Abdominoperineal Excision Procedure Research Articles

Purse string closure of perineal defects after abdominoperineal excision.

The aim of this study was to describe a new technique of perineal closure following abdominoperineal excision (APE) using purse-string perineal skin closure (PSPC). Between January 2016 and May 2021, 15 consecutives patients who had an APE procedure were included in this retrospective single-center study. All indications of APE were considered, as well as all types of APE. We analyzed the patient characteristics and peri-operative features, including overall (Clavien 1 to 5) and severe (Clavien 3 and 4) postoperative morbidity, length of stay (LOS), and long-term results (median time to perineal wound closure and rate of perineal incisional hernia). The patients included 11 men and four women, with a mean age of 64 ± 13 [33-80] years. The indication of APE was an epidermoid carcinoma of the anal canal (n = 5) or an adenocarcinoma of the rectum (n = 10). The mean operating time was 220 ± 88.64 [70-360] min. The overall morbidity rate was 60%, the severe morbidity rate 26%, and reoperation rate 26%. The median length of stay was 9 ± 6.5days. After a mean follow-up of 23.5 ± 20.3months, the median time to perineal wound closure was 96 ± 60days, the persistent perineal sinus rate was 6% (n = 2), and one patient developed a perineal incisional hernia. Purse-string closure of perineal wounds is a safe and effective technique for perineal wound closure after APE. The short LOS allowed an early return home.

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

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

Multicenter study of surgical and oncologic outcomes of extra-levator versus conventional abdominoperineal excision for lower rectal cancer

BackgroundThe surgical and oncological outcome of extra-levator abdominoperineal excision (ELAPE) procedure remains unclear in low rectal cancer. MethodsA total of 194 cases of rectal cancer patients underwent ELAPE or conventional abdominoperineal excision (APE) procedure were analyzed in four hospitals’ databases from January 2010 to December 2015. Clinicopathological data, overall survival (OS), disease free survival (DFS) and local recurrence free survival (LRFS) of patients were compared between two groups. ResultsThe operation time spent in perineal phase was significantly shorter in the ELAPE group than that in conventional APE procedure (P < 0.001). There were more specimens with excellent or good quality in ELAPE group compared to conventional APE group (P = 0.033). Patients whom underwent ELAPE procedures showed significantly better OS, DFS and LRFS than those underwent conventional APE procedures. Patients with preoperative stage cT3∼T4 (P = 0.033, P = 0.008, P = 0,033), cN+ (P = 0.002, P < 0.001, P = 0.006) and pathological stage III-IV (P = 0.023, P = 0.008, P = 0.016) were associated with significant benefits from ELAPE procedure in terms of OS, DFS and LRFS. DFS differed significantly between two groups of patients whom got preoperative chemoradiation therapy (P = 0.009) or postoperative chemotherapy (P = 0.029). For patients of pathological stage IIII-IV without preoperative chemoradiation, ELAPE procedures resulted in statistically better OS (P = 0.018) and DFS (P = 0.030). ELAPE procedure was an independent risk factor of OS, DFS and LRFS in multivariate analysis. ConclusionLow rectal cancer patients might benefit from ELAPE procedure on both surgical and oncological outcomes, especially in patients with relatively advanced tumors, inspite of the effects of pre-operative radio- and chemotherapy.

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 41months 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 ± 3.6days vs 14.6 ± 1.0days, p = 0.03). The median interval between ELAPE and initiation of adjuvant chemo was 54days (range 32-120days) compared to 50days (range 30-100days) in patients undergoing conventional APE. A delay in initiating adjuvant chemotherapy of more than 12weeks 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.

Fluorescence to highlight the urethra: a human cadaveric study

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

Repair of Perineal Hernia Following Abdominoperineal Excision with Biological Mesh: A Systematic Review.

