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

Short- and mid-term outcomes of abdominoperineal resection with perineal mesh insertion: a single-centre experience

PURPOSE

Abdominoperineal resection (APR) remains a key procedure for the treatment of low rectal/anorectal cancers. However, perineal wound closure remains challenging, particularly in extralevator abdominoperineal resection (ELAPR) due to gapped tissue planes. Different approaches have been attempted to improve perineal wound repair. The aim of this study is to report our 6-year experience in perineal wound closure utilising biological mesh.

METHODS

We conducted a retrospective study using data from our prospectively maintained database, including patients who underwent APR with perineal mesh closure between 2016 and 2021.

RESULTS

49  patients underwent APR with perineal mesh reconstruction for low rectal cancer during the 6-year period. Of these, 63% were males, with a mean age of 68 (± 11), and a mean BMI of 27.9 (± 13.7). 49% (24) of patients received neoadjuvant therapy. 88% (43) of patients underwent standard "S-APR" and only 12% (6) underwent ELAPR. Majority of procedures were laparoscopic (87.8%) with conversion rate of 6.9%. Mean length of stay was 11.7 (± 11.6). The perineal wound infection rate was 30% and only two patient required mesh removal due to entero-cutaneous perineal fistula and pelvic abscess. Perineal hernia was found in only two patients (4.1%). CRM was negative in 81.6% of the patients. Mean follow-up period was 29.2 (± 16.5) months, and disease recurrence occurred in 9 (18.3%) patients with average number of months for recurrence of 21 (± 7). Overall survival during the follow-up period was 91%.

CONCLUSION

Our series shows a favourable short- and medium-term outcome with routine insertion of mesh for perineal wound closure.

Surgical treatment of rectal cancer: prospective cohort study about good oncologic results and low rates of abdominoperineal excision

OBJECTIVES

the purpose of this study was to evaluate the outcome of rectal cancer surgery, in a unit adopting the principles of total mesorectal excision (TME) with a high restorative procedure rate and with a low rate of abdominoperineal excision (APE).

METHODS

we enrolles patients with extraperitoneal rectal cancer undergoing TME or TME+APE. Patients with mid rectal tumors underwent TME, and patients with tumors of the lower rectum and no criteria for APE underwent TME and intersphincteric resection. Those in which the intersphincteric space was invaded and in those with a free distal margin less than 1cm or a tumor free radial margin were unattainable underwent APE or extralevator abdominoperineal excision (ELAPE). We assessed local recurrence rates, overall survival and involvement of the radial margin.

RESULTS

sixty (89.6%) patients underwent TME and seven (10.4%) TME + APE, of which five underwent ELAPE. The local recurrence, in pacientes undergoing TME+LAR, was 3.3% and in patients undergoing APE, 14.3%. The local recurrence rate (p=0.286) or the distant recurrence rate (p=1.000) was similar between groups. There was no involvement of radial margins. Survival after 120 months was similar (p=0.239).

CONCLUSION

rectal malignancies, including those located in the low rectum, may be surgically treated with a low rate of APE without compromising oncological principles and with a low local recurrence rates.

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.

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

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.

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

Purpose

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

Methods

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

Results

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

Conclusion

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

Supplementary Information

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

Surgical Techniques for Abdominoperineal Resection for Rectal Cancer: One Size Does Not Fit All

Abdominoperineal resection (APR) of rectal cancer is associated with poorer oncological outcomes than anterior resection. This may be due to higher rates of intra-operative perforation (IOP) and circumferential resection margin (CRM) involvement causing higher recurrence rates and surgical complications. To address these concerns, several centers advocated a change in technique from a standard APR to a more radical extra-levator abdominoperineal excision (ELAPE). Initial reports showed that ELAPE reduced IOP rates and CRM involvement but increased wound complications and longer surgical duration. However, many of these studies had unacceptable rates of IOP and CRM before retraining in ELAPE. This may indicate that it was a sub-optimal surgical technique, which improved upon training, that had influenced the high CRM and IOP rates rather than the technique itself. Subsequent studies demonstrated that the CRM involvement rate for ELAPE was not always lower than for standard APR and, in some cases, significantly higher. The morbidity of ELAPE can be high, with studies reporting higher adverse events than APR, especially in terms of wound complications from the larger perineal incision required in ELAPE. Whether ELAPE improves short- or long-term oncological outcomes for patients has not been clearly demonstrated. The authors propose that all centers performing rectal cancer surgery audit surgical outcomes of patients undergoing APR or ELAPE and examine CRM involvement, IOP rates, and local recurrence rates, preferably through a national body. If rates of adverse technical or oncological outcomes exceed acceptable levels, then retraining in the appropriate surgical techniques may be indicated.

