Extralevator abdominoperineal excision

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  • Extralevator abdominoperineal excision - APE

  • Extralevator abdominoperineal excision - APE

  • Extralevator abdominoperineal excision - APEIntroduction

    APR LAROptimalisation surgical technique (TME)Increasing rates local control survivalAPRTumors less than 6 cmNo optimalisation surgical technique perineal phaseMore local recurrence LARDutch TME trial LR 12% 29%MERCURY trial LR 12% 33%

  • Extralevator abdominoperineal excision - APEIntroductionAPR - LARWorse outcome LARDutch TME-trial APRCRM +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 - APEIntroductionAPRDifficult conventional techniqueHigh risk bowel perforationSpecimen waist lower borderCRM close rectumStudy posterior perineal approachMore cylindrical specimenReduction bowel perforation positive CRM

  • Extralevator abdominoperineal excision - APEIntroductionConventional techniqueOutside mesorectum pelvic floorMobilisation from levator musclesExcision anal canal ischiorectal fat lower portion levator musclesWaist surgical specimen

  • Extralevator abdominoperineal excision - APEMethodsAPE extended posterior perineal approachNo dissection mesorectum off levator musclesStop mobilisation upper border coccyx below autonomic nerves below vesicles

  • Extralevator abdominoperineal excision - APEMethodsProne jack-knife positionAnus closed double purse-string sutureDissection outside subcutaneous portion external anal sphincterDissection outer surface levator muscles until insertion pelvic side wallDisarticulation coccyxDivision Waldeyers fascia levator musclesDissection off prostate posterior vagina

  • Extralevator abdominoperineal excision - APEMethods

  • Extralevator abdominoperineal excision - APEMethods

  • Extralevator abdominoperineal excision - APEMethods

  • Extralevator abdominoperineal excision - APEMethodsAPRWound complications35-66% (pre-op RTX extensive dissection)Various flap techniquesGluteus maximus flap reconstructionArises iliac bone, sacrum coccyx and insertion lateral femurRotational musculocutaneous flap based craniallyLarge defect bilateral based cranially and distally

  • Extralevator abdominoperineal excision - APEMethodsGluteus maximus flap reconstructionLocal anesthesia adrenalineSubcutaneous tissue incised gluteus maximus and fascia1/3rd muscle divided medial borderAvoid sciatic nerve !Further submuscular dissection cranially and mediallySutured four layersMuscle, Scarpas fascia, deep dermis, skin

  • Extralevator abdominoperineal excision - APEMethods

  • Extralevator abdominoperineal excision - APEMethodsGluteus maximus flap reconstructionTwo drains (deep muscle along flap subcutis)Kept 4-6 daysSurgical tape dressingDecubital mattressSpecific mobilisation schedule

  • Extralevator abdominoperineal excision - APEResultsPatient characteristics28 patients19 men and 9 women median age 66 (range 49-86 yrs)T3-T4 tumour lower rectum MRIAll neoadjuvant treatment6 patients intraoperative radiotherapySingle surgeon performed resection

  • Extralevator abdominoperineal excision - APEResults

    Inadvertent bowel perforation 1 patient23 patients unilateral flap 5 bilateralOperating time 80 min 110 min3 wound infection of which 1 partial wound rupture 1 postoperative bleeding24 other primary healing no delay

  • Extralevator abdominoperineal excision - APEResultsHistopathological examinationT0 2 patients, T3 20 patients, T4 6 patientsCRM +(< 1mm) 2 patients (T4)Median FU 16 months (1-45)2 patients local recurrence8 patients died 4 no disease 3 distant M+ 1 local recurrence and distant M+

  • Extralevator abdominoperineal excision - APEDiscussionPosterior perineal approach alternative conventional APRPoor results after APRAPR common procedure tumours < 6 cmT1-T2 tumours utralow anterior resection partial resection IAS / less extensive posterior perineal resectionLow rate perforation and CRM involvementLR rate 7% low T3-T4 tumoursShort FU time

  • Extralevator abdominoperineal excision - APEDiscussionSurgical technique posterior perineal approach No dissection mesorectum off levator musclesPerineal part prone jack-knife positionLevator muscle resected en bloc anal canalCylindrical specimenLower risk LR and bowel perforationExcellent exposure

  • Extralevator abdominoperineal excision - APEDiscussionLow rate perineal wound complicationsExtensive resection posterior perineal approachFlap reconstructions superior primary closureIntact muscular layers without strainGluteus maximus flap superiorRectus abdominis flap technically more demandingDistant donor-site morbidity- denervated not contractileNo functional disordes good cosmetic outcomePlastic surgeon

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