ABSTRACT
Introduction
Crohn's disease (CD) often leads to complex anorectal complications, posing significant challenges in surgical management. Transperineal abdominoperineal resection (TpAPR) has emerged as a minimally invasive alternative to APR. This study aims to evaluate the safety and efficacy of TpAPR compared to APR in patients with CD.
Methods
A retrospective analysis was conducted on 19 CD patients who underwent either minimally invasive TpAPR (n = 11) or APR (n = 8) between 2008 and 2023 from a single institution. The primary outcomes were assessed: intraoperative blood loss, operative time, and surgical site infection (SSI) rates.
Results
The minimally invasive TpAPR group exhibited significantly reduced intraoperative blood loss (223 mL vs. 533 mL, p = 0.04) and a lower incidence of SSI rates (36.4% vs. 75%, p = 0.07). Operative time and hospital stay were comparable between groups.
Conclusion
Minimally invasive TpAPR demonstrates potential benefits over APR in reducing blood loss and SSI rates in CD patients. Further large‐scale studies are warranted to confirm these findings.
Keywords: Crohn's disease, intraoperative blood loss, minimally invasive surgery, surgical site infection (SSI), transperineal abdominoperineal resection (TpAPR)
1. Introduction
Crohn's disease (CD) is a chronic inflammatory condition affecting the gastrointestinal tract, often resulting in severe anorectal complications such as fistulas, abscesses, and strictures [1]. These complications still represent clinical challenges in the surgical intervention due to obliterated dissection planes and distorted pelvic anatomy [2, 3].
Abdominoperineal resection (APR) has been selected as the standard surgical approach for severe anorectal complications; however, APR often results in higher surgical complications such as extensive blood loss and surgical site infection (SSI) rates [4, 5]. Recently, minimally invasive techniques, including laparoscopic and robotic surgeries, have transformed surgery for colorectal cancer by improving visualization and precision, reducing postoperative complications, and shortening recovery times [6, 7]. For patients with lower rectal cancer, transperineal abdominoperineal resection (TpAPR) also emerged as a viable option for managing complex anorectal conditions [5, 8]. This approach might offer advantages such as reduced intraoperative blood loss and improved access to the pelvic floor, which may enhance outcomes in patients with rectal cancer [9]. On the other hand, the clinical benefit of TpAPR in benign diseases such as CD still remains controversial due to the difficulty in recognizing atypical anorectal anatomy [10]. It is critical for patients with severe anorectal complications from CD to minimize nerve‐associated complications such as urinary and sexual dysfunction [11].
Then, we hypothesize that the appropriate technique of minimally invasive TpAPR can reduce severe complications for patients with CD who have already chosen the surgical option since 2008. This study evaluated the safety and efficacy of minimally invasive TpAPR for complex anorectal CD, focusing on short‐term outcomes such as blood loss, operative time, and SSI rates compared to APR.
2. Materials and Methods
2.1. Samples, and Data Collection
A retrospective analysis was conducted on 19 patients diagnosed with CD who underwent either minimally invasive TpAPR (n = 11) or APR (n = 8) at our institution between January 2008 and December 2023. Patients were divided into two groups based on the surgical approach: patients treated with conventional APR from January 2008 to December 2015, and those who underwent transperineal APR (TpAPR) from January 2016 to December 2023. Inclusion criteria encompassed patients with complex anorectal CD unresponsive to medical therapy. Exclusion criteria included patients with concurrent malignancies or those unfit for surgery. The short‐term surgical outcomes were evaluated with blood loss, operative time, SSI rates, the hospital stay, and postoperative complications classified by the Clavien‐Dindo classification. This study was conformed to the provisions of the Declaration of Helsinki and approved by the institutional review board of Okayama University (2004‐028). Before surgical treatment, patients with CD received informed consent from physicians and provided written informed consent.
2.2. Surgical Procedure of Minimally Invasive TpAPR
Patient was placed in the lithotomy position, enabling simultaneous access to the abdominal and perineal regions. To prevent bacterial contamination, the anus was securely closed using a double‐layer suture technique. A circumferential incision is made around the anus, and dissection proceeds through the subcutaneous tissue to expose the external sphincter muscles. In patients of CD with associated anal fistulas, complete excision of the perineal region, including fistula tracts, was performed to mitigate the risk of fistula‐associated carcinoma [12].
