Abdominoperineal resection: Is extralevator approach better?

Sameer Kadam, MS, MRCS, Pankaj Gandhi, FRCS, William Garrett, FRCS, Peter Webb, FRCS, Henk Wegstapel, FRCS

Medway Maritime Hospital, Kent, United Kingdom

Introduction: Abdominoperineal resection (APR) with total mesorectal excision (TME) is considered the gold standard treatment for low rectal cancers where the sphincter cannot be preserved. Recent evidence suggests that an extralevator (ELAPR) approach significantly reduces the rate of local recurrence. Our experience with conventional APR at Medway Maritime Hospital is similar if not better than current published evidence. We aim to prove that adequate resection margins and low rates of local recurrence can be achieved with the conventional approach for APR’s

Methods and Procedures: A retrospective review of all patients undergoing APR (laparoscopic and open) at Medway Maritime Hospital from October 2001 to October 2011 was performed. Data was collected by interrogating the hospital computer system for radiological images, histopathology, and discharge notifications. Patient case notes were reviewed for the operation record. Notes were missing for 3 patients. All 4 consultant surgeons (3 laparoscopic) used the conventional TME technique rather than ELAPR.

Results: Over the last decade, 104 patients underwent APR for low rectal cancer; 59 laparoscopic and 45 open (6 lap converted to open). There were 5 (4.8%) intra-operative perforations (IOP) although only 2 were proven on histology. 5 (4.8%) patients had circumferential resection margin (CRM) involvement. The local recurrence rate was 10.5% (11/104) [3.8% (2/52) in the last 5 years]. For the laparoscopic APR subgroup, the local recurrence rate was 5% (3/59) with no recurrences in the last 5 years indicating an improvement in local recurrence rates with experience. 70 (67%) patients received neoadjuvant chemoradiotherapy prior to surgery. 28 (27%) patients developed perineal wound complications. The median length of hospital stay was 10 days (Range: 3 – 124 days). No patient died within 30 days of the procedure. The median survival was 43 months (Range: 3 – 133 months). The 1, 3, 5 and 10 year survival rates were 95.2%, 80.7%, 56.9% and 33.4 % respectively. These survival, IOP, CRM and local recurrence rates are better than most recent published literature.

Conclusion: Conventional approach for APR is a safe and effective treatment option for low rectal cancers; especially in patients receiving preoperative neoadjuvant chemoradiotherapy. A low IOP, CRM involvement and local recurrence rate can be achieved in high volume centres with experienced specialist colorectal surgeons. Our experience, however, may question the benefit of the extralevator approach.

Session: Poster Presentation

Program Number: P105