Journal of Gastrointestinal Surgery

https://doi.org/10.1007/s11605-018-3750-9

EVIDENCE-BASED CURRENT SURGICAL PRACTICE

Abdominoperineal Resection for Rectal Cancer in the Twenty-First

Century: Indications, Techniques, and Outcomes
Alexander T. Hawkins 1,2 & Katherine Albutt 1 & Paul E. Wise 3 & Karim Alavi 4 & Ranjan Sudan 5 & Andreas M. Kaiser 6 &
Liliana Bordeianou 1 & on behalf of the Continuing Education Committee of the SSAT

Received: 13 July 2017 / Accepted: 16 March 2018

# 2018 The Society for Surgery of the Alimentary Tract

Abstract
Background Management of low rectal cancer continues to be a challenge, and decision making regarding the need for an
abdominoperineal resection (APR) in patients with low-lying tumors is complicated. Furthermore, choices need to be made
regarding need for modification of the surgical approach based on tumor anatomy and patient goals.
Discussion In this article, we address patient selection, preoperative planning, and intraoperative technique required to perform
the three types of abdominoperineal resections for rectal cancer: extrasphincteric, extralevator, and intersphincteric. Attention is
paid not only to traditional oncologic outcomes such as recurrence and survival but also to patient-reported outcomes and quality
of life.

Keywords Rectal cancer . Total mesorectal excision . Abdominoperineal resection . Abdominoperineal excision . Extralevator
abdominoperineal excision . APR . APE . ELAPE

Introduction

Alexander T. Hawkins and Katherine Albutt have contributed equally and
share first authorship.
Disclosure Information
Authors: Alexander T. Hawkins, M.D., M.P.H., has nothing to disclose.
Katherine Albutt, M.D., M.P.H., has nothing to disclose. Paul E. Wise,
M.D., has nothing to disclose. Karim Alavi, M.D., M.P.H., has nothing to
disclose. Ranjan Sudan, M.D., has nothing to disclose. Andreas M.
Kaiser, M.D., has nothing to disclose. Liliana Bordeianou, M.D.,
M.P.H., nothing to disclose. Editors-in-Chief: Richard A. Hodin, M.D.,
Timothy M. Pawlik, M.D., M.P.H., Ph.D., has nothing to disclose. CME
Overseers: Arbiter: Timothy M. Pawlik, M.D., M.P.H., Ph.D., has
nothing to disclose. Vice-Arbiter: Melanie Morris, M.D., has nothing to
disclose. Question Reviewers: Melanie Morris, M.D., has nothing to
disclose. Luca Stocchi, M.D., has nothing to disclose.
CME questions for this article available to SSAT members at http://ssat.
com/jogscme/
Learning Objectives After completing this manuscript, the reader will
be able to describe the historical background of the abdominoperineal
resection (APR) for rectal cancer, appreciate the preoperative workup
and planning for the procedure, understand the three variants of APR
(intersphincteric, extrasphincteric, and extralevator), and be familiar with
postoperative outcomes.
* Alexander T. Hawkins
alexander.hawkins@vanderbilt.edu
Extended author information available on the last page of the article
Colorectal adenocarcinoma remains the second most com-
mon cancer and the third leading cause of cancer death in the
USA. Much has changed in the surgical management of
rectal carcinoma since it was first identified, from a pallia-
tive defunctioning colostomy in the eighteenth century to
today’s complex laparoscopic and robotic resections. This
article aims to provide an overview of the indications, tech-
niques, and outcomes for abdominoperineal resection for
rectal cancer in the twenty-first century.
Historical Background
Once a fatal disease, rectal cancer was considered incurable
until the 18th century. It was at that time that Giovanni
Morgagni first proposed resection of the rectum as a modality
to treat the condition. Pioneers of surgery revolutionized tech-
niques that decreased recurrence and increased survival:
Jacques Lisfranc performed the first successful excision of a
rectal tumor in 1826, Emil Kocher closed the anus to reduce
spillage and infection in 1874, Carl Gaussenbauer performed
the first resection via an abdominal approach in 1879, and
Paul Kraske developed a new technique for removing the

