Extralevator Abdominoperineal Excision Group Research Articles

Comparison of the clinical efficacy of laparoscopic extralevator abdominoperineal excision (ELAPE) and non-ELAPE for low rectal cancer.

This study was performed to retrospectively analyze and compare the related clinical indicators between extralevator abdominoperineal excision (ELAPE) and non-ELAPE under laparoscopic for low rectal cancer. From June 2018 to September 2021, a total of 80 patients with low rectal cancer who underwent either of the above two types of surgeries at our Hospital were enrolled. Patients were divided into the ELAPE group and non-ELAPE group based on the different surgical methods. Preoperative general indicators, intraoperative indicators, postoperative complications, positive circumferential resection margin rate, local recurrence rate, hospital stay length, hospital expenses, and other related indicators were compared between the two groups. There were no significant differences in the comparison of preoperative indexes between the ELAPE group and non-ELAPE group, including age, preoperative BMI, and gender. Similarly, there were no significant differences in abdominal operation time, total operation time, and the number of intraoperative lymph nodes dissected between the two groups. However, the perineal operation time, intraoperative blood loss, intraoperative perforation rate, and positive circumferential resection margin rate were significantly different between the two groups. In the comparison of postoperative indexes, perineal complications, postoperative hospital stay length, and IPSS score were significantly different between the two groups. The use of ELAPE in treating T3-4NxM0 phase low rectal cancer was superior to non-ELAPE in reducing intraoperative perforation rate, positive circumferential resection margin rate, local recurrence rate, etc.

Short-term advantages of ELAPE over APR

Introduction Conventional abdominoperineal resection (APR) has a high rate of local recurrence. Extralevator abdominoperineal excision (ELAPE) can potentially diminish the rate of intraoperative tumour perforation (IOTP) and can provide wider circumferential resection margins (CRM) but at the price of higher perineal complication rate. The aim of our study was to compare the short term results of conventional APR to ELAPE. Materials and methods Thirty-five consecutively operated APRs compared to 38 also consecutively operated ELAPEs. Prospectively collected short-term outcome data were analysed retrospectively. Results There was no difference in demographics, disease stage or tumour location between groups. IOTP rate and CRM positivity rates were similar between the two groups (p = .608). No difference was found in major (Clavien-Dindo III–V) complications, but we found statistically significant difference in minor (Clavien-Dindo I–II) complications (p = .01) in favour of the ELAPE group. Frequency of perineal SSI was lower in ELAPE group, but the difference was not significant (p = .320). Intraoperative iatrogenic complications occurred at significantly lower rate in ELAPE group (p = .035). Also, postoperative morbidity connected with the dissection in the perineal phase (e.g. urine incontinence, urinary retention) was significantly lower (p = .018) after ELAPE. Discussion and conclusions In our experience ELAPE operations may diminish the rate of Clavien-Dindo I–II complications compared to conventional APR. This effect is ensuing from the decrease of intraoperative iatrogenic complications and from the decrease of minor postoperative complications.

Multicenter study of surgical and oncologic outcomes of extra-levator versus conventional abdominoperineal excision for lower rectal cancer

BackgroundThe surgical and oncological outcome of extra-levator abdominoperineal excision (ELAPE) procedure remains unclear in low rectal cancer. MethodsA total of 194 cases of rectal cancer patients underwent ELAPE or conventional abdominoperineal excision (APE) procedure were analyzed in four hospitals’ databases from January 2010 to December 2015. Clinicopathological data, overall survival (OS), disease free survival (DFS) and local recurrence free survival (LRFS) of patients were compared between two groups. ResultsThe operation time spent in perineal phase was significantly shorter in the ELAPE group than that in conventional APE procedure (P < 0.001). There were more specimens with excellent or good quality in ELAPE group compared to conventional APE group (P = 0.033). Patients whom underwent ELAPE procedures showed significantly better OS, DFS and LRFS than those underwent conventional APE procedures. Patients with preoperative stage cT3∼T4 (P = 0.033, P = 0.008, P = 0,033), cN+ (P = 0.002, P < 0.001, P = 0.006) and pathological stage III-IV (P = 0.023, P = 0.008, P = 0.016) were associated with significant benefits from ELAPE procedure in terms of OS, DFS and LRFS. DFS differed significantly between two groups of patients whom got preoperative chemoradiation therapy (P = 0.009) or postoperative chemotherapy (P = 0.029). For patients of pathological stage IIII-IV without preoperative chemoradiation, ELAPE procedures resulted in statistically better OS (P = 0.018) and DFS (P = 0.030). ELAPE procedure was an independent risk factor of OS, DFS and LRFS in multivariate analysis. ConclusionLow rectal cancer patients might benefit from ELAPE procedure on both surgical and oncological outcomes, especially in patients with relatively advanced tumors, inspite of the effects of pre-operative radio- and chemotherapy.

