Extralevator versus standard abdominoperineal excision in locally advanced rectal cancer: a retrospective study with long-term follow-up
- 155 Downloads
To analyze the results of abdominoperineal excisions (APE) for locally advanced rectal cancer at our institution before and after the adoption of extralevator abdominoperineal excision (ELAPE) with a special reference to long-term survival.
A retrospective cohort study conducted in a tertiary referral center. All consecutive patients operated for locally advanced (TNM classification T3–4) rectal cancer with APE in 2004–2009 were compared to patients with similar tumors operated with ELAPE in 2009–2016.
Forty-two ELAPE and 27 APE patients were included. Circumferential resection margin (CRM) was less than 1 mm (R1-resection) in 10 (24%) of ELAPE patients and 11 (41%) of APE patients (p = 0.1358). Intraoperative perforation (IOP) occurred in 4 (10%) patients and 6 (22%) patients in ELAPE and APE groups, respectively (p = 0.1336). There were 3 (7%) local recurrences (LRs) in ELAPE group and 5 (19%) in APE (p = 0.2473). There were no statistical differences in adverse events, overall survival, or disease-free survival between ELAPE and APE groups.
We found a non-significant tendency to lower rates of IOP and positive CRM as well as lower rate of LR in the ELAPE group. Long-term survival and adverse events did not differ between the groups. ELAPE is beneficial for the surgeon in offering better vicinity to the perineal area and better work ergonomics. These technical aspects and the clinically very important tendency to lower rate of LR support the use of ELAPE technique in spite of the lack of survival benefit.
KeywordsAbdominoperineal excision Adverse events Extralevator Local recurrence Rectal cancer Survival
This study was supported by research grants from the TYKS Foundation, the Turunmaa Duodecim Society, and Turku University Hospital (EVO grant no. 13191).
Compliance with ethical standards
Conflict of interest
The authors declare that they have no conflict of interest.
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. For this type of study, formal consent is not required.
- 4.Wibe A, Syse A, Andersen E, Tretli S, Myrvold HE, Soreide O, Norwegian Rectal Cancer G (2004) Oncological outcomes after total mesorectal excision for cure for cancer of the lower rectum: anterior vs. abdominoperineal resection. Dis Colon Rectum 47(1):48–58. https://doi.org/10.1007/s10350-003-0012-y CrossRefPubMedGoogle Scholar
- 5.Nagtegaal ID, van de Velde CJ, Marijnen CA, van Krieken JH, Quirke P, Dutch Colorectal Cancer G, Pathology Review C (2005) Low rectal cancer: a call for a change of approach in abdominoperineal resection. J Clin Oncol 23(36):9257–9264. https://doi.org/10.1200/JCO.2005.02.9231 CrossRefPubMedGoogle Scholar
- 6.Gravante G, Miah A, Mann CD, Stephenson JA, Gani MA, Sharpe D, Norwood M, Boyle K, Miller A, Hemingway D (2016) Circumferential resection margins and perineal complications after neoadjuvant long-course chemoradiotherapy followed by extralevator abdominoperineal excision of the rectum: five years of activity at a single institution. J Surg Oncol 114(1):86–90. https://doi.org/10.1002/jso.24257 CrossRefPubMedGoogle Scholar
- 8.Prytz M, Angenete E, Bock D, Haglind E (2016) Extralevator abdominoperineal excision for low rectal cancer—extensive surgery to be used with discretion based on 3-year local recurrence results: a registry-based, observational national cohort study. Ann Surg 263(3):516–521. https://doi.org/10.1097/SLA.0000000000001237 CrossRefPubMedPubMedCentralGoogle Scholar
