Annals of Coloproctology

Case Report

Malignant disease,Rare disease & stoma

Malignant Melanoma of Anorectum: Two Case Reports: Binh Van Pham, Jae Hyun Kang, Huynh Huu Phan, Min Soo Cho, Nam Kyu Kim; Ann Coloproctol. 2021;37(1):65-70. Published online February 28, 2021; DOI: https://doi.org/10.3393/ac.2020.01.07.1

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Malignant melanoma of the anorectum is a rare disorder. Patients often present with local symptoms similar to benign diseases. The prognosis is very poor, and almost all patients die because of metastases. We report 2 female patients with unremarkable histories. Both of them received previous operations before visiting our center after they were diagnosed with anorectal malignant melanoma. One case underwent abdominoperineal resection and postoperative chemotherapy. The other had been treated with ultralow anterior resection followed by immunotherapy.

Citations

Citations to this article as recorded by

A Rare Entity: Primary Malignant Melanoma of the Anorectum
Jeongmin Choi, Jong Whan Kim
Journal of Digestive Cancer Research.2024; 12(1): 44. CrossRef
Anorectal Malignant Melanoma Post- Hemorrhoidectomy
Ramazan Kozan, Ozkan Akpinar, Meral Toker
Acta Médica Portuguesa.2024; 37(7-8): 556. CrossRef
Immunotherapy for anorectal melanoma: A case report
Nicholas L. Vitagliano, Muhammad B. Darwish, Roger W. Hsiung
Current Problems in Cancer: Case Reports.2024; 15: 100302. CrossRef
Amelanotic Malignant Melanoma With Atypical Divergent Neuroendocrine Differentiation: A Report of an Unusual and Rare Case of Anorectal Bleeding
Shamiliprabha MG, Anand CD, Supriya Verma, Nivethitha S, Jaison J John
Cureus.2024;[Epub] CrossRef
Anorectal melanoma: systematic review of the current literature of an aggressive type of melanoma
Giovanni Paolino, Antonio Podo Brunetti, Carolina De Rosa, Carmen Cantisani, Franco Rongioletti, Andrea Carugno, Nicola Zerbinati, Mario Valenti, Domenico Mascagni, Giulio Tosti, Santo Raffaele Mercuri, Riccardo Pampena
Melanoma Research.2024;[Epub] CrossRef
Prolapsed anorectal malignant melanoma presenting as hemorrhoids
Busara Songtanin, Kenneth Nugent, Sameer Islam
Baylor University Medical Center Proceedings.2023; 36(1): 89. CrossRef
Long recurrence-free survival of localized rectal melanoma after abdominoperineal resection in comparison to partial excision and highlighting the place of immunotherapy: A case report
Othmane Bourouail, Noureddine Njoumi, Youssef Elmahdaouy, Mohamed Fahssi, Mbarek Yaka, Abderrahmane Hejjouji, Abdelmounaim Ait Ali
JRSM Open.2023; 14(2): 205427042211480. CrossRef
Challenges in managing anorectal melanoma, a rare malignancy
Jyotirmoy Biswas, Lakshmi Deepak Bethineedi, Arkadeep Dhali, Jamal Miah, Sukanta Ray, Gopal Krishna Dhali
International Journal of Surgery Case Reports.2023; 105: 108093. CrossRef
Organ preservation in anorectal melanoma: A tempting challenge—a case report
Mohamed Mehdi Trabelsi, Neirouz Kammoun, Marwa Inoubli, Mohamed Ali Chaouch, Haifa Ben Romdhane, Wafa Koubaa, Hichem Jerraya
SAGE Open Medical Case Reports.2023;[Epub] CrossRef
Primary anorectal amelanotic melanoma with liver, lungs and lymph nodal metastases
James R Marak, Gaurav Raj, Shivam Dwivedi, Ariba Zaidi
BMJ Case Reports.2023; 16(11): e257510. CrossRef
Treatment of Hemorrhoid in Unusual Condition-Pregnancy
Hyo Seon Ryu
The Ewha Medical Journal.2022;[Epub] CrossRef

Original Article

Short-term Outcomes of an Extralevator Abdominoperineal Resection in the Prone Position Compared With a Conventional Abdominoperineal Resection for Advanced Low Rectal Cancer: The Early Experience at a Single Institution: Seungwan Park, Hyuk Hur, Byung Soh Min, Nam Kyu Kim; Ann Coloproctol. 2016;32(1):12-19. Published online February 29, 2016; DOI: https://doi.org/10.3393/ac.2016.32.1.12

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Abstract PDF

Purpose

This study compared the perioperative and pathologic outcomes between an extralevator abdominoperineal resection (APR) in the prone position and a conventional APR.

