- Email: [email protected]
Short-term outcomes of the prone perineal approach for extra-levator abdomino-perineal excision (elAPE)
t h e s u r g e o n 1 0 ( 2 0 1 2 ) 3 4 2 e3 4 6
Available online at www.sciencedirect.com
The Surgeon, Journal of the Royal Colleges of Surgeons of Edinburgh and Ireland www.thesurgeon.net
Short-term outcomes of the prone perineal approach for extra-levator abdomino-perineal excision (elAPE) R.S.J. Dalton, N.J. Smart, T.J. Edwards, I. Chandler*, I.R. Daniels Exeter Colorectal Unit and Dept of Histopathology, Royal Devon & Exeter Hospital, Barrack Road, Exeter, Devon EX2 5DW, United Kingdom
article info
abstract
Article history:
Background: Many studies report that low rectal cancer treated with abdomino-perineal
Received 5 April 2011
excision (APE) have higher rates of CRM involvement with associated local recurrence
Received in revised form
and worse survival when compared to low anterior resection. We present a single
15 August 2011
surgeon’s short-term outcomes using the prone perineal extra-levator (elAPE) approach.
Accepted 4 October 2011
Methods: Thirty-one patients between 2006 and 2010 underwent elAPE with curative intent.
Available online 15 November 2011
Data was collected prospectively recording patient tumour characteristics and histological outcome. Outcome measures included circumferential resection margins, recurrence rates, 30-day morbidity and mortality.
Keywords: Abdominoperineal excision (APE)
Results: Mean distance of tumour from anal verge was 3.63 SD 1.52 cm. 14 patients had
Rectal cancer
pre-operative chemo-radiotherapy. The involved circumferential resection margin rate
Circumferential
resection
margin
Extra-levator excision (elAPE)
was 3.2%. Median follow-up was 20 (0e45) months, with overall mortality of 13.3% and 30 day mortality of 6.6%.
(CRM) abdomino-perineal
Conclusions: The prone position elAPE has a low circumferential resection margin involved rate and, through improved vision, reduces the risk of inadvertent tumour or specimen perforation. ª 2011 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.
Introduction Over one hundred years ago Sir W. Ernest Miles described the technique of abdomino-perineal excision (APE) as a surgical approach for rectal cancer.1 He further developed the technique to include en-bloc resection of associated lymph nodes, and reported a recurrence rate of 29.5% and operative mortality of 31%.2 His surgical technique involved extirpation of the rectum from below and formation of an abdominal colostomy, the perineal portion of the operation being performed with the patient on their side. However, sphincter preserving surgery for middle and upper third rectal tumours was shown to be safe in the middle of the twentieth century
and the number of restorative operations increased.3 The development of stapling devices in the late 1970’s, and the demonstration that distal margins of 2 cm did not compromise local disease control, meant that lower anterior resections could be performed, thus further reducing the need for APE.4,5 Using cancer registry data the APE rate for rectal cancer reduced across England from 30.5% in 1998 to 23% in 2004.6 The reporting of total mesorectal excision (TME) by RJ Heald in 1982 and the recognition of the importance of the circumferential resection margin (CRM) have reduced the rates of local recurrence and improved survival.7,8 More recently outcomes have been further improved through magnetic resonance imaging (MRI) to evaluate the local extent
* Corresponding author. Tel.: þ447766147501. E-mail addresses: [email protected], [email protected] (I. Chandler). 1479-666X/$ e see front matter ª 2011 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.surge.2011.10.001
t h e s u r g e o n 1 0 ( 2 0 1 2 ) 3 4 2 e3 4 6
of the disease, and use of chemo-radiotherapy (CRT) to downstage locally advanced tumours managed through the multidisciplinary team (MDT) process.9,10 Despite these advances many series still report that low rectal cancers treated with APE have higher rates of local recurrence and worse survival when compared to low anterior resection (LAR).11e14 In the MERCURY Study dataset, when rectal cancers below 6 cm were assessed the rates of involved CRM were 12% vs 31.9% for low anterior resection and APE respectively despite standardised MRI, MDT and pathological assessment.15 Recently published data has reported that by performing a ‘cylindrical’ approach to the perineal dissection there is a reduction in involved circumferential resection margins (CRM).16,17 However, we questioned the need for a wide perineal resection of ischio-anal fat, instead remaining extra-levator in the plane of dissection, and only excising ischio-anal fat if the potential CRM was compromised. Using the concepts of MRI staging (defined using the MERCURY Study protocols9), selective pre-operative CRT and a standardized reporting proforma for APE, based on the work of Quirke,18 we present a single surgeon’s short-term outcomes using this extra-levator (elAPE) approach with the perineal dissection performed in the prone position.
