The application of extralevator abdomino-perineal excision (ELAPE) and total mesorectal excision has improved the prognosis of rectal cancer. However, compared with anterior resection for rectal cancer, the circumferential resection margin (CRM) positive rate and intraoperative perforation (IOP) rate are still high. The ELAPE can reduce the CRM positive rate and IOP rate, therefore reduce postoperative local recurrence rate and increase the survival rate of patients. The disadvantage of its trauma, longer operative time, and higher perineum complication in ELAPE is controversial. This review mainly discusses the key points of operative procedure, advantages and disadvantages, research status and development prospects of ELAPE.
Digestive System Surgical Procedures ; methods ; Humans ; Mesentery ; surgery ; Perineum ; surgery ; Prognosis ; Rectal Neoplasms ; surgery ; Rectum ; surgery

Abdomen/surgery* ; Humans ; Laparoscopy/methods* ; Pelvic Floor/surgery* ; Perineum/surgery* ; Proctectomy ; Rectal Neoplasms/surgery*

The introduction of total mesorectal excision and the use of neoadjuvant therapy has led to improved prognosis of rectal cancer. Circumferential resection margin(CRM) is one of the main prognostic factors. Positive CRM is associated with adverse prognosis. It is of clinical significance to clarify different patterns of CRM involvement, the exact definitions, and associated factors. TME quality assessment and accurate determination of CRM involvement are crucial in the pathologic examination of rectal cancer. Extended abdominoperineal resection during which the levator muscles are resected en bloc with the anus and lower rectum may be superior than conventional abdominoperineal resection (APR) in terms of obtaining a negative CRM.
Humans ; Perineum ; pathology ; surgery ; Prognosis ; Rectal Neoplasms ; diagnosis ; pathology ; surgery ; Rectum ; pathology ; surgery

OBJECTIVETo report a case of APPEAR performed using a laparoscopic-assisted approach.

METHODSA laparoscopic-assisted APPEAR was performed with end-to-end anastomosis on October 12, 2010 for a patient with low rectal cancer who received neoadjuvant chemoradiation. After total mesorectal excision was completed laparoscopically, a crescent-shape incision was then made in the middle perineum. The distal part of the rectum was dissected with electrocautery. An double-stapling end-to-end anastomosis was performed after transaction of the rectum.

RESULTSTotal operative time was 195 minutes. The perineal approach cost 30 minutes. The estimated blood loss was 50 ml. First stoma output with flatus was on postoperative day 3, and the patient resumed liquid diet. The patient was discharged on postoperative day 7. There were no complications including pelvic sepsis, perineal infection, or anastomotic leak.

CONCLUSIONThe APPEAR procedure can be performed safely with the abdominal approach completed laparoscopically.

Humans ; Laparoscopy ; Male ; Middle Aged ; Perineum ; surgery ; Rectal Neoplasms ; surgery ; Rectum ; surgery

Abdominoperineal excision (APE) procedure is still the main approach to low rectal cancer patients with short distance from the anal verge, obvious invasion of adjacent organs and narrow pelvis. Although the principle of TME (total mesorectal excision) needs to be obeyed in the abdominal phase of APE procedure, it does not reach the consensus for the perineal phase. The important reason is the lack of definite anatomic landmarks in the perineal phase, thus the standardization of the procedure remains hard. In 2014, Swedish surgeon, professor Holm, proposed the new conception to classify the APE procedure into three types, which were intersphincteric APE, the extralavator APE and the ischioanal APE, based on the anatomic landmarks with perineal fascias, nervous and blood vessels. In this paper, we combine the review of literatures and our experiences of treatment to introduce and discuss these three types of APE procedures. This new concept is based on anatomic landmarks which makes the category of APE procedure more definitive, the anatomic dissection more clear and the standardization and adoption of APE procedure much easier.
Abdomen ; surgery ; Anatomic Landmarks ; Digestive System Surgical Procedures ; Humans ; Perineum ; surgery ; Rectal Neoplasms ; surgery

