Surgical and oncological short-term outcomes of prone extralevator abdominoperineal excision for low rectal cancer

Abstract

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 performed in 67 patients and prone extralevator abdominoperineal excision in 22 patients. There were no statistical significant differences between groups regarding pathological stage, median number of harvested lymph node, intraoperative perforation, circumferential resections margins involvement and recurrence rates. Surgical outcomes were statistically different between groups. Twenty-six patients (29%) developed perineal complications, 21% of the abdominoperineal resection patients and 55% of the prone extralevator abdominoperineal excision ( p < 0.001). Most of these complications were due to delayed perineal wound healing (12.4%), and wound abscesses (4.5%). However, the readmission rate and median length of hospital stay was higher in the abdominoperineal resection group ( p < 0.001). Conclusion Prone extralevator abdominoperineal excision is comparable to standard abdominoperineal resection. It was associated to a decrease in length of hospital stay and readmission rate, although more perineal complications occurred. We cannot recommend it as a standard technique for all low rectal cancer. Notwithstanding, prone extralevator abdominoperineal excision can be considered a more radical approach when there is sphincter complex or levators muscles invasion.

Brazilian society of surgical oncology: Guidelines for the surgical treatment of mid‐low rectal cancer

“…This new technique showed better oncological results by minimizing “surgical waisting” at the level of the puborectal muscle, which is the main cause of positive CM and tumoral or mesorectal perforations 57 . The reason for the superiority of the oncological results and the radicality of the new technique is that in APEs, the levator muscles and the mesorectum are removed en bloc together with the anal canal 58 …”

“…57 The reason for the superiority of the oncological results and the radicality of the new technique is that in APEs, the levator muscles and the mesorectum are removed en bloc together with the anal canal. 58 Although the results of recently published systematic reviews comparing ELAPE and conventional APE are not yet conclusive with regard to the superiority of one technique over the other, [59][60][61][62][63][64] ELAPE may be indicated in the treatment of low rectal cancer to avoid the adverse oncological results of inadvertent perforations and positive circumferential resection margins (CRMs) that are associated more closely with the conventional technique. Surgery is indicated mainly for tumors of the lower and ultra-low rectum, especially when the involvement of levator ani muscles are suspected or confirmed.…”

“…In addition, the pronated position may facilitate the performance of a perineal resection because it offers better ergonomics and a better visualization of the dissection planes, especially for tumors located in the anterior rectal wall. 56,58,65…”

“…165 The complication rate after ELAPE can reach up to 55% when combined with neoadjuvant radiotherapy. 58 Although the direct comparison between flap reconstruction and primary closure is difficult to interpret because of patient selection biases and the heterogeneous group of flaps used in practice, a recent systematic review and meta-analysis that included 18 studies with analysis of 17 913 patients (1567 with flap reconstructions and 16 346 with primary closure) showed that the group subjected to primary closure had a higher overall complication rate and a higher rate of major complication. 3 Conversely, the group undergoing myocutaneous flap reconstruction was associated with a longer operative time, increased risk of perineal wound dehiscence, deep surgical site infection, enterocutaneous fistula, and reoperation.…”

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“…In the last JCOL number, the National Cancer Institute presents a retrospective series of ELAPE performed from 2003 to 2015, confronting fifty patients undergoing standard APEs against 22 ELAPE. 15 All patients received nCRT and were operated in the prone position. According to the authors, ELAPE was indicated selectively in cases of sphincter complex or levator invasion, and a routine indication could not be established due to the increased perineal complications.…”