Improved Outcomes in Colon and Rectal Surgery part 30 pdf

  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 resection for a T2N1 rectal adenocarcinoma. She had received preoperative. 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 anterior 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 complications, 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 cancer. Abraham and colleagues found a 10% decrease (60.1–49.9%) in the rate of APR from 1989 to 2001 as compared with low anterior 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 colorectal 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 typically left with profound sphincter dysfunction or fistulae following a protracted recovery. A two-staged operation, consisting 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 mortality, 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 perineum 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, especially 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 thromboembolism.(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 radiation. 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 abdominal 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 metastatic disease and synchronous colon lesions. After confirmation of resectability, a self-retaining retractor is placed.  abdominoperineal resection 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 colostomy, 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 description of total mesorectal excision.(12) After identifying this avascular 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 fascia in males is dissected down to the pelvic floor anteriorly. Unless the tumor is anterior, it is not necessary to expose the seminal vesicles 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.  improved outcomes in colon and rectal surgery 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 carried 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 portion 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 surgery 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 morbidity. 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 resection 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 significant 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, leading 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 perineal 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 peritoneum 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 peritoneum 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.  abdominoperineal resection 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 decreasing 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 available 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 contamination. 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 myocutaneous (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 healing 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 irradiated 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 prolonged 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 commonly, the bleeding from the sacrum will come from the venous plexus. If present, the basivertebral vein, which connects the internal vertebral venous system to the presacral system, can bleed profusely and be difficult to control. Ideally, by taking sharp dissection down the presacral plane, there should be little to no bleeding.(32, 33) Unfortunately this space may be nonexistent in certain patients or obliterated in an irradiated field. Bleeding from the sacrum 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 packing may be removed in 48–72 hours.(36) Occasionally, reoperation is necessary to control postoperative perineal hemorrhage.  improved outcomes in colon and rectal surgery 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 abdominal and pelvic procedures, the most striking difference is the perineal dissection and ensuing perineal 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, anteriorly 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 secondary to complications, such as pelvic abscess or hematoma) that produce a fixed fibrotic cavity are likely to result in a nonhealing perineal wound.(30) Artioukh et al. reviewed their series of APR non healing wounds and found several possible contributing factors, including distant metastases, excessive alcohol consumption, cigarette smoking, transfusion requirement and chemoradiation. Other studies have also observed the increased risk in perineal 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 development 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 resection 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 vaginectomy advocated by some versus the intersphincteric proctectomy (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% incidence 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 inflammatory 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 evidence 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.  abdominoperineal resection 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 problem, 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 extensive 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 secondary 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 complex 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 perineum 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 necessitates repeat surgery with reduction of intestines and repeat packing. Perineal hernias are a rare complication and occur in about 1% of patients after APR. This figure increases to 3% after pelvic exenteration. Initial symptoms include perineal bulging, often associated 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 hernias 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 ultimately 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 recurrent 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 technique of perineal hernia repair using Permacol® mesh. Using a perineal approach, they isolated and ligated the sac in the standard 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  improved outcomes in colon and rectal surgery 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. REFERENCES 1. 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Am Surg 2005; 71(10): 837–40. 18. Rosen L, Veidenheimer MC, Coller JA et al. Mortality, morbidity, and patterns of recurrence after abdominoperineal resection for cancer of the rectum. Dis Colon Rectum 1982; 25: 202–8. 19. Irvin IT, Goligher JC. A controlled clinical trial of three different methods of perineal wound management following excision of the rectum. Br J Surg 1975; 62: 287–91. 20. Silen W, Glotzer DJ. The prevention and treatment of the persistent perineal sinus. Surgery 1974; 75: 535–42. 