Comparison of short- and long-term outcomes after extralevator abdominoperineal excision and standard abdominoperineal excision for rectal cancer: a systematic review and meta-analysis

Supine bottom-up extralevator abdominoperineal excision for anorectal adenocarcinoma is not inferior to standard approach and may be thus safely performed

BACKGROUND

Extralevator abdominoperineal excision (APE) for rectal carcinoma has been described in order to improve pathological and oncological results compared to standard APE. To obtain the same oncological advantages as extralevator APE, we have previously described a new procedure starting by a perineal approach: the supine bottom-up APE. Our objective is to compare oncological and surgical outcomes between the supine bottom-up APE and the standard APE.

METHODS

All patients with low rectal adenocarcinoma requiring APE were retrospectively included and divided into 2 groups: supine bottom-up APE (Group A) and standard APE (Group B).

RESULTS

From 2008 to 2016, 61 patients were divided into Groups A (n = 30) and B (n = 31). Postoperative outcomes and median length of stay were similar between groups. Patients from Group A had a significantly longer distal margin (30 [8-120] vs. 20 [1.5-60] mm, p = 0.04) and higher number of harvested lymph nodes (14.5 [0-33] vs. 11 [5-25], p = 0.03) than those from Group B. Circumferential resection margin involvement was similar between groups (28 vs. 22%, p = 0.6), whereas tumors from Group A were significantly larger and more frequently classified as T4 than those from Group B. Operative time was significantly shorter in Group A (437.5 [285-655] minutes) than in Group B (537.5 [361-721] minutes, p = 0.0009). At the end of follow-up, local recurrence occurred in 7 and 16% of patients from Groups A and B (p = 0.68). Three-year overall and disease-free survival rates were similar between groups (87 vs. 90%, p = 0.62 and 61 vs. 63%, p = 0.88, respectively).

CONCLUSION

Our findings suggest that supine bottom-up APE doesn't impair surgical outcomes, pathological results, overall and disease-free survivals in comparison with standard APE. This new procedure may be thus safely performed and decrease the operative time. Further randomized multicentric studies are required to confirm these results.

Long-term outcomes after extra-levator versus conventional abdominoperineal excision for low rectal cancer

Purpose

Extralevator (ELAPE) and abdominoperineal excision (APE) are two major surgical approaches for low rectal cancer patients. Although excellent short-term efficacy is achieved in patients undergoing ELAPE, the long-term benefits have not been established. In this study we evaluated the safety, pathological and survival outcomes in rectal cancer patients who underwent ELAPE and APE.

Methods

One hundred fourteen patients were enrolled, including 68 in the ELAPE group and 46 in the APE group at the Beijing Chaoyang Hospital, Capital Medical University from January 2011 to November 2020. The baseline characteristics, overall survival (OS), progression-free survival (PFS), and local recurrence-free survival (LRFS) were calculated and compared between the two groups.

Results

Demographics and tumor stage were comparable between the two groups. The 5-year PFS (67.2% versus 38.6%, log-rank P = 0.008) were significantly improved in the ELAPE group compared to the APE group, and the survival advantage was especially reflected in patients with pT3 tumors, positive lymph nodes or even those who have not received neoadjuvant chemoradiotherapy. Multivariate analysis showed that APE was an independent risk factor for OS (hazard ratio 3.000, 95% confidence interval 1.171 to 4.970, P = 0.004) and PFS (hazard ratio 2.730, 95% confidence interval 1.506 to 4.984, P = 0.001).

Conclusion

 Compared with APE, ELAPE improved long-term outcomes for low rectal cancer patients, especially among patients with pT3 tumors, positive lymph nodes or those without neoadjuvant chemoradiotherapy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-022-01692-y.

Short-term advantages of ELAPE over APR

INTRODUCTION

Conventional abdominoperineal resection (APR) has a high rate of local recurrence. Extralevator abdominoperineal excision (ELAPE) can potentially diminish the rate of intraoperative tumour perforation (IOTP) and can provide wider circumferential resection margins (CRM) but at the price of higher perineal complication rate. The aim of our study was to compare the short term results of conventional APR to ELAPE.

MATERIALS AND METHODS

Thirty-five consecutively operated APRs compared to 38 also consecutively operated ELAPEs. Prospectively collected short-term outcome data were analysed retrospectively.

RESULTS

There was no difference in demographics, disease stage or tumour location between groups. IOTP rate and CRM positivity rates were similar between the two groups (p = .608). No difference was found in major (Clavien-Dindo III-V) complications, but we found statistically significant difference in minor (Clavien-Dindo I-II) complications (p = .01) in favour of the ELAPE group. Frequency of perineal SSI was lower in ELAPE group, but the difference was not significant (p = .320). Intraoperative iatrogenic complications occurred at significantly lower rate in ELAPE group (p = .035). Also, postoperative morbidity connected with the dissection in the perineal phase (e.g. urine incontinence, urinary retention) was significantly lower (p = .018) after ELAPE.

DISCUSSION AND CONCLUSIONS

In our experience ELAPE operations may diminish the rate of Clavien-Dindo I-II complications compared to conventional APR. This effect is ensuing from the decrease of intraoperative iatrogenic complications and from the decrease of minor postoperative complications.

Brazilian society of surgical oncology: Guidelines for the surgical treatment of mid-low rectal cancer

BACKGROUND

Colorectal cancer (CRC) is the third leading cause of cancer in North America, Western Europe, and Brazil, and represents an important public health problem. It is estimated that approximately 30% of all the CRC cases correspond to tumors located in the rectum, requiring complex multidisciplinary treatment. In an effort to provide surgeons who treat rectal cancer with the most current information based on the best evidence in the literature, the Brazilian Society of Surgical Oncology (SBCO) has produced the present guidelines for rectal cancer treatment that is focused on the main topics related to daily clinical practice.

OBJECTIVES

The SBCO developed the present guidelines to provide recommendations on the main topics related to the treatment of mid-low rectal cancer based on current scientific evidence.

METHODS

Between May and June 2021, 11 experts in CRC surgery met to develop the guidelines for the treatment of mid-low rectal cancer. A total of 22 relevant topics were disseminated among the participants. The methodological quality of a final list with 221 sources was evaluated, all the evidence was examined and revised, and the treatment guideline was formulated by the 11-expert committee. To reach a final consensus, all the topics were reviewed via a videoconference meeting that was attended by all 11 of the experts.

RESULTS

The prepared guidelines contained 22 topics considered to be highly relevant in the treatment of mid-low rectal cancer, covering subjects related to the tests required for staging, surgical technique-related aspects, recommended measures to reduce surgical complications, neoadjuvant strategies, and nonoperative treatments. In addition, a checklist was proposed to summarize the important information and offer an updated tool to assist surgeons who treat rectal cancer provide the best care to their patients.

CONCLUSION

These guidelines summarize concisely the recommendations based on the most current scientific evidence on the most relevant aspects of the treatment of mid-low rectal cancer and are a practical guide that can help surgeons who treat rectal cancer make the best therapeutic decision.

Is extralevator abdominoperineal resection necessary for low rectal carcinoma in the neoadjuvant chemoradiotherapy era?

Background: We aimed to compare the short-term surgical and early surgical oncological outcomes of abdominoperineal resection (APR) and extralevator APR (ELAPR) in patients with low rectal carcinoma that have received neoadjuvant chemoradiotherapy (NACRT), whose abdominal procedures were performed laparoscopically.Methods: One hundred and four patients who underwent APR or ELAPR for stage II/III low rectal carcinoma NACRT between 2013 and 2016 were evaluated by reviewing the standard charts for colorectal carcinoma.Results: Median follow-up for patients in APR group was 56 months(24-67 months) and 52 months(27-64 months) for ELAPR group. The postoperative complication rates were higher in ELAPR than in APR (perineal wound infection 38% vs. 22.5%(p = .03), perineal wound dehiscence 57% vs. 25%(p = .01), persistent perineal pain 28.5% vs. 13%(p = .01), urinary dysfunction 23% vs. 14.5%(p = .02), reoperation 16.5% vs. 4.8%(p = .03), respectively). Circumferential resection margin positivity, the number of lymph nodes dissected, and the rate of intra-operative perforation of the tumor were similar for both surgical techniques. Local recurrence rates at postoperative 2 years were also similar after APR and ELAPR (8% vs. 9.5%, p = .2).Conclusion: We conclude that in the era of routinely used NACRT, ELAPR is not superior to conventional APR for stage II/III low rectal carcinomas. ELAPR is associated with increased morbidity and has no short-term surgical oncological advantage over APR.

