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Zwart WH, Dijkstra EA, Hospers GAP, Marijnen CAM, Putter H, Folkesson J, Van de Velde CJH, Roodvoets AGH, Meershoek-Klein Kranenbarg E, Glimelius B, Van Etten B, Nilsson PJ. Perineal wound complications after total neoadjuvant therapy or chemoradiotherapy followed by abdominoperineal excision in patients with high-risk locally advanced rectal cancer in the RAPIDO trial. BJS Open 2025; 9:zraf043. [PMID: 40276906 PMCID: PMC12022605 DOI: 10.1093/bjsopen/zraf043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2025] [Accepted: 02/22/2025] [Indexed: 04/26/2025] Open
Abstract
BACKGROUND Perineal wound complications (PWCs) occur in 15-30% of patients after abdominoperineal excision (APE) and are associated with adverse events, such as delayed wound healing, prolonged hospitalization, a delay in initiating postoperative chemotherapy, and decreased quality of life. Preoperative radiotherapy and chemotherapy are risk factors for wound complications. It is unknown whether total neoadjuvant treatment (TNT) affects the risk of PWCs compared with chemoradiotherapy (CRT). METHODS This study compared patients from the experimental (EXP; short-course radiotherapy, chemotherapy, and surgery as TNT) and standard-of-care (STD; CRT, surgery, and postoperative chemotherapy depending on hospital policy) treatment arms of the RAPIDO trial who underwent APE within 6 months after preoperative treatment. The primary outcome was the incidence of PWCs (infection, abscess, dehiscence, wound discharge, presacral abscess affecting the perineum) of any grade ≤ 30 days after APE. Secondary outcomes were the incidence of PWCs >30 days after APE, length of hospital stay, characteristics associated with PWCs, and oncological outcomes in patients with versus without PWC. RESULTS Of the 901 patients who started treatment (460 in EXP arm, 441 in STD arm), 153 (33%) and 160 (36%) underwent APE after TNT and CRT, respectively. After TNT and CRT, the incidence of PWCs ≤30 days after APE, readmission, and reoperation was 54 of 153 (35%) versus 53 of 160 (33%) (P = 0.69), 9% versus 12% (P = 0.54), and 7% versus 8% (P = 0.75), respectively. The median length of hospital stay was 2-3 days longer for patients with PWC. Univariable analysis revealed that pretreatment albumin <35 g/l, hypertension, and haemoglobin ≤ 8.0 mmol/l were associated with PWC. Oncological outcomes were similar between patients with and without PWCs. CONCLUSION In the RAPIDO trial, TNT and CRT resulted in a similar incidence of PWCs among patients with high-risk locally advanced rectal cancer who underwent APE.
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Affiliation(s)
- Wouter H Zwart
- Department of Medical Oncology, University Medical Centre Groningen, Groningen, the Netherlands
| | - Esmée A Dijkstra
- Department of Medical Oncology, University Medical Centre Groningen, Groningen, the Netherlands
| | - Geke A P Hospers
- Department of Medical Oncology, University Medical Centre Groningen, Groningen, the Netherlands
| | - Corrie A M Marijnen
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands
- Department of Radiation Oncology Sciences, Leiden University Medical Centre, Leiden, the Netherlands
| | - Hein Putter
- Department of Biomedical Data Sciences, Leiden University Medical Centre, Leiden, the Netherlands
| | - Joakim Folkesson
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | | | - Annet G H Roodvoets
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | | | - Bengt Glimelius
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Boudewijn Van Etten
- Department of Surgery, University Medical Centre Groningen, Groningen, the Netherlands
| | - Per J Nilsson
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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Littlejohn JB, Brister KA. Management of Recurrent Anal Cancer. Surg Oncol Clin N Am 2025; 34:91-101. [PMID: 39547772 DOI: 10.1016/j.soc.2024.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2024]
Abstract
Locoregional failure or recurrence after completion of chemoradiation for anal squamous cell carcinoma occurs in up to 27% of patients. Complete restaging with multimodality imaging should be performed to evaluate the extent of local disease and distant metastases. Extensive discussion in multidisciplinary tumor board and with necessary specialties is vital to assess possibility of R0 resection. Salvage surgery with R0 resection through abdominoperineal resection and possible exenteration is recommended with pedicled flap for perineal reconstruction. Five year overall survival rates are ∼50%. Successful management of recurrent anal squamous cell carcinoma relies on careful patient selection, multidisciplinary collaboration, and R0 resection.
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Affiliation(s)
- James Blake Littlejohn
- Department of Surgery, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216, USA
| | - Kelly Ann Brister
- Department of Surgery, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216, USA.
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Gendia A, Rehman M, Lin CW, Malik K, Khalil K, Ihedioha U, Kang P, Evans J, Ahmed J. Short- and mid-term outcomes of abdominoperineal resection with perineal mesh insertion: a single-centre experience. Int J Colorectal Dis 2023; 38:220. [PMID: 37606697 DOI: 10.1007/s00384-023-04507-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/10/2023] [Indexed: 08/23/2023]
Abstract
PURPOSE Abdominoperineal resection (APR) remains a key procedure for the treatment of low rectal/anorectal cancers. However, perineal wound closure remains challenging, particularly in extralevator abdominoperineal resection (ELAPR) due to gapped tissue planes. Different approaches have been attempted to improve perineal wound repair. The aim of this study is to report our 6-year experience in perineal wound closure utilising biological mesh. METHODS We conducted a retrospective study using data from our prospectively maintained database, including patients who underwent APR with perineal mesh closure between 2016 and 2021. RESULTS 49 patients underwent APR with perineal mesh reconstruction for low rectal cancer during the 6-year period. Of these, 63% were males, with a mean age of 68 (± 11), and a mean BMI of 27.9 (± 13.7). 49% (24) of patients received neoadjuvant therapy. 88% (43) of patients underwent standard "S-APR" and only 12% (6) underwent ELAPR. Majority of procedures were laparoscopic (87.8%) with conversion rate of 6.9%. Mean length of stay was 11.7 (± 11.6). The perineal wound infection rate was 30% and only two patient required mesh removal due to entero-cutaneous perineal fistula and pelvic abscess. Perineal hernia was found in only two patients (4.1%). CRM was negative in 81.6% of the patients. Mean follow-up period was 29.2 (± 16.5) months, and disease recurrence occurred in 9 (18.3%) patients with average number of months for recurrence of 21 (± 7). Overall survival during the follow-up period was 91%. CONCLUSION Our series shows a favourable short- and medium-term outcome with routine insertion of mesh for perineal wound closure.
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Affiliation(s)
- Ahmed Gendia
- Colorectal Department, Northampton University Hospital, Northampton, NN1 5BD, UK.
| | - Masood Rehman
- Colorectal Department, Northampton University Hospital, Northampton, NN1 5BD, UK
| | - Cindy W Lin
- Colorectal Department, Northampton University Hospital, Northampton, NN1 5BD, UK
| | - Kamran Malik
- Colorectal Department, Northampton University Hospital, Northampton, NN1 5BD, UK
| | - Khalil Khalil
- Colorectal Department, Northampton University Hospital, Northampton, NN1 5BD, UK
| | - Ugo Ihedioha
- Colorectal Department, Northampton University Hospital, Northampton, NN1 5BD, UK
| | - Peter Kang
- Colorectal Department, Northampton University Hospital, Northampton, NN1 5BD, UK
| | - John Evans
- Colorectal Department, Northampton University Hospital, Northampton, NN1 5BD, UK
| | - Jamil Ahmed
- Colorectal Department, Northampton University Hospital, Northampton, NN1 5BD, UK
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Gielen AHC, Colier E, Qiu SS, Keymeulen KBMI, Stassen LPS, Melenhorst J. Research highlight: surgical outcomes of gluteal VY plasty after extensive abdominoperineal resection or total pelvic exenteration. Langenbecks Arch Surg 2023; 408:157. [PMID: 37088846 PMCID: PMC10123027 DOI: 10.1007/s00423-023-02896-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 04/13/2023] [Indexed: 04/25/2023]
Abstract
OBJECTIVE To describe a suitable alternative technique for reconstruction of the pelvic floor after extensive resection. To review our outcomes of gluteal VY plasty in the reconstruction of the pelvic floor after extensive abdominoperineal resection (conventional or extralevator abdominoperineal resection, total pelvic exenteration, or salvage surgery). DESIGN Retrospective cohort study. SETTING An academic hospital and tertiary referral centre for the treatment of locally advanced or locally recurrent rectal cancer, and salvage surgery in The Netherlands. PATIENTS Forty-one consecutive patients who underwent a pelvic floor reconstruction with gluteal VY plasty at Maastricht University Medical Centre between January 2017 and February 2021 were included. The minimum duration of follow-up was 2 years. MAIN OUTCOME MEASURES Perineal herniation is the primary outcome measure. Furthermore, the occurrence of minor and major postoperative complications and long-term outcomes were retrospectively assessed. RESULTS Thirty-five patients (85.4%) developed one or more complications of whom twenty-one patients experienced minor complications and fourteen patients developed major complications. Fifty-seven percent of complications was not related to the VY reconstruction. Six patients (14.6%) recovered without any postoperative complications during follow-up. Three patients developed a perineal hernia. CONCLUSIONS A gluteal VY plasty is a suitable technique for reconstruction of the pelvic floor after extensive perineal resections resulting in a low perineal hernia rate, albeit the complication rate remains high in this challenging group of patients.
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Affiliation(s)
- Anke H C Gielen
- Department of Surgery, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ, Maastricht, the Netherlands
| | - Evie Colier
- Department of Surgery, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ, Maastricht, the Netherlands
- GROW School for Oncology and Reproduction, Maastricht, The Netherlands
| | - Shan S Qiu
- Department of Plastic Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Kristien B M I Keymeulen
- Department of Surgery, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ, Maastricht, the Netherlands
- GROW School for Oncology and Reproduction, Maastricht, The Netherlands
| | - Laurents P S Stassen
- Department of Surgery, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ, Maastricht, the Netherlands
- GROW School for Oncology and Reproduction, Maastricht, The Netherlands
| | - Jarno Melenhorst
- Department of Surgery, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ, Maastricht, the Netherlands.
- GROW School for Oncology and Reproduction, Maastricht, The Netherlands.
