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Surgical Endoscopy May 2022Extraperitoneal colostomy (EPC) after laparoscopic abdominoperineal resection (APR) remains a challenge for surgeons. This study aims to summarize our laparoscopic EPC...
BACKGROUND
Extraperitoneal colostomy (EPC) after laparoscopic abdominoperineal resection (APR) remains a challenge for surgeons. This study aims to summarize our laparoscopic EPC method and assess its effects versus a transperitoneal colostomy (TPC) for patients with rectal tumors.
METHODS
A total of 133 patients with rectal cancer treated with laparoscopic APR between May 2009 and May 2020 were retrospectively reviewed. The clinical data, including demographics, comorbidities, tumor stage, colostomy duration, and complications were compared between the EPC group and the TPC group.
RESULTS
The EPC group included 83 patients whose extraperitoneal tunnels were created using a cannula through a trocar port, and the TPC group included 50 patients whose stomata were formed traditionally. There were no differences in colostomy time [(23.1 ± 6) min vs. (21.4 ± 4) min, P = 0.078], number of parastomal dermatitis patients (5 vs. 2, P = 0.916), or number of stomal stenoses (1 vs. 1, P = 0.715) between the EPC and TPC groups. No cases of parastomal hernia developed in the EPC group, whereas 4 patients were diagnosed with a parastomal hernia; the difference between the two groups was statistically significant (P = 0.036).
CONCLUSIONS
Laparoscopic EPC have a lower incidence of parastomal hernia than TPC. It is easy and inexpensive to create an extraperitoneal tunnel using a cannula through a trocar port.
Topics: Cannula; Colostomy; Humans; Incisional Hernia; Laparoscopy; Proctectomy; Rectal Neoplasms; Retrospective Studies; Surgical Instruments
PubMed: 34160698
DOI: 10.1007/s00464-021-08621-9 -
Langenbeck's Archives of Surgery Aug 2023Empty pelvis syndrome (EPS) has been defined as a complications arising as a sequel of empty space created after extensive pelvic surgery involving perineal resection....
INTRODUCTION
Empty pelvis syndrome (EPS) has been defined as a complications arising as a sequel of empty space created after extensive pelvic surgery involving perineal resection. However this definition has been heterogenous throughout the limited literature available. Hence, EPS is a significant yet under recognized complication vexing both patients and surgeons. Even till date, prevention and management of EPS remain a challenge. Various preventive strategies have been employed each with its own complications. Few small studies mentioned incidence of this dreaded complication in between 20 and 40%. But most of these studies quote vague evidence and especially only after TPE surgeries. To the best of our knowledge, incidence after APR and PE has never been mentioned in literature.
PURPOSE
To assess the clinical burden of empty pelvis syndrome in patients undergoing abdominoperineal resection (APR), posterior exenteration (PE), or total pelvic exenteration (TPE) for low rectal cancers.
METHODS
This is a retrospective audit from a high-volume tertiary cancer center in India. Patients who underwent APR, PE, or TPE between the years 2013 to 2021 were screened and analyzed for incidence, presentation, and management of empty pelvic syndrome (EPS).
RESULTS
A total of 1224 patients' electronic medical records were screened for complications related to empty pelvis. The overall incidence of EPS was 95/1224 (7%) with 55/1024 (5%) in APR, 8/39 (20.5%) in PE, and 32/143 (21.9%) in TPE. The most common clinical presentation was small bowel obstruction 43/95 (45.2%) and most presented late, 56/95 (60%), i.e., after 30 days of surgery. Most of the patients who had EPS were managed conservatively 55/95 (57%).
CONCLUSION
EPS is a significant clinical problem that can lead to major morbidity, especially after exenterative surgeries warranting effective preventive strategies.
Topics: Humans; Retrospective Studies; Pelvis; Intestinal Obstruction; Perineum; Proctectomy; Neoplasms
PubMed: 37615748
DOI: 10.1007/s00423-023-03069-y -
Surgery Nov 2021Perineal wound complications after extralevator abdominoperineal resection for cancer are common with no consensus on optimal reconstructive technique. We compared... (Observational Study)
Observational Study
Perineal reconstruction after extralevator abdominoperineal resection: Differences among minimally invasive, open, or open with a vertical rectus abdominis myocutaneous flap approaches.
BACKGROUND
Perineal wound complications after extralevator abdominoperineal resection for cancer are common with no consensus on optimal reconstructive technique. We compared short- and long-term results of laparoscopic abdominoperineal resection with open surgery ± vertical rectus abdominis myocutaneous flap.