Surgical Treatment of Low-Lying Rectal Cancer: Updates

Despite innovative advancements, distally located rectal cancer remains a critical disease of challenging management. The crucial location of the tumor predisposes it to a circumferential resection margin (CRM) that tends to involve the anal sphincter complex and surrounding organs, with a high incidence of delayed anastomotic complications and the risk of the pelvic sidewall or rarely inguinal lymph node metastases. In this regard, colorectal surgeons should be aware of other issues beyond total mesorectal excision (TME) performance. For decades, the concept of extralevator abdominoperineal resection to avoid compromised CRM has been introduced. However, the complexity of deep pelvic dissection with poor visualization in low-lying rectal cancer has led to transanal TME. In contrast, neoadjuvant chemoradiotherapy (NCRT) has allowed for the execution of more sphincter-saving procedures without oncologic compromise. Significant tumor regression after NCRT and complete pathologic response also permit applying the watch-and-wait protocol in some cases, now with more solid evidence. This review article will introduce the current surgical treatment options, their indication and technical details, and recent oncologic and functional outcomes. Lastly, the novel characteristics of distal rectal cancer, such as pelvic sidewall and inguinal lymph node metastases, will be discussed along with its tailored and individualized treatment approach.

Outcomes of robotic partial excision of the levator ani muscle for locally advanced low rectal cancer invading the ipsilateral pelvic floor at the anorectal ring level

PURPOSE

The purpose of this study is to evaluate partial excision of the levator ani muscle (PELM) enables preservation of anal sphincter function although levator ani muscle (LAM) was invaded.

METHODS

Functional outcomes and oncologic outcomes of 23 consecutive patients who underwent robotic PELM for low rectal cancer at the anorectal ring level invading or abutting the ipsilateral LAM are analysed.

RESULTS

Secured resection margins were achieved, especially for the circumferential resection margin. During a median follow-up of 44 months, the 3-year local recurrence rate was 14.4%. Among patients who underwent diverting ileostomy closure, mean Memorial Sloan Kettering Cancer Center Bowel Function Instrument and Wexner scores were 68.3 ± 11.9 and 10.7 ± 5.3, respectively, at 1 year after closure.

CONCLUSION

PELM is a sphincter-preserving alternative to abdominoperineal resection (APR) or extralevator APR for low rectal cancer invading the ipsilateral LAM at the level of the anorectal ring.

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

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.

Methods of Colostomy Construction: No Effect on Parastomal Hernia Rate: Results from Stoma-const-A Randomized Controlled Trial

OBJECTIVE

The primary objective of this trial was to compare the parastomal hernia rates 1 year after the construction of an end colostomy by 3 surgical techniques: cruciate incision, circular incision in the fascia and using prophylactic mesh. Secondary objectives were evaluation of postoperative complications, readmissions/reoperations, and risk factors for parastomal hernia.

SUMMARY OF BACKGROUND DATA

Colostomy construction techniques have been explored with the aim to improve function and reduce stoma complications, but parastomal herniation is frequent with an incidence of approximately 50%.

METHODS

A randomized, multicenter trial was performed in 3 hospitals in Sweden and Denmark; all patients scheduled to receive an end colostomy were asked to participate. Parastomal hernia within 12 months was determined by computed tomography of the abdomen in prone position and by clinical assessment. Complications, readmissions, reoperations, and risk factors were also assessed.

RESULTS

Two hundred nine patients were randomized to 1 of the 3 arms of the study. Patient demographics were similar in all 3 groups. Assessment of parastomal hernia was possible in 185 patients. The risk ratio (95% confidence interval) for parastomal hernia was 1.25 (0.83; 1.88), and 1.22 (0.81; 1.84) between cruciate versus circular and cruciate versus mesh groups, respectively. There were no statistically significant differences between the groups with regard to parastomal hernia rate. Age and body mass index were found to be associated with development of a parastomal hernia.

CONCLUSION

We found no significant differences in the rates of parastomal hernia within 12 months of index surgery between the 3 surgical techniques of colostomy construction.

