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1、HS,61 yr old maleNo significant medical history18 month hx of perianal pain,pruritus ani and occasional PR bleedingEUA Deep posterior anal fissure surrounded by area of induration and thickeningBiopsies-chronically inflamed and fibrotic squamocolumnar anal mucosaConsistent with fissure in ano,Backgr
2、ound,Symptoms unresponsive to topical Rxo/e Large posterior fissure and associated skin tag,BRBPRCrohns Disease suspectedScheduled for EUA Rectum in urgently and SBFT,Background,Biopsies at colonoscopy in EUA-Low Rectal Tumour extending into anusHistology-Anal gland vs Rectal cancerModerately differ
3、entiated AdenocarcinomaMRI pelvisIncreased soft tissue thickening posterior to superficial perianal areaNumber of mesorectal lymph nodes seenDoes not extend above internal sphincterT4N1M0 Rectal Adenocarcinoma,Work Up,MRI image,Number of palpable hard satellite lesions up to 3cm from anal verge alon
4、g perianal skin Neoadjuvant treatmentChemotherapy-5FURadiotherapy encompassing perianal skin,inguinal nodes and external iliac nodesEUA Tumour at 3cm,bulky,friable perianal skinScheduled for APR and VRAM flap reconstruction,Oncology,APRLower midline laparotomyLeft colon and rectum mobilisedTotal mes
5、orectum excisionSigmoid colon dived and proximal end brought out as colostomy Wide perineal resection performedRectum delived through anus and resected in fullHaemostasis achieved,Surgery,photo,Perineal defect,Reconstruction perineal defect with right VRAM FlapVRAM raised through lateral incisionAnt
6、 rectus sheath opened and muscle dissected from post rectus sheathInferior deep epigastric artery pedicle preservedDeepithelialisation of skin over muscleMuscle mobilised to cover defectAbdominal closure with prolene mesh,suturesPerineum closure with sutures,Surgery,UnremarkableWounds clean and heal
7、thySatisfactory stoma careDischarged day 16 post opHistologyFor discussionOncologyFor adjuvant chemotherapy in Letterkenny,Post op,Pre neoadjuvant biopsy,Resected specimen,Immunohistochemistry,Colorectal cancer surgery,Right Hemicolectomy,Left Hemicolectomy,Anterior Resection,Indicated for rectal ca
8、ncer in the lower third of rectumAPRs involves removal of the anus,the rectum,part of the sigmoid colon and ther associated lymph nodesIncisions are made in the abdomen and perineum Remaining sigmoid colon brought out as a colostomy,Abdominoperineal Resection,Abdominoperineal Resection(APR),Abdomino
9、perineal Resection(APR),First described by Ernest Miles in 1908By the 1920s,recurrence rates were down to 30%-gold standard at that timeSeveral modifications were proposed to promote locoregional control and survival,with little successBetter suture material and devices enabling low anastomoses hera
10、lded a shift toward sphincter-saving approaches with respect to cancer of the rectumAnterior resection replaced APR as the mainstay of therapy in the 1950sThere was concern that sphincter-saving surgery might increase local recurrenceIt was in this setting that total mesorectal excision(TME)was firs
11、t described in 1982 by Heald and colleagues,Abdominoperineal Resection,The TME concept is based on the locoregional recurrence preference of rectal carcinomaTherefore adequate en bloc clearance of the rectal mesentry,including its blood supply and lymphatic drainage,would minimize possible disease r
12、elapseTME is now considered the Gold Standard adjunctive therapy for colorectal cancer,Total Mesorectal Excision,Improved surgical techniques(eg total mesorectal excision and autonomic nerve preservation)have shown a corresponding decrease in local recurrence rates and increase in overall survival o
13、f patients with rectal cancerHowever local recurrence and survival after an APR have not improved to the same degree as that seen after an anterior resectionThis difference has been attributed to relative smaller tissue volumes around the tumour and higher rates of cancer at circumferential resectio
14、n margins(CRM)after an APR compared with an anterior resection,APR,As tumour-free lateral margins have been demonstrated to be an important prognostic factor for local recurrence and survival,an extensive resection is frequently requiredIn an attempt to improve healing,several techniques for perinea
15、l closure have been describedEpiploplastyGracilis FlapVertical Myocutaneus FlapGluteus Maximus Flap,Cylindrical APR,They facilitate closure of the perineal defect with healthy and well-vascularized tissue without placing the tissue under undue tensionThe vertical rectus abdominis myocutaneous(VRAM)f
16、lap is also useful in creating a neo-vagina after posterior colpectomyThere is a lack of information in the literature concerning the efficacy of VRAM flap reconstruction after APR,Cylindrical APR,Lefevre et at evaluated the results of a VRAM flap after APR for anal cancer95 patients underwent APR,i
17、ncluding 43 patients who subsequently received a VRAM flapSurvival in the 2 groups was equivalent despite the presence of more advanced cancers in the VRAM flap cohort They concluded VRAM is an effective technique for reducing both the perineal complication rate and wound-healing delay in patients u
18、ndergoing APR for AC that does not increase abdominal wall morbidity,Annals of Surgery,Oct 09,Long term treatment of fissures in ano-Could their be an underlying malignacy?Advancements in treating rectal cancersCylindrical APR and VRAM flapsSTUDENTSDifferent colorectal cancer operationsThank You,Discussion Points,
