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Laparoscopic translevator approach to abdominoperineal resection for rectal adenocarcinoma: feasibility and short-term oncologic outcomes

Abstract

Background

The extra-levator approach to abdominal perineal resection (APR) was developed in order to reduce the rates of positive circumferential resection margin. This approach, however, is associated with significant morbidity. We postulate that a less radical resection of the levators done laparoscopically could significantly decrease the rate of perineal complications while ensuring an oncologically adequate specimen. To date, to our knowledge, there are no reports in the literature describing a laparoscopic translevator approach for APR. The purpose of this study is to describe our initial experience with this approach and assess our short-term oncologic and clinical outcomes.

Methods

This is a retrospective study of patients who underwent laparoscopic APR with intra-abdominal levator transection for rectal cancer from 2012 to 2014 at a single tertiary care institution. Main outcome measures include: perineal flap rates, post-operative complications, length of stay, distance from tumour to circumferential resection margin, R0 status, and disease recurrence. Data are presented as median (interquartile range) unless otherwise noted.

Results

Seventeen cases were identified. Patient age was 61 (range 34–75), and 59 % were male. Pre-operative distance of the tumour from the anal verge was 2.6 cm (0.4–3.9). Post-operative length of stay was 4 (4–6) days. One patient required a perineal flap for reconstruction. Four patients (22 %) had perineal complications (three wound infections and one hernia). No patients reported sexual dysfunction, and one (5 %) developed urinary retention. Five (29 %) patients had a complete pathological response. The circumferential resection margin was 1.5 (0.8–2.5) cm, with no positive margins reported. The number of retrieved lymph nodes was 12 (range 2–30). Follow-up was 9.7 months (range 20 days–23 months), during which one patient developed recurrent disease.

Conclusions

This study describes a novel surgical approach to APR that has the potential to both decrease perineal complications and provide excellent oncologic results.

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References

  1. 1.

    Nissan A, Guillem JG, Paty PB, Douglas Wong W, Minsky B, Saltz L, Cohen AM (2001) Abdominoperineal resection for rectal cancer at a specialty center. Dis Colon Rectum 44:27–35 (discussion 35–26)

  2. 2.

    Bernstein TE, Endreseth BH, Romundstad P, Wibe A (2009) Circumferential resection margin as a prognostic factor in rectal cancer. Br J Surg 96:1348–1357

  3. 3.

    Kennelly RP, Rogers AC, Winter DC (2013) Multicentre study of circumferential margin positivity and outcomes following abdominoperineal excision for rectal cancer. Br J Surg 100:160–166

  4. 4.

    Kelly SB, Mills SJ, Bradburn DM, Ratcliffe AA, Borowski DW (2011) Effect of the circumferential resection margin on survival following rectal cancer surgery. Br J Surg 98:573–581

  5. 5.

    den Dulk M, Marijnen CA, Putter H, Rutten HJ, Beets GL, Wiggers T, Nagtegaal ID, van de Velde CJ (2007) Risk factors for adverse outcome in patients with rectal cancer treated with an abdominoperineal resection in the total mesorectal excision trial. Ann Surg 246:83–90

  6. 6.

    How P, Shihab O, Tekkis P, Brown G, Quirke P, Heald R, Moran B (2011) A systematic review of cancer related patient outcomes after anterior resection and abdominoperineal excision for rectal cancer in the total mesorectal excision era. Surg Oncol 20:e149–e155

  7. 7.

    den Dulk M, Putter H, Collette L, Marijnen CA, Folkesson J, Bosset JF, Rodel C, Bujko K, Pahlman L, van de Velde CJ (2009) The abdominoperineal resection itself is associated with an adverse outcome: the European experience based on a pooled analysis of five European randomised clinical trials on rectal cancer. Eur J Cancer 45:1175–1183

  8. 8.

    Nagtegaal ID, van de Velde CJ, Marijnen CA, van Krieken JH, Quirke P (2005) Low rectal cancer: a call for a change of approach in abdominoperineal resection. J Clin Oncol 23:9257–9264

  9. 9.

    Holm T, Ljung A, Haggmark T, Jurell G, Lagergren J (2007) Extended abdominoperineal resection with gluteus maximus flap reconstruction of the pelvic floor for rectal cancer. Br J Surg 94:232–238

  10. 10.

    West NP, Anderin C, Smith KJ, Holm T, Quirke P (2010) Multicentre experience with extralevator abdominoperineal excision for low rectal cancer. Br J Surg 97:588–599

  11. 11.

    Huang A, Zhao H, Ling T, Quan Y, Zheng M, Feng B (2014) Oncological superiority of extralevator abdominoperineal resection over conventional abdominoperineal resection: a meta-analysis. Int J Colorectal Dis 29:321–327

  12. 12.

    West NP, Finan PJ, Anderin C, Lindholm J, Holm T, Quirke P (2008) Evidence of the oncologic superiority of cylindrical abdominoperineal excision for low rectal cancer. J Clin Oncol 26:3517–3522

  13. 13.

    Stelzner S, Koehler C, Stelzer J, Sims A, Witzigmann H (2011) Extended abdominoperineal excision vs. standard abdominoperineal excision in rectal cancer—a systematic overview. Int J Colorectal Dis 26:1227–1240

  14. 14.

