• Ernest Miles (1869–1947) devised the approach in the 1930s as a curative procedure for all rectal cancers. It involves resection of the anus, rectum, and a portion of the sigmoid colon, as well as a wide perineal and lymph node dissection.
• Abdominoperineal resection (APR) is now reserved for conditions where the rectum needs to be removed and there is involvement of the primary sphincter complex or tumors in the lower third of the rectum that do not have adequate clearance for sphincter preservation. It requires a permanent colostomy.
• Laparoscopy-assisted APR and low anterior resection (LAR) are more commonly performed today. LAR is a modified technique that allows for sphincter preservation.

• Modified lithotomy
• Trendelenburg, as needed

Midline abdominal and perineal

5–10 hours

500–1,500 mL

7–10 days

• 2 table set-up (abdominal and pelvic sets)
• Long pelvic instruments, stapling devices
• Cystoscopy set with ureteric stents

Incidence

• Colorectal cancer is the 4th most common cancer and the second leading cause (10%) of all cancer-related deaths.
• From 2003 to 2007, the median age at diagnosis for colorectal cancer was 70 years of age. At diagnosis, about 20% had distant metastasis.
• 5–10% of all colorectal cancers are associated with a familial colorectal cancer syndrome, and an additional 15–20% are associated with a familial disposition.
• Risk for colorectal cancer increases with age (90% of cases occur in patients >50 years), and with a diet rich in red meat and animal fat.
• Aspirin, NSAIDs, and COX-2 inhibitors have been reported to have protective effects against colorectal cancer.

Prevalence

• As of January 1, 2007, in the US there were approximately 1,112,493 men and women alive with a history of colon and/or rectal cancer.
• Based on rates from 2005 to 2007, 5.12% of men and women born today will be diagnosed with cancer of the colon and/or rectum during their lifetime.
• High incidence of local recurrence despite margin-free resection

• Anemia from bleeding or occult blood loss
• Pelvic metastasis: Bladder dysfunction, sacral or sciatic neuropathy, and vaginal discharge or bleeding
• Secondary to metastatic disease: Abdominal pain from hepatomegaly; skeletal pain from bone metastasis; ascites from peritoneal dissemination; and liver dysfunction.

• The overall 5-year relative survival in the US for 1999–2006 was 65.0%; for high-risk patients it is 20%.
• Hormone replacement therapy has been shown to significantly reduce mortality in women with colorectal cancer.

History

• Inflammatory bowel diseases (Crohns disease, ulcerative colitis), inherited colon cancers (familial adenomatous polyposis, Gardner syndrome, Peutz–Jeghers syndrome, juvenile polyposis, and hereditary non-polyposis colon cancer)
• Careful assessment of the sequelae and complications of the primary colonic/rectal pathology, medical comorbidities, nutritional and functional status

Signs/Physical Exam

• Systemic signs of inflammatory bowel disease (IBD)
• Anemia, weight loss, fever of unknown origin
• Abdominal wall and/or internal colonic fistulae
• Palpable mass in the recto-sigmoid on examination

Labs/Studies

• CBC, PT/PTT, creatinine, prealbumin, and LFTs
• Electrolytes if on diuretics, ACE I, renal insufficiency
• Colonoscopic evaluation (location, size, and number of masses)
• CT scan (tumor location, size, perirectal and vascular involvement, peritoneal and liver metastasis)
• Other tests (TEG, ECG, CXR, cardiac echocardiogram, exercise stress test, PFTs) as indicated

• Anxiolytic and analgesic medications, as needed
• Gastric volume reducing and acid-neutralizing medications, if indicated
• Continue appropriate medications (antibiotics, anti-inflammatory/immunomodulators, antihypertensives, antiarrhythmics, and others) as needed
• There is an increasing trend to use alvimopan to hasten recovery of bowel function.

• Blood consent for possible transfusion
• Consent for epidural catheter for postoperative analgesia
• Potential for postoperative intubation and intensive care

• Prophylactic cefotetan or cefoxitin; metronidazole plus an aminoglycoside may be used for cephalosporin allergy.
• Gram-negative aerobes and anaerobic bacteria
• Mechanical bowel preparation decreases fecal bulk, but does not decrease the concentration of bacteria in the stool.

• General anesthesia with ETT
• Epidural catheter for postoperative analgesia: Need to rule out contraindications, review medication list (herbals, clopidogrel, low-molecular-weight heparin, or other drugs that alter coagulation), consider preoperative PT/PTT/INR or other advanced coagulation tests as needed (TEG, PFA). Not contraindicated with usual thromboprophylaxis for postoperative DVT (heparin 5,000 U SQ BID).

• ASA standard monitors
• Arterial line (beat-to-beat blood pressure monitoring, systolic pressure variation [SPV] to evaluate intravascular volume status, blood draws for lab work); consider placing the arterial line pre-induction for high-risk patients.
• 2 large-bore IVs for volume resuscitation if needed. Central line access is not usually necessary unless there is poor IV access or a need for postoperative TPN.
• Foley catheter: Ureteric stents are placed preoperatively to identify ureters during the resection.

Standard induction technique and strategies to maintain hemodynamic stability and full stomach precautions if indicated

• Avoid nitrous oxide. Air–oxygen mixture with an FiO₂ of 0.5 will help identify oxygenation issues early.
• Continuous epidural infusion of local anesthetic/narcotic mixture may be used for analgesia throughout the procedure.
• Nasogastric tube placement may be requested.
• Volume: APR is a major procedure with complex bowel resection; bleeding may be encountered from the presacral venous plexus. Additionally, insensible fluid losses can result. Intravascular volume status and maintenance of organ perfusion should be closely monitored.
• Surgeon may request intraoperative indigo carmine to rule out injury to the ureters; it may temporarily result in a decrease in the pulse oximeter reading.
• Blood glucose, serum electrolytes, ABG, ACT and other coagulation parameters as may be checked needed.

• Standard extubation criteria
• Post-extubation sensory–motor exam and evaluation of epidural puncture site for effectiveness and complications