Cylindrical APR

30
CYLINDRICAL APR PETER HEWETT

description

 

Transcript of Cylindrical APR

Page 1: Cylindrical APR

CYLINDRICAL APRPETER HEWETT

Page 2: Cylindrical APR

DOORS OF DUBLIN

Page 3: Cylindrical APR

DOORS OF ZANZIBAR

Page 4: Cylindrical APR

British Journal of SurgeryVolume 97, Issue 4, pages 588–599, April 2010

RECTUMS OF EUROPE

Page 5: Cylindrical APR

Local recurrence has not improved to the same degree as seen with anterior resection after the introduction of TME.

Significant reduction in tissue volume around the tumour in APR specimens compared with Anterior resection specimens

Greater CRM positivity Greater local recurrence Poorer 5 year cancer specific survival

Page 6: Cylindrical APR
Page 7: Cylindrical APR
Page 9: Cylindrical APR
Page 10: Cylindrical APR
Page 11: Cylindrical APR

Cylindrical AP Resection

Mobilisation of the mesorectum down to the origins of the levator muscles.

Stoma formation and closure Patient is rotated into the prone

position Extended perineal resection

Page 12: Cylindrical APR

Extended Perineal resection Excision of the sphincter complex Follows the inferior surface of the

levators to a point laterally where they originate from the pelvic sidewall

The point should be just inferior to the level where the abdominal procedure was terminated

Coccyx can be removed in continuity with the main specimen

Repair of defect with a gluteal flap.

Page 13: Cylindrical APR
Page 14: Cylindrical APR
Page 15: Cylindrical APR
Page 16: Cylindrical APR
Page 17: Cylindrical APR
Page 18: Cylindrical APR
Page 19: Cylindrical APR
Page 20: Cylindrical APR

Advantages (literature)

Reduced rate of perforation Reduced rate of CRM 70% more tissue outside the internal

sphincter / muscularis propria at the tumour

14.5mm extra tissue posteriorly and 4mm at anterior and lateral margins at the tumour.

Page 21: Cylindrical APR

J Clin Oncol. 2008 Jul 20;26(21):3517-22. Epub 2008 Jun 9.

Evidence of the oncologic superiority of cylindrical abdominoperineal excision for low rectal cancer.

West NP, Finan PJ, Anderin C, Lindholm J, Holm T, Quirke P.

Pathology and Tumour Biology, Leeds Institute of Molecular Medicine, University of Leeds, United Kingdom. Karolinska University Hospital, Stockholm, Sweden

Page 22: Cylindrical APR

Extralevator APR removed more tissue from outside the smooth muscle layer per slice (median area 2120 versus 1259 mm2; P < 0·001) leading to a reduction in CRM involvement (from 49·6 to 20·3 per cent; P < 0·001) and IOP (from 28·2 to 8·2 per cent; P < 0·001) compared with standard surgery. However, extralevator surgery was associated with an increase in perineal wound complications (from 20 to 38·0 per cent; P = 0·019).

Page 23: Cylindrical APR

Multicentre experience with extralevator abdominoperineal excision for low rectal cancer†

N. P. West1,*, C. Anderin3, K. J. E. Smith2, T. Holm3, P. Quirke1

British Journal of SurgeryVolume 97, Issue 4, pages 588–599, April 2010

Page 24: Cylindrical APR

Advantages

Good visualisation anterior structures with plane easily seen and dissected

Easy control of bleeders Decreased perforation rate One surgeon Easy to teach Easy to assist Perineal operator does not get wet Possibly less blood loss

Page 25: Cylindrical APR

Disadvantages

Learning curve as to how far to dissect into the pelvis

Unaccustomed plane Coccygeal division leaves bare bone in

a potentially contaminated field. No further access to abdomen during

the perineal dissection No difference in postoperative

recovery Perineal wound complications

Page 26: Cylindrical APR

Tips

If the excised sigmoid colon is very fatty amputate it so that the rectum can be delivered easily.

If there is anterior attachment of the tumour take care in reflecting the rectum.

If possible mobilise an omental pedicle to place in the pelvis.

Remember the drain!

Page 27: Cylindrical APR

Tips

Page 28: Cylindrical APR
Page 29: Cylindrical APR

© The ASCRS 2010. 2

FIGURE 1.Pelvic Floor Reconstruction Using Human Acellular Dermal Matrix After Cylindrical Abdominoperineal Resection.Han, Jia; Wang, Zhen; Gao, Zhi; Xu, Hui; Yang, Zeng; Jin, Mu

Diseases of the Colon & Rectum. 53(2):219-223, February 2010.DOI: 10.1007/DCR.0b013e3181b715b5

FIGURE 1. Use of human acellular dermal matrix for reconstruction of pelvic floor.

Page 30: Cylindrical APR