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Khattak MA, Khan AN, Jafferi S, Iqbal Y, Abdulrasheed H, McArthur D. Perineal Wound Healing Following Abdominoperineal Resection of the Rectum. Cureus 2024; 16:e66318. [PMID: 39238678 PMCID: PMC11377100 DOI: 10.7759/cureus.66318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2024] [Indexed: 09/07/2024] Open
Abstract
OBJECTIVE This study aimed to investigate perineal wound healing rates following abdominoperineal resection (APR) or extralevator abdominoperineal excision (ELAPE) for rectal cancer, with a focus on identifying associated risk factors and outcomes. METHODOLOGY A retrospective analysis was conducted on patients undergoing APR or ELAPE for rectal cancer in a tertiary centre between 2013 and 2020. Data on demographics, comorbidities, surgical techniques, and perineal wound outcomes were collected and analyzed using Statistical Package for the Social Sciences (IBM SPSS Statistics for Windows, IBM Corp., Version 27.0, Armonk, NY). Statistical significance was set at p<0.05. RESULTS A total of 87 patients were included, with a mean age of 64 years and the majority being male (66.7%). Neoadjuvant radiotherapy was administered in 87.4% of cases. Perineal wound complications were documented in 52 cases (59.8%), with major complications observed in 11 cases (12.6%). Healing within six months was achieved in 48 patients (55.2%), while 39 patients (44.8%) developed chronic perineal wounds. Logistic regression analysis revealed omentoplasty as a significant predictor of perineal wound healing rate showing a significant negative association (p=0.0289). CONCLUSION Perineal wound healing rates following APR or ELAPE varied. While most patients achieved complete healing, chronic perineal wounds presented challenges. Omentoplasty was associated with lower odds of healing, suggesting the need for further investigation into its role. These findings underscore the importance of patient counselling and multidisciplinary management strategies to optimize outcomes in rectal cancer surgery.
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Affiliation(s)
- Muhammad Ali Khattak
- Urology, Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, GBR
| | | | - Salman Jafferi
- General Surgery, Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, GBR
| | - Yasir Iqbal
- Acute and General Medicine, Queen Elizabeth Hospital Birmingham, Birmingham, GBR
| | - Habeeb Abdulrasheed
- Urology, Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, GBR
| | - David McArthur
- General Surgery, Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, GBR
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Surgical Outcomes of VRAM vs. Gracilis Flaps in Vulvo-Perineal Reconstruction Following Oncologic Resection: A Proportional Meta-Analysis. Cancers (Basel) 2022; 14:cancers14174300. [PMID: 36077834 PMCID: PMC9454697 DOI: 10.3390/cancers14174300] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 08/29/2022] [Accepted: 08/30/2022] [Indexed: 11/17/2022] Open
Abstract
Simple Summary The rate of perineal complications after abdominoperineal reconstruction for the treatment of cancers ranges from 25% to 60% in the literature. It is well-established in current literature that direct closure has a higher complication rate than closure with a flap. Several reconstructive options have been proposed to fill the dead space with well-vascularized tissue. Every surgeon would like to be comfortable in selecting which flap has superiority in terms of surgical outcome. In the absence of a meta-analysis on the subject due to the scarcity of RCT and comparative studies, we used a proportional meta-analysis to analyze the surgical outcomes after reconstruction with either VRAM flap or gracilis flap following oncologic resection of the vulvo-perineal region. Abstract Pelvic exenteration and abdominoperineal resection are radical techniques commonly used for locally advanced or recurrent pelvic malignancy with high morbidity due to large pelvic defects. Flaps can help provide healthy, well-vascularized, non-irradiated tissues to fill pelvic dead space. We conducted a proportional meta-analysis to compare surgical outcomes of vertical rectus abdominus myocutaneous flap (VRAM) vs. gracilis flap for vulvo-perineal reconstruction following oncologic resection. A comprehensive literature search was conducted in the MEDLINE, PubMed, Embase, Google Scholar, and Cochrane Library databases. Proportional meta-analysis was performed to compare the surgical outcomes of using VRAM or gracilis flaps. Our review yielded 16 eligible studies. The pooled resolution rate of overall donor site complications for VRAM flap (pooled proportion = 0.576 [95% CI 0.387, 0.754]) was significantly higher than the pooled rate of overall donor site complications of gracilis flap (pooled proportion = 0.160 [95% CI 0.058, 0.295]). Partial and total flap necrosis were similar in both groups. There was no statistically significant difference between minor and major complications for both flaps. Both flaps can be used safely for vulvo-perineal reconstruction following oncologic resection with similar recipient site outcomes, although the VRAM flap will have more donor site complications than the gracilis flap.
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Wilkins S, Yap R, Mendis S, Carne P, McMurrick PJ. Surgical Techniques for Abdominoperineal Resection for Rectal Cancer: One Size Does Not Fit All. Front Surg 2022; 9:818097. [PMID: 35284486 PMCID: PMC8907259 DOI: 10.3389/fsurg.2022.818097] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 01/31/2022] [Indexed: 11/13/2022] Open
Abstract
Abdominoperineal resection (APR) of rectal cancer is associated with poorer oncological outcomes than anterior resection. This may be due to higher rates of intra-operative perforation (IOP) and circumferential resection margin (CRM) involvement causing higher recurrence rates and surgical complications. To address these concerns, several centers advocated a change in technique from a standard APR to a more radical extra-levator abdominoperineal excision (ELAPE). Initial reports showed that ELAPE reduced IOP rates and CRM involvement but increased wound complications and longer surgical duration. However, many of these studies had unacceptable rates of IOP and CRM before retraining in ELAPE. This may indicate that it was a sub-optimal surgical technique, which improved upon training, that had influenced the high CRM and IOP rates rather than the technique itself. Subsequent studies demonstrated that the CRM involvement rate for ELAPE was not always lower than for standard APR and, in some cases, significantly higher. The morbidity of ELAPE can be high, with studies reporting higher adverse events than APR, especially in terms of wound complications from the larger perineal incision required in ELAPE. Whether ELAPE improves short- or long-term oncological outcomes for patients has not been clearly demonstrated. The authors propose that all centers performing rectal cancer surgery audit surgical outcomes of patients undergoing APR or ELAPE and examine CRM involvement, IOP rates, and local recurrence rates, preferably through a national body. If rates of adverse technical or oncological outcomes exceed acceptable levels, then retraining in the appropriate surgical techniques may be indicated.
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Affiliation(s)
- Simon Wilkins
- Cabrini Monash University Department of Surgery, Cabrini Hospital, Malvern, VIC, Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- *Correspondence: Simon Wilkins
| | - Raymond Yap
- Cabrini Monash University Department of Surgery, Cabrini Hospital, Malvern, VIC, Australia
| | - Shehara Mendis
- Department of Oncology Research, Cabrini Hospital, Malvern, VIC, Australia
| | - Peter Carne
- Cabrini Monash University Department of Surgery, Cabrini Hospital, Malvern, VIC, Australia
- Colorectal Unit, Department of Surgery, Alfred Hospital, Melbourne, VIC, Australia
| | - Paul J. McMurrick
- Cabrini Monash University Department of Surgery, Cabrini Hospital, Malvern, VIC, Australia
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Flap Reconstruction of Perineal Defects after Pelvic Exenteration: A Systematic Description of Four Choices of Surgical Reconstruction Methods. Plast Reconstr Surg 2021; 147:1420-1435. [PMID: 33973948 DOI: 10.1097/prs.0000000000007976] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND The treatment of locally advanced or recurrent anorectal cancer requires radical surgery such as extralevator abdominoperineal resection and pelvic exenteration. Larger defects require flap reconstruction. The authors evaluated outcomes of different perineal reconstruction techniques. METHODS A systematic search was performed in the PubMed, Embase, and Cochrane databases. Studies reporting outcomes on perineal flap reconstruction in patients with anal or colorectal cancer were included. Data on patient characteristics, surgical details, perineal and donor-site complications, revision surgery, mortality, and quality of life were extracted. Articles were assessed using the Group Reading Assessment and Diagnostic Evaluation approach. RESULTS The authors included 58 mainly observational studies comprising 1988 patients. Seventy-three percent of patients had rectal cancer. The majority of 910 abdominoperineal resection patients underwent reconstruction with rectus abdominis flaps (91 percent). Dehiscence (15 to 32 percent) and wound infection (8 to 16 percent) were the most common complications. Partial flap necrosis occurred in 2 to 4 percent and flap loss occurred in 0 to 2 percent. Perineal herniation was seen in 6 percent after gluteal flap reconstruction and in 0 to 1 percent after other types of reconstruction. Donor-site complications were substantial but were reported inconsistently. CONCLUSIONS Clinical outcome data on perineal reconstruction after exenterative surgery are mostly of very low quality. Perineal reconstruction after pelvic exenteration is complex and requires a patient-tailored approach. Primary defect size, reconstruction aims, donor-site availability, and long-term morbidity should be taken into account. This review describes the clinical outcomes of four flap reconstruction techniques. Shared clinical decision-making on perineal reconstruction should be based on these present comprehensive data.
