Skip to main content
SpringerLink
Log in

Extralevator versus standard abdominoperineal excision in locally advanced rectal cancer: a retrospective study with long-term follow-up

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

Abstract

Purpose

To analyze the results of abdominoperineal excisions (APE) for locally advanced rectal cancer at our institution before and after the adoption of extralevator abdominoperineal excision (ELAPE) with a special reference to long-term survival.

Methods

A retrospective cohort study conducted in a tertiary referral center. All consecutive patients operated for locally advanced (TNM classification T3–4) rectal cancer with APE in 2004–2009 were compared to patients with similar tumors operated with ELAPE in 2009–2016.

Results

Forty-two ELAPE and 27 APE patients were included. Circumferential resection margin (CRM) was less than 1 mm (R1-resection) in 10 (24%) of ELAPE patients and 11 (41%) of APE patients (p = 0.1358). Intraoperative perforation (IOP) occurred in 4 (10%) patients and 6 (22%) patients in ELAPE and APE groups, respectively (p = 0.1336). There were 3 (7%) local recurrences (LRs) in ELAPE group and 5 (19%) in APE (p = 0.2473). There were no statistical differences in adverse events, overall survival, or disease-free survival between ELAPE and APE groups.

Conclusions

We found a non-significant tendency to lower rates of IOP and positive CRM as well as lower rate of LR in the ELAPE group. Long-term survival and adverse events did not differ between the groups. ELAPE is beneficial for the surgeon in offering better vicinity to the perineal area and better work ergonomics. These technical aspects and the clinically very important tendency to lower rate of LR support the use of ELAPE technique in spite of the lack of survival benefit.

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

Similar content being viewed by others

References

  1. 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. https://doi.org/10.1002/bjs.5489

    Article  CAS  PubMed  Google Scholar 

  2. Miles WE (1908) A method of performing abdomino-perineal excision for carcinoma of the rectum and of the terminal portion of the pelvic colon. Lancet 2:1812–1813

    Article  Google Scholar 

  3. Eriksen MT, Wibe A, Syse A, Haffner J, Wiig JN, Norwegian Rectal Cancer G, Norwegian Gastrointestinal Cancer G (2004) Inadvertent perforation during rectal cancer resection in Norway. Br J Surg 91(2):210–216. https://doi.org/10.1002/bjs.4390

    Article  CAS  PubMed  Google Scholar 

  4. 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. https://doi.org/10.1007/s10350-003-0012-y

    Article  PubMed  Google Scholar 

  5. 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 23(36):9257–9264. https://doi.org/10.1200/JCO.2005.02.9231

    Article  PubMed  Google Scholar 

  6. Gravante G, Miah A, Mann CD, Stephenson JA, Gani MA, Sharpe D, Norwood M, Boyle K, Miller A, Hemingway D (2016) Circumferential resection margins and perineal complications after neoadjuvant long-course chemoradiotherapy followed by extralevator abdominoperineal excision of the rectum: five years of activity at a single institution. J Surg Oncol 114(1):86–90. https://doi.org/10.1002/jso.24257

    Article  PubMed  Google Scholar 

  7. Stelzner S, Hellmich G, Sims A, Kittner T, Puffer E, Zimmer J, Bleyl D, Witzigmann H (2016) Long-term outcome of extralevator abdominoperineal excision (ELAPE) for low rectal cancer. Int J Color Dis 31(10):1729–1737. https://doi.org/10.1007/s00384-016-2637-z

    Article  Google Scholar 

  8. Prytz M, Angenete E, Bock D, Haglind E (2016) Extralevator abdominoperineal excision for low rectal cancer—extensive surgery to be used with discretion based on 3-year local recurrence results: a registry-based, observational national cohort study. Ann Surg 263(3):516–521. https://doi.org/10.1097/SLA.0000000000001237

