Annals of Surgical Oncology

, Volume 19, Issue 3, pp 786–793 | Cite as

Focus on Extralevator Perineal Dissection in Supine Position for Low Rectal Cancer Has Led to Better Quality of Surgery and Oncologic Outcome

  • Ingrid S. Martijnse
  • Ralph L. Dudink
  • Nicholas P. West
  • Dareczka Wasowicz
  • Grard A. Nieuwenhuijzen
  • Ineke van Lijnschoten
  • Hendrik Martijn
  • Valery E. Lemmens
  • Cornelis J. van de Velde
  • Iris D. Nagtegaal
  • Phil Quirke
  • Harm J. Rutten
Colorectal Cancer



After abdominoperineal excision (APE), the presence of tumor cells in the circumferential resection margin (R1) and iatrogenic tumor perforations are still frequent and result in an increased rate of local recurrences. In this study, a standardized supine APE with an increased focus on the perineal dissection (sPPD) is compared to the customary supine APE.


From 2000 to 2010, a total of 246 patients underwent APE for rectal cancer (sPPD and customary supine APE). All patients were staged with preoperative magnetic resonance imaging (MRI) and received neoadjuvant treatment (n = 203) when margins were involved or threatened (cT3 + and T4). As a result of a quality improvement program in 2006, the surgical technique was modified: it became standardized, emphasis was placed on the perineal dissection, and pelvic dissection was limited to avoid false routes when following the total mesorectal excision planes deep into the pelvis.


Overall, the percentage of involved circumferential resection margins (CRMs) was 10%. In the period before introducing sPPD, the R1 percentages for cT0–3 and cT4 tumors were 6.8 and 30.2%, compared to 2.2 and 5.7% after introduction of sPPD (P = 0.001). Risk factors for R1 resection were preoperative T4 tumors (14.9%, P = 0.011), tumor perforation (33.3%, P = 0.002), fistulating tumors (35.7%, P = 0.002), mucus-producing tumors (23.1%, P = 0.006), or bulky tumors (66.7%, P < 0.001).


The objective of surgical treatment of low rectal cancer is to obtain negative resection margins and subsequently reduce the risk of local recurrence. A combination of the appropriate preoperative treatment and standardized surgical technique such as sPPD can achieve this goal.


Rectal Cancer Total Mesorectal Excision Local Recurrence Rate Circumferential Resection Margin Levator Muscle 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



PQ and NW are supported by Yorkshire Cancer Research.


The work was not sponsored, no disclaimers from any of the authors.


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Copyright information

© Society of Surgical Oncology 2011

Authors and Affiliations

  • Ingrid S. Martijnse
    • 1
  • Ralph L. Dudink
    • 1
  • Nicholas P. West
    • 2
  • Dareczka Wasowicz
    • 1
  • Grard A. Nieuwenhuijzen
    • 1
  • Ineke van Lijnschoten
    • 3
  • Hendrik Martijn
    • 4
  • Valery E. Lemmens
    • 5
  • Cornelis J. van de Velde
    • 6
  • Iris D. Nagtegaal
    • 7
  • Phil Quirke
    • 2
  • Harm J. Rutten
    • 1
  1. 1.Department of Colorectal SurgeryCatharina HospitalEindhovenThe Netherlands
  2. 2.Pathology and Tumour BiologyLeeds Institute of Molecular Medicine, University of LeedsLeedsUK
  3. 3.Pathology and Medical Microbiology InstitutePAMM EindhovenEindhovenThe Netherlands
  4. 4.Department of RadiotherapyCatharina HospitalEindhovenThe Netherlands
  5. 5.Department of ResearchComprehensive Cancer Centre SouthEindhovenThe Netherlands
  6. 6.Department of SurgeryLeiden University Medical CenterLeidenThe Netherlands
  7. 7.Department of PathologyRadboud University Medical CenterNijmegenThe Netherlands

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