Extralevator abdominoperineal excision (Elape): A retrospective cohort study

Negative pressure wound management in perineal wound status post abdominoperineal resection and extralevator abdominoperineal excision: a meta-analysis and trial sequential analysis

PURPOSE

Recent evidence-based publications disclosed that negative pressure wound therapy (NPWT) may reduce the incidence rate of surgical site infection (SSI) and length of stay (LOS) compared with conventional drainage in patient status post abdominoperineal resection (APR) and extralevator abdominoperineal excision (ELAPE).

METHODS

Data sources: Eligible randomized controlled trials and retrospective and prospective studies published before January 2023 were retrieved from databases (Cochrane Library, PubMed, and Embase).

STUDY SELECTION

(a) The study involved patients undergoing ELAPE or APR with postoperative NPWT; (b) the study compared NWPT with conventional drainage and reported at least one outcome of interest (i.e., SSI); and (c) the study provided adequate information to calculate the effect estimated for meta-analysis.

INTERVENTIONS

We calculated the odds ratio (ORs) and mean differences (MDs) with 95% confidence intervals (CIs).

MAIN OUTCOME MEASURES

The measure outcomes included surgical site infection(SSI) and length of stay (LOS).

RESULTS

Eight articles, involving 547 patients, met the selection criteria. Compared to conventional drainage, NPWT was associated with a significantly lower SSI rate (fixed effect, OR 0.29; 95% CI 0.18-0.45; I² = 0%) in eight studies and 547 patients. Besides, NPWT was associated with a shorter LOS (fixed effect, MD - 2.00; CI - 2.60 to - 1.39; I² = 0%) than conventional drainage in three studies and 305 patients. In a trial sequential analysis, the cumulative number of patients in the analyses of both outcomes exceeded the required information size and surpassed the significance boundary in favor of NPWT, suggesting conclusive results.

CONCLUSION

NPWT is superior to conventional drainage in both SSI rate and LOS, and the statistical power of SSI and LOS are confirmed by trial sequential analysis.

Long-term follow-up of bilateral gracilis reconstruction following extra-levator abdominoperineal excision

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.

Laparoscopic extralevator abdominoperineal excision in distal rectal cancer patients: a retrospective comparative study

BACKGROUND

At present, abdominoperineal excision with neoadjuvant chemoradiotherapy (nCRT) is one of the treatment modalities of distal rectal cancer. Our study analyzed the effects of laparoscopic extralevator abdominoperineal resection (ELAPE) compared with laparoscopic conventional abdominoperineal resection(cAPR) in the treatment of distal rectal cancer.

METHODS

Retrospective analysis was conducted on the clinicopathological data of 177 distal rectal cancer patients treated with a laparoscopic abdominoperineal resection between 2011 and 2018. The patients were divided into four groups as follows: ELAPE without nCRT (group A), cAPR without nCRT (group B), ELAPE with long-course nCRT (group C) and cAPR with long-course nCRT (group D).

RESULTS

Positive circumferential resection margin (CRM), local recurrence rate, 3-year disease-free survival (DFS) and 3-year overall survival (OS) did not differ between group A and group B. The rate of positive CRM in group C was lower than group D (4.4% vs. 11.9%, respectively), although the difference was not significant (P = 0.377). The 3-year local recurrence rate in group C was lower compared with group D (6.6% vs. 16.7%, respectively), although the difference was not significant (P = 0.135). Three-year DFS and 3-year OS were not different between groups C and D.

CONCLUSIONS

This study showed that the effect of laparoscopic ELAPE in patients with low-risk rectal cancer is similar to laparoscopic cAPR, revealing that laparoscopic cAPR can be routinely selected for patients with low-risk rectal cancer. Furthermore, laparoscopic ELAPE has a tendency to reduce the rate of positive CRM and local recurrence in patients with high-risk rectal cancer. Laparoscopic ELAPE can be routinely considered for patients with high-risk rectal cancer.

Extralevator Abdominoperineal Excision (ELAPE) is Not Superior to Abdominoperineal Excision (APE) in the Era of Neoadjuvant Treatment in Rectal Cancer

Aim: To evaluate the effect of extralevator abdominoperineal excision of the rectum (ELAPE) on the circumferential resection margin (CRM) and overall survival in comparison to standard abdominoperineal excision of the rectum (APE) in patients with advanced rectal cancer. Material and Methods: This retrospective study encompasses patients with advanced rectal cancer operated on with two different methods: prone Jack-Knife position ELAPE and APE. In part of them, neoadjuvant chemoradiation was conducted. Postoperative patient, tumor, and outcome data were analyzed in terms of differences in CRM positivity and overall survival. Results: Of 67 patients treated with either APE (52) or ELAPE (15), 43 were male and 24 were female. Neoadjuvant treatment was conducted on 49 of the total patients. Complete pathological response (T0) was achieved in 3 patients. Positive CRM was reported in 7 patients (11.5 %), 3 in ELAPE and 4 in APE group (p = 0.348). The overall postoperative complication rate was 56.7%. Mean survival period was 42.2 months. Overall survival rate for both groups was 67.2 %. No statistical differences were seen between the ELAPE and APE procedure in terms of overall survival (p = 0.483). Conclusions: Differences between the use of ELAPE and APE in terms of CRM positivity and overall survival were not statistically significant. Therefore, we conclude that ELAPE is not superior to standard APE in the treatment of advanced rectal cancer.

Flap Reconstruction of Perineal Defects after Pelvic Exenteration: A Systematic Description of Four Choices of Surgical Reconstruction Methods

BACKGROUND

The treatment of locally advanced or recurrent anorectal cancer requires radical surgery such as extralevator abdominoperineal resection and pelvic exenteration. Larger defects require flap reconstruction. The authors evaluated outcomes of different perineal reconstruction techniques.

METHODS

A systematic search was performed in the PubMed, Embase, and Cochrane databases. Studies reporting outcomes on perineal flap reconstruction in patients with anal or colorectal cancer were included. Data on patient characteristics, surgical details, perineal and donor-site complications, revision surgery, mortality, and quality of life were extracted. Articles were assessed using the Group Reading Assessment and Diagnostic Evaluation approach.

RESULTS

The authors included 58 mainly observational studies comprising 1988 patients. Seventy-three percent of patients had rectal cancer. The majority of 910 abdominoperineal resection patients underwent reconstruction with rectus abdominis flaps (91 percent). Dehiscence (15 to 32 percent) and wound infection (8 to 16 percent) were the most common complications. Partial flap necrosis occurred in 2 to 4 percent and flap loss occurred in 0 to 2 percent. Perineal herniation was seen in 6 percent after gluteal flap reconstruction and in 0 to 1 percent after other types of reconstruction. Donor-site complications were substantial but were reported inconsistently.

CONCLUSIONS

Clinical outcome data on perineal reconstruction after exenterative surgery are mostly of very low quality. Perineal reconstruction after pelvic exenteration is complex and requires a patient-tailored approach. Primary defect size, reconstruction aims, donor-site availability, and long-term morbidity should be taken into account. This review describes the clinical outcomes of four flap reconstruction techniques. Shared clinical decision-making on perineal reconstruction should be based on these present comprehensive data.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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