Your SlideShare is downloading. ×
Cylindrical APR
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×

Saving this for later?

Get the SlideShare app to save on your phone or tablet. Read anywhere, anytime - even offline.

Text the download link to your phone

Standard text messaging rates apply

Cylindrical APR

2,344
views

Published on


0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total Views
2,344
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
75
Comments
0
Likes
1
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide

Transcript

  • 1. CYLINDRICAL APR
    PETER HEWETT
  • 2. DOORS OF DUBLIN
  • 3. DOORS OF ZANZIBAR
  • 4. RECTUMS OF EUROPE
    British Journal of Surgery
    Volume 97, Issue 4, pages 588–599, April 2010
  • 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.
  • 7.
  • 8.
  • 9.
  • 10.
  • 11. 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
  • 12. 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.
  • 13.
  • 14.
  • 15.
  • 16.
  • 17.
  • 18.
  • 19.
  • 20. Advantages (literature)
    Reduced rate of perforation
    Reduced rate of CRM
    70% more tissue outside the internal sphincter / muscularispropria at the tumour
    14.5mm extra tissue posteriorly and 4mm at anterior and lateral margins at the tumour.
  • 21. J ClinOncol. 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
  • 22. ExtralevatorAPR removed more tissue from outside the smooth muscle layer per slice (median area 2120 versus 1259 mm2; 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).
  • 23. Multicentre experience with extralevatorabdominoperineal excision for low rectal cancer†
    N. P. West1,*,
    C. Anderin3,
    K. J. E. Smith2,
    T. Holm3,
    P. Quirke1
    British Journal of Surgery
    Volume 97, Issue 4, pages 588–599, April 2010
  • 24. 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
  • 25. 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
  • 26. 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!
  • 27. Tips
  • 28.
  • 29. 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.
    © The ASCRS 2010.
    2