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Comparison of perineal morbidity between biologic mesh reconstruction and primary closure following extralevator abdominoperineal excision: a systematic review and meta-analysis

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International Journal of Colorectal Disease Aims and scope Submit manuscript

Abstract

Aim

Extralevator abdominoperineal excision (ELAPE) for rectal cancer leaves a greater perineal defect which might result in significant perineal morbidity, and how to effectively close perineal defects remains a challenge for surgeons. This study aimed to comparatively evaluate the perineal-related complications of biologic mesh reconstruction and primary closure following ELAPE.

Method

The electronic databases PubMed, EMBASE, Cochrane Library, and Web of Science were searched to screen out all eligible studies, which compared biologic mesh reconstruction with primary closure for perineal-related complications following ELAPE. Pooled data of perineal-related complications including overall wound complications, hernia, infection, dehiscence, chronic sinus, and chronic pain (12 months after surgery) were analyzed.

Results

A total of four studies (one randomized controlled trial and three cohort studies) involving 544 patients (346 biologic mesh vs 198 primary closure) were included. With a median follow-up of 18.5 months (range, 2–71.5 months). Analysis of the pooled data indicated that the perineal hernia rate was significantly lower in biologic mesh reconstruction as compared to primary closure (OR, 0.38; 95% CI, 0.22–0.69; P = 0.001). There were no statistically significant differences between the two groups in terms of total perineal wound complications rate (P = 0.70), as well as rates of perineal wound infection (P = 0.97), wound dehiscence (P = 0.43), chronic sinus (P = 0.28), and chronic pain (12 months after surgery; P = 0.75).

Conclusion

Biologic mesh reconstruction after extralevator abdominoperineal excision appears to have a lower hernia rate, with no differences in perineal wound complications.

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Data availability

All data generated or analyzed during this study are included in this published article.

References

  1. Holm T, Ljung A, Häggmark T, Jurell G, Lagergren J (2007) Extended abdominoperineal resection with gluteus maximus flap reconstruction of the pelvic floor for rectal cancer. Br J Surg 94:232–238

    Article  CAS  Google Scholar 

  2. West NP, Anderin C, Smith KJ, Holm T, Quirke P (2010) Multicentre experience with extralevator abdominoperineal excision for low rectal cancer. Br J Surg 97:588–599

    Article  CAS  Google Scholar 

  3. Negoi I, Hostiuc S, Paun S, Negoi RI, Beuran M (2016) Extralevator vs conventional abdominoperineal resection for rectal cancer-a systematic review and meta-analysis. Am J Surg 212:511–526

    Article  Google Scholar 

  4. Han JG, Wang ZJ, Wei GH, Gao ZG, Yang Y, Zhao BC (2012) Randomized clinical trial of conventional versus cylindrical abdominoperineal resection for locally advanced lower rectal cancer. Am J Surg 204:274–282

    Article  Google Scholar 

  5. Lehtonen T, Räsänen M, Carpelan-Holmström M, Lepistö A (2019) Oncological outcomes before and after the extralevator abdominoperineal excision era in rectal cancer patients treated with abdominoperineal excision in a single centre, high volume unit. Color Dis 21:183–190

    Article  CAS  Google Scholar 

  6. Colov EP, Klein M, Gögenur I (2016) Wound complications and perineal pain after extralevator versus standard abdominoperineal excision: a nationwide study. Dis Colon Rectum 59:813–821

    Article  Google Scholar 

  7. Musters GD, Buskens CJ, Bemelman WA, Tanis PJ (2014) Perineal wound healing after abdominoperineal resection for rectal cancer: a systematic review and meta-analysis. Dis Colon Rectum 57:1129–1139

    Article  Google Scholar 

  8. Haubner F, Ohmann E, Pohl F, Strutz J, Gassner HG (2012) Wound healing after radiation therapy: review of the literature. Radiat Oncol 7:162

    Article  Google Scholar 

  9. Foster JD, Tou S, Curtis NJ et al (2018) Closure of the perineal defect after abdominoperineal excision for rectal adenocarcinoma-ACPGBI Position Statement. Color Dis null:5–23

    Article  Google Scholar 

  10. Milburn ML, Holton LH, Chung TL et al (2008) Acellular dermal matrix compared with synthetic implant material for repair of ventral hernia in the setting of peri-operative Staphylococcus aureus implant contamination: a rabbit model. Surg Infect 9:433–442

    Article  Google Scholar 

  11. Han JG, Xu HM, Song WL, Jin ML, Gao JS, Wang ZJ, Yang XQ (2009) Histologic analysis of acellular dermal matrix in the treatment of anal fistula in an animal model. J Am Coll Surg 208:1099–1106

