Long-term oncological outcomes of extralevator versus standard abdominoperineal resection with 20 years' experience

Why clinicians should know about it

• Picked for Surgery (paper of the day, 23 August 2026).

Abstract

BACKGROUND/AIM: Extralevator abdominoperineal excision (ELAPE) was introduced to improve oncological quality in low rectal cancer surgery by reducing circumferential resection margin (CRM) positivity and intraoperative specimen perforation (IOP) compared with standard abdominoperineal resection (s-APR). However, its impact on long-term survival remains unclear. This study aimed to compare s-APR and ELAPE in terms of surgical quality parameters and their effects on disease-free survival (DFS) and overall survival (OS). MATERIALS AND METHODS: This retrospective single-center study included 203 patients with non-metastatic distal rectal adenocarcinoma (0-5 cm from the anal verge) who underwent APR between 2001 and 2020. Patients treated between 2001 and 2009 underwent s-APR (n = 109), whereas those treated between 2010 and 2020 underwent ELAPE (n = 94). Demographic, clinicopathological, and survival data were analyzed. Survival outcomes were evaluated using Kaplan-Meier analysis and compared between groups using the log-rank test. RESULTS: CRM positivity was significantly lower in the ELAPE group compared with the s-APR group (13.8% vs. 28.4%, p = 0.007). Intraoperative specimen perforation occurred less frequently in the ELAPE group (2.1% vs. 17.4%, p < 0.001). Local recurrence rates were significantly lower following ELAPE (13.4% vs. 26.1%, p = 0.037), whereas distant metastasis rates did not differ significantly between groups (19.5% vs. 12.2%, p = 0.189). Three- and five-year OS rates were 81.1% and 70.3% in the ELAPE group and 74.5% and 63.3% in the s-APR group, respectively, without statistically significant differences (p = 0.241). No significant difference in DFS was observed between the two techniques (p = 0.408). CONCLUSION: ELAPE was associated with improved surgical quality, reflected by lower CRM positivity and specimen perforation rates. However, these advantages did not translate into a significant long-term survival benefit.

Abstract as published, via PubMed.