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Cylindrical abdominoperineal resection rationale, technique and controversies. JOURNAL OF COLOPROCTOLOGY 2021. [DOI: 10.1016/j.jcol.2013.08.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
AbstractSurgery remains the cornerstone in rectal cancer treatment. Abdominoperineal excision (APE), described more than 100 years ago, remains as an important procedure for the treatment of selected advanced distal tumors with direct invasion of the anal sphincter or preoperative fecal incontinence. Historically, oncological outcomes of patients undergoing APE have been worse when compared to sphincter preserving operations. More recently, it has been suggested that patients undergoing APE for distal rectal cancer are more likely to have positive circumferential resection margins and intraoperative perforation, known surrogate markers for local recurrence. Recently, an alternative approach known as “Extralevator Abdominoperineal Excision” has been described in an effort to improve rates of circumferential margin positivity possibly resulting in better oncological outcomes compared to the standard procedure. The objective of this paper is to provide a technical description and compare available data of both Extralevator and Standard abdominal perineal excision techniques.
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Smith N, Waters PS, Peacock O, Kong JC, Lynch AC, McCormick JJ, Heriot A, Warrier SK. Abdominoperineal excision in Australasia: clinical outcomes, predictive factors and recent trends of nonrestorative rectal cancer surgery. Colorectal Dis 2020; 22:1614-1625. [PMID: 32663900 DOI: 10.1111/codi.15263] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 05/20/2020] [Indexed: 12/13/2022]
Abstract
AIM The decision to perform an abdominoperineal excision (APR) rather than restorative bowel resection relies on a number of clinical factors. There remains great variability in APR rates internationally. The aim of this study was to demonstrate trends of APR surgery in low rectal cancer (< 6 cm from the anal verge) in Australasia and identify predictors of nonrestoration. METHOD This study reviewed a prospectively maintained colorectal registry - the Binational Colorectal Cancer Audit (BCCA) - from general/colorectal surgical units across Australia and New Zealand. Data were analysed to determine factors predictive of nonrestorative resection. Patients were analysed based on the presence (control) or absence (comparison) of a primary anastomosis. RESULTS Of 3628 patients with rectal cancer, 2096 were diagnosed with low rectal cancer between 2007 and 2017. The incidence of APR remained constant over the study period, with 58% of all resections of low rectal cancer being APR. The majority of resections were performed by consultants in urban hospitals (86% vs 14%). Tumours ≤ 3 cm from the anal verge, T4, M1 disease and neoadjuvant therapy were the greatest predictors of APR (P < 0.001). A significantly increased rate of restorative surgery was observed in public hospital settings (59% vs 41%, P < 0.05). The rate of positive circumferential resection margin (CRM) was 7.95%, with significantly increased rates in patients undergoing APR (12.2% vs 6.2%, P < 0.001). CRM positivity was increased in open approaches, T4, N2 and M1 staged disease and in an emergency/urgent setting (P < 0.001 and P < 0.045, respectively). Significantly increased wound and pulmonary complications were observed in the APR cohort (P < 0.01). CONCLUSION The rates of APR in Australia and New Zealand remain high but are comparable to international figures, with one-third of rectal cancers being treated by APR. The main determinants of APR are tumour height, T stage and neoadjuvant therapy requirement. CRM positivity was higher in APR patients.
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Affiliation(s)
- N Smith
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Epworth Healthcare, Melbourne, Victoria, Australia
| | - P S Waters
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Epworth Healthcare, Melbourne, Victoria, Australia
| | - O Peacock
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Epworth Healthcare, Melbourne, Victoria, Australia
| | - J C Kong
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Epworth Healthcare, Melbourne, Victoria, Australia
| | - A C Lynch
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Epworth Healthcare, Melbourne, Victoria, Australia
| | - J J McCormick
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Epworth Healthcare, Melbourne, Victoria, Australia
| | - A Heriot
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Epworth Healthcare, Melbourne, Victoria, Australia
| | - S K Warrier
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Epworth Healthcare, Melbourne, Victoria, Australia
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Güven HE, Aksel B. Is extralevator abdominoperineal resection necessary for low rectal carcinoma in the neoadjuvant chemoradiotherapy era? Acta Chir Belg 2020; 120:334-340. [PMID: 31250735 DOI: 10.1080/00015458.2019.1634925] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background: We aimed to compare the short-term surgical and early surgical oncological outcomes of abdominoperineal resection (APR) and extralevator APR (ELAPR) in patients with low rectal carcinoma that have received neoadjuvant chemoradiotherapy (NACRT), whose abdominal procedures were performed laparoscopically.Methods: One hundred and four patients who underwent APR or ELAPR for stage II/III low rectal carcinoma NACRT between 2013 and 2016 were evaluated by reviewing the standard charts for colorectal carcinoma.Results: Median follow-up for patients in APR group was 56 months(24-67 months) and 52 months(27-64 months) for ELAPR group. The postoperative complication rates were higher in ELAPR than in APR (perineal wound infection 38% vs. 22.5%(p = .03), perineal wound dehiscence 57% vs. 25%(p = .01), persistent perineal pain 28.5% vs. 13%(p = .01), urinary dysfunction 23% vs. 14.5%(p = .02), reoperation 16.5% vs. 4.8%(p = .03), respectively). Circumferential resection margin positivity, the number of lymph nodes dissected, and the rate of intra-operative perforation of the tumor were similar for both surgical techniques. Local recurrence rates at postoperative 2 years were also similar after APR and ELAPR (8% vs. 9.5%, p = .2).Conclusion: We conclude that in the era of routinely used NACRT, ELAPR is not superior to conventional APR for stage II/III low rectal carcinomas. ELAPR is associated with increased morbidity and has no short-term surgical oncological advantage over APR.
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Affiliation(s)
- Hikmet Erhan Güven
- Department of General Surgery, Health Sciences University, Gülhane Training and Research Hospital, Ankara, Turkey
| | - Bülent Aksel
- Department of General Surgery, Health Sciences University, Ankara Oncology Training and Research Hospital, Ankara, Turkey
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8
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Schellerer VS, Bartholomé L, Langheinrich MC, Grützmann R, Horch RE, Merkel S, Weber K. Donor Site Morbidity of Patients Receiving Vertical Rectus Abdominis Myocutaneous Flap for Perineal, Vaginal or Inguinal Reconstruction. World J Surg 2020; 45:132-140. [PMID: 32995931 PMCID: PMC7752873 DOI: 10.1007/s00268-020-05788-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2020] [Indexed: 12/20/2022]
Abstract
Background Management of donor site closure after harvesting a vertical rectus abdominis myocutaneous (VRAM) flap is discussed heterogeneously in the literature. We aim to analyze the postoperative complications of the donor site depending on the closure technique. Methods During a 12-year period (2003–2015), 192 patients in our department received transpelvic VRAM flap reconstruction. Prospectively collected data were analyzed retrospectively. Results 182 patients received a VRAM flap reconstruction for malignant, 10 patients for benign disease. The median age of patients was 62 years. 117 patients (61%) received a reconstruction of donor site by Vypro® mesh, 46 patients (24%) by Vicryl® mesh, 23 patients (12%) by direct closure and 6 patients (3%) by combination of different meshes. 32 patients (17%) developed in total 34 postoperative complications at the donor site. 22 complications (11%) were treated conservatively, 12 (6%) surgically. 17 patients (9%) developed incisional hernia during follow-up, with highest incidence in the Vicryl® group (n = 8; 17%) and lowest in the Vypro® group (n = 7; 6%). Postoperative parastomal hernias were found in 30 patients (16%) including three patients with simultaneous hernia around an urostomy and a colostomy. The highest incidence of parastomal hernia was found in patients receiving primary closure of the donor site (n = 6; 26%), the lowest incidence in the Vypro® group (n = 16; 14%). Conclusion The use of Vypro® mesh for donor site closure appears to be associated with a low postoperative incidence of complications and can therefore be recommended as a preferred technique.