Methods Low rectal cancers treated at the Royal Devon and Exeter Hospital by elAPE from a single surgeon (IRD) were examined using data collected prospectively from the local cancer registry. Patient age at the time of surgery, gender, height of tumour from anal verge, pre and post-operative chemoradiotherapy, mortality, morbidity, TNM histology, CRM involvement, follow-up, and disease recurrence were recorded. Ethical approval was not deemed to be necessary. All treatment decisions were ratified by the Hospital Multidisciplinary Team (MDT).
343
skin incision made around the anus, with a transverse incision across the perineum, parallel incisions laterally over the perianal skin that taper towards the coccyx (Fig. 1). Lateral and posterior dissection is then performed through the ischio-anal fossa, dependent upon the degree of tumour invasion to expose the coccyx and the pelvic floor. The pelvic floor is then opened from the coccyx, which in some cases is excised and the muscle is taken from the origin of the levator ani. Division of the endopelvic fascia allows re-entry into the TME plane. The degree of excision is dependent upon tumour position and stage. Based upon the initial staging pre-operative MRI the extent of adipose excision from the ischio-anal fossa and the necessity of coccygectomy is planned. A wider excision is performed on the side of the tumour for laterally placed tumours. Those tumours with a posterior element often required coccygectomy to ensure CRM clearance. Once the posterior part of the mesorectum has been identified through division of the endopelvic fascia, the swab is retrieved and the specimen reflected through the defect. The anterior dissection can then be performed anterior to Denonvillier’s fascia or rectovaginal septum. If the tumour is adherent to the vagina then posterior vaginal resection is carried out en bloc with the specimen. The excised specimen is illustrated in Fig. 2. We used a vertical rectus abdominis myocutaneous (VRAM) flap to reconstruct the perineum of the first patient and cross-linked acellular porcine dermal collagen (Permacol, Covidien, Gosport, UK) to reconstruct the pelvic floor,19 with the pelvic cavity filled with the fully mobilised omental pedicle of the subsequent 30 patients.
Pre-operative staging All patients were pre-operatively staged using MRI (MERCURY Protocols9) for local rectal cancer staging and CT for distant disease. After MDT discussion, patients with disease extending beyond or involving the mesorectal fascia (<1 mm) were treated with pre-operative CRT (45Gy and oral capecitabine) for 5 weeks. A further MRI was performed 6 weeks following completion of CRT to define response followed by surgery.
Surgical technique The surgical technique involves an open abdominal approach with the patient in the Lloyd Davis position. The omentum is mobilised as a pedicle using the left gastro-epiploic vessels. The colostomy is fashioned after the inferior mesenteric artery and vein have been divided and the abdominal dissection has been taken down to the sacro-coccyggeal joint. The peritoneal reflection divided anteriorly off the bladder or seminal vesicles to preserve the reflection. A swab is placed behind the mesorectum and the abdomen closed. The patient is then positioned in the prone jack-knife position, and a ‘church-window’
Fig. 1 e A “church window” incision. The patient is in the prone jack-knife position with the buttocks taped apart and an encircling silk suture to close the anal canal.
344
t h e s u r g e o n 1 0 ( 2 0 1 2 ) 3 4 2 e3 4 6
Fig. 2 e Excised specimen following extra-levator Abdominoperineal excision. These photographs show the lateral (left) and anterior (right) views of a specimen. In this case the coccyx was preserved and the site of the coccyx is identified with the finger. The anterior specimen shows the bulk of extra-levator tissue removed in this case as the disease was into the levator ani muscles, although the final CRM was 10 mm.
Pathological reporting Histopathological assessment has been performed in all cases by a single pathologist using the criteria and having received training as described by Professor P. Quirke.18 Circumferential resection margins were defined as tumour cells extending to <1 mm from the margin.
