Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1375_Библиотеки_им_академика_М_И_Перельмана.pdf
254
B.M.E. Hansson
:
d
b
Follow-
up
a
Recurrence
(%)
Mortality
Infection Other
No. complications (%)
5 2 0 29 (80.6) 31
>85%
nonabsorbable
b
Nonabsorbable 2 0 0 20 (74.1) 23
NS 4 3 1 7 (53.8) 7
Median
27
,
c
(59.7–78.3)
69.4%
3.8%
(1.0–9.4)
10.8%
(5.3–18.9)
NS NS 0 7 (53.8) 14
91%
(6.1–20.2)
nonabsorbable
Type of
stoma Type of sutures
EI
No.
repairs
Mod.
MINORS
index
10 36 EC, LC,
Time
period
1991
Reference
Table 23.2 Study characteristics and outcomes of suture repair of parastomal hernia
Rubin etal. [10] 1983–
11 16 EC, LC Nonabsorbable 0 5 3 6 (46.2) 38
1999
Cheung etal. [11] 1990–
10 14 EC, El,
Rieger etal. [12] 1990–
LI, LC
11 27 10 C,
1999–
2002
Riansuwan etal.
17 IC
2005
[13]
11 13 9 C, 4
– 106 – – 11.8%
2006
Weighted pooled
Pastor etal. [14] 1999–
% (95% CI)
Values are mean months follow-up unless otherwise stated
Excluding in-hospital deaths
C indicates colostomy, EC end colostomy, EI end ileostomy, IC ileal conduit, LC loop colostomy, LI loop ileostomy, NS not specied
a
Median of reported follow-up of studies with >12months follow-up
Weighted pooled proportion (xed effects model) using only studies with >12months mean follow-up
b
c
d
IC
23 Parastomal Hernia: Optimal Strategies forRepair
255
Fig. 23.2 Local repair with mesh
explained by the intra-abdominal pressure and the tangential forces working on the
abdominal wall leading to ongoing widening of the keyhole according to Laplace’s
law (T=P×R/2) [17]. Therefore, the Keyhole technique is no longer advised.
With the Sugarbaker technique, a mesh without a hole is used after lateralization
of the bowel.
The technique was rst described by Sugarbaker in 1985 [16]. At that time, the
mesh was only sutured to the fascial edges. As we have learned from incisional
hernia repair, an overlap of 3–5cm between the mesh and the adjacent fascia is
mandatory to prevent recurrent hernias [18]. Therefore, the Sugarbaker technique
was modied according to Fig.23.4.
256
B.M.E. Hansson
:
c
a
Follow-
up
Median
36
b
Recurrence
(%)
Mortality
Mesh
infection Other
No. complications (%)
Wound
infection
Type of
stoma Material; technique
2 0 9 0 15 (25.9) 51
PPM; ‘Stove pipe
hat’
24 EI,
3 LI
0 1 1 NS 3 (18.8) 33
PPM (7), PE (6),
PPM; KH 0 0 0 0 0 (0) 7
Vicryl (1); KH (14),
CRE-PPM (2)
IC
EI
PPM; KH 0 0 0 0 1 (20.0) 12
EI
17.2%
(11.9–23.4)
0%
(0.0–
2.3)
8.3%
(4.5–
13.7)
2.6%
(0.7–
6.4)
(0.4–5.5)
No.
repairs
Amin etal. [20] 1999 9 9 1 C, 8
10 5 4 C, 1
2000
Kald etal. [21] 1999–
– 157 – – 1.9%
Weighted
pooled% (95-CI)
C indicates colostomy, CRE-PPM central ring enforced polypropylene mesh, EC end colostomy, El end ileostomy, IC ileal conduit, LC loop colostomy, LI loop
11 16 12 C, 3
2002
9 8 EC PPM; KH 1 0 0 0 0 (0) 38
1997–
1993–
Venditti etal.
2006
1996
Lüning and
Spillenaar-
[18]
Bilgen [19]
Mod.
