title: Extralevator Abdominoperineal Excision for Low Rectal Cancer--Extensive Surgery to Be Used With Discretion Based on 3-Year Local Recurrence Results: A Registry-based, Observational National Cohort Study.
abstract: OBJECTIVE
  The aim of this prospective registry-based population study was to investigate the efficacy of extralevator abdominoperineal excision (ELAPE) regarding local recurrence rates within 3 years after surgery.
  
  
  BACKGROUND
  Local recurrence of rectal cancer is more common after abdominoperineal excision (APE) than after anterior resection. Extralevator abdominoperineal excision was introduced to address this problem. No large-scale studies with long-term oncological outcomes have been published.
  
  
  METHODS
  All Swedish patients operated on with an APE and registered in the Swedish ColoRectal Cancer Registry 2007 to 2009 were included (n = 1397) and analyzed with emphasis on the perineal part of the operation. Local recurrence at 3 years was collected from the registry.
  
  
  RESULTS
  The local recurrence rates at 3 years [median follow-up, 3.43 years (APE, 3.37 years; ELAPE, 3.41 years; not stated: 3.43 years)] were significantly higher for ELAPE compared with APE (relative risk, 4.91). Perioperative perforation was also associated with an increased risk of local recurrence (relative risk, 3.62). There was no difference in 3-year overall survival between APE and ELAPE. In the subgroup of patients with very low tumors (≤4  cm from the anal verge), no significant difference in the local recurrence rate could be observed.
  
  
  CONCLUSIONS
  Extralevator abdominoperineal excision results in a significantly increased 3-year local recurrence rate as compared with standard APE. Intraoperative perforation seems to be an important risk factor for local recurrence. In addition to significantly increased 3-year local recurrence rates, the significantly increased incidence of wound complications leads to the conclusion that ELAPE should only be considered in selected patients at risk of intraoperative perforation.
authors.affiliation: *Department of Surgery, Institute of Clinical Sciences, Scandinavian Surgical Outcomes Research Group, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden †Department of Surgery, NU-Hospital Organization, Trollhättan, Sweden.
authors.forename: Mattias
authors.initials: M
authors.lastname: Prytz
authors.forename: Eva
authors.initials: E
authors.lastname: Angenete
authors.forename: David
authors.initials: D
authors.lastname: Bock
authors.forename: Eva
authors.initials: E
authors.lastname: Haglind
mesh_terms: D000005:Abdomen / Q000601:surgery; D000368:Aged; D013505:Digestive System Surgical Procedures / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000517:prevention & control*; D009367:Neoplasm Staging; D010502:Perineum / Q000601:surgery; D011446:Prospective Studies; D012004:Rectal Neoplasms / Q000473:pathology / Q000601:surgery*; D012042:Registries; D012307:Risk Factors; D011795:Surveys and Questionnaires; D013548:Sweden