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Jenkins E, Humphrey H, Finan C, Rogers P, McDermott FG, Smart NJ, Daniels IR, Watts AM. Long-term follow-up of bilateral gracilis reconstruction following extra-levator abdominoperineal excision. J Plast Reconstr Aesthet Surg 2023; 76:198-207. [PMID: 36527901 DOI: 10.1016/j.bjps.2022.10.025] [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: 05/08/2022] [Revised: 10/05/2022] [Accepted: 10/11/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Colorectal operations such as an extra-levator abdominoperineal (elAPE) excision for locally advanced or recurrent cancer create a significant perineal tissue deficit. Options for perineal reconstruction include bilateral pedicled gracilis muscle flaps (BPGMF). Fashioning the gracili into a 'weave' creates a muscular sling that supports pelvic contents and is a novel technique. Our series reports the outcomes of the BPGMF in 50 patients undergoing surgery for pelvic cancer. METHOD This is a retrospective, single-centre study of patients undergoing reconstruction of perineal defects using BPGMF. All surgeries took place between January 2008 and February 2021. The primary outcome measured was perineal wound healing. The secondary outcomes measured were complications of surgical sites and length of hospital stay (short term), flap integrity on follow-up imaging and functional outcomes (long term). RESULTS Fifty patients underwent perineal reconstruction using BPGMF (26 males). The median age was 62 years. The 30-day mortality was 2% (n = 1). The average follow-up period was 2 years. Complete perineal wound healing was 86% (42/49) at outpatient follow-up. Complication rates for the donor site and reconstructed site were 14% and 22%, respectively. Complications included infection (2% donor site, 12% perineum), haematoma (4% donor site), dehiscence (2% donor site, 4% perineum) and seroma (3% donor site, 2% perineum). CONCLUSION BPGMF offers a reliable and technically simple muscle flap to reconstruct large perineal defects. The muscle flap integrity appears maintained on follow-up imaging despite a lack of flap monitoring tools. This cohort had minimal functional impairment following BPGMF.
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Affiliation(s)
- E Jenkins
- Department of Plastic & Reconstructive Surgery, Royal Devon & Exeter Hospital, UK.
| | - H Humphrey
- Department of Colorectal Surgery, Royal Devon & Exeter Hospital, UK
| | - C Finan
- Department of Radiology, Royal Devon & Exeter Hospital, UK
| | - P Rogers
- Department of Radiology, Royal Devon & Exeter Hospital, UK
| | - F G McDermott
- Department of Colorectal Surgery, Royal Devon & Exeter Hospital, UK
| | - N J Smart
- Department of Colorectal Surgery, Royal Devon & Exeter Hospital, UK
| | - I R Daniels
- Department of Colorectal Surgery, Royal Devon & Exeter Hospital, UK
| | - A M Watts
- Department of Plastic & Reconstructive Surgery, Royal Devon & Exeter Hospital, UK
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Somashekhar SP, Saklani A, Dixit J, Kothari J, Nayak S, Sudheer OV, Dabas S, Goud J, Munikrishnan V, Sugoor P, Penumadu P, Ramachandra C, Mehendale S, Dahiya A. Clinical Robotic Surgery Association (India Chapter) and Indian rectal cancer expert group’s practical consensus statements for surgical management of localized and locally advanced rectal cancer. Front Oncol 2022; 12:1002530. [PMID: 36267970 PMCID: PMC9577482 DOI: 10.3389/fonc.2022.1002530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 09/16/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction There are standard treatment guidelines for the surgical management of rectal cancer, that are advocated by recognized physician societies. But, owing to disparities in access and affordability of various treatment options, there remains an unmet need for personalizing these international guidelines to Indian settings. Methods Clinical Robotic Surgery Association (CRSA) set up the Indian rectal cancer expert group, with a pre-defined selection criterion and comprised of the leading surgical oncologists and gastrointestinal surgeons managing rectal cancer in India. Following the constitution of the expert Group, members identified three areas of focus and 12 clinical questions. A thorough review of the literature was performed, and the evidence was graded as per the levels of evidence by Oxford Centre for Evidence-Based Medicine. The consensus was built using the modified Delphi methodology of consensus development. A consensus statement was accepted only if ≥75% of the experts were in agreement. Results Using the results of the review of the literature and experts’ opinions; the expert group members drafted and agreed on the final consensus statements, and these were classified as “strong or weak”, based on the GRADE framework. Conclusion The expert group adapted international guidelines for the surgical management of localized and locally advanced rectal cancer to Indian settings. It will be vital to disseminate these to the wider surgical oncologists and gastrointestinal surgeons’ community in India.
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Affiliation(s)
- S. P. Somashekhar
- Department of Surgical Oncology, Manipal Hospital, Bengaluru, Karnataka, India
- *Correspondence: S. P. Somashekhar,
| | - Avanish Saklani
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Jagannath Dixit
- Department of GI Surgery, HCG Hospital, Bengaluru, Karnataka, India
| | - Jagdish Kothari
- Department of Surgical Oncology HCG Hospital, Ahmedabad, Gujarat, India
| | - Sandeep Nayak
- Department of Surgical Oncology, Fortis Hospital, Bengaluru, Karnataka, India
| | - O. V. Sudheer
- Department of GI Surgery and Surgical Oncology, Amrita Institute of Medical Science, Kochi, Kerala, India
| | - Surender Dabas
- Department of Surgical Oncology, BL Kapur-Max Superspeciality Hospital, Delhi, India
| | - Jagadishwar Goud
- Department of Surgical Oncology, AOI Hospital, Hyderabad, Telangana, India
| | | | - Pavan Sugoor
- Department of Surgical Oncology, Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka, India
| | | | - C. Ramachandra
- Director and Head, Department of Surgical Oncology, Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka, India
| | - Shilpa Mehendale
- Director and Head, Department of Surgical Oncology, Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka, India
| | - Akhil Dahiya
- Department of Clinical and Medical Affairs, Intuitive Surgical, California, CA, United States
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Shah R, Kamble R, Herieka M, Dalal M. A National Survey on Perineal Reconstruction Following Standard and Extralevator Abdominoperineal Excision: Current Practices and Trends in the UK. Cureus 2022; 14:e28339. [PMID: 36034060 PMCID: PMC9400553 DOI: 10.7759/cureus.28339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/24/2022] [Indexed: 11/05/2022] Open
Abstract
Background Challenging perineal defects resulting from extralevator (ELAPE) and standard abdominoperineal excision (APE) have given rise to an emerging multidisciplinary approach between colorectal and plastic surgeons. At present, there is a relative paucity of evidence on best practice. This study sought to assess current national practice concerning perineal reconstruction following APE/ELAPE in the United Kingdom (UK) and to determine the factors involved in reconstruction choice. Methodology An anonymised survey was circulated to consultant plastic surgeons at all 48 UK centres performing perineal reconstruction following APE/ELAPE. Responses were collected between October 2021 and April 2022. Results Complete responses were received from 24 units nationally. All units had a dedicated APE/ELAPE service. Overall, 70% adopted a standardised reconstructive approach, the most common being the inferior gluteal artery perforator flap (n = 11). Significant variation was identified in the reconstructive technique. Similar differences were observed in the perceived importance of surgical factors guiding the reconstructive decision-making process, the top priorities being the size of the defect and previous radiotherapy. Conclusions The variability of responses suggests a lack of national consensus on optimal reconstruction following APE/ELAPE, despite the majority of centres employing a standardised approach to reconstruction. Our study highlights important surgical decision-making factors and provides valuable insight to aid in developing national collaborative evidence-based guidelines on best practice.