Results Between April 2006 and February 2010 31 consecutive patients underwent elAPE for low rectal cancer having been assessed through the MDT process and with no evidence of distant metastases (the only exclusion criteria). Eight patients (25.8%) were female and 23 (74.2%) male. Mean patient age was 66.8 SD 11.4 years, with mean tumour height from the anal verge of 3.63 SD 1.52 cm. The distribution of tumour circumferential position is shown in Table 1, with MRI (preCRT) stage and pathological stage shown in Table 2. Fourteen patients had pre-operative CRT. One patient received only 2 weeks of oral capecitabine as it was stopped due to the onset of chest pain. CRM was involved in one patient (3.2%). This was in a patient with a T4N2 tumour on pathological staging that was also T4N2 on pre-operative MRI with limited response to CRT. On pathological assessment the plane of excision was mesorectal (grade 1) and extra-levator in perineal resection plane. CRM ranged from 0.8 to 15 mm (the distribution is given in Table 3). Six cases were reported as CRM distance “>5 mm” on the histopathology report. If it is assumed that >5 mm is 6.0 mm then the mean was 6.4 mm and the SD 3.11 mm.
Median follow-up was 20 (range 1e45) months with local recurrence occurring in the 1 patient (3.2%) with involved CRM. Overall mortality was 4 (13.3%), the cause of death of one patient being anaplastic thyroid cancer, metastatic rectal cancer in the patient with an involved CRM with local recurrence, and two from post-operative complications within 30days (pulmonary embolism, and secondary to pelvic bleeding). Three patients developed distant metastases during follow up. Outcomes are summarized in Table 4. Six patients had breakdown of the perineal wound requiring topical negative pressure wound therapy (V.A.C. therapy, KCI medical Ltd, Kidlington, UK). One patient had skin paddle necrosis of a VRAM flap requiring revision on day 8 post-op. One patient developed a perineal wound haematoma and nine had minor wound discharge and/or infection
Table 1 e Patient demographics and Tumour characteristics. Total number of patients Gender Female (%) Mean age (years) Mean tumour height (cm) Pre-op CRT (%) Circumferential position: Anterior Anterolateral Posterior Posterolateral Lateral Circumferential Not recorded Coccyx resection (%)
31 8 (25.8%) 66.8 SD 11.4 3.63 SD 1.52 14 (45.2%) 8 (25.8%) 6 (19.4%) 2 (6.5%) 4 (12.9%) 4 (12.9%) 6 (19.4%) 1 (3.2%) 10 (32.3%)
t h e s u r g e o n 1 0 ( 2 0 1 2 ) 3 4 2 e3 4 6
Table 2 e MRI (pre-CRT) stage and pathological stage. MRI stage (pre-CRT)
TX T0 T1 T2 T3 T4
Pathological stage
N0
N1/2
N0
N1/2
1 0 1 8 10 1
0 0 0 1 6 3
0 4 4 8 9 0
0 0 0 2 3 1
resulting in delayed wound healing. Three developed an MRIdetected perineal hernia, of which one to date has been symptomatic and required surgical repair.
Discussion This series demonstrates that when performing an elAPE it is possible to achieve CRM involvement rates comparable to LAR in patients when staged and managed through MDT care. Historically a number of studies have found that an APE is associated with higher rates of CRM involvement when compared with LAR.11e14 It has recently been reported that the quality of APE surgery was poor.6 It is recognised that CRM involvement is a strong prognostic indicator for local recurrence and overall survival and therefore can be used as a marker for quality of both MDT decision-making and surgical technique.9 Recent series showed significantly higher rates of CRM involvement with APE of 21.4% compared to 7.4% for low anterior resection.15 Five-year survival in the APE group was 55% compared to 67% in the low AR group.20 Pooled data from five European rectal cancer trials (Swedish, Dutch, German, EORTC and Polish rectal cancer trials, 3633 patients) suggest that APE itself is associated with a higher risk of CRM involvement, being found in 10.6% of patients undergoing APE compared to 5% of those with low AR. Five year local recurrence rates and overall survival for low AR and APE respectively were 11.4% versus 19.7%, and 70.1% versus 59.5%.21 The higher CRM involvement rates in these studies may be related to the TME technique in the APE where the mesorectal fascia is followed, coning down towards the pelvic floor onto the sphincter complex.22 It has been suggested that this may increase the risk of CRM involvement and bowel perforation, and therefore dividing the levator ani lateral to the sphincter complex creating a more ‘cylindrical’ specimen (as originally described by Miles) may improve outcomes. Using this ‘cylindrical approach,’ Holm et al. reported a series of 28 patients with locally advanced T3/T4 tumours
