gms | German Medical Science

Background: Local recurrence rate for rectal cancer has markedly improved with the introduction of total mesorectal excision (TME). However, improvement was much better for anterior resection than for abdominoperineal excision (APE). Extralevator abdominoperineal excision (ELAPE) was introduced to improve surgical technique, and short term outcome with respect to inadvertent bowel perforation and involved circumferential margin were promising. This study investigates prospectively long term outcome of patients operated on with ELAPE compared to a similar cohort of patients operated on with conventional APE.

Materials and methods: A prospective database held at Dresden-Friedrichstadt General Hospital was queried for all patients who underwent either conventional APE or ELAPE for locally advanced rectal cancer no more than 6 cm from the anal verge from 1997 to 2012. To ensure comparable groups, we excluded patients without neoadjuvant therapy. In-hospital mortality and macroscopically incomplete tumor resection (R2) were excluded as well. Demographic and tumor data were thoroughly compared between the two groups. Primary outcome measure was local recurrence, secondary outcome measures were cause-specific and overall survival.

Results: We identified 72 patients, 36 in each group. Patients were comparable with respect to age, CEA-level, clinical T-category, distant metastases, pathologic staging, and grading. Median distance from the anal verge was significantly lower for patients who underwent ELAPE (4 cm vs. 2cm, p = 0.021), and more patients were node positive on clinical staging. Inadvertent bowel perforation could completely be avoided in the ELAPE group, but amounted to 16.2 % in the APE group (p = 0.025). Median follow-up for surviving patients was 126 months in the APE group and 63 months in the ELAPE group. Cumulative local recurrence rate at 5 years was 18.0 % in the APE group compared to 5.9 % in the ELAPE group (p = 0.162). Local recurrence without distant metastases occurred in 15.4 % in the APE group but was not observed in the ELAPE group (p = 0.041). We did not detect significant differences in cause specific nor in overall survival.

Conclusion: ELAPE provides the solution to technical difficulties that are inherent in conventional APE, because it has the potential to eradicate inadvertent bowel perforation. Furthermore recurrence rate at 5 years was reduced by 12.1 % and showed a significant difference in patients who did not suffer from distant metastases at the time of local recurrence. We conclude that ELAPE should be the standard procedure for locally advanced low rectal cancer.