The TpAPR procedure employs a minimally invasive transperineal approach, leveraging advanced visualization tools for precise dissection. A single‐port laparoscopic device is inserted into the perineal wound, allowing for insufflation and the use of laparoscopic instruments. In cases where extensive tissue involvement results in a larger perineal defect, additional purse‐string sutures are used to secure the single‐port device. Under laparoscopic guidance, dissection progresses cephalad through the ischioanal fossa, carefully navigating the levator ani muscles to reach the pelvic cavity. When dissecting the connective tissue cephalad along the levator ani muscle, the superficial transverse perineal muscle serves as an anterior landmark. Entering anterior to this muscle carries a risk of urethral injury. The incision site on the levator ani varies depending on the location of the fistula. When the levator ani is incised dorsal to the superficial transverse perineal muscle, the dissection proceeds toward the lateral aspect of the prostate or vaginal wall. Because a dense venous plexus is present in this region, the critical step is to expose the lateral surface of the prostate or vagina without injuring the plexus, thereby minimizing bleeding. Once this surface is clearly identified, dissection can be continued along it to facilitate safe anterior mobilization.
Simultaneously, the abdominal team performs laparoscopic mobilization of the rectum and sigmoid colon, ensuring meticulous adherence to anatomical planes. Once the rectum is transected at a predetermined level under laparoscopic visualization, the rectum and associated structures are extracted through the perineal incision. This dual‐team approach minimizes pelvic floor manipulation and provides enhanced control during abdominal dissection. After specimen extraction, the perineal wound is inspected for residual tissue or bleeding. Primary closure of the perineal defect is performed following meticulous hemostasis. For larger defects, negative pressure wound therapy (NPWT) may be employed to promote healing and reduce the risk of infection. When surgeons are limited, the procedure is performed by a single team in a sequential manner, first performing the laparoscopic abdominal part, followed by the transperineal part.
3. Statistical Analysis
Data were analyzed using GraphPad Prism version 10. Continuous variables were compared using the Student's t‐test, while categorical variables were analyzed using the Chi‐Square test. A p‐value of < 0.05 was considered statistically significant.
4. Results
4.1. Patient Demographics
The baseline clinical characteristics, including age, gender distribution, disease duration, and nutritional index such as Glasgow Prognostic Score (GPS), inflammation index such as CRP and CD activity index (CDAI), were comparable between the TpAPR and APR groups (Table 1). None had emergency surgery in either group. Then, there were no patients with a cumulative steroid dose of ≥ 3 g prior to surgery in either group. Furthermore, the condition and severity of anorectal lesions, such as strictures, fistulas, and abscesses, did not differ significantly between the groups, reflecting a similar level of disease complexity (Table 2).
TABLE 1.
Clinical background of 19 patients with Crohn's disease who undertook abdominoperineal resection.
| APR | TpAPR | p | |
|---|---|---|---|
| Patients | 8 | 11 | n.s. |
| Gender (male/female) | 5/3 | 8/3 | n.s. |
| Site of CD (Ileocolitis/Colitis) | 4/4 | 3/8 | n.s. |
| Age at onset of CD (mean, range) | 23.7 (19–37) | 28.1 (11–59) | n.s. |
| Age at surgery of APR (mean, range) | 39.5 (32–45) | 45.5 (20–72) | n.s. |
| Duration from onset of CD to APR (mean, range) | 15.8 | 17.3 | n.s. |
| Average follow‐up period after APR (year) | 10.5 | 5.7 | 0.002 |
| Wound class | 2.75 | 3 | n.s. |
| ASA | 2 | 1.73 | n.s. |
| GPS | 0.88 ± 0.35 | 0.27 ± 0.20 | n.s |
| CRP (md/dL, mean ± S.D.) | 1.59 ± 0.86 | 0.52 ± 0.19 | n.s |
| Albumin (g/dL, mean ± S.D.) | 3.58 ± 0.25 | 3.51 ± 0.19 | n.s |
| CDAI (mean ± S.D.) | 94.1 ± 18.0 | 79.5 ± 12.4 | n.s |
Note: C‐reactive protein and albumin levels were obtained from preoperative blood tests.