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Abstract
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.
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Affiliation(s)
- Géza Papp
- Surgical-Oncosurgical Department, Uzsoki Teaching Hospital, Budapest, Hungary
| | - Kristóf Dede
- Surgical-Oncosurgical Department, Uzsoki Teaching Hospital, Budapest, Hungary
| | - Attila Bursics
- Surgical-Oncosurgical Department, Uzsoki Teaching Hospital, Budapest, Hungary
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Partial myocutaneous gluteal flap for perineal reconstruction of extralevator abdominoperineal defects. A single surgeon series of 49 cases in 8 years, and a modification of the technique. J Plast Reconstr Aesthet Surg 2021; 75:125-136. [PMID: 34353736 DOI: 10.1016/j.bjps.2021.06.007] [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: 08/10/2020] [Revised: 02/03/2021] [Accepted: 06/02/2021] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Extralevator abdominoperineal excision (ELAPE) for low rectal tumours necessitates a reliable method of reconstructing the perineum. The senior author developed the partial myocutaneous gluteal (PMG) flap. We present 49 consecutive reconstructions with the refinement of the original procedure. METHODS We conducted a retrospective observational review of patients undergoing ELAPE and PMG reconstruction from 2012 to 2019, with at least 1 year follow-up. The procedure was modified iteratively following our original series, to minimise perineal herniation, specifically by greater mobilisation of the inferior gluteus maximus muscle and separation of the muscle and fasciocutaneous components, allowing closure of the defect around the coccygeal remnant. Perineal herniation and wound complications were recorded. Laparoscopic and open resection techniques were compared, as were outcomes before and after modification of the flap. RESULTS There were no flap failures in our cohort of 49 patients. Two patients (4%) required return to theatre acutely for perineal wound complications: one wound dehiscence and one flap-related haematoma. Five patients had evidence of perineal hernia, three prior to any modification of the flap and two following. Three had symptoms of which two required elective repair. The flap modifications were made in response to these cases. There were no significant differences in perineal outcomes for laparoscopic versus open, and before and after flap modification. CONCLUSIONS Over the last 8 years, we have refined our perineal reconstruction technique following instances of perineal herniation and major wound dehiscence. We believe that the PMG flap provides robust and reliable option for the reconstruction of perineal extralevator abdominoperineal defects.
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Comparison of perineal morbidity between biologic mesh reconstruction and primary closure following extralevator abdominoperineal excision: a systematic review and meta-analysis. Int J Colorectal Dis 2021; 36:893-902. [PMID: 33409565 DOI: 10.1007/s00384-020-03820-7] [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] [Accepted: 12/11/2020] [Indexed: 02/04/2023]
Abstract
AIM Extralevator abdominoperineal excision (ELAPE) for rectal cancer leaves a greater perineal defect which might result in significant perineal morbidity, and how to effectively close perineal defects remains a challenge for surgeons. This study aimed to comparatively evaluate the perineal-related complications of biologic mesh reconstruction and primary closure following ELAPE. METHOD The electronic databases PubMed, EMBASE, Cochrane Library, and Web of Science were searched to screen out all eligible studies, which compared biologic mesh reconstruction with primary closure for perineal-related complications following ELAPE. Pooled data of perineal-related complications including overall wound complications, hernia, infection, dehiscence, chronic sinus, and chronic pain (12 months after surgery) were analyzed. RESULTS A total of four studies (one randomized controlled trial and three cohort studies) involving 544 patients (346 biologic mesh vs 198 primary closure) were included. With a median follow-up of 18.5 months (range, 2-71.5 months). Analysis of the pooled data indicated that the perineal hernia rate was significantly lower in biologic mesh reconstruction as compared to primary closure (OR, 0.38; 95% CI, 0.22-0.69; P = 0.001). There were no statistically significant differences between the two groups in terms of total perineal wound complications rate (P = 0.70), as well as rates of perineal wound infection (P = 0.97), wound dehiscence (P = 0.43), chronic sinus (P = 0.28), and chronic pain (12 months after surgery; P = 0.75). CONCLUSION Biologic mesh reconstruction after extralevator abdominoperineal excision appears to have a lower hernia rate, with no differences in perineal wound complications.
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Zaheer Ahmad N, Abbas MH, Al-Naimi NMAB, Parvaiz A. Meta-analysis of biological mesh reconstruction versus primary perineal closure after abdominoperineal excision of rectal cancer. Int J Colorectal Dis 2021; 36:477-492. [PMID: 33392663 DOI: 10.1007/s00384-020-03827-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/18/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Extralevator abdominoperineal excision (ELAPE) of rectal cancer has been proposed to achieve better oncological outcomes. The resultant wide perineal wound, however, presents a challenge for primary closure and subsequent wound healing. This meta-analysis compared the outcomes of primary perineal closure with those of biological mesh reconstruction. METHODS The Medline and Embase search was performed for the publications comparing primary perineal closure to biological mesh reconstruction. Early perineal wound complications (seroma, infection, dehiscence) and late perineal wound complications (perineal hernia, chronic pain, and chronic sinus) were analyzed as primary endpoints. Intraoperative blood loss, operation time, and hospital stay were compared as secondary endpoints. RESULTS There was no significant difference in the overall early wound complications after primary closure or biological mesh reconstruction (odds ratio (OR) of 0.575 with 95% confidence interval (CI) of 0.241 to 1.373 and a P value of 0.213). The incidence of perineal hernia after 1 year was significantly high after primary closure of the perineal wounds (OR of 0.400 with 95% CI of 0.240 to 0.665 and a P value of 0.001). No significant differences were observed among other early and late perineal wound complications. The operation time and hospital stay were shorter after primary perineal closure (p 0.001). CONCLUSION A lower incidence of perineal hernia and comparable early perineal wound complications after biological mesh reconstruction show a relative superiority over primary closure. More randomized studies are required before a routine biological mesh reconstruction can be recommended for closure of perineal wounds after ELAPE.
