Biological mesh versus primary closure for pelvic floor reconstruction following extralevator abdominoperineal excision: a meta-analysis / 中华胃肠外科杂志

Objective: To compare the morbidity of perineum-related complication between biological mesh and primary closure in closing pelvic floor defects following extralevator abdominoperineal excision (ELAPE). Methods: A literature search was performed in PubMed, Embase, Cochrane Library, Web of Science, Wanfang database, Chinese National Knowledge Infrastructure, VIP database, and China Biological Medicine database for published clinical researches on perineum-related complications following ELAPE between January 2007 and August 2020. Literature inclusion criteria: (1) study subjects: patients undergoing ELAPE with rectal cancers confirmed by colonoscopy pathological biopsy or surgical pathology; (2) study types: randomized controlled studies or observational studies comparing the postoperative perineum-related complications between the two groups (primary perineal closure and reconstruction with a biological mesh) following ELAPE; (3) intervention measures: biological mesh reconstruction used as the treatment group, and primary closure used as the control group; (4) outcome measures: the included literatures should at least include one of the following postoperative perineal complications: overall perineal wound complications, perineal wound infection, perineal wound dehiscence, perineal hernia, chronic sinus, chronic perineal pain (postoperative 12-month), urinary dysfunction and sexual dysfunction. Literature exclusion criteria: (1) data published repeatedly; (2) study with incomplete or wrong original data and unable to obtain original data. Two reviewers independently performed screening, data extraction and assessment on the quality of included studies. Review Manager 5.3 software was used for meta-analysis. The mobidities of perineum-related complications, including overall perineal wound (infection, dehiscence, hernia, chronic sinus) and perineal chronic pain (postoperative 12-month), were compared between the two pelvic floor reconstruction methods. Finally, publication bias was assessed, and sensitivity analysis was used to evaluate the stability of the results. Results: A total of five studies, including two randomized controlled studies and three observational controlled studies, with 650 patients (399 cases in the biological mesh group and 251 cases in primary closure group) were finally included. Compared with primary closure, biological mesh reconstruction had significantly lower ratio of perineal hernia (RR=0.37, 95%CI: 0.21-0.64, P<0.001). No significant differences in ratios of overall perineal wound complication, perineal wound infection, perineal wound dehiscence, perineal chronic sinus and perineal chronic pain (postoperative 12-month) were found between the two groups (all P>0.05). Conclusion: Compared with primary closure, pelvic floor reconstruction following ELAPE with biological mesh has the advantage of a lower incidence of perineal hernia.

Research progress on urogenital function preservation in extralevator abdominoperineal resection / 中华胃肠外科杂志

Extralevator abdominoperineal excision (ELAPE) has been suggested to potentially improve oncological outcomes in advanced low rectal cancer patients. However, the urogenital function impairment as one of the main complications deteriorates the quality of life in these patients. The key point to prevent urogenital function impairment is to avoid autonomic nerve injury, including the superior and inferior hypogastric nerve plexus and neurovascular bundle. Three areas should be especially focused during surgery, including the posterolateral aspect of the prostate during the separation of the rectum from prostate, the lateral wall of ischioanal fossa and the area in front of anal canal. Previous presumption supposed that extended resection, though promoting oncologic outcomes, might lead to enlarged injury to surrounding vessels and nerves that deteriorated patients′ urogenital function. But recent studies show that postoperative urogenital function outcomes of rectal cancer patients who underwent ELAPE are not inferior to conventional APE after the induction of minimal invasive approaches including laparoscopic and robotic surgery. Their quality of life can be comparable with patients who underwent conventional APE, and are even better in some particular area. Moreover, as further improvement of ELAPE procedure has been made, the concept of individualized ELAPE addressed the importance of personalized surgical procedure based on tumor stage and location, dedicating to avoid injury to vessels and nerves through preserving more surrounding tissues. Urogenital function outcomes, as part of postoperative outcomes, get more and more attention in recent years. We review current studies on urogenital function after ELAPE from anatomy to clinical research, in order to raise surgeons′ attention of nerve preservation technique and to improve their understanding of ELAPE procedure.

