肝臓学および胃腸疾患ジャーナル
オープンアクセス

概要

Oncological results of extralevator APR, quality of life and long-term complications perineal wounds

Danilov M.A

Abdomeno-perineal resection (APR) is a gold standard of the surgical treatment low rectal cancer and anal cancer today, despite the fact that the proportion of sphincter-preserving operations is increasing every day and the role of combined cancer treatment methods is increasing to. “Conventional” APR proposed by K.Miles has a rather significant drawback – the high level of positive circumferential resection margin (CRM). These disappointing results led to search for ways to improve them, and T.Holm proposed a modification of traditional method and introduced the “extralevator” or “cylindric” APE into practice.The essence of this operation is the wide transection of levator muscles at the places of their attachment of the pelvis, thereby crating an additional layer of tissues, which significantly reduces the rate of obtaining a positive CRM and local recurrence. Currently, the extralevator APR is widely used both in Russia and around the world.

Aim

The study of long-term oncological results, the quality of life of patients and the assessment of the condition of the perineal wound in the long term.

Materials and methods

Patients who, from 2008 to 2015, who underwent cylindrical APR, were assessed for quality of life using questionnaires QLQ-CR30 and CR29 of the European Organization for the Study and Treatment of Cancer (EORTC).

Results

112 cylindrical APR (62 men, 50 women) were performed in our center, of which 68 were laparoscopic (61%) and 44 were open (39%), there were no postoperative mortality. A histological study of the specimen in two cases revealed a positive CRM (1.7%), no intraoperative tumor perforation was noted. The follow-up median was 58 months; there were no cases of local recurrence during the entire observation period, but 8 patients died at different times for various non-cancer reasons (7%), 12 patients developed distant metastases (11%), all received systemic chemotherapy treatment, 2 of them performed liver resection. Complications of perineal wounds 

were in 25% of patients. Half of patients complained of constant pain in perineum. The quality of life was assessed 7-46 months after surgery, the health indicator  was 70.6, which was comparable with the reference value of EORTC and the world average, even in comparison with patients who performed conventional APR. The CR29 module revealed fairly high average rates of frequent urination (48.1%), urinary incontinence (30.5%) and impotence (79.1%) in men.

Conclusions

 Cylindrical APR reduces the probability of local recurrence, but does not affect the processes of distant metastasis. Extended resection of the perineal tissue does not reduce the overall QoL compared to traditional APR, but leads to high rates of perineal wound complications. Urinary disorders is also noted in the long-term time, in connection with which it is necessary to improve the technique of cylindrical APR.