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Kasai S, Kagawa H, Shiomi A, Hino H, Manabe S, Yamaoka Y, Maeda C, Tanaka Y, Kinugasa Y. Incidence and risk factors for perineal hernia after robotic abdominoperineal resection: a single-center, retrospective cohort study. Tech Coloproctol 2024; 28:79. [PMID: 38965146 DOI: 10.1007/s10151-024-02961-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 06/08/2024] [Indexed: 07/06/2024]
Abstract
BACKGROUND Perineal hernia (PH) is a late complication of abdominoperineal resection (APR) that may compromise a patient's quality of life. The frequency and risk factors for PH after robotic APR adopting recent rectal cancer treatment strategies remain unclear. METHODS Patients who underwent robotic APR for rectal cancer between December 2011 and June 2022 were retrospectively examined. From July 2020, pelvic reinforcement procedures, such as robotic closure of the pelvic peritoneum and levator ani muscles, were performed as prophylactic procedures for PH whenever feasible. PH was diagnosed in patients with or without symptoms using computed tomography 1 year after surgery. We examined the frequency of PH, compared characteristics between patients with PH (PH+) and without PH (PH-), and identified risk factors for PH. RESULTS We evaluated 142 patients, including 53 PH+ (37.3%) and 89 PH- (62.6%). PH+ had a significantly higher rate of preoperative chemoradiotherapy (26.4% versus 10.1%, p = 0.017) and a significantly lower rate of undergoing pelvic reinforcement procedures (1.9% versus 14.0%, p = 0.017). PH+ had a lower rate of lateral lymph node dissection (47.2% versus 61.8%, p = 0.115) and a shorter operative time (340 min versus 394 min, p = 0.110). According to multivariate analysis, the independent risk factors for PH were preoperative chemoradiotherapy, not undergoing lateral lymph node dissection, and not undergoing a pelvic reinforcement procedure. CONCLUSIONS PH after robotic APR for rectal cancer is not a rare complication under the recent treatment strategies for rectal cancer, and performing prophylactic procedures for PH should be considered.
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Affiliation(s)
- S Kasai
- Division of Colon and Rectal Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
- Department of Gastrointestinal Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
| | - H Kagawa
- Division of Colon and Rectal Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan.
| | - A Shiomi
- Division of Colon and Rectal Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - H Hino
- Division of Colon and Rectal Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - S Manabe
- Division of Colon and Rectal Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Y Yamaoka
- Division of Colon and Rectal Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - C Maeda
- Division of Colon and Rectal Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Y Tanaka
- Division of Colon and Rectal Surgery, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Y Kinugasa
- Department of Gastrointestinal Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
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Fu J, Zhang X, Li G, Xu Z, Zhou J, Yuan H, Xi J, Wang Y. Pelvic Floor Peritoneum Closure Reduces Severe Postoperative Complications in Rectal Cancer Patients After Laparoscopic Anterior Rectal Resection. Surg Laparosc Endosc Percutan Tech 2024; 34:35-42. [PMID: 37725832 DOI: 10.1097/sle.0000000000001226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 07/31/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND Laparoscopic anterior rectal resection (LAR) is a commonly performed surgery for rectal cancer patients. Pelvic floor peritoneum closure (PC), a vital procedure in conventional anterior rectal resection, is not routinely performed in LAR. STUDY DESIGN A total of 1118 consecutive patients with rectal cancer receiving LAR were included in this retrospective study. Patients were allocated into the PC group and the non-PC group. The occurrence of postoperative complications was compared between the 2 groups. Influential factors in anastomotic leakage (AL) were explored using univariate and multivariate logistic regression. RESULTS There was no difference between the groups in terms of baseline characteristics. The occurrence of postoperative complications was similar between the groups. The PC group had significantly shorter postoperative hospitalization and longer operation duration compared with the non-PC group. The occurrences of Clavien-Dindo (CD) III-IV complications, CD III-IV AL, and reoperation were significantly lower in the PC group than the non-PC group. PC and a protective ileostomy were independent protective factors for CD III-IV AL. CONCLUSION PC could reduce the occurrence of CD III-IV complications, especially CD III-IV AL, and the rate of secondary surgery, especially in patients with a lower body mass index and patients who did not receive protective ileostomies.
