Top

Published in:

Open Access 01-12-2022 | Rectal Cancer | Research

Long-term outcomes of laparoscopic Extralevator Abdominoperineal excision with modified position change for low rectal Cancer treatment

Authors: Shaowei Sun, Shengbo Sun, Xiangyun Zheng, Jiangtao Yu, Wenchang Wang, Qing Gong, Guowei Zhao, Jing Li, Huanhu Zhang

Published in: BMC Cancer | Issue 1/2022

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.

Available only for authorised users

Christian CK, Kwaan MR, Betensky RA, Breen EM, Zinner MJ, Bleday R. Risk factors for perineal wound complications following abdominoperineal resection. Dis Colon Rectum. 2005;48(1):43–8. https://doi.org/10.1007/s10350-004-0855-x.CrossRefPubMed

Nagtegaal ID, van de Velde CJ, Marijnen CA, van Krieken JH, Quirke P. Low rectal cancer: a call for a change of approach in abdominoperineal resection. J Clin Oncol. 2005;23(36):9257–64. https://doi.org/10.1200/JCO.2005.02.9231.CrossRefPubMed

Tekkis PP, Heriot AG, Smith J, Thompson MR, Finan P, Stamatakis JD. Comparison of circumferential margin involvement between restorative and nonrestorative resections for rectal cancer. Color Dis. 2005;7(4):369–74. https://doi.org/10.1111/j.1463-1318.2005.00767.x.CrossRef

Law WL, Chu KW. Abdominoperineal resection is associated with poor oncological outcome. Br J Surg. 2004;91(11):1493–9. https://doi.org/10.1002/bjs.4723.CrossRefPubMed

den Dulk M, Putter H, Collette L, Marijnen C, Folkesson J, Bosset JF, et al. The abdominoperineal resection itself is associated with an adverse outcome: the European experience based on a pooled analysis of five European randomised clinical trials on rectal cancer. Eur J Cancer. 2009;45(7):1175–83. https://doi.org/10.1016/j.ejca.2008.11.039.CrossRef

Anderin C, Martling A, Hellborg H, Holm T. A population-based study on outcome in relation to the type of resection in low rectal cancer. Dis Colon Rectum. 2010;53(5):753–60. https://doi.org/10.1007/DCR.0b013e3181cf7e27.CrossRefPubMed

Bernstein TE, Endreseth BH, Romundstad P, Wibe A. Circumferential resection margin as a prognostic factor in rectal cancer. Br J Surg. 2009;96(11):1348–57. https://doi.org/10.1002/bjs.6739.CrossRefPubMed

Marr R, Birbeck K, Garvican J, Macklin CP, Tiffin NJ, Parsons WJ, et al. The modern abdominoperineal excision: the next challenge after total mesorectal excision. Ann Surg. 2005;242(1):74–82. https://doi.org/10.1097/01.sla.0000167926.60908.15.CrossRefPubMedPubMedCentral

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

10.

West NP, Anderin C, Smith KJ, Holm T, Quirke P. Multicentre experience with extralevator abdominoperineal excision for low rectal cancer. Br J Surg. 2010;97(4):588–99. https://doi.org/10.1002/bjs.6916.CrossRefPubMed

11.

De Nardi P, Summo V, Vignali A, Capretti G. Standard versus extralevator abdominoperineal low rectal cancer excision outcomes: a systematic review and meta-analysis. Ann Surg Oncol. 2015;22(9):2997–3006. https://doi.org/10.1245/s10434-015-4368-8.CrossRefPubMed

12.

Keller DS, Lawrence JK, Delaney CP. Prone jackknife position is not necessary to achieve a cylindrical abdominoperineal resection: demonstration of the lithotomy position. Dis Colon Rectum. 2014;57(2):251. https://doi.org/10.1097/DCR.0000000000000047.CrossRefPubMed

13.

Chi P, Chen ZF, Lin HM, Lu XR, Huang Y. Laparoscopic extralevator abdominoperineal resection for rectal carcinoma with transabdominal levator transection. Ann Surg Oncol. 2013;20(5):1560–6. https://doi.org/10.1245/s10434-012-2675-x.CrossRefPubMed

14.