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Affiliation(s)
- Vera S Schellerer
- Department of Surgery, University Medical Center Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Krankenhausstrasse 12, 91054, Erlangen, Germany.
| | - Lenka Bartholomé
- Department of Surgery, University Medical Center Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Krankenhausstrasse 12, 91054, Erlangen, Germany
| | - Melanie C Langheinrich
- Department of Surgery, University Medical Center Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Krankenhausstrasse 12, 91054, Erlangen, Germany
| | - Robert Grützmann
- Department of Surgery, University Medical Center Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Krankenhausstrasse 12, 91054, Erlangen, Germany
| | - Raymund E Horch
- Department of Plastic Surgery, University Medical Center Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Krankenhausstrasse 12, 91054, Erlangen, Germany
| | - Susanne Merkel
- Department of Surgery, University Medical Center Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Krankenhausstrasse 12, 91054, Erlangen, Germany
| | - Klaus Weber
- Department of Surgery, University Medical Center Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Krankenhausstrasse 12, 91054, Erlangen, Germany
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Tao Y, Han JG, Wang ZJ. Extralevator abdominoperineal excision for advanced low rectal cancer: Where to go. World J Gastroenterol 2020; 26:3012-3023. [PMID: 32587445 PMCID: PMC7304102 DOI: 10.3748/wjg.v26.i22.3012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 03/27/2020] [Accepted: 05/26/2020] [Indexed: 02/06/2023] Open
Abstract
Since its introduction, extralevator abdominoperineal excision (ELAPE) in the prone position has gained significant attention and recognition as an important surgical procedure for the treatment of advanced low rectal cancer. Most studies suggest that because of adequate resection and precise anatomy, ELAPE could decrease the rate of positive circumferential resection margins, intraoperative perforation, and may further decrease local recurrence rate and improve survival. Some studies show that extensive resection of pelvic floor tissue may increase the incidence of wound complications and urogenital dysfunction. Laparoscopic/robotic ELAPE and trans-perineal minimally invasive approach allow patients to be operated in the lithotomy position, which has advantages of excellent operative view, precise dissection and reduced postoperative complications. Pelvic floor reconstruction with biological mesh could significantly reduce wound complications and the duration of hospitalization. The proposal of individualized ELAPE could further reduce the occurrence of postoperative urogenital dysfunction and chronic perianal pain. The ELAPE procedure emphasizes precise anatomy and conforms to the principle of radical resection of tumors, which is a milestone operation for the treatment of advanced low rectal cancer.
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Affiliation(s)
- Yu Tao
- Department of General Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
| | - Jia-Gang Han
- Department of General Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
| | - Zhen-Jun Wang
- Department of General Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
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A Systematic Review and Meta-analysis on Omentoplasty for the Management of Abdominoperineal Defects in Patients Treated for Cancer. Ann Surg 2020; 271:654-662. [DOI: 10.1097/sla.0000000000003266] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Franz C, Lang HM, Ghamarnejad O, Khajeh E, Mehrabi A, Ulrich A, Schneider M, Büchler MW, Kulu Y. Prognostic Impact of Ventral Versus Dorsal Tumor Location After Total Mesorectal Excision of Rectal Cancer. Ann Surg Oncol 2019; 27:430-438. [PMID: 31549320 DOI: 10.1245/s10434-019-07842-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND Multidisciplinary treatment of rectal cancer, including neoadjuvant treatment, total mesorectal excision, and adjuvant chemotherapy, have improved oncological outcome. Preoperative radiation therapy is advocated by national and international guidelines in all patients with AJCC stage II and III rectal cancer. Although this treatment reduces local recurrence rates with no effect on overall survival, there are possible short- and long-term side effects of radiation exposure, so patients should be carefully selected for neoadjuvant radiation therapy. METHODS We analyzed whether ventral or dorsal tumor location affects local recurrence rates following radical rectal resection. Patients who underwent radical rectal resection for mid or low rectal cancer in our department between October 2001 and December 2013 were included. Prognostic indicators for local recurrence were analyzed using univariate and multivariate analyses. RESULTS Overall, 480 patients met the inclusion criteria. Univariate analysis identified surgical procedure (hazard ratio [HR] 1.9, p = 0.006), ventral tumor location (HR 3.8, p < 0.001), and a pathologic circumferential resection margin (pCRM) (HR 9.3, p < 0.001) as prognostic factors of local recurrence. Multivariate analysis revealed tumor location (HR 3.5, p < 0.001) and pCRM (HR 6.0, p = 0.002) as independent factors for local recurrence. Neoadjuvant treatment of AJCC stage II and III tumors reduced the local recurrence rate at ventral but not at dorsal tumor locations (p < 0.001). CONCLUSIONS Ventral versus dorsal tumor location is an independent prognostic factor for local recurrence. Tumor location may aid in patient selection for neoadjuvant treatment.
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Affiliation(s)
- Clemens Franz
- Department of General, Visceral and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Hans M Lang
- Department of General, Visceral and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Omid Ghamarnejad
- Department of General, Visceral and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Elias Khajeh
- Department of General, Visceral and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Alexis Ulrich
- Chirurgische Klinik I, Lukaskrankenhaus Neuss, Neuss, Germany
| | - Martin Schneider
- Department of General, Visceral and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany.
| | - Yakup Kulu
- Department of General, Visceral and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany
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12
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Zheng Y, Han JG, Wang ZJ, Gao ZG, Wei GH, Zhai ZW, Zhao BC. Preliminary Outcome of Individualized Abdominoperineal Excision for Locally Advanced Low Rectal Cancer. Chin Med J (Engl) 2018; 131:1268-1274. [PMID: 29786037 PMCID: PMC5987495 DOI: 10.4103/0366-6999.232810] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND The introduction of individualized abdominoperineal excision (APE) may minimize operative trauma and reduce the rate of complications. The purpose of this study was to evaluate the safety and efficacy of individualized APE for low rectal cancer. METHODS Fifty-six patients who underwent individualized APE from June 2011 to June 2015 were evaluated retrospectively in Beijing Chaoyang Hospital, Capital Medical University. The main outcome measures were circumferential resection margin (CRM) involvement, intraoperative perforation, postoperative complications, and local recurrence. Statistical analysis was performed using SPSS version 16.0. RESULTS Fifty (89%) patients received preoperative chemoradiotherapy: 51 (91%) patients were treated with the sacrococcyx preserved; 27 (48%) patients with the levator ani muscle partially preserved bilaterally; 20 (36%) patients with the levator ani muscle partially preserved unilaterally and the muscle on the opposite side totally preserved; 7 (13%) patients with intact levator ani muscle and part of the ischioanal fat bilaterally dissected; and 2 (4%) patients with part of the ischioanal fat and intact lavator ani muscle dissected unilaterally and the muscle on the opposite side partially preserved. The most common complications included sexual dysfunction (12%), perineal wound complications (13%), urinary retention (7%), and chronic perineal pain (5%). A positive CRM was demonstrated in 3 (5%) patients, and intraoperative perforations occurred in 2 (4%) patients. On multiple logistic regression analysis, longer operative time (P = 0.032) and more intraoperative blood loss (P = 0.006) were significantly associated with perineal procedure-related complications. The local recurrence was 4% at a median follow-up of 53 months (range: 30-74 months). CONCLUSION With preoperative chemoradiotherapy, individualized APE may be a relatively safe and feasible approach for low rectal cancer with acceptable oncological outcomes.
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Affiliation(s)
- Yi Zheng
- Department of General Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
| | - Jia-Gang Han
- Department of General Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
| | - Zhen-Jun Wang
- Department of General Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
| | - Zhi-Gang Gao
- Department of General Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
| | - Guang-Hui Wei
- Department of General Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
| | - Zhi-Wei Zhai
- Department of General Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
| | - Bao-Cheng Zhao
- Department of General Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
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13
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Xanthis A, Greenberg D, Jha B, Olafimihan O, Miller R, Fearnhead N, Davies J, Hall N. Local recurrence after 'standard' abdominoperineal resection: do we really need ELAPE? Ann R Coll Surg Engl 2018; 100:111-115. [PMID: 29022795 PMCID: PMC5838690 DOI: 10.1308/rcsann.2017.0161] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2017] [Indexed: 01/11/2023] Open
Abstract
Introduction Low rectal cancers requiring abdominoperineal resection tend to have a worse prognosis than higher tumours, which may be treated by anterior resection. One of the reasons for this may be inadequate local surgery, in particular the narrow waist of the resection specimen of a standard abdominoperineal resection may be associated with a high positive circumferential resection margin. The extralevator abdominoperineal excision (ELAPE) aims to improve the R0 resection rate but carries significant morbidity. We examined our own results of standard abdominoperineal resection to assess the need for a change of policy. Methods We operformed a retrospective analysis of consecutive standard abdominoperineal resections for rectal cancer in a single centre from June 2002 to December 2011. Results A total of 102 patients underwent standard abdominoperineal resection with curative intent; 19 had no preoperative treatment, 42 had short course radiotherapy, 9 had long course radiotherapy and 32 had neoadjuvant chemotherapy followed by long course chemoradiotherapy. In 17/102(16.6%), there was a positive circumferential resection margin. Over a median follow up of 32 months, 20 patients developed recurrence of any type. Local recurrence occurred in five patients (two of which also had distant recurrence), of whom two had a positive circumferential resection margin (P = 0.10). Actuarial two-year local only recurrence was 3.4% and any recurrence was 17.7%. Overall five-year cancer specific survival was 77%. Conclusions In this series we found low rates of local recurrence after standard abdominoperineal resection even with a circumferential margin rate positivity of 16.6%.Performing an ELAPE in selected cases may improve these results further but is not necessarily required for all patients.
