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Diseases of the Colon & Rectum Volume 58: 5 (2015)
7. Kariv R, Remzi FH, Lian L, et al. Preoperative colorectal neoplasia increases risk for pouch neoplasia in patients with restorative proctocolectomy. Gastroenterology. 2010;139:806–812.e1. 8. Ault GT, Nunoo-Mensah JW, Johnson L, Vukasin P, Kaiser A, Beart RW Jr. Adenocarcinoma arising in the middle of ileoanal pouches: report of five cases. Dis Colon Rectum. 2009;52:538–541. 9. Lee SW, Sonoda T, Milsom JW. Three cases of adenocarcinoma following restorative proctocolectomy with hand-sewn anastomosis for ulcerative colitis: a review of reported cases in the literature. Colorectal Dis. 2005;7:591–597. 10. Um JW, M’Koma AE. Pouch-related dysplasia and adenocarcinoma following restorative proctocolectomy for ulcerative colitis. Tech Coloproctol. 2011;15:7–16. 11. Ozdemir Y, Kiran RP, Erem HH, et al. Functional outcomes and complications after restorative proctocolectomy and ileal pouch anal anastomosis in the pediatric population. J Am Coll Surg. 2014;218:328–335.
Luca Stocchi, M.D. Jorge Silva-Velazco, M.D. Feza H. Remzi, M.D. Cleveland, Ohio
Time to Rethink ELAPE? To the Editor—Han et al1 present a cohort of patients who underwent extralevator abdominoperineal excision (ELAPE) and recommend its general use for the management of very low rectal cancer in all patients. Ever since Holm et al2 reinvigorated interest in the original operation of Miles, ELAPE has divided opinions. Holm never suggested that ELAPE was an operation for all patients. It is a niche operation to be used when disease dictates the need for a wide perineal dissection. It does nothing to improve the anterior margin (often the site of circumferential resection margin (CRM) positivity) and creates a huge defect requiring either a muscle graft or a biological mesh for closure. This results in a much longer operation and a greatly increased cost. Significant morbidity is inevitable, and oncological gains have only been shown in series where the initial CRM positivity rates were unacceptably high.3 It is hard to countenance a coccygectomy on a patient with an anteriorly placed tumor who will still end up with a positive CRM, but now has chronic pain as an added impediment. Multiple centers have shown that abdominoperineal excision performed by appropriately trained surgeons results in adequate surgical clearance for most patients.4,5 A multicenter study from Spain published earlier this year definitively shows this to be the case.6 The problems posed by anterior tumors will only be resolved by increased use of partial vaginectomy or prostatectomy, not by unnecessarily radical excision of posterior and lateral tissue. The article of Han et al, rather than endorsing the widespread use of ELAPE, highlights all of the problems associated with the technique. High levels of morbidity
and no impact on positivity rates for anterior tumors are the calling cards of ELAPE. A local recurrence rate of 5% refutes even the most tenuous argument of an oncological benefit from this operation. It is time to listen to the growing voices of reason and assign ELAPE for all to the pages of history, under the title “nunquam iterum." REFERENCEs 1. Han JG, Wang ZJ, Qian Q, et al. A prospective multicenter clinical study of extralevator abdominoperineal resection for locally advanced low rectal cancer. Dis Colon Rectum. 2014;57:1333–1340. 2. Holm T, Ljung A, Häggmark T, Jurell G, Lagergren J. Extended abdominoperineal resection with gluteus maximus flap reconstruction of the pelvic floor for rectal cancer. Br J Surg. 2007;94:232–238. 3. West NP, Anderin C, Smith KJ, Holm T, Quirke P; European Extralevator Abdominoperineal Excision Study Group. Multicentre experience with extralevator abdominoperineal excision for low rectal cancer. Br J Surg. 2010;97:588–599. 4. Kennelly RP, Rogers AC, Winter DC; Abdominoperineal Excision Study Group. Multicentre study of circumferential margin positivity and outcomes following abdominoperineal excision for rectal cancer. Br J Surg. 2013;100:160–166. 5. Messenger DE, Cohen Z, Kirsch R, et al. Favorable pathologic and long-term outcomes from the conventional approach to abdominoperineal resection. Dis Colon Rectum. 2011;54:793–802. 6. Ortiz H, Ciga MA, Armendariz P, et al.; Spanish Rectal Cancer Project. Multicentre propensity score-matched analysis of conventional versus extended abdominoperineal excision for low rectal cancer. Br J Surg. 2014;101:874–882.
