Clinical Experience In Laparoscopic Extra-levator Abdominoperineal Excision (ELAPE) For The Low Rectal Cancer

Background:For a long time, abdominal perineal resection (abdomino-perineal resection,APR) has been used as the "gold standard" of surgical treatment for the lowrectal cancer where anus cannot be preserved in the operation. However,recently large number of studies have done comparison of the radical surgerywith sphincter preservation. The local recurrence rate after APR surgery ishigher, and the long-term survival rate is lower. Even on the basis of theapplication of the principle of TME, the therapeutic did not improve. Similarly,the rate of circumferential resection margin (CRM) involvement and theincidence of intraoperative perforation (IOP) of ARP for low rectal cancer arestill higher. These reasons lead to a high local recurrence rate and a lowerlong-term survival rate after APR. For these cases, Some European surgeonshave proposed a new surgical concept of management for low rectal cancer:extralevator abdominoperineal excision, which is called ELAPE for short.ELAPE emphasized on the principles that the operation should be performedon the extralevator plane and it needs en bloc resection of the levator animuscle, mesorectum and anal canal. So more surrounding tissues could beremoved and the CRM positive rate and the intraoperative perforation ratewould be lower. The laparoscopic technique has gradually come in action,some surgeons begin to explore the application of laparoscopically completedELAPE surgery. It has benefit of not only outstanding the features of ELAPE surgery of lower CRM positive rate and surgical perforation rate, but alsobrought merits of small wound, less bleeding and clear anatomical vision forlaparoscopic dissection.Objective:Extralevator abdominoperineal excision still has some issues not yetconclusive. A retrospective study to summarize the indications and the safety isdone in this study, including safety, feasibility and radical of this technique.Methods:From2011.1to2012.12, First Hospital of Jilin University had24cases oflaparoscopic resection of the ultra low lying rectal cancer where anus could notbe preserved in patients. All of24cases accepted laparoscopic resection ofrectal cancer in the same period. The clinical data of the24cases is analyzedretrospectively.Results:All of the cases accepted operation had successful laparoscopic ELAPE.The operative time ranges from105min to300min, and the average operativetime was (182.08±53.87) min; Intraoperative blood loss ranges from70ml to220ml, and the mean intraoperative blood loss was (109.33±34.97) ml; Thecases which needed lymph node dissection in abdominal, pelvic and inguinallymph nodes had longer operative time and more intraoperative blood loss.Intestinal perforation did not occur in any of the24cases. All patients hadindwelling pelvic drainage tube, resection specimens had no "surgical waist’.All cases did not use the muscle flap or patch to repair defects of perineal. Thetime of first postoperative stoma flatus ranges from2to7days, and the average time was（3.13±1.36）days; The time of first bowel movement occurred from2to7days, and the average time was (3.67±1.37) days; The restoration time ofbowel sounds ranges from1to5days, and the average time was (2.46±0.98)days; The time of taking adequate food ranges from1to5days, and theaverage time is (2.83±1.24) days; Ambulation time ranges from1to4days,and the average time is (2.63±0.77) days; The drainage volume of perinealdrainage tube is505ml/d, and the average volume is (80.35±51.75) ml/d; Thetime of removing perineal drainage tube ranges from3to9days, and theaverage time is (6.21±1.47) days; The postoperative hospital stay ranges from7to35days, and the average time is (11.17±6.16) days. There are eightcases(seven persons) of the24patients had postoperative complications,including seven cases of perineal incision infection, one case of incompleteintestinal obstruction. The patients with perineal incision infected werefollowed up in a month, the wound has healed. Patients with incompleteintestinal obstruction were completely cured to discharge from the hospitalafter active symptomatic and supportive treatment, and no one died in theperioperative period. The number of lymph node dissection ranges from12-45,and the average number is（17.08±6.95）; The number of positive lymph nodedissection ranges from0-17, and the average number is （2.92±4.94）. Thepostoperative pathological prompted that there are22cases of adenocarcinoma,(19cases of differentiated,1case of poorly differentiated and two cases ofmucinous adenocarcinoma), one case of signet ring cell carcinoma, and1caseof malignant melanoma. the tumor length of postoperative measurements is2to6cm, and the average (3.47±1.00) cm; The distance from the proximal resection margin to the tumor ranges from3-19cm and the average distance is(7.01±4.19) cm; The distance from the distal margin to the tumor ranges from2-5cm and average distance is (3.53±0.96) cm. There are no statisticallydifferences. TNM staging:6patients with stageⅠ,4cases of stageⅡ,11casesof stage ⅢB,3cases of stage ⅢC. The postoperative pathologic surgicalmargins were negative.Conclusion:Laparoscopic extralevator abdominoperineal excision is safe and feasible.Compared with conventional extralevator abdominoperineal excision, it has themerits of small trauma, little intraoperative blood loss and aesthetic outlook.Meanwhile, it has extra advantages as we have cut levator ani musclesthrough the abdomen laparoscopically which is usually done through perinealdissection while performing ELAPE by laparoscopic surgery, and it avoidsdifficulty of changing position and speed up the time of surgery. No doubt, thistechnique should be used based on master laparoscopic techniques premise.Laparoscopic extralevator abdominoperineal excision still belongs to the newlylaunched technology. Bulk cases report is still missing, a result of long termsurvival results need further study.