Long-term outcomes of biological mesh repair following extra levator abdominoperineal excision of the rectum: an observational study of 100 patients

Extracellular Matrix Scaffold-Assisted Tumor Vaccines Induce Tumor Regression and Long-Term Immune Memory

Injectable scaffold delivery is a strategy to enhance the efficacy of cancer vaccine immunotherapy. The choice of scaffold biomaterial is crucial, impacting both vaccine release kinetics and immune stimulation via the host response. Extracellular matrix (ECM) scaffolds prepared from decellularized tissues facilitate a pro-healing inflammatory response that promotes local cancer immune surveillance. Here, an ECM scaffold-assisted therapeutic cancer vaccine that maintains an immune microenvironment consistent with tissue reconstruction is engineered. Several immune-stimulating adjuvants are screened to develop a cancer vaccine formulated with decellularized small intestinal submucosa (SIS) ECM scaffold co-delivery. It is found that the STING pathway agonist cyclic di-AMP most effectively induces cytotoxic immunity in an ECM scaffold vaccine, without compromising key interleukin 4 (IL-4) mediated immune pathways associated with healing. ECM scaffold delivery enhances therapeutic vaccine efficacy, curing 50-75% of established E.G-7OVA lymphoma tumors in mice, while none are cured with soluble vaccine. SIS-ECM scaffold-assisted vaccination prolonged antigen exposure is dependent on CD8+ cytotoxic T cells and generates long-term antigen-specific immune memory for at least 10 months post-vaccination. This study shows that an ECM scaffold is a promising delivery vehicle to enhance cancer vaccine efficacy while being orthogonal to characteristics of pro-healing immune hallmarks.

A comparison of surgical techniques for perineal wound closure following perineal excision: a systematic review and network meta-analysis

BACKGROUND

To mitigate pelvic wound issues following perineal excision of rectal or anal cancer, a number of techniques have been suggested as an alternative to primary closure. These methods include the use of a biological/dual mesh, omentoplasty, muscle flap, and/or pelvic peritoneum closure. The aim of this network analysis was to compare all the available surgical techniques used in the attempt to mitigate issues associated with an empty pelvis.

METHODS

An electronic systematic search using MEDLINE databases (PubMed), EMBASE, and Web of Science was performed (Last date of research was March 15th, 2023). Studies comparing at least two of the aforementioned surgical techniques for perineal wound reconstruction during abdominoperineal resection, pelvic exenteration, or extra levator abdominoperineal excision were included. The incidence of primary healing, complication, and/or reintervention for perineal wound were evaluated. In addition, the overall incidence of perineal hernia was assessed.

RESULTS

Forty-five observational studies and five randomized controlled trials were eligible for inclusion reporting on 146,398 patients. All the surgical techniques had a comparable risk ratio (RR) in terms of primary outcomes. The pooled network analysis showed a lower RR for perineal wound infection when comparing primary closure (RR 0.53; Crl 0.33, 0.89) to muscle flap. The perineal wound dehiscence RR was lower when comparing both omentoplasty (RR 0.59; Crl 0.38, 0.95) and primary closure (RR 0.58; Crl 0.46, 0.77) to muscle flap.

CONCLUSIONS

Surgical options for perineal wound closure have evolved significantly over the last few decades. There remains no clear consensus on the "best" option, and tailoring to the individual remains a critical factor.

Perineal wound complications after vertical rectus abdominis myocutaneous flap and mesh closure following abdominoperineal surgery and pelvic exenteration of anal and rectal cancers: A meta-analysis

