Improved Outcomes in Colon and Rectal Surgery part 30 pdf

Lloyd-Davies’ synchronous approach to the abdomen and peri-neum with the patient in the lithotomy position eliminated the cumbersome and sometimes dangerous need to reposition the patien

 Abdominoperineal resection

W Brian Perry, Fia Yi, Clarence Clark, and Danny Kim

ChAllenging CAse

A 64-year-old woman is 7 days s/p an abdominopernneal

resec-tion for a T2N1 rectal adenocarcinoma She had received

preop-erative Her perineal wound has developed increased tenderness,

is swollen, and is draining pus

CAse MAnAgeMent

The patient’s wound is opened and the patient is started on three

times a day dressing changes After 2 days the wound is clean and

a vacuum assisted closure (VAC) dressing is placed

introduCtion

Abdominoperineal resection (APR) completely removes the

dis-tal colon, rectum, and anal sphincter complex using both

ante-rior abdominal and perineal incisions, resulting in a permanent

colostomy Developed more than 100 years ago, it remains an

important tool in the treatment of rectal cancer despite advances

in sphincter-sparing procedures We will examine a brief history

of this procedure, current operative techniques and

complica-tions, expected results, (both oncologic and with regard to quality

of life), and what the future may hold for this procedure

Several recent reports have noted the increase in the use of

sphincter-sparing options for patients diagnosed with rectal

can-cer Abraham and colleagues found a 10% decrease (60.1–49.9%)

in the rate of APR from 1989 to 2001 as compared with low

ante-rior resection (LAR) using national administrative data.(1) When

controlled for several variables, including patient demographics

and hospital volume, patients were 28% more likely to have an

LAR later in the study period Schoetz notes that LAR

outnum-bers APR three to one in the submitted case logs of recent

color-ectal fellows.(2) This ratio is similar to that found in the Swedish

rectal cancer registry, where approximately 25% of over 12,000

patients with rectal cancer underwent APR from 1995–2002.(3)

In no study or registry, however, has APR been eliminated

history

Early in the twentieth century, most patients with rectal cancer

underwent perineal procedures to address typically advanced,

symptomatic disease These included the transcoccygeal Kraske

approach and the transsphincteric approach developed by Bevan

in America, later attributed to A York Mason Patients were

typi-cally left with profound sphincter dysfunction or fistulae

follow-ing a protracted recovery A two-staged operation, consistfollow-ing of

an initial laparotomy and colostomy followed by perineal excision,

was used until the 1930’s with reasonable results

The operation we now know as APR was first described by

Miles in 1908, but initial reports showed a high operative

mortal-ity, up to 42% Improvements in perioperative care that came later

reduced this considerably Refinements in technique continued

through the first half of the twentieth century Gabriel described

the operation in one stage, with the abdominal portion done supine and the perineal portion done in the left lateral position Lloyd-Davies’ synchronous approach to the abdomen and peri-neum with the patient in the lithotomy position eliminated the cumbersome and sometimes dangerous need to reposition the patient while under anesthesia.(4) Recent advances have included total mesorectal excision in patients undergoing APR and the addition of methods to enhance perineal wound healing, espe-cially in patients who have received neoadjuvant chemoradiation Minimally invasive techniques are also being applied to APR, with good initial results

PAtient PrePArAtion And Positioning

Preparation for abdominoperineal resection starts with marking the ideal placement of the colostomy by the primary surgeon or enterostomal nurse.(5) Patients are instructed to take a mechani-cal bowel preparation the day before surgery consisting of sodium phosphate solution or polyethylene glycol Placement of an epidural catheter may be considered to improve postoperative analgesia and to reduce postoperative ileus.(6) Before induction of general anesthesia, intermittent pneumatic compression devices are placed

on the lower extremities to reduce the risk of venous thromboem-bolism.(7) Intravenous antibiotics with efficacy against enteric flora are administered 60 minutes before incision to decrease rate of surgical site infection.(8) The abdomen and perineum are prepped and appropriate monitoring is placed

After induction of anesthesia, a urinary catheter is inserted; ure-teral stents should be considered if the patient has had prior pelvic surgery, tumor extension into the urinary tract, or prior pelvic radi-ation The patient is placed in the lithotomy position using Allen stirrups with padding to prevent lower limb acute compartment syndrome.(9) Positioning also includes symmetric hip extension, knee flexion, and thigh abduction (Figure 27.1) Ultimately the legs are balanced in the stirrups, such that the weight is resting on the feet and the ankle and knee are in line with the opposite shoulder

A rectal exam is performed under anesthesia followed by irrigation with dilute betadine solution to remove any residual stool

oPerAtive teChnique

The operative technique used today varies little from Ernest Miles’ description in 1908.(10) Unlike Miles’ method we prefer the two-team approach with the patient in lithotomy position rather than lateral semi-prone position A nonabsorbable purse-string suture is placed around the anus The abdomen and perineum are prepared with antiseptic solution and draped with openings for the abdomi-nal and perineal dissections The abdomen and pelvis are accessed through a midline hypogastric incision that extends to the right

of or through the umbilicus The abdomen is explored for meta-static disease and synchronous colon lesions After confirmation of resectability, a self-retaining retractor is placed

Figure 27.1 Leg positioning for abdominoperineal resection.

