Annals of Surgical Oncology

, Volume 22, Issue 9, pp 2997–3006 | Cite as

Standard Versus Extralevator Abdominoperineal Low Rectal Cancer Excision Outcomes: A Systematic Review and Meta-analysis

  • Paola De Nardi
  • Valeria Summo
  • Andrea Vignali
  • Giovanni Capretti
Colorectal Cancer


The extended, extralevator abdominoperineal excision has been described with the aim of improving oncological low rectal cancer patient outcomes.

Materials and Methods

A systematic literature review was conducted using Medline/PubMed, Embase, Cochrane library, and Ovid for standard and extralevator abdominoperineal rectal cancer excision studies between 1995 and 2013. A total of 1,270 articles were identified and screened, and of these, 58 reports (1 randomized, 5 case–control and 52 cohort studies) were included for the qualitative analysis, and 6 were included for the quantitative analysis. The primary endpoints included intraoperative tumor perforation, the circumferential resection margin involvement, local recurrence rate, and the perineal wound complication rate. The secondary endpoints included the length of postoperative hospital stay and quality of life. Comprehensive Rev Men, version 5.2 was used for the statistical calculations.


A significant difference in the circumferential resection margin involvement rate [odds ratio (OR) 2.9; p < .001], intraoperative perforation (OR 4.30; p < .001), local recurrence rate (OR 2.52; p = .02), and length of hospital stay (OR 1.06; p < .001) in favor of the extended group was observed. Additionally, the perineal wound complications were higher in the extended group (OR 0.62; p = .007). No difference in quality of life was observed.


Our analysis confirms the oncological advantages of the extended abdominoperineal excision method. Although the perineal wound complications were higher, the length of postoperative hospital stay was shorter, and quality of life was not inferior to the conventional resection method.


Total Mesorectal Excision Circumferential Resection Margin Circumferential Resection Margin Involvement Perineal Wound Complication Perineal Wind Complication 
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.



The Authors have no commercial interest and have no financial support for the present study.