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Sun S, Sun S, Zheng X, Yu J, Wang W, Gong Q, Zhao G, Li J, Zhang H. Long-term outcomes of laparoscopic Extralevator Abdominoperineal excision with modified position change for low rectal Cancer treatment. BMC Cancer 2022; 22:916. [PMID: 36002810 PMCID: PMC9404665 DOI: 10.1186/s12885-022-10019-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 08/16/2022] [Indexed: 11/10/2022] Open
Abstract
Background Extralevator abdominoperineal excision (ELAPE) has been recommended for treating low rectal cancer due to its potential advantages in improving surgical safety and oncologic outcomes as compared to conventional abdominoperineal excision (APE). In ELAPE, however, whether the benefits of intraoperative position change to a prone jackknife position outweighs the associated risks remains controversial. This study is to introduce a modified position change in laparoscopic ELAPE and evaluate its feasibility, safety and the long-term therapeutic outcomes. Methods Medical records of 56 consecutive patients with low rectal cancer underwent laparoscopic ELAPE from November 2013 to September 2016 were retrospectively studied. In the operation, a perineal dissection in prone jackknife position was firstly performed and the laparoscopic procedure was then conducted in supine position. Patient characteristics, intraoperative and postoperative outcomes, pathologic and 5-year oncologic outcomes were analyzed. Results The mean operation time was 213.5 ± 29.4 min and the mean intraoperative blood loss was 152.7 ± 125.2 ml. All the tumors were totally resected, without intraoperative perforation, conversion to open surgery, postoperative 30-day death, and perioperative complications. All the patients achieved pelvic peritoneum reconstruction without the usage of biological mesh. During the follow-up period, perineal hernia was observed in 1 patient, impaired sexual function in 1 patient, and parastomal hernias in 3 patients. The local recurrence rate was 1.9% and distant metastasis was noted in 12 patients. The 5-year overall survival rate was 76.4% and the 5-year disease-free survival rate was 70.9%. Conclusions Laparoscopic ELAPE with modified position change is a simplified, safe and feasible procedure with favorable outcomes. The pelvic peritoneum can be directly closed by the laparoscopic approach without the application of biological mesh. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-022-10019-2.
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Affiliation(s)
- Shaowei Sun
- Department of Gastrointestinal Surgery, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, Weihai, 264200, Shandong Province, China
| | - Shengbo Sun
- Department of Gastrointestinal Surgery, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, Weihai, 264200, Shandong Province, China
| | - Xiangyun Zheng
- Department of Gastrointestinal Surgery, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, Weihai, 264200, Shandong Province, China
| | - Jiangtao Yu
- Department of Gastrointestinal Surgery, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, Weihai, 264200, Shandong Province, China
| | - Wenchang Wang
- Department of Gastrointestinal Surgery, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, Weihai, 264200, Shandong Province, China
| | - Qing Gong
- Department of Gastrointestinal Surgery, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, Weihai, 264200, Shandong Province, China
| | - Guowei Zhao
- Department of Gastrointestinal Surgery, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, Weihai, 264200, Shandong Province, China
| | - Jing Li
- Department of Gastrointestinal Surgery, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, Weihai, 264200, Shandong Province, China
| | - Huanhu Zhang
- Department of Gastrointestinal Surgery, Weihai Municipal Hospital, Cheeloo College of Medicine, Shandong University, Weihai, 264200, Shandong Province, China.
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6
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Zhang H, Li G, Cao K, Zhai Z, Wei G, Ye C, Zhao B, Wang Z, Han J. Long-term outcomes after extra-levator versus conventional abdominoperineal excision for low rectal cancer. BMC Surg 2022; 22:242. [PMID: 35733206 PMCID: PMC9219120 DOI: 10.1186/s12893-022-01692-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 06/13/2022] [Indexed: 11/10/2022] Open
Abstract
PURPOSE Extralevator (ELAPE) and abdominoperineal excision (APE) are two major surgical approaches for low rectal cancer patients. Although excellent short-term efficacy is achieved in patients undergoing ELAPE, the long-term benefits have not been established. In this study we evaluated the safety, pathological and survival outcomes in rectal cancer patients who underwent ELAPE and APE. METHODS One hundred fourteen patients were enrolled, including 68 in the ELAPE group and 46 in the APE group at the Beijing Chaoyang Hospital, Capital Medical University from January 2011 to November 2020. The baseline characteristics, overall survival (OS), progression-free survival (PFS), and local recurrence-free survival (LRFS) were calculated and compared between the two groups. RESULTS Demographics and tumor stage were comparable between the two groups. The 5-year PFS (67.2% versus 38.6%, log-rank P = 0.008) were significantly improved in the ELAPE group compared to the APE group, and the survival advantage was especially reflected in patients with pT3 tumors, positive lymph nodes or even those who have not received neoadjuvant chemoradiotherapy. Multivariate analysis showed that APE was an independent risk factor for OS (hazard ratio 3.000, 95% confidence interval 1.171 to 4.970, P = 0.004) and PFS (hazard ratio 2.730, 95% confidence interval 1.506 to 4.984, P = 0.001). CONCLUSION Compared with APE, ELAPE improved long-term outcomes for low rectal cancer patients, especially among patients with pT3 tumors, positive lymph nodes or those without neoadjuvant chemoradiotherapy.
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Affiliation(s)
- Haoyu Zhang
- Department of General Surgery, Beijing Chaoyang Hosptial, Capital Medical University, No. 8 Gongtinan Lu, Chaoyang District, Beijing, People's Republic of China
| | - Ganbin Li
- Department of General Surgery, Beijing Chaoyang Hosptial, Capital Medical University, No. 8 Gongtinan Lu, Chaoyang District, Beijing, People's Republic of China
| | - Ke Cao
- Department of General Surgery, Beijing Chaoyang Hosptial, Capital Medical University, No. 8 Gongtinan Lu, Chaoyang District, Beijing, People's Republic of China
| | - Zhiwei Zhai
- Department of General Surgery, Beijing Chaoyang Hosptial, Capital Medical University, No. 8 Gongtinan Lu, Chaoyang District, Beijing, People's Republic of China
| | - Guanghui Wei
- Department of General Surgery, Beijing Chaoyang Hosptial, Capital Medical University, No. 8 Gongtinan Lu, Chaoyang District, Beijing, People's Republic of China
| | - Chunxiang Ye
- Department of General Surgery, Beijing Chaoyang Hosptial, Capital Medical University, No. 8 Gongtinan Lu, Chaoyang District, Beijing, People's Republic of China
| | - Baocheng Zhao
- Department of General Surgery, Beijing Chaoyang Hosptial, Capital Medical University, No. 8 Gongtinan Lu, Chaoyang District, Beijing, People's Republic of China
| | - Zhenjun Wang
- Department of General Surgery, Beijing Chaoyang Hosptial, Capital Medical University, No. 8 Gongtinan Lu, Chaoyang District, Beijing, People's Republic of China.
| | - Jiagang Han
- Department of General Surgery, Beijing Chaoyang Hosptial, Capital Medical University, No. 8 Gongtinan Lu, Chaoyang District, Beijing, People's Republic of China.
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Blok RD, Sharabiany S, Stoker J, Laan ETM, Bosker RJI, Burger JWA, Chaudhri S, van Duijvendijk P, van Etten B, van Geloven AAW, de Graaf EJR, Hoff C, Hompes R, Leijtens JWA, Rothbarth J, Rutten HJT, Singh B, Vuylsteke RJCLM, de Wilt JHW, Dijkgraaf MGW, Bemelman WA, Musters GD, Tanis PJ. Cumulative 5-year Results of a Randomized Controlled Trial Comparing Biological Mesh With Primary Perineal Wound Closure After Extralevator Abdominoperineal Resection (BIOPEX-study). Ann Surg 2022; 275:e37-e44. [PMID: 33534231 DOI: 10.1097/sla.0000000000004763] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine long-term outcomes of a randomized trial (BIOPEX) comparing biological mesh and primary perineal closure in rectal cancer patients after extralevator abdominoperineal resection and preoperative radiotherapy, with a primary focus on symptomatic perineal hernia. SUMMARY BACKGROUND DATA BIOPEX is the only randomized trial in this field, which was negative on its primary endpoint (30-day wound healing). METHODS This was a posthoc secondary analysis of patients randomized in the BIOPEX trial to either biological mesh closure (n = 50; 2 dropouts) or primary perineal closure (n = 54; 1 dropout). Patients were followed for 5 years. Actuarial 5-year probabilities were determined by the Kaplan-Meier statistic. RESULTS Actuarial 5-year symptomatic perineal hernia rates were 7% (95% CI, 0-30) after biological mesh closure versus 30% (95% CI, 10-49) after primary closure (P = 0.006). One patient (2%) in the biomesh group underwent elective perineal hernia repair, compared to 7 patients (13%) in the primary closure group (P = 0.062). Reoperations for small bowel obstruction were necessary in 1/48 patients (2%) and 5/53 patients (9%), respectively (P = 0.208). No significant differences were found for chronic perineal wound problems, locoregional recurrence, overall survival, and main domains of quality of life and functional outcome. CONCLUSIONS Symptomatic perineal hernia rate at 5-year follow-up after abdominoperineal resection for rectal cancer was significantly lower after biological mesh closure. Biological mesh closure did not improve quality of life or functional outcomes.