The small bowel is packed into the upper abdomen with a moist

towel The sigmoid and descending colons are then mobilized at

the white line of Toldt in the left lateral gutter After confirming

adequate mobilization of the descending colon for an end

colos-tomy, the left ureter is identified and preserved The peritoneum

incision is carried anterior followed by incision of the right lateral

peritoneum The right ureter is identified and preserved and the

peritoneal incisions are connected anteriorly at the base of the

bladder For convenience, the proximal sigmoid can be divided

with a linear stapling device and the cut end used as a handle

to aid with the dissection A finger is passed below the inferior

mesenteric vessels with the plan to leave the sigmoid branches

This helps minimize vascular compromise of the stoma It is

unnecessary to ligate the inferior mesenteric artery at its origin as

this has not been shown to increase survival.(11)

The superior hemorrhoidal vessels are transected The presacral

space is entered without breaching the endopelvic fascia and with

preservation of the mesorectum consistent with Heald’s descrip-tion of total mesorectal excision.(12) After identifying this avas-cular plane, the dissection is aided by using a lighted St Mark’s retractor to hold the mesorectum anteriorly As the dissection continues distally, Waldeyer’s fascia is divided with electrocautery

or sharply to avoid injuring the presacral venous plexus Staying in the avascular plane posteriorly and laterally minimizes bleeding The lateral ligaments are cauterized or suture-ligated close to the pelvic side wall to maximize the radial margins Denonvillier’s fas-cia in males is dissected down to the pelvic floor anteriorly Unless the tumor is anterior, it is not necessary to expose the seminal vesi-cles in males thus avoiding injury to the nervi erigentes In females, the presence of an anteriorly based tumor may require perform-ance of a posterior vaginectomy When the pelvic floor is reached circumferentially around the rectum, the abdominal portion of the dissection is completed Once the pelvic dissection is completed, the colostomy is created and the abdomen is closed

When the abdominal operator has determined that the lesion

is resectable the perineal dissection begins simultaneously with

the abdominal portion of the case The perineal dissection

begins with an elliptical incision from the perineal body in males

or the posterior vaginal introitus in females to a point midway

between the anus and coccyx The incision should include the

entirety of the external sphincter muscle, but does not need

to extend laterally to the ischial tuberosities Dissection is

car-ried down to the levator ani muscles with cautery to minimize

bleeding The inferior hemorrhoidal arteries located

posterior-laterally are ligated Using a finger on the tip of the coccyx as a

guide, the posterior dissection is directed anterior to the coccyx

and the anococcygeal raphe is divided When all that remains

are the anterior attachments, the specimen is drawn through the

opening and used to provide traction to continue the

remain-ing dissection The specimen is then removed and the pelvis is

irrigated If sufficient levator muscle remains, the pelvic floor

is reapproximated to reduce the risk for perineal herniation

Drains are placed and secured followed by closure of the skin

with interrupted permanent or absorbable monofilament suture

in a vertical mattress fashion

PreservAtion of sexuAl And urinAry funCtion

As described by Kyo et al the neuroanatomy begins with the

sym-pathetic nerve fibers that travel through the lumbar splanchnic

nerves to the superior hypogastric plexus and then divide into

two hypogastric nerves Parasympathetic fibers emerge from

the second, third, and fourth sacral spinal nerves as the pelvic

splanchnic nerves and join the hypogastric nerves to form the

inferior hypogastric (pelvic) plexus The pelvic plexus is

rectan-gular and its midpoint is located at the tips of the seminal vesicles

on either side of the rectum (Figure 27.2) The most caudal

por-tion of the pelvic plexus travels at the posterolateral border of the

prostate, lateral to the prostatic capsular arteries and veins and

reaches the hilum of the penis.(13)

The rate of urinary dysfunction and impotence after rectal

sur-gery ranges from 33% to 70% and 20% to 46%, respectively, while

20–60% of potent patients are unable to ejaculate.(14) A surprisingly

large proportion of patients suffer various urinary tract problems

and sexual problems due to extended lymphadenectomy involving

the hypogastric nerve plexus Therefore, preservation of the pelvic

autonomic nerves lowers the incidence of sexual and urinary

mor-bidity With preservation of the superior hypogastric nerve plexus,

ejaculation is maintained in 90% of the patients.(15)

Utilizing precise dissection with preservation of autonomic nerves

Kim et al noted an erection rate of 80%, penetration ability rate of

75% with only 5.5% of patients in their study reporting complete

inability for erection and intercourse Study by Shirouzu et al showed

oncologic equivalence between previously described extensive

resec-tion pre-1984 and plexus preserving low rectal surgery post-1985

with local recurrence rates 9.1 and 3.9%, respectively and 10-year,

disease-free survival rate of 77% and 81.5%, respectively No

signifi-cant difference was noted among the groups.(16)