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Affiliation(s)
- Jie Fu
- Department of General Surgery and Guangdong Provincial Key Laboratory of Precision Medicine for Gastrointestinal Tumor, Nanfang Hospital, The First School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong
- Department of General Surgery, University of Chinese Academy of Sciences, Shenzhen Hospital, Shenzhen
| | - Xuehua Zhang
- Department of General Surgery and Guangdong Provincial Key Laboratory of Precision Medicine for Gastrointestinal Tumor, Nanfang Hospital, The First School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong
| | - Gaohua Li
- Department of General Surgery and Guangdong Provincial Key Laboratory of Precision Medicine for Gastrointestinal Tumor, Nanfang Hospital, The First School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong
| | - Zhenzhao Xu
- Department of General Surgery and Guangdong Provincial Key Laboratory of Precision Medicine for Gastrointestinal Tumor, Nanfang Hospital, The First School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong
| | - Jinfan Zhou
- Department of General Surgery and Guangdong Provincial Key Laboratory of Precision Medicine for Gastrointestinal Tumor, Nanfang Hospital, The First School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong
| | - Haitao Yuan
- Department of General Surgery and Guangdong Provincial Key Laboratory of Precision Medicine for Gastrointestinal Tumor, Nanfang Hospital, The First School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong
| | - Jiafei Xi
- Stem Cell and Regenerative Medicine Lab, Beijing Institute of Radiation Medicine, Beijing, China
| | - Yanan Wang
- Department of General Surgery and Guangdong Provincial Key Laboratory of Precision Medicine for Gastrointestinal Tumor, Nanfang Hospital, The First School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong
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Riva CG, Kelly ME, Vitellaro M, Rottoli M, Aiolfi A, Ferrari D, Bonitta G, Rausa E. A comparison of surgical techniques for perineal wound closure following perineal excision: a systematic review and network meta-analysis. Tech Coloproctol 2023; 27:1351-1366. [PMID: 37843643 DOI: 10.1007/s10151-023-02868-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 09/28/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND To mitigate pelvic wound issues following perineal excision of rectal or anal cancer, a number of techniques have been suggested as an alternative to primary closure. These methods include the use of a biological/dual mesh, omentoplasty, muscle flap, and/or pelvic peritoneum closure. The aim of this network analysis was to compare all the available surgical techniques used in the attempt to mitigate issues associated with an empty pelvis. METHODS An electronic systematic search using MEDLINE databases (PubMed), EMBASE, and Web of Science was performed (Last date of research was March 15th, 2023). Studies comparing at least two of the aforementioned surgical techniques for perineal wound reconstruction during abdominoperineal resection, pelvic exenteration, or extra levator abdominoperineal excision were included. The incidence of primary healing, complication, and/or reintervention for perineal wound were evaluated. In addition, the overall incidence of perineal hernia was assessed. RESULTS Forty-five observational studies and five randomized controlled trials were eligible for inclusion reporting on 146,398 patients. All the surgical techniques had a comparable risk ratio (RR) in terms of primary outcomes. The pooled network analysis showed a lower RR for perineal wound infection when comparing primary closure (RR 0.53; Crl 0.33, 0.89) to muscle flap. The perineal wound dehiscence RR was lower when comparing both omentoplasty (RR 0.59; Crl 0.38, 0.95) and primary closure (RR 0.58; Crl 0.46, 0.77) to muscle flap. CONCLUSIONS Surgical options for perineal wound closure have evolved significantly over the last few decades. There remains no clear consensus on the "best" option, and tailoring to the individual remains a critical factor.
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Affiliation(s)
- C G Riva
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy
| | - M E Kelly
- School of Medicine, Trinity College Dublin, Dublin, Ireland
- The Trinity St. James's Cancer Institute, Dublin, Ireland
| | - M Vitellaro
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy.
