Transperineal minimally invasive APE: preliminary outcomes in a multicenter cohort

Abstract

Background Abdominoperineal excision (APE) for rectal cancer is associated with a relatively high risk of positive margins and postoperative morbidity, particularly related to perineal wound healing problems. It is unknown whether the use of a minimally invasive approach for the perineal part of these procedures can improve postoperative outcomes without oncological compromise. The aim of this study was to evaluate the feasibility of minimally invasive transperineal abdominoperineal excision (TpAPE) Methods This multicenter retrospective cohort study included all patients having TpAPE for primary low rectal cancer. The primary endpoint was the intraoperative complication rate. Secondary endpoints included major morbidity (Clavien-Dindo ≥ 3), histopathology results, and perineal wound healing. Results A total of 32 TpAPE procedures were performed in five centers. A bilateral extralevator APE (ELAPE) was performed in 17 patients (53%), a unilateral ELAPE in 7 (22%), and an APE in 8 (25%). Intraoperative complications occurred in five cases (16%) and severe postoperative morbidity in three cases (9%). There were no perioperative deaths. A positive margin (R1) was observed in four patients (13%) and specimen perforation occurred in two (6%). The unilateral extralevator TpAPE group had worse specimen quality and a higher proportion of R1 resections than the bilateral ELAPE or standard APE groups. The rate of uncomplicated perineal wound healing was 53% (n = 17) and three patients (9%) required surgical reintervention. Conclusions TpAPE seems to be feasible with acceptable perioperative morbidity and a relatively low rate of perineal wound dehiscence, while histopathological outcomes remain suboptimal. Additional evaluation of the viability of this technique is needed in the form of a prospective trial with standardization of the procedure, indication, audit of outcomes and performed by surgeons with vast experience in transanal total mesorectal excision.

Transanal total mesorectal excision for abdominoperineal resection is associated with poor oncological outcomes in rectal cancer patients: A word of caution from a multicentric Canadian cohort study

“…Nonetheless, the overall results would be deemed unacceptable for any surgical approach for rectal cancer, and in this case there is a possible association with incomplete specimens which is in keeping with previous findings [19][20][21][22]. In contrast to the taTME-APR results the oncological outcomes for those who underwent taTME-LAR at the same centres were in keeping with those for conventional approaches.…”

Author’s reply to “The nerve of blaming the curve”

“…We thank Dr. Orangio, Dr. Bergamaschi and colleagues for their comments on our article “Transperineal minimally invasive APE: preliminary outcomes in a multicenter cohort” [ 1 , 2 ]. It is true that the transanal minimally invasive surgery (TAMIS) approach to an (extralevator) abdominoperineal excision is a new surgical concept and requires detailed assessment to judge its real impact and potential clinical benefit.…”

Essential updates 2020/2021: Advancing precision medicine for comprehensive rectal cancer treatment

“… 42 Transperineal APE (TpAPE) has emerged as an advanced approach to TaTME, and it can address the technical difficulty encountered during a perineal procedure (Figure 2 ). 43 , 44 …”