Zhang X, Wang Z, Liang J, Zhou Z. Transabdominal extralevator abdominoperineal excision (eLAPE) performed by laparoscopic approach with no position change. J Laparoendosc Adv Surg Tech A. 2015;25(3):202–6. https://doi.org/10.1089/lap.2014.0413.CrossRefPubMed

15.

Xiao Y, Xu L, Qiu H, Wu B, Lin G, Sun X, et al. Feasibility and short-outcomes of laparoscopic extralevator abdominoperineal excision without changing position for distal rectal cancer. Zhonghua Wai Ke Za Zhi. 2014;52(11):826–30.PubMed

16.

Dalton RS, Smart NJ, Edwards TJ, Chandler I, Daniels IR. Short-term outcomes of the prone perineal approach for extra-levator abdomino-perineal excision (elAPE). Surgeon. 2012;10(6):342–6. https://doi.org/10.1016/j.surge.2011.10.001.CrossRefPubMed

17.

Angenete E, Correa-Marinez A, Heath J, González E, Wedin A, Prytz M, et al. Ostomy function after abdominoperineal resection--a clinical and patient evaluation. Int J Color Dis. 2012;27(10):1267–74. https://doi.org/10.1007/s00384-012-1463-1.CrossRef

18.

Shen Y, Yang T, Zeng H, Meng W, Wang Z. Efficacy of pelvic peritoneum closure after laparoscopic Extralevator Abdominoperineal excision for rectal Cancer. J Gastrointest Surg. 2021;25(10):2668–78. https://doi.org/10.1007/s11605-021-05046-6.CrossRefPubMed

19.

Williams NS, Patel J, George BD, Hallan RI, Watkins ES. Development of an electrically stimulated neoanal sphincter. Lancet. 1991;338(8776):1166–9. https://doi.org/10.1016/0140-6736(91)92031-v.CrossRefPubMed

20.

Samalavicius NE, Klimasauskiene V, Janusonis V, Samalavicius RS, Janusonis T, Dulskas A. Abdominoperineal resection for low rectal neuroendocrine carcinoma after neoadjuvant chemotherapy using the Senhance robotic system with articulating Radia instrument - a video vignette. Color Dis. 2022;24(6):798–9. https://doi.org/10.1111/codi.16065.CrossRef

21.

Shihab OC, Heald RJ, Holm T, How PD, Brown G, Quirke P, et al. A pictorial description of extralevator abdominoperineal excision for low rectal cancer. Color Dis. 2012;14(10):e655–60. https://doi.org/10.1111/j.1463-1318.2012.03181.x.CrossRef

22.

Jensen KK, Rashid L, Pilsgaard B, Møller P, Wille-Jørgensen P. Pelvic floor reconstruction with a biological mesh after extralevator abdominoperineal excision leads to few perineal hernias and acceptable wound complication rates with minor movement limitations: single-Centre experience including clinical examination and interview. Color Dis. 2014;16(3):192–7. https://doi.org/10.1111/codi.12492.CrossRef

23.

Carpelan A, Karvonen J, Varpe P, Rantala A, Kaljonen A, Grönroos J, et al. Extralevator versus standard abdominoperineal excision in locally advanced rectal cancer: a retrospective study with long-term follow-up. Int J Color Dis. 2018;33(4):375–81. https://doi.org/10.1007/s00384-018-2977-y.CrossRef

24.

Kipling SL, Young K, Foster JD, Smart NJ, Hunter AE, Cooper E, et al. Laparoscopic extralevator abdominoperineal excision of the rectum: short-term outcomes of a prospective case series. Tech Coloproctol. 2014;18(5):445–51. https://doi.org/10.1007/s10151-013-1071-2.CrossRefPubMed

25.

Han JG, Wang ZJ, Gao ZG, Xu HM, Yang ZH, Jin ML. Pelvic floor reconstruction using human acellular dermal matrix after cylindrical abdominoperineal resection. Dis Colon Rectum. 2010;53(2):219–23. https://doi.org/10.1007/DCR.0b013e3181b715b5.CrossRefPubMed

26.

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. J Laparoendosc Adv Surg Tech A. 2016;26(1):40–6. https://doi.org/10.1089/lap.2015.0325.CrossRefPubMed

27.