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Affiliation(s)
- A Xanthis
- Colorectal Unit, Addenbrooke's Hospital , Cambridge , UK
| | - D Greenberg
- Public Health England, National Cancer Registration and Analysis Service, Fulbourn , Cambridge , UK
| | - B Jha
- Public Health England, National Cancer Registration and Analysis Service, Fulbourn , Cambridge , UK
| | - O Olafimihan
- Colorectal Unit, Addenbrooke's Hospital , Cambridge , UK
| | - R Miller
- Colorectal Unit, Addenbrooke's Hospital , Cambridge , UK
| | - N Fearnhead
- Colorectal Unit, Addenbrooke's Hospital , Cambridge , UK
| | - J Davies
- Colorectal Unit, Addenbrooke's Hospital , Cambridge , UK
| | - N Hall
- Colorectal Unit, Addenbrooke's Hospital , Cambridge , UK
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Pai A, Eftaiha SM, Melich G, Park JJ, Lin PYK, Prasad LM, Marecik SJ. Robotic Site Adjusted Levator Transection for Carcinoma of the Rectum: A Modification of the Existing Cylindrical Abdominoperineal Resection for Eccentrically Located Tumors. World J Surg 2017; 41:590-595. [PMID: 27778072 DOI: 10.1007/s00268-016-3735-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Today, extralevator abdominoperineal resection is the standard of care for low rectal cancers with sphincter involvement or location precluding anastomosis. This procedure, while effective from an oncologic point of view, is morbid, with a high incidence of wound complications and genitourinary, and sexual dysfunction. We present a modification of this procedure via a robotic approach, which maintains the radicality while reducing the soft tissue loss and potentially the morbidity. METHODS Over a 2-year period, five patients (four men and one woman) with eccentric low rectal cancers following neoadjuvant chemoradiation underwent a robot-assisted modified abdominoperineal resection with wide levator transection on the tumor side and conservative levator division on the opposite side. These patients were prospectively followed. Perioperative outcomes, pathologic specimen measures, wound-related problems, and local and systemic recurrences were documented and analyzed. RESULTS All procedures were successfully completed without conversion. Average body mass index was 32 kg/m2. The mean operative time and blood loss were 370 min and 130 ml, respectively. All specimens had an intact mesorectal envelope with no tumor perforations, and the mean lymph node yield was 16. There were no urinary complications or perineal wound infections. At a median follow-up of 14 months, all patients remain disease-free. CONCLUSIONS Modified robotic cylindrical abdominoperineal resection with site adjusted levator transection for rectal cancer is an oncologically sound operation in eccentrically located tumors. It maintains the radicality of conventional extralevator abdominoperineal resection, while also reducing the soft tissue loss and thereby potentially the morbidity.
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Affiliation(s)
- Ajit Pai
- Division of Colon and Rectal Surgery, Advocate Lutheran General Hospital, 1550 N. Northwest Highway, Suite 107, Park Ridge, IL, 60068, USA.,Department of Surgical Oncology, Apollo Hospitals, Chennai, India
| | | | - George Melich
- Division of Colon and Rectal Surgery, Advocate Lutheran General Hospital, 1550 N. Northwest Highway, Suite 107, Park Ridge, IL, 60068, USA.,Department of General Surgery, Royal Columbian Hospital, University of British Columbia, New Westminister, BC, Canada
| | - John J Park
- Division of Colon and Rectal Surgery, Advocate Lutheran General Hospital, 1550 N. Northwest Highway, Suite 107, Park Ridge, IL, 60068, USA
| | - Pey-Yi Kevin Lin
- Division of Colon and Rectal Surgery, Advocate Lutheran General Hospital, 1550 N. Northwest Highway, Suite 107, Park Ridge, IL, 60068, USA
| | - Leela M Prasad
- Division of Colon and Rectal Surgery, Advocate Lutheran General Hospital, 1550 N. Northwest Highway, Suite 107, Park Ridge, IL, 60068, USA.,Division of Colon and Rectal Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Slawomir J Marecik
- Division of Colon and Rectal Surgery, Advocate Lutheran General Hospital, 1550 N. Northwest Highway, Suite 107, Park Ridge, IL, 60068, USA.,Division of Colon and Rectal Surgery, University of Illinois at Chicago, Chicago, IL, USA
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15
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Kamali D, Sharpe A, Musbahi A, Reddy A. Oncological and quality of life outcomes following extralevator versus standard abdominoperineal excision for rectal cancer. Ann R Coll Surg Engl 2017; 99:402-409. [PMID: 28462642 DOI: 10.1308/rcsann.2017.0038] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION There is increasing and conflicting research debating the oncological benefits of extralevator abdominoperineal excision (ELAPE) compared with standard abdominoperineal excision (SAPE). However, there is very little in the literature on the long-term effects on patients' wellbeing following the two procedures. The aim of this study was to determine the oncological outcomes and long-term quality of life (QoL) of patients at two hospitals having undergone ELAPE or SAPE. METHODS Consecutive patients with rectal cancer who underwent either ELAPE or SAPE between January 2009 and June 2015 at a single centre were analysed. Oncological outcomes were determined by histology and follow-up imaging. QoL data were obtained prospectively using the QLQ-C30 and QLQ-CR29 questionnaires. RESULTS A total of 48 patients (36 male, 12 female; 27 ELAPE, 21 SAPE) were reviewed. The mean age was 67.4 years and the median follow-up duration was 44 months (range: 6-79 months). Four patients (2 ELAPE, 2 SAPE) developed local recurrence. Rates of distant metastasis were similar (ELAPE: 11%, SAPE: 14%). There was no significant difference in mean global health status score (ELAPE: 77.3, SAPE: 65.3). Impotence was the most frequently reported problem (mean symptom scores of 89.7 and 78.8 for ELAPE and SAPE respectively). CONCLUSIONS This is the largest study with the longest follow-up period that compares QoL after ELAPE with that after SAPE. Although more radical in nature, ELAPE did not demonstrate any significant impact on QoL compared with SAPE. There was no significant difference in long-term oncological outcome between the groups. Impotence remains a significant problem for all patients and they should be well informed of this risk prior to surgery.
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Affiliation(s)
- D Kamali
- South Tees Hospitals NHS Foundation Trust, UK
| | - A Sharpe
- South Tees Hospitals NHS Foundation Trust, UK
| | - A Musbahi
- South Tees Hospitals NHS Foundation Trust, UK
| | - A Reddy
- South Tees Hospitals NHS Foundation Trust, UK
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16
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Schiltz B, Buchs NC, Penna M, Scarpa CR, Liot E, Morel P, Ris F. Biological mesh reconstruction of the pelvic floor following abdominoperineal excision for cancer: A review. World J Clin Oncol 2017; 8:249-254. [PMID: 28638794 PMCID: PMC5465014 DOI: 10.5306/wjco.v8.i3.249] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2017] [Revised: 04/12/2017] [Accepted: 05/15/2017] [Indexed: 02/06/2023] Open
Abstract
Extralevator abdominoperineal excision and pelvic exenteration are mutilating operations that leave wide perineal wounds. Such large wounds are prone to infection and perineal herniation, and their closure is a major concern to most surgeons. Different approaches to the perineal repair exist, varying from primary or mesh closure to myocutaneous flaps. Each technique has its own associated advantages and potential complications and the ideal approach is still debated. In the present study, we reviewed the current literature and our own local data regarding the use of biological mesh for perineal wound closure. Current evidence suggests that the use of biological mesh carries an acceptable risk of wound complications compared to primary closure and is similar to flap reconstruction. In addition, the rate of perineal hernia is lower in early follow-up, while long-term hernia occurrence appears to be similar between the different techniques. Finally, it is an easy and quick reconstruction method. Although more expensive than primary closure, the cost associated with the use of a biological mesh is at least equal, if not less, than flap reconstruction.
