Short-term Outcomes of an Extralevator Abdominoperineal Resection in the Prone Position Compared With a Conventional Abdominoperineal Resection for Advanced Low Rectal Cancer: The Early Experience at a Single Institution (original) (raw)
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International Journal of Colorectal Disease, 2018
Background Extralevator abdominoperineal excision (ELAPE) probably improves the oncological quality of low rectal cancer surgery, as compared to standard abdominoperineal excision (SAPE), possibly due to lower rates of accidental perioperative bowel perforations and lower rates of circumferential resection margin (CRM) positivity. The procedure may however, increase post-operative morbidity. The aim of this paper was to compare outcomes of SAPE and ELAPE for carcinoma of the lower rectum. Methods This is a retrospective study of patients operated on at a single colorectal unit, in a provincial hospital in Denmark. Consecutive patients undergoing abdominoperineal excision (APE) between 2006 and 2012 were included. During this period, a gradual paradigm shift occurred towards adopting ELAPE, although both procedures were performed without a clear selection strategy. We reviewed medical records, including the pathological and radiological data. Patients were divided into two groups, SAPE and ELAPE. Main endpoints were rates of positive CRM, intraoperative bowel perforations, local recurrence rate, length of hospital stay, operative time, and perineal woundrelated complications. Results One hundred and seven patients were included (median age 68 years, range 42-88 years; men = 72). The SAPE group included 39 patients and the ELAPE group 68 patients. Intraoperative bowel perforation was significantly lower in the ELAPE group (20.5 % SAPE vs 7.4 % EL-APE, p = 0.045). The rate of positive CRM was not significantly different (2.6 % SAPE vs 7.4 % ELAPE, p = 0.413). The local recurrence rate was not statistically significant (17.9 % SAPE vs 13.2 % ELAPE, p = 0.513). In the ELAPE group, operative time and hospital stay were significantly longer than the SAPE group (p = 0.001 and p = 0.021, respectively). Conclusions We found low rates of positive CRM after APE compared with the literature. ELAPE did not reduce these rates, and although the local recurrence rate was lower, this did not reach statistical significance. ELAPE has significantly reduced the rate of intraoperative bowel perforation and can optimize low rectal cancer surgery in selected patients. We found no significant differences between the two procedures regarding wound-related complications. A tailored approach and a larger trial with longer follow-up are needed to evaluate long-term results.
Colorectal Disease, 2014
The conventional, synchronous combined, abdomino-perineal excision (APE) for low rectal cancer is associated with intra-operative tumour perforation and tumour involved circumferential resection margins (CRM+). Several studies have demonstrated worse rates of local recurrence and survival after APE than after low anterior resection (LAR). Extra-levator APE (ELAPE) in the prone position may reduce the risk of perforation and involved resection margins and may therefore improve outcome. The aim of this study was to report the outcome after the introduction of ELAPE in a prospective study of consecutive patients from a single colorectal unit.
Journal of Coloproctology, 2018
Introduction In recent years, a standardized surgical approach for low rectal cancer was proposed and adopted in many centres. The extralevator abdominoperineal excision introduce an extensive resection of the pelvic floor and demonstrated superiority if the procedure is done in the prone jack-knife position, especially regarding intraoperative perforation and circumferential resections margins. The aim of this study is to evaluate the surgical and oncological short-term outcomes of prone extralevator abdominoperineal excision. Methods All patients registered in our institution from January 2003 to January 2015 who underwent abdominoperineal resection or prone extralevator abdominoperineal excision for low rectal cancer after preoperative chemoradiation were retrospectively included from prospective maintained data base and were compared regarding surgical and oncological outcomes. Results Eighty-nine patients underwent curative intent resections. Abdominoperineal resection was perf...
Annals of medicine and surgery (2012), 2018
The use of abdominoperineal resection (APR) in the management of low rectal cancer has received criticism over high rates of incomplete resection due to tumour involvement at the circumferential resection margin. Extralevator abdominoperineal resection has been advocated as a means of improving complete resection. However, Extralevator abdominoperineal resection can result in increased cost, morbidity and reduced quality of life.This study aims to assess the histological features and long-term outcomes of patients undergoing standard abdominoperineal resection and discusses the potential role of Extralevator abdominoperineal resection in this cohort. A retrospective review of a prospectively maintained database of rectal cancer patients at a single centre. Patients undergoing standard APR were included from 01/06/2007 to 31/05/2012 to allow a minimum 2-year follow-up. Data was collected on age, gender, co-morbidity, pre-operative stage, neo-adjuvant therapy, histology, recurrence an...
