Extralevator Abdominoperineal Excision – Review
Total mesorectal excision (TME) has considerably decreased rectal cancer local recurrence rates to 5 to 15%. However oncologic outcomes of rectal cancer treated with abdominoperineal excision remained worse (with local recurrence rates around 40%) than those treated with TME. Positive circumferential resection margins and intraoperative perforation seemed to be the major responsibles for the worse overall survival in these patients. Holm et al described extralevator abdominoperineal excision a technic with a wider perineal dissection, in order to overcome these issues. We conducted a literature review on the oncological outcomes and surgical complications of ELAPE and conventional abdominoperineal excision. The recognition that conventional abdominoperineal excision was a bad oncological surgery and the description of ELAPE shifted the main focus of this surgery back to the perineal part in order toachieve local recurrence rates equal to those of TME. The literature confirms that ELAPE has very good oncological results with the decrease of local recurrence rates. Regarding surgical complications, there seems to be no difference between ELAPE and conventional abdominoperineal excision. ELAPE is a promising technique, which improves overall survival in patients with rectal cancer.
2. L. Pahlman and B. Glimelius, “Local recurrences after surgical treatment for rectal carcinoma” Acta Chir Scand, no. 150, pp. 331–335, 1984.
3. R. Heald, E. Husband, and R. Ryall, “The mesorectum in rectal cancer surgery: the clue to pelvic recurrence?” Br J Surg., no. 69, pp. 613–616, 1982.
4. J. MacFarlane, R. Ryall, and R. J. Heald, “Mesorectal excision for rectal cancer” Lancet, no. 341, pp. 457–460, 1993.
5. R. Heald, B. Moran, R. Ryall, R. Sexton, and J. MacFarlane, “Rectal cancer: the Basingstoke experience of total mesorectal excision, 1978-1997” Arch Surg, no. 133, pp. 894–899, 1998.
6. M. AL, H. T, and R. LE, “Effect of a surgical training programme on outcome of rectal cancer in the County of Stockholm: Stockholm Colorectal Cancer Study Group, Basingstoke Bowel Cancer Research Project” Lancet, no. 356, pp. 93–96, 2000.
7. P. Quirke, P. Durdey, and M. Dixon, “Local recurrence of rectal adenocarcinoma due to inadequate surgical resection: Histopathological study of lateral tumor spread and surgical excision” Lancet, no. 2, pp. 996–999, 1986.
8. R. Heald and R. Ryall, “Recurrence and survival after total mesorectal excision for rectal cancer” Lancet, no. 1, pp. 1479–1482, 1986.
9. W. A, M. B, and N. J, “A national strategic change in treatment policy for rectal cancer: implementation of total mesorectal excision as routine treatment in Norway. A national audit” Dis Colon Rectum, no. 45, pp. 857–866, 2002.
10. A. Martling, T. Holm, L. E. Rutqvist, H. Johansson, B. J. Moran, R. J. Heald, and B. Cedermark, “Impact of a surgical training programme on rectal cancer outcomes in Stockholm” Br. J. Surg, vol. 92, no. 2, pp. 225–9, Feb. 2005.
11. I. D. Nagtegaal, C. J. H. van de Velde, and E. van der Worp, “Macroscopic evaluation of rectal cancer resection specimen: Clinical significance of the pathologist in quality control” J Clin Oncol, no. 20, pp. 1729–1734, 2002.
12. N. Maughan and P. Quirke, “Modern management of colorectal cancer – a pathologist´s view” Scand J Surg, no. 92, pp. 11–19, 2003.
13. J. F. Bosset, L. Collette, G. Calais, L. Mineur, P. Maingon, L. Radosevic-Jelic, A. Daban, E. Bardet, A. Beny, J. C. Ollier, and E. R. G. Trial, “Chemotherapy with preoperative radiotherapy in rectal cancer” N Engl J Med, vol. 355, no. 11, pp. 1114–1123, 2006.
