title: Anterior Perineal PlanE for Ultra-low Anterior Resection of the Rectum (the APPEAR technique): a prospective clinical trial of a new procedure.
abstract: OBJECTIVE
  The APPEAR procedure was developed to allow sphincter-preserving rectal resection for both benign and malignant pathology, which would traditionally require abdominoperineal excision or completion proctectomy, if treated by conventional means. This clinical trial (clinicaltrials.gov: NCT00534131) evaluated the short-term clinical and physiological results of this procedure.
  
  
  METHODS
  Fourteen patients were enrolled, 7 with neoplasia, 5 with ulcerative colitis, and 2 with traumatic rectal damage. Patients were evaluated preoperatively, and at a median of 2 years after surgery.
  
  
  RESULTS
  Nine of 14 patients underwent ileostomy reversal and were followed up for a minimum of 1 year, with 1 patient awaiting closure. Four patients have not yet been considered for ileostomy reversal due to anastomotic perineal fistulae. Transient sexual dysfunction was noted in 3 of 14 patients, but no urological problems occurred. When the APPEAR procedure was performed for neoplasia or trauma, postoperative median Wexner continence score was 5 (range 0-8, n = 6), with a median defecation frequency of 3 (range 1-8/day). All cancers were completely excised with no local recurrence. Following APPEAR with restorative proctocolectomy for ulcerative colitis, median Wexner continence score was 2 (range 0-6, n = 3), with a median daily defecatory frequency of 3 (range 1-5). Preoperative SF-36 scores did not change significantly following ileostomy closure, and anorectal physiological testing was unaltered following perineal dissection.
  
  
  CONCLUSIONS
  The APPEAR procedure provides an alternative technique to effect an ultra-low sphincter-saving anastomosis, when this is not possible by conventional surgery. Morbidity was encountered and greater experience will be required to fully assess this approach. Nevertheless, this is a promising new procedure with the potential to reduce the need for a permanent stoma even further than is currently the case.
authors.affiliation: Centre for Academic Surgery, Institute for Cell and Molecular Science, Barts and the London, Queen Mary's School of Medicine and Dentistry, University of London, London, United Kingdom. n.s.williams@qmul.ac.uk
authors.forename: Norman S
authors.initials: NS
authors.lastname: Williams
authors.forename: Jamie
authors.initials: J
authors.lastname: Murphy
authors.forename: Charles H
authors.initials: CH
authors.lastname: Knowles
mesh_terms: D000328:Adult; D000368:Aged; D001003:Anal Canal / Q000503:physiopathology; D015331:Cohort Studies; D003093:Colitis, Ulcerative / Q000503:physiopathology / Q000601:surgery*; D013505:Digestive System Surgical Procedures / Q000379:methods*; D005260:Female; D006801:Humans; D007081:Ileostomy; D008297:Male; D008875:Middle Aged; D010502:Perineum / Q000601:surgery*; D010865:Pilot Projects; D020127:Recovery of Function; D012004:Rectal Neoplasms / Q000473:pathology / Q000503:physiopathology / Q000601:surgery*; D012007:Rectum / Q000293:injuries* / Q000601:surgery*; D016896:Treatment Outcome