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Neşşar G, Demirbağ AE, Celep B, Elbir OH, Kayaalp C. Extralevator abdominoperineal excision versus conventional surgery for low rectal cancer: a single surgeon experience. ULUSAL CERRAHI DERGISI 2016; 32:244-247. [PMID: 28149119 DOI: 10.5152/ucd.2016.3251] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Accepted: 08/30/2015] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Extralevator abdominoperineal excision (ELAPE) reduces the risk of positive circumferential resection margin (CRM) and of intraoperative perforation (IOP), both of which are associated with high local recurrence rates and poor survival outcomes for rectal cancer. The aim of this study was to compare the results of ELAPE with conventional abdominoperineal excision (APE) for low rectal cancer. MATERIAL AND METHODS A total of 25 consecutive patients underwent ELAPE for low rectal cancer between November 2008 and September 2011. Fifty-six patients treated by conventional APE prior to 2008 were selected from our rectal cancer database for comparison as a historical cohort. RESULTS The mean follow-up was 44.7 months in the ELAPE group, and 70.6 months in the APE group. Patients undergoing ELAPE had a lower CRM positivity and IOP rate than APE (12% vs. 20%, p=0,531; 4% vs. 8,9%, p=0,826; respectively). The ELAPE group was associated with higher perineal wound complications than the APE group (16.0% vs. 1.8%, p=0.030). Local recurrence rates for patients in both groups did not differ significantly (4.0% vs. 3.6%, p=1.0). CONCLUSION The results of this study suggest that ELAPE technique was associated with less CRM involvement and reduced rates of IOP but markedly higher rates of postoperative perineal complications occurred as compared to conventional surgery. ELAPE must be reserved for advanced low rectal cancers.
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Affiliation(s)
- Gürel Neşşar
- Clinic of Gastrointestinal Surgery, Türkiye Yüksek İhtisas Hospital, Ankara, Turkey
| | - Ali Eba Demirbağ
- Clinic of Gastrointestinal Surgery, Türkiye Yüksek İhtisas Hospital, Ankara, Turkey
| | - Bahadır Celep
- Department of General Surgery, Kocatepe University School of Medicine, Afyon, Turkey
| | - Orhan Hayri Elbir
- Clinic of Gastrointestinal Surgery, Türkiye Yüksek İhtisas Hospital, Ankara, Turkey
| | - Cüneyt Kayaalp
- Department of Gastrointestinal Surgery, İnönü University Turgut Özal Medical Center, Malatya, Turkey
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18
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Long-term outcome of extralevator abdominoperineal excision (ELAPE) for low rectal cancer. Int J Colorectal Dis 2016; 31:1729-37. [PMID: 27631643 DOI: 10.1007/s00384-016-2637-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/24/2016] [Indexed: 02/04/2023]
Abstract
PURPOSE Extralevator abdominoperineal excision (ELAPE) was introduced to improve outcomes for low-lying locally advanced rectal cancers (LARC) not amenable to sphincter preserving procedures. This study investigates prospectively outcomes of patients operated on with ELAPE compared with a similar cohort of patients operated on with conventional APE. METHODS After the exclusion of patients without neoadjuvant therapy, in-hospital mortality, and incomplete metastatectomy, we identified 72 consecutive patients who had undergone either conventional APE (n = 36) or ELAPE (n = 36) for LARC ≤6 cm from the anal verge. The primary outcome measure was local recurrence at 5 years, and secondary outcome measures were cause-specific and overall survival. RESULTS Median distance from the anal verge was significantly lower in the ELAPE group (2 vs. 4 cm, p = 0.029). Inadvertent bowel perforation could be completely avoided in the ELAPE group, but amounted to 16.7 % in the conventional APE group (p = 0.025). Cumulative local recurrence rate at 5 years was 18.2 % in the APE group compared to 5.9 % in the ELAPE group (p = 0.153). Local recurrence without distant metastases occurred in 15.5 % in the APE group but was not observed in the ELAPE group (p = 0.039). We did not detect significant differences in cause-specific nor in overall survival. CONCLUSION ELAPE results in lower local recurrence rates as compared with conventional APE. We conclude that the extralevator approach should be the procedure of choice for advanced low rectal cancer not amenable to sphincter preserving procedures.
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19
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Wound Complications and Perineal Pain After Extralevator Versus Standard Abdominoperineal Excision: A Nationwide Study. Dis Colon Rectum 2016; 59:813-21. [PMID: 27505109 DOI: 10.1097/dcr.0000000000000639] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Extralevator abdominoperineal excision was introduced as an alternative to conventional abdominoperineal excision for low rectal cancers. The perineal dissection is more extensive with extralevator abdominoperineal excision and leaves a greater defect. OBJECTIVE The aim of this study was to evaluate, on a national basis, the risk of perineal wound complications, pain, and hernia after conventional and extralevator abdominoperineal excision performed for low rectal cancer. DESIGN This was a retrospective study collecting data from the Danish Colorectal Cancer Group database and from electronic medical files of patients. SETTINGS The study was conducted at Danish surgical departments. PATIENTS A total of 445 patients operated between 2009 and 2012 with extralevator or conventional abdominoperineal excision were included. MAIN OUTCOME MEASURES The main end points of this study were perineal wound complications and pain lasting for >30 days after the operation. RESULTS The 2 groups were demographically similar except for a higher ASA score in the conventional group. In the extralevator group, neoadjuvant chemoradiation was more frequent (71% vs 41%; p < 0.001), T stage was higher (more T3 tumors; 52% vs 38%; p = 0.006), and more tumors were fixed (21% vs 12%; p = 0.02). Perineal wound complications and pain were more frequent after extralevator versus conventional excision (44% vs 25%; p < 0.001 and 38% vs 22%; p < 0.001). After multivariate analyses, neoadjuvant chemoradiation, extralevator excision, and operation early in the study period were found to have a significant influence on the risk of long-term wound complications. Neoadjuvant chemoradiation and wound complications were significant risk factors for long-term perineal pain. Results were similar after subgroup analyses on low tumors only. LIMITATIONS This was a retrospective study. The 2 groups were not completely comparable at baseline. CONCLUSIONS Neoadjuvant chemoradiation, extralevator compared with conventional excision, and operation early in the study period were significant factors for predicting perineal wound complications. Neoadjuvant chemoradiation and wound complications were predictors of long-term perineal pain.
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20
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Similar long-term overall and disease-free survival after conventional and extralevator abdominoperineal excision-a nationwide study. Int J Colorectal Dis 2016; 31:1341-7. [PMID: 27129851 DOI: 10.1007/s00384-016-2596-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/22/2016] [Indexed: 02/04/2023]
Abstract
PURPOSE The purpose of the present study was to assess, compare, and identify factors of importance for long-term overall (OS) and disease-free (DFS) survival after conventional (cAPE) and extralevator abdominoperineal excision (ELAPE) on a nationwide basis. METHODS This was a database study based on data from a nationwide colorectal cancer database. Patients undergoing surgery for rectal cancer in the period January 1, 2009 to August 31, 2012 were examined. Factors of importance for disease-free and overall survival were identified by multivariate Cox regressions. RESULTS Five hundred patients were included in the final population. Two hundred seventy-six were operated by ELAPE and 224 by APE. Disease-free and overall survival did not differ between groups (4-year DFS 67 and 66 % after cAPE and ELAPE, respectively, (log-rank p = 0.82); 4-year OS 74 and 77 % after cAPE and ELAPE, respectively, (log-rank p = 0.59)). In Cox regression, the type of procedure did not affect DFS or OS. Factors of importance for DFS included increasing age, ypN-positive disease and neoadjuvant chemoradiation therapy. Factors of importance for OS included increasing age, circumferential resection margin (CRM) positivity, fixation of the tumor, blood transfusion, and increasing American Society of Anesthesiologists (ASA) score. CONCLUSIONS In this nationwide study, we did not find any differences in DFS or OS after extralevator versus conventional abdominal perineal excision, and the type of procedure did not affect survival after adjusted analyses.
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Park S, Hur H, Min BS, Kim NK. Short-term Outcomes of an Extralevator Abdominoperineal Resection in the Prone Position Compared With a Conventional Abdominoperineal Resection for Advanced Low Rectal Cancer: The Early Experience at a Single Institution. Ann Coloproctol 2016; 32:12-9. [PMID: 26962531 PMCID: PMC4783506 DOI: 10.3393/ac.2016.32.1.12] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Accepted: 11/10/2015] [Indexed: 02/08/2023] Open
Abstract
Purpose This study compared the perioperative and pathologic outcomes between an extralevator abdominoperineal resection (APR) in the prone position and a conventional APR. Methods Between September 2011 and March 2014, an extralevator APR in the prone position was performed on 13 patients with rectal cancer and a conventional APR on 26 such patients. Patients' demographics and perioperative and pathologic outcomes were obtained from the colorectal cancer database and electronic medical charts. Results Age and preoperative carcinoembryonic antigen (CEA) level were significantly different between the conventional and the extralevator APR in the prone position (median age, 65 years vs. 55 years [P = 0.001]; median preoperative CEA level, 4.94 ng/mL vs. 1.81 ng/mL [P = 0.011]). For perioperative outcomes, 1 (3.8%) intraoperative bowel perforation occurred in the conventional APR group and 2 (15.3%) in the extralevator APR group. In the conventional and extralevator APR groups, 12 (46.2%) and 6 patients (46.2%) had postoperative complications, and 8 (66.7%) and 2 patients (33.4%) had major complications (Clavien-Dindo III/IV), respectively. The circumferential resection margin involvement rate was higher in the extralevator APR group compared with the conventional APR group (3 of 13 [23.1%] vs. 3 of 26 [11.5%]). Conclusion The extralevator APR in the prone position for patients with advanced low rectal cancer has no advantages in perioperative and pathologic outcomes over a conventional APR for such patients. However, through early experience with a new surgical technique, we identified various reasons for the lack of favorable outcomes and expect sufficient experience to produce better peri- or postoperative outcomes.
