Conventional Abdominoperineal Excision Research Articles

Feasibility of Perineal Defect Reconstruction with Simplified Fasciocutaneous Inferior Gluteal Artery Perforator (IGAP) Flaps after Tumor Resection of the Lower Rectum: Incidence and Outcome in an Interdisciplinary Approach.

Extralevator abdominoperineal excision (ELAPE) is a relatively new surgical technique for low rectal cancers, enabling a more radical approach than conventional abdominoperineal excision (APE) with a potentially better oncological outcome. To date, no standard exists for reconstruction after extended or extralevator approaches of abdominoperineal (ELAPE) resection for lower gastrointestinal cancer or inflammatory tumors. In the recent literature, techniques with myocutaneous flaps, such as the VY gluteal flap, the pedicled gracilis flap, or the pedicled rectus abdominis flaps (VRAM) are primarily described. We propose a tailored concept with the use of bilateral adipo-fasciocutaneous inferior gluteal artery perforator (IGAP) advancement flaps in VY fashion after ELAPE surgery procedures. This retrospective cohort study analyzes the feasibility of this concept and is, to our knowledge, one of the largest published series of IGAP flaps in the context of primary closure after ELAPE procedures. In a retrospective cohort analysis, we evaluated all the consecutive patients with rectal resections from Jan 2017 to Sep 2021. All the patients with abdominoperineal resection were included in the study evaluation. The primary endpoint of the study was the proportion of plastic reconstruction and inpatient discharge. Out of a total of 560 patients with rectal resections, 101 consecutive patients with ELAPE met the inclusion criteria and were included in the study evaluation. The primary direct defect closure was performed in 72 patients (71.3%). In 29 patients (28.7%), the defect was closed with primary unilateral or bilateral IGAP flaps in VY fashion. The patients' mean age was 59.4 years with a range of 25-85 years. In 84 patients, the indication of the operation was lower rectal cancer or anal cancer recurrence, and non-oncological resections were performed in 17 patients. Surgery was performed in a minimally invasive abdominal approach in combination with open perineal extralevatoric abdominoperineal resection (ELAPE) and immediate IGAP flap reconstruction. The rate of perineal early complications after plastic reconstruction was 19.0%, which needed local revision due to local infection. All these interventions were conducted under general anesthesia (Clavien-Dindo IIIb). The mean length of the hospital stay was 14.4 days after ELAPE, ranging from 3 to 53 days. Since radical resection with a broad margin is the standard choice in primary, sphincter-infiltrating rectal cancer and recurrent anal cancer surgery in combination with ELAPE, the choice technique for pelvic floor reconstruction is under debate and there is no consensus. Using IGAP flaps is a reliable, technical, easy, and safe option, especially in wider defects on the pelvic floor with minimal donor site morbidity and an acceptable complication (no flap necrosis) rate. The data for hernia incidence in the long term are not known.

Long-term outcomes of laparoscopic Extralevator Abdominoperineal excision with modified position change for low rectal Cancer treatment

BackgroundExtralevator abdominoperineal excision (ELAPE) has been recommended for treating low rectal cancer due to its potential advantages in improving surgical safety and oncologic outcomes as compared to conventional abdominoperineal excision (APE). In ELAPE, however, whether the benefits of intraoperative position change to a prone jackknife position outweighs the associated risks remains controversial. This study is to introduce a modified position change in laparoscopic ELAPE and evaluate its feasibility, safety and the long-term therapeutic outcomes.MethodsMedical records of 56 consecutive patients with low rectal cancer underwent laparoscopic ELAPE from November 2013 to September 2016 were retrospectively studied. In the operation, a perineal dissection in prone jackknife position was firstly performed and the laparoscopic procedure was then conducted in supine position. Patient characteristics, intraoperative and postoperative outcomes, pathologic and 5-year oncologic outcomes were analyzed.ResultsThe mean operation time was 213.5 ± 29.4 min and the mean intraoperative blood loss was 152.7 ± 125.2 ml. All the tumors were totally resected, without intraoperative perforation, conversion to open surgery, postoperative 30-day death, and perioperative complications. All the patients achieved pelvic peritoneum reconstruction without the usage of biological mesh. During the follow-up period, perineal hernia was observed in 1 patient, impaired sexual function in 1 patient, and parastomal hernias in 3 patients. The local recurrence rate was 1.9% and distant metastasis was noted in 12 patients. The 5-year overall survival rate was 76.4% and the 5-year disease-free survival rate was 70.9%.ConclusionsLaparoscopic ELAPE with modified position change is a simplified, safe and feasible procedure with favorable outcomes. The pelvic peritoneum can be directly closed by the laparoscopic approach without the application of biological mesh.