Laparoscopic Versus Open Extralevaor Abdominoperineal Excision for Lower Rectal Cancer: A Retrospective Cohort Study in Single Institute

Background: To explore the safety and efficacy of laparoscopic extralevator abdominoperineal excision (La-ELAPE) and open extralevator abdominoperineal excision (Op-ELAPE) for patients with lower rectal cancer. Materials and Methods: Consecutive 101 patients with lower rectal cancer who underwent La-ELAPE or Op-ELAPE in our institution from January 2014 and May 2018 were analyzed retrospectively. The patients' clinicopathological data and postoperative outcomes were compared between the two groups. Results: A total of 101 patients were enrolled in the study, 43 (42.6%) patients successfully underwent La-ELAPE and 58 (57.4%) Op-ELAPE. The Op-ELAPE group had more intraoperative blood loss (P = .03), and longer postoperative hospital stay (P = .01) compared with the La-ELAPE group. There were no significant differences between the two group in terms of the operation time (P = .08), circumferential resection margin positivity (P = 1.00), intraoperative perforation (P = .73), and number of positive lymph nodes (P = .91). There were no significant differences in postoperative complications such as colostomy-associated issues (P = .79), intestinal obstruction (P = 1.00), urinary retention (P = 1.00), perineal wound complications (P = .64), and chronic perineal pain (P = .70) between the two groups. According to the Kaplan-Meier survival analysis and log rank test, the overall survival rate and progression-free survival rate between the two groups also showed no significant difference. Conclusion: This study showed that La-ELAPE significantly reduced the intraoperative blood loss and the postoperative hospital stay without increasing postoperative morbidity for patients with lower rectal cancer when compared with Op-ELAPE. It suggests that La-ELAPE is safe and effective for patients with lower rectal cancer. For the experienced endoscopic surgeons, the La-ELAPE might be an alternative surgical treatment.

Response Assessment with MRI after Chemoradiotherapy in Rectal Cancer: Current Evidences

Baseline magnetic resonance imaging (MRI) has become the primary staging modality for surgical plans and stratification of patient populations for more efficient neoadjuvant treatment. Patients who exhibit a complete response to chemoradiotherapy (CRT) may achieve excellent local tumor control and better quality of life with organ-preserving treatments such as local excision or even watch-and-wait management. Therefore, the evaluation of tumor response is a key factor for determining the appropriate treatment following CRT. Although post-CRT MRI is generally accepted as the first-choice method for evaluating treatment response after CRT, its application in the clinical decision process is not fully validated. In this review, we will discuss various oncologic treatment options from radical surgical technique to organ-preservation strategies for achieving better cancer control and improved quality of life following CRT. In addition, the current status of post-CRT MRI in restaging rectal cancer as well as the main imaging features that should be evaluated for treatment planning will also be described for the tailored treatment.

Extralevator abdominoperineal excision versus abdominoperineal excision for low rectal cancer: a meta-analysis

BACKGROUND

Extralevator abdominoperineal excision (ELAPE) has become a popular procedure for low rectal cancer as compared with abdominoperineal excision (APE). No definitive answer has been achieved whether one is superior to the other. This study aimed to evaluate the safety and efficacy of ELAPE for low rectal cancer with meta-analysis.

METHODS

The Web of Science, Cochrane Library, Embase, and PubMed databases before September 2019 were comprehensively searched to retrieve comparative trials of ELAPE and APE for low rectal cancer. Pooled analyses of the perioperative variables, surgical complications, and oncological variables were performed. Odds ratio (OR) and mean differences (MD) from each trial were pooled using random or fixed effects model depending on the heterogeneity of the included studies. A subgroup analysis or a sensitivity analysis was conducted to explore the potential source of heterogeneity when necessary.

RESULTS

This meta-analysis included 17 studies with 4049 patients, of whom 2248 (55.5%) underwent ELAPE and 1801 (44.5%) underwent APE. There were no statistical differences regarding the circumferential resection margin positivity (13.0% vs. 16.2%, OR = 0.69, 95% CI = 0.42-1.14, P = 0.15) and post-operative perineal wound complication rate (28.9% vs. 24.1%, OR = 1.21, 95% CI = 0.75-1.94, P = 0.43). The ELAPE was associated with lower rate of intraoperative perforation (6.6% vs. 11.3%, OR = 0.50, 95% CI = 0.39-0.64, P < 0.001) and local recurrence (8.8% vs. 20.5%, OR = 0.29, 95% CI = 0.21-0.41, P < 0.001) when compared with APE.

CONCLUSIONS

The ELAPE was associated with a reduction in the rate of intra-operative perforation and local recurrence, without any increase in the circumferential resection margin positivity and post-operative perineal wound complication rate when compared with APE in the surgical treatment of low rectal cancer.

[Evidence-based surgery of rectal cancer]

Over the past four decades, the treatment algorithms for rectal cancer have fundamentally changed, which resulted in a considerable improvement of oncological outcomes. In this context, the surgical concept of total mesorectal excision and the implementation of multimodal treatment strategies represent key milestones. These improvements were complemented by a standardized histopathological work-up of the surgical specimen and the introduction of high-resolution magnetic resonance imaging (MRI) diagnostics. In addition, novel surgical techniques have been introduced, such as laparoscopic and robotic rectal resection. Other technological innovations include intraoperative pelvic neuromonitoring and fluorescence imaging. This review highlights the current evidence for selected, sometimes controversially discussed principles of surgical treatment strategies in rectal cancer.

Primary vs myocutaneous flap closure of perineal defects following abdominoperineal resection for colorectal disease: a systematic review and meta-analysis

AIM

Perineal wound complications after abdominoperineal resection (APR) have become a major clinical challenge. Myocutaneous flap closure has been proposed in place of primary closure to improve wound healing. We conducted this comprehensive meta-analysis to evaluate the current scientific evidence of primary closure vs myocutaneous flap closure of perineal defects following APR for colorectal disease.

METHODS

We systematically searched the MEDLINE, Embase, PubMed, Web of Science and Cochrane Library databases to identify all relevant studies. After data extraction from the included studies, meta-analysis was performed to compare perioperative outcomes of primary closure and myocutaneous flap closure.

RESULTS

Eighteen studies with a total of 17 913 patients (16 346 primary closure vs 1567 myocutaneous flap closure) were included. We found that primary closure was significantly associated with higher total perineal wound complications (P = 0.007), major perineal wound complications (P < 0.001) and perineal wound infection (P = 0.001). On the other hand, myocutaneous flap closure takes more operation time (P < 0.001) and increases the risk of perineal wound dehiscence (P = 0.01), deep surgical site infection (P < 0.001), enterocutaneous fistulas (P = 0.03) and return to the operating room (P = 0.0005). There were no significant differences between the two groups for other outcomes.

CONCLUSIONS

This is the first systematic review with meta-analysis comparing primary closure with myocutaneous flap closure of perineal defects after APR for colorectal disease. Although taking more operation time and an increased risk of specific complications, the pooled results have validated the use of myocutaneous flaps for reducing total/major perineal wound complications. More investigations are needed to draw definitive conclusions on this dilemma.

Oncological outcomes before and after the extralevator abdominoperineal excision era in rectal cancer patients treated with abdominoperineal excision in a single centre, high volume unit

AIM

The extralevator abdominoperineal excision (ELAPE) has been expected to reduce the risk of positive circumferential resection margins (CRMs) and local recurrence in locally advanced distal rectal cancer. The aim was to determine whether there is any difference in local recurrence rates between patients who were operated on for distal rectal cancer before and after the introduction of ELAPE in our unit.

PATIENTS AND METHODS

In all, 206 patients with distal rectal cancer without distant metastases (T1-4N0-2M0) were treated with curative intent. The patients were divided into two cohorts operated in 2000-2007 (A) and 2008-2014 (B). The ELAPE procedure was introduced in 2008. Since then, it has been used in cases of T4 and T3 tumours with threatened margins. In T1-T3 tumours without threatened margins a conventional abdominal perineal excision has been performed.

