Endoscopically assisted extralevator abdominoperineal excision

Short-Term Outcomes with Standardized Transperineal Minimally Invasive Abdominoperineal Excision for Rectal Cancer

BACKGROUND

Transperineal abdominoperineal excision (TpAPE) is an emerging approach for low rectal cancers but is technically challenging. Based on an anatomical study we conducted previously, we have standardized the TpAPE procedure. Here, we aimed to validate the feasibility of the standardized TpAPE by investigating the short-term outcomes.

METHODS

From January 2018 to November 2020, a total of 405 patients underwent laparoscopic or robotic rectal resection for rectal cancer in our institution. For the current study, we analyzed data for the 31 patients who underwent TpAPE. The abdominal phase was performed synchronously with the perineal phase using either a laparoscopic or robotic approach. Short-term outcomes included operative and pathological results.

RESULTS

Of the 31 cases, we identified anterior quadrant tumor invasion in 21. Most of the cases were advanced, with 6 staged as cT3 and 20 as T4. Of the 27 cases not involving distant metastasis, neoadjuvant therapy was performed in 19. No inadvertent rectal perforation or urethral injury was found intraoperatively. The median procedural duration to specimen removal was 250 min (interquartile range, 204-287), and the median intraoperative blood loss was 10 ml (interquartile range, 5-40). Regarding postoperative complications, perineal wound infection developed in 11 cases. A positive circumferential resection margin was found in 3, corresponding to the positive rate of 9.7%. These three cases were among the first 12 cases involving standardized TpAPE.

CONCLUSIONS

The current results indicate that TpAPE can be performed safely and might represent a useful option for low rectal cancer resection.

Transperineal minimally invasive abdominoperineal excision for rectal cancer based on anatomical analysis of the muscular structure

INTRODUCTION

Transperineal minimally invasive abdominoperineal excision (TpAPE) may help minimize surgical invasiveness and make it possible to perform two-team surgery, although this procedure is regarded as difficult. The anatomical structures are complicated and have not been clearly defined, particularly on the anterior side of the anorectal junction in men. We investigated the anatomical configuration around the anterior wall of the anorectal junction, focusing on the structure of the striated muscles, to establish a standard procedure for TpAPE.

METHODS

We scrutinized the T₂ -weighted MRI scans of 106 men, and two male cadavers were used to examine the muscular structure surrounding the anorectal junction. We established our standardized procedure for TpAPE based on these anatomical studies. We also analyzed the clinicopathological findings from five men who had undergone TpAPE at our institution.

RESULTS

Using MRI, we detected band-like muscles bilaterally, just medial to the puborectal muscle in all analyzed patients, which we termed the rectal anterolateral muscle. We also detected the muscles that may correspond to the rectal anterolateral muscle when inspecting the cadavers. The standardized TpAPE procedures were carried out uneventfully for the five cases, and intraoperative complications such as urethral injury and inadvertent rectal perforation did not occur.

CONCLUSION

We standardized the TpAPE procedure based on anatomical examination of the muscular structure around the anal canal. The findings can contribute to safe implementation of TpAPE.

Transperineal minimally invasive APE: preliminary outcomes in a multicenter cohort

Background

Abdominoperineal excision (APE) for rectal cancer is associated with a relatively high risk of positive margins and postoperative morbidity, particularly related to perineal wound healing problems. It is unknown whether the use of a minimally invasive approach for the perineal part of these procedures can improve postoperative outcomes without oncological compromise. The aim of this study was to evaluate the feasibility of minimally invasive transperineal abdominoperineal excision (TpAPE)

Methods

This multicenter retrospective cohort study included all patients having TpAPE for primary low rectal cancer. The primary endpoint was the intraoperative complication rate. Secondary endpoints included major morbidity (Clavien–Dindo ≥ 3), histopathology results, and perineal wound healing.

Results

A total of 32 TpAPE procedures were performed in five centers. A bilateral extralevator APE (ELAPE) was performed in 17 patients (53%), a unilateral ELAPE in 7 (22%), and an APE in 8 (25%). Intraoperative complications occurred in five cases (16%) and severe postoperative morbidity in three cases (9%). There were no perioperative deaths. A positive margin (R1) was observed in four patients (13%) and specimen perforation occurred in two (6%). The unilateral extralevator TpAPE group had worse specimen quality and a higher proportion of R1 resections than the bilateral ELAPE or standard APE groups. The rate of uncomplicated perineal wound healing was 53% (n = 17) and three patients (9%) required surgical reintervention.

Conclusions

TpAPE seems to be feasible with acceptable perioperative morbidity and a relatively low rate of perineal wound dehiscence, while histopathological outcomes remain suboptimal. Additional evaluation of the viability of this technique is needed in the form of a prospective trial with standardization of the procedure, indication, audit of outcomes and performed by surgeons with vast experience in transanal total mesorectal excision.