14. A. Wibe, A. Syse, and E. Andersen, “Oncological outcomes after total mesorectal excision for cure for cancer of the lower rectum: anterior versus abdominoperineal resection” Dis Colon Rectum, vol. 47, no. 1, pp. 48–58, 2004.
15. I. D. Nagtegaal, C. J. H. van de Velde, C. a M. Marijnen, J. H. J. M. van Krieken, and P. Quirke, “Low rectal cancer: a call for a change of approach in abdominoperineal resection.,” J. Clin. Oncol., vol. 23, no. 36, pp. 9257–9264, 2005.
16. G. Salerno, I. Chandler, A. Wotherspoon, K. Thomas, B. Moran, and G. Brown, “Sites of surgical wasting in the abdominoperineal specimen” Br. J. Surg., vol. 95, no. 9, pp. 1147–54, Sep. 2008.
17. G. Brown, C. Richards, and R. Newcombe, “Rectal carcinoma: thin-section MR imaging for staging 28 patients” Radiology, no. 211, pp. 215–222, 1999.
18. B.-T. RG, B. GL, and V. RF, “Accuracy of magnetic resonance imaging in prediction of tumour-free resection margin in rectal cancer surgery” Lancet, no. 357, pp. 497–504, 2001.
19. R. Marr, K. Birbeck, J. Garvican, C. P. Macklin, N. J. Tiffin, W. J. Parsons, M. F. Dixon, N. P. Mapstone, D. Sebag Montefiore, N. Scott, D. Johnston, P. Sagar, P. Finan, and P. Quirke, “The modern abdominoperineal excision: the next challenge after total mesorectal excision” Ann. Surg., vol. 242, no. 1, pp. 74–82, 2005.
20. M. den Dulk, C. A. M. Marijnen, H. Putter, H. J. T. Rutten, G. L. Beets, T. Wiggers, I. D. Nagtegaal, and C. J. H. van de Velde, “Risk factors for adverse outcome in patients with rectal cancer treated with an abdominoperineal resection in the total mesorectal excision trial” Ann. Surg., vol. 246, no. 1, pp. 83–90, Jul. 2007.
21. N. Dehni, N. McFadden, D. McNamara, M. Guiguet, E. Tiret, and R. Parc, “Oncologic results following abdominoperineal resection for adenocarcinoma of the low rectum,” Dis Colon Rectum, no. 46, pp. 867–874, 2003.
22. T. Holm, A. Ljung, T. Häggmark, G. Jurell, and J. Lagergren, “Extended abdominoperineal resection with gluteus maximus flap reconstruction of the pelvic floor for rectal cancer” Br. J. Surg., vol. 94, no. 2, pp. 232–8, Feb. 2007.
23. T. Holm, “Controversies in abdominoperineal excision” Surg. Oncol. Clin. N. Am., vol. 23, no. 1, pp. 93–111, Jan. 2014.
24. O. C. Shihab, R. J. Heald, T. Holm, P. D. How, G. Brown, P. Quirke, and B. J. Moran, “A pictorial description of extralevator abdominoperineal excision for low rectal cancer” Color. Dis., vol. 14, no. 10, 2012.
25. Lynn, Patricio B., Habr-Gama, Angelita, Perez, Rodrigo O., Grzona, Esteban, Sabbagh, Charles, & Gama Rodrigues, Joaquim J. “Cylindrical abdominoperineal resection rationale, technique and controversies” Journal of Coloproctology (Rio de Janeiro), 33(3), 167-173, 2013.
26. T. Holm, “Abdominoperineal resection revisited: is positioning an important issue?” Dis. Colon Rectum, vol. 54, no. 8, pp. 921–2, Aug. 2011.
27. T. Iwamura, M. Hotokezaka, T.-A. Eto, T. Taniguchi, and K. Chijiiwa, “Advantage of the right lateral position compared with the lithotomy position during the perineal procedure in abdominoperineal resection” Dig. Surg., vol. 23, no. 1–2, pp. 32–7, Jan. 2006.