Table 3 e Distribution of CRM. Distance to CRM (mm) <1.0 1.0e5.0 5.1e10.0 >10.0
Frequency 1 8 16 (including 6 reported as >5 mm) 6
345
Table 4 e Summary of outcomes. CRM involvement (%) Local recurrence (%) Distant recurrence (%) Median follow-up Overall mortality (%) 30 day mortality (%)
1 (3.2%) 1 (3.2%) 3 (9.7%) 20 months (range 0e45) 4 (12.9%) 2 (6.5%)
with a 7.1% CRM involvement rate, using the prone jack-knife technique.23 A further study of a single surgeon changing from the conventional APE technique to wider perineal dissection reduced CRM involvement from 36.5% to 12%, and intraoperative perforation from 12.8% to 0.0%.24 With low tumours requiring an APE the sphincter muscle often forms the CRM, whereas with higher tumours the CRM is relatively protected by the mesorectum. Therefore taking more tissue outside of the sphincters may help reduce CRM involvement rates. This was recently demonstrated by the European Extralevator APE study group who compared elAPE with standard APE excisions16 and showed that the median distance of the tumour to the nearest CRM was significantly greater in the elAPE group (4.0 versus 1.5 mm, p ¼ 0.001). There was a significantly lower rate of CRM involvement in the elAPE group of 20.3% compared to 49.6% in the standard APE group and a significantly lower intra-operative perforation rate when the perineal dissection was carried out in the prone jack-knife position compared to the Lloyd-Davis position (6.4% versus 20.7%, p ¼ 0.027). Inadvertent perforation during surgery has been shown to increase local recurrence and reduce survival.16,24 In our series there were no intraoperative perforations. The associated morbidity of the elAPE technique is higher than series reporting conventional APEs,16 due to a larger perineal wound that requires closure, often in patients who have had neo-adjuvant CRT. The optimum method for closing the perineal defect has yet to be defined, but both biologic mesh19 and tissue flaps25 have been described with encouraging results.
Conclusion The extra-levator approach in a prone position has a low rate of involved CRMs with reduced the risk of inadvertent perforation.
references
1. Miles WE. A method of performing APE for carcinoma of the rectum and at the terminal portion of the pelvic colon. Lancet 1908;2:1812e3. 2. Dixon CF. Anterior resection for malignant lesions of the upper part of the rectum and lower part of the sigmoid. Ann Surg 1948;128(3):425e42. 3. Miles WE. Cancer of the rectum. Lettsomian Lectures 1923. London. 4. Williams NS, Dixon MF, Johnston D. Reappraisal of the 5cm rule of distal excision for carcinoma of the rectum: a study of
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5.
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7. 8.
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15.
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distal intramural spread and of patients survival. Br J Surg 1983;70(3):150e4. Heald RJ. Towards fewer colostomies e the impact of circular stapling devices on the surgery of rectal cancer in a district hospital. Br J Surg 1980;67(3):198e200. Morris E, Quirke P, Thomas JD, Fairley L, Cottier B, Forman D. Unacceptable variation in abdominoperineal excision rates for rectal cancer: time to intervene? Gut 2008; 57:1690e7. Heald RJ, Ryall R. The mesorectum in rectal cancer surgery e the clue to pelvic recurrence. Br J Surg 1982;69:613e6. Quirke P, Durdey P, Dixon MF, Williams NS. Local recurrence of rectal adenocarcinoma due to inadequate surgical resection. Histopathological study of lateral tumour spread and surgical excision. Lancet 1986;2(8514):996e9. MERCURY Study Group. Diagnostic accuracy of pre-operative magnetic resonance imaging is predicting curative resection of rectal cancer: prospective observational study. BMJ 2006; 333(7572):779e84. Sauer R, Becker H, Hohenberger W, Rodel C, Wittekond C, Fietkau R, et al. Pre-operative versus post-operative Chemoradiotherapy for rectal cancer. N Eng J Med 2004;351: 1731e40. Nagtegaal ID, van de Velde CJH, Marijnen CAM, van Krieken JHJM, Quirke P. Low rectal cancer: a call for a change of approach in abdominoperineal resection. J Clin Oncol 2005; 3(36):9257e64. Tekkis PP, Heriot AG, Smith J, Thompson MR, Finan P, Stamatakis JD. Comparison of circumferential margin involvement between restorative and nonrestorative resections for rectal cancer. Colorectal Dis 2005;7:369e74. Wibe A, Syse A, Andersen E, Tretli S, Myrvold HE, Soreide O. Oncological outcomes after total mesorectal excision for cure for cancer of the lower rectum: anterior vs. abdominoperineal resection. Dis Colon Rectum 2004;47:48e58. Marr R, Birbeck K, Garvican J, Macklin CP, Tiffin NJ, Parsons WJ, et al. The modern abdominoperineal excision, the next challenge after Total Mesorectal Excision. Ann Surg 2005;242(1):74e82. Shihab OC, Brown G, Daniels IR, Heald RJ, Quirke P, Moran BJ. Patients with low rectal cancer treated by abdominoperineal excision have worse tumours and higher involved margin