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Affiliation(s)
- Robin D Blok
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
- LEXOR, Center for Experimental and Molecular Medicine, Oncode Institute, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Sarah Sharabiany
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Jaap Stoker
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, the Netherlands
| | - Ellen T M Laan
- Department of Sexology and Psychosomatic Gynecology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | | | | | - Sanjay Chaudhri
- Department of Surgery, University Hospitals Leicester, Leicester, United Kingdom
| | | | - Boudewijn van Etten
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | | | - Eelco J R de Graaf
- Department of Surgery, IJsselland Hospital, Capelle aan de IJssel, the Netherlands
| | - Christiaan Hoff
- Department of Surgery, Medical Center Leeuwarden, Leeuwarden, the Netherlands
| | - Roel Hompes
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | | | - Joost Rothbarth
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Harm J T Rutten
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - Baljit Singh
- Department of Surgery, University Hospitals Leicester, Leicester, United Kingdom
| | | | - Johannes H W de Wilt
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Marcel G W Dijkgraaf
- Department of Epidemiology and Data Science, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Willem A Bemelman
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Gijsbert D Musters
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Pieter J Tanis
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
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Abstract
INTRODUCTION Conventional abdominoperineal resection (APR) has a high rate of local recurrence. Extralevator abdominoperineal excision (ELAPE) can potentially diminish the rate of intraoperative tumour perforation (IOTP) and can provide wider circumferential resection margins (CRM) but at the price of higher perineal complication rate. The aim of our study was to compare the short term results of conventional APR to ELAPE. MATERIALS AND METHODS Thirty-five consecutively operated APRs compared to 38 also consecutively operated ELAPEs. Prospectively collected short-term outcome data were analysed retrospectively. RESULTS There was no difference in demographics, disease stage or tumour location between groups. IOTP rate and CRM positivity rates were similar between the two groups (p = .608). No difference was found in major (Clavien-Dindo III-V) complications, but we found statistically significant difference in minor (Clavien-Dindo I-II) complications (p = .01) in favour of the ELAPE group. Frequency of perineal SSI was lower in ELAPE group, but the difference was not significant (p = .320). Intraoperative iatrogenic complications occurred at significantly lower rate in ELAPE group (p = .035). Also, postoperative morbidity connected with the dissection in the perineal phase (e.g. urine incontinence, urinary retention) was significantly lower (p = .018) after ELAPE. DISCUSSION AND CONCLUSIONS In our experience ELAPE operations may diminish the rate of Clavien-Dindo I-II complications compared to conventional APR. This effect is ensuing from the decrease of intraoperative iatrogenic complications and from the decrease of minor postoperative complications.
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Affiliation(s)
- Géza Papp
- Surgical-Oncosurgical Department, Uzsoki Teaching Hospital, Budapest, Hungary
| | - Kristóf Dede
- Surgical-Oncosurgical Department, Uzsoki Teaching Hospital, Budapest, Hungary
| | - Attila Bursics
- Surgical-Oncosurgical Department, Uzsoki Teaching Hospital, Budapest, Hungary
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Yang SY, Cho MS, Kim NK. Outcomes of robotic partial excision of the levator ani muscle for locally advanced low rectal cancer invading the ipsilateral pelvic floor at the anorectal ring level. Int J Med Robot 2021; 17:e2310. [PMID: 34255412 DOI: 10.1002/rcs.2310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Revised: 06/24/2021] [Accepted: 07/09/2021] [Indexed: 02/01/2023]
Abstract
PURPOSE The purpose of this study is to evaluate partial excision of the levator ani muscle (PELM) enables preservation of anal sphincter function although levator ani muscle (LAM) was invaded. METHODS Functional outcomes and oncologic outcomes of 23 consecutive patients who underwent robotic PELM for low rectal cancer at the anorectal ring level invading or abutting the ipsilateral LAM are analysed. RESULTS Secured resection margins were achieved, especially for the circumferential resection margin. During a median follow-up of 44 months, the 3-year local recurrence rate was 14.4%. Among patients who underwent diverting ileostomy closure, mean Memorial Sloan Kettering Cancer Center Bowel Function Instrument and Wexner scores were 68.3 ± 11.9 and 10.7 ± 5.3, respectively, at 1 year after closure. CONCLUSION PELM is a sphincter-preserving alternative to abdominoperineal resection (APR) or extralevator APR for low rectal cancer invading the ipsilateral LAM at the level of the anorectal ring.
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Affiliation(s)
- Seung Yoon Yang
- Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Min Soo Cho
- Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Nam Kyu Kim
- Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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10
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Wang C, You J, Shen Z, Jiang K, Gao Z, Ye Y. Perineal wound complication risk factors and effects on survival after abdominoperineal resection of rectal cancer: a single-centre retrospective study. Int J Colorectal Dis 2021; 36:821-830. [PMID: 33528748 DOI: 10.1007/s00384-021-03840-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/08/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE This study determined the risk factors associated with perineal wound complications (PWCs) and investigated their effect on overall survival in patients with rectal cancer who underwent abdominoperineal resection (APR). METHODS The clinicopathologic and follow-up data of patients who underwent APR for primary rectal cancer between 1998 and 2018 were reviewed. PWCs were defined as any perineal wound that required surgical intervention, antibiotics, or delayed healing for more than 2 weeks. The primary objective was identifying the risk factors of PWC after APR. The effect of PWC on survival was also investigated as a secondary objective. RESULTS Two hundred and twenty patients were included in the final analyses and 49 had PWCs. An operative time of > 285 min (odds ratio: 2.440, 95% confidence interval (CI): 1.257-4.889) was found to be independently associated with PWCs. When the follow-up time was > 60 months, patients with PWCs had a significantly lower overall survival rate than patients without PWC (n = 156; mean over survival: 187 and 164 months in patients without and with PWCs, respectively; P = 0.045). Poor differentiation (hazard ratio (HR): 1.893, 95% CI: 1.127-3.179), lymph node metastasis (HR: 2.063, 95% CI: 1.228-3.467), and distant metastasis (HR: 3.046, 95% CI: 1.551-5.983) were associated with poor prognosis. CONCLUSION Prolonged operative time increases the risk of PWCs, and patients with PWCs have a lower long-term survival rate than patients without PWCs. Therefore, surgeons should aim to reduce the operative time to minimise the risk of PWC in patients undergoing APR for rectal cancer.
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Affiliation(s)
- Chao Wang
- Department of Gastrointestinal Surgery, Peking University People's Hospital, Beijing, 100044, People's Republic of China.,Laboratory of Surgical Oncology, Peking University People's Hospital, Beijing, 100044, People's Republic of China.,Beijing Key Laboratory of Colorectal Cancer Diagnosis and Treatment Research, Peking University People's Hospital, Beijing, 100044, People's Republic of China
| | - Junyu You
- Gastrointestinal Cancer Centre, Peking University Cancer Hospital, Beijing, 100142, People's Republic of China
| | - Zhanlong Shen
- Department of Gastrointestinal Surgery, Peking University People's Hospital, Beijing, 100044, People's Republic of China.,Laboratory of Surgical Oncology, Peking University People's Hospital, Beijing, 100044, People's Republic of China
| | - Kewei Jiang
- Department of Gastrointestinal Surgery, Peking University People's Hospital, Beijing, 100044, People's Republic of China.,Beijing Key Laboratory of Colorectal Cancer Diagnosis and Treatment Research, Peking University People's Hospital, Beijing, 100044, People's Republic of China
| | - Zhidong Gao
- Department of Gastrointestinal Surgery, Peking University People's Hospital, Beijing, 100044, People's Republic of China. .,Laboratory of Surgical Oncology, Peking University People's Hospital, Beijing, 100044, People's Republic of China.
| | - Yingjiang Ye
- Department of Gastrointestinal Surgery, Peking University People's Hospital, Beijing, 100044, People's Republic of China. .,Laboratory of Surgical Oncology, Peking University People's Hospital, Beijing, 100044, People's Republic of China. .,Beijing Key Laboratory of Colorectal Cancer Diagnosis and Treatment Research, Peking University People's Hospital, Beijing, 100044, People's Republic of China.
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A tailored approach to abdominoperineal resection for rectal cancer: multicentre analysis of short-term outcomes and impact on oncological survival. Langenbecks Arch Surg 2021; 406:813-819. [PMID: 33638682 DOI: 10.1007/s00423-021-02122-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 02/08/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE Abdominoperineal resection of the rectum has evolved over the last century, with few modifications until 2007, when extralevator abdominoperineal resection was introduced, which improved local disease control but resulted in a significant rise in perineal complications. We adopted a modified approach in which dissection was tailored according to magnetic resonance-defined tumour involvement. The aim of this study was to assess short-term and long-term oncological outcomes following a tailored abdominoperineal resection (APR) approach. METHODS This study was a retrospective review of prospectively maintained databases at three centres: Portsmouth NHS Trust (UK), Poole General Hospital (UK) and Champalimaud's Cancer Foundation, Portugal. The study included consecutive patients who underwent abdominoperineal resection from October 2008 until April 2018 under the supervision of the senior author. Oncological outcomes, including overall survival and disease-free survival, were used as the main outcome measures. RESULTS A total of 584 patients underwent rectal cancer surgery during the study period. The APR ratio was 65/584 (11%). The median age was 66 years. Neoadjuvant treatment was administered to 74% of patients. Of the patients, 91% underwent surgery via a minimally invasive approach. The median hospital stay was 7 days. Patients were followed up for a median of 41 months. Only four patients had positive resection margins. The 5-year overall and disease-free survival rates were 64% and 62%, respectively. CONCLUSION Our data suggest that tailored APR has similar short-term and long-term oncological outcomes compared with extralevator abdominoperineal resection but reduced perineal wound complications. We believe this approach could be a safe alternative but recommend a larger sample size to accurately assess its effectiveness.
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Yang Y, Yu L, Wang M, Mu Y, Li J, Shang F, Wu X, Liu T, Shi J. A new surgical approach of direct perineal wound full-thick closure for perineal wound of abdominoperineal resection for rectal carcinoma: A prospective cohort trial. Int Wound J 2020; 17:1817-1828. [PMID: 32755065 PMCID: PMC7754419 DOI: 10.1111/iwj.13470] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 07/11/2020] [Accepted: 07/14/2020] [Indexed: 12/13/2022] Open
Abstract
Perineal wound complications after APR have high morbidity in the colorectal surgical department. Although some approaches have been figured out to solve this clinical focus, the outcomes are still not satisfied. Herein, this prospective comparative clinical trial has been designed to evaluate a new surgical procedure of direct perineal wound full-thick closure (DPWC), compared with conventional perineal wound closure (CPWC), with hopes of making wound healing with less complications. In addition, an evaluation of an incision negative wound pressure therapy, as another focus in this field, was also analysed in the DPWC group. A total of 44 participants in our department were recruited from March 2018 to March 2020, divided into two groups randomly, CPWC group and DPWC group. The patients' characteristics, such as age, gender, BMI, smoking, alcohol consumption, comorbidities, CEA level, and high-risk of invasion, were recorded without statistical significance between the CPWC group and DPWC group. After the same standard abdominal phase, these two groups were performed in different perineal phases. And then, operative and postoperative outcomes were analysed with different statistical methods. Data on wound healing time and length of stay in the DPWC group were shorter than those in the CPWC group (P < .05). Furthermore, cases of wound infection within 30 days in the DPWC group were also less than that in the CPWC group (P < .05). However, no difference was found between the incisional negative pressure wound therapy assisted group (NPA group) and non- incisional negative pressure wound therapy assisted group (non-NPA group). During this study, hypoalbuminemia, as an independent high-risk factor, impacted perineal wound healing. (P = .0271) In conclusion, DPWC is a new surgical approach, which can lead to a better outcome than DPWC, and it can be another surgical procedure for clinicians. In addition, hypoalbuminemia should be interfered for avoiding perineal wound complications.