A comparative study of standard versus extralevator abdominoperineal resections

Background: The aim was to compare short term outcomes between patients undergoing standard abdominoperineal resection (APR) with those that had an extralevator abdominoperineal excision (ELAPE).Methods: A retrospective study was done on 123 consecutive patients who underwent an abdominoperineal resection for low rectal cancer at the Townsville hospital between August 2003 and January 2015. Data was collected from medical records. Short term oncological outcomes were compared between the APR and ELAPE group.Results: The circumferential resection margin (CRM) involvement rate was significantly lower in the ELAPE group 13.2% versus 19.3% in the APR group. The local recurrence rates in the two groups were not significantly different: 16.8% in the ELAPE versus 17.4% in the APR group. Intraoperative perforations were lower in the ELAPE group 15.3% versus 23.2 % in the APR group. The post-operative wound infection rate was however higher in the ELAPE group 20.3% versus 12.4 % in the APR group.Conclusions: ELAPE was shown to be superior in the CRM and intraoperative perforation rate but the local recurrence rates were similar. ELAPE had a higher wound complication rate than APR.

The LOREC APE registry: operative technique, oncological outcome and perineal wound healing after abdominoperineal excision.

The Low Rectal Cancer Development programme (LOREC) perineal wound healing registry was developed to record data on abdominoperineal excision (APE) for rectal cancer in colorectal units in England between 2012 and 2014, to understand current practice in operative technique and results. Surgeons wishing to participate received secure Web-based access to the registry. Data were collected on preoperative staging, neoadjuvant treatment, operative details, histopathology, early outcome and follow up at 12months. Forty-two units entered 266 patients. Of these, 172 (65%) patients underwent extralevator APE (ELAPE) and 94 had non-ELAPE procedures. On preoperative staging, 64% were mrT3/4, and 67% received neoadjuvant treatment. For the ELAPE group the perineal wound was closed primarily with mesh in 55% of patients, without mesh in 15% and with a flap in 21%. For non-ELAPE procedures, 54% of wounds were closed primarily without mesh, 29% primarily with mesh and 5% by a flap. Wound breakdown occurred in 30% and 31% of patients in the ELAPE and non-ELAPE groups, respectively, and was more common after neoadjuvant radiotherapy. Donor-site complications occurred in 17% of patients treated with a flap. Perineal morbidity was recorded in 11% of patients at 12months. On histopathology, the resection margin was positive in 13% of patients in the ELAPE group and in 4% of patients in the non-ELAPE group. The LOREC registry provides a picture of current APE practice in England. ELAPE was used in two-thirds of patients but does not appear to confer any additional morbidity. Primary closure with mesh appeared as effective as flap reconstruction. The prevalence of an involved resection margin was lower than reported in many historical series but still remains high in the ELAPE group.

Extralevator abdominoperineal excision versus conventional surgery for low rectal cancer: a single surgeon experience.