A meta-analysis research was implemented to appraise the perineal wound complications (PWCs) after vertical rectus abdominis myocutaneous (VRAM) flap and mesh closure (MC) following abdominoperineal surgery (AS) and pelvic exenteration (PE) of anal and rectal cancers. Inclusive literature research till April 2023 was done and 2008 interconnected researches were revised. Of the 20 picked researches, enclosed 2972 AS and PE of anal and rectal cancers persons were in the utilized researchers' starting point, 1216 of them were utilizing VRAM flap, and 1756 were primary closure (PC). Odds ratio (OR) and 95% confidence intervals (CIs) were utilized to appraise the consequence of VRAM flap in treating AS and PE of anal and rectal cancers by the dichotomous approach and a fixed or random model. VRAM flap had significantly lower PWCs (OR, 0.64; 95% CI, 0.42-0.98, p < 0.001), and major PWCs (OR, 0.50; 95% CI, 0.32-0.80, p = 0.004) compared to PC in AS and PE of anal and rectal cancers persons. However, VRAM flap and PC had no significant difference in minor PWCs (OR, 1; 95% CI, 0.54-1.85, p = 1.00) in AS and PE of anal and rectal cancer persons. VRAM flap had significantly lower PWCs, and major PWCs, however, no significant difference was found in minor PWCs compared to PC in AS and PE of anal and rectal cancers persons. However, caution needs to be taken when interacting with its values since there was a low sample size of most of the chosen research found for the comparisons in the meta-analysis.

Closure of pelvic peritoneum with bladder peritoneum flap reconstruction after laparoscopic extralevator abdominoperineal excision: A prospective stage II study

BACKGROUND

Extralevator abdominoperineal resection (ELAPE) has increased perineal wound complications due to the extended resection area. Closure of the pelvic peritoneum (CPP) may exclude the abdominal content from descending into the pelvic cavity and reduce the incidence of perineal complications after ELAPE. We have previously introduced bladder peritoneum flap reconstruction (BLAPER) as a novel method for patients in whom traditional CPP is not possible. The aim of the present study was to report the development and preliminary outcomes of BLAPER.

METHODS

This is a prospective single-arm study at the development and exploration phase and fulfills the IDEAL framework stage II. Ultralow rectal cancer patients with rigid pelvis who underwent ELAPE with BLAPER were enrolled. Primary outcomes were intraoperative complications and postoperative complications within 1 month after surgery.

RESULTS

Among 27 patients included, the overall success rate of BLAPER was 96.3% (26/27). Indocyanine green fluorescence imaging and antiadhesive barrier placement were introduced to improve the BLAPER technique. The incidence of major pelvic wound complications was 7.7%. No patient who underwent BLAPER has suffered small bowel obstruction (SBO), presence of small bowel in the retrourogenital space, or perineal hernia (PH).

CONCLUSIONS

BLAPER is safe and may prevent the small bowel from descending into the retrourogenital space and subsequently developing PH and SBO without increasing the intraoperative and postoperative complications. BLAPER may serve as an option when the primary suture of the pelvic peritoneum is not feasible.

Short- and mid-term outcomes of abdominoperineal resection with perineal mesh insertion: a single-centre experience

PURPOSE

Abdominoperineal resection (APR) remains a key procedure for the treatment of low rectal/anorectal cancers. However, perineal wound closure remains challenging, particularly in extralevator abdominoperineal resection (ELAPR) due to gapped tissue planes. Different approaches have been attempted to improve perineal wound repair. The aim of this study is to report our 6-year experience in perineal wound closure utilising biological mesh.

METHODS

We conducted a retrospective study using data from our prospectively maintained database, including patients who underwent APR with perineal mesh closure between 2016 and 2021.

RESULTS

49  patients underwent APR with perineal mesh reconstruction for low rectal cancer during the 6-year period. Of these, 63% were males, with a mean age of 68 (± 11), and a mean BMI of 27.9 (± 13.7). 49% (24) of patients received neoadjuvant therapy. 88% (43) of patients underwent standard "S-APR" and only 12% (6) underwent ELAPR. Majority of procedures were laparoscopic (87.8%) with conversion rate of 6.9%. Mean length of stay was 11.7 (± 11.6). The perineal wound infection rate was 30% and only two patient required mesh removal due to entero-cutaneous perineal fistula and pelvic abscess. Perineal hernia was found in only two patients (4.1%). CRM was negative in 81.6% of the patients. Mean follow-up period was 29.2 (± 16.5) months, and disease recurrence occurred in 9 (18.3%) patients with average number of months for recurrence of 21 (± 7). Overall survival during the follow-up period was 91%.