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Affiliation(s)
- Yong‐Ping Yang
- The Department of General Surgerythe Second Hospital of Jilin UniversityChangchunChina
| | - Ling‐Yun Yu
- The Department of Ear Nose and Throat Surgerythe First Hospital of Jilin UniversityChangchunChina
| | - Min Wang
- The Department of General Surgerythe Second Hospital of Jilin UniversityChangchunChina
| | - Yu Mu
- The Department of General Surgerythe Second Hospital of Jilin UniversityChangchunChina
| | - Jian‐Nan Li
- The Department of General Surgerythe Second Hospital of Jilin UniversityChangchunChina
| | - Feng‐Jia Shang
- The Department of General Surgerythe Second Hospital of Jilin UniversityChangchunChina
| | - Xian‐Feng Wu
- The Department of General Surgerythe Second Hospital of Jilin UniversityChangchunChina
| | - Tong‐Jun Liu
- The Department of General Surgerythe Second Hospital of Jilin UniversityChangchunChina
| | - Jian Shi
- The Department of General Surgerythe Second Hospital of Jilin UniversityChangchunChina
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Sancho-Muriel J, Ocaña J, Cholewa H, Nuñez J, Muñoz P, Flor B, García JC, García-Granero E, Die J, Frasson M. Biological mesh reconstruction versus primary closure for preventing perineal morbidity after extralevator abdominoperineal excision: a multicentre retrospective study. Colorectal Dis 2020; 22:1714-1723. [PMID: 32619064 DOI: 10.1111/codi.15225] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 06/10/2020] [Indexed: 02/08/2023]
Abstract
AIM The aim of the study was to compare the incidence of perineal hernia and the perineal wound morbidity following extralevator abdominoperineal excision (ELAPE) between two groups - primary perineal closure and reconstruction with a biological mesh. METHOD One hundred and forty-seven consecutive patients who underwent ELAPE for primary rectal cancer between January 2007 and December 2018 in two tertiary referral centres were retrospectively identified from prospective databases. Perineal closure was carried out via primary closure or with a biological mesh (porcine dermal collagen mesh). Outcome measures were perineal hernia and perineal wound morbidity (infection, dehiscence, persistent sinus and chronic pain). RESULTS A total of 139 patients were included in the study. A prophylactic mesh was used in 80 (57.5%) and primary closure was practised in 59 (42.4%) patients. The median follow-up was 30 (interquartile range 46.88) months. Thirty patients (21.6%) developed perineal hernia. No significant differences were found between prophylactic mesh and primary closure (16.3% vs 23.3%, P = 0.07). The median period between surgery and hernia diagnosis was 8 months in the primary closure group and 24 months in the mesh group (P < 0.01). Perineal wound morbidity was significantly higher in the prophylactic mesh group (55% vs 33.9%, P < 0.01). CONCLUSION In our study, the use of a biological mesh did not reduce the rate of perineal hernia, although it did delay its appearance. Perineal closure using a biological mesh may increase perineal morbidity, both acute and chronic.
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Affiliation(s)
- J Sancho-Muriel
- Division of Coloproctology, Department of General and Digestive Surgery, La Fe University Hospital, Valencia, Spain
| | - J Ocaña
- Division of Coloproctology, Department of General and Digestive Surgery, Ramón y Cajal University Hospital, Madrid, Spain
| | - H Cholewa
- Division of Coloproctology, Department of General and Digestive Surgery, La Fe University Hospital, Valencia, Spain
| | - J Nuñez
- Division of Coloproctology, Department of General and Digestive Surgery, Ramón y Cajal University Hospital, Madrid, Spain
| | - P Muñoz
- Division of Coloproctology, Department of General and Digestive Surgery, Ramón y Cajal University Hospital, Madrid, Spain
| | - B Flor
- Division of Coloproctology, Department of General and Digestive Surgery, La Fe University Hospital, Valencia, Spain
| | - J C García
- Division of Coloproctology, Department of General and Digestive Surgery, Ramón y Cajal University Hospital, Madrid, Spain
| | - E García-Granero
- Division of Coloproctology, Department of General and Digestive Surgery, La Fe University Hospital, Valencia, Spain
| | - J Die
- Division of Coloproctology, Department of General and Digestive Surgery, Ramón y Cajal University Hospital, Madrid, Spain
| | - M Frasson
- Division of Coloproctology, Department of General and Digestive Surgery, La Fe University Hospital, Valencia, Spain
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Liu B, Farquharson J. The quality of lymph node harvests in extralevator abdominoperineal excisions. BMC Surg 2020; 20:241. [PMID: 33066759 PMCID: PMC7565360 DOI: 10.1186/s12893-020-00898-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 10/07/2020] [Indexed: 01/07/2023] Open
Abstract
Background Lymph node (LN) harvest in colorectal cancer resections is a well-recognised prognostic factor for disease staging and determining survival, particularly for node-negative (N0) diseases. Extralevator abdominoperineal excisions (ELAPE) aim to prevent “waisting” that occurs during conventional abdominoperineal resections (APR) for low rectal cancers, and reducing circumferential resection margin (CRM) infiltration rate. Our study investigates whether ELAPE may also improve the quality of LN harvests, addressing gaps in the literature. Methods This retrospective observational study reviewed 2 sets of 30 consecutive APRs before and after the adoption of ELAPE in our unit. The primary outcomes are the total LN counts and rates of meeting the standard of 12-minimum, particularly for those with node-negative disease. The secondary outcomes are the CRM involvement rates. Baseline characteristics including age, sex, laparoscopic or open surgery and the use of neoadjuvant chemoradiotherapy were accounted for in our analyses. Results Median LN counts were slightly higher in the ELAPE group (16.5 vs. 15). Specimens failing the minimum 12-LN requirements were almost significantly fewer in the ELAPE group (OR 0.456, P = 0.085). Among node-negative rectal cancers, significantly fewer resections failed the 12-LN standard in the ELAPE group than APR group (OR 0.211, P = 0.044). ELAPE led to a near-significant decrease in CRM involvement (OR 0.365, P = 0.088). These improvements were persistently observed after taking into account baselines and potential confounders in regression analyses. Conclusion ELAPE provides higher quality of LN harvests that meet the 12-minimal requirements than conventional APR, particularly in node-negative rectal cancers. The superiority is independent of potential confounding factors, and may implicate better clinical outcomes.
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Affiliation(s)
- Ben Liu
- Department of General Surgery, New Cross Hospital, The Royal Wolverhampton NHS Trust, Wolverhampton Road, Wolverhampton, WV10 0QP, West Midlands, UK.
| | - Ja'Quay Farquharson
- Department of General Surgery, New Cross Hospital, The Royal Wolverhampton NHS Trust, Wolverhampton Road, Wolverhampton, WV10 0QP, West Midlands, UK
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15
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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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Garcia-Henriquez N, Galante DJ, Monson JRT. Selection and Outcomes in Abdominoperineal Resection. Front Oncol 2020; 10:1339. [PMID: 33014775 PMCID: PMC7461900 DOI: 10.3389/fonc.2020.01339] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 06/26/2020] [Indexed: 01/14/2023] Open
Abstract
Since the initial descriptions of the abdominoperineal resection by Sir William Ernest Miles which was then followed by the perfection of the total mesorectal excision by Professor Bill Heald, the surgical management of rectal cancer has made tremendous strides. However, even with the advent and sophistication of neoadjuvant therapy, there remains a formidable amount of patients requiring an abdominoperineal resection. The purpose of this review is to delineate the indication and selection process by which patients are determined to require an abdominoperineal resection, as well as the oncologic and overall outcomes associated with the operation.
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Affiliation(s)
| | | | - John R. T. Monson
- Advent Health Medical Group, Center for Colon and Rectal Surgery, Orlando, FL, United States
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Xiao H, Huang R, Li X, Wang Z. Laparoscopic Versus Open Extralevaor Abdominoperineal Excision for Lower Rectal Cancer: A Retrospective Cohort Study in Single Institute. J Laparoendosc Adv Surg Tech A 2020; 31:71-76. [PMID: 32706627 DOI: 10.1089/lap.2020.0352] [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: 12/18/2022] Open
Abstract
Background: To explore the safety and efficacy of laparoscopic extralevator abdominoperineal excision (La-ELAPE) and open extralevator abdominoperineal excision (Op-ELAPE) for patients with lower rectal cancer. Materials and Methods: Consecutive 101 patients with lower rectal cancer who underwent La-ELAPE or Op-ELAPE in our institution from January 2014 and May 2018 were analyzed retrospectively. The patients' clinicopathological data and postoperative outcomes were compared between the two groups. Results: A total of 101 patients were enrolled in the study, 43 (42.6%) patients successfully underwent La-ELAPE and 58 (57.4%) Op-ELAPE. The Op-ELAPE group had more intraoperative blood loss (P = .03), and longer postoperative hospital stay (P = .01) compared with the La-ELAPE group. There were no significant differences between the two group in terms of the operation time (P = .08), circumferential resection margin positivity (P = 1.00), intraoperative perforation (P = .73), and number of positive lymph nodes (P = .91). There were no significant differences in postoperative complications such as colostomy-associated issues (P = .79), intestinal obstruction (P = 1.00), urinary retention (P = 1.00), perineal wound complications (P = .64), and chronic perineal pain (P = .70) between the two groups. According to the Kaplan-Meier survival analysis and log rank test, the overall survival rate and progression-free survival rate between the two groups also showed no significant difference. Conclusion: This study showed that La-ELAPE significantly reduced the intraoperative blood loss and the postoperative hospital stay without increasing postoperative morbidity for patients with lower rectal cancer when compared with Op-ELAPE. It suggests that La-ELAPE is safe and effective for patients with lower rectal cancer. For the experienced endoscopic surgeons, the La-ELAPE might be an alternative surgical treatment.