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

PurposeExtralevator (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.MethodsOne 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.ResultsDemographics 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.

Postoperative MRI Findings Following Conventional and Extralevator Abdominoperineal Excision in Low Rectal Cancer.

Aim: The disparity in outcomes for low rectal cancer may reflect differences in operative approach and quality. The extralevator abdominoperineal excision (ELAPE) was developed to reduce margin involvement in low rectal cancers by widening the excision of the conventional abdominoperineal excision (c-APE) to include the posterior pelvic diaphragm. This study aimed to determine the prevalence and localization of inadvertent residual pelvic diaphragm on postoperative MRI after intended ELAPE and c-APE.Methods: A total of 147 patients treated with c-APE or ELAPE for rectal cancer were included. Postoperative MRI was performed on 51% of the cohort (n = 75) and evaluated with regard to the residual pelvic diaphragm by a radiologist trained in pelvic MRI. Patient records, histopathological reports, and standardized photographs were assessed. Pathology and MRI findings were evaluated independently in a blinded fashion. Additionally, preoperative MRIs were evaluated for possible risk factors for margin involvement.Results: Magnetic resonance imaging-detected residual pelvic diaphragm was identified in 45 (75.4%) of 61 patients who underwent ELAPE and in 14 (100%) of 14 patients who underwent c-APE. An increased risk of margin involvement was observed in anteriorly oriented tumors with 16 (22%) of 73 anteriorly oriented tumors presenting with margin involvement vs. 7 (9%) of 74 non-anteriorly oriented tumors (p = 0.038).Conclusion: Residual pelvic diaphragm following abdominoperineal excision can be depicted by postoperative MRI. Inadvertent residual pelvic diaphragm (RPD) was commonly found in the series of patients treated with the ELAPE technique. Anterior tumor orientation was a risk factor for circumferential resection margin (CRM) involvement regardless of surgical approach.

SP1.1.2Perineal reconstruction following extralevator abdominoperineal excision of rectum - Is IGAP flap a feasible option

Abstract Aim Extra-levator abdomino-perineal excision for low rectal cancer has been shown to reduce tumor perfoation rates and incidence of local recurrence when compared to a conventional abdominoperineal excision. This is however associated with increased wound complications. This study was done to evaluate the feasibility of an inferior gluteal artery flap in patients undergoing ELAPE. Methods This was retrospective analysis was done at tertiary centre for all patients who underwent an ELAPE over a period of 7 years (December 2013 to July 2020). Patient demographic, relevant co morbidities and the data regarding chemotherapy and radiotherapy were analysed. Results A Total of 33 patients underwent ELAPE with an IGAP flap wound reconstruction. The mean age was 68 (44-86) with a mean BMI of 27 (25-45). 26 patients out of 33 (82%) received neoadjuvant treatment for cancer. The mean LoS was 11 days (6-31). The perineal wound complications were graded as per Clavein Dindo classification and 56 % had no wound complications recorded. 07/33 had Grade I and 06/33 had Grade II complications. Conclusion IGAP flap closure for perineal defects, does offer the advantage of compatibility with both minimally invasive and open procedures and the avoidance of using irradiated tissue. This case series does demonstrate the feasibility of IGAP flaps as viable option to cover perineal defects following radical low rectal cancer surgery with low morbidity.

