Long-term outcomes of laparoscopic Extralevator Abdominoperineal excision with modified position change for low rectal Cancer treatment

Abstract

Background: Extralevator abdominoperineal excision (ELAPE) has been recommended for treating low rectal cancer due to its potential advantages in improving surgical safety and oncologic outcomes as compared to conventional abdominoperineal excision (APE). In ELAPE, however, whether the benefits of intraoperative position change to a prone jackknife position outweighs the associated risks remains controversial. This study is to introduce a modified position change in laparoscopic ELAPE and evaluate its feasibility, safety and the long-term therapeutic outcomes.

Methods: Medical records of 56 consecutive patients with low rectal cancer underwent laparoscopic ELAPE from November 2013 to September 2016 were retrospectively studied. In the operation, a perineal dissection in prone jackknife position was firstly performed and the laparoscopic procedure was then conducted in supine position. Patient characteristics, intraoperative and postoperative outcomes, pathologic and 5-year oncologic outcomes were analyzed.

Results: The mean operation time was 213.5 ± 29.4 min and the mean intraoperative blood loss was 152.7 ± 125.2 ml. All the tumors were totally resected, without intraoperative perforation, conversion to open surgery, postoperative 30-day death, and perioperative complications. All the patients achieved pelvic peritoneum reconstruction without the usage of biological mesh. During the follow-up period, perineal hernia was observed in 1 patient, impaired sexual function in 1 patient, and parastomal hernias in 3 patients. The local recurrence rate was 1.9% and distant metastasis was noted in 12 patients. The 5-year overall survival rate was 76.4% and the 5-year disease-free survival rate was 70.9%.

Conclusions: Laparoscopic ELAPE with modified position change is a simplified, safe and feasible procedure with favorable outcomes. The pelvic peritoneum can be directly closed by the laparoscopic approach without the application of biological mesh.

Keywords: Exralevator abdominoperineal resection; Long-term; Low rectal cancer; Position change; Survival analysis.

Fig. 1

Perineal operative procedure. A incision range in the prone jackknife position, B rectum was separated to the upper rim of seminal vesicle in male patients, C the loop ligature of anus rectum was performed with a sterile specimen bag

Fig. 2

The location of the trocars (trocar A 10 mm, trocar B 12 mm, trocar C, D and E 5 mm)

Fig. 3

The pelvic peritoneum was directly closed by the laparoscopic approach. A, B the closure of pelvic peritoneum in the male patient; C, D the closure of pelvic peritoneum in the female patient

Fig. 4

Kaplan-Meier curves showing overall and disease-free survival. A survival curves of overall survival. B survival curves of disease-free survival