Stadards in Abdominoperineal Resection

Transcription

1 Stadards in Abdominoperineal Resection Manuel Francisco T. Roxas, MD, FPCS, FPSCRS, FACS Clinical Associate Professor, University of the Philippines Chief, Section of Colorectal Surgery, Department of Health Jose R Reyes Memorial Medical Center Director, The Medical City Colorectal Clinic and Fellowship Program

2 DISCLOSURES Previous lecturer for Johnson and Johnson Covidien Nestle Novartis Sanofi Unilab

3 Objectives At the end of the session the participants should be able to describe: 1. Historical development of abdominoperineal resection to present standards 2. Technique of extralevator and ischioanal APR

4 Ernest Miles Advocated meticulous removal of Pelvic colon, mesocolon and lymph nodes Wide perineal dissection around anus 1937 Hugh Devine introduced lithotomy position through adjustable leg rests 1938 Lloyd Davis proposed synchronous A-P resection Clinics in Colorectal Surgery Vol 20 N0 3, 2007

5 Claude Dixon Indication for APR APR < 10 cm Easily palpable High grade malignancy, locally advanced Obese patient, small pelvis British Medical Journal May 4, 1968

6 Era of Total Mesorectal Excision Proposed Total Mesorectal Excision in 1982 Sphincter-preservation in majority (> 80%) Pelvic Nerve preservation Local recurrence rates of 3.7% Bill Heald Current Gold Standard for mid to low rectal cancers

7 Worse Outcomes after APR Anterior Resections APR p value 1. Nagtegaal, et al, Survival - Perforations - (+) CRM 57.6% 2.5% 10.7% 38.5% 13.7% 30.4% < Tekkis, et al, (+) CRM 7.5% 16.7% < (OR 3.3) 3. Tilney, et al, (+) CRM 6.7% 17.6% Youssef, et al, (+) CRM 5.0% 26.0% -

8 Salerno, et al. Sites of Surgical Wasting in the Abdominoperineal Specimen. Br J Surg, 2008 Sep; 95(9): Surgical waist usually between 3.5 and 4.2 cm FAV Smaller amounts of perirectal tissue resected at this level (P < 0.001) Corresponds to puborectalis

9 Surgical Waisting

10 Cylindrical Technique Removed more tissue Greater distance from sphincters circumferentially Lower CRM involvement and perforations

11 Avoiding the APR Waist : Cylindrical APR

12 West NP, Quirke P, Holm T. et al. Evidence of the Oncologic Superiority of Cylindrical Abdominoperineal Excision for Low Rectal Cancer. J Clin Oncol Jul 20; 26(21): Hypothesis: extended prone perineal dissection results in a more cylindrical specimen and should improve outcomes Retrospective pathologic analysis of 128 APR patients; potentially curable: Stockholm vs Leeds Cylindrical vs. standard technique (+) CRM 14.8% vs 40.6% (p<0.001) Intraop perforation 3.7% vs 22.8% (p=0.255)

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15 Br J Surg Apr;97(4): doi: /bjs.6916.Multicentre experience with extralevator abdominoperineal excision for low rectal cancer 176 extralevator APE from 11 European colorectal surgeons vs 124 standard APR from 1 UK centre Extralevator APR significantly Removed more tissue Reduced CRM involvement Perforations Increased perineal wound complications

16 Manual of Total Mesorectal Excision, 2013 Torbjorn Holm Intersphincteric APR Extralevator APR Ischioanal APR

17 Short-term Outcome of ELAPE for Rectal Cancer. Stelzner S, et al. IJCD 2011 Jul; 26(7) Conventional APE n = 46 ELAPE n = 28 RRR p value Perforation 15.2% 0 p = (+) CRM 4.9% 0 p = Wound infecton 17.4% 10.7% p < 0.518

18 Extended APE vs Standard APE in Rectal Cancer A Systematic Review. Stelzner et al. IJCD 2011 Oct; 26(10) Standard APE N = 4147 Extended APE N = 1097 RRR p value Perforation 10.4% 4.1 % RRR = 60.6% p = (+) CRM 15.4% 9.6% RRR = 37.7% p = Local recurrence 11.9% 6.6% RRR = 44.5% p < 0.001

19 RCT of Conventional Vs Cylindrical APR for Locally Advanced Lower Rectal Cancer. Han JG, et al. Am J Surg Sep (204(3) Perineal operating time Total operating time Perineal defect size Conventional APR n = 32 Cylindrical APR n = 35 p value 46 min 32 min p < min 190 min p = cm2 64 cm2 p < Blood loss 300 cc 200 cc p = Total X-sectional tissue area size X-sectional tissue outside IS/MP 1738 mm mm2 p < mm mm2 p < Perineal pain 1 vas 4 vas p < 0.01