Extralevator abdominoperineal excision versus abdominoperineal excision for low rectal cancer: a meta-analysis / 中华医学杂志(英文版)

Background@#Extralevator abdominoperineal excision (ELAPE) has become a popular procedure for low rectal cancer as compared with abdominoperineal excision (APE). No definitive answer has been achieved whether one is superior to the other. This study aimed to evaluate the safety and efficacy of ELAPE for low rectal cancer with meta-analysis.@*Methods@#The Web of Science, Cochrane Library, Embase, and PubMed databases before September 2019 were comprehensively searched to retrieve comparative trials of ELAPE and APE for low rectal cancer. Pooled analyses of the perioperative variables, surgical complications, and oncological variables were performed. Odds ratio (OR) and mean differences (MD) from each trial were pooled using random or fixed effects model depending on the heterogeneity of the included studies. A subgroup analysis or a sensitivity analysis was conducted to explore the potential source of heterogeneity when necessary.@*Results@#This meta-analysis included 17 studies with 4049 patients, of whom 2248 (55.5%) underwent ELAPE and 1801 (44.5%) underwent APE. There were no statistical differences regarding the circumferential resection margin positivity (13.0% vs. 16.2%, OR = 0.69, 95% CI = 0.42-1.14, P = 0.15) and post-operative perineal wound complication rate (28.9% vs. 24.1%, OR = 1.21, 95% CI = 0.75-1.94, P= 0.43). The ELAPE was associated with lower rate of intraoperative perforation (6.6% vs. 11.3%, OR = 0.50, 95% CI = 0.39-0.64, P < 0.001) and local recurrence (8.8% vs. 20.5%, OR = 0.29, 95% CI = 0.21-0.41, P < 0.001) when compared with APE.@*Conclusions@#The ELAPE was associated with a reduction in the rate of intra-operative perforation and local recurrence, without any increase in the circumferential resection margin positivity and post-operative perineal wound complication rate when compared with APE in the surgical treatment of low rectal cancer.

Application value of biological mesh in the pelvic floor reconstruction of extralevator abdominoperineal excision for advanced low rectal cancer / 中华消化外科杂志

Objective To investigate the application value of biological mesh in the pelvic floor reconstruction of extralevator abdominoperineal excision (ELAPE) for advanced low rectal cancer (RC).Methods The retrospective cohort study was conducted.The clinicopathological data of 228 patients with advanced low RC who underwent ELAPE in the Beijing Chaoyang Hospital of Capital Medical University between August 2008 and December 2016 were collected.Of 228 patients,174 using biological mesh closure and 54 using primary closure were respectively allocated into the biological mesh group and primary closure group.Observation indicators:(1)intra-and post-operative situations;(2) postoperative complications (including short-term and long-term complications);(3) follow-up and survival situations.Follow-up using outpatient examination and telephone interview was performed to detect postoperative long-term complications,tumor recurrence or metastasis and overall survival up to December,2017.Measurement data with normal distribution were represented as（ x） ±s,and comparison between groups was analyzed using the independent-sample t test.Measurement data with skewed distribution were described as M (range),and comparison between groups was analyzed using the nonparametric test.Comparisons of count data were evaluated by the chi-square test or Fisher exact probability.Results (1)Intra-and post-operative situations:all the patients underwent successful ELAPE.The perineal operation time,time of indwelling perineal drainage-tube and hospital expenses were respectively (60 ± 50)minutes,(11.6 ± 2.4) days,(57 781± 11 337) yuan in the biological mesh group and (50±21) minutes,(8.9± 1.7) days,(53 714± 13 395)yuan in the primary closure group,with statistically significant differences between groups (t =3.327,7.691,-2.203,P＜0.05).The total operation time and duration of postoperative hospital stay were respectively (242±53) minutes,(13.0±5.0) days in the biological mesh group and (228±51) minutes,(12.0±5.0) days in the primary closure group,with no statistically significant difference between groups (t =1.701,1.309,P＞0.05).(2) Postoperative complications:26 and 19 patients in the biological mesh group and primary closure group had respectively perineal wound complications (1 patient combined with multiple complications),showing a statistically significant difference between groups (x2 =10.660,P＜0.05).The perineal wound infection,perineal hernia and disruption of perineal wound were respectively detected in 20,6,1 patients in the biological mesh group and 12,7,3 patients in the primary closure group,showing statistically significant differences between groups (x2 =3.931,5.282,P＜0.05).(3) Follow-up and survival situations:174 patients in the biological mesh group were followed up for 64 months (range,13-112 months),and 54 patients in the primary closure group were followed up for 51 months (range,23-76 months).The local recurrence rate,distal metastasis rate and overall survival rate were respectively 5.17％ (9/174),20.11％ (35/174),77.59％ (135/174) in the biological mesh group and 7.41％(4/54),24.07％(13/54),79.63％(43/54) in the primary closure group,with no statistically significant difference between groups (x2 =0.080,0.389,0.101,P＞0.05).Conclusions The biological mesh in the pelvic floor reconstruction of ELAPE for advanced low RC is safe and feasible.Compared with primary closure,biological mesh closure will extend perineal operation time and time of indwelling perineal drainage-tube,and increase hospital expenses,but doesn't affect total operation time and duration of postoperative hospital stay,meanwhile,it can also reduce the overall perineal wound complications,especially in perineal wound infection,perineal hernia and disruption of perineal wound.