CONCLUSION

Our series shows a favourable short- and medium-term outcome with routine insertion of mesh for perineal wound closure.

Pelvic exenteration: a review of current issues/controversies

Management of advanced or recurrent pelvic cancer has evolved dramatically over the past few decades. Patients who were previously considered inoperable are now candidates for potentially curative surgery and avoid suffering with intractable symptoms. Up to 10% of primary rectal cancers present with isolated advanced local disease and between 10% and 15% of patients develop localized recurrence following proctectomy. Advances in surgical technique, reconstruction and multidisciplinary involvement have led to a reduction in mortality and morbidity and culminated in higher R0 resection rates with superior longer-term survival outcomes. Recent studies boast over 50% 5-year survival for rectal with an R0 resection. Exenteration has cemented itself as an important treatment option for advanced primary/recurrent pelvic tumours, however, there are still a few controversies. This review will discuss some of these issues, including: limitations of resection and the approach to high/wide tumours; the role of acute exenteration; re-exenteration; exenteration in the setting of metastatic disease and palliation; the role of radiotherapy (including intra-operative and re-irradiation); management of the empty pelvis; and the impact on quality of life and function.

Is it worthwhile to perform closure of the pelvic peritoneum in laparoscopic extralevator abdominoperineal resection?

PURPOSE

There is no uniformity in the use of closure of the pelvic peritoneum (CPP) after laparoscopic extralevator abdominoperineal excision (ELAPE). This study aimed to evaluate the short-term outcomes of CPP after ELAPE and provide supporting evidence for the performance of CPP in laparoscopic ELAPE.

METHODS

Patients with rectal cancer who underwent ELAPE from January 2014 to April 2019 were retrospectively investigated. CPP was routinely performed unless it was not feasible. The main outcome was the difference in the occurrence of perineal hernia (PH), small bowel obstruction (SBO) and perineal wound complications between laparoscopic and open ELAPE, which were compared using Kaplan-Meier curves.

RESULTS

Of the 244 patients included, 104 received laparoscopic ELAPE, and 140 received open ELAPE. Patients in the laparoscopic group suffered a higher incidence of PH (11.5% (12/104) vs. 5.0% (7/140), p = 0.049), SBO (10.6% (11/104) vs. 7.9% (11/140), p = 0.433) and major perineal wound complications (12.5% (13/104) vs. 7.9% (11/140), p = 0.228) than those in the open group. Multivariate analysis showed that no-CPP was an independent risk factor for the occurrence of PH (p = 0.022, OR 3.436, 95% CI 1.199-9.848) and major perineal wound complications (p = 0.012, OR 3.683, 95% CI 1.337-10.146).

CONCLUSION

In this comparative cohort study with a risk of allocation bias, CPP was associated with a lower incidence of radiological PH and major perineal wound complications regardless of the surgical approach. Thus, we believe CPP could serve as an option L-ELAPE for the prevention of perineal complications. To further determine the impact of CPP on postoperative complications after ELAPE, a prospective multicentre study is needed.

Empty pelvis syndrome: a systematic review of reconstruction techniques and their associated complications

AIM

Empty pelvis syndrome is a major contributor to morbidity following pelvic exenteration. Several techniques for filling the pelvis have been proposed; however, there is no consensus on the best approach. We evaluated and compared the complications associated with each reconstruction technique with the aim of determining which is associated with the lowest incidence of complications related to the empty pelvis.

METHOD

The systematic review protocol was prospectively registered with PROSPERO (CRD42021239307). PRISMA-P guidelines were used to present the literature. PubMed and MEDLINE were systematically searched up to 1 February 2021. A dataset containing predetermined primary and secondary outcomes was extracted.