Surgical and oncological short-term outcomes of prone extralevator abdominoperineal excision for low rectal cancer

Introduction In recent years, a standardized surgical approach for low rectal cancer was proposed and adopted in many centres. The extralevator abdominoperineal excision introduce an extensive resection of the pelvic floor and demonstrated superiority if the procedure is done in the prone jack-knife position, especially regarding intraoperative perforation and circumferential resections margins. The aim of this study is to evaluate the surgical and oncological short-term outcomes of prone extralevator abdominoperineal excision.

Methods All patients registered in our institution from January 2003 to January 2015 who underwent abdominoperineal resection or prone extralevator abdominoperineal excision for low rectal cancer after preoperative chemoradiation were retrospectively included from prospective maintained data base and were compared regarding surgical and oncological outcomes.

Results Eighty-nine patients underwent curative intent resections. Abdominoperineal resection was performed in 67 patients and prone extralevator abdominoperineal excision in 22 patients. There were no statistical significant differences between groups regarding pathological stage, median number of harvested lymph node, intraoperative perforation, circumferential resections margins involvement and recurrence rates. Surgical outcomes were statistically different between groups. Twenty-six patients (29%) developed perineal complications, 21% of the abdominoperineal resection patients and 55% of the prone extralevator abdominoperineal excision (p < 0.001). Most of these complications were due to delayed perineal wound healing (12.4%), and wound abscesses (4.5%). However, the readmission rate and median length of hospital stay was higher in the abdominoperineal resection group (p < 0.001).

Conclusion Prone extralevator abdominoperineal excision is comparable to standard abdominoperineal resection. It was associated to a decrease in length of hospital stay and readmission rate, although more perineal complications occurred. We cannot recommend it as a standard technique for all low rectal cancer. Notwithstanding, prone extralevator abdominoperineal excision can be considered a more radical approach when there is sphincter complex or levators muscles invasion.

The quality of lymph node harvests in extralevator abdominoperineal excisions

Background

Lymph node (LN) harvest in colorectal cancer resections is a well-recognised prognostic factor for disease staging and determining survival, particularly for node-negative (N0) diseases. Extralevator abdominoperineal excisions (ELAPE) aim to prevent “waisting” that occurs during conventional abdominoperineal resections (APR) for low rectal cancers, and reducing circumferential resection margin (CRM) infiltration rate. Our study investigates whether ELAPE may also improve the quality of LN harvests, addressing gaps in the literature.

Methods

This retrospective observational study reviewed 2 sets of 30 consecutive APRs before and after the adoption of ELAPE in our unit. The primary outcomes are the total LN counts and rates of meeting the standard of 12-minimum, particularly for those with node-negative disease. The secondary outcomes are the CRM involvement rates. Baseline characteristics including age, sex, laparoscopic or open surgery and the use of neoadjuvant chemoradiotherapy were accounted for in our analyses.

Results

Median LN counts were slightly higher in the ELAPE group (16.5 vs. 15). Specimens failing the minimum 12-LN requirements were almost significantly fewer in the ELAPE group (OR 0.456, P = 0.085). Among node-negative rectal cancers, significantly fewer resections failed the 12-LN standard in the ELAPE group than APR group (OR 0.211, P = 0.044). ELAPE led to a near-significant decrease in CRM involvement (OR 0.365, P = 0.088). These improvements were persistently observed after taking into account baselines and potential confounders in regression analyses.

Conclusion

ELAPE provides higher quality of LN harvests that meet the 12-minimal requirements than conventional APR, particularly in node-negative rectal cancers. The superiority is independent of potential confounding factors, and may implicate better clinical outcomes.

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

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

Extralevator abdominoperineal excision for advanced low rectal cancer: Where to go

Since its introduction, extralevator abdominoperineal excision (ELAPE) in the prone position has gained significant attention and recognition as an important surgical procedure for the treatment of advanced low rectal cancer. Most studies suggest that because of adequate resection and precise anatomy, ELAPE could decrease the rate of positive circumferential resection margins, intraoperative perforation, and may further decrease local recurrence rate and improve survival. Some studies show that extensive resection of pelvic floor tissue may increase the incidence of wound complications and urogenital dysfunction. Laparoscopic/robotic ELAPE and trans-perineal minimally invasive approach allow patients to be operated in the lithotomy position, which has advantages of excellent operative view, precise dissection and reduced postoperative complications. Pelvic floor reconstruction with biological mesh could significantly reduce wound complications and the duration of hospitalization. The proposal of individualized ELAPE could further reduce the occurrence of postoperative urogenital dysfunction and chronic perianal pain. The ELAPE procedure emphasizes precise anatomy and conforms to the principle of radical resection of tumors, which is a milestone operation for the treatment of advanced low rectal cancer.