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Affiliation(s)
- Nasir Zaheer Ahmad
- Department of Surgery, University Hospital Limerick, St Nessan's Rd, Dooradoyle, Co., Limerick, V94 F858, Republic of Ireland.
| | - Muhammad Hasan Abbas
- Department of Surgery, Russells Hall Hospital NHS Trust, Pensnett Rd, West Midlands, Dudley, DY1 2HQ, UK
| | | | - Amjad Parvaiz
- Faculty of Health Sciences, University of Portsmouth, Portsmouth, UK.,Colorectal Department, Poole NHS Trust Poole UK, Poole, UK
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Garcia-Henriquez N, Galante DJ, Monson JRT. Selection and Outcomes in Abdominoperineal Resection. Front Oncol 2020; 10:1339. [PMID: 33014775 PMCID: PMC7461900 DOI: 10.3389/fonc.2020.01339] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 06/26/2020] [Indexed: 01/14/2023] Open
Abstract
Since the initial descriptions of the abdominoperineal resection by Sir William Ernest Miles which was then followed by the perfection of the total mesorectal excision by Professor Bill Heald, the surgical management of rectal cancer has made tremendous strides. However, even with the advent and sophistication of neoadjuvant therapy, there remains a formidable amount of patients requiring an abdominoperineal resection. The purpose of this review is to delineate the indication and selection process by which patients are determined to require an abdominoperineal resection, as well as the oncologic and overall outcomes associated with the operation.
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Affiliation(s)
| | | | - John R. T. Monson
- Advent Health Medical Group, Center for Colon and Rectal Surgery, Orlando, FL, United States
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Nonoperative Management Versus Radical Surgery of Rectal Cancer After Neoadjuvant Therapy-Induced Clinical Complete Response: A Markov Decision Analysis. Dis Colon Rectum 2020; 63:1080-1089. [PMID: 32398412 DOI: 10.1097/dcr.0000000000001665] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Nonoperative management of rectal cancer was introduced for patients with clinical complete response after neoadjuvant chemoradiotherapy to avoid short- and long-term surgical morbidity related to radical resection. OBJECTIVE The purpose of this study was to determine the expected life-years and quality-adjusted life-years for nonoperative management and radical resection of locally advanced rectal cancer after clinical complete response following neoadjuvant chemoradiotherapy. DESIGN Markov modeling was used to simulate nonoperative management and radical surgery for a base case scenario over a 10-year time horizon. Estimates for various clinical variables were obtained after extensive literature search. Outcome was expressed in both life-years and quality-adjusted life-years. Deterministic sensitivity analyses were completed to assess the impact of variation in key parameters. SETTING A decision model using a Markov model was designed. PATIENTS The base case was a 65-year-old man with a distal rectal tumor who had achieved clinical complete response after neoadjuvant chemoradiotherapy. MAIN OUTCOME MEASURES Life-years and quality-adjusted life-years were measured. RESULTS Quality-adjusted life-years (5.79 for nonoperative management vs 5.62 for radical surgery) and life-years (6.92 for nonoperative management vs 6.96 for radical surgery) were similar between nonoperative management and radical surgery. The preferred treatment strategy changed with variations in the probability of local regrowth in nonoperative management, the probability of salvage surgery for regrowth in nonoperative management, utilities associated with nonoperative management and low anterior resection, and the utility of low anterior resection syndrome. The model was not sensitive to (dis)utilities associated with stoma, chemotherapy, or postoperative morbidity and mortality. LIMITATIONS The study was limited by assumptions inherent to modeling studies. CONCLUSIONS Nonoperative management and radical surgery resulted in similar (quality-adjusted) life-years. Nonoperative management should therefore be considered as a reasonable treatment option. See Video Abstract at http://links.lww.com/DCR/B246. MANEJO NO-QUIRÚRGICO VERSUS CIRUGÍA RADICAL DEL CÁNCER RECTAL DESPUÉS DE LA RESPUESTA CLÍNICA COMPLETA INDUCIDA POR TERAPIA NEOADYUVANTE: UN ANÁLISIS DE DECISIÓN DE MARKOV: Se introdujo el tratamiento no quirúrgico del cáncer rectal para pacientes con respuesta clínica completa después de la quimiorradioterapia neoadyuvante para evitar la morbilidad quirúrgica a corto y largo plazo relacionada con la resección radical.Determinar los años de vida esperados y los años de vida ajustados por calidad para el tratamiento no-quirúrgico y la resección radical del cáncer rectal localmente avanzado, después de la respuesta clínica completa siguiente de la quimiorradioterapia neoadyuvante.El modelo de Markov se usó para simular el manejo no-quirúrgico y la cirugía radical para un escenario de caso base en un horizonte temporal de 10 años. Se obtuvieron estimaciones para diversas variables clínicas después de una extensa búsqueda bibliográfica. El resultado se expresó tanto en años de vida como en años de vida ajustados por calidad. Se completaron análisis determinísticos de sensibilidad para evaluar el impacto de la variación en los parámetros clave.Se diseñó un modelo de decisión utilizando un modelo de Markov.El caso base fue un hombre de 65 años con un tumor rectal distal que había logrado una respuesta clínica completa después de la quimiorradioterapia neoadyuvante.Años de vida y años de vida ajustados por calidad.Los años de vida ajustados por calidad (5.79 para el tratamiento no-quirúrgico frente a 5.62 para la cirugía radical) y los años de vida (6.92 para el tratamiento no-quirúrgico frente a 6.96 para la cirugía radical) fueron similares entre el tratamiento no-quirúrgico y la cirugía radical. La estrategia de tratamiento preferida cambió con las variaciones en la probabilidad de nuevo crecimiento local en el manejo no-operatorio, la probabilidad de cirugía de rescate para el rebrote en el manejo no-operatorio, las utilidades asociadas con el manejo no-operatorio, y la resección anterior baja y la utilidad de el syndrome de resección anterior baja. El modelo no era sensible a las (des) utilidades asociadas con el estoma, la quimioterapia o la morbilidad y mortalidad postoperatorias.El estudio estuvo limitado por suposiciones inherentes a los estudios de modelado.El manejo no-quirúrgico y la cirugía radical resultaron en años de vida similares (ajustados por calidad). Por lo tanto, el tratamiento no-quirúrgico debe considerarse como una opción de tratamiento razonable. Consulte Video Resumen en http://links.lww.com/DCR/B246.
