Skip to main content
SpringerLink
Log in

Oncological superiority of extralevator abdominoperineal resection over conventional abdominoperineal resection: a meta-analysis

  • Original Article
  • Published:
International Journal of Colorectal Disease Aims and scope Submit manuscript

Abstracts

Purpose

The oncological superiority, i.e., lower circumferential resection margin (CRM) involvement, lower intraoperative perforation (IOP), and local recurrence (LR) rates, of extralevator abdominoperineal resection (EAPR) over conventional abdominoperineal resection (APR) for rectal cancer is inconclusive. This meta-analysis systematically compared the rates of CRM involvement, IOP, and LR of rectal cancer patients treated by EAPR and APR, respectively.

Methods

An electronic literature search of MEDLINE, EMBASE, and Cochrane Library through May 2013 was performed by two investigators independently to identify studies evaluating the CRM involvement, IOP, and LR rates of EAPR and APR, and search results were cross-checked to reach a consensus. Data was extracted accordingly. A Mantel–Haenszel random effects model was used to calculate the odds ratio (OR) with 95 % confidence intervals (95 % CI).

Results

Six studies with a total of 881 patients were included. Meta-analysis of CRM involvement and IOP data from all six studies demonstrated significant lower CRM involvement (OR, 0.36; 95%CI, 0.23–0.58; P < 0.0001) and IOP (OR, 0.31; 95%CI, 0.12–0.80; P = 0.02) rates of EAPR. Data from four studies also showed that EAPR was associated with a lower LR rate than APR (OR, 0.27; 95%CI, 0.08–0.95; P = 0.04). No differences of between-study heterogeneity or publication bias were seen in any of the meta-analyses.

Conclusions

Extralevator abdominoperineal resection could achieve better CRM involvement outcome and lower IOP and LR rates, demonstrating an oncological superiority over conventional abdominoperineal resection.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

References

  1. Graham JS, Cassidy J (2012) Adjuvant therapy in colon cancer. Expert Rev Anticancer Ther 12(1):99–109

    Article  CAS  PubMed  Google Scholar 

  2. Rajput A, Bullard Dunn K (2007) Surgical management of rectal cancer. Semin Oncol 34(3):241–249

    Article  PubMed  Google Scholar 

  3. Kim NK, Kim MS, Al-Asari SF (2012) Update and debate issues in surgical treatment of middle and low rectal cancer. J Korean Soc Coloproctol 28(5):230–240

    Article  PubMed Central  PubMed  Google Scholar 

  4. Heald RJ, Husband EM, Ryall RD (1982) The mesorectum in rectal cancer surgery—the clue to pelvic recurrence? Br J Surg 69(10):613–616

    Article  CAS  PubMed  Google Scholar 

  5. Heald RJ, Moran BJ, Ryall RD, Sexton R, MacFarlane JK (1998) Rectal cancer: the Basingstoke experience of total mesorectal excision, 1978–1997. Arch Surg Aug 133(8):894–899

    CAS  Google Scholar 

  6. Martijn H, Voogd AC, van de Poll-Franse LV, Repelaer van Driel OJ, Rutten HJT, Coebergh JWW (2003) Improved survival of patients with rectal cancer since 1980: a population-based study. Eur J Cancer 39(14):2073–2079

    Article  CAS  PubMed  Google Scholar 

  7. Kapiteijn E, Putter H, van de Velde CJ; Cooperative investigators of the Dutch ColoRectal Cancer Group (2002) Impact of the introduction and training of total mesorectal excision on recurrence and survival in rectal cancer in The Netherlands. Br J Surg 89(9):1142–1149

    Article  Google Scholar 

  8. Visser O, Bakx R, Zoetmulder FA, Levering CC, Meijer S, Slors JF, van Lanschot JJ (2007) The influence of total mesorectal excision on local recurrence and survival in rectal cancer patients: a population-based study in Greater Amsterdam. J Surg Oncol 95(6):447–454

    Article  CAS  PubMed  Google Scholar 

  9. den Dulk M, Putter H, Collette L, Marijnen CA, Folkesson J, Bosset JF, Rodel C, Bujko K, Pahlman 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 randomised clinical trials on rectal cancer. Eur J Cancer 45(7):1175–1183

    Article  Google Scholar 

  10. Wibe A, Syse A, Andersen E, Tretli S, Myrvold HE, Soreide O, Norwegian Rectal Cancer G (2004) Oncological outcomes after total mesorectal excision for cure for cancer of the lower rectum: anterior vs. abdominoperineal resection. Dis Colon Rectum 47(1):48–58