RESULTS

There was no significant difference in overall survival or cancer-specific survival between the two time periods. The local recurrence rate was 15.5% in group A and 6.7% in group B (P = 0.048), although there was no significant difference in the cumulative local recurrence rate. Intra-operative tumour perforation occurred significantly more often during the earlier period when ELAPE was not in use: group A 15/71 (21.1%) vs group B 11/135 (8.1%), P = 0.01. CRM was positive more often in group A (16.4%) vs group B (7.4%), P = 0.054.

CONCLUSION

The local recurrence rate, intra-operative tumour perforation and positive CRM rate were significantly lower during the later period when more extensive surgery (ELAPE) was performed for locally advanced T3-T4 rectal cancer with threatened margins.

Application of modified primary closure of the pelvic floor in laparoscopic extralevator abdominal perineal excision for low rectal cancer

AIM

To introduce a novel, modified primary closure technique of laparoscopic extralevator abdominal perineal excision (LELAPE) for low rectal cancer.

METHODS

We retrospectively analyzed data from 76 patients with rectal cancer who underwent LELAPE from March 2013 to May 2016. Patients were classified into the modified primary closure group (32 patients) and the biological mesh closure group (44 patients). The total operating time, reconstruction time, postoperative stay duration, total cost, postoperative complications and tumor recurrence were compared.

RESULTS

All surgery was successfully performed. The pelvic reconstruction time was 14.6 ± 3.7 min for the modified primary closure group, which was significantly longer than that of the biological mesh closure group (7.2 ± 1.9 min, P < 0.001). The total operating time was not different between the two groups (236 ± 20 min vs 248 ± 43 min, P = 0.143). The postoperative hospital stay duration was 8.1 ± 1.9 d, and the total cost was 9297 ± 1260 USD for the modified primary closure group. Notably, both of these categories were significantly lower in this group than those of the biological mesh closure group (P = 0.001 and P = 0.003, respectively). There were no differences observed between groups when comparing other perioperative data, long-term complications or oncological outcomes.

CONCLUSION

The modified primary closure method for reconstruction of the pelvic floor in LELAPE for low rectal cancer is technically feasible, safe and cost-effective.

Oncological outcomes of abdominoperineal resection for the treatment of low rectal cancer: A retrospective review of a single UK tertiary centre experience

Background

The use of abdominoperineal resection (APR) in the management of low rectal cancer has received criticism over high rates of incomplete resection due to tumour involvement at the circumferential resection margin. Extralevator abdominoperineal resection has been advocated as a means of improving complete resection. However, Extralevator abdominoperineal resection can result in increased cost, morbidity and reduced quality of life.

This study aims to assess the histological features and long-term outcomes of patients undergoing standard abdominoperineal resection and discusses the potential role of Extralevator abdominoperineal resection in this cohort.

Method

A retrospective review of a prospectively maintained database of rectal cancer patients at a single centre. Patients undergoing standard APR were included from 01/06/2007 to 31/05/2012 to allow a minimum 2-year follow-up. Data was collected on age, gender, co-morbidity, pre-operative stage, neo-adjuvant therapy, histology, recurrence and mortality.

Results

Seventy patients were identified (45 (64%) male, median age 67; (range 36–85)). 12 (17.1%) patients had a positive circumferential resection margin; 4 (6.1%) tumours were located anteriorly, 8 (11%) were located posteriorly or laterally and may potentially have been completely resected with extralevator abdomino-perineal resection, Number-needed to treat = 9. Positive circumferential resection margin was more common in advanced tumours (p < 0.001). Local recurrence was more common with positive circumferential resection margins (16.7% Vs 0%, p = 0.027), with no statistically significant difference in 5-year survival, although there was a tendency towards worse survival in these patients.

Conclusion

Positive circumferential resection margin following APR resulted in significantly increased local recurrence with a trend towards poorer survival outcomes. Extralevator abdomino-perineal resection may have benefited some of these patients with locally advanced tumours and postero-lateral recurrences. However, this has to be balanced against exposing patients to increased risk of adverse events. We would recommend selective use of Extralevator abdominoperineal resection for locally advanced and node-positive tumours although further studies to help refine selection criteria are required with long-term follow-up.

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A single high-volume Centre, retrospective study.

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5 years data of low rectal cancer patients undergoing standard abdomino-perineal resection of rectum (APR).

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Positive CRM is associated with increased local recurrence.

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This study reports that careful selection of patients for ELAPE is vital.

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The numbers needed to treat are 9.

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ELAPE is advisable in locally advanced and postero-lateral low rectal cancers.

Extended pelvic resection for rectal and anal canal tumors is a significant risk factor for perineal wound infection: a retrospective cohort study

PURPOSE

Perineal wound infection (PWI) rates are high after abdominoperineal resection (APR) and total pelvic exenteration (TPE). This study identified risk factors for PWI after surgery for anorectal tumors and examined the relationship between the surgical excision volume with the PWI degree.

METHODS

A retrospective review involving 135 patients who underwent surgical excision of anorectal tumors was performed. Superficial PWI included cellulitis and superficial dehiscence; deep PWI included major dehiscence, perineal abscess, and presacral abscess. The adjacent organ resection type was classified according to the dead space size formed by surgical excision.

RESULTS

Of the 135 patients, 119 underwent APR, and 16 underwent TPE. PWI occurred in 75 patients (superficial PWI, 44; deep PWI, 31). Adjacent organ resection was an independent risk factor for PWI. The cases with adjacent organ resection were classified into small-defect APR, large-defect APR, and TPE. Large-defect APR and TPE cases had significantly higher rates of deep PWI than APR cases without adjacent organ resection.

CONCLUSIONS

Adjacent organ resection involving the removal of one or more organs and that involving wide-range muscle resection are strong risk factors for deep PWI.

Perineal Wound Complications Following Extralevator Abdominoperineal Excision: Experience of a Regional Cancer Center

Extralevator abdominoperineal excision (ELAPE) results in a large perineal defect which needs reconstruction by a flap or biological mesh. The incidence of perineal wound complications is thought to be higher following an ELAPE compared to conventional abdominoperineal excision (APE). WE aimed to analyze the perineal wound complications following ELAPE in our institution. This was a retrospective analysis of all consecutive patients who underwent an APE (conventional and ELAPE) procedure in our institution between 2012 and 2015. We retrieved the demographic data, treatment data, and pathological data from the case records. Reconstruction of the perineal defect after a prone perineal dissection was performed using a local muscle flap. The incidence of perinealwound complications, hospital stay, and time to initiate adjuvant chemotherapy was compared between the two groups. A total of 71 patients underwent APE over a period of 41 months of which 21 patients underwent ELAPE. The perineal dissection during ELAPE was done in the prone position in 18 patients and in the supine position in 3 patients. Perineal wound complications were seen in 9 patients (42%) who underwent ELAPE compared to 17 patients (34%) who underwent conventional APE (p = 0.52). The mean duration of hospital stay was significantly longer in patients who underwent ELAPE when compared to those who underwent conventional APE (22.9 ± 3.6 days vs 14.6 ± 1.0 days, p = 0.03). The median interval between ELAPE and initiation of adjuvant chemo was 54 days (range 32-120 days) compared to 50 days (range 30-100 days) in patients undergoing conventional APE. A delay in initiating adjuvant chemotherapy of more than 12 weeks was seen in 4 patients (19%) following ELAPE. The incidence of perineal wound complications following ELAPE in this study was comparable to that reported in literature. Although the hospital stay following ELAPE was significantly longer than that following conventional APE in our institution, it did not unduly prolong initiation of adjuvant chemotherapy. Improving the perineal reconstruction techniques and selecting patients who will benefit from ELAPE may help to reduce the wound complications.

Extralevator versus standard abdominoperineal excision in locally advanced rectal cancer: a retrospective study with long-term follow-up

PURPOSE

To analyze the results of abdominoperineal excisions (APE) for locally advanced rectal cancer at our institution before and after the adoption of extralevator abdominoperineal excision (ELAPE) with a special reference to long-term survival.

