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Extended APER- An Update

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Talk given By Miss Helen Chave , Consultant Colorectal Surgeon, Salisbury NHS Foundation Trust, at the Dukes' Club AGM 2011.

Talk given By Miss Helen Chave , Consultant Colorectal Surgeon, Salisbury NHS Foundation Trust, at the Dukes' Club AGM 2011.

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Extended APER- An Update Extended APER- An Update Presentation Transcript

  • APR – Old or New Helen Chave Consultant Colorectal Sugeon Salisbury NHS Foundation Trust
  • APER - the challenges
    • poorer oncological results
    • high morbidity
      • unhealed perineum
    • training
    Dukes' club, April 2011
  • Quality of care - optimal surgery
    • Abdominoperineal excision -2008
  • Oncological outcomes
    • increased CRM +ve x2-3 (1,2,3,8)
    • increased perforation rate x4 (1,4,7)
    • increased LR (5,6,7,8)
    • decreased survival (1,3,7,8,9)
    Dukes' club, April 2011
    • Nagtegaal ID. J Clin Oncol 2005; 23 (36): 9257-64
    • Tilney HS. Dic Colon Rectum. 2007 Jan; 50 (1): 29-36
    • Kim JS. Ann Surg Oncol. 2009; 16 (5): 1266-73
    • Eriksen MT. Br J Surg. 2004 Feb; 91 (2): 210-6
    • Heald RJ. Dis Colon Rectum. 1997; 40 (7): 747-51
    • Ptok H. Eur J Surg Oncol. 2007 Sep; 33 (7): 854-61.
    • Marr R. Ann Surg. 2005; 242 (1): 74-82
    • Den Dulk M. Eur J Cancer. 2009; 45 (7): 1175-83
  • CRM involvement Dukes' club, April 2011 Anterior resection APE Nagtegaal 2002 10.7% 30.4% Wibe 2004 5% 12% ACPGBI 2004 5.7% 16.7% MERCURY 2004 7.6% 29% Den Bulk 2009 5% 10.6%
  • Extralevator APR Dukes' club, April 2011 n= CRM (%) IOP (%) Holm, 2007 28 7 3.5 LR 7% median f/u 16 mths West, 2008 27 14.8 3.7 Bebenek, 2009 210 7.6 4.3 2 yr LR 4.4% Davies, 2009 40 0 Not reported 5% median f/u 88 mths (4-125)
  • Dukes' club, April 2011
  •  
  • The Concept Dukes' club, April 2011
  • Dukes' club, April 2011
  • Prone or lithotomy?
    • CRM involvement
      • no difference
    • IOP
      • prone jack-knife 8/125 (6.4%)
      • lithotomy/Lloyd-Davis 6/29 (20.6%)
      • P=0.027
      • West NP et al. BJS 2010
    Dukes' club, April 2011
  • Why did we start?
    • no data on CRM positivity or tumour perforation
    • anterior resection LR < 2%
    • APER LR 16%
    • visited Torbjorn Holm
    • MERCURY II
    Dukes' club, April 2011
  • Jan 07-March 11
    • 31 (9 female)
      • 7 tertiary referrals
    • mean age 67 (range 44-82)
    • median tumour 8mm (range 0 – 50)
    • 12 neoadjuvant treatment
    • 4 en-bloc prostatectomy
    • all dual operating
    • MERCURY II
    Dukes' club, April 2011
  • Mortality and morbidity
    • no postoperative deaths
    • 1 ureteric injury
    • 1 stoma retraction
    • 1 flap failure
    Dukes' club, April 2011
  • Before and after ELAPE Dukes' club, April 2011 Standard APR ELAPE P value +ve CRM 16.7 10 Perforation 6.7 0 Local recurrence 20 3.3 Distance from dentate line 17.8 mm 5.7 mm 0.003 LN harvest 12.2 15.2 LOS 23.6 16.3 0.03
  • Dukes' club, April 2011
  • Perineal wound failure
    • Common 1-3
    • Long term problems 2,4
    • Bullard et al. Dis C olon Rectum 2005.
    • Chadwick et al. Colorectal Dis 2006.
    • Kim et al. Int J Radiat Oncol Biol Phys 1997.
    • Kapoor et al. Am Surg 2005.
    Dukes' club, April 2011
  • Current trends
    • Increasing use of radiotherapy
      • Single most important risk factor 3
    • ElAPE
      • removes significantly more tissue than conventional procedure 5
    3. Chadwick et al. Colorectal Dis. 2006. 5. West et al. J Clin Oncol 2008 . Dukes' club, April 2011
