Uterine retroversion and gluteal transposition flap for postoperative perineal evisceration after extralevator abdominoperineal resection

Anal squamous cell carcinoma (ASCC) is the most common histological subtype of malignant tumor affecting the anal canal. Chemoradiotherapy (CRT) is the first-line treatment in nearly all cases, ensuring complete clinical response in up to 80% of patients. Abdominoperineal resection (APR) is typically reserved as salvage therapy in those patients with persistent or recurrent tumor after CRT. In locally advanced tumors, an extralevator abdominoperineal excision (ELAPE), which entails excision of the anal canal and levator muscles, might be indicated to obtain negative resection margins. In this setting, the combination of highly irradiated tissue and large surgical defect increases the risk of developing postoperative perineal wound complications. One of the most dreadful complications is perineal evisceration (PE), which requires immediate surgical treatment to avoid irreversibile organ damage. Different techniques have been described to prevent perineal complications after ELAPE, although none of them have reached consensus. In this technical note, we present a case of PE after ELAPE performed for a recurrent ASCC. Perineal evisceration was approached by combining a uterine retroversion with a gluteal transposition flap to obtain wound healing and reinforcement of the pelvic floor at once, when a mesh placement is not recommended.

Comparison of the clinical efficacy of laparoscopic extralevator abdominoperineal excision (ELAPE) and non-ELAPE for low rectal cancer

This study was performed to retrospectively analyze and compare the related clinical indicators between extralevator abdominoperineal excision (ELAPE) and non-ELAPE under laparoscopic for low rectal cancer. From June 2018 to September 2021, a total of 80 patients with low rectal cancer who underwent either of the above two types of surgeries at our Hospital were enrolled. Patients were divided into the ELAPE group and non-ELAPE group based on the different surgical methods. Preoperative general indicators, intraoperative indicators, postoperative complications, positive circumferential resection margin rate, local recurrence rate, hospital stay length, hospital expenses, and other related indicators were compared between the two groups. There were no significant differences in the comparison of preoperative indexes between the ELAPE group and non-ELAPE group, including age, preoperative BMI, and gender. Similarly, there were no significant differences in abdominal operation time, total operation time, and the number of intraoperative lymph nodes dissected between the two groups. However, the perineal operation time, intraoperative blood loss, intraoperative perforation rate, and positive circumferential resection margin rate were significantly different between the two groups. In the comparison of postoperative indexes, perineal complications, postoperative hospital stay length, and IPSS score were significantly different between the two groups. The use of ELAPE in treating T3-4NxM0 phase low rectal cancer was superior to non-ELAPE in reducing intraoperative perforation rate, positive circumferential resection margin rate, local recurrence rate, etc.

Supine bottom-up extralevator abdominoperineal excision for anorectal adenocarcinoma is not inferior to standard approach and may be thus safely performed

BACKGROUND

Extralevator abdominoperineal excision (APE) for rectal carcinoma has been described in order to improve pathological and oncological results compared to standard APE. To obtain the same oncological advantages as extralevator APE, we have previously described a new procedure starting by a perineal approach: the supine bottom-up APE. Our objective is to compare oncological and surgical outcomes between the supine bottom-up APE and the standard APE.

METHODS

All patients with low rectal adenocarcinoma requiring APE were retrospectively included and divided into 2 groups: supine bottom-up APE (Group A) and standard APE (Group B).

RESULTS

From 2008 to 2016, 61 patients were divided into Groups A (n = 30) and B (n = 31). Postoperative outcomes and median length of stay were similar between groups. Patients from Group A had a significantly longer distal margin (30 [8-120] vs. 20 [1.5-60] mm, p = 0.04) and higher number of harvested lymph nodes (14.5 [0-33] vs. 11 [5-25], p = 0.03) than those from Group B. Circumferential resection margin involvement was similar between groups (28 vs. 22%, p = 0.6), whereas tumors from Group A were significantly larger and more frequently classified as T4 than those from Group B. Operative time was significantly shorter in Group A (437.5 [285-655] minutes) than in Group B (537.5 [361-721] minutes, p = 0.0009). At the end of follow-up, local recurrence occurred in 7 and 16% of patients from Groups A and B (p = 0.68). Three-year overall and disease-free survival rates were similar between groups (87 vs. 90%, p = 0.62 and 61 vs. 63%, p = 0.88, respectively).