Extralevator abdominoperineal excision for low rectal cancer: oncological outcome after five-year follow-up

ABSTRACT BACKGROUND: Extralevator abdominoperineal excision (ELAPE) is a surgical technique that is indicated for low rectal cancer where sphincter preservation is not possible. Compared to conventional abdominoperineal excision major advantages of ELAPE are the risk reduction of intraoperative bowel perforation and positive circumferential margin which lead to a better oncological outcome. The aim of this study was to present our results in ELAPE surgery METHODS: From February 2011 to February 2015, 40 patients underwent surgery for low rectal cancer at the Oncology Institute of Vojvodina. The collected data included sex, age, preoperative staging, neoadjuvant treatment, operative time, rate of intraoperative bowel perforation, rate of positive circumferential resection margins, histopathological analysis, postoperative mortality, tumour, node and metastasis (TNM) classification, local recurrence (LR) rate and presence of distant metastases RESULTS: Positive circumferential margin was found in three (7.5%) patients while eight (20%) patients had intraoperative bowel perforation. LR during follow-up was seen in seven (17.5%) patients, three of them had intraoperative bowel perforation and two patients had positive circumferential margin. The estimated five-year cumulative incidence of LR is 7%. Distant metastases occurred in 18 (45%) patients. The estimated five-year survival rate is 62% CONCLUSION: The study shows satisfactory five-year survival rates of 62% in a highly complex patient group treated by ELAPE procedure Keywords: rectal cancer, extralevator abdominoperineal excision, local recurrence, overall survival

Perineal Wound Outcomes after Extralevator Abdominoperineal Excision for Rectal Adenocarcinoma- A Tertiary Care Centre Experience

Abstract Extralevator Abdominoperineal excision (ELAPE) for low rectal cancer results in a large perineal defect, often requiring reconstruction by a biological or absorbable mesh or a flap as compared to conventional Abdominoperineal excision (CAPE). Although there are indications for oncological superiority with ELAPE, the incidence of wound-related complications is postulated to be higher when compared to CAPE due to the removal of more amount of tissue around the anorectum. On the other hand, the incidence of inadvertent rectal tube perforation during dissection is lesser in ELAPE and hence perineal wound breakdown and infection are postulated to be lesser in some other studies. We conducted a retrospective study in the department of colorectal surgery, Christian Medical College; Vellore from 2011 to 2017 to compare the perineal wound-related complications following CAPE and ELAPE. The data were retrieved from the prospectively maintained computerized inpatient and out-patient follow up records and comparisons were made in terms of incidence of perineal wound outcomes, need for reoperations and duration of hospital stay. A total of 138 patients underwent CAPE and 57 patients underwent ELAPE over a period of 7 years. There was no statistical difference in baseline characteristics and patients who underwent neo-adjuvant chemoradiation between the two groups. Perineal wound complications were seen in 63% (87) of the patients after CAPE compared to 64.9% (37) of the patients after ELAPE. There was no perineal herniation or wound dehiscence following ELAPE, whereas these complications occurred in 1 and 5 patients respectively after CAPE. Similarly, the incidence of reoperations was 8% in CAPE as compared to 5.4% in ELAPE although not statistically significant. There was no difference in the length of hospital stay. Hence, in our experience, perineal wound complications were similar in the Extralevator approach to APE (ELAPE) as compared to conventional APE (CAPE) for rectal adenocarcinoma.

