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Journal of Gastrointestinal Surgery

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01-10-2021 | Rectal Cancer | Original Article

Efficacy of Pelvic Peritoneum Closure After Laparoscopic Extralevator Abdominoperineal Excision for Rectal Cancer

Authors: Yu Shen, Tinghan Yang, Hanjiang Zeng, Wenjian Meng, Ziqiang Wang

Published in: Journal of Gastrointestinal Surgery | Issue 10/2021

Abstract

Background

The descent of the small bowel into the pelvic dead space after extralevator abdominoperineal excision (ELAPE) presents a higher risk for postoperative complications. The aim of the present study was to evaluate the efficacy of pelvic peritoneum closure in preventing the small bowel from descending into the pelvic dead space and the potential consequences of this approach.

Methods

Patients with rectal cancer undergoing laparoscopic ELAPE from March 2014 to January 2019 were retrospectively investigated. Closure of the pelvic peritoneum (CPP) was routinely performed unless it was not feasible. All patients with pelvic peritoneum reconstruction were included in the CPP group, and patients without pelvic peritoneum reconstruction were included in the no-CPP group. The main outcomes included the incidences of the small bowel descending into the retro-urogenital space (space between the bladder/uterus and the sacrum on axial CT scans), perineal wound complications, perineal hernia, and small bowel obstruction (SBO).

Results

Of the 100 patients included, 79 received CPP, and 21 did not. Fewer patients with pelvic peritoneum closure had small bowels residing in the retro-urogenital space than patients without closure (17.7% vs 42.9%, p=0.014). The incidence of SBO was also lower in the CPP group (7.6% vs. 23.8%, p=0.034). Multivariable analysis showed that no-CPP (p=0.014) was an independent risk factor for the small bowel descending into the retro-urogenital space.

Conclusion

CPP may prevent the small bowel from descending into the retro-urogenital dead space in patients undergoing laparoscopic ELAPE without increasing the incidence of perineal wound complications. Prospective studies are warranted to confirm the efficacy of CPP in preventing SBO and perineal hernia.

Holm T, Ljung A, Haggmark T, Jurell G, Lagergren J. Extended abdominoperineal resection with gluteus maximus flap reconstruction of the pelvic floor for rectal cancer. The British journal of surgery. 2007;94(2):232-8. doi:https://doi.org/10.1002/bjs.5489.CrossRefPubMed

Khan MAS, Ang CW, Hakeem AR, Scott N, Saunders RN, Botterill I. The Impact of Tumour Distance From the Anal Verge on Clinical Management and Outcomes in Patients Having a Curative Resection for Rectal Cancer. Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract. 2017;21(12):2056-65. doi:https://doi.org/10.1007/s11605-017-3581-0.CrossRef

West NP, Finan PJ, Anderin C, Lindholm J, Holm T, Quirke P. Evidence of the oncologic superiority of cylindrical abdominoperineal excision for low rectal cancer. Journal of clinical oncology : official journal of the American Society of Clinical Oncology. 2008;26(21):3517-22. doi:https://doi.org/10.1200/jco.2007.14.5961.CrossRef

Thomas PW, Blackwell JEM, Herrod PJJ, Peacock O, Singh R, Williams JP et al. Long-term outcomes of biological mesh repair following extra levator abdominoperineal excision of the rectum: an observational study of 100 patients. Techniques in coloproctology. 2019;23(8):761-7. doi:https://doi.org/10.1007/s10151-019-02056-0.CrossRefPubMedPubMedCentral

Orr JW, Jr., Shingleton HM, Hatch KD, Taylor PT, Partridge EE, Soong SJ. Gastrointestinal complications associated with pelvic exenteration. American journal of obstetrics and gynecology. 1983;145(3):325-32. doi:https://doi.org/10.1016/0002-9378(83)90719-6.CrossRefPubMed

Burns EM, Currie A, Bottle A, Aylin P, Darzi A, Faiz O. Minimal-access colorectal surgery is associated with fewer adhesion-related admissions than open surgery. The British journal of surgery. 2013;100(1):152-9. doi:https://doi.org/10.1002/bjs.8964.CrossRefPubMed

Bockova M, Hoch J, Kestlerova A, Amler E. The dead space after extirpation of rectum. Current management and searching for new materials for filling. Physiol Res. 2019;68(Suppl 4):S509-s15. doi:https://doi.org/10.33549/physiolres.934390.CrossRefPubMed

Yan X, Su H, Zhang S, Zhou L, Lu J, Yang X et al. Pelvic peritoneum closure reduces postoperative complications of laparoscopic abdominoperineal resection: 6-year experience in single center. Surgical endoscopy. 2020. doi:https://doi.org/10.1007/s00464-020-07414-w.