Therapeutic effect of extralevator abdominoperineal excision in combination with conventional abdominoperineal excision on distal rectal cancer:A Meta-analysis / 西安交通大学学报(医学版)

Objective To explore the short and long-term efficacy of extralevator abdominoperineal excision (ELAPE)vs.conventional abdominoperineal excision (APE)on distal rectal cancer.Methods Relevant studies were identified by search of Medline,EMBASE,and Web of Science published between January 1,2008 and February 28,2015,and included in the systematic review and meta-analysis with Stata software (version 12.0). Results Our Meta-analysis included 14 studies involving 3278 patients,of whom 1843 (56.2%)underwent ELAPE and 1435 (43.8%)underwent APE.Compared with patients undergoing APE,those undergoing ELAPE had a significantly reduced risk of intraoperative bowel perforation (IBP)involvement (OR=0 .55 ,95% CI= 0 .37-0 .85 ),but no significant reduction in the occurrence of CRM positivity (OR=0 .81 ,95% CI=0 .52-1 .25 ), local recurrence (LR)(OR=0.49,95% CI=0.18-1.30),wound complications (WCs)(OR=0.93,95% CI=0.65-1.35)or in-hospital death (IHD)(OR=0.89,95% CI=0.47-1.71).Conclusion ELAPE can reduce the risk of IBP but not for CRM positivity or LR when compared with APE.Therefore,more higher-quality studies are needed to verify the short-and long-term effects of ELAPE procedure on distal rectal cancer.

Advantage of extralevator abdominoperineal excision comparing to the conventional abdominoperineal excision for low rectal cancer: a Meta-analysis / 中南大学学报(医学版)

Objective:Whether extralevator abdominoperineal excision (ELAPE) improves survival and safety remains controversial.Systematic review of all comparative studies to define the superiority of ELAPE to conventional abdominoperineal excision (APE).Methods:Corresponding data,with case-control studies or cohorts regarding intraoperative perforation rate,the local recurrence rate and postoperative complications in the ELAPE group and the APE group,were retrieved from PubMed,Embase,the Cochrane Library,Chinese Biomedical Literature (CMB),VIP,China National Knowledge Infrastructure (CNKI),and Wanfang Database.Meta-analysis was performed by using RenMan 5.2.Results:A total of 10 articles were included.Intraperative perforation rate (MD=0.54,95％ CI 0.31 to 1.39,P=0.03),local recurrence rate (MD=0.30,95％ CI 0.21 to 0.42,P＜0.001) in the ELAPE group was significantly lower than that in the APE group.The difference in positive margin rate between the 2 groups was not statistically significant (P=0.07).Conclusion:Through gap repair of episiotomy and individualized therapy can improve ELAPE postoperative quality of life.ELAPE shows certain advantages in treating lower rectal cancer comparing to APE,but it should pay attention to individualized treatment.More studies through large sample multi-center,medium and long term randomized design are necessary to determine the effect of surgery on tumor.

