Oerskov Kim Morgenstjerne, Bondeven Peter, Laurberg Søren, Hagemann-Madsen Rikke H, Christensen Henrik Kidmose, Lauridsen Henrik, Pedersen Bodil Ginnerup
Department of Radiology, Aarhus University Hospital, Aarhus, Denmark.
Department of Surgery, Randers Regional Hospital, Randers, Denmark.
Front Surg. 2021 Nov 16;8:771107. doi: 10.3389/fsurg.2021.771107. eCollection 2021.
The disparity in outcomes for low rectal cancer may reflect differences in operative approach and quality. The extralevator abdominoperineal excision (ELAPE) was developed to reduce margin involvement in low rectal cancers by widening the excision of the conventional abdominoperineal excision (c-APE) to include the posterior pelvic diaphragm. This study aimed to determine the prevalence and localization of inadvertent residual pelvic diaphragm on postoperative MRI after intended ELAPE and c-APE. A total of 147 patients treated with c-APE or ELAPE for rectal cancer were included. Postoperative MRI was performed on 51% of the cohort ( = 75) and evaluated with regard to the residual pelvic diaphragm by a radiologist trained in pelvic MRI. Patient records, histopathological reports, and standardized photographs were assessed. Pathology and MRI findings were evaluated independently in a blinded fashion. Additionally, preoperative MRIs were evaluated for possible risk factors for margin involvement. Magnetic resonance imaging-detected residual pelvic diaphragm was identified in 45 (75.4%) of 61 patients who underwent ELAPE and in 14 (100%) of 14 patients who underwent c-APE. An increased risk of margin involvement was observed in anteriorly oriented tumors with 16 (22%) of 73 anteriorly oriented tumors presenting with margin involvement vs. 7 (9%) of 74 non-anteriorly oriented tumors ( = 0.038). Residual pelvic diaphragm following abdominoperineal excision can be depicted by postoperative MRI. Inadvertent residual pelvic diaphragm (RPD) was commonly found in the series of patients treated with the ELAPE technique. Anterior tumor orientation was a risk factor for circumferential resection margin (CRM) involvement regardless of surgical approach.
低位直肠癌治疗结果的差异可能反映了手术方式和质量的不同。经腹会阴联合外括约肌切除（ELAPE）术的研发目的是通过扩大传统经腹会阴联合切除术（c-APE）的切除范围以包括盆腔后膈，从而减少低位直肠癌的切缘受累情况。本研究旨在确定在实施ELAPE和c-APE术后的MRI检查中意外残留盆腔膈的发生率及定位。共纳入147例接受c-APE或ELAPE治疗的直肠癌患者。队列中的51%（n = 75）患者接受了术后MRI检查，并由一名接受过盆腔MRI培训的放射科医生对残留盆腔膈进行评估。对患者记录、组织病理学报告和标准化照片进行了评估。病理和MRI检查结果由专人在不知情的情况下独立评估。此外，对术前MRI进行评估以寻找可能的切缘受累风险因素。在接受ELAPE的61例患者中，45例（75.4%）经磁共振成像检测到残留盆腔膈，在接受c-APE的14例患者中，14例（100%）检测到残留盆腔膈。在前位肿瘤患者中观察到切缘受累风险增加，73例前位肿瘤中有16例（22%）出现切缘受累，而74例非前位肿瘤中有7例（9%）出现切缘受累（P = 0.038）。经腹会阴联合切除术后的残留盆腔膈可通过术后MRI显示。在采用ELAPE技术治疗的患者系列中普遍发现意外残留盆腔膈（RPD）。无论采用何种手术方式，肿瘤位于前方都是环周切缘（CRM）受累的一个风险因素。
