The combined abdominal and perineal approach for dissection of the lower rectum. The development of new indications

A short-term study of laparoscopic-dominant individualised levator ani resection in abdominoperineal resection: A retrospective investigation

OBJECTIVE

The objective is to investigate if laparoscopic-dominant abdominoperineal resection (LDAPR) with individualised levator ani resection inhibits local recurrence (LR) and prolongs survival as compared to laparoscopic abdominoperineal resection (APR).

MATERIALS AND METHODS

Rectal cancer surgery cases were retrospectively identified from September 2014 to December 2019. LDAPR-treated group (55 patients) and the APR-treated group (71 patients) were included in the study. The operation time, circumferential resection margin (CRM), intraoperative tumor surgery (ITP), post-operative complications, the 2-year overall survival (OS) and LR were compared in the two groups.

RESULTS

The CRM and ITP were significantly reduced in the LDAPR as compared to the APR group (3.6% vs. 16.9%, t = 5.522, P = 0.019; 3.6% vs. 14.1%, t = 3.926, P = 0.048). In terms of post-operative complications, the incidence of urinary retention in LDAPR was significantly reduced than the APR group (10.9% vs. 25.4%, χ2 = 4.139, P = 0.041). Similarly, perineal pain at 6 months or 1 year after surgery was significantly down-regulated in LDAPR than in the APR group (72.7% vs. 88.7%, χ2 = 5.320, P = 0.021; 18.2% vs. 43.2%, χ2 = 8.288, P = 0.004). However, there was no statistically significant difference in the post-operative complications between the LDAPR and APR groups. Finally, LDAPR led to a significantly improved 2-year OS and a reduced LR compared to APR.

CONCLUSION

LDAPR reduces CMR, ITP and LR and simplified the perineum operation, subsequently protecting the pelvic autonomic nerves. Compared to the conventional APR, LDAPR is a promising procedure worth adopting for rectal cancer treatment.

Anatomical, surgical and clinical considerations related with operative procedures performed in combined abdominal and perineal approaches for the treatment of lower rectal cancer

Background and aim Combined abdominal and perineal (anterior or posterior) approaches used in lower rectal cancer surgery have been based on similar anatomical and surgical features. The main aim of this manuscript is to evaluate the results of combined approaches performed for lower rectal cancer and to comment on surgical and anatomical features of the operations.

Methods Anatomical, surgical and clinical details of the combined abdominal and perineal approaches performed for lower rectal cancer were evaluated by reviewing published articles about this subject in English in PubMed, EMBASE, Cochrane library and other sources.

Results Ten articles including case reports were found on combined abdominal and perineal approaches published between 2003 and 2015. There were 83 patients who had been operated by using combined approaches for lower rectal cancer surgical treatment in these series. While the circular resection margine positivity had not been reported in the cases; the mean Wexner continence score had been reported between 5 and 5.5. The most important dissatisfaction of these surgical methods has been reported as persistent perineal fistulas encountered 9.6% of the patients in average in the postoperative period.

Conclusion The APPEAR (Anterior Perineal Plane for Ultra Low Anterior Resection) procedure is the most known surgical procedure in which the combined abdominal and anterior perineal approach is used. Combined abdominal and perineal (anterior or posterior) approaches can be described as surgical procedures in which the sphincter-saving extrasphincteric dissection and proximal segmental sphincteric excision techniques are performed.

Critical surgical errors by junior fellows and trainees in low rectal cancer surgery: How to overcome?(A cross-sectional study)

Aim

Technical difficulties are usually reported in low rectal cancer (LRC) surgery. Moreover inadvertent surgical errors could happen mostly due to lack of experience of the assisting surgeons. Unfortunately, these errors may end up with raising a permanent stoma. In this study we are reporting seven inadvertent surgical mishaps during surgeries for LRC which resulted in failure of the planned circular end to end anastomosis and how we approached them by different salvage techniques.

Patients and methods

All surgical mistakes were salvaged by two of our senior consultants with intraoperative decision to shift to another approach to attain intestinal continuity. Two patients had direct handswen coloanal anastomosis, three received colon pull through and two with redo stapled circular end to end anastomosis after shifting to the anterior perineal plane. Postoperative assessment of the functional state using wexner score was done for all cases.