It has been reported that the conventional abdominoperineal excision has the disadvantages of higher rates of positive circumferential resection margin and intraoperative bowel perforation, which affect the prognosis. The technique of extralevator abdominoperineal excision proposed by Holm et al is used to overcome these disadvantages. But this new concept of abdominoperineal excision causes other new problems, such as increased complexity, major trauma and more complications. With further studies, the advanced knowledge about the indications, modifications and complications of this technique has been obtained by the domestic and overseas surgeons. This article reviews the characteristics of extralevator abdominoperineal excision and its indications, research progress and major associated complications.
Digestive System Surgical Procedures ; methods ; Humans ; Perineum ; surgery ; Prognosis ; Rectal Neoplasms ; surgery ; Rectum ; surgery

Abominoperineal resection (APR) is the main approach of lower rectal cancer treatment. Recently, it was found that conventional APR had higher incidence rate of positive circumferential resection margin(CRM) and intraoperative perforation (IOP), which was the crucial reason of local recurrence and worse prognosis. Extralevator abdominoperineal excision(ELAPE) procedure was proposed by European panels including surgeons, radiologist and pathologists, and considered to lower the positive rates of CRM and IOP. Definitive surgical planes and anatomic landmarks are the cores of this procedure, which are the prerequisite for the guarantee of safety and smoothness of surgery. To realize the anatomy of muscles, fascias, blood vessels and nervous of perineal region is the base of carrying out ELAPE procedure. In this paper, we introduce the key anatomy related to ELAPE procedure and summarize the principle of ELAPE procedure as "two planes and four landmarks", which will be beneficial to the popularization and application.
Abdomen ; surgery ; Digestive System Surgical Procedures ; Humans ; Perineum ; surgery ; Rectal Neoplasms ; surgery

Objective: To compare the morbidity of perineum-related complication between biological mesh and primary closure in closing pelvic floor defects following extralevator abdominoperineal excision (ELAPE). Methods: A literature search was performed in PubMed, Embase, Cochrane Library, Web of Science, Wanfang database, Chinese National Knowledge Infrastructure, VIP database, and China Biological Medicine database for published clinical researches on perineum-related complications following ELAPE between January 2007 and August 2020. Literature inclusion criteria: (1) study subjects: patients undergoing ELAPE with rectal cancers confirmed by colonoscopy pathological biopsy or surgical pathology; (2) study types: randomized controlled studies or observational studies comparing the postoperative perineum-related complications between the two groups (primary perineal closure and reconstruction with a biological mesh) following ELAPE; (3) intervention measures: biological mesh reconstruction used as the treatment group, and primary closure used as the control group; (4) outcome measures: the included literatures should at least include one of the following postoperative perineal complications: overall perineal wound complications, perineal wound infection, perineal wound dehiscence, perineal hernia, chronic sinus, chronic perineal pain (postoperative 12-month), urinary dysfunction and sexual dysfunction. Literature exclusion criteria: (1) data published repeatedly; (2) study with incomplete or wrong original data and unable to obtain original data. Two reviewers independently performed screening, data extraction and assessment on the quality of included studies. Review Manager 5.3 software was used for meta-analysis. The mobidities of perineum-related complications, including overall perineal wound (infection, dehiscence, hernia, chronic sinus) and perineal chronic pain (postoperative 12-month), were compared between the two pelvic floor reconstruction methods. Finally, publication bias was assessed, and sensitivity analysis was used to evaluate the stability of the results. Results: A total of five studies, including two randomized controlled studies and three observational controlled studies, with 650 patients (399 cases in the biological mesh group and 251 cases in primary closure group) were finally included. Compared with primary closure, biological mesh reconstruction had significantly lower ratio of perineal hernia (RR=0.37, 95%CI: 0.21-0.64, P<0.001). No significant differences in ratios of overall perineal wound complication, perineal wound infection, perineal wound dehiscence, perineal chronic sinus and perineal chronic pain (postoperative 12-month) were found between the two groups (all P>0.05). Conclusion: Compared with primary closure, pelvic floor reconstruction following ELAPE with biological mesh has the advantage of a lower incidence of perineal hernia.
Humans ; Pelvic Floor/surgery* ; Perineum/surgery* ; Proctectomy ; Rectum/surgery* ; Surgical Mesh

OBJECTIVEThe aim of this study is to introduce a new type of cross suture in closing peritoneal incision after abdominoperineal resection (APR) for rectal cancer.

