Laparoscopic Extralevator Abdominoperineal Excision Research Articles

Laparoscopic extralevator abdominoperineal resection for low rectal cancer: The myth of reinventing the wheel.

To review oncological outcomes of laparoscopic extralevator abdominoperineal excision (LAP-ELAPE) for low rectal cancer.In locally advanced low rectal cancer, ELAPE which is en-bloc resection of levator muscles along with the tumor in a prone position has significantly decreased the rate of having either positive circumferential resection margin (CRM) or tumor perforation. The aim of the study was to determine the oncological outcomes of laparoscopic extralevator abdominoperineal excision (LAP-ELAPE) for low rectal cancer. This retrospective study was performed at Shaukat Khanum Cancer Hospital and Research Centre Lahore. Patients who underwent ELAPE for low rectal and anal cancer from January 2014 to December 2019 were selected. Data was collected using an electronic database through a hospital information system. A total of 82 patients were included in the study having a median age of 39 years. Clinically preoperative tumor sizes were T2:2, T3:65, T4:15. Neo-adjuvant chemo radiotherapy was administered to 79 (96.3%) patients. Pathologically tumor sizes were T0:12, T2:15, T3:50, T4:5 with 79.2% (n=65) R0 resections. The mean operative time was 340.36±64.51 minutes and the mean blood loss was 99 milliliters. The mean postoperative hospital stay was 6.58±4.64 days. Seventeen (20.7%) cases had pathological circumferential resection margins positive (pCRM<1mm). However, tumor perforation was found in 8(9.8%) patients. Ninety days mortality was none while 36 patients experienced recurrence (local: 23, distant: 30, local + distant 17). The median survival time was 53.00±2.69 months. For locally advanced low rectal cancer, ELAPE has evolved as a safe oncological procedure with acceptable outcomes.

Closure of pelvic peritoneum with bladder peritoneum flap reconstruction after laparoscopic extralevator abdominoperineal excision: A prospective stage II study.

Extralevator abdominoperineal resection (ELAPE) has increased perineal wound complications due to the extended resection area. Closure of the pelvic peritoneum (CPP) may exclude the abdominal content from descending into the pelvic cavity and reduce the incidence of perineal complications after ELAPE. We have previously introduced bladder peritoneum flap reconstruction (BLAPER) as a novel method for patients in whom traditional CPP is not possible. The aim of the present study was to report the development and preliminary outcomes of BLAPER. This is a prospective single-arm study at the development and exploration phase and fulfills the IDEAL framework stage II. Ultralow rectal cancer patients with rigid pelvis who underwent ELAPE with BLAPER were enrolled. Primary outcomes were intraoperative complications and postoperative complications within 1 month after surgery. Among 27 patients included, the overall success rate of BLAPER was 96.3% (26/27). Indocyanine green fluorescence imaging and antiadhesive barrier placement were introduced to improve the BLAPER technique. The incidence of major pelvic wound complications was 7.7%. No patient who underwent BLAPER has suffered small bowel obstruction (SBO), presence of small bowel in the retrourogenital space, or perineal hernia (PH). BLAPER is safe and may prevent the small bowel from descending into the retrourogenital space and subsequently developing PH and SBO without increasing the intraoperative and postoperative complications. BLAPER may serve as an option when the primary suture of the pelvic peritoneum is not feasible.

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.

Efficacy and Safety of Modified Pelvic Peritoneum Reconstruction with Unidirectional Barbed Suture in Laparoscopic Extralevator Abdominoperineal Excision.