RESULTS

Eighteen studies fulfilled our criteria; these included 375 patients with mainly rectal and gynaecological cancer. Only three studies had a follow-up greater than 2 years. Six surgical interventions were identified. Mesh reconstruction and breast prosthesis were associated with low rates of small bowel obstruction (SBO), entero-cutaneous fistulas and perineal hernia. Findings for myocutaneous flaps were similar; however, they were associated with high rates of perineal wound complications. Omentoplasty was found to have a high perineal wound infection rate (40%). Obstetric balloons were found to have the highest rates of perineal wound dehiscence and SBO. Silicone expanders effectively kept small bowel out of the pelvis, although rates of pelvic collections remained high (20%).

CONCLUSION

The morbidity associated with an empty pelvis remains considerable. Given the low quality of the evidence with small patient numbers, strong conclusions in favour of a certain technique and comparison of these interventions remains challenging.

Cumulative 5-year Results of a Randomized Controlled Trial Comparing Biological Mesh With Primary Perineal Wound Closure After Extralevator Abdominoperineal Resection (BIOPEX-study)

OBJECTIVE

To determine long-term outcomes of a randomized trial (BIOPEX) comparing biological mesh and primary perineal closure in rectal cancer patients after extralevator abdominoperineal resection and preoperative radiotherapy, with a primary focus on symptomatic perineal hernia.

SUMMARY BACKGROUND DATA

BIOPEX is the only randomized trial in this field, which was negative on its primary endpoint (30-day wound healing).

METHODS

This was a posthoc secondary analysis of patients randomized in the BIOPEX trial to either biological mesh closure (n = 50; 2 dropouts) or primary perineal closure (n = 54; 1 dropout). Patients were followed for 5 years. Actuarial 5-year probabilities were determined by the Kaplan-Meier statistic.

RESULTS

Actuarial 5-year symptomatic perineal hernia rates were 7% (95% CI, 0-30) after biological mesh closure versus 30% (95% CI, 10-49) after primary closure (P = 0.006). One patient (2%) in the biomesh group underwent elective perineal hernia repair, compared to 7 patients (13%) in the primary closure group (P = 0.062). Reoperations for small bowel obstruction were necessary in 1/48 patients (2%) and 5/53 patients (9%), respectively (P = 0.208). No significant differences were found for chronic perineal wound problems, locoregional recurrence, overall survival, and main domains of quality of life and functional outcome.

CONCLUSIONS

Symptomatic perineal hernia rate at 5-year follow-up after abdominoperineal resection for rectal cancer was significantly lower after biological mesh closure. Biological mesh closure did not improve quality of life or functional outcomes.

Efficacy of Pelvic Peritoneum Closure After Laparoscopic Extralevator Abdominoperineal Excision for Rectal Cancer

BACKGROUND

The descent of the small bowel into the pelvic dead space after extralevator abdominoperineal excision (ELAPE) presents a higher risk for postoperative complications. The aim of the present study was to evaluate the efficacy of pelvic peritoneum closure in preventing the small bowel from descending into the pelvic dead space and the potential consequences of this approach.

METHODS

Patients with rectal cancer undergoing laparoscopic ELAPE from March 2014 to January 2019 were retrospectively investigated. Closure of the pelvic peritoneum (CPP) was routinely performed unless it was not feasible. All patients with pelvic peritoneum reconstruction were included in the CPP group, and patients without pelvic peritoneum reconstruction were included in the no-CPP group. The main outcomes included the incidences of the small bowel descending into the retro-urogenital space (space between the bladder/uterus and the sacrum on axial CT scans), perineal wound complications, perineal hernia, and small bowel obstruction (SBO).

RESULTS

Of the 100 patients included, 79 received CPP, and 21 did not. Fewer patients with pelvic peritoneum closure had small bowels residing in the retro-urogenital space than patients without closure (17.7% vs 42.9%, p=0.014). The incidence of SBO was also lower in the CPP group (7.6% vs. 23.8%, p=0.034). Multivariable analysis showed that no-CPP (p=0.014) was an independent risk factor for the small bowel descending into the retro-urogenital space.

CONCLUSION

CPP may prevent the small bowel from descending into the retro-urogenital dead space in patients undergoing laparoscopic ELAPE without increasing the incidence of perineal wound complications. Prospective studies are warranted to confirm the efficacy of CPP in preventing SBO and perineal hernia.

