Extralevator Abdominoperineal Excision Improves Overall Survival Compared to Standard Abdominoperineal Excision: A Systematic Review and Meta‐Analysis

ABSTRACT Background In advanced low rectal cancer, the surgical technique chosen can affect long‐term oncological outcomes. Extralevator abdominoperineal excision (ELAPE) was developed to improve radicality compared with standard abdominoperineal excision (APE). Although earlier analyses suggested reduced local recurrence and mortality with ELAPE, its survival benefit remains debated, and concerns about wound complications persist. This meta‐analysis compared ELAPE and APE, focusing on oncological outcomes. Methods The protocol was registered on PROSPERO (CRD42023412308). A systematic search of PubMed, Embase, and CENTRAL was performed (April 14, 2023). Comparative studies of ELAPE versus APE were included. Data were synthesized using random‐effects models. For overall survival (OS), disease‐free survival (DFS), and local recurrence‐free survival (LRFS), hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated, with individual patient data extracted from Kaplan–Meier curves. Results Thirty‐eight studies, including over 5000 patients, were analyzed. ELAPE reduced mortality by 46% (HR 0.54, 95% CI 0.40–0.73) and achieved a 5‐year OS of 83% (CI 0.53–0.95) versus 69% (CI 0.40–0.88) for APE. ELAPE improved DFS (HR 0.74, 95% CI 0.55–0.99), with a 5‐year DFS of 87% (CI 0.50–0.98) compared with 65% (CI 0.24–0.92) for APE. LRFS favored ELAPE but was not significant (HR 0.67, 95% CI 0.45–1.00). Rates of perineal wound complications did not differ (OR 1.39, 95% CI 0.81–2.40). Conclusion ELAPE improves OS and DFS compared with APE without increasing wound complications. These findings support the broader application of ELAPE in rectal cancer treatment.