rectum perineally in 1885. In the late nineteenth century, new
techniques rapidly developed including Vincent Czerny’s at-
tempt at a combined abdominal and perineal resection.
Unfortunately, these techniques were marred by intolerable
complication rates, dismal functional results, high rates of
recurrence (as high as 80%), and poor survival (operative
mortality rates around 20% and 3-year survival at < 15%).1
Recognizing the problem of local recurrence, Sir William
Ernest Miles realized the need for a more radical anal and
rectal excision, introducing the basis of modern rectal cancer
surgery with his seminal publication in the Lancet in 1908. By
understanding the natural history of the disease and the con-
cept of lymphatic spread, he designed a procedure—the
abdominoperineal resection (APR)—to remove the rectum
and the “upward zone of spread” with an “anatomically cor-
rect” resection.2 The original Miles operation included resec-
tion of the whole pelvic colon and mesorectum, lymphadenec-
tomy of the iliac bifurcation, and a wide perineal resection
including the anus and levator ani muscles. See Table 1 for
basic principles of Miles resection.3
While mortality was high initially, Miles’s concept and
execution led to a dramatically reduced recurrence rate of
29%. Attempts to further reduce operative mortality by
performing the procedure in two stages, an initial laparoto-
my and colostomy followed by perineal excision at a later
date, were advocated by many.4 In 1934, Martin Kirschner
demonstrated a combined and synchronous approach to the
APR with two surgical teams working in parallel fashion to
perform a one-stage operation. For decades, APR was the
standard of care for all rectal cancers. Over time, several
pathological studies demonstrated that lymphatic spread oc-
curred mainly cephalad and gave credence to the concept of
sparing part of the rectum without compromising the onco-
logic outcome.
With new techniques such as sphincter preservation, total
mesorectal excision (TME), and oncologically sound low
Table 1 Basic principles of Miles abdominoperineal resection
Principle 1 Creation of a permanent abdominal anus (colostomy)
Principle 2 Removal of the whole pelvic colon (with the exception
of the part from which the colostomy is made),
because its blood supply is contained in the zone
of upward spread
Principle 3 Resection of the whole of the pelvic mesocolon
below the point where it crosses the common
iliac artery, together with a strip of peritoneum
at least an inch wide on either side
Principle 4 Removal of the group of lymph nodes situated
over the bifurcation of the common iliac artery
Principle 5 Wide perineal resection including the levator ani
muscle (to extirpate the lateral and downward
zones of spread)
J Gastrointest Surg
anterior resections (LARs), the indications for APR became
increasingly limited.5,6
Indications
Improved techniques and advances in technology have led to
steadily decreasing APR rates. Indeed, the necessary distal
resection margin (DRM) for cure of these cancers continues
to decrease with a better understanding of cancer biology,
especially as maintenance of intestinal continuity and sphinc-
ter preservation have become the goal of operative treatment.
What was once the “5 cm rule” for DRM was effectively
challenged and reduced to margins of 1 cm or less in the
setting of TME and multimodality therapy. The emergence
and tolerability of neoadjuvant therapy has led to improved
local control and significant downstaging and downsizing of
these cancers, rendering a sphincter-preserving approach fea-
sible in many cases.7 These anatomic and pathologic discov-
eries paralleled the development of technological advances,
such as circular staplers, that further facilitated low pelvic
anastomoses. Together, the acceptance of the smaller DRM,
adoption of TME, emergence of improved neoadjuvant ther-
apy, and technological advances have dramatically reduced
the frequency with which APR is performed.8
Despite the decreasing APR rates over the past 50 years, it
remains the appropriate approach for many situations. We
advocate for an APR tailored to the aims of resection
(Fig. 1). For example, an intersphincteric approach remains
the procedure of choice for complete resection of rectal mu-
cosa at risk for neoplasia in patients with Crohn’s disease. At
the other end of the spectrum, a more extensive APR is im-
perative for cancers that involve the sphincter complex or that
cannot be removed with an adequate DRM. Finally, an APR
may be the best surgery for elderly adults as well as those with
poor baseline functional status.
Patient Selection