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Xiao H, Huang R, Li X, Wang Z. Laparoscopic Versus Open Extralevaor Abdominoperineal Excision for Lower Rectal Cancer: A Retrospective Cohort Study in Single Institute. J Laparoendosc Adv Surg Tech A 2020; 31:71-76. [PMID: 32706627 DOI: 10.1089/lap.2020.0352] [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] [Indexed: 12/18/2022] Open
Abstract
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.
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Affiliation(s)
- Hui Xiao
- Department of General Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Rui Huang
- Department of Key Laboratory, Capital Institute of Pediatrics, Beijing, People's Republic of China
| | - Xiangnan Li
- Department of General Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Zhenjun Wang
- Department of General Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People's Republic of China
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Extralevator abdominoperineal excision versus abdominoperineal excision for low rectal cancer: a meta-analysis. Chin Med J (Engl) 2020; 132:2446-2456. [PMID: 31651517 PMCID: PMC6831059 DOI: 10.1097/cm9.0000000000000485] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
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.
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Abstract
BACKGROUND Reconstruction of the pelvic floor defect caused by extralevator abdominoperineal excision poses a challenge for the surgeon. OBJECTIVE The aim of this study was to analyze the long-term perineal wound complications in patients undergoing conventional primary closure versus biological mesh-assisted repair after extralevator abdominoperineal excision. DESIGN This was a single-institution retrospective observational study. SETTINGS The study was conducted at a tertiary academic medical center. PATIENTS Patients with low advanced rectal cancer undergoing extralevator abdominoperineal excision from August 2008 to December 2016 (N = 228) were included. INTERVENTIONS All of the patients received extralevator abdominoperineal excision operation. MAIN OUTCOME MEASURES The primary outcome measure was perineal wound complications after the operation. RESULTS Of the 228 patients who underwent extralevator abdominoperineal excision, 174 received biological mesh repair and 54 received primary closure. Preoperative radiotherapy was administered to 89 patients (51.1%) in the biological mesh group and 20 patients (37.0%) in the primary closure group. The biological mesh group had significantly lower rates of perineal wound infection (11.5% vs 22.2%; p = 0.047), perineal hernia (3.4% vs 13.0%; p = 0.022), wound dehiscence (0.6% vs 5.6%; p = 0.042), and total perineal wound complications (14.9% vs 35.2%; p = 0.001) compared with the primary closure group. Multivariable logistic regression analysis showed preoperative radiotherapy (p < 0.001), conventional primary closure (p < 0.001), and intraoperative bowel perforation (p= 0.001) to be significantly associated with perineal procedure-related complications. LIMITATIONS This was a single-center retrospective study. CONCLUSIONS Although perineal wound repair with biological mesh prolongs the operative time of perineal portion, the perineal drainage retention time, and the length of hospital stay, it may reduce perineal procedure-related complications and improve wound healing. Preoperative radiotherapy and intraoperative bowel perforation appear to be independent predictors of perineal complications. See Video Abstract at http://links.lww.com/DCR/B42. COMPLICACIONES DE LA HERIDA PERINEAL DESPUÉS DE LA EXCISIÓN ABDOMINOPERINEAL EXTRA-ELEVADORA EN CASO DE CÁNCER DE RECTO BAJO: La reconstrucción del defecto en el suelo pélvico, resultado de una resección abdominoperineal extra-elevadora plantea un desafío para el cirujano.El analisis de las complicaciones de la herida perineal a largo plazo en pacientes sometidos a un cierre primario convencional versus una reparación asistida por malla biológica después de una resección abdominoperineal extra-elevadora.Estudio retrospectivo observacional en una sola institución.Investigación realizada en un centro médico académico terciario.Se incluyeron los pacientes con cáncer rectal bajo avanzado que se sometieron a una resección abdominoperineal extra-elevadora desde agosto de 2008 hasta diciembre de 2016 (n= 228).Todos aquellos pacientes que fueron sometidos a una resección abdominoperineal extra-elevadora.Todas las complicaciones de la herida perineal en el postoperatorio.De los 228 pacientes que se sometieron a una resección abdominoperineal extra-elevadora, 174 fueron reparados con una malla biológica y 54 se beneficiaron de un cierre primario. La radioterapia preoperatoria se administró a 89 (51,1%) pacientes en el grupo de malla biológica y 20 (37,0%) pacientes en el grupo de cierre primario. El grupo de malla biológica tuvo tasas significativamente más bajas de infección de la herida perineal (11.5% vs. 22.2%; p = 0.047), hernia perineal (3.4% vs. 13.0%; p = 0.022), dehiscencia de la herida (0.6% vs. 5.6%; p = 0,042) y complicaciones perineales de la herida (14,9% frente a 35,2%; p = 0,001) en comparación con el grupo de cierre primario. El análisis de regresión logística multivariable mostró que la radioterapia preoperatoria (p <0.001), el cierre primario convencional (p <0.001) y la perforación intestinal intra-operatoria (p = 0.001) se asociaron significativamente como complicaciones relacionadas con el procedimiento perineal.Estudio retrospectivo de centro único.Aunque la reparación de la herida perineal con malla biológica prolonga el tiempo perineal de la operación, la presencia y duración del drenaje perineal y la hospitalización pueden reducir las complicaciones relacionadas con el procedimiento perineal y mejorar la cicatrización de la herida. La radioterapia preoperatoria y la perforación intestinal intra-operatorias parecen ser predictores independientes de complicaciones perineales. Vea el Resumen del Video en http://links.lww.com/DCR/B42.