METHODS
This is a single-institution retrospective observational study of 204 consecutive patients with advanced low rectal cancer who underwent extralevator abdominoperineal resection from January 2010 to August 2020. Main outcome measures were short-term results, wound complications, and incisional, parastomal, and perineal hernia rates.
RESULTS
Fifty-five (27%) patients had a laparoscopic approach, 80 (39%) open, and 69 (33%) open + vertical rectus abdominis myocutaneous flap. The groups had similar median length of follow up (P = .75). Patients' age and radiation, intraoperative and postoperative complications, mortality, and readmission rates were similar among the 3 groups. Perineal wound infection and dehiscence rates were not influenced by surgical approach. Laparoscopy resulted in higher perineal (7.3 vs 2.5 vs 0%; P = .047) and parastomal (23.6 vs 13.8 vs 5.8%; P = .016) hernia rates than did open or open + vertical rectus abdominis myocutaneous flap. Patients who underwent an open approach had a higher body mass index and rate of prior surgeries and preoperative ostomies. Laparoscopic and open approaches had significantly shorter operative times (300 vs 303 vs 404 minutes, respectively; P < .001) and shorter length of stay (7.6 vs 10.8 vs 11.12, respectively; P = .006) compared to open with a flap approach.
CONCLUSION
Open and open + vertical rectus abdominis myocutaneous flap approaches for reconstruction after abdominoperineal resection had lower parastomal and perineal hernias rates but similar postoperative morbidity as did the laparoscopic approach.
Topics: Female; Follow-Up Studies; Humans; Male; Middle Aged; Minimally Invasive Surgical Procedures; Myocutaneous Flap; Perineum; Postoperative Care; Proctectomy; Plastic Surgery Procedures; Rectal Neoplasms; Rectum; Rectus Abdominis; Reoperation; Retrospective Studies
PubMed: 34144816
DOI: 10.1016/j.surg.2021.05.027 -
Diseases of the Colon and Rectum Sep 2020As multidisciplinary treatment modalities for rectal cancer continue to evolve, neoadjuvant chemoradiation then surgical resection is a common approach. Robotic-assisted...
INTRODUCTION
As multidisciplinary treatment modalities for rectal cancer continue to evolve, neoadjuvant chemoradiation then surgical resection is a common approach. Robotic-assisted abdominoperineal resection is becoming more prevalent in part because of better visualization and instrument mobility within the pelvis. After abdominoperineal resection, postoperative perineal wound complications remain a significant risk. Pelvic reconstruction lowers this risk, and a pedicled rectus abdominis muscle flap is frequently used to achieve this. Traditional flap harvest requires laparotomy, resulting in violation of both rectus sheaths and a large midline scar. Robotic harvest of the rectus abdominis muscle for pelvic reconstruction after abdominoperineal resection is a novel approach with foreseeable benefits.
TECHNIQUE
After completion of abdominoperineal resection, 2 additional trocars are inserted in the lateral abdomen, and the robot is reoriented toward the posterior abdominal wall. The peritoneum and posterior rectus sheath are incised, and dissection is carried superiorly and inferiorly in a sagittal plane to reveal the rectus abdominis muscle. The muscle body is separated from the anterior rectus sheath. Once the inferior epigastric artery is identified, the superior pole of the muscle is transected. Continued lateral dissection ensures flap mobility for placement within the pelvis. After obtaining proper reach, the robot is undocked, and the flap is sutured in place through the perineal defect.
RESULTS
After trocar placement and robot repositioning, both the colorectal and plastic surgeons trade places at the console. Robotic flap harvest precludes the need for laparotomy. The anterior rectus sheath remains unviolated and the patient avoids an additional midline scar. The aforementioned benefits of robot-assisted abdominoperineal resection, namely increased visualization and maneuverability, were also found applicable when robotically harvesting this flap.
CONCLUSIONS
This technique exemplifies an additional minimally invasive technique for patients pursuing abdominoperineal resection. With knowledge of this novel approach, surgeons can better tailor their operations to benefit the patient.
Topics: Colorectal Surgery; Humans; Minimally Invasive Surgical Procedures; Neoadjuvant Therapy; Perineum; Proctectomy; Plastic Surgery Procedures; Rectus Abdominis; Robotic Surgical Procedures; Surgery, Plastic; Surgical Flaps
PubMed: 33216503
DOI: 10.1097/DCR.0000000000001715 -
Diseases of the Colon and Rectum Aug 2023
Laparoscopic Abdominoperineal Resection With En Bloc Vaginal Resection and Immediate Neovaginal Reconstruction With Colonic Flap and Pelvic Floor Reconstruction With Mucosa-Removed Colonic Flap.
