Top

Published in:

Open Access 01-08-2019 | Rectal Cancer | Original Article

Long-term outcomes of biological mesh repair following extra levator abdominoperineal excision of the rectum: an observational study of 100 patients

Authors: P. W. Thomas, J. E. M. Blackwell, P. J. J. Herrod, O. Peacock, R. Singh, J. P. Williams, N. G. Hurst, W. J. Speake, A. Bhalla, J. N. Lund

Published in: Techniques in Coloproctology | Issue 8/2019

Abstract

Background

Current evidence suggests that pelvic floor reconstruction following extralevator abdominoperineal excision of rectum (ELAPER) may reduce the risk of perineal herniation of intra-abdominal contents. Options for reconstruction include mesh and myocutaneous flaps, for which long-term follow-up data is lacking. The aim of this study was to evaluate the long-term outcomes of biological mesh (Surgisis^®, Biodesign™) reconstruction following ELAPER.

Methods

A retrospective review of all patients having ELAPER in a single institution between 2008 and 2018 was perfomed. Clinic letters were scrutinised for wound complications and all available cross sectional imaging was reviewed to identify evidence of perineal herniation (defined as presence of intra-abdominal content below a line between the coccyx and the lower margin of the pubic symphysis on sagittal view).

Results

One hundred patients were identified (median age 66, IQR 59–72 years, 70% male). Median length of follow-up was 4.9 years (IQR 2.3–6.7 years). One, 2- and 5-year mortality rates were 3, 8 and 12%, respectively. Thirty three perineal wounds had not healed by 1 month, but no mesh was infected and no mesh needed to be removed. Only one patient developed a symptomatic perineal hernia requiring repair. On review of imaging a further 7 asymptomatic perineal hernias were detected. At 4 years the cumulative radiologically detected perineal hernia rate was 8%.

Conclusions

This study demonstrates that pelvic floor reconstruction using biological mesh following ELAPER is both safe and effective as a long-term solution, with low major complication rates. Symptomatic perineal herniation is rare following mesh reconstruction, but may develop sub clinically and be detectable on cross-sectional imaging.

Wibe A, Syse A, Andersen E et al (2004) Oncological outcomes after total mesorectal excision for cure for cancer of the lower rectum: anterior vs. abdominoperineal resection. Dis Colon Rectum 47:48–58. https://doi.org/10.1007/s10350-003-0012-y CrossRefPubMed

West NP, Finan PJ, Anderin C et al (2008) Evidence of the oncologic superiority of cylindrical abdominoperineal excision for low rectal cancer. J Clin Oncol 26:3517–3522. https://doi.org/10.1200/JCO.2007.14.5961 CrossRefPubMed

West NP, Anderin C, Smith KJE et al (2010) Multicentre experience with extralevator abdominoperineal excision for low rectal cancer. Br J Surg 97:588–599. https://doi.org/10.1002/bjs.6916 CrossRefPubMed

Eriksen MT, Wibe A, Syse A et al (2004) Inadvertent perforation during rectal cancer resection in Norway. Br J Surg 91:210–216. https://doi.org/10.1002/bjs.4390 CrossRefPubMed

Negoi I, Hostiuc S, Paun S et al (2016) Extralevator vs conventional abdominoperineal resection for rectal cancer—a systematic review and meta-analysis. Am J Surg 212:511–526. https://doi.org/10.1016/J.AMJSURG.2016.02.022 CrossRefPubMed

Bianco F, Romano G, Tsarkov P et al (2017) Extralevator with vs nonextralevator abdominoperineal excision for rectal cancer: the RELAPe randomized controlled trial. Color Dis 19:148–157. https://doi.org/10.1111/codi.13436 CrossRef

Mauvais F, Sabbagh C, Brehant O et al (2011) The current abdominoperineal resection: oncological problems and surgical modifications for low rectal cancer. J Visc Surg 148:e85–e93. https://doi.org/10.1016/J.JVISCSURG.2011.03.001 CrossRefPubMed

Miles WE (1971) A method of performing abdomino-perineal excision for carcinoma of the rectum and of the terminal portion of the pelvic colon (1908). CA Cancer J Clin 21:361–364. https://doi.org/10.3322/canjclin.21.6.361 CrossRefPubMed

Holm T, Ljung A, Häggmark T et al (2007) Extended abdominoperineal resection with gluteus maximus flap reconstruction of the pelvic floor for rectal cancer. Br J Surg 94:232–238. https://doi.org/10.1002/bjs.5489 CrossRefPubMed

10.

Bignell M, Chave H, Branagan G (2018) Outcome of surgery for recurrent anal cancer: results from a tertiary referral centre. Color Dis 20:771–777. https://doi.org/10.1111/codi.14098 CrossRef

11.

Howell AM, Jarral OA, Faiz O et al (2013) How should perineal wounds be closed following abdominoperineal resection in patients post radiotherapy—primary closure or flap repair? Best evidence topic (BET). Int J Surg 11:514–517. https://doi.org/10.1016/J.IJSU.2013.05.004 CrossRefPubMed

12.