CONCLUSION

Our findings suggest that supine bottom-up APE doesn't impair surgical outcomes, pathological results, overall and disease-free survivals in comparison with standard APE. This new procedure may be thus safely performed and decrease the operative time. Further randomized multicentric studies are required to confirm these results.

Tailored concept for the plastic closure of pelvic defects resulting from extralevator abdominoperineal excision (ELAPE) or pelvic exenteration

PURPOSE

No standard exists for reconstruction after extralevator abdominoperineal excision (ELAPE) and pelvic exenteration. We propose a tailored concept with the use of bilateral gluteal V-Y advancement flaps in non-extended ELAPE and with vertical myocutaneous rectus abdominis muscle (VRAM) flaps in extended procedures. This retrospective study analyzes the feasibility of this concept.

PATIENTS AND METHODS

We retrieved all consecutive patients after ELAPE or pelvic exenteration for rectal, anal, or vulva cancer with flap repair from a prospective database. Perineal wound complications were defined as the primary endpoint. Outcomes for the two different flap reconstructions were analyzed.

RESULTS

From 2005 to 2021, we identified 107 patients who met the study criteria. Four patients underwent exenteration with VRAM flap repair after previous V-Y flap fashioning. Therefore, we report on 75 V-Y and 36 VRAM flaps. The V-Y group contained more rectal carcinomas, and the VRAM group exhibited more patients with recurrent cancer, more multivisceral resections, and longer operation times. Perineal wound complications occurred in 21.3% in the V-Y group and in 36.1% in the VRAM group (p = 0.097). Adjusted odds ratio for perineal wound complication was not significantly different for the two flap types.

CONCLUSION

Concerning perineal wound complications, our concept yields favorable results for V-Y flap closure indicating that this less invasive approach is sufficient for non-extended ELAPE. Advantages are a shorter operation time, less donor site morbidity, and the option of a second repair. VRAM flaps were reserved for larger wounds after pelvic exenteration or vaginal repair.

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.

Is it worthwhile to perform closure of the pelvic peritoneum in laparoscopic extralevator abdominoperineal resection?

PURPOSE

There is no uniformity in the use of closure of the pelvic peritoneum (CPP) after laparoscopic extralevator abdominoperineal excision (ELAPE). This study aimed to evaluate the short-term outcomes of CPP after ELAPE and provide supporting evidence for the performance of CPP in laparoscopic ELAPE.

METHODS

Patients with rectal cancer who underwent ELAPE from January 2014 to April 2019 were retrospectively investigated. CPP was routinely performed unless it was not feasible. The main outcome was the difference in the occurrence of perineal hernia (PH), small bowel obstruction (SBO) and perineal wound complications between laparoscopic and open ELAPE, which were compared using Kaplan-Meier curves.

RESULTS

Of the 244 patients included, 104 received laparoscopic ELAPE, and 140 received open ELAPE. Patients in the laparoscopic group suffered a higher incidence of PH (11.5% (12/104) vs. 5.0% (7/140), p = 0.049), SBO (10.6% (11/104) vs. 7.9% (11/140), p = 0.433) and major perineal wound complications (12.5% (13/104) vs. 7.9% (11/140), p = 0.228) than those in the open group. Multivariate analysis showed that no-CPP was an independent risk factor for the occurrence of PH (p = 0.022, OR 3.436, 95% CI 1.199-9.848) and major perineal wound complications (p = 0.012, OR 3.683, 95% CI 1.337-10.146).