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13
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Prone Compared With Lithotomy for Abdominoperineal Resection: A Systematic Review and Meta-analysis. J Surg Res 2019; 243:469-480. [DOI: 10.1016/j.jss.2019.07.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 06/09/2019] [Accepted: 07/03/2019] [Indexed: 12/15/2022]
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Laparoscopic extralevator abdominoperineal resection versus laparoscopic abdominoperineal resection for lower rectal cancer: A retrospective comparative study from China. Int J Surg 2019; 71:158-165. [PMID: 31526895 DOI: 10.1016/j.ijsu.2019.09.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 09/05/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND This study was performed to compare the short- and long-term outcomes of laparoscopic extralevator abdominoperineal resection (LELAPR) versus laparoscopic abdominoperineal resection (LAPR) in patients with lower rectal cancer. METHODS Consecutive patients who underwent LELAPR or LAPR in our unit from September 2009 to December 2015 were retrospectively reviewed. The patients' clinicopathological data and short- and long-term outcomes were compared and analyzed. RESULTS Of the 111 patients included in this study, 58 (52%) patients underwent LAPR and 53 (48%) LELAPR. A negative circumferential resection margin was achieved in all the two groups of patients. The LELAPR group had a longer operation time (P = 0.049), more intraoperative blood loss (P = 0.037), shorter hospitalization after surgery (P = 0.002), fewer lymph nodes harvested (P = 0.001), fewer positive lymph nodes (P = 0.002), and a shorter maximum tumor diameter (P < 0.001) compared with the LAPR group. There were also lower rates of intraoperative perforation (P = 0.039) and death (P = 0.013) in the LELAPR group. However, there were no significant differences in the rates of local recurrence (P = 0.144), metastasis (P = 0.111), overall survival (P = 0.404), disease-free survival (P = 0.515), or progression-free survival (P = 0.210) between the two groups. There were no significant differences in postoperative complications including postoperative hernia (P = 0.918), urinary retention (P = 0.579), intestinal obstruction (P = 1.0), and perineal wound complications (P = 0.252). CONCLUSIONS Compared with LAPR, the LELAPR approach significantly reduced the rate of intraoperative perforation and postoperative death without increasing postoperative complications. LELAPR was beneficial to patients with ulcerative, anterior and advanced lower rectal cancer.
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Thomas PW, Blackwell JEM, Herrod PJJ, Peacock O, Singh R, Williams JP, Hurst NG, Speake WJ, Bhalla A, Lund JN. Long-term outcomes of biological mesh repair following extra levator abdominoperineal excision of the rectum: an observational study of 100 patients. Tech Coloproctol 2019; 23:761-767. [PMID: 31392530 PMCID: PMC6736926 DOI: 10.1007/s10151-019-02056-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 07/29/2019] [Indexed: 02/08/2023]
Abstract
Background Current evidence suggests that pelvic floor reconstruction following extralevator abdominoperineal excision of rectum (ELAPER) may reduce the risk of perineal herniation of intra-abdominal contents. Options for reconstruction include mesh and myocutaneous flaps, for which long-term follow-up data is lacking. The aim of this study was to evaluate the long-term outcomes of biological mesh (Surgisis®, Biodesign™) reconstruction following ELAPER. Methods A retrospective review of all patients having ELAPER in a single institution between 2008 and 2018 was perfomed. Clinic letters were scrutinised for wound complications and all available cross sectional imaging was reviewed to identify evidence of perineal herniation (defined as presence of intra-abdominal content below a line between the coccyx and the lower margin of the pubic symphysis on sagittal view). Results One hundred patients were identified (median age 66, IQR 59–72 years, 70% male). Median length of follow-up was 4.9 years (IQR 2.3–6.7 years). One, 2- and 5-year mortality rates were 3, 8 and 12%, respectively. Thirty three perineal wounds had not healed by 1 month, but no mesh was infected and no mesh needed to be removed. Only one patient developed a symptomatic perineal hernia requiring repair. On review of imaging a further 7 asymptomatic perineal hernias were detected. At 4 years the cumulative radiologically detected perineal hernia rate was 8%. Conclusions This study demonstrates that pelvic floor reconstruction using biological mesh following ELAPER is both safe and effective as a long-term solution, with low major complication rates. Symptomatic perineal herniation is rare following mesh reconstruction, but may develop sub clinically and be detectable on cross-sectional imaging.
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Affiliation(s)
- P W Thomas
- Department of Colorectal Surgery, Royal Derby Hospital, Derby, DE22 3NE, UK
| | - J E M Blackwell
- Department of Colorectal Surgery, Royal Derby Hospital, Derby, DE22 3NE, UK
| | - P J J Herrod
- Department of Colorectal Surgery, Royal Derby Hospital, Derby, DE22 3NE, UK. .,Medical Research Council-Arthritis Research UK Centre for Musculoskeletal Ageing Research, University of Nottingham, Royal Derby Hospital, Derby, DE22 3DT, UK.
| | - O Peacock
- Department of Colorectal Surgery, Royal Derby Hospital, Derby, DE22 3NE, UK
| | - R Singh
- Department of Radiology, Royal Derby Hospital, Derby, DE22 3NE, UK
| | - J P Williams
- Department of Colorectal Surgery, Royal Derby Hospital, Derby, DE22 3NE, UK.,Medical Research Council-Arthritis Research UK Centre for Musculoskeletal Ageing Research, University of Nottingham, Royal Derby Hospital, Derby, DE22 3DT, UK
| | - N G Hurst
- Department of Colorectal Surgery, Royal Derby Hospital, Derby, DE22 3NE, UK
| | - W J Speake
- Department of Colorectal Surgery, Royal Derby Hospital, Derby, DE22 3NE, UK
| | - A Bhalla
- Department of Colorectal Surgery, Royal Derby Hospital, Derby, DE22 3NE, UK
| | - J N Lund
- Department of Colorectal Surgery, Royal Derby Hospital, Derby, DE22 3NE, UK.,Medical Research Council-Arthritis Research UK Centre for Musculoskeletal Ageing Research, University of Nottingham, Royal Derby Hospital, Derby, DE22 3DT, UK
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16
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Ito E, Yoshida M, Ohdaira H, Kitajima M, Suzuki Y. Case series of in situ pelvic floor reconstruction combining levator ani suture and negative pressure wound therapy for abdominoperineal resection. Ann Med Surg (Lond) 2019; 43:64-67. [PMID: 31198553 PMCID: PMC6556482 DOI: 10.1016/j.amsu.2019.05.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 05/18/2019] [Accepted: 05/27/2019] [Indexed: 11/27/2022] Open
Abstract
Background Abdominoperineal resection (APR) is a standard surgical technique for low rectum cancer with a low recurrence rate. There are some problems associated with APR such as perineal hernia and perineal surgical site infection. Recently, the prophylactic efficacy of negative pressure wound therapy (NPWT) for surgical site infection has been reported. Herein, we analyzed the efficacy of in situ pelvic floor reconstruction combining levator ani suture and NPWT after APR for perineal hernia and perineal surgical site infection. Methods We analyzed six patients treated by laparoscopic APR with NPWT combined with levator ani suture retrospectively. The primary endpoints were surgical site infection within 30 days and perineal hernia within 1 year after surgery. The day following surgery, we performed NPWT for the perineal wound using the VAC® abdominal wound management system (KCI, San Antonio, TX, USA). Results There were four male and two female patients ranging in age from 69 to 86 years (mean: 76 years). The mean NPTW duration was 17 days (13–20 days). The length of the postoperative hospital stay was 14–22 days (median: 18 days). There was no patient with surgical site infection within 30 days or with perineal hernia within 1 year after surgery. Conclusion We experienced the in situ pelvic floor reconstruction combining levator ani suture and NPWT after laparoscopic APR for perineal hernia and perineal surgical site infection. This combination treatment was safe and may be effective for preventing surgical site infection and perineal hernia. Although APR has some unresolved problems such as perineal hernia and perineal surgical site infection. NPWT decreased perineal wound infection after APR but not reduced deep wound infection rates. Our procedure was able to reconstruct without foreign materials and provided sufficient separation from internal organs to perform safe NPWT. The in situ pelvic floor reconstruction combining levator ani suture and NPWT after laparoscopic APR was safe and may be effective for preventing surgical site infection and perineal hernia.