| | - M Rottoli
- Surgery of the Alimentary Tract, IRCCS Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy
| | - A Aiolfi
- General Surgery, Istituto Clinico Sant'Ambrogio, Milan, Italy
| | - D Ferrari
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - G Bonitta
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy
| | - E Rausa
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy
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Zhang P, Wang A, Bian C, Zhou H. Robotic anterior resection and partial peritonectomy for rectal cancer with peritoneal carcinomatosis-A video vignette. Colorectal Dis 2023; 25:2110-2111. [PMID: 37574702 DOI: 10.1111/codi.16708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 06/30/2023] [Accepted: 07/09/2023] [Indexed: 08/15/2023]
Affiliation(s)
- Peng Zhang
- Division of Colorectal Surgery, Changzheng Hospital, Navy Medical University, Shanghai, China
| | - Anqi Wang
- Division of Colorectal Surgery, Changzheng Hospital, Navy Medical University, Shanghai, China
| | - Ce Bian
- Division of Colorectal Surgery, Changzheng Hospital, Navy Medical University, Shanghai, China
| | - Haiyang Zhou
- Division of Colorectal Surgery, Changzheng Hospital, Navy Medical University, Shanghai, China
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Shen Y, Yang TH, Deng X, Wu Q, Wei M, Meng W, Wang ZQ. Closure of pelvic peritoneum with bladder peritoneum flap reconstruction after laparoscopic extralevator abdominoperineal excision: A prospective stage II study. J Surg Oncol 2023; 128:851-859. [PMID: 37462103 DOI: 10.1002/jso.27382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 06/14/2023] [Accepted: 06/19/2023] [Indexed: 09/11/2023]
Abstract
BACKGROUND Extralevator abdominoperineal resection (ELAPE) has increased perineal wound complications due to the extended resection area. Closure of the pelvic peritoneum (CPP) may exclude the abdominal content from descending into the pelvic cavity and reduce the incidence of perineal complications after ELAPE. We have previously introduced bladder peritoneum flap reconstruction (BLAPER) as a novel method for patients in whom traditional CPP is not possible. The aim of the present study was to report the development and preliminary outcomes of BLAPER. METHODS This is a prospective single-arm study at the development and exploration phase and fulfills the IDEAL framework stage II. Ultralow rectal cancer patients with rigid pelvis who underwent ELAPE with BLAPER were enrolled. Primary outcomes were intraoperative complications and postoperative complications within 1 month after surgery. RESULTS Among 27 patients included, the overall success rate of BLAPER was 96.3% (26/27). Indocyanine green fluorescence imaging and antiadhesive barrier placement were introduced to improve the BLAPER technique. The incidence of major pelvic wound complications was 7.7%. No patient who underwent BLAPER has suffered small bowel obstruction (SBO), presence of small bowel in the retrourogenital space, or perineal hernia (PH). CONCLUSIONS BLAPER is safe and may prevent the small bowel from descending into the retrourogenital space and subsequently developing PH and SBO without increasing the intraoperative and postoperative complications. BLAPER may serve as an option when the primary suture of the pelvic peritoneum is not feasible.
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Affiliation(s)
- Yu Shen
- Department of General Surgery, Colorectal Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Ting-Han Yang
- Department of General Surgery, Colorectal Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Xiangbing Deng
- Department of General Surgery, Colorectal Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Qingbin Wu
- Department of General Surgery, Colorectal Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Mingtian Wei
- Department of General Surgery, Colorectal Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Wenjian Meng
- Department of General Surgery, Colorectal Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Zi-Qiang Wang
- Department of General Surgery, Colorectal Cancer Center, West China Hospital, Sichuan University, Chengdu, China
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Wang Z, Kou Z, Yalikun D, Tan A, Liang R. Efficacy and Safety of Modified Pelvic Peritoneum Reconstruction with Unidirectional Barbed Suture in Laparoscopic Extralevator Abdominoperineal Excision. J Laparoendosc Adv Surg Tech A 2023; 33:253-256. [PMID: 36126305 DOI: 10.1089/lap.2022.0387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Extralevator abdominoperineal excision (ELAPE) procedure leaves a large pelvic floor defect, and can result in a high rate of perineal hernia. Pelvic peritoneum reconstruction (PPR) could reduce the rate of perineal hernia. In this article, the authors reconstructed pelvic peritoneum by retracing running sutures with unidirectional barbed thread after laparoscopic ELAPE. The aim of the study is to evaluate the efficacy and safety of PPR by retracing running sutures with unidirectional barbed thread in laparoscopic ELAPE. Materials and Methods: Intact clinical data were collected retrospectively from 27 distal rectal cancer patients who underwent laparoscopic ELAPE. All the patients underwent PPR by retracing running sutures with unidirectional barbed thread in the operation. Pooled data of perineal-related complications were analyzed. Results: After retracing running sutures, the tension of pelvic peritoneum was enhanced. Of the 27 patients included, 2 patients had perineal dehiscence and 1 patient developed bowel obstruction. There were no instances of perineal hernia and pelvic peritoneal internal hernia. Conclusions: PPR by retracing running sutures with unidirectional barbed thread in laparoscopic can reduce the risk of perineal hernia.
