title: Anterior Perineal PlanE for ultra-low Anterior Resection of the rectum (APPEAR) technique: A systematic review.
abstract: BACKGROUND
  The Anterior Perineal PlanE for ultra-low Anterior Resection of the rectum (APPEAR) technique utilises a perineal incision to facilitate resection of the distal rectum. The aim of this study was to review use of the APPEAR technique, assessing patient selection, indications, complications and outcomes, both oncological and functional.
  
  
  METHODS
  A systematic review was carried out to identify studies reporting outcomes following rectal resection via an anterior perineal incision, with no limits on year or language. All studies were included. Quality of studies was assessed using the methodological index for non-randomised studies (MINORS) score.
  
  
  RESULTS
  Thirteen studies were identified from 1985 to 2013. 174 patients (102 male), ranging from 21 to 82 years, underwent surgery at eleven centres in seven countries. Maximum experience at one centre is 60 cases. 9 cases were performed for rectal dysplasia, 141 for rectal cancer; 96 resections were R0 (remaining 45 unstated). 14 cases were carried out laparoscopically. 30-day mortality was 2.3% (4 patients); there were 2 further deaths from systemic recurrence. Permanent stoma rate was 8/155 (5%). The most frequent complication was perineal or vaginal fistulation (26 patients): 6 underwent reoperation; 15 healed with conservative management; 5 required a permanent stoma. Functional outcomes were variably reported; median stool frequency was 3/24hrs with average Wexner scores of 5-5.5.
  
  
  CONCLUSIONS
  In selected patients the APPEAR technique offers avoidance of permanent colostomy with good oncological outcomes. The majority of studies had short follow up periods and longer-term outcomes will need evaluation.
authors: Blizard Institute, National Centre for Bowel Research & Surgical Innovation, Barts and The London School of Medicine & Dentistry, Queen Mary University London, 2 Newark Street, London, E1 2AT, United Kingdom. Electronic address: klynes@nhs.net.
authors: Kathryn
authors: K
authors: Lynes
authors: Blizard Institute, National Centre for Bowel Research & Surgical Innovation, Barts and The London School of Medicine & Dentistry, Queen Mary University London, 2 Newark Street, London, E1 2AT, United Kingdom.
authors: Norman S
authors: NS
authors: Williams
authors: Blizard Institute, National Centre for Bowel Research & Surgical Innovation, Barts and The London School of Medicine & Dentistry, Queen Mary University London, 2 Newark Street, London, E1 2AT, United Kingdom.
authors: Christopher L
authors: CL
authors: Chan
authors: Blizard Institute, National Centre for Bowel Research & Surgical Innovation, Barts and The London School of Medicine & Dentistry, Queen Mary University London, 2 Newark Street, London, E1 2AT, United Kingdom.
authors: Mohamed A
authors: MA
authors: Thaha
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003125:Colostomy; D005260:Female; D006801:Humans; D010535:Laparoscopy; D008297:Male; D008875:Middle Aged; D010502:Perineum / Q000601:surgery*; D012002:Rectal Diseases / Q000601:surgery*; D012086:Reoperation; D054047:Surgical Stomas; D016896:Treatment Outcome; D055815:Young Adult
keywords: Inflammatory bowel disease; Perineal incision; Rectal cancer; Rectal stricture; Rectal surgery