Extra Levator Abdomino Perineal Resection

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1. Extralevator Abdomino -perineal Resection Dr Harsh Shah MS, FMAS, DNB, MCh (GI) Kaizen Hospital Ahmedabad

2. Evolution of rectal cancer surgery APR – Miles (1908) Invention of circular stapler (1970) TME by Heald (1982) TEMS Gerhard Buess (1983) Extralevator APR – T. Holm (2007)

3. Principles of rectal cancer surgery Neoadjuvant CTRT High ligation of IMA Circumferential resection margin Total mesorectal excision Sharp dissection of mesorectal fascia Autonomic nerve preservation Distal margin - 0.5 to 1cm

4. Classification of lower rectal tumours ( Rulier et al)

5. Indications of APR Carcinoma rectum with involvement of external sphincter or levators Carcinoma rectum with poor sphincter function Carcinoma anal canal (failed neo-adjuvant CTRT)

6. Standard APR

7. Problems with conventional APR High local recurrence rate (10-25%) Positive CRM at lower border of mesorectum Risk of inadvertent bowel perforation Perineal wound related morbidity (15-55%) Infection, dehiscence, hernia Law WL, Chu KW. Abdominoperineal resection is associated with poor oncological outcome. Br J Surg 2004;91:1493—9.

8. APR vs AR/LAR

9. Why results of APR are poor ? Tumour related factors Higher T stage Poor tumour biology Anatomical factor Mesorectum is very thin in lower rectum Technical factors Poor visibility during deep rectal mobilization Poor perineal exposure (62% of rectal perforations) Too economical resection (preserving levators for closure)

10. Extralevator APR

11. Anatomy of L evator A ni muscles

12. Pelvic floor muscles – Superior view Puborectalis Rectum Pubococcygeus Iliococcygeus Tendinous arch Coccygeus Sacrococcygeal ligament

13. Pelvic floor muscles – Inferior view Puborectalis Rectum Pubococcygeus Iliococcygeus

14. Ischiorectal Fossa

15. Anatomy of fascia

16. Pre-op preparation Antibiotic prophylaxis Mechanical bowel preparation Thromboprophylaxis Marking of stoma site

17. Technique- T. Holm (2007) Abdominal part Mesorectum not dissected off levators Mobilization is stopped Upper border of coccyx posteriorly Just below autonomic nerves laterally Just below seminal vesicles(males) & cervix(females) anteriorly Divided sigmoid brought out as stoma

18. Perineal part- Prone jack-knife position with legs apart

19. Perineal part- Technique Anus closed with double purse string suture Tear drop incision extended cranially to lower part of sacrum Dissection continues just outside s/c portion of external anal sphincter Levators exposed circumferentially upto insertion

20. Prone position Tear drop incision

21. Technique- cont. Coccyx disarticulated from sacrum Higher up division of presacral fascia Entry into pelvis Presacral fascia 2. fascia propria 3. Waldeyer’s Fascia. Blue line- abdominal dissection, Red line- Perineal dissection

22. Incision Coccyx disarticulaton

23. Division of levator muscles

24. Technique- cont. Levator muscles divided Specimen brought out & dissected off prostate/posterior vaginal wall Fascia propria 2. Denonvillier’s fascia

25. Cylindrical specimen with the cuff of levator muscles Wide perineal defect

26. Need for Perineal wound reconstruction Wider defect created Skin & ischio-rectal fat left for closure Neoadjuvant RT Advantages Fills the dead space Obtain skin healing Allows rapid discharge

27. Perineal wound reconstruction Flaps Gluteus maximus MCF Unilateral Bilateral Rectus abdominis MCF Inferior epigastric artery Need change of posture Gracilis flap Medial circumflex femoral artery Disadvantages Donor site morbidity Longer operating time Need for plastic surgeon

28. Perineal wound reconstruction Mesh Biological – acellular collagen (porcine, human) Shorter operating time Can be performed by colorectal surgeon No donor site morbidity Disadvantages: Seroma Chronic pelvic pain

29. Advantages of ELAPE Larger amount of tissue removed around the tumour Fat Muscle Lymphatics Prone position gives better visualization of anatomy Rate of tumour perforation are lower

30. ELAPE vs Conventional APR

31. Meta-analysis Huang et al – 2014 Yu et al – 2014 Zhou et al – 2015 De Nardi - 2015 Negoi et al - 2016

32. Oncological superiority of extralevator abdomino perineal resection over conventional abdominoperineal resection: a meta-analysis: Huang et al: Int J Colorectal Dis (2014) Six studies with a total of 881 patients 1 RCT, 1 Prospective study, 4 restrospective study 8.2 % 2

33. Oncological superiority of extralevator abdomino perineal resection over conventional abdominoperineal resection: a meta- analysis: Huang et al: Int J Colorectal Dis (2014 ) ELAP compared to APR lower CRM involvement (OR, 0.36; 95%CI, 0.23–0.58; P <0.0001 ) Lower IOP (OR , 0.31; 95%CI, 0.12–0.80; P =0.02) lower LR rate (OR, 0.27; 95%CI, 0.08–0.95; P = 0.04) Increased post-op morbidity in ELAP (p=0.67) Subgroup analysis(Neoadjuvant CTRT) also revealed the same results Conclusions : ELAP achieved oncologically superior results as compared to APR

34. Negoi et al AJS 2016 Studies ELAPE/APR OR p value

35. Negoi et al AJS 2016 Studies ELAPE/APR OR p value

36. Limitations of ELAP Need to change of posture Longer operative time Need for perineal wound reconstruction P erineal wound related complication Anterior CRM not affected Chronic pelvic pain Sexual dysfunction

37. Effect of Neo-adjuvant CTRT

38. Limitations of present studies Only one RCT, with low sample size Heterogeneous pre-operative treatment Neoadjuvant therapy Dose/duration Selection bias Extent of levator resection Type reconstruction Learning curve for ELAP Quadrant oriented interpretation of CRM not available

39. Mesh vs flaps Reconstruction of the perineum following extralevator abdomino - perineal excision for carcinoma of the lower rectum: a systematic review: Foster et al : colorectal dis 2012 11 cohort studies 255 patients - flap repair and 85 - biological mesh repair no significant difference in the rates of perineal wound complications or perineal hernia formation Increased trend towards use of flaps for neo-adjuvant CTRT group

40. MRI

41. Partial ELAP Partial right or left ELAP can be performed Can improve perineal wound healing Anteriorly located tumours Resection of posterior vaginal wall, partial prostatectomy/Anterior exenteration can be planned

42. Summary- ELAPE Levators resected en block with specimen Avoids waist formation in specimen Need for perineal wound reconstruction Flaps or mesh gives equally good results

43. Take Home Message Superiority to APR not proven Need for high quality studies Selective use of ELAPE/asymmetrical ELAPE is recommended Pre-operative MRI should be performed Anteriorly located tumours need special attention

44. Thank You