Abbreviations: APR: abdominoperineal resection, ASA: American Society of Anesthesiologists, CD: Crohn's Disease, CDAI: CD activity index, CRP: C‐reactive protein, GPS: Glasgow prognostic score, S.D.: standard deviation, Tp: transperineal.
TABLE 2.
Assessment of clinical conditions before abdominoperineal resection in 19 patients with Crohn's disease.
| Case | APR | TpAPR | |||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | |
| Complex fistula | + | + | + | + | + | + | + | ||||||||||||
| Anorectal stenosis | + | + | + | + | + | + | + | + | + | + | + | + | + | + | |||||
| Rectal fistula | + | + | + | ||||||||||||||||
| Rectovaginal fistula | + | + | + | + | |||||||||||||||
| Perirectal abscess | + | + | |||||||||||||||||
| Fistula cancer | + | + | |||||||||||||||||
| Bleeding | + | ||||||||||||||||||
Abbreviations: APR: abdominoperineal resection, Tp: transperineal.
4.2. Operative Outcomes of Minimally Invasive TpAPR
The TpAPR group exhibited a significantly lower intraoperative blood loss compared to the APR group, with mean losses of 223.6 and 533.8 mL, respectively (p = 0.04), underscoring the potential of the minimally invasive approach to reduce surgical trauma (Table 3). The groups' mean operating times were comparable, with the traditional APR group taking 330 min and the minimally invasive TpAPR group taking 350 min (p = 0.33). Similarly, the length of hospital stay did not differ significantly, with mean durations of 28 days in the TpAPR group and 34.75 days in the APR group (p = 0.26).
TABLE 3.
Assessment of operative outcomes in abdominoperineal resection.
| APR (n = 8) | TpAPR (n = 11) | p | |
|---|---|---|---|
| Operation time (min) (mean ± S.D.) | 330.3 ± 30.7 | 350.9 ± 34.2 | 0.33 |
| Bleeding (g) | 533.8 ± 147.6 | 223.6 ± 63.0 | 0.04 |
| Hospital stay (day) | 34.75 ± 9.58 | 28.00 ± 3.90 | 0.26 |
| Complication (n: Clavien‐Dindo ≧ II) | 6 (75%) | 7 (63.6%) | n.s. |
Abbreviations: APR: abdominoperineal resection, S.D.: standard deviation Tp: transperineal.
4.3. Postoperative Complications of Minimally Invasive TpAPR
In both groups, the postoperative complications were relatively low (Table 4). Although this difference was not statistically significant (p = 0.07), the minimally invasive TpAPR group showed a tendency toward a reduced incidence of SSIs, occurring in 36.4% of patients as opposed to 75% in the APR group. Crucially, neither group experienced any significant issues categorized as Clavien‐Dindo grade III or above. The findings indicate that minimally invasive TpARP might be an acceptable and safe treatment option for patients with CD.
TABLE 4.
Postoperative outcome of surgical complication.
| APR (n = 8) | TpAPR (n = 11) | ||||
|---|---|---|---|---|---|
| n | % | n | % | p | |
| Stoma related complication | 3 | 37.5 | 2 | 18.2 | n.s. |
| Peristomal pyoderma gangreus | 2 | 0 | |||
| Peristomal fistula | 1 | 0 | |||
| Peristomal abscess | 0 | 1 | |||
| Peristomal hernia | 0 | 0 | |||
| Parastomal stricture | 0 | 1 | |||
| SSI | 6 | 75 | 4 | 36.4 | 0.07 |
| Incisional (surperficial + deep) | 4 | 50.0 | 3 | 27.2 | |
| Organ space | 3 | 37.5 | 2 | 18.2 | |
| Delayed perineal wound healing | 4 | 50.0 | 3 | 27.2 | n.s. |
| Sexual dysfunction | 0 | 0 | |||
| Adhesive intestinal obstruction | 1 | 12.5 | 2 | 18.8 | n.s. |
Note: The surgical complication indicates Clavien‐Dindo ≧ II.
Abbreviations: APR: abdominoperineal resection, Tp: transperineal.
5. Discussion
This study demonstrates that minimally invasive TpAPR might provide potential advantages over APR in the surgical management of complex anorectal CD, particularly in reducing intraoperative blood loss and showing a trend toward lower rates of SSIs. These findings align with previous reports highlighting the benefits of minimally invasive techniques in improving short‐term outcomes [13, 14].