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Affiliation(s)
- Hui Xiao
- Department of General Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Rui Huang
- Department of Key Laboratory, Capital Institute of Pediatrics, Beijing, People's Republic of China
| | - Xiangnan Li
- Department of General Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Zhenjun Wang
- Department of General Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People's Republic of China
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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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Extralevator abdominoperineal excision versus abdominoperineal excision for low rectal cancer: a meta-analysis. Chin Med J (Engl) 2020; 132:2446-2456. [PMID: 31651517 PMCID: PMC6831059 DOI: 10.1097/cm9.0000000000000485] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Extralevator abdominoperineal excision (ELAPE) has become a popular procedure for low rectal cancer as compared with abdominoperineal excision (APE). No definitive answer has been achieved whether one is superior to the other. This study aimed to evaluate the safety and efficacy of ELAPE for low rectal cancer with meta-analysis. METHODS The Web of Science, Cochrane Library, Embase, and PubMed databases before September 2019 were comprehensively searched to retrieve comparative trials of ELAPE and APE for low rectal cancer. Pooled analyses of the perioperative variables, surgical complications, and oncological variables were performed. Odds ratio (OR) and mean differences (MD) from each trial were pooled using random or fixed effects model depending on the heterogeneity of the included studies. A subgroup analysis or a sensitivity analysis was conducted to explore the potential source of heterogeneity when necessary. RESULTS This meta-analysis included 17 studies with 4049 patients, of whom 2248 (55.5%) underwent ELAPE and 1801 (44.5%) underwent APE. There were no statistical differences regarding the circumferential resection margin positivity (13.0% vs. 16.2%, OR = 0.69, 95% CI = 0.42-1.14, P = 0.15) and post-operative perineal wound complication rate (28.9% vs. 24.1%, OR = 1.21, 95% CI = 0.75-1.94, P = 0.43). The ELAPE was associated with lower rate of intraoperative perforation (6.6% vs. 11.3%, OR = 0.50, 95% CI = 0.39-0.64, P < 0.001) and local recurrence (8.8% vs. 20.5%, OR = 0.29, 95% CI = 0.21-0.41, P < 0.001) when compared with APE. CONCLUSIONS The ELAPE was associated with a reduction in the rate of intra-operative perforation and local recurrence, without any increase in the circumferential resection margin positivity and post-operative perineal wound complication rate when compared with APE in the surgical treatment of low rectal cancer.
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Han JG, Wang ZJ, Gao ZG, Wei GH, Yang Y, Zhai ZW, Zhao BC, Yi BQ. Perineal Wound Complications After Extralevator Abdominoperineal Excision for Low Rectal Cancer. Dis Colon Rectum 2019; 62:1477-1484. [PMID: 31567926 DOI: 10.1097/dcr.0000000000001495] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Reconstruction of the pelvic floor defect caused by extralevator abdominoperineal excision poses a challenge for the surgeon. OBJECTIVE The aim of this study was to analyze the long-term perineal wound complications in patients undergoing conventional primary closure versus biological mesh-assisted repair after extralevator abdominoperineal excision. DESIGN This was a single-institution retrospective observational study. SETTINGS The study was conducted at a tertiary academic medical center. PATIENTS Patients with low advanced rectal cancer undergoing extralevator abdominoperineal excision from August 2008 to December 2016 (N = 228) were included. INTERVENTIONS All of the patients received extralevator abdominoperineal excision operation. MAIN OUTCOME MEASURES The primary outcome measure was perineal wound complications after the operation. RESULTS Of the 228 patients who underwent extralevator abdominoperineal excision, 174 received biological mesh repair and 54 received primary closure. Preoperative radiotherapy was administered to 89 patients (51.1%) in the biological mesh group and 20 patients (37.0%) in the primary closure group. The biological mesh group had significantly lower rates of perineal wound infection (11.5% vs 22.2%; p = 0.047), perineal hernia (3.4% vs 13.0%; p = 0.022), wound dehiscence (0.6% vs 5.6%; p = 0.042), and total perineal wound complications (14.9% vs 35.2%; p = 0.001) compared with the primary closure group. Multivariable logistic regression analysis showed preoperative radiotherapy (p < 0.001), conventional primary closure (p < 0.001), and intraoperative bowel perforation (p= 0.001) to be significantly associated with perineal procedure-related complications. LIMITATIONS This was a single-center retrospective study. CONCLUSIONS Although perineal wound repair with biological mesh prolongs the operative time of perineal portion, the perineal drainage retention time, and the length of hospital stay, it may reduce perineal procedure-related complications and improve wound healing. Preoperative radiotherapy and intraoperative bowel perforation appear to be independent predictors of perineal complications. See Video Abstract at http://links.lww.com/DCR/B42. COMPLICACIONES DE LA HERIDA PERINEAL DESPUÉS DE LA EXCISIÓN ABDOMINOPERINEAL EXTRA-ELEVADORA EN CASO DE CÁNCER DE RECTO BAJO: La reconstrucción del defecto en el suelo pélvico, resultado de una resección abdominoperineal extra-elevadora plantea un desafío para el cirujano.El analisis de las complicaciones de la herida perineal a largo plazo en pacientes sometidos a un cierre primario convencional versus una reparación asistida por malla biológica después de una resección abdominoperineal extra-elevadora.Estudio retrospectivo observacional en una sola institución.Investigación realizada en un centro médico académico terciario.Se incluyeron los pacientes con cáncer rectal bajo avanzado que se sometieron a una resección abdominoperineal extra-elevadora desde agosto de 2008 hasta diciembre de 2016 (n= 228).Todos aquellos pacientes que fueron sometidos a una resección abdominoperineal extra-elevadora.Todas las complicaciones de la herida perineal en el postoperatorio.De los 228 pacientes que se sometieron a una resección abdominoperineal extra-elevadora, 174 fueron reparados con una malla biológica y 54 se beneficiaron de un cierre primario. La radioterapia preoperatoria se administró a 89 (51,1%) pacientes en el grupo de malla biológica y 20 (37,0%) pacientes en el grupo de cierre primario. El grupo de malla biológica tuvo tasas significativamente más bajas de infección de la herida perineal (11.5% vs. 22.2%; p = 0.047), hernia perineal (3.4% vs. 13.0%; p = 0.022), dehiscencia de la herida (0.6% vs. 5.6%; p = 0,042) y complicaciones perineales de la herida (14,9% frente a 35,2%; p = 0,001) en comparación con el grupo de cierre primario. El análisis de regresión logística multivariable mostró que la radioterapia preoperatoria (p <0.001), el cierre primario convencional (p <0.001) y la perforación intestinal intra-operatoria (p = 0.001) se asociaron significativamente como complicaciones relacionadas con el procedimiento perineal.Estudio retrospectivo de centro único.Aunque la reparación de la herida perineal con malla biológica prolonga el tiempo perineal de la operación, la presencia y duración del drenaje perineal y la hospitalización pueden reducir las complicaciones relacionadas con el procedimiento perineal y mejorar la cicatrización de la herida. La radioterapia preoperatoria y la perforación intestinal intra-operatorias parecen ser predictores independientes de complicaciones perineales. Vea el Resumen del Video en http://links.lww.com/DCR/B42.
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Affiliation(s)
- Jia Gang Han
- Department of General Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
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Song M, Geng J, Wang L, Li Y, Zhu X, Li X, Mi L, Wu A, Peng Y, Yao Y, Zhang Y, Wang H, Shi C, Cai Y, Wang W. Excluding the ischiorectal fossa irradiation during neoadjuvant chemoradiotherapy with intensity-modulated radiotherapy followed by abdominoperineal resection decreases perineal complications in patients with lower rectal cancer. Radiat Oncol 2019; 14:138. [PMID: 31382984 PMCID: PMC6683419 DOI: 10.1186/s13014-019-1338-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 07/15/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND The aim of this study was to explore the impact of including or excluding the ischiorectal fossa (IRF) within the clinical target volume during neoadjuvant chemoradiotherapy (NCRT) using intensity modulated radiotherapy, in locally advanced lower rectal cancer (LALRC). METHODS We retrospectively analysed the data of 220 LALRC patients who received NCRT followed by abdominoperineal resection between January 2009 and January 2015. Six patients were excluded because of loss to follow-up, 90 patients received IRF irradiation (IRF group) while 124 patients did not (NIRF group). Survival, patterns of recurrence, and treatment toxicities were compared between the two groups. RESULTS Overall, patient/treatment variables were well balanced except for surgical technique. Perineal wound complications in the IRF and NIRF groups, were 40.0 and 24.2%, respectively (p = 0.010); corresponding 3-year perineal recurrence rates, local recurrence free survival, overall survival, and distant relapse free survival were 4.4% vs. 2.4% (p = 0.670), 88.1% vs. 95.0% (p = 0.079), 82.6% vs. 88.4% (p = 0.087), and 61.9% vs. 81.0% (p = 0.026), respectively. Multivariate analyses demonstrated the following factors to be significantly related to perineal wound complications: irradiation of the IRF (odds ratio [OR] 2.892, p = 0.002), anaemia (OR 3.776, p = 0.010), operation duration > 180 min (OR 2.486, p = 0.007), and interval between radiotherapy and surgery > 8 weeks (OR 2.400, p = 0.010). CONCLUSIONS Exclusion of the IRF from the clinical target volume during NCRT using intensity-modulated radiotherapy in LALRC could lower the incidence of perineal wound complications after abdominoperineal resection, without compromising oncological outcomes.
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Affiliation(s)
- Maxiaowei Song
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, People's Republic of China
| | - Jianhao Geng
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, People's Republic of China
| | - Lin Wang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department 3 of Gastrointestinal Surgery, Peking University Cancer Hospital and Institute, Beijing, 100142, People's Republic of China
| | - Yongheng Li
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, People's Republic of China
| | - Xianggao Zhu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, People's Republic of China
| | - Xiaofan Li
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, People's Republic of China
| | - Lan Mi
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital and Institute, Beijing, 100142, People's Republic of China
| | - Aiwen Wu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department 3 of Gastrointestinal Surgery, Peking University Cancer Hospital and Institute, Beijing, 100142, People's Republic of China
| | - Yifan Peng
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department 3 of Gastrointestinal Surgery, Peking University Cancer Hospital and Institute, Beijing, 100142, People's Republic of China
| | - Yunfeng Yao
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department 3 of Gastrointestinal Surgery, Peking University Cancer Hospital and Institute, Beijing, 100142, People's Republic of China
| | - Yangzi Zhang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, People's Republic of China
| | - Hongzhi Wang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, People's Republic of China
| | - Chen Shi
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, People's Republic of China
| | - Yong Cai
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, People's Republic of China.
| | - Weihu Wang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, Beijing, 100142, People's Republic of China.
