TorbjörnHolm

KarolinskaUniversityHospital

Stockholm,Sweden

WherearewenowwithELAPE?

LocallyrecurrentrectalcancerWemustnotforgetthehistory!

RT+ RT- Total

AR 26/22412% 59/24624% 85/47018%

APE 51/32916% 94/33528% 145/66422%

• LocalrecurrencerateswerenotsignificantlyrelatedtotypeofsurgerybeforeTME

• APEwasperformedin59%ofthepatients(664/1134)

• 136patients,tumours<5cm(1978-1995)• 23%APE• Localrecurrencerateatsixyears

Curative Noncurative Total

AR 1/85 3/20 4/105(4%)

APE 4/15 5/16 9/31(29%)

Dis ColonRectum1997;40:747-751

ProblemsassociatedwithconventionalAPE

• InadvertentbowelperforationsignificantlymorecommonafterAPE

AR APE

Norway 4% 15%

Sweden 3% 14%

Holland 3% 14%

NorwegianRectalCancerGroupBrJSurg2004;91:210-16

ProblemsassociatedwithconventionalAPE

• TumourinvolvedcircumferentialresectionmarginsignificantlymorecommonafterAPE(CRM+ve)

AR APE

• DutchTMETrial 12% 29%

• MERCURYTrial 12% 33%

JClinOncol2005;23:9257-9264

LocalrecurrenceandsurvivalafterAPE,inrelationtoCRMstatus

ProblemsassociatedwithconventionalAPE

• SynchronouscombinedAPEisnotastandardisedoperation

• Resultsarevariableandsuboptimal

• Resultspoorerthanafteranteriorresection– Perforations– Involvedmargins

AbdominoperinealResectionConventionalAPE

AchangingconceptofAPE

• Inordertoimprovesurgeryinlowrectalcancer,anattemptwasmadetodefinethesurgicalplanesoftheperineumandthepelvicfloorandtodescribetheAPEprocedureanatomically.

DefiningthesurgicalplanesonMRIimprovessurgeryforcancerofthelowrectum

OliverCShihab,RichardJHeald,EricRullier,GinaBrown,Torbjorn Holm,PhilipQuirke,BrendanJMoranLancetOncology2009

WhyELAPE?

• ELAPEwasdescribedin

ordertoreduceratesof

perforationand

involvedCRMforlow,

advancedtumours

Patientswithcancerinfiltratingtheinter-sphinctericplaneorthreateningthelevator

needsamoreorlessradicalELAPE

ThreatenedCRM

Indicationsforextra-levator APEinrectalcancer

• Low,advancedtumoursthreateningCRM

– LowMRF,levator orexternalsphincter

ExtralevatorAPE

Lowerratesof:• Bowelperforation• CRMinvolvement• Localrecurrence

Increasedriskof:• Perinealwoundcomplications

AnnSurgOncol(2015)22:2997–3006

BJS2014;101:874–882

APE1981

Excluded72

APE1909

ConventionalAPE1429 ELAPE480

Propensityscorematching

Followedupfor2years 447 448

ConventionalAPEmatchedtoELAPEby:

• Sex• ASA• Neoadjuvanttreatment• Tumourlevel(0–6cm)• PathologicalTNMstage• Typeofresection(R0,CRM)• Qualityofmesorectal

excision

ConventionalAPE ELAPE

1429 480

Excluded 982(69%) 32(3%)

447 448

Conclusion:ELAPEdoesnotimproveratesofCRMinvolvement,intraoperativetumourperforation,localrecurrenceormortality

Comment:HighproportionofexcludedpatientsintheconventionalAPEgroupResultsnotsurprisingwithmatchingforqualityofsurgery

ELAPE ConventionalAPE(n=301) (n=253) p

NeoadjuvantChemo-radiation 211(70%) 114(45%) <0.001Tumourlevel<5cm 267(90%) 159(64%) <0.001ColorectalSurgeon 283(94%) 164(65%) <0.001Tumourperforation 14(5%) 9(4%) 0.28R0resection 253(84%) 233(93%) 0.006

Conclusion:ResectionoflowrectalcancersbyELAPEdidnotimproveshorttermoncologicalresultscomparedwithconventionalAPE

Comment:MoreadvancedandlowtumoursinELAPEgroupNospecimenqualitycontrol

(AnnSurg 2015;261:933–938)

APE ELAPE Undeterminedn=209(16%) n=518(39%) n=592(45%)

<5cmfromanalverge 58(28%) 386(75%) 353(61%)NeoadjuvantRT 144(69%) 456(88%) 472(80%)CRM+ 58(28%) 152(29%) 238(40%)

