Abdominoperineal resection (APR)
Abdominoperineal resection (APR) is a surgical procedure that involves the removal of the anus, rectum, and a portion of the sigmoid colon, along with the surrounding mesentery. This operation is primarily indicated for patients with low rectal cancer, advanced anal cancer, or metastatic pelvic disease. During the procedure, a stoma is created through an opening in the abdomen, allowing the upper part of the colon to connect to the outside of the body. The surgery aims to eliminate cancerous tissue, control disease progression, or alleviate symptoms associated with advanced cancer.
Preparation for APR includes comprehensive medical evaluations and possible pre-surgical treatments like chemotherapy or radiation therapy. The surgery itself can be performed via traditional open techniques or laparoscopically, which may offer benefits such as reduced blood loss and quicker recovery. Despite being considered moderately safe, APR carries risks including infection, urinary dysfunction, and complications related to the stoma.
Long-term outcomes can vary based on individual patient factors and disease characteristics, with improved survival rates noted in recent studies due to better surgical techniques and treatments. However, research also indicates that APR may not be effective in certain cases, particularly following unsuccessful chemoradiation for specific types of cancer, highlighting the need for alternative treatment strategies in those situations.
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Abdominoperineal resection (APR)
ALSO KNOWN AS: Abdominoperineal excision, anorectal excision, anoproctectomy
DEFINITION: Abdominoperineal resection (APR) is the surgical removal of the anus, rectum, and surrounding membrane called the mesentery, as well as the lower part of the colon supported by the mesentery. The upper part of the colon is rerouted through a new opening (ostomy) in the lower abdomen, forming an opening called a stoma.
Cancers treated: Low rectal cancer, advanced anal cancer, metastatic pelvic disease
Why performed: APR is performed to remove cancerous tissue, thereby curing or controlling the cancer or relieving symptoms of advanced disease. APR is the preferred procedure for large rectal tumors and tumors near the anal sphincter, but other tumor characteristics and patient-specific factors are also considered.
Patient preparation: A series of medical tests are completed to plan effective treatment and to evaluate the patient’s fitness for major surgery. A specialist counsels the patient and helps choose the location for the stoma required by the APR. Radiation therapy, chemotherapy, or both may be recommended before the procedure. Certain patient medications may need to be stopped, the patient’s bowel must be cleaned, and the patient’s stomach must be empty.
Steps of the procedure: APR is scheduled and performed in a hospital. Sensors are placed to monitor the patient’s condition. An intravenous line is started, and an antibiotic is infused. General anesthetic is administered, and a breathing tube is placed. The patient is positioned, a urinary is inserted, and the sites are prepared.
APR is a complex operation requiring incisions first on the abdomenabdominal resectionand then on the perineumperineal resectionwhich may be performed by one or two surgeons. Abdominal resection prepares the lower colon and rectum for removal during the perineal resection and forms the stoma. Perineal resection frees the anus and removes all the diseased tissue.
To begin, the surgeon makes a midline incision in the abdomen large enough to see the tumor and to examine and other organs for metastases. If the tumor is removable, then the procedure continues.
Within the abdomen, rectal blood vessels are tied, and the mesentery is clamped. The lower colon is freed from attachments. The peritoneum is divided, enabling the surgeon to free the rectum. The tied blood vessels and clamped mesentery are divided and sealed. Then, the ostomy opening is made in the abdomen. The colon is divided. The lower end of the colon is covered and tucked below the peritoneum for removal during the perineal resection, and the peritoneum is closed. The upper end of the colon is passed through the ostomy opening, the colon segment is sized to an appropriate length, and the edge of the cut end is folded back and stitched to the abdomen, forming a stoma. Next, other organs are examined for cancerif other lesions or metastases are found, then they may also be removed. Finally, the abdominal cavity is inspected and cleaned, and the abdominal incision is closed.
On the perineum, the surgeon makes an elliptical incision around the anus. Blood vessels are clamped, and then tied as needed. The anus is freed from attachments, including as much surrounding tissue as possible without disturbing major blood vessels, nerves, and healthy organshowever, if the cancer has spread into these structures, then part or all of these structures may be included. The anus is pulled out, as well as the rectum and lower colon are freed during the abdominal resection. All tissues are taken to the laboratory for histopathologic evaluation. Finally, the pelvic cavity is inspected and cleaned, and the perineal incision is closed, with a small tube inserted to drain excess fluid.
The abdominal resection may also be performed laparoscopicallythrough multiple small incisions in the abdomenusing a laparoscopea small fiber-optic or digital camerainserted through one such incision to monitor the procedure. This method has various advantages for the patient, including less blood loss during the procedure, faster recovery time, and, in some cases, lower morbidity and fewer instances of hospital readmission post-operation. The laparoscopic procedure follows much the same steps as the open procedure.
After the procedure: Anesthetic is stopped, and the breathing tube is removed. The urinary catheter and the intravenous line are kept. A clear collection pouchostomy applianceis fitted over the stoma. The patient is transferred to the recovery room, then to a hospital room. Medications are given to control pain and infection. The patient slowly progresses to a normal diet. The ostomy is monitoredonce it starts functioning, the patient learns how to care for the stoma, empty and change pouches, and manage bowel function. At home, the patient follows the physician’s instructions about medications, activities, and diet. Further treatment with radiation therapy, chemotherapy, or both may be recommended.
Risks: APR is moderately safe, with low mortality. Risks relate to anesthesia, infection, and inadvertent damage to other structures. Side effects are common because of the complex anatomy and the difficulty of operating within the bony pelvis. The most frequent side effects are urinary dysfunction and infection, perineal infections or bleeding, and ostomy-related problems. Less frequent side effects are male impotence and infertility, abdominal wound infection, and intestinal obstruction.
Results: The long-term outcome varies considerably with patient-specific factorsdisease stage, overall health, and body characteristicsamong medical institutions, and with therapeutic combinations. The five-year survival rate has increased as the recurrence rate has decreased because of more complete removal of diseased tissue and more effective therapeutic combinations. Survival is improved significantly by the removal of metastases.
In 2024, a study published in The Journal of Clinical Medicine looked at outcomes after failed chemoradiation treatment (CRT) for anal squamous cell cancer (SCC). Researchers determined that APR intended to salvage treatment for SCC after unsuccessful chemoradiation did not lend to positive rates of disease-specific survival. Furthermore, there was few instances of a non-recurrence of SCC. The article listed several indicators that pointed toward relapses. These included positive lymph nodes and evidence of lymphovascular invasion in specimens. The studies suggested alternative treatments aside from APR needed to be identified for SCC following unsuccessful CRT.
Bibliography
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