METHODSThis new type of cross suture was firstly proposed and applied in a small cohort in our hospital. In this study, we reported its efficacy and safety. From Feb 2018 to May 2018, 8 cases (5 male, 3 female) of rectal cancer from the Sixth Affiliated Hospital of Sun Yat-Sen University receiving APR with new cross suture, were analyzed retrospectively. The median age was 45.5 years and the median distance between tumor distant border and anal verge was 2.5 cm. Three patients received neoadjuvant therapy. The detailed procedures of new cross suture are listed as follows: (1)Marking the margin: an oval circle around the anus is designed. The anterior incision reaches middle peritoneum, and the posterior incision is close to the coccyx apex. Two triangle incisions are made at the 3 and 9 point directions of lithotomy position, respectively. (2)Tumor resection: purse string suture is made to close the anus, then cut open the peritoneal skin and fatty tissue according to the principles of total mesorectal resection(TME). Reserve the fatty tissue in the ischiorectal space as much as possible. R0 resection is required. Approximate the pelvic muscles and fatty tissue in the ischiorectal space to reduce residual cavity; (3)Close the peritoneal incision by absorbable stitch: Two intracutaneous stiches in the anterior and posterior parts of the incision are made. Then four intracutaneous circle stiches along the two triangles are performed. The incision appears like a "cross" after tighting these stiches. A drainage was placed in presacral space.

RESULTSAll procedures were successfully conducted in 8 cases and no severe complication occurred after surgery. The median volume of whole surgery bleeding was 100 ml and the median time of the peritoneal surgery was 50 minutes. The median volume of drainage was 95 ml in the first 3 postoperative days. The median time of drainage removal was 5 days. Seven cases received primary wound healing without superficial(wound infection and dehiscence) or deep perineal wound(perineal abscess and presacral abscess) complications. Presacral abscess occurred in one case. The median time of primary wound healing was 11 days.

CONCLUSIONThe new cross suture for perineal incision after APR procedure is simple with satisfying efficacy. The drainage of residue cavity in the presacral space is complete. The cross suture reduces the time of primary wound healing and decreases scars.

Female ; Humans ; Male ; Middle Aged ; Perineum ; surgery ; Rectal Neoplasms ; surgery ; Retrospective Studies ; Suture Techniques ; Sutures

OBJECTIVETo explore the feasibility and safety of abdominosacral resection for patients with locally advanced primary low rectal cancer.

METHODSA total of 97 low rectal cancer patients were amenable to surgery but not anal sphincter preservation were included in this study and divided into the abdominoperineal resection group(n=49) and abdominosacral resection group(n=48) according to the order of alternative admission time between June 2010 and January 2012. Intraoperative and postoperative parameters were compared between the two groups.

RESULTSThe surgery went well and no perioperative mortality in the two groups. Compared with abdominoperineal resection group, the operative time of abdominosacral resection group(including the 2nd position adjustment time) was longer[(188±45) min vs. (143±48) min, P=0.000], the unexpected prostate or vagina injury incidence was lower [0 vs. 14.3%(7/49), P=0.032), and the perineal wound infection rate was lower [2.1% (1/48) vs. 18.4% (9/49), P=0.040].

CONCLUSIONAbdominosacral excision is feasible and safe for patients with locally advanced primary low rectal cancer.

Abdomen ; surgery ; Digestive System Surgical Procedures ; Humans ; Perineum ; Rectal Neoplasms ; surgery ; Treatment Outcome