Extralevator abdominoperineal excision (ELAPE) reduces the risk of positive circumferential resection margin (CRM) and of intraoperative perforation (IOP), both of which are associated with high local recurrence rates and poor survival outcomes for rectal cancer. The aim of this study was to compare the results of ELAPE with conventional abdominoperineal excision (APE) for low rectal cancer. A total of 25 consecutive patients underwent ELAPE for low rectal cancer between November 2008 and September 2011. Fifty-six patients treated by conventional APE prior to 2008 were selected from our rectal cancer database for comparison as a historical cohort. The mean follow-up was 44.7 months in the ELAPE group, and 70.6 months in the APE group. Patients undergoing ELAPE had a lower CRM positivity and IOP rate than APE (12% vs. 20%, p=0,531; 4% vs. 8,9%, p=0,826; respectively). The ELAPE group was associated with higher perineal wound complications than the APE group (16.0% vs. 1.8%, p=0.030). Local recurrence rates for patients in both groups did not differ significantly (4.0% vs. 3.6%, p=1.0). The results of this study suggest that ELAPE technique was associated with less CRM involvement and reduced rates of IOP but markedly higher rates of postoperative perineal complications occurred as compared to conventional surgery. ELAPE must be reserved for advanced low rectal cancers.

Long-term outcome of extralevator abdominoperineal excision (ELAPE) for low rectal cancer.

Extralevator abdominoperineal excision (ELAPE) was introduced to improve outcomes for low-lying locally advanced rectal cancers (LARC) not amenable to sphincter preserving procedures. This study investigates prospectively outcomes of patients operated on with ELAPE compared with a similar cohort of patients operated on with conventional APE. After the exclusion of patients without neoadjuvant therapy, in-hospital mortality, and incomplete metastatectomy, we identified 72 consecutive patients who had undergone either conventional APE (n=36) or ELAPE (n=36) for LARC ≤6cm from the anal verge. The primary outcome measure was local recurrence at 5years, and secondary outcome measures were cause-specific and overall survival. Median distance from the anal verge was significantly lower in the ELAPE group (2 vs. 4cm, p=0.029). Inadvertent bowel perforation could be completely avoided in the ELAPE group, but amounted to 16.7% in the conventional APE group (p=0.025). Cumulative local recurrence rate at 5years was 18.2% in the APE group compared to 5.9% in the ELAPE group (p=0.153). Local recurrence without distant metastases occurred in 15.5% in the APE group but was not observed in the ELAPE group (p=0.039). We did not detect significant differences in cause-specific nor in overall survival. ELAPE results in lower local recurrence rates as compared with conventional APE. We conclude that the extralevator approach should be the procedure of choice for advanced low rectal cancer not amenable to sphincter preserving procedures.

OC-100 Lorec registry–interim analysis of operative technique and perineal wound healing outcomes after abdomino-perineal excision

Introduction The LOREC perineal wound healing registry was developed to record data on abdomino-perineal excision (APE) for rectal cancer in colorectal units across the UK between 2012 and 2014 to understand current practice in operative techniques and patient outcomes. Initial interim results are reported. Method Surgeons wishing to participate received secure web-based access to the registry. Collected data included pre-operative staging, operative details, pathology, early outcome and follow-up at 12 months. Results Overall 43 units entered a total of 259 patients undergoing APE. These included 168 extralevator APE (ELAPE) procedures (65%) and 91 non-ELAPEs, comprising 73 ‘standard’ APE, 9 intersphincteric, 2 ischio-anal and 7 unspecified procedures. The ELAPE and non-ELAPE groups are compared. In the ELAPE group there were 120 males (71%) with a median age of 66 years (range 38–93). In the non-ELAPE group there were 64 males (70%) with a median age of 68 years (range 32–97). The perineal component was performed prone in 151 (90%) of the ELAPE group versus 13 (14%) of the non-ELAPE group. The coccyx was removed in 123 (73%) of the ELAPEs and 7 (8%) of the non-ELAPEs. In the ELAPE group primary skin closure for the perineal component was performed in 119 (71%) while in 34 (20%) a flap was used (13 VRAM, 9 local myocutaneous and 12 fascio-cutaneous flaps). In 15 cases (9%) the surgeons reported no closure. In 111 (66%) a mesh, generally biological, was used in perineal closure. Mesh was most commonly used where the closure was primary but 9 flap closures also used mesh. In the non-ELAPE group primary closure was more common, being used in 76 (84%) while in 5 (5%) a flap was used. In 10 cases (11%) the surgeons reported no closure. Mesh was used less frequently in non-ELAPEs, with only 30 (33%) using a mesh; the majority (57%) of these were non-biological. Primary healing was achieved in 29% of ELAPE patients, the majority of whom were closed primarily, compared to 9% in the non-ELAPE group. There was no difference in wound healing by 4 weeks and both groups had a small number of patients who took more than 3 months to heal completely. There was no significant difference in length of hospital stay for the two groups. There was one post-operative death in each group; a peritonitis of unknown cause in the ELAPE group and a GI bleed in the non-ELAPE group. Conclusion The LOREC registry has been a success in providing a summary of current practice and will be valuable in informing the design of future trials assessing APE techniques and reconstruction. In this series, ELAPE is performed in the majority of patients and primary closure with mesh appears to offer effective skin closure compared to flap. Disclosure of interest None Declared.

