title: Focus on extralevator perineal dissection in supine position for low rectal cancer has led to better quality of surgery and oncologic outcome.
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.
authors.affiliation: Department of Colorectal Surgery, Catharina Hospital, Eindhoven, The Netherlands.
authors.forename: Ingrid S
authors.initials: IS
authors.lastname: Martijnse
authors.forename: Ralph L
authors.initials: RL
authors.lastname: Dudink
authors.forename: Nicholas P
authors.initials: NP
authors.lastname: West
authors.forename: Dareczka
authors.initials: D
authors.lastname: Wasowicz
authors.forename: Grard A
authors.initials: GA
authors.lastname: Nieuwenhuijzen
authors.forename: Ineke
authors.initials: I
authors.lastname: van Lijnschoten
authors.forename: Hendrik
authors.initials: H
authors.lastname: Martijn
authors.forename: Valery E
authors.initials: VE
authors.lastname: Lemmens
authors.forename: Cornelis J
authors.initials: CJ
authors.lastname: van de Velde
authors.forename: Iris D
authors.initials: ID
authors.lastname: Nagtegaal
authors.forename: Phil
authors.initials: P
authors.lastname: Quirke
authors.forename: Harm J
authors.initials: HJ
authors.lastname: Rutten
mesh_terms: D034861:Abdominal Wall / Q000601:surgery; D013505:Digestive System Surgical Procedures / Q000379:methods*; D004210:Dissection / Q000379:methods; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D018482:Muscle, Skeletal / Q000601:surgery; D009364:Neoplasm Recurrence, Local; D010502:Perineum / Q000601:surgery*; D012004:Rectal Neoplasms / Q000473:pathology / Q000601:surgery*; D016683:Supine Position