20 RCT of Conventional Vs Cylindrical APR for Locally Advanced Lower Rectal Cancer. Han JG, et al. Am J Surg Sep (204(3) Over-all Survival Conventional APR n = 32 Disease-free Survival Cylindrical APRn = 35 p value (+) CRM 9 2 p = 0.13 Perforation 5 2 p = Local recurrence 4 1 p = 0.48

21 Results of extralevator APR for low rectal ca including quality of life and long term wound complications. Welsch T, et al. Int J Colorectal Dis 2013 pr; 28(4) Retrospective review; 30 pts (+) CRM in 2 cases (^>&%) No bowel perforation No local recurrence after 28.3 months Perineal wound complications in 46.6%; managed conservatively Persistent perineal pain in 50% Quality of life levels are maintained, though genitourinary functions are impaired

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23 Factors associated with oncologic outcomes after APR compared with restorative resection for low rectal ca: patient- and tumor-related or technical factors only?.. Reshef A, et al. DCR 2012 Jan; 55(1) Retrospective review APR = 413; Restorative resection = 993 APR pts : older, higher ASA; worse tumor differentiation; higher stage (p<0.001) Local recurrence: APR 7% vs RR 3% (p=0.02) Overall survival: APR 56% vs.rr 71% (p<0.001) DFS: APR 54% VS RR 70% (p<0.001)

24 Factors associated with oncologic outcomes after APR compared with restorative resection for low rectal ca: patient- and tumor-related or technical factors only?.. Reshef A, et al. DCR 2012 Jan; 55(1) Conclusions: Technical factors alone are unlikely to be responsible for the worse outcomes after abdominoperineal resection A combination of patient- and tumor-related factors that may have indicated the choice of the procedure also probably contribute to the worse outcomes.

25 Focus on extralevator perineal dissection in supine position (sppd) for low rectal ca has led to better quality of surgery and oncologic outcome. Martijnse IS, et al. Ann Surg Onco 2012 Mar; 19(3) 246 pts; (112 traditional vs.134 sppd; 101 of which were perineal first) (+) CRM overall = 10% R1 specimen before and after sppd: ct0-3: 6.8% down to 2.2% ct4: 30.2% down to 5.7% (p=0.001) Decreased local recurrence: ct4: 25% down to 2.4%; ypt4: 34% down to 5.6% Over-all survival improvement: 83% up to 92%

26 Focus on extralevator perineal dissection in supine position (sppd) for low rectal ca has led to better quality of surgery and oncologic outcome. Martijnse IS, et al. Ann Surg Onco 2012 Mar; 19(3) Conclusions: Focus on perineal dissection improves quality of surgery and oncologic outcomes Not all pts require more radical resection

27 Anterior-entry APR: a variation in the method of perineal dissection.. Simunovic M et al. Ann Surg Onco 2012 Mar; 19(3) 10 cases Quality of surgical specimens was high 1 (+) CRM 1 perforation Conclusion: Anterior entry is feasible and may minimize rates of (+) radial margins

28 Outcome of extralevator APE compared with standard surgery: results from a single centre. Asplund D, et al. Colorectal Dis 2012 Oct; 14(10) Standard APE N = 79 Extralevator APE n = 79 p value (+) CRM 20% 17% No difference Perforation 10% 13% No difference Local recurrence 8.9% 8.9% No difference Perineal wound infection Perineal wound revision 28% 46% p < % 22% p< 0.05 Hospital stay 11 days 12 days p < 0.05

29 A comparison of published rates of resection margin involvement and intra-operative perforation between standard and cylindrical APE for low rectal cancer. Krishna A,,, et al. Colorectal Dis Jan: 15(1) Review of 6 independent hospital and population based patient series no evidence that extralevator APE significantly lowered CRM and perforation compared with standard APE Conclusion: Need for RCT

30 Multicentre study of CRM positivity and outcomes following APE for rectal ca. Kennelly RP, et al. Br J Surg Jan; 100(1) 5 hospital databases; 302 pts Neoadjuvant CRT in 50% T3 T 4 = 62.9% (+) N = 42.1% (+) CRM = 13.9 % Multivariate analysis: Risk factors for (+) CRM pt4 (OR =19.92, 95% CI ) (+) N (OR = 3.04; 95% CI ) (+) CRM was a risk factor for local recurrene ( p = 0.022) and decreased survival (p = 0.001)

