Abdomino-Perineal Resection for Low Rectal and Anal Malignancies in Ibadan, SOUTHWEST NIGERIA

Abstract

Background:

Colonic tumours are the third most common tumours in the Nigerian cancer registry after breast and cervical carcinoma. Tumours involving the distal rectum and anus are increasingly a significant portion of all colorectal and anal malignancies in Nigeria. The patients frequently present with advanced disease. Abdomino-Perineal resection (APR), is thus an essential modality of treatment alongside chemo-radiation. The aim of the study was to review the surgical outcomes of APR done for low rectal and anal malignancies in a resource poor setting in sub-Saharan Africa.

Materials and Methods:

The demographic data, clinical features, management offered and outcomes of all patients who had had abdomino-perineal resection for colonic and anal malignancies at the University College Hospital, Ibadan, Nigeria between 2007 and 2013 were included in this study.

Results:

Over the 6-year period, 61 patients had abdomino-perineal resection for low colonic and anal malignancies in our institution. The indications were primary rectal carcinoma in 46 (75.4%) patients and anal carcinoma in 15 (24.6%) patients. The age ranged from 19-77 years with a mean of 48 years and median of 54 years. Majority were males in 33 (54.1%) patients. A fifth (20%) of the patients presented as emergency with large bowel obstruction that necessitated initial colostomy. Bleeding per rectum in 45 patients (73.8%), Weight loss in 26 patients (42.6%) and Tenesmus in 16 patients (26.2%) patients were the predominant complaints. All the patients were at stage AJCC 2A-3C (Duke Stage C or D) at presentation. Almost a third (66%) of the patients was incontinent of feaces. Palliative surgery was done for all the patients. The duration of follow up was between 3-36 months with a mean of 22 months. A total of 53 (86.9%) patients are alive after an average post-operative duration of 24 months, with 14 pts (23%) having local recurrence, and 22(36.1%) patients with hepatic metastases. Lymph nodal involvement was statistically significantly related to the survival status of the patients. Neo-adjuvant and adjuvant chemo-radiation did not affect outcomes in terms of local recurrence and survival.

Conclusion:

Abdomino-perineal resection is still the option of treatment in this environment for low rectal and anal malignancies in this environment. Early presentation and effective treatment shall improve the outcome.

Introduction

Over 1 million people are diagnosed with colorectal cancer yearly worldwide1. It is the 3^rd most common cancer in the United State of America accounting for 9% of all cancer1. It is one of the 3^rd leading causes of cancer related death in USA2.It is the 3^rd most common tumour in Nigeria3. An average of 70 cases per year was found in Ibadan from 2002 to 20064. Rectal cancer is one of the most commonly diagnosed cancers worldwide. It accounts for 20% of all patients with colorectal cancer1. In Nigeria, rectal cancer accounts for 64-69% of colorectal cancer5.

Abdomino-perineal resection (APR) of the rectum including the anus is the surgical option for the tumour involving the distal rectum and the anus. It was first described by Ernest Miles in 19086 and it gained acceptance by most surgeons because it affords the chance of complete excision of the tumour thus minimising local recurrence7. Recently low anterior resection with colorectal or coloanal anastomosis is replacing abdomino-perineal resection8 particularly with the introduction of stapling devices9,10,11.

The aim of the study was to review the surgical outcomes of APR done for low rectal and anal malignancies in Ibadan, Southwest Nigeria.

Reports

Methods

After obtaining approval of the institutional review board (IRB) , we performed a retrospective study of all patients who had abdomino-perineal resection (APR) for low rectal and anal malignancies at the University College Hospital, Ibadan, Nigeria between 2007 and 2013. The data collected included demographic information and details regarding the clinical presentation, diagnostic process, neo-adjuvant chemo-radiation, operative details, adjuvant treatments, post- operative course, follow-up and survival patterns following APR. Patient’s follow-up was dictated clinically. Complications that developed during post operative period were graded using the Dindo-Clavien grading of complications12.

Tumour recurrence was diagnosed using clinical examination, abdominal ultrasound and computerised tomographic scan. They were classified as either local recurrence if the tumour was found in the perineum around the operation site or metastatic if found elsewhere.

The data was analysed using Statistical Package for Social Statistics (SPSS) version 17. The categorical variables were presented using frequency tables, percentages and bar charts. Neo-adjuvant and adjuvant treatment effect on the patients’ survival was assessed and a test of significance was carried out using Chi-square.

