Anterior Perineal Approach for Low Colorectal Anastomosis

Abstract

In this report we describe our experience with conservative rectal resection using a combined abdominoperineal approach that allows low colorectal anastomosis to be performed without damaging the sphincter muscles. This series includes 30 men and 30 women operated on for rectal cancer (45 cases) and various other malignant (10 cases) and benign (5 cases) conditions of the lower two thirds of the rectum. Colorectal anastomosis was performed by hand in 27 cases and with an EEA 31 stapler in 33 cases; transit was temporarily inactivated by transverse loop colostomy in 80% of cases. 4 postoperative deaths were recorded (4/60 = 6.6%). Spontaneously reversed perineal fistula which occurred in 10 patients was the main postoperative complication. Functional results were satisfactory in all but 3 patients who required colostomy. In female patients this procedure is very simple; in males the use of surgical staplers has greatly obviated the anatomically related difficulties. This procedure would appear to be a useful alternative for restoration of intestinal patency in cases where the abdominal approach alone is unfeasible.

Anterior Perineal PlanE for ultra-low Anterior Resection of the rectum (APPEAR) technique: A systematic review

“…The literature search identified thirteen studies from eleven centres in seven different countries. Papers included covered eight case series [4,[15][16][17][18][19][20][21], four case reports [5,[22][23][24] and one report from a prospective clinical study [11]. Two centres had published results for the same patients twice (at different time points); the earlier study was not included in the totals calculated.…”

“…Most papers described the surgical techniques and operative method as per the description of the APPEAR procedure by Williams et al [11]. There were some minor variations; the French surgeons used two teams operating simultaneously, advising that this reduced the duration of surgery although operative time was not reported [4]. In one centre a sagittal incision in the anterior perineum was used in contrast to the usual transverse crescenteric incision [16].…”

“…80% of patients but advised in their discussion that this should be carried out as a 'wise precaution' [4].…”

“…Overall 34 patients were TNM stage 1, 62 were TNM stage II and 37 were stage III; 1 patient had a complete pathological response. 7 patients underwent surgery for Dukes' D stage rectal cancer, 5 with hepatic metastases and 2 with distant nodal involvement; these were all included in a French publication from 1988 [4]. The majority of patients undergoing surgery for rectal cancer had no details provided about neoadjuvant therapy, for those that did 45% (18/40) underwent combined chemo-radiotherapy.…”

“…The use of the anterior perineal plane to resect the distal rectum was initially described by Cuneo in 1908 and published in a French surgical textbook in 1926 [3] as quoted in a French paper from 1988 [4]. The French surgeons went on to utilise the procedure themselves, publishing a large case series [4]. It is unclear why there was no further uptake of the procedure following this.…”