Background: Extralevator abdominoperineal excision (ELAPE) procedure leaves a large pelvic floor defect, and can result in a high rate of perineal hernia. Pelvic peritoneum reconstruction (PPR) could reduce the rate of perineal hernia. In this article, the authors reconstructed pelvic peritoneum by retracing running sutures with unidirectional barbed thread after laparoscopic ELAPE. The aim of the study is to evaluate the efficacy and safety of PPR by retracing running sutures with unidirectional barbed thread in laparoscopic ELAPE. Materials and Methods: Intact clinical data were collected retrospectively from 27 distal rectal cancer patients who underwent laparoscopic ELAPE. All the patients underwent PPR by retracing running sutures with unidirectional barbed thread in the operation. Pooled data of perineal-related complications were analyzed. Results: After retracing running sutures, the tension of pelvic peritoneum was enhanced. Of the 27 patients included, 2 patients had perineal dehiscence and 1 patient developed bowel obstruction. There were no instances of perineal hernia and pelvic peritoneal internal hernia. Conclusions: PPR by retracing running sutures with unidirectional barbed thread in laparoscopic can reduce the risk of perineal hernia.

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.

[Analysis of preliminary efficacy on pelvic floor lifting technique in laparoscopic extralevator abdominoperineal excision for rectal cancer].

目的： 探讨盆底提升技术在腹腔镜肛提肌外腹会阴联合切除术（ELAPE）治疗直肠癌的初步疗效。 方法： 采用回顾性队列研究方法，收集2017年1月至2020年12月潍坊市人民医院肛肠外科收治的60例行腹腔镜ELAPE低位直肠癌患者的临床资料。按照手术方式的不同，分为联合盆底提升技术的腹腔镜ELAPE组28例（盆底提升组）和传统腹腔镜ELAPE组32例（传统组）。两组患者临床基线资料的比较，差异无统计学意义（均P>0.05）。比较两组患者的手术时间、术中出血量、术中标本穿孔率、淋巴结获取数目、环周切缘阳性率、术后排便时间、盆腔引流管拔除时间、尿潴留、术后住院时间和术后并发症情况。 结果： 与传统组比较，盆底提升组手术时间缩短[（225.7±26.7）min比（281.9±66.8）min，t=4.166，P=0.004]，术中出血量减少[（125.7±60.2）ml比（204.4±188.7）ml，t=2.111，P=0.002]，术后尿潴留发生率降低[7.1%（2/28）比28.1%（9/32），χ(2)=4.390，P=0.036]。而两组术中标本穿孔率、淋巴结清扫数目、术后环周切缘阳性率、术后排粪时间、盆腔引流管拔除时间、术后住院时间和术后并发症差异均无统计学意义（均P>0.05）。 结论： 盆底提升技术可缩短腹腔镜ELAPE的手术时间及减少术中出血量，且更好地保护低位直肠癌患者术后的排尿功能，降低尿潴留发生率，术后短期疗效良好。.

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

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. 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. 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). 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.

Continuous Negative Pressure Drainage with Intermittent Irrigation Leaded to a Risk Reduction of Perineal Surgical Site Infection Following Laparoscopic Extralevator Abdominoperineal Excision for Low Rectal Cancer.

PurposeHigh rate of perineal surgical site infection (SSI) is the most common complication following abdominoperineal resection (APR), especially for extralevator abdominoperineal excision (ELAPE). The purpose of this study was to investigate the effect of continuous negative pressure drainage combined with intermittent irrigation (CNPDCII) in the presacral space on the perineal SSI following laparoscopic ELAPE for low rectal cancer.Patients and MethodsThe clinical data of 99 patients with low rectal cancer who underwent laparoscopic ELAPE surgery were retrospectively analyzed. Among the 99 patients, 46 patients received CNPDCII and 53 patients received conventional drainage in the presacral space after ELAPE. Self-made irrigation drainage tube: took a silicone drainage tube, cut 3 side holes at every 2cm intervals at the front end, and fixed a flexible tube of an intravenous needle at the front end of the silicone drainage tube. The conventional drainage tube or self-made irrigation drainage tube was placed in the presacral space and poked out from the inside of the ischial tuberosity. The incidence of SSI and other perioperative indicators between the two groups was compared within 30 days after surgery.ResultsThere was no statistical difference in clinicopathological features between the two groups of patients (p>0.05). A statistically lower rate of SSI was found in CNPDCII group (17.4%, 8/46) than the conventional drainage group (35.8%, 19/53). The drainage tube retention time (7.8±1.2 d VS 9.4±1.6 d) and the postoperative hospital stay (9.7±1.4 d VS 11.9±2.3 d) in CNPDCII group were significantly shortened than the conventional drainage group. There was no statistical difference in operating theatre time and intraoperative blood loss between the two groups. Multivariate analysis confirmed that CNPDCII was an independent protective factor for SSI after ELAPE.ConclusionCNPDCII can effectively reduce the incidence of SSI following laparoscopic ELAPE, which is simple, safe and effective.