Methods

Between September 2011 and March 2014, an extralevator APR in the prone position was performed on 13 patients with rectal cancer and a conventional APR on 26 such patients. Patients' demographics and perioperative and pathologic outcomes were obtained from the colorectal cancer database and electronic medical charts.

Results

Age and preoperative carcinoembryonic antigen (CEA) level were significantly different between the conventional and the extralevator APR in the prone position (median age, 65 years vs. 55 years [P = 0.001]; median preoperative CEA level, 4.94 ng/mL vs. 1.81 ng/mL [P = 0.011]). For perioperative outcomes, 1 (3.8%) intraoperative bowel perforation occurred in the conventional APR group and 2 (15.3%) in the extralevator APR group. In the conventional and extralevator APR groups, 12 (46.2%) and 6 patients (46.2%) had postoperative complications, and 8 (66.7%) and 2 patients (33.4%) had major complications (Clavien-Dindo III/IV), respectively. The circumferential resection margin involvement rate was higher in the extralevator APR group compared with the conventional APR group (3 of 13 [23.1%] vs. 3 of 26 [11.5%]).

Conclusion

The extralevator APR in the prone position for patients with advanced low rectal cancer has no advantages in perioperative and pathologic outcomes over a conventional APR for such patients. However, through early experience with a new surgical technique, we identified various reasons for the lack of favorable outcomes and expect sufficient experience to produce better peri- or postoperative outcomes.

Citations

Citations to this article as recorded by

Management of left-sided malignant colorectal obstructions with curative intent: a network meta-analysis
Tyler McKechnie, Jeremy E. Springer, Zacharie Cloutier, Victoria Archer, Karim Alavi, Aristithes Doumouras, Dennis Hong, Cagla Eskicioglu
Surgical Endoscopy.2023; 37(6): 4159. CrossRef
Prone Versus Supine Position in Abdominoperineal Resection: Outcomes in the Laparoscopic Era
Cecilia Ferrari, Carmen Martinez Sanchez, Jesus Bollo, Pilar Hernandez, Lorena Cambeiro, Claudia Codina, Eduardo Targarona
Journal of Laparoendoscopic & Advanced Surgical Techniques.2021; 31(4): 382. CrossRef
Surgical Treatment of Low-Lying Rectal Cancer: Updates
Cristopher Varela, Nam Kyu Kim
Annals of Coloproctology.2021; 37(6): 395. CrossRef
Perioperative and oncological outcomes of abdominoperineal resection in the prone position vs the classic lithotomy position: A systematic review with meta‐analysis
Jose Wilson B. Mesquita‐Neto, Hassan Mouzaihem, Francisco Igor B. Macedo, Lance K. Heilbrun, Donald W. Weaver, Steve Kim
Journal of Surgical Oncology.2019; 119(7): 979. CrossRef
Prone Compared With Lithotomy for Abdominoperineal Resection: A Systematic Review and Meta-analysis
Tyler McKechnie, Yung Lee, Jeremy E. Springer, Aristithes G. Doumouras, Dennis Hong, Cagla Eskicioglu
Journal of Surgical Research.2019; 243: 469. CrossRef
Perineal Wound Complications After Extralevator Abdominoperineal Excision for Low Rectal Cancer
Jia Gang Han, Zhen Jun Wang, Zhi Gang Gao, Guang Hui Wei, Yong Yang, Zhi Wei Zhai, Bao Cheng Zhao, Bing Qiang Yi
Diseases of the Colon & Rectum.2019; 62(12): 1477. CrossRef
Critical and Challenging Issues in the Surgical Management of Low-Lying Rectal Cancer
Aeris Jane D. Nacion, Youn Young Park, Seung Yoon Yang, Nam Kyu Kim
Yonsei Medical Journal.2018; 59(6): 703. CrossRef
EXTRALEVATOR ABDOMINOPERINEAL EXCISION OF THE RECTUM: SHORT-TERM OUTCOMES IN COMPARISON WITH CONVENTIONAL SURGERY
R. A. Murashko, I. B. Uvarov, E. A. Ermakov, V. B. Kaushanskiy, R. V. Konkov, D. D. Sichinava, B. N. Sadikov
Koloproktologia.2017; (4): 34. CrossRef
Extralevator Abdominoperineal Resection in the Prone Position
Young Jin Kim
Annals of Coloproctology.2016; 32(1): 1. CrossRef

Case Report

Mesh-Based Transperineal Repair of a Perineal Hernia After a Laparoscopic Abdominoperineal Resection: Taek-Gu Lee, Sang-Jeon Lee; Ann Coloproctol. 2014;30(4):197-200. Published online August 26, 2014; DOI: https://doi.org/10.3393/ac.2014.30.4.197

