Extralevator abdominoperineal resection(elape)

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EXTRALEVATOR ABDOMINOPERINEAL RESECTION(ELAPE) Dr.A.Joseph Stalin

EXTRALEVATOR ABDOMINOPERINEAL RESECTION(ELAPE)

Dr.A.Joseph Stalin M.Ch PGPROF.DR.R.RAJARAMANS UNITCENTRE FOR ONCOLOGYGOVT ROYAPETTAH HOSPITALCHENNAICONTENTSCONCEPT OF ELAPE

SURGICAL TECHNIQUE

MERITS/DEMERITS

EVIDENCE BASED MEDICINE IN ELAPE

VIDEO

ELAPE- HISTORYFirst successful rectal excision by Jacques Lisfranc 1826 perineal approach.

Next 70 80 yrs rectal cancer treated through perineal approach with high morbidity and local recurrance.

1908 Earnest Miles described Abdomino perineal excision(APE)

MILES CONCEPTAfter a decade-long audit of his rectal resections, he noted a local recurrance rate of over 95% within 13 years.

He described three zones of local spread from rectal cancers:

-Downward to perianal skin, -Lateral along levator ani and internal iliac nodes, -Upward corresponding with proximal lymphatic drainage to the mesocolon.

When performing the operation, the abdominal phase is performed first with the patient in an exaggerated Trendelenburg posture.

Once a laparotomy has been performed, via a median incision, a loop colostomy is fashioned in the left iliac fossa with the apex of the sigmoid colon.

The sigmoid colon is then divided about 2 inches distal to the stoma site (thus creating a loop sigmoid colostomy with a blind ending distal portion).

The pelvic colon (sigmoid colon) is then mobilized and the inferior mesenteric artery is divided below the sigmoid branches.

Attention then turns to the rectal mobilization and the remainder of the operation is now practically bloodless and should be rapidly proceeded with.

The anterior and posterior rectal mobilization is done bluntly whereas the lateral ligaments of the rectum are divided with scissor.

The rectal mobilization continues down to the upper surface of the levatores ani.

The abdominal cavity is then lavaged with saline and closed.

The patient is now placed in the right lateral position so that the perineal portion of the operation can be proceeded with.

An incision is made from the sacro-coccygeal joint to within an inch of the anus.

A semicircular incision is then made around the anus, in such a manner as to take a wide area of skin and fat.

The coccyx is removed and the levatores divided as far outward as their origin from the white line. Any residual attachments of the rectum to the sacrum or vagina/prostate are divided and the specimen is removed.

The chasm is then irrigated with saline and the skin closed over two drains.

The patient is then placed in the supine position and a small opening is made into the extruded bowel to allow of the escape of flatus.

First major modification in 1930s with adoption of the lithotomy-Trendelenberg position popularized by Lloyd Davis.

For a large part of the rest of the century, Miles APE with or without lithotomy positioning remained the gold standard.

Local recurrance rate around 15%

TME CONCEPTBased on pathological-clinical studies from the 1980s showing distal spread in the mesorectum and a significant relation between CRM involvement and local recurrence

Encompasses:Excision of complete mesorectum in mid and lower third cancers down to the pelvic floorComplete CRM clearance by sharp dissection

Heald RJ, Husband EM, Ryall RDH. The mesorectum in rectal cancer surgery: the clue to pelvic recurrence? Br J Surg. 1982;69:613-616.

Effect of a surgical training programme on outcome of rectal cancer in the County of Stockholm. Martling et al. Lancet 2000

21 st CenturyThe use of mechanical stapling devices ,

Increasing knowledge of patterns of spread with acceptance of smaller distal margins ,

Development of neoadjuvant therapies and

Application of local excision and transanal endoscopic microsurgery have led to

Sphincter-sparing surgery becoming a priority after oncological safety for most rectal cancers APR is performed in less than 15% of cases

INDICATION :

Invasion of external sphincter. Low AR cannot be done. The widespread adoption of total mesorectal excision has improved outcomes in anterior resection but a similar improvement has not been evident in APE.

