title: A national perspective on the decline of abdominoperineal resection for rectal cancer.
abstract: OBJECTIVE
  To assess rates of abdominoperineal excision of the rectum (APER) for rectal cancer between centers and over time, and to evaluate the influence of patient characteristics, including social deprivation, on APER rate.
  
  
  METHODS
  Data on patients undergoing APER or anterior resection (AR) in England were extracted from a national administrative database for the years 1996 to 2004. The primary outcome was the proportion of patients presenting with rectal cancer undergoing APER. Hierarchical logistic regression was used to identify independent factors associated with a nonrestorative resection.
  
  
  RESULTS
  Data on 52,643 patients were analyzed, 13,109(24.9%) of whom underwent APER. The APER rate significantly reduced over the study period from 29.4% to 21.2% (P < 0.001). Operative mortality following AR decreased significantly during the period of study (5.1% to 4.2%, P = 0.002), while that following APER did not (P = 0.075). Male patients were more likely to undergo APER (P < 0.001), whereas those with an emergency presentation more commonly underwent AR (P < 0.001). Independent predictors of increased APER rate were male gender (odds ratio [OR] = 1.239, P < 0.001) and social deprivation (most vs. least deprived; OR = 1.589, P < 0.001), whereas increasing patient age (OR = 0.977, P = 0.027 per 10-year increase), year of study (2003/4 vs. 1996/7; OR = 0.646, P < 0.001) and initial presentation as an emergency (OR = 0.713, P < 0.001) were associated with lower APER rates. After accounting for case-mix, there was significant between-center variability in APER rates.
  
  
  CONCLUSIONS
  Socially deprived patients were more likely to undergo abdominoperineal resection. Significant improvements in rates of nonrestorative resection were seen over time but although short-term outcomes following AR have improved, those following APER have not. Permanent stoma rates following rectal cancer surgery may be considered a surrogate marker of surgical quality.
authors.affiliation: Department of Biosurgery and Surgical Technology, Imperial College London, St. Mary's Hospital, London, England.
authors.forename: Henry S
authors.initials: HS
authors.lastname: Tilney
authors.forename: Alexander G
authors.initials: AG
authors.lastname: Heriot
authors.forename: Sanjay
authors.initials: S
authors.lastname: Purkayastha
authors.forename: Anthony
authors.initials: A
authors.lastname: Antoniou
authors.forename: Paul
authors.initials: P
authors.lastname: Aylin
authors.forename: Ara W
authors.initials: AW
authors.lastname: Darzi
authors.forename: Paris P
authors.initials: PP
authors.lastname: Tekkis
mesh_terms: D000005:Abdomen / Q000601:surgery*; D000368:Aged; D016009:Chi-Square Distribution; D013505:Digestive System Surgical Procedures / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D016015:Logistic Models; D008297:Male; D010043:Outcome and Process Assessment, Health Care; D010502:Perineum / Q000601:surgery*; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D012004:Rectal Neoplasms / Q000601:surgery*; D012307:Risk Factors; D012959:Socioeconomic Factors; D006113:United Kingdom