CONCLUSION

In this comparative cohort study with a risk of allocation bias, CPP was associated with a lower incidence of radiological PH and major perineal wound complications regardless of the surgical approach. Thus, we believe CPP could serve as an option L-ELAPE for the prevention of perineal complications. To further determine the impact of CPP on postoperative complications after ELAPE, a prospective multicentre study is needed.

[Biological mesh versus primary closure for pelvic floor reconstruction following extralevator abdominoperineal excision: a meta-analysis]

Objective: To compare the morbidity of perineum-related complication between biological mesh and primary closure in closing pelvic floor defects following extralevator abdominoperineal excision (ELAPE). Methods: A literature search was performed in PubMed, Embase, Cochrane Library, Web of Science, Wanfang database, Chinese National Knowledge Infrastructure, VIP database, and China Biological Medicine database for published clinical researches on perineum-related complications following ELAPE between January 2007 and August 2020. Literature inclusion criteria: (1) study subjects: patients undergoing ELAPE with rectal cancers confirmed by colonoscopy pathological biopsy or surgical pathology; (2) study types: randomized controlled studies or observational studies comparing the postoperative perineum-related complications between the two groups (primary perineal closure and reconstruction with a biological mesh) following ELAPE; (3) intervention measures: biological mesh reconstruction used as the treatment group, and primary closure used as the control group; (4) outcome measures: the included literatures should at least include one of the following postoperative perineal complications: overall perineal wound complications, perineal wound infection, perineal wound dehiscence, perineal hernia, chronic sinus, chronic perineal pain (postoperative 12-month), urinary dysfunction and sexual dysfunction. Literature exclusion criteria: (1) data published repeatedly; (2) study with incomplete or wrong original data and unable to obtain original data. Two reviewers independently performed screening, data extraction and assessment on the quality of included studies. Review Manager 5.3 software was used for meta-analysis. The mobidities of perineum-related complications, including overall perineal wound (infection, dehiscence, hernia, chronic sinus) and perineal chronic pain (postoperative 12-month), were compared between the two pelvic floor reconstruction methods. Finally, publication bias was assessed, and sensitivity analysis was used to evaluate the stability of the results. Results: A total of five studies, including two randomized controlled studies and three observational controlled studies, with 650 patients (399 cases in the biological mesh group and 251 cases in primary closure group) were finally included. Compared with primary closure, biological mesh reconstruction had significantly lower ratio of perineal hernia (RR=0.37, 95%CI: 0.21-0.64, P<0.001). No significant differences in ratios of overall perineal wound complication, perineal wound infection, perineal wound dehiscence, perineal chronic sinus and perineal chronic pain (postoperative 12-month) were found between the two groups (all P>0.05). Conclusion: Compared with primary closure, pelvic floor reconstruction following ELAPE with biological mesh has the advantage of a lower incidence of perineal hernia.

Efficacy of Pelvic Peritoneum Closure After Laparoscopic Extralevator Abdominoperineal Excision for Rectal Cancer

BACKGROUND

The descent of the small bowel into the pelvic dead space after extralevator abdominoperineal excision (ELAPE) presents a higher risk for postoperative complications. The aim of the present study was to evaluate the efficacy of pelvic peritoneum closure in preventing the small bowel from descending into the pelvic dead space and the potential consequences of this approach.

METHODS

Patients with rectal cancer undergoing laparoscopic ELAPE from March 2014 to January 2019 were retrospectively investigated. Closure of the pelvic peritoneum (CPP) was routinely performed unless it was not feasible. All patients with pelvic peritoneum reconstruction were included in the CPP group, and patients without pelvic peritoneum reconstruction were included in the no-CPP group. The main outcomes included the incidences of the small bowel descending into the retro-urogenital space (space between the bladder/uterus and the sacrum on axial CT scans), perineal wound complications, perineal hernia, and small bowel obstruction (SBO).