APE is associated with higher rates of circumferential resection margin involvement, local recurrence and reduced cancer specific survivalProblem with lower rectal cancer Absence of mesorectal margin cushion

Difficult technical dissection due to lack of planes

High positive radial margin rate (~36%) for distal third rectal location

Universal Problem Distal Third Location Dutch TME trial

AR APRPositive margins 10.7% 30.4%Perforations 2.5% 13.7%Survival 57.6% 38.5%

Nagtegaal et al. J Clin Oncol 2005; 23:9257

ELAPE the Solution?Br J Surg.2007 Feb;94(2):232-8.Extended abdominoperineal resection with gluteus maximus flap reconstruction of the pelvic floor for rectal cancer.Holm T1,Ljung A,Hggmark T,Jurell G,Lagergren J.AbstractBACKGROUND:Intraoperative tumour perforation, positive tumour margins, wound complications and local recurrence are frequent difficulties with conventional abdominoperineal resection (APR) for rectal cancer. An alternative technique is the extended posterior perineal approach with gluteus maximus flap reconstruction of the pelvic floor. The aim of this study was to report the technique and early experience of extended APR in a select cohort of patients. Between 2001 and 2005, 28 patients with low rectal cancer were treated accordingly at the Karolinska Hospital.

CONCLUSION:The extended posterior perineal approach with gluteus maximus flap reconstruction in APR has a low risk of bowel perforation, CRM involvement and local perineal wound complications. The rate of local recurrence may be lower than with conventional APR.

27SURGICAL TECHNIQUE -Principle -Abdominal phase -Perineal phase -Reconstruction PRINCIPLES OF SURGERYExtend of resection is that of described by Miles but by employing TME principles.

Levator muscles are excised enbloc with mesorectum,lower rectum & anus

Thereby avoiding waist of the specimen seen in conventional APR

Purpose: To reduce bowel perforation and CRM(circumferential margin positivity)

A.ELAPE(Cylindrical APR)

APR

ELAPE

ABDOMINAL PHASEIn APR , mesorectum is mobilised upto the pelvic floor

In ELAPE, mesorectal mobilisation is limited

Dorsally : sacrococcygeal junction

Ventrally : seminal vesicles(male),cervix(female)

Laterally : lateral ligamentPERINEAL PHASEProne Jack knife vs Supine lithotomy

Prone position preferred Pros: Improved visibility, easier retraction by assistant reduced perforation, reduced CRM positivity

Cons: long operative time as patient position needs to be changed.

Unable to perform rectus or gracilis transfer

PERINEAL PHASEAnus closed with purse string suture.

Tear drop incision made encircling anus unto tip of cocyx.

External sphincter identified and dissection continued outside levator muscle .

Levator muscles are followed until their origin in pelvic sidewall (white line)

INCISION

Mesorectum entered just anterior to coccyx or through sacrococcyxeal junction after removing coccyx.

Pelvic floor is divided (levator)

Dissection continues anteriorly onto the prostate /vagina

Cylindrical specimen is excised.

ELAPE in supine position

RECONSTRUCTION Primary closure +/- omentoplasty

Rotation / advancement flaps

Gluteus, gracilis, rectus

Free flaps Mesh Prolene / PTFE (Goretex) Biologic

GLUTEUS FLAP

GRACILIS FLAP

RECTUS ABDOMINUS FLAP

BIOLOGICAL MESH

MERITSGood visualisation anterior structures with plane easily seen and dissectedEasy control of bleedersDecreased perforation rateOne surgeonEasy to teachEasy to assistPerineal operator does not get wetPossibly less blood lossDEMERITSLearning curve as to how far to dissect into the pelvis

Unaccustomed plane

Coccygeal division leaves bare bone in a potentially contaminated field.

No further access to abdomen during the perineal dissection

No difference in anterior/posterior margin only lateral margin clearance is increased

Perineal wound complicationsEVIDENCE BASED MEDICINE

APRELAPEPOSITIONSUPINESUPINE +/- PRONEABDOMINAL PHASETME UPTO PELVIC FLOORTME SHORT OF PELVIC FLOORPERINEAL PHASEEXTERNAL SPHINCTER REMOVEDLEVATOR ANI REMOVED COMPLETELYWOUND COMPLCATIONLESSHIGHCRM POSITIVITYHIGHLESSCONCLUSIONTechnique of ELAPE has evolved mainly to reduce CRM positivity in lower rectal cancer

Decision to perform ELAPE is taken preoperatively not intraoperatively.

Extend of resection same as that of described by Miles but by employing TME principle and smaller perineal incisionCONCLUSIONAccepted and