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Affiliation(s)
- Seungwan Park
- Division of Colon and Rectal Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hyuk Hur
- Division of Colon and Rectal Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Byung Soh Min
- Division of Colon and Rectal Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Nam Kyu Kim
- Division of Colon and Rectal Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Hassel K, Andersson K, Koinberg IL, Wennström B. Postoperative wound infections after a proctectomy--Patient experiences. Int J Qual Stud Health Well-being 2016; 11:30393. [PMID: 26900139 PMCID: PMC4761680 DOI: 10.3402/qhw.v11.30393] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/07/2016] [Indexed: 12/12/2022] Open
Abstract
Poor perineal wound healing and infections after proctectomy surgery cause a significant proportion of physical and psychological morbidities, such as pain, leakage, and abscesses. In the long run, some of these symptoms will lead to extended periods of hospitalization. These kinds of postoperative complications are also associated with delays in possible chemotherapy treatment. The aim of this study was to describe patient experiences of perineal wound infections following proctectomy due to rectal cancer, and the importance of the communication with and the self-care support from the nurse for these patients. Five women and five men (61-87 years, median age 71 years) were included and interviewed. A qualitative content analysis of the interviews was carried out and the following main categories emerged: "Managing postoperative complications," "Being independent," "Feeling safe," and "Accepting the situation." A perineal wound infection after a proctectomy is devastating for the individual patient. The limitations and changes to the patients' lives turn into new daily routines, which force them to find new ways to live and to accept the situation. For many of them, the infections remained for several months and, sometimes, for years. The ability to lead an independent life is drastically reduced, but through continuity in care it is possible to create a feeling of safety. Information, communication, and self-care support are all important and valuable factors for recovery. Specialized care containing an action plan is therefore needed in clinical practice to reduce the number of perineal wound infections postoperatively and should be initiated when the patient is discharged from the ward and continue until recovery.
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Affiliation(s)
- Karin Hassel
- Department of Surgery, Skaraborg Hospital, Skövde, Sweden
| | | | - Inga-Lill Koinberg
- Institute of Health and Care Science, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Berith Wennström
- Department of Surgery, Skaraborg Hospital, Skövde, Sweden.,Department of Anaesthesia, Skaraborg Hospital, Skövde, Sweden;
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De Palma GD, Luglio G. Quality of life in rectal cancer surgery: What do the patient ask? World J Gastrointest Surg 2015; 7:349-355. [PMID: 26730279 PMCID: PMC4691714 DOI: 10.4240/wjgs.v7.i12.349] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2015] [Revised: 09/13/2015] [Accepted: 10/12/2015] [Indexed: 02/06/2023] Open
Abstract
Rectal cancer surgery has dramatically changed with the introduction of the total mesorectal excision (TME), which has demonstrated to significantly reduce the risk of local recurrence. The combination of TME with radiochemotherapy has led to a reduction of local failure to less than 5%. On the other hand, surgery for rectal cancer is also impaired by the potential for a significant loss in quality of life. This is a new challenge surgeons should think about nowadays: If patients live more, they also want to live better. The fight against cancer cannot only be based on survival, recurrence rate and other oncological endpoints. Patients are also asking for a decent quality of life. Rectal cancer is probably a paradigmatic example: Its treatment is often associated with the loss or severe impairment of faecal function, alteration of body anatomy, urogenital problems and, sometimes, intractable pain. The evolution of laparoscopic colorectal surgery in the last decades is an important example, which emphasizes the importance that themes like scar, recovery, pain and quality of life might play for patients. The attention to quality of life from both patients and surgeons led to several surgical innovations in the treatment of rectal cancer: Sphincter saving procedures, reservoir techniques (pouch and coloplasty) to mitigate postoperative faecal disorders, nerve-sparing techniques to reduce the risk for sexual dysfunction. Even more conservative procedures have been proposed alternatively to the abdominal-perineal resection, like the local excisions or transanal endoscopic microsurgery, till the possibility of a wait and see approach in selected cases after radiation therapy.
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Goedhart-de Haan AMS, Langenhoff BS, Petersen D, Verheijen PM. Laparoscopic repair of perineal hernia after abdominoperineal excision. Hernia 2015; 20:741-6. [PMID: 26643606 DOI: 10.1007/s10029-015-1449-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 11/22/2015] [Indexed: 12/30/2022]
Abstract
PURPOSE Perineal hernia is a challenging complication after abdominoperineal excision (APE) of the rectum. Surgical repair can be accomplished using challenging abdominal or transperineal approaches. A laparoscopic repair using a Proceed mesh might be an easy and effective alternative. METHODS We describe a multi-center case-series of twelve patients with a symptomatic perineal hernia treated by laparoscopic mesh repair. A cone-shaped 10 × 15 cm Proceed Mesh was tacked to the promontory or sacrum and sutured to the pelvic sidewalls and the anterior peritoneum. RESULTS Twelve patients underwent laparoscopic repair of their perineal hernia. Four men and eight women presented with a symptomatic perineal hernia after abdominoperineal excision between 2008 and 2013 and underwent a laparoscopic repair with a Proceed mesh. The median age at presentation was 53 years (range 39-68 years). The mean total theater time was 119 min (range 75-200 min). No conversion to an open procedure was needed. No early complications where seen. The mean hospital stay was 2.25 days (range 1-4 days). Three patients showed recurrence, of whom two had a defect in the middle of the proceed mesh, one had a defect anterior to the previous perineal hernia. All 3 patients underwent a redo-laparoscopic repair with mesh. CONCLUSION In this case series we present an alternative approach for the surgical repair of perineal hernias. Based on our experience, perineal hernia after APE can be repaired safely and effectively using the described laparoscopic technique.
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Affiliation(s)
| | - B S Langenhoff
- Department of Surgery, Twee Steden Hospital, Tilburg, The Netherlands
| | - D Petersen
- Department of Surgery, St Andrew's Hospital, Spring Hill, Australia
| | - P M Verheijen
- Department of Surgery, Meander Medical Centre, Amersfoort, The Netherlands
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25
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Palter VN, MacLellan S, Ashamalla S. Laparoscopic translevator approach to abdominoperineal resection for rectal adenocarcinoma: feasibility and short-term oncologic outcomes. Surg Endosc 2015; 30:3001-6. [PMID: 26487217 DOI: 10.1007/s00464-015-4589-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 09/19/2015] [Indexed: 12/31/2022]
Abstract
BACKGROUND The extra-levator approach to abdominal perineal resection (APR) was developed in order to reduce the rates of positive circumferential resection margin. This approach, however, is associated with significant morbidity. We postulate that a less radical resection of the levators done laparoscopically could significantly decrease the rate of perineal complications while ensuring an oncologically adequate specimen. To date, to our knowledge, there are no reports in the literature describing a laparoscopic translevator approach for APR. The purpose of this study is to describe our initial experience with this approach and assess our short-term oncologic and clinical outcomes. METHODS This is a retrospective study of patients who underwent laparoscopic APR with intra-abdominal levator transection for rectal cancer from 2012 to 2014 at a single tertiary care institution. Main outcome measures include: perineal flap rates, post-operative complications, length of stay, distance from tumour to circumferential resection margin, R0 status, and disease recurrence. Data are presented as median (interquartile range) unless otherwise noted. RESULTS Seventeen cases were identified. Patient age was 61 (range 34-75), and 59 % were male. Pre-operative distance of the tumour from the anal verge was 2.6 cm (0.4-3.9). Post-operative length of stay was 4 (4-6) days. One patient required a perineal flap for reconstruction. Four patients (22 %) had perineal complications (three wound infections and one hernia). No patients reported sexual dysfunction, and one (5 %) developed urinary retention. Five (29 %) patients had a complete pathological response. The circumferential resection margin was 1.5 (0.8-2.5) cm, with no positive margins reported. The number of retrieved lymph nodes was 12 (range 2-30). Follow-up was 9.7 months (range 20 days-23 months), during which one patient developed recurrent disease. CONCLUSIONS This study describes a novel surgical approach to APR that has the potential to both decrease perineal complications and provide excellent oncologic results.
