Abdominoperineal resection (APR)

Panorama general

An abdominoperineal resection (APR) is an operation that removes the last part of the colon along with the rectum and anus. The surgeon then brings the end of the remaining colon through a permanent opening in the abdominal wall, called a colostomy. Stool leaves the body through this opening and goes into a pouch, which is secured to the body.

Abdominoperineal resection also may be called abdominoperineal excision.

Removal of the rectum is called a proctectomy. An APR is a type of proctectomy that also includes removal of the anus and sphincters. The anal sphincters are muscles around the rectum and anus that control passage of gas and bowel movements.

An APR is most often used to treat cancer that is very low in the rectum where removal of the rectum, anus and sphincters is necessary to treat the cancer.

Less often, an APR may be used to treat severe inflammatory bowel disease, including Crohn's disease and ulcerative colitis.

Types

Surgical approaches

APR may be performed as open surgery or as minimally invasive surgery. Open surgery uses one large cut, also called an incision, through the abdomen wall muscles. Minimally invasive surgery uses several smaller incisions instead of one large incision.

Minimally invasive surgery includes both laparoscopic and robotic surgery.

In laparoscopic surgery, the surgeon uses carbon dioxide gas to inflate the abdomen. The surgeon then puts a camera and surgical tools through the small incisions to operate. The surgeon controls the tools directly by hand while looking at a 2D camera screen. In robotic surgery, the surgeon controls the tools from a remote console while looking at a magnified, 3D view.

Minimally invasive surgery is associated with fewer complications and faster recovery compared with open surgery. But not everyone can have a minimally invasive approach. It depends on the patient and the reason for surgery.

Extralevator abdominoperineal excision (ELAPE)

An APR also can vary in how much tissue is removed from around the tumor. One approach is called an extralevator abdominoperineal excision (ELAPE).

During an ELAPE the surgeon removes more of the pelvic floor muscles around the tumor. The pelvic floor is a group of muscles that support the organs in the pelvis. An ELAPE may be necessary when a low rectal cancer has grown into these muscles.

An ELAPE creates a larger wound in the perineum, which is the area between the genitals and anus. It increases the risk of wound healing problems, long-lasting pain and development of a perineal hernia. A perineal hernia occurs when there is a weak area in the pelvic floor where other organs, such as small bowel, may push through. A plastic surgeon may be needed to help close the hole.

Por qué se hace

There are several reasons an APR may be done.

Low rectal cancer. An abdominoperineal resection (APR) may be needed when a low rectal cancer involves the anal sphincter muscles. It also may be needed if there is not enough healthy tissue to remove the cancer and still save these muscles.

The goal is to remove the cancer and enough nearby tissue so that no cancer cells are found at the edges of the removed tissue. These edges are called surgical margins.

Your care team considers several things when planning your surgery. These include the size and location of the tumor and how close it is to the anus and sphincter muscles. You may have a physical exam, blood tests and imaging tests such as an MRI.

You also may have endoscopic tests such as a sigmoidoscopy. A sigmoidoscopy is like a colonoscopy but it only looks at the lower colon and rectum.

The findings from these tests help your care team decide whether the sphincter muscles can be saved and which surgery may work for you.

Anal cancer. An APR also may be used to treat anal cancer. Some types of anal cancers can go away entirely with just chemotherapy and radiation. When anal cancer remains or returns after these treatments, an APR can be used as a salvage procedure to cure the cancer. This is sometimes referred to as a "salvage" surgery.

Inflammatory bowel disease. Less often, an APR may be used to treat severe inflammatory bowel disease. This can include Crohn's disease that affects the rectum and anus and some instances of ulcerative colitis.

Other conditions. An APR also may be considered for other noncancer-related conditions such as severe loss of bowel control, called incontinence. It also may be used for rectal prolapse, which is a condition where the rectum slips outside of the anus.

APR compared with LAR

Low anterior resection (LAR) is another operation that involves removal of the rectum. Here's how it differs from an APR.

With a low anterior resection, the surgeon removes the affected part of the rectum but leaves the anus, sphincter muscles and a small amount of lower rectum in place. Unlike an APR, an LAR does not always require a permanent colostomy. The bowel can be reconnected, allowing stool to continue to pass through the anus. Sometimes this requires the creation of a temporary ileostomy.

A temporary ileostomy is when the small bowel is brought through an opening in the abdominal wall. Intestinal contents pass through this opening into a pouch. This bypasses the colon entirely until the new connection between the colon and the lower rectum has healed. For some people, a reconnection is not advised. A permanent colostomy is created, but the lower rectum, anus and sphincters stay in place.

Riesgos

An APR is a major surgery. Possible risks and complications include:

• Bleeding.
• Blood clots, including a blood clot in a deep vein of the legs, which is called a deep vein thrombosis, or in the lungs, which is called a pulmonary embolism.
• Infection in the abdominal or perineal wound.
• Slow or poor wound healing of the perineal wound, possibly leading to a chronic opening or tract.
• A perineal hernia. This happens when tissue or an organ pushes through a weak area in the pelvic floor.
• Changes in urinary function caused by damage to nerves in the pelvis. These may include urinary incontinence or retention.
• Changes in sexual function caused by damage to nerves in the pelvis. These may include trouble with erections and ejaculation.
• A blocked bowel caused by scar tissue after surgery.
• Parastomal hernia. This is a widening of the hole in the abdominal wall around the colostomy. It can lead to other organs or tissues slipping into the widened opening.