METHODS

A retrospective cohort study conducted in a tertiary referral center. All consecutive patients operated for locally advanced (TNM classification T3-4) rectal cancer with APE in 2004-2009 were compared to patients with similar tumors operated with ELAPE in 2009-2016.

RESULTS

Forty-two ELAPE and 27 APE patients were included. Circumferential resection margin (CRM) was less than 1 mm (R1-resection) in 10 (24%) of ELAPE patients and 11 (41%) of APE patients (p = 0.1358). Intraoperative perforation (IOP) occurred in 4 (10%) patients and 6 (22%) patients in ELAPE and APE groups, respectively (p = 0.1336). There were 3 (7%) local recurrences (LRs) in ELAPE group and 5 (19%) in APE (p = 0.2473). There were no statistical differences in adverse events, overall survival, or disease-free survival between ELAPE and APE groups.

CONCLUSIONS

We found a non-significant tendency to lower rates of IOP and positive CRM as well as lower rate of LR in the ELAPE group. Long-term survival and adverse events did not differ between the groups. ELAPE is beneficial for the surgeon in offering better vicinity to the perineal area and better work ergonomics. These technical aspects and the clinically very important tendency to lower rate of LR support the use of ELAPE technique in spite of the lack of survival benefit.

Extralevator Abdominal Perineal Excision Versus Standard Abdominal Perineal Excision: Impact on Quality of the Resected Specimen and Postoperative Morbidity

BACKGROUND

Abdominal perineal excision (APE) has been associated with a high risk of positive circumferential resection margin (CRM+) and local recurrence rates in the treatment of rectal cancer. An alternative extralevator approach (ELAPE) has been suggested to improve the quality of resection by avoiding coning of the specimen decreasing the risk of tumor perforation and CRM+. The aim of this study is to compare the quality of the resected specimen and postoperative complication rates between ELAPE and "standard" APE.

METHODS

All patients between 1998 and 2014 undergoing abdominal perineal excision for primary or recurrent rectal cancer at a single Institution were reviewed. Between 1998 and 2008, all patients underwent standard APE. In 2009 ELAPE was introduced at our Institution and all patients requiring APE underwent this alternative procedure (ELAPE). The groups were compared according to pathological characteristics, specimen quality (CRM status, perforation and failure to provide the rectum and anus in a single specimen-fragmentation) and postoperative morbidity.

RESULTS

Fifty patients underwent standard APEs, while 22 underwent ELAPE. There were no differences in CRM+ (10.6 vs. 13.6%; p = 0.70) or tumor perforation rates (8 vs. 0%; p = 0.30) between APE and ELAPE. However, ELAPE were less likely to result in a fragmented specimen (42 vs. 4%; p = 0.002). Advanced pT-stage was also a risk factor for specimen fragmentation (p = 0.03). There were no differences in severe (Grade 3/4) postoperative morbidity (13 vs. 10%; p = 0.5). Perineal wound dehiscences were less frequent among ELAPE (52 vs 13%; p < 0.01). Despite short follow-up (median 21 mo.), 2-year local recurrence-free survival was better for patients undergoing ELAPE when compared to APE (87 vs. 49%; p = 0.04).

CONCLUSIONS

ELAPE may be safely implemented into routine clinical practice with no increase in postoperative morbidity and considerable improvements in the quality of the resected specimen of patients with low rectal cancers.

Standard versus extralevator abdominoperineal excision and oncologic outcomes for patients with distal rectal cancer: A meta-analysis

BACKGROUND

The role of extralevator abdominoperineal excision (ELAPE) for distal rectal cancer remains controversial, and the procedure is not widely accepted or practiced.

METHODS

An electronic search of Medline, EMBASE, Web of Science, and similar databases for articles in English was performed from the inception of the study until October 31, 2017. Two reviewers extracted information and independently assessed the quality of included studies by the methodological index for nonrandomized studies, then data were analyzed with Review Manager 5.3 software and Stata version 12.0 software.

RESULTS

Our meta-analysis included 17 studies with 3479 patients, of whom 1915 (55.0%) underwent ELAPE and 1564 (44.0%) underwent abdominoperineal excision (APE). Compared with patients undergoing APE, patients undergoing ELAPE had a significant reduced risk of no more than 3 years local recurrence (LR) (risk ratio [RR] = 0.27, 95% confidence interval [CI] = 0.08-0.94), 3-year mortality (odds ratio [OR] = 0.45, 95% CI = 0.20-0.97), intraoperative bowel perforation (IBP) involvement (RR = 0.48, 95% CI = 0.31-0.74), and circumferential resection margin (CRM) positivity (RR = 0.66, 95% CI = 0.43-1.00) at the threshold level.

CONCLUSIONS

The application of ELAPE is more effective in reducing the chance of 3 years LR, mortality, IBP involvement and CRM positivity than conventional APE, and worthy of being widely applied in surgical treatment of the distal rectal cancer.

Abdominoperineal Excision: Technical Challenges in Optimal Surgical and Oncological Outcomes after Abdominoperineal Excision for Rectal Cancer

Treatment results in rectal cancer have improved significantly during the recent two decades, but local control and survival after abdominoperineal excision (APE) have not improved to the same degree as that seen after anterior resection (AR). The reason for this is an increased risk of inadvertent bowel perforations and tumor involved margins after APE as compared with AR. The conventional synchronous combined APE has not been a standardized procedure and consequently oncological outcomes have varied considerably between different institutions and in different reports. With the new concept of APE, based on well-defined anatomical structures, the procedure can be categorized as intersphincteric APE, extralevator APE, and ischioanal APE. This article discusses the technical aspects and results from this approach.

A systematic review of transabdominal levator division during abdominoperineal excision of the rectum (APER)

BACKGROUND

The aim of the present study was to evaluate the surgical technique, short-term oncological and perioperative outcomes for the transabdominal division of the levator ani muscles during abdominoperineal excision of the rectum (APER).

METHODS

A systematic review was performed to identify studies reporting on transabdominal division of the levator ani during APER. A comprehensive literature search was performed using a combination of free-text terms and controlled vocabulary when applicable on the following databases: MEDLINE, EMBASE, Science Citation Index Expanded and Cochrane Central Register of Controlled Trials in the Cochrane Library. The search period was from January 1945 to December 2015. The following search headings were used: "transabdominal", "transpelvic", "abdominal" or "pelvic" combined with either "levator" or "extralevator" and with "abdominoperineal".

RESULTS

Nine publications were identified reporting on 99 participants. The male/female distribution was 1.44:1, respectively, and the mean age was 56.6 (30-77) years. All tumours were less than 5 cm from the anal verge. The preoperative radiological staging was T2 in 18% of cases, T3 in 53.5% and T4 in 28.5%. Transabdominal division of the levators was performed laparoscopically in 55 cases, robotically in 34 and open in 10. The mean operating time was 255 (177-640) min. Mean intraoperative blood loss was 140 (92-500) ml. There were no conversions to open. Circumferential resection margins were positive in two cases, and there was one intraoperative perforation. Mean post-operative length of stay was 9.3 (3-67) days. Follow-up (from 0 to 31 months) revealed 19 perineal wound infections, 15 cases of sexual dysfunction and 7 cases of urinary retention. There was no mortality and 1 readmission.

CONCLUSIONS

Transabdominal division of the levators during APER is feasible and reproducible, with acceptable perioperative and good early oncological outcomes. Further comparative studies are needed.

A pilot randomized study comparing extralevator with conventional abdominoperineal excision for low rectal cancer after neoadjuvant chemoradiation

AIM

The aims of this study were to assess the feasibility of performing an extralevator abdominoperineal excision (ELAPE) after neoadjuvant chemoradiation (NCRT), to compare the rates of circumferential resection margin (CRM) involvement and intra-operative perforation (IOP) of the specimen, and to assess the amount of tissue removed around the muscularis propria (MP)/internal sphincter (IS) of the lower rectum in patients with low rectal cancer undergoing ELAPE compared with conventional abdominoperineal excision (CAPE) after NCRT.

METHOD

This was an open-label, parallel-arm pilot randomized trial conducted in India. Twenty patients were randomized to one of the study arms. The surgical specimens were fixed, serially cross-sectioned and photographed. Using specialized morphometry software, the amount of tissue resected with each operation was measured.