Comparison of perineal morbidity between biologic mesh reconstruction and primary closure following extralevator abdominoperineal excision: a systematic review and meta-analysis

AIM

Extralevator abdominoperineal excision (ELAPE) for rectal cancer leaves a greater perineal defect which might result in significant perineal morbidity, and how to effectively close perineal defects remains a challenge for surgeons. This study aimed to comparatively evaluate the perineal-related complications of biologic mesh reconstruction and primary closure following ELAPE.

METHOD

The electronic databases PubMed, EMBASE, Cochrane Library, and Web of Science were searched to screen out all eligible studies, which compared biologic mesh reconstruction with primary closure for perineal-related complications following ELAPE. Pooled data of perineal-related complications including overall wound complications, hernia, infection, dehiscence, chronic sinus, and chronic pain (12 months after surgery) were analyzed.

RESULTS

A total of four studies (one randomized controlled trial and three cohort studies) involving 544 patients (346 biologic mesh vs 198 primary closure) were included. With a median follow-up of 18.5 months (range, 2-71.5 months). Analysis of the pooled data indicated that the perineal hernia rate was significantly lower in biologic mesh reconstruction as compared to primary closure (OR, 0.38; 95% CI, 0.22-0.69; P = 0.001). There were no statistically significant differences between the two groups in terms of total perineal wound complications rate (P = 0.70), as well as rates of perineal wound infection (P = 0.97), wound dehiscence (P = 0.43), chronic sinus (P = 0.28), and chronic pain (12 months after surgery; P = 0.75).

CONCLUSION

Biologic mesh reconstruction after extralevator abdominoperineal excision appears to have a lower hernia rate, with no differences in perineal wound complications.

[Prophylaxis of parastomal, perineal and incisional hernias in colorectal surgery]

This article gives an overview of the relevant evidence from the literature on the topic of prophylactic use of meshes to prevent incisional and parastomal hernias in colorectal surgery. In addition, based on a structured literature search the incidence of hernias in colorectal surgery over the past 5 years was analyzed. A slight majority (54%) of articles recommended the use of prophylactic mesh implantation in colorectal surgery. The prophylactic use of meshes appears to reduce the risk of hernias in colorectal surgery but is associated with a slightly increased perioperative wound infection rate. Parastomal hernias are associated with higher incidence rates compared with incisional hernias and also appear to benefit more from prophylactic mesh implantation. The evidence in the literature is still unclear regarding the use of synthetic or biological implants due to the lack of randomized controlled trials. Perineal hernias were excluded from the analysis due to the incomparability of the mainly casuistic literature. An overview is given in the discussion. The analysis of the literature and also in reflection of our own experience comes to the conclusion that the disrupted integrity of the abdominal wall due to the operation should be prophylactically reinforced with a mesh after colorectal surgery. An evidence-based recommendation is not possible based on the current state of research on implantation techniques, e.g. onlay, sublay intraperitoneal onlay mesh (IPOM) and selection of the implant.

Case Report: Biologic graft placement with subsequent radiation therapy following radical vulvectomy for adenoid cystic carcinoma of the Bartholin's gland

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Biologic graft should be considered for defects unable to be closed primarily.

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Radiation therapy should not be a contraindication to biologic graft placement.

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Consider biologic graft placement in areas not amenable to surgical flap creation.

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Biologic grafts should be considered in gynecologic oncology patients.

Adenoid cystic carcinoma (ACC) of the Bartholins gland, first described by Klob in 1864, is a rare form of vulvar cancer comprising approximately 2–7% of all invasive vulvar lesions (Cardosi, 2001). Treatment consists of excision followed by radiation therapy (Cardosi, 2001; Anaf, 1999; Barcellini, 2020). Progression is indolent with later recurrence and metastases in comparison to other forms of vulvar cancer (Yang, 2006). Resection remains the gold standard for treatment followed by radiation therapy if margins are positive (Cardosi, 2001; Yang, 2006; Chang et al., 2019). We present a case of ACC of the Bartholins gland that underwent radical vulvectomy and Surgisis graft placement due to the extent of disease resection. Radiation therapy was then pursued due to positive margins with no wound breakdown despite this being the most common complication of vulvectomy with or without radiation therapy (Leminen et al., 2000). To our knowledge this is only the second case of Cook Biodesign graft placement after vulvectomy and first case of subsequent local radiation therapy to the area.