When considering radical excision of a rectal cancer, the lo-
cation of the tumor, ability to obtain adequate margins, patient
preference, patient functional status, and preoperative bowel
function must guide patient selection. A thorough physical
exam, including a digital rectal exam (DRE), can help deter-
mine whether an APR is indicated. Distance from landmarks
such as the anal verge is to be discouraged as the sole deter-
minant, due to a lack of standardization of terms and differ-
ences in anal canal length. Inability to “hook” the levators
distal to the tumor on DRE indicates a low distal resection
margin that usually necessitates an APR, though exceptions
can be made for T1 tumors in patients willing to undergo
partial or total intersphincteric LARs.8
J Gastrointest Surg
Fig. 1 Algorithm for selection of
appropriate APR technique. CRM
circumferential resection margin
Imaging and Staging
For both prognosis and treatment, accurate staging of rectal
cancer is essential. Axial imaging should be obtained to facil-
itate appropriate operative planning. Metastatic disease bur-
den should be assessed with computed tomography (CT) scan
of the chest, abdomen, and pelvis. Tumor and nodal staging is
achieved with either MRI or endorectal ultrasound (EUS),
though MRI is preferred. Through evaluation of the circum-
ferential resection margin (CRM), the MERCURY trial deter-
mined that MRI can independently predict surgical resectabil-
ity, overall survival, and local recurrence.9 Furthermore, the
MERCURY II trial validated MRI assessment of the low rec-
tal plane, reducing pathologic CRM involvement and
avoiding overtreatment through selective preoperative therapy
and rationalized use of permanent colostomy. It also high-
lights the importance of posttreatment restaging with MRI.10
Based on this data, we recommend MRI instead of EUS both
before and after neoadjuvant treatment to assess sphincter in-
volvement and need for APR.
Neoadjuvant Therapy
Multimodality therapy, represented by neoadjuvant chemo-
therapy and radiation, in locally advanced (cT3–T4) rectal
cancer has resulted in tumor shrinkage, potentially facilitating
R0 resection and reduced rates of recurrence, both locally and
distantly. Radiotherapy on the order of 45–50.4 Gy in 25–28
doses is standard, given in conjunction with chemotherapy,
typically 5-FU and leucovorin. After 6–8 weeks to allow for
tumor response, most patients proceed to surgery. While this is
the standard of care in the USA, short-course radiotherapy is
also an option as well, especially for those with metastatic
disease. Interestingly, neoadjuvant therapy does not seem to
facilitate sphincter preservation or meaningfully increase the
rate of anterior resection.11–13
The decision to pursue neoadjuvant therapy is based on
stage, level, and patient/provider preference. Current national
guidelines recommend neoadjuvant chemoradiation therapy
for patients who are clinically staged T3 or greater, have clin-
ical nodal disease, or have a threatened margin on MRI.
Patients who are clinical staged as T1–2 with no evidence of
nodal disease may proceed to upfront resection.14
Preoperative Planning
Preoperative stoma marking and education ensures optimal
positioning and facilitates stoma care and function. The use
of preoperative oral antibiotics is recommended to reduce
SSI.15 Mechanical bowel preparation facilitates complete
evacuation of the colon when safe and feasible. Preoperative
intravenous antibiotics should be administered within 1 h of
incision, and deep venous thrombosis prophylaxis is standard.
In cases where identification of the ureter is expected to be
more challenging, such as in obese patients or those having
undergone previous pelvic surgery, preoperative ureteral stent
placement may be considered to facilitate identification of the
ureter.
Laparoscopic Versus Open APR
When performed with a transanal extraction, the cosmetic
result of a laparoscopic APR is striking with an abdomen
notable only for a few port sites and colostomy without a large
laparotomy incision. The data on laparoscopic versus open
APR generally parallel outcomes of laparoscopic surgery—
less pain, shorter length of stay (LOS), and earlier return of
bowel function.16 Results of studies investigating oncologic
outcomes are mixed. Earlier studies, including a meta-analy-
sis, suggested oncologic equivalence for laparoscopic versus
open APR.17,18 The COREAN trial randomized patients with
mid or low rectal cancers to either laparoscopic or open resec-
tion with 12.6% of patients in the trial undergoing an APR. Of
those patients, CRM positivity was similar between open and
laparoscopic groups (8.3 vs 5.3%).19 The MRC CLASICC

