Laparoscopic extralevator abdominoperineal extirpation of the rectum: long-term results

Objective: comparative assessment of long-term oncological results of laparoscopic extralevator and traditional abdominal-perineal resection (APR).

Materials and methods. The analysis of immediate and long-term oncological results of treatment of 92 patients who underwent traditional laparoscopic and extralevator APR for low rectal cancer. Inclusion criteria were tumors of the lower ampullar rectum, excluding the performance of sphincter-sparing surgical interventions, and patients’ age up to 75 years. Exclusion criteria: distant metastases, histologically confirmed squamous cell carcinoma. Analysis of immediate and long-term results was carried out.

Results. The main group included patients who underwent extralevator APR (n = 62), patients in the control group (n = 30) underwent traditional APR. There were no significant differences in the type of neoadjuvant and adjuvant treatment in the comparison groups (p >0.05). In the group of patients operated on in the volume of extralevator APR, 42 received neoadjuvant chemoradiotherapy versus 19 patients in the group of traditional APR, there was no statistically significant difference (p = 0.21). In the extralevator APR group, perineal plastic surgery was performed significantly more often than in the traditional APR group (p = 0.001). When evaluating the immediate results, there was a statistically significant difference in the total number of complications between the study groups, such complications as bladder dysfunction following after surgery, inflammatory pelvic disease in the perineal wound, perineal hernia occurred significantly more often in the traditional APR group than in the extralevator APR group (p >0.05). In terms of overall and disease-free survival, the groups differed statistically significantly: 5-year overall survival in the main group was 90 % versus 62.5 % in the control group (p = 0.03), 5-year disease-free survival in the main group was 98.5 % versus 65 % in the control group, respectively (p = 0.01).

Conclusions. Extralevator APR of the rectum is the most radical surgical intervention than with the traditional APR technique due to the lower risk of a positive circumferention resection margin, therefore, reducing the incidence of local recurrence, and as a result, improving overall and disease-free survival rates compared to the traditional technique.

1. West N.P., Anderin C., Holm K.J. et al. Multicentre experience with extralevator abdominoperineal excision for low rectal cancer. Br J Surg 2010;97:588–99. DOI: 10.1002/bjs.6916.

2. Shen Z., Ye Y., Zhang X. et al. Prospective controlled study of the safety and oncological outcomes of ELAPE procure with definitive anatomic landmarks versus conventional APE for lower rectal cancer. Eur J Cancer 2015;41:472–7. DOI: 10.1016/j.ejso.2015.01.017.

3. Salerno G., Chandler I., Wotherspoon A. et al. Sites of surgical wasting in the abdominoperineal specimen. Br J Surg 2008;9:1147–54. DOI: 10.1002/bjs.6231.

4. Prytz M., Angenete E., Ekelund J. et al. Extralevator abdominoperineal 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. DOI: 10.1007/s00384-014-1932-9.

5. Ortiz H., Ciga M.A., Armendariz P. et al. Multicentre propensity score matched analysis of conventional versus extended abdominoperineal excision for low rectal cancer. Br J Surg 2014;101:874–82. DOI: 10.1002/bjs.9522.

6. Zhou X., Sun T., Xie H. et al. Extralevator abdominoperineal excision for low rectal cancer: a systematic review and meta-analysis of the short-term outcome. Colorect Dis 2015;17:474–81. DOI: 10.1111/codi.12921.

7. Wang Y.L., Dai Y., Jiang J.B. et al. Application of laparoscopic extralevator abdominoperineal excision in locally advanced low rectal. Chin M Med J (Engl) 2015;128:1340–5. DOI: 10.4103/0366-6999.156779.

8. Hussain A., Mahmood F., Torrance A.D. et al. Oncological outcomes of abdominoperineal resection for the treatment of low rectal cancer: a retrospective review of a single UK tertiary centre experience. Ann Med Surg (Lond) 2018;34:28–33. DOI: 10.1016/j.amsu.2018.06.007.

9. Colov E.P., Klein M., Gögenur I. Wound complications and perineal pain after extralevator versus standard abdominoperineal excision: a nationwide study. Dis Colon Rectum 2016;59:813–21. DOI: 10.1097/DCR.0000000000000639.

10. Stelzner S., Hellmich G., Sims A. et al. Long-term outcome of extralevator abdominoperineal excision (ELAPE) for low rectal cancer. Int J Colorect Dis 2016;31:1729–37.

11. Foster J.D., Tou S., Curtis N.J. et al. Closure of the perineal defect after abdominoperineal excision for rectal adenocarcinoma – ACPGBI position statement. Colorect Dis 2018;20:5–23. DOI: 10.1111/codi.14348.

12. Tsarkov P.V., Fedorov D.N., Kravchenko A.Yu. et al. Combined abdominotranssacral appro ach with the patient turned on the abdomen during extralevator extirpation of the rectum. Khirurgiya. Zhurnal im. N.I. Pirogova = Surgery. N.I. Pirogov Journal 2011;(5):43. (In Russ.).

13. Qi X., Liu M., Tan F. et al. Laparoscopic extralevator abdominoperineal resection versus laparoscopic abdominoperineal resection for lower rectal cancer: A retrospective comparative study from China. Int J Surg 2019;71;158–16. DOI: 10.1016/j.ijsu.2019.09.010.

14. Negoi I., Hostiuc S., Paun S. et al. Extralevator vs conventional abdominoperineal resection for rectal cancer – a systematic review and meta-analysis. Am J Surg 2016;212;511–26. DOI: 10.1016/j.amjsurg.2016.02.022.

15. Stelzner S., Holm T., Moran B.J. et al. Deep pelvic anatomy revisited for a description of crucial steps in extralevator abdominoperineal excision for rectal cancer. Dis Colon Rectum 2011;54;947–57. DOI: 10.1097/DCR.0b013e31821c4bac.

16. Murashko R.A., Uvarov I.B., Ermakov E.A. Extralevator abdominoperineal extirpation of the rectum: short-term results compared to conventional technique. Koloproktologiya = Coloproctology 2017;4(62):34–9. (In Russ.).

17. Carpelan A., Karvonen J., Varpe P. et al. Extralevator versus standard abdominoperineal excision in locally advanced rectal cancer: a retrospective study with long-term follow-up. Int J Colorect Dis 2018;33;375–81. DOI: 10.1007/s00384-018-2977-y.

18. Adam I.J., Mohamdee M.O., Martin I.G. et al. Role of circumferential margin involvement in the local recurrence of rectal cancer. Lancet 1994;344:707–11.