RESULTS

Of the 100 patients included, 79 received CPP, and 21 did not. Fewer patients with pelvic peritoneum closure had small bowels residing in the retro-urogenital space than patients without closure (17.7% vs 42.9%, p=0.014). The incidence of SBO was also lower in the CPP group (7.6% vs. 23.8%, p=0.034). Multivariable analysis showed that no-CPP (p=0.014) was an independent risk factor for the small bowel descending into the retro-urogenital space.

CONCLUSION

CPP may prevent the small bowel from descending into the retro-urogenital dead space in patients undergoing laparoscopic ELAPE without increasing the incidence of perineal wound complications. Prospective studies are warranted to confirm the efficacy of CPP in preventing SBO and perineal hernia.

Comparison of perineal morbidity between biologic mesh reconstruction and primary closure following extralevator abdominoperineal excision: a systematic review and meta-analysis

AIM

Extralevator abdominoperineal excision (ELAPE) for rectal cancer leaves a greater perineal defect which might result in significant perineal morbidity, and how to effectively close perineal defects remains a challenge for surgeons. This study aimed to comparatively evaluate the perineal-related complications of biologic mesh reconstruction and primary closure following ELAPE.

METHOD

The electronic databases PubMed, EMBASE, Cochrane Library, and Web of Science were searched to screen out all eligible studies, which compared biologic mesh reconstruction with primary closure for perineal-related complications following ELAPE. Pooled data of perineal-related complications including overall wound complications, hernia, infection, dehiscence, chronic sinus, and chronic pain (12 months after surgery) were analyzed.

RESULTS

A total of four studies (one randomized controlled trial and three cohort studies) involving 544 patients (346 biologic mesh vs 198 primary closure) were included. With a median follow-up of 18.5 months (range, 2-71.5 months). Analysis of the pooled data indicated that the perineal hernia rate was significantly lower in biologic mesh reconstruction as compared to primary closure (OR, 0.38; 95% CI, 0.22-0.69; P = 0.001). There were no statistically significant differences between the two groups in terms of total perineal wound complications rate (P = 0.70), as well as rates of perineal wound infection (P = 0.97), wound dehiscence (P = 0.43), chronic sinus (P = 0.28), and chronic pain (12 months after surgery; P = 0.75).

CONCLUSION

Biologic mesh reconstruction after extralevator abdominoperineal excision appears to have a lower hernia rate, with no differences in perineal wound complications.

Perineal Turn over Perforator Flap: A Novel Surgical Technique for Combined Perineal and Posterior Vaginal Wall Reconstruction

Extralevator Abdominoperineal Excision (ELAPE) and Abdominoperineal Resection create complex perineal defects made more challenging when combined with additional resection of the posterior vaginal wall. This composite defect requires the restoration of a functional vagina, in addition to the obliteration of the large perineal dead space, a need to reduce donor site, and perineal wound morbidity. Previously described fasciocutaneous and myocutaneous flaps for such defects are associated with long operations requiring intra-operative mobilization and are linked to post-operative complications including herniation, evisceration, flap loss, donor site morbidity and poor cosmetic outcome, amongst other issues. Herein we describe the case of a 60-year-old female patient that underwent combined ELAPE and posterior vaginectomy for anal squamous cell carcinoma. This complex defect was reconstructed using an extended version of the Perineal Turn-Over (PTO) flap based on the Internal Pudendal artery perforator.

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.

Robot-assisted laparoscopic repair of perineal hernia after abdominoperineal resection: A case report and review of the literature

INTRODUCTION

Perineal hernia is a protrusion of the pelvic floor containing intra-abdominal viscera. The occurrence of postoperative perineal hernia after abdominoperineal resection (APR) is rare, but reports have indicated a recent increase in occurrence following surgical treatment for rectal cancer. This has been attributed to a shift towards extralevator abdominoperineal resection, together with more frequent and long-term use of neoadjuvant therapy.

