Cylindrical APR

1. CYLINDRICAL APR PETER HEWETT

2. DOORS OF DUBLIN

3. DOORS OF ZANZIBAR

4. British Journal of Surgery Volume 97, Issue 4, pages 588–599, April 2010 RECTUMS OF EUROPE

5. Local recurrence has not improved to the same degree as seen with anterior resection after the introduction of TME. Significant reduction in tissue volume around the tumour in APR specimens compared with Anterior resection specimens Greater CRM positivity Greater local recurrence Poorer 5 year cancer specific survival

6. Cylindrical AP Resection Mobilisation of the mesorectum down to the origins of the levator muscles. Stoma formation and closure Patient is rotated into the prone position Extended perineal resection

7. Extended Perineal resection Excision of the sphincter complex Follows the inferior surface of the levators to a point laterally where they originate from the pelvic sidewall The point should be just inferior to the level where the abdominal procedure was terminated Coccyx can be removed in continuity with the main specimen Repair of defect with a gluteal flap.

8. Advantages (literature) Reduced rate of perforation Reduced rate of CRM 70% more tissue outside the internal sphincter / muscularis propria at the tumour 14.5mm extra tissue posteriorly and 4mm at anterior and lateral margins at the tumour.

9. J Clin Oncol . 2008 Jul 20;26(21):3517-22. Epub 2008 Jun 9. Evidence of the oncologic superiority of cylindrical abdominoperineal excision for low rectal cancer. West NP , Finan PJ , Anderin C , Lindholm J , Holm T , Quirke P . Pathology and Tumour Biology, Leeds Institute of Molecular Medicine, University of Leeds, United Kingdom. Karolinska University Hospital, Stockholm, Sweden

10. Extralevator APR removed more tissue from outside the smooth muscle layer per slice (median area 2120 versus 1259 mm 2 ; P < 0·001) leading to a reduction in CRM involvement (from 49·6 to 20·3 per cent; P < 0·001) and IOP (from 28·2 to 8·2 per cent; P < 0·001) compared with standard surgery. However, extralevator surgery was associated with an increase in perineal wound complications (from 20 to 38·0 per cent; P = 0·019).

11. Multicentre experience with extralevator abdominoperineal excision for low rectal cancer † N. P. West 1,* , C. Anderin 3 , K. J. E. Smith 2 , T. Holm 3 , P. Quirke 1 British Journal of Surgery Volume 97, Issue 4, pages 588–599, April 2010

12. Advantages Good visualisation anterior structures with plane easily seen and dissected Easy control of bleeders Decreased perforation rate One surgeon Easy to teach Easy to assist Perineal operator does not get wet Possibly less blood loss

13. Disadvantages Learning curve as to how far to dissect into the pelvis Unaccustomed plane Coccygeal division leaves bare bone in a potentially contaminated field. No further access to abdomen during the perineal dissection No difference in postoperative recovery Perineal wound complications

14. Tips If the excised sigmoid colon is very fatty amputate it so that the rectum can be delivered easily . If there is anterior attachment of the tumour take care in reflecting the rectum. If possible mobilise an omental pedicle to place in the pelvis. Remember the drain!

15. Tips

16. © The ASCRS 2010. 2 FIGURE 1. Pelvic Floor Reconstruction Using Human Acellular Dermal Matrix After Cylindrical Abdominoperineal Resection. Han, Jia; Wang, Zhen; Gao, Zhi; Xu, Hui; Yang, Zeng; Jin, Mu Diseases of the Colon & Rectum. 53(2):219-223, February 2010. DOI: 10.1007/DCR.0b013e3181b715b5 FIGURE 1. Use of human acellular dermal matrix for reconstruction of pelvic floor.