Year : 2021 | Volume
: 4 | Issue : 2 | Page : 37--38
Abdomino perineal resection: Is this still a management option?
Fazl Q Parray
Professor and Head Colorectal Surgery, Sher-i-Kashmir Institute of Medical Sciences, Soura, Srinagar-190011, JK, India
Prof. Fazl Q Parray
44-Rawal Pora,Govt Housing Colony,Sanat Nagar,Srinagar-190005, JK
|How to cite this article:|
Parray FQ. Abdomino perineal resection: Is this still a management option?.Indian J Colo-Rectal Surg 2021;4:37-38
|How to cite this URL:|
Parray FQ. Abdomino perineal resection: Is this still a management option?. Indian J Colo-Rectal Surg [serial online] 2021 [cited 2022 Jan 18 ];4:37-38
Available from: https://www.ijcrsonweb.org/text.asp?2021/4/2/37/330164
The progress made in the diagnostics, therapeutics, multimodal treatments for carcinoma rectum in the last 2 decades is remarkable. The concept of permanent stoma after abdominoperineal resection (APR) in the past would send shivers through the spine of patients and a sizable number of patients would prefer death than to have a stoma. Now with the help of neoadjuvant treatment, staplers, advanced diagnostics such as MRI, endocoil MRI, TRUS, emergence of transanal surgeries, and concepts of ultralow resections, the number of permanent stomas in these patients has markedly decreased., But at times, an over-enthusiastic attitude about sphincter preserving surgeries like ultra-low resection, transanal transabdominal procedures, intersphincteric resections, and transanal total mesorectal excision might prove counterproductive. Since all these procedures get reconstructed with a low coloanal anastomosis and deprive the subjects of the lowest sensitive zone of rectum ending up at times with nocturnal accidents, frequency, flatus/or fecal incontinence and leading to lack of confidence, social embarrassment, loss of workdays and significant depression(Low anterior resection syndrome). Some of these patients may end up with a big disadvantage of perineal colostomy rather than the benefit of a sphincter preserving operation. Thus, such surgeries which invite a very low anastomosis should be done on a selective basis after assessing a good anal tone, a thorough discussion with the patient, and explaining all the issues pertaining to the quality of life (QOL). Patients with cancers in low rectum, decreased anal tone, and lack of motivation should be offered an APR which continues to be a gold standard in such patients, offering an excellent QOL with lots of freedom, decreased chances of local recurrence, and minimal loss of workdays. A very well-made Abdominal colostomy can be managed very well with excellent stoma appliances, especially when you are preoperatively motivated psychologically by a stoma therapist and the site is professionally marked at the correct site and you are geared up to accept it and lead an independent life without anybody's help. Concerns about loss of work days, sexual life, and unwanted stool frequency can also be addressed by well-trained stoma therapist and operating surgeon. APR even though considered an "Old option" but still continues to be a "Gold option" in management of many low rectal cancers. The message need not to be misinterpreted that probably the author is more in favor of APR rather than sphincter-saving procedure in all cases of low rectal cancers. No ,that is is not correct. I am myself in favor of sphincter saving procedures but APR continues to be a golden option in selected cases of low rectal cancer. Such patient group may comprise of: elderly people with a low sphincter tone, unfavorable histology, locally invading tumors, mentally unfit and people with very low energy levels.
The meta-analysis suggests that LAR has a higher 5-year survival rate, low CRM rate, local recurrence, and complications rate than APR in selected low rectal cancer patients, LAR is a better option than APR. Despite our rigorous methodology, the inherent limitations of the included studies should be considered, and conclusions drawn from our pooled results should be interpreted with caution. Future prospective, multicenter, and randomized trials including small number of cases, preoperative radiotherapy, chemotherapy, and/or neoadjuvant chemoradiation administered to the patients will be useful to confirm this conclusion.
Other study showed no difference in global QOL after sphincter-preserving surgery compared to APR.
Bowel problems like constipation and diarrhea are seen in lesser number of patients of APR than sphincter preservation. Incontinence was the main complaint of ISR.APR patients suffered mainly on male sexual function when compared to sphincter preserving surgery but this finding may be biased in this study as most APR patients belonged to elderly age group. The main conclusion was that patients with low rectal cancer may not always profit "at any price "after sphincter preservation surgeries and should be told and explained that global QOL is not always worse after APR when compared to sphincter preserving surgery.
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