Extralevator abdominoperineal excision

Extralevator abdominoperineal excision (ELAPE) has been introduced to alleviate the disappointing results of conventional abdominoperineal excision (APE) with respect to inadvertent bowel perforation, positive circumferential resection margins (CRM), and local recurrence rates. The main principle of this operation is to shift the resection plane away from the anorectal junction, which is the area at highest risk of perforation and CRM positivity. This is accomplished by resection of the levator ani muscle, which is followed at its outer surface close to its origin at the pelvic side wall. The anterior region is also addressed with comfortable access to the dissection area by placement of the patient in prone jackknife position. All measures aim to avoid a waist at the anorectal junction. This article describes the procedure in detail, including strategies to close the perineal defect. In a brief review of the literature, the favorable results of ELAPE are discussed. Conclusion. It can be concluded that the perineal phase of ELAPE is highly standardized and can be taught in a step-by-step fashion. There is evidence that ELAPE results in lower rates of inadvertent bowel perforations, lower rates of positive CRM, and lower rates of local recurrence.

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.

Abstract: Perineal Reconstruction after Extralevator Abdominoperineal Excision (ELAPE): Current Trends-What Is the Future?

AIM: Extralevator abdominoperineal excision (ELAPE) is becoming the main treatment modality for locally advanced low rectal cancer as substantial evidence link ELAPE with superior oncological outcomes than conventional abdominoperineal excision.1 However, the extended resection performed in ELAPE creates an extensive three-dimensional soft tissue perineal defect within a previously irradiated field, increasing perineal wound complications to 40–60%.1 Various methods have been described in order to reduce perineal wound morbidity including primary closure, flaps and biological meshes but the ideal technique remains controversial, making perineal reconstruction post-ELAPE challenging for the plastic surgeon.1 The primary objective of this study is to appraise the post-ELAPE perineal reconstruction techniques in a UK tertiary institution. The secondary aim is to identify the technique that fulfils the principles of an ideal perineal reconstruction (function, reliability, and cosmesis). METHODS: All patients that had undergone ELAPE and perineal reconstruction between 2009 and 2017 were reviewed retrospectively. Data included patients’ demographics, neo-adjuvant chemo-radiotherapy, histopathology, imaging, duration of surgery, reconstructive method, follow-up period and complications. RESULTS: Seventy-three (n=73) cases were identified. 81% of the patients had neo-adjuvant chemoradiotherapy. Gluteus maximus muscular flaps (35%, 26) were associated with a higher complication rate(62%). These included perineal collection(36%), perineal pain(35%) and perineal hernia(19%). Vertical Rectus Abdominal Muscular flaps’ (9,5%, 7) complication rate was 33% (1 flap necrosis, 1 perineal sinus and 1 perineal collection). Lotus petal (8%, 4) and Inferior Gluteal Artery Perforator V-Y advancement flaps’ (8%, 4) complication rates were 75% and 16% respectively. The above flaps required an average of 134 min (range 118–145) additional operating time. Internal pudendal artery (IPA) perforator flaps, predominantly the PTO (Perineal Turn Over) flap2, were introduced in 2014 and gained popularity (35%, 26) as they are quick (mean operating time 52 min) and provide good results with only 8.6% complication rate (1 perineal hernia and 1 superficial wound dehiscence). Review of this group’s radiotherapy scans showed that IPA perforators are consistently out of radiotherapy zone. Overall complications in all flaps were higher in irradiated patients and smokers. CONCLUSION: Techniques involving muscular dissection are associated with higher morbidity rates (20–62%) reflecting similar trends in the literature.1 IPA turnover perforator flaps such as the PTO flap2, that do not involve perforator transposition at 90° angle (as in lotus petal flaps) are associated with the lowest morbidity rate. Their concept supports the ideal reconstruction principles: a) Function: the thick gluteal dermis acts as an autologous (as opposed to biological meshes) dermal vascularised substitute that strengthens the pelvic floor and prevents perineal hernia 2 b) Reliability: the perforators are consistent and always protected from radiotherapy ensuring good flap vascularity; the gluteal subcutaneous fat obliterates the dead space reducing collections and infections.2 c) Cosmesis: recreation of the natal cleft providing good aesthetic outcome.

Abdominoperineal excision or extralevator abdominoperineal excision: which is the best oncological treatment?