Bullard KM, Trudel JL, Baxter NN, Rothenberger DA (2005) Primary perineal wound closure after preoperative radiotherapy and abdominoperineal resection has a high incidence of wound failure. Dis Colon Rectum 48:438–443. https://doi.org/10.1007/s10350-004-0827-1 CrossRefPubMed

13.

Nisar PJ, Scott HJ (2009) Myocutaneous flap reconstruction of the pelvis after abdominoperineal excision. Color Dis 11:806–816. https://doi.org/10.1111/j.1463-1318.2008.01743.x CrossRef

14.

Musters GD, Klaver CEL, Bosker RJI et al (2017) Biological mesh closure of the pelvic floor after extralevator abdominoperineal resection for rectal cancer. Ann Surg 265:1074–1081. https://doi.org/10.1097/SLA.0000000000002020 CrossRefPubMed

15.

Blok RD, de Jonge J, de Koning MA et al (2019) Propensity score adjusted comparison of pelviperineal morbidity with and without omentoplasty following abdominoperineal resection for primary rectal cancer. Dis Colon Rectum 62:952–959. https://doi.org/10.1097/DCR.0000000000001349 CrossRefPubMed

16.

Peacock O, Pandya H, Sharp T et al (2012) Biological mesh reconstruction of perineal wounds following enhanced abdominoperineal excision of rectum (APER). Int J Colorectal Dis 27:475–482. https://doi.org/10.1007/s00384-011-1325-2 CrossRefPubMed

17.

Foster JD, Tou S, Curtis NJ et al (2018) Closure of the perineal defect after abdominoperineal excision for rectal adenocarcinoma—ACPGBI Position Statement. Color Dis 20:5–23. https://doi.org/10.1111/codi.14348 CrossRef

18.

Boereboom CL, Watson NFS, Sivakumar R et al (2009) Biological tissue graft for pelvic floor reconstruction after cylindrical abdominoperineal excision of the rectum and anal canal. Tech Coloproctol 13:257–258. https://doi.org/10.1007/s10151-009-0512-4 CrossRefPubMed

19.

Peacock O, Simpson JA, Tou SI et al (2014) Outcomes after biological mesh reconstruction of the pelvic floor following extra-levator abdominoperineal excision of rectum (APER). Tech Coloproctol 18:571–577. https://doi.org/10.1007/s10151-013-1107-7 CrossRefPubMed

20.

Dinnewitzer A, Meissnitzer M, Meissnitzer T et al (2015) Dynamic magnetic resonance imaging evaluation of pelvic reconstruction with porcine dermal collagen mesh following extra-levator abdominoperineal excision for primary rectal cancer. Int J Colorectal Dis 30:491–496. https://doi.org/10.1007/s00384-015-2169-y CrossRefPubMed

21.

Henrik Kidmose Christensen PNTTSL (2011) Perineal repair after extralevator abdominoperineal excision for low rectal cancer. Dis Colon 54:711–717. https://doi.org/10.1007/dcr.0b013e3182163c89 CrossRef

22.

Butt HZ, Salem MK, Vijaynagar B et al (2013) Perineal reconstruction after extra-levator abdominoperineal excision (eLAPE): a systematic review. Int J Colorectal Dis 28:1459–1468. https://doi.org/10.1007/s00384-013-1660-6 CrossRefPubMed

23.

Harries RL, Luhmann A, Harris DA et al (2014) Prone extralevator abdominoperineal excision of the rectum with porcine collagen perineal reconstruction (Permacol^TM): high primary perineal wound healing rates. Int J Colorectal Dis 29:1125–1130. https://doi.org/10.1007/s00384-014-1963-2 CrossRefPubMed

24.

Balla A, Batista Rodríguez G, Buonomo N et al (2017) Perineal hernia repair after abdominoperineal excision or extralevator abdominoperineal excision: a systematic review of the literature. Tech Coloproctol 21:329–336. https://doi.org/10.1007/s10151-017-1634-8 CrossRefPubMed

25.

Sayers AE, Patel RK, Hunter IA (2015) Perineal hernia formation following extralevator abdominoperineal excision. Color Dis 17:351–355. https://doi.org/10.1111/codi.12843 CrossRef

26.

Dindo D, Demartines N, Clavien P-A (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240:205–213. https://doi.org/10.1097/01.sla.0000133083.54934.ae CrossRefPubMedPubMedCentral

27.

Musters GD, Buskens CJ, Bemelman WA, Tanis PJ (2014) Perineal wound healing after abdominoperineal resection for rectal cancer: a systematic review and meta-analysis. Dis Colon Rectum 57:1129–1139. https://doi.org/10.1097/DCR.0000000000000182 CrossRefPubMed

28.

Schiltz B, Buchs NC, Penna M et al (2017) Biological mesh reconstruction of the pelvic floor following abdominoperineal excision for cancer: a review. World J Clin Oncol 8:249. https://doi.org/10.5306/wjco.v8.i3.249 CrossRefPubMedPubMedCentral

29.