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Affiliation(s)
- Zhiqiang Wang
- Department of Anorectal Surgery, the Second Hospital of Tianjin Medical University, Tianjin, China
| | - Zhiyong Kou
- Department of Oncology, the First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Dilimulati Yalikun
- Department of Anorectal Surgery, the Second Hospital of Tianjin Medical University, Tianjin, China
| | - Ailin Tan
- Department of Anorectal Surgery, the Second Hospital of Tianjin Medical University, Tianjin, China
| | - Rui Liang
- Department of Pathology, the Second Hospital of Tianjin Medical University, Tianjin, China
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7
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Huang W, Wei ZQ, Qiu YH, Tang G, Sun H. Effects of wound infection on prognosis after laparoscopic abdominoperineal resection of rectal cancer. Front Oncol 2023; 12:1036241. [PMID: 36686786 PMCID: PMC9846744 DOI: 10.3389/fonc.2022.1036241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Accepted: 11/28/2022] [Indexed: 01/06/2023] Open
Abstract
Background In two facilities in Chongqing, this research sought to retrospectively evaluate the effects of perineal wound infection on survival after laparoscopic abdominoperineal resection (LAPR) of rectal cancer. Methods To obtain clinical information on patients who underwent LAPR between January 2013 and December 2021, we performed a multicenter cohort study. A total of 473 patients were enrolled: 314 in the non-infection group and 159 in the group with perineal infection. The general data, perioperative conditions, and tumor outcomes between groups were analyzed. The infection rates, recurrence rates, and survival rates of the two centers were compared. Results The age, height, weight, body mass index (BMI), preoperative complications, preoperative treatment, and intraoperative conditions of patients in the LAPR infection group were not statistically different from those in the non-infection group. The percentage of men, typical postoperative hospital stay, length of initial postoperative therapy, and recurrence and metastasis rates were all considerably higher in the infection group than those in the non-infection group. Wound infection was an independent factor affecting tumor recurrence and metastasis after LAPR as well as an independent factor shortening patient survival time according to multivariate analysis. The incidence of wound infection, the rate of recurrence, and the rate of mortality did not vary significantly across sites. Conclusion Wound infection after LAPR increases the mean postoperative hospital stay, prolongs the time to first postoperative treatment, and decreases the disease-free survival (DFS) and overall survival (OS). Therefore, decreasing the rate of LAPR wound infection is expected to shorten the postoperative hospital stay and prolong the patient DFS and OS. Patients with postoperative infection may require intensive adjuvant therapy.
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Affiliation(s)
- Wang Huang
- Department of Gastrointestinal Surgery, Chongqing University Cancer Hospital, Chongqing, China
| | - Zheng-qiang Wei
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yu-hao Qiu
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Gang Tang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Hao Sun
- Department of Gastrointestinal Surgery, Chongqing University Cancer Hospital, Chongqing, China,*Correspondence: Hao Sun,
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Luo W, Lu T, Xu Z, Qian C, Li F, Xiao Y, Jia Y, Zhang B. A Novel Technique With Ileal Mesentery to Reconstruct the Pelvic Peritoneum After Pelvic Dissection With End Colostomy for Rectal Cancer. Dis Colon Rectum 2022; 65:e910-e913. [PMID: 35671241 DOI: 10.1097/dcr.0000000000002490] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND After abdominoperineal resection, low anterior resection, and end colostomy for lower rectal cancer, it is necessary to reconstruct the pelvic peritoneum to avoid small bowel obstruction, perineal hernia, and radiation enteritis in patients for whom postoperative radiotherapy is planned. However, pelvic peritoneal closure is technically difficult in patients who lack enough peritoneum to cover the defect or have received neoadjuvant radiation and have a rigid pelvis. IMPACT OF INNOVATION The impact of this innovation is to reconstruct the pelvic peritoneum with the distal ileal mesentery laparoscopically. TECHNOLOGY, MATERIALS AND METHODS After removal of the tumor, the distal ileal mesentery was selected to completely cover the defect. Subsequently, suturing of the ileal mesentery to the posterior wall of the urinary bladder and all sides of the pelvic cavity was performed. Finally, the patients were returned to the headfirst supine position to ensure that there was no small bowel falling into the pelvic dead space. PRELIMINARY RESULTS All surgical procedures were successfully performed laparoscopically from January 2019 to April 2021. No perineal complications or intestinal obstructions occurred during the follow-up period. CONCLUSIONS AND FUTURE DIRECTIONS This novel technique was found to be safe and effective. Moreover, it provided an economical method for the reconstruction of the pelvic peritoneum using autologous material, which could preserve the small intestine in the abdomen to avoid related complications. Additional larger series of patients with longer follow-up are needed to validate the safety and feasibility of this method.