  • Dukes' club, April 2011
  • Options
    • Omentoplasty
    • Biological mesh
    • Myocutaneous flaps
    Dukes' club, April 2011
  • Omentoplasty
    • Only case control data
    • Reduces perineal dehiscence 6 , time to wound healing 7,8 and length of stay 7
    • Reduces incidence of major pelvic complcations 9
    • Increased incidence of ileus and length of stay 10
    6 . Hay et al. Eur J Surg 1997. 7. Poston et al. Ann R Coll Surg Engl 1991. 8 . John et al. Int J Colorectal Dis 1991. 9 . Hultman et al. Ann Plast Surg 2010. 10. Klaver et al. Int J Colorectal Dis. 2008. Dukes' club, April 2011
  • Biological mesh
    • No case controlled studies
    • 4 case series (Total 33)
    • Increase in perineal pain
    11. Han JG, DCR, 2010 12. Wille-Jorgensen, Int J Colorectal Dis, 2009 13. Abhinav K, Eur j Surg Oncol, 2009 14. Jess P, Colorectal Dis, 2010 Dukes' club, April 2011
  • Myocutaneous Flaps
    • Only case control data
    • Reduced wound complications 15-17 , less delayed wound healing 15 and less reoperations 15
    • Prolongs operative time by 2h 4,18 but this is not associated with increased complications or length of stay 4,15,18,19
    15. Radice et al. Br J Surg 1999. 16. Shibata et al.Ann Surg Oncol 1999. 17. Persichetti et al. Ann Plast Surg 2007 18. Chan et al. Colorectal Dis 2010. 19. Petrie et al. Int J Colorectal Dis 2009. Dukes' club, April 2011
  • VRAM Flap
    • Comparative data
    • Significant improvements in perineal wound healing 15, 20-22
    • No evidence of significant donor site morbidity 23-26
    • Superior to thigh flaps 24 and omentoplasty 27
    20. Chessin et al. Ann Surg Oncol 2005. 21. Ferenschild et al. World J Surg 2005. 22. Tei et al. Br J Surg 2003. 23. Butler et al. J Am Coll Surg 2008. 24. Nelson et al. Plast Reconstr Surg 2009. 25. Tobin et al. Plast Reconstr Surg. 1988. 26. Skene et al. Br J Surg 1990. 27. Lefevre et al. Ann Surg 2009. Dukes' club, April 2011
  • Recommendations
    • After radiotherapy or ElAPE the perineal defect should not be closed primarily but rather an adjunct should be employed (Grade of Recommendation B)
    • A flap is probably the best method for closing the perineal defect (Grade of Recommendation D)
    • More comparative data is needed to clarify the relative benefits of different types of myocutaneous flaps and biological meshes.
    Dukes' club, April 2011
  • Dukes' club, April 2011
  • Dukes' club, April 2011
  • Dukes' club, April 2011
  • Dukes' club, April 2011
  • Dukes' club, April 2011
  • Dukes' club, April 2011
  • Dukes' club, April 2011
  • Dukes' club, April 2011
  • Dukes' club, April 2011
  • Dukes' club, April 2011
  • Dukes' club, April 2011
  • Salisbury experience
    • November 2000 – Feb 2011
    • 54 patients (22 female, av. age 66)
      • Rectal 37
        • ElAPE 31
        • Traditional APE 6
      • Anal 17
      • Laparoscopic top end 15 (one converted)
    • VRAM 48
    Dukes' club, April 2011
  • Morbidity
    • Recipient:
      • Flap loss 2 (4%)
      • Infected pelvic haematoma 2 (4%)
      • Flap tip necrosis 1 (2%)
      • Perineal hernia 1 (2%)
    • Donor site
      • Infected biological mesh 2 (4%)
      • Incisional hernia 1 (2%)
    Dukes' club, April 2011
  • Where did LOREC come from?
    • Variation in APE rates
    • High CRM involvement
    • Poor outcomes in APE
  • Proportion APE -28 LOREC MDTs Mean 24% (14 -44%) National Cancer Intelligence Network (Andy McMeeking)
  •  
  • Summary
    • Oncology
    • Morbidity
    • Training
    Dukes' club, April 2011