Meta-analysis of biological mesh reconstruction versus primary perineal closure after abdominoperineal excision of rectal cancer

BACKGROUND

Extralevator abdominoperineal excision (ELAPE) of rectal cancer has been proposed to achieve better oncological outcomes. The resultant wide perineal wound, however, presents a challenge for primary closure and subsequent wound healing. This meta-analysis compared the outcomes of primary perineal closure with those of biological mesh reconstruction.

METHODS

The Medline and Embase search was performed for the publications comparing primary perineal closure to biological mesh reconstruction. Early perineal wound complications (seroma, infection, dehiscence) and late perineal wound complications (perineal hernia, chronic pain, and chronic sinus) were analyzed as primary endpoints. Intraoperative blood loss, operation time, and hospital stay were compared as secondary endpoints.

RESULTS

There was no significant difference in the overall early wound complications after primary closure or biological mesh reconstruction (odds ratio (OR) of 0.575 with 95% confidence interval (CI) of 0.241 to 1.373 and a P value of 0.213). The incidence of perineal hernia after 1 year was significantly high after primary closure of the perineal wounds (OR of 0.400 with 95% CI of 0.240 to 0.665 and a P value of 0.001). No significant differences were observed among other early and late perineal wound complications. The operation time and hospital stay were shorter after primary perineal closure (p 0.001).

CONCLUSION

A lower incidence of perineal hernia and comparable early perineal wound complications after biological mesh reconstruction show a relative superiority over primary closure. More randomized studies are required before a routine biological mesh reconstruction can be recommended for closure of perineal wounds after ELAPE.

Perineal Wound Closure Following Abdominoperineal Resection and Pelvic Exenteration for Cancer: A Systematic Review and Meta-Analysis

Simple Summary

Abdominoperineal resection (APR) and pelvic exenteration (PE) for the treatment of cancer (mainly anal and rectal cancers) require extensive pelvic resection with a high rate of postoperative complications. The objective of this work was to systematically review and meta-analyze the effects of vertical rectus abdominis myocutaneous flap (VRAMf) and mesh closure on perineal morbidity following APR and PE. The studies were distributed as follows: Group A comparing primary closure (PC) and VRAMf, Group B comparing PC and mesh closure, Group C comparing PC and VRAMf in PE. The meta-analysis of Groups A and B showed PC to be associated with an increase in the rate of total and major perineal wound complications. PC was associated with a decrease in total and major perineal complications in Group C.

Abstract

Background. Abdominoperineal resection (APR) and pelvic exenteration (PE) for the treatment of cancer require extensive pelvic resection with a high rate of postoperative complications. The objective of this work was to systematically review and meta-analyze the effects of vertical rectus abdominis myocutaneous flap (VRAMf) and mesh closure on perineal morbidity following APR and PE (mainly for anal and rectal cancers). Methods. We searched PubMed, Cochrane, and EMBASE for eligible studies as of the year 2000. After data extraction, a meta-analysis was performed to compare perineal wound morbidity. The studies were distributed as follows: Group A comparing primary closure (PC) and VRAMf, Group B comparing PC and mesh closure, and Group C comparing PC and VRAMf in PE. Results. Our systematic review yielded 18 eligible studies involving 2180 patients (1206 primary closures, 647 flap closures, 327 mesh closures). The meta-analysis of Groups A and B showed PC to be associated with an increase in the rate of total (Group A: OR 0.55, 95% CI 0.43–0.71; p < 0.01/Group B: OR 0.54, CI 0.17–1.68; p = 0.18) and major perineal wound complications (Group A: OR 0.49, 95% CI 0.35–0.68; p < 0.001/Group B: OR 0.38, 95% CI 0.12–1.17; p < 0.01). PC was associated with a decrease in total (OR 2.46, 95% CI 1.39–4.35; p < 0.01) and major (OR 1.67, 95% CI 0.90–3.08; p = 0.1) perineal complications in Group C. Conclusions. Our results confirm the contribution of the VRAMf in reducing major complications in APR. Similarly, biological prostheses offer an interesting alternative in pelvic reconstruction. For PE, an adapted reconstruction must be proposed with specialized expertise.

