Oncological outcomes of abdominoperineal resection for the treatment of low rectal cancer: A retrospective review of a single UK tertiary centre experience

Hussain, Anwar; Mahmood, Fahad; Torrance, Andrew; Clarke, H.; Howitt, Cordelia; Dawson, Robin

doi:10.1016/j.amsu.2018.06.007

Cited by 15 publications

(11 citation statements)

References 34 publications

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“…A recent study reported that 10.3% of patients showed a pathological complete response to neoadjuvant therapy in a single UK tertiary center, further confirming the influence of neoadjuvant therapy. [45] Thus, the CRM positivity rate in the two groups might not be accurate, given the effects of neoadjuvant therapy. Further studies are needed to elucidate the effects of neo-adjuvant therapy ion the CRM positivity rate.…”

Section: Discussionmentioning

confidence: 99%

Extralevator abdominoperineal excision versus abdominoperineal excision for low rectal cancer

Cui

Liu

et al. 2019

Chinese Medical Journal

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Background:Extralevator abdominoperineal excision (ELAPE) has become a popular procedure for low rectal cancer as compared with abdominoperineal excision (APE). No definitive answer has been achieved whether one is superior to the other. This study aimed to evaluate the safety and efficacy of ELAPE for low rectal cancer with meta-analysis.Methods:The Web of Science, Cochrane Library, Embase, and PubMed databases before September 2019 were comprehensively searched to retrieve comparative trials of ELAPE and APE for low rectal cancer. Pooled analyses of the perioperative variables, surgical complications, and oncological variables were performed. Odds ratio (OR) and mean differences (MD) from each trial were pooled using random or fixed effects model depending on the heterogeneity of the included studies. A subgroup analysis or a sensitivity analysis was conducted to explore the potential source of heterogeneity when necessary.Results:This meta-analysis included 17 studies with 4049 patients, of whom 2248 (55.5%) underwent ELAPE and 1801 (44.5%) underwent APE. There were no statistical differences regarding the circumferential resection margin positivity (13.0% vs. 16.2%, OR = 0.69, 95% CI = 0.42–1.14, P = 0.15) and post-operative perineal wound complication rate (28.9% vs. 24.1%, OR = 1.21, 95% CI = 0.75–1.94, P = 0.43). The ELAPE was associated with lower rate of intraoperative perforation (6.6% vs. 11.3%, OR = 0.50, 95% CI = 0.39–0.64, P < 0.001) and local recurrence (8.8% vs. 20.5%, OR = 0.29, 95% CI = 0.21–0.41, P < 0.001) when compared with APE.Conclusions:The ELAPE was associated with a reduction in the rate of intra-operative perforation and local recurrence, without any increase in the circumferential resection margin positivity and post-operative perineal wound complication rate when compared with APE in the surgical treatment of low rectal cancer.

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Section: Discussionmentioning

confidence: 99%

Extralevator abdominoperineal excision versus abdominoperineal excision for low rectal cancer

Cui

Liu

et al. 2019

Chinese Medical Journal

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“…The most important risk factors for CRM positivity, however, were T4 stage, tumour height ≤ 3 cm and local lymph node involvement. Perhaps with this information it could be postulated that certain 'high-risk' patients are more suitable for extralevator excision and would be likely to benefit in terms of oncological resection and CRM clearance [21]. In the UK LOREC was instituted to improve national performance regarding rectal cancer [22].…”

Section: Discussionmentioning

confidence: 99%

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

et al. 2020

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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.

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“…In the earlier days of colorectal surgery for malignant tumors of the lower third of rectum, the operation of choice was the abdomino-perineal resection (APR) in which the sigmoid, the rectum, and the anus were excised leaving the levator ani muscle complex intact in both sides. In this way, the specimen resembles an hourglass due to the characteristic “waist” in the middle [8]. However, given the incomplete resection rate and the high local recurrence compared to low anterior resection of rectum (LARR) [9] colorectal surgical community has nowadays moved towards the ELAPE.…”

Section: Discussionmentioning

confidence: 99%

An anatomic anal sphincter-saving procedure for rectal cancers located at anorectal junction

et al. 2019

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Background This study aims to present the feasibility of the open approach of hemilevator excision (HLE) as a promising alternative of the laparoscopic and/or robotic ones for the treatment of low rectal cancer extending to the ipsilateral puborectalis muscle. Methods A 60-year-old male patient with a high-grade differentiated rectal adenocarcinoma at the right side of the lower rectum invading puborectalis muscle. The proposed operation consists of a combination of extralevator abdomino-perineal excision (ELAPE), intersphicteric resection (ISR), and low anterior resection (LAR) since it resects the ipsilateral to tumor levator ani muscle (LAM) from its attachment at the internal obturator fascia and the deep part of ipsilateral external anal sphincter (EAS), while the distal part of dissection is completed in the intersphincteric space taking out the internal anal sphincter (IAS). At the contralateral side of the tumor, the dissection plane follows the classic route of LAR. Results Pathology proved the oncologic adequacy of resection. MRI at the fourth postoperative week showed clearly the right aspect of anorectal junction free of tumor. Anorectal manometry revealed a fair anorectal function which is in accordance with the findings of clinical assessment of patient after restoring large bowel continuity (post-op Wexner score, 7). Conclusion This is the first case of the open HLE that seems to be a good alternative compared to ELAPE or conventional APR, as it offers oncologic adequacy and a fair anorectal function.

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Oncological outcomes of abdominoperineal resection for the treatment of low rectal cancer: A retrospective review of a single UK tertiary centre experience

Cited by 15 publications

References 34 publications

Extralevator abdominoperineal excision versus abdominoperineal excision for low rectal cancer

Extralevator abdominoperineal excision versus abdominoperineal excision for low rectal cancer

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

An anatomic anal sphincter-saving procedure for rectal cancers located at anorectal junction

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