Originally published as JCO Early Release 10.1200/JCO.2007.14.5961 on June 9 2008

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Evidence of the Oncologic Superiority of Cylindrical Abdominoperineal Excision for Low Rectal Cancer

Nicholas P. West, Paul J. Finan, Claes Anderin, Johan Lindholm, Torbjorn Holm, Philip Quirke

From Pathology and Tumour Biology, Leeds Institute of Molecular Medicine, University of Leeds; and Department of Colorectal Surgery, Leeds General Infirmary, Leeds, United Kingdom; and Department of Coloproctology; and Department of Pathology, Karolinska University Hospital, Stockholm, Sweden

Corresponding author: Phillip Quirke, PhD FRCPath, Gastrointestinal Cancer Research Group, Pathology and Tumour Biology, Yorkshire Cancer Research and Liz Dawn Translational Science Centre, Leeds Institute of Molecular Medicine, Wellcome Trust Brenner Building, Level 4, Room 4.20a, St James's University Hospital, Beckett St Leeds, LS9 7TF, United Kingdom; e-mail: patpq{at}leeds.ac.uk

Purpose Abdominoperineal excision (APE) of the rectum and anus for rectal cancer continues to have greater local recurrence and poorer survival than that seen following anterior resection. Changing to an extended prone perineal dissection results in a more cylindrical specimen and should improve outcomes.

Patients and Methods One hundred twenty-eight specimens from patients who underwent APE that was performed for potentially curable primary rectal adenocarcinoma were dissected according to standard protocol in Leeds and Stockholm between 1997 and 2007 and were studied. Tissue morphometry was performed on the cross sectional photographs of 93 patient cases.

Results The cylindrical technique removed more tissue in the distal rectum and in all slices that contained tumor compared with the standard operation (both P < .0001). Greater distance was observed from the muscularis propria or internal sphincter to the anterior, posterior, and lateral resection margins (all P < .0001). This was associated with lower circumferential resection margin (CRM) involvement (14.8% v 40.6%; P = .013) and intraoperative perforations (3.7% v 22.8%; P = .0255). An increase in the amount of tissue removed in the distal rectum (P < .0001) was demonstrated by a single surgeon who changed from the standard to the cylindrical technique during the study period; the change was associated with a reduction in CRM positivity (from 36.2% to 12.5%) and in perforations (from 12.8% to 0.0%).

Conclusion Cylindrical APE performed in the prone position for low rectal cancer removes more tissue around the tumor that leads to a reduction in CRM involvement and intraoperative perforations, which should reduce local disease recurrence. The cylindrical technique has the potential to improve patient outcomes substantially if appropriate surgical education programs are developed.

published online ahead of print at www.jco.org on June 9, 2008.

N.W. is supported by the United Kingdom Department of Health Academic Clinical Fellowship program, and P.Q. is supported by grants from Yorkshire Cancer Research and the Experimental Cancer Medicine Centre Initiative.

Authors’ disclosures of potential conflicts of interest and author contributions are found at the end of this article.

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