trial had 13% of their cohort undergo APR and showed no
difference in the 5-year disease-free survival rate between
open and laparoscopic approaches (36.2 vs 41.4%,
respectively).20 However, two recent, randomized controlled
trials examining the larger role of laparoscopy in rectal cancer
resection have questioned these conclusions. The ACOSOG
Z6051 trial randomized patients with rectal cancer to a lapa-
roscopic or open resection with over 20% of patients under-
going APR. While no difference was seen in length of stay,
readmission, or severe complications, patients with stage II or
III rectal cancer who underwent laparoscopic resection failed
to meet the criterion for non-inferiority for pathologic out-
comes when compared to open resection.21 A similar study
reached the same conclusions, although the rate of APR was
< 10% in that study.22 Long-term clinical outcomes are pend-
ing from both trials. In light of this data, the surgical approach
needs to be tailored to the surgeon’s skill in laparoscopic sur-
gery, need for concomitant procedures, and stage, location,
and CRM status of the tumor. In some patients, a hybrid of
laparoscopic intra-abdominal colon mobilization and open
proctectomy though a smaller incision should be a
consideration.
Robotic-assisted surgery has been forwarded as a tool to
improve minimally invasive outcomes in APR. Small case
studies have shown the feasibility of the approach.23,24 An
analysis of a large, national cancer database comparing lapa-
roscopic and robotic low anterior resection found that after
propensity matching, robotic surgery was associated with low-
er conversion rates (9.5 vs 16.4%, P < 0.001). There were no
significant differences in lymph node retrieval, margin status,
30-day mortality, readmission, or LOS.25 Controlled studies
examining the role of the robot in rectal cancer resection are
currently ongoing.26 Preliminary data from the ROLLAR trial
did not suggest superiority to laparoscopic surgery from the
standpoint of quality of TME, but full results are pending.27
While minimally invasive techniques have some clear ad-
vantages, current data questions its role in improving onco-
logic outcomes for the treatment of rectal cancer. Therefore, a
minimally invasive approach can be considered by surgeons
with advanced training, provided that the surgeon is confident
that the anatomical planes visualized on a preoperative MRI
allow for an oncologically sound resection.
Traditional Extrasphincteric APR
General Concepts
Removal of the distal colon, entire rectum and mesorectum,
anal canal, and anus with construction of a permanent end
colostomy is the hallmark of an APR. The abdominal and
perineal phases of the operation may proceed sequentially or
concomitantly.
J Gastrointest Surg
Technique
The abdominal portion of the operation generally follows the
same technique as an LAR with TME. The perineal portion is
designed to excise the anal canal with a wide margin and can
either be performed in lithotomy or in prone position after
closure of the abdomen and creation of the stoma. While tra-
ditionally performed in lithotomy, some surgeons advocate for
prone positioning (as Miles described) after completion of the
intra-abdominal portion, including abdominal closure (see be-
low), especially for tumors that are located more anteriorly.
This approach is supported by data showing decreases in op-
erative time, blood loss, and complication rates with prone
jackknife positioning.28 Prone positing can be used when
performing an en bloc vaginectomy or when planning a flap
reconstruction. To prevent contamination, the anus can be
securely sutured closed. An elliptical incision is then made
around the anus outside the sphincter complex (using the coc-
cyx, perineal body, and ischia as guides) (Fig. 2a).
Subsequently, the ischiorectal fat is circumferentially dissect-
ed until the levators are reached. The abdominal cavity is
entered by cutting the anococcygeal ligament to enter the
presacral space (the coccyx can be excised, if needed, to fa-
cilitate entry or a margin-negative resection). The specimen is
then exteriorized through the posterior opening, after lateral
division of the levators (Fig. 2b), to allow dissection of the
remainder of the specimen away from the vagina/prostate. The
specimen is then removed through the perineal wound. The
wound is then extensively washed out and closed. Depending
on the size of the defect, it may either be closed in multiple
layers or necessitate alternative closure techniques. A closed-
suction drain can be left in the deep space, through either the
abdominal or perineal incision. At this stage, a standard tre-
phine is created and the distal colon is brought through the
abdominal wall at the intended colostomy site and matured in
the traditional fashion as the abdomen is closed. This step may
be completed before flipping to the prone position, as pelvic
drain placement should be the one desired. Mesh prophylaxis
at the time of stoma formation appears safe and effective in