Hellinga J, Khoe PC, van Etten B, Hemmer PH, Havenga K, Stenekes MW, et al. Fasciocutaneous Lotus petal flap for Perineal wound reconstruction after Extralevator Abdominoperineal excision: application for reconstruction of the pelvic floor and creation of a Neovagina. Ann Surg Oncol. 2016;23(12):4073–9. https://doi.org/10.1245/s10434-016-5332-y.CrossRefPubMed

28.

Hultman CS, Sherrill MA, Halvorson EG, Lee CN, Boggess JF, Meyers MO, et al. Utility of the omentum in pelvic floor reconstruction following resection of anorectal malignancy: patient selection, technical caveats, and clinical outcomes. Ann Plast Surg. 2010;64(5):559–62. https://doi.org/10.1097/SAP.0b013e3181ce3947.CrossRefPubMed

29.

Sancho-Muriel J, Ocaña J, Cholewa H, Nuñez J, Muñoz P, Flor B, et al. Biological mesh reconstruction versus primary closure for preventing perineal morbidity after extralevator abdominoperineal excision: a multicentre retrospective study. Color Dis. 2020;22(11):1714–23. https://doi.org/10.1111/codi.15225.CrossRef

30.

Tao Y, Han JG, Wang ZJ. Comparison of perineal morbidity between biologic mesh reconstruction and primary closure following extralevator abdominoperineal excision: a systematic review and meta-analysis. Int J Color Dis. 2021;36(5):893–902. https://doi.org/10.1007/s00384-020-03820-7.CrossRef

31.

Lehtonen T, Räsänen M, Carpelan-Holmström M, Lepistö A. Oncological outcomes before and after the extralevator abdominoperineal excision era in rectal cancer patients treated with abdominoperineal excision in a single Centre, high volume unit. Color Dis. 2019;21(2):183–90. https://doi.org/10.1111/codi.14468.CrossRef

32.

Qiu M, Hu J, Yang D, Cosgrove DP, Xu R. Pattern of distant metastases in colorectal cancer: a SEER based study. Oncotarget. 2015;6(36):38658–66. https://doi.org/10.18632/oncotarget.6130.CrossRefPubMedPubMedCentral

Title: Long-term outcomes of laparoscopic Extralevator Abdominoperineal excision with modified position change for low rectal Cancer treatment
Authors: Shaowei Sun
Shengbo Sun
Xiangyun Zheng
Jiangtao Yu
Wenchang Wang
Qing Gong
Guowei Zhao
Jing Li
Huanhu Zhang
Publication date: 01-12-2022
Publisher: BioMed Central
Keywords: Rectal Cancer
Rectal Cancer
Published in: BMC Cancer / Issue 1/2022
Electronic ISSN: 1471-2407
DOI: https://doi.org/10.1186/s12885-022-10019-2

Webinar | 19-02-2024 | 17:30 (CET)

Keynote webinar | Spotlight on antibody–drug conjugates in cancer

Watch now

Antibody–drug conjugates (ADCs) are novel agents that have shown promise across multiple tumor types. Explore the current landscape of ADCs in breast and lung cancer with our experts, and gain insights into the mechanism of action, key clinical trials data, existing challenges, and future directions.

Dr. Véronique Diéras

Prof. Fabrice Barlesi

Developed by: Springer Medicine

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 1/2022

The survival impact of palliative chemotherapy dose modifications on metastatic colon cancer

Prognostic significance of prognostic nutritional index and systemic immune‐inflammation index in patients after curative breast cancer resection: a retrospective cohort study

FCER1G positively relates to macrophage infiltration in clear cell renal cell carcinoma and contributes to unfavorable prognosis by regulating tumor immunity

Association between the efficacy and immune-related adverse events of pembrolizumab and chemotherapy in non-small cell lung cancer patients: a retrospective study

The effect of Orem-based self-care education on improving self-care ability of patients undergoing chemotherapy: a randomized clinical trial

Dynamic trajectory of platelet counts after the first cycle of induction chemotherapy in AML patients

Keynote webinar | Spotlight on antibody–drug conjugates in cancer