Evaluation of the impact of implementing the prone jackknife position for the perineal phase of abdominoperineal excision of the rectum.

BACKGROUND

Abdominoperineal excision of rectum has been associated with poor oncological specimens and high local recurrence rates in comparison with restorative surgery. The role of recent changes in operative position has yet to be evaluated.

OBJECTIVES

This study aimed to determine whether a change in the perineal phase from the Lloyd-Davies position to the prone jackknife position might improve excision margins and oncological outcomes.

METHODS

A single-institution review of a prospectively maintained database comparing the quality of excision and oncological outcomes after abdominoperineal excision in conventional and prone position was performed. Consecutive abdominoperineal excisions performed for adenocarcinoma of the rectum between January 1999 and April 2008 were included.

RESULTS

Abdominoperineal excision cases were assessed including 63 in the Lloyd-Davies position and 58 in the prone jackknife position. The 5-year local recurrence rate was 5% in the prone jackknife group in comparison with 23% in the Lloyd-Davies group (p = 0.03) by life table analysis. For local recurrence, the most significant and independent risk factors were a favorable effect of having the patient in the prone jackknife position for the perineal phase of abdominoperineal excision (HR 0.2; 95% CI 0.04-0.81) and, unfavorably, a positive circumferential resection margin (HR 7.1; 95% CI 2.4-20). Lymph node involvement (N2) was an independent risk factor for overall survival (HR 4.6; 95% CI 2.1-9.5) and relapse of disease (HR 4.0; 95% CI 0.7-9.4).

LIMITATIONS

This study has some limitations because it is a retrospective review of a prospective database.

CONCLUSION

These data suggest that the rate of local recurrence after abdominoperineal excision may be lowered by adaptation of the prone jackknife position.