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Affiliation(s)
- Eisaku Ito
- Department of Surgery, International University of Health and Welfare Hospital, Japan
| | - Masashi Yoshida
- Department of Surgery, International University of Health and Welfare Hospital, Japan
| | - Hironori Ohdaira
- Department of Surgery, International University of Health and Welfare Hospital, Japan
| | - Masaki Kitajima
- Department of Surgery, International University of Health and Welfare Hospital, Japan
| | - Yutaka Suzuki
- Department of Surgery, International University of Health and Welfare Hospital, Japan
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17
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[Assessment of individualized treatment of rectal carcinoma]. Chirurg 2019; 90:279-286. [PMID: 30767062 DOI: 10.1007/s00104-019-0807-6] [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: 10/27/2022]
Abstract
Individualized and tailored treatment plays a crucial role in the rating of special operation techniques or certain treatment strategies following defined quality criteria and indicators. Deviations from clearly defined recommendations in guidelines must therefore be justified, documented and evaluated as precisely as possible. The aim of this leading article is to examine the individualized treatment of rectal cancer based on existing evidence and to discuss its role in the light of routinely used treatment algorithms. In addition to a web-based literature search the current German national S3 guidelines on colorectal cancer were also included. In the treatment of cancer in the middle and lower third of the rectum, individual, patient and tumor-related parameters are of decisive importance from the pretreatment stage to the actual surgery up to aftercare and adjuvant therapy to enable interdisciplinary decision making for optimal treatment.
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18
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Mesquita-Neto JWB, Mouzaihem H, Macedo FIB, Heilbrun LK, Weaver DW, Kim S. Perioperative and oncological outcomes of abdominoperineal resection in the prone position vs the classic lithotomy position: A systematic review with meta-analysis. J Surg Oncol 2019; 119:979-986. [PMID: 30729542 DOI: 10.1002/jso.25402] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 01/26/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND OBJECTIVES This study is a systematic review with meta-analysis designed to compare the perioperative and oncological outcomes of the abdominoperineal resection (APR) carried out in the prone jack-knife position (P-APR) vs the classic lithotomy position (C-APR). METHODS We conducted an electronic search through PubMed utilizing the PRISMA guidelines. We included all randomized and nonrandomized studies which allowed for comparative analysis between the two groups. Research that focused on and analyzed the extralevator abdominal excision were excluded. Pooled variables and number of events were analyzed using the random-effect model. RESULTS The final analysis included seven nonrandomized retrospective cohorts encompassing 1663 patients. P-APR was associated with decreased operative time (OT) (DM, -43.8 minutes; P < 0.01) and estimated blood loss (EBL) (DM, 86.9 mL; P < 0.01). There were no observed differences regarding perineal wound infections (PWI) (odds ratio [OR], 0.36; P = 0.18), intraoperative perforation of rectum (IOP) (OR, 0.98; P = 0.97), circumferential resection margin (CRM) positivity (OR, 1.02; P = 0.98) or 5-year LR (OR, 1.00; P = 0.99). CONCLUSION The prone approach for APR is associated with decreased EBL and OT, although not with any change in the incidence of PWI or IOP. Moreover, surgical positioning per se does not appear to affect the CRM positivity rates or LR rate.
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Affiliation(s)
- Jose Wilson B Mesquita-Neto
- Department of Surgery, Barbara-Ann Karmanos Comprehensive Cancer Center, Detroit Medical Center/Wayne State University School of Medicine, Detroit, Michigan
| | - Hassan Mouzaihem
- Department of Surgery, Barbara-Ann Karmanos Comprehensive Cancer Center, Detroit Medical Center/Wayne State University School of Medicine, Detroit, Michigan
| | - Francisco Igor B Macedo
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida
| | - Lance K Heilbrun
- Department of Biostatistics, Barbara-Ann Karmanos Comprehensive Cancer Center, Detroit Medical Center/Wayne State University School of Medicine, Detroit, Michigan
| | - Donald W Weaver
- Department of Surgery, Barbara-Ann Karmanos Comprehensive Cancer Center, Detroit Medical Center/Wayne State University School of Medicine, Detroit, Michigan
| | - Steve Kim
- Department of Surgery, Barbara-Ann Karmanos Comprehensive Cancer Center, Detroit Medical Center/Wayne State University School of Medicine, Detroit, Michigan
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Levic K, Bulut O, Hansen TP, Gögenur I, Bisgaard T. Malignant colorectal polyps: endoscopic polypectomy and watchful waiting is not inferior to subsequent bowel resection. A nationwide propensity score-based analysis. Langenbecks Arch Surg 2018; 404:231-242. [PMID: 30206683 DOI: 10.1007/s00423-018-1706-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 08/28/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND AIMS The optimal treatment of patients with malignant colorectal polyps is unsettled. The surgical dilemma following polypectomy is selecting between watchful waiting (WW) and subsequent bowel resection (SBR), but the long-term survival outcomes have not been established yet. This nationwide study compared survival of patients after WW or SBR. METHODS Danish nationwide study with 100% follow-up of all patients with malignant colorectal polyps (the Danish Colorectal Cancer Group database) in a 10-year period from 2001 to 2011. All patients' charts and histological reports were individually reviewed. Survival rates were calculated with Cox proportional hazard model after propensity score matching. RESULTS A total of 692 patients were included (WW, 424 (61.3%), SBR, 268 (38.7%)) with a mean follow-up of 7.5 years (3-188 months). Following propensity score matching, there was no significant difference in overall or disease-free survival (p = 0.344 and p = 0.184) or rate of local recurrence (WW, 7.2%, SBR, 2%, p = 0.052) or distant metastases (WW, 3.3%, SBR, 4.6%, p = 0.77). In the SBR group, there was no residual tumor or lymph node metastases in the resected specimen in 82.5% of the patients. CONCLUSION Subsequent bowel resection may not be superior to endoscopic polypectomy and watchful waiting with regard to overall and disease-free survival in patients with malignant colorectal polyps.