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Affiliation(s)
- Vanessa N Palter
- Department of Surgery, University of Toronto, 600 University Ave., Rm 440, Toronto, ON, M5G 1X5, Canada.
| | - Steven MacLellan
- Department of Surgery, University of Toronto, 600 University Ave., Rm 440, Toronto, ON, M5G 1X5, Canada
- Humber River Hospital, 2111 Finch Ave West, Toronto, ON, M3N 1N1, Canada
| | - Shady Ashamalla
- Department of Surgery, University of Toronto, 600 University Ave., Rm 440, Toronto, ON, M5G 1X5, Canada
- Sunnybrook Health Sciences Centre, 2075 Bayview Ave, T2015, Toronto, M4N 3M5, Canada
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De Nardi P, Summo V, Vignali A, Capretti G. Standard versus extralevator abdominoperineal low rectal cancer excision outcomes: a systematic review and meta-analysis. Ann Surg Oncol 2015; 22:2997-3006. [PMID: 25605518 DOI: 10.1245/s10434-015-4368-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Indexed: 12/27/2024]
Abstract
BACKGROUND The extended, extralevator abdominoperineal excision has been described with the aim of improving oncological low rectal cancer patient outcomes. MATERIALS AND METHODS A systematic literature review was conducted using Medline/PubMed, Embase, Cochrane library, and Ovid for standard and extralevator abdominoperineal rectal cancer excision studies between 1995 and 2013. A total of 1,270 articles were identified and screened, and of these, 58 reports (1 randomized, 5 case-control and 52 cohort studies) were included for the qualitative analysis, and 6 were included for the quantitative analysis. The primary endpoints included intraoperative tumor perforation, the circumferential resection margin involvement, local recurrence rate, and the perineal wound complication rate. The secondary endpoints included the length of postoperative hospital stay and quality of life. Comprehensive Rev Men, version 5.2 was used for the statistical calculations. RESULTS A significant difference in the circumferential resection margin involvement rate [odds ratio (OR) 2.9; p < .001], intraoperative perforation (OR 4.30; p < .001), local recurrence rate (OR 2.52; p = .02), and length of hospital stay (OR 1.06; p < .001) in favor of the extended group was observed. Additionally, the perineal wound complications were higher in the extended group (OR 0.62; p = .007). No difference in quality of life was observed. CONCLUSIONS Our analysis confirms the oncological advantages of the extended abdominoperineal excision method. Although the perineal wound complications were higher, the length of postoperative hospital stay was shorter, and quality of life was not inferior to the conventional resection method.
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Affiliation(s)
- Paola De Nardi
- Department of Surgery, San Raffaele Scientific Institute, Milan, Italy,
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Kulu Y, Tarantino I, Billeter AT, Diener MK, Schmidt T, Büchler MW, Ulrich A. Comparative Outcomes of Neoadjuvant Treatment Prior to Total Mesorectal Excision and Total Mesorectal Excision Alone in Selected Stage II/III Low and Mid Rectal Cancer. Ann Surg Oncol 2015; 23:106-13. [PMID: 26305025 DOI: 10.1245/s10434-015-4832-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Indexed: 12/23/2022]
Abstract
BACKGROUND Current guidelines advocate that all rectal cancer patients with American Joint Committee on Cancer (AJCC) stages II and III disease should be subjected to neoadjuvant therapy. However, improvements in surgical technique have resulted in single-digit local recurrence rates with surgery only. METHODS Operative, postoperative, and oncological outcomes of patients with and without neoadjuvant therapy were compared between January 2002 and December 2013. For this purpose, all patients resected with low anterior rectal resection (LAR) and total mesorectal excision (TME) who had or had not been irradiated were identified from the authors' prospectively maintained database. Patients who were excluded were those with high rectal cancer or AJCC stage IV disease; in the surgery-only group, patients with AJCC stage I disease or with pT4Nx rectal cancer; and in the irradiated patients, patients with ypT4Nx or cT4Nx rectal cancer. RESULTS Overall, 454 consecutive patients were included. A total of 342 (75 %) patients were irradiated and 112 (25 %) were not irradiated. Median follow-up for all patients was 48 months. Among patients with and without irradiation, pathological circumferential resection margin positivity rates (2.9 vs. 1.8 %, p = 0.5) were not different. At 5 years, in irradiated patients compared with surgery-only patients, the incidence of local recurrence was decreased (4.5 vs. 3.8 %, p = 0.5); however, systemic recurrences occurred more frequently (10 vs. 17.8 %, p = 0.2). Irradiation did not affect overall or disease-free survival (neoadjuvant treatment vs. surgery-only: 84.9 vs. 88.2 %, p = 0.9; 76 vs. 79.1 %, p = 0.8). CONCLUSIONS The current study adds to the growing evidence that suggests a selective rather than generalized indication for neoadjuvant treatment in stages II and III rectal cancer.
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Affiliation(s)
- Yakup Kulu
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Ignazio Tarantino
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Adrian T Billeter
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Markus K Diener
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Thomas Schmidt
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Alexis Ulrich
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany.
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Dinnewitzer A, Meissnitzer M, Meissnitzer T, Nawara C, Augschöll C, Buchner S, Mayer F, Öfner D. Dynamic magnetic resonance imaging evaluation of pelvic reconstruction with porcine dermal collagen mesh following extra-levator abdominoperineal excision for primary rectal cancer. Int J Colorectal Dis 2015; 30:491-6. [PMID: 25700810 DOI: 10.1007/s00384-015-2169-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/10/2015] [Indexed: 02/04/2023]
Abstract
PURPOSE Extra-levator abdominoperineal excision for rectal cancer includes resection of the levator ani muscle and therefore makes pelvic reconstruction advisable. The aim of our study was to evaluate morphologic and functional long-term results of pelvic floor augmentation with porcine dermal collagen mesh by dynamic magnetic resonance imaging and clinical examination. METHODS Twenty consecutive patients underwent perineal reconstruction with porcine dermal collagen mesh following extra-levator abdominoperineal excision for primary rectal adenocarcinoma with curative intent between 2009 and 2012. Patient perioperative and postoperative data were collected prospectively. There were one cancer-related and two noncancer-related deaths in the follow-up period, and another three patients refused the dynamic magnetic resonance imaging. RESULTS Fourteen patients were included in the study. The median time period from surgery to dynamic magnetic resonance imaging and clinical examination was 31 months (range 19-56). Wound infections were observed in 43% (6 of 14) of these patients in the postoperative period, but no mesh had to be removed. No focal mesh defect, no damage on the suture line, and no perineal hernia were detected on dynamic magnetic resonance imaging. Clinical examination revealed no pathological findings in any patient. CONCLUSIONS The implantation of a porcine dermal collagen mesh is an effective and reliable option for pelvic floor reconstruction after extra-levator abdominoperineal excision. Despite a high incidence of primary wound infections, the healing rate was satisfactory, no mesh had to be removed, and long-term stability could be achieved.
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Affiliation(s)
- Adam Dinnewitzer
- Department of Surgery, Paracelsus Medical University, Muellner Hauptstraße 48, 5020, Salzburg, Austria,
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Asplund D, Prytz M, Bock D, Haglind E, Angenete E. Persistent perineal morbidity is common following abdominoperineal excision for rectal cancer. Int J Colorectal Dis 2015; 30:1563-70. [PMID: 26245948 PMCID: PMC4624814 DOI: 10.1007/s00384-015-2328-1] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/26/2015] [Indexed: 02/07/2023]
Abstract
PURPOSE Short-term complications related to the perineal wound after abdominoperineal excision (APE) are a well-known problem. Perineal morbidity in the longer term is an almost unexplored area. The aim of this cross-sectional study was to investigate the prevalence of perineal symptoms 3 years after APE for rectal cancer, to identify potential risk factors and to explore the relationship between perineal morbidity and global quality of life. METHOD All patients who underwent APE in Sweden between 2007 and 2009 (n = 1373) were identified through the Swedish Colorectal Cancer Registry. Surviving patients were contacted 3 years after surgery and asked about participation. A total of 545 patients completed a detailed questionnaire. Clinical data was collected from the registry and surgical charts. RESULTS Perineal symptoms occurred in 50 % of all patients 3 years after APE and more frequently in women (58 vs. 44 %; p = 0.001). Delayed healing of the perineal wound (>4 weeks) occurred in 25 % of all patients and more frequently after extralevator APE (ELAPE) than after conventional APE (32 vs. 11 %, p < 0.001). Delayed healing was associated with an increased risk of more severe perineal symptoms (relative risk (RR) 1.50, 95 % confidence interval (95 % CI) 1.09-2.05). Patients with more severe perineal symptoms (n = 129) had a significantly lower global quality of life as measured by EQ-5D visual analogue scale (VAS; median 75 vs. 83 points on the 100-point scale; p < 0.001). CONCLUSION Persistent perineal symptoms are common after APE and may have an impact on patients' quality of life. Delayed wound healing may be a risk factor for persistent symptoms. Further studies are needed to identify avoidable clinical factors for the development of persistent perineal morbidity. CLINICALTRIALS. GOV IDENTIFIER NCT01296984.