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Affiliation(s)
- Wenjun Luo
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
- Department of Gastrointestinal Surgery, Suining Central Hospital, Suining, China
| | - Tingting Lu
- Department of Gastrointestinal Surgery, Suining Central Hospital, Suining, China
| | - Zhengwen Xu
- Department of Gastrointestinal Surgery, Suining Central Hospital, Suining, China
| | - Chuan Qian
- Department of Gastrointestinal Surgery, Suining Central Hospital, Suining, China
| | - Fugen Li
- Department of Gastrointestinal Surgery, Suining Central Hospital, Suining, China
| | - Yanling Xiao
- Department of Gastrointestinal Surgery, Suining Central Hospital, Suining, China
| | - Yingdong Jia
- Department of Gastrointestinal Surgery, Suining Central Hospital, Suining, China
| | - Bo Zhang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
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Manabe T, Mizuuchi Y, Tsuru Y, Kitagawa H, Fujimoto T, Koga Y, Nakamura M, Noshiro H. Retrospective analysis of risk factors for postoperative perineal hernia after endoscopic abdominoperineal excision for rectal cancer. BMC Surg 2022; 22:88. [PMID: 35260127 PMCID: PMC8903566 DOI: 10.1186/s12893-022-01538-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 02/28/2022] [Indexed: 12/01/2022] Open
Abstract
Background In contrast to open-surgery abdominoperineal excision (APE) for rectal cancer, postoperative perineal hernia (PPH) is reported to increase after extralevator APE and endoscopic surgery. In this study, therefore, we aimed to determine the risk factors for PPH after endoscopic APE. Methods A total 73 patients who underwent endoscopic APE for rectal cancer were collected from January 2009 to March 2020, and the risk factors for PPH were analyzed retrospectively. Results Nineteen patients (26%) developed PPH after endoscopic APE, and the diagnosis of PPH was made at 9–393 days (median: 183 days) after initial surgery. Logistic regression analysis showed that absence of pelvic peritoneal closure alone increased the incidence of PPH significantly (odds ratio; 13.76, 95% confidence interval; 1.48–1884.84, p = 0.004). Conclusions This preliminary study showed that pelvic peritoneal closure could prevent PPH after endoscopic APE.
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Affiliation(s)
- Tatsuya Manabe
- Department of Surgery, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga, 849-8501, Japan.
| | - Yusuke Mizuuchi
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Yasuhiro Tsuru
- Department of Surgery, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga, 849-8501, Japan
| | - Hiroshi Kitagawa
- Department of Surgery, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga, 849-8501, Japan
| | - Takaaki Fujimoto
- Department of Surgery, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga, 849-8501, Japan
| | - Yasuo Koga
- Department of Surgery, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga, 849-8501, Japan
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Hirokazu Noshiro
- Department of Surgery, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga, 849-8501, Japan
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Shen Y, Yang T, Zeng H, Meng W, Wang Z. Is it worthwhile to perform closure of the pelvic peritoneum in laparoscopic extralevator abdominoperineal resection? Langenbecks Arch Surg 2022; 407:1139-1150. [PMID: 35083567 DOI: 10.1007/s00423-021-02412-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 12/14/2021] [Indexed: 02/05/2023]
Abstract
PURPOSE There is no uniformity in the use of closure of the pelvic peritoneum (CPP) after laparoscopic extralevator abdominoperineal excision (ELAPE). This study aimed to evaluate the short-term outcomes of CPP after ELAPE and provide supporting evidence for the performance of CPP in laparoscopic ELAPE. METHODS Patients with rectal cancer who underwent ELAPE from January 2014 to April 2019 were retrospectively investigated. CPP was routinely performed unless it was not feasible. The main outcome was the difference in the occurrence of perineal hernia (PH), small bowel obstruction (SBO) and perineal wound complications between laparoscopic and open ELAPE, which were compared using Kaplan-Meier curves. RESULTS Of the 244 patients included, 104 received laparoscopic ELAPE, and 140 received open ELAPE. Patients in the laparoscopic group suffered a higher incidence of PH (11.5% (12/104) vs. 5.0% (7/140), p = 0.049), SBO (10.6% (11/104) vs. 7.9% (11/140), p = 0.433) and major perineal wound complications (12.5% (13/104) vs. 7.9% (11/140), p = 0.228) than those in the open group. Multivariate analysis showed that no-CPP was an independent risk factor for the occurrence of PH (p = 0.022, OR 3.436, 95% CI 1.199-9.848) and major perineal wound complications (p = 0.012, OR 3.683, 95% CI 1.337-10.146). CONCLUSION In this comparative cohort study with a risk of allocation bias, CPP was associated with a lower incidence of radiological PH and major perineal wound complications regardless of the surgical approach. Thus, we believe CPP could serve as an option L-ELAPE for the prevention of perineal complications. To further determine the impact of CPP on postoperative complications after ELAPE, a prospective multicentre study is needed.
