Extralevator abdominoperineal excision

1. Extralevator abdominoperineal
excision - APE

2. Extralevator abdominoperineal
excision - APE

3. Extralevator abdominoperineal
excision - APE
Introduction• APR <> LAR
– Optimalisation surgical technique (TME)
– Increasing rates – local control – survival
• APR
– Tumors less than 6 cm
– No optimalisation surgical technique – perineal
phase
– More local recurrence <> LAR
– Dutch TME trial LR 12% <> 29%
– MERCURY trial LR 12% <> 33%

4. Extralevator abdominoperineal
excision - APE
Introduction• APR - LAR
– Worse outcome <> LAR
– Dutch TME-trial APR
– CRM +LR 30% OS 38%
– CRM - LR 9% OS 72%
– Significantly more inadvertent bowel
perforation
AR APR
Norway 4% 15%
Sweden 3% 14%
Holland 3% 14%

5. Extralevator abdominoperineal
excision - APE
Introduction
• APR
– Difficult – conventional technique
– High risk bowel perforation
– Specimen waist lower border
– CRM close rectum
– Study posterior perineal approach
– More cylindrical specimen
– Reduction bowel perforation – positive
CRM

6. Extralevator abdominoperineal
excision - APE
Introduction
– Conventional technique
– Outside mesorectum –
pelvic floor
– Mobilisation from levator
muscles
– Excision anal canal –
ischiorectal fat – lower
portion levator muscles
– “Waist” surgical specimen

7. Extralevator abdominoperineal
excision - APE
Methods
– APE – extended posterior
perineal approach
– No dissection mesorectum
off levator muscles
– Stop mobilisation upper
border coccyx – below
autonomic nerves – below
vesicles

8. Extralevator abdominoperineal
excision - APE
Methods
– Prone jack-knife position
– Anus closed double purse-string
suture
– Dissection outside subcutaneous
portion external anal sphincter
– Dissection outer surface levator
muscles until insertion pelvic side wall
– Disarticulation coccyx
– Division Waldeyer’s fascia – levator
muscles
– Dissection off prostate –posterior
vagina

9. Extralevator abdominoperineal
excision - APE
Methods

10. Extralevator abdominoperineal
excision - APE
Methods

11. Extralevator abdominoperineal
excision - APE
Methods

12. Extralevator abdominoperineal
excision - APE
Methods• APR
– Wound complications
– 35-66% (pre-op RTX – extensive
dissection)
– Various flap techniques
– Gluteus maximus flap reconstruction
– Arises iliac bone, sacrum – coccyx and
insertion lateral femur
– Rotational musculocutaneous flap based
cranially
– Large defect bilateral – based cranially and
distally

13. Extralevator abdominoperineal
excision - APE
Methods
• Gluteus maximus flap reconstruction
– Local anesthesia adrenaline
– Subcutaneous tissue incised gluteus
maximus and fascia
– 1/3rd muscle divided medial border
– Avoid sciatic nerve !
– Further submuscular dissection
cranially and medially
– Sutured four layers
» Muscle, Scarpa’s fascia, deep
dermis, skin

14. Extralevator abdominoperineal
excision - APE
Methods

15. Extralevator abdominoperineal
excision - APE
Methods
• Gluteus maximus flap reconstruction
– Two drains (deep muscle – along flap
subcutis)
– Kept 4-6 days
– Surgical tape dressing
– Decubital mattress
– Specific mobilisation schedule

16. Extralevator abdominoperineal
excision - APE
Results• Patient characteristics
– 28 patients
– 19 men and 9 women – median
age 66 (range 49-86 yrs)
– T3-T4 tumour lower rectum MRI
– All neoadjuvant treatment
– 6 patients intraoperative
radiotherapy
– Single surgeon performed
resection

17. Extralevator abdominoperineal
excision - APE
Results
– Inadvertent bowel perforation 1 patient
– 23 patients unilateral flap – 5 bilateral
– Operating time 80 min – 110 min
– 3 wound infection of which 1 partial wound rupture
– 1 postoperative bleeding
– 24 other primary healing no delay

18. Extralevator abdominoperineal
excision - APE
Results
– Histopathological examination
– T0 2 patients,T3 20 patients,T4 6
patients
– CRM +(< 1mm) 2 patients (T4)
– Median FU 16 months (1-45)
– 2 patients local recurrence
– 8 patients died
– 4 no disease – 3 distant M+ – 1
local recurrence and distant M+

19. Extralevator abdominoperineal
excision - APE
Discussion
– Posterior perineal approach alternative conventional APR
–Poor results after APR
–APR common procedure tumours < 6 cm
–T1-T2 tumours utralow anterior resection partial
resection IAS / less extensive posterior perineal resection
– Low rate perforation and CRM involvement
–LR rate 7% low T3-T4 tumours
–Short FU time

20. Extralevator abdominoperineal
excision - APE
Discussion
– Surgical technique posterior perineal approach
–No dissection mesorectum off levator muscles
–Perineal part prone jack-knife position
–Levator muscle resected en bloc anal canal
–Cylindrical specimen
–Lower risk LR and bowel perforation
–Excellent exposure

21. Extralevator abdominoperineal
excision - APE
Discussion
– Low rate perineal wound complications
–Extensive resection posterior perineal approach
–Flap reconstructions superior primary closure
–Intact muscular layers without strain
– Gluteus maximus flap superior
–Rectus abdominis flap technically more demanding
–Distant donor-site morbidity- denervated – not contractile
–No functional disordes – good cosmetic outcome
–Plastic surgeon

22. Thank you