Methods of Closure

The perineal wound can be packed open, partially closed, or

com pletely closed The peritoneal defect above the pelvic space

can also be sutured closed or left open Adjunctive procedures such as drainage of the pelvic space, with or without continuous irrigation, and omental plugging may also be considered Rates of primary healing after perineal wounds are closed range from 4% to 92%.(10, 17, 19) Open packing relegates all wounds

to secondary healing, is inconvenient, and often painful but may result in a lower rate of chronic perineal sinus formation.(19) Closure of the pelvic peritoneum has been advocated to prevent perineal evisceration and postoperative small bowel obstruction However, it may prevent obliteration of the pelvic cavity, lead-ing to formation of a persistent perineal sinus.(20) Loops of small bowel may also become incarcerated in small defects in the peritoneal closure, resulting in postoperative bowel obstruction Two studies compared various methods of peritoneal and peri-neal closure Irvin and Goligher (19) prospectively randomized

106 patients undergoing proctectomy to one of three methods of perineal closure: open packing of the perineal wound; primary closure of the perineal wound without closure of the pelvic peri-toneum with suction drainage of the pelvis; and primary closure

of the peritoneal and perineal wounds The overall complication rate was high: repeated surgery was necessary in 21% of patients

in the open packing group, most often because of hemorrhage, and in 25% and 19% of the two closed groups, most commonly for drainage of abscesses Primary healing occurred in 45% of the patients with primary closure of both the perineum and perito-neum and in 43% of patients with open peritoneal and closed perineal wounds

In a prospective study part of a multicentre trial in Germany, Meyer et al published a standardized technique of perineal closure that reduced wound complication rates from 17% to 5.4% The principle of their approach was to close the perineal wound tightly

in multiple layers (specifically the muscle and ischiorectal as well

as subcutaneous fat) which help to avoid the accumulation of fluid

Figure 27.2 Nerve supply to the rectum.

within the wound cavity The residual amount of fluid is then

removed by closed suction drainage Additionally, it is thought

that the addition of antibiotic carriers provides local infectious

prophylaxis leading to lower rates of perineal wound infection

(21) This has also been demonstrated in two other prospective

randomized studies and can be considered an adjunct in

decreas-ing the overall morbidity of the perineal wound.(22, 23)

Myocutaneous flaps have been increasingly utilized in the initial

repair of the perineal defect, especially in patients who have

had preoperative radiation therapy Chessin et al at Memorial

Sloan Kettering reviewed their experience with rectus abdominis

myocutaneous (RAM) flap closures of the perineal defect

Comparing the RAM flap group to a historical control, they found

that the incidence of perineal wound complications was 15.8% in

the RAM flap group compared to the 44.1% in the control.(24)

Butler et al also looked at vertical rectus abdominis myocutaneous

flaps in previously irradiated patients undergoing APR There was

a significantly lower incidence of perineal abscess (9% vs 37%),

major perineal wound dehiscence (9% vs 30%) and drainage

procedures required for perineal or pelvic fluid collections (3%

vs 25%).(25)

In an effort to fill the pelvic space after rectal resection, Page

et al advocates an omental plug They describe mobilization of

the omentum on the left gastroepiploic arterial pedicle, with

sub-sequent placement in the pelvis Advantages include increased

local blood flow and lymphatic drainage, and obliteration of the

pelvic space The omental plug also has the advantage of keeping

the small bowel out of the pelvis, thereby decreasing the chance of

radiation enteritis in patients who require postoperative radiation

therapy The authors report primary healing in 26 of 34 patients

(77%).(26) A recent publication by PJ Nilsson reviewed all

avail-able English language publications on the use of omentoplasty

in APR wound closure Primary wound healing was the primary

outcome measure Most authors reported positive results after

omentoplasty and one study showed significant improvement in

perineal healing rate at 6 months Significant reduction in sinus

formation and wound dehiscence also was reported.(27) Despite

these promising results, there needs to be randomized trials with

well-described patient categories, end points and follow up to

firmly assess whether omentoplasty should be a standard part of

the wound closure

CoMPliCAtions

Abscess

Abscess formation, intraperitoneal or of the perineal wound, is

the most common major complication after APR.(17) Incidence

of abscess formation ranges from 11% to 16% (17, 18, 28) In

some small series, the incidence of perineal wound infection is

100%.(19) This can be attributed to the large dead space

remain-ing after resection of the rectum and from fecal

contamina-tion In a retrospective review of patients who had neoadjuvant

chemoradiation followed by APR, Butler observed that there

was a significant decrease of perineal abscess formation (3% vs

37%) after the placement of a vertical rectus abdominis

myocu-taneous (VRAM) flap to the perineum The well-vascularized

flap eliminates the dead space in the pelvis, reducing the risk of

fluid collection The use of a VRAM flap should be considered in patients who are at high risk for postoperative perineal wound complications.(25) Alternatively, an omental pedicle flap sutured

to the perineal wound has been observed to decrease the rate of abscess formation.(29)