Intraoperative blood loss is one of the points to investigate the clinical benefit of minimally invasive TpAPR. Smaller incisions and less invasive techniques inherently lead to decreased tissue trauma and, consequently, lower blood loss [15, 16]. Studies on other minimally invasive approaches, such as laparoscopic and robotic‐assisted surgeries, have similarly reported reductions in blood loss compared to open procedures [17]. TpAPR approaches for surgical treatment of CD remain unknown, primarily due to the relatively small number of procedures performed compared to malignancies such as rectal and anal cancers [8, 18]. Our retrospective study shows the significantly lower intraoperative blood loss observed in the TpAPR group (223.6 mL) compared to the APR group (533.8 mL, p = 0.04). TpAPR techniques enable precise dissection, minimizing inadvertent vascular injury, which is particularly important in the inflamed and fibrotic pelvic anatomy associated with CD [8]. Enhanced visualization through the laparoscopic approach focuses on targeted pelvic dissection, reducing the need for extensive abdominal manipulation and minimizing trauma to highly vascularized tissues [11]. The approach might facilitate more effective hemostasis compared to APR due to the precise dissection of the rectal wall, particularly in challenging areas such as the posterior surface of the prostate for even patients with CD.
The incidence of SSIs in the TpAPR group (36.4%) was notably lower than in the APR group (75%), although this difference did not reach statistical significance (p = 0.07). This trend might reflect the reduced tissue trauma and improved wound management techniques associated with minimally invasive approaches. For skin defect at perineum, NPWT was useful to improve the outcome [19]. The absence of Clavien‐Dindo grade III or higher complications in both groups suggests that the safety profile of TpAPR for patients with CD.
In addition to reducing blood loss and SSIs, the potential for autonomic nerve preservation in TpAPR should be given attention. Preservation of autonomic nerves is crucial in benign conditions such as CD, where avoiding complications like urinary and sexual dysfunction significantly impacts postoperative quality of life. The improved visualization and precise dissection afforded by TpAPR can facilitate the preservation of pelvic autonomic nerves, as evidenced by the absence of postoperative sexual dysfunction in our cohort.
Our findings suggest that TpAPR is a feasible and effective surgical option for patients with complex anorectal CD. The reduction in blood loss and potential for lower SSI rates are particularly relevant in this patient with CD, where minimizing surgical trauma is critical. However, the study's small sample size and retrospective design limit the generalizability of these results. Although TpAPR should allow for shorter operative times due to the two‐team approach, in our cohort, the learning curve and technical complexity may have offset this advantage. Moreover, in several TpAPR cases, extended perineal procedures such as urethral preservation and pelvic floor reconstruction were needed, which may have prolonged the overall duration. Furthermore, it is necessary for operators to understand the unique condition of TpAPR due to severe inflammation. Larger, multicenter prospective studies are needed to validate these findings and further explore the long‐term outcomes of TpAPR in CD.
In summary, TpAPR demonstrates potential as a minimally invasive alternative to APR for complex anorectal CD. By reducing intraoperative blood loss and SSI, TpAPR should be considered a promising option for surgical management of patients with complex anorectal CD.
Author Contributions
Y.K. designed the study. Y.K. collected the data. Y.K. and N.K. wrote the draft and analyzed the data. Y.K., N.K., R.S., T.I., S.H., Y.M., K.S., F.T., and S.K. performed treatment for the individuals. T.F. supervised all patients. All authors have read and approved the manuscript and agree to be held accountable for all aspects of the report.
Ethics Statement
The study was approved by the institutional review board of Okayama University (2004‐028). The study was conducted in accordance with the Declaration of Helsinki.
Consent
Written informed consent was obtained from all patient participants included in the study.
Conflicts of Interest
The authors declare no conflicts of interest.
Acknowledgments
Authors would like to thank Ms. Takanaga for collecting the patient data.
Kondo Y., Kanaya N., Shoji R., et al., “Clinical Impacts of Minimally Invasive Transperineal Abdominoperineal Resection in Crohn's Disease: A Retrospective Analysis,” Asian Journal of Endoscopic Surgery 18, no. 1 (2025): e70149, 10.1111/ases.70149.
Funding: This work was supported by JSPS KAKENHI grant reference (24K11823).
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.