RESULTS

There was a nonsignificant trend towards more IOPs (30% vs 0%, P = 0.06) and a higher CRM involvement rate (40% vs 20%, P = 0.32) in the CAPE arm. ELAPE removed a significantly greater amount of tissue around the IS/MP when compared with CAPE (mean ± SD: 1911.39 ± 382 mm² vs 1132.03 ± 371 mm² , P < 0.001). The mean distance from the IS/MP to the CRM was significantly greater in the ELAPE arm both in the posterior (mean ± SD: 28.28 ± 3 mm vs 9.63 ± 3 mm, P < 0.001) and lateral (mean ± SD: 13.69 ± 3 mm vs 9.72 ± 3 mm, P = 0.009) parts of the rectum but not in the anterior part (mean ± SD: 6.74 ± 2 mm vs 6.10 ± 4 mm, P = 0.64). The short-term morbidity was not significantly different between the two procedures.

CONCLUSION

ELAPE removed more tissue in the lower rectum and resulted in a lower rate of IOP and CRM involvement when compared with CAPE, even after NCRT.

Predictors of Perineal Wound Complications and Prolonged Time to Perineal Wound Healing After Abdominoperineal Resection

BACKGROUND

Perineal wound following abdominoperineal resection (APR) is associated with high complication rate and delayed healing. We aim to evaluate the risk factors for delayed wound healing and wound complications following APR.

METHODS

A retrospective review of patients who underwent APR was performed. Non-delayed wound healing occurred within 6 weeks. Major complications included infection, necrosis, and dehiscence that required surgical interventions. Minor complications included drainage and superficial dehiscence that were treated conservatively. Patients were compared for type of wound closure (primary vs. flap reconstruction). Effect of patients' demographic and clinical variables on time to healing, and on major and minor wound complications was examined.

RESULTS

215 patients were identified, of which 175 (81 %) had primary closure and 40 (19 %) had flap reconstruction. Overall, major wound complications occurred in 14 (7 %) of patients and minor wound complications occurred in 48 (22 %). Mean time to wound healing was 6.3 weeks in the primary closure group and 9.3 weeks in the flap reconstruction group (p = 0.02). Delayed wound healing occurred in 44 (25 %) of the primary closure group and in 25 (62 %) of the flap reconstruction group (p < 0.001). Delayed wound healing was associated with smoking (p = 0.005), hypoalbuminemia (p = 0.05), neoadjuvant chemotherapy (p = 0.02), and flap reconstruction (p = 0.03). Hypoalbuminemia was associated with major wound complications (p = 0.002), while neoadjuvant chemotherapy was associated with minor wound complications (p = 0.01).

CONCLUSIONS

Wound complications and delayed healing are related to patients' nutritional status, smoking, and neoadjuvant chemotherapy. Patients with these risk factors are at risk of delayed wound healing even if they underwent flap reconstruction.

Extralevator with vs nonextralevator abdominoperineal excision for rectal cancer: the RELAPe randomized controlled trial

AIM

A randomized controlled trial was conducted to test the null hypothesis that there is no difference in circumferential resection margin (CRM) between extralevator abdominoperineal excision (ELAPE) and non-ELAPE for rectal cancer.

METHOD

This was a multicentre, randomized controlled trial registered as NCT01702116. Patients with rectal cancer involving the external anal sphincter were randomized to ELAPE or non-ELAPE following neoadjuvant chemoradiation. Randomization was performed according to Consolidated Standards of Reporting Trials (CONSORT) guidelines. The primary end-point was CRM (in mm), defined as the shortest distance between the tumour and the cut edge of the specimen. Pathologists and centralized pathology were blinded to the patients' study arm. Interrater reliability (IRR) was assessed using Kendall's coefficient. Intra-operative perforation (IOP) was any rectal defect determined at pathology. Complications were classified using the Clavien-Dindo classification. Participating surgeons were retrained and credentialed. A sample size calculation showed that 34 subjects would provide sufficient power to reject the null hypothesis.

RESULTS

Thirty-four patients underwent the allocated intervention. Seventeen patients treated with ELAPE were comparable with 17 patients treated with non-ELAPE regarding age, gender, body mass index (BMI), American Society of Anesthesiology (ASA) class and pre-existing comorbidities. CRM depth (7.14 ± 5.76 mm vs 2.98 ± 3.28 mm, P = 0.016) and involvement rates (5.8% vs 41.0%, P = 0.04) were significantly increased in patients treated with ELAPE. The IRR for CRM was 0.78. There were no significant differences in IOP (5.8% vs 11.7%, P = 0.77) and complication rates (29% vs 29%, P = 0.97).

CONCLUSIONS

ELAPE was associated with statistically improved CRM with no difference in IOP and complication rates compared with non-ELAPE for rectal cancer involving the external anal sphincter.

Survival after Abdominoperineal and Sphincter-Preserving Resection in Nonmetastatic Rectal Cancer: A Population-Based Time-Trend and Propensity Score-Matched SEER Analysis

Background. Abdominoperineal resection (APR) has been associated with impaired survival in nonmetastatic rectal cancer patients. It is unclear whether this adverse outcome is due to the surgical procedure itself or is a consequence of tumor-related characteristics. Study Design. Patients were identified from the Surveillance, Epidemiology, and End Results database. The impact of APR compared to coloanal anastomosis (CAA) on survival was assessed by Cox regression and propensity-score matching. Results. In 36,488 patients with rectal cancer resection, the APR rate declined from 31.8% in 1998 to 19.2% in 2011, with a significant trend change in 2004 at 21.6% (P < 0.001). To minimize a potential time-trend bias, survival analysis was limited to patients diagnosed after 2004. APR was associated with an increased risk of cancer-specific mortality after unadjusted analysis (HR = 1.61, 95% CI: 1.28-2.03, P < 0.01) and multivariable adjustment (HR = 1.39, 95% CI: 1.10-1.76, P < 0.01). After optimal adjustment of highly biased patient characteristics by propensity-score matching, APR was not identified as a risk factor for cancer-specific mortality (HR = 0.85, 95% CI: 0.56-1.29, P = 0.456). Conclusions. The current propensity score-adjusted analysis provides evidence that worse oncological outcomes in patients undergoing APR compared to CAA are caused by different patient characteristics and not by the surgical procedure itself.

Extralevator abdominoperineal excision versus conventional surgery for low rectal cancer: a single surgeon experience

OBJECTIVE

Extralevator abdominoperineal excision (ELAPE) reduces the risk of positive circumferential resection margin (CRM) and of intraoperative perforation (IOP), both of which are associated with high local recurrence rates and poor survival outcomes for rectal cancer. The aim of this study was to compare the results of ELAPE with conventional abdominoperineal excision (APE) for low rectal cancer.

MATERIAL AND METHODS

A total of 25 consecutive patients underwent ELAPE for low rectal cancer between November 2008 and September 2011. Fifty-six patients treated by conventional APE prior to 2008 were selected from our rectal cancer database for comparison as a historical cohort.

RESULTS

The mean follow-up was 44.7 months in the ELAPE group, and 70.6 months in the APE group. Patients undergoing ELAPE had a lower CRM positivity and IOP rate than APE (12% vs. 20%, p=0,531; 4% vs. 8,9%, p=0,826; respectively). The ELAPE group was associated with higher perineal wound complications than the APE group (16.0% vs. 1.8%, p=0.030). Local recurrence rates for patients in both groups did not differ significantly (4.0% vs. 3.6%, p=1.0).

CONCLUSION

The results of this study suggest that ELAPE technique was associated with less CRM involvement and reduced rates of IOP but markedly higher rates of postoperative perineal complications occurred as compared to conventional surgery. ELAPE must be reserved for advanced low rectal cancers.

[Spincter preservation after selective chemoradiotherapy of rectal cancer. Interim results of the OCUM study]

BACKGROUND

In a prospective multicenter observational study (OCUM) neoadjuvant chemoradiotherapy (nRCT) was selectively administered depending on the risk of local recurrence and based on the distance between tumor and mesorectal fascia in pretherapeutic high-resolution magnetic resonance imaging (MRI).