Anatomy-based staging of the American Joint Committee on Cancer for scientific surgical planning of low rectal cancer / 中华消化外科杂志

Compared with patients with high-middle rectal cancer,local recurrent rate of low rectal cancer in patients is worse.The poor outcome of low rectal cancer is due to the unique anatomical features of the low rectum and the lack of clearly defined anatomical excision planes.Therefore,how to use the appropriate imaging methods,evaluate accurately preoperative cancer staging,plan feasible surgical plane and select the appropriate surgical approach,these will be very important for radical resection of rectal cancer.Therefore,the quality of life and long-term survival of the patients will be improved.

Clinical efficacy of laparoscopic extralevator abdominoperineal excision for low rectal cancer without turning position / 中华消化外科杂志

Objective To explore the clinical efficacy of laparoscopic extralevator abdominoperineal excision (laparoscopic ELAPE) for low rectal cancer with modified Lloyd-Davies lithotomy position and without turning position.Methods The retrospective cross-sectional study was conducted.The clinicopathological data of 27 patients with low rectal cancer who underwent laparoscopic ELAPE without turning position in the West China Hospital of Sichuan University from September 2013 to January 2015 were collected.The modified Lloyd-Davies lithotomy position was used in perineal resection.Observation indicators:(1) surgical situation;(2) postoperative recovery situation;(3) postoperative pathological examination situation;(4) follow-up and survival situations.Follow-up using outpatient examination and telephone interview was performed to detect postoperative complications,survival of patients and tumor recurrence or metastasis up to March 2017.Measurement data with normal distribution were represented as (x)±s.Measurement data with skewed distribution were described as M (range).Results (1) Surgical situation:A total of 27 patients received laparoscopic ELAPE without turning position,and operation time and volume of intraoperative blood loss were (198±51)minutes and (85±66)mL.Among 5 of 27 patients with intraoperative complications,1 with intestinal perforation received successful intraoperative repair,1with presacral haemorrhage received successful hemostasis by intraoperative gauze pressing,1 with left and right pelvic plexus injury didn't receive special treatment,1 with left pelvic plexus injury + left internal iliac vein injury didn't receive special treatment and were repaired in vascular injury repair,1 with right neurovascular bundle injury didn't receive special treatment of nerve injury and received successful hemostasis by ultrasonic scalpel.There was no perforation in the site of the tumor.Number of lymph node dissected was 14 (range,9-22),and number of lymph node dissected ≥ 12 and ＜ 12 were detected in 15 and 12 patients,respectively.(2)Postoperative recovery situation:time to anal exsufflation and time for fluid diet intake in 27 patients were respectively (78±21)hours and (83±21)hours.Of 27 patients,8 with postoperative complications were improved by conservative treatment,including 1 in Clavien-Dindo Ⅰ (volume of perineal exudation ＞ 100 mL) and 7 in Clavien-Dindo Ⅱ (3 with pulmonary infection,2 with chylous fistula,1 with perineal incision infection and 1 with hematuria).There was no death within 30 days postoperatively.The median duration of hospital stay of 27 patients was 7 days (range,6-8 days).(3) Postoperative pathological examination situation:of 27 patients,1 and 26 had respectively positive and negative circumferential margins and median distance of circumferential margin was 0.7 cm (range,0.1-1.1 cm).T stage:14,12 and 1 patients were respectively detected in T2,T3 and T4.N stage:18,6 and 3 patients were respectively found in N0,N1 and N2.(4) Follow-up and survival situations:25 of 27 patients were followed up for 2-32 months,with a median time of 24 months.During the follow-up,5 had complications after discharge from hospital.Of 5 patients,2 with persistent anal pain didn't receive special treatment and were not relieved,and 3 with sexual dysfunction didn't receive special treatment and were followed up or observed.Of 25 patients,2 died of tumor-related diseases,1 died of non-tumor-related disease and other 22 had survival.No local tumor recurrence was detected.Eight patients had tumor distant metastases,including 4 with pulmonary metastases,3 with hepatic metastases and 1 with brain metastasis.Conclusion Laparoscopic ELAPE by modified Lloyd-Davies lithotomy position without turning position is safe and feasible,with closing pelvic floor peritoneum in stage Ⅰ.