OC-004 Lorec registry – interim analysis of operative technique, pathology and oncological outcomes after abdomino-perineal excision

<h3>Introduction</h3> The LOREC perineal wound healing registry was developed to record data on abdomino-perineal excision (APE) for rectal cancer in colorectal units across the UK between 2012 and 2014 to understand current practice. Initial interim results are reported. <h3>Method</h3> Surgeons wishing to participate received secure web-based access to the registry. Collected data included pre-operative staging, neo-adjuvant treatment, operative details, pathology, early outcome and follow-up at 12 months. <h3>Results</h3> Overall 43 units entered a total of 259 patients undergoing APE. These included 168 extralevator APE (ELAPE) procedures (65%) and 91 non-ELAPEs, comprising 73 ‘standard’ APE, 9 intersphincteric, 2 ischioanal and 7 unspecified procedures. The ELAPE and non-ELAPE groups are compared. This indication for APE was oncological in 98% with only 5 cases having APE for functional reasons, eg weak sphincters. On pre-op MRI the ELAPE group had higher grade tumours, with 112 (67%) staged on MRI as T3/4 compared with 47 (54%) for non-ELAPEs. ELAPEs also had a higher incidence of predicted positive lymph nodes, with 97 (58%) N1/2 compared with 38 (43%) for non-ELAPEs. The circumferential resection margin was predicted as less likely to be clear in the ELAPE group, 68 (45%), versus 38 (53%) in the non-ELAPE group. Metastatic disease was reported in 6% of the ELAPE group and 3% of the non-ELAPEs. The majority of patients received pre-operative treatment, most commonly chemoradiotherapy. Overall, the response to treatment was graded on MRI as mixed fibrosis and tumour in 32%, while 38% showed mainly or only tumour and 29% showed small or no residual tumour. Multivisceral resection was undertaken in 19 (11%) of ELAPEs and 7 (8%) of non-ELAPEs, the vast majority involving the vagina. Operative complications were recorded in 8%. These included rectal perforation (7 cases), urethral injury (6 cases), ureteric injury (2 cases) and 9 cases of ‘other’ complications. On pathology similar proportions had higher grade tumours: 81 (52%) T3/4 in the ELAPE group compared with the 41 (47%) in the non-ELAPE group. The ELAPEs were more likely to be node-positive, 55 (35%), versus 23 (27%) in the non-ELAPEs. A positive resection margin was reported in 21 (14%) of ELAPEs and 2 (2%) of non-ELAPEs. Perforation was noted in 3 patients in each group. The quality of TME was graded as mesorectal plane intact in 112 (67%) of ELAPEs and 46 (51%) of non-ELAPEs. The quality of the levator plane was graded as complete levator wrap in 110 (65%) of ELAPEs. <h3>Conclusion</h3> It appears that surgeons are using ELAPE in more advanced cases but R1 rates of 14% suggest these are challenging and further means of improving outcomes should be explored. <h3>Disclosure of interest</h3> None Declared.

