Low abdominoperineal excision rates are associated with high-workload surgeons and lower tumour height. Is further specialization needed?

Abstract

Variations in the height of tumour did not explain the variation in APE use. Specialist high-volume surgeons undertook fewer APEs and those they performed were closer to the dentate line than low-volume nonspecialist surgeons.

Risk adjusted benchmarking of abdominoperineal excision for rectal adenocarcinoma in the context of the Belgian PROCARE improvement project

“…In an effort to circumvent the problem of missing information on the location of the tumour, the distance from the tumour to the dentate line mentioned in pathology reports was compared with APE rates. Variation in APE use were not explained by variation of the distance to the dentate line; specialist high volume surgeons undertook fewer APE and those they performed were in tumours closer to the dentate line than low volume non-specialist surgeons 21. Tumour location is very important and should also be known in patients undergoing sphincter sparing procedures.…”

Association of Coloproctology of Great Britain & Ireland (ACPGBI): Guidelines for the Management of Cancer of the Colon, Rectum and Anus (2017) – Surgical Management

“…An English National Development Programme (http://www.lorec.nhs.uk) for colorectal MDT's was delivered between 2010 and 2013 and focused on preoperative clinical and radiological assessment, selective preoperative radiotherapy and chemoradiotherapy, optimal surgical treatment and accurate pathological analysis of the resected specimen (Moran et al ., ). The background to this initiative was the marked variation in APE rates across England (Morris et al ., ; Morris et al ., ) and the poor outcomes following APE due to a high CRM involvement rate and subsequent recurrence. A key element of this programme was optimal preoperative planning by clinical assessment and imaging.…”

“…Case-mix and an increasingly elderly population may explain some of this variation but surgical approach and technical aspects are also important. The lowest rates tend to be achieved by specialist high-volume surgeons (Morris et al, 2011). The LOREC programme has addressed some of these issues.…”

Tailored‐made robotic abdominoperineal resection, using the da Vinci Xi, for a regrowth of rectal tumour after complete clinical response – a video vignette

“…Controversy persists as to the optimal surgical technique for abdominoperineal excision of the rectum (APER) . Extralevator dissection has been advocated by certain groups who claim to have better R0 resection rates and a reduced incidence of perforation .…”