Abdominoperineal resection (APR) is not just a mutilating operation. It also profoundly alters the lifestyle of a patient. It is therefore the most dreaded of all colorectal operations, and as such it is not uncommon for a surgeon to be told, “I would rather die than to have a stoma.” Fortunately, in current practice, APR is fast disappearing to become an “endangered” operation.

Diminishing requirement for APR is brought about by a combination of advances in anastomotic techniques, advent of transanal local excision, advances in chemoradiotherapy, and a better appreciation of the natural history of anorectal cancer (Table 33.1).

For over 50 years, following the description by Miles in 1908 (1), APR was the only treatment for anorectal cancer until the introduction, followed by the slow acceptance, of anterior resection by Dixon in 1948 (2). This was a high-risk operation with significant anastomotic leak rates and mortality. Circular surgical staples popularized in the 1980s, and now accepted worldwide, allow for a safer and lower anastomosis.

A seminal advance in surgical technique is total mesorectal excision (TME) as championed by Heald (3). It dramatically improves local control of rectal cancer and allows ultra-low anterior resection to be performed. APR can be further avoided by using intersphincteric dissection with coloanal anastomosis (4,5). Functional results are not necessarily compromised by such low anastomoses because of colonic pouches, end-to-side anastomosis, or coloplasty, as well as adopting very precise rectal dissection that preserves pelvic sympathetic and parasympathetic nerves (6,7,8,9). Although transanal local excision and transanal endoscopic microscopic (TEM) excision have significant recurrence rates of 20–25%, it is an important option for the very elderly and infirmed patients who are not suitable for major surgery (10).

In 1974, Norman Nigro pioneered the use of chemoradiotherapy in place of APR for anal cancers (11). The results were just as good, with the bonus of avoiding a permanent stoma. It quickly became the treatment of choice for nonadenocarcinoma anal cancers. APR is therefore reserved for salvaging failed chemoradiotherapy.

At present, neoadjuvant chemoradiotherapy can achieve a response rate of up to 60% for rectal adenocarcinomas, and a complete response rate of 20% in some cases (12,13). These response rates will continue to improve with ever-improving chemotherapeutic agents. With significant shrinkage and downstaging of tumors, more sphincter-saving procedures can be performed, which otherwise would require APR. The most exciting information would be the long-term outcomes of those cancers with clinical complete response. If survival and recurrence rates are similar to those of surgical excision, the need for APR will be further reduced. With metastatic rectal cancer, the standard approach has been rectal surgery first, including an APR, before chemotherapy, followed by liver or lung resections when possible (14). The rationale is to have surgical reduction of tumor bulk as well as to prevent future complications from the primary tumor such as intestinal obstruction or bleeding. The removal of the primary tumor may also prolong survival by about 5 months (15,16). This paradigm may need to be changed.

The age-standardized relative survival ratio for metastatic colorectal cancer in the United States is 5.4% for males and 7.5% for females. In Singapore, which has similar cancer survival data as Europe, it is 3.5% and 2.8%, respectively (17). With such poor survival, surgeons must take a step back to reflect on the wisdom of rushing into a mutilating operation. There are reports suggesting that, with improved chemotherapy, the incidence of future primary tumor complications is 10% or less, much lower than what is generally assumed (18). The response rate, including complete response, to neoadjuvant chemoradiotherapy is gradually increasing. It is therefore increasingly difficult to justify APR for metastatic rectal cancer especially if there is complete response to chemoradiotherapy.

APR should be an operation of last resort when surgery is needed and sphincter salvage is not possible, such as when an adenocarcinoma has invaded the sphincter muscles or when chemoradiotherapy has failed (Fig. 33.1). Palliative APR is sometimes indicated for symptom control, but accurate preoperative assessment is critical because cutting through tumor tissues would invariably lead to local recurrence. Tumor fungating through a perineal wound is one of the most distressing problems to manage. To the purist laparoscopic colorectal surgeons, hand-assisted laparoscopic abdominoperineal resection (HAL-APR) is an oxymoron. The ultimate goal of laparoscopic surgery is to avoid having a tumor extraction abdominal scar; therefore, APR is an ideal full laparoscopic operation as the tumor is removed from the perineum. Nevertheless, the advantages of hand-assisted laparoscopic colorectal surgery over conventional open
surgery have been shown to be similar to full laparoscopic surgery (19). The remaining problem is the incisional scar from placement of the handport. Although it can be partially hidden in the skin crease of a Pfannenstiel incision, it is best to position the scar on the planned end-colostomy site to hide the scar completely.