Surgery of tumors of the lower third of the rectum is particularly difficult due to the complex anatomy of the pelvis, which can lead to an incomplete radical resection. Abdominoperineal excision (APE) is the operation of choice for tumors of the low rectum that infiltrate levatorani or sphincter muscles. Regardless, APE causes an important morbidity, a higher incidence of circumferential resection margin (CRM) infiltration, iatrogenic tumor perforation incidence and worsens the mesorectum quality due to the conicity induced during surgery while dissection between both distal mesorectum and levatorani planes is performed. An extralevator abdominoperineal excision (ELAPE), which involves a broader resection of the pelvic floor muscles, would theoretically reduce the risk of CRM infiltration and tumor perforation rate, independently from the position (prone vs . supine) or the approach (open vs . laparoscopic). This review is focused on the analysis of the scientific evidence published so far comparing both techniques, APE or ELAPE. In spite of some publications observe a possible benefit in terms of reduction in CRM involvement, iatrogenic perforations or local recurrence, there is not enough evidence to affirm the superiority of ELAPE compared to conventional APE in terms of oncological results. In general, similar rates of postoperative complications are described for both techniques. Further prospective, controlled and randomized studies are needed to conclude which of the two techniques is the best oncological treatment.

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.

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

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. 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. 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±382mm2 vs 1132.03±371mm2 , 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±3mm vs 9.63±3mm, P<0.001) and lateral (mean±SD: 13.69±3mm vs 9.72±3mm, P=0.009) parts of the rectum but not in the anterior part (mean±SD: 6.74±2mm vs 6.10±4mm, P=0.64). The short-term morbidity was not significantly different between the two procedures. 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.

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

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. 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. 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). 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 (Elape): A retrospective cohort study.

IntroductionExtralevator abdominoperineal excision (ELAPE) is relatively new surgical technique for low rectal cancers. It is a more radical approach than conventional abdominoperineal excision (APE) with potentially better oncological outcome. The aim of this study was to analyse short term results of ELAPE compared with conventional abdominoperineal excision.MethodsData were collected prospectively for 72 patients who underwent abdominoperineal excision (APE) for low rectal carcinomas from 2010 to 2014. Of these 24 patients underwent ELAPE with biological prosthetic mesh used to close the perineal defect.ResultsThe median age of patients was 68 (37–87). Positive circumferential resection margin (1/24 vs. 8/48) and Intra operative perorations (0/24 vs. 6/48) compared favourably with ELAPE.ConclusionsShort term results from this study support that ELAPE has better oncological outcome.

Biologic Mesh Reconstruction of the Pelvic Floor after Extralevator Abdominoperineal Excision: A Systematic Review.

The aim of this review is to provide an overview of the evidence for the use of biologic mesh in the reconstruction of the pelvic floor after extralevator abdominoperineal excision of the rectum (ELAPE). A systematic search of PubMed was conducted using the search terms: "ELAPE," "extralevator abdominoperineal excision of rectum," or "extralevator abdominoperineal resection." The search yielded 17 studies. Biologic mesh was used in perineal reconstruction in 463 cases. There were 41 perineal hernias reported but rates were not consistently reported in all studies. The most common complications were perineal wound infection (n = 93), perineal sinus and fistulae (n = 26), and perineal haematoma or seroma (n = 11). There were very few comparative studies, with only one randomized control trial (RCT) identified that compared patients undergoing ELAPE with perineal reconstruction using a biological mesh, with patients undergoing a conventional abdominoperineal excision of the rectum with no mesh. There was no significant difference in perineal hernia rates or perineal wound infections between the groups. Other comparative studies comparing the use of biologic mesh with techniques, such as the use of myocutaneous flaps, were of low quality. Biologic mesh-assisted perineal reconstruction is a promising technique to improve wound healing and has comparable complications rates to other techniques. However, there is not enough evidence to support its use in all patients who have undergone ELAPE. Results from high-quality prospective RCTs and national/international collaborative audits are required.