Short-term Outcomes of an Extralevator Abdominoperineal Resection in the Prone Position Compared With a Conventional Abdominoperineal Resection for Advanced Low Rectal Cancer: The Early Experience at a Single Institution

PURPOSE: This study compared the perioperative and pathologic outcomes between an extralevator abdominoperineal resection (APR) in the prone position and a conventional APR. METHODS: Between September 2011 and March 2014, an extralevator APR in the prone position was performed on 13 patients with rectal cancer and a conventional APR on 26 such patients. Patients' demographics and perioperative and pathologic outcomes were obtained from the colorectal cancer database and electronic medical charts. RESULTS: Age and preoperative carcinoembryonic antigen (CEA) level were significantly different between the conventional and the extralevator APR in the prone position (median age, 65 years vs. 55 years [P = 0.001]; median preoperative CEA level, 4.94 ng/mL vs. 1.81 ng/mL [P = 0.011]). For perioperative outcomes, 1 (3.8%) intraoperative bowel perforation occurred in the conventional APR group and 2 (15.3%) in the extralevator APR group. In the conventional and extralevator APR groups, 12 (46.2%) and 6 patients (46.2%) had postoperative complications, and 8 (66.7%) and 2 patients (33.4%) had major complications (Clavien-Dindo III/IV), respectively. The circumferential resection margin involvement rate was higher in the extralevator APR group compared with the conventional APR group (3 of 13 [23.1%] vs. 3 of 26 [11.5%]). CONCLUSION: The extralevator APR in the prone position for patients with advanced low rectal cancer has no advantages in perioperative and pathologic outcomes over a conventional APR for such patients. However, through early experience with a new surgical technique, we identified various reasons for the lack of favorable outcomes and expect sufficient experience to produce better peri- or postoperative outcomes.

Amputación abdominoperineal extraelevador como tratamiento de neoplasias anorrectales localmente avanzadas. Experiencia inicial / Extralevator abdominoperineal resection as treatment of locally advanced anorectal neoplasias. Initial experience

Introducción: la amputación abdominoperineal (AAP) fue durante muchas años el tratamiento de elección para los tumores de recto bajo y especialmente aquellos con compromiso del aparato esfinteriano. Algunas modificaciones a la técnica original, sugieren el aumento de la radicalidad a través de una resección cilíndrica (amputación abdominoperineal extraelevador). Esta estrategia permite ampliar los márgenes de resección circunferencial, con menor posibilidad de perforación o apertura tumoral, permitiendo así una menor recidiva local y mejores resultados oncológicos. El siguiente trabajo tiene por objetivo exponer los aspectos técnicos más relevantes y los resultados de la experiencia inicial con esta variante técnica. Diseño: Serie de casos. Pacientes y métodos: se analizaron todos los pacientes sometidos a una amputación abdominoperineal extraelevador (AAPE) intervenidos en el Sanatorio Güemes, en el período comprendido desde mayo 2011 hasta septiembre del 2013. Fueron analizadas variables: demográficas, índice ASA (American Society of Anesthesiologist), índice de masa corporal (IMC), distancia del tumoral margen anal, tipo de cirugía, estadía hospitalaria y la morbilidad perioperatoria. Resultados: se incluyeron 5 pacientes, 4 de ellos pertenecían al sexo masculino. La media de edad fue de 61 años mientras que para el IMC fue de 29,8. Solamente en 1 paciente se realizó el abordaje laparoscópico. El tiempo operatorio medio fue de 266 minutos. La estadía hospitalaria en promedio fue de 8,6 días. Se registraron las siguientes complicaciones: dehiscencia parcial de colgajo cutáneo en 2 pacientes, fistula uretral (1 paciente) y eventración de la incisión mediana (1 paciente). El seguimiento medio de la serie fue de1 5 (8-24) meses. No hubo mortalidad en la serie. Un paciente presento una recidiva local...

