Abstract
BackgroundCurrent evidence suggests that pelvic floor reconstruction following extralevator abdominoperineal excision of rectum (ELAPER) may reduce the risk of perineal herniation of intra-abdominal contents. Options for reconstruction include mesh and myocutaneous flaps, for which long-term follow-up data is lacking. The aim of this study was to evaluate the long-term outcomes of biological mesh (Surgisis®, Biodesign™) reconstruction following ELAPER.MethodsA retrospective review of all patients having ELAPER in a single institution between 2008 and 2018 was perfomed. Clinic letters were scrutinised for wound complications and all available cross sectional imaging was reviewed to identify evidence of perineal herniation (defined as presence of intra-abdominal content below a line between the coccyx and the lower margin of the pubic symphysis on sagittal view).ResultsOne hundred patients were identified (median age 66, IQR 59–72 years, 70% male). Median length of follow-up was 4.9 years (IQR 2.3–6.7 years). One, 2- and 5-year mortality rates were 3, 8 and 12%, respectively. Thirty three perineal wounds had not healed by 1 month, but no mesh was infected and no mesh needed to be removed. Only one patient developed a symptomatic perineal hernia requiring repair. On review of imaging a further 7 asymptomatic perineal hernias were detected. At 4 years the cumulative radiologically detected perineal hernia rate was 8%.ConclusionsThis study demonstrates that pelvic floor reconstruction using biological mesh following ELAPER is both safe and effective as a long-term solution, with low major complication rates. Symptomatic perineal herniation is rare following mesh reconstruction, but may develop sub clinically and be detectable on cross-sectional imaging.
Highlights
An abdominoperineal excision of the rectum (APER) may be required for patients with a rectal cancer less than 6 cm from the anal verge, where an anterior resection with anastomosis is not possible [1]
Concern over coning of the specimen with standard perineal dissection, leading to perforation and circumferential resection margin (CRM) involvement [2,3,4,5,6] with poorer oncological outcomes compared to a low anterior resection [7] led to the widespread adoption of extralevator abdominoperineal excision of rectum (ELAPER)
All patients having an ELAPER for low rectal cancer or a salvage procedure for anal cancer with biological mesh reconstruction were identified using a prospectively maintained colorectal multidisciplinary team database
Summary
An abdominoperineal excision of the rectum (APER) may be required for patients with a rectal cancer less than 6 cm from the anal verge, where an anterior resection with anastomosis. The ELAPER technique, based upon the original description of APER by Miles [8], involves excision of a wide area of tissue around the rectal tumour, and division of the levators at their origin, producing a cylinder of tissue and avoiding wasting seen with standard technique [9]. This larger cylindrical specimen improves oncological outcome but leaves a large pelvic floor defect requiring reconstruction to avoid perineal herniation [10]. The aim of this study was to evaluate long-term outcome data following a biological mesh pelvic floor reconstruction in a large cohort
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