A low incidence of perineal hernia when using a biological mesh after extralevator abdominoperineal excision with or without pelvic exenteration or distal sacral resection in locally advanced rectal cancer patients

Background

Extralevator abdominoperineal excision (ELAPE), abdominoperineal excision (APE) or pelvic exenteration (PE) with or without sacral resection (SR) for locally advanced rectal cancer leaves a significant defect in the pelvic floor. At first, this defect was closed primarily. To prevent perineal hernias, the use of a biological mesh to restore the pelvic floor has been increasing. The aim of this study, was to evaluate the outcome of the use of a biological mesh after ELAPE, APE or PE with/without SR.

Methods

A retrospective study was conducted on patients who had ELAPE, APE or PE with/without SR with a biological mesh (Permacol™) for pelvic reconstruction in rectal cancer in our center between January 2012 and April 2015. The endpoints were the incidence of perineal herniation and wound healing complications.

Results

Data of 35 consecutive patients [22 men, 13 women; mean age 62 years (range 31–77 years)] were reviewed. Median follow-up was 24 months (range 0.4–64 months). Perineal hernia was reported in 3 patients (8.6%), and was asymptomatic in 2 of them. The perineal wound healed within 3 months in 37.1% (n = 13), within 6 months in 51.4% (n = 18) and within 1 year in 62.9% (n = 22). In 17.1% (n = 6), the wound healed after 1 year. It was not possible to confirm perineal wound healing in the remaining 7 patients (20.0%) due to death or loss to follow-up. Wound dehiscence was reported in 18 patients (51.4%), 9 of whom needed vacuum-assisted closure therapy, surgical closure or a flap reconstruction.

Conclusions

Closure of the perineal wound after (EL)APE with a biological mesh is associated with a low incidence of perineal hernia. Wound healing complications in this high-risk group of patients are comparable to those reported in the literature.

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.

Laparoscopic extralevator abdominoperineal resection versus laparoscopic abdominoperineal resection for lower rectal cancer: A retrospective comparative study from China

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.

A Novel Laparoscopic Technique With a Bladder Peritoneum Flap Closure for Pelvic Cavity for Patients With Rigid Pelvic Peritoneum After Neoadjuvant Radiotherapy in Laparoscopic Extralevator Abdominoperineal Excision

BACKGROUND

In laparoscopic extralevator abdominoperineal excision, reconstruction of the pelvic peritoneum helps to prevent the small intestine from adhering to pelvic wall tissues, thus avoiding small-bowel obstruction and perineal complications. However, there are difficulties in pelvic peritoneum closure if the patient has received preoperative radiotherapy and has a rigid pelvis. We report a novel laparoscopic method for pelvic peritoneum reconstruction using the bladder peritoneum flap in laparoscopic extralevator abdominoperineal excision after neoadjuvant radiotherapy.

TECHNIQUE

After transection of the rectum, if the patient had a rigid pelvis, we chose to perform the novel technique for the pelvic peritoneum closure in a 3-step approach. The flap has an arch shape with the bottom at the anterior wall of the pelvic cavity entrance. The height of the arched flap is equal to the distance from the bladder to the sacral promontory. The peritoneum was incised with electrocautery at the planned level and peeled off the bladder. The bladder peritoneum flap was then rotated to cover the entrance of the pelvic cavity and sutured to the brim of the pelvis.

RESULTS

Acceptable postoperative short-term and long-term outcomes (5- to 22-month follow-ups) were achieved in 3 patients who underwent bladder peritoneum flap closure.

CONCLUSIONS

The bladder peritoneum flap appears to be safe and feasible for intracorporeal closure of the pelvic cavity in laparoscopic extralevator abdominoperineal excision after neoadjuvant radiotherapy. The procedure provides a novel option for patients with severe fibrosis of the pelvis when another peritoneum reconstruction method is not feasible.

Total Mesorectal Excision for Mid-Rectal Cancer Without Anastomosis: Low Hartmann’s Operation or Intersphincteric Abdomino-Perineal Excision?

