title: Low rectal cancer: a call for a change of approach in abdominoperineal resection.
abstract: OBJECTIVE
  Despite the major improvements that have been made due to total mesorectal excision (TME), low rectal cancer still remains a challenge.
  
  
  METHODS
  By investigating a prospective randomized rectal cancer trial in which surgeons had undergone training in TME the factors responsible for the poor outcome were determined and a new method for assessing the quality of surgery was tested.
  
  
  RESULTS
  Survival differed greatly between abdominoperineal resection (APR) and anterior resection (AR; 38.5% v 57.6%, P = .008). Low rectal carcinomas have a higher frequency of circumferential margin involvement (26.5% v 12.6%, P < .001). More positive margins were present in the patients operated with APR (30.4%) compared to AR (10.7%, P = .002). Furthermore, more perforations were present in these specimens (13.7% v 2.5%, P < .001). The plane of resection lies within the sphincteric muscle, the submucosa or lumen in more than 1/3 of the APR cases, and in the remainder lay on the sphincteric muscles.
  
  
  CONCLUSIONS
  We systematically described and investigated the pathologic properties of low rectal cancer in general, and APR in particular, in a prospective randomized trial including surgeons who had been trained in TME. The poor prognosis of the patients with an APR is ascribed to the resection plane of the operation leading to a high frequency of margin involvement by tumor and perforation with this current surgical technique. The clinical results of this operation could be greatly improved by adopting different surgical techniques and possibly greater use of radiochemotherapy.
authors.affiliation: Department of Pathology, University Medical Centre, St Radboud, Nijmegen, the Netherlands.
authors.forename: Iris D
authors.initials: ID
authors.lastname: Nagtegaal
authors.forename: Cornelius J H
authors.initials: CJ
authors.lastname: van de Velde
authors.forename: Corrie A M
authors.initials: CA
authors.lastname: Marijnen
authors.forename: Jan H J M
authors.initials: JH
authors.lastname: van Krieken
authors.forename: Philip
authors.initials: P
authors.lastname: Quirke
mesh_terms: D001003:Anal Canal / Q000601:surgery; D003131:Combined Modality Therapy; D013505:Digestive System Surgical Procedures / Q000592:standards*; D004502:Education, Medical, Continuing; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D011787:Quality of Health Care; D018714:Radiotherapy, Adjuvant; D012004:Rectal Neoplasms / Q000188:drug therapy / Q000473:pathology* / Q000532:radiotherapy / Q000601:surgery*; D016896:Treatment Outcome