PWE-393 Reconstruction of the pelvic floor after abdominoperineal excision

Introduction Extralevator abdominoperineal excision (ELAPE) involves the en bloc excision of the levator muscles and the rectum and the wider excision can increase morbidity and wound complications tthat will require some form of perineal reconstruction. The aim of this review is to provide an overview of the evidence for the use of biological mesh in the reconstruction of the pelvic floor after abdominoperineal excision. Method A systematic search of PubMed was conducted using the search terms ‘ELAPE’, ‘extralevator abdominoperineal excision of rectum’ or ‘extralevator abdominoperineal resection’ . The search yielded 17 studies for analysis after inclusion and exclusion criteria were applied. Results There were a total of 1055 patients across 17 studies. A biological mesh was used in perineal reconstruction in 463 patients with 206 patients using cross-linked porcine dermal collagen (PermacolTM), 44 using porcine intestinal submucosa (Surgisis©), 136 using human acellular dermal matrix (HADM) and 9 using a combination of PermacolTM and Surgisis©. Two studies did not specify the type of biological mesh used. There were 41 perineal hernias reported but rates were not consistently reported in all studies. The most common complications were perineal wound infection and perineal pain. However, there are no standardised measures for reporting perineal outcomes following ELAPE. There are very few studies comparing the use of biological mesh for perineal reconstruction for ELAPE. Two case series compared biological mesh with myocutaneous flaps and one series compared laparoscopic ELAPE with laparoscopic and open APER. Only one RCT was identified that compared patients undergoing ELAPE with perineal reconstruction using a biological mesh, with patients undergoing a conventional APER with no mesh. There was no significant difference in perineal hernia rates or perineal wound infections between the two groups although there were fewer positive circumferential resection margins in the ELAPE group. Conclusion The literature suggests that perineal closure using a biological mesh produces wound infection and complication rates that are comparable to other methods of reconstruction such as myocutaneous flaps. Biological mesh-assisted perineal reconstruction is a promising technique to improve wound healing but the results from high-quality prospective RCTs are required or national/international collaborative audits using statistical process control as a methodology of assessment of improvement. Disclosure of interest None Declared.

Extralevator abdominoperineal excision versus traditional abdominoperineal excision in the treatment of low rectal cancer

To compare the safety and efficacy between extralevator abdominoperineal excision(ELAPE) and traditional abdominoperineal excision(APE) in patients with low rectal cancer. From January 2011 to December 2013, 61 patients undergoing abdominoperineal excision for low rectal cancer at the Department of Gastrointestinal Surgery, Peking University People's Hospital were enrolled. The safety and efficacy of two procedure groups, ELAPE group (33 patients) and traditional APE group (28 patients) were reviewed retrospectively. Less intraoperative blood loss [(201 ± 147) ml vs. (343 ± 308) ml, P=0.022], shorter exhaust time [(3.8 ± 1.5) d vs. (4.6 ± 1.6) d, P=0.039] and lower perineal wound complication rate (9.1% vs. 25.0%, P=0.042) were observed in the ELAPE group as compared to the traditional APE group. However, longer operation time [(292 ± 46) min vs. (256 ± 28) min, P=0.008] and perineal drainage removal time [(11.1 ± 4.8) d vs. (7.1 ± 2.7) d, P<0.01] were noted in the ELAPE group than those in the traditional APE group. Number of lymph node retrieved and positive lymph node retrieved was not significantly different between two groups. The ELAPE group had lower rate of IOP (intraoperative perforation) (6.1% vs. 17.9%, P=0.055), but no significant difference was found. There were no significant differences in bowel movement, diet restoring time, average perineal drainage, postoperative hospitalization time and removing perineal stitches time between the two groups (all P>0.05). ELAPE possesses less intraoperative blood loss and lower perineal wound complication rate than traditional APE. ELAPE is associated with better safety and efficacy than traditional APE.