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Ito E, Yoshida M, Ohdaira H, Kitajima M, Suzuki Y. Case series of in situ pelvic floor reconstruction combining levator ani suture and negative pressure wound therapy for abdominoperineal resection. Ann Med Surg (Lond) 2019; 43:64-67. [PMID: 31198553 PMCID: PMC6556482 DOI: 10.1016/j.amsu.2019.05.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 05/18/2019] [Accepted: 05/27/2019] [Indexed: 11/27/2022] Open
Abstract
Background Abdominoperineal resection (APR) is a standard surgical technique for low rectum cancer with a low recurrence rate. There are some problems associated with APR such as perineal hernia and perineal surgical site infection. Recently, the prophylactic efficacy of negative pressure wound therapy (NPWT) for surgical site infection has been reported. Herein, we analyzed the efficacy of in situ pelvic floor reconstruction combining levator ani suture and NPWT after APR for perineal hernia and perineal surgical site infection. Methods We analyzed six patients treated by laparoscopic APR with NPWT combined with levator ani suture retrospectively. The primary endpoints were surgical site infection within 30 days and perineal hernia within 1 year after surgery. The day following surgery, we performed NPWT for the perineal wound using the VAC® abdominal wound management system (KCI, San Antonio, TX, USA). Results There were four male and two female patients ranging in age from 69 to 86 years (mean: 76 years). The mean NPTW duration was 17 days (13–20 days). The length of the postoperative hospital stay was 14–22 days (median: 18 days). There was no patient with surgical site infection within 30 days or with perineal hernia within 1 year after surgery. Conclusion We experienced the in situ pelvic floor reconstruction combining levator ani suture and NPWT after laparoscopic APR for perineal hernia and perineal surgical site infection. This combination treatment was safe and may be effective for preventing surgical site infection and perineal hernia.
Although APR has some unresolved problems such as perineal hernia and perineal surgical site infection. NPWT decreased perineal wound infection after APR but not reduced deep wound infection rates. Our procedure was able to reconstruct without foreign materials and provided sufficient separation from internal organs to perform safe NPWT. The in situ pelvic floor reconstruction combining levator ani suture and NPWT after laparoscopic APR was safe and may be effective for preventing surgical site infection and perineal hernia.
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Affiliation(s)
- Eisaku Ito
- Department of Surgery, International University of Health and Welfare Hospital, Japan
| | - Masashi Yoshida
- Department of Surgery, International University of Health and Welfare Hospital, Japan
| | - Hironori Ohdaira
- Department of Surgery, International University of Health and Welfare Hospital, Japan
| | - Masaki Kitajima
- Department of Surgery, International University of Health and Welfare Hospital, Japan
| | - Yutaka Suzuki
- Department of Surgery, International University of Health and Welfare Hospital, Japan
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Zhan TC, Zhang DK, Gu J, Li M. Surgical complications after different therapeutic approaches for locally advanced rectal cancer. World J Gastrointest Oncol 2019; 11:393-403. [PMID: 31139309 PMCID: PMC6522767 DOI: 10.4251/wjgo.v11.i5.393] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Revised: 03/16/2019] [Accepted: 03/26/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Preoperative radiochemotherapy is widely used in locally advanced rectal cancer. It can improve local control of rectal cancer. However, some researchers believe it increases the incidence of surgical complications. They doubt its safety. Patients with locally advanced rectal cancer receive three different treatments in our hospital, including long-course radiochemotherapy, short-course radiotherapy, and surgery directly. We can compare their differences in postoperative complications.
AIM To investigate surgical complications caused by different preoperative radiotherapy regimens.
METHODS We retrospectively analyzed 1197 patients admitted between 2008 and 2010 with locally advanced rectal cancer. Three hundred and forty-six patients were treated with preoperative long-course radiochemotherapy (25 × 2 Gy) followed by total mesorectal excision (TME) 6–8 wk later, and 259 patients received short-course radiotherapy (10 × 3 Gy) and subsequently TME 7–10 d later. The remaining 592 patients underwent TME alone without neoadjuvant therapy. According to Clavien–Dindo classification, surgical complications were evaluated for up to 30 d after discharge from hospital.
RESULTS There were no deaths in 30 d in all groups after treatment. The major complications were anastomotic leakage and perineal wound complications. The results suggested that both long-course [odds ratio (OR) = 3.624, 95% confidence interval (CI): 1.689–7.775, P = 0.001] and short-course (OR = 5.150, 95%CI: 1.828–14.515, P = 0.002) radiotherapy were associated with anastomotic leakage. Temporary ileostomy was a protective factor for anastomotic leakage (OR = 6.211, 95%CI: 2.525–15.385, P < 0.001). The severity of anastomotic leakage did not increase in patients following preoperative radiotherapy (P = 0.411). Compared with TME alone, short-course radiotherapy was associated with an increase in perineal wound complications (OR = 5.565, 95%CI: 2.203–14.057, P < 0.001), but long-course radiotherapy seemed safe regarding this complication (OR = 1.692, 95%CI: 0.651–4.394, P = 0.280). Although the severity of perineal wound complications increased in patients following short-course radiotherapy (P < 0.001), additional intervention was not necessary.
CONCLUSION Radiotherapy increased the incidence but not severity of anastomotic leakage. Short-course radiotherapy was also accompanied with perineal wound complications, but intervention appeared unnecessary to ameliorate the complications.
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Affiliation(s)
- Tian-Cheng Zhan
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Colorectal Surgery, Peking University Cancer Hospital and Institute, Beijing Cancer Hospital, Beijing 100142, China
| | - Da-Kui Zhang
- Department of General Surgery, China–Japan Friendship Hospital, Beijing 100029, China
| | - Jin Gu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Colorectal Surgery, Peking University Cancer Hospital and Institute, Beijing Cancer Hospital, Beijing 100142, China
| | - Ming Li
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Colorectal Surgery, Peking University Cancer Hospital and Institute, Beijing Cancer Hospital, Beijing 100142, China
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Perineal Wound Complications Following Extralevator Abdominoperineal Excision: Experience of a Regional Cancer Center. Indian J Surg Oncol 2018; 9:211-214. [PMID: 29887703 DOI: 10.1007/s13193-018-0741-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 03/28/2018] [Indexed: 01/28/2023] Open
Abstract
Extralevator abdominoperineal excision (ELAPE) results in a large perineal defect which needs reconstruction by a flap or biological mesh. The incidence of perineal wound complications is thought to be higher following an ELAPE compared to conventional abdominoperineal excision (APE). WE aimed to analyze the perineal wound complications following ELAPE in our institution. This was a retrospective analysis of all consecutive patients who underwent an APE (conventional and ELAPE) procedure in our institution between 2012 and 2015. We retrieved the demographic data, treatment data, and pathological data from the case records. Reconstruction of the perineal defect after a prone perineal dissection was performed using a local muscle flap. The incidence of perinealwound complications, hospital stay, and time to initiate adjuvant chemotherapy was compared between the two groups. A total of 71 patients underwent APE over a period of 41 months of which 21 patients underwent ELAPE. The perineal dissection during ELAPE was done in the prone position in 18 patients and in the supine position in 3 patients. Perineal wound complications were seen in 9 patients (42%) who underwent ELAPE compared to 17 patients (34%) who underwent conventional APE (p = 0.52). The mean duration of hospital stay was significantly longer in patients who underwent ELAPE when compared to those who underwent conventional APE (22.9 ± 3.6 days vs 14.6 ± 1.0 days, p = 0.03). The median interval between ELAPE and initiation of adjuvant chemo was 54 days (range 32-120 days) compared to 50 days (range 30-100 days) in patients undergoing conventional APE. A delay in initiating adjuvant chemotherapy of more than 12 weeks was seen in 4 patients (19%) following ELAPE. The incidence of perineal wound complications following ELAPE in this study was comparable to that reported in literature. Although the hospital stay following ELAPE was significantly longer than that following conventional APE in our institution, it did not unduly prolong initiation of adjuvant chemotherapy. Improving the perineal reconstruction techniques and selecting patients who will benefit from ELAPE may help to reduce the wound complications.
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Carpelan A, Karvonen J, Varpe P, Rantala A, Kaljonen A, Grönroos J, Huhtinen H. Extralevator versus standard abdominoperineal excision in locally advanced rectal cancer: a retrospective study with long-term follow-up. Int J Colorectal Dis 2018; 33:375-381. [PMID: 29445870 DOI: 10.1007/s00384-018-2977-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/07/2018] [Indexed: 02/04/2023]
Abstract
PURPOSE To analyze the results of abdominoperineal excisions (APE) for locally advanced rectal cancer at our institution before and after the adoption of extralevator abdominoperineal excision (ELAPE) with a special reference to long-term survival. METHODS A retrospective cohort study conducted in a tertiary referral center. All consecutive patients operated for locally advanced (TNM classification T3-4) rectal cancer with APE in 2004-2009 were compared to patients with similar tumors operated with ELAPE in 2009-2016. RESULTS Forty-two ELAPE and 27 APE patients were included. Circumferential resection margin (CRM) was less than 1 mm (R1-resection) in 10 (24%) of ELAPE patients and 11 (41%) of APE patients (p = 0.1358). Intraoperative perforation (IOP) occurred in 4 (10%) patients and 6 (22%) patients in ELAPE and APE groups, respectively (p = 0.1336). There were 3 (7%) local recurrences (LRs) in ELAPE group and 5 (19%) in APE (p = 0.2473). There were no statistical differences in adverse events, overall survival, or disease-free survival between ELAPE and APE groups. CONCLUSIONS We found a non-significant tendency to lower rates of IOP and positive CRM as well as lower rate of LR in the ELAPE group. Long-term survival and adverse events did not differ between the groups. ELAPE is beneficial for the surgeon in offering better vicinity to the perineal area and better work ergonomics. These technical aspects and the clinically very important tendency to lower rate of LR support the use of ELAPE technique in spite of the lack of survival benefit.