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Abstract PDF

A perineal hernia (PH) is formed by a protrusion of intra-abdominal viscera through a defect in the pelvic floor. This is a rare complication after a conventional abdominoperineal resection (APR). However, the risk of a PH may be increased after a laparoscopic resection because this technique can cause fewer postoperative adhesions, predisposing the small bowel to sliding down toward the pelvis. However, only a few case reports describe the transperineal approach for the repair of a PH after a laparoscopic APR. We present a case of a PH after a laparoscopic APR; the PH was repaired with synthetic mesh by using a transperineal approach. A transperineal approach using a mesh to reconstruct the pelvic floor is less invasive and more effective. We suggest that this technique should probably be the first choice for treating an uncomplicated PH that occurs after a laparoscopic APR.

Citations

Citations to this article as recorded by

Perineal hernia after abdominoperineal resection – a systematic review
Sajad Ahmad Salati, Amr Y. Arkoubi
Polish Journal of Surgery.2022; 94(6): 61. CrossRef
The impact of laparoscopic technique on the rate of perineal hernia after abdominoperineal resection of the rectum
Anna J. Black, Ahmer Karimuddin, Manoj Raval, Terry Phang, Carl J. Brown
Surgical Endoscopy.2021; 35(6): 3014. CrossRef
The Application of Extraperitoneal Ostomy Combined with Pelvic Peritoneal Reconstruction in Laparoscopic Abdominoperineal Resection for Rectal Cancer
Sen Wang, Qingyang Meng, Jun Gao, Yuqin Huang, Jie Wang, Yang Chong, Youquan Shi, Huaicheng Zhou, Wei Wang, Dong Tang, Daorong Wang
Gastroenterology Research and Practice.2019; 2019: 1. CrossRef
Perineal hernia mesh repair: a fixation with glue, sutures and tacks. How to do it
L. Hassan, A. Beunis, M. Ruppert, V. Dhooghe, S. Van den Broeck, G. Hubens, N. Komen
Acta Chirurgica Belgica.2019; 119(6): 406. CrossRef
Case report of perineal hernia after laparoscopic abdominoperineal resection
Kumpei Honjo, Kazuhiro Sakamoto, Shunsuke Motegi, Ryoichi Tsukamoto, Shinya Munakata, Kiichi Sugimoto, Hirohiko Kamiyama, Makoto Takahashi, Yutaka Kojima, Tetsu Fukunaga, Yoshiaki Kajiyama, Seiji Kawasaki
Asian Journal of Endoscopic Surgery.2018; 11(2): 173. CrossRef
Transvaginal Small Bowel Evisceration following Abdominoperineal Resection
Enver Kunduz, Huseyin Bektasoglu, Samet Yigman, Huseyin Akbulut
Case Reports in Surgery.2018; 2018: 1. CrossRef
Composite mesh and gluteal fasciocutaneous rotation flap for perineal hernia repair after abdominoperineal resection: a novel technique
Marios Papadakis, Gunnar Hübner, Marzena Bednarek, Mohamed Arafkas
Updates in Surgery.2017; 69(1): 109. CrossRef
Perineal hernia repair after abdominoperineal excision or extralevator abdominoperineal excision: a systematic review of the literature
A. Balla, G. Batista Rodríguez, N. Buonomo, C. Martinez, P. Hernández, J. Bollo, E. M. Targarona
Techniques in Coloproctology.2017; 21(5): 329. CrossRef
Short-term Outcomes of an Extralevator Abdominoperineal Resection in the Prone Position Compared With a Conventional Abdominoperineal Resection for Advanced Low Rectal Cancer: The Early Experience at a Single Institution
Seungwan Park, Hyuk Hur, Byung Soh Min, Nam Kyu Kim
Annals of Coloproctology.2016; 32(1): 12. CrossRef

Original Articles

Treatment Outcomes of Anorectal Melanoma: Byung Min Choi, Hyoung Ran Kim, Hae-Ran Yun, Seung Ho Choi, Yong Beom Cho, Hee Cheol Kim, Seong Hyeon Yun, Woo Yong Lee, Ho-Kyung Chun; J Korean Soc Coloproctol. 2011;27(1):27-30. Published online February 28, 2011; DOI: https://doi.org/10.3393/jksc.2011.27.1.27

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Abstract PDF

Purpose

An anorectal melanoma (AM) is a very rare tumor. However, sufficient data supporting effective surgical options for the disease do not exist. This retrospective review aimed to analyze treatment outcomes for an AM.

Methods

From June 1999 to December 2008, we retrospectively reviewed a prospectively collected consecutive series of 19 patients who had undergone a surgical resection for an AM at a single institute. Surgical method and clinicopathological factors were analyzed.