    Article  PubMed  PubMed Central  Google Scholar 

  9. Bianco F, Romano G, Tsarkov P, Stanojevic G, Shroyer K, Giuratrabocchetta S, Bergamaschi R, International Rectal Cancer Study G (2016) Extralevator with vertical rectus abdominis myocutaneous flap vs. non-extralevator abdominoperineal excision for rectal cancer: the RELAPe randomized controlled trial. Color Dis. https://doi.org/10.1111/codi.13436

  10. 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. https://doi.org/10.1016/j.amjsurg.2012.05.001

    Article  PubMed  Google Scholar 

  11. Perdawood SK, Lund T (2015) Extralevator versus standard abdominoperineal excision for rectal cancer. Tech Coloproctol 19(3):145–152. https://doi.org/10.1007/s10151-014-1243-8

    Article  CAS  PubMed  Google Scholar 

  12. 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(4):472–477. https://doi.org/10.1016/j.ejso.2015.01.017

    Article  CAS  PubMed  Google Scholar 

  13. 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 26(21):3517–3522. https://doi.org/10.1200/JCO.2007.14.5961

    Article  PubMed  Google Scholar 

  14. 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. https://doi.org/10.1002/bjs.6916

    Article  CAS  PubMed  Google Scholar 

  15. 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 Color Dis 26(7):919–925. https://doi.org/10.1007/s00384-011-1157-0

    Article  Google Scholar 

  16. Ortiz H, Ciga MA, Armendariz P, Kreisler E, Codina-Cazador A, Gomez-Barbadillo J, Garcia-Granero E, Roig JV, Biondo S, Spanish Rectal Cancer P (2014) Multicentre propensity score-matched analysis of conventional versus extended abdominoperineal excision for low rectal cancer. Br J Surg 101(7):874–882. https://doi.org/10.1002/bjs.9522

    Article  CAS  PubMed  Google Scholar 

  17. Prytz M, Angenete E, Ekelund J, Haglind E (2014) Extralevator abdominoperineal excision (ELAPE) for rectal cancer—short-term results from the Swedish Colorectal Cancer Registry. Selective use of ELAPE warranted. Int J Color Dis 29(8):981–987. https://doi.org/10.1007/s00384-014-1932-9

    Article  Google Scholar 

  18. Klein M, Fischer A, Rosenberg J, Gogenur I, Danish Colorectal Cancer G (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(5):933–938. https://doi.org/10.1097/SLA.0000000000000910

    Article  PubMed  Google Scholar 

  19. 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 Color Dis 26(10):1227–1240. https://doi.org/10.1007/s00384-011-1235-3

    Article  Google Scholar 

  20. 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 Color Dis 29(2):183–191. https://doi.org/10.1007/s00384-013-1793-7

    Article  Google Scholar 

  21. 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(9):2997–3006. https://doi.org/10.1245/s10434-015-4368-8

    Article  PubMed  Google Scholar 

  22. Negoi I, Hostiuc S, Paun S, Negoi RI, Beuran M (2016) Extralevator vs conventional abdominoperineal resection for rectal cancer—a systematic review and meta-analysis. Am J Surg 212(3):511–526. https://doi.org/10.1016/j.amjsurg.2016.02.022

    Article  PubMed  Google Scholar 

  23. Zhou X, Sun T, Xie H, Zhang Y, Zeng H, Fu W (2015) Extralevator abdominoperineal excision for low rectal cancer: a systematic review and meta-analysis of the short-term outcome. Color Dis 17(6):474–481. https://doi.org/10.1111/codi.12921

    Article  CAS  Google Scholar 

  24. Klein M, Colov E, Gogenur I (2016) Similar long-term overall and disease-free survival after conventional and extralevator abdominoperineal excision—a nationwide study. Int J Color Dis 31(7):1341–1347. https://doi.org/10.1007/s00384-016-2596-4

    Article  Google Scholar 

  25. Jensen KK, Rashid L, Pilsgaard B, Moller P, Wille-Jorgensen P (2014) Pelvic floor reconstruction with a biological mesh after extralevator abdominoperineal excision leads to few perineal hernias and acceptable wound complication rates with minor movement limitations: single-centre experience including clinical examination and interview. Colorectal Dis 16(3):192–197. https://doi.org/10.1111/codi.12492

