Abstract
Background
Abdominoperineal resection for rectal cancer is related to the high frequency of local recurrences, risk of inadvertent bowel perforation, and disease-positive tumor margin. An alternative technique to this procedure, however, is the abdominosacral amputation of the rectum (ASAR). The aim of this study was to report on the technique and share our experience of ASAR on the cohort of consecutively operated patients.
Methods
In its anterior stage, ASAR follows the rules of total mesorectal excision. In its posterior part, the patient is positioned in a prone jackknife position and the coccyx and the last sacral vertebra (if necessary) are removed, enabling a sharp and directly visualized resection of the tumor and other structures critical to local recurrence. Between 1998 and 2007, a total of 210 low-rectal cancer patients were so treated at our clinic.
Results
Bowel perforation occurred in 9 patients, the circumferential resection margin was positive in 16 patients, and 38 patients had local wound complications. Seven (4.4%) of 158 patients with 2-year follow-up developed local recurrence, whereas 5-year observed and relative survivals were 68.3% and 73.2%, respectively.
Conclusions
ASAR has a low risk of bowel perforation, circumferential resection margin involvement, and local wound complications. The local recurrence rate is lower and survival better than with conventional abdominoperineal resection.
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References
Kapiteijn E, Marijnen CAM, Nagtegaal ID, et al. Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. N Engl J Med. 2001;345:638–46.
Wibe A, Moller B, Norstein J, et al. A national strategic change in treatment policy for rectal cancer—implementation of total mesorectal excision as routine treatment in Norway: a national audit. Dis Colon Rectum. 2002;45:857–66.
Adam IJ, Mohamdee MO, Martin IG, et al. Role of circumferential margin involvement in the local recurrence of rectal cancer. Lancet. 1994;344:707–11.
Quirke P, Durdey P, Dixon MF, Williams NS. Local recurrence of rectal adenocarcinoma due to inadequate surgical resection: histopathological study of lateral tumor spread and surgical excision. Lancet. 1986;2:996–9.
Marr R, Birbeck K, Garvican J, et al. The modern abdominoperineal excision: the next challenge after total mesorectal excision. Ann Surg. 2005;242:74–82.
Nagtegaal ID, van de Velde CJH, Marijnen CAM, van Krieken JHJM, Quirke P. Low rectal cancer: a call for a change of approach in abdominoperineal resection. J Clin Oncol. 2005;23:9257–64.
Miles WE. A method of performing abdominoperineal excision for carcinoma of the rectum of the terminal portion of the pelvic colon. Lancet. 1908;2:1812–3.
Nagtegaal ID, Quirke P. What is the role for the circumferential margin in the modern treatment of rectal cancer? J Clin Oncol. 2008;26:303–12.
Bębenek M, Pudełko M, Cisarż K, et al. Therapeutic results in low-rectal cancer patients treated with abdominosacral resection are similar to those obtained by means of anterior resection in mid- and upper-rectal cancer cases. Eur J Surg Oncol. 2007;33:320–3.
Bębenek M. Abdominosacral resection (ASR) is not related to the risk of neurological complications in patients with low rectal cancer. Colorectal Dis. 2009;11:373–6.
Bębenek M. Influence of neoadjuvant radio(chemo)therapy on wound healing in lower-rectal cancer patients subjected to abdominosacral resection (ASR). World J Colorectal Surg. 2008; 1:Article 10.
Liebermann-Meffert D. History of the International Society of Surgery/Societe International de Chirurgie (ISS/SIC). I. Short story of Theodor Kocher’s life and relationship to the International Society of Surgery. World J Surg. 2000;24:2–9.
Classic articles in colonic and rectal surgery. Paul Kraske 1851–1930. Extirpation of high carcinomas of the large bowel. Dis Colon Rectum. 1984;27:499–503.
Sauerbruch F, Schmieden V. Chirurgische Operationslehre. Vol 4. Leipzig: Verlag von Johan Ambrosius Barth; 1933.