Results

The median age was 61.4 years (range, 46 to79 years). Main symptoms were an anal mass, hematochezia, perianal pain, tenesmus, fecal incontinence, and bowel habit change. The average duration of symptoms before diagnosis was 7.8 months (range, 1 to 36 months). S-100 and HMB-45 were positive in all patients, even in non-melanin pigmentation. There were 12 abdominoperineal resections (APRs) and 7 wide local excisions (WEs). The APR showed longer overall survival when compared with the WE (64.1 months vs. 10.9 months, P < 0.001). No patients who underwent a WE survived more than 13 months.

Conclusion

A high index of suspicion is necessary to establish the diagnosis for an AM in patients with anal symptoms, and S-100 and HMB-45 can be useful markers for an AM. Even with the small number of cases and the short follow-up, our data suggest that an APR for an AM may provide longer survival than a WE.

Citations

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Optimal surgical management strategy for treatment of primary anorectal malignant melanoma—a systematic review and meta-analysis
Hugo C. Temperley, Niall J. O’Sullivan, Alan Keyes, Dara O. Kavanagh, John O. Larkin, Brian J. Mehigan, Paul H. McCormick, Michael E. Kelly
Langenbeck's Archives of Surgery.2022; 407(8): 3193. CrossRef
Trends in the management of anorectal melanoma: A multi-institutional retrospective study and review of the world literature
Josh Bleicher, Jessica N Cohan, Lyen C Huang, William Peche, T Bartley Pickron, Courtney L Scaife, Tawnya L Bowles, John R Hyngstrom, Elliot A Asare
World Journal of Gastroenterology.2021; 27(3): 267. CrossRef
Survival following surgical treatment for anorectal melanoma seems similar for local excision and extensive resection regardless of nodal involvement
E. Jutten, S. Kruijff, A.B. Francken, H.L. van Westreenen, K.P. Wevers
Surgical Oncology.2021; 37: 101558. CrossRef
Response to Kahlke et al
Audrius Dulskas
Colorectal Disease.2021; 23(11): 3029. CrossRef
Three Cases of Anorectal Malignant Melanoma Treated with Laparoscopic Abdominoperineal Resection
Shin Yoshida, Nobuaki Suzuki, Shinobu Tomochika, Yoshitaro Shindo, Yukio Tokumitsu, Michihisa Iida, Shigeru Takeda, Tatsuya Ioka, Shoichi Hazama, Tsuzuri Shirahama, Hiroo Kawano, Eiji Ikeda, Hiroaki Nagano
The Japanese Journal of Gastroenterological Surgery.2021; 54(9): 644. CrossRef
Spectrum of presentation in primary anorectal malignant melanoma and its management
Barun Kumar Singh, Samrat Ray, Shashi Dhawan, Samiran Nundy
BMJ Case Reports.2021; 14(10): e245449. CrossRef
Surgical treatment of anorectal melanoma: a systematic review and meta-analysis
Esther Jutten, Schelto Kruijff, Anne Brecht Francken, Martijn F Lutke Holzik, Barbara L van Leeuwen, Henderik L van Westreenen, Kevin P Wevers
BJS Open.2021;[Epub] CrossRef
Long-term Oncologic Outcome and Its Relevant Factors in Anal Cancer in Korea: A Nationwide Data Analysis
Hyuk Hur, Kyu-Won Jung, Byung-Woo Kim, Chang-Mo Oh, Young-Joo Won, Jae Hwan Oh, Nam Kyu Kim
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Primary anorectal malignant melanoma with laparoscopic abdominoperineal resection: a case study and review of the relevant literature
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Less is more: A systematic review and meta-analysis of the outcomes of radical versus conservative primary resection in anorectal melanoma
Henry G. Smith, Jessica Glen, Nancy Turnbull, Howard Peach, Ruth Board, Miranda Payne, Martin Gore, Karen Nugent, Myles J.F. Smith
European Journal of Cancer.2020; 135: 113. CrossRef
Anorectal Malignant Melanoma: Retrospective Analysis of Six Patients and Review of the Literature
Ibrahim Atak
Prague Medical Report.2018; 119(2-3): 97. CrossRef
Extensive surgery and lymphadenectomy do not improve survival in primary melanoma of the anorectum: results from analysis of a large database (SEER)
A. Ciarrocchi, R. Pietroletti, F. Carlei, G. Amicucci
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Das anorektale maligne Melanom
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Abdominoperineal Resection Provides Better Local Control But Equivalent Overall Survival to Local Excision of Anorectal Malignant Melanoma
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Anorectal malignant melanoma: retrospective analysis of management and outcome in a single Portuguese Institution
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Characteristics and Survival of Korean Anal Cancer From the Korea Central Cancer Registry Data
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Incidence and Survival Patterns of Rare Anal Canal Neoplasms Using the Surveillance Epidemiology and End Results Registry
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Rectal melanoma
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Abdominoperineal Resection in the Treatment of Locally-advanced Low Rectal Cancer: Is Preoperative Chemoradiation Advantageous?.: Kim, Jeong Yeon , Kim, Jin Soo , Kim, Young Wan , Hur, Hyuk , Min, Byung Soh , Kim, Nam Kyu; J Korean Soc Coloproctol. 2010;26(2):129-136.; DOI: https://doi.org/10.3393/jksc.2010.26.2.129