Rory P. Kennelly, M.D. Desmond C. Winter, M.D., F.R.C.S.I. Dublin, Ireland
Must We Continue to Look for Excuses? To the Editor–I have devoted the majority of my professional career to understanding human papillomavirus–related anorectal disease to prevent anal cancer. Although I disagree with many of the findings in Crawshaw et al,1 first and foremost, I agree that all patients at risk for anal cancer should be followed closely with treatment of high-grade squamous intraepithelial lesions (HSILs) to prevent progression to cancer. It is also true that, although no studies have prospectively examined high-resolution anoscopy (HRA)–guided targeted HSIL ablation, there is still convincing evidence in multiple retrospective studies cited by the authors2–4 that it does prevent cancer. Most recently, I reported progression to cancer out to 10 years in only 2% of more than 700 patients undergoing HRA-targeted HSIL ablation, far less than this series report of 6% at 5 years for expectant management.5
Diseases of the Colon & Rectum Volume 58: 5 (2015)
7. Kariv R, Remzi FH, Lian L, et al. Preoperative colorectal neoplasia increases risk for pouch neoplasia in patients with restorative proctocolectomy. Gastroenterology. 2010;139:806–812.e1. 8. Ault GT, Nunoo-Mensah JW, Johnson L, Vukasin P, Kaiser A, Beart RW Jr. Adenocarcinoma arising in the middle of ileoanal pouches: report of five cases. Dis Colon Rectum. 2009;52:538–541. 9. Lee SW, Sonoda T, Milsom JW. Three cases of adenocarcinoma following restorative proctocolectomy with hand-sewn anastomosis for ulcerative colitis: a review of reported cases in the literature. Colorectal Dis. 2005;7:591–597. 10. Um JW, M’Koma AE. Pouch-related dysplasia and adenocarcinoma following restorative proctocolectomy for ulcerative colitis. Tech Coloproctol. 2011;15:7–16. 11. Ozdemir Y, Kiran RP, Erem HH, et al. Functional outcomes and complications after restorative proctocolectomy and ileal pouch anal anastomosis in the pediatric population. J Am Coll Surg. 2014;218:328–335.
Luca Stocchi, M.D. Jorge Silva-Velazco, M.D. Feza H. Remzi, M.D. Cleveland, Ohio
Time to Rethink ELAPE? To the Editor—Han et al1 present a cohort of patients who underwent extralevator abdominoperineal excision (ELAPE) and recommend its general use for the management of very low rectal cancer in all patients. Ever since Holm et al2 reinvigorated interest in the original operation of Miles, ELAPE has divided opinions. Holm never suggested that ELAPE was an operation for all patients. It is a niche operation to be used when disease dictates the need for a wide perineal dissection. It does nothing to improve the anterior margin (often the site of circumferential resection margin (CRM) positivity) and creates a huge defect requiring either a muscle graft or a biological mesh for closure. This results in a much longer operation and a greatly increased cost. Significant morbidity is inevitable, and oncological gains have only been shown in series where the initial CRM positivity rates were unacceptably high.3 It is hard to countenance a coccygectomy on a patient with an anteriorly placed tumor who will still end up with a positive CRM, but now has chronic pain as an added impediment. Multiple centers have shown that abdominoperineal excision performed by appropriately trained surgeons results in adequate surgical clearance for most patients.4,5 A multicenter study from Spain published earlier this year definitively shows this to be the case.6 The problems posed by anterior tumors will only be resolved by increased use of partial vaginectomy or prostatectomy, not by unnecessarily radical excision of posterior and lateral tissue. The article of Han et al, rather than endorsing the widespread use of ELAPE, highlights all of the problems associated with the technique. High levels of morbidity
and no impact on positivity rates for anterior tumors are the calling cards of ELAPE. A local recurrence rate of 5% refutes even the most tenuous argument of an oncological benefit from this operation. It is time to listen to the growing voices of reason and assign ELAPE for all to the pages of history, under the title “nunquam iterum." REFERENCEs 1. Han JG, Wang ZJ, Qian Q, et al. A prospective multicenter clinical study of extralevator abdominoperineal resection for locally advanced low rectal cancer. Dis Colon Rectum. 2014;57:1333–1340. 2. Holm T, Ljung A, Häggmark T, Jurell G, Lagergren J. Extended abdominoperineal resection with gluteus maximus flap reconstruction of the pelvic floor for rectal cancer. Br J Surg. 2007;94:232–238. 3. West NP, Anderin C, Smith KJ, Holm T, Quirke P; European Extralevator Abdominoperineal Excision Study Group. Multicentre experience with extralevator abdominoperineal excision for low rectal cancer. Br J Surg. 2010;97:588–599. 4. Kennelly RP, Rogers AC, Winter DC; Abdominoperineal Excision Study Group. Multicentre study of circumferential margin positivity and outcomes following abdominoperineal excision for rectal cancer. Br J Surg. 2013;100:160–166. 5. Messenger DE, Cohen Z, Kirsch R, et al. Favorable pathologic and long-term outcomes from the conventional approach to abdominoperineal resection. Dis Colon Rectum. 2011;54:793–802. 6. Ortiz H, Ciga MA, Armendariz P, et al.; Spanish Rectal Cancer Project. Multicentre propensity score-matched analysis of conventional versus extended abdominoperineal excision for low rectal cancer. Br J Surg. 2014;101:874–882.
Rory P. Kennelly, M.D. Desmond C. Winter, M.D., F.R.C.S.I. Dublin, Ireland
Must We Continue to Look for Excuses? To the Editor–I have devoted the majority of my professional career to understanding human papillomavirus–related anorectal disease to prevent anal cancer. Although I disagree with many of the findings in Crawshaw et al,1 first and foremost, I agree that all patients at risk for anal cancer should be followed closely with treatment of high-grade squamous intraepithelial lesions (HSILs) to prevent progression to cancer. It is also true that, although no studies have prospectively examined high-resolution anoscopy (HRA)–guided targeted HSIL ablation, there is still convincing evidence in multiple retrospective studies cited by the authors2–4 that it does prevent cancer. Most recently, I reported progression to cancer out to 10 years in only 2% of more than 700 patients undergoing HRA-targeted HSIL ablation, far less than this series report of 6% at 5 years for expectant management.5