Table 23.3 Study characteristics and outcomes of onlay mesh repair of parastomal hernia
11 15 IC PPM; KH 0 0 2 0 1 (6.7) 15
MINORS
index
1982–
Time
period
Ho and Fawcett
Reference
1988–
2002
2001
De Ruiter and
Bijnen [16]
[15]
Steele etal. [17] 1988–
11 58 31 EC,
11 46 C CRE-PPM 0 3 1 0 7 (15.2) 51
Weighted pooled proportion (xed effects model) using only studies with >12months mean follow-up
Values are mean months follow-up unless otherwise stated
ileostomy, NS not specied
Median of reported follow-up of studies with >12months follow-up
a
b
c
23 Parastomal Hernia: Optimal Strategies forRepair
Fig. 23.3 Keyhole technique
257
Fig. 23.4 Sugarbaker
technique
258
B.M.E. Hansson
The Sugarbaker technique has a recurrence rate of 10.2% when repaired with a
ePTFE mesh [11, 13, 19]. No publications on long-term outcome of other meshes
are available so far.
Berger and coworkers reported on the use of a Sandwich technique, which combines both Keyhole and Sugarbaker techniques using PVDF-PP mesh (Dynamesh
®
[17]. After a follow-up of 20months, one out of 47 (2.1%) had a recurrence. While
outcome is positive, more studies are needed to validate these results [19].
Meta-analysis of all studies on laparoscopic repair shows that the Sugarbaker
technique has the best results and is recommended when patient and surgeon are t
for laparoscopy [11, 13, 20–22].
Open Repair
The open modied Sugarbaker technique is an excellent alternative when a laparoscopic
approach is not suitable. Reviewing the literature showed only one study reporting on 20
repairs. No mesh infections occurred and 3 out of 20 hernias recurred (15%) [22].
Conclusion
Parastomal hernia continues to be a common complication of stoma surgery that can
have a signicant impact on quality of life and may even carry life-threatening risk.
An organized approach to these patients with multidisciplinary management is
essential. Choice of surgical repair depends on patient factors; however, a minimally invasive approach is feasible in many circumstances (Fig.23.5).
)
Fig. 23.5 Flowsheet
23 Parastomal Hernia: Optimal Strategies forRepair
259
References
1. Pearl RK.Parastomal hernias. World J Surg. 1989;13:569–72.
2. Cingi A, Carik T, Sever A, Aktan AO.Enterostomy site hernias: a clinical and computerized
tomographic evaluation. Dis Colon Rectum. 2006;49:1559–63.
3. Moreno-Matias J, Serra-Aracil X, Darnell-Martin A, Bonbardo- Junca J, Mora-Lopez L,
Alcantara-Moral M, Ayguavives-Garnica I, Navarro-Soto S.The prevalence of parastomal
hernia after formation of an end colostomy. Color Dis. 2009;11:173–7.
4. Pilgrim CHC, McIntyre R, Bailey M.Prospective audit of parastomal hernia: prevalence and
associates comorbidities. Dis Colon Rectum. 2010;53:71–6.
5. Nastro P, Knowles CH, McGrath A, Porrett TRC, Lunniss PJ.Complications of intestinal sto-
mas. Br JSurg. 2010;97:1885–9.
6. Janes A, Weisby L, Israelsson LA. Parastomal hernia: clinical and radiological denitions.
Hernia. 2011;15:189–92.
7. Nasvall P, Wikner F, Gunnarsson U, Rutegard J, Stringard K. A comparision between 3D
ultrasonography, CT scanning and ndings at surgery in patients with stomal complaints. Int
JColor Dis. 2014;29:1263–6.
8. Smietanski M, Szczepkowski M, Alexandre JA, Berger D, Bury K, Conze J, Hansson B, Janes
A, Miserez M, Mandala V, Montgamery A, Morales-Conde S, Muysoms F.European Hernia
Society classication of parastomal hernias. Hernia. 2014;18:1–6.
9. Stravos AA, Muysoms F etal. EHS parastomal hernia guidelines. Submitted in Hernia.
10. Krogsgaard M, Pilsgaard B, Borglit TB, Bentzen J, Balleby L, Krarup PM.Symptom load and
individual symptoms before and after repair of parastomal hernia: a prospective single centre
study. Color Dis. 2017;19:200.
11. Hansson BME, Slater NJ, Schouten van der Velden AP, Groenewoud HMM, Buyne OR, de
Hingh IJT, Bleichrodt RP. Surgical techniques for parastomal hernia repair: a systematic
review of the literature. Ann Surg. 2012;255:685–95.
12. Rosin JD, Bonardi RA.Paracolostomy hernia repair with Marlex mesh: a new technique. Dis
Colon Rectum. 1977;20:299–302.
13. Hansson BME, Morales-Conde S, Mussack T, Valdes J, Muysoms FE, Bleichrodt
RP.Laparoscopic modied Sugarbaker technique is safe and has a low recurrence rate: a multicenter cohort study. Surg Endosc. 2013;27:494–500.
