Transcript apr - Pilgrims Hospital

Dr Richard Downey
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HS, 61 yr old male
No significant medical history
18 month hx of perianal pain, pruritus ani
and occasional PR bleeding
EUA
Deep posterior anal fissure surrounded by
area of induration and thickening
◦ Biopsies-chronically inflamed and fibrotic
squamocolumnar anal mucosa
◦ Consistent with fissure in ano
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Symptoms unresponsive to topical Rx
o/e Large posterior fissure and associated
skin tag, BRBPR
Crohn’s Disease suspected
Scheduled for EUA Rectum in urgently and
SBFT
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Biopsies at colonoscopy in EUA-Low Rectal
Tumour extending into anus
◦ Histology-Anal gland vs Rectal cancer
◦ Moderately differentiated Adenocarcinoma
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MRI pelvis
◦ Increased soft tissue thickening posterior to
superficial perianal area
◦ Number of mesorectal lymph nodes seen
◦ Does not extend above internal sphincter
◦ T4N1M0 Rectal Adenocarcinoma
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Number of palpable hard satellite lesions up
to 3cm from anal verge along perianal skin
Neoadjuvant treatment
◦ Chemotherapy-5FU
◦ Radiotherapy encompassing perianal skin, inguinal
nodes and external iliac nodes
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EUA
Tumour at 3cm, bulky, friable perianal skin
Scheduled for APR and VRAM flap
reconstruction
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APR
Lower midline laparotomy
Left colon and rectum mobilised
Total mesorectum excision
Sigmoid colon dived and proximal end brought out
as colostomy
◦ Wide perineal resection performed
◦ Rectum delived through anus and resected in full
◦ Haemostasis achieved
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photo
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Reconstruction perineal defect with right
VRAM Flap
◦ VRAM raised through lateral incision
◦ Ant rectus sheath opened and muscle dissected
from post rectus sheath
◦ Inferior deep epigastric artery pedicle preserved
◦ Deepithelialisation of skin over muscle
◦ Muscle mobilised to cover defect
◦ Abdominal closure with prolene mesh, sutures
◦ Perineum closure with sutures
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Unremarkable
Wounds clean and healthy
Satisfactory stoma care
Discharged day 16 post op
Histology
◦ For discussion
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Oncology
◦ For adjuvant chemotherapy in Letterkenny
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Indicated for rectal cancer in the lower third
of rectum
APRs involves removal of the anus, the
rectum, part of the sigmoid colon and ther
associated lymph nodes
Incisions are made in the abdomen and
perineum
Remaining sigmoid colon brought out as a
colostomy
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First described by Ernest Miles in 1908
By the 1920s, recurrence rates were down to 30%-gold
standard at that time
Several modifications were proposed to promote
locoregional control and survival, with little success
Better suture material and devices enabling low
anastomoses heralded a shift toward sphincter-saving
approaches with respect to cancer of the rectum
Anterior resection replaced APR as the mainstay of therapy
in the 1950s
There was concern that sphincter-saving surgery might
increase local recurrence
It was in this setting that total mesorectal excision (TME)
was first described in 1982 by Heald and colleagues
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The TME concept is based on the locoregional
recurrence preference of rectal carcinoma
Therefore adequate en bloc clearance of the
rectal mesentry, including its blood supply
and lymphatic drainage, would minimize
possible disease relapse
TME is now considered the Gold Standard
adjunctive therapy for colorectal cancer
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Improved surgical techniques (eg total
mesorectal excision and autonomic nerve
preservation) have shown a corresponding
decrease in local recurrence rates and increase in
overall survival of patients with rectal cancer
However local recurrence and survival after an
APR have not improved to the same degree as
that seen after an anterior resection
This difference has been attributed to relative
smaller tissue volumes around the tumour and
higher rates of cancer at circumferential resection
margins (CRM) after an APR compared with an
anterior resection
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As tumour-free lateral margins have been
demonstrated to be an important prognostic
factor for local recurrence and survival, an
extensive resection is frequently required
In an attempt to improve healing, several
techniques for perineal closure have been
described
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Epiploplasty
Gracilis Flap
Vertical Myocutaneus Flap
Gluteus Maximus Flap
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They facilitate closure of the perineal defect
with healthy and well-vascularized tissue
without placing the tissue under undue
tension
The vertical rectus abdominis myocutaneous
(VRAM) flap is also useful in creating a neovagina after posterior colpectomy
There is a lack of information in the literature
concerning the efficacy of VRAM flap
reconstruction after APR
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Lefevre et at evaluated the results of a VRAM flap
after APR for anal cancer
95 patients underwent APR, including 43 patients
who subsequently received a VRAM flap
Survival in the 2 groups was equivalent despite
the presence of more advanced cancers in the
VRAM flap cohort
They concluded VRAM is an effective technique
for reducing both the perineal complication rate
and wound-healing delay in patients undergoing
APR for AC that does not increase abdominal wall
morbidity
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Long term treatment of fissures in ano-Could
their be an underlying malignacy??
Advancements in treating rectal cancers
Cylindrical APR and VRAM flaps
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STUDENTS
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◦ Different colorectal cancer operations
Thank You