28. I. S. Martijnse, R. L. Dudink, N. P. West, D. Wasowicz, G. A. Nieuwenhuijzen, I. Lijnschoten, H. Martijn, V. E. Lemmens, C. J. Velde, I. D. Nagtegaal, P. Quirke, and H. J. Rutten, “Focus on Extralevator Perineal Dissection in Supine Position for Low Rectal Cancer Has Led to Better Quality of Surgery and Oncologic Outcome,” Annals of Surgical Oncology, vol. 19, no. 3. pp. 786–793, 2012.
29. L. F. Campos-Lobato, L. Stocchi, D. W. Dietz, I. C. Lavery, V. W. Fazio, and M. F. Kalady, “Prone or lithotomy positioning during an abdominoperineal resection for rectal cancer results in comparable oncologic outcomes,” Dis Colon Rectum, vol. 54, no. 8, pp. 939–946, 2011.
30. D. S. Keller, J. K. Lawrence, and C. P. Delaney, “Prone jackknife position is not necessary to achieve a cylindrical abdominoperineal resection: demonstration of the lithotomy position” Dis. Colon Rectum, vol. 57, no. 2, p. 251, Feb. 2014.
31. B. Flor-Lorente, M. Frasson, and E. Montilla, “Extralevator abdominoperineal resection in the prone position” Cirugía española, vol. 92 Suppl 1, pp. 30–9, Mar. 2014.
32. C. Anderin, F. Granath, A. Martling, and T. Holm, “Local recurrence after prone vs supine abdominoperineal excision for low rectal cancer” Colorectal Dis., vol. 15, no. 7, pp. 812–5, Jul. 2013.
33. R. Durai, M. Harilingham, and H. Benziger, “Uterine flap: a simple method to reconstruct perineal defect following extralevator abdominoperineal resection in women” Ann. R. Coll. Surg. Engl., vol. 95, no. 6, p. 442, Sep. 2013.
34. A. Touny, H. Othman, S. Maamoon, S. Ramzy, and H. Elmarakby, “Perineal reconstruction using pedicled vertical rectus abdominis myocutaneous flap (VRAM)” J. Surg. Oncol., vol. 110, no. 6, pp. 752–7, Nov. 2014.
35. D. B. Saleh, J. A. Callear, M. Basheer, and P. Mohammed, “The partial myocutaneous gluteal flap reconstruction of extralevator abdominoperineal defects in irradiated patients” Ann. Plast. Surg., vol. 74, no. 4, pp. 403–7, Apr. 2015.
36. J. A. Palmer, C. P. Vernon, B. J. Cummings, and F. L. Moffat, “Gracilis myocutaneous flap for reconstructing perineal defects resulting from radiation and radical surgery” Can. J. Surg., vol. 26, no. 6, pp. 510–2, Nov. 1983.
37. G. D. Musters, W. A. Bemelman, R. J. I. Bosker, J. W. A. Burger, P. van Duijvendijk, B. van Etten, A. A. W. van Geloven, E. J. R. de Graaf, C. Hoff, N. de Korte, J. W. A. Leijtens, H. J. T. Rutten, B. Singh, A. van de Ven, R. J. C. L. M. Vuylsteke, J. H. W. de Wilt, M. G. W. Dijkgraaf, and P. J. Tanis, “Randomized controlled multicentre study comparing biological mesh closure of the pelvic floor with primary perineal wound closure after extralevator abdominoperineal resection for rectal cancer (BIOPEX-study)” BMC Surg., vol. 14, p. 58, Jan. 2014.
38. N. P. West, P. J. Finan, C. Anderin, J. Lindholm, T. Holm, and P. Quirke, “Evidence of the oncologic superiority of cylindrical abdominoperineal excision for low rectal cancer” J. Clin. Oncol., vol. 26, no. 21, pp. 3517–22, Jul. 2008.
39. P. De Nardi, V. Summo, A. Vignali, and G. Capretti, “Standard Versus Extralevator Abdominoperineal Low Rectal Cancer Excision Outcomes: A Systematic Review and Meta-analysis,” Ann. Surg. Oncol., 2015.