Background and Aims:

In mid-rectal cancer, the low colorectal anastomosis is, although feasible, sometimes avoided. The aim was to compare low Hartmann’s procedure with intersphincteric abdomino-perineal excision of the rectum, in patients operated with total mesorectal excision for mid-rectal cancer in whom the low anastomosis was technically feasible but for patient-related reasons undesired.

Material and Methods:

A total of 64 consecutive patients with mid-rectal cancer who underwent low Hartmann’s procedure (n = 34) or intersphincteric abdomino-perineal excision (n = 30) at one colorectal unit were compared regarding patient demography, short-term oncology, surgical outcome at 3 and 24 months, and long-term overall survival.

Results:

There were no significant differences between intersphincteric abdomino-perineal excision and Hartmann’s procedure regarding age, gender distribution, body mass index, preoperative radiotherapy, tumor level, or cancer stages. Operation time was shorter in Hartmann’s procedure as compared with intersphincteric abdomino-perineal excision, median 174 and 256 min, (P < 0.001), and intraoperative blood loss was increased, 600 and 500 mL, respectively (P = 0.045). Number of lymph nodes and circumferential resection margin were comparable. In Hartmann’s procedure compared with intersphincteric abdomino-perineal excision, the need for reoperation was 24% and 3%, (P = 0.020), complications classified as Clavien–Dindo 3–4 occurred in 32% and 10%, (P = 0.031), pelvic abscess in 21% and 10%, (P = 0.313), and mortality within 90 days was 3% and 0%, respectively, (P = 0.938). In intersphincteric abdomino-perineal excision, the perineal wound was not healed at 3 months in 13%, and in Hartmann’s procedure 15% had chronic secretion from the anorectal remnant at 2 years postoperatively.

Conclusion:

The results from this study suggest that intersphincteric abdomino-perineal excision might be an alternative to Hartmann’s procedure in patients with mid-rectal cancer, in whom a low colorectal anastomosis is undesired.

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

Background

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

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

Method

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

Results

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

Conclusion

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

•

A single high-volume Centre, retrospective study.

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

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Positive CRM is associated with increased local recurrence.

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

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The numbers needed to treat are 9.

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

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

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Local recurrence after 'standard' abdominoperineal resection: do we really need ELAPE?

Introduction Low rectal cancers requiring abdominoperineal resection tend to have a worse prognosis than higher tumours, which may be treated by anterior resection. One of the reasons for this may be inadequate local surgery, in particular the narrow waist of the resection specimen of a standard abdominoperineal resection may be associated with a high positive circumferential resection margin. The extralevator abdominoperineal excision (ELAPE) aims to improve the R0 resection rate but carries significant morbidity. We examined our own results of standard abdominoperineal resection to assess the need for a change of policy. Methods We operformed a retrospective analysis of consecutive standard abdominoperineal resections for rectal cancer in a single centre from June 2002 to December 2011. Results A total of 102 patients underwent standard abdominoperineal resection with curative intent; 19 had no preoperative treatment, 42 had short course radiotherapy, 9 had long course radiotherapy and 32 had neoadjuvant chemotherapy followed by long course chemoradiotherapy. In 17/102(16.6%), there was a positive circumferential resection margin. Over a median follow up of 32 months, 20 patients developed recurrence of any type. Local recurrence occurred in five patients (two of which also had distant recurrence), of whom two had a positive circumferential resection margin (P = 0.10). Actuarial two-year local only recurrence was 3.4% and any recurrence was 17.7%. Overall five-year cancer specific survival was 77%. Conclusions In this series we found low rates of local recurrence after standard abdominoperineal resection even with a circumferential margin rate positivity of 16.6%.Performing an ELAPE in selected cases may improve these results further but is not necessarily required for all patients.

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.

Novel anal sphincter saving procedure with partial excision of levator-ani muscle in rectal cancer invading ipsilateral pelvic floor

Purpose

Tumors at the level of the anorectal junction had required total levator-ani muscle excision to achieve an adequate resection margin. However, in the cases of tumor invading ipsilateral levator-ani muscle and intact external sphincter, en bloc resection of rectum with levator-ani muscle including tumor would be possible. This hemilevator excision (HLE) technique enables preserving the anal sphincter function while obtaining oncologic clearance and avoiding permanent colostomy in those patients. This study aimed to evaluate the surgical outcomes and feasibility of HLE.