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Abstract PDF: PURPOSE
An abdominoperineal resection (APR) has a poor prognosis. However, limited studies about the prognostic factors in APR and the role of preoperative chemoradiotherapy (CRT) have been performed even though in rectal cancer, the application of preoperative CRT provides better local control compared to postoperative CRT. The aim of this study was to identify the prognostic factors and the impact of preoperative CRT in patients who undergo an APR.
METHODS
A retrospective analysis was conducted with a total of 133 patients who underwent an APR, cT3, cT4, or cN(+) patients, for rectal cancer between January 1995 and October 2004. Fifty-one patients treated with preoperative CRT (Group 1) were compared with 82 APR patients treated with postoperative CRT (Group 2). Oncologic outcomes were compared between the two groups, and the clinicopathologic factors affecting the treatment outcomes were evaluated.
RESULTS
The median follow-up period was 61.2 mo (range 6 to 194 mo). Circumferential margin (CRM) involvement was significantly associated with local recurrence (LR) and with disease-free survival in APR patients (P<0.001, P=0.011). The 5-yr LR rate was significantly lower in Group 1 than in Group 2 (P=0.013) in the univariate analysis, but no difference was noted in multivariate analysis (P=0.315). In Group 1, CRM involvement, tumor size, and lymph node metastasis were significantly lower than they were in Group 2 (P=0.043, P=0.003, P<0.001).
CONCLUSION
For achieving adequate oncologic outcomes in APR patients, an adequate CRM should be acquired with an optimal operation. In addition, preoperative CRT would be helpful for high-risk APR patients with a threatening CRM margin, providing the benefit of tumor downstaging.

The Long-term Oncological Outcome of a Sphincter-saving Resection and an Abdominoperineal Resection for Lower Rectal Cancer.: Jung, Sang Hun , Yu, Chang Sik , Choi, Pyong Wha , Kim, Dae Dong , Hong, Dong Hyun , Kim, Hee Cheol , Kim, Jin Cheon; J Korean Soc Coloproctol. 2007;23(3):186-193.; DOI: https://doi.org/10.3393/jksc.2007.23.3.186

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Abstract PDF

Purpose
The oncological safety of a sphincter-saving resection (SSR) in lower rectal cancer is widely accepted, and both an abdominoperineal resection (APR) and a SSR are used in potentially curative surgery. This retrospective study was performed to compare the long-term oncological outcomes after an APR and a SSR in patients with lower rectal cancer (within 5 cm from the anal verge). Methods: We recruited 441 lower rectal cancer patients who underwent curative resections (APR: 305, SSR: 136) between 1995 and 2000. A total mesorectal excision and autonomic nerve preservation were routinely performed. The median follow- up period was 65 months. Results: Most demographic findings were comparable between the groups; however, the APR groups revealed more advanced pathological characteristics (tumor depth, size, cell differentiation, and metastatic LN number). The local recurrence rates after an APR and a SSR were 12.8% and 7.4%, respectively (P= 0.09). An independent risk factor of local recurrence was LN metastasis only. Distant recurrence was higher in the APR group (26.4%) than in the SSR group (13.2%), but on multivariate analysis the difference was not significant (P=0.17). The 5-year cancer-specific survival rates after an APR and a SSR were 73.2% and 87.6%, respectively (P<0.05). Particularly, there was a significant survival difference for stage III patients (APR: 59.0% vs. SSR: 83.0%, P<0.05). However, an APR was not an independent prognostic factor for cancer-specific survival in the multivariate analysis (P=0.07). Conclusions: An APR per se did not influence local recurrence after a curative resection for lower rectal cancer. The poor cancer-specific survival in the stage III APR group might be attributed to increased distant metastasis due to its more distal location.