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.

Trans-perineal minimally invasive approach during extralevator abdominoperineal excision for advanced low rectal cancer: A retrospective cohort study

BACKGROUND

This study is to evaluate trans-perineal minimally invasive approach for extralevator abdominoperineal excision (TP-ELAPE) in a synchronous lithotomy position for locally advanced low rectal cancer.

METHODS

Between May 2013 and February 2016, 14 patients with locally advanced low rectal cancer underwent TP-ELAPE for the perineal phase of extralevator abdominoperineal excision, and 18 patients underwent conventional ELAPE.

RESULTS

There was no positive circumferential resection margin in both groups. Patients who received TP-ELAPE had similar bowel perforation rate (7.1% vs. 5.6%, p = 1.000), longer transperineal operative time (100 vs. 40 min, p < 0.001) and higher surgical difficulty visual analog scale (VAS) scores (6 vs. 2, p < 0.001), while had shorter total procedure time (215 vs. 260 min, p = 0.015), lower VAS pain scores on day 1 postoperatively (5 vs. 6.5, p = 0.049), shorter postoperative anus exhausting time (22 h vs 28 h, p = 0.006), and shorter postoperative hospital stay (11.5 d vs 13.5d, p = 0.028) compared with patients who received conventional ELAPE. There was no local recurrence with median follow-up time of 53 months in the TP-ELAPE group and 51 months in the conventional ELAPE group. There were no differences for disease-free survival (p = 0.835) and overall survival (p = 0.829) between groups.

CONCLUSIONS

TP-ELAPE approach in the synchronous lithotomy position might be a feasible approach for low rectal cancer, while ensuring a radical and safe surgical procedure.

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.

Fluorescence to highlight the urethra: a human cadaveric study

Background

Urethral injury is a complication feared by surgeons performing transanal TME (TaTME) or abdominoperineal excision (APE) procedures. Injury during TaTME occurs when the prostate is inadvertently mobilised or as a direct injury similar to the direct injury during the perineal dissection of APE procedures. We performed a proof of principle study to assess the feasibility of using indocyanine green (ICG) to fluoresce the urethra in human cadavers.

Methods

Indocyanine green at varying doses was mixed with Instillagel and infiltrated into the urethra of male human cadavers. The urethra was exposed through either a perineal incision or by mobilisation of the prostate during a TaTME dissection and fluorescence observed using a PINPOINT laparoscope (NOVADAQ). Brightness was assessed on the images using ImageJ (National Institute of Health).

Results

Eight cadavers were included in the study. Fluorescence was visualised in the urethra in all eight cadavers. Minimal dissection was required to obtain fluorescence transperineally. In one cadaver, the urethra was demonstrated under fluorescence using a simulated TaTME with additional fluorescence also being observed in the prostate. There was no correlation between brightness and dosing.

Conclusions

This novel proof of principle study demonstrates a simple way in which the urethra may be easily identified preventing it from injury during surgery.

Electronic supplementary material

The online version of this article (doi:10.1007/s10151-017-1615-y) contains supplementary material, which is available to authorized users.

Abdomino-endoscopic perineal excision of the rectum for benign and malignant pathology: Technique considerations for true transperineal verus transanal total mesorectal excision endoscopic proctectomy

PURPOSE

Transanal minimally invasive surgery using single port instrumentation is now well described for the performance of total mesorectal excision with restorative colorectal/anal anastomosis most-often in conjunction with transabdominal multiport assistance. While non-restorative abdomino-endoscopic perineal excision of the anorectum is conceptually similar, it has been less detailed in the literature.

METHODS

Consecutive patients undergoing non-restorative ano-proctectomy including a transperineal endoscopic component were analysed. All cases commenced laparoscopically with initial medial to lateral mobilisation of any left colon and upper rectum. The lower anorectal dissection started via an intersphincteric or extrasphincteric incision for benign and malignant pathology, respectively, and following suture closure and circumferential mobilisation of the anorectum, a single port (GelPOINT Path, Applied Medical) was positioned allowing the procedure progress endoscopically in all quadrants up to the cephalad dissection level. Standard laparoscopic instrumentation was used. Specimens were removed perineally.

RESULTS

Of the 13 patients (median age 55 years, median BMI 28.75 kg/m2, median follow-up 17 months, 6 males), ten needed completion proctectomy for ulcerative colitis following prior total colectomy (three with concomitant parastomal hernia repair) while three required abdominoperineal resection for locally advanced rectal cancer following neoadjuvant chemoradiotherapy. Median operative time was 190 min, median post-operative discharge day was 7. Eleven specimens were of high quality. Four patients developed perineal wound complications (one chronic sinus, two abscesses needing drainage) within median 17-month follow-up.

CONCLUSION

Convergence of transabdominal and transanal technology and technique allows accuracy in combination operative performance. Nuanced appreciation of transperineal operative access should allow specified standardisation and innovation.

