Advertisement

International Journal of Colorectal Disease

, Volume 31, Issue 10, pp 1729–1737 | Cite as

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

  • Sigmar StelznerEmail author
  • Gunter Hellmich
  • Anja Sims
  • Thomas Kittner
  • Eric Puffer
  • Joerg Zimmer
  • Dorothea Bleyl
  • Helmut Witzigmann
Original Article

Abstract

Purpose

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.

Methods

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 ≤6 cm from the anal verge. The primary outcome measure was local recurrence at 5 years, and secondary outcome measures were cause-specific and overall survival.

Results

Median distance from the anal verge was significantly lower in the ELAPE group (2 vs. 4 cm, 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 5 years 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.

Conclusion

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.

Keywords

Abdominoperineal excision Extralevator Rectal cancer Local recurrence Survival Surgery 

Notes

Acknowledgments

The maintenance of the database at the Coloproctologic Unit of Dresden-Friedrichstadt General Hospital is supported by a grant of the Tumor Center Dresden.

Compliance with ethical standards

Disclosures

All authors declare no conflicts of interest.

References

  1. 1.
    Williams NS, Johnston D (1984) Survival and recurrence after sphincter-saving resection and abdominoperineal resection for carcinoma of the middle third of the rectum. Br J Surg 71:278–282CrossRefPubMedGoogle Scholar
  2. 2.
    McCall LJ, Cox MR, Wattchow DA (1995) Analysis of local recurrence rates after surgery alone for rectal cancer. Int J Colorectal Dis 10:126–132Google Scholar
  3. 3.
    Heald RJ, Husband EM, Ryall RDH (1982) The mesorectum in rectal cancer surgery – the clue to pelvic recurrence? Br J Surg 69:613–616Google Scholar
  4. 4.
    Heald RJ, Moran BJ, Ryall RDH, Sexton R, MacFarlane JK (1998) The Basingstoke experience of total mesorectal excision, 1978–1997. Arch Surg 133:894–899CrossRefPubMedGoogle Scholar
  5. 5.
    den Dulk M, Putter H, Collette L, Marijnen CA, Folkesson J, Bosset JF, Rödel C, Bujko K, Påhlman L, van de Velde CJ (2009) The abdominoperineal resection itself is associated with an adverse outcome: the European experience based on a pooled analysis of five European randomized clinical trials on rectal cancer. Eur J Cancer 45:1175–1183CrossRefGoogle Scholar
  6. 6.
    Salerno G, Chandler I, Wotherspoon A, Thomas K, Moran B, Brown G (2008) Sites of surgical waisting in the abdominoperineal specimen. Br J Surg 95:1147–1154CrossRefPubMedGoogle Scholar
  7. 7.
    How P, Shihab O, Tekkis P, Brown G, Quirke P, Heald R, Moran B (2011) A systematic review of cancer related patient outcomes after anterior resection and abdominoperineal excision for rectal cancer in the total mesorectal excision era. Surg Oncol 20:e149–e155CrossRefPubMedGoogle Scholar
  8. 8.
    Holm T, Ljung A, Häggmark T, Jurell G, Lagergren J (2007) Extended abdominoperineal resection with gluteus maximus flap reconstruction of the pelvic floor for rectal cancer. Br J Surg 94:232–238CrossRefPubMedGoogle Scholar
  9. 9.
    Stelzner S, Holm T, Moran BJ, Heald R, Witzigmann H, Zorenkov D, Wedel T (2011) Deep pelvic anatomy revisited for a description of crucial steps in extralevator abdominoperineal excision for rectal cancer. Dis Colon Rectum 54:947–957CrossRefPubMedGoogle Scholar
  10. 10.
    West NP, Anderin C, Smith KJE, Holm T, Quirke P (2010) Multicentre experience with extralevator abdominoperineal excision for low rectal cancer. Br J Surg 97:588–599CrossRefPubMedGoogle Scholar
  11. 11.
    Nicholls J (2013) No more‚ ‘standard’ abdominoperineal excision. Colorectal Dis 15:1329–1330Google Scholar
  12. 12.
    Sauer R, Becker H, Hohenberger W, Rödel C, Wittekind C, Fietkau R, Martus P, Tschmelitsch J, Hager E, Hess CF, Karstens JH, Liersch T, Schmidberger H, Raab R, German Rectal Cancer Study Group (2004) Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med 351:1731–1740CrossRefPubMedGoogle Scholar
  13. 13.