Incision and drainage with local wound care is the treatment

of choice for local perineal wound abscesses There is a small increased risk of developing a perineal sinus after opening the skin of a subcutaneous abscess.(30) Thus if the incision is heal-ing well, the abscess may be amenable to percutaneous drainage

In addition, percutaneous drainage is the preferred treatment of presacral and pelvic abscesses.(31)

Intraoperative Hemorrhage

Hemorrhage during surgery can usually be attributed to an error

in technique, but when faced with a pelvis that had previously received radiation therapy, hemorrhage may be unavoidable Bleeding may occur when dissection begins at the sigmoid This

is usually easily identified and controlled In the previously irradi-ated pelvis, planes become distorted making it difficult to identify vital structures It is easy to stray laterally, which may result in iliac vessel injury These must be repaired immediately to avoid pro-longed hemorrhage In a pelvis that has not received radiation, or

if there is minimal fibrosis, meticulous dissection in the proper plane down to the lateral stalks usually yields minimal bleeding The most troublesome bleeding in the pelvis comes from the posterior dissection along the sacrum Very rarely, there will be a prominent medial sacral artery that may be injured More com-monly, the bleeding from the sacrum will come from the venous plexus If present, the basivertebral vein, which connects the inter-nal vertebral venous system to the presacral system, can bleed profusely and be difficult to control Ideally, by taking sharp dis-section down the presacral plane, there should be little to no bleed-ing.(32, 33) Unfortunately this space may be nonexistent in certain patients or obliterated in an irradiated field Bleeding from the sac-rum can be controlled by packing, suture ligation, electrocautery, finger compression, or thumbtack compression

Thumbtack compression is a quick, safe, and effective method of controlling sacral bleeding There are several commercial applica-tion devices available; however, using a clamp or forceps with finger applications works equally as well (Figure 27.3) Thumbtacks also prevent damage to the surround venous plexus that may occur when using the other methods of attempting hemostasis, such as direct suture ligation or excessive cauterization.(33, 34)

Postoperative Hemorrhage

Bleeding after the completion of the surgery is uncommon (<4%) and is most commonly associated with perineal wounds that are packed open.(35) When the perineal wound is packed open, it

is hemostatic until the first dressing change when the tampon-ade is released As the packing is removed, it may pull away clot from surrounding tissues that can result in more bleeding Conservative treatment can be attempted with adequate resusci-tation if needed, a reapplication of packing, and placement of the patient on strict bed rest If the patient remains stable, the pack-ing may be removed in 48–72 hours.(36) Occasionally, reopera-tion is necessary to control postoperative perineal hemorrhage

Given that nearly all APR wounds are currently closed primarily,

this complication is rare.(37, 38)

Perineal Wound Complications

When comparing abdominoperineal resection with other

abdom-inal and pelvic procedures, the most striking difference is the

peri-neal dissection and ensuing periperi-neal wound Treatment of this

wound has long been the center of debate and controversy Miles

in his original description in 1908, recommended open packing,

and his technique is still used by some surgeons Over the following

75 years, many techniques to treat the perineal wound have been

developed, including partial closure, primary closure, and closure

with continuous irrigation or omental plugging For purposes of

discussion, perineal wound complications of abdominoperineal

resection can be divided into four categories: hemorrhage, abscess,

perineal sinus, and perineal hernia

Non Healing Wound and Perineal Sinus

Perineal sinus is defined as a perineal wound that remains unhealed

for a minimum of 6 months Characteristics include a fixed fibrotic

pelvic cavity, a long, narrow track lined with a thick unyielding peel,

and a small external opening.(39)

Silen and Glotzer compared the pelvic space after APR with

the fixed pleural space after pneumonectomy The pelvic space

is bound posteriorly and laterally by the rigid bony pelvis,

ante-riorly by the relatively unyielding genitourinary structures,

infe-riorly by the slightly mobile perineal floor (if surgically closed),

and superiorly by the peritoneal contents Of all these borders,

certainly the peritoneal structures are the most mobile They

contend that the pelvic space after APR is filled not with

gran-ulation tissue but with a combination of upward migration of

the perineal soft tissues and descent of the peritoneal contents

and argue that any forces (either iatrogenic, such as closure of

the peritoneum or prolonged packing of the pelvis, or

second-ary to complications, such as pelvic abscess or hematoma) that

produce a fixed fibrotic cavity are likely to result in a nonheal-ing perineal wound.(30) Artioukh et al reviewed their series of APR non healing wounds and found several possible contrib-uting factors, including distant metastases, excessive alcohol consumption, cigarette smoking, transfusion requirement and chemoradiation

Other studies have also observed the increased risk in peri-neal wound infection and nonhealing in those who have been exposed to radiotherapy The Swedish Rectal Cancer trial showed

an increase in wound infection from 10% to 20% and the Dutch Colorectal Cancer Group had a 31% perineal complication rate even in those exposed to short-course radiation.(40, 41)