A two-centre experience of transanal total mesorectal excision

AIM

Transanal total mesorectal excision (TaTME) offers a promising alternative to the standard surgical abdominopelvic approach for rectal cancer. The aim of this study was to report a two-centre experience of this technique, focusing on the short-term and oncological outcome.

METHOD

From May 2013 to May 2015, 40 selected patients with histologically proven rectal adenocarcinoma underwent TaTME in two institutions and were prospectively entered on an online international registry.

RESULTS

Forty patients (80% men, mean body mass index 27.4 kg/m² ) requiring TME underwent TaTME. Procedures included low anterior resection (n = 31), abdominoperineal excision (n = 7) and proctocolectomy (n = 2). A minimally invasive approach was attempted in all cases, with three conversions. The mean operation time was 368 min and 16 patients (40%) had a synchronous abdominal and transanal approach. There was no mortality and 16 postoperative complications occurred, of which 68.8% were minor. The median length of stay was 7.5 (3-92) days. A complete or near-complete TME specimen was delivered in 39 (97.5%) cases with a mean number of 20 lymph nodes harvested. R0 resection was achieved in 38 (95%) patients. After a median follow-up of 10.7 months, there were no local recurrences and six (15%) patients had developed distant metastases.

CONCLUSION

TaTME appears to be feasible, safe and reproducible, without compromising the oncological principles of rectal cancer surgery. It is an attractive option for patients for whom laparoscopy is likely to be particularly difficult. These encouraging results should encourage larger studies with assessment of long-term function and the oncological outcome.

Transanal total mesorectal excision: Myths and reality

Transanal total mesorectal excision (TaTME) is a new and promising approach for the treatment of rectal cancer. Whilst the experience is still limited, there are growing evidences that this approach might overcome the limits of standard low anterior resection. TaTME might help to decrease the conversion rate especially in difficult patients, and to improve the pathological results, while preserving the urogenital function. Evaluation of data from large registries and randomized studies should help to draw firmer conclusions. Beyond these technical considerations, the next challenge seems to be clearly the safe introduction of this approach, motivating the development of dedicated courses.

Transanal total mesorectal excision for rectal cancer: the journey towards a new technique and its current status

INTRODUCTION

The surgical approach to total mesorectal excision (TME) for rectal cancer has undergone a substantial evolution with the adoption of more minimally invasive procedures. Transanal TME (taTME) is the latest advanced technique pioneered to tackle difficult pelvic dissections. Areas covered: The evolution of TME surgery from open to laparoscopic, robotic and transanal techniques was explored in this review. The outcomes to date on the latest approach, taTME, are reviewed and the future direction of rectal cancer surgery proposed. A literature search was performed using Embase, Medline, Web of Science and Cochrane databases for articles published between January 2005 to May 2016 using the keywords 'transanal', 'TME', 'laparoscopy', 'robotics', 'minimally invasive', 'outcomes' and 'training'. Expert commentary: Surgical experience in taTME is growing and randomised controlled trials have been planned and initiated worldwide. However, the learning curve for this procedure remains to be established and a structured training programme is necessary to ensure safe introduction and dissemination of the technique in the clinical setting. Further innovation including stereotactic navigation and more specialised transanal equipment are currently being explored and are likely to enhance the technique further.

Transanal rectal resection: an initial experience of 20 cases

AIM

Low anterior resection (LAR) can present a formidable surgical challenge, particularly for tumours located in the distal third of the rectum. Transanal total mesorectal excision (taTME) aims to overcome some of these difficulties. We report our initial experience with this technique.

METHOD

From June 2013 to September 2014, 20 selected patients underwent transanal rectal resection for various malignant and benign low rectal pathologies. All patients with rectal cancer were discussed at a multidisciplinary team meeting. Data were entered into a prospective managed international database.

RESULTS

Of the 20 patients (14 male), seventeen (85%) had rectal cancer lying at a median distance of 2 cm (range 0-7) from the anorectal junction. The operations performed included LAR (16). Abdominoperineal excision (2) and completion proctectomy (2), all of which were performed by a minimally invasive approach with three conversions. The mean operation time was 315.3 min. There were six postoperative complications of which two (10%) were Clavien-Dindo Grade IIIb (pelvic haematoma and a late contained anastomotic leakage). The median length of stay was 7 days. The TME specimen was intact in 94.1% of cancer cases. The mean number of harvested lymph nodes was 23.2. There was only one positive circumferential resection margin (tumour deposit; R1 rate 5.9%). One patient developed a distant recurrence (median follow-up 10 months, range 6-21).

CONCLUSION

TaTME was safe in this small series of patients. It is especially attractive in patients with a narrow and irradiated pelvis and a tumour in the lower third of the rectum. TaTME is technically demanding, but the good outcomes should prompt randomized studies and prospective registration of all taTME cases in an international registry.