Perineal hernia (PerH) following abdominoperineal excision (APE) procedure is a recognized complication. PerH was considered an infrequent complication of APE procedure; however, PerH rates of up to 45% have been reported in recent publications following a laparoscopic APE procedure. Various methods of repair of PerH with the use of synthetic meshes or myocutaneous flap have been described, although there is no general agreement on an optimal strategy. The use of biological meshes for different operations is growing in popularity, and these have been promoted as being superior and safer when compared to synthetic meshes. Although the use of biologics is becoming popular claims of better outcomes are largely unsupported by evidence. The aim of this systematic review is to evaluate the currently available evidence supporting the use of biologic or biosynthetic meshes for the repair of PerH that develop following an APE. A systematic review of all English language literature relevant to repair of PerH following APE with biologic or biosynthetic mesh published between January 1, 2000 and July 31, 2016 was carried out using MEDLINE, EMBASE, and the Cochrane Library of Systematic Reviews for relevant literature. Searches were performed using a combination of Medical Subject Headings (MeSH) terms and text words "PerH," "APE," "morbidity," "biologics," "biosynthetic," and "hernia." Studies in which the use of biological meshes was not reported were excluded from the review. Various outcome measures, including operative technique, complication rates, recurrence rates, type of mesh, management of recurrences, and risk factors, were extracted. Oxford Centre for Evidence-based Medicine - Levels of Evidence (March 2009) was used to assess the quality of evidence. The systematic review of the literature identified three case reports, four case series, and one pooled analysis that were included in the final review. Overall, these studies were of poor quality providing level 4 evidence. Various different approaches and techniques of repair of PerH were described; however, it was difficult to extract information with regard to the primary and secondary outcome measures. There is no general agreement to the optimal operative strategy to repair PerH following an APE. There is insufficient evidence to recommend any specific operative approach or repair technique for PerH following an APE.

Application of da Vinci robotic surgical system in radical resection of gastric and colorectal cancer: a report of 647 cases

To investigate the feasibility and safety of robotic-assisted radical resection of gastric and colorectal cancer. The clinical data of 305 patients who received radical resection of gastric cancer and 342 patients who received radical resection of colorectal cancer both accomplished by the da Vinci robotic surgical system at the Southwest Hospital, Third Military Medical University from March 2010 to December 2014 were retrospectively analyzed. In gastric cancer group, radical total gastrectomy were performed in 69 cases, proximal gastrectomy in 11 cases, distal gastrectomy in 213 cases and 12 cases of gastric stump cancer.In colorectal cancer group, radical resection of the right colon were performed in 6 cases, left colon in 4 cases, transverse colon in 1 case, sigmoid colon low anterior resection procedure in 24 cases, rectal low anterior resection procedure in 222 cases, abdominoperineal excision procedure in 79 cases and Hartmann procedure in 6 cases. All cases had robotic-assisted radical resection successfully. In gastric cancer group, the mean operation time was (226±62) minutes, the mean blood loss was (125±77) ml, the mean number of harvested lymph nodes was 34±10; the mean time for patients taking normal activity was (3.2±1.5) days, the mean time for gastrointestinal function recovery was (3.1±1.3) days, the mean time for taking liquid food was (3.5±1.9) days. The mean hospitalization was (7.9±3.7) days postoperatively. In colorectal group, the mean operation time was (181±61) minutes, the mean blood loss was (110±93) ml, the mean number of harvested lymph nodes was 19±6; the mean time for patients taking normal activity was (2.9±1.5) days, passage of first flatus was (2.7±1.7) days. The mean hospitalization was (7.1±1.6) days postoperatively. Surgical complications occurred in 28 patients (9.2%) of gastric cancer group and 30 patients (8.8%) of colorectal cancer group, all the cases were recovery before leaving hospital with non-operation therapy. The short-term efficiency was obvious. Robotic-assisted radical resection for gastric and colorectal cancer is a feasible and safe surgical procedure combined the minimal trauma and fast recovery.

