Extralevator abdominoperineal excision for rectal cancer with biological mesh for pelvic floor reconstruction

Abstract

GoalTo share our experience of extra-levator abdominoperineal excision (ELAPE) for low rectal cancer, focusing on perineal repair with biological mesh.MethodsWe retrospectively analyzed medical records of all patients with low rectal cancer who underwent the ELAPE procedure using biological mesh for perineal repair at the Gastrointestinal Surgery of Nanjing Drum Power Hospital between January 2013 and September 2015. All patients were closely followed up to now.ResultsA total of 17 patients underwent ELAPE for low rectal cancer was screened. Of these, 15 patients had primary rectal cancer, 1 had local recurrent rectal cancer, and 1 had malignant melanoma. All patients underwent ELAPE successfully without intestinal perforation and got stage I healing in perineum wound without incision infection, dehiscence, cystocele perinealis, urethral dysfunction or intestinal obstruction. Perineum wound hematoma developed in just one patient and had successful percutaneous drainage in one week. During the follow-up, there was no recurrence, perineal hernia, sexual dysfunction, urinary retention, or bowel obstruction. Two patients described slight pain in the sacrococcygeal region without special handling.ConclusionELAPE is applicable to low rectal cancer. Biological mesh reconstruction of perineal defect seems to be safe and effective, with high patient compliance.

European Society of Coloproctology guidance on the use of mesh in the pelvis in colorectal surgery

“…Two studies had a considerable range in the timing of follow‐up (Harries et al [96], between 1 and 85 months; Peacock et al [101]: between 1 and 54 months). There was also a study with no clear follow‐up timing [100].…”

A low incidence of perineal hernia when using a biological mesh after extralevator abdominoperineal excision with or without pelvic exenteration or distal sacral resection in locally advanced rectal cancer patients

“…Twenty-two of them (39.3%) received preoperative radiotherapy [ 18 ]. On the other hand, none of the patients ( n = 17) in the study by Ge et al, developed perineal complications after the use of a biological mesh [ 19 ]. However, the patients in this study did not receive preoperative radiotherapy [ 19 ].…”

“…On the other hand, none of the patients ( n = 17) in the study by Ge et al, developed perineal complications after the use of a biological mesh [ 19 ]. However, the patients in this study did not receive preoperative radiotherapy [ 19 ]. In preoperatively irradiated patients who had APE with primary closure, wound complications occur in 40–45% [ 4 – 6 ].…”

Application of modified primary closure of the pelvic floor in laparoscopic extralevator abdominal perineal excision for low rectal cancer

“…Various methods have been developed for perineal wound healing after ELAPE. Of these, perineal closure with myocutaneous flaps, biological or synthetic mesh placement, and omentoplasty with perineal closure are currently the most widely performed[ 8 - 12 ]. Myocutaneous flaps can be obtained by various approaches, including gluteal rotation/advancement flaps[ 16 ], inferior gluteal artery myocutaneous island transposition flaps (IGAM)[ 17 ], transverse rectus/vertical rectus abdominis (TRAM/VRAM)[ 18 , 19 ], and gracilis[ 20 ].…”

“…Thus, how to reconstruct the pelvic floor and close the perineum after massive resection has become a major concern and challenge in laparoscopic ELAPE (LELAPE). The established reconstruction methods include: primary perineal closure, omentoplasty, biological or synthetic mesh placement, myocutaneous flaps, and negative wound pressure therapy[ 8 - 12 ]. These methods all have their own advantages as well as restrictions, and no consensus has been reached so far.…”