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Affiliation(s)
- Yu Shen
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Guo Xue Xiang 37#, Chengdu, Sichuan Province, China
| | - Tinghan Yang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Guo Xue Xiang 37#, Chengdu, Sichuan Province, China
| | - Hanjiang Zeng
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Wenjian Meng
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Guo Xue Xiang 37#, Chengdu, Sichuan Province, China
| | - Ziqiang Wang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Guo Xue Xiang 37#, Chengdu, Sichuan Province, China.
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Pelvic floor peritoneum reconstruction is a protective factor for defecation dysfunction after laparoscopic anterior resection in patients with middle and low rectal cancer. Surg Today 2022; 52:1320-1328. [PMID: 34997334 DOI: 10.1007/s00595-021-02445-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 12/13/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE The pelvic cavity is a monolithic structure whose integrity plays an important role in the pelvic organ function. Currently, pelvic floor peritoneum reconstruction (PFPR) is rarely performed during laparoscopic surgery for middle and low rectal cancer patients. This study evaluated the effect of PFPR using barbed wire during laparoscopic surgery on the postoperative defecation function in middle and low rectal cancer patients. METHODS This was a retrospective study involving a total of 252 middle and low rectal cancer patients who had been subjected to laparoscopic-assisted anterior resection of rectal cancer at Shanghai Changhai Hospital from March 2018 to April 2020. The Wexner and low anterior resection syndrome (LARS) scores were used to evaluate the postoperative defecation function among patients. A Wexner score ≥ 8 and LARS score ≥ 30 were considered to indicate major defecation dysfunction. RESULTS A total of 229 patients (52 patients subjected to PFPR) were followed up, and the Wexner and LARS scores were recorded. The follow-up rate was 90.87%, the mean follow-up time was 22.88 ± 6.93 months, the stoma rate was 64.29%, the ileostomy reduction surgical rate was 90.74%, and the stoma duration was 7.64 ± 2.94 months. Regarding the assessment of postoperative defecation dysfunction using the Wexner score, a multivariate analysis revealed that a long operation time (odds ratio [OR], 0.991; 95% confidence interval [CI], 0.984-0.999, p = 0.026) and radiotherapy (OR, 0.352; 95% CI, 0.156-0.797, p = 0.012) were independent risk factors for major defecation dysfunction, while a high tumor location (OR, 1.318; 95% CI, 1.151-1.657, p = 0.001) and PFPR (OR, 4.770; 95% CI, 1.435-15.857, p = 0.011) were independent protective factors for major defecation dysfunction. Regarding the assessment of the postoperative defecation function using the LARS score, a multivariate analysis revealed that a high tumor location (OR, 1.293; 95% CI, 1.125-1.486, p < 0.001) and PFPR (OR, 3.010; 95% CI, 1.345-6.738, p = 0.007) were independent protective factors for major defecation dysfunction. A subgroup analysis showed that the postoperative Wexner score (3.13 ± 2.79 vs. 4.71 ± 3.45 p = 0.003) and LARS score (21.77 ± 8.62 vs. 25.14 ± 8.78 p = 0.015) were lower for patients with PFPR than for patients without PFPR. Regarding patients with low rectal cancer, those with PFPR had a lower LARS score than those without it (23.62 ± 8.94 vs. 28.40 ± 7.90, p = 0.022), but there was no significant difference in the Wexner score between the groups. A total of 9.76% of patients with PFPR and 48.89% of those without PFPR showed an intestinal accumulation in the sacral front (p < 0.001). CONCLUSIONS PFPR and a high tumor location are protective factors for postoperative defecation dysfunction in middle and low rectal cancer patients. PFPR can be routinely performed during laparoscopic surgery.