Citations

Citations to this article as recorded by

Essential knowledge and technical tips for total mesorectal excision and related procedures for rectal cancer
Min Soo Cho, Hyeon Woo Bae, Nam Kyu Kim
Annals of Coloproctology.2024; 40(4): 384. CrossRef
Long-term Result for Rectal Cancer in Cases of a Curative Resection after Preoperative Chemoradiotherapy
Dong Hyun Lee, Sang Hun Jung, Jae Hwang Kim, Min Chul Shim
Journal of the Korean Society of Coloproctology.2007; 23(6): 503. CrossRef

Oncological Outcome after Abdominoperineal Resection for Low Rectal Cancer.: Oh, Seung Yeop , Lee, Ho Won , Suh, Kwang Wook; J Korean Soc Coloproctol. 2006;22(6):396-401.

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Abstract PDF: PURPOSE
Literature shows that low rectal cancer, that especially undergoing abdominoperineal resection (APR), is worse than mid or high rectal cancer. Two reasons have been proposed: diverse lymphatic channels in the low rectum, and technical difficulty in performing the APR. By comparison with the results reported in representative literature, we tried to find out whether low rectal cancer is really worse oncologically than high rectal cancer.
METHODS
For 133 patients who underwent an APR from 1995 to 2005, we examined the pathological characteristics of the cancer, the recurrence, the metastasis, the survival rates, and the prognostic factors.
RESULTS
The patient distribution according to stage was 15.9% in stage I, 33.6% in stage II, and 50.4% in stage III. The overall 5-year actuarial survival rate (5SR) of patients undergoing a curative resection (n=113) was 74.6%. Local pelvic recurrence was found in 11.5% of the patiennts, and systemic metastasis was noted in 14.2%. Among several prognostic variables, lymph node metastasis, the number of metastatic lymph nodes, adjuvant chemotherapy, and the distance between the tumor border and the dentate line were significant factors. In the multivariate analysis, lymph node metastasis was the most significant prognostic factor.
CONCLUSIONS
It is true that a curative resection in low rectal cancer is difficult due to the anatomy of pelvis, so knowledge of the anatomic features of the pelvis and surgical skill are important. definitely, acceptable oncological results can be attamed if the rule of curative resection is obeyed. We also found that lymph node involvement was the most significant prognostic factor in low rectal cancer.

Case Report

The Rectus Abdominis Myocutaneous Flap for the Immediate Reconstruction of Partial Vaginal Defects Following the Extended Abdominoperineal Resection of Recurrent Rectal Cancer.: Lee, Suk Hwan , Yoo, Young Chun; J Korean Soc Coloproctol. 2006;22(3):210-213.

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Abstract PDF: Extensive resection including posterior vaginal wall may be required for the advanced low rectal cancer or recurrent rectal cancer in order to achieve the tumor free circumferential margins. We describe closure of a vaginal defect with rectus abdominis musculocutaneous flap after extended abdominoperineal resection, hysterectomy and partial colpectomy in a patient with recurrent rectal cancer with the special reference to the surgical technique.

Review

Sharp Pelvic Dissection for Abdominoperineal Resection for Distal Rectal Cancer Based on Anatomical and MRI Knowledge.: Kim, Nam Kyu; J Korean Soc Coloproctol. 2005;21(4):258-267.

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Abstract PDF: Even though sphincter saving surgery such as coloanal anastomosis or intersphincteric resection have been popular in era of Total Mesorectal Excision (TME) in distal rectal cancer, unreasonable sphincter saving surgery might cause a couple of troublesome complications in terms of oncologic or functional outcomes. Since preoperative staging work up recently have been developed with MRI or MDCT, it is important to assess whether rectal cancer invaded into surrounding sphincter or levator ani muscle based on MRI or MDCT coronal image study. If tumor is located at a very close distance or has invaded the adjacent sphincter muscle, the need of abdominoperineal resection is definite without any hesitation for curative resection. But, the actual number of cases of APR have been decreased in favor of sphincter preserving surgery even APR remains an important therapeutic option in the surgical treatment of low rectal cancer. Indication case for APR have become a intersphincteric resection or ultralow anterior resection and coloanal anastomosis Even patients who showed invasion of sphincter underwent sphincter saving surgery, lately proven safe in terms of recurrence and defecation functions. On practical view points on operative techniques, abdominal phase are same as TME techniques. Sharp pelvic dissection must be carried out along the visceral fascia enveloping the mesorectum to the levator ani muscle with preservation of pelvic autonomic nerve. Perineal phase dissection is a key process in APR. During perineal dissection, inadequate resection margin and blunt tissue dissection along the nonanatomical plane encourage implantation of a malignant cell and local recurrence. Moreever, it could lead to serious complications such as prostatic urethral injury, vaginal wall perforation, perineal sinus and fistula. Massive bleeding from pelvic side wall major vessels injury. Especially in males with very narrow pelvis, pelvic dissection is very difficult due to deep narrow and blunt sacral curvature of the pelvis. It is nearly impossible to reach the levator ani muscle and result in perineal dissections performed on excessively high levels. For colorectal surgeons with insufficient experience, it is difficult to dissect the rectum from the perineum upto the seminal vesicle level. In the classic pattern, anterior and lateral dissection from the prostate or vagina after the completion of posterior dissection. The dissected proximal colon was delivered outward through the perineal wound and with traction of the delivered portion of the colon, anterior dissection was performed. However, in patients with narrow pelvis, such delivery of the proximal colon through perineal wound can result in fractured tumor and local recurrence due to limited operation field. Therefore, it is mandatory that specimen must be delivered in situ after posterior, anterior and lateral dissection. During posterior dissection, gluteus muscle must be observed and removal of the ischiorectal fat tissue should be accomplished. In lateral dissection, levator ani muscle must be divided near the bony insertion. Finally, during anterior dissection, seminal vesicle and prostate gland must be exposed and neurovascular bundle observed at the 10 and 2 o'clock direction. In addition to TME on abdominal phase, Sharp Anatomical Perineal Dissection (SAPD) empowered by 3D concept based on MRI is a key process for prevention of local recurrence in APR.