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Affiliation(s)
- Anu Carpelan
- Department of Digestive Surgery and Urology, Turku University Hospital and University of Turku, Kiinanmyllynkatu 4-8, 20520, Turku, Finland.
| | - J Karvonen
- Department of Digestive Surgery and Urology, Turku University Hospital and University of Turku, Kiinanmyllynkatu 4-8, 20520, Turku, Finland
| | - P Varpe
- Department of Digestive Surgery and Urology, Turku University Hospital and University of Turku, Kiinanmyllynkatu 4-8, 20520, Turku, Finland
| | - A Rantala
- Department of Digestive Surgery and Urology, Turku University Hospital and University of Turku, Kiinanmyllynkatu 4-8, 20520, Turku, Finland
| | - A Kaljonen
- Biostatistics, Department of Clinical Medicine, University of Turku, Turku, Finland
| | - J Grönroos
- Department of Digestive Surgery and Urology, Turku University Hospital and University of Turku, Kiinanmyllynkatu 4-8, 20520, Turku, Finland
| | - H Huhtinen
- Department of Digestive Surgery and Urology, Turku University Hospital and University of Turku, Kiinanmyllynkatu 4-8, 20520, Turku, Finland
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Zhang Y, Wang D, Zhu L, Wang B, Ma X, Shi B, Yan Y, Zhou C. Standard versus extralevator abdominoperineal excision and oncologic outcomes for patients with distal rectal cancer: A meta-analysis. Medicine (Baltimore) 2017; 96:e9150. [PMID: 29384902 PMCID: PMC6393134 DOI: 10.1097/md.0000000000009150] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND The role of extralevator abdominoperineal excision (ELAPE) for distal rectal cancer remains controversial, and the procedure is not widely accepted or practiced. METHODS An electronic search of Medline, EMBASE, Web of Science, and similar databases for articles in English was performed from the inception of the study until October 31, 2017. Two reviewers extracted information and independently assessed the quality of included studies by the methodological index for nonrandomized studies, then data were analyzed with Review Manager 5.3 software and Stata version 12.0 software. RESULTS Our meta-analysis included 17 studies with 3479 patients, of whom 1915 (55.0%) underwent ELAPE and 1564 (44.0%) underwent abdominoperineal excision (APE). Compared with patients undergoing APE, patients undergoing ELAPE had a significant reduced risk of no more than 3 years local recurrence (LR) (risk ratio [RR] = 0.27, 95% confidence interval [CI] = 0.08-0.94), 3-year mortality (odds ratio [OR] = 0.45, 95% CI = 0.20-0.97), intraoperative bowel perforation (IBP) involvement (RR = 0.48, 95% CI = 0.31-0.74), and circumferential resection margin (CRM) positivity (RR = 0.66, 95% CI = 0.43-1.00) at the threshold level. CONCLUSIONS The application of ELAPE is more effective in reducing the chance of 3 years LR, mortality, IBP involvement and CRM positivity than conventional APE, and worthy of being widely applied in surgical treatment of the distal rectal cancer.
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Affiliation(s)
- Yunfeng Zhang
- Department of the Second Thoracic Surgery, the First Affiliated Hospital of Xi’an Jiaotong University
| | - Duo Wang
- Department of General Surgery, the Second Affiliated Hospital of Xi’an Medical College
| | - Lizhe Zhu
- Department of Breast Surgery, the First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi Province, China
| | - Bin Wang
- Department of Breast Surgery, the First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi Province, China
| | - Xiaoxia Ma
- Department of Breast Surgery, the First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi Province, China
| | - Bohui Shi
- Department of Breast Surgery, the First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi Province, China
| | - Yu Yan
- Department of Breast Surgery, the First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi Province, China
| | - Can Zhou
- Department of Breast Surgery, the First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi Province, China
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Kamali D, Reddy A, Imam S, Omar K, Jha A, Jha M. Short-term surgical outcomes and patient quality of life between robotic and laparoscopic extralevator abdominoperineal excision for adenocarcinoma of the rectum. Ann R Coll Surg Engl 2017; 99:607-613. [PMID: 29022779 PMCID: PMC5696922 DOI: 10.1308/rcsann.2017.0093] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2017] [Indexed: 12/28/2022] Open
Abstract
Introduction Some studies advocate a laparoscopic extralevator abdominoperineal excision (l-ELAPE) approach for low rectal cancer. The da Vinci™ robot (r-ELAPE) technique has potential to overcome some limitations of l-ELAPE, such as reduction of the learning curve and more precise tissue handling. It is unknown whether this approach results in improved surgical or quality of life outcomes compared with l-ELAPE. This study aimed to address this issue. Methods Consecutive patients having undergone either robotic or laparoscopic ELAPE for adenocarcinoma were studied. All operations were performed by two surgeons experienced in laparoscopic and recently introduced robotic surgery. Surgical outcomes were determined by postoperative histology and short-term complications. Quality of life was prospectively assessed using the European Organisation for Research and Treatment of Cancer QLC-CR30 and QLC-CR29 questionnaires. Results A total of 22 patients (11 r-ELAPE) with a median follow-up of 13 months (8 months robotic; 22 months laparoscopic) were studied. The groups were similarly matched for age, gender, American Society of Anesthesiologists status, preoperative chemoradiotherapy and tumour height. All had R0 resection. There was no significant difference in short-term surgical outcomes between groups. There was no significant difference in mean global health scores between the two groups (74 ± 14 r-ELAPE vs. 73 ± 10 l-ELAPE). The r-ELAPE group had a lower mean impotence score compared with the I-ELAPE group (55.5 ± 40 vs. 72.2 ± 44), although this was not statistically significant. Conclusions The newly introduced r-ELAPE was non-inferior to l-ELAPE in either patient quality of life or surgical outcomes. Robotic surgery could be particularly beneficial in the technically challenging area of low rectal cancer surgery with a shorter learning curve than laparoscopy.
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Affiliation(s)
- D Kamali
- South Tees NHS Trust, James Cook University Hospital, Middlesbrough, UK
| | - A Reddy
- South Tees NHS Trust, James Cook University Hospital, Middlesbrough, UK
| | - S Imam
- South Tees NHS Trust, James Cook University Hospital, Middlesbrough, UK
| | - K Omar
- South Tees NHS Trust, James Cook University Hospital, Middlesbrough, UK
| | - A Jha
- South Tees NHS Trust, James Cook University Hospital, Middlesbrough, UK
| | - M Jha
- South Tees NHS Trust, James Cook University Hospital, Middlesbrough, UK
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Noh GT, Han J, Cheong C, Han YD, Kim NK. Novel anal sphincter saving procedure with partial excision of levator-ani muscle in rectal cancer invading ipsilateral pelvic floor. Ann Surg Treat Res 2017; 93:195-202. [PMID: 29094029 PMCID: PMC5658301 DOI: 10.4174/astr.2017.93.4.195] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Revised: 04/17/2017] [Accepted: 04/21/2017] [Indexed: 12/14/2022] Open
Abstract
Purpose Tumors at the level of the anorectal junction had required total levator-ani muscle excision to achieve an adequate resection margin. However, in the cases of tumor invading ipsilateral levator-ani muscle and intact external sphincter, en bloc resection of rectum with levator-ani muscle including tumor would be possible. This hemilevator excision (HLE) technique enables preserving the anal sphincter function while obtaining oncologic clearance and avoiding permanent colostomy in those patients. This study aimed to evaluate the surgical outcomes and feasibility of HLE. Methods Data on 13 consecutive patients who underwent HLE for pathologically proven low rectal cancer were retrospectively collected. All 13 patients presented low rectal cancer at the anorectal ring level that was suspected to invade or abut to the ipsilateral side of the levator-ani muscle. Results A secure resection margin was achieved in all cases, and anastomotic leakage occurred in 2 patients. During follow-up, 3 patients experienced tumor recurrence (2 systemic and 1 local). Among 6 patients who underwent diverting ileostomy closure after the index operation, 2 complained of fecal incontinence. The other 4 patients without fecal incontinence showed <10 times of bowel movement per day. Accessing their incontinence scale, mean Wexner score was 9.4. Conclusion HLE is a novel sphincter-preserving technique that can be a treatment option for low rectal cancer invading ipsilateral levator-ani muscle, which has been an indication for abdominoperineal resection (APR) or extralevator APR. However, the long-term oncologic and functional outcomes of this procedure still need to be assessed to confirm its validity.
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Affiliation(s)
- Gyoung Tae Noh
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Jeonghee Han
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Chinock Cheong
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Yoon Dae Han
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Nam Kyu Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
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Seshadri RA, West NP, Sundersingh S. A pilot randomized study comparing extralevator with conventional abdominoperineal excision for low rectal cancer after neoadjuvant chemoradiation. Colorectal Dis 2017; 19:O253-O262. [PMID: 28503808 DOI: 10.1111/codi.13726] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Accepted: 04/05/2017] [Indexed: 02/08/2023]
Abstract
AIM The aims of this study were to assess the feasibility of performing an extralevator abdominoperineal excision (ELAPE) after neoadjuvant chemoradiation (NCRT), to compare the rates of circumferential resection margin (CRM) involvement and intra-operative perforation (IOP) of the specimen, and to assess the amount of tissue removed around the muscularis propria (MP)/internal sphincter (IS) of the lower rectum in patients with low rectal cancer undergoing ELAPE compared with conventional abdominoperineal excision (CAPE) after NCRT. METHOD This was an open-label, parallel-arm pilot randomized trial conducted in India. Twenty patients were randomized to one of the study arms. The surgical specimens were fixed, serially cross-sectioned and photographed. Using specialized morphometry software, the amount of tissue resected with each operation was measured. RESULTS There was a nonsignificant trend towards more IOPs (30% vs 0%, P = 0.06) and a higher CRM involvement rate (40% vs 20%, P = 0.32) in the CAPE arm. ELAPE removed a significantly greater amount of tissue around the IS/MP when compared with CAPE (mean ± SD: 1911.39 ± 382 mm2 vs 1132.03 ± 371 mm2 , P < 0.001). The mean distance from the IS/MP to the CRM was significantly greater in the ELAPE arm both in the posterior (mean ± SD: 28.28 ± 3 mm vs 9.63 ± 3 mm, P < 0.001) and lateral (mean ± SD: 13.69 ± 3 mm vs 9.72 ± 3 mm, P = 0.009) parts of the rectum but not in the anterior part (mean ± SD: 6.74 ± 2 mm vs 6.10 ± 4 mm, P = 0.64). The short-term morbidity was not significantly different between the two procedures. CONCLUSION ELAPE removed more tissue in the lower rectum and resulted in a lower rate of IOP and CRM involvement when compared with CAPE, even after NCRT.