A Novel Laparoscopic Technique With a Bladder Peritoneum Flap Closure for Pelvic Cavity for Patients With Rigid Pelvic Peritoneum After Neoadjuvant Radiotherapy in Laparoscopic Extralevator Abdominoperineal Excision.

In laparoscopic extralevator abdominoperineal excision, reconstruction of the pelvic peritoneum helps to prevent the small intestine from adhering to pelvic wall tissues, thus avoiding small-bowel obstruction and perineal complications. However, there are difficulties in pelvic peritoneum closure if the patient has received preoperative radiotherapy and has a rigid pelvis. We report a novel laparoscopic method for pelvic peritoneum reconstruction using the bladder peritoneum flap in laparoscopic extralevator abdominoperineal excision after neoadjuvant radiotherapy. After transection of the rectum, if the patient had a rigid pelvis, we chose to perform the novel technique for the pelvic peritoneum closure in a 3-step approach. The flap has an arch shape with the bottom at the anterior wall of the pelvic cavity entrance. The height of the arched flap is equal to the distance from the bladder to the sacral promontory. The peritoneum was incised with electrocautery at the planned level and peeled off the bladder. The bladder peritoneum flap was then rotated to cover the entrance of the pelvic cavity and sutured to the brim of the pelvis. Acceptable postoperative short-term and long-term outcomes (5- to 22-month follow-ups) were achieved in 3 patients who underwent bladder peritoneum flap closure. The bladder peritoneum flap appears to be safe and feasible for intracorporeal closure of the pelvic cavity in laparoscopic extralevator abdominoperineal excision after neoadjuvant radiotherapy. The procedure provides a novel option for patients with severe fibrosis of the pelvis when another peritoneum reconstruction method is not feasible.

Short-term surgical outcomes and patient quality of life between robotic and laparoscopic extralevator abdominoperineal excision for adenocarcinoma of the rectum.

Introduction Some studies advocate a laparoscopic extralevator abdominoperineal excision (l-ELAPE) approach for low rectal cancer. The da Vinci™ robot (r-ELAPE) technique has potential to overcome some limitations of l-ELAPE, such as reduction of the learning curve and more precise tissue handling. It is unknown whether this approach results in improved surgical or quality of life outcomes compared with l-ELAPE. This study aimed to address this issue. Methods Consecutive patients having undergone either robotic or laparoscopic ELAPE for adenocarcinoma were studied. All operations were performed by two surgeons experienced in laparoscopic and recently introduced robotic surgery. Surgical outcomes were determined by postoperative histology and short-term complications. Quality of life was prospectively assessed using the European Organisation for Research and Treatment of Cancer QLC-CR30 and QLC-CR29 questionnaires. Results A total of 22 patients (11 r-ELAPE) with a median follow-up of 13 months (8 months robotic; 22 months laparoscopic) were studied. The groups were similarly matched for age, gender, American Society of Anesthesiologists status, preoperative chemoradiotherapy and tumour height. All had R0 resection. There was no significant difference in short-term surgical outcomes between groups. There was no significant difference in mean global health scores between the two groups (74 ±14 r-ELAPE vs. 73 ±10 l-ELAPE). The r-ELAPE group had a lower mean impotence score compared with the I-ELAPE group (55.5±40 vs. 72.2±44), although this was not statistically significant. Conclusions The newly introduced r-ELAPE was non-inferior to l-ELAPE in either patient quality of life or surgical outcomes. Robotic surgery could be particularly beneficial in the technically challenging area of low rectal cancer surgery with a shorter learning curve than laparoscopy.

