Introduction The LOREC perineal wound healing registry was developed to record data on abdomino-perineal excision (APE) for rectal cancer in colorectal units across the UK between 2012 and 2014 to understand current practice. Initial interim results are reported.
Method Surgeons wishing to participate received secure web-based access to the registry. Collected data included pre-operative staging, neo-adjuvant treatment, operative details, pathology, early outcome and follow-up at 12 months.
Results Overall 43 units entered a total of 259 patients undergoing APE. These included 168 extralevator APE (ELAPE) procedures (65%) and 91 non-ELAPEs, comprising 73 ‘standard’ APE, 9 intersphincteric, 2 ischioanal and 7 unspecified procedures. The ELAPE and non-ELAPE groups are compared.
This indication for APE was oncological in 98% with only 5 cases having APE for functional reasons, eg weak sphincters.
On pre-op MRI the ELAPE group had higher grade tumours, with 112 (67%) staged on MRI as T3/4 compared with 47 (54%) for non-ELAPEs. ELAPEs also had a higher incidence of predicted positive lymph nodes, with 97 (58%) N1/2 compared with 38 (43%) for non-ELAPEs. The circumferential resection margin was predicted as less likely to be clear in the ELAPE group, 68 (45%), versus 38 (53%) in the non-ELAPE group. Metastatic disease was reported in 6% of the ELAPE group and 3% of the non-ELAPEs.
The majority of patients received pre-operative treatment, most commonly chemoradiotherapy. Overall, the response to treatment was graded on MRI as mixed fibrosis and tumour in 32%, while 38% showed mainly or only tumour and 29% showed small or no residual tumour.
Multivisceral resection was undertaken in 19 (11%) of ELAPEs and 7 (8%) of non-ELAPEs, the vast majority involving the vagina. Operative complications were recorded in 8%. These included rectal perforation (7 cases), urethral injury (6 cases), ureteric injury (2 cases) and 9 cases of ‘other’ complications.
On pathology similar proportions had higher grade tumours: 81 (52%) T3/4 in the ELAPE group compared with the 41 (47%) in the non-ELAPE group. The ELAPEs were more likely to be node-positive, 55 (35%), versus 23 (27%) in the non-ELAPEs. A positive resection margin was reported in 21 (14%) of ELAPEs and 2 (2%) of non-ELAPEs. Perforation was noted in 3 patients in each group. The quality of TME was graded as mesorectal plane intact in 112 (67%) of ELAPEs and 46 (51%) of non-ELAPEs. The quality of the levator plane was graded as complete levator wrap in 110 (65%) of ELAPEs.
Conclusion It appears that surgeons are using ELAPE in more advanced cases but R1 rates of 14% suggest these are challenging and further means of improving outcomes should be explored.
Disclosure of interest None Declared.
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