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rates compared with patients treated by anterior resection. Dis Colon Rectum 2010;53(1):53e6. West NP, Anderin C, Smith KJE, Holm T, Quirke P. Multicentre experience with extralevator abdominoperineal excision for low rectal cancer. Br J Surg 2010;97:588e99. Chambers W, Khan A, Waters R, Lindsey I, George B, Mortensen N, et al. Examination of outcome following abdominoperineal resection for adenocarcinoma in Oxford. Colorectal Dis 2010;12:1192e7. Quirke P, Morris E. Reporting colorectal cancer. Histopathology 2007;50(1):103e12. Wille-Jørgensen P, Pilsgaard B, Møller P. Reconstruction of the pelvic floor with a biological mesh after abdominoperineal excision for rectal cancer. Int J Colorectal Dis 2009;24(3):323e5. Birbeck KF, Macklin CP, Tiffin NJ, Parsons W, Dixon MF, Mapstone NP, et al. Rates of circumferential resection margin involvement vary between surgeons and predict outcomes in rectal cancer surgery. Ann Surg 2002;235:449e57. den Dulk M, Putter H, Collette L, Marijnen CA, Folkesson J, Bosset JF, et al. The abdominoperineal resection itself is associated with an adverse outcome: the European experience based on a pooled analysis of five european randomised clinical trials in rectal cancer. Eur J Cancer 2009; 45:1175e83. den Dulk M, Marijnen CA, Putter H, Rutten HJ, Beets GL, Wiggers T, et al. Risk factors for adverse outcome in patients with rectal cancer treated with an abdominoperineal resection in the total mesorectal excision trial. Ann Surg 2007; 246(1):83e90. Holm T, Ljung A, Haggmark T, Jurell G, Lagergren J. Extended abdominoperineal resection with gluteus maximus flap reconstruction of the pelvic floor for rectal cancer. Br J Surg 2007;94:232e8. Bebenek M, Pudelko M, Cisarz K, Balcerzak A, Tupikowski W, Wojciechowski L, et al. Therapeutic results in low-rectal cancer patients treated with abdominosacral resection are similar to those obtained by means of anterior resection in mid- and upper-rectal cancer cases. EJSO 2007;33:320e3. Chan S, Miller M, Ng R, Ross D, Roblin P, Carapeti E, et al. Use of myocutaneous flaps for perineal closure following abdominoperineal excision of the rectum for adenocarcinoma. Colorectal Dis 2010;12(6):555e60.
Available online at www.sciencedirect.com
The Surgeon, Journal of the Royal Colleges of Surgeons of Edinburgh and Ireland www.thesurgeon.net
Short-term outcomes of the prone perineal approach for extra-levator abdomino-perineal excision (elAPE) R.S.J. Dalton, N.J. Smart, T.J. Edwards, I. Chandler*, I.R. Daniels Exeter Colorectal Unit and Dept of Histopathology, Royal Devon & Exeter Hospital, Barrack Road, Exeter, Devon EX2 5DW, United Kingdom
article info
abstract
Article history:
Background: Many studies report that low rectal cancer treated with abdomino-perineal
Received 5 April 2011
excision (APE) have higher rates of CRM involvement with associated local recurrence
Received in revised form
and worse survival when compared to low anterior resection. We present a single
15 August 2011
surgeon’s short-term outcomes using the prone perineal extra-levator (elAPE) approach.
Accepted 4 October 2011
Methods: Thirty-one patients between 2006 and 2010 underwent elAPE with curative intent.
Available online 15 November 2011
Data was collected prospectively recording patient tumour characteristics and histological outcome. Outcome measures included circumferential resection margins, recurrence rates, 30-day morbidity and mortality.
Keywords: Abdominoperineal excision (APE)
Results: Mean distance of tumour from anal verge was 3.63 SD 1.52 cm. 14 patients had
Rectal cancer
pre-operative chemo-radiotherapy. The involved circumferential resection margin rate
Circumferential
resection
margin
Extra-levator excision (elAPE)
was 3.2%. Median follow-up was 20 (0e45) months, with overall mortality of 13.3% and 30 day mortality of 6.6%.