Topics: Female; Humans; Pelvic Floor; Surgical Flaps; Laparoscopy; Proctectomy; Mucous Membrane; Perineum; Rectal Neoplasms
PubMed: 37235861
DOI: 10.1097/DCR.0000000000002645 -
International Journal of Colorectal... May 2022Delayed perineal wound healing is a common complication after abdominoperineal resection (APR) in rectal cancer. The primary aim of this study was to evaluate the number...
PURPOSE
Delayed perineal wound healing is a common complication after abdominoperineal resection (APR) in rectal cancer. The primary aim of this study was to evaluate the number of patients with delayed wound healing after APR. Secondary aims were to identify risk factors, and describe treatment.
METHODS
Prospectively collected data from the Swedish Colorectal Cancer Registry (SCRCR) was used for retrospective analysis of APR performed at Skåne University Hospital Malmö between 2013 and 2018. Medical charts were retrospectively reviewed. Delayed healing was defined as non-healed perineal wound 30 days postoperatively. Patients undergoing extralevator APR requiring reconstruction were excluded. Statistical analysis was made using SPSS. Risk factors for impaired wound healing were analyzed using a multivariable model.
RESULTS
A total of 162 patients were included, of which 114 underwent standard APR (sAPR) and 48 patients intersphincteric APR (isAPR). In the total population, 69% (111/162) were male, with median age 71 (26-87). The overall healing rate was 52% (85/162); 44% (50/114) in sAPR vs 73% (35/48) in isAPR (P < 0.001). Risk factors for impaired healing after multivariable analysis were BMI > 30 (OR 7.0; CI 95% 1.8-26.2, P = 0.004), reoperation (OR 7.9; CI 95% 1.6-39.8, P = 0.013), neoadjuvant radiotherapy (OR 5.2; CI 95% 1.02-25.1, P = 0.047) and sAPR (OR 2.598; CI 95% 1.05-6.41, P = 0.038). Eight percent (13/162) required an intervention (Clavien-Dindo ≥ 3).
CONCLUSION
Delayed perineal wound healing is a frequent complication after APR but the majority could be treated conservatively. Several risk factors were identified. Further studies aiming at interventions reducing delayed perineal wound healing after APR are warranted.
Topics: Aged; Female; Humans; Male; Perineum; Postoperative Complications; Proctectomy; Rectal Neoplasms; Retrospective Studies; Wound Healing
PubMed: 35396618
DOI: 10.1007/s00384-022-04141-7 -
International Wound Journal Feb 2021We explored the effects of incisional negative pressure wound therapy in perineal wound infections after abdominoperineal resection. We retrospectively evaluated 146...
We explored the effects of incisional negative pressure wound therapy in perineal wound infections after abdominoperineal resection. We retrospectively evaluated 146 patients who underwent abdominal perineal resection from December 2004 to December 2019 and compared conventional gauze dressing (controls) with incisional negative pressure wound therapy. We compared patients' characteristics, surgical factors, and perineal infection rates between groups, and patients' characteristics, surgical factors, and negative pressure therapy use between perineal infection vs non-infection groups, as well as the risk factors for perineal infections. In the negative pressure therapy group, compared with controls, the number of men, smoking prevalence, blood transfusion, drainage via the perineal wound, and intraoperative blood loss were significantly lower (p < 0.05, p < 0.05, p < 0.05, p < 0.001, p < 0.01, respectively), and operation time was significantly longer (p < 0.05). Infections were significantly less common in the negative pressure group (p < 0.05). In the univariate analysis, the infection-positive group had significantly higher laparoscopic surgery (p < 0.01) and negative pressure wound therapy-free rates (p < 0.01), and significantly more intraoperative blood loss (p < 0.05). Multivariate analysis using these three factors and preoperative radiotherapy showed that incisional negative pressure wound therapy-free status was a risk factor for infection. Incisional negative pressure wound therapy was beneficial in managing perineal wound infections after abdominoperineal resection.
