Abdominoperineal Resection (APR)

Introduction

Abdominoperineal resection (APR) is a major operation utilized mainly in the management of cancers of the distal rectum and anus. It entails excision of the rectum, anus, and the overlying tissues, which leads to the permanent closure of the anal opening and the creation of a colostomy. The operation is usually performed in the case of low rectal cancers when sphincter-saving operations cannot be done because of the close relationship of the tumor with the muscles of the anal sphincter.

Initially performed in the early 20th century, APR has made considerable improvements. Through the use of contemporary surgical methods, imaging devices, and preoperative treatments, patient outcomes and quality of life have dramatically improved.

What Is the Treatment/Procedure?

Abdominoperineal resection is a radical surgery that combines two incisions—one in the abdomen and one in the perineum (the area around the anus)—to remove the rectum and anus completely. As the anal opening is removed, patients require a permanent colostomy, an opening in the abdominal wall for the passage of stool into a colostomy bag.

APR is typically used when cancer affects the lower third of the rectum or the anal canal and cannot be effectively removed with sphincter-saving techniques. It is often performed after or in conjunction with neoadjuvant therapies, such as chemotherapy and radiation, to shrink the tumor and increase the chances of a complete resection.

Indications

The main indications for APR include:

• Low rectal cancer (especially if it invades the sphincter muscles)
• Anal canal cancer
• Recurrent rectal cancer after previous surgeries or treatments
• Chronic inflammatory bowel disease complications with neoplastic changes
• Pelvic malignancies involving the rectum and anus
• Poor sphincter function not suitable for anastomosis (reconnection)

Procedure Details

Preoperative Preparation

• Imaging (MRI, CT scan, PET scan) to assess tumor size and spread.
• Bowel prep may be required.
• Neoadjuvant chemoradiation therapy in cases of locally advanced cancer.

Surgical Steps

1. Abdominal Phase:
   • A midline abdominal incision is made.
   • The sigmoid colon and rectum are mobilized.
   • The blood supply to the rectum is ligated.
   • The distal rectum is dissected down to the pelvic floor.
2. Perineal Phase:
   • An elliptical incision is made around the anus.
   • The anal canal and remaining rectum are dissected and removed through the perineal wound.
   • The pelvic floor is reconstructed or left to heal secondarily.
   • The perineal wound is closed or managed with flaps depending on tissue loss.
3. Colostomy Creation:
   • A stoma (colostomy) is created on the left side of the abdomen.
   • The colon is brought out through the abdominal wall and sutured to the skin.
   • A colostomy bag is attached to collect waste.

Surgical Duration: 3 to 5 hours, depending on complexity.

Effectiveness

APR is highly effective in treating cancers that are not amenable to sphincter-preserving surgeries. The effectiveness depends on:

• Tumor stage and grade
• Margins achieved during surgery
• Response to neoadjuvant therapy
• Absence of metastasis

Survival rates vary based on disease stage:

• Stage I: 80–90%
• Stage II: 60–75%
• Stage III: 40–60%
• Stage IV: <20%

When sphincter preservation is not feasible, APR continues to be the preferred treatment for low-lying rectal and anal cancers.

Risks and Side Effects

Like all major surgeries, APR carries risks and potential complications:

Surgical Risks:

• Bleeding
• Infection
• Injury to nearby organs (bladder, ureters, prostate)
• Wound dehiscence

Postoperative Complications:

• Perineal wound complications (slow healing, infection)
• Hernia at the colostomy site
• Urinary retention or sexual dysfunction
• Pelvic abscess
• Deep vein thrombosis (DVT)

Long-term Side Effects:

• Permanent colostomy
• Changes in body image and lifestyle
• Possible phantom rectal sensations
• Fatigue, especially if receiving chemotherapy

Recovery and Aftercare

Hospital Stay: 7–10 days (may vary)

Initial Recovery:

• Early mobilization is encouraged.
• Pain management with epidural or PCA pumps.
• Stoma care training begins during the hospital stay.

Wound Care:

• Perineal wounds may require special dressings.
• In some cases, a vacuum-assisted closure (VAC) device is used.

Lifestyle Adjustments:

• Colostomy care is a significant part of recovery.
• Diet modifications might be needed.
• Counseling and support groups can aid emotional adaptation.

Follow-Up:

• Regular oncologic follow-up for surveillance.
• Imaging and colonoscopy as indicated.
• Monitoring of CEA (Carcinoembryonic Antigen) levels.

Cost and Availability

APR is widely available in tertiary care centers and cancer hospitals globally. The cost of APR varies significantly depending on the country, the hospital, whether the procedure is done laparoscopically or open, and the presence of insurance coverage.

Patient Experiences

Patient experiences vary depending on the clinical situation, quality of surgical care, and postoperative support. Some common themes in patient stories include:

• Initial shock at the idea of living with a colostomy.
• Gradual adaptation with support from stoma nurses and support groups.
• Return to normal life, including work and social activities, within months.
• Improved survival and quality of life, especially when cancer is detected early.

Some patients report phantom rectum sensations, while others adjust quite well emotionally and physically with proper counseling and guidance.

Cost in Different Countries

Note: These costs include pre-op tests, surgery, anesthesia, hospital stay, and immediate post-op care, but not long-term follow-up or chemotherapy.

 

Frequently Asked Questions (FAQ)

Q1. Is APR a cure for rectal cancer?

It can be, especially if the cancer is localized and completely removed. Cure rates are highest in early-stage disease.

Q2. Will I have to live with a colostomy forever?

Yes, APR involves permanent removal of the anus, making a colostomy necessary.

Q3. Can the surgery be done laparoscopically or robotically?

Yes, minimally invasive approaches are available and can reduce hospital stay and wound complications.

Q4. What are the signs of complications after APR?

Fever, pain, foul discharge from the wound, bleeding, or swelling should be promptly reported.

Q5. Can I lead a normal life after APR?

Yes, most patients adapt well with proper support and training. You can travel, work, and exercise with a colostomy.

Abdominoperineal resection (APR) is still a mainstay operation for the management of cancers of the lower rectum and anal canal. While the prospect of a permanent colostomy may be intimidating, refinement of surgical methods, preoperative treatment, and postoperative management have ensured that the operation is safer and more reliable than ever before.

With education, rehabilitation, and support in place, the majority of patients have full active lives following surgery. Knowledge about the procedure, preparation, and collaboration with an interdisciplinary team are important to gain optimal results.