(CRM) abdomino-perineal
Conclusions: The prone position elAPE has a low circumferential resection margin involved rate and, through improved vision, reduces the risk of inadvertent tumour or specimen perforation. ª 2011 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.
Introduction Over one hundred years ago Sir W. Ernest Miles described the technique of abdomino-perineal excision (APE) as a surgical approach for rectal cancer.1 He further developed the technique to include en-bloc resection of associated lymph nodes, and reported a recurrence rate of 29.5% and operative mortality of 31%.2 His surgical technique involved extirpation of the rectum from below and formation of an abdominal colostomy, the perineal portion of the operation being performed with the patient on their side. However, sphincter preserving surgery for middle and upper third rectal tumours was shown to be safe in the middle of the twentieth century
and the number of restorative operations increased.3 The development of stapling devices in the late 1970’s, and the demonstration that distal margins of 2 cm did not compromise local disease control, meant that lower anterior resections could be performed, thus further reducing the need for APE.4,5 Using cancer registry data the APE rate for rectal cancer reduced across England from 30.5% in 1998 to 23% in 2004.6 The reporting of total mesorectal excision (TME) by RJ Heald in 1982 and the recognition of the importance of the circumferential resection margin (CRM) have reduced the rates of local recurrence and improved survival.7,8 More recently outcomes have been further improved through magnetic resonance imaging (MRI) to evaluate the local extent
* Corresponding author. Tel.: þ447766147501. E-mail addresses: [email protected], [email protected] (I. Chandler). 1479-666X/$ e see front matter ª 2011 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.surge.2011.10.001
t h e s u r g e o n 1 0 ( 2 0 1 2 ) 3 4 2 e3 4 6
of the disease, and use of chemo-radiotherapy (CRT) to downstage locally advanced tumours managed through the multidisciplinary team (MDT) process.9,10 Despite these advances many series still report that low rectal cancers treated with APE have higher rates of local recurrence and worse survival when compared to low anterior resection (LAR).11e14 In the MERCURY Study dataset, when rectal cancers below 6 cm were assessed the rates of involved CRM were 12% vs 31.9% for low anterior resection and APE respectively despite standardised MRI, MDT and pathological assessment.15 Recently published data has reported that by performing a ‘cylindrical’ approach to the perineal dissection there is a reduction in involved circumferential resection margins (CRM).16,17 However, we questioned the need for a wide perineal resection of ischio-anal fat, instead remaining extra-levator in the plane of dissection, and only excising ischio-anal fat if the potential CRM was compromised. Using the concepts of MRI staging (defined using the MERCURY Study protocols9), selective pre-operative CRT and a standardized reporting proforma for APE, based on the work of Quirke,18 we present a single surgeon’s short-term outcomes using this extra-levator (elAPE) approach with the perineal dissection performed in the prone position.
Methods Low rectal cancers treated at the Royal Devon and Exeter Hospital by elAPE from a single surgeon (IRD) were examined using data collected prospectively from the local cancer registry. Patient age at the time of surgery, gender, height of tumour from anal verge, pre and post-operative chemoradiotherapy, mortality, morbidity, TNM histology, CRM involvement, follow-up, and disease recurrence were recorded. Ethical approval was not deemed to be necessary. All treatment decisions were ratified by the Hospital Multidisciplinary Team (MDT).
343
skin incision made around the anus, with a transverse incision across the perineum, parallel incisions laterally over the perianal skin that taper towards the coccyx (Fig. 1). Lateral and posterior dissection is then performed through the ischio-anal fossa, dependent upon the degree of tumour invasion to expose the coccyx and the pelvic floor. The pelvic floor is then opened from the coccyx, which in some cases is excised and the muscle is taken from the origin of the levator ani. Division of the endopelvic fascia allows re-entry into the TME plane. The degree of excision is dependent upon tumour position and stage. Based upon the initial staging pre-operative MRI the extent of adipose excision from the ischio-anal fossa and the necessity of coccygectomy is planned. A wider excision is performed on the side of the tumour for laterally placed tumours. Those tumours with a posterior element often required coccygectomy to ensure CRM clearance. Once the posterior part of the mesorectum has been identified through division of the endopelvic fascia, the swab is retrieved and the specimen reflected through the defect. The anterior dissection can then be performed anterior to Denonvillier’s fascia or rectovaginal septum. If the tumour is adherent to the vagina then posterior vaginal resection is carried out en bloc with the specimen. The excised specimen is illustrated in Fig. 2. We used a vertical rectus abdominis myocutaneous (VRAM) flap to reconstruct the perineum of the first patient and cross-linked acellular porcine dermal collagen (Permacol, Covidien, Gosport, UK) to reconstruct the pelvic floor,19 with the pelvic cavity filled with the fully mobilised omental pedicle of the subsequent 30 patients.