Heald RJ, Husband EM, Ryall RD. The mesorectum in rectal cancer surgery—the clue to pelvic recurrence? Br J Surg. 1982;69:613–6.
Heald RJ. The “holy plane” of rectal cancer. J R Soc Med. 1988;81:503–8.
den Dulk M, Putter H, Collette L, et al. The abdominoperineal resection itself is associated with an adverse outcome: the European experience based on a pooled analysis of five European randomized clinical trials on rectal cancer. Eur J Cancer. 2009;45:1175–83.
Holm T, Ljung A, Häggmark T, Jurell G, Lagergren J. Extended abdominoperineal resection with gluteus maximus flap reconstruction of the pelvic floor for rectal cancer. Br J Surg. 2007;94:232–8.
West NP, Finan PJ, Anderin C, et al. Evidence of the oncologic superiority of cylindrical abdominoperineal excision for low rectal cancer. J Clin Oncol. 2008;26:3517–22.
Guillem JG, Minsky BD. Extended perineal resection of distal rectal cancers: surgical advance, increased utilisation of neoadjuvant therapies, proper patients selection or all of the above? J Clin Oncol. 2008;26:3481–2.
Carlson HW, editor. Modern operative surgery. Vol 2. London: Cassell; 1924.
Wanebo HJ, Gaker DL, Whitehill R, Morgan RF, Constable WC. Pelvic recurrence of rectal cancer. Options for curative resection. Ann Surg. 1987;205:482–95.
Wanebo HJ, Antoniuk P, Koness RJ, et al. Pelvic resection of recurrent rectal cancer: technical considerations and outcomes. Dis Colon Rectum. 1999;42:1438–48.
Avradopoulos KA, Vezeridis MP, Wanebo HJ. Pelvic exenteration for recurrent rectal cancer. Adv Surg. 1996;29:215–33.
Zacherl J, Schiessel R, Windhager R, et al. Abdominosacral resection of recurrent rectal cancer in the sacrum. Dis Colon Rectum. 1999;42:1035–40.
Mannaerts GH, Rutten HJ, Martijn H, et al. Abdominosacral resection for primary irresectable and locally recurrent rectal cancer. Dis Colon Rectum. 2001;44:806–14.
Bakx R, van Tinteren H, van Lanschot JJ, Zoetmulder FA. Surgical treatment of locally recurrent rectal cancer. Eur J Surg Oncol. 2004;30:857–63.
Spiliotis J, Datsis A. The surgical approach to locally recurrent rectal cancer. Tech Coloproctol. 2004;8(Suppl 1):S33–5.
Localio SA, Eng K, Gouge TH, et al. Abdominosacral resection for carcinoma of the midrectum: ten years experience. Ann Surg. 1978;188:475–80.
Localio SA, Eng K, Coppa GF. Abdominosacral resection for midrectal cancer. A fifteen-year experience. Ann Surg. 1983;198:320–4.
Eng K, Localio SA. Abdominosacral resection of the rectum. Ann Chir Gynaecol. 1986;75:100–5.
Eng K, Localio SA. Abdominosacral resection for midrectal cancer. Hepatogastroenterology. 1992;39:207–11.
Swedish Rectal Cancer Trial. Improved survival with preoperative radiotherapy in resectable rectal cancer. N Engl J Med. 1997;336:980–7.
Salerno G, Chandler I, Wotherspoon A, et al. Sites of surgical waisting in the abdominoperineal specimen. Br J Surg. 2008;95:1147–54.
Bębenek M, Wojnar A. Infra-levator lymphatic drainage of low rectal cancers. Preliminary results. Ann Surg Oncol. 2009;16:887–92.
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Bębenek, M. Abdominosacral Amputation of the Rectum for Low Rectal Cancers: Ten Years of Experience. Ann Surg Oncol 16, 2211–2217 (2009). https://doi.org/10.1245/s10434-009-0517-2
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DOI: https://doi.org/10.1245/s10434-009-0517-2