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Affiliation(s)
- Katarina Levic
- Gastrounit-Surgical Division, Center for Surgical Research, Copenhagen University Hospital Hvidovre, Kettegaards Allé 30, DK-2650 Hvidovre, Copenhagen, Denmark.
| | - Orhan Bulut
- Gastrounit-Surgical Division, Center for Surgical Research, Copenhagen University Hospital Hvidovre, Kettegaards Allé 30, DK-2650 Hvidovre, Copenhagen, Denmark
- Institution of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Tine Plato Hansen
- Institution of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Pathology, Herlev University Hospital, Copenhagen, Denmark
- Danish Colorectal Cancer Group, Copenhagen, Denmark
| | - Ismail Gögenur
- Institution of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Center for Surgical Science, Department of Surgery, Zealand University Hospital, Køge, Denmark
- Danish Colorectal Cancer Group, Copenhagen, Denmark
| | - Thue Bisgaard
- Gastrounit-Surgical Division, Center for Surgical Research, Copenhagen University Hospital Hvidovre, Kettegaards Allé 30, DK-2650 Hvidovre, Copenhagen, Denmark
- Institution of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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de’Angelis N, Pigneur F, Martínez-Pérez A, Vitali GC, Landi F, Torres-Sánchez T, Rodrigues V, Memeo R, Bianchi G, Brunetti F, Espin E, Ris F, Luciani A. Predictors of surgical outcomes and survival in rectal cancer patients undergoing laparoscopic total mesorectal excision after neoadjuvant chemoradiation therapy: the interest of pelvimetry and restaging magnetic resonance imaging studies. Oncotarget 2018; 9:25315-25331. [PMID: 29861874 PMCID: PMC5982752 DOI: 10.18632/oncotarget.25431] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Accepted: 04/28/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Locally advanced rectal cancer (LARC) requires a multimodal therapy tailored to the patient and tumor characteristics. Pretreatment magnetic resonance imaging (MRI) is necessary to stage the primary tumor, while restaging MRI, which is not systematically performed, may be of interest to identify poor responders to neoadjuvant chemoradiation therapy (NCRT), and redefine therapeutic approach. The EuMaRCS study group aimed to investigate the role and accuracy of pretreatment (including pelvimetry) and restaging MRIs in predicting surgical difficulties and surgical outcomes in LARC therapy. METHODS Patients with mid or low LARC who were administered NCRT, who underwent laparoscopic total mesorectal excision, and for whom pretreatment and restaging MRIs were available, were included. RESULTS MRIs of 170 patients (median age: 61 years) were reanalyzed by the same radiologist. Pelvimetry differed significantly between males and females, but no gender difference was noted in the clinical and tumor characteristics. Tumor volume and tumor height assessed on the restaging MRI were associated, respectively, with operative time and estimated blood loss. Conversion was predicted by tumor volume, interischial distance and pubic tubercle height. The quality of the surgical resection was found to be a predictor of overall and disease-free survival. The sensitivity and specificity of tumor regression grade 1 to identify a pathologic complete response were 76.9% and 89.3%, respectively. CONCLUSIONS In LARC management, pelvimetry and restaging MRI may be useful to predict surgical difficulties and surgical outcomes. However, the main independent predictor of patient survival appears to be the achievement of a successful surgical resection.
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Affiliation(s)
- Nicola de’Angelis
- Unit of Digestive, Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Henri Mondor Hospital, AP-HP, University of Paris Est, UPEC, Créteil, France
| | - Frederic Pigneur
- Department of Radiology, Henri Mondor Hospital, AP-HP, University of Paris Est, UPEC, Créteil, France
| | - Aleix Martínez-Pérez
- Unit of Colorectal Surgery, Department of General and Digestive Surgery, Hospital Universitario Doctor Peset, Valencia, Spain
| | - Giulio Cesare Vitali
- Service of Abdominal Surgery, Geneva University Hospitals and Medical School, Geneva, Switzerland
| | - Filippo Landi
- Unit of Colorectal Surgery, Department of General and Digestive Surgery, Hospital Universitario Vall d’Hebron, Barcelona, Spain
| | - Teresa Torres-Sánchez
- Unit of Colorectal Surgery, Department of General and Digestive Surgery, Hospital Universitario Doctor Peset, Valencia, Spain
| | - Victor Rodrigues
- Unit of Colorectal Surgery, Department of General and Digestive Surgery, Hospital Universitario Vall d’Hebron, Barcelona, Spain
| | - Riccardo Memeo
- Unit of Digestive, Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Henri Mondor Hospital, AP-HP, University of Paris Est, UPEC, Créteil, France
| | - Giorgio Bianchi
- Unit of Digestive, Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Henri Mondor Hospital, AP-HP, University of Paris Est, UPEC, Créteil, France
| | - Francesco Brunetti
- Unit of Digestive, Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Henri Mondor Hospital, AP-HP, University of Paris Est, UPEC, Créteil, France
| | - Eloy Espin
- Unit of Colorectal Surgery, Department of General and Digestive Surgery, Hospital Universitario Vall d’Hebron, Barcelona, Spain
| | - Frederic Ris
- Service of Abdominal Surgery, Geneva University Hospitals and Medical School, Geneva, Switzerland
| | - Alain Luciani
- Department of Radiology, Henri Mondor Hospital, AP-HP, University of Paris Est, UPEC, Créteil, France
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21
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Zhang X, Wu Q, Hu T, Gu C, Bi L, Wang Z. Laparoscopic Versus Conventional Open Abdominoperineal Resection for Rectal Cancer: An Updated Systematic Review and Meta-Analysis. J Laparoendosc Adv Surg Tech A 2018; 28:526-539. [PMID: 29406806 DOI: 10.1089/lap.2017.0593] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Affiliation(s)
- Xubing Zhang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Qingbin Wu
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Tao Hu
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Chaoyang Gu
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Liang Bi
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Ziqiang Wang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
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22
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Carpelan A, Karvonen J, Varpe P, Rantala A, Kaljonen A, Grönroos J, Huhtinen H. Extralevator versus standard abdominoperineal excision in locally advanced rectal cancer: a retrospective study with long-term follow-up. Int J Colorectal Dis 2018; 33:375-381. [PMID: 29445870 DOI: 10.1007/s00384-018-2977-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/07/2018] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
- Anu Carpelan
- Department of Digestive Surgery and Urology, Turku University Hospital and University of Turku, Kiinanmyllynkatu 4-8, 20520, Turku, Finland.