    Schmiegel W, Pox C, Adler G, Fleig W, Fölsch UR, Frühmorgen P, Graeven U, Hohenberger W, Holstege A, Junginger T, Kühlbacher T, Porschen R, Propping P, Riemann JF, Sauer R, Sauerbruch T, Schmoll HJ, Zeitz M, Selbmann HK (2004) S3-guideline conference “Colorectal Cancer 2004”. Z Gastroenterol 42:1129–1177 [in German]CrossRefPubMedGoogle Scholar
  14. 14.
    Shihab OC, Moran BJ, Heald RJ, Quirke P, Brown G (2009) MRI staging of low rectal cancer. Eur Radiol 19:643–650CrossRefPubMedGoogle Scholar
  15. 15.
    Battersby NJ, How P, Moran B, Stelzner S, West NP, Branagan G, Strassburg J, Quirke P, Tekkis P, Pedersen BG, Gudgeon M, Heald B, Brown G, MERCURY II Study Group (2016) Prospective validation of a low rectal cancer magnetic resonance imaging staging system and development of a local recurrence risk stratification model: the MERCURY II study. Ann Surg 263:751–760Google Scholar
  16. 16.
    Stelzner S, Hellmich G, Schubert C, Puffer E, Haroske G, Witzigmann H (2011) Short term outcome of extra-levator abdominoperineal excision for rectal cancer. Int J Colorectal Dis 26:919–925Google Scholar
  17. 17.
    Quirke P, Morris E (2007) Reporting colorectal cancer. Histopathology 50:103–112CrossRefPubMedGoogle Scholar
  18. 18.
    Han JG, Wang ZJ, Wei GH, Gao ZG, Yang Y, Zhao BC (2012) Randomized clinical trial of conventional versus cylindrical abdominoperineal resection for locally advanced lower rectal cancer. Am J Surg 204:274–282CrossRefPubMedGoogle Scholar
  19. 19.
    Palmer G, Anderin C, Martling A, Holm T (2014) Local control and survival after extralevator abdominoperineal excision for locally advanced or low rectal cancer. Colorectal Dis 16:527–532Google Scholar
  20. 20.
    Martijnse IS, Dudink RL, West NP, Wasowicz D, Nieuwenhuijzen GA, van Lijnschoten I, Martijn H, Lemmens VE, van de Velde CJ, Nagtegaal ID, Quirke P, Rutten HJ (2012) Focus on extralevator perineal dissection in supine position for low rectal cancer has led to better quality of surgery and oncologic outcome. Ann Surg Oncol 19:786–793CrossRefPubMedGoogle Scholar
  21. 21.
    Shen Z, Ye Y, Zhang X, Xie Q, Yin M, Yang X, Jiang K, Liang B, Wang S (2015) Prospective controlled study of the safety and oncological outcomes of ELAPE procure with definitive anatomic landmarks versus conventional APE for lower rectal cancer. Eur J Surg Oncol 41:472–477CrossRefPubMedGoogle Scholar
  22. 22.
    Welsch T, Mategakis V, Contin P, Kulu Y, Büchler MW, Ulrich A (2013) Results of extralevator abdominoperineal resection for low rectal cancer including quality of life and long-term wound complications. Int J Colorectal Dis 28:503–510Google Scholar
  23. 23.
    Han JG, Wang ZJ, Qian Q, Dai Y, Zhang ZQ, Yang JS, Li F, Li XB (2014) A prospective multicenter clinical study of extralevator abdominoperineal resection for locally advanced rectal cancer. Dis Colon Rectum 57:1333–1340CrossRefPubMedGoogle Scholar
  24. 24.
    Stelzner S, Koehler C, Stelzer J, Sims A, Witzigmann H (2011) Extended abdominoperineal excision vs. standard abdominoperineal excision in rectal cancer – a systematic overview. Int J Colorectal Dis 26:1227–1240CrossRefPubMedGoogle Scholar
  25. 25.
    Perdawood SK, Lund T (2015) Extralevator versus standard abdominoperineal excision for rectal cancer. Tech Coloproctol 19:145–152CrossRefPubMedGoogle Scholar
  26. 26.
    Yu HC, Peng H, He XS, Zhao RS (2014) Comparison of short- and long-term outcomes after extralevator abdominoperineal excision and standard abdominoperineal excision for rectal cancer: a systematic review and meta-analysis. Int J Colorectal Dis 29:183–191Google Scholar
  27. 27.
    De Campos-Lobato LF, Stocchi L, Dietz DW, Lavery IC, Fazio VW, Kalady MF (2011) Prone or lithotomy positioning during an abdominoperineal resection for rectal cancer results in comparable oncologic outcomes. Dis Colon Rectum 54:939–946CrossRefPubMedGoogle Scholar
  28. 28.
    Kenelly RP, Rogers AC, Winter DC, Abdominoperineal Excision Study Group (2013) Multicentre study of circumferential margin positivity and outcomes following abdominoperineal excision for rectal cancer. Br J Surg 100:160–166CrossRefGoogle Scholar
  29. 29.
