P-0293 Benefits From The Abdominosacral Approach In Prone Jackknife Position In Patients With Low Rectal Cancers – Virtual Surgery

Abstract

ABSTRACT Introduction From the oncological surgeon's perspective, rectal cancers constitute a more serious challenge than tumors located in the remaining parts of the large intestine. This is related to the fact that the rectum lies extraperitoneally in the pelvic cavity. Anatomical relationships in the minor pelvis markedly hinder the possibilities of retaining oncological aseptics and completeness of resection – particularly in the case of low-rectal tumors. At the onset of the 21st century, surgical treatment of most low-rectal tumors is based on the technique of abdominoperineal resection (APR), which was proposed by Miles as early as 1908. Optimal resection of the primary tumor, along with the area of its lymphatic drainage, is virtually impossible using this technique due to the previously mentioned anatomical relationships. These limitations are reflected by the high frequencies of isolated local recurrence and poor survival rates in patients subjected to APR. Due to obvious reasons, recent years have been a period of an ongoing search for novel surgical techniques that would replace “historical” APR. “Conservative” and “radical” approaches may be distinguished among attempts at surgical treatment optimization. Methods The “radical” approach involved the implementation of a technique of abdominosacral amputation of the rectum (ASAR) which was developed at our clinic. The idea behind this method is a sacral approach in a prone jackknife position by means of coccygectomy, along with the removal of terminal segments of the sacrum when needed. The free surgical approach enables sharp dissection under direct vision and guarantees optimal resection of CRM-negative surgical specimens. Since the ASAR technique has been improved upon for over a decade, its long-term therapeutic results are already available. These results are as favorable as those obtained by means of TME in upper- and mid-rectal cancer cases. Along with low morbidity rates, these results suggest that ASAR should be implemented as a routine technique for low-rectal cancer resection. The aim of this report is to share our nearly 15-year experiences with ASAR and present technical details of this procedure suing the form of “virtual surgery.” Results Between February 15th, 1998 and February 15th, 2012, 318 consecutive patients with stage II and III low-rectal adenocarcinomas (located within 6 cm from the anorectal junction) underwent ASAR at the 1st Department of Surgical Oncology, Regional Comprehensive Cancer Center (RCCC) in Wroclaw, Poland. Most patients had preoperative radiotherapy in accordance with compulsory standards. Our analysis included 277 low-rectal cancer patients operated on before February 15th, 2010 (i.e. with at least 2-year follow-up data). Five-year relative survival years and local recurrence rates determined in this group corresponded to 74% and 3.8%, respectively. Conclusion In conclusion, this analysis showed satisfactory outcomes of patients who were operated on by means of ASAR, and confirmed that extensive sacral approach during the second stage of this procedure raises possibilities of retaining oncological aseptics and completeness of the resection.