Wound Complications and Perineal Pain After Extralevator Versus Standard Abdominoperineal Excision: A Nationwide Study

BACKGROUND: Extralevator abdominoperineal excision was introduced as an alternative to conventional abdominoperineal excision for low rectal cancers. The perineal dissection is more extensive with extralevator abdominoperineal excision and leaves a greater defect. OBJECTIVE: The aim of this study was to evaluate, on a national basis, the risk of perineal wound complications, pain, and hernia after conventional and extralevator abdominoperineal excision performed for low rectal cancer. DESIGN: This was a retrospective study collecting data from the Danish Colorectal Cancer Group database and from electronic medical files of patients. SETTINGS: The study was conducted at Danish surgical departments. PATIENTS: A total of 445 patients operated between 2009 and 2012 with extralevator or conventional abdominoperineal excision were included. MAIN OUTCOME MEASURES: The main end points of this study were perineal wound complications and pain lasting for >30 days after the operation. RESULTS: The 2 groups were demographically similar except for a higher ASA score in the conventional group. In the extralevator group, neoadjuvant chemoradiation was more frequent (71% vs 41%; p < 0.001), T stage was higher (more T3 tumors; 52% vs 38%; p = 0.006), and more tumors were fixed (21% vs 12%; p = 0.02). Perineal wound complications and pain were more frequent after extralevator versus conventional excision (44% vs 25%; p < 0.001 and 38% vs 22%; p < 0.001). After multivariate analyses, neoadjuvant chemoradiation, extralevator excision, and operation early in the study period were found to have a significant influence on the risk of long-term wound complications. Neoadjuvant chemoradiation and wound complications were significant risk factors for long-term perineal pain. Results were similar after subgroup analyses on low tumors only. LIMITATIONS: This was a retrospective study. The 2 groups were not completely comparable at baseline. CONCLUSIONS: Neoadjuvant chemoradiation, extralevator compared with conventional excision, and operation early in the study period were significant factors for predicting perineal wound complications. Neoadjuvant chemoradiation and wound complications were predictors of long-term perineal pain.