    Article  CAS  PubMed  Google Scholar 

  26. 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. Color Dis 14(9):1052–1059. https://doi.org/10.1111/j.1463-1318.2012.03169.x

    Article  CAS  Google Scholar 

  27. 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. Tech Coloproctol 16(5):355–362. https://doi.org/10.1007/s10151-012-0851-4

    Article  CAS  PubMed  Google Scholar 

  28. National Institute for Health and Welfare. Specialised somatic health care. Care periods in 2014. Finnish official statistics. Available in Finnish and Swedish at https://www.thl.fi/fi/tilastot/tilastot-aiheittain/erikoissairaanhoidon-palvelut/somaattinen-erikoissairaanhoito. Accessed 21st of March 2017

  29. Glimelius B, Tiret E, Cervantes A, Arnold D (2013) Rectal cancer: ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Ann Oncol 24(Suppl 6):vi81–vi88. https://doi.org/10.1093/annonc/mdt240

    Article  PubMed  Google Scholar 

  30. Shihab OC, Heald RJ, Holm T, How PD, Brown G, Quirke P, Moran BJ (2012) A pictorial description of extralevator abdominoperineal excision for low rectal cancer. Color Dis 14(10):e655–e660. https://doi.org/10.1111/j.1463-1318.2012.03181.x

    Article  CAS  Google Scholar 

  31. Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240(2):205–213

    Article  PubMed  PubMed Central  Google Scholar 

  32. Baca B, Beart RW, Jr., Etzioni DA (2011) Surveillance after colorectal cancer resection: a systematic review. Dis Colon Rectum 54 (8):1036–1048. doi:https://doi.org/10.1007/DCR.0b013e31820db364

  33. Palmer G, Anderin C, Martling A, Holm T (2014) Local control and survival after extralevator abdominoperineal excision for locally advanced or low rectal cancer. Color Dis 16(7):527–532. https://doi.org/10.1111/codi.12610

    Article  CAS  Google Scholar 

  34. Asplund D, Haglind E, Angenete E (2012) Outcome of extralevator abdominoperineal excision compared with standard surgery: results from a single centre. Color Dis 14(10):1191–1196. https://doi.org/10.1111/j.1463-1318.2012.02930.x

    Article  CAS  Google Scholar 

  35. How P, West NP, Brown G (2014) An MRI-based assessment of standard and extralevator abdominoperineal excision specimens: time for a patient tailored approach? Ann Surg Oncol 21(3):822–828. https://doi.org/10.1245/s10434-013-3378-7

    Article  PubMed  Google Scholar 

  36. Holm T (2014) Controversies in abdominoperineal excision. Surg Oncol Clin N Am 23(1):93–111. https://doi.org/10.1016/j.soc.2013.09.005

    Article  PubMed  Google Scholar 

Download references

Funding

This study was supported by research grants from the TYKS Foundation, the Turunmaa Duodecim Society, and Turku University Hospital (EVO grant no. 13191).

Author information

Authors and Affiliations

  1. Department of Digestive Surgery and Urology, Turku University Hospital and University of Turku, Kiinanmyllynkatu 4-8, 20520, Turku, Finland

    Anu Carpelan, J. Karvonen, P. Varpe, A. Rantala, J. Grönroos & H. Huhtinen

  2. Biostatistics, Department of Clinical Medicine, University of Turku, Turku, Finland

    A. Kaljonen

Authors
  1. Anu Carpelan
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. J. Karvonen
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. P. Varpe
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. A. Rantala
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. A. Kaljonen
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. J. Grönroos
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. H. Huhtinen
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Anu Carpelan.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. For this type of study, formal consent is not required.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Carpelan, A., Karvonen, J., Varpe, P. et al. Extralevator versus standard abdominoperineal excision in locally advanced rectal cancer: a retrospective study with long-term follow-up. Int J Colorectal Dis 33, 375–381 (2018). https://doi.org/10.1007/s00384-018-2977-y

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00384-018-2977-y

Keywords

Search

Navigation