title: Extralevator Abdominal Perineal Excision Versus Standard Abdominal Perineal Excision: Impact on Quality of the Resected Specimen and Postoperative Morbidity.
abstract: Abdominal perineal excision (APE) has been associated with a high risk of positive circumferential resection margin (CRM+) and local recurrence rates in the treatment of rectal cancer. An alternative extralevator approach (ELAPE) has been suggested to improve the quality of resection by avoiding coning of the specimen decreasing the risk of tumor perforation and CRM+. The aim of this study is to compare the quality of the resected specimen and postoperative complication rates between ELAPE and "standard" APE.
  
  
  
  All patients between 1998 and 2014 undergoing abdominal perineal excision for primary or recurrent rectal cancer at a single Institution were reviewed. Between 1998 and 2008, all patients underwent standard APE. In 2009 ELAPE was introduced at our Institution and all patients requiring APE underwent this alternative procedure (ELAPE). The groups were compared according to pathological characteristics, specimen quality (CRM status, perforation and failure to provide the rectum and anus in a single specimen-fragmentation) and postoperative morbidity.
  
  
  
  Fifty patients underwent standard APEs, while 22 underwent ELAPE. There were no differences in CRM+ (10.6 vs. 13.6%; p = 0.70) or tumor perforation rates (8 vs. 0%; p = 0.30) between APE and ELAPE. However, ELAPE were less likely to result in a fragmented specimen (42 vs. 4%; p = 0.002). Advanced pT-stage was also a risk factor for specimen fragmentation (p = 0.03). There were no differences in severe (Grade 3/4) postoperative morbidity (13 vs. 10%; p = 0.5). Perineal wound dehiscences were less frequent among ELAPE (52 vs 13%; p < 0.01). Despite short follow-up (median 21 mo.), 2-year local recurrence-free survival was better for patients undergoing ELAPE when compared to APE (87 vs. 49%; p = 0.04).
  
  
  
  ELAPE may be safely implemented into routine clinical practice with no increase in postoperative morbidity and considerable improvements in the quality of the resected specimen of patients with low rectal cancers.
authors.affiliation: Angelita and Joaquim Gama Institute, Rua Manoel da Nóbrega 1564, São Paulo, SP, 04001-005, Brazil.|School of Medicine, University of São Paulo, Rua Manoel da Nóbrega 1564, São Paulo, SP, 04001-005, Brazil.
authors.forename: Angelita
authors.initials: A
authors.lastname: Habr-Gama
authors.affiliation: Angelita and Joaquim Gama Institute, Rua Manoel da Nóbrega 1564, São Paulo, SP, 04001-005, Brazil.
authors.forename: Guilherme P
authors.initials: GP
authors.lastname: São Julião
authors.affiliation: Angelita and Joaquim Gama Institute, Rua Manoel da Nóbrega 1564, São Paulo, SP, 04001-005, Brazil.
authors.forename: Adrian
authors.initials: A
authors.lastname: Mattacheo
authors.affiliation: Angelita and Joaquim Gama Institute, Rua Manoel da Nóbrega 1564, São Paulo, SP, 04001-005, Brazil.
authors.forename: Luiz Felipe
authors.initials: LF
authors.lastname: de Campos-Lobato
authors.affiliation: Angelita and Joaquim Gama Institute, Rua Manoel da Nóbrega 1564, São Paulo, SP, 04001-005, Brazil.
authors.forename: Edgar
authors.initials: E
authors.lastname: Aleman
authors.affiliation: Angelita and Joaquim Gama Institute, Rua Manoel da Nóbrega 1564, São Paulo, SP, 04001-005, Brazil.
authors.forename: Bruna B
authors.initials: BB
authors.lastname: Vailati
authors.affiliation: Angelita and Joaquim Gama Institute, Rua Manoel da Nóbrega 1564, São Paulo, SP, 04001-005, Brazil.|School of Medicine, University of São Paulo, Rua Manoel da Nóbrega 1564, São Paulo, SP, 04001-005, Brazil.
authors.forename: Joaquim
authors.initials: J
authors.lastname: Gama-Rodrigues
authors.affiliation: Angelita and Joaquim Gama Institute, Rua Manoel da Nóbrega 1564, São Paulo, SP, 04001-005, Brazil. rodrigo.operez@gmail.com.|Colorectal Surgery Division, School of Medicine, University of São Paulo, Rua Manoel da Nóbrega 1564, São Paulo, SP, 04001-005, Brazil. rodrigo.operez@gmail.com.|Ludwig Institute for Cancer Research São Paulo Branch, Rua Manoel da Nóbrega 1564, São Paulo, SP, 04001-005, Brazil. rodrigo.operez@gmail.com.
authors.forename: Rodrigo Oliva
authors.initials: RO
authors.lastname: Perez
mesh_terms: D000005:Abdomen; D000328:Adult; D000368:Aged; D059186:Chemoradiotherapy, Adjuvant; D005260:Female; D006801:Humans; D008297:Male; D000072662:Margins of Excision; D008875:Middle Aged; D020360:Neoadjuvant Therapy / Q000379:methods; D009364:Neoplasm Recurrence, Local / Q000473:pathology / Q000601:surgery / Q000628:therapy; D010502:Perineum / Q000601:surgery; D011183:Postoperative Complications; D012004:Rectal Neoplasms / Q000473:pathology / Q000601:surgery* / Q000628:therapy; D012307:Risk Factors; D016896:Treatment Outcome