    Ortiz H, Ciga MA, Armendariz P, Kreisler E, Codina-Cazador A, Gomez-Barbadillo J, Garcia-Granero E, Roig JV, Biondo S, Spanish Rectal Cancer Project (2014) Multicentre propensity score-matched analysis of conventional versus extended abdominoperineal excision for low rectal cancer. Br J Surg 101:874–882CrossRefPubMedGoogle Scholar
  30. 30.
    Prytz M, Angenete E, Bock D, Haglind E (2015) Extralevator abdominoperineal excision for low rectal cancer—extensive surgery to be used with discretion based on 3-year local recurrence results: a registry based oberservational national cohort study. Ann Surg. doi: 10.1097/SLA.0000000000001237 Google Scholar
  31. 31.
    Klein M, Fischer A, Rosenberg J, Gögenur I, Danish Colorectal Cancer Group (DCCG) (2015) Extralevatory abdominoperineal excision (ELAPE) does not result in reduced rate of tumor perforation or rate of positive circumferential resection margin: a nationwide database study. Ann Surg 261:933–938CrossRefPubMedGoogle Scholar
  32. 32.
    Asplund D, Haglind E, Angenete E (2012) Outcome of extralevator abdominoperineal excision compared with standard surgery. Results from a single centre. Colorectal Dis 14:1191–1196CrossRefPubMedGoogle Scholar
  33. 33.
    Huang A, Zhao H, Ling T, Quan Y, Zheng M, Feng B (2014) Oncological superiority of extralevator abdominoperineal resection over conventional abdominoperineal resection: a meta-analysis. Int J Colorectal Dis 29:321–327CrossRefPubMedGoogle Scholar
  34. 34.
    De Nardi P, Summo V, Vignali A, Capretti G (2015) Standard versus extralevator abdominoperineal low rectal cancer excision outcomes: a systematic review and meta-analysis. Ann Surg Oncol 22:2997–3006CrossRefPubMedGoogle Scholar
  35. 35.
    Krishna A, Rickard MJ, Keshava A, Dent OF, Chapuis PH (2013) A comparison of published rates of resection margin involvement and intra-operative perforation between standard and ‘cylindrical’ abdominoperineal excision for low rectal cancer. Colorectal Dis 15:57–65Google Scholar
  36. 36.
    Zhou X, Sun T, Xie T, Zhang Y, Zheng H, Fu W (2014) Extralevator abdominoperineal excision for low rectal cancer: a systematic review and meta-analysis of the short-term outcome. Colorectal Dis 17:474–481Google Scholar
  37. 37.
    Messenger DE, Cohen Z, Kirsch R, O'Connor BI, Victor JC, Huang H, McLeod RS (2011) Favorable pathologic and long-term outcomes from the conventional approach to abdominoperineal resection. Dis Colon Rectum 54:793–802CrossRefPubMedGoogle Scholar
  38. 38.
    Dehni N, McFadden N, McNamara DA, Guiguet M, Tiret E, Parc R (2003) Oncologic results following abdominoperineal resection for adenocarcinoma of the low rectum. Dis Colon Rectum 46:867–874CrossRefPubMedGoogle Scholar
  39. 39.
    Nissan A, Guillem JG, Paty PB, Douglas Wong W, Minsky B, Saltz L, Cohen AM (2001) Abdominoperineal resection for rectal cancer at a specialty center. Dis Colon Rectum 44:27–36CrossRefPubMedGoogle Scholar
  40. 40.
    Foster JD, Pathak S, Smart NJ, Branagan G, Longman RJ, Thomas MG, Francis N (2012) Reconstruction of the perineum following extralevator abdominoperineal excision for carcinoma of the lower rectum: a systematic review. Colorectal Dis 14:1052–1059Google Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2016

Authors and Affiliations

  • Sigmar Stelzner
    • 1
    Email author
  • Gunter Hellmich
    • 1
  • Anja Sims
    • 1
  • Thomas Kittner
    • 2
  • Eric Puffer
    • 3
  • Joerg Zimmer
    • 4
  • Dorothea Bleyl
    • 5
  • Helmut Witzigmann
    • 1
  1. 1.Department of General and Visceral SurgeryDresden-Friedrichstadt General Hospital, Teaching Hospital of the Technical University of DresdenDresdenGermany
  2. 2.Department of RadiologyDresden-Friedrichstadt General Hospital, Teaching Hospital of the Technical University of DresdenDresdenGermany
  3. 3.Institute of PathologyDresden-Friedrichstadt General Hospital, Teaching Hospital of the Technical University of DresdenDresdenGermany
  4. 4.Department of Radiation OncologyDresden-Friedrichstadt General Hospital, Teaching Hospital of the Technical University of DresdenDresdenGermany
  5. 5.Department of OncologyDresden-Friedrichstadt General Hospital, Teaching Hospital of the Technical University of DresdenDresdenGermany

Personalised recommendations