PRESENTATION OF CASE

Here, we report the case of a patient who underwent APR for cancer. Twenty months postoperative, a perineal hernia was detected. The patient was electively scheduled for surgery. Robot-assisted laparoscopy was performed using the da Vinci Surgical System. The perineal hernia was repaired by primary closure with the placement of Symbotex Composite mesh as reinforcement for the pelvic floor. The surgery was performed without any adverse events, and the patient was discharged the day after surgery. Clinical follow-up proceeded at the designated time intervals without difficulties.

DISCUSSION

Recurrence rates of perineal hernia remain high, and surgeons face numerous challenges related to poor view, suturing and mesh placement in the deep pelvis. Numerous approaches have been described, but there is still no consensus as to the optimal repair technique for perineal hernia.

CONCLUSION

Symptomatic perineal hernias can feasibly be repaired with robot-assisted laparoscopy. Furthermore, suturing and mesh placement require less effort with the robot approach when compared to the open and laparoscopic approaches. These promising findings are demonstrated in the included video.

Application of modified primary closure of the pelvic floor in laparoscopic extralevator abdominal perineal excision for low rectal cancer

AIM

To introduce a novel, modified primary closure technique of laparoscopic extralevator abdominal perineal excision (LELAPE) for low rectal cancer.

METHODS

We retrospectively analyzed data from 76 patients with rectal cancer who underwent LELAPE from March 2013 to May 2016. Patients were classified into the modified primary closure group (32 patients) and the biological mesh closure group (44 patients). The total operating time, reconstruction time, postoperative stay duration, total cost, postoperative complications and tumor recurrence were compared.

RESULTS

All surgery was successfully performed. The pelvic reconstruction time was 14.6 ± 3.7 min for the modified primary closure group, which was significantly longer than that of the biological mesh closure group (7.2 ± 1.9 min, P < 0.001). The total operating time was not different between the two groups (236 ± 20 min vs 248 ± 43 min, P = 0.143). The postoperative hospital stay duration was 8.1 ± 1.9 d, and the total cost was 9297 ± 1260 USD for the modified primary closure group. Notably, both of these categories were significantly lower in this group than those of the biological mesh closure group (P = 0.001 and P = 0.003, respectively). There were no differences observed between groups when comparing other perioperative data, long-term complications or oncological outcomes.

CONCLUSION

The modified primary closure method for reconstruction of the pelvic floor in LELAPE for low rectal cancer is technically feasible, safe and cost-effective.

Abdominoperineal Resection for Rectal Cancer in the Twenty-First Century: Indications, Techniques, and Outcomes

BACKGROUND

Management of low rectal cancer continues to be a challenge, and decision making regarding the need for an abdominoperineal resection (APR) in patients with low-lying tumors is complicated. Furthermore, choices need to be made regarding need for modification of the surgical approach based on tumor anatomy and patient goals.

DISCUSSION

In this article, we address patient selection, preoperative planning, and intraoperative technique required to perform the three types of abdominoperineal resections for rectal cancer: extrasphincteric, extralevator, and intersphincteric. Attention is paid not only to traditional oncologic outcomes such as recurrence and survival but also to patient-reported outcomes and quality of life.

Perineal Wound Closure Using Biological Mesh Following Extralevator Abdominoperineal Excision

AIMS

This study aimed to describe the short-term perineal healing rates in patients with perineal reconstruction using a biological mesh following extralevator abdominoperineal excision (elAPE).

METHODS

In a retrospective, descriptive single-centre cohort study, 88 consecutive patients treated with elAPE and perineal closure using a biological mesh between January 2011 and December 2015 were reviewed. All available data from electronic hospital records was collected. Patients were followed for 1 year following surgery and perineal wound status assessed at 3 months and at 1 year.

RESULTS

In total, 63 patients were male and all but 8 patients were treated for primary rectal cancer. All patients but 3 had received radiotherapy prior to surgery. Multivisceral excisions were performed in 19 patients. Omentoplasty was performed in 55 patients and 3 different types of meshes were used during the study period. At 3 months, 58 patients (66%) had a healed perineum. No association was detected between patient, tumour or perioperative characteristics and perineal wound status at 3 months. At 1 year, 4 patients were deceased and among the remaining 84, the perineal wound was healed in 77 patients (92%).