Results

All surgical mistakes had been overcomed after shifting to the transanal and/or perineal approach and we were able to regain intestinal continuity in all cases Circumferential and distal margins were free in all specimens. Two patients showed optimal continence with wexner score 3,5 respectively, Two had suboptimal continence Wexner 6,7. Female patient with iatrogenic rectovaginal fistula suffered from poor quality of life and asked for permanent stoma.

Conclusion

All trainees and junior fellows in should receive a clearly defined training program and focused education with different staplers; additionally they should work under supervision of the senior consultants who should be sufficiently experienced with different salvage approaches.

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Low rectal cancer surgery is demanding even in the hands of experienced colorectal surgeons.

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Inadvertent surgical errors could happen due to lack of experience of the assisting surgeons.

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Salvage procedures may be the key to restore intestinal continuity.

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All trainees and junior fellows in colorectal units should receive a clearly defined training programs.

Extragastrointestinal stromal tumor in the rectovaginal septum associated with acute arterial occlusion

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EGIST in rectovaginal septum with unusual presentation (excessive vaginal bleeding).

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EGIST was misdiagnosed by MRI as vaginal leiomyoma.

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The first report of untreated EGIST associated with acute arterial occlusion.

Extragastrointestinal stromal tumors (EGISTs) arise from atypical sites, such as the omentum, mesentery, retroperitoneal space, urinary bladder, or rectovaginal septum, and account for fewer than 10% of gastrointestinal stromal tumors (GISTs). Most EGISTs are asymptomatic at the time of diagnosis, due to the fact that they rarely cause symptoms until they grow to greater than 10 cm in diameter. Common presenting symptoms are a feeling of vaginal fullness and increased urinary frequency. Cases described in previous reports have been treated with surgery with or without targeted therapy. Here we report an unusual case of an EGIST at the rectovaginal septum presenting with excessive vaginal bleeding and acute arterial occlusion. This rectovaginal mass was successfully removed using the abdominoperineal approach and did not require targeted therapy.

A quest for sphincter-saving surgery in ultralow rectal tumours-a single-centre cohort study

INTRODUCTION

Despite the progress in the treatment of colorectal cancer, there is still no optimal strategy for tumours located adjacent to the anal sphincter. This study aims to evaluate oncological and functional results of surgery for rectal cancer in unfavourable locations in proximity to anal sphincters.

MATERIALS AND METHODS

Patients with rectal cancer, which was either initially infiltrating the anal sphincter or located in the close proximity of the sphincter, were included in the study. Patients were submitted to extralevator abdominoperineal resection (APR), intersphincteric resection, or transanal total mesorectal excision (TaTME). Primary outcomes were perioperative data: operative time, blood loss, complications, length of stay (LOS), and 30-day mortality. Secondary outcomes were pathological quality of the specimens and functional outcome 6 months after defunctioning ileostomy closure.

RESULTS

Among patients with cancer adjacent to the anal sphincter, 13 (25%) underwent APR, 14 (27%) patients were submitted to intersphincteric resection, and 25 (48%) patients were treated with the TaTME approach. Operative time was 240 (210-270 IQR) for APR, 212.5 (170-260 IQR) for intersphincteric resection, and 270 (240-330 IQR) for TaTME (p = 0.018). Perioperative morbidity was 31% for APR, 36% for intersphincteric resections, and 12% for the TaTME group (p = 0.181). Complete mesorectal excision was achieved in 92% of specimens in the TaTME group, 93% in intersphincteric resections, and 78% in the APR group (p = 0.72). Median circumferential resection margin in APR was 6 mm (4-7 IQR), in intersphincteric resections 7.5 mm (2.5-10 IQR), and in the TaTME group 4 mm (2.8-8 IQR). All patients after intersphincteric resections developed major low anterior resection syndrome (LARS). Four patients in the TaTME group developed minor LARS, and 21 had major LARS.

CONCLUSION

Sphincter-saving rectal resections are a feasible alternative to APR with good clinical, pathological, and oncological outcomes. Intersphincteric resections and TaTME seem to be equal in terms of clinicopathological results. The functional outcome is yet to be investigated.

TRIAL REGISTRATION

The study was retrospectively registered in Thai Clinical Trials Registry (23-07-2018, ID TCTR20180724001 ).