OC-100 Lorec registry–interim analysis of operative technique and perineal wound healing outcomes after abdomino-perineal excision

Introduction The LOREC perineal wound healing registry was developed to record data on abdomino-perineal excision (APE) for rectal cancer in colorectal units across the UK between 2012 and 2014 to understand current practice in operative techniques and patient outcomes. Initial interim results are reported. Method Surgeons wishing to participate received secure web-based access to the registry. Collected data included pre-operative staging, operative details, pathology, early outcome and follow-up at 12 months. Results Overall 43 units entered a total of 259 patients undergoing APE. These included 168 extralevator APE (ELAPE) procedures (65%) and 91 non-ELAPEs, comprising 73 ‘standard’ APE, 9 intersphincteric, 2 ischio-anal and 7 unspecified procedures. The ELAPE and non-ELAPE groups are compared. In the ELAPE group there were 120 males (71%) with a median age of 66 years (range 38–93). In the non-ELAPE group there were 64 males (70%) with a median age of 68 years (range 32–97). The perineal component was performed prone in 151 (90%) of the ELAPE group versus 13 (14%) of the non-ELAPE group. The coccyx was removed in 123 (73%) of the ELAPEs and 7 (8%) of the non-ELAPEs. In the ELAPE group primary skin closure for the perineal component was performed in 119 (71%) while in 34 (20%) a flap was used (13 VRAM, 9 local myocutaneous and 12 fascio-cutaneous flaps). In 15 cases (9%) the surgeons reported no closure. In 111 (66%) a mesh, generally biological, was used in perineal closure. Mesh was most commonly used where the closure was primary but 9 flap closures also used mesh. In the non-ELAPE group primary closure was more common, being used in 76 (84%) while in 5 (5%) a flap was used. In 10 cases (11%) the surgeons reported no closure. Mesh was used less frequently in non-ELAPEs, with only 30 (33%) using a mesh; the majority (57%) of these were non-biological. Primary healing was achieved in 29% of ELAPE patients, the majority of whom were closed primarily, compared to 9% in the non-ELAPE group. There was no difference in wound healing by 4 weeks and both groups had a small number of patients who took more than 3 months to heal completely. There was no significant difference in length of hospital stay for the two groups. There was one post-operative death in each group; a peritonitis of unknown cause in the ELAPE group and a GI bleed in the non-ELAPE group. Conclusion The LOREC registry has been a success in providing a summary of current practice and will be valuable in informing the design of future trials assessing APE techniques and reconstruction. In this series, ELAPE is performed in the majority of patients and primary closure with mesh appears to offer effective skin closure compared to flap. Disclosure of interest None Declared.

OC-004 Lorec registry – interim analysis of operative technique, pathology and oncological outcomes after abdomino-perineal excision

<h3>Introduction</h3> The LOREC perineal wound healing registry was developed to record data on abdomino-perineal excision (APE) for rectal cancer in colorectal units across the UK between 2012 and 2014 to understand current practice. Initial interim results are reported. <h3>Method</h3> Surgeons wishing to participate received secure web-based access to the registry. Collected data included pre-operative staging, neo-adjuvant treatment, operative details, pathology, early outcome and follow-up at 12 months. <h3>Results</h3> Overall 43 units entered a total of 259 patients undergoing APE. These included 168 extralevator APE (ELAPE) procedures (65%) and 91 non-ELAPEs, comprising 73 ‘standard’ APE, 9 intersphincteric, 2 ischioanal and 7 unspecified procedures. The ELAPE and non-ELAPE groups are compared. This indication for APE was oncological in 98% with only 5 cases having APE for functional reasons, eg weak sphincters. On pre-op MRI the ELAPE group had higher grade tumours, with 112 (67%) staged on MRI as T3/4 compared with 47 (54%) for non-ELAPEs. ELAPEs also had a higher incidence of predicted positive lymph nodes, with 97 (58%) N1/2 compared with 38 (43%) for non-ELAPEs. The circumferential resection margin was predicted as less likely to be clear in the ELAPE group, 68 (45%), versus 38 (53%) in the non-ELAPE group. Metastatic disease was reported in 6% of the ELAPE group and 3% of the non-ELAPEs. The majority of patients received pre-operative treatment, most commonly chemoradiotherapy. Overall, the response to treatment was graded on MRI as mixed fibrosis and tumour in 32%, while 38% showed mainly or only tumour and 29% showed small or no residual tumour. Multivisceral resection was undertaken in 19 (11%) of ELAPEs and 7 (8%) of non-ELAPEs, the vast majority involving the vagina. Operative complications were recorded in 8%. These included rectal perforation (7 cases), urethral injury (6 cases), ureteric injury (2 cases) and 9 cases of ‘other’ complications. On pathology similar proportions had higher grade tumours: 81 (52%) T3/4 in the ELAPE group compared with the 41 (47%) in the non-ELAPE group. The ELAPEs were more likely to be node-positive, 55 (35%), versus 23 (27%) in the non-ELAPEs. A positive resection margin was reported in 21 (14%) of ELAPEs and 2 (2%) of non-ELAPEs. Perforation was noted in 3 patients in each group. The quality of TME was graded as mesorectal plane intact in 112 (67%) of ELAPEs and 46 (51%) of non-ELAPEs. The quality of the levator plane was graded as complete levator wrap in 110 (65%) of ELAPEs. <h3>Conclusion</h3> It appears that surgeons are using ELAPE in more advanced cases but R1 rates of 14% suggest these are challenging and further means of improving outcomes should be explored. <h3>Disclosure of interest</h3> None Declared.