Jones H, Moran B, Crane S et al (2017) The LOREC APE registry: operative technique, oncological outcome and perineal wound healing after abdominoperineal excision. Color Dis 19:172–180. https://doi.org/10.1111/codi.13423 CrossRef

30.

Aslam MI, Baloch N, Mann C et al (2019) Simultaneous stoma reinforcement and perineal reconstruction with biological mesh—a multicentre prospective observational study. Ann Med Surg 38:28–33. https://doi.org/10.1016/J.AMSU.2018.12.006 CrossRef

31.

Musters GD, Bemelman WA, Bosker RJ et al (2014) Randomized controlled multicentre study comparing biological mesh closure of the pelvic floor with primary perineal wound closure after extralevator abdominoperineal resection for rectal cancer (BIOPEX-study). BMC Surg 14:58. https://doi.org/10.1186/1471-2482-14-58 CrossRefPubMedPubMedCentral

32.

Anderin C, Martling A, Lagergren J et al (2012) Short-term outcome after gluteus maximus myocutaneous flap reconstruction of the pelvic floor following extra-levator abdominoperineal excision of the rectum. Color Dis 14:1060–1064. https://doi.org/10.1111/j.1463-1318.2011.02848.x CrossRef

33.

Konstantinovic ML, Lagae P, Zheng F et al (2005) Comparison of host response to polypropylene and non-cross-linked porcine small intestine serosal-derived collagen implants in a rat model. BJOG 112:1554–1560. https://doi.org/10.1111/j.1471-0528.2005.00688.x CrossRefPubMed

34.

Ayubi FS, Armstrong PJ, Mattia MS, Parker DM (2008) Abdominal wall hernia repair: a comparison of Permacol^® and Surgisis^® grafts in a rat hernia model. Hernia 12:373–378. https://doi.org/10.1007/s10029-008-0359-z CrossRefPubMed

35.

Sainfort A, Denis Hallouard I, Hartmann D et al (2016) Xenograft biologic mesh in parietal and general surgery: technical assessment and review of clinical effectiveness and safety data. J Visc Surg 153:403–417. https://doi.org/10.1016/J.JVISCSURG.2016.08.002 CrossRefPubMed

36.

Pascual G, Sotomayor S, Rodríguez M et al (2015) Extraperitoneal and intraperitoneal behavior of several biological meshes currently used to repair abdominal wall defects. J Biomed Mater Res Part B Appl Biomater 103:365–372. https://doi.org/10.1002/jbm.b.33219 CrossRef

37.

Bulut O, Rasmussen HB, Jess P (2012) Use of a balloon catheter in management of the pelvic space following laparoscopic abdominoperineal excision. Color Dis 14:e623–e626. https://doi.org/10.1111/j.1463-1318.2012.03027.x CrossRef

38.

Foster JD, Pathak S, Smart NJ et al (2012) Reconstruction of the perineum following extralevator abdominoperineal excision for carcinoma of the lower rectum: a systematic review. Color Dis 14:1052–1059. https://doi.org/10.1111/j.1463-1318.2012.03169.x CrossRef

39.

Lee P, Tan WJ, Brown K, Solomon MJ (2018) Addressing the empty pelvic syndrome following total pelvic exenteration: does mesh reconstruction help? Color Dis 21:365–369. https://doi.org/10.1111/codi.14523 CrossRef

Title: Long-term outcomes of biological mesh repair following extra levator abdominoperineal excision of the rectum: an observational study of 100 patients
Authors: P. W. Thomas
J. E. M. Blackwell
P. J. J. Herrod
O. Peacock
R. Singh
J. P. Williams
N. G. Hurst
W. J. Speake
A. Bhalla
J. N. Lund
Publication date: 01-08-2019
Publisher: Springer International Publishing
Keywords: Rectal Cancer
Rectal Cancer
Published in: Techniques in Coloproctology / Issue 8/2019
Print ISSN: 1123-6337
Electronic ISSN: 1128-045X
DOI: https://doi.org/10.1007/s10151-019-02056-0

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Long-term outcomes of biological mesh repair following extra levator abdominoperineal excision of the rectum: an observational study of 100 patients

Abstract

Background

Methods

Results

Conclusions

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

Please log in to get access to this content

Other articles of this Issue 8/2019

Novel approach for hepatic flexure mobilization with infracolic, suprapancreatic, medial-to-lateral approach

Feasibility of a subcutaneous gluteal turnover flap without donor site scar for perineal closure after abdominoperineal resection for rectal cancer

3D printed model-based simulation of laparoscopic surgery for descending colon cancer with a concomitant abdominal aortic aneurysm

The laparoscopic medial-to-lateral approach to the splenic flexure

Use of three-dimensional virtual images for planning surgery of complex anal fistulas: a new technology available via smartphone

Diverticular disease epidemiology: acute hospitalisations are growing fastest in young men