Your surgical team will take steps to lower these risks. You may receive antibiotics to help prevent infection. You also may receive medicine to help prevent blood clots. Your care team may put devices on your legs that gently squeeze them to keep blood moving. The surgical team also works to control bleeding and close the wound carefully.

Problems with the perineal wound are among the more common complications of an APR. The risk of healing problems may be higher in people who have had radiation therapy before surgery. The risk also may be higher in people with:

• Inflammatory bowel disease.
• Diabetes.
• Obesity.
• Smoking history
• Use of steroids or other medicines that suppress the immune system.
• A larger perineal wound.

If the wound is too large to close safely, surgeons may use tissue from another part of your body to close the wound. This is called a tissue flap. Other methods also may be used to rebuild the area.

A hernia can develop months or years after APR. It may cause a bulge or pain. It also may cause discomfort when sitting or standing, urinary problems or, less often, a blocked bowel. Some perineal hernias need another surgery. The surgeon may repair the pelvic floor with surgical mesh or a tissue flap.

Cómo prepararte

Before your APR surgery, you'll meet with your surgical team to talk about the operation and your recovery.

An APR requires a permanent colostomy. Before surgery, it's common to meet with a nurse who specializes in caring for an ostomy. The nurse can explain how to care for the colostomy. The nurse also will help choose where on your abdomen to place the colostomy.

Your care team may ask you to clean out your bowel before surgery. This is called a bowel preparation. It usually includes medicine to help purge the stool from your colon as well as antibiotics taken by mouth.

Follow the eating, drinking, medicine and bowel preparation instructions your care team gives you.

Your team also takes steps to lower your risk of infection and blood clots. Antibiotics usually are given shortly before surgery. You also receive treatment to help prevent blood clots.

Qué esperar

Before the procedure

An APR is performed in an operating room. Your care team positions your body carefully to protect nerves and pressure points. You lie on your back with your legs raised and supported. The position gives the surgeon access to both the abdomen and the perineum.

During the procedure

An APR requires general anesthesia. General anesthesia uses medicine that puts you into a sleep-like state, so you don't feel pain during surgery. You have a breathing tube during the surgery. The surgery may take several hours.

An APR has two main parts. One part is done through the abdomen. The other is done through the perineum.

During the abdominal part, the surgeon separates the colon and rectum from nearby structures. For rectal cancer, the surgeon also removes nearby fatty tissue and lymph nodes.

The surgeon divides the colon and brings the remaining end through an opening in the abdominal wall. This creates a permanent colostomy. Stool leaves the body through the stoma, which is the opening made in the belly. It then collects in an ostomy pouch worn on the abdomen.

During the perineal part, the surgeon makes a cut around the anus. The anus, sphincter muscles and rectum are removed through this area.

With ELAPE, the surgeon removes a wider area of pelvic floor muscle when needed. This is done to remove a tumor that has grown into those muscles.

After the tissue is removed, the surgeon closes the perineal wound. Many wounds can be closed with stitches. A larger wound may need to be rebuilt using a tissue flap or another method.

The number and size of scars in your abdomen will depend on whether surgery is open or minimally invasive. There also will likely be a scar in the perineal area where the anus is removed and the wound is closed.

After the procedure

After surgery, your care team may use a special recovery plan designed to help you recover sooner and lower your risk of complications. The plan includes steps to manage pain and help you return to your usual activities.

Your care team will encourage you to start moving as soon as it is safe. Walking can help with recovery and may help you leave the hospital sooner. You also may start eating regular food soon after surgery.

You may spend several days in the hospital after an APR. Recovery at home often takes 6 to 8 weeks, although the perineal wound and other effects of surgery may take longer to heal.

You learn how to care for your permanent colostomy. This happens before and after surgery. You learn how to manage the stoma at home and adjust to daily life with a colostomy.

Your perineal wound needs time to heal. Some people have pain or trouble sitting and walking after APR. These problems may continue after the first few weeks of recovery. Physical therapy and follow-up care may help with movement and daily activities.

Resultados

When an APR is used to treat cancer, the goal is to remove the whole tumor and some nearby tissue. After surgery, a doctor who examines tissue for signs of disease, called a pathologist, checks the removed tissue for cancer cells. The goal is to have no cancer cells at the edges of the removed tissue. These edges are called surgical margins.

These results help your care team understand how far the cancer spread and help guide your follow-up care. Your team also considers other features of the cancer and any treatment you had before surgery.

Many people adjust to life with a permanent colostomy. Recovery and long-term quality of life are different for each person. Some people continue to have issues with bladder function or sexual function after surgery.

Research suggests that overall quality of life after an APR may be similar to quality of life after low anterior resection (LAR) for many people.

Follow-up care can help your care team identify and manage concerns that affect your health and quality of life after abdominoperineal resection.