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

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. 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. 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%). 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.

Extralevatory abdominoperineal excision (ELAPE) does not result in reduced rate of tumor perforation or rate of positive circumferential resection margin: a nationwide database study.

To evaluate the oncological results and possible benefits associated with extralevatory abdominoperineal excision (ELAPE) when compared with conventional abdominoperineal excision (APE). ELAPE was introduced in 2007 with the purpose of reducing the rate of positive resection margins after resection of low rectal cancers. Preliminary studies have shown promising results. No large-scale or nationwide data have been presented. Database study based on data from the Danish Colorectal Cancer Group's prospective database. Data on all ELAPEs and APEs performed in Denmark in the period January 1, 2009, through August 2012 were retrieved and evaluated for differences in demography, tumor characteristics, and oncological results. Uni- and multivariate logistic regression analyses were performed to identify risk factors for resection with a positive circumferential resection margin (CRM+). A total of 554 patients were included, 301(54%) were operated by ELAPE; 253(46%) by APE. Sixty-three percent were men, median (interquartile range) age was 69 (61-76 years) years, and tumors removed had predominantly T-stages T2 and T3 (32% and 45%, respectively). Overall, CRM+ was found in 13% of patients. When divided according to type of procedure, we found no significant differences in demography and tumor T- and N-stages. Resections with a CRM+ were more common after ELAPE (16% vs 7%; P = 0.006). After uni- and multivariate logistic regression analyses, surgery by ELAPE remained a risk factor for a CRM+ [odds ratio, 2.59 (95% confidence interval, 1.31-5.12); P = 0.006). In this nationwide study, resection of low rectal cancers by ELAPE did not improve short-term oncological results, when compared with conventional APE.

肛提肌外腹会阴联合切除术治疗低位直肠癌的研究进展

传统的腹会阴联合直肠切除术(abdominoperineal excision, APE)存在环周切缘阳性率高及术中穿孔率较高而影响预后的缺点。肛提肌外腹会阴联合切除术(exralevator abdominoperineal excision, ELAPE)被报道具有肿瘤学优势，最近应用越来越多。尽管相关报道很多，但是，ELAPE是否比传统APE具有优势仍然有很多争议。本文就ELAPE治疗低位直肠癌的研究进展做一综述。 It has been reported that the conventional abdominoperineal excision has the disadvantages of higher rates of positive circumferential resection margin and intraoperative bowel perforation. Extralevator abdominoperineal excision (ELAPE) has become increasingly used because of some evidence of improved oncological outcome. 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 paper was to review the research progression of extralevator abdominoperineal excision for low rectal cancer.

Local recurrence after prone vs supine abdominoperineal excision for low rectal cancer

Tumour-involved circumferential resection margins (CRMs) and intra-operative perforation (IOP) are well known risk factors for local recurrence after surgery for low rectal cancer. In conventional abdominoperineal excision (APE) the patient remains in the supine position for the perineal part of the procedure. However, turning the patient to the prone position may improve visualization which potentially might reduce the risk of involved CRMs and IOP and thus improve local control. The study was carried out to assess local recurrence rates after APE in relation to the positioning of the patient during the perineal part of the procedure. This cohort study includes 466 patients having APE for low rectal cancer between 2001 and December 2010. Data were retrieved from the regional rectal cancer registry in Stockholm and from a retrospective review of patient files. An incomplete resection was reported in 12.4% after APE in the supine position and in 6.8% after APE in the prone position (P=0.038). Corresponding figures for IOP were 12.4% and 4.0% (P<0.001). Prone APE was associated with a 39% relative reduction in local recurrence events compared with APE in the supine position, although the difference was not statistically significant (hazard ratio 0.61, 95% CI 0.27-1.37). APE in the prone position reduced the incidence of incomplete resection and IOP, but the study did not find a statistically significant difference in local failure rates related to the position of the patient.