Methods

Data on 13 consecutive patients who underwent HLE for pathologically proven low rectal cancer were retrospectively collected. All 13 patients presented low rectal cancer at the anorectal ring level that was suspected to invade or abut to the ipsilateral side of the levator-ani muscle.

Results

A secure resection margin was achieved in all cases, and anastomotic leakage occurred in 2 patients. During follow-up, 3 patients experienced tumor recurrence (2 systemic and 1 local). Among 6 patients who underwent diverting ileostomy closure after the index operation, 2 complained of fecal incontinence. The other 4 patients without fecal incontinence showed <10 times of bowel movement per day. Accessing their incontinence scale, mean Wexner score was 9.4.

Conclusion

HLE is a novel sphincter-preserving technique that can be a treatment option for low rectal cancer invading ipsilateral levator-ani muscle, which has been an indication for abdominoperineal resection (APR) or extralevator APR. However, the long-term oncologic and functional outcomes of this procedure still need to be assessed to confirm its validity.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Biological Mesh Closure of the Pelvic Floor After Extralevator Abdominoperineal Resection for Rectal Cancer: A Multicenter Randomized Controlled Trial (the BIOPEX-study)

OBJECTIVE

To determine the effect of biological mesh closure on perineal wound healing after extralevator abdominoperineal resection (eAPR).

BACKGROUND

Perineal wound complications frequently occur after eAPR with preoperative radiotherapy for rectal cancer. Cohort studies have suggested that biological mesh closure of the pelvic floor improves perineal wound healing.

METHODS

Patients were randomly assigned to primary closure (standard arm) or biological mesh closure (intervention arm). A non-cross-linked porcine acellular dermal mesh was sutured to the pelvic floor remnants in the intervention arm, followed by a layered closure of the ischioanal and subcutaneous fat and skin similar to the control intervention. The outcome of the randomization was concealed from the patient and perineal wound assessor. The primary endpoint was the rate of uncomplicated perineal wound healing defined as a Southampton wound score of less than 2 at 30 days postoperatively. Patients were followed for 1 year.

RESULTS

In total, 104 patients were randomly assigned to primary closure (n = 54; 1 dropouts) and biological mesh closure (n = 50; 2 dropouts). Uncomplicated perineal wound healing rate at 30 days was 66% (33/50; 3 not evaluable) after primary closure, which did not significantly differ from 63% (30/48) after biological mesh closure [relative risk 1.056; 95% confidence interval (CI) 0.7854-1.4197; P = 0.7177). Freedom from perineal hernia at 1 year was 73% (95% CI 60.93-85.07) versus 87% (95% CI 77.49-96.51), respectively (P = 0.0316).

CONCLUSIONS

Perineal wound healing after eAPR with preoperative radiotherapy for rectal cancer was not improved when using a biological mesh. A significantly lower 1-year perineal hernia rate after biological mesh closure is a promising secondary finding that needs longer follow-up to determine its clinical relevance.

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

AIM

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

METHOD

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

RESULTS

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

CONCLUSION

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

Biological mesh reconstruction of the pelvic floor following abdominoperineal excision for cancer: A review

Extralevator abdominoperineal excision and pelvic exenteration are mutilating operations that leave wide perineal wounds. Such large wounds are prone to infection and perineal herniation, and their closure is a major concern to most surgeons. Different approaches to the perineal repair exist, varying from primary or mesh closure to myocutaneous flaps. Each technique has its own associated advantages and potential complications and the ideal approach is still debated. In the present study, we reviewed the current literature and our own local data regarding the use of biological mesh for perineal wound closure. Current evidence suggests that the use of biological mesh carries an acceptable risk of wound complications compared to primary closure and is similar to flap reconstruction. In addition, the rate of perineal hernia is lower in early follow-up, while long-term hernia occurrence appears to be similar between the different techniques. Finally, it is an easy and quick reconstruction method. Although more expensive than primary closure, the cost associated with the use of a biological mesh is at least equal, if not less, than flap reconstruction.