14. Hansson BME, de Hingh IHJT, Bleichrodt RP.Laparoscopic parastomal hernia repair is fea-
sible and safe: early results of a prospective clinical study including 55 consecutive patients.
Surg Endosc. 2007;21:989–93.
15. Hansson BME, van Nieuwenhoven EJ, Bleichrodt RP.Promising new technique in the repair
of parastomal hernia. Surg Endosc. 2003;17:1789–91.
16. Sugarbaker PH.Peritoneal approach to prosthetic mesh repair of paraostomy hernias. Ann
Surg. 1985;201:344–6.
17. Berger D, Bientzle M. Polyvinylidene uoride: a suitable mesh material for laparoscopic
incisional and parastomal hernia repair! A prospective, observational study with 344 patients.
Hernia. 2009;13:167–72.
18. de Vries Reilingh TS, van Geldere D, Langenhorst B, de Jong D, van der Wilt GJ, van Goor H,
Bleichrodt RP.Repair of large midline incisional hernias with polypropylene mesh: comparison of three operative techniques. Hernia. 2004;8:56–9.
19. Stelzner S, Hellmich G, Ludwig K.Repair of paracolostomy hernias with a prosthetic mesh in the
intraperitoneal onlay position: modied Sugarbaker technique. Dis Colon Rectum. 2004;47:185–91.
20. Levy S, Plymale MA, Miller MT, Davenport DL, Roth JS.Laparoscopic parastomal hernia
repair: no different than a laparoscopic ventral hernia repair? Surg Endosc. 2016;30:1542–6.
21. DeAsis F, Lapin B, Gitelis M, Ujiki M.Current state of laparoscopic parastomal hernia repair:
a meta-analysis. World JGastroenterol. 2015;21:8670–7.
22. DeAsis FJ, Linn JG, Lapin B, Denham W, Carbray JM. Modied laparoscopic Sugarbaker
repair decreases recurrence rates of parastomal hernia. Surgery. 2015;158:954–9.
23. Hansson BME, Bleichrodt RP, De Hingh IH. Laparoscopic parastomal hernia repair using a
keyhole technique results in a high recurrence rate. Surg Endosc. 2009;23:1456–9.
Part VII
Optimizing Pelvic Dissection for Rectal Cancer
Proctectomy forAdvanced Rectal
Cancer: APE or ELAPE?
TorbjörnHolm
Introduction
Ernest Miles’ paper “A method of performing abdomino-perineal excision for carcinoma of the rectum and of the terminal portion of the pelvic colon” was published
in The Lancet in 1908 [1]. This description of an abdominoperineal excision of the
rectum has since been called “the Miles’ operation” and had a strong impact on
rectal cancer surgery. In the original description of the procedure, the rectum was
bluntly mobilized down to the sacrococcygeal articulation, to the prostate, and to
“the upper surface of the levatores ani” laterally, thus leaving the mesorectum
attached to the pelvic oor. After mobilization of the rectum, a colostomy was created, and the abdominal wall was closed. The patient was turned over and placed in
the right lateral and semi-prone position. Miles emphasized that the levator muscles
should be divided “as far outwards as their origin from the white line so as to include
the lateral zone of spread,” and as a result the perineal part of the operation included
a wide excision of skin, fat, and pelvic oor (levator muscles).
The Lancet paper had an enormous impact on the surgical community, and for many
decades, the “Miles operation” was the gold standard procedure for all rectal carcinomas. However, the concept of removing the entire rectum, the anus, and the perineum
in all patients with rectal cancer was gradually abandoned. An increasing experience
with bowel reconstruction, including developments of stapling instruments, led to a
new concept of anterior resection (AR) and low anterior resection (LAR), which
became the standard procedures for tumors of the upper and mid- rectum [2–6].
For tumors of the lower rectum, most surgeons continued to perform abdominoperineal excision (APE), although the extensive perineal approach described by
Miles was more or less neglected and the synchronous combined APE was
24
T. Holm (*)
Section of Coloproctology, Department of Surgical Gastroenterology,
Karolinska University Hospital, Stockholm, Sweden
e-mail: torbjorn.holm@ki.se
© Springer International Publishing AG 2018
C.M. Schlachta, P. Sylla (eds.), Current Common Dilemmas in Colorectal Surgery,
https://doi.org/10.1007/978-3-319-70117-2_24
263
264
T. Holm
introduced as a feasible procedure which became popular and gained widespread
use in the treatment of low rectal cancer [7]. During the synchronous combined
operation, the perineal part is carried out simultaneously with the pelvic part of the
abdominal procedure, with the patient in the supine lithotomy or Lloyd-Davies
position; the rectum with its mesorectum is rst mobilized down to the pelvic oor,
and the perineal surgeon then enters the pelvic cavity just in front of the coccyx, the
levator muscles are divided on both sides, and nally the rectum is dissected off the
prostate or the vagina, and the specimen is delivered through the perineum.
