Multicentre, randomised trial comparing acellular porcine collagen implant versus gluteus maximus myocutaneous flap for reconstruction of the pelvic floor after extended abdominoperineal excision of rectum: study protocol for the Nordic Extended Abdominoperineal Excision (NEAPE) study

INTRODUCTION

Different surgical techniques are used to cover the defect in the floor of the lesser pelvis after an 'extralevator' or 'extended' abdominoperineal excision for advanced rectal cancer. However, these operations are potentially mutilating, and the reconstruction method of the pelvic floor has been studied only sparsely. We aim to study whether a porcine-collagen implant is superior or equally beneficial to a gluteus maximus myocutaneous flap as a reconstruction method.

METHODS AND ANALYSIS

This is a multicentre non-blinded randomised controlled trial with the experimental arm using a porcine-collagen implant and the control arm using a gluteus maximus muscle and skin rotation flap. Considered for inclusion are patients with rectal cancer, who are operated on with a wide abdominoperineal rectal excision including most of the levator muscles and where the muscle remnants cannot be closed in the midline with sutures. Patients with a primary or recurrent rectal cancer with an estimated survival of more than a year are eligible. The randomisation is computer generated with a concealed sequence and stratified by participating hospital and preoperative radiotherapy regimen. The main outcome is physical performance 6 months after surgery measured with the timed-stands test. Secondary outcomes are perineal wound healing, surgical complications, quality of life, ability to sit and other outcomes measured at 3, 6 and 12 months after surgery. To be able to state experimental arm non-inferiority with a 10% margin of the primary outcome with 90% statistical power and assuming 10% attrition, we aim to enrol 85 patients from May 2011 onwards.

ETHICS AND DISSEMINATION

The study has been approved by the Regional Ethical Review board at Umeå University (protocol no: NEAPE-2010-335-31M). The results will be disseminated through patient associations and conventional scientific channels.

TRIAL REGISTRATION NUMBER

NCT01347697; Pre-results.

Perineal closure following extralevator abdominoperineal excision for cancer of the rectum

AIM

Extralevator abdominoperineal resection (ELAPE) may be complicated by perineal wound healing problems and herniation. We report a consecutive series of 38 such patients with selective use of a fasciocutaneous V-Y buttock advancement flap (BAF).

METHOD

Data were collected on a series of patients undergoing ELAPE for rectal malignancy between August 2011 and July 2017. Demographics, management and outcomes were recorded prospectively. Perineal wound problems were considered as 'major' if they required packing; otherwise, they were classed as 'minor'.

RESULTS

Thirty-eight patients [eight female and 30 male; median age 63 (range: 35-89) years] underwent ELAPE. Thirty-seven had an adenocarcinoma of the rectum and one had a malignant melanoma. The median tumour height (from the anal verge) was 30 (range: 0-80) mm. Sixteen patients had a BAF. The median length of stay was 10 (range: 6-25) days. Primary perineal healing occurred in 18 (47%) patients. Major wound breakdown occurred in three (10%) patients and minor wound breakdown in 17 (45%). Two of the 16 patients having a BAF had major wound breakdown: one wound took 9 weeks to heal completely and the other took 9 months. Of the 22 patients who did not have a BAF, one had a major wound breakdown which closed by 3 months. There were no perineal fistulae or chronic sinuses. There were two perineal herniae that were successfully repaired by perineal insertion of biological mesh (Permacol™; Covidien, Dublin, Ireland).

CONCLUSIONS

Selective use of a BAF for perineal closure can give good results in terms of healing and an acceptably low early perineal herniation rate.

Exploring minimally invasive options: Laparoscopic transabdominal levator transection for low rectal cancers

Extralevator abdominoperineal excision (ELAPE) of the rectum offers wider circumferential margin and decreased rate of intraoperative tumour perforation. However, the need to change the position of the patient in between abdominal and perineal stages of the procedure and extended perineal resection result in increased morbidity and operative time. Evolving technique of laparoscopic transabdominal controlled division of levator ani muscles under direct vision could address these issues while providing all benefits of ELAPE for patients with low rectal cancers.

Management of the Perineal Defect after Abdominoperineal Excision

The optimal management of the perineal defect following abdominoperineal excision for anorectal malignancy remains a source of debate. The repopularization of extralevator resection means colorectal surgeons are confronted with larger perineal wounds. There are several surgical options available-primary perineal closure and drainage, omentoplasty, biological or synthetic mesh placement, musculocutaneous flap repair, and negative wound pressure therapy. These options are discussed along with the potential benefits and complications of each. There remains no consensus on which management strategy is superior; thus, each case must be tailored for each individual patient. Surgical expertise and availability of a multidisciplinary team approach are important considerations.

Endoscopically assisted extralevator abdominoperineal excision

AIM

Extralevator abdominoperineal excision (ELAPE) has been advocated to optimize clearance of lower third rectal cancers with an involved or threatened circumferential resection margin. ELAPE could reduce positive margins and specimen perforation compared with standard abdominoperineal excision. However, there can be difficulties with ELAPE, particularly in identifying the anterior plane in male patients. Usually, the dissection is performed in the prone position, which can be hazardous, particularly in obese patients in whom wound problems are commonly encountered. We describe an endoscopically assisted approach for ELAPE in the lithotomy position.

METHOD

Three male patients with a rectal tumour located at the anorectal junction underwent an endoscopically assisted ELAPE in the lithotomy position after preoperative radiotherapy.

RESULTS

All the procedures were performed successfully with operation times of 180, 390 and 420 mins. There were no instances of intra-operative perforation or other complications. One patient developed postoperative intestinal obstruction which resolved on conservative management. There were no wound complications. Histopathological examination demonstrated clear margins and intact mesorectal planes in each patient.

CONCLUSION

We report a good outcome in three patients after endoscopically assisted ELAPE. This approach allows the patient to be operated on in the lithotomy position giving excellent views of the anterior dissection.