with primary gynecological or urological pathology were excluded.
MAIN OUTCOME MEASURES
The primary outcome was flap complication rate. Secondary outcomes included perineal hernia rate, donor site complications, emergency department consult after discharge, readmission <90 days, and length of stay. Data were analyzed using univariate and multivariate techniques.
RESULTS
A total of 135 patients (79 female, median age 58 years) were included: 68 rectus, 52 gluteal, and 15 gracilis flap reconstructions. Median follow-up was 46 months. Rates of both major and minor flap complications were similar for rectus and gluteal flaps, even when controlling for differences between groups via multivariate analysis ( p > 0.9), including extent of resection and use of mesh. For all flaps, American Society of Anesthesiology score ≥3 was the only independent predictor of major, but not minor, flap complications. For rectus and gluteal flaps, smoking, female sex, and American Society of Anesthesiology score ≥3 were independent predictors of major flap complications ( p < 0.05).
LIMITATIONS
This study was limited by its retrospective nature and potential selection bias associated with flap choice; it was also impossible to quantify defect size.
CONCLUSION
Gluteal flaps have similar complication rates to rectus flaps and may be considered for patients who are otherwise suitable for minimally invasive abdominoperineal resection. See Video Abstract at http://links.lww.com/DCR/B866 .Una comparación de los colgajos miocutáneos perineales después de la escisión abdominoperineal del recto para patología anorectal.
ANTECEDENTES
La reconstrucción con colgajo después de la resección abdominoperineal se ha utilizado para abordar el defecto de tejido blando resultante y reducir las complicaciones postoperatorias de la herida. Los colgajos miocutáneos verticales del recto abdominal han sido la elección tradicional, pero los colgajos locorregionales han atraído la atención en la resección mínimamente invasiva porque evitan la disección abdominal adicional. Sin embargo, existen pocos datos que comparen los tipos de colgajos.
Topics: Female; Humans; Middle Aged; Myocutaneous Flap; Postoperative Complications; Proctectomy; Rectal Neoplasms; Rectum; Retrospective Studies
PubMed: 35156364
DOI: 10.1097/DCR.0000000000002271 -
Colorectal Disease : the Official... Nov 2019
Topics: Colostomy; Hernia, Ventral; Humans; Proctectomy; Rectum; Surgical Mesh
PubMed: 31674123
DOI: 10.1111/codi.14873 -
Diseases of the Colon and Rectum Aug 2019Abdominoperineal resection is associated with a high incidence of perineal complications, and whether this is reduced by an omentoplasty is still unclear. (Comparative Study)
Comparative Study Observational Study
BACKGROUND
Abdominoperineal resection is associated with a high incidence of perineal complications, and whether this is reduced by an omentoplasty is still unclear.
OBJECTIVE
This study aimed to investigate the impact of omentoplasty on pelviperineal morbidity in patients undergoing abdominoperineal resection for rectal cancer.
DESIGN
This was a retrospective comparative cohort study using propensity score analyses to reduce potential confounding.
SETTING
The study was undertaken in 2 teaching hospitals and 1 university hospital.
PATIENTS
Patients who underwent abdominoperineal resection for primary rectal cancer between 2000 and 2017 were included.
MAIN OUTCOME MEASURES
The main end points were primary perineal wound healing at 30 days and overall and specific pelviperineal morbidity until the end of the study period.
RESULTS
Among 254 included patients, 106 had an omentoplasty. The primary perineal wound healing rate at 30 days was similar for omentoplasty and no omentoplasty (65% vs 60%; p = 0.422), also after adjusting for potential confounding by propensity score analysis (OR, 0.89; 95% CI, 0.45-1.75). Being free from any pelviperineal complication at 6 months (75% vs 79%; p = 0.492), absence of any pelviperineal morbidity until 1 year (54% vs 49%; p = 0.484), and incidence of persistent perineal sinus (6% vs 10%; p = 0.256) were also similar in both groups. The unadjusted higher perineal hernia rate after omentoplasty (18% vs 7%; p = 0.011) did not remain statistically significant after regression analysis including the propensity score (OR, 1.34; 95% CI, 0.46-3.88). Complications related to the omentoplasty itself were observed in 8 patients, of whom 6 required reoperation.
LIMITATIONS
This study was limited by the retrospective and nonrandomized design causing some heterogeneity between the 2 cohorts.
CONCLUSION
In this multicenter study using propensity score analyses, the use of omentoplasty did not lower the incidence or the duration of pelviperineal morbidity in patients undergoing abdominoperineal resection for rectal cancer, and omentoplasty itself was associated with a risk of reoperation. See Video Abstract at http://links.lww.com/DCR/A918.
Topics: Aged; Female; Follow-Up Studies; Humans; Incidence; Male; Netherlands; Omentum; Perineum; Postoperative Complications; Proctectomy; Propensity Score; Plastic Surgery Procedures; Rectal Neoplasms; Retrospective Studies; Treatment Outcome
PubMed: 30747743
DOI: 10.1097/DCR.0000000000001349