    Article  PubMed  Google Scholar 

  11. Law WL, Chu KW (2004) Abdominoperineal resection is associated with poor oncological outcome. Br J Surg 91(11):1493–1499

    Article  CAS  PubMed  Google Scholar 

  12. Chuwa EW, Seow-Choen F (2006) Outcomes for abdominoperineal resections are not worse than those of anterior resections. Dis Colon Rectum 49(1):41–49

    Article  PubMed  Google Scholar 

  13. Shihab OC, Brown G, Daniels IR, Heald RJ, Quirke P, Moran BJ (2010) 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 53(1):53–56

    Article  PubMed  Google Scholar 

  14. Salerno G, Chandler I, Wotherspoon A, Thomas K, Moran B, Brown G (2008) Sites of surgical wasting in the abdominoperineal specimen. Br J Surg 95(9):1147–1154

    Article  CAS  PubMed  Google Scholar 

  15. Kusters M, Beets GL, van de Velde CJ, Beets-Tan RG, Marijnen CA, Rutten HJ, Putter H, Moriya Y (2009) A comparison between the treatment of low rectal cancer in Japan and The Netherlands, focusing on the patterns of local recurrence. Ann Surg 249(2):229–235

    Article  PubMed  Google Scholar 

  16. Nagtegaal ID, van de Velde CJ, Marijnen CA, van Krieken JH, Quirke P, Dutch Colorectal Cancer G, Pathology Review C (2005) Low rectal cancer: a call for a change of approach in abdominoperineal resection. J Clin Oncol : Off J Am Soc Clin Oncol 23(36):9257–9264

    Article  Google Scholar 

  17. Holm T, Ljung A, Haggmark 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(2):232–238

    Article  CAS  PubMed  Google Scholar 

  18. West NP, Finan PJ, Anderin C, Lindholm J, Holm T, Quirke P (2008) Evidence of the oncologic superiority of cylindrical abdominoperineal excision for low rectal cancer. J Clin Oncol : Off J Am Soc Clin Oncol 26(21):3517–3522

    Article  Google Scholar 

  19. Vaughan-Shaw PG, King AT, Cheung T, Beck NE, Knight JS, Nichols PH, Nugent KP, Pilkington SA, Smallwood JA, Mirnezami AH (2011) Early experience with laparoscopic extralevator abdominoperineal excision within an enhanced recovery setting: analysis of short-term outcomes and quality of life. Ann Roy Coll Surg Engl 93(6):451–459

    Article  CAS  Google Scholar 

  20. Welsch T, Mategakis V, Contin P, Kulu Y, Buchler MW, Ulrich A (2013) Results of extralevator abdominoperineal resection for low rectal cancer including quality of life and long-term wound complications. Intl J Colorectal Dis 28(4):503–510

    Article  Google Scholar 

  21. Kennelly RP, Rogers AC, Winter DC, Abdominoperineal Excision Study G (2013) Multicentre study of circumferential margin positivity and outcomes following abdominoperineal excision for rectal cancer. Br J Surg 100(1):160–166

    Article  Google Scholar 

  22. 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(7):793–802

    Article  PubMed  Google Scholar 

  23. Asplund D, Haglind E, Angenete E (2012) Outcome of extralevator abdominoperineal excision compared with standard surgery: results from a single centre. Colorectal Dis : Off J Assoc Coloproctol G B Irel 14(10):1191–1196

    Article  CAS  Google Scholar 

  24. Hiranyakas A, da Silva G, Wexner SD, Ho YH, Allende D, Berho M (2013) Factors influencing circumferential resection margin in rectal cancer. Colorectal Dis : Off J Assoc Coloproctol G B Irel 15(3):298–303

    Article  CAS  Google Scholar 

  25. Moher D, Liberati A, Tetzlaff J, Altman DG, Group P (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. J Clin Epidemiol 62(10):1006–1012

    Article  Google Scholar 

  26. 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(3):274–282

    Article  PubMed  Google Scholar 

  27. 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(3):786–793

    Article  PubMed  Google Scholar 

  28. Stelzner S, Hellmich G, Schubert C, Puffer E, Haroske G, Witzigmann H (2011) Short-term outcome of extra-levator abdominoperineal excision for rectal cancer. Intl J Colorectal Dis 26(7):919–925