Pre-operative staging All patients were pre-operatively staged using MRI (MERCURY Protocols9) for local rectal cancer staging and CT for distant disease. After MDT discussion, patients with disease extending beyond or involving the mesorectal fascia (<1 mm) were treated with pre-operative CRT (45Gy and oral capecitabine) for 5 weeks. A further MRI was performed 6 weeks following completion of CRT to define response followed by surgery.
Surgical technique The surgical technique involves an open abdominal approach with the patient in the Lloyd Davis position. The omentum is mobilised as a pedicle using the left gastro-epiploic vessels. The colostomy is fashioned after the inferior mesenteric artery and vein have been divided and the abdominal dissection has been taken down to the sacro-coccyggeal joint. The peritoneal reflection divided anteriorly off the bladder or seminal vesicles to preserve the reflection. A swab is placed behind the mesorectum and the abdomen closed. The patient is then positioned in the prone jack-knife position, and a ‘church-window’
Fig. 1 e A “church window” incision. The patient is in the prone jack-knife position with the buttocks taped apart and an encircling silk suture to close the anal canal.
344
t h e s u r g e o n 1 0 ( 2 0 1 2 ) 3 4 2 e3 4 6
Fig. 2 e Excised specimen following extra-levator Abdominoperineal excision. These photographs show the lateral (left) and anterior (right) views of a specimen. In this case the coccyx was preserved and the site of the coccyx is identified with the finger. The anterior specimen shows the bulk of extra-levator tissue removed in this case as the disease was into the levator ani muscles, although the final CRM was 10 mm.
Pathological reporting Histopathological assessment has been performed in all cases by a single pathologist using the criteria and having received training as described by Professor P. Quirke.18 Circumferential resection margins were defined as tumour cells extending to <1 mm from the margin.
Results Between April 2006 and February 2010 31 consecutive patients underwent elAPE for low rectal cancer having been assessed through the MDT process and with no evidence of distant metastases (the only exclusion criteria). Eight patients (25.8%) were female and 23 (74.2%) male. Mean patient age was 66.8 SD 11.4 years, with mean tumour height from the anal verge of 3.63 SD 1.52 cm. The distribution of tumour circumferential position is shown in Table 1, with MRI (preCRT) stage and pathological stage shown in Table 2. Fourteen patients had pre-operative CRT. One patient received only 2 weeks of oral capecitabine as it was stopped due to the onset of chest pain. CRM was involved in one patient (3.2%). This was in a patient with a T4N2 tumour on pathological staging that was also T4N2 on pre-operative MRI with limited response to CRT. On pathological assessment the plane of excision was mesorectal (grade 1) and extra-levator in perineal resection plane. CRM ranged from 0.8 to 15 mm (the distribution is given in Table 3). Six cases were reported as CRM distance “>5 mm” on the histopathology report. If it is assumed that >5 mm is 6.0 mm then the mean was 6.4 mm and the SD 3.11 mm.
Median follow-up was 20 (range 1e45) months with local recurrence occurring in the 1 patient (3.2%) with involved CRM. Overall mortality was 4 (13.3%), the cause of death of one patient being anaplastic thyroid cancer, metastatic rectal cancer in the patient with an involved CRM with local recurrence, and two from post-operative complications within 30days (pulmonary embolism, and secondary to pelvic bleeding). Three patients developed distant metastases during follow up. Outcomes are summarized in Table 4. Six patients had breakdown of the perineal wound requiring topical negative pressure wound therapy (V.A.C. therapy, KCI medical Ltd, Kidlington, UK). One patient had skin paddle necrosis of a VRAM flap requiring revision on day 8 post-op. One patient developed a perineal wound haematoma and nine had minor wound discharge and/or infection
Table 1 e Patient demographics and Tumour characteristics. Total number of patients Gender Female (%) Mean age (years) Mean tumour height (cm) Pre-op CRT (%) Circumferential position: Anterior Anterolateral Posterior Posterolateral Lateral Circumferential Not recorded Coccyx resection (%)
31 8 (25.8%) 66.8 SD 11.4 3.63 SD 1.52 14 (45.2%) 8 (25.8%) 6 (19.4%) 2 (6.5%) 4 (12.9%) 4 (12.9%) 6 (19.4%) 1 (3.2%) 10 (32.3%)
t h e s u r g e o n 1 0 ( 2 0 1 2 ) 3 4 2 e3 4 6
Table 2 e MRI (pre-CRT) stage and pathological stage. MRI stage (pre-CRT)
TX T0 T1 T2 T3 T4
Pathological stage
N0
N1/2
N0
N1/2
1 0 1 8 10 1
0 0 0 1 6 3
0 4 4 8 9 0
0 0 0 2 3 1
resulting in delayed wound healing. Three developed an MRIdetected perineal hernia, of which one to date has been symptomatic and required surgical repair.
