The document discusses different techniques for performing an abdominoperineal resection (APR) for rectal cancer. It outlines problems with the conventional synchronous APR approach and proposes changing to standardized inter-sphincteric, extra-levator, or ischio-anal APR depending on tumor location. Each technique is defined by its relationship to anatomical structures. Indications, advantages, and positioning considerations are provided for each type of APR.

1. Positioning and technique of a wide perineal resection ESO-ESSO Master Class in Colorectal Cancer Surgery 12 – 17 February 2011 Cascais, Portugal Torbjörn Holm MD PhD Section of Coloproctology Department of Surgery Karolinska University Hospital Stockholm, Sweden

2. Outline Problems associated with conventional APR Changing concept of APR Inter-sphincteric APR Extra-levator APR Ischio-anal APR Indications for APR in rectal cancer Patient unsuitable for bowel reconstruction Tumour extending less than 1 cm from dentate line Tumour threatening CRM Locally advanced cancer

3. APR in rectal cancer Sir Ernest Miles (1869-1947) Lancet 1908

4. Miles’ Perineal Dissection

5. APER (Miles)

6. Copyright ©2008 BMJ Publishing Group Ltd. Morris, E et al. Gut 2008;57:1690-1697 Problems associated with conventional APR Variation in the use of rectal operations by English NHS hospital trust

7. APR performed in 75-80 % in Sweden 1995 - 2008 APR in low rectal cancer (0-6 cm above anal verge) LAR APR Hartmann

9. Conventional APR - synchronous combined

10. Problems associated with conventional APR Synchronous combined APR is not a standardised operation Results are variable and suboptimal Results poorer than after anterior resection Perforations Involved margins

11. Problems associated with conventional APR Inadvertent bowel perforation significantly more common after APR AR APR Norway 4% 15% Sweden 3% 14% Holland 3% 14%

12. Norwegian Rectal Cancer Group Br J Surg 2004; 91: 210-16

13. Problems associated with conventional APR Tumour involved circumferential resection margin significantly more common after APR (CRM +ve) AR APR Dutch TME Trial 12% 29% MERCURY Trial 12% 33%

14. Problems associated with conventional APR Data from the Dutch TME Trial Local recurrence Survival APR CRM + 30 % 38 % CRM - 9 % 72 % Nagtegaal et al. J Clin Oncol 23; 9257 – 9264, 2005

15. Abdominoperineal Resection Conventional APR Abandon Redrawn from Gordon & Nivatvongs QMP 1999 by A.Tøttrup, Aarhus

16. Changing concept of APR Three different APR procedures Related to defined anatomical structures Inter-sphincteric Extra-levator Ischio-anal Each procedure should be standardised Indications should be defined for each procedure Based on appropriate staging – MRI, ultrasonography and clinical examination

17. Inter-sphincteric APR Redrawn from Gordon & Nivatvongs QMP 1999 by A.Tøttrup, Aarhus

18. Extra levator APR Redrawn from Gordon & Nivatvongs QMP 1999 by A.Tøttrup, Aarhus

19. Ischio-anal APR Redrawn from Gordon & Nivatvongs QMP 1999 by A.Tøttrup, Aarhus

20. Indications for APR in rectal cancer Inter-sphincteric APR Patient unsuitable for bowel reconstruction Preoperative history of incontinence High risk of anastomotic leak Co-morbidity – crucial to prevent leakage + fatal outcome Patients preference Options Hartmann’s procedure Inter-sphincteric APR

21. Problems associated with Hartmann's procedure Pelvic sepsis –abscess New tumour in remnant rectal stump Soiling, (bleeding, pain) Proctoscopy may be difficult and painful

22. Overall rate of pelvic abscess 31/163 19% Transsection < 2cm Transsection > 2cm above pelvic floor above pelvic floor Pelvic 24/73 33% 7/90 8% abscess Dis. Colon Rectum 2005; 48: 251–255

23. CONCLUSION : Surgical alternatives to Hartmann’s procedure should be considered when the level of transsection is <2 cm above the pelvic floor, particularly in males.

24. Swedish experience Ersta Hospital 1995 – 2004 (M. Machado) 82 patients had a Hartmann’s procedure Overall rate of pelvic abscess 21% (17/82) High transsection 0% (0/19) Low transsection (TME) 27% (17/63)

25. Inter-sphincteric APR - probably better than low Hartmann’s Potential benefits Reduced rate of pelvic sepsis Eliminates the risk of metachronous cancer No disabling symptoms from rectal stump No need for surveillance of rectal stump Drawbacks Prolongs operation time Perineal wound infection

26. Indications for APR in rectal cancer Extra-levator APR Tumour extending less than 1 cm from dentate line Inter-sphincteric APR (adenomas, T1 cancer) Extra-levator APR (T2 – T4 cancer) Tumour threatening CRM Extra-levator APR

27. Tumour threatening CRM Threatened CRM

34. Indications for APR in rectal cancer Ischio-anal APR Locally advanced cancer infiltrating Levator muscles Ischio-anal fat Perianal skin Perforated cancer with abscess or fistula in ischio-anal fossa

35. Tumour perforating into ischio-anal fossa

36. Supine or prone approach Inter-sphincteric APR: Supine Extra-levator APR: Prone preferable, Supine possible Ischio-anal APR: Prone

37. Supine versus prone? Risk of inadvertent perforation West et al. BJS 2010; 97: 588–599

38. Phase 1 Supine position Warm cloud mattress Split legs Trendelenburgs position Support for the shoulders Catheterisation of the bladder (closed)

39. Operating table

40. Warmcloud mattress

41. Patient in the supine position Planned incision and position of the stoma

42. Stoma, drain and catheter (suprapubic)

43. Phase 2 Turning session Mobilizer Jack-knife position Leg support devices Special pillow for the face

44. Mobilizer

45. Moving the patient to the prone Jack-knife position with a mobilizer

46. Operating table for prone position Chest and abdomen cushions from TEMPUR company

47. Facepillow From the MIZUHOSI company; 7” gentle touch pillow

49. Patient in the Jack-knife position

50. When is APR the correct choice? Conclusion Assess patient and tumour Anal function, co-morbidity, patient preference Very low or threatened CRM If APR the correct choice – what type of APR? Inter-sphincteric Extra-levator Ischio-anal Extent of procedure must be planned preoperatively Avoid changing approach during surgery

51. Colorectal surgery at Karolinska Institutet Workshop and Symposium May 4-6, 2011 Stockholm, Sweden Welcome