Abdominoperineal excision in Australasia: clinical outcomes, predictive factors and recent trends of nonrestorative rectal cancer surgery

Abstract

Aim The decision to perform an abdominoperineal excision (APR) rather than restorative bowel resection relies on a number of clinical factors. There remains great variability in APR rates internationally. The aim of this study was to demonstrate trends of APR surgery in low rectal cancer (< 6 cm from the anal verge) in Australasia and identify predictors of nonrestoration. Method This study reviewed a prospectively maintained colorectal registrythe Binational Colorectal Cancer Audit (BCCA)from general/colorectal surgical units across Australia and New Zealand. Data were analysed to determine factors predictive of nonrestorative resection. Patients were analysed based on the presence (control) or absence (comparison) of a primary anastomosis. Results Of 3628 patients with rectal cancer, 2096 were diagnosed with low rectal cancer between 2007 and 2017. The incidence of APR remained constant over the study period, with 58% of all resections of low rectal cancer being APR. The majority of resections were performed by consultants in urban hospitals (86% vs 14%). Tumours ≤ 3 cm from the anal verge, T4, M1 disease and neoadjuvant therapy were the greatest predictors of APR (P < 0.001). A significantly increased rate of restorative surgery was observed in public hospital settings (59% vs 41%, P < 0.05). The rate of positive circumferential resection margin (CRM) was 7.95%, with significantly increased rates in patients undergoing APR (12.2% vs 6.2%, P < 0.001). CRM positivity was increased in open approaches, T4, N2 and M1 staged disease and in an emergency/urgent setting (P < 0.001 and P < 0.045, respectively). Significantly increased wound and pulmonary complications were observed in the APR cohort (P < 0.01). Conclusion The rates of APR in Australia and New Zealand remain high but are comparable to international figures, with one-third of rectal cancers being treated by APR. The main determinants of APR are tumour height, T stage and neoadjuvant therapy requirement. CRM positivity was higher in APR patients.

Rectal washout during abdominoperineal resection for rectal cancer has no impact on the oncological outcome

“…Also, minimally invasive surgery has continued to increase and is currently the surgical technique of choice in over 50% of rectal cancer resections in Sweden [15]. In Sweden, Denmark, Australia, New Zealand and the United States, APR has been reported to account for 19%–38% of rectal cancer resections [14,15,29,30]. In our previous survey of the current practice of RW in Sweden, 6% of the responding units routinely performed RW in open APR, and 16% in minimally invasive APR [25].…”

“…In this area the mesorectum tapers, making it technically difficult to achieve a clear circumferential resection margin. The risk of intraoperative perforation is also increased, translating to poorer oncological outcomes, including higher rates of LR and impaired overall and disease-free survival [10][11][12][13][14]. Therefore, it is important to explore any possible impact of RW on oncological outcomes in APR.…”