Abdominoperineal Excision: Technical Challenges in Optimal Surgical and Oncological Outcomes after Abdominoperineal Excision for Rectal Cancer

Abstract

Treatment results in rectal cancer have improved significantly during the recent two decades, but local control and survival after abdominoperineal excision (APE) have not improved to the same degree as that seen after anterior resection (AR). The reason for this is an increased risk of inadvertent bowel perforations and tumor involved margins after APE as compared with AR. The conventional synchronous combined APE has not been a standardized procedure and consequently oncological outcomes have varied considerably between different institutions and in different reports. With the new concept of APE, based on well-defined anatomical structures, the procedure can be categorized as intersphincteric APE, extralevator APE, and ischioanal APE. This article discusses the technical aspects and results from this approach.

Keywords

abdominoperineal excision - extralevator APE - rectal cancer

• References

• 1 Miles WE. A method of performing abdomino-perineal excision for carcinoma of the rectum and of the terminal portion of the pelvic colon. Lancet 1908; 2: 1812-1813
• 2 Collins DC. End-results of the Miles' combined abdominoperineal resection versus the segmental anterior resection. A 25-year postoperative follow-up in 301 patients. Am J Proctol 1963; 14: 258-261
• 3 Vandertoll DJ, Beahrs OH. Carcinoma of the rectum and low sigmoid. Evaluation of anterior resection in 1766 favourable lesions. Arch Surg 1965; 90: 793-798
• 4 Schmitz RL, Nelson PA, Martin GB, Boghossian HM. Synchronous (two-team) abdominoperineal resection of the rectum. AMA Arch Surg 1958; 77 (04) 492-497
• 5 Påhlman L, Glimelius B. Local recurrences after surgical treatment for rectal carcinoma. Acta Chir Scand 1984; 150 (04) 331-335
• 6 Cedermark B, Dahlberg M, Glimelius B, Påhlman L, Rutqvist LE, Wilking N. ; Swedish Rectal Cancer Trial. Improved survival with preoperative radiotherapy in resectable rectal cancer. N Engl J Med 1997; 336 (14) 980-987
• 7 Heald RJ, Husband EM, Ryall RD. The mesorectum in rectal cancer surgery--the clue to pelvic recurrence?. Br J Surg 1982; 69 (10) 613-616
• 8 MacFarlane JK, Ryall RD, Heald RJ. Mesorectal excision for rectal cancer. Lancet 1993; 341 (8843): 457-460
• 9 Kapiteijn E, Marijnen CA, Nagtegaal ID. , et al; Dutch Colorectal Cancer Group. Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. N Engl J Med 2001; 345 (09) 638-646
• 10 Martling AL, Holm T, Rutqvist LE, Moran BJ, Heald RJ, Cedemark B. Effect of a surgical training programme on outcome of rectal cancer in the County of Stockholm. Stockholm Colorectal Cancer Study Group, Basingstoke Bowel Cancer Research Project. Lancet 2000; 356 (9224): 93-96
• 11 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 cancer of the lower rectum: anterior vs. abdominoperineal resection. Dis Colon Rectum 2004; 47 (01) 48-58
• 12 Marr R, Birbeck K, Garvican J. , et al. The modern abdominoperineal excision: the next challenge after total mesorectal excision. Ann Surg 2005; 242 (01) 74-82
• 13 den Dulk M, Putter H, Collette L. , 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 (07) 1175-1183
• 14 Heald RJ, Smedh RK, Kald A, Sexton R, Moran BJ. Abdominoperineal excision of the rectum--an endangered operation. Norman Nigro Lectureship. Dis Colon Rectum 1997; 40 (07) 747-751
• 15 Salerno G, Daniels IR, Brown G. Magnetic resonance imaging of the low rectum: defining the radiological anatomy. Colorectal Dis 2006; 8 (Suppl. 03) 10-13
• 16 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 (36) 9257-9264
• 17 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 (02) 210-216
• 18 Morris E, Quirke P, Thomas JD, Fairley L, Cottier B, Forman D. Unacceptable variation in abdominoperineal excision rates for rectal cancer: time to intervene?. Gut 2008; 57 (12) 1690-1697