Silen and Glotzer recommended that the peritoneal contents

be allowed to descend into the pelvis, the space be kept irrigated and well drained to prevent fluid accumulation, and any packing used in the perineal wound be removed early to prevent develop-ment of fibrotic wound edges Despite the excellent description

of perineal healing by Silen and Glotzer and the development

of multiple techniques for perineal closure, nonhealing perineal wounds remain a common problem Bacon and Nuguid noted a 40% incidence of persistent perineal sinus in 1042 patients after rectal resection.(42) In almost 500 patients who underwent APR

at the Lahey and Mayo Clinics, 14–24% had unhealed perineal wounds at 6 months

risk fACtors

Inflammatory bowel disease versus carcinoma Rectal

resec-tion is most commonly performed to treat low rectal cancer

or inflammatory bowel disease Often the extent of soft tissue resection is much greater in the treatment of rectal cancer with complete removal of the levator musculature or posterior vagi-nectomy advocated by some versus the intersphincteric proctec-tomy (sparing the external anal sphincter and the levator ani) often used in surgical treatment of inflammatory bowel disease

An increase in perineal wound complications might be expected after APR to treat cancer, but Irvin and Goligher found a 9% inci-dence of unhealed perineal wounds in the treatment of cancer, compared with a 33% incidence in proctectomies performed for inflammatory bowel disease.(19) A more contemporary review

of the risk factors for perineal wound complications undertaken

by Christian et al determined that higher rates of major wound complications occurred in patients who had APR performed for anal cancer (50%) as compared to rectal cancer (10%) or inflam-matory bowel disease (8%) The reasons are unclear although the extensive tissue dissection involved in a cancer operation with larger soft tissue loss may be a possibility.(43) There is some evi-dence to support this in studies that have shown that tumor size can be a risk factor for poor wound healing

Radiation Therapy Radiation therapy is often used in the

treatment of rectal and anal neoplasia both preoperatively and postoperatively Christian et al found that preoperative radiation therapy for anal cancer patients appeared to be a risk factor for poor wound healing Artioukh et al also found that patients who had received preoperative radiotherapy were prone to wound complications (39% vs 6.7% who did not have radiotherapy)

Fecal Contamination Fecal contamination during proctectomy

significantly decreases primary healing and may increase the risk

Figure 27.3 Thumbtack occlusion of bleeding basivertebral vein.

of chronic perineal sinus formation This complication is

presum-ably related to the development of pelvic infection with secondary

development of a fixed abscess cavity that makes obliteration of the

pelvic space more difficult.(30) Fecal contamination may also lead

to a higher incidence of perineal wound tumor recurrence

treAtMent

Nonhealing perineal wounds develop in 8% to 69% of patients

undergoing APR.(10, 18, 19, 28) Because of the scope of the

prob-lem, many techniques have been developed to ensure complete

healing Early efforts included operative debridement with wide

drainage, including coccygectomy and even partial sacral resection

(20) These measures were designed to eliminate the rigid fibrotic

space that always accompanies a nonhealing perineal wound Often

these measures resulted in eventual healing but required

exten-sive wound care for many months Despite this treatment, some

wounds failed to heal

Alternative methods to improve healing and decrease wound

care have been developed Oomen et al published a set of guidelines

in treating persistent perineal sinuses or complex perineal wounds

with an overall 80% success rate in healing Their algorithm

consisted of VAC therapy for large defects before placing muscle

flaps in order to decrease the size of the defect Depending on sinus

length, they either placed a transposition of rectus abdominal

muscle (for sinuses > 10 cm) or a gracilis muscle/gluteal thigh flap

(sinus < 8 cm) Initially success rate was 57%, but after

second-ary surgery in some of the patients, their success rate increased to

80% Ultimately, the best outcomes were in patients who received

the gracilis or gluteal thigh flap.(44)

The VAC® closure system has also been used more to assist in

dealing with complex perineal wounds that result after extensive

operative debridement’s for persistent perineal sinuses Pemberton

at the Mayo Clinic (45) published a review of their results with

various techniques in dealing with perineal sinuses In patients

with difficult perineal sinuses requiring debridement and removal

of the coccyx and caudal part of the sacrum, the VAC® system

had complete resolution of the sinus in nearly all of their patients

While their evidence is anecdotal, there are documented reports

with healing rates up to 95%.(46, 47)

Omentoplasty is another technique that has been evaluated in

both the primary repair of the perineal wound as well as in

com-plex perineal sinus disease Yamamoto et al reported six patients

with persistent perineal sinuses who underwent omentoplasty

The perineal sinus tract was completely excised and

communica-tion with the pelvis attained The left or right gastroepiploic vessels

were then ligated and the omentum brought down to the

peri-neum where it was lightly sutured to the skin After a 28-month

follow-up period, 83% of the patients had completely healed

wounds without any complications.(48)