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Affiliation(s)
- R A Seshadri
- Department of Surgical Oncology, Cancer Institute (WIA), Chennai, India
| | - N P West
- Pathology and Tumour Biology, Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK
| | - S Sundersingh
- Department of Oncopathology, Cancer Institute (WIA), Chennai, India
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Bianco F, Romano G, Tsarkov P, Stanojevic G, Shroyer K, Giuratrabocchetta S, Bergamaschi R. Extralevator with vs nonextralevator abdominoperineal excision for rectal cancer: the RELAPe randomized controlled trial. Colorectal Dis 2017; 19:148-157. [PMID: 27369739 DOI: 10.1111/codi.13436] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 05/12/2016] [Indexed: 02/08/2023]
Abstract
AIM A randomized controlled trial was conducted to test the null hypothesis that there is no difference in circumferential resection margin (CRM) between extralevator abdominoperineal excision (ELAPE) and non-ELAPE for rectal cancer. METHOD This was a multicentre, randomized controlled trial registered as NCT01702116. Patients with rectal cancer involving the external anal sphincter were randomized to ELAPE or non-ELAPE following neoadjuvant chemoradiation. Randomization was performed according to Consolidated Standards of Reporting Trials (CONSORT) guidelines. The primary end-point was CRM (in mm), defined as the shortest distance between the tumour and the cut edge of the specimen. Pathologists and centralized pathology were blinded to the patients' study arm. Interrater reliability (IRR) was assessed using Kendall's coefficient. Intra-operative perforation (IOP) was any rectal defect determined at pathology. Complications were classified using the Clavien-Dindo classification. Participating surgeons were retrained and credentialed. A sample size calculation showed that 34 subjects would provide sufficient power to reject the null hypothesis. RESULTS Thirty-four patients underwent the allocated intervention. Seventeen patients treated with ELAPE were comparable with 17 patients treated with non-ELAPE regarding age, gender, body mass index (BMI), American Society of Anesthesiology (ASA) class and pre-existing comorbidities. CRM depth (7.14 ± 5.76 mm vs 2.98 ± 3.28 mm, P = 0.016) and involvement rates (5.8% vs 41.0%, P = 0.04) were significantly increased in patients treated with ELAPE. The IRR for CRM was 0.78. There were no significant differences in IOP (5.8% vs 11.7%, P = 0.77) and complication rates (29% vs 29%, P = 0.97). CONCLUSIONS ELAPE was associated with statistically improved CRM with no difference in IOP and complication rates compared with non-ELAPE for rectal cancer involving the external anal sphincter.
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Affiliation(s)
- F Bianco
- Division of Colorectal Surgery, State University of New York, Stony Brook, New York, USA.,Department of Colorectal Surgery, National Cancer Institute, Naples, Italy
| | - G Romano
- Department of Colorectal Surgery, National Cancer Institute, Naples, Italy
| | - P Tsarkov
- Department of Colorectal Surgery, Sechenov First Moscow State Medical University, Moscow, Russia
| | - G Stanojevic
- Department of Colorectal Surgery, School University of Niš, Niš, Serbia
| | - K Shroyer
- Department of Pathology, State University of New York, Stony Brook, New York, USA
| | - S Giuratrabocchetta
- Division of Colorectal Surgery, State University of New York, Stony Brook, New York, USA
| | - R Bergamaschi
- Division of Colorectal Surgery, State University of New York, Stony Brook, New York, USA
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Kehrer A, Lamby P, Miranda BH, Prantl L, Dolderer JH. Flap design and perfusion are keys of success: Axial fasciocutaneous posterior thigh flaps for deep small pelvic defect reconstruction. Clin Hemorheol Microcirc 2017; 64:305-318. [DOI: 10.3233/ch-168105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Andreas Kehrer
- Department of Plastic, Hand- and Reconstructive Surgery, University Medical Center Regensburg, Germany
| | - Philipp Lamby
- Department of Plastic, Hand- and Reconstructive Surgery, University Medical Center Regensburg, Germany
| | - Benjamin H. Miranda
- Department of Plastic and Reconstructive Surgery, Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK
| | - Lukas Prantl
- Department of Plastic, Hand- and Reconstructive Surgery, University Medical Center Regensburg, Germany
| | - Juergen H. Dolderer
- Department of Plastic, Hand- and Reconstructive Surgery, University Medical Center Regensburg, Germany
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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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Sumrien H, Newman P, Burt C, McCarthy K, Dixon A, Pullyblank A, Lyons A. The use of a negative pressure wound management system in perineal wound closure after extralevator abdominoperineal excision (ELAPE) for low rectal cancer. Tech Coloproctol 2016; 20:627-31. [PMID: 27380256 DOI: 10.1007/s10151-016-1495-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Accepted: 05/04/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND Perineal wound healing is a significant challenge after extralevator abdominoperineal excision (ELAPE) due to a high rate of wound breakdown. Negative pressure therapy has proven benefits in open wounds, and recently a negative pressure system has been developed for use on closed wounds at high risk of breakdown, such as apronectomy and hysterectomy. The aim of the present study was to determine whether negative pressure therapy applied to closed perineal wounds after ELAPE improved wound healing and compare outcomes to the published literature and outcomes from a historical cohort of patients who had undergone 'standard' abdominoperineal resection (APR) and primary closure of the perineal wounds. METHODS Prospective data on consecutive patients having ELAPE in the period from November 2012 to April 2015 were collected. The pelvic floor defect was reconstructed with biologic mesh. The adipose tissue layer was closed with vicryl sutures, a suction drain was left in the deep layer, the subcuticular layer and skin were closed, and the negative pressure system was applied. Any wound breakdown within the first 30 days postoperatively was recorded. RESULTS Of the 32 consecutive ELAPE patients whose perineal wounds were closed within 30 days with the use of the negative pressure system, there was 1 patient with major perineal wound breakdown and 2 patients with a 1 cm superficial wound defect, which needed no further treatment. In the remaining 29 (90 %) patients, the perineal wounds healed fully without complications. Twenty-five patients underwent standard APR in 2010-2011 with primary closure of their perineal wounds. Ten out of 25(40 %) of patients who had undergone standard APR and primary closure of perineal wounds had major wound complications (p = 0.01). CONCLUSIONS Our results suggest that after ELAPE the application of a negative pressure system to the perineal wound closed with biologic mesh may reduce perineal wound complications and may reduce the need for major perineal reconstruction.
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Affiliation(s)
- H Sumrien
- Department of Colorectal Surgery, Southmead Hospital, Bristol, UK.
| | - P Newman
- Department of Colorectal Surgery, Southmead Hospital, Bristol, UK
| | - C Burt
- Department of Colorectal Surgery, Southmead Hospital, Bristol, UK
| | - K McCarthy
- Department of Colorectal Surgery, Southmead Hospital, Bristol, UK
| | - A Dixon
- Department of Colorectal Surgery, Southmead Hospital, Bristol, UK
| | - A Pullyblank
- Department of Colorectal Surgery, Southmead Hospital, Bristol, UK
| | - A Lyons
- Department of Colorectal Surgery, Southmead Hospital, Bristol, UK
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Extralevator vs conventional abdominoperineal resection for rectal cancer-A systematic review and meta-analysis. Am J Surg 2016; 212:511-26. [PMID: 27317475 DOI: 10.1016/j.amjsurg.2016.02.022] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Revised: 02/23/2016] [Accepted: 02/27/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND The aim of this study was to compare the short-term morbidity and long-term oncologic benefits of extralevator abdominoperineal excision (ELAPE) with conventional abdominoperineal resection (CAPR) for patients with rectal cancer. METHODS Electronic search of the Cochrane Library, MEDLINE, EMBASE, Korean Journal, and J-EAST database from 2007 until August 2015 was carried out. We considered randomized controlled trials and nonrandomized comparative studies comparing ELAPE with CAPR to be eligible, if they included patients with rectal cancers. RESULTS A total of 1 randomized controlled trials and 10 nonrandomized comparative studies met the inclusion criteria, involving 1,736 patients in the ELAPE group and 1,320 in the CAPR group. The ELAPE was associated with a significantly lower intraoperative perforation rate. There were no differences regarding the circumferential margin involvement, R0 resections, and local recurrence rate. There was less blood loss in ELAPE patients. CONCLUSIONS The ELAPE significantly lowered the intraoperative perforation rate, with no benefits regarding circumferential resection margin involvement and local recurrence rate.
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Affiliation(s)
- Young Jin Kim
- Colorectal Cancer Clinic, Department of Surgery, Chonnam National University Medical School, Gwangju, Korea
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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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Extralevatorische abdominoperineale Rektumextirpation beim tiefen Rektumkarzinom. Chirurg 2015; 86:992. [DOI: 10.1007/s00104-015-0078-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Putte DV, Nieuwenhove YV, Willaert W, Pattyn P, Ceelen W. Organ preservation in rectal cancer: current status and future perspectives. COLORECTAL CANCER 2015. [DOI: 10.2217/crc.15.18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
With the introduction of population screening initiatives, more patients may be amenable to local, transanal excision (LE) of early-stage rectal cancer. The most important drawback of LE is the risk of understaging node-positive disease. The most powerful predictors of node-positive disease are lymphatic invasion, submucosal invasion depth and width, tumor budding and poor differentiation. Therefore, LE should be reserved for low-risk T1 tumors in those reluctant or unable to undergo major surgery. Neoadjuvant chemoradiation followed by LE for T2 tumors allows adequate local control, and is currently being compared with anterior resection alone in randomized trials. A mere watchful waiting approach has been proposed in clinical complete responders to chemoradiation. However, given the very poor accuracy of current imaging modalities to predict a true pathological complete response, this strategy should not be offered outside of well-controlled trials.
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Affiliation(s)
- Dirk Vande Putte
- Department of Gastrointestinal Surgery, Ghent University Hospital, De Pintelaan 185, B-9000 Ghent, Belgium
| | - Yves Van Nieuwenhove
- Department of Gastrointestinal Surgery, Ghent University Hospital, De Pintelaan 185, B-9000 Ghent, Belgium
| | - Wouter Willaert
- Department of Gastrointestinal Surgery, Ghent University Hospital, De Pintelaan 185, B-9000 Ghent, Belgium
| | - Piet Pattyn
- Department of Gastrointestinal Surgery, Ghent University Hospital, De Pintelaan 185, B-9000 Ghent, Belgium
| | - Wim Ceelen
- Department of Gastrointestinal Surgery, Ghent University Hospital, De Pintelaan 185, B-9000 Ghent, Belgium
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