Clinical efficacy of laparoscopic extralevator abdominoperineal excision for low rectal cancer without turning position

Objective To explore the clinical efficacy of laparoscopic extralevator abdominoperineal excision (laparoscopic ELAPE) for low rectal cancer with modified Lloyd-Davies lithotomy position and without turning position. Methods The retrospective cross-sectional study was conducted. The clinicopathological data of 27 patients with low rectal cancer who underwent laparoscopic ELAPE without turning position in the West China Hospital of Sichuan University from September 2013 to January 2015 were collected. The modified Lloyd-Davies lithotomy position was used in perineal resection. Observation indicators: (1) surgical situation; (2) postoperative recovery situation; (3) postoperative pathological examination situation; (4) follow-up and survival situations. Follow-up using outpatient examination and telephone interview was performed to detect postoperative complications, survival of patients and tumor recurrence or metastasis up to March 2017. Measurement data with normal distribution were represented as ±s. Measurement data with skewed distribution were described as M (range). Results (1) Surgical situation: A total of 27 patients received laparoscopic ELAPE without turning position, and operation time and volume of intraoperative blood loss were (198±51)minutes and (85±66)mL. Among 5 of 27 patients with intraoperative complications, 1 with intestinal perforation received successful intraoperative repair, 1 with presacral haemorrhage received successful hemostasis by intraoperative gauze pressing, 1 with left and right pelvic plexus injury didn′t receive special treatment, 1 with left pelvic plexus injury + left internal iliac vein injury didn′t receive special treatment and were repaired in vascular injury repair, 1 with right neurovascular bundle injury didn′t receive special treatment of nerve injury and received successful hemostasis by ultrasonic scalpel. There was no perforation in the site of the tumor. Number of lymph node dissected was 14 (range, 9-22), and number of lymph node dissected ≥12 and 100 mL) and 7 in Clavien-DindoⅡ (3 with pulmonary infection, 2 with chylous fistula, 1 with perineal incision infection and 1 with hematuria). There was no death within 30 days postoperatively. The median duration of hospital stay of 27 patients was 7 days (range, 6-8 days). (3) Postoperative pathological examination situation: of 27 patients, 1 and 26 had respectively positive and negative circumferential margins and median distance of circumferential margin was 0.7 cm (range, 0.1-1.1 cm). T stage: 14, 12 and 1 patients were respectively detected in T2, T3 and T4. N stage: 18, 6 and 3 patients were respectively found in N0, N1 and N2. (4) Follow-up and survival situations: 25 of 27 patients were followed up for 2-32 months, with a median time of 24 months. During the follow-up, 5 had complications after discharge from hospital. Of 5 patients, 2 with persistent anal pain didn′t receive special treatment and were not relieved, and 3 with sexual dysfunction didn′t receive special treatment and were followed up or observed. Of 25 patients, 2 died of tumor-related diseases, 1 died of non-tumor-related disease and other 22 had survival. No local tumor recurrence was detected. Eight patients had tumor distant metastases, including 4 with pulmonary metastases, 3 with hepatic metastases and 1 with brain metastasis. Conclusion Laparoscopic ELAPE by modified Lloyd-Davies lithotomy position without turning position is safe and feasible, with closing pelvic floor peritoneum in stage Ⅰ. Key words: Rectal neoplasms, low; Extralevator abdominoperineal excision; Laparoscopy; Position

Laparoscopic extralevator abdominoperineal excision of the rectal cancer in the elderly

