Download - Extralevator abdominoperineal excision
Extralevator abdominoperineal
excision - APE
Extralevator abdominoperineal excision
- APE
Extralevator abdominoperineal excision
- 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%
Extralevator abdominoperineal excision
- 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
Extralevator abdominoperineal excision -
APEIntroduction
– Conventional technique– Outside mesorectum – pelvic
floor–Mobilisation from levator
muscles– Excision anal canal –
ischiorectal fat – lower portion levator muscles– “Waist” surgical specimen
Extralevator abdominoperineal excision -
APEMethods
– APE – extended posterior perineal approach– No dissection mesorectum
off levator muscles– Stop mobilisation upper
border coccyx – below autonomic nerves – below vesicles
Extralevator abdominoperineal excision -
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
Extralevator abdominoperineal excision -
APEMethods
Extralevator abdominoperineal excision -
APEMethods
Extralevator abdominoperineal excision -
APEMethods
Extralevator abdominoperineal excision -
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
Extralevator abdominoperineal excision -
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
Extralevator abdominoperineal excision -
APEMethods
Extralevator abdominoperineal excision -
APEMethods
• Gluteus maximus flap reconstruction
– Two drains (deep muscle – along flap subcutis)
– Kept 4-6 days
– Surgical tape dressing
– Decubital mattress
– Specific mobilisation schedule
Extralevator abdominoperineal excision -
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
Extralevator abdominoperineal excision -
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
Extralevator abdominoperineal excision -
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+
Extralevator abdominoperineal excision -
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
Extralevator abdominoperineal excision -
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
Extralevator abdominoperineal excision -
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