    Article  Google Scholar 

  29. Vaughan-Shaw PG, Cheung T, Knight JS, Nichols PH, Pilkington SA, Mirnezami AH (2012) 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. Techn Coloproctol 16(5):355–362

    Article  CAS  Google Scholar 

  30. West NP, Anderin C, Smith KJ, Holm T, Quirke P, European Extralevator Abdominoperineal Excision Study G (2010) Multicentre experience with extralevator abdominoperineal excision for low rectal cancer. Br J Surg 97(4):588–599

    Article  Google Scholar 

  31. Janjan NA, Khoo VS, Abbruzzese J, Pazdur R, Dubrow R, Cleary KR, Allen PK, Lynch PM, Glober G, Wolff R, Rich TA, Skibber J (1999) Tumor downstaging and sphincter preservation with preoperative chemoradiation in locally advanced rectal cancer: the M. D. Anderson Cancer Center experience. Int J Radiat Oncol Biol Phys 44(5):1027–1038

    Article  CAS  PubMed  Google Scholar 

  32. Maas M, Nelemans PJ, Valentini V, Das P, Rödel C, Kuo LJ, Calvo FA, García-Aguilar J, Glynne-Jones R, Haustermans K, Mohiuddin M, Pucciarelli S, Small W Jr, Suárez J, Theodoropoulos G, Biondo S, Beets-Tan RG, Beets GL (2010) Long-term outcome in patients with a pathological complete response after chemoradiation for rectal cancer: a pooled analysis of individual patient data. Lancet Oncol 11(9):835–844

    Article  PubMed  Google Scholar 

  33. Stelzner S, Koehler C, Stelzer J, Sims A, Witzigmann H (2011) Extended abdominoperineal excision vs. standard abdominoperineal excision in rectal cancer—a systematic overview. Intl J Colorectal Dis 26(10):1227–1240

    Article  Google Scholar 

  34. Tekkis PP, Heriot AG, Smith J, Thompson MR, Finan P, Stamatakis JD; Association of Coloproctology of Great Britain and Ireland (2005) Comparison of circumferential margin involvement between restorative and nonrestorative resections for rectal cancer. Colorectal Dis 7(4):369–374

    Article  Google Scholar 

  35. Wittekind C, Compton C, Quirke P, Nagtegaal I, Merkel S, Hermanek P, Sobin LH (2009) A uniform residual tumor (R) classification: integration of the R classification and the circumferential margin status. Cancer 115(15):3483–3488

    Article  PubMed  Google Scholar 

  36. García-Aguilar J, Hernandez de Anda E, Sirivongs P, Lee SH, Madoff RD, Rothenberger DA (2003) A pathologic complete response to preoperative chemoradiation is associated with lower local recurrence and improved survival in rectal cancer patients treated by mesorectal excision. Dis Colon Rectum 46(3):298–304

    Article  PubMed  Google Scholar 

Download references

Conflict of interest

The authors declare that they have no conflicts of interest.

Author information

Authors and Affiliations

  1. Department of Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197, Ruijin 2nd Rd, Shanghai, 20002, People’s Republic of China

    Ao Huang, Hongchao Zhao, Tianlong Ling, Yingjun Quan, Minhua Zheng & Bo Feng

  2. Shanghai Institute of Digestive Surgery, Shanghai, China

    Ao Huang, Hongchao Zhao, Yingjun Quan, Minhua Zheng & Bo Feng

  3. Shanghai Minimally Invasive Surgery Center, Shanghai, China

    Ao Huang, Hongchao Zhao, Tianlong Ling, Yingjun Quan, Minhua Zheng & Bo Feng

  4. Department of Surgery, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China

    Tianlong Ling

Authors
  1. Ao Huang
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Hongchao Zhao
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Tianlong Ling
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Yingjun Quan
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Minhua Zheng
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Bo Feng
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding authors

Correspondence to Minhua Zheng or Bo Feng.

Additional information

Ao Huang and Hongchao Zhao are co-first authors

Rights and permissions

Reprints and permissions

About this article

Cite this article

Huang, A., Zhao, H., Ling, T. et al. Oncological superiority of extralevator abdominoperineal resection over conventional abdominoperineal resection: a meta-analysis. Int J Colorectal Dis 29, 321–327 (2014). https://doi.org/10.1007/s00384-013-1794-6

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00384-013-1794-6

Keywords

Search

Navigation