Abdominoperineal Resection For Low Rectal Cancer Research Articles

Operative Approach Does Not Impact Radial Margin Positivity in Distal Rectal Cancer

Robotic surgery is attractive for resection of low rectal cancer due to greater dexterity and visualization, but its benefit is poorly understood. We aimed to determine if operative approach impacts radial margin positivity (RMP) and postoperative outcomes among patients undergoing abdominoperineal resection (APR). This was a retrospective cohort study of patients from the National Surgical Quality Improvement Program who underwent APR for low rectal cancer from 2016 to 2019. Patients were stratified by operative approach: robotic, laparoscopic, and open APR (R-APR, L-APR, and O-APR). Emergent cases were excluded. The primary outcome was RMP. 30-day postoperative outcomes were also evaluated, using logistic regression analysis. Among 1,807 patients, 452 (25.0%) underwent R-APR, 474 (26.2%) L-APR, and 881 (48.8%) O-APR. No differences regarding RMP (13.5% R-APR vs. 10.8% L-APR vs. 12.3% O-APR, p = 0.44), distal margin positivity, positive nodes, readmission, or operative time were observed between operative approaches. Adjusted analysis confirmed that operative approach did not predict RMP (p > 0.05 for all). Risk factors for RMP included American Society of Anesthesiologists (ASA) classification III (ASA I-II ref; OR 1.46, p = 0.039), pT3-4 stage (T0-2 ref, OR 4.02, p < 0.001), pN2 stage (OR 1.98, p = 0.004), disseminated cancer (OR 1.90, p = 0.002), and lack of preoperative radiation (OR 1.98, p < 0.01). No difference in RMP was observed among R-APR, L-APR, and O-APR. Postoperatively, R-APR yielded greater benefit when compared to O-APR, but was comparable to that of L-APR. Minimally invasive surgery may be an appropriate option and worthy consideration for patients with distal rectal cancer requiring APR.

Outcomes of robotic partial excision of the levator ani muscle for locally advanced low rectal cancer invading the ipsilateral pelvic floor at the anorectal ring level.

The purpose of this study is to evaluate partial excision of the levator ani muscle (PELM) enables preservation of anal sphincter function although levator ani muscle (LAM) was invaded. Functional outcomes and oncologic outcomes of 23 consecutive patients who underwent robotic PELM for low rectal cancer at the anorectal ring level invading or abutting the ipsilateral LAM are analysed. Secured resection margins were achieved, especially for the circumferential resection margin. During a median follow-up of 44months, the 3-year local recurrence rate was 14.4%. Among patients who underwent diverting ileostomy closure, mean Memorial Sloan Kettering Cancer Center Bowel Function Instrument and Wexner scores were 68.3±11.9 and 10.7±5.3, respectively, at 1year after closure. PELM is a sphincter-preserving alternative to abdominoperineal resection (APR) or extralevator APR for low rectal cancer invading the ipsilateral LAM at the level of the anorectal ring.

Parastomal and incisional hernia following laparoscopic/open abdominoperineal resection: is there a real difference?

The aim of the present study was to explore incidence and severity of parastomal hernia (PSH) formation during the first 2years after open/laparoscopic abdominoperineal resection (APR). This was a retrospective cohort study conducted in a single institution. All patients who underwent laparoscopic/open APR for low rectal cancer within a 10-year study period were assessed for study eligibility. In total, 148 patients were included in the study (97 patients after laparoscopic APR; 51 patients after open APR). There were no statistically significant differences between study subgroups regarding demographic and clinical features. The incidence of PSH detected by physical examination was significantly higher in patients after laparoscopic APR 1year after the surgery (50.5% vs. 19.6%, p < 0.001) and 2years after the surgery (57.7% vs. 29.4%, p = 0.001). The incidence of radiologically detected PSH was significantly higher in laparoscopically operated patients after 1year (58.7% vs. 35.3%, p = 0.007) and after 2years (61.8% vs. 37.2%, p = 0.004). The mean diameter of PSH was similar in both study subgroups. The incidence of incisional hernia was significantly higher in patients who underwent open APR after 1year (25.5% vs. 7.2%, p = 0.002) and after 2years (31.3% vs. 7.2%, p < 0.001). The risk of PSH development after laparoscopic APR appears to be significantly higher in comparison with patients undergoing open APR. Higher incidence of PSH should be considered a potential disadvantage of minimally invasive approach to patients with low rectal cancer.