Feasibility and short-outcomes of laparoscopic extralevator abdominoperineal excision without changing position for distal rectal cancer

To evaluate the short-term outcomes of laparoscopic extralevator abdominoperineal excision (ELAPE) without changing position during operation. Totally 51 patients with distal advanced rectal cancer received surgical operation in Peking Union Midical College Hospital from September 2011 to April 2014. There were 29 male and 22 female patients with a mean age of (61 ± 10) years. Twenty-six percent of the patients received preoperative concomitant chemotherapy and radiation. Twenty-seven patients underwent laparoscopic abdominoperineal excision (APE) procedure, while 24 patients underwent ELAPE procedure. In both groups, patients were kept Lithotomy-Trendelenburg position during operation. The fat tissue in ischialrectal fossa was not routinely removed, except the tumor invasion. All the patients' pelvic peritoneum was closed by continuous suturing, and subcutaneous tissue and skin by interrupted suturing. Retrospectively compare the pathoclinical features, operation time, bleeding, node retrieval, lateral margin and complications by t-text and χ(2) test respectively between ELAPE and APE procedures both by laparoscopic approach. No significant differences were found in term of age, gender, BMI, distance from anal verge, percentage of neoadjuvant chemoradiation, and TNM staging between these two groups (all P > 0.05). The operation time was significantly shorter in ELAPE group ((181 ± 41) minutes vs. (228 ± 58) minutes, t = -3.265, P = 0.002). The bleeding volume was less in ELAPEE group (50 (80) ml vs 80 (100) ml (M(QR)), Z = -2.259, P = 0.024). The lateral margin, urinal retention and perineal wound healing were comparable for these two groups. No pelvic hernia was found during the postoperative follow-up (2 to 34 months) in both groups (all P > 0.05). Laparoscopic extralevator abdominoperineal excision without changing position is feasible for distal rectal cancer. Some essential steps can be simultaneously accomplished during operation without changing position. Closing the pelvic peritoneum is important for preventing the intestine dropping from abdominal cavity to presacral cavity.

No observable difference in operative oncological outcomes between extra-levator versus standard abdominoperineal excision

In recent years, concerns have arisen regarding the poorer outcomes of patients undergoing abdominoperineal excision (APE), compared with those having total mesorectal excision (TME). This was attributed to higher rates of involved circumferential resection margins (CRMs) and tumour perforations after APE, and was thought to have occurred due to adherence of the TME plane to the puborectalis sling. This apparent disparity was addressed by the re-introduction of a more radical approach to APE surgery, which closely mirrored the operation described by Miles [1]. The procedure, extra-levator abdominoperineal excision (ELAPE), entails a more extensive, wider perineal dissection down to the origin of the levators. Several retrospective studies have reported a reduction in rates of CRM positivity and intraoperative perforation with ELAPE, compared with standard APE (SAPE). Each of these histopathological findings is deemed a crucial marker in determining prognosis for low rectal cancer. Thus, pathological assessment of the resected specimen, as a surrogate marker of oncological superiority, can also be used as a surrogate marker for long-term outcome. Although the loco-regional clearance obtained by ELAPE may be superior to SAPE, the substantial perineal defect, which is often too large for primary closure, can result in delayed wound healing and perineal herniation. Asplund [2] compared outcomes for 158 patients with low rectal cancer, half of whom underwent SAPE and half ELAPE. No advantage for ELAPE was shown, in terms of local recurrence, intraoperative perforation and CRM positivity, but higher rates of perineal wound complications were reported. This is in contradiction to other studies demonstrating higher rates of CRM positivity and intraoperative perforations with SAPE. Having adopted the ELAPE technique (performed with the patient in the prone position), we sought to ascertain whether the wider cylindrical dissection offers any oncological advantage over SAPE, through comparing the pathological findings of our resected specimens. We studied 34 consecutive patients who underwent APE: 17 underwent SAPE and 17 ELAPE. The results are outlined in Table 1. There was no difference in patient demographics or tumour T stage between the two groups. Similar proportions of patients in each group had received preoperative radiotherapy, ELAPE: 71 % (12) and SAPE: 88 % (15) (p = 0.40). The mean distance to the CRM did not differ between groups, ELAPE: 6.5 mm and SAPE: 5.8 mm (p = 0.80), nor did the R0 resection rate, ELAPE: 82 % (14) SAPE: 71 % (12) (p = 0.69). There was 1 intraoperative tumour perforation in the ELAPE group (6 %), and 2 (12 %) of the SAPE specimens were perforated (p = 1.00). Comparable mean numbers of lymph nodes were harvested (ELAPE: 8.9 and SAPE: 8.6) (p = 0.90). Throughout the period, that ELAPE was performed tumour perforation, and R1 or 2 resections occurred sporadically and did not correlate with a perceived learning curve. We have not detected any difference in short-term surrogate markers for oncological outcome between ELAPE and SAPE. Our numbers are small; however, the results mirror those of Asplund et al. [2] who reported a specimen perforation rate of 13 % (ELAPE) versus 10 % (SAPE), and CRM positivity of 17 and 20 %, respectively. The Asplund study failed to find any oncological advantage of K. J. Gash (&) L. Cooper N. Smart R. Longman M. Thomas University Hospitals Bristol NHS Foundation Trust, Bristol BS2 8HW, UK e-mail: kat_jg@hotmail.com