preventing parastomal hernia; however, limitations of the pri-
mary evidence justify larger, more rigorous randomized con-
trolled trials.29,30
Complications
Challenging anatomy, complex patient positioning, and long
operative times all subject APR patients to the risks of major
surgery. As with other colorectal operations, injury to adjacent
organs such as the spleen, small bowel, pancreas, and gastric
body is possible during the abdominal portion of the operation
as are injuries to pelvic structures during the perineal portion.
Life-threatening hemorrhage is rare and usually arises from
injury to the presacral plexus or internal iliac vessels.
J Gastrointest Surg
Fig. 2 Perineal dissection. a The anus is sutured closed. The coccyx,
perineal body, and ischia are identified. b The specimen is exteriorized
through the posterior opening with lateral division of the levators
Inadvertent injury to the large-caliber and high-pressure veins
contained within the presacral complex can lead to catastroph-
ic bleeding that may be difficult to control. Postoperative ileus
can be an expected physiologic response with an incidence of
up to 30%.31 Early postoperative small bowel obstruction may
also occur and is often cited to be the most frequent compli-
cation in the early postoperative period, likely due to small
bowel adhering to the presacral space. Complications related
to the need for a permanent colostomy such as parastomal
hernias and stomal prolapse are also possible in both the short
and long terms.
Numerous technical challenges are associated with rectal
resection, including preservation of the ureters and urethra, sa-
cral venous plexus, and pelvic autonomic nerves, all of which
play critical roles in genitourinary and sexual function. During
the abdominal portion of the operation, the ureter is at risk,
while during the anterior portion of the perineal resection in
males, the membranous urethra is more susceptible to inadver-
tent injury. Ligation of the superior rectal arteries, mobilization
of the upper mesorectum, dissection deep in the pelvis, and the
most cephalad portion of the perineal dissection are the portions
of the operation most commonly associated with ureteral injury.
Both the sympathetic and parasympathetic components of
the pelvic autonomic nervous system may be subject to injury,
leading to urinary and sexual dysfunction in both males and
females. At the level of their origin from the aortic plexus
during high ligation of the artery and also during dissection
at the sacral promontory into the TME plane, sympathetic
nerves are at risk. During the lateral dissection, especially dur-
ing the division of lateral ligaments and anterolateral dissec-
tion, the parasympathetic nerves may also be compromised.
Lastly, damage to the inferior hypogastric nerve plexus may
occur during dissection of the rectum from adjacent structures
including the bladder, ureter, prostate, seminal vesicles, corpus
cavernosa, and others. Additional risk factors for urinary dys-
function include tumor < 5 cm from the anal verge, neoadju-
vant radiation therapy, age > 65 years, and intra-abdominal
sepsis.32 Similarly, sexual dysfunction may occur postopera-
tively in both men and women and is related to the degree of
pelvic nerve dissection. Damage to autonomic nerves as well
as anatomic changes within the pelvis are thought to lead to
retrograde ejaculation, erectile dysfunction, diminished sexual
drive, vaginal dryness, altered orgasm, and dyspareunia,
among others. Reported rates of sexual dysfunction in such
patients range from 23 to 69% in men and from 19 to 62% in
women following surgery for rectal cancer.33 Nerve dysfunc-
tion should be discussed with patients prior to surgery, and care
should be taken to prevent accidental injury intraoperatively.
Categorized as clean-contaminated procedures, patients
undergoing APR are at risk of developing superficial or
intra-abdominal surgical site infections (SSIs). Studies cite a
wide range of SSI incidence among patients undergoing colo-
rectal cancer surgery, ranging from 1 to 30% with an average
of around 10%.34 A recent multicenter randomized control
trial analyzed the incidence of SSI in 582 patients undergoing
laparoscopic colorectal resections. The incidence of SSI in
rectal surgery was significantly higher than that in colon sur-
gery (relative risk 1.65, 95% CI 1.02–2.67).35 For APR spe-
cifically, the incidence of incisional SSI was 24% and organ/
space SSI was 9.5%. Consistent with previous reports, APR
and colostomy creation were found to be independently pre-
dictive of the development of incisional SSI.
The creation of a perineal wound poses a unique risk to
patients undergoing APR, and complications are common.
The range of complications spans from perineal hemorrhage
to persistent perineal sinus and perineal hernia.36 The risk of
perineal wound complications following an APR ranges from
14 to 80% in some series and includes surgical site infection,