  1. 1.
    Heald RJ, Husband EM, Ryall RD. The mesorectum in rectal cancer surgery—the clue to pelvic recurrence? Br J Surg. 1982;69:613–6.PubMedCrossRefGoogle Scholar
  2. 2.
    Elferink MA, van Steenbergen LN, Krijnen P, et al.; Working Group Output of the Netherlands Cancer Registry. Marked improvements in survival of patients with rectal cancer in the Netherlands following changes in therapy, 1989–2006. Eur J Cancer. 2010;46:1421–9.PubMedCrossRefGoogle Scholar
  3. 3.
    Nagtegaal ID, van de Velde CJ, Marijnen CA, van Krieken JH, Quirke P; Dutch Colorectal Cancer Group; Pathology Review Committee. Low rectal cancer: a call for a change of approach in abdominoperineal resection. J Clin Oncol. 2005;23:9257–64.PubMedCrossRefGoogle Scholar
  4. 4.
    den Dulk M, Marijnen CA, Putter H, et al. Risk factors for adverse outcome in patients with rectal cancer treated with an abdominoperineal resection in the total mesorectal excision trial. Ann Surg. 2007;246:83–90.CrossRefGoogle Scholar
  5. 5.
    den Dulk M, Putter H, Collette L, Marijnen CA, Folkesson J, Bosset JF, et al. The abdominoperineal resection itself is associated with an adverse outcome: the European experience based on a pooled analysis of five European randomised clinical trials on rectal cancer. Eur J Cancer. 2009;45:1175–83.CrossRefGoogle Scholar
  6. 6.
    Krishna A, Rickard MJ, Keshava A, Dent OF, Chapuis PH. 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. 2013;15:57–65.PubMedCrossRefGoogle Scholar
  7. 7.
    Eriksen MT, Wibe A, Syse A, Haffner J, Wiig JN; Norwegian Rectal Cancer Group; Norwegian Gastrointestinal Cancer Group. Inadvertent perforation during rectal cancer resection in Norway. Br J Surg. 2004;91:210–6.PubMedCrossRefGoogle Scholar
  8. 8.
    Stelzner S, Koehler C, Stelzer J, Sims A, Witzigmann H. Extended abdominoperineal excision vs. standard abdominoperineal excision in rectal cancer—a systematic overview. Int J Colorectal Dis. 2011;26:1227–40.PubMedCrossRefGoogle Scholar
  9. 9.
    Holm T, Ljung A, Haggmark T, Jurell G, Lagergren J. Extended abdominoperineal resection with gluteus maximus flap reconstruction of the pelvic floor for rectal cancer. Br J Surg. 2007;94:232–8.PubMedCrossRefGoogle Scholar
  10. 10.
    Miles WE. A method of performing abdominoperineal excision for carcinoma of the rectum and of the terminal portion of the pelvic colon. Lancet. 1908;2:1812–3.CrossRefGoogle Scholar
  11. 11.
    Higgins JP, Green S. Cochrane handbook for systematic reviews of interventions. Version 5.1.0 [updated March 2011]. The Cochrane Collaboration; 2011.Google Scholar
  12. 12.
    Stelzner S, Hellmich G, Schubert C, Puffer E, Haroske G, Witzigmann H. Short term outcome of extra-levator abdominoperineal excision for rectal cancer. Int J Colorectal Dis. 2011;26:919–25.PubMedCrossRefGoogle Scholar
  13. 13.
    Asplund D, Haglind E, Angenete E. Outcome of extralevator abdominoperineal excision compared with standard surgery: results from a single centre. Colorectal Dis. 2012;14:1191–6.PubMedCrossRefGoogle Scholar
  14. 14.
    Han JG, Wang ZJ, Wei GH, Gao ZG, Yang Y, Zhao BC. Randomized clinical trial of conventional versus cylindrical abdominoperineal resection for locally advanced lower rectal cancer. Am J Surg. 2012;204:274–82.PubMedCrossRefGoogle Scholar
  15. 15.
    Vaughan Shaw PG, Cheung T, Knight JS, Nichols PH, Pilkington SA, Mirnezami AH. A prospective case–control study of extralevator abdominoperineal excision (ELAPE) of the rectum versus conventional laparoscopic and open abdominoperineal excision: comparative analysis of short-term outcomes and quality of life. Tech Coloproctol. 2012;16:355–62.PubMedCrossRefGoogle Scholar
  16. 16.
    West NP, Anderin C, Smith KJE, Holm T, Quirke P; European Extralevator Abdominoperineal Excision Study Group. Multicentre experience with extralevator abdominoperineal excision for low rectal cancer. Br J Surg. 2010;97:588–99.PubMedCrossRefGoogle Scholar
  17. 17.
