abdominoperineal resection

[https://nci-media.cancer.gov/pdq/media/images/415509.jpg See image on National Cancer Institute website]

The principal indication for AP resection is a rectal carcinoma situated in the distal (lower) one-third of the rectum.American Cancer Society.

Detailed Guide: Colon and Rectum Cancer. cancer.org. URL: [http://www.cancer.org/docroot/CRI/content/CRI_2_4_4x_Surgery_10.asp?sitearea= http://www.cancer.org/docroot/CRI/content/CRI_2_4_4x_Surgery_10.asp?sitearea=] {{webarchive |url=https://web.archive.org/web/20080507195556/http://www.cancer.org/docroot/CRI/content/CRI_2_4_4x_Surgery_10.asp?sitearea= |date=May 7, 2008 }}. Accessed on: February 5, 2008. Other indications include recurrent or residual anal carcinoma (squamous cell carcinoma) following initial, usually definitive combination chemoradiotherapy.

APRs involves removal of the anus, the rectum and part of the sigmoid colon along with the associated (regional) lymph nodes, through incisions made in the abdomen and perineum. The end of the remaining sigmoid colon is brought out permanently as an opening, called a stoma, which is used by the patient in conjunction with a colostomy pouch, on the surface of the abdomen.

The perineal part of the operation may be performed with intersphincteric dissection, leaving the external sphincter and levator muscles in-situ. This results in a smaller defect in the perineum and may be preferable when a margin to healthy tissue is not an issue, e.g. in IBD surgery.{{cite journal | vauthors = Åkerlund V, Nikberg M, Wagner P, Chabok A | title = Hartmann's Procedure Versus Intersphincteric Abdominoperineal Excision in Patients with Rectal Cancer: Report from the Swedish Colorectal Cancer Registry (SCRCR) | journal = Annals of Surgery Open | volume = 5 | issue = 2 | pages = e428 | date = June 2024 | pmid = 38911665 | pmc = 11191996 | doi = 10.1097/AS9.0000000000000428 }}

This operation is one of the less commonly performed by general surgeons, although they are specifically trained to perform this operation. As low case volumes in rectal surgery have been found to be associated with higher complication rates,{{cite journal | vauthors = Schrag D, Panageas KS, Riedel E, Cramer LD, Guillem JG, Bach PB, Begg CB | title = Hospital and surgeon procedure volume as predictors of outcome following rectal cancer resection | journal = Annals of Surgery | volume = 236 | issue = 5 | pages = 583–592 | date = November 2002 | pmid = 12409664 | pmc = 1422616 | doi = 10.1097/00000658-200211000-00008 }}{{cite journal | vauthors = Marusch F, Koch A, Schmidt U, Pross M, Gastinger I, Lippert H | title = Hospital caseload and the results achieved in patients with rectal cancer | journal = The British Journal of Surgery | volume = 88 | issue = 10 | pages = 1397–1402 | date = October 2001 | pmid = 11578299 | doi = 10.1046/j.0007-1323.2001.01873.x | s2cid = 3095483 | doi-access = free }} it is often centralised in larger centres,{{cite journal | vauthors = Martling A, Holm T, Cedermark B | title = [Skills by training. Education and case volume are strong prognostic factors in rectal cancer surgery] | language = sv | journal = Läkartidningen | volume = 102 | issue = 6 | pages = 374–376 | year = 2005 | pmid = 15754678 }} where case volumes are higher.

There are several advantages in terms of outcomes if the surgery can be performed laparoscopically{{cite journal | vauthors = Simorov A, Reynoso JF, Dolghi O, Thompson JS, Oleynikov D | title = Comparison of perioperative outcomes in patients undergoing laparoscopic versus open abdominoperineal resection | journal = American Journal of Surgery | volume = 202 | issue = 6 | pages = 666–70 | date = December 2011 | pmid = 21983001 | doi = 10.1016/j.amjsurg.2011.06.029 }}

An APR, generally, results in a worse quality of life than the less invasive lower anterior resection (LAR).{{cite journal | vauthors = McLeod RS | title = Comparison of quality of life in patients undergoing abdominoperineal extirpation or anterior resection for rectal cancer | journal = Annals of Surgery | volume = 233 | issue = 2 | pages = 157–158 | date = February 2001 | pmid = 11176119 | pmc = 1421195 | doi = 10.1097/00000658-200102000-00002 }}{{cite journal | vauthors = Grumann MM, Noack EM, Hoffmann IA, Schlag PM | title = Comparison of quality of life in patients undergoing abdominoperineal extirpation or anterior resection for rectal cancer | journal = Annals of Surgery | volume = 233 | issue = 2 | pages = 149–156 | date = February 2001 | pmid = 11176118 | pmc = 1421194 | doi = 10.1097/00000658-200102000-00001 }} Thus, LARs are generally the preferred treatment for rectal cancer insofar as this is surgically feasible.

William Ernest Miles (1869–1947), an English surgeon first performed the surgery of removing the rectum in 1907. He assumed that the rectal cancer can spread in both upwards and downward directions, thus necessitating the removal of the entire rectum together with the anal sphincters, resulting in a permanent stoma by connecting the proximal end of the descending colon to the skin. Mile's operation became the gold standard for treating rectal cancer because his technique successfully reduced the rate of cancer recurrence.{{cite journal | vauthors = Ganapathi SK, Subbiah R, Rudramurthy S, Kakkilaya H, Ramakrishnan P, Chinnusamy P | title = Laparoscopic anterior resection: Analysis of technique over 1000 cases | journal = Journal of Minimal Access Surgery | volume = 17 | issue = 3 | pages = 356–362 | date = 2021 | pmid = 33605924 | pmc = 8270051 | doi = 10.4103/jmas.JMAS_132_20 | doi-access = free }}{{cite journal | vauthors = Miles WE | title = A method of performing abdomino-perineal excision for carcinoma of the rectum and of the terminal portion of the pelvic colon (1908) | journal = CA: A Cancer Journal for Clinicians| volume = 21 | issue = 6 | pages = 361–364 | year = 1971 | pmid = 5001853 | doi = 10.3322/canjclin.21.6.361 | s2cid = 73293240 | doi-access = free }}

To reduce the incidence of death and suffering of the patients associated with the APR procedure, Henri Albert Hartmann introduced the anterior resection of the rectum by preserving the distal rectum and anal sphincters, while producing end-sigmoid colostomy. There were attempts to restore bowel continuity by joining the proximal colon with the rectum, but the high incidence of leakage from the anastomotic site caused an increased risk of death to patients. It was only in 1948, Claude Dixon successfully connected the proximal bowel to the rectum, thus allowing patients to have a 64% 5-year survival rate.

• Stoma (medicine)
• Total mesorectal excision

{{reflist|30em}}

• [http://my.clevelandclinic.org/disorders/colorectal_cancer/hic_laparoscopic_abdominoperineal_resection_basic_surgical_steps.aspx Laparoscopic Abdominoperineal Resection: Basic Surgical Steps]—Cleveland Clinic
• [https://web.archive.org/web/20120326121902/http://www.surgeryvideos.info/2011/06/abdominoperineal-resection-surgery.html APR Surgery Videos]

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Category:Digestive system surgery