OBJECTIVE

Frequency and quality of abdominoperineal excision (APE) and sphincter preserving operations.

PATIENTS AND METHODS

Of 642 patients treated in 13 hospitals 389 received surgery alone and 253 nRCT followed by surgery. By univariate and multivariate analysis risk factors for APE were determined. Quality parameters were the quality grade of mesorectal excision, the pathohistological involvement of the circumferential resection margin and intraoperative local dissemination of tumor cells.

RESULTS AND DISCUSSION

In 12.8 % of the patients APE was performed. Independent risk factors for APE were tumor location in the lower third of the rectum and the individual hospitals, where APE varied between 0 and 32 %. This variation was chiefly caused by the different case mix. Hospitals with a high APE rate (> 30 %) treated significantly more patients with very low lying carcinomas (< 3 cm above the anal verge) and more advanced tumors. The median height of the tumor in cases of APE was nearly equal in all participating hospitals. Independent on the number of cases the quality of rectal surgery was high. Within the patient groups of primary surgery and nRCT the oncological quality parameter did not significantly differ between sphincter preservation and APE. As far as sphincter preservation is concerned the results justify a selective application of nRCT in patients with rectal carcinoma. The long-term results still have to be awaited.

Long-term outcome of extralevator abdominoperineal excision (ELAPE) for low rectal cancer

PURPOSE

Extralevator abdominoperineal excision (ELAPE) was introduced to improve outcomes for low-lying locally advanced rectal cancers (LARC) not amenable to sphincter preserving procedures. This study investigates prospectively outcomes of patients operated on with ELAPE compared with a similar cohort of patients operated on with conventional APE.

METHODS

After the exclusion of patients without neoadjuvant therapy, in-hospital mortality, and incomplete metastatectomy, we identified 72 consecutive patients who had undergone either conventional APE (n = 36) or ELAPE (n = 36) for LARC ≤6 cm from the anal verge. The primary outcome measure was local recurrence at 5 years, and secondary outcome measures were cause-specific and overall survival.

RESULTS

Median distance from the anal verge was significantly lower in the ELAPE group (2 vs. 4 cm, p = 0.029). Inadvertent bowel perforation could be completely avoided in the ELAPE group, but amounted to 16.7 % in the conventional APE group (p = 0.025). Cumulative local recurrence rate at 5 years was 18.2 % in the APE group compared to 5.9 % in the ELAPE group (p = 0.153). Local recurrence without distant metastases occurred in 15.5 % in the APE group but was not observed in the ELAPE group (p = 0.039). We did not detect significant differences in cause-specific nor in overall survival.

CONCLUSION

ELAPE results in lower local recurrence rates as compared with conventional APE. We conclude that the extralevator approach should be the procedure of choice for advanced low rectal cancer not amenable to sphincter preserving procedures.

Time to Chemotherapy After Abdominoperineal Resection: Comparison Between Primary Closure and Perineal Flap Reconstruction

BACKGROUND

Wound complications are frequent flowing abdominoperineal resection (APR); this can lengthen the time to chemotherapy. Flap reconstruction is being used in an attempt to improve wound healing.

OBJECTIVES

To assess the effect of flap reconstruction after APR on time to perineal wound healing and administration of adjuvant chemotherapy in patients with rectal adenocarcinoma.

METHODS

A retrospective review of patients who underwent APR for rectal adenocarcinoma between 2002 and 2012 was performed. Patients were divided into two groups based on type of perineal wound closure (primary vs. flap). Patients were compared for time to perineal wound healing, and time to adjuvant chemotherapy.

RESULTS

115 patients were identified; of whom 67 received adjuvant chemotherapy. 56 (84%) patients underwent primary closure while 11 (16%) underwent flap reconstruction. There was no difference in time to perineal wound healing (6.8 vs. 6.3 weeks, p = 0.40) and time to receive adjuvant chemotherapy (9.3 vs. 10.7 weeks, p = 0.79) between the primary closure and flap reconstruction groups, respectively. 25 (45%) of the primary closure group had a delay in receiving adjuvant chemotherapy versus 6 (55%) of the flap reconstruction group (p = 0.55). Delay in receiving adjuvant chemotherapy because of perineal wound complications occurred in 18 (32%) patients with primary closure versus 3 (28%) patients with flap reconstruction (p = 0.14).

CONCLUSIONS

Flap reconstruction does not reduce the length of time to initiating chemotherapy; there was no difference in length of healing between the two groups. Therefore, flap reconstruction should be selectively used based on the size of the perineal defect.

Extralevator Abdominoperineal Excision for Low Rectal Cancer--Extensive Surgery to Be Used With Discretion Based on 3-Year Local Recurrence Results: A Registry-based, Observational National Cohort Study

Objectives:

The aim of this prospective registry-based population study was to investigate the efficacy of extralevator abdominoperineal excision (ELAPE) regarding local recurrence rates within 3 years after surgery.

Background:

Local recurrence of rectal cancer is more common after abdominoperineal excision (APE) than after anterior resection. Extralevator abdominoperineal excision was introduced to address this problem. No large-scale studies with long-term oncological outcomes have been published.

Methods:

All Swedish patients operated on with an APE and registered in the Swedish ColoRectal Cancer Registry 2007 to 2009 were included (n = 1397) and analyzed with emphasis on the perineal part of the operation. Local recurrence at 3 years was collected from the registry.

Results:

The local recurrence rates at 3 years [median follow-up, 3.43 years (APE, 3.37 years; ELAPE, 3.41 years; not stated: 3.43 years)] were significantly higher for ELAPE compared with APE (relative risk, 4.91). Perioperative perforation was also associated with an increased risk of local recurrence (relative risk, 3.62). There was no difference in 3-year overall survival between APE and ELAPE. In the subgroup of patients with very low tumors (≤4 cm from the anal verge), no significant difference in the local recurrence rate could be observed.

Conclusions:

Extralevator abdominoperineal excision results in a significantly increased 3-year local recurrence rate as compared with standard APE. Intraoperative perforation seems to be an important risk factor for local recurrence. In addition to significantly increased 3-year local recurrence rates, the significantly increased incidence of wound complications leads to the conclusion that ELAPE should only be considered in selected patients at risk of intraoperative perforation.

Transanal Pull-Through Procedure with Delayed versus Immediate Coloanal Anastomosis for Anus-Preserving Curative Resection of Lower Rectal Cancer: A Case-Control Study

This case-control study compared the effectiveness and safety of transanal pull-through procedure (TPP) with delayed or immediate coloanal anastomosis (CAA) for anus-preserving curative resection of lower rectal cancer. Lower rectal cancer patients (n = 128) were hospitalized between January 2003 and December 2013 for elective anus-preserving curative resection through a TPP with delayed (n = 72) or immediate (n = 56) CAA. Main outcome measures including surgical safety, resection radicality, and defecation function were assessed. The two groups were comparable in age, sex, gross pathology, histology, and tumor-node-metastasis staging. Both the delayed and immediate CAA TPPs had similar resection radicality and safety profiles. The immediate CAA was associated with a significantly higher risk of anastomotic leakage and defecation impairment. None of patients in the delayed CAA group experienced anastomotic leakage. In conclusion, TPP with delayed CAA may be superior to immediate CAA in minimizing the risk of anastomotic leakage and relevant surgical morbidities, and does not require a temporary ileostomy and second-look restoration of ostomy.

Extralevator vs conventional abdominoperineal resection for rectal cancer-A systematic review and meta-analysis

BACKGROUND

The aim of this study was to compare the short-term morbidity and long-term oncologic benefits of extralevator abdominoperineal excision (ELAPE) with conventional abdominoperineal resection (CAPR) for patients with rectal cancer.

METHODS

Electronic search of the Cochrane Library, MEDLINE, EMBASE, Korean Journal, and J-EAST database from 2007 until August 2015 was carried out. We considered randomized controlled trials and nonrandomized comparative studies comparing ELAPE with CAPR to be eligible, if they included patients with rectal cancers.