Topics: Adult; Aged; Aged, 80 and over; Female; Humans; Male; Middle Aged; Negative-Pressure Wound Therapy; Perineum; Proctectomy; Rectal Neoplasms; Retrospective Studies; Surgical Wound Infection
PubMed: 33236842
DOI: 10.1111/iwj.13499 -
Diseases of the Colon and Rectum May 2022Perineal hernia is a well-known, rare complication following abdominoperineal resection for rectal cancer. Due to its rarity, the literature on its surgical repair is...
BACKGROUND
Perineal hernia is a well-known, rare complication following abdominoperineal resection for rectal cancer. Due to its rarity, the literature on its surgical repair is comprised of case reports and small case series, and not one surgical approach has been established as superior.
OBJECTIVE
This study aimed to identify the repair methods used at our institution and their outcomes. We hypothesized that a perineal approach would have a similar recurrence rate to a transabdominal repair with shorter hospital length of stay.
DESIGN
This study was a retrospective case series.
SETTINGS
This study was conducted in a large, single institution setting.
PATIENTS
Patients who underwent surgical repair for perineal hernia from January 2009 to December 2019 were included.
MAIN OUTCOME MEASURES
The primary outcomes were perineal hernia recurrence, surgical approach to repair, and length of stay.
RESULTS
We identified 36 patients who underwent surgical repair of perineal hernia at our institution. Twenty patients received neoadjuvant chemoradiation therapy. Most patients (29) had previously undergone abdominoperineal resection; 5 were robotic, 15 were laparoscopic, 1 was robotic converted to open, and 8 were open. Patients were repaired through a perineal approach (22) or transabdominally (14). The median length of stay was 4 days (1-12) after a perineal approach and 8 days (3-18) after a transabdominal approach. At a median follow-up of 12.7 months (1-72), there were 4 recurrences after perineal repair and 3 recurrences after transabdominal repair.
LIMITATIONS
This study was limited by its small sample size (36), the retrospective and nonrandomized nature of the case series, and a lack of routine postoperative imaging. A median follow-up length of 12.7 months may not be adequate to detect all recurrences.
CONCLUSIONS
This case series supports the perineal approach for surgical repair; it should be the first approach considered, as it is less invasive and may be associated with shorter length of stay compared to an open transabdominal approach. Male gender and neoadjuvant chemotherapy may be possible risk factors for the development of perineal hernia after abdominoperineal resection. See Video Abstract at http://links.lww.com/DCR/B856.
REPARACIN QUIRRGICA DE HERNIA PERINEAL POSOPERATORIA UN CASO PARA EL ABORDAJE PERINEAL
ANTECEDENTES:La hernia perineal es una complicación rara y bien conocida después de la resección abdominoperineal por cáncer de recto. Debido a su rareza, la literatura sobre su reparación quirúrgica se compone de informes de casos y pequeñas series de casos, y ningún abordaje quirúrgico se ha establecido como superior.OBJETIVO:El presente estudio tuvo como objetivo identificar los métodos de reparación utilizados en nuestra institución y sus resultados. Presumimos que un abordaje perineal tendría una tasa de recurrencia similar a una reparación transabdominal, con una estancia hospitalaria más corta.DISEÑO:Ésta es una serie de casos retrospectiva.AJUSTES:El escenario fue una gran institución única.PACIENTES:Los pacientes que se sometieron a reparación quirúrgica por hernia perineal desde enero del 2009 hasta diciembre del 2019 se incluyeron en la revisión.PRINCIPALES MEDIDAS DE RESULTADO:Los resultados primarios fueron la recurrencia de la hernia perineal, el abordaje quirúrgico para la reparación y la duración de la estadía.RESULTADOS:Identificamos 36 pacientes que fueron sometidos a reparación quirúrgica de hernia perineal en nuestra institución. La mayoría de los pacientes recibieron quimiorradioterapia neoadyuvante (n = 20). La mayoría de los pacientes (n = 29) se habrían sometido previamente a una resección abdominoperineal (n = 5 robótica, n = 15 laparoscópica, n = 1 robótica convertida a abierta, n = 8 abierta). Los pacientes fueron reparados mediante un abordaje perineal (n = 22) o transabdominal (n = 14). La mediana de la estancia hospitalaria fue de 4 días (rango, 1-12) después de un abordaje perineal y de 8 días (rango 3-18) después de un abordaje transabdominal. En una mediana de seguimiento de 12,7 meses (rango, 1-72) hubo 4 recurrencias después de la reparación perineal y 3 recurrencias después de la transabdominal.LIMITACIONES:El tamaño de la muestra pequeño (n = 36), la naturaleza retrospectiva y no aleatorizada de la serie de casos, la falta de imágenes posoperatorias de rutina, la mediana de seguimiento de 12,7 meses puede no ser adecuada para detectar todas las recurrencias.CONCLUSIONES:Esta serie de casos apoya el abordaje perineal para la reparación quirúrgica; debe ser el primer abordaje considerado, ya que es menos invasivo y puede estar asociado con una estadía más corta en comparación con el abordaje transabdominal abierto. El sexo masculino y la quimioterapia neoadyuvante podrían ser posibles factores de riesgo para el desarrollo de hernia perineal después de la resección abdominoperineal. Consulte Video Resumen en http://links.lww.com/DCR/B856. (Traducción- Dr. Francisco M. Abarca-Rendon).