Original Article

Oncologic Results according to Operative Method after a Curative Resection for Low Rectal Cancers.: Kim, Kwang Hee , Sin, Jin Yong , Hong, Kwan Hee; J Korean Soc Coloproctol. 2005;21(4):233-240.

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Abstract PDF: PURPOSE
Although the current trend is to use a sphincter- saving operation (SSO) for management of distal rectal cancer, an abdominoperineal resection (APR) is widely performed in low rectal cancers. Numerous studies have reported that lateral margin is an important prognostic factor for recurrence in low rectal cancers. In regard to curability, the presence of an involved lateral margin after a resection of a low rectal cancer is currently accepted as being an indicator of a non-curative resection. Indeed, the higher rate of positive lateral margins after APRs than after a SSO may explain the inferior oncologic outcomes of APRs. Therefore, the purpose of this study was to analyse the oncologic results of 'curative' APRs and SSOs.
METHODS
This retrospective study included 111 patients who had undergone surgical treatment between 1995 and 2000 with either an APR (n=65) or a SSO (n=46). The oncological outcomes of the patients who had undergone an APR were compared with those of the patients who had undergone a SSO. Univariate and multivariate analyses were used to evaluate the data.
RESULTS
The distal resection margin and the mean distance between the tumor low margin and the dentate line were significantly different between the two groups. However, the disease-free and the overall survivals, as well as the frequency of local recurrence and that of overall recurrence, after rectal excision did not differ between the two groups. Multivariate analyses showed that the method of surgery was not a significant independent factor in predicting either disease-free survival or overall survival. However, advanced stage III was a significant predictor of outcome after the operation.
CONCLUSIONS
The type of operation did not affect the oncological outcome after a 'curative' resection for distal rectal cancer.

Multicenter Study

Factors Influenceing the Oncologic Results after Abdominoperineal Resection: Does the Introduction of Laparoscopic Procedures Influence the Oncologic Results?.: Heo, Youn Jung , Cho, Hyeon Min , Kim, Jun Gi , Won, Yong Sung , Jun, Kyong Hwa , Chin, Hyung Min , Park, Woo Bae , Chun, Chung Soo; J Korean Soc Coloproctol. 2004;20(5):311-318.

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Abstract PDF: PURPOSE
Although indications for abdominoperineal resection (APR) are decreasing due to the widespread of sphincter-saving procedures, APR is still the mainstay in the treatment of rectal cancer. The purpose of this study is to demonstrate the appropriateness of laparoscopic APR in terms of oncologic parameters.
METHODS
From January 1984 to December 2003, 110 patients with a rectal adenocarcinoma who underwent APR were involved in this study. The data were grouped according to five main items: 1) patient demographic data, 2) operative procedure, 3) gross tumor findings, 4) pathologic tumor findings, and 5) perioperative treatment. Each item was subdivided by factors that could influence the oncologic results, and univariate analyses were performed. Thereafter, a multivariate analysis was performed with those factors considered statistically significant.
RESULTS
The mean follow-up period was 106.01+/-9.98 months, the local recurrence rate was 23.6%, and distant metastasis rate was 31.8%. The five-year survival rate was 58.1%, and the ten-year survival rate was 51.1%. Multivariate analysis after univariate analyses showed that independent prognostic factors influencing local recurrence were preoperative CEA level, T-stage, and preoperative radiation therapy. Factors influencing distant metastasis were preoperative CEA level, N-stage, and preoperative radiation therapy. Univariate analysis showed that the laparoscopic approach was beneficial in terms of local recurrence; however, with the multivariate analysis, this was not statistically evident. Prognostic factors influencing long-term survival in the multivariate analysis were preoperative CEA level, stage, and perineural invasion.
CONCLUSIONS
Laparoscopic APR was not significantly different from an open procedure in terms of oncologic outcomes. In the near future, a randomized prospective multicenter trial should tell us which approach is more beneficial.

