Extended APER- An Update

APR – Old or New Helen Chave Consultant Colorectal Sugeon Salisbury NHS Foundation Trust

APER - the challenges ,[object Object],[object Object],[object Object],[object Object],Dukes' club, April 2011

Quality of care - optimal surgery ,[object Object]

Oncological outcomes ,[object Object],[object Object],[object Object],[object Object],Dukes' club, April 2011 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

CRM involvement Dukes' club, April 2011 Anterior resection APE Nagtegaal 2002 10.7% 30.4% Wibe 2004 5% 12% ACPGBI 2004 5.7% 16.7% MERCURY 2004 7.6% 29% Den Bulk 2009 5% 10.6%

Extralevator APR Dukes' club, April 2011 n= CRM (%) IOP (%) Holm, 2007 28 7 3.5 LR 7% median f/u 16 mths West, 2008 27 14.8 3.7 Bebenek, 2009 210 7.6 4.3 2 yr LR 4.4% Davies, 2009 40 0 Not reported 5% median f/u 88 mths (4-125)

The Concept Dukes' club, April 2011

Prone or lithotomy? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Dukes' club, April 2011

Why did we start? ,[object Object],[object Object],[object Object],[object Object],[object Object],Dukes' club, April 2011

Jan 07-March 11 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Dukes' club, April 2011

Mortality and morbidity ,[object Object],[object Object],[object Object],[object Object],Dukes' club, April 2011

Before and after ELAPE Dukes' club, April 2011 Standard APR ELAPE P value +ve CRM 16.7 10 Perforation 6.7 0 Local recurrence 20 3.3 Distance from dentate line 17.8 mm 5.7 mm 0.003 LN harvest 12.2 15.2 LOS 23.6 16.3 0.03

Perineal wound failure ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Dukes' club, April 2011

Current trends ,[object Object],[object Object],[object Object],[object Object],3. Chadwick et al. Colorectal Dis. 2006. 5. West et al. J Clin Oncol 2008 . Dukes' club, April 2011

Options ,[object Object],[object Object],[object Object],Dukes' club, April 2011

Omentoplasty ,[object Object],[object Object],[object Object],[object Object],6 . Hay et al. Eur J Surg 1997. 7. Poston et al. Ann R Coll Surg Engl 1991. 8 . John et al. Int J Colorectal Dis 1991. 9 . Hultman et al. Ann Plast Surg 2010. 10. Klaver et al. Int J Colorectal Dis. 2008. Dukes' club, April 2011

Biological mesh ,[object Object],[object Object],[object Object],11. Han JG, DCR, 2010 12. Wille-Jorgensen, Int J Colorectal Dis, 2009 13. Abhinav K, Eur j Surg Oncol, 2009 14. Jess P, Colorectal Dis, 2010 Dukes' club, April 2011

Myocutaneous Flaps ,[object Object],[object Object],[object Object],15. Radice et al. Br J Surg 1999. 16. Shibata et al.Ann Surg Oncol 1999. 17. Persichetti et al. Ann Plast Surg 2007 18. Chan et al. Colorectal Dis 2010. 19. Petrie et al. Int J Colorectal Dis 2009. Dukes' club, April 2011

VRAM Flap ,[object Object],[object Object],[object Object],[object Object],20. Chessin et al. Ann Surg Oncol 2005. 21. Ferenschild et al. World J Surg 2005. 22. Tei et al. Br J Surg 2003. 23. Butler et al. J Am Coll Surg 2008. 24. Nelson et al. Plast Reconstr Surg 2009. 25. Tobin et al. Plast Reconstr Surg. 1988. 26. Skene et al. Br J Surg 1990. 27. Lefevre et al. Ann Surg 2009. Dukes' club, April 2011

Recommendations ,[object Object],[object Object],[object Object],Dukes' club, April 2011

Salisbury experience ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Dukes' club, April 2011

Morbidity ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Dukes' club, April 2011

Where did LOREC come from? ,[object Object],[object Object],[object Object]

Proportion APE -28 LOREC MDTs Mean 24% (14 -44%) National Cancer Intelligence Network (Andy McMeeking)

Summary ,[object Object],[object Object],[object Object],Dukes' club, April 2011

Extended APER- An Update

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Extended APER- An Update

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