Inadvertent perforation of the rectum during abdominoperineal resection

BACKGROUND: Intraoperative inadvertent perforation of the rectum is a potentially avoidable complication of abdominoperineal resection (APR). Although widely thought to be detrimental, the impact of inadvertent perforation on outcome has not been conclusively determined, especially after controlling for potential confounding variables. The objective of this study was to determine if inadvertent perforation of the rectum during APR for rectal cancer is an independent risk factor for the adverse outcomes of local recurrence and/or death. METHODS: This retrospective cohort study included all patients who underwent APR for primary adenocarcinoma of the rectum at a single teaching hospital from 1980 to 1990. Data were obtained regarding patient demographics, presence of inadvertent perforation, histopathological characteristics, adjuvant therapy, local recurrence, and survival. RESULTS: Of 178 patients included in the study, 42 (24%) had inadvertent perforation. By univariate analysis, local recurrence was significantly higher in the perforated group than the nonperforated group (54% vs 17%; P <0.001). Similarly, 5-year survival was significantly decreased with inadvertent perforation (29% vs 59%; P = 0.003). Multivariate analysis controlling for stage, grade, age, sex, and adjuvant therapy showed inadvertent perforation to be an independent risk factor for both increased local recurrence and decreased 5-year survival (Hazard Ratio for each model). CONCLUSIONS: Inadvertent perforation of the rectum during APR is associated with increased local recurrence and decreased 5-year survival. The detrimental implications of inadvertent perforation during APR mandates meticulous avoidance.