    West NP, Finan PJ, Anderin C, Lindholm J, Holm T, Quirke P. Evidence of the oncologic superiority of cylindrical abdominoperineal excision for low rectal cancer. J Clin Oncol. 2008;26:3517–22.PubMedCrossRefGoogle Scholar
  18. 18.
    Dalton RS, Smart NJ, Edwards TJ, Chandler I, Daniels IR. Short-term outcomes of the prone perineal approach for extra-levator abdomino-perineal excision (elAPE). Surgeon. 2012;10:342–6.PubMedCrossRefGoogle Scholar
  19. 19.
    MERCURY Study group. Diagnostic accuracy of preoperative magnetic resonance imaging in predicting curative resection of rectal cancer: prospective observational study. BMJ. 2006;333:779.PubMedCentralCrossRefGoogle Scholar
  20. 20.
    Guillou PJ, Quirke P, Thorpe H, et al.; MRC CLASICC trial group. Short term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASSIC trial): multicentre, randomized controlled trial. Lancet. 2005;365:1718–26.PubMedCrossRefGoogle Scholar
  21. 21.
    Huang A, Zhao H, Tianlong Ling T, Quan Y, Zheng M, Feng B. Oncological superiority of extralevator abdominoperineal resection over conventional abdominoperineal resection: a meta-analysis. Int J Colorectal Dis. 2014;29:321–7.PubMedCrossRefGoogle Scholar
  22. 22.
    Yu HC, Peng H, He XS, Zhao RS. 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. 2014;29:183–91.PubMedCrossRefGoogle Scholar
  23. 23.
    Anderin C, Martling A, Hellborg BA, Holm T. A population based study on outcome in relation to the type of resection in low rectal cancer. Dis Colon Rectum. 2010;53:753–60.PubMedCrossRefGoogle Scholar
  24. 24.
    Tayyab M, Sharma A, Ragg J, Macdonald AW, Gunn J, Hartley JE, et al. Evaluation of the impact of implementing the prone jacknife position for the perineal phase of abdominoperineal excision of the rectum. Dis Colon Rectum. 2012;55:316–21.PubMedCrossRefGoogle Scholar
  25. 25.
    de Campos-Lobato L, Stocchi L, Dietz DW, Lavery IC, Fazio VW, Kalady MF. Prone or lithotomy positioning during an abdominoperineal resection for rectal cancer results in comparable oncologic outcomes. Dis Colon Rectum. 2011;54:939–46.PubMedCrossRefGoogle Scholar
  26. 26.
    Peeters KC, Marijnen CA, Nagtegaal ID, et al.; Dutch Colorectal Cancer Group. The TME trial after a median follow-up of 6 years: increased local control but no survival benefit in irradiated patients with resectable rectal carcinoma. Ann Surg. 2007;246:693–701.PubMedCrossRefGoogle Scholar
  27. 27.
    Martijnse IS, Dudink RL, West NP, et al. 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. 2012;19:786–93.PubMedCrossRefGoogle Scholar
  28. 28.
    Bullard KM, Trudel JL, Baxter NN, Rothenberger DA. Primary perineal wound closure after preoperative radiotherapy and abdominoperineal resection has a high incidence of wound failure. Dis Colon Rectum. 2005;48:438–43.PubMedCrossRefGoogle Scholar
  29. 29.
    Chadwick MA, Vieten D, Pettitt E, Dixon AR, Roe AM. Short course preoperative radiotherapy is the single most important risk factor for perineal wound complications after abdominoperineal excision of the rectum. Colorectal Dis. 2006;8:756–61.PubMedCrossRefGoogle Scholar
  30. 30.
    Nisar PJ, Scott HJ. Myocutaneous flap reconstruction of the pelvis after abdominoperineal excision. Colorectal Dis. 2009;11:806–16.PubMedCrossRefGoogle Scholar
  31. 31.
    Chan S, Miller M, Ross D, Roblin P, Carapeti E, Williams AB, et al. Use of myocutaneous flaps for perineal closure following abdominoperineal excision of the rectum for adenocarcinoma. Colorectal Dis. 2010;12:555–60.PubMedCrossRefGoogle Scholar
  32. 32.
    Stelzner S, Holm T, Moran B, Heald RJ, Witzigmann H, Zorenkov D, et al. Deep pelvic anatomy revisited for a description of crucial steps in extralevator abdominoperineal excision for rectal cancer. Dis Colon Rectum. 2011;54:947–57.PubMedCrossRefGoogle Scholar
  33. 33.
    Baker RP, White EE, Titu L, Duthie GS, Lee PW, Monson JR. Does laparoscopic abdominoperineal resection of the rectum compromise long term survival? Dis Colon Rectum. 2002;45:1481–5.PubMedCrossRefGoogle Scholar
