Better operative outcomes achieved with the prone jackknife vs. lithotomy position during abdominoperineal resection in patients with low rectal cancer

Abstract

BackgroundLithotomy (LT) and prone jackknife positions (PJ) are routinely used for abdominoperineal resection (APR). The present study compared the clinical, pathological, and oncological outcomes of PJ-APR vs. LT-APR in low rectal cancer patients in order to confirm which position will provide more benefits to patients undergoing APR.MethodsThis is a retrospective study of consecutive patients with low rectal cancer who underwent curative APR between January 2002 and December 2011. Patients were matched 1:2 (PJ-APR = 74 and LT-APR = 37 patients) based on gender and age. Perioperative data, postoperative outcomes, and survival were compared between the two approaches.ResultsHospital stay was shorter with PJ-APR compared with LT-APR (P < 0.05). Compared with LT-APR, duration of anesthesia (234 ± 50.8 vs. 291 ± 69 min, P = 0.022) and surgery (183 ± 44.8 vs. 234 ± 60 min, P = 0.016) was shorter with PJ-APR, and estimated blood losses were smaller (549 ± 218 vs. 674 ± 350 mL, P < 0.001). Blood transfusions were required in 37.8% of LT-APR patients and in 8.1% of PJ-APR patients (P < 0.001). There was no difference in the distribution of N stages (P = 0.27). Median follow-up was 47.1 (13.6–129.7) months. Postoperative complications were reported by fewer patients after PJ-APR compared with LT-APR (14.9% vs. 32.4%, P = 0.030). There were no significant differences in overall survival, disease-free survival, local recurrence, and distant metastasis (P > 0.05).ConclusionsThe PJ position provided a better exposure for low rectal cancer and had a lower operative risk and complication rates than LT-APR. However, there was no difference in rectal cancer prognosis between the two approaches. PJ-APR might be a better choice for patients with low rectal cancer.

Estudo comparativo entre a amputação de reto na posição clássica de Lloyd-Davies e em decúbito ventral.

“…Regarding the technical aspects of the comparison between the two surgical positions of interest for the abdominoperineal amputation of the rectum, we observed a statistically significant difference of the average surgical and anesthetic times, the Lloyd-Davies position having significantly faster execution in both features. Our data were contrary to other studies in the international literature, in which the ventral position was faster 23,24 .…”

Perioperative and oncological outcomes of abdominoperineal resection in the prone position vs the classic lithotomy position: A systematic review with meta‐analysis

“…Moreover, the surgeon's and especially the assistants’ positions are uncomfortable, making hemostasis challenging and dissection laborious. Notwithstanding the fact P‐APR requires patient repositioning, Liu et al reported that the median time to complete this step is only 18 minutes, and the benefit of the better exposure overcompensates for this extra step. Indeed, a pooled analysis showed that the prone approach can significantly decrease the OT by 43 minutes (Figure A).…”

“…The proponents of the ELAPE advocate that the cylindrical resection dramatically decreases the CRM positivity, and this has led those in favor of the prone position to point the better exposure as a contributor to better local control . However, even for ELAPE, CRM is only a surrogate marker of local control, and its clinical impact on recurrence and survival is less clear.…”

“…Interestingly, the secondary outcomes reported by these studies show an improvement in operative time (OT), decreased blood loss and fewer perineal wound infections (PWI). Some authors suggest that these benefits are likely secondary to the adoption of the prone position during ELAPE, which yields a better surgical exposure, faster dissection, decreased blood loss, and a more precise perineal wound closure . Indeed, a national survey from the United Kingdom showed that approximately one‐third of the surgeons prefer the prone position during APRs .…”

“…Some authors suggest that these benefits are likely secondary to the adoption of the prone position during ELAPE, which yields a better surgical exposure, faster dissection, decreased blood loss, and a more precise perineal wound closure. 5,10 Indeed, a national survey from the United Kingdom showed that approximately one-third of the surgeons prefer the prone position during APRs. 11 Although the rational to adopt this practice seems appealing, there is no definitive data to support this surgical approach.…”