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Journal of Gastrointestinal Surgery :... Aug 2018Management of low rectal cancer continues to be a challenge, and decision making regarding the need for an abdominoperineal resection (APR) in patients with low-lying... (Review)
Review
BACKGROUND
Management of low rectal cancer continues to be a challenge, and decision making regarding the need for an abdominoperineal resection (APR) in patients with low-lying tumors is complicated. Furthermore, choices need to be made regarding need for modification of the surgical approach based on tumor anatomy and patient goals.
DISCUSSION
In this article, we address patient selection, preoperative planning, and intraoperative technique required to perform the three types of abdominoperineal resections for rectal cancer: extrasphincteric, extralevator, and intersphincteric. Attention is paid not only to traditional oncologic outcomes such as recurrence and survival but also to patient-reported outcomes and quality of life.
Topics: Abdomen; Evidence-Based Medicine; Humans; Margins of Excision; Neoplasm Recurrence, Local; Patient Selection; Perineum; Proctectomy; Quality of Life; Rectal Neoplasms; Survival Rate
PubMed: 29663303
DOI: 10.1007/s11605-018-3750-9 -
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 -
World Journal of Surgical Oncology Dec 2023Robot-assisted surgery has proven to be a safe and feasible approach for the management of rectal cancer, including abdominoperineal resection (APR). However, it often...
BACKGROUND
Robot-assisted surgery has proven to be a safe and feasible approach for the management of rectal cancer, including abdominoperineal resection (APR). However, it often incurs longer operative times and higher costs. This study aimed to overcome these limitations by adopting a synchronous approach utilizing an optimized team composition.
METHODS
Data on patients who underwent robot-assisted APR at our facility between June 2022 and June 2023 were analyzed. The key points of the optimized approach included the following: At the start of the surgery, the surgeon performed an anococcygeal ligament resection from the perineal side while the bedside assistants set up the ports. Then, through console manipulation, the presacral fascia, elevated by previously placed gauze, was easily and safely incised, providing access to the perineal region.
RESULTS
A total of nine patients were included in this study. The median operation time was 231 min, and the intraoperative blood loss was 170 ml. The operation time was reduced to 167.5 min, and the blood loss was 80.5 ml in cases without a trainee. Surgical site infections, classified as Clavien-Dindo grade II complications, were observed in two cases, but no obvious urinary or erectile dysfunction was observed.
CONCLUSION
The study results indicate that the challenges associated with APR can be efficiently addressed without requiring additional personnel by streamlining team composition and the synchronous approach. This optimization strategy minimizes the need for a larger surgical team, while maximizing the utilization of surgical time and resources.
Topics: Male; Humans; Robotic Surgical Procedures; Proctectomy; Rectal Neoplasms; Retrospective Studies; Treatment Outcome; Laparoscopy
PubMed: 38124092
DOI: 10.1186/s12957-023-03260-x -
Chirurgia (Bucharest, Romania : 1990) Oct 2021The present study compares abdominoperineal resection (APR) performed by minimally invasive and open approach, regarding preoperative selection criteria, intraoperative...
The present study compares abdominoperineal resection (APR) performed by minimally invasive and open approach, regarding preoperative selection criteria, intraoperative and early postoperative aspects, in choosing the suitable technique performed by surgical teams with experience in both open and minimally invasive surgery (MIS). This is a retrospective study, conducted between 2008-2020. Two hundred thirty-three patients with APR performed for low rectal or anal cancer were included. The cohort was divided into two groups, depending on the surgical approach used: Minimally Invasive Surgery (laparoscopic and robotic procedures) and Open Surgery (OS). The perioperative characteristics were analyzed in order to identify the optimal approach and a possible selection criteria. We identified a high percentage of patients with a history of abdominal surgery in the open group (p = .0002). Intraoperative blood loss was significantly higher in the open group (p= .02), with an increased number of simultaneous resections (p = .041). The early postoperative outcome was marked by significantly lower morbidity in the MIS group (p = .005), with mortality recorded only in the open group (3 cases), in patients that associated severe comorbidities. The hystopathological results identified a significant number of patients with stage T2 in the MIS group (p= .037). Minimally invasive surgery provides a major advantage to APR, by avoiding an additional incision, the specimen being extracted through the perineal wound. The success of MIS APR seems to be assured by a good preoperative selection of the patients, alongside with experienced surgical teams in both open and minimally invasive rectal resections. The lack of conversion identified in robotic APR confirm the technical superiority over laparoscopic approach.
Topics: Humans; Laparoscopy; Proctectomy; Rectal Neoplasms; Retrospective Studies; Robotic Surgical Procedures; Treatment Outcome
PubMed: 34749853
DOI: 10.21614/chirurgia.116.5.573 -
Laparoscopic Abdominoperineal Resection With Bilateral Seminal Vesicle Excision: Video Presentation.Diseases of the Colon and Rectum Feb 2023
Topics: Male; Humans; Seminal Vesicles; Laparoscopy; Abdomen; Proctectomy; Biopsy; Rectal Neoplasms
PubMed: 36538679
DOI: 10.1097/DCR.0000000000002449 -
Journal of the American College of... Dec 2018
Topics: Myocutaneous Flap; Perforator Flap; Perineum; Proctectomy; Rectus Abdominis
PubMed: 30470281
DOI: 10.1016/j.jamcollsurg.2018.10.006 -
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 -
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 -
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 -
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