LAUSR

Miles’ abdominoperineal excision (APE) aimed to achieve a cylindrical specimen by stopping the mesorectal dissection above the pelvic floor, while the perineal dissection included excision of the levator ani muscles from the obturator internus [1]. Over the years, Miles’ technique was modified to the standard APE (without excision of the levators), which resulted in a specimen with a waist and increased circumferential resection margin (CRM) involvement rates. In more recent times, the classic Miles [2] has been embraced again under the name of extralevator APE (ELAPE). Although colorectal surgeons are all well aware of the technical difficulties of the Miles’ APE, van Oostendorp et al. are making this operation more difficult with the application of a minimally invasive approach of transperineal abdominoperineal excision (tpAPE). van Oostendorp et al. published a “feasibility” study with “acceptable” morbidity and relatively low rates of perineal wound dehiscence [3]. The study by van Oostendorp et al. was designed as a multicenter retrospective cohort of 32 patients operated upon in five “expert centers” (average of 6.4 cases per year; range 1–12) between 2014 and 2018. Of note, 63% of the patients received long-term neoadjuvant chemoradiotherapy, whereas 9.4% received a short course. The management of the perineal wound included primary closure in 56% of the patients, closure with myocutaneous flap in 19%, with absorbable mesh in 22%, and with non-absorbable mesh in 3%. 46.9% of the patients had delayed wound healing. Serious intraoperative complications occurred in 16% of the patients including CO2 embolus, intraoperative rectal perforation, ureteral and pelvic wall injury. The quality of total mesorectal excision specimens was: 48.4% complete, 41.9% nearly complete, and 9.7% incomplete. van Oostendorp et al. concluded that tpAPE is “feasible” with “low rates” of perineal wound dehiscence, and “suboptimal” histopathological outcomes. The latter was not unexpected given the preoperative magnetic resonance imaging findings such as threatened CRM < 1 mm (66%); tumor located at or below the level of the anorectal junction (69%); direct tumor invasion into the sphincter complex (31.3%), the levator ani muscle (12.5%), and prostate or vagina (6.3%). van Oostendorp et al. are proposing to embrace tpAPE with a high incidence of severe intraoperative complications directly related to a new “learning curve.” Perhaps, an oversight was made in the New York State memorandum which reads “a learning curve is not a valid justification for patient injury” [4].