Results

Over the 6-year period, 61 patients had abdomino-perineal resection for low rectal and anal malignancies in this study. Thirty-three (54%) patients were males and twenty-eight. (46%) patients were females giving a male/female ratio of approximately 1. The age ranged from 19 – 77 years with a mean of 48year while 52 (85.2%) patients were aged above 40 years (Figure 1 shows the age distribution). The mean BMI was 23kg/m². Other clinico-pathological parameters are as shown in Table 1. About 11(18%) patients were overweight, with BMI greater than 25Kg/m². The indications for APR were primary rectal carcinoma in 46 (75.4%) patients and anal carcinoma in 15 (24.6%). The duration of symptoms as seen in Figure 2, ranged from 8 – 104 weeks (median: 24 weeks). Twenty percent (12 patients) of the patients presented as emergency with large bowel obstruction that necessitated initial faecal diversion. Bleeding per rectum was the main presentation in (73.8%) patients, weight loss in (42.6%) and tenesmus in (26.2%) patients. Other symptoms at presentation are highlighted in Table 2.Fifty one (84%) patients were in stage AJCC III at presentation, 6(9.8%) were in stage IV while 4 (6.6%) had stage II disease. Nineteen (31%) were incontinent of faeces. Thirteen (21.3%) patients had neo-adjuvant chemotherapy whereas 49(80.3%) patients had adjuvant chemotherapy. Forty nine percent of patients (30 patients) had at least one post- operative complication (mainly perineal wound dehiscence in 18% and abdominal wound infection in 11.5%. Fifteen (24.6%) patients had grade I complication, 2 (3.3%) patients had grade II complication while 13 (21.3%) patients had grade IIIa complications in accordance with Dindo-Clavien Grading of Surgical Complications. Early post-operative complications correlated significantly with the duration of hospital stay (p value=0.00). There was one (1.6%) peri-operative mortality. Most patients 56(91.8%) patients were admitted for 11 – 20days. The duration of follow-up shown in Figure 3 was between 3 months and 3 years (median: 19 months) and 53(86.9%) are alive at 22 months post-surgery. Fourteen patients (23%) had local recurrence and 22 (36.1%) patients had hepatic metastasis. Surgery was palliative and 8 patients died in this study. Lymph node involvement was found to be significantly related to the survival status of the patient (p value= 0.017) but not significant to determine the presence of liver metastases (p value= 0.12). Adjuvant chemotherapy was significantly related to the survival status of the patients (p value= 0.031) but not significant for local recurrence or metastasis (p values of 0.24 and 0.11 respectively). Neo-adjuvant and adjuvant chemo-radiation were found not to significantly affect the outcome in terms of local recurrence and survival (p value=0.29).

Table 1: Clinico-pathologic characteristics of the patients

	FREQUENCY	PERCENTAGES
Body Mass Index
Normal weight	50	82
Overweight	11	18
Luminal Involvement
Anterior	9	14.8
Circumferential	17	27.9
Hemi-circumferential	8	13.1
Lateral	10	16.4
Posterior	5	8.2
Unspecified	12	19.7
AJCC Staging
II	4	6.6
III	51	83.6
IV	6	9.8
Distance from anal verge
1cm	4	6.6
2cm	16	26.2
3cm	11	18.0
4cm	10	16.4
5cm	7	11.5
6cm	13	21.3

Table 2: Presenting complaints

Symptoms	Frequency	Percentage
Anal pain	3	4.9
Bleeding P.R	45	73.8
Change in bowel habits	1	1.6
Feacal inconcistency	1	1.6
Obstipation	5	8.2
Tenesmus	2	3.3
Weight loss	4	6.6
Total	61	100

Figure 1:

Age Distribution in years

Figure 2:

Duration of symptom in weeks

Figure3.

Duration of follow up in months

Discussion

Rectal carcinoma in Africa is on the increase in the last two decades13. The peak age of presentation with features consistent with low rectal and anal malignancies in our centre was between 50 and 59 years with median age of 54 years. This is comparable to those from other African studies13,14,15 but lower compared to those from western countries7,16,17. Bleeding per rectum was the commonest presentation in majority of our patients. Most of our patients presented with advanced disease; this is comparable to the study of Alatise et al11. It is the usual presentation pattern in most African communities18 as patients seek local treatment for haemorrhoids13 before eventually presenting for expert management. Emergency presentation rate of 20% in this study is similar to the study of Naaeder et al18 from Ghana as well as the work of Chester et al19 from the United Kingdom. Abdomino-perineal resection is still the standard surgical procedure for low rectal and anal malignancies especially when the anal sphincter was involved16. The number of abdomino-perineal resection done over the study period was high compared with those performed in some other tertiary institutions in Nigeria11 and abroad7. This is partly due to late presentation of the patients, as more than 30% of patients in this study already had sphincter involvement at presentation.

The early complication rate of 49% in our patients was comparable to similar studies from Nigeria11 but higher than those from Kenya15, India20 and United State of America7. The complications were mainly Grade I, II and IIIa; no higher grade was found12. Perineal and abdominal wound infection constituted the majority of the complications and thus accounted for prolonged hospital admission in some of our patients. The longest follow-up duration was 3years and only 23% of patients were followed up for two or more years; that was the trend in most developing countries15 as most patients could not afford the costs and when they develop complications. Twenty three percent of our patients had local recurrence and mostly within 2 years of surgery. This high value was because majority of our patients had stage III and IV disease at presentation. This compared well to the work of Fujita et al21 from Japan where local recurrence rate of 17.9% and 25.9% for stage III tumour in patients who had lateral pelvic lymph node dissection and those who did not have respectively were reported. Other studies from western countries showed low rates of local recurrence22. Neo-adjuvant treatment has been shown to down-stage the tumour and make sphincter saving surgery more feasible22, 23, 24, only 16% our patients had neo-adjuvant chemo-radiation. This might account for the high rate of local recurrence and metastatic disease during the period of follow up. High cost of chemotherapy and limited availability of radiotherapy service were the reasons why some of our patients did not receive neo-adjuvant and adjuvant treatment. Being a retrospective study with limited number of patients, conclusions drawn may not be as representative as a prospective study.

Conclusions

Abdomino-perineal resection still remains the surgical option of choice in patients with low rectal and anal carcinoma especially when there is sphincter involvement. Outcome of treatment in term of survival status and local recurrent rate can be significantly improved with preoperative radiation and chemotherapy as well as adjuvant treatment. The significantly high cost of treatment hindered optimal neo-adjuvant and adjunct chemo-radiation in this environment.