An MRI-based Assessment of Standard and Extralevator Abdominoperineal Excision Specimens: Time for a Patient Tailored Approach?

The extralevator abdominoperineal excision (ELAPE) has been proposed as oncologically superior to standard abdominoperineal excision (SAPE). However, little is known regarding comparative margins achieved in ELAPE and SAPE. The purpose of this study was to compare patterns of tissue removal between these two groups that can aid patient selection. Twenty APE specimens, comprising 10 SAPEs and 10 ELAPEs, were selected randomly from a single UK centre. Transverse slices of pathological specimens were matched to corresponding axial MRI images obtained from conventional pelvic MRI imaging. Measurements from the muscularis propria to the resection margin [muscularis to margin (MTM) distance] were recorded by height (from anal verge) and quadrant for each surgical group. MTM distances achieved on histopathological assessment were also compared to MRI assessed distances necessary to achieve a clear CRM. ELAPE specimens had a greater mean MTM distance than for SAPE (7.75 vs. 5.61 mm, p = 0.02). ELAPE had significantly greater MTM distances in lateral and posterior quadrants (p < 0.05) than SAPE at 30-49 mm. There was no significant difference in mean anterior distances (1.57 vs. 1.16 mm, p = 0.507) with the smallest difference at a height of 60-69 mm. Two (2 %) of pathological MTM distances within ELAPE group failed to achieve the minimum MRI assessed distance compared with 30 (23 %) in the SAPE group, which had higher CRM positivity. ELAPE appears to confer oncological benefit over SAPE but with notable exceptions, including tumours located above and below the puborectalis sling and anteriorly at the level of prostate where exenteration may be more appropriate.

Short-term outcome of extra-levator abdominoperineal excision for rectal cancer

Extra-levator abdominoperineal excision (ELAPE) has been introduced to avoid oncologic problems encountered with conventional abdominoperineal excision (APE) such as high rates of inadvertent bowel perforation and of positive circumferential resection margin. We compare our short-term results of this new approach with a historic patient cohort. From 1997 until 2010, we performed 46 consecutive conventional APE and 28 ELAPE after neoadjuvant therapy with a macroscopically complete resection in the true pelvis. Patient data was prospectively collected in our colorectal tumor database. Patient and tumor characteristics were compared as were the rates of inadvertent bowel perforation, of circumferential margin involvement, and of wound abscesses. The rates of inadvertent bowel perforation, of circumferential margin involvement, and of wound abscesses were 15.2% vs. 0 (p = 0.04), 4.9% vs. 0 (p = 0.511), and 17.4% vs. 10.7% (p = 0.518), respectively, in the conventional APE vs. ELAPE group. With a significant reduction of the bowel perforation rate and a reduction of circumferential margin involvement and wound abscess formation, ELAPE improves important surrogate parameters for local recurrence rate and survival.