Cylindrical Abdominoperineal Resection Dr Richard Downey

Background HS, 61 yr old male No significant medical history 18 month hx of perianal pain, pruritus ani and occasional PR bleeding EUA Deep posterior anal fissure surrounded by area of induration and thickening Biopsies-chronically inflamed and fibrotic squamocolumnar anal mucosa Consistent with fissure in ano

Background Symptoms unresponsive to topical Rx o/e Large posterior fissure and associated skin tag, BRBPR Crohn’s Disease suspected Scheduled for EUA Rectum in urgently and SBFT

Work Up Biopsies at colonoscopy in EUA-Low Rectal Tumour extending into anus Histology-Anal gland vs Rectal cancer Moderately differentiated Adenocarcinoma MRI pelvis Increased soft tissue thickening posterior to superficial perianal area Number of mesorectal lymph nodes seen Does not extend above internal sphincter T4N1M0 Rectal Adenocarcinoma

MRI image

Oncology Number of palpable hard satellite lesions up to 3cm from anal verge along perianal skin Neoadjuvant treatment Chemotherapy-5FU Radiotherapy encompassing perianal skin, inguinal nodes and external iliac nodes EUA Tumour at 3cm, bulky, friable perianal skin Scheduled for APR and VRAM flap reconstruction

Surgery APR Lower midline laparotomy Left colon and rectum mobilised Total mesorectum excision Sigmoid colon dived and proximal end brought out as colostomy Wide perineal resection performed Rectum delived through anus and resected in full Haemostasis achieved

Perineal defect photo

Surgery Reconstruction perineal defect with right VRAM Flap VRAM raised through lateral incision Ant rectus sheath opened and muscle dissected from post rectus sheath Inferior deep epigastric artery pedicle preserved Deepithelialisation of skin over muscle Muscle mobilised to cover defect Abdominal closure with prolene mesh, sutures Perineum closure with sutures

Post op Unremarkable Wounds clean and healthy Satisfactory stoma care Discharged day 16 post op Histology For discussion Oncology For adjuvant chemotherapy in Letterkenny

Pre neoadjuvant biopsy

Resected specimen

Immunohistochemistry

Colorectal cancer surgery

Right Hemicolectomy

Left Hemicolectomy

Anterior Resection

Abdominoperineal Resection Indicated for rectal cancer in the lower third of rectum APRs involves removal of the anus, the rectum, part of the sigmoid colon and ther associated lymph nodes Incisions are made in the abdomen and perineum Remaining sigmoid colon brought out as a colostomy

Abdominoperineal Resection (APR)

Abdominoperineal Resection (APR)

Abdominoperineal Resection First described by Ernest Miles in 1908 By the 1920s, recurrence rates were down to 30%-gold standard at that time Several modifications were proposed to promote locoregional control and survival, with little success Better suture material and devices enabling low anastomoses heralded a shift toward sphincter-saving approaches with respect to cancer of the rectum Anterior resection replaced APR as the mainstay of therapy in the 1950s There was concern that sphincter-saving surgery might increase local recurrence It was in this setting that total mesorectal excision (TME) was first described in 1982 by Heald and colleagues

Total Mesorectal Excision The TME concept is based on the locoregional recurrence preference of rectal carcinoma Therefore adequate en bloc clearance of the rectal mesentry, including its blood supply and lymphatic drainage, would minimize possible disease relapse TME is now considered the Gold Standard adjunctive therapy for colorectal cancer

APR Improved surgical techniques (eg total mesorectal excision and autonomic nerve preservation) have shown a corresponding decrease in local recurrence rates and increase in overall survival of patients with rectal cancer However local recurrence and survival after an APR have not improved to the same degree as that seen after an anterior resection This difference has been attributed to relative smaller tissue volumes around the tumour and higher rates of cancer at circumferential resection margins (CRM) after an APR compared with an anterior resection

Cylindrical APR As tumour-free lateral margins have been demonstrated to be an important prognostic factor for local recurrence and survival, an extensive resection is frequently required In an attempt to improve healing, several techniques for perineal closure have been described Epiploplasty Gracilis Flap Vertical Myocutaneus Flap Gluteus Maximus Flap

Cylindrical APR They facilitate closure of the perineal defect with healthy and well-vascularized tissue without placing the tissue under undue tension The vertical rectus abdominis myocutaneous (VRAM) flap is also useful in creating a neo- vagina after posterior colpectomy There is a lack of information in the literature concerning the efficacy of VRAM flap reconstruction after APR

Annals of Surgery, Oct 09 Lefevre et at evaluated the results of a VRAM flap after APR for anal cancer 95 patients underwent APR, including 43 patients who subsequently received a VRAM flap Survival in the 2 groups was equivalent despite the presence of more advanced cancers in the VRAM flap cohort They concluded VRAM is an effective technique for reducing both the perineal complication rate and wound-healing delay in patients undergoing APR for AC that does not increase abdominal wall morbidity

Thank You Discussion Points Long term treatment of fissures in ano-Could their be an underlying malignacy?? Advancements in treating rectal cancers Cylindrical APR and VRAM flaps STUDENTS Different colorectal cancer operations Thank You