Topics: Humans; Incisional Hernia; Male; Postoperative Complications; Proctectomy; Rectal Neoplasms; Recurrence; Retrospective Studies
PubMed: 34907986
DOI: 10.1097/DCR.0000000000002374 -
Colorectal Disease : the Official... Jul 2022In low rectal cancers without sphincter involvement a permanent stoma can be avoided without compromising oncological safety. Functional outcomes following coloanal... (Meta-Analysis)
Meta-Analysis Review
AIM
In low rectal cancers without sphincter involvement a permanent stoma can be avoided without compromising oncological safety. Functional outcomes following coloanal anastomosis (CAA) compared to abdominoperineal excision (APR) may be significantly different. This study examines all available comparative quality of life (QoL) data for patients undergoing CAA versus APR for low rectal cancer.
METHODS
Published studies with comparative data on QoL outcomes following CAA versus APR for low rectal cancer were extracted from electronic databases. The study was registered with PROSPERO and adhered to PRISMA (Preferred Reporting Items in Systematic Reviews and Meta-analyses) guidelines. Data was combined using random-effects models.
RESULTS
Seven comparative series examined QoL in 527 patients. There was no difference in the numbers receiving neoadjuvant radiotherapy in the APR and CAA groups (OR: 1.19, 95% CI: 0.78-1.81, p = 0.43). CAA was associated with higher mean scores for physical functioning(std mean diff -7.08, 95% CI: -11.92 to -2.25, p = 0.004) and body image (std. mean diff 11.11, 95% CI: 6.04-16.18, p < 0.0001). Male sexual problems were significantly increased in patients who had undergone APR compared to CAA (std. mean diff -16.20, 95% CI: -25.76 to -6.64, p = 0.0009). Patients who had an APR reported more fatigue, dyspnoea and appetite loss. Those who had a CAA reported higher scores for both constipation and diarrhoea.
DISCUSSION
It is reasonable to offer a CAA to motivated patients where oncological outcomes will not be threatened. QoL outcomes appear to be superior when intestinal continuity is maintained, and permanent stoma avoided.
Topics: Humans; Male; Anal Canal; Anastomosis, Surgical; Proctectomy; Quality of Life; Rectal Neoplasms; Treatment Outcome
PubMed: 35194919
DOI: 10.1111/codi.16099 -
Asian Journal of Endoscopic Surgery Apr 2022In male patients with low rectal cancer undergoing abdominoperineal resection (APR), successful dissection of the anterior anorectum is key to reducing the risk of...
INTRODUCTION
In male patients with low rectal cancer undergoing abdominoperineal resection (APR), successful dissection of the anterior anorectum is key to reducing the risk of circumferential resection margin involvement, intraoperative bowel perforation, and local recurrence, but it is challenging. To overcome difficulties dissecting the anterior anorectum, we present a safe and feasible procedure using a transperineal endoscopic approach during APR (TpAPR).
MATERIALS AND SURGICAL TECHNIQUE
The male patient is placed in the prone jackknife position. TpAPR precedes the procedure from an abdominal approach. We use some pelvic tissues as clear anatomical landmarks to dissect the anterior anorectum. The key steps of this procedure are shown in the video.
DISCUSSION
The identification of a clear anatomical dissection plane of the anterior anorectum is difficult because of the complex surgical anatomy of the region. Clear anatomical landmarks for dissection of the anterior anorectum are necessary for safe implementation of this procedure. Therefore, TpAPR in the prone jackknife position can be performed to obtain better visualization of each anatomical landmark at a glance.
Topics: Humans; Male; Patient Positioning; Perineum; Proctectomy; Prone Position; Rectal Neoplasms; Treatment Outcome
PubMed: 34655173
DOI: 10.1111/ases.13001