The quality of lymph node harvests in extralevator abdominoperineal excisions
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The quality of lymph node harvests in extralevator abdominoperineal excisions Ben Liu* and Ja’Quay Farquharson
Abstract Background: Lymph node (LN) harvest in colorectal cancer resections is a well-recognised prognostic factor for disease staging and determining survival, particularly for node-negative (N0) diseases. Extralevator abdominoperineal excisions (ELAPE) aim to prevent “waisting” that occurs during conventional abdominoperineal resections (APR) for low rectal cancers, and reducing circumferential resection margin (CRM) infiltration rate. Our study investigates whether ELAPE may also improve the quality of LN harvests, addressing gaps in the literature. Methods: This retrospective observational study reviewed 2 sets of 30 consecutive APRs before and after the adoption of ELAPE in our unit. The primary outcomes are the total LN counts and rates of meeting the standard of 12-minimum, particularly for those with node-negative disease. The secondary outcomes are the CRM involvement rates. Baseline characteristics including age, sex, laparoscopic or open surgery and the use of neoadjuvant chemoradiotherapy were accounted for in our analyses. Results: Median LN counts were slightly higher in the ELAPE group (16.5 vs. 15). Specimens failing the minimum 12-LN requirements were almost significantly fewer in the ELAPE group (OR 0.456, P = 0.085). Among node-negative rectal cancers, significantly fewer resections failed the 12-LN standard in the ELAPE group than APR group (OR 0.211, P = 0.044). ELAPE led to a near-significant decrease in CRM involvement (OR 0.365, P = 0.088). These improvements were persistently observed after taking into account baselines and potential confounders in regression analyses. Conclusion: ELAPE provides higher quality of LN harvests that meet the 12-minimal requirements than conventional APR, particularly in node-negative rectal cancers. The superiority is independent of potential confounding factors, and may implicate better clinical outcomes. Keywords: Rectal cancers, Abdominoperineal excisions, Lymph nodes Background Abdominoperineal resections (APR) are the established curative surgical treatment for low rectal cancers within 4 cm from the anal verge [1]. A high rate of intraoperative bowel perforation (IBP) and risks of positive circumferential resection margin (CRM), both strong predictors of survival [2] had been reported to be as high as 30.4% in the Dutch TME trial [3] and 30.2% in the MERCURY *Correspondence: [email protected] Department of General Surgery, New Cross Hospital, The Royal Wolverhampton NHS Trust, Wolverhampton Road, Wolverhampton WV10 0QP, West Midlands, UK
trial [4]. These have subsequently been correlated with higher recurrence rates and reduced survival after APR [5]. Extralevator Abdominoperineal Excision (ELAPE) had been described to standardise a cylindrical specimen without a “waist” in order to minimise CRM involvement, and early outcomes have been favourable [6–8] In addition to CRM, the identification of lymph node (LN)
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