The decision to perform an abdominoperineal resection (APR) over restorative bowel resection relies on a number of clinical factors. There remains great variability in APR rates internationally. The aim of this study was to demonstrate trends of APR surgery in low rectal cancer (<6cm) in Australasia and identify predictors of non-restoration.
A review of a prospectively maintained colorectal registry- the Binational Colorectal Cancer Audit(BCCA) from General/Colorectal Surgical Units across Australia and New Zealand. Data were analysed to determine factors predictive of non-restorative resection. Patients were analysed based on the presence (control) or absence (comparison) of a primary anastomosis.
Of 3628 patients with rectal cancer, 2096 patients were diagnosed with low rectal cancer between 2007 and 2017. The incidence of APR remained constant over the study period with 58% of all low rectal cancer resections undergoing APR. The majority of resections were performed by consultants in urban hospitals (86%v14%). Tumours at or less than 3cm from anal verge, T4, M1 disease and neoadjuvant therapy were the greatest predictors of APR (p<0.001). A significantly increased rate of restorative surgery was observed in the public hospital setting (59%v41%, p<0.05). CRM positivity was 7.95% with significantly increased rates in patients undergoing APR (12.2%v6.2%, p<0.001). CRM was increased in open approaches, T4, N2 and M1 staged disease and in an emergency/urgent setting (p<0.001,0.045 respectively). Significantly increased wound and pulmonary complications were observed in the APR cohort(p<0.01).
The rates of APR in Australia and New Zealand remain high but comparable internationally with one third of rectal cancers undergoing APR. The main determinants of APR are tumour height, T stage and neoadjuvant therapy requirement. CRM positivity was higher in APR patients.

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