Dan Asplund

Outcome of extralevator abdominoperineal excision compared with standard surgery: results from a single centre

Aim  Extralevator abdominoperineal excision (APE) for low rectal tumours has been introduced to achieve improved local radicality. Fewer positive margins and intraoperative perforations have been reported compared with standard APE. The aim of this retrospective study was to compare short‐term complications and results of the two techniques in our institution.

Role of matrix metalloproteinases in tumour invasion: immunohistochemistry of peritoneum from peritoneal carcinomatosis

Colorectal cancer is one of the most common forms of cancer. Spread of tumour to the peritoneal cavity may lead to seeding of cancer cells that adhere to and invade the peritoneal membrane causing peritoneal carcinomatosis. Matrix metalloproteinases (MMPs) play an essential role in cancer cell invasion and dissemination. The aim of this study was to evaluate the morphology and presence of matrix metalloproteinases in peritoneal carcinomatosis. Biopsy samples of the parietal peritoneum were taken from patients undergoing cytoreductive surgery for peritoneal carcinomatosis. The samples were fixed in formalin, dehydrated and embedded in paraffin prior to cutting into 4-µm slices. Staining with haematoxylin/eosin was used for morphology studies, and MMP-1, MMP-2 and TIMP-1 levels were evaluated using immunohistochemistry and light microscopy. The microscopically tumour-free areas of the peritoneal membrane were thin compared to the peripheral invasion zone and the areas invaded by tumour. Peritoneum invaded by tumour was richly vascularised and contained inflammatory cells. MMP-1 was expressed in tumour-free peritoneum and in the invasion zone between tumour and peritoneal tissue, but not in tumour-invaded areas. MMP-2 and TIMP-1 were mostly expressed in the proximity of blood vessels and inflammatory cells in tumour-invaded areas, but was not seen in tumour-free areas. MMPs play an important role in the process of cancer cell invasion of the peritoneum in peritoneal carcinomatosis. The peripheral zone of the tumour appears to be of importance for tumour invasion.

Correction to: Pretreatment quality of life in patients with rectal cancer is associated with intrusive thoughts and sense of coherence

The original version of this article, unfortunately, contained errors.

Reply to Stelzner et al

Dear Sir, We are grateful for the comments made by Stelzner et al. [1] regarding our article ‘Outcome of extralevator abdominoperineal excision compared with standard surgery: results from a single centre’ [2]. We agree that case mix and variations in surgical technique may be two important explanations for the diverging results in the literature. It is also possible that some degree of heterogeneity due to case mix is present in our study. We have performed a subgroup analysis that included only tumours located within 4 cm from the anal verge. The results in this subgroup did not differ from those in the entire group, but the perforation rate was higher in the extralevator abdominoperineal excision (ELAPE) group compared with some other series [3,4], and we congratulate those authors on their good results. The results of standard APE in our study showed low rates of circumferential resection margin involvement compared with figures reported for controls in some other studies [3–5]. Again case mix could in part explain these results. In conclusion, although pooled data [6] indicate superiority to extended APE, our results with a higher number of wound revisions indicate that improvements in the technique could be made. Regardless of the method of reconstruction there are a considerable number of patients with wound complications after ELAPE [5,7,8]. These issues should be addressed, as should details of when to apply the technique, to achieve results that are acceptable in all perspectives.