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Focus on Extralevator Perineal Dissection in Supine Position for Low Rectal Cancer Has Led to Better Quality of Surgery and Oncologic Outcome

  • Colorectal Cancer
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Background

After abdominoperineal excision (APE), the presence of tumor cells in the circumferential resection margin (R1) and iatrogenic tumor perforations are still frequent and result in an increased rate of local recurrences. In this study, a standardized supine APE with an increased focus on the perineal dissection (sPPD) is compared to the customary supine APE.

Methods

From 2000 to 2010, a total of 246 patients underwent APE for rectal cancer (sPPD and customary supine APE). All patients were staged with preoperative magnetic resonance imaging (MRI) and received neoadjuvant treatment (n = 203) when margins were involved or threatened (cT3 + and T4). As a result of a quality improvement program in 2006, the surgical technique was modified: it became standardized, emphasis was placed on the perineal dissection, and pelvic dissection was limited to avoid false routes when following the total mesorectal excision planes deep into the pelvis.

Results

Overall, the percentage of involved circumferential resection margins (CRMs) was 10%. In the period before introducing sPPD, the R1 percentages for cT0–3 and cT4 tumors were 6.8 and 30.2%, compared to 2.2 and 5.7% after introduction of sPPD (P = 0.001). Risk factors for R1 resection were preoperative T4 tumors (14.9%, P = 0.011), tumor perforation (33.3%, P = 0.002), fistulating tumors (35.7%, P = 0.002), mucus-producing tumors (23.1%, P = 0.006), or bulky tumors (66.7%, P < 0.001).

Conclusions

The objective of surgical treatment of low rectal cancer is to obtain negative resection margins and subsequently reduce the risk of local recurrence. A combination of the appropriate preoperative treatment and standardized surgical technique such as sPPD can achieve this goal.

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Acknowledgment

PQ and NW are supported by Yorkshire Cancer Research.

Disclosure

The work was not sponsored, no disclaimers from any of the authors.

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Authors and Affiliations

  1. Department of Colorectal Surgery, Catharina Hospital, Eindhoven, The Netherlands

    Ingrid S. Martijnse MD, Ralph L. Dudink BSc, Dareczka Wasowicz MD, PhD, Grard A. Nieuwenhuijzen MD, PhD & Harm J. Rutten MD, FRCS, PhD

  2. Pathology and Tumour Biology, Leeds Institute of Molecular Medicine, University of Leeds, Leeds, UK

    Nicholas P. West MBChB, PhD & Phil Quirke FRCPath, PhD

  3. Pathology and Medical Microbiology Institute, PAMM Eindhoven, Eindhoven, The Netherlands

    Ineke van Lijnschoten MD, PhD

  4. Department of Radiotherapy, Catharina Hospital, Eindhoven, The Netherlands

    Hendrik Martijn MD, PhD

  5. Department of Research, Comprehensive Cancer Centre South, Eindhoven, The Netherlands

    Valery E. Lemmens PhD

  6. Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands

    Cornelis J. van de Velde MD, FRCS, PhD

  7. Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands

    Iris D. Nagtegaal

Authors
  1. Ingrid S. Martijnse MD
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  2. Ralph L. Dudink BSc
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  3. Nicholas P. West MBChB, PhD
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  4. Dareczka Wasowicz MD, PhD
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  6. Ineke van Lijnschoten MD, PhD
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  7. Hendrik Martijn MD, PhD
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  8. Valery E. Lemmens PhD
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  9. Cornelis J. van de Velde MD, FRCS, PhD
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  10. Iris D. Nagtegaal
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  11. Phil Quirke FRCPath, PhD
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  12. Harm J. Rutten MD, FRCS, PhD
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Corresponding author

Correspondence to Harm J. Rutten MD, FRCS, PhD.

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Martijnse, I.S., Dudink, R.L., West, N.P. et al. 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, 786–793 (2012). https://doi.org/10.1245/s10434-011-2004-9

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  • DOI: https://doi.org/10.1245/s10434-011-2004-9

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