RESULTS

A total of 1 randomized controlled trials and 10 nonrandomized comparative studies met the inclusion criteria, involving 1,736 patients in the ELAPE group and 1,320 in the CAPR group. The ELAPE was associated with a significantly lower intraoperative perforation rate. There were no differences regarding the circumferential margin involvement, R0 resections, and local recurrence rate. There was less blood loss in ELAPE patients.

CONCLUSIONS

The ELAPE significantly lowered the intraoperative perforation rate, with no benefits regarding circumferential resection margin involvement and local recurrence rate.

Short-term Outcomes of an Extralevator Abdominoperineal Resection in the Prone Position Compared With a Conventional Abdominoperineal Resection for Advanced Low Rectal Cancer: The Early Experience at a Single Institution

Purpose

This study compared the perioperative and pathologic outcomes between an extralevator abdominoperineal resection (APR) in the prone position and a conventional APR.

Methods

Between September 2011 and March 2014, an extralevator APR in the prone position was performed on 13 patients with rectal cancer and a conventional APR on 26 such patients. Patients' demographics and perioperative and pathologic outcomes were obtained from the colorectal cancer database and electronic medical charts.

Results

Age and preoperative carcinoembryonic antigen (CEA) level were significantly different between the conventional and the extralevator APR in the prone position (median age, 65 years vs. 55 years [P = 0.001]; median preoperative CEA level, 4.94 ng/mL vs. 1.81 ng/mL [P = 0.011]). For perioperative outcomes, 1 (3.8%) intraoperative bowel perforation occurred in the conventional APR group and 2 (15.3%) in the extralevator APR group. In the conventional and extralevator APR groups, 12 (46.2%) and 6 patients (46.2%) had postoperative complications, and 8 (66.7%) and 2 patients (33.4%) had major complications (Clavien-Dindo III/IV), respectively. The circumferential resection margin involvement rate was higher in the extralevator APR group compared with the conventional APR group (3 of 13 [23.1%] vs. 3 of 26 [11.5%]).

Conclusion

The extralevator APR in the prone position for patients with advanced low rectal cancer has no advantages in perioperative and pathologic outcomes over a conventional APR for such patients. However, through early experience with a new surgical technique, we identified various reasons for the lack of favorable outcomes and expect sufficient experience to produce better peri- or postoperative outcomes.

Current topics in the multimodality treatment of locally advanced rectal cancer

The multimodality approach to the treatment of locally advanced rectal cancer has evolved to include neoadjuvant radiotherapy with or without concurrent chemotherapy, total mesorectal excision and adjuvant fluoropyrimidine-based chemotherapy. Though this broad strategy has yielded improvements in local control compared with historical data, overall survival remains largely unchanged. Current investigations focus on improving patient selection through new imaging modalities, improving surgical techniques, incorporating more aggressive systemic treatment regimens and the selective use of radiation. Here, we review emerging data regarding newer staging techniques, neoadjuvant chemotherapy, optimal timing of surgery, selective use of radiation and nonoperative approaches to the management of locally advanced rectal cancers.

Laparoscopic translevator approach to abdominoperineal resection for rectal adenocarcinoma: feasibility and short-term oncologic outcomes

BACKGROUND

The extra-levator approach to abdominal perineal resection (APR) was developed in order to reduce the rates of positive circumferential resection margin. This approach, however, is associated with significant morbidity. We postulate that a less radical resection of the levators done laparoscopically could significantly decrease the rate of perineal complications while ensuring an oncologically adequate specimen. To date, to our knowledge, there are no reports in the literature describing a laparoscopic translevator approach for APR. The purpose of this study is to describe our initial experience with this approach and assess our short-term oncologic and clinical outcomes.

METHODS

This is a retrospective study of patients who underwent laparoscopic APR with intra-abdominal levator transection for rectal cancer from 2012 to 2014 at a single tertiary care institution. Main outcome measures include: perineal flap rates, post-operative complications, length of stay, distance from tumour to circumferential resection margin, R0 status, and disease recurrence. Data are presented as median (interquartile range) unless otherwise noted.

RESULTS

Seventeen cases were identified. Patient age was 61 (range 34-75), and 59 % were male. Pre-operative distance of the tumour from the anal verge was 2.6 cm (0.4-3.9). Post-operative length of stay was 4 (4-6) days. One patient required a perineal flap for reconstruction. Four patients (22 %) had perineal complications (three wound infections and one hernia). No patients reported sexual dysfunction, and one (5 %) developed urinary retention. Five (29 %) patients had a complete pathological response. The circumferential resection margin was 1.5 (0.8-2.5) cm, with no positive margins reported. The number of retrieved lymph nodes was 12 (range 2-30). Follow-up was 9.7 months (range 20 days-23 months), during which one patient developed recurrent disease.

CONCLUSIONS

This study describes a novel surgical approach to APR that has the potential to both decrease perineal complications and provide excellent oncologic results.

Standard versus extralevator abdominoperineal low rectal cancer excision outcomes: a systematic review and meta-analysis

BACKGROUND

The extended, extralevator abdominoperineal excision has been described with the aim of improving oncological low rectal cancer patient outcomes.

MATERIALS AND METHODS

A systematic literature review was conducted using Medline/PubMed, Embase, Cochrane library, and Ovid for standard and extralevator abdominoperineal rectal cancer excision studies between 1995 and 2013. A total of 1,270 articles were identified and screened, and of these, 58 reports (1 randomized, 5 case-control and 52 cohort studies) were included for the qualitative analysis, and 6 were included for the quantitative analysis. The primary endpoints included intraoperative tumor perforation, the circumferential resection margin involvement, local recurrence rate, and the perineal wound complication rate. The secondary endpoints included the length of postoperative hospital stay and quality of life. Comprehensive Rev Men, version 5.2 was used for the statistical calculations.

RESULTS

A significant difference in the circumferential resection margin involvement rate [odds ratio (OR) 2.9; p < .001], intraoperative perforation (OR 4.30; p < .001), local recurrence rate (OR 2.52; p = .02), and length of hospital stay (OR 1.06; p < .001) in favor of the extended group was observed. Additionally, the perineal wound complications were higher in the extended group (OR 0.62; p = .007). No difference in quality of life was observed.

CONCLUSIONS

Our analysis confirms the oncological advantages of the extended abdominoperineal excision method. Although the perineal wound complications were higher, the length of postoperative hospital stay was shorter, and quality of life was not inferior to the conventional resection method.

Extralevator abdominoperineal excision for low rectal cancer: a systematic review and meta-analysis of the short-term outcome

AIM

The superiority of extralevator abdominoperineal excision (ELAPE) over conventional abdominoperineal excision (APE) remains controversial, despite the publication of many studies on this issue. The aim of this meta-analysis was to provide a clear, evidence-based comparison of the two procedures.

METHOD

A systematic review and meta-analysis was conducted through a comprehensive search of the PubMed, EMBASE/Medline and Cochrane Central Library databases for all studies comparing ELAPE with conventional APE for low rectal cancer. Pooled data on circumferential resection margin (CRM) positivity, intra-operative bowel perforation, perineal wound complications and local recurrence were analysed.

RESULTS

Seven studies, involving a total of 2672 patients, were included. Analysis of the pooled data did not reveal a significant difference between the two operations regarding CRM positivity [risk ratio (RR) = 0.79, 95% CI: 0.40-1.57; P = 0.50, I(2)  = 86%] and perineal wound complications (RR = 0.91, 95% CI: 0.71-1.16; P = 0.44, I(2)  = 49%), and showed a borderline reduced risk of intra-operative bowel perforation for ELAPE, but still did not reveal a significant difference between the two groups (RR = 0.61, 95% CI: 0.37-1.00; P = 0.05, I(2)  = 58%).

CONCLUSION

The current evidence does not indicate a statistically significant superiority of ELAPE over conventional APE in terms of CRM positivity and intra-operative bowel perforation.