Background: abdominoperineal resection (APR) has been, for many years, the treatment of choice for low rectal tumors, or those with sphincter involvement. In recent years, technical modifications (extralevator abdominoperineal resection) were performed, increasing the radicality of the original surgery. Thus oncologic outcomes were improved, with a decrease in the values of tumor perforation, circumferential resection margins involvement and a consequent lower local recurrence rates. This paper attempts to show the initial experience in this type of procedure. Design: Case series. Patients and methods: all patients who underwent extralevator abdominoperineal resection (EAPR) in the Sanatorio Güemes in the period from May 2011 to September 2013 were included. The variables analyzed were: demographic, ASA index (American Society of Anesthesiologist), body mass index (BMI), tumor distance from the anal verge, type of surgery, hospital stay, and intraoperative and postoperative complications. Results: five extralevator abdominoperineal resection were performed in 4 males. The mean age was 61 years and the mean BMI was 29.8. Only 1 laparoscopic approach was performed. The mean operative time was 266 min. The hospital stay was 8.6 days. The postoperative complications were: partial flap dehiscence (2 patients), urethral fistula (1 patient) and median incision hernia (1 patient). The median follow-up was 15 (8-24) months. Only one patient had a local recurrence...

Four-arm single docking full robotic surgery for low rectal cancer: techniques and post-operative outcomes / Cirurgia totalmente robótica para o tratamento do câncer do reto distal: técnicas e resultados do pós-operatório imediato

BACKGROUND: laparoscopic rectal surgery has not yet achieved a high penetration rate because of its steep learning curve and its relatively high conversion rate. Robotic rectal resection represents the main indication of the use of the robotic platform in colorectal surgery. The aim of this study was to present an early experience with robotic surgery to treat mid and low rectal cancer focusing on the technique and early postoperative outcomes. METHODS: from December 2012 to October 2013, a total of 16 patients with colorectal diseases were operated on using a four-arm single docking full robotic procedure (daVinci Si Surgical System). The treatment of six consecutive patients who underwent robotic rectal cancer surgery for mid or low rectal adenocarcinoma was prospectively analyzed regarding technique standardization, pathological findings and postoperative outcomes. RESULTS: there were no conversions and one intraoperative complication. The mean operative time was 245 min (180-360 min). The mean console time was 170 min (110-240 min). All patients underwent a standardized totally robotic rectal dissection. There were no mortality or urinary dysfunction and one complication (postoperative ileo-16%). The median length of hospital stay was 6 (4-11 days). The median number of lymph nodes harvested was 22 (7-38), and distal and circumferential resection margins were negative in all specimen. R0 resection was achieved in all cases and complete total mesorectal excision in five specimen and nearly complete in one. CONCLUSION: standardized robotic rectal surgery is a promising alternative to treat patients with mid or low rectal cancer and is expected to overcome the low penetration rate of laparoscopic surgery in this field. This technique was successfully performed in six patients with excellent immediate postoperative and pathological results. Additional studies in a large series of patients are necessary to confirm those advantages. (AU)

INTRODUÇÃO: a utilização da cirurgia videolaparoscópica para o tratamento do câncer do reto ainda não apresentou uma alta penetração devido a longa curva de aprendizado e a uma taxa de conversão relativamente alta. A ressecção retal robótica é a principal indicação para o uso da plataforma robótica na cirurgia colorretal. O objetivo desse estudo é apresentar as técnicas e os resultados pós-operatórios imediatos com o uso da cirurgia robótica para o tratamento do câncer do reto distal. PACIENTES E MÉTODOS: no período de dezembro de 2012 a outubro de 2013 foram operados 16 pacientes com patologias colorretais utilizando o robô daVinci SI Surgical System. O tratamento de 6 consecutivos pacientes portadores de câncer do reto do terço médio e do terço inferior foram prospectivamente avaliados quanto a sistematização técnica, achados patológicos e evolução pós-operatória. RESULTADOS: não houve conversão e ocorreu uma complicação intraoperatória. A duração média das operações foi de 245 minutos (180-360 minutos) e o tempo médio do uso do console foi de 170 minutos (110-240 minutos). Ocorreu uma complicação pós-operatória (Íleo) e não houveram nenhuma disfunção urinária ou mortalidade. A duração média da internação hospitalar foi de 6 dias (4-11 dias). O número médio de linfonodos examinados foi de 22 (7-38) e todas as peças tinham margens distal e circunferencial negativas. Ressecção RO foi observada em todos os casos e o grau de excisão total do mesorreto foi completo em 5 peças e quase completo em uma. CONCLUSÃO: cirurgia robótica sistematizada esta tendo uma crescente aceitação e é uma ótima alternativa para o tratamento dos pacientes com câncer do reto distal. Esta tecnologia foi utilizada em 6 pacientes com excelentes resultados não só na recuperação pós-operatória imediata como também nos achados da avaliação patológica. Grandes series randomizadas são importantes para confirmar as possíveis vantagens dessa nova tecnologia. (AU)