CONCLUSION

The use of biological meshes in perineal reconstruction following elAPE is feasible and safe, and the perineal wound is healed in the majority of the patients within 3 months.

Extralevator abdominoperineal excision versus conventional surgery for low rectal cancer: a single surgeon experience

OBJECTIVE

Extralevator abdominoperineal excision (ELAPE) reduces the risk of positive circumferential resection margin (CRM) and of intraoperative perforation (IOP), both of which are associated with high local recurrence rates and poor survival outcomes for rectal cancer. The aim of this study was to compare the results of ELAPE with conventional abdominoperineal excision (APE) for low rectal cancer.

MATERIAL AND METHODS

A total of 25 consecutive patients underwent ELAPE for low rectal cancer between November 2008 and September 2011. Fifty-six patients treated by conventional APE prior to 2008 were selected from our rectal cancer database for comparison as a historical cohort.

RESULTS

The mean follow-up was 44.7 months in the ELAPE group, and 70.6 months in the APE group. Patients undergoing ELAPE had a lower CRM positivity and IOP rate than APE (12% vs. 20%, p=0,531; 4% vs. 8,9%, p=0,826; respectively). The ELAPE group was associated with higher perineal wound complications than the APE group (16.0% vs. 1.8%, p=0.030). Local recurrence rates for patients in both groups did not differ significantly (4.0% vs. 3.6%, p=1.0).

CONCLUSION

The results of this study suggest that ELAPE technique was associated with less CRM involvement and reduced rates of IOP but markedly higher rates of postoperative perineal complications occurred as compared to conventional surgery. ELAPE must be reserved for advanced low rectal cancers.

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

AIM

The superiority of extralevator abdominoperineal excision (ELAPE) over conventional abdominoperineal excision (APE) remains controversial, despite the publication of many studies on this issue. The aim of this meta-analysis was to provide a clear, evidence-based comparison of the two procedures.

METHOD

A systematic review and meta-analysis was conducted through a comprehensive search of the PubMed, EMBASE/Medline and Cochrane Central Library databases for all studies comparing ELAPE with conventional APE for low rectal cancer. Pooled data on circumferential resection margin (CRM) positivity, intra-operative bowel perforation, perineal wound complications and local recurrence were analysed.

RESULTS

Seven studies, involving a total of 2672 patients, were included. Analysis of the pooled data did not reveal a significant difference between the two operations regarding CRM positivity [risk ratio (RR) = 0.79, 95% CI: 0.40-1.57; P = 0.50, I(2)  = 86%] and perineal wound complications (RR = 0.91, 95% CI: 0.71-1.16; P = 0.44, I(2)  = 49%), and showed a borderline reduced risk of intra-operative bowel perforation for ELAPE, but still did not reveal a significant difference between the two groups (RR = 0.61, 95% CI: 0.37-1.00; P = 0.05, I(2)  = 58%).

CONCLUSION

The current evidence does not indicate a statistically significant superiority of ELAPE over conventional APE in terms of CRM positivity and intra-operative bowel perforation.

Prospective controlled study of the safety and oncological outcomes of ELAPE procure with definitive anatomic landmarks versus conventional APE for lower rectal cancer

BACKGROUND

The use of extra-levator abdominoperineal resection (ELAPE) procedure for lower rectal cancer is controversial. It is unclear whether the ELAPE procedure could improve surgical safety and lead to better oncological outcomes.

METHODS

Sixty-nine lower rectal cancer patients who underwent ELAPE (36 cases) or conventional abdominoperineal resection (APE; 33 cases) between June 2011 and February 2013 were prospectively investigated. Clinicopathological variables including blood loss, intraoperative perforation (IOP) rate, circumferential resection margin (CRM) involvement, lymph node harvest, the postoperative complications, urinary and sexual function, quality of life (QOL), local recurrence rate and survival were recorded and compared.