PerineAl herniA And evisCerAtion

Perineal hernias are fortunately very rare and often troublesome

to diagnose Perineal hernia after abdominoperineal resection is

defined as bulging of peritoneal contents through an intact perineal

wound, and perineal evisceration describes extrusion of small

or large bowel through an open perineal wound However, other

unusual contents have been described, including a leiomyoma,

an aggressive angiomyoma and a large bladder diverticulum.(49) Evisceration typically occurs immediately after surgery and neces-sitates repeat surgery with reduction of intestines and repeat pack-ing Perineal hernias are a rare complication and occur in about 1%

of patients after APR This figure increases to 3% after pelvic exen-teration Initial symptoms include perineal bulging, often associ-ated with fullness or pain on sitting.(50, 51) Occasionally, patients complain of voiding problems if herniated bowel compressed the bladder.(52) Rarely, skin breakdown occurs, resulting in exposed bowel in the perineum Perineal hernias, like parastomal and inci-sional hernias, do not always require repair Indications for surgery are similar for all three postoperative hernias: patient discomfort refractory to conservative therapy, bowel obstruction, incarcera-tion, and impending skin loss Cosmesis alone should rarely merit surgical repair

Risk factors that predispose patients to developing perineal her-nias are not entirely clear Coccygectomy, previous hysterectomy, pelvic irradiation, excessive length of the small-bowel mesentery, the larger size of the female pelvis, and possibly the failure to close the peritoneal defect have been implicated as possible causes.(53,

54, 55) So et al described 80% of their patients having perineal wounds that were laid open or had multiple large drains inserted through the wound which they postulate may have weaken the wound and allow hernia formation.(56)

Diagnosis of perineal hernias can be difficult as traditional fluoroscopic imaging techniques often do not identify them Other modalities have been used to include herniography, CT, and dynamic MRI A comparative study of dynamic MRI and dynamic cystocolpoproctography showed that MRI was the only modality that identified levator ani hernias.(49)

There is a paucity in large published series to describe which technique of perineal defect closure is superior Various case reports and retrospective reviews provide much of the literature

in this respect In a review of the literature, closure techniques have ranged from the use of simple suture closure, prosthetic mesh, human dura mater allograft (57), gracilis myocutaneous flap (58), gluteus flap and retroflexion of the uterus or bladder (59) So et al described their experience with closures and ulti-mately found that recurrence rates were equal (20%) between simple and mesh closures Their repair consisted of simple closure of the levator defect with nonabsorbable sutures The approach to the repair was also felt to be a point of consideration

in planning the operation For the most part, a perineal approach was adequate with the abdominal approach reserved for recur-rent hernias, or those in whom laparotomy is necessary for other reasons The abdominal approach also provides good visualiza-tion when suturing the mesh to the bony pelvis A combined

AP approach is rarely necessary except under unusual circum-stances Skipworth et al published their experience and tech-nique of perineal hernia repair using Permacol® mesh Using a perineal approach, they isolated and ligated the sac in the stand-ard fashion before proceeding to close the perineal defect with 4-O PDS (polydiaxonone) suture The mesh was then fashioned

to the contours of the defect and sutured in place, tension free, with interrupted 2-O Prolene sutures A small suction drain was then left superficial to the mesh and the thin, residual perineal fascia closed with Vicryl sutures They reported no recurrence

in the 18 months following the repair There are also a

grow-ing number of case reports and prospective studies in the use of

laparoscopy for perineal hernia repairs Dulucq et al describe

their experience in a prospective study done over the course of

a year with three patients that had received laparoscopic mesh

repairs of their perineal hernia defects A composite mesh was

fixed laterally to the border of the levator muscle, anteriorly

to the posterior face of the vagina with nonabsorbable sutures

and posteriorly with tacks to the sacral periosteum One suction

drain was placed The reported benefits include adequate

visu-alization of pelvic anatomy, the ability to look for recurrence,

and fast recovery Long term results have yet to be published for

laparoscopic perineal hernia repairs, but this may be an

attrac-tive option for patients and surgeons as it often avoids making

large incisions in areas that have already been irradiated and can

therefore be difficult to heal.(60) Before embarking on a repair

of any postoperative perineal hernia it is imperative to exclude

the possibility of cancer recurrence

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 Indications and outcomes for treatment of recurrent rectal cancer

