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01-03-2012 | Colorectal Cancer

Focus on Extralevator Perineal Dissection in Supine Position for Low Rectal Cancer Has Led to Better Quality of Surgery and Oncologic Outcome

Authors: Ingrid S. Martijnse, MD, Ralph L. Dudink, BSc, Nicholas P. West, MBChB, PhD, Dareczka Wasowicz, MD, PhD, Grard A. Nieuwenhuijzen, MD, PhD, Ineke van Lijnschoten, MD, PhD, Hendrik Martijn, MD, PhD, Valery E. Lemmens, PhD, Cornelis J. van de Velde, MD, FRCS, PhD, Iris D. Nagtegaal, Phil Quirke, FRCPath, PhD, Harm J. Rutten, MD, FRCS, PhD

Published in: Annals of Surgical Oncology | Issue 3/2012

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.

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Title: Focus on Extralevator Perineal Dissection in Supine Position for Low Rectal Cancer Has Led to Better Quality of Surgery and Oncologic Outcome
Authors: Ingrid S. Martijnse, MD
Ralph L. Dudink, BSc
Nicholas P. West, MBChB, PhD
Dareczka Wasowicz, MD, PhD
Grard A. Nieuwenhuijzen, MD, PhD
Ineke van Lijnschoten, MD, PhD
Hendrik Martijn, MD, PhD
Valery E. Lemmens, PhD
Cornelis J. van de Velde, MD, FRCS, PhD
Iris D. Nagtegaal
Phil Quirke, FRCPath, PhD
Harm J. Rutten, MD, FRCS, PhD
Publication date: 01-03-2012
Publisher: Springer-Verlag
Published in: Annals of Surgical Oncology / Issue 3/2012
Print ISSN: 1068-9265
Electronic ISSN: 1534-4681
DOI: https://doi.org/10.1245/s10434-011-2004-9

At a glance: The STEP trials

Springer Medicine

Focus on Extralevator Perineal Dissection in Supine Position for Low Rectal Cancer Has Led to Better Quality of Surgery and Oncologic Outcome

Abstract

Background

Methods

Results

Conclusions

At a glance: The STEP trials

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

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