• 19 Birbeck KF, Macklin CP, Tiffin NJ. , et al. Rates of circumferential resection margin involvement vary between surgeons and predict outcomes in rectal cancer surgery. Ann Surg 2002; 235 (04) 449-457
• 20 Radcliffe A. Can the results of anorectal (abdominoperineal) resection be improved: are circumferential resection margins too often positive?. Colorectal Dis 2006; 8 (03) 160-167
• 21 Dayal S, Moran B. LOREC: the English Low Rectal Cancer National Development Programme. Br J Hosp Med (Lond) 2013; 74 (07) 377-380
• 22 Holm T, Ljung A, Häggmark 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 (02) 232-238
• 23 Stelzner S, Holm T, Moran BJ. , et al. Deep pelvic anatomy revisited for a description of crucial steps in extralevator abdominoperineal excision for rectal cancer. Dis Colon Rectum 2011; 54 (08) 947-957
• 24 Shihab OC, Heald RJ, Rullier E. , et al. Defining the surgical planes on MRI improves surgery for cancer of the low rectum. Lancet Oncol 2009; 10 (12) 1207-1211
• 25 Tøttrup A, Frost L. Pelvic sepsis after extended Hartmann's procedure. Dis Colon Rectum 2005; 48 (02) 251-255
• 26 Molina Rodríguez JL, Flor-Lorente B, Frasson M. , et al. Low rectal cancer: abdominoperineal resection or low Hartmann resection? A postoperative outcome analysis. Dis Colon Rectum 2011; 54 (08) 958-962
• 27 Eriksen MH, Maina P, Jensen KH. Low risk of pelvic sepsis after intersphincteric proctectomy in patients with low rectal cancer. Dan Med J 2014; 61 (12) A4972
• 28 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 (21) 3517-3522
• 29 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 (10) 1227-1240
• 30 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 (02) 183-191
• 31 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 (03) 274-282
• 32 Prytz M, Angenete E, Ekelund J, Haglind E. Extralevator abdominoperineal excision (ELAPE) for rectal cancer--short-term results from the Swedish Colorectal Cancer Registry. Selective use of ELAPE warranted. Int J Colorectal Dis 2014; 29 (08) 981-987
• 33 West NP, Anderin C, Smith KJ, 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 (04) 588-599
• 34 Holm T, Rutqvist LE, Johansson H, Cedermark B. Abdominoperineal resection and anterior resection in the treatment of rectal cancer: results in relation to adjuvant preoperative radiotherapy. Br J Surg 1995; 82 (09) 1213-1216
• 35 Nicholls J. No more ‘standard’ abdominoperineal excision. Colorectal Dis 2013; 15 (11) 1329-1330
• 36 Mathis KL, Larson DW, Dozois EJ. , et al. Outcomes following surgery without radiotherapy for rectal cancer. Br J Surg 2012; 99 (01) 137-143
• 37 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 (03) 438-443
• 38 Sayers AE, Patel RK, Hunter IA. Perineal hernia formation following extralevator abdominoperineal excision. Colorectal Dis 2015; 17 (04) 351-355
• 39 Khoo AK, Skibber JM, Nabawi AS. , et al. Indications for immediate tissue transfer for soft tissue reconstruction in visceral pelvic surgery. Surgery 2001; 130 (03) 463-469
• 40 Nisar PJ, Scott HJ. Myocutaneous flap reconstruction of the pelvis after abdominoperineal excision. Colorectal Dis 2009; 11 (08) 806-816
• 41 McAllister E, Wells K, Chaet M, Norman J, Cruse W. Perineal reconstruction after surgical extirpation of pelvic malignancies using the transpelvic transverse rectus abdominal myocutaneous flap. Ann Surg Oncol 1994; 1 (02) 164-168
• 42 Tobin GR, Day TG. Vaginal and pelvic reconstruction with distally based rectus abdominis myocutaneous flaps. Plast Reconstr Surg 1988; 81 (01) 62-73
• 43 Christensen HK, Nerstrøm P, Tei T, Laurberg S. Perineal repair after extralevator abdominoperineal excision for low rectal cancer. Dis Colon Rectum 2011; 54 (06) 711-717
• 44 Foster JD, Pathak S, Smart NJ. , et al. Reconstruction of the perineum following extralevator abdominoperineal excision for carcinoma of the lower rectum: a systematic review. Colorectal Dis 2012; 14 (09) 1052-1059