- 9.Bianco F, Romano G, Tsarkov P, Stanojevic G, Shroyer K, Giuratrabocchetta S, Bergamaschi R, International Rectal Cancer Study G (2016) Extralevator with vertical rectus abdominis myocutaneous flap vs. non-extralevator abdominoperineal excision for rectal cancer: the RELAPe randomized controlled trial. Color Dis. https://doi.org/10.1111/codi.13436
- 12.Shen Z, Ye Y, Zhang X, Xie Q, Yin M, Yang X, Jiang K, Liang B, Wang S (2015) Prospective controlled study of the safety and oncological outcomes of ELAPE procure with definitive anatomic landmarks versus conventional APE for lower rectal cancer. Eur J Surg Oncol 41(4):472–477. https://doi.org/10.1016/j.ejso.2015.01.017 CrossRefPubMedGoogle Scholar
- 16.Ortiz H, Ciga MA, Armendariz P, Kreisler E, Codina-Cazador A, Gomez-Barbadillo J, Garcia-Granero E, Roig JV, Biondo S, Spanish Rectal Cancer P (2014) Multicentre propensity score-matched analysis of conventional versus extended abdominoperineal excision for low rectal cancer. Br J Surg 101(7):874–882. https://doi.org/10.1002/bjs.9522 CrossRefPubMedGoogle Scholar
- 17.Prytz M, Angenete E, Ekelund J, Haglind E (2014) Extralevator abdominoperineal excision (ELAPE) for rectal cancer—short-term results from the Swedish Colorectal Cancer Registry. Selective use of ELAPE warranted. Int J Color Dis 29(8):981–987. https://doi.org/10.1007/s00384-014-1932-9 CrossRefGoogle Scholar
- 18.Klein M, Fischer A, Rosenberg J, Gogenur I, Danish Colorectal Cancer G (2015) Extralevatory abdominoperineal excision (ELAPE) does not result in reduced rate of tumor perforation or rate of positive circumferential resection margin: a nationwide database study. Ann Surg 261(5):933–938. https://doi.org/10.1097/SLA.0000000000000910 CrossRefPubMedGoogle Scholar
- 20.Yu HC, Peng H, He XS, Zhao RS (2014) Comparison of short- and long-term outcomes after extralevator abdominoperineal excision and standard abdominoperineal excision for rectal cancer: a systematic review and meta-analysis. Int J Color Dis 29(2):183–191. https://doi.org/10.1007/s00384-013-1793-7 CrossRefGoogle Scholar
- 25.Jensen KK, Rashid L, Pilsgaard B, Moller P, Wille-Jorgensen 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. Colorectal Dis 16(3):192–197. https://doi.org/10.1111/codi.12492 CrossRefPubMedGoogle Scholar
- 26.Foster JD, Pathak S, Smart NJ, Branagan G, Longman RJ, Thomas MG, Francis N (2012) Reconstruction of the perineum following extralevator abdominoperineal excision for carcinoma of the lower rectum: a systematic review. Color Dis 14(9):1052–1059. https://doi.org/10.1111/j.1463-1318.2012.03169.x CrossRefGoogle Scholar
- 27.Vaughan-Shaw PG, Cheung T, Knight JS, Nichols PH, Pilkington SA, Mirnezami AH (2012) A prospective case-control study of extralevator abdominoperineal excision (ELAPE) of the rectum versus conventional laparoscopic and open abdominoperineal excision: comparative analysis of short-term outcomes and quality of life. Tech Coloproctol 16(5):355–362. https://doi.org/10.1007/s10151-012-0851-4 CrossRefPubMedGoogle Scholar
- 28.National Institute for Health and Welfare. Specialised somatic health care. Care periods in 2014. Finnish official statistics. Available in Finnish and Swedish at https://www.thl.fi/fi/tilastot/tilastot-aiheittain/erikoissairaanhoidon-palvelut/somaattinen-erikoissairaanhoito. Accessed 21st of March 2017
- 32.Baca B, Beart RW, Jr., Etzioni DA (2011) Surveillance after colorectal cancer resection: a systematic review. Dis Colon Rectum 54 (8):1036–1048. doi: https://doi.org/10.1007/DCR.0b013e31820db364