  34. 34.
    Scheidbach H, Schneider C, Konradt J, Bärlehner E, Köhler L, Wittekind CH, et al. Laparoscopic abdominoperineal resection and anterior resection with curative intent for carcinoma of the rectum. Surg Endosc. 2002;16:7–13.PubMedCrossRefGoogle Scholar
  35. 35.
    Wibe A, Syse A, Andersen E, Tretli S, Myrvold HE, Søreide O; Norwegian Rectal Cancer Group. Oncological outcomes after total mesorectal excision for cure for the lower rectum: anterior vs abdomino-perineal resection. Dis Colon Rectum. 2004;47:48–58.PubMedCrossRefGoogle Scholar
  36. 36.
    Marr R, Birbeck K, Garvican J, et al. The modern abdominoperineal excision: the next challenge after total mesorectal excision. Ann Surg. 2005;242:74–82.PubMedCentralPubMedCrossRefGoogle Scholar
  37. 37.
    Tekkis PP, Heriot AG, Smith J, Thompson MR, Finan P, Stamatakis JD; Association of Coloproctology of Great Britain and Ireland. Comparison of circumferential margin involvement between restorative and non restorative resections for rectal cancer. Colorectal Dis. 2005;7:369–74.PubMedCrossRefGoogle Scholar
  38. 38.
    Ptok H, Marusch F, Kuhn R, Gastinger I, Lippert H. Influence of hospital volume on the frequency of abdominoperineal resection and long-term oncological outcomes in low rectal cancer. Eur J Surg Oncol. 2007;33:854–61.PubMedCrossRefGoogle Scholar
  39. 39.
    Strassburg J, Junginger T, Trinh T, Püttcher O, Oberholzer K, Heald RJ, et al. Magnetic resonance imaging (MRI)-based indication for neoadjuvant treatment of rectal carcinoma and the surrogate CRM status. Int J Colorectal Dis. 2008;23:1099–107.PubMedCrossRefGoogle Scholar
  40. 40.
    Sideris L, Zenasni F, Vernerey D, et al. Quality of life of patients operated on for low rectal cancer: impact on the type of surgery and patients’ characteristics. Dis Colon Rectum. 2005;48:2180–91.Google Scholar
  41. 41.
    Chambers W, Khan A, Waters R, Lindsey I, George B, Mortensen N, et al. Examination of outcome following abdominoperineal resection for adenocarcinoma in Oxford. Colorectal Dis. 2010;12:1192–7.PubMedCrossRefGoogle Scholar
  42. 42.
    Kim JS, Hur H, Kim NK, et al. Oncologic outcomes after radical surgery following preoperative chemoradiotherapy for locally advanced lower rectal cancer: abdominoperineal resection versus sphincter-preserving procedure. Ann Surg Oncol. 2009;16:1266–73.PubMedCrossRefGoogle Scholar
  43. 43.
    Shihab OC, Brown G, Daniels IR, Heald RJ, Quirke P, Moran BJ. Patients with low rectal cancer treated by abdominoperineal excision have worse tumors and higher involved margin rates compared with patients treated by anterior resection. Dis Colon Rectum. 2010;53:53–6.PubMedCrossRefGoogle Scholar
  44. 44.
    Smedh K, Khani MH, Kraaz W, Raab Y, Strand E. Abdominoperineal excision with partial anterior en bloc resection in multimodal management of low rectal cancer: a strategy to reduce local recurrence. Dis Colon Rectum. 2006;49:833–40.PubMedCrossRefGoogle Scholar
  45. 45.
    Bebenek M. Abdominosacral amputation of the rectum for low rectal cancers: ten years of experience. Ann Surg Oncol. 2009;16:2211–7.PubMedCrossRefGoogle Scholar
  46. 46.
    Davies M, Harries D, Hirst G, Beynon R, Morgan AR, Carr ND, et al. Local recurrence after abdominoperineal resection. Colorectal Dis. 2009;11:39–43.PubMedCrossRefGoogle Scholar
  47. 47.
    Han JG, Wang ZJ, Gao ZG, Xu HM, Yang ZH, Jin ML. Pelvic floor reconstruction using human acellular dermal matrix after cylindrical abdominoperineal resection. Dis Colon Rectum. 2010;53:219–23.PubMedCrossRefGoogle Scholar
  48. 48.
    Welsch T, Mategakis V, Contin P, Kulu Y, Büchler MW, Ulrich A. Results of extralevator abdominoperineal resection for low rectal cancer including quality of life and long term wound complications. Int J Colorectal Dis. 2013;28:503–10.PubMedCrossRefGoogle Scholar
  49. 49.
    Law WL, Chu KW. Abdominoperineal resection is associated with poor oncologic outcome. Br J Surg. 2004;91:1493–9.PubMedCrossRefGoogle Scholar
