Is biological mesh recommended for a patient with locally advanced or recurrent rectal cancer undergoing extra levator abdominoperineal excision (ELAPE)?

Biological Mesh for ELAPE in Rectal Cancer

Direct Recommendation

Biological mesh reconstruction should be considered for pelvic floor closure after extralevator abdominoperineal excision (ELAPE), primarily to reduce the risk of perineal hernia, though it does not improve early wound healing compared to primary closure. 1

Evidence-Based Rationale

Primary Wound Healing Outcomes

The highest quality evidence comes from the BIOPEX multicenter randomized controlled trial, which demonstrated:

• No significant difference in uncomplicated perineal wound healing at 30 days between biological mesh (63%) and primary closure (66%) 1
• Overall early wound complications (seroma, infection, dehiscence) show no statistical difference between approaches (OR 0.575,95% CI 0.241-1.373, P=0.213) 2
• Perineal wound infection rates are equivalent between groups 3

Long-Term Hernia Prevention

The most compelling advantage of biological mesh is significant reduction in perineal hernia formation:

• Perineal hernia incidence is significantly lower with biological mesh (OR 0.38,95% CI 0.22-0.69, P=0.001) compared to primary closure 3
• The BIOPEX trial showed 1-year freedom from perineal hernia of 87% with mesh versus 73% with primary closure (P=0.0316) 1
• Long-term observational data (median 4.9 years follow-up) demonstrates only 8% cumulative radiologically detected perineal hernia rate at 4 years with mesh reconstruction 4
• Symptomatic perineal herniation requiring repair is rare (only 1 of 100 patients in one series) 4

Safety Profile

Biological mesh demonstrates acceptable safety:

• No mesh infections requiring removal in prospective series of 34 patients 5
• Only 9% perineal complications requiring surgical intervention, with no mesh removals 5
• No mesh needed removal in 100-patient long-term follow-up series 4

Practical Considerations

Operative factors favor primary closure for resource-limited settings:

• Operation time is significantly shorter with primary closure 2
• Hospital stay is shorter after primary closure (P<0.001) 2
• Median operative time with mesh is 248 minutes (range 120-340 minutes) 5

Clinical Decision Algorithm

When to Use Biological Mesh:

1. Standard ELAPE with wide pelvic floor defect - particularly when levator muscles are extensively resected 6
2. Patients with prior pelvic radiotherapy - who have higher wound complication risk 1
3. Younger patients with longer life expectancy - where long-term hernia prevention matters most 4
4. Patients at high risk for hernia - based on defect size and tissue quality 5

When Primary Closure May Be Acceptable:

1. Limited resource settings where mesh cost is prohibitive 2
2. Patients with very short life expectancy where hernia prevention is less relevant 4
3. Smaller perineal defects where primary closure is technically feasible without tension 5

Important Caveats

• Myocutaneous flaps are NOT routinely needed when using biological mesh - the mesh alone provides adequate reconstruction without additional flap procedures 5, 4
• This differs from anal cancer APR, where NCCN guidelines specifically recommend myocutaneous flap reconstruction due to radiation exposure 7
• Chronic pain and chronic sinus rates are equivalent between mesh and primary closure at 12 months 3
• Wound dehiscence rates show no significant difference between approaches 3

Guideline Context

While specific guidelines do not mandate biological mesh for ELAPE, the surgical principles are clear:

• ELAPE technique requires cylindrical specimen excision to avoid waist effect and achieve negative circumferential margins 7, 6
• The European Society for Medical Oncology emphasizes that ELAPE dissection must stop at the levator plane from above and continue from below 6
• The resultant wide perineal defect presents a reconstruction challenge that biological mesh addresses effectively 2