Moreno-Sanz C, Manzanera-Diaz M, Cortina-Oliva FJ, de Pedro-Conal J, Clerveus M, Picazo-Yeste J. Pelvic reconstruction after abdominoperineal resection: a pilot study using an absorbable synthetic prosthesis. Techniques in coloproctology. 2011;15(4):455-9. doi:https://doi.org/10.1007/s10151-011-0763-8.CrossRefPubMed

10.

Blok RD, Hagemans JAW, Klaver CEL, Hellinga J, van Etten B, Burger JWA et al. A Systematic Review and Meta-analysis on Omentoplasty for the Management of Abdominoperineal Defects in Patients Treated for Cancer. Annals of surgery. 2019;271:654-62. doi:https://doi.org/10.1097/sla.0000000000003266.CrossRef

11.

Carboni F, Federici O, Giofre M, Zazza S, Valle M. Empty pelvis syndrome: the use of breast prosthesis in the prevention of complications. Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland. 2019;21(11):1321-5. doi:https://doi.org/10.1111/codi.14737.CrossRef

12.

Peirce C, Martin S. Management of the Perineal Defect after Abdominoperineal Excision. Clin Colon Rectal Surg. 2016;29(2):160-7. doi:https://doi.org/10.1055/s-0036-1580627.CrossRefPubMedPubMedCentral

13.

Matsuhashi N, Takahashi T, Nonaka K, Tanahashi T, Imai H, Sasaki Y et al. Laparoscopic technique and safety experience with barbed suture closure for pelvic cavity after abdominoperineal resection. World journal of surgical oncology. 2013;11:115. doi:https://doi.org/10.1186/1477-7819-11-115.CrossRefPubMedPubMedCentral

14.

Musters GD, Klaver CEL, Bosker RJI, Burger JWA, van Duijvendijk P, van Etten B et al. Biological Mesh Closure of the Pelvic Floor After Extralevator Abdominoperineal Resection for Rectal Cancer: A Multicenter Randomized Controlled Trial (the BIOPEX-study). Annals of surgery. 2017;265(6):1074-81. doi:https://doi.org/10.1097/sla.0000000000002020.CrossRefPubMed

15.

Nisar PJ, Scott HJ. Myocutaneous flap reconstruction of the pelvis after abdominoperineal excision. Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland. 2009;11(8):806-16. doi:https://doi.org/10.1111/j.1463-1318.2008.01743.x.CrossRef

16.

Wang YL, Zhang X, Mao JJ, Zhang WQ, Dong H, Zhang FP et al. Application of modified primary closure of the pelvic floor in laparoscopic extralevator abdominal perineal excision for low rectal cancer. World journal of gastroenterology. 2018;24(30):3440-7. doi:https://doi.org/10.3748/wjg.v24.i30.3440.CrossRefPubMedPubMedCentral

17.

Van Cutsem E, Cervantes A, Adam R, Sobrero A, Van Krieken JH, Aderka D et al. ESMO consensus guidelines for the management of patients with metastatic colorectal cancer. Ann Oncol. 2016;27(8):1386-422. doi:https://doi.org/10.1093/annonc/mdw235.CrossRefPubMed

18.

Diagnosis, Treatment Guidelines For Colorectal Cancer Working Group C. Chinese Society of Clinical Oncology (CSCO) diagnosis and treatment guidelines for colorectal cancer 2018 (English version). Chin J Cancer Res. 2019;31(1):117-34. doi:https://doi.org/10.21147/j.issn.1000-9604.2019.01.07.CrossRef

19.

Yang X, Jin C, Deng X, Wang M, Zhang Y, Wei M et al. Laparoscopic Extralevator Abdominoperineal Excision of the Rectum with Primary Suturing: Short-Term Outcomes from Single-Institution Study. Journal of laparoendoscopic & advanced surgical techniques Part A. 2016;26(1):40-6. doi:https://doi.org/10.1089/lap.2015.0325.CrossRef

20.

Yang T, Wei M, Deng X, Meng W, Wang Z. A Novel Laparoscopic Technique With a Bladder Peritoneum Flap Closure for Pelvic Cavity for Patients With Rigid Pelvic Peritoneum After Neoadjuvant Radiotherapy in Laparoscopic Extralevator Abdominoperineal Excision. Diseases of the colon and rectum. 2019;62(9):1136-40. doi:https://doi.org/10.1097/dcr.0000000000001435.CrossRefPubMed

21.

Katayama H, Kurokawa Y, Nakamura K, Ito H, Kanemitsu Y, Masuda N et al. Extended Clavien-Dindo classification of surgical complications: Japan Clinical Oncology Group postoperative complications criteria. Surgery today. 2016;46(6):668-85. doi:https://doi.org/10.1007/s00595-015-1236-x.CrossRefPubMed

22.

