Extra levator versus Standard abdominoperineal excision for rectal cancer: Is there any oncological benefit?

D Kamali, A Musbahi, A Sharpe, A Reddy, Y Viswanath. James Cook University Hospital, Middlesbrough U.K.

Introduction:

There are conflicting reports about the superiority of extralevator abdominoperineal excision (ELAPE) over standard abdominoperineal excision (SAPE), with only one randomized controlled trial to date showing that ELAPE results in lower perforation rates and less circumferential resection margin (CRM) compared to SAPE. The primary aim of this study was to compare oncological and postoperative outcomes of patients with rectal cancer undergoing ELAPE with those having undergone SAPE.

Method:

Data were collected on all ELAPE and SAPE resections for rectal cancer at a major surgical unit between January 2009 to December 2014 using medical patient records, radiology, pathology and microbiology information. This included nature of surgery, pathological circumferential margin positivity (CRM), tumour perforation rates and postoperative complications. Categorical data was statistically analysed using fisher exact tests where appropriate. A P value of <0.05 was considered to be statistically significant.

Results:

A total of 45 patients (35 males) with a mean age of 67.4 years were included in the study. Six had received open ELAPE while 18 had laparoscopic procedure. There were 8 open SAPE and 13 laparoscopic procedures. Adjuvant treatment was delivered for CRM positivity on post-operative imaging in 7 SAPE and 13 ELAPE patients. Post-operative circumferential margin positivity was not significantly different between the two patient groups, with no CRM involvement in 91.3% in the ELAPE group and 100% in the SAPE group . There were no significant differences in either post-op collection rates (13% v 4.5%), or post-op bleeding between ELAPE and SAPE, respectively. Ten patients in ELAPE and 5 in SAPE had perineal wound breakdown. There were no reported cases of perineal herniation in either surgical group.  No patients suffered post-op DVT. Total recurrence rate was greater in SAPE patients compared to ELAPE patients (24% versus 17% respectively) although this did not reach statistical significance.

Conclusion:

There were low rates of CRM positivity in both groups of patients. ELAPE did not reduce the rate of CRM positivity. Local recurrence rates were lower in patients undergoing ELAPE however; this did not reach statistical significance. There was no significant difference in oncological or post-operative outcomes between SAPE and ELAPE resections at our unit. A larger trial with longer follow up is needed.

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