Extralevator abdominoperineal excision

Extralevator abdominoperineal

excision - APE

Extralevator abdominoperineal excision

- APE


- APEIntroduction• APR <> LAR

– Optimalisation surgical technique (TME)– Increasing rates – local control – survival

• APR– Tumors less than 6 cm– No optimalisation surgical technique –

perineal phase– More local recurrence <> LAR– Dutch TME trial LR 12% <> 29%–MERCURY trial LR 12% <> 33%


- APEIntroduction• APR - LAR

– Worse outcome <> LAR– Dutch TME-trial APR– CRM + LR 30% OS 38% – CRM - LR 9% OS 72%

– Significantly more inadvertent bowel perforation

AR APRNorway 4% 15%Sweden 3% 14%Holland 3% 14%

Extralevator abdominoperineal excision -

APEIntroduction

• APR– Difficult – conventional technique– High risk bowel perforation– Specimen waist lower border– CRM close rectum

– Study posterior perineal approach–More cylindrical specimen– Reduction bowel perforation –

positive CRM


APEIntroduction

– Conventional technique– Outside mesorectum – pelvic

floor–Mobilisation from levator

muscles– Excision anal canal –

ischiorectal fat – lower portion levator muscles– “Waist” surgical specimen


APEMethods

– APE – extended posterior perineal approach– No dissection mesorectum

off levator muscles– Stop mobilisation upper

border coccyx – below autonomic nerves – below vesicles


APEMethods

– Prone jack-knife position– Anus closed double purse-string suture– Dissection outside subcutaneous portion external

anal sphincter– Dissection outer surface levator muscles until

insertion pelvic side wall– Disarticulation coccyx– Division Waldeyer’s fascia – levator muscles– Dissection off prostate –posterior vagina


APEMethods


APEMethods• APR

– Wound complications– 35-66% (pre-op RTX – extensive

dissection)– Various flap techniques

– Gluteus maximus flap reconstruction– Arises iliac bone, sacrum – coccyx

and insertion lateral femur– Rotational musculocutaneous flap

based cranially– Large defect bilateral – based

cranially and distally


APEMethods

• Gluteus maximus flap reconstruction– Local anesthesia adrenaline– Subcutaneous tissue incised

gluteus maximus and fascia– 1/3rd muscle divided medial

border– Avoid sciatic nerve !– Further submuscular dissection

cranially and medially– Sutured four layers

»Muscle, Scarpa’s fascia, deep dermis, skin


APEMethods


APEMethods

• Gluteus maximus flap reconstruction

– Two drains (deep muscle – along flap subcutis)

– Kept 4-6 days

– Surgical tape dressing

– Decubital mattress

– Specific mobilisation schedule


APEResults

• Patient characteristics– 28 patients– 19 men and 9 women –

median age 66 (range 49-86 yrs)

– T3-T4 tumour lower rectum MRI

– All neoadjuvant treatment– 6 patients intraoperative

radiotherapy– Single surgeon performed

resection


APEResults

– Inadvertent bowel perforation 1 patient

– 23 patients unilateral flap – 5 bilateral– Operating time 80 min – 110 min– 3 wound infection of which 1 partial

wound rupture – 1 postoperative bleeding– 24 other primary healing no delay


APEResults

– Histopathological examination

– T0 2 patients, T3 20 patients, T4 6 patients

– CRM +(< 1mm) 2 patients (T4)

– Median FU 16 months (1-45)

– 2 patients local recurrence

– 8 patients died

– 4 no disease – 3 distant M+ – 1 local recurrence and distant M+


APEDiscussion

– Posterior perineal approach alternative conventional APR

–Poor results after APR

–APR common procedure tumours < 6 cm

–T1-T2 tumours utralow anterior resection partial resection IAS / less extensive posterior perineal resection

– Low rate perforation and CRM involvement

–LR rate 7% low T3-T4 tumours

–Short FU time


APEDiscussion

– Surgical technique posterior perineal approach

–No dissection mesorectum off levator muscles

–Perineal part prone jack-knife position

–Levator muscle resected en bloc anal canal

–Cylindrical specimen

–Lower risk LR and bowel perforation

–Excellent exposure


APEDiscussion

– Low rate perineal wound complications

–Extensive resection posterior perineal approach

–Flap reconstructions superior primary closure

–Intact muscular layers without strain

– Gluteus maximus flap superior

–Rectus abdominis flap technically more demanding

–Distant donor-site morbidity- denervated – not contractile

–No functional disordes – good cosmetic outcome

–Plastic surgeon

Thank you

Extralevator abdominoperineal excision

Health & Medicine

Transcript of Extralevator abdominoperineal excision