abscess, dehiscence, and delayed healing. A retrospective re-
view of patients undergoing an APR found a major perineal
wound complication (> 2 cm dehiscence, perineal abscess, or
any wound requiring reoperation or readmission) which oc-
curred in 14% of patients and a minor perineal wound com-
plication (< 2 cm dehiscence, stitch abscess, or sinus tracts)
which occurred in 24%.37
Survivorship
For patients undergoing APR with curative intent, perhaps
one of the most devastating complications is local recurrence.
Variable results regarding recurrence rates for traditional
extrasphincteric APR have been reported. A retrospective re-
view of 655 patients undergoing APR for low rectal cancers in
whom a 1-cm histologically negative DRM could not be
achieved by a sphincter-preserving approach documented a
5-year cumulative local recurrence rate of 5.5%.38 Data from
the National Surgical Adjuvant Breast and Bowel Project
(NSABP) R-01 reveals a similar local recurrence rate of 5%
for patients undergoing an APR.39
A recent retrospective pooled analysis of 14 rectal cancer
studies identified positive CRMs in 10% of APR specimens as
compared to 5% of anterior resection specimens.40 Among
these patients, local recurrence rates were elevated (20 vs
11%) and 5-year survival was worse (59 vs 70%) in patients
who underwent APR as opposed to LAR. However, cancers in
patients undergoing APR tend to be lower and more locally
advanced at the time of operation. Standardization and perfor-
mance improvement of the perineal phase have led to a reduc-
tion in margin positivity and local recurrence. Focus on these
elements on the national level in the Netherlands has closed
the gap between APR and LAR CRM positivity.41 Such im-
provements in technique have rendered it possible for a patient
undergoing APR to have comparable oncologic outcomes to
patients undergoing LAR, despite the presence of a lower and
perhaps more advanced cancer. Among patients undergoing
APR, 5-year cause-specific survival and all-stage disease-free
survival were 91.3 and 90.2%, respectively.38
Extralevator APR
General Concepts
Despite the advent of TME and preoperative chemoradiation,
local failure remained a prominent issue with the traditional
extrasphincteric APR. Compared with patients undergoing
LAR, patients undergoing APR have higher rates of positive
resection margins, higher rates of local recurrence, and poorer
survival. The frequency of CRM involvement for APR has not
diminished with TME. CRM involvement in the APR speci-
mens is related to the removal of less tissue at the level of the
J Gastrointest Surg
tumor in an APR (“coning in”). Where possible, a more rad-
ical operation should be considered for all low rectal
cancers.40,42 A biological basis for this comes with the obser-
vation that the distal rectum is devoid of the mesorectum. Any
extension though the muscularis propria can result in a posi-
tive CRM. In 2005, Nagtegaal et al. called for a radical change
of approach, citing the high frequency of margin involvement
and perforation using traditional APR techniques. 43
Alternative approaches involving a wide perineal resection
evolved, with terms including “extended APR,” “extralevator
abdominoperineal excision (ELAPE),” “cylindrical APR,” or
“Holm cylindrical abdominoperineal excision” used to de-
scribe such an approach. The essential difference with this
approach is the lateral extent of rectal resection, a principle
of Miles that had long been forgotten.
Technique
In this technique, the lateral limits of resection are extended to
the origin of the levator muscles at the pelvic sidewall
(Fig. 3c). This is a more extensive resection than the minimal
division of the levators, if any, that occurs close to the external
anal sphincter in the traditional APR (Fig. 3b). The abdominal
portion of the procedure ends higher in the pelvis, at the upper
border of the coccyx posteriorly, just below the autonomic
nerves laterally and anteriorly just below the seminal vesicles
in men or just below the cervix uteri in women. The divided
left colon is brought out to form a colostomy, and the abdomen
is closed. At this point, the surgeon begins the perineal dissec-
tion. After the skin and the extrasphincteric ischioanal fat are
incised, the surgeon then pulls the ischioanal flaps laterally
along the levator ani to allow division of the levator ani mus-
cle along its sidewall attachments to avoid “coning in” and
creating a “waist” in the specimen. This allows removal of
more tissue around the tumors involving the levator ani and
decreases a risk of tumor perforation at the point of separation
of the rectum from the levator muscles.
A modification of the full ELAPE is the “selective
extralevator dissection.” This technique utilizes preopera-
tive imaging and examination to only apply the full ELAPE
on the side of the tumor while leaving the levator intact on
the opposite side. The selective use of the ELAPE is
championed as not all patients seem to benefit from the
technique, and there are significantly more short-term com-
plications after extralevator APR.44 ELAPE should be the
preferred approach for low rectal tumors with involvement
of the levators. For those cases in which levators are not
involved, as shown in preoperative MRI, the current evi-
dence is insufficient to recommend ELAPE over conven-
tional APR. This stresses the importance of preoperative
MRI at both initial diagnosis and following neoadjuvant
therapy in determining the best approach for an individual
patient with potentially threatened CRM.10,45
J Gastrointest Surg
Fig. 3 Planes for APR resection. a Intersphincteric. b Extrasphincteric. c
Extralevator. Artwork by Wali Johnson, M.D.
Complications
Not surprisingly, when compared to conventional APR,
extralevator APR patients have increased perineal
complications.46 The increase in tissue resection makes clo-
sure more difficult. Prytz et al. found significantly more post-
operative wound infections for ELAPE than for APR (20 vs
12%).44 Sexual dysfunction, urinary retention, and chronic
perineal pain all appear to be increased in ELAPE.47,48
Chronic perineal pain is associated with coccygectomy, but
the pain gradually eased over time. Various methods of
perineal wound reconstruction have been proposed to lower
the rate of perineal wound complications.
Survivorship
As mentioned above, ELAPE was developed as a response to
poor short- and long-term oncologic outcomes with traditional
APR. Early studies have shown improved immediate patho-
logic results, but larger and more recent data with long-term
oncological results calls into question the value of ELAPE. In
an early report comparing ELAPE to conventional APR, Holm
et al. demonstrated a marked reduction in CRM involvement
and perforation with ELAPE.49 West et al. compared 176
extralevator APRs with 124 standard resections. Extralevator
APR removed more tissue, leading to a reduction in CRM
involvement from 50 to 20% and intraoperative perforation
from 28 to 8% compared with standard surgery.46 Similarly,
low rates of CRM involvement and perforation have been sub-
sequently observed.45,48,50 Standing in contrast to these find-
ings, a population-based study from Denmark of 554 patients
reported that not only did resection of low rectal cancers by
ELAPE fail to improve short-term oncological results, but the
operation was an independent risk factor for a positive CRM.51
Data on long-term oncologic results is mixed. A random-
ized controlled trial by Han et al. reported reduced recurrence
rates after ELAPE, suggesting that there is an oncological
advantage with ELAPE in comparison with traditional APR
in patients with T3 and T4 tumors.48 In a subsequent study, the
same group reported a local recurrence rate of 4.9% at a me-
dian follow-up of 44 months.47 Ortiz and colleagues described
propensity score-matched data on 914 patients with no advan-
tage for ELAPE in CRM involvement, intraoperative tumor
perforation, local recurrence, or mortality.52 The largest and
most robust follow-up study to date was recently reported by
Prytz et al. In a population-based analysis of 519 ELAPE
patients, the local recurrence rates at 3 years were significantly
higher for ELAPE compared with APR. There was no differ-
ence in the 3-year overall survival between APR and ELAPE.
However, in the subgroup of patients with very low tumors (≤
4 cm from the anal verge), no significant difference in the local
recurrence rate could be observed.53
In light of the recognized increased morbidity of ELAPE
along with the mixed long-term oncologic results, more data is
needed to substantiate the claim that ELAPE is the superior
oncologic treatment for rectal cancer. It should be used with
discretion, primarily for cases with a high risk of intraoperative
perforation or explicit involvement of the levators on MRI.
Intersphincteric APR
Intersphincteric APR has a unique role in the surgical arma-
mentarium, and it is mostly limited to the patients who present