Cylindrical abdominoperineal resection rationale, technique and controversies / Amputação abdominoperineal cilíndrica racional, técnica e controvérsias

Surgery remains the cornerstone in rectal cancer treatment. Abdominoperineal excision (APE), described more than 100 years ago, remains as an important procedure for the treatment of selected advanced distal tumors with direct invasion of the anal sphincter or preoperative fecal incontinence. Historically, oncological outcomes of patients undergoing APE have been worse when compared to sphincter preserving operations. More recently, it has been suggested that patients undergoing APE for distal rectal cancer are more likely to have positive circumferential resection margins and intraoperative perforation, known surrogate markers for local recurrence. Recently, an alternative approach known as "Extralevator Abdominoperineal Excision" has been described in an effort to improve rates of circumferential margin positivity possibly resulting in better oncological outcomes compared to the standard procedure. The objective of this paper is to provide a technical description and compare available data of both Extralevator and Standard abdominal perineal excision techniques. (AU)

Um dos pilares mais importantes no tratamento do câncer de reto ainda é a ressecção cirúrgica. A amputação de reto, ou excisão abdomino-perineal do reto (APE), descrita há mais de 100 anos, continua sendo um procedimento importante para o tratamento de tumores retais distais que invadem o aparelho esfincteriano ou em casos de incontinência pré-operatória. Entretanto, os resultados oncológicos dos pacientes submetidos à APE são piores quando comparados com os pacientes submetidos a procedimentos com preservação esfincteriana. Recentemente, foi sugerido que os pacientes submetidos à APE por câncer de reto distal apresentam mais frequentemente margem radial positiva, assim como perfuração intraoperatória do tumor, fatos reconhecidamente associados à recidiva local. Uma nova técnica cirúrgica conhecida como "Amputação de reto extraelevador ou cilíndrica" tem sido descrita em um esforço para reduzir as taxas de margem radial positivas, sugerindo melhores resultados oncológicos quando comparada com o procedimento convencional. O objetivo deste trabalho é descrever a técnica deste procedimento e comparar seus resultados com os obtidos com a técnica convencional de acordo com a evidência disponível. (AU)

Amputación abdominoperineal cilíndrica: racionalidad y aspectos técnicos / Cylindric Abdominoperineal Resection: rational and technique

La resección quirúrgica sigue siendo la piedra angular de la terapia curativa en el cáncer de recto. La amputación abdominoperineal implica la remoción en bloque del recto, mesorrecto, aparato esfinteriano y el ano; con la creación de una colostomía definitiva. Esta cirugía es la propuesta para pacientes sin posibilidad de conservación esfinteriana. Este grupo representa aproximadamente el 80% de los pacientes con lesiones a menos de 5 cm del margen anal y aquellos con una continencia preoperatoria deficiente. Recientemente una modificación de la técnica denominada “Amputación abdominoperineal extraelevador” destinada a la ampliación del margen circunferencial sugiere mejores resultados oncológicos que la técnica clásica. El siguiente trabajo tiene por objetivo caracterizar y describir a la amputación abdominoperineal cilíndrica en comparación a la técnica clásica.

Surgery remains the cornerstone in rectal cancer treatment. Abdominoperineal resection involves the en bloc removal of the rectum, mesorectum, sphincters and anus with confection of a definitive colostomy. This surgery is indicated in patients without the possibility of sphincter preservation. This group represents approximately 80% of patients with lesions <5 cm from the anal verge and those with preoperative incontinence. Recently “Extralevator Abdominoperineal Excision” has been described to improve rates of circumferential margin positivity suggesting better oncological outcomes compared to the standard procedure. The objective of this paper is to provide a technical description and compare available data of both Extralevator and Standard techniques.