Centre for Academic Surgery, Institute for Cell and Molecular Science, Barts and the London, Queen Mary's School of Medicine and Dentistry, University of London, London, England, UK.
Ann Surg Oncol. 2010 May;17(5):1357-8. doi: 10.1245/s10434-009-0877-7. Epub 2009 Dec 29.
Sphincter-saving rectal resections have become commonplace in the surgical treatment of malignant rectal pathology. However, restoration of gastrointestinal continuity by means of conventional techniques proves technically challenging in cases of very low rectal pathology, with resultant variable requirements for a permanent stoma. The APPEAR procedure (Anterior Perineal PlanE for Ultralow Anterior Resection of the rectum) is a novel sphincter-saving resection technique to restore gastrointestinal continuity in those who would otherwise require a permanent stoma with conventional abdominal resections. It ensures that the distal rectum is excised and the anastomosis is constructed under direct vision while simultaneously preserving the anal sphincter and its somatic nerve supply in their entirety.
This procedure is indicated in the following instances: proven lower-third rectal carcinomas where anatomical restrictions prevent satisfactory rectal dissection and/or transection with a potential inadequate distal clearance margin; ileoanal pouch formation for ulcerative colitis or familial adenomatous polyposis where retained rectal tissue is at risk of future malignancy; short or strictured rectal stumps where pelvic dissection is hazardous and thus prevents restoration of gastrointestinal continuity.
The APPEAR technique is a feasible alternative sphincter-saving procedure to further reduce the requirement of permanent stoma in the treatment for ultralow rectal pathology; however, it is appreciated that a larger study group with long-term follow-up is required. This technique should facilitate laparoscopic rectal resection because large and distal tumors can be dissected and excised through the perineal wound, ensuring adequate distal clearance and the anastomosis constructed under vision at an appropriate level. Furthermore, the requirement for an abdominal incision is avoided, improving cosmesis.
在直肠恶性病变的外科治疗中，保肛直肠切除术已成为常规。然而，对于低位直肠病变，通过常规技术恢复胃肠道连续性具有一定挑战性，导致永久性造口术的需求存在差异。APPEAR 手术（直肠超低位前切除术的会阴前平面）是一种新的保肛直肠切除技术，用于在常规腹部切除时需要永久性造口的患者中恢复胃肠道连续性。该手术确保在直视下切除远端直肠并构建吻合口，同时完整保留肛门括约肌及其体神经供应。
以下情况下适用该手术：经证实的下段直肠癌，解剖学限制妨碍了满意的直肠分离和/或横断，可能存在不足的远端切缘；溃疡性结肠炎或家族性腺瘤性息肉病患者需行回肠肛管吻合术，保留的直肠组织有未来恶变的风险；直肠残端短或狭窄，盆腔分离有危险，从而无法恢复胃肠道连续性。
APPEAR 技术是一种可行的保肛替代手术，可以进一步降低低位直肠病变治疗中永久性造口的需求；然而，需要更大的研究组和长期随访来证实。该技术有助于腹腔镜直肠切除术，因为可以通过会阴切口分离和切除较大和远端的肿瘤，确保足够的远端切缘，并在合适的水平下进行吻合口的直视构建。此外，避免了腹部切口，改善了美观。