Original Articles

Factors Affective Sexual Function after Abdominoperineal Resection for Patients with Rectal Cancer.: Yoo, Jang Hak , Kim, Hee Cheol , Cho, Young Kyu , Namgung, Hwan , Kim, Mi Sook , Lee, Hae Ok , Yu, Chang Sik , Kim, Jin Cheon; J Korean Soc Coloproctol. 2002;18(4):234-239.

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Abstract PDF: BACKGROUND
Abdominoperineal resection (APR) combined with autonomic nerve preservation (ANP) is proven to reduce sexual dysfunction. However, Sexual dysfunction after APR combined ANP occurs as many as 59% of case. PURPOSE: The aims of this study were to assess prog nostic value of various postoperative factors affective sexual function after APR combined with ANP and to suggest a clinical relevant factors for the improvement of sexual function.
METHODS
This was a cross sectional descriptive study. Data were collected using individual-based interviews from 63 patients who underwent APR during the period of Feb. 2001 and April. 2001. The tool for this study was developed by the researcher through modification of the QLQ-CR38 (European Organization for Research and Treatment of Cancer, 1999).
RESULTS
The severity of sexual function showed significant differences according to occupation, intervals after operation, colostomy irrigation. Intervals of longer than 18 month after operation was associated with better sexual function. In multiple regression analysis, colostomy related problems, colostomy irrigation, colostomy complications, intervals after operation, recurrence affected sexual function significantly.
CONCLUSIONS
Colostomy related problems, colostomy irrigation, colostomy complications, intervals after operation and recurrence appear to be associated with sexual function after APR.

Clinical Analysis of Surgical Treatment for Mid and Lower Rectal Cancers.: Moon, Yang Joo , Kim, Byung Seok , Moon, Duk Jin , Park, Ju Sub; J Korean Soc Coloproctol. 2000;16(6):451-455.

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Abstract PDF: PURPOSE
The aim of this retrospective study was to evaluate the risk of local recurrence such as patients who were treated for Dukes stage B and C low rectal cancer by abdominoperineal resection (APR) or low anterior resection (LAR).
METHODS
From 1985 to 1995, 81 patients with low rectal cancers which were within 3~8 cm from the anal verge were treated by curative resection, 38 by APR and 43 by LAR. The present study examined clinical and tumor characteristics, type of intervention as potential predictors of local recurrence. Retrospective data were analysed by univariate Chi-square tests.
RESULTS
Local recurrence was diagnosed in 17 of 81 patients with a median follow-up period of 24 months. The local recurrence rate was 23.6% (9 of 38) after APR and 18.6% (8 of 43) after LAR. There was no difference in local recurrence between patients who had APR and LAR (P=0.58). Also we could not find any significant differences among age (< or =65 vs >65 years, P=0.53), sex (M vs F, P=0.57), sized of tumors (< or =5 vs >5 cm, P=0.32), distance from anal verge (< or =5 vs >5 cm, P=0.57), Dukes stage (B vs C, P=0.22), histological grade (well and moderate vs poorly, P=0.17), distance from distal resection margin (< or =2 vs >2 cm, P=0.35).
CONCLUSIONS
The tumor factors such as Dukes' stage were more critical for pelvic recurrences than other patient factors.

Case Report

A Case of Leiomyosarcoma of the Rectum.: Kim, Jin Ho , Oh, Seong Taek , Jeon, Hae Myung , Kim, In Chul; J Korean Soc Coloproctol. 1998;14(3):643-648.

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Abstract PDF: Leiomyosarcoma of the rectum is a extremely rare disease without well documented report on its management and prognosis. The most complicated problem lies on the correct diagnosis. Many pathologic and histologic criteria have been proposed to make it clear. The treatment of rectal leiomyosarcoma is controversial. Some authors recommand wide local excison for low-grade tumors as much as 2 cm in diameter. However, radical abdominoperineal resection is the procedure of choice. Leiomyosarcoma of the rectum is resistant to radiotherapy, and no single effective chemotherapeutic drug has been found yet, although adriamycin is effective in one third of all cases. The local recurrence rate was much higher in patients receiving wide local excision and the overall 5-year or 10-year survival rate is similar. We report a case of rectal leiomyosarcoma and review the literature.

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