Intra-operative perforation: a risk factor for prognosis of low rectal cancer after abdominoperineal resection

This study was designed to explore the influence of intra-operative perforation on prognosis of low rectal cancer after APR and to investigate the risk factors of perforation. Perforation is not scarce during the procedure of abdominoperineal resection (APR). There is no consensus on perforation rate and related risk factor for APR. Data of 925 patients who received APR for low rectal cancer between January 2000 and August 2008 were reviewed. The intra-operative perforation rate was 7.4 % (68/925). The recurrence rate was 28.6 % in patients with intra-operative perforation compared with 6.8 % in patients with no perforation (P < 0.001); 5-year survival rate in patients with perforation was 41.4 and 66.3 % in patients with no perforation. Univariate analysis showed that intra-operative perforation affected recurrence rate and survival significantly (P < 0.001, P < 0.001); multivariate analysis revealed that intra-operative perforation was an independent prognostic factors for recurrence (RR: 3.087, P < 0.001), while not for survival (RR: 1.331, P = 0.051). Patients aged more than 70 years, T3 tumor and treated by general surgeon had higher perforation rate (P = 0.001, P = 0.004, P = 0.008). Intra-operative perforation affected the prognosis of low rectal cancer after APR significantly. Elderly patient aged more than 70 years, T3 tumor and general surgeon who performed operation were three risk factors of increased perforation rate.

Evaluation of short‐term outcomes after laparoscopically assisted abdominoperineal resection for low rectal cancer

To investigate the feasibility, safety and short-term efficacy of laparoscopic techniques applied in the abdominoperineal resection (APR) for low rectal cancer. The clinical data of 236 patients with APR from January 2010 to January 2012 were analysed retrospectively, including 100 patients underwent laparoscopically assisted APR (LAAPR group), 136 cases of open APR (OAPR group). The demographics, tumor and procedure-related parameters, perioperative results and short-term oncological outcomes were evaluated using t-test or χ(2) -test. The demographic data of the two groups were comparable. Perioperative results were better after laparoscopic surgery, with less intraoperative blood loss (P = 0.017), earlier return of bowel function (P < 0.05) and lower complication rates (P = 0.015). No significant differences were detected between the two groups in operation time, tumor size, specimen length, the distance of tumor from the anal verge, lymph nodes removed and the status of circumferential resection margin (P > 0.05). During the follow-up period of 17-38 months (average, 26 months), the overall survival rates were not significantly different between the two groups [82.5% (80/97) versus 82.7% (110/133), P > 0.05]. The differences in recurrence and metastasis between the two groups were not statistically significant. Laparoscopically assisted APR for low rectal cancer is safe and effective. It has the advantages of less bleeding, rapid postoperative recovery and fewer complications, without affecting the radical degree of the surgery. Further studies are needed to fully assess oncological outcomes in the future.

Assessment of abdominoperineal resection rate as a surrogate marker of hospital quality in rectal cancer surgery

Rates of abdominoperineal resection (APR) have been suggested as a solitary surrogate marker for comparing overall hospital quality in rectal cancer surgery. This study investigated the value of this marker by examining the associations between hospital APR rates and other quality indicators. Hospital-level correlations between risk-adjusted APR rates for low rectal cancer and six risk-adjusted outcomes and six care processes were performed (such as 30-day mortality, complications, timely treatment). The ability of APR rates to discriminate between hospitals' performance was examined by means of hospital variance results in multilevel regression models and funnel plots. A linked population-based data set identified 1703 patients diagnosed in 2007 and 2008 who underwent surgery for rectal cancer. Some 15.9 (95 per cent confidence interval (c.i.) 14.2 to 17.6) per cent of these patients had an APR. Among 707 people with low rectal cancer, 38.2 (34.6 to 41.8) per cent underwent APR. Although risk-adjusted hospital rates of APR for low rectal cancer varied by up to 100 per cent, only one hospital (1 per cent) fell outside funnel plot limits and hospital variance in multilevel models was not very large. Lower hospital rates of APR for low rectal cancer did not correlate significantly with better hospital-level outcomes or process measures, except for recording of pathological stage (r = -0.55, P = 0.019). Patients were significantly more likely to undergo APR for low rectal cancer if they attended a non-tertiary metropolitan hospital (adjusted odds ratio 2.14, 95 per cent c.i. 1.11 to 4.15). APR rates do not appear to be a useful surrogate marker of overall hospital performance in rectal cancer surgery.