    Article  Google Scholar 

  12. Han JG, Wang ZJ, Gao ZG, Xu HM, Yang ZH, Jin ML (2010) Pelvic floor reconstruction using human acellular dermal matrix after cylindrical abdominoperineal resection. Dis Colon Rectum 53:219–523

    Article  Google Scholar 

  13. Alam NN, Narang SK, Köckerling F, Daniels IR, Smart NJ (2016) Biologic mesh reconstruction of the pelvic floor after extralevator abdominoperineal excision: a systematic review. Front Surg 3:9

    Article  Google Scholar 

  14. McMenamin DM, Clements D, Edwards TJ, Fitton AR, Douie WJP (2011) Rectus abdominis myocutaneous flaps for perineal reconstruction: modifications to the technique based on a large single-centre experience. Ann R Coll Surg Engl 93:375–381

    Article  CAS  Google Scholar 

  15. Hellinga J, Khoe PC, van Etten B et al (2016) Fasciocutaneous lotus petal flap for perineal wound reconstruction after extralevator abdominoperineal excision: application for reconstruction of the pelvic floor and creation of a neovagina. Ann Surg Oncol 23:4073–4079

    Article  Google Scholar 

  16. Hultman CS, Sherrill MA, Halvorson EG, Lee CN, Boggess JF, Meyers MO, Calvo BA, Kim HJ (2010) Utility of the omentum in pelvic floor reconstruction following resection of anorectal malignancy: patient selection, technical caveats, and clinical outcomes. Ann Plast Surg 64:559–562

    Article  CAS  Google Scholar 

  17. Blok Robin D, de Jonge J, de Koning MA et al (2019) Propensity score adjusted comparison of pelviperineal morbidity with and without omentoplasty following abdominoperineal resection for primary rectal cancer. Dis Colon Rectum 62:952–959

    Article  CAS  Google Scholar 

  18. Blok Robin D, Hagemans Jan AW, Klaver Charlotte EL et al (2020) A systematic review and meta-analysis on omentoplasty for the management of abdominoperineal defects in patients treated for cancer. Ann Surg 271:654–662

    Article  CAS  Google Scholar 

  19. Moher D, Liberati A, Tetzlaff J, Altman DG, Group P (2009) Preferred reporting items for systematic reviews and metaanalyses: the PRISMA statement. J Clin Epidemiol 62:1006–1012

    Article  Google Scholar 

  20. Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA (editors) (2019) Cochrane Handbook for Systematic Reviews of Interventions version 6.0 (updated July 2019). Cochrane. Available from www.training.cochrane.o-rg/handbook. Accessed 31 July 2020

  21. Stang A (2010) Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. Eur J Epidemiol 25:603–605

    Article  Google Scholar 

  22. Han JG, Wang ZJ, Gao ZG, Wei GH, Yang Y, Zhai ZW, Zhao BC, Yi BQ (2019) Perineal wound complications after extralevator abdominoperineal excision for low rectal cancer. Dis Colon Rectum 62:1477–1484

    Article  Google Scholar 

  23. Sancho-Muriel J, Ocaña J, Cholewa H et al (2020) Biologic mesh reconstruction versus primary closure for preventing perineal morbidity after extralevator abdominoperineal excision. A multicenter retrospective study. Color Dis undefined:undefined

    Google Scholar 

  24. Wang YL, Zhang X, Mao JJ, Zhang WQ, Dong H, Zhang FP, Dong SH, Zhang WJ, Dai Y (2018) Application of modified primary closure of the pelvic floor in laparoscopic extralevator abdominal perineal excision for low rectal cancer. World J Gastroenterol 24:3440–3447

    Article  Google Scholar 

  25. Musters GD, Klaver CEL, Bosker RJI, Burger JWA, van Duijvendijk P, van Etten B, van Geloven AAW, de Graaf EJR, Hoff C, Leijtens JWA, Rutten HJT, Singh B, Vuylsteke RJCLM, de Wilt JHW, Dijkgraaf MGW, Bemelman WA, Tanis PJ (2017) Biological mesh closure of the pelvic floor after extralevator abdominoperineal resection for rectal cancer: a multicenter randomized controlled trial (the BIOPEX-study). Ann Surg 265:1074–1081

    Article  Google Scholar 

  26. Butt HZ, Salem MK, Vijaynagar B, Chaudhri S, Singh B (2013) Perineal reconstruction after extra-levator abdominoperineal excision (eLAPE): a systematic review. Int J Color Dis 28:1459–1468