    Stelzner S, Hellmich G, Schubert C, Puffer E, Haroske G, Witzigmann H (2011) Short-term outcome of extra-levator abdominoperineal excision for rectal cancer. Int J Colorectal Dis 26:919–925

  15. 15.

    Asplund D, Haglind E, Angenete E (2012) Outcome of extralevator abdominoperineal excision compared with standard surgery: results from a single centre. Colorectal Dis 14:1191–1196

  16. 16.

    Han JG, Wang ZJ, Wei GH, Gao ZG, Yang Y, Zhao BC (2012) Randomized clinical trial of conventional versus cylindrical abdominoperineal resection for locally advanced lower rectal cancer. Am J Surg 204:274–282

  17. 17.

    Klein M, Fischer A, Rosenberg J, Gogenur I (2015) Extralevatory abdominoperineal excision (elape) does not result in reduced rate of tumor perforation or rate of positive circumferential resection margin: a nationwide database study. Ann Surg 5:933–938

  18. 18.

    van Leersum N, Martijnse I, den Dulk M, Kolfschoten N, Le Cessie S, van de Velde C, Tollenaar R, Wouters M, Rutten HJ (2014) Differences in circumferential resection margin involvement after abdominoperineal excision and low anterior resection no longer significant. Ann Surg 259:1150–1155

  19. 19.

    Chi P, Chen ZF, Lin HM, Lu XR, Huang Y (2013) Laparoscopic extralevator abdominoperineal resection for rectal carcinoma with transabdominal levator transection. Ann Surg Oncol 20:1560–1566

  20. 20.

    Marecik SJ, Zawadzki M, Desouza AL, Park JJ, Abcarian H, Prasad LM (2011) Robotic cylindrical abdominoperineal resection with transabdominal levator transection. Dis Colon Rectum 54:1320–1325

  21. 21.

    Ortiz H, Ciga MA, Armendariz P, Kreisler E, Codina-Cazador A, Gomez-Barbadillo J, Garcia-Granero E, Roig JV, Biondo S (2014) Multicentre propensity score-matched analysis of conventional versus extended abdominoperineal excision for low rectal cancer. Br J Surg 101:874–882

  22. 22.

    De Nardi P, Summo V, Vignali A, Capretti G (2015) Standard versus extralevator abdominoperineal low rectal cancer excision outcomes: a systematic review. Ann Surg Oncol. epub ahead of print. Jan 2015. Accessed Aug 1 2015

  23. 23.

    Welsch T, Mategakis V, Contin P, Kulu Y, Buchler MW, Ulrich A (2012) Results of extralevator abdominoperineal resection for low rectal cancer including quality of life and long-term wound complications. Int J Colorectal Dis 28:503–510

  24. 24.

    Martijnse IS, Holman F, Nieuwenhuijzen GA, Rutten HJ, Nienhuijs SW (2012) Perineal hernia repair after abdominoperineal rectal excision. Dis Colon Rectum 55:90–95

  25. 25.

    Butt HZ, Salem MK, Vijaynagar B, Chaudhri S, Singh B (2013) Perineal reconstruction after extra-levator abdominoperineal excision (eLAPE): a systematic review. Int J Colorectal Dis 28:1459–1468

  26. 26.

    Perdawood SK, Lund T (2015) Extralevator versus standard abdominoperineal excision for rectal cancer. Tech Coloproctol 19:145–152

  27. 27.

    Yu HC, Peng H, He XS, Zhao RS (2014) Comparison of short- and long-term outcomes after extralevator abdominoperineal excision and standard abdominoperineal excision for rectal cancer: a systematic review and meta-analysis. Int J Colorectal Dis 29:183–191

  28. 28.

    Raftopoulos I, Reed JF 3rd, Bergamaschi R (2011) Circumferential resection margin involvement after laparoscopic abdominoperineal excision for rectal cancer. Colorectal Dis 14:431–437

  29. 29.

    Wang Z, Zhang XM, Liang JW, Hu JJ, Zeng WG, Zhou ZX (2014) Evaluation of short-term outcomes after laparoscopically assisted abdominoperineal resection for low rectal cancer. ANZ J Surg 84:842–846

  30. 30.

    Jefferies MT, Evans MD, Hilton J, Chandrasekaran TV, Beynon J, Khot U (2012) Oncological outcome after laparoscopic abdominoperineal excision of the rectum. Colorectal Dis 14:967–971

  31. 31.

    Peacock O, Simpson JA, Tou SI, Hurst NG, Speake WJ, Tierney GM, Lund JN (2014) Outcomes after biological mesh reconstruction of the pelvic floor following extra-levator abdominoperineal excision of rectum (APER). Tech Coloproctol 18:571–577

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Author information

Correspondence to Vanessa N. Palter.

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Disclosures

Drs. Palter, MacLellan, and Ashamalla have no conflicts of interest or financial ties to disclose.

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Cite this article

Palter, V.N., MacLellan, S. & Ashamalla, S. Laparoscopic translevator approach to abdominoperineal resection for rectal adenocarcinoma: feasibility and short-term oncologic outcomes. Surg Endosc 30, 3001–3006 (2016). https://doi.org/10.1007/s00464-015-4589-8

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Keywords

  • Laparoscopic abdominal perineal resection
  • Translevator approach
  • Perineal wound complications