Sunesen KG, Buntzen S, Tei T, Lindegaard JC, Norgaard M, Laurberg S. Perineal healing and survival after anal cancer salvage surgery: 10-year experience with primary perineal reconstruction using the vertical rectus abdominis myocutaneous (VRAM) flap. Annals of surgical oncology. 2009;16(1):68-77. doi:https://doi.org/10.1245/s10434-008-0208-4.CrossRefPubMed

23.

Blok RD, Musters GD, Borstlap WAA, Buskens CJ, Bemelman WA, Tanis PJ. Snapshot Study on the Value of Omentoplasty in Abdominoperineal Resection with Primary Perineal Closure for Rectal Cancer. Annals of surgical oncology. 2018;25(3):729-36. doi:https://doi.org/10.1245/s10434-017-6273-9.CrossRefPubMed

24.

ten Broek RP, Issa Y, van Santbrink EJ, Bouvy ND, Kruitwagen RF, Jeekel J et al. Burden of adhesions in abdominal and pelvic surgery: systematic review and met-analysis. BMJ (Clinical research ed). 2013;347:f5588.

25.

Andersen P, Jensen KK, Erichsen R, Froslev T, Krarup PM, Madsen MR et al. Nationwide population-based cohort study to assess risk of surgery for adhesive small bowel obstruction following open or laparoscopic rectal cancer resection. BJS open. 2017;1(2):30-8. doi:https://doi.org/10.1002/bjs5.5.CrossRefPubMedPubMedCentral

26.

Morimoto Y, Takahashi H, Fujii M, Miyoshi N, Uemura M, Matsuda C et al. Visceral obesity is a preoperative risk factor for postoperative ileus after surgery for colorectal cancer: Single-institution retrospective analysis. Annals of gastroenterological surgery. 2019;3(6):657-66. doi:https://doi.org/10.1002/ags3.12291.CrossRefPubMedPubMedCentral

27.

Sugawara K, Kawaguchi Y, Nomura Y, Suka Y, Kawasaki K, Uemura Y et al. Perioperative Factors Predicting Prolonged Postoperative Ileus After Major Abdominal Surgery. Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract. 2018;22(3):508-15. doi:https://doi.org/10.1007/s11605-017-3622-8.CrossRef

28.

Zhu P, Liang Z, Fu J, Chen W, Wang Z, Jiang H et al. Procalcitonin in abdominal exudate to predict prolonged postoperative ileus following colorectal carcinoma surgery. The International journal of biological markers. 2013;28(2):187-91. doi:https://doi.org/10.5301/jbm.5000028.CrossRefPubMed

29.

van den Beukel BA, de Ree R, van Leuven S, Bakkum EA, Strik C, van Goor H et al. Surgical treatment of adhesion-related chronic abdominal and pelvic pain after gynaecological and general surgery: a systematic review and meta-analysis. Hum Reprod Update. 2017;23(3):276-88. doi:https://doi.org/10.1093/humupd/dmx004.CrossRefPubMed

30.

Harshaw DH, Jr., Gardner B, Vives A, Sundaram KN. The effect of technical factors upon complications from abdominal perineal resections. Surgery, gynecology & obstetrics. 1974;139(5):756-8.

31.

Robles Campos R, Garcia Ayllon J, Parrila Paricio P, Cifuentes Tebar J, Lujan Mompean JA, Liron Ruiz R et al. Management of the perineal wound following abdominoperineal resection: prospective study of three methods. The British journal of surgery. 1992;79(1):29-31. doi:https://doi.org/10.1002/bjs.1800790108.CrossRefPubMed

32.

Musters GD, Sloothaak DA, Roodbeen S, van Geloven AA, Bemelman WA, Tanis PJ. Perineal wound healing after abdominoperineal resection for rectal cancer: a two-centre experience in the era of intensified oncological treatment. International journal of colorectal disease. 2014;29(9):1151-7. doi:https://doi.org/10.1007/s00384-014-1967-y.CrossRefPubMed

Title: Efficacy of Pelvic Peritoneum Closure After Laparoscopic Extralevator Abdominoperineal Excision for Rectal Cancer
Authors: Yu Shen
Tinghan Yang
Hanjiang Zeng
Wenjian Meng
Ziqiang Wang
Publication date: 01-10-2021
Publisher: Springer US
Keywords: Rectal Cancer
Rectal Cancer
Published in: Journal of Gastrointestinal Surgery / Issue 10/2021
Print ISSN: 1091-255X
Electronic ISSN: 1873-4626
DOI: https://doi.org/10.1007/s11605-021-05046-6

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Efficacy of Pelvic Peritoneum Closure After Laparoscopic Extralevator Abdominoperineal Excision for Rectal Cancer

Abstract

Background

Methods

Results

Conclusion

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Methods

Results

Conclusion

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