1. Cylindrical Abdominoperineal Resection
Dr Richard Downey

2. 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

3. 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

4. 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

5. MRI image

6. 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

7. 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

8. Perineal defect
photo

9. 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

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

11. Pre neoadjuvant biopsy

12. Resected specimen

13. Immunohistochemistry

14. Colorectal cancer surgery

15. Right Hemicolectomy

16. Left Hemicolectomy

17. Anterior Resection

18. 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

19. Abdominoperineal Resection (APR)

20. Abdominoperineal Resection (APR)

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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