| | - J Karvonen
- Department of Digestive Surgery and Urology, Turku University Hospital and University of Turku, Kiinanmyllynkatu 4-8, 20520, Turku, Finland
| | - P Varpe
- Department of Digestive Surgery and Urology, Turku University Hospital and University of Turku, Kiinanmyllynkatu 4-8, 20520, Turku, Finland
| | - A Rantala
- Department of Digestive Surgery and Urology, Turku University Hospital and University of Turku, Kiinanmyllynkatu 4-8, 20520, Turku, Finland
| | - A Kaljonen
- Biostatistics, Department of Clinical Medicine, University of Turku, Turku, Finland
| | - J Grönroos
- Department of Digestive Surgery and Urology, Turku University Hospital and University of Turku, Kiinanmyllynkatu 4-8, 20520, Turku, Finland
| | - H Huhtinen
- Department of Digestive Surgery and Urology, Turku University Hospital and University of Turku, Kiinanmyllynkatu 4-8, 20520, Turku, Finland
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Negoi I, Hostiuc S, Negoi RI, Beuran M. Laparoscopic vs open complete mesocolic excision with central vascular ligation for colon cancer: A systematic review and meta-analysis. World J Gastrointest Oncol 2017; 9:475-491. [PMID: 29290918 PMCID: PMC5740088 DOI: 10.4251/wjgo.v9.i12.475] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Revised: 07/08/2017] [Accepted: 09/07/2017] [Indexed: 02/05/2023] Open
Abstract
AIM To compare the effectiveness of laparoscopic complete mesocolic excision (CME) with central vascular ligation (L-CME) with its open (O-CME) counterpart.
METHODS We conducted an electronic search of the PubMed/MEDLINE, Excerpta Medica Database, Web of Science Core Collection, Cochrane Center Register of Controlled Trails, Cochrane Database of Systematic Reviews, SciELO, and Korean Journal databases from their inception until May 2017. We considered randomized controlled trials (RCTs) and controlled clinical trials (CCTs) that included patients with colonic cancer comparing L-CME and O-CME. Primary outcomes included the quality of the resected specimen (lymph nodes retrieved, complete mesocolic plane excision, tumor to arterial high tie, resected mesocolon surface). Secondary outcomes included the three-year and five-year overall and disease-free survival rates, recurrence of the disease, surgical data, and postoperative morbidity and mortality. Two authors of the review screened the methodological quality of the eligible trials and independently extracted data from individual studies.
RESULTS A total of one RCT and eleven CCTs (four from Europe and seven from Asia) met the inclusion criteria for the current meta-analysis. These studies involved 1619 patients in L-CME and 1477 patients in O-CME. The L-CME was associated with the same quality of the resected specimen, with no differences regarding the retrieved lymphnodes (MD = -1.06, 95%CI: -3.65 to 1.53, P = 0.42), and tumor to high tie distance (MD = 14.26 cm, 95%CI: -4.30 to 32.82, P = 0.13); the surface of the resected mesocolon was higher in the L-CME group (MD = 11.75 cm2, 95%CI: 9.50 to 13.99, P < 0.001). The L-CME was associated with a lower rate of blood transfusions (OR = 0.45, 95%CI: 0.27 to 0.75, P = 0.002), faster recovery of gastrointestinal function, and less postoperative overall complication rate. The L-CME approach was associated with a statistical significant better three-year overall (OR = 2.02, 95%CI: 1.31 to 3.12, P = 0.001, I2 = 28%) and disease-free (OR = 1.45, 95% CI: 1.00 to 2.10, P = 0.05, I2 = 0%) survival.
CONCLUSION The laparoscopic approach offers the same quality of the resected specimen as the open approach in complete mesocolic excision with central vascular ligation for colon cancer. The laparoscopic complete mesocolic excision with central vascular ligation is superior in all perioperative results and at least non-inferior in long-term oncological outcomes.
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Affiliation(s)
- Ionut Negoi
- Department of General Surgery, Emergency Hospital of Bucharest, Carol Davila University of Medicine and Pharmacy Bucharest, Bucharest 014461, Romania
| | - Sorin Hostiuc
- National Institute of Legal Medicine Mina Minovici, Carol Davila University of Medicine and Pharmacy Bucharest, Bucharest 014461, Romania
| | - Ruxandra Irina Negoi
- Department of Anatomy, Carol Davila University of Medicine and Pharmacy Bucharest, Bucharest 014461, Romania
| | - Mircea Beuran
- Emergency Hospital of Bucharest, Carol Davila University of Medicine and Pharmacy Bucharest, Bucharest 014461, Romania
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Zhang Y, Wang D, Zhu L, Wang B, Ma X, Shi B, Yan Y, Zhou C. Standard versus extralevator abdominoperineal excision and oncologic outcomes for patients with distal rectal cancer: A meta-analysis. Medicine (Baltimore) 2017; 96:e9150. [PMID: 29384902 PMCID: PMC6393134 DOI: 10.1097/md.0000000000009150] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
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.
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Affiliation(s)
- Yunfeng Zhang
- Department of the Second Thoracic Surgery, the First Affiliated Hospital of Xi’an Jiaotong University
| | - Duo Wang
- Department of General Surgery, the Second Affiliated Hospital of Xi’an Medical College
| | - Lizhe Zhu
- Department of Breast Surgery, the First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi Province, China
| | - Bin Wang
- Department of Breast Surgery, the First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi Province, China
| | - Xiaoxia Ma
- Department of Breast Surgery, the First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi Province, China
| | - Bohui Shi
- Department of Breast Surgery, the First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi Province, China
| | - Yu Yan
- Department of Breast Surgery, the First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi Province, China
| | - Can Zhou
- Department of Breast Surgery, the First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi Province, China
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