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1、HS, 61 yr old maleNo significant medical history18 month hx of perianal pain, pruritus ani and occasional PR bleedingEUA Deep posterior anal fissure surrounded by area of induration and thickeningBiopsies-chronically inflamed and fibrotic squamocolumnar anal mucosaConsistent with fissure in anoBackg
2、roundBackgroundSymptoms unresponsive to topical Rxo/e Large posterior fissure and associated skin tag, BRBPRCrohns Disease suspectedScheduled for EUA Rectum in urgently and SBFTBackgroundBackgroundBiopsies at colonoscopy in EUA-Low Rectal Tumour extending into anusHistology-Anal gland vs Rectal canc
3、erModerately differentiated AdenocarcinomaMRI pelvisIncreased soft tissue thickening posterior to superficial perianal areaNumber of mesorectal lymph nodes seenDoes not extend above internal sphincterT4N1M0 Rectal AdenocarcinomaWork UpWork UpMRI imageMRI imageNumber of palpable hard satellite lesion
4、s up to 3cm from anal verge along perianal skin Neoadjuvant treatmentChemotherapy-5FURadiotherapy encompassing perianal skin, inguinal nodes and external iliac nodesEUA Tumour at 3cm, bulky, friable perianal skinScheduled for APR and VRAM flap reconstructionOncologyOncologyAPRLower midline laparotom
5、yLeft colon and rectum mobilisedTotal mesorectum excisionSigmoid colon dived and proximal end brought out as colostomy Wide perineal resection performedRectum delived through anus and resected in fullHaemostasis achievedSurgerySurgeryphotoPerineal defectPerineal defectReconstruction perineal defect
6、with right VRAM FlapVRAM raised through lateral incisionAnt rectus sheath opened and muscle dissected from post rectus sheathInferior deep epigastric artery pedicle preservedDeepithelialisation of skin over muscleMuscle mobilised to cover defectAbdominal closure with prolene mesh, suturesPerineum cl
7、osure with suturesSurgerySurgeryUnremarkableWounds clean and healthySatisfactory stoma careDischarged day 16 post opHistologyFor discussionOncologyFor adjuvant chemotherapy in LetterkennyPost opPost opPre neoadjuvant biopsyPre neoadjuvant biopsyResected specimenResected specimenImmunohistochemistryI
8、mmunohistochemistryColorectal cancer surgeryColorectal cancer surgeryRight HemicolectomyRight HemicolectomyLeft HemicolectomyLeft HemicolectomyAnterior ResectionAnterior ResectionIndicated for rectal cancer in the lower third of rectumAPRs involves removal of the anus, the rectum, part of the sigmoi
9、d colon and ther associated lymph nodesIncisions are made in the abdomen and perineum Remaining sigmoid colon brought out as a colostomyAbdominoperineal ResectionAbdominoperineal ResectionAbdominoperineal Resection Abdominoperineal Resection (APR)(APR)Abdominoperineal Resection Abdominoperineal Rese
10、ction (APR)(APR)First described by Ernest Miles in 1908By the 1920s, recurrence rates were down to 30%-gold standard at that timeSeveral modifications were proposed to promote locoregional control and survival, with little successBetter suture material and devices enabling low anastomoses heralded a
11、 shift toward sphincter-saving approaches with respect to cancer of the rectumAnterior resection replaced APR as the mainstay of therapy in the 1950sThere was concern that sphincter-saving surgery might increase local recurrenceIt was in this setting that total mesorectal excision (TME) was first de
12、scribed in 1982 by Heald and colleaguesAbdominoperineal ResectionAbdominoperineal ResectionThe TME concept is based on the locoregional recurrence preference of rectal carcinomaTherefore adequate en bloc clearance of the rectal mesentry, including its blood supply and lymphatic drainage, would minim
13、ize possible disease relapseTME is now considered the Gold Standard adjunctive therapy for colorectal cancerTotal Mesorectal ExcisionTotal Mesorectal ExcisionImproved surgical techniques (eg total mesorectal excision and autonomic nerve preservation) have shown a corresponding decrease in local recu
14、rrence rates and increase in overall survival of patients with rectal cancerHowever local recurrence and survival after an APR have not improved to the same degree as that seen after an anterior resectionThis difference has been attributed to relative smaller tissue volumes around the tumour and hig
15、her rates of cancer at circumferential resection margins (CRM) after an APR compared with an anterior resectionAPRAPRAs tumour-free lateral margins have been demonstrated to be an important prognostic factor for local recurrence and survival, an extensive resection is frequently requiredIn an attemp
16、t to improve healing, several techniques for perineal closure have been describedEpiploplastyGracilis FlapVertical Myocutaneus FlapGluteus Maximus FlapCylindrical APRCylindrical APRThey facilitate closure of the perineal defect with healthy and well-vascularized tissue without placing the tissue und
17、er undue tensionThe vertical rectus abdominis myocutaneous (VRAM) flap is also useful in creating a neo-vagina after posterior colpectomyThere is a lack of information in the literature concerning the efficacy of VRAM flap reconstruction after APRCylindrical APRCylindrical APRLefevre et at evaluated
18、 the results of a VRAM flap after APR for anal cancer95 patients underwent APR, including 43 patients who subsequently received a VRAM flapSurvival in the 2 groups was equivalent despite the presence of more advanced cancers in the VRAM flap cohort They concluded VRAM is an effective technique for r
19、educing both the perineal complication rate and wound-healing delay in patients undergoing APR for AC that does not increase abdominal wall morbidityAnnals of Surgery, Oct 09Annals of Surgery, Oct 09Long term treatment of fissures in ano-Could their be an underlying malignacy?Advancements in treating rectal cancersCylindrical APR and VRAM flapsSTUDENTSDifferent colorectal cancer operationsThank YouDiscussion PointsDiscussion Points