Feasibility and short-outcomes of laparoscopic extralevator abdominoperineal excision without changing position for distal rectal cancer

To evaluate the short-term outcomes of laparoscopic extralevator abdominoperineal excision (ELAPE) without changing position during operation. Totally 51 patients with distal advanced rectal cancer received surgical operation in Peking Union Midical College Hospital from September 2011 to April 2014. There were 29 male and 22 female patients with a mean age of (61 ± 10) years. Twenty-six percent of the patients received preoperative concomitant chemotherapy and radiation. Twenty-seven patients underwent laparoscopic abdominoperineal excision (APE) procedure, while 24 patients underwent ELAPE procedure. In both groups, patients were kept Lithotomy-Trendelenburg position during operation. The fat tissue in ischialrectal fossa was not routinely removed, except the tumor invasion. All the patients' pelvic peritoneum was closed by continuous suturing, and subcutaneous tissue and skin by interrupted suturing. Retrospectively compare the pathoclinical features, operation time, bleeding, node retrieval, lateral margin and complications by t-text and χ(2) test respectively between ELAPE and APE procedures both by laparoscopic approach. No significant differences were found in term of age, gender, BMI, distance from anal verge, percentage of neoadjuvant chemoradiation, and TNM staging between these two groups (all P > 0.05). The operation time was significantly shorter in ELAPE group ((181 ± 41) minutes vs. (228 ± 58) minutes, t = -3.265, P = 0.002). The bleeding volume was less in ELAPEE group (50 (80) ml vs 80 (100) ml (M(QR)), Z = -2.259, P = 0.024). The lateral margin, urinal retention and perineal wound healing were comparable for these two groups. No pelvic hernia was found during the postoperative follow-up (2 to 34 months) in both groups (all P > 0.05). Laparoscopic extralevator abdominoperineal excision without changing position is feasible for distal rectal cancer. Some essential steps can be simultaneously accomplished during operation without changing position. Closing the pelvic peritoneum is important for preventing the intestine dropping from abdominal cavity to presacral cavity.

Abdominoperineal excision following preoperative radiotherapy for rectal cancer: unfavorable prognosis even with negative circumferential resection margin.