Discussion This series demonstrates that when performing an elAPE it is possible to achieve CRM involvement rates comparable to LAR in patients when staged and managed through MDT care. Historically a number of studies have found that an APE is associated with higher rates of CRM involvement when compared with LAR.11e14 It has recently been reported that the quality of APE surgery was poor.6 It is recognised that CRM involvement is a strong prognostic indicator for local recurrence and overall survival and therefore can be used as a marker for quality of both MDT decision-making and surgical technique.9 Recent series showed significantly higher rates of CRM involvement with APE of 21.4% compared to 7.4% for low anterior resection.15 Five-year survival in the APE group was 55% compared to 67% in the low AR group.20 Pooled data from five European rectal cancer trials (Swedish, Dutch, German, EORTC and Polish rectal cancer trials, 3633 patients) suggest that APE itself is associated with a higher risk of CRM involvement, being found in 10.6% of patients undergoing APE compared to 5% of those with low AR. Five year local recurrence rates and overall survival for low AR and APE respectively were 11.4% versus 19.7%, and 70.1% versus 59.5%.21 The higher CRM involvement rates in these studies may be related to the TME technique in the APE where the mesorectal fascia is followed, coning down towards the pelvic floor onto the sphincter complex.22 It has been suggested that this may increase the risk of CRM involvement and bowel perforation, and therefore dividing the levator ani lateral to the sphincter complex creating a more ‘cylindrical’ specimen (as originally described by Miles) may improve outcomes. Using this ‘cylindrical approach,’ Holm et al. reported a series of 28 patients with locally advanced T3/T4 tumours
Table 3 e Distribution of CRM. Distance to CRM (mm) <1.0 1.0e5.0 5.1e10.0 >10.0
Frequency 1 8 16 (including 6 reported as >5 mm) 6
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Table 4 e Summary of outcomes. CRM involvement (%) Local recurrence (%) Distant recurrence (%) Median follow-up Overall mortality (%) 30 day mortality (%)
1 (3.2%) 1 (3.2%) 3 (9.7%) 20 months (range 0e45) 4 (12.9%) 2 (6.5%)
with a 7.1% CRM involvement rate, using the prone jack-knife technique.23 A further study of a single surgeon changing from the conventional APE technique to wider perineal dissection reduced CRM involvement from 36.5% to 12%, and intraoperative perforation from 12.8% to 0.0%.24 With low tumours requiring an APE the sphincter muscle often forms the CRM, whereas with higher tumours the CRM is relatively protected by the mesorectum. Therefore taking more tissue outside of the sphincters may help reduce CRM involvement rates. This was recently demonstrated by the European Extralevator APE study group who compared elAPE with standard APE excisions16 and showed that the median distance of the tumour to the nearest CRM was significantly greater in the elAPE group (4.0 versus 1.5 mm, p ¼ 0.001). There was a significantly lower rate of CRM involvement in the elAPE group of 20.3% compared to 49.6% in the standard APE group and a significantly lower intra-operative perforation rate when the perineal dissection was carried out in the prone jack-knife position compared to the Lloyd-Davis position (6.4% versus 20.7%, p ¼ 0.027). Inadvertent perforation during surgery has been shown to increase local recurrence and reduce survival.16,24 In our series there were no intraoperative perforations. The associated morbidity of the elAPE technique is higher than series reporting conventional APEs,16 due to a larger perineal wound that requires closure, often in patients who have had neo-adjuvant CRT. The optimum method for closing the perineal defect has yet to be defined, but both biologic mesh19 and tissue flaps25 have been described with encouraging results.
Conclusion The extra-levator approach in a prone position has a low rate of involved CRMs with reduced the risk of inadvertent perforation.
references
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