40. X.-T. Wang, D.-G. Li, L. Li, F.-B. Kong, L.-M. Pang, and W. Mai, “Meta-analysis of oncological outcome after abdominoperineal resection or low anterior resection for lower rectal cancer” Pathol. Oncol. Res., vol. 21, no. 1, pp. 19–27, Jan. 2015.
41. A. Huang, H. Zhao, T. Ling, Y. Quan, M. Zheng, and B. Feng, “Oncological superiority of extralevator abdominoperineal resection over conventional abdominoperineal resection: a meta-analysis” Int. J. Colorectal Dis., vol. 29, no. 3, pp. 321–7, Mar. 2014.
42. H.-C. Yu, H. Peng, X.-S. He, and R.-S. Zhao, “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., vol. 29, no. 2, pp. 183–91, Feb. 2014.
43. A. Krishna, M. J. F. X. Rickard, a. Keshava, O. F. Dent, and P. H. Chapuis, “A comparison of published rates of resection margin involvement and intra-operative perforation between standard and ‘cylindrical’ abdominoperineal excision for low rectal cancer,” Color. Dis., vol. 15, no. 1, pp. 57–65, 2013.
44. West NP, Anderin C, Smith KJ, Holm T, Quirke P, “European Extralevator Abdominoperineal Excision Study Group. Multicentre experience with extralevator abdominoperineal excision for low rectal cancer” Br J Surg. 2010 Apr;97(4):588-99.
45. Stelzner S, Hellmich G, Schubert C, Puffer E, Haroske G, Witzigmann H, “Short-term outcome of extra-levator abdominoperineal excision for rectal cancer” Int J Colorectal Dis. 2011 Jul;26(7):919-25.
46. Vaughan-Shaw PG, Cheung T, Knight JS, Nichols PH, Pilkington SA, Mirnezami AH. “A prospective case-control study of extralevator abdominoperineal excision (ELAPE) of the rectum versus conventional laparoscopic and open abdominoperineal excision: comparative analysis of short-term outcomes and quality of life” Tech Coloproctol. 2012 Oct;16(5):355-62.
47. Asplund D, Haglind E, Angenete E. “Outcome of extralevator abdominoperineal excision compared with standard surgery: results from a single centre” Colorectal Dis. 2012 Oct;14(10):1191-6.
48. Angenete E, Correa-Marinez A, Heath J, González E, Wedin A, Prytz M, Asplund D, Haglind E. “Ostomy function after abdominoperineal resection--a clinical and patient evaluation.” Int J Colorectal Dis. 2012 Oct;27(10):1267-74.
49. Han JG, Wang ZJ, Qian Q et al. “A prospective multicenter clinical study of extralevator abdominoperineal resection for locally advanced low rectal cancer” Dis Colon Rectum 2014; 57: 1333–40.
50. Ortiz H, Ciga MA, Armendariz P et al. “Multicentre propensity score-matched analysis of conventional versus extended abdomino-perineal excision for low rectal cancer” Br J Surg 2014; 101: 874–82.
51. Prytz M, Angenete E, Ekelund J, Haglind E. “Extralevator abdo- minoperineal excision (ELAPE) for rectal cancer short-term results from the Swedish Colorectal Cancer Registry. Selective use of ELAPE warranted.” Int J Colorectal Dis 2014; 29: 981–7. 11.
52. Klein M, Fischer A, Rosenberg J, Gögenur I; Danish Colorectal Cancer Group (DCCG). “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. 2015 May;261(5):933-8.
53. Zhou X, Sun T, Xie H, Zhang Y, Zeng H, Fu W. “Extralevator abdominoperineal excision for low rectal cancer: a systematic review and meta-analysis of the short-term outcome” Colorectal Dis. 2015 Jun;17(6):474-81.
54. Eriksen MT, Wibe A, Syse A, Haffner J, Wiig JN; Norwegian Rectal Cancer Group;Norwegian Gastrointestinal Cancer Group. “Inadvertent perforation during rectal cancer resection in Norway”. Br J Surg. 2004 Feb;91(2):210-6. PubMed PMID:14760670.