Conclusion:ELAPEresultsinasignificantlyincreased3-yearlocalrecurrencerateascomparedwithstandardAPE;OR=4.10(95%CI1.19–14.08)

Comment:NodataonrateofLRorperforationsHigher,smalltumourscomparedtolowmoreadvancedtumoursNospecimenqualitycontrolandhighCRM+rateinbothgroups

(AnnSurg 2015Apr21.[Epub])

ComparisonsELAPEvs.”standard”or“conventional”APE

“Theadjective‘standard’begantobeappliedtoAPE,

butithadnomeaningbecauseitwasnotpossibleto

describeitanatomically”

ProfessorJohnNichollsColorectalDisease201315,1329–1330

Whatisa“standard”APE?

Prytzetal.IntJColorectalDis(2014)29:981–987

ComparisonsELAPEvs.”standard”or“conventional”APE

• ResultsafteranteriorresectionimprovedwithTMEsurgery

• ConventionalAPEwasnotastandardizedprocedure

• ResultsafterAPEwerestillpoorinpopulationbasedstudies

• ResultsseemedtoimproveafterintroductionofELAPE

• SomecomparisonsfavorELAPEwhileothersshownodifferencebetweenELAPEand“standard”APE

• “Standard”APEhasprobablychangedwithtimeandincreasingknowledge,andisnowamoreorlessextensiveELAPE

ChangingconceptofAPE

• TheAPEprocedureshouldbetailoredtothetumourandtothepatient

• Relatedtodefinedanatomicalstructures

– Inter-sphincteric

– Extra-levator

– Ischio-anal

• Eachprocedureshouldbestandardised

• Indicationsshouldbedefinedforeachprocedure

• Basedonappropriatestaging– MRI,ultrasoundandclinicalexamination

Inter-sphincteric APE

IndicationsforAPEinrectalcancerInter-sphinctericAPE

• PatientunsuitableforbowelreconstructionPreoperativehistoryofincontinence

Highriskofanastomotic leak

Co-morbidity– crucialtopreventleakage+fataloutcome

Patientspreference

– OptionsHartmann’sprocedure

Inter-sphinctericAPE

Tumourperforatingintoischio-analspace

Ischio-anal APE

Indicationsforischio-analAPE

• Locallyadvancedcancerinfiltrating– Levatormuscles– Ischio-analfat– Perianalskin

• Perforatedcancerwithabscessorfistulainischio-analfossa

Supineorproneapproach

• Inter-sphincteric APE: Supine• Extra-levatorAPE: Pronepreferable,Supinepossible• Ischio-analAPE: Prone

Whyproneposition?

• Excellentviewimprovesteaching

• Posteriorvagina,prostateandautonomicnerveseasiertosee

• Bettercontroloftheprocedure

KarolinskaExperienceELAPE2000-2012

• 193patients 81female 112malePreoperativetumourstage(MRI)• T1–T3 67 35%• T4 126 65%

• Radiotherapy 102 48%• Radio-chemotherapy 91 47%• Nopreoperativetreatment 105%

• Pelvicexenteration 25 13%• ExtendedELAPE 56 29%• ELAPEalone 112 58%

KarolinskaExperienceELAPE2000-2012

• Postoperativemortality 6 3%

• Histopathology

T0-T2 69 36%

T3-T4 124 64%

CRM+ 20 10%

Perforations 19 10%

KarolinskaExperienceELAPE2000-2012

FollowupAugust2013 Medianfollowup31months

• Localrecurrence 12/187 6%

• Rectalcancerdeaths 44/187 23%

• Alldeaths 55/187 29%

KarolinskaExperienceELAPE2000-2012Cumulativeincidenceoflocalrecurrence

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1.00

0.00

0 1 2 3 4 5Time (Year)

Kaplan-Meier failure estimate

KarolinskaExperienceELAPE2000-2012Survival

0 1 2 3 4 5Survival Time year

0,0

0,1

0,2

0,3

0,4

0,5

0,6

0,7

0,8

0,9

1,0

Cum

ulat

ive

Prop

ortio

n Su

rviv

ing

APEinlowrectalcancerConclusion

• Assesspatientandtumour– Analfunction,co-morbidity,patientpreference– VerylowtumourorthreatenedCRM

• PlanprocedureaccordingtoMRIandclinicalassessment

• IfAPEthecorrectchoice– whattypeofAPE?– Inter-sphincteric– Extra-levator (moreorlessextensive)– Ischio-anal(moreorlessextensive)

• Goodlocalcontrolandsurvivalcanbeachievealsoinlocallyadvancedrectalcancer