APR Technique of a wide perineal resection

Advanced Course on Rectal Cancer 8-10 September 2008 The Hague, The Netherlands
Torbjrn Holm MD PhD Section of Coloproctology Department of Surgery Karolinska University Hospital Stockholm, Sweden

Abdominoperineal resection in rectal cancer

Indications for APR in rectal cancer
Development of surgical perspectives

Problems associated with conventional APR

Bowel perforation Involved circumferential margin Perineal wound infection - dehiscence

Optimised technique in APR

Indications for APR in rectal cancer

Sir Ernest Miles (1869-1947)

Lancet 1908

Indications for APR in rectal cancer

Rates of APR varies significantly (<10% - 50%) Local recurrence rates higher after APR than AR Local recurrence rates after APR varies (5-30%) Higher local recurrence rates with low APR rates
Selection of distal, advanced tumours for APR?

Indications for APR in rectal cancer

Present indications specialised centres (tumours 0-5 cm above dentate line)
Distal resection margin < 1 cm ? Invaded external sphincter or levator ani Impaired anal function

< 10% APR overall ( RJ Heald)

Indications for APR in rectal cancer Reality

(tumours 0-6 cm above anal verge) APR performed in 75% in Sweden 2006 APR performed in 82% in Norway 1993-99 (Wibe et al.)

Conventional APR - synchronous combined

Dissection planes in conventional APR

Problems associated with APR

Inadvertent bowel perforation significantly more common after APR AR APR Norway Sweden Holland 4% 3% 3% 15% 14% 14%

Norwegian Rectal Cancer Group

Br J Surg 2004; 91: 210-16

Problems associated with APR

Tumour involved circumferential resection margin significantly more common after APR (CRM +ve) AR Dutch TME Trial MERCURY Trial 12% 12% APR 29% 33%

Data from the Dutch TME Trial

Local recurrence APR CRM + CRM 30 % 9% 38 % 72 % Survival

Nagtegaal et al. J Clin Oncol 23; 9257 9264, 2005

Optimised technique in APR -posterior perineal approach

Aim
Reduced rate of perforation Reduced rate of CRM+ Reduced rate of perineal wound infection

Improved oncological results

APR Posterior perineal approach

Patient in prone jack-knife position Surgeon between legs Assistants on each side Good exposure Sacral resection may be performed m. Gluteus maximus may be used as flap

The CRM is not formed by the sphincter muscles. The levator is resected en bloc the anal canal

Dissection planes in extended APR

Abdominal dissection stops above levator muscles Leaving levator muscles attached to the mesorectum

Posterior approach - good exposure in large, bulky tumours

The final part of a pelvic exenteration in locally advanced low rectal cancer may be performed by the posterior approach

Gluteus maximus flap Good postoperative cosmetic result

Data from Leeds and Stockholm

Conventional APR n= 101 Mean cross sectional tissue area/slice (mm2) around tumour Involved CRM 1411 Cylindrical APR n= 27 2550

p 0.0001

40.6%

14.8%

p=0.013

Bowel perforation

22.8%

3.7%

p=0.025

Extended APR Karolinska experience 2001-2007 60 patients Median follow-up 19 months (3-86)
Histo-pathological stage y p T0 y p T1 y p T2 y p T3 y p T4 3 (5 %) 3 (5 %) 12 (20 %) 26 (43 %) 16 (27%)

Extended APR Karolinska experience 2001-2007 60 patients

Neoadjuvant treatment
ypT0 n=3 No treatment RT only RT chemo 0 3 0 ypT1 n=3 1 0 2 ypT2 n=12 0 9 3 ypT3 n=26 1 18 7 ypT4 n=16 1 7 8 Total n=60 3 (5 %) 37 (62 %) 20 (33 %)

Extended APR Karolinska experience 2001-2007 60 patients

Outcome
ypT0 n=3 Bowel perforation CRM involvement R1 resection Local recurrence (median 19 months) Death (any cause) 0 0 0 0 ypT1 n=3 0 0 0 0 ypT2 n=12 0 0 0 0 ypT3 n=26 3 3 1 0 ypT4 n=16 2 7 7 2 Total n=60 5 (8%) 10 (17%) 8 (13%) 2 (3%)

16 (27%)

Karolinska Hospital Current treatment intention

T1 T2 tumours above anal canal

Preoperative radiotherapy + ultra low anterior resection with inter-sphincteric dissection

Karolinska Hospital Current treatment intention

T3 T4 tumours 0-5 cm above anal canal or fixed to pelvic floor, coccyx - sacrum Preoperative radio-chemotherapy + Abdominoperineal resection with posterior perineal approach

Conclusions
Cylindrical APR in the prone position removes more tissue around the tumour, leading to Reduced rates of: Bowel perforations Tumour positive resection margins This probably improves local control and survival