  50. 50.
    Chuwa EW, Seow-Choen F. Outcomes for abdominoperineal resections are not worse than those of anterior resection. Dis Colon Rectum. 2006;49:41–9.PubMedCrossRefGoogle Scholar
  51. 51.
    Ferenschild FT, Dawson I, de Wilt JH, de Graaf EJ, Groenendijk RP, Tetteroo GW. Total mesorectal excision for rectal cancer in an unselected population: quality assessment in a low volume center. Int J Colorectal Dis. 2009;24:923–9.PubMedCentralPubMedCrossRefGoogle Scholar
  52. 52.
    Hermanek P, Merkel S, Fietkau R, Rödel C, Hohenberger W. Regional lymph node metastasis and locoregional recurrence of rectal carcinoma in the era of TME surgery. Int J Colorectal Dis. 2010;25:359–68.PubMedCrossRefGoogle Scholar
  53. 53.
    Kneist W, Heintz A, Wolf HK, Junginger T. Total excision of the mesorectum in cancer of the lower and middle rectum. Oncological and functional results. Chirurg. 2003;74:125–31.PubMedGoogle Scholar
  54. 54.
    Lee SH, Hernandez de Anda E, Finne CO, Madoff RD, Garcia-Aguilar J. The effect of circumferential tumor location in clinical outcomes of rectal cancer patients treated with total mesorectal excision. Dis Colon Rectum. 2005;48:2249–57.PubMedCrossRefGoogle Scholar
  55. 55.
    Chiappa A, Biffi R, Bertani E, et al. Surgical outcomes after total mesorectal excision for rectal cancer. J Surg Oncol. 2006;94:182–93.PubMedCrossRefGoogle Scholar
  56. 56.
    Kusters M, Marijnen CA, van de Velde CJ, et al. Patterns of local recurrence in rectal cancer: a study of Dutch TME trial. Eur J Surg Oncol. 2010;36:470–6.PubMedCrossRefGoogle Scholar
  57. 57.
    Nissan A, Guillem JG, Paty PB, Douglas Wong W, Minsky B, Saltz L, et al. Abdominoperineal resection for low rectal cancer at a specialty center. Dis Colon Rectum. 2001;44:27–35.PubMedCrossRefGoogle Scholar
  58. 58.
    Dehni N, McFadden N, McNamara DA, Guiguet M, Tiret E, Parc R. Oncologic results following abdominoperineal resection for adenocarcinoma of the low rectum. Dis Colon Rectum. 2003;46:867–74.PubMedCrossRefGoogle Scholar
  59. 59.
    Okaro AC, Worthington T, Stebbing JF, Broughton M, Caffarey S, Marks CG. Curative resection for low rectal adenocarcinoma: abdominoperineal vs. anterior resection. Colorectal Dis. 2006;8:645–9.PubMedCrossRefGoogle Scholar
  60. 60.
    Silberfein EJ, Kattepogu KM, Hu CY, et al. Long term survival and recurrence outcomes following surgery for distal rectal cancer. Ann Surg Oncol. 2010;17:2863–9.PubMedCentralPubMedCrossRefGoogle Scholar
  61. 61.
    Allal AS, Bieri S, Pelloni A, et al. Sphincter sparing surgery after preoperative radiotherapy for low rectal cancer: feasibility, oncologic results and quality of life outcomes. Br J Cancer. 2000;82:1131–7.PubMedCentralPubMedCrossRefGoogle Scholar
  62. 62.
    Grumann MM, Noack EM, Hoffmann IA, Schlag PM. Comparison of quality of life in patients undergoing abdominoperineal extirpation or anterior resection for rectal cancer. Ann Surg. 2001;233:149–56.PubMedCentralPubMedCrossRefGoogle Scholar
  63. 63.
    Camilleri-Brennan J, Steele RJ. Objective assessment of morbidity and quality of life after surgery for low rectal cancer. Colorectal Dis. 2002;4:61–6.PubMedCrossRefGoogle Scholar
  64. 64.
    Gosselink MP, Busschbach JJ, Dijkhuis CM, Stassen LP, Hop WC, Schouten WR. Quality of life after total mesorectal excision for rectal cancer. Colorectal Dis. 2006;8:15–22.PubMedCrossRefGoogle Scholar
  65. 65.
    Schmidt CE, Bestmann B, Küchler T, Longo WE, Kremer B. Prospective evaluation of quality of life of patients receiving either abdominoperineal resection or sphincter-preserving procedure for rectal cancer. Ann Surg Oncol. 2005;12:117–23.PubMedCrossRefGoogle Scholar

Copyright information

© Society of Surgical Oncology 2015

Authors and Affiliations

  • Paola De Nardi
    • 1
  • Valeria Summo
    • 1
  • Andrea Vignali
    • 1
  • Giovanni Capretti
    • 1
  1. 1.Department of SurgerySan Raffaele Scientific InstituteMilanItaly

Personalised recommendations