RESULTS

Blood loss (P = 0.021), perineal wound complication (P = 0.039), IOP rate (P = 0.028), local recurrence (P = 0.034) were significantly less frequent in the ELAPE group. There was greater CRM involvement in the conventional APE group but no statistical difference between the two groups. Urinary function, sexual function and QOL were not significantly different between the two groups. Overall survival and progression-free survival were not significantly different between two groups, even when survival was analyzed according to TNM stage, T stage, N stage, and with or without neoadjuvant chemoradiotherapy. In patients who underwent ELAPE there was no statistical difference in postoperative complications between younger and elderly patients (age ≥60).

CONCLUSIONS

ELAPE procedure with definitive anatomic landmarks demonstrated surgical safety and decreased local recurrence for lower rectal cancer patients including the elderly, but there were no survival improvements in compared to conventional APE procedure.

Improved quality of care for patients undergoing an abdominoperineal excision for rectal cancer

INTRODUCTION

New diagnostics, the emergence of total mesorectal excision and neoadjuvant treatments have improved outcome for patients with rectal cancer. Patients with distal rectal cancer undergoing an abdominoperineal excision seem to do worse compared to those treated with sphinctersparing techniques. The aim of this study was to evaluate the quality of care for patients undergoing an abdominoperineal excision for distal rectal cancer during the last 15 years.

MATERIALS AND METHODS

All patients with rectal cancer, who underwent an abdominoperineal excision between December 1996 and December 2010 in 5 Dutch hospitals were analysed. Patients were divided into three cohorts; 1996-2001, 2001-2005 and 2006-2010. All data was extracted from medical records.

RESULTS

477 patients were identified. There was no significant difference in sex, age, BMI, prior pelvic surgery and ASA stages between the cohorts. MRI became a standard tool in the work-up, the use increased from 4.5% in the first, to 95.1% in the last cohort (p < 0.0001). Neoadjuvant treatment shifted from predominantly none (64.9% in cohort 1) to short course radiotherapy (66.7% in cohort 2) and chemoradiation therapy (55.7% in cohort 3). There was a trend towards a decreased circumferential resection margin involvement in the cohorts (18.8%, 16.7% and 11.4%; p = 0.142). Accidental bowel perforations have significantly decreased from 28.6%, and 21.7% to 9.2% in cohort 3 (p < 0.0001).

CONCLUSION

Significant improvements in work-up, neoadjuvant and surgical treatment have been made for patients with low rectal cancer, undergoing an abdominoperineal excision. These improvements result in improved short term outcome.

Local control and survival after extralevator abdominoperineal excision for locally advanced or low rectal cancer

AIM

Conventional, synchronous combined, abdominoperineal excision (APE) for low rectal cancer is associated with intra-operative tumour perforation and tumour involvement of the circumferential resection margin (CRM+). Several studies have demonstrated worse rates of local recurrence and survival after APE than after low anterior resection (LAR). Extralevator APE (ELAPE) in the prone position may reduce the risk of perforation and involvement of resection margins and may therefore improve outcome. The aim of this study was to report the outcome after the introduction of ELAPE in a prospective study of consecutive patients from a single colorectal unit.

METHOD

Between January 2000 and March 2013, 193 patients with low rectal cancer were treated with ELAPE at the Karolinska University Hospital, Stockholm, Sweden. All patients were recorded in the regional rectal cancer quality registry, where data on treatment and follow-up are prospectively reported.

RESULTS

Preoperative staging with MRI assessed the tumour to be locally advanced (mrT4) in 126 (65%) of the 193 patients. The median tumour level above the anal verge was 3 cm. Intra-operative perforation occurred in 19 patients (10%) and histopathology revealed a positive CRM in 39 patients (20%). Until August 2013 [median follow-up 31 (0-156) months] local recurrence was detected in 12 patients. Five-year cancer specific survival was estimated to 68%.

CONCLUSION

Good local control and survival may be achieved with ELAPE in patients with low, advanced rectal cancer.