Early experience with laparoscopic extralevator abdominoperineal excision within an enhanced recovery setting: analysis of short-term outcomes and quality of life

Abstract

INTRODUCTION Conventional abdominoperineal excision for low rectal cancer has a higher local recurrence and reduced survival compared to anterior resection. An extralevator abdominoperineal excision (ELAPE) may improve outcome through removal of increased tissue in the distal rectum. Experience with ELAPE is limited and no studies have reported on quality of life (QOL) following this procedure. We describe a minimally invasive approach to ELAPE within an enhanced recovery programme, and present short-term results and QOL analyses. METHODS All laparoscopic ELAPEs were included in a prospective database. Demographics, intra-operative and post-operative outcomes were evaluated. Postoperative QOL was assessed using the European Organisation for Research and Treatment of Cancer (EORTC) questionnaires QLQ-C30 and QLQ-CR29. RESULTS Thirteen laparoscopic ELAPEs were performed over a two-year period. All were enrolled in an enhanced recovery programme. The median age was 76. The median tumour height was 20mm (range: 0–50mm) from the dentate line and all patients received neoadjuvant treatment. The median duration of surgery was 300 minutes (range: 120–488 minutes), the mean blood loss was 150ml and one procedure was converted to open surgery. There was no circumferential resection margin involvement or tumour perforation. The median duration of use of intravenous fluid, patient controlled analgesia and urinary catheterisation was 2, 2 and 2.5 days respectively and the median length of hospital stay was 7.5 days. Two patients developed perineal wound dehiscence. QOL analysis revealed high global health status (90.8), physical (91.3), emotional (98.3) and social functioning (100) scores, which compared favourably with EORTC reference values and published QOL scores following conventional abdominoperineal excision. CONCLUSIONS Laparoscopic ELAPE within an enhanced recovery setting is a feasible and safe approach with acceptable short-term outcomes and post-operative quality of life.

Reconstruction of the perineum following extralevator abdominoperineal excision for carcinoma of the lower rectum: a systematic review

“…The results of the five studies which reported biological mesh repair are shown in Table 4. In a porcine mesh was used in four [19,20,26,27] and human mesh in one [17]. Data for each repair method were pooled.…”

Prospective controlled study of the safety and oncological outcomes of ELAPE procure with definitive anatomic landmarks versus conventional APE for lower rectal cancer

“…In fact, the previous procedure named as ELAPE was mixed with cases that underwent "cylindrical APE". 15,16 The fat tissue of ischiorectal fossa might provide the support force and decrease the tension of the perineal wound. Our preliminary results showed that the ELAPE procedure, dissecting along the anatomic landmarks of outface of levator, could decrease the perineal would complication rate even by direct suture compared with conventional APE procedures.…”

Perineal Wound Healing After Abdominoperineal Resection for Rectal Cancer

“…23,31 the biological meshes consisted in 4 studies of crosslinked porcine meshes 23,26,27,39 and 1 study of non-crosslinked porcine meshes. 24,28,31,39 if only 2 studies were included in which all patients underwent neoadjuvant radiotherapy, perineal wound problems after eaPR occurred in a pooled percentage of 7.3% (95% Ci, 1.5-29.3; i 2 = 0%, χ 2 = 0.81; n = 20). 16,24 Perineal wound problems after eaPR and in at least 75% of the patients treated with radiotherapy occurred in a pooled percentage of 24.3% (95% Ci, 14.1-38.6; i 2 = 21%, χ 2 = 0.28; 4 studies, n = 78).…”

“…28 in 1 study, both cross-linked and non-cross-linked meshes were used, 31 and, in 2 studies, human dermal meshes were used. 24,31 Perineal hernias after biological mesh closure following eaPR were reported in a pooled percentage of 8.2% (95% Ci, 4.8-13.6; i 2 = 0%, χ 2 = 0.45; 6 studies, n = 188). 24,28,31,39 if only 2 studies were included in which all patients underwent neoadjuvant radiotherapy, perineal wound problems after eaPR occurred in a pooled percentage of 7.3% (95% Ci, 1.5-29.3; i 2 = 0%, χ 2 = 0.81; n = 20).…”