and colorectal liver and lung metastasis

Harry L Reynolds Jr, Christopher T Siegel, and Jason Robke

ChallengIng Case

A 74 year old male underwent low anterior resection of the rectum

one year previously after preoperative chemotherapy and

radia-tion Final pathology revealed a yPT2N0M0 lesion He received

post operative chemotherapy as well In follow up he was noted to

have an elevated carcinoembrionic antigen of seven Digital exam

revealed a palpable mass at the finger tip It was one half

circum-ferential, posteriorly based, involving the left pelvic sidewall and

was fixed Located at five cm from the verge on rigid proctoscopic

exam, it was just at the top of the anorectal ring and involved the

previous anastomosis Computed Tomographic (CT) scan of the

chest abdomen and pelvis revealed a posteriorly based mass

adja-cent to the sacrum without boney erosion It suggested

involve-ment of the left pelvic sidewall There was a two cm hypodense

lesion in segment three of the liver The chest was clear Positron

Emission Tomography revealed intense uptake in the pelvis and

in the hypodense area of the left lobe of the liver noted on CT

Magnetic Resonance Imaging of the pelvis confirmed extension

into the pelvic sidewall but did not reveal boney involvement of

the sacrum Colonoscopy cleared the proximal colon Biopsies

confirmed a moderately well differentiated adenocarcinoma

Case ManageMent

The patient received a preoperative radiation boost to the pelvis

supplemented with capecitabine He was re-explored and

under-went abdominal perineal resection The left internal iliac artery

and vein were ligated and partially excised with a portion of the

left pelvic sidewall He received an intraoperative radiation boost to

the left sidewall and sacrum where the tumor was adherent It was

difficult to differentiate tumor from scarring over the sacrum, but

there was no gross boney involvement Intraoperative ultrasound

of the liver revealed no other liver lesions and the left lateral

seg-ment metastasis was excised after the pelvic work was completed

He was reconstructed with an end descending colostomy He was

referred to oncology for further postoperative chemotherapy

IntroduCtIon

Of the many challenges presented to the surgeon, patients

presenting with recurrent rectal cancer can be among the most

daunting Likewise patients with metastatic disease to the liver

or lung can be a technical challenge and can be difficult to sort

out as to who is an appropriate operative candidate These

patients are best treated with a multidisciplinary approach with a

Colorectal or General Surgeon serving as the team leader.(1) In

this chapter we explore, in three separate sections, the

indica-tions and outcomes for surgical intervention in patients with:

1 Recurrent rectal cancer, 2 Liver metastasis, and 3 Lung

metas-tasis Contributing authors include a Colon and Rectal Surgeon,

a Hepatobiliary Surgeon, and a Thoracic Surgeon

reCurrent reCtal CanCer

Recurrent rectal cancers are among the most challenging for the Colon and Rectal Surgeon to manage A multidisciplinary approach is truly essential in planning a comprehensive treat-ment plan if success is to be achieved The surgeon that takes on these cases assumes the responsibility of organizing and lead-ing a team of sub specialists consistlead-ing of Medical and Radiation Oncologists, Urologists, Radiologists, Pathologists, Enterostomal Therapists, and in selected cases, Plastic Surgeons, Vascular Surgeons, Gynecologic surgeons, Hepatobiliary Surgeons, Thoracic Surgeons, and Intensivists The complexity of these patients makes it essen-tial that they be treated at centers with the staff and resources necessary to undertake their care.(1, 2)

Assessing Resectability

A thorough workup of the patient first consists of a careful history and physical exam Fitness for surgery should be assessed carefully as one can expect a significant physiologic insult in those who come to operation Many will require extended en bloc resections of adjacent organs with the potential for blood loss and volume shifts not usually seen at initial proctectomy Preoperative assessment by appropriate sub specialists with emphasis on cardiac and pulmonary optimiza-tion may be necessary in these frequently elderly patients In some patients surgical risk may be deemed prohibitive and nonoperative management with combinations of chemotherapy and radiation and/or stenting or palliative diversion may be necessary

Assessing the extent of local and metastatic disease is best achieved with careful physical and proctoscopic exam supple-mented with appropriate radiologic imaging The importance

of digital examination cannot be overemphasized Determining location with respect to the sphincter complex and adjacent structures including vagina, uterus, prostate, seminal vesicles, bladder, pelvic sidewall, and sacrum can be preliminarily assessed with a careful digital rectal and vaginal exam Bulk, mobility, and fixation to surrounding structures should be carefully considered with the digital Pelvic recurrences are frequently extramucosal and may not be appreciated endoscopically but may be felt on digital Rigid proctoscopic and digital exams are essential in determining relationships to the sphincter complex as even with pelvic recurrences, sphincter sparing options may be available in selected patients Involvement of the sphincter complex typically necessitates abdominal perineal resection (APR)

A full colonoscopy is performed to rule out synchronous lesions Radiographic workup typically consists of PET CT to rule out extrapelvic metastatic disease PET CT may identify patients with unsuspected metastatic disease, thus preventing overly aggressive surgical intervention Watson reported a change in planned surgical intervention in 37% of patients based on PET

CT imaging in patients with recurrent colorectal cancer.(3)

High quality spiral CT scanning of the chest abdomen and

pelvis is frequently performed as well to define any

question-able metastatic lesions and to better define the extent of pelvic

disease Pelvic MRI is felt by most authors to be the preferred

imaging modality for establishing the extent of adjacent organ

involvement for purposes of preoperative planning MRI can

provide insight as to whether pelvic sidewall, seminal vesicles,

prostate, bladder, ureters, vascular structures, gynecologic

struc-tures, or sacrum are involved.(4–8) Although imaging can assist

in preop planning, no radiographic study can reliably

differenti-ate fibrosis and scarring from tumor, particularly in an irradidifferenti-ated

