Extralevator abdominoperineal excision for low rectal cancer: a systematic review and meta-analysis of the short-term outcome

Aim: The superiority of extralevator abdominoperineal excision (ELAPE) over conventional abdominoperineal excision (APE) remains controversial, despite the publication of many studies on this issue. The aim of this meta-analysis was to provide a clear, evidence-based comparison of the two procedures.

Method: A systematic review and meta-analysis was conducted through a comprehensive search of the PubMed, EMBASE/Medline and Cochrane Central Library databases for all studies comparing ELAPE with conventional APE for low rectal cancer. Pooled data on circumferential resection margin (CRM) positivity, intra-operative bowel perforation, perineal wound complications and local recurrence were analysed.

Results: Seven studies, involving a total of 2672 patients, were included. Analysis of the pooled data did not reveal a significant difference between the two operations regarding CRM positivity [risk ratio (RR) = 0.79, 95% CI: 0.40-1.57; P = 0.50, I(2) = 86%] and perineal wound complications (RR = 0.91, 95% CI: 0.71-1.16; P = 0.44, I(2) = 49%), and showed a borderline reduced risk of intra-operative bowel perforation for ELAPE, but still did not reveal a significant difference between the two groups (RR = 0.61, 95% CI: 0.37-1.00; P = 0.05, I(2) = 58%).

Conclusion: The current evidence does not indicate a statistically significant superiority of ELAPE over conventional APE in terms of CRM positivity and intra-operative bowel perforation.