Abdominoperineal resection (APR), or abdominoperineal excision of the rectum (APER), is a type of surgery for the treatment of predominantly low rectal carcinoma in which the sigmoid colon, rectum, and anal canal are removed leaving behind a permanent colostomy.
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Indications
Most commonly in patients with low rectal cancers that are either within 5cm of the anal verge or otherwise not possible to get a negative distal margin, or that show invasion of local structures such as the external sphincter. Less common indications include inflammatory bowel disease or fecal incontinence not amenable to sphincter-sparing surgery.
Procedure
Informed written consent is obtained. As the name suggests, there are two components to the operation: the abdominal stage and the perineal stage. The abdominal stage involves mobilization of distal sigmoid colon, dissection of superior rectal artery, mobilization of the rectum, total mesorectal excision 2. The perineal stage involves suturing of the anus and ligation of the inferior hemorrhoidal and pudendal vessels 2. Although historically performed as an open procedure, the abdominal stage can be performed laparoscopically 5.
Complications
General complications associated with major abdominal surgery include intraabdominal abscess, ileus, small bowel obstruction, iatrogenic injury to adjacent structures or stoma complications e.g. ischemia, prolapse, parastomal hernia.
Perineal complications such as delayed wound healing or dehiscence are specific to this procedure as it involves a perineal step that other colorectal procedures do not.
Radiographic appearances
These imaging appearances are described here for the normal postoperative status without complication or recurrent disease process.
Plain radiograph
Absence of gas pattern of the sigmoid, rectum and anal canal with visualization of surgical metallic clips, though an anastomotic staple line will not be visible as might be expected after an anterior resection.
CT
Sigmoid colon, rectum and anal canal will be absent along with presence of permanent colostomy in left iliac region. The rest of the pelvic organs may have displaced for occupying the resultant post-surgical space. A degree of presacral soft tissue thickening is a common postoperative finding after abdominoperineal resection as a result of the body filling the cavity left by the rectal excision 5. This can be difficult to tell apart from local recurrent disease and may persist for a long time 5. PET-CT can be used to differentiate this normal finding from recurrent disease 6.
History
First described in 1908 by William Ernest Miles (1869–1947), an English surgeon 4. As a result, it is also rarely known as the Miles procedure 5.
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