with inflammatory bowel disease (IBD)-related dysplasia or
malignancy that does not involve the anal sphincter complex.
For Crohn’s patients and for a select group of ulcerative colitis
patients (poor baseline continence, shortened bowel, etc.) in
whom an ileal pouch anal anastomosis is not advisable, an
intersphincteric APR with end ileostomy is the recommended
procedure.
Intersphincteric APR may also be considered for patients
with very low rectal cancers in which the tumor does not
directly involve the anal sphincter complex, yet a transection
below the level of the tumor requires sphincter removal to
assure a reasonable DRM.8
Technique
The abdominal portion of the procedure remains the same as
the extrasphincteric APR. So, as long as there is no tumor in
the anus, the perineal portion can be performed through the
intersphincteric plane as the goal is merely to resect the entire
rectal wall (Fig. 3a). The intersphincteric plane allows resec-
tion of the mucosa, submucosa, and muscularis, while
avoiding unnecessary removal of the external sphincter, which
is not a part of the rectum. This allows for easier, tension-free
primary closure of the sphincter complex.
Complications and Survivorship
Data on intersphincteric APR is limited due to the narrow
indication for the procedure. Bauer et al. studied 388 patients
with IBD undergoing an intersphincteric resection and found
rates of perineal wound non-healing and sexual dysfunction to
be less than 1%, respectively.54 Further data on the use of an
intersphincteric approach for rectal cancer will be generated
by the HAPIrect trial, in which Hartmann’s procedure will be
compared with intersphincteric abdominoperineal excision in
patients with rectal cancer unsuitable for an anterior
resection.55
Patient-Centered Outcomes
In addition to oncologic outcomes, patient-centered out-
comes (PCOs) are an equally important endpoint for pa-
tients with rectal cancer undergoing APR. PCOs in pa-
tients with locally advanced rectal cancer are important
to study because the treatment is multimodal and impacts
not only overall quality of life (QOL) but also, specifical-
ly, bladder, bowel, and sexual function. A recent 5-year
prospective study of health-related QOL after colorectal
cancer demonstrated that both rectal cancer and the pres-
ence of a permanent stoma are risk factors for poorer
QOL.56 A number of studies have examined PCOs for
patients with an APR relative to those undergoing LAR.
J Gastrointest Surg
A 2012 Cochrane Review on QOL after resection for rec-
tal cancer identified 35 observational studies (with 5127
patients) that used validated QOL instruments in patients
who underwent anterior resection or APR. While the stud-
ies included in the review did not allow for definitive
conclusions as to the superiority of QOL of people after
LAR or APR, the included studies challenged the assump-
tion that anterior resection patients fare better.57 More
recent prospective studies have helped to clarify PCOs
after APR. How et al. compared the 1-year QOL in pa-
tients after APR versus LAR for low rectal cancer and
found that patients who underwent LAR were younger
and had worse GI function (including issues with incon-
tinence). In contrast, patients who underwent LAR report-
ed better sexual function.58 Russel et al. studied 987 pa-
tients with rectal cancer and found no difference in the
overall QOL between the APR and LAR groups at 1 year
after surgery. Baseline sexual function and symptoms in
the GI tract were worse in the patients who underwent
APR, which they suggested was related to the low loca-
tion of the rectal tumor. However, there was no difference
in the sexual function between the APR and LAR groups
at 1 year, whereas the patients who underwent LAR had
worse GI symptoms after surgery than did those who
underwent APR.59 Though a large amount of heterogene-
ity exists in the literature, APR patients should be
counseled preoperatively in regard to potential issues with
urinary function, sexual function, and body image.
Conclusions
The APR has evolved significantly since the time of Miles.
However, the same principles of radical resection with the
goal of cure remain. The addition of neoadjuvant therapy,
MRI imaging, extended resection in patients with threatened
margins, and novel closure techniques all add nuance to the
procedure and allow for tailoring the extent of resection.
Despite these adjuncts and nuances, thoughtful and meticu-
lous surgery offers the patient undergoing APR the best
chance for survival and function after their resection.
Acknowledgements The authors would like to acknowledge Wali
Johnson, M.D., for Fig. 3a–c. The authors would like to thank Anne
Hawkins for her proofreading and editing.
Author Contribution All authors have provided substantial contributions
to the conception or design of the work or to the acquisition, analysis, or
interpretation of the data for the work; drafted the work or revised it
critically for important intellectual content; approved the version to be
published; and agreed to be accountable for all aspects of the work in
ensuring that questions related to the accuracy or integrity of any part of
the work are appropriately investigated and resolved.
J Gastrointest Surg
Funding Information This work was not funded.
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J Gastrointest Surg