31 Multicentre study of CRM positivity and outcomes following APE for rectal ca. Kennelly RP,, et al. Br J Surg Jan; 100(1) Conclusion: (+) CRM was dictated by tumor stage, not by center or surgeon. Wide extralevator APE is probably required only for very advanced tumors

32 A 12-year experience of the Trendelenberg perineal approach for APR. Toshniwal S, et al. ANZ J Surg Apr 17 Retrospective review 53 pts; 87% received neoadjuvant therapy 11% morbidity Local recurrence = 4% at 5 years 5 year survival = 66% Conclusion: APR in lithotomy position can be done with acceptable perineal morbidity and oncologic safety, achieving (-) CRM in a cylindrical specimen

33 Analysis of outcome using a levator sparing technique of APE of rectum and anus. Cylindrical ELAPE is not necessary in all patients. Ramsay G., et al. Eur J Surg Oncol Nov; 39 (11) Retrospective review from APE in 43 out of 361 rectal cancers Neoadjuvant CRT in 98% 38 month follow up: 4.6% local recurrence 18.6% mortality Conclusion: With neoadjuvant CRT, levator sparing excision of the rectum is safe, with less morbidity and perioperative complications

34 Is the jury out?

35 Laparoscopic APR Study Method Patients Results 1. Ng et al 2009 RCT 99 (51 lap) Earlier BM and ambulation Less analgesia 2. Iroatulum, et al 1998 Case control 15 (8 lap) Shorter hospital stay by 50% 3. Araulo et al 2003 RCT 28 (13 lap) Shorter OR and anesthesia time 4. Fleshman et al Wong et al 2006 Retros review Prospective cohort 194 (42 lap) Shorter hospital stay Higher rate of perineal infections 102 (71 lap) Less bloos loss and BT Less abdominal wound and chest infections Better survival

36 Laparoscopic APR Similar outcomes compared to open Specimen retrieval Nodes Margins Cancer Outcomes Local recurrence Survival But did not mention extralevator or cylindrical

37 Laparoscopic extralevator APE of the rectum: shortterm outcomes of a prospective case series. Kiplinf AL., et al. Tech Coloproctol 2013 Oct (EPUB) 28 pts Conversion rate 18% (+) CRM in 3 (10.8%) No perforations Mean length of stay = 7 days Perinal wound complications in 25% 38 month follow up Local recurrence of 11% Overall survival = 75% Disease-free survival = 71%

38 Transabdominal Levator Transection Laparoscopic Chi Pi, et al. Ann Surg Oncol May: 20 (5) Robotic Marecik, SJ, et al. DCR Oct; 54 (10) Kang Cy, et al. Am Surg Oct; 78 (10)

39 DIVISION OF COLORECTAL SURGERY UP PHILIPPINE GENERAL HOSPITAL Initiated MDT, TME and Extralevator APR in APR pts APR rate = 27.8% Mean distance = 1.5 cm Pre-op RT = 67.5% Long course CRT = 50.4% Short course RT = 17.1%

40 DIVISION OF COLORECTAL SURGERY UP PHILIPPINE GENERAL HOSPITAL Operations done: Residents 64.1% vs Consultants 35.9% Open 72.7% vs Lap 27.4% Lithotomy 54.7% vs prone 45.3% Multivisceral resections = 29.1% THBSO, posterior vaginectomy, pprostatectomy Stage II or III = 64.1% Pathologic complete response = 6.8%

41 DIVISION OF COLORECTAL SURGERY UP PHILIPPINE GENERAL HOSPITAL Results: waisting = 36.11% Perforations = 15.4% (+) CRM = 16.5% Significant factors associated with (+) CRM Males (OR 5.26; 95% CI ) Radiotherapy (OR = 7.87; 95% CI )

42 DIVISION OF COLORECTAL SURGERY UP PHILIPPINE GENERAL HOSPITAL Results: Factors with trends towards lower adverse pathologic outcomes (waisting, perforations and CRM positivity), though not statistically significant: Prone (vs lithotomy) Lap (vs. open) Consultant (vs. resident) Long course CRT (vs Short course RT)

43 CONCLUSION Achieve better pathologic and oncologic outcomes with APR through: focused perineal phase Irrespective of: perineal phase position or abdominal phase procedure Aiming for a cylindrical or lollipop shaped specimen with negative margins and perforations more experienced surgeons after long course chemoradiotherapy if warranted

44 THANK YOU