Recent surgical advances in colorectal cancer excision: toward optimal outcomes

Colorectal cancer is the third most common cancer affecting both males and females in the western world. Despite all the developments in the current treatment of colorectal cancer, it is still continuing to be an important factor of patient morbidity and mortality worldwide. Surgery is the mainstay of treatment for colorectal cancer. Over the last decade, there have been major changes and developments in the surgical treatment. Understanding the importance of the anatomy, technological advances in minimally invasive surgery and effects of chemoradiotherapy have changed the approaches to colorectal cancer treatment. Today, novel treatment strategies must be targeted not only minimally invasive approaches, but also aiming to increase patients’ quality of life without compromising the oncological principles.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Management of the Perineal Defect after Abdominoperineal Excision

The optimal management of the perineal defect following abdominoperineal excision for anorectal malignancy remains a source of debate. The repopularization of extralevator resection means colorectal surgeons are confronted with larger perineal wounds. There are several surgical options available-primary perineal closure and drainage, omentoplasty, biological or synthetic mesh placement, musculocutaneous flap repair, and negative wound pressure therapy. These options are discussed along with the potential benefits and complications of each. There remains no consensus on which management strategy is superior; thus, each case must be tailored for each individual patient. Surgical expertise and availability of a multidisciplinary team approach are important considerations.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A Systematic Review of Outcomes After Transanal Mesorectal Resection for Rectal Cancer

BACKGROUND

Transanal mesorectal resection has been developed to facilitate minimally invasive proctectomy for rectal cancer.

OBJECTIVE

The purpose of this study was to evaluate the evidence regarding technical parameters, oncological outcomes, morbidity, and mortality after transanal mesorectal resection.

DATA SOURCES

The Cochrane Library, PubMed, and MEDLINE databases were reviewed.

STUDY SELECTION

Systematic review of the literature from January 2005 to September 2015 was used for study selection.

INTERVENTION

Intervention included transanal mesorectal resection for rectal cancer.

MAIN OUTCOME MEASURES

Technical parameters, histological outcomes, morbidity, and mortality were the outcomes measured.

RESULTS

Fifteen predominately retrospective studies involving 449 patients were included (mean age, 64.3 years; 64.1% men). Different platforms were used. The operative mortality rate was 0.4% and the cumulative morbidity rate 35.5%. Circumferential resection margins were clear in 98%, and the resected mesorectum was grade III in 87% of patients. Median follow-up was 14.7 months. There were 4 local recurrences (1.5%) and 12 patients (5.6%) with metastatic disease. No study followed patients long enough to report on 5-year overall and disease-free survival rates. Functional outcome was only reported in 3 studies.

LIMITATIONS

A low number of procedures were performed by expert early adopters. There are no comparative or randomized data included in this study and inconsistent reporting of outcome variables.

CONCLUSIONS

Transanal mesorectal resection for rectal cancer may enhance negative circumferential margin rates with a reasonable safety profile. Contemporary randomized, controlled studies are required before there can be universal recommendation.

Sparing Sphincters and Laparoscopic Resection Improve Survival by Optimizing the Circumferential Resection Margin in Rectal Cancer Patients

The goal of rectal cancer treatment is to minimize the local recurrence rate and extend the disease-free survival period and survival. For this aim, obtainment of negative circumferential radial margin (CRM) plays an important role. This study evaluated predictive factors for positive CRM status and its effect on patient survival in mid- and distal rectal tumors.Patients who underwent curative resection for rectal cancer were included. The main factors were demographic data, tumor location, surgical technique, neoadjuvant therapy, tumor diameter, tumor depth, lymph node metastasis, mesorectal integrity, CRM, the rate of local recurrence, distant metastasis, and overall and disease-free survival. Statistical analyses were performed by using the Chi-squared test, Fisher exact test, Student t test, Mann-Whitney U test and the Mantel-Cox log-rank sum test.A total of 420 patients were included, 232 (55%) of whom were male. We observed no significant differences in patient characteristics or surgical treatment between the patients who had positive CRM and who had negative CRM, but a higher positive CRM rate was observed in patients undergone abdominoperineal resection (APR) (P < 0.001). Advanced T-stage (P < 0.001), lymph node invasion (P = 0.001) and incomplete mesorectum (P = 0.007) were encountered significantly more often in patients with positive CRM status. Logistic regression analysis revealed that APR (P < 0.001) and open resection (P = 0.046) were independent predictors of positive CRM status. Moreover, positive CRM was associated with decreased 5-year overall and disease-free survival (P = 0.002 and P = 0.004, respectively).This large single-institution series demonstrated that APR and open resection were independent predictive factors for positive CRM status in rectal cancer. Positive CRM independently decreased the 5-year overall and disease-free survival rates.