Oncological outcomes before and after the extralevator abdominoperineal excision era in rectal cancer patients treated with abdominoperineal excision in a single centre, high volume unit

Abstract

Aim The extralevator abdominoperineal excision (ELAPE) has been expected to reduce the risk of positive circumferential resection margins (CRMs) and local recurrence in locally advanced distal rectal cancer. The aim was to determine whether there is any difference in local recurrence rates between patients who were operated on for distal rectal cancer before and after the introduction of ELAPE in our unit. Patients and methods In all, 206 patients with distal rectal cancer without distant metastases (T1‐4N0‐2M0) were treated with curative intent. The patients were divided into two cohorts operated in 2000–2007 (A) and 2008–2014 (B). The ELAPE procedure was introduced in 2008. Since then, it has been used in cases of T4 and T3 tumours with threatened margins. In T1–T3 tumours without threatened margins a conventional abdominal perineal excision has been performed. Results There was no significant difference in overall survival or cancer‐specific survival between the two time periods. The local recurrence rate was 15.5% in group A and 6.7% in group B (P = 0.048), although there was no significant difference in the cumulative local recurrence rate. Intra‐operative tumour perforation occurred significantly more often during the earlier period when ELAPE was not in use: group A 15/71 (21.1%) vs group B 11/135 (8.1%), P = 0.01. CRM was positive more often in group A (16.4%) vs group B (7.4%), P = 0.054. Conclusion The local recurrence rate, intra‐operative tumour perforation and positive CRM rate were significantly lower during the later period when more extensive surgery (ELAPE) was performed for locally advanced T3–T4 rectal cancer with threatened margins.

Sphincter‐saving surgery for ultra‐low rectal carcinoma initially indicated for abdominoperineal resection: Is it safe on a long‐term follow‐up?

“…B, Disease-free survival between classical APR and ELAPE. 32 A propensity score-matched SEER analysis reported worse oncological outcomes in patients undergoing APR compared to colo-anal anastomosis (CAA), with similar results to our data: OS5 was 65.6% for APR versus 76.7%…”

“…A large Swedish cohort showed a significantly higher local recurrence rates at 3 years for ELAPE compared with APR (relative risk 4.91) 30 . Residual tumoral volume remains the major risk factor for positive CRM, which is the best guide to tailor the technique between classical APR and ELAPE 32 . A propensity score‐matched SEER analysis reported worse oncological outcomes in patients undergoing APR compared to colo‐anal anastomosis (CAA), with similar results to our data: OS5 was 65.6% for APR versus 76.7% for CAA ( p < .001) 17 .…”

Widespread anorectal lymphovascular networks and tissue drainage: analyses from submucosal India ink injection and indocyanine green fluorescence imaging

“…Our anatomical findings [6] demonstrated that ELAPE reduced CRM-positive rates compared to APR (49.6% vs. 20.3%, P < 0.001). Lehtonen et al [8] showed that ELAPE for T3-4 lower RC reduced local recurrence rates (6.7% vs. 15.5%, P = 0.048). Shen et al [9] reported that ELAPE improved overall survival (41.5 months vs. 29.8 months, P = 0.028) and disease-free survival (38.5 months vs. 29.3 months, P = 0.027).…”

“…To improve prognosis, extralevator abdominoperineal excision (ELAPE), a more extensive procedure than standard APR, was introduced [5]. ELAPE has been reported to improve oncological outcomes [6][7][8][9] due to its enlarged resection area; however, some studies have reported that ELAPE does not improve outcomes [10][11][12].…”

Long-Term Outcomes After Extra-Levator Versus Conventional Abdominoperineal Excision for Low Rectal Cancer

“…In 2007, Holm et al 5,6 proposed the concept of extralevator abdominoperineal excision (ELAPE), which fully exposes the perineum and pelvic oor easily and resection of the anal canal and levator muscles to avoid a "surgical waist" 7 . Although some studies have concluded that there was no signi cant difference in positive CRM and IOP rates between ELAPE and APE, the majority of studies have demonstrated superiority of ELAPE 8,9 . A further study reported that ELAPE reduces the positive CRM and IOP rates to 20.3 per cent and 8.2 per cent, respectively 10 .…”