59. Russell MM, Ganz PA, Lopa S, Yothers G, Ko CY, Arora A et al. 3. Patients with inflammatory bowel disease (IBD)-related
Comparative effectiveness of sphincter-sparing surgery versus malignancy that does not involve the anal sphincter complex
abdominoperineal resection in rectal cancer: patient-reported out- 4. All patients that undergo neo-adjuvant chemoradiation therapy
comes in National Surgical Adjuvant Breast and Bowel Project
randomized trial R-04. Ann Surg. 2015;261(1):144–8. doi:https:// Risk factors for post-operative urinary dysfunction include all of the fol-
doi.org/10.1097/sla.0000000000000594. lowing EXCEPT:
1. Grade of Tumor
2. Tumor < 5 cm from the anal verge
Questions: 3. Neoadjuvant radiation therapy
Pre-operative work up should include all of the following EXCEPT: 4. Age > 65 years
1. Appointment with a Wound Ostomy Care Nurse Five-year local recurrence after an APR with negative margins is
approximately:
2. Pelvic MRI
1. 1%
3. CT scan of chest, abdomen and pelvis
2. 5%
4. Brain MRI
3. 10%
With regards to pathologic outcomes, the main conclusion from the
ACOSOG Z6051 trial was that: 4. 20%
1. A laparoscopic approach is superior The essential difference between and extralevator and extrasphincteric
APR is:
2. A robotic approach is superior
1. Lateral extent of rectal resection to divide levator muscles at their
3. An open approach is superior
origin.
4. A laparoscopic approach fails to meet the criteria for non-inferiority
2. Siting of the ostomy in the right lower quadrant.
Intersphincteric APR is appropriate for:
3. Use of a higher dose of radiation in preoperative therapy.
1. Patient with anal cancer
4. Prone positioning
2. Patients with poor pre-operative continence

Affiliations

Alexander T. Hawkins 1,2 & Katherine Albutt 1 & Paul E. Wise 3 & Karim Alavi 4 & Ranjan Sudan 5 & Andreas M. Kaiser 6 &
Liliana Bordeianou 1

1 4
Department of Surgery, Section of Colon and Rectal Surgery, Department of Surgery, UMass Memorial Medical Center,
Massachusetts General Hospital, Boston, MA, USA Worcester, MA, USA
2 5
Division of General Surgery, Section of Colon and Rectal Department of Surgery, Duke University Medical Center,
Surgery, Vanderbilt University, 1161 21st Ave South, Room Durham, NC, USA
D5248 MCN, Nashville, TN 37232, USA 6
Department of Colorectal Surgery, University of Southern
3
Section of Colon and Rectal Surgery, Washington University in California, Los Angeles, CA, USA
St. Louis, St. Louis, MO, USA