Turkish Journal of Surgery, 2016
INTRODUCTION As originally described by Miles (1), abdominoperineal excision (APE) has long been the standard treatment for tumors of the middle and lower rectum. It achieves the greatest possible distal margin of resection by removing the anus in continuity with the rectum. Total mesorectal excision (TME), recommended by Heald et al. (2), has led to a decrease in perineal amputation numbers and has become the oncologic standard in the last 30 years. However, the rates of circumferential resection margin (CRM) positivity and of intraoperative perforation (IOP) is higher in abdominoperineal excision as compared to anterior excision. Recently, Holm's studies have generated a renewed interest on the abdominoperineal excision technique (3). In this operation, the levator muscles are excised from their origins on the pelvic side walls and removed en bloc with the tumor. The aim of this approach is to reduce both the rate of CRM positivity and IOP, which are associated with high rates of local recurrence and poor survival outcomes in patients with rectal cancer (4-8). Although there are many similarities between what Miles has previously described and what Holm recently defined, there are major differences that should be recognized e.g. Miles did not use the prone position and did not undertake a total mesorectal excision. This study was designed to compare the results of extralevator abdominoperineal excision (ELAPE) with the conventional APE approach. MATERIAL AND METHODS Patients Between November 2008 and December 2011, 25 patients with low rectal cancer underwent ELAPE in the prone jack-knife position. Nine patients (36.0%) received neoadjuvant long-term chemoradiotherapy. A consecutive series of 56 patients that were treated by conventional APE in the lithotomy position between 2003 and 2008 were selected from our prospectively collected rectal cancer database for comparison as a historical cohort. Eight of these patients (14.3%) had received neoadjuvant chemoradiotherapy. Chemoradiation indication was defined as T3-4/N+ tumors for both group of patients. Surgeries were performed at 6 to 8 weeks after neoadjuvant therapy. Low rectal cancer was defined as tumors in the lower third of the rectum. Digital rectal examination, plain chest x-ray, colonoscopy, abdominal ultrasonography, and computerized tomography were used for staging both before and after chemoradiotherapy. All operations were performed by the same consultant surgeon who had undergone additional training on the extralevator technique. All patients were followed up prospectively. Patient informed consent was obtained for the operation presented in the study. Our study has been
Journal of the Egyptian National Cancer Institute, 2013
Introduction: This study aimed to investigate local control and survival rates following abdominoperineal resection (APR) compared with low anterior resection (LAR) in lower and middle rectal cancer. Methods: In this retrospective study, 153 patients with newly histologically proven rectal adenocarcinoma located at low and middle third that were treated between 2004 and 2010 at a tertiary hospital. The tumors were pathologically staged according to the 7th edition of the American Joint Committee on Cancer (AJCC) staging system. Surgery was applied for 138 (90%) of the patients, of which 96 (70%) underwent LAR and 42 were (30%) treated with APR. Total mesorectal excision was performed for all patients. In addition, 125 patients (82%) received concurrent (neoadjuvant, adjuvant or palliative) pelvic chemoradiation, and 134 patients (88%) received neoadjuvant, adjuvant or concurrent chemotherapy. Patients' follow-up ranged from 4 to 156 (median 37) months. Results: Of 153 patients, 89 were men and 64 were women with a median age of 57 years. One
Oncologic superiority of extralevator abdominoperineal excision for low rectal cancer
Archive of Oncology, 2013
Background: Rectal cancer treatment has been dramatically improved during the last two decades in terms of a lower local recurrence rate and prolonged survival. This improvement was achieved mainly due to a better surgical technique (implementation of a total mesorectal excision-TME) and neoadjuvant chemo and radio therapy. A more radical approach to abdominoperineal excision, extralevator abdominoperineal excision technique in the prone Jackknife position, may improve the oncological outcome. The aim of this study is to show our early experience by using extralevator abdominoperineal excision. Methods: Extralevator abdominoperineal excision has been used routinely at Oncology Institute of Vojvodina since 2011. In the last 23 months, we had 11 operations. Clinical and pathological data were obtained from operative protocols, histopathological data and patients? medical history. Results: An audit of results showed reduced rate of intra-operative perforations and circumferential resec...
South African Journal of Surgery, 2021
BACKGROUND: Extralevator abdominoperineal excision (ELAPE) is a surgical technique that is indicated for low rectal cancer where sphincter preservation is not possible. Compared to conventional abdominoperineal excision major advantages of ELAPE are the risk reduction of intraoperative bowel perforation and positive circumferential margin which lead to a better oncological outcome. The aim of this study was to present our results in ELAPE surgery METHODS: From February 2011 to February 2015, 40 patients underwent surgery for low rectal cancer at the Oncology Institute of Vojvodina. The collected data included sex, age, preoperative staging, neoadjuvant treatment, operative time, rate of intraoperative bowel perforation, rate of positive circumferential resection margins, histopathological analysis, postoperative mortality, tumour, node and metastasis (TNM) classification, local recurrence (LR) rate and presence of distant metastases RESULTS: Positive circumferential margin was found...
Abdominoperineal Resections for Rectal Cancer: Reducing the Risk of Local Recurrence
Seminars in Colon and Rectal Surgery, 2010
Treatment of patients with distal and locally advanced rectal cancer is challenging. In many series, abdominoperineal resection for distal rectal cancer is related to a high percentage of local recurrences. Some authors relate this high percentage of local recurrence to the abdominoperineal resection itself, considering it to be a poor operation for distal rectal cancer, while other authors relate it to technically inadequate resections: a high incidence of positive circumferential resection margins is seen because of coning of the specimen when the mesorectal fascia is followed or because of inadvertent perforation of the rectal wall. In many other series an acceptable low percentage of local recurrence after abdominoperineal resection is reported. These authors have consistently advocated a wide perineal resection, resecting the levator ani muscle en bloc with the specimen. These enhanced perineal resections are not standardized in the surgical world. We reviewed the literature and describe technical considerations for performing the perineal phase in abdominoperineal resection to reduce circumferential resection margin positivity and local recurrence rates. Semin Colon Rectal Surg 21:81-86