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The aim of our study was to estimate recurrence and survival after conventional APR and evaluate risk factors of recurrence.Danish rectal cancer patients operated with APR 01.5.2001-31.12.2006 were included, and follow-up was checked by September 2009. The cumulative risk of local recurrence (LR), the distant recurrence (DR), the over-all survival (OS), and the cancer-specific survival (CSS) were calculated by Kaplan-Meier analysis: risk factors were evaluated using the Coxproportional hazards model.An APR was performed in 1125 patients with a median follow-up of 57 months (range 25-93). Intra-operative tumour perforation was seen in 108 (10%) patients, and LR developed in 93 (8%). After 5 years the cumulative LR was 11% (95% CI 9-13), DR 30% (95% CI 27-33), OS 56% (95% CI 53-60) and CSS 68% (95% CI 65-71). Multivariate analysis showed that intraoperative tumour perforation was a major risk factor for LR (HR = 2.39), DR and impaired survival.Intra-operative tumour perforation in APR should be avoided, as it increases the risk of LR and impairs survival. Using the cylindrical extralevator method willprobably reduce the perforation rate.