Impact of neoadjuvant chemoradiation on perineal wound healing after abdominoperineal resection for lower rectal cancer

To evaluate the impact of neoadjuvant chemoradiation on perineal wound healing following abdominoperineal resection(APR) for lower rectal cancer. Data of 93 patients who underwent APR for low rectal cancer between January 2005 and January 2009 in Peking Union Medical College Hospital were reviewed, including patients who received neoadjuvant chemoradiation (n=29) and those undergoing surgery alone(n=64). Perineal wound healing was the primary outcome measurement. Condition of wound healing was classified as good, moderate, and poor and was compared between the two groups. Twenty nine patients in the neoadjuvant group received preoperative regional radiation(50 Gy, 25 fractions/5 weeks) with synchronous FOLFOX4 chemotherapy(fluorouracil and oxaliplatin). In the neoadjuvant group, wound healing after APR was good in 18 patients(62.1%), moderate in 6(20.7%), and poor in 5(17.2%). In patients who had surgery alone, wound healing after APR was good in 41 patients(64.1%), moderate in 15(23.4%), and poor in 8(12.5%). There was no significant difference in the incidence of wound infection(poor wound healing)between the two groups(P=0.773). Neoadjuvant chemoradiation therapy is not associated with increased perineal wound infection following abdominoperineal resection for low rectal cancer.

Risk Factors for Adverse Outcome in Patients With Rectal Cancer Treated With an Abdominoperineal Resection in the Total Mesorectal Excision Trial

This study was performed to identify tumor- and patient-related risk factors for distal rectal cancer in patients treated with an abdominoperineal resection (APR) associated with positive circumferential resection margin (CRM), local recurrence (LR), and overall survival (OS). The introduction of total mesorectal excision (TME) has improved the outcome of patients with rectal cancer. However, survival of patients treated with an APR improved less than of those treated with low anterior resections (LAR). Besides, an APR is associated with a higher LR rate. Patients were selected from the TME trial, which is a randomized, multicenter trial, studying the effects of preoperative radiotherapy (RT) in 1861 patients. Of the Dutch patients, 455 underwent an APR. Location of the bulk of the tumor was scored with surgery, pathology, or other reports. CRM was available from pathology reports. A positive CRM was found in 29.6% of all patients, 44% for anterior, 21% for lateral, 23% for posterior, and 17% for (semi)circular tumor location (P < 0.0001). In a multivariate analysis, T-stage, N-stage, and tumor location were independent risk factors for CRM. If a (partial) resection of the vaginal wall was performed in women, 47.8% of patients still had a positive CRM. T-stage, N-stage, and CRM were risk factors for LR and age, T-stage, N-stage, CRM, and distance of the inferior tumor margin to the anal verge for OS. Age, T-stage, N-stage, CRM, distance of the tumor to the anal verge, and tumor location were independent risk factors for adverse outcome in patients treated with an APR for low rectal cancer. Anterior location, specifically in women, more often requires downstaging and/or more extended resection to obtain free margins.

Long-term results of modified graciloplasty for sphincter replacement after rectal excision.

OBJECTIVE: Restoration of the anal sphincter by means of electrically stimulated (dynamic) graciloplasty is a new therapeutic option for patients with severe faecal incontinence or those having abdomino-perineal resection (APR) of the anorectum. The present study reviews the outcome of total anorectal reconstruction (TAR) after APR for low rectal cancer or recurrent anal cancer. METHODS: From 1992 to 2000, 35 of 64 patients treated with dynamic graciloplasty had a TAR performed either synchronously (n=26) or as a secondary procedure one to five years after rectal excision (n = 9). RESULTS: The most frequent complication was injury or erosion of the neorectum (n = 9) which, was avoided with increasing surgical experience. Defaecation disorders and consequent incontinence were the most common functional problem and had to be treated with periodical enemas. CONCLUSION: Although sphincter replacement by means of TAR after APR led to poorer functional results than those achieved in patients treated with dynamic graciloplasty for faecal incontinence, TAR remains a valid treatment option for patients who do not tolerate a permanent stoma.