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Shen Y, Yang T, Zeng H, Meng W, Wang Z. Efficacy of Pelvic Peritoneum Closure After Laparoscopic Extralevator Abdominoperineal Excision for Rectal Cancer. J Gastrointest Surg 2021; 25:2668-2678. [PMID: 34244951 DOI: 10.1007/s11605-021-05046-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 05/17/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND The descent of the small bowel into the pelvic dead space after extralevator abdominoperineal excision (ELAPE) presents a higher risk for postoperative complications. The aim of the present study was to evaluate the efficacy of pelvic peritoneum closure in preventing the small bowel from descending into the pelvic dead space and the potential consequences of this approach. METHODS Patients with rectal cancer undergoing laparoscopic ELAPE from March 2014 to January 2019 were retrospectively investigated. Closure of the pelvic peritoneum (CPP) was routinely performed unless it was not feasible. All patients with pelvic peritoneum reconstruction were included in the CPP group, and patients without pelvic peritoneum reconstruction were included in the no-CPP group. The main outcomes included the incidences of the small bowel descending into the retro-urogenital space (space between the bladder/uterus and the sacrum on axial CT scans), perineal wound complications, perineal hernia, and small bowel obstruction (SBO). RESULTS Of the 100 patients included, 79 received CPP, and 21 did not. Fewer patients with pelvic peritoneum closure had small bowels residing in the retro-urogenital space than patients without closure (17.7% vs 42.9%, p=0.014). The incidence of SBO was also lower in the CPP group (7.6% vs. 23.8%, p=0.034). Multivariable analysis showed that no-CPP (p=0.014) was an independent risk factor for the small bowel descending into the retro-urogenital space. CONCLUSION CPP may prevent the small bowel from descending into the retro-urogenital dead space in patients undergoing laparoscopic ELAPE without increasing the incidence of perineal wound complications. Prospective studies are warranted to confirm the efficacy of CPP in preventing SBO and perineal hernia.
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Affiliation(s)
- Yu Shen
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Guo Xue Xiang 37#, Chengdu, Sichuan Province, China
| | - Tinghan Yang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Guo Xue Xiang 37#, Chengdu, Sichuan Province, China
| | - Hanjiang Zeng
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Wenjian Meng
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Guo Xue Xiang 37#, Chengdu, Sichuan Province, China.
| | - Ziqiang Wang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Guo Xue Xiang 37#, Chengdu, Sichuan Province, China.
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Transperineal minimally invasive abdominoperineal resection for low rectal cancer: standardized technique and clinical outcomes. Surg Endosc 2021; 35:7236-7245. [PMID: 34254186 DOI: 10.1007/s00464-021-08633-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 07/05/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Despite the increasing utilization of transanal total mesorectal excision as a promising approach for low rectal cancer, the feasibility and safety of transperineal minimally invasive abdominoperineal resection (tp-APR) remain unclear. METHODS In total, 25 patients who underwent tp-APR between April 2017 and May 2020 (tp-APR group) and 27 patients who underwent conventional laparoscopic APR between May 2009 and September 2016 (lap-APR group) for low rectal cancer were enrolled in this retrospective study. Clinical outcomes were compared between the groups before and after propensity score matching. The primary outcome was the incidence of the overall postoperative complications with Clavien-Dindo grade II or above. Standardized technique of tp-APR was also demonstrated. RESULTS On comparison, operative time, intraoperative blood loss, and overall postoperative complications with Clavien-Dindo grade II or above were significantly less in the tp-APR group both before and after propensity score matching. The rates of urinary disturbance and perineal wound infection were significantly less in the tp-APR group after matching. Further, postoperative hospital stay was significantly shorter in the tp-APR group both before and after matching. However, pathological outcomes did not differ between the groups before and after matching. There has been no local recurrence in the tp-APR group with a median follow-up period of 18 months. CONCLUSION Standardized tp-APR for low rectal cancer is feasible and seems superior to conventional laparoscopic APR in terms of short-term outcomes. Further larger-scale studies with a longer follow-up period are required to evaluate oncological outcomes.
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