Pelvic peritoneum reconstruction using the bladder peritoneum flap in laparoscopic extralevator abdominoperineal excision: A multi-center, prospective single-arm cohort study (IDEAL Phase 2A)

INTRODUCTION

Extralevator abdominoperineal excision (ELAPE) may cause various surgical complications including disruption of perineal wound, perineal hernia and adhesive small-bowel obstruction. Pelvic peritoneum reconstruction (PPR) could prevent those complications, but it may not always be achievable, especially in patients with severe pelvic fibrosis after neoadjuvant radiotherapy. Our previous study has reported the application of the PPR using the bladder peritoneum flap in laparoscopic ELAPE. The aim of the study is to evaluate the short-term clinical, technical and safety outcomes of PPR using the bladder peritoneum flap in laparoscopic ELAPE.

METHODS AND ANALYSIS

This is a multi-center prospective single-arm cohort study and fulfill the IDEAL 2A stage principle. Rectal cancer patients undergoing laparoscopic ELAPE, suffering rigid pelvis or huge perineal peritoneum defect, and having difficulty in primary perineal wound closure will be considered eligible. Main exclusion criteria are being complicated with urgent complications, ASA grade >3 and accompanied with mental illness. After informed consent, 30 patients are planned to be included in the study. Standard laparoscopic ELAPE with pelvic peritoneal floor reconstruction using bladder peritoneum flap are to be performed. The surgical safety is to be evaluated after one-year follow-up. Primary endpoints are the occurrence of intraoperative and postoperative complications of PPR using the bladder peritoneum flap. Second endpoints are overall complication rate within 30 days after surgery, extent of small intestine falling down to pelvic cavity, and other follow-up consequences within 1 year after surgery.

ETHICS AND DISSEMINATION

This experiment was approved by the Biomedical Ethics Committee of West China Hospital of Sichuan University.

TRIAL REGISTRATION

NCT04177407.

Extralevator abdominoperineal excision for advanced low rectal cancer: Where to go

Since its introduction, extralevator abdominoperineal excision (ELAPE) in the prone position has gained significant attention and recognition as an important surgical procedure for the treatment of advanced low rectal cancer. Most studies suggest that because of adequate resection and precise anatomy, ELAPE could decrease the rate of positive circumferential resection margins, intraoperative perforation, and may further decrease local recurrence rate and improve survival. Some studies show that extensive resection of pelvic floor tissue may increase the incidence of wound complications and urogenital dysfunction. Laparoscopic/robotic ELAPE and trans-perineal minimally invasive approach allow patients to be operated in the lithotomy position, which has advantages of excellent operative view, precise dissection and reduced postoperative complications. Pelvic floor reconstruction with biological mesh could significantly reduce wound complications and the duration of hospitalization. The proposal of individualized ELAPE could further reduce the occurrence of postoperative urogenital dysfunction and chronic perianal pain. The ELAPE procedure emphasizes precise anatomy and conforms to the principle of radical resection of tumors, which is a milestone operation for the treatment of advanced low rectal cancer.

A low incidence of perineal hernia when using a biological mesh after extralevator abdominoperineal excision with or without pelvic exenteration or distal sacral resection in locally advanced rectal cancer patients

Background

Extralevator abdominoperineal excision (ELAPE), abdominoperineal excision (APE) or pelvic exenteration (PE) with or without sacral resection (SR) for locally advanced rectal cancer leaves a significant defect in the pelvic floor. At first, this defect was closed primarily. To prevent perineal hernias, the use of a biological mesh to restore the pelvic floor has been increasing. The aim of this study, was to evaluate the outcome of the use of a biological mesh after ELAPE, APE or PE with/without SR.

