Abdominal Perineal Resection (APR) Surgery

Introduction

Abdominal Perineal Resection (APR) is a serious operation commonly employed in the management of rectal cancer that is very low in the rectum or at the level of the anus. The operation entails the removal of the rectum, anus, and surrounding tissues, and the formation of a permanent colostomy. Ever since it was first introduced in the early 20th century, APR has been a vital operation for the management of some colorectal cancers that cannot be treated with sphincter-sparing operations.

APR is still a viable option, even with advances in colorectal cancer therapy such as neoadjuvant treatment and minimally invasive surgical procedures, for some patients because of tumor location or intolerance of other therapies. Both caregivers and patients should know this surgery, its advantages, disadvantages, and expectations for recovery.

What is the treatment/procedure?

Abdominal perineal resection is a surgical procedure used primarily to treat cancers of the lower rectum and anus. It is typically performed when tumors are too close to the anal sphincter muscles, making it impossible to remove them without compromising bowel control.

During the APR procedure:

• The surgeon removes the distal part of the sigmoid colon, the entire rectum, the anal canal, and the surrounding lymph nodes and tissues.
• A permanent colostomy is created, where the end of the remaining colon is brought through an opening in the abdominal wall to form a stoma, through which waste exits the body.
• The perineal wound (where the anus was removed) is closed, and in some cases, a flap of muscle or tissue may be used for reconstruction.

Indications

APR is indicated in the following conditions:

• Low rectal cancer, especially when it invades the anal sphincter complex.
• Recurrent rectal cancer not amenable to sphincter-preserving surgery.
• Anal cancer resistant to chemoradiation.
• Invasive anal melanoma or other rare anorectal tumors.
• Crohn’s disease or severe trauma involving the anal canal, though rarely.

The key consideration is that the disease involves or is close to the anal sphincters, making continence preservation unfeasible.

Procedure Details

Preoperative Preparation

• Detailed imaging (MRI, CT scan) to evaluate tumor spread.
• Colonoscopy and biopsy.
• Neoadjuvant chemoradiotherapy may be used to shrink the tumor.
• Bowel preparation and stoma site marking.

Surgical Procedure

1. Abdominal Phase:
   • Performed via open surgery, laparoscopy, or robotic-assisted methods.
   • The sigmoid colon and rectum are mobilized and blood vessels are ligated.
   • The distal rectum is disconnected.
2. Perineal Phase:
   • The patient is repositioned to a prone or lithotomy position.
   • The anal canal and surrounding tissues are excised.
   • The perineal wound is closed, sometimes with tissue flaps.
3. Colostomy Creation:
   • The proximal colon end is brought to the abdominal surface to form a stoma.

Duration

The surgery typically lasts 3 to 6 hours, depending on the technique and complexity.

Effectiveness

APR is a curative procedure for selected patients with low rectal cancers. Its success largely depends on:

• Complete removal of cancer with clear margins.
• Absence of distant metastasis.
• Effective neoadjuvant therapy prior to surgery.

Long-term outcomes:

• 5-year survival rates for localized rectal cancers treated with APR range between 60% and 60–75%.
• Local recurrence rates have declined due to better imaging, surgical techniques, and preoperative therapy.

Risks and Side Effects

Like all major surgeries, APR has potential risks:

Surgical Risks:

• Bleeding
• Infection
• Blood clots (DVT)
• Injury to nearby organs (bladder, ureters)

Long-term Complications:

• Perineal wound complications: delayed healing, infections, chronic pain.
• Stoma-related issues: prolapse, retraction, or skin irritation.
• Sexual and urinary dysfunction due to nerve damage.
• Psychological impact due to permanent colostomy.

Proper surgical planning and post-op care reduce these risks significantly.

Recovery and Aftercare

Hospital Stay

• The average hospital stay is 7–10 days.
• Pain management, wound care, and colostomy training are provided.

Recovery Timeline

• 4–6 weeks before returning to daily light activities.
• Full recovery may take up to 3 months.

Aftercare includes:

• Stoma care education with a stoma nurse.
• Dietary modifications to manage bowel output.
• Wound care for perineal healing.
• Physical therapy if needed.
• Psychological counseling to cope with body image changes.

Regular follow-up for cancer surveillance is critical.

Cost and Availability

The cost of APR surgery varies based on the country, hospital type, surgical approach (open vs. robotic), and additional treatments (like radiation or chemotherapy).

Factors influencing cost:

• Surgeon’s experience
• Type of facility (public vs. private)
• Use of advanced surgical techniques
• Hospital stay duration

Availability is generally widespread in tertiary care hospitals and cancer centers across the globe, especially in countries with advanced oncological services.

Patient Experiences

Patient experiences post-APR are varied. Key points include:

• Many patients express relief and satisfaction when cancer is successfully removed.
• Initial challenges with stoma care and emotional adaptation are common.
• Support groups and counseling greatly help patients adjust to life post-APR.
• With proper training, most patients regain independence in daily activities.

Some quotes from patients:

“The first few weeks were hard, but my stoma nurse was a savior. Now, I hardly notice it anymore.”
– Ramesh, 58, India

“What mattered most was being cancer-free. I can live with a stoma, but not with fear.”
– Anna, 63, USA

 

Cost in Different Countries

Note: These are average estimates and may vary by hospital, city, and patient condition.

Frequently Asked Questions (FAQs)

Q1: Is APR the only option for rectal cancer?
A: Not always. If the tumor is higher in the rectum, sphincter-preserving surgeries may be possible.

Q2: Will I need a permanent colostomy?
A: Yes. APR removes the anus, necessitating a permanent colostomy.

Q3: Can I live a normal life with a stoma?
A: Absolutely. With proper care and support, most patients adapt well and lead full lives.

Q4: How painful is the recovery?
A: Pain is manageable with medications. The perineal wound may take longer to heal and cause discomfort initially.

Q5: Is robotic APR better than open surgery?
A: Robotic surgery may offer faster recovery and less pain, but results are similar in terms of cancer control.

Q6: Can cancer come back after APR?
A: While recurrence is possible, proper follow-up and adjuvant therapy reduce the risk.

Conclusion

Abdominoperineal Resection (APR) is still a crucial surgery to treat low rectal and anal cancers in the event that sphincter preservation is not possible. Although it entails a lifestyle adjustment in the form of a colostomy, the surgery provides a high opportunity for a cure and long-term survival.

Improved surgical techniques, preoperative planning, and postoperative care have ensured the procedure is safer and easier. Patients undergoing APR must be well-informed, emotionally stable, and adequately prepared with tools for post-operative living.

For anyone undergoing APR, the experience can be intimidating, but with the appropriate care team and support network, it is completely feasible to move ahead confidently and live well beyond cancer.