Objective To investigate the safety and feasibility of laparoscopic ELAPE for elderly patients with low advanced rectal cancer. Methods Totally 48 cases patients with low advanced rectal cancer surgery aged over 65 years old were analyzed retrospectively, who come from Beijing Hospital between Jan 2012 and Jan 2015.A total of 26 cases underwent Laparoscopic extralevator abdominoperineal excision(L-ELAPE)and 22 cases underwent Laparoscopic abdominoperineal excision(L-APE). Clinical data including general data, operation time, intraoperative blood loss, complications, pathological data, postoperative in hospitalization were retrospectively analyzed in patients. Results The mean operation time between L-ELAPE and APE group was(312±46)min vs.(245±62)min, mean intraoperative blood loss was(170±74)ml vs.(250±109)ml, Operative complications was 26.9% vs.27.3%, harvested lymph node was(16.0±5.8)cm vs.(15.0±7.2)cm, intraoperative bowel perforation(IOP)rate was 0% vs.18.2%, CRM involvement was 3.8% vs.13.6%, mean postoperative hospital stay(days)was(13.1±4.6)d vs.(13.7±6.1)d.The mean operating time of L-ELAPE group was longer and mean intraoperative blood loss was much less than APE group, IOP rate and circumferential resection margin(CRM)involvement were higher in APE group(P<0.05). Conclusions L-ELAPE is a safe and feasibility alternative approach for elder patients with rectal cancer.It is related with less intraoperative blood loss, IOP rate, CRM involvement and longer operating time contrast with L-APE. Key words: Rectal neoplasms; Laparoscopy

Laparoscopic modify extralevator abdominoperineal resection for rectal carcinoma in the prone position

Background: Laparoscopic technique applying for low rectal Carcinoma excision and the extralevator technique applying for abdominoperineal resection are involved with emerging technologies. The aim of this study was to introduce a modified approach of a direct visible resection: the levator muscles with laparoscopic technique and the alteration of patient’s position to a PJK position for the perineal resection of T3–T4 low rectal carcinoma. Methods: A 54-year-old woman with rectal carcinoma within 4 cm of the anal verge, the pathology confirmed adenocarcinoma. The enteroscopy showed that a cauliflower-like carcinoma was seen in the back of rectum. MRI and ERUS showed that the carcinoma of the lower rectum infiltrate muscular rand no enlarged lymph node around the rectum be noted. Preoperative TNM-staging was T3NxM0, and the patient was underwent an modified approach of a direct visible resection: the laparoscopic technique and the alteration to PJK position. Results: The operation cost 180 min with bleeding of about 50 mL. The patient recovers well postoperation and discharged from hospital on the 7th day. Conclusions: Laparoscopic modify extralevator abdominoperineal excision (ELAPE) for rectal carcinoma can be safely performed without the occurrence of short-term complications.

PWE-393 Reconstruction of the pelvic floor after abdominoperineal excision

Introduction Extralevator abdominoperineal excision (ELAPE) involves the en bloc excision of the levator muscles and the rectum and the wider excision can increase morbidity and wound complications tthat will require some form of perineal reconstruction. The aim of this review is to provide an overview of the evidence for the use of biological mesh in the reconstruction of the pelvic floor after abdominoperineal excision. Method 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 for analysis after inclusion and exclusion criteria were applied. Results There were a total of 1055 patients across 17 studies. A biological mesh was used in perineal reconstruction in 463 patients with 206 patients using cross-linked porcine dermal collagen (PermacolTM), 44 using porcine intestinal submucosa (Surgisis©), 136 using human acellular dermal matrix (HADM) and 9 using a combination of PermacolTM and Surgisis©. Two studies did not specify the type of biological mesh used. There were 41 perineal hernias reported but rates were not consistently reported in all studies. The most common complications were perineal wound infection and perineal pain. However, there are no standardised measures for reporting perineal outcomes following ELAPE. There are very few studies comparing the use of biological mesh for perineal reconstruction for ELAPE. Two case series compared biological mesh with myocutaneous flaps and one series compared laparoscopic ELAPE with laparoscopic and open APER. Only one RCT was identified that compared patients undergoing ELAPE with perineal reconstruction using a biological mesh, with patients undergoing a conventional APER with no mesh. There was no significant difference in perineal hernia rates or perineal wound infections between the two groups although there were fewer positive circumferential resection margins in the ELAPE group. Conclusion The literature suggests that perineal closure using a biological mesh produces wound infection and complication rates that are comparable to other methods of reconstruction such as myocutaneous flaps. Biological mesh-assisted perineal reconstruction is a promising technique to improve wound healing but the results from high-quality prospective RCTs are required or national/international collaborative audits using statistical process control as a methodology of assessment of improvement. Disclosure of interest None Declared.

