Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Jun 14, 2020; 26(22): 3012-3023
Published online Jun 14, 2020. doi: 10.3748/wjg.v26.i22.3012
Extralevator abdominoperineal excision for advanced low rectal cancer: Where to go
Yu Tao, Jia-Gang Han, Zhen-Jun Wang
Yu Tao, Jia-Gang Han, Zhen-Jun Wang, Department of General Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
Author contributions: Tao Y, Han JG, and Wang ZJ conceived and designed the research; Tao Y, Han JG and Wang ZJ performed the research; Tao Y, Han JG and Wang ZJ wrote the paper.
Conflict-of-interest statement: There is no conflict of interest associated with any of the senior author or other coauthors contributed their efforts in this manuscript.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Jia-Gang Han, MD, Professor, Department of General Surgery, Beijing Chaoyang Hospital, Capital Medical University, No. 8 Gongtinan Road, Chaoyang District, Beijing 100020, China.
Received: December 31, 2019
Peer-review started: December 31, 2019
First decision: February 19, 2020
Revised: March 27, 2020
Accepted: May 26, 2020
Article in press: May 26, 2020
Published online: June 14, 2020

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.

Keywords: Extralevator abdominoperineal excision, Advanced rectal cancer, Advantages, Complications, Pelvic reconstruction, Intraoperative position, Trans-perineal approach, Laparoscopic/robotic-extralevator abdominoperineal excision, Individual-extralevator abdominoperineal excision

Core tips: Since extralevator abdominoperineal excision procedure (ELAPE) was proposed, the surgical approach and technique have been gradually developed, and recognized by an increasing number of colorectal surgeons. This is a first review to report in detail the research progress and controversies of ELAPE in the last decade including advantages of procedure, incidence of postoperative complications, controversies about operative position, development of laparoscopic/robotic technologies and proposal of individualized treatment /trans-perineal approach.