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Affiliation(s)
- Dan Asplund
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, SSORG - Scandinavian Surgical Outcomes Research Group, Sahlgrenska University Hospital/Östra, 416 85, Gothenburg, Sweden.
| | - Mattias Prytz
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, SSORG - Scandinavian Surgical Outcomes Research Group, Sahlgrenska University Hospital/Östra, 416 85, Gothenburg, Sweden
- Department of Surgery, NU Hospital group, Trollhättan, Sweden
| | - David Bock
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, SSORG - Scandinavian Surgical Outcomes Research Group, Sahlgrenska University Hospital/Östra, 416 85, Gothenburg, Sweden
| | - Eva Haglind
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, SSORG - Scandinavian Surgical Outcomes Research Group, Sahlgrenska University Hospital/Östra, 416 85, Gothenburg, Sweden
| | - Eva Angenete
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, SSORG - Scandinavian Surgical Outcomes Research Group, Sahlgrenska University Hospital/Östra, 416 85, Gothenburg, Sweden
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Han JG, Wang ZJ, Qian Q, Dai Y, Zhang ZQ, Yang JS, Li F, Li XB. A prospective multicenter clinical study of extralevator abdominoperineal resection for locally advanced low rectal cancer. Dis Colon Rectum 2014; 57:1333-1340. [PMID: 25379997 DOI: 10.1097/dcr.0000000000000235] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Recent studies have shown that extralevator abdominoperineal resection has the potential for reduced circumferential resection margin involvement, intraoperative bowl perforation, and local recurrence rates; however, it has been suggested that extended resection may be associated with increased morbidity because of the formation of a larger perineal defect. OBJECTIVE This study was undertaken to demonstrate the feasibility and complications of extralevator abdominoperineal resection for locally advanced low rectal cancer in China. DESIGN This was a prospective cohort study. SETTING The study was conducted at 7 university hospitals throughout China. PATIENTS A total of 102 patients underwent this procedure for primary locally advanced low rectal cancer between August 2008 and October 2011. MAIN OUTCOME MEASURES The main outcome measures comprised circumferential resection margin involvement, intraoperative perforation, postoperative complications, and local recurrence. RESULTS The most common complications included sexual dysfunction (40.5%), perineal complications (23.5%), urinary retention (18.6%), and chronic perineal pain (13.7%). Chronic perineal pain was associated with coccygectomy (p < 0.001), and the pain gradually eased over time. Reconstruction of the pelvic floor with biological mesh was associated with a lower rate of perineal dehiscence (p = 0.006) and overall perineal wound complications (p = 0.02) in comparison with primary closure. A positive circumferential margin was demonstrated in 6 (5.9%) patients, and intraoperative perforations occurred in 4 (3.9%) patients. All circumferential margin involvements and intraoperative perforations were located anteriorly. The local recurrence was 4.9% at a median follow-up of 44 months (range, 18-68 months). LIMITATIONS This was a nonrandomized, uncontrolled study. CONCLUSIONS Extralevator abdominoperineal resection performed in the prone position for low rectal cancer is a relatively safe approach with acceptable circumferential resection margin involvement, intraoperative perforations, and local recurrences. Reconstruction of the pelvic floor with biological mesh might lower the rate of perineal wound complications (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A161).
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Affiliation(s)
- Jia Gang Han
- 1Department of General Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People's Republic of China 2Department of General Surgery, Zhongnan Hospital of Wuhan University, Wuhan, People's Republic of China 3Department of General Surgery, Qilu Hospital of Shandong University, Shandong, People's Republic of China 4Department of General Surgery, the First Hospital of Huairou District, Beijing, People's Republic of China 5Department of General Surgery, the People's Hospital of Daxing District, Beijing, People's Republic of China 6Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, People's Republic of China 7Department of General Surgery, Luhe Teaching Hospital, Capital Medical University, Beijing, People's Republic of China
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Jensen KK, Rashid L, Pilsgaard B, Møller P, Wille-Jørgensen P. Pelvic floor reconstruction with a biological mesh after extralevator abdominoperineal excision leads to few perineal hernias and acceptable wound complication rates with minor movement limitations: single-centre experience including clinical examination and interview. Colorectal Dis 2014; 16:192-7. [PMID: 24251666 DOI: 10.1111/codi.12492] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Accepted: 10/18/2013] [Indexed: 12/14/2022]
Abstract
AIM The aim of the study was to describe long-term subjective and objective results of pelvic floor reconstruction using an absorbable biological mesh after extralevator abdominoperineal excision (ELAPE) for low rectal cancer. METHOD Records of 53 patients who had an ELAPE with reconstruction of the pelvic floor with a Permacol® mesh between August 2007 and August 2011 were reviewed. Thirty-one of the patients were called for interview and clinical examination. RESULTS Three (6%) patients developed perineal hernia, 11 had fistulae (nine of which were treated successfully), four patients had a perineal abscess and four patients had superficial wound infections. Removal of the mesh was necessary in one case, while another patient needed implantation of a new mesh. In 13 of the 31 interviewed patients, long-term pain was present, but resolved after a median of 8 months (3-56). No major sitting or movement disabilities were encountered. Three-year survival was 82%, and no local recurrences were found. CONCLUSION Pelvic floor reconstruction with a biological mesh is a feasible solution when performing ELAPE for low rectal cancer, although long-term pain is a frequent complication.
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Affiliation(s)
- K K Jensen
- Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
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Oncological superiority of extralevator abdominoperineal resection over conventional abdominoperineal resection: a meta-analysis. Int J Colorectal Dis 2014; 29:321-7. [PMID: 24385025 DOI: 10.1007/s00384-013-1794-6] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/03/2013] [Indexed: 02/04/2023]
Abstract
PURPOSE The oncological superiority, i.e., lower circumferential resection margin (CRM) involvement, lower intraoperative perforation (IOP), and local recurrence (LR) rates, of extralevator abdominoperineal resection (EAPR) over conventional abdominoperineal resection (APR) for rectal cancer is inconclusive. This meta-analysis systematically compared the rates of CRM involvement, IOP, and LR of rectal cancer patients treated by EAPR and APR, respectively. METHODS An electronic literature search of MEDLINE, EMBASE, and Cochrane Library through May 2013 was performed by two investigators independently to identify studies evaluating the CRM involvement, IOP, and LR rates of EAPR and APR, and search results were cross-checked to reach a consensus. Data was extracted accordingly. A Mantel-Haenszel random effects model was used to calculate the odds ratio (OR) with 95 % confidence intervals (95 % CI). RESULTS Six studies with a total of 881 patients were included. Meta-analysis of CRM involvement and IOP data from all six studies demonstrated significant lower CRM involvement (OR, 0.36; 95%CI, 0.23-0.58; P < 0.0001) and IOP (OR, 0.31; 95%CI, 0.12-0.80; P = 0.02) rates of EAPR. Data from four studies also showed that EAPR was associated with a lower LR rate than APR (OR, 0.27; 95%CI, 0.08-0.95; P = 0.04). No differences of between-study heterogeneity or publication bias were seen in any of the meta-analyses. CONCLUSIONS Extralevator abdominoperineal resection could achieve better CRM involvement outcome and lower IOP and LR rates, demonstrating an oncological superiority over conventional abdominoperineal resection.
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Extralevator abdominoperineal excision (ELAPE) for rectal cancer--short-term results from the Swedish Colorectal Cancer Registry. Selective use of ELAPE warranted. Int J Colorectal Dis 2014; 29:981-7. [PMID: 24950793 PMCID: PMC4101252 DOI: 10.1007/s00384-014-1932-9] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/12/2014] [Indexed: 02/04/2023]
Abstract
PURPOSE Local recurrences are more common after abdominoperineal excision (APE) than after anterior resection of rectal cancer. Extralevator APE was introduced to address this problem. This prospective registry-based population study aims to investigate the efficacy of extralevator APE (ELAPE) in improving short-term oncological outcome. METHODS All Swedish patients operated with any kind of abdominoperineal excision and registered in the Swedish Rectal Cancer Registry 2007-2009 were included (n = 1,397) and analyzed with emphasis on the perineal part of the operation. Short-term perioperative and oncological results were collected from the registry. RESULTS Extralevator APE did not result in fewer intraoperative perforations or involved circumferential resection margins as compared to standard APE for the entire group. Intraoperative perforations were significantly fewer for patients with low tumours (≤4 cm) (ELAPE: n = 28/386 versus APE: n = 9/58) (p = 0.043) and for early (T0-T2) T-stages (ELAPE: n = 3/172 versus APE: n = 6/75) (p = 0.025). There were significantly more post-operative wound infections for ELAPE than for APE (n = 106 (20.4 %) versus n = 25 (12.0 %), p = 0.011). CONCLUSIONS The short-term results indicate that selective use of extralevator APE can be warranted, for example, for subgroups with low tumours. In conclusion, selective use of the extralevator APE is advocated as not all patients seem to benefit from the technique, and there are significantly more short-term complications after extralevator APE.
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