Application of laparoscopic extralevator abdominoperineal excision in locally advanced low rectal cancer.

Background:When compared with conventional abdominoperineal resection (APR), extralevator abdominoperineal excision (ELAPE) has been demonstrated to reduce the risk of local recurrence for the treatment of locally advanced low rectal cancer. Combined with the laparoscopic technique, laparoscopic ELAPE (LELAPE) has the potential to reduce invasion and hasten postoperative recovery. In this study, we aim to investigate the advantages of LELAPE in comparison with conventional APR.Methods:From October 2010 to February 2013, 23 patients with low rectal cancer (T3–4N0–2M0) underwent LELAPE; while during the same period, 25 patients were treated with conventional APR. The patient characteristics, intraoperative data, postoperative complications, and follow-up results were retrospectively compared and analyzed.Results:The basic patient characteristics were similar; but the total operative time for the LELAPE was longer than that of the conventional APR group (P = 0.014). However, the operative time for the perineal portion was comparable between the two groups (P = 0.328). The LELAPE group had less intraoperative blood loss (P = 0.022), a lower bowel perforation rate (P = 0.023), and a positive circumferential margin (P = 0.028). Moreover, the patients, who received the LELAPE, had a lower postoperative Visual Analog Scale, quicker recovery of bowel function (P = 0.001), and a shorter hospital stay (P = 0.047). However, patients in the LELAPE group suffered more chronic perineal pain (P = 0.002), which may be related to the coccygectomy (P = 0.033). Although the metastasis rate and mortality rate were similar between the two groups, the local recurrence rate of the LELAPE group was statistically improved (P = 0.047).Conclusions:When compared with conventional APR, LELAPE has the potential to reduce the risk of local recurrence, and decreases operative invasion for the treatment of locally advanced low rectal cancer.

Perineal hernia formation following extralevator abdominoperineal excision.

Extralevator abdominoperineal excision (ELAPE) has become increasingly used because of some evidence of improved oncological outcome. It is, however, thought to be associated with a higher incidence of perineal hernia formation, although the exact incidence is not known. The aim of this study was to identify the incidence of perineal hernia after ELAPE. The case notes of patients over a 54-month period were reviewed. The perineal closure technique, perineal complications and management plan were recorded. During the study period, 56 patients underwent ELAPE, of whom 24 (44%) developed a perineal wound complication. Primary perineal closure was performed with (eight patients) and without (32 patients) insertion of a biological mesh or myocutaneous flap. Perineal hernia was the commonest complication (26%) and occurred in nine (45%) of 20 patients who had a laparoscopic ELAPE. Perineal hernia formation was the commonest perineal complication of ELAPE and occurred in nearly half of patients having a laparoscopic ELAPE.

[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.

Laparoscopic extralevator abdominoperineal excision of the rectum: short-term outcomes of a prospective case series

Laparoscopic approaches for the resection of low rectal cancer and the extralevator technique for abdominoperineal excision are both becoming increasingly popular. There are little published data regarding the combined application of these techniques to the resection of low rectal tumours. The aim of this study was to assess the feasibility of such an approach and to appraise short-term outcomes in a consecutive series of patients undergoing laparoscopic extralevator abdominoperineal excision (ELAPE). Consecutive patients undergoing laparoscopic ELAPE at our institution between 2008 and 2011 were identified from a prospectively maintained database. The abdominal phase of the operation was performed laparoscopically, and following extralevator resection, the perineum was reconstructed using a biologic mesh. All patients were enrolled in an enhanced recovery programme. Of 166 patients undergoing radical resection of rectal cancer at our institution between 2008 and 2011, 28 underwent laparoscopic ELAPE. Median age was 70 years, median body mass index was 27.5 kg/m(2), and 71% were male. The conversion rate to laparotomy was 18%. Three patients (10.8%) had circumferential resection margins <1 mm; no intraoperative tumour perforation occurred. The median length of stay was 7 days, with a 30-day readmission rate of 21% and no 30-day mortality. Post-operative perineal wound complications occurred in 25%. At median 38-month follow-up (range 23-66 months), overall survival was 75%, disease-free survival was 71%, and there were three local recurrences (11%). Laparoscopic extralevator abdominoperineal excision can be safely performed without compromising short-term outcomes.