To evaluate whether an abdominoperineal excision (APE) is associated with increased local recurrence (LR) and shortened disease-free survival (DFS) in mid-low rectal cancer with a negative circumferential resection margin (CRM). 283 consecutive cases of mid-low rectal cancer underwent preoperative 30 Gy/10 F radiotherapy and surgery in Peking University Cancer Hospital between August 2003 and August 2009. Patients with positive CRM and intraoperative distant metastasis were precluded according to exclusion criteria. Survival analyses were performed in patients with APE or non-APE procedures. 256 of the 283 (90.5%) cases were enrolled in the analysis, including 78 (30.5%) and 178 (69.5%) cases who received APE and non-APE procedures. Fewer female patients (P = 0.016), lower level of tumor (P = 0.000) and higher body mass index (P = 0.006) were found in the APE group. On univariate analysis, the APE group had a higher LR rate (5.1% vs 1.1%, P = 0.036) and decreased DFS (73.1% vs 83.4%, P = 0.021). On multivariate analysis, APE procedure was also an independent risk factor for LR (HR = 5.960, 1.085-32.728, P = 0.040) and decreased DFS (HR = 2.304, 1.298-4.092, P = 0.004). In stratified analysis for lower rectal cancer, APE procedure was still an independent risk factor for higher LR rate (5.6% vs 0%, P = 0.024) and shortened DFS (91.5% vs 73.6%, P = 0.002). Following preoperative 30 Gy/10 F radiotherapy, APE procedure was still a predictor for LR and decreased DFS even with negative CRM. More intensive preoperative treatment should be planned for the candidates who are scheduled to receive APE with optimal imaging assessment.

Differences in Circumferential Resection Margin Involvement After Abdominoperineal Excision and Low Anterior Resection No Longer Significant

The aim of this study was to evaluate whether the abdominoperineal excision (APE) is associated with an increased risk of circumferential resection margin (CRM) involvement after rectal cancer surgery in comparison with low anterior resection (LAR). The oncologic inferiority of the APE technique in comparison with LAR has been widely reported in literature. However, because of large evolvement in rectal cancer care, outcomes after APE may have improved since then. The population-based dataset of the Dutch Surgical Colorectal Audit was used selecting 5017 patients with primary rectal cancer undergoing surgery in 2010 to 2011. Propensity scores were calculated for the likelihood of performing an APE given relevant patient and tumor characteristics, and used in the multivariate analysis of CRM involvement. The APE was associated with a slight, nonsignificant, increased risk of CRM involvement [odds ratio (OR) = 1.33; confidence interval (CI) = 0.93-1.90]. Absolute percentages of CRM involvement were 8% and 12% after LAR and APE, respectively.In the subgroup analysis, advanced rectal tumors (cT3-4) were associated to a higher risk of CRM involvement after APE (OR = 1.61; CI = 1.05-1.90), whereas smaller tumors (cT1-2) were not (OR = 0.62; CI = 0.27-1.40). The results suggest that on a national level the APE procedure itself is not a strong predictor anymore for CRM involvement after rectal cancer surgery. However, in advanced tumors, results after APE are inferior to LAR.

Multicentre study of circumferential margin positivity and outcomes following abdominoperineal excision for rectal cancer

Rectal cancer outcomes following abdominoperineal excision (APE) have been inferior to those for anterior resection, including more positive circumferential resection margins (CRMs). An erroneously conservative interpretation of APE (rather than a radical resection termed 'extralevator') has been proposed as the cause. In this multicentre study, factors contributing to CRM positivity were examined following APE according to its original description. Data were collected from five hospital databases up to June 2011 including small- and larger-volume units (3 hospitals had 5 or fewer and 2 hospitals had more than 5 APE procedures per year). Primary outcome measures were CRM status; secondary outcomes were local recurrence and death. Of 327 patients, 302 patients had complete data for analysis. Some 50·0 per cent of patients had neoadjuvant chemoradiotherapy. Histopathological examination showed that 62·9 per cent had tumour category T3 or T4 cancers, 42·1 per cent had node-positive disease and the CRM positivity rate was 13·9 per cent. Multivariable analysis showed only pathological tumour category pT4 (odds ratio 19·92, 95 per cent confidence interval 6·48 to 68·61) and node positivity (odds ratio 3·04, 1·32 to 8·05) to be risk factors for a positive circumferential margin. CRM positivity was a risk factor for local recurrence (P = 0·022) and decreased overall survival (P = 0·001). Hospital volume had no impact on the likelihood of CRM positivity (P = 0·435). In patients undergoing APE by appropriately trained surgeons using a standardized approach, margin positivity was dictated by tumour stage, but not by centre or surgeon.