Although there were gradual improvements in the treatment of rectal cancer during the twentieth century, local control remained a major problem after surgery,
with local recurrence rates of up to 40% after potentially curative resections [8]
(Fig.24.1).
With the development of total mesorectal excision (TME), as described by Bill
Heald, treatment results improved dramatically, both concerning local control and
survival. Heald reported a local recurrence rate around 5% and a cancer-specic
survival around 70% at 5years, without radiotherapy [9, 10]. During the recent two
decades, the TME technique has been introduced in many countries, and subsequently the results with regard to local control and cancer survival have improved
signicantly. Local recurrence rates are now reported to be less than 10% in
population- based studies [11, 12].
Consequently, teaching rectal cancer surgery has mainly focused on the operative technique of TME and AR. Although the technique used for the abdominal part
of an APE was modied along the lines of TME, little attention was given to the
perineal part of the procedure. Thus, most surgeons adopted the technique of sharp
dissection under direct vision outside the mesorectal fascia down to the pelvic oor,
with the aim to save autonomic nerves and to create a perfect specimen with an
Fig. 24.1 Patient with a
large local recurrence
growing in the perineum
after a standard APR
24 Proctectomy forAdvanced Rectal Cancer: APE or ELAPE?
265
intact mesorectal fascia. The perineal part, however, was often completed in the
conventional way, with dissection close to the external sphincter and with the division of the levator muscles close to the rectal wall. With the patient in the supine
lithotomy position, it is difcult to achieve an optimal view, especially anteriorly,
and therefore parts of the perineal dissection are often done with blunt dissection
when this approach is used.
Problems Related totheConventional APE
With an increasing focus on oncological outcomes and improved audit, several
authors have acknowledged the fact that local control and survival after APE have
not improved to the same degree as that seen after AR.In one study based on 561
patients from Leeds, UK, it was reported that patients undergoing APE had a higher
local failure rate (22.3 vs. 13.5%) and a poorer survival (52.3 vs. 65.8%) compared
with patients who had an AR during the same time period [13].
In another paper based on data from ve different European trials, it was reported
that the APE procedure was associated with an increased risk of circumferential
resection margin (CRM) involvement, an increased local recurrence rate, and a
decreased cancer-specic survival [14]. A large cohort study from Norway also
reported a higher local recurrence rate (15 vs. 10%) and a poorer 5-year survival (55
vs. 68%) after APE than after AR [12].
These differences in oncological outcomes between the two procedures may be
explained by several factors, including anatomical difculties and the surgical technique associated with standard APE surgery. In the lower rectum, the surrounding
mesorectum is reduced in size and disappears at the top of the sphincters. Below this
level, the sphincter muscle forms the circumferential resection margin (CRM). As
mentioned above, the abdominal dissection during a conventional APE is often carried out along the mesorectum, all the way down to the pelvic oor and the top of
the puborectalis muscle, with the mesorectum being mobilized off the levator muscles. The perineal dissection then follows the external sphincter to meet the pelvic
dissection at the top of the anal canal (Fig.24.2). With this technique the retrieved
specimen often has a typical “waist” at 3–5cm from the distal end, corresponding
to the top of the external sphincter at the level of the puborectalis muscle and the
lowest part of the mesorectum (Fig.24.3).
The inward coning at the pelvic oor carries the dissection close to the rectal
wall, and several studies have reported higher rates of bowel perforation and tumor
involvement of the CRM after APE as compared with AR.Nagtegaal etal. assessed
846 AR specimens and 373 APE specimens from the Dutch TME trial and found
that the plane of resection was within the sphincter muscle, the submucosa or lumen
in more than 1/3 of the APE cases, and in the remainder was on the sphincter muscles. This resulted in a positive CRM rate of 30.4% after APE versus 10.7% after
AR and a perforation rate of 13.7% after APE versus 2.5% after AR [15]. Similarly,
population-based reports from Sweden, Norway, and Holland have shown a threefold increase in perforation rates after APE compared to AR (14–15% vs. 3–4%)