A prospective case–control study of extralevator abdominoperineal excision (ELAPE) of the rectum versus conventional laparoscopic and open abdominoperineal excision: comparative analysis of short-term outcomes and quality of life

Conventional abdominoperineal excision (APE) of the rectum is associated with higher circumferential resection margin (CRM) involvement, increased local recurrence, and reduced survival compared to anterior resection. A more radical extralevator APE (ELAPE) technique may improve oncological outcome. However, this technique may confer additional morbidity, and little comparative data on short-term outcomes have been reported. This study compares short-term outcomes and quality of life (QOL) after open and laparoscopic ELAPE, laparoscopic APE (LAPE), and open APE (OAPE). Data on all ELAPE and 10 consecutive LAPE and OAPE were extracted from a prospective database. Perioperative care and follow-up were standardized. QOL was assessed using EORTC questionnaires. Sixteen ELAPE (14 laparoscopic), 10 LAPE, and 10 OAPE were included. Demographics, tumour stage, and neoadjuvant therapy use were comparable. Operative time was higher with ELAPE than LAPE and OAPE (295, 207.5, and 157.5min, respectively, p=0.01). A porcine collagen perineal mesh was used in 9 patients undergoing ELAPE but in no LAPE or OAPE patients. No difference in 30-day complications, re-admission, or length of stay was noted. ELAPE and LAPE were associated with earlier removal of urinary catheter (p=0.02), yet other enhanced recovery after surgery (ERAS) parameters were equivalent. All ELAPE resections were R0 with no positive CRM identified. One LAPE and 2 OAPE were R1 resections. Analysis revealed no deterioration in QOL with ELAPE, with equivalent global health status. The results of this study suggest that ELAPE is not associated with deterioration in short-term outcomes or QOL when compared with LAPE or OAPE.

Early experience with laparoscopic extralevator abdominoperineal excision within an enhanced recovery setting: analysis of short-term outcomes and quality of life

Conventional abdominoperineal excision for low rectal cancer has a higher local recurrence and reduced survival compared to anterior resection. An extralevator abdominoperineal excision (ELAPE) may improve outcome through removal of increased tissue in the distal rectum. Experience with ELAPE is limited and no studies have reported on quality of life (QOL) following this procedure. We describe a minimally invasive approach to ELAPE within an enhanced recovery programme, and present short-term results and QOL analyses. All laparoscopic ELAPEs were included in a prospective database. Demographics, intra-operative and post-operative outcomes were evaluated. Postoperative QOL was assessed using the European Organisation for Research and Treatment of Cancer (EORTC) questionnaires QLQ-C30 and QLQ-CR29. Thirteen laparoscopic ELAPEs were performed over a two-year period. All were enrolled in an enhanced recovery programme. The median age was 76. The median tumour height was 20 mm (range: 0-50 mm) from the dentate line and all patients received neoadjuvant treatment. The median duration of surgery was 300 minutes (range: 120-488 minutes), the mean blood loss was 150 ml and one procedure was converted to open surgery. There was no circumferential resection margin involvement or tumour perforation. The median duration of use of intravenous fluid, patient controlled analgesia and urinary catheterisation was 2, 2 and 2.5 days respectively and the median length of hospital stay was 7.5 days. Two patients developed perineal wound dehiscence. QOL analysis revealed high global health status (90.8), physical (91.3), emotional (98.3) and social functioning (100) scores, which compared favourably with EORTC reference values and published QOL scores following conventional abdominoperineal excision. Laparoscopic ELAPE within an enhanced recovery setting is a feasible and safe approach with acceptable short-term outcomes and post-operative quality of life.