Methods

A retrospective study was conducted on patients who had ELAPE, APE or PE with/without SR with a biological mesh (Permacol™) for pelvic reconstruction in rectal cancer in our center between January 2012 and April 2015. The endpoints were the incidence of perineal herniation and wound healing complications.

Results

Data of 35 consecutive patients [22 men, 13 women; mean age 62 years (range 31–77 years)] were reviewed. Median follow-up was 24 months (range 0.4–64 months). Perineal hernia was reported in 3 patients (8.6%), and was asymptomatic in 2 of them. The perineal wound healed within 3 months in 37.1% (n = 13), within 6 months in 51.4% (n = 18) and within 1 year in 62.9% (n = 22). In 17.1% (n = 6), the wound healed after 1 year. It was not possible to confirm perineal wound healing in the remaining 7 patients (20.0%) due to death or loss to follow-up. Wound dehiscence was reported in 18 patients (51.4%), 9 of whom needed vacuum-assisted closure therapy, surgical closure or a flap reconstruction.

Conclusions

Closure of the perineal wound after (EL)APE with a biological mesh is associated with a low incidence of perineal hernia. Wound healing complications in this high-risk group of patients are comparable to those reported in the literature.

Combined use of a petal flap and V-Y advancement flap for reconstruction of presacral defects following rectal resection

BACKGROUND

The aim of this study was to evaluate the efficacy of a combination of flaps for the reconstruction of presacral defects following abdominoperineal resections: a paramedian vertically oriented caudally based lotus petal flap for presacral defects combined with a horizontal V-Y advancement flap for closure of the superficial donor site defect.

METHODS

A retrospective study was conducted on patients with a residual defect following an abdominoperineal resection between 2010 and 2017 in the Noordwest Ziekenhuisgroep. The primary endpoint was complications related to the reconstruction.

RESULTS

Twelve patients were included, all reconstructions healed well. Three patients had a grade I or II complication (Clavien Dindo classification).

CONCLUSIONS

Use of a petal flap and V-Y advancement flap for reconstruction of presacral defects was found to be safe and simple, and should, therefore, be considered in the management of such problems.

Feasibility of a subcutaneous gluteal turnover flap without donor site scar for perineal closure after abdominoperineal resection for rectal cancer

BACKGROUND

Abdominoperineal resection (APR) carries a high risk of perineal wound morbidity. Perineal wound closure using autologous tissue flaps has been shown to be advantageous, but there is no consensus as to the optimal method. The aim of this study was to evaluate the feasibility of a novel gluteal turnover flap (GT-flap) without donor site scar for perineal closure after APR.

METHODS

Consecutive patients who underwent APR for primary or recurrent rectal cancer were included in a prospective non-randomised pilot study in two academic centres. Perineal reconstruction consisted of a unilateral subcutaneous GT-flap, followed by midline closure. Feasibility was defined as uncomplicated perineal wound healing at 30 days in at least five patients, and a maximum of two flap failures.

RESULTS

Out of 17 potentially eligible patients, 10 patients underwent APR with GT-flap-assisted perineal wound closure. Seven patients had pre-operative radiotherapy. Median-added theatre time was 38 min (range 35-44 min). Two patients developed a superficial perineal wound dehiscence, most likely because of the excessive width of the skin island. Two other patients developed purulent discharge and excessive serosanguinous discharge, respectively, resulting in four complicated wounds at 30 days. No flap failure occurred, and no radiological or surgical reinterventions were performed. Median length of hospital stay was 10 days (IQR 8-12 days).

CONCLUSIONS

The GT-flap for routine perineal wound closure after APR seems feasible with limited additional theatre time, but success seems to depend on correct planning of the width of the flap. The potential for reducing perineal morbidity should be evaluated in a randomised controlled trial.