pelvis Radiation induced inflammatory changes in the pelvis can

be PET positive as well, and can be confused for metastatic disease

Although imaging can assist with planning, the ultimate

determi-nation of involvement and resectability is made at operation

Reviewing previous operative notes and pathology reports can

provide insight into the adequacy of initial resection and can be

helpful in assessing likelihood of resectability at reoperation Those

that have had an optimal cancer operation at the first exploration

with total mesorectal excision (TME) and high ligation of the

infe-rior mesenteric artery can be expected to have a much more

diffi-cult reexploration With TME and high ligation initially, combined

with previous radiation therapy, recognizable planes are typically

absent Those with more proximal tumors, non-TME initial

resec-tions, and/or ligation of the superior rectal vs the inferior

mesen-teric artery (IMA) may well have some pelvic plane preservation,

making reexploration not so daunting a task Those that have had

a proper TME with a coloanal anastomosis or abdominal perineal

resection can be expected to have more difficult lesions to deal with,

as recurrences can be expected to be adherent to adjacent

struc-tures, outside of the proper mesorectum These tumors recur in

the sidewall, sacrum, anastomosis, perineal wound or in the

gyne-cologic or urologic organs Those that recur laterally in the pelvic

sidewall or posteriorly on the sacrum are particularly challenging

in terms of obtaining an R0 resection An R0 resection refers to a

complete resection with microscopically clear margins R1

resec-tion implies microscopic disease is left, and R2 implies gross

dis-ease is left behind Those that recur at the anastomosis or anteriorly

in the adjacent vagina, uterus, prostate, seminal vesicle, or bladder

can frequently be completely excised with en bloc adjacent organ

resection.(9) Likewise, the occasional patient who presents with an

isolated nodal recurrence, high along the IMA after an initial low

ligation, may be resectable as well

Pelvic sidewall recurrences can be very difficult to resect

sec-ondary to the extensive internal iliac arterial and venous branches

encountered Anatomy is distorted by tumor and scar, and the

des-moplastic reaction associated with tumor and previous radiation

can make dissection hazardous as venous bleeding can be

signifi-cant Likewise sacral recurrences below S1-2 typically can

techni-cally be resected, but morbidity and mortality can be significant

(10) Local, limited anastomotic recurrences post low anterior

resec-tion and perineal recurrences post APR, without lateral or sacral

extension, are more likely to be amenable to R0 resection.(9)

Patients with extrapelvic metastatic disease are typically not offered

extended exenterative procedures However, in selected otherwise fit

patients presenting with isolated resectable liver or lung metastasis,

it may be appropriate to proceed with extended resection In those

with nonresectable metastatic extrapelvic disease, pelvic exenterative procedures are felt to be contraindicated by most

Role of Chemotherapy and Radiation

Our approach to a diagnosed pelvic recurrence initially involves evaluation by medical and radiation oncology to determine if an additional radiation boost can be delivered to the pelvis This will usually be administered with concomitant 5-FU based chemo-therapy Most patients will have received either preop or postop chemoradiotherapy with there first resection Most will receive an additional preop boost of 30–40 Gy to the site, particularly if it is

a bulky recurrence, with plans for surgical exploration ~8 weeks post radiation.(11–15) This is assuming the interval between radi-ation and reirradiradi-ation is >6 months and the small intestine can

be excluded from the planned field.(11) This approach seems to

be well tolerated by most in our institution and has been validated

by others.(11–15) It is important to ensure exclusion of the small intestine from the pelvis with reirradiation Dresen reports that if the small intestine is not excluded planned operation before irra-diation may be undertaken for placement of a spacer for exclusion The spacer could be biologic such as the omentum or a nonbio-logic such as a breast prosthesis or tissue expander The patient is typically diverted at the time of spacer placement.(11)

Intraoperative radiation therapy (IORT) can be offered via a dedicated fixed intraop unit, a mobile unit or via after-loading catheters place intraoperatively This is a particularly valuable treatment adjunct to patients with sidewall involvement, sacral involvement, or major vascular involvement, where an extended resection of involved areas cannot technically be accomplished or will not be tolerated by the patient This can be technically deliv-ered to areas directly involved by tumor while shielding organs particularly sensitive to radiation (i.e., ureters, small intestine, and bladder).While no randomized trial has been performed to dem-onstrate the value of IORT, such a trial is unlikely to be performed Positive circumferential margins in rectal cancer have been associ-ated with excessively high local recurrence rates as demonstrassoci-ated

by Quirke and others even after preop radiochemotherapy.(16, 17) It would seem illogical, and perhaps unethical, to randomize patients to a nontreatment arm with a known or suspected posi-tive margin when a modality such as IORT, with little morbid-ity when applied appropriately, is available There are multiple studies, with historical controls, demonstrating decreases in local recurrence and survival improvement, with little morbidity, when IORT is applied appropriately.(5, 18–26) We feel that IORT is an essential piece of the treatment algorithm It is frequently very difficult to differentiate a true positive margin from the fibrosis and scarring associated with previous radiation therapy and pre-vious pelvic surgery Although frozen section analysis of surgical margins can be helpful if positive, if we are clinically concerned about margin status, IORT will be administered regardless of fro-zen section results Local recurrence rates in our institution have been very favorable with this approach.(27) Likewise, others have demonstrated favorable results with this approach.(5, 18–26) With the addition of IORT to our armamentarium, it seems overly aggressive to perform sacrectomy in all cases with sacral adherence Adherence to the presacral fascia is present in virtually all patients who have undergone a TME and it is very difficult to