    Article  Google Scholar 

  27. Thomas PW, Blackwell JEM, Herrod PJJ, Peacock O, Singh R, Williams JP, Hurst NG, Speake WJ, Bhalla A, Lund JN (2019) Long-term outcomes of biological mesh repair following extra levator abdominoperineal excision of the rectum: an observational study of 100 patients. Tech Coloproctol 23:761–767

    Article  CAS  Google Scholar 

  28. Christensen HK, Nerstrøm P, Tei T, Laurberg S (2011) Perineal repair after extralevator abdominoperineal excision for low rectal cancer. Dis Colon Rectum 54:711–717

    Article  Google Scholar 

  29. Balla A, Batista Rodríguez G, Buonomo N, Martinez C, Hernández P, Bollo J, Targarona EM (2017) Perineal hernia repair after abdominoperineal excision or extralevator abdominoperineal excision: a systematic review of the literature. Tech Coloproctol 21:329–336

    Article  CAS  Google Scholar 

  30. Jensen KK, Rashid L, Pilsgaard B, Møller P, Wille-Jørgensen P (2014) Pelvic floor reconstruction with a biological mesh after extralevator abdominoperineal excision leads to few perineal hernias and acceptable wound complication rates with minor movement limitations: single-centre experience including clinical examination and interview. Color Dis 16:192–197

    Article  CAS  Google Scholar 

  31. Baloch N, Nilsson PJ, Nordenvall C, Abraham-Nordling M (2019) Perineal wound closure using biological mesh following extralevator abdominoperineal excision. Dig Surg 36:281–288

    Article  Google Scholar 

  32. Han JG, Wang ZJ, Qian Q, Dai Y, Zhang ZQ, Yang JS, Li F, Li XB (2014) A prospective multicenter clinical study of extralevator abdominoperineal resection for locally advanced low rectal cancer. Dis Colon Rectum 57:1333–1340

    Article  Google Scholar 

  33. Güven HE, Aksel B (2019) Is extralevator abdominoperineal resection necessary for low rectal carcinoma in the neoadjuvant chemoradiotherapy era? Acta Chir Belg undefined:1–7

    Google Scholar 

  34. Han JG, Wang ZJ, Wei GH, Zhai ZW, Zhao BC (2020) Trans-perineal minimally invasive approach during extralevator abdominoperineal excision for advanced low rectal cancer: a retrospective cohort study. Asian J Surg undefined:undefined

    Google Scholar 

  35. Kaufmann R, Jairam AP, Mulder IM, Wu Z, Verhelst J, Vennix S, Giesen LJX, Clahsen-van Groningen MC, Jeekel J, Lange JF (2017) Characteristics of different mesh types for abdominal wall repair in an experimental model of peritonitis. Br J Surg 104:1884–1893

    Article  CAS  Google Scholar 

  36. Deeken CR, Melman L, Jenkins ED, Greco SC, Frisella MM, Matthews BD (2011) Histologic and biomechanical evaluation of crosslinked and non-crosslinked biologic meshes in a porcine model of ventral incisional hernia repair. J Am Coll Surg 212:880–888

    Article  Google Scholar 

Download references

Funding

This study received funding from the National Natural Science Foundation of China (82070685); Capital Health Research and Development of Special (2018-1-2032); Project of Beijing Chaoyang Hospital 1351 talents’ training (CYXZ-2017-09); Beijing Municipal Administration of Hospitals Incubating Program (PX2019012); and the Scientific Research and Cultivation Fund of Capital Medical University.

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Authors and Affiliations

  1. Department of General Surgery, Beijing Chaoyang Hospital, Capital Medical University, No. 8 Gongtinan Road, Chaoyang District, Beijing, 100020, People’s Republic of China

    Yu Tao, Jia Gang Han & Zhen Jun Wang

  2. Beijing, China

    Zhen Jun Wang

Authors
  1. Yu Tao
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  2. Jia Gang Han
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  3. Zhen Jun Wang
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Contributions

Study conception and design: Han, Wang

Acquisition of data: Tao, Han, Wang

Analysis and interpretation of data: Tao, Han, Wang

Drafting of manuscript: Tao, Han, Wang

Final approval: Tao, Han, Wang

Critical revision: Han, Wang

Corresponding authors

Correspondence to Jia Gang Han or Zhen Jun Wang.

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Tao, Y., Han, J.G. & Wang, Z.J. Comparison of perineal morbidity between biologic mesh reconstruction and primary closure following extralevator abdominoperineal excision: a systematic review and meta-analysis. Int J Colorectal Dis 36, 893–902 (2021). https://doi.org/10.1007/s00384-020-03820-7

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  • DOI: https://doi.org/10.1007/s00384-020-03820-7

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