21. Meyer L, Bereuter M, Marusch F et al. Perineal wound closure after abdomino-perineal excision of the rectum. Tech Coloproctol 2004; (8 suppl 1): S230–4. 22. Gruessner U, Clemens M, Pahlplatz PV et al. Septocoll Study Group. Improvement of perineal wound healing by local administration of gentamicin-impregnated collagen fleeces after abdominoperineal excision of rectal cancer. Am J Surg 2001; 182: 502–9. 23. Mendel V. Rektumexstirpation-Ergebnisse mit einem Kollagen-Gentamycin-verbund bei der abdomino-perinealen Rektumexstirpation. Forum Lokale Antibiose “Der Schwamm”, Essex Pharma GmbH, 1995; 50–1. 24. Chessin DB, Hartley J, Cohen AM et al. Rectus flap reconstruction decreases perineal wound complications after pelvic chemoradiation and surgery: a cohort study. Ann of Surg Onc 2005; 12(2): 104–10. 25. Butler CE, Gundeslioglu AO, Rodriguez-Bigas MA. Outcomes of immediate vertical rectus abdominis myocutaneous flap reconstruction for irradiated abdominoperineal resection defects. J Am Coll Surg 2008; 206(4): 694–702. 26. Page CP, Carlton PK, Becker DW. Closure of the pelvic and perineal wounds after removal of the rectum and anus. Dis Colon Rectum 1980; 23: 2–9. 27. Nilsson PJ. Omentoplasty in Abdominoperineal Resection: A review of the literature using a systematic approach. Dis Colon Rectum 2006; 49: 1354–61. 28. Pollard CW, Nivatvongs S, Rojanasakul A, Ilstrup DM. Carcinoma of the rectum. Profiles of intraoperative and early  abdominoperineal resection postoperative complications. Dis Colon Rectum 1994; 37: 866–74. 29. Broux ED, Parc Y, Rondelli F et al. Sutured perineal omentoplasty after abdominoperineal resection for adenocarcinoma of the lower rectum. Dis Col Rect 2005; 48: 476–82. 30. Baudot PE, Keighley MRB, Alexander-Williams J. Perineal wound healing after proctectomy for carcinoma and inflammatory disease. Br J Surg 1980; 67: 275–6. 31. Michalson AE, Brown BP. Warnock NG, Simonson TM. Presacral abscesses: percutaneous transperineal drainage with use of bone landmarks and fluoroscopic guidance. Radiology 1994; 190: 574–5. 32. Wang O, Shi W, Zhaw Y, Zhou W, He Z. New concepts in severe presacral hemorrhage during proctectomy. Arch Surg 1985; 120: 1013–20. 33. Arnaud JP, Tuech JJ, Pessaux P. Management of presacral venous bleeding with the use of thumbtacks. Dig Sur 2000; 17(6): 651–2. 34. Nivatvongs S, Fang DT. The use of thumbtacks to stop mas- sive presacral hemorrhage. Dis Colon Rectum 1986; 29: 589–90. 35. Rothenberger DA, Wong WD. Abdominoperineal resection for adenocarcinoma of the low rectum. World J Surg 1992; 16: 478–85. 36. de Canniere L, RosiPre A, Michel LA. Synchronous abdominoperineal resection without transfusion. Br J Surg 1993; 80: 1194–5. 37. Petrelli NJ, Nagel S, Rodriguez-Bigas M et al. Morbidity and mortality following abdominoperineal resection for rectal adenocarcinoma. Am Surg 1993; 59: 400–4. 38. Tompkins RG, Warshaw AL. Improved management of the perineal wound after proctectomy. Ann Surg 1985; 202: 760–5. 39. Anthony JP, Mathes SJ. The recalcitrant perineal wound after rectal extirpation. Arch Surg 1990; 125: 1371–7. 40. Fasth S, Hulten L, Ojerskog B. Omission of pelvic peritoneal closure after abdominoperineal rectal excision. Ann Chir Gynaecol 1977; 66: 181–3. 41. Scott H, Brown AC. Is routine drainage of pelvic anastomosis necessary? Am Surg 1996; 62: 452–7. 42. 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Surgical Endoscopy 2006; 20(3): 414–8.   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 radiation. 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 circumferential, 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 adjacent to the sacrum without boney erosion. It suggested involvement 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 underwent 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 segment 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 indications and outcomes for surgical intervention in patients with: 1. Recurrent rectal cancer, 2. Liver metastasis, and 3. Lung metastasis. 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 treatment plan if success is to be achieved. The surgeon that takes on these cases assumes the responsibility of organizing and leading a team of sub specialists consisting 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 essential 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 supplemented 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)  indications and outcomes for treatment of recurrent rectal cancer 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 structures, or sacrum are involved.(4–8) Although imaging can assist in preop planning, no radiographic study can reliably differentiate fibrosis and scarring from tumor, particularly in an irradiated 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 inferior mesenteric artery can be expected to have a much more difficult 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 resections, and/or ligation of the superior rectal vs. the inferior mesenteric 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 structures, outside of the proper mesorectum. These tumors recur in the sidewall, sacrum, anastomosis, perineal wound or in the gynecologic 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 resection implies microscopic disease is left, and R2 implies gross disease 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 secondary 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 significant. Likewise sacral recurrences below S1-2 typically can technically be resected, but morbidity and mortality can be significant. (10) Local, limited anastomotic recurrences post low anterior resection 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 chemotherapy. 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 radiation and reirradiation 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 irradiation 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 delivered 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 associated with excessively high local recurrence rates as demonstrated 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 positive margin when a modality such as IORT, with little morbidity 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 previous 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 frozen 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 . 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. created and the abdomen is closed.  improved outcomes in colon and rectal surgery When the abdominal operator has determined that the lesion is resectable the perineal dissection begins simultaneously. recurrence  improved outcomes in colon and rectal surgery 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

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