Advances and challenges in treatment of locally advanced rectal cancer

Dramatic improvements in the outcomes of patients with rectal cancer have occurred over the past 30 years. Advances in surgical pathology, refinements in surgical techniques and instrumentation, new imaging modalities, and the widespread use of neoadjuvant therapy have all contributed to these improvements. Several questions emerge as we learn of the benefits or lack thereof for components of the current multimodality treatment in subgroups of patients with nonmetastatic locally advanced rectal cancer (LARC). What is the optimal surgical technique for distal rectal cancers? Do all patients need postoperative chemotherapy? Do all patients need radiation? Do all patients need surgery, or is a nonoperative, organ-preserving approach warranted in selected patients? Answering these questions will lead to more precise treatment regimens, based on patient and tumor characteristics, that will improve outcomes while preserving quality of life. However, the idea of shifting the treatment paradigm (chemoradiotherapy, total mesorectal excision, and adjuvant therapy) currently applied to all patients with LARC to a more individually tailored approach is controversial. The paradigm shift toward organ preservation in highly selected patients whose tumors demonstrate clinical complete response to neoadjuvant treatment is also controversial. Herein, we highlight many of the advances and resultant controversies that are likely to dominate the research agenda for LARC in the modern era.

Laparoscopic repair of postoperative perineal hernia using a two-mesh technique

AIM

Perineal herniation following abdomino-perineal excision of the rectum (APER) can be debilitating. Repair options include a transabdominal (laparoscopic or open), perineal or a combined approach, but there is no consensus on the optimal technique. We describe a novel laparoscopic two-mesh technique and short- to medium-term outcomes.

METHOD

Six patients underwent this operation between 2008 and 2014. Patients were positioned in a modified Lloyd-Davies position, allowing perineal access, and steep Trendelenburg to aid displacement of small bowel from the pelvis. A polypropylene mesh was shaped, placed over the hernial defect, tacked postero-laterally and sutured antero-laterally to reconstitute the pelvic diaphragm. A second larger mesh (composite) was placed over the first supporting mesh and secured with tacks and sutures, overlapping the hernial defect, preventing small bowel contact with the mesh.

RESULTS

The median time from the index operation to presentation of the hernia was 5 months. One patient with dense small bowel adhesions from the primary repair had a combined laparoscopic and perineal approach. The median operating time was 141 min and median length of stay was 3 days. There were no intra-operative complications and no recurrences over a follow-up of 1-76 months.

CONCLUSION

We describe a novel laparoscopic technique for perineal hernia repair following APER with a low recurrence rate in the intermediate term.

Transabdominal extralevator abdominoperineal excision (eLAPE) performed by laparoscopic approach with no position change

As a new surgical technique, extralevator abdominoperineal excision (eLAPE) is recommended for the treatment of low rectal cancer. The patient's position is changed to a prone jackknife position before extralevator excision is performed via the perineal approach. Whether the extralevator excision can be completed through a transabdominal route under laparoscopy is controversial. This study was designed to introduce a modified technique of laparoscopic-assisted eLAPE and to evaluate the feasibility and safety of this technique. With no change of position, laparoscopic eLAPE was performed in 12 patients with low rectal cancer through a transabdominal route between February 2012 and August 2013. There was no case with bowel perforation and positive circumferential resection margins among these 12 patients. The mean operative time was 177.1 minutes, and the mean intraoperative blood loss was 92.5 mL. The mean time to passing of first flatus was 2.3 days, and the mean postoperative hospital stay was 7.5 days. There was no case with bladder dysfunction. No patients suffered from sexual dysfunction during the follow-up period. Without the change of the patient's position, eLAPE can be performed through a transabdominal route by the laparoscopic approach. The procedure of the former eLAPE is simplified without compromising oncologic outcome.

Persistent perineal morbidity is common following abdominoperineal excision for rectal cancer

PURPOSE

Short-term complications related to the perineal wound after abdominoperineal excision (APE) are a well-known problem. Perineal morbidity in the longer term is an almost unexplored area. The aim of this cross-sectional study was to investigate the prevalence of perineal symptoms 3 years after APE for rectal cancer, to identify potential risk factors and to explore the relationship between perineal morbidity and global quality of life.

METHOD

All patients who underwent APE in Sweden between 2007 and 2009 (n = 1373) were identified through the Swedish Colorectal Cancer Registry. Surviving patients were contacted 3 years after surgery and asked about participation. A total of 545 patients completed a detailed questionnaire. Clinical data was collected from the registry and surgical charts.

RESULTS

Perineal symptoms occurred in 50 % of all patients 3 years after APE and more frequently in women (58 vs. 44 %; p = 0.001). Delayed healing of the perineal wound (>4 weeks) occurred in 25 % of all patients and more frequently after extralevator APE (ELAPE) than after conventional APE (32 vs. 11 %, p < 0.001). Delayed healing was associated with an increased risk of more severe perineal symptoms (relative risk (RR) 1.50, 95 % confidence interval (95 % CI) 1.09-2.05). Patients with more severe perineal symptoms (n = 129) had a significantly lower global quality of life as measured by EQ-5D visual analogue scale (VAS; median 75 vs. 83 points on the 100-point scale; p < 0.001).

CONCLUSION

Persistent perineal symptoms are common after APE and may have an impact on patients' quality of life. Delayed wound healing may be a risk factor for persistent symptoms. Further studies are needed to identify avoidable clinical factors for the development of persistent perineal morbidity. CLINICALTRIALS.

GOV IDENTIFIER

NCT01296984.

Analysis of the prognostic factors for low rectal cancer with the pT1-2NxM0 stage after abdominoperineal resection

OBJECTIVE

This study was designed to explore the factors influencing local recurrence and survival for low rectal cancer with pT1-2NxM0 stage after an abdominoperineal resection (APR).

METHODS

Data of 429 patients confirmed to have pT1-2NxM0 after APR were reviewed.

RESULTS

The recurrence rate in patients with intraoperative perforation, less than 12 lymph nodes (LNs) harvested, T2 staging, and positive circumferential resection margin (CRM) was 25.1, 19.9, 9.5, and 26.1% compared with 6.9, 7.0, 0, and 5.8% in patients with no perforation, 12 or more LNs harvested, T1, and negative CRM. The 5-year survival rate in patients with age of at least 70, perforation, less than 12 LNs harvested, T2, and positive CRM was 71.1, 60.8, 58.8, 69.9, and 46.0%, but 73.4, 73.5, 73.8, 89.4, and 75.0% in patients with age less than 70, no perforation, 12 or more LNs harvested, T1, and negative CRM. Meanwhile, patients with N0, N1, and N2 had a survival rate of 90.7, 69.9, and 63.9%. Multivariate analysis showed that perforation (P<0.001), number of LNs harvested (P<0.001), T staging (P<0.001), differentiation (P=0.045), and CRM status (P=0.002) were associated with local recurrence, whereas age of the patients (P=0.023), N staging (P<0.001), differentiation (P=0.011), and CRM status (P=0.004) were associated with survival.

CONCLUSION

APR was affected by patients' age, operation performer, perforation, number of LNs harvested, T staging, N staging, differentiation, and CRM status. Perforation, number of LNs harvested, T staging, differentiation, and CRM status were independent factors for recurrence; meanwhile, age of the patients, N staging, differentiation, and CRM status were independent factors influencing survival.

Intra-operative perforation: a risk factor for prognosis of low rectal cancer after abdominoperineal resection

This study was designed to explore the influence of intra-operative perforation on prognosis of low rectal cancer after APR and to investigate the risk factors of perforation. Perforation is not scarce during the procedure of abdominoperineal resection (APR). There is no consensus on perforation rate and related risk factor for APR. Data of 925 patients who received APR for low rectal cancer between January 2000 and August 2008 were reviewed. The intra-operative perforation rate was 7.4 % (68/925). The recurrence rate was 28.6 % in patients with intra-operative perforation compared with 6.8 % in patients with no perforation (P < 0.001); 5-year survival rate in patients with perforation was 41.4 and 66.3 % in patients with no perforation. Univariate analysis showed that intra-operative perforation affected recurrence rate and survival significantly (P < 0.001, P < 0.001); multivariate analysis revealed that intra-operative perforation was an independent prognostic factors for recurrence (RR: 3.087, P < 0.001), while not for survival (RR: 1.331, P = 0.051). Patients aged more than 70 years, T3 tumor and treated by general surgeon had higher perforation rate (P = 0.001, P = 0.004, P = 0.008). Intra-operative perforation affected the prognosis of low rectal cancer after APR significantly. Elderly patient aged more than 70 years, T3 tumor and general surgeon who performed operation were three risk factors of increased perforation rate.