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Huu Phu L, Tat Bang H, Van Viet U, Danh Tan H, Tin NT. Complications Rate and Related Factors After Laparoscopic Sphincter-Preserving Total Mesorectal Excision for Low Rectal Cancer: A Single-Center Study in Vietnam. Cureus 2024; 16:e60734. [PMID: 38774464 PMCID: PMC11107394 DOI: 10.7759/cureus.60734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2024] [Indexed: 05/24/2024] Open
Abstract
BACKGROUND Colorectal cancer is a significant health concern. Surgery remains a critical component of the multimodal treatment strategy. The laparoscopic sphincter-preserving total mesorectal excision (TME) is increasingly utilized and effective, offering enhanced quality of life for patients compared to previous traditional methods. OBJECTIVES This study aims to determine the rate of complications and the related factors associated with complications following laparoscopic sphincter-preserving total mesorectal excision for low rectal cancer. METHODS This retrospective study was conducted at the University Medical Center of Ho Chi Minh City from March 2022 to March 2023. It included patients aged 18 years and older diagnosed with low rectal cancer who underwent laparoscopic sphincter-preserving total mesorectal excision. Data on patient demographics, surgical details, and postoperative complications were retrospectively collected and analyzed. Follow-ups were conducted up to six months after surgery. RESULTS Of the 83 patients included, the postoperative complications rate was 14.5%. The complications observed included surgical wound infections (five cases), anastomotic leaks (five cases, including three recto-vaginal fistulas and two pelvic abscesses), urinary retention (one case), and pneumonia (one case). A significant finding was the higher rate of distant metastases in patients with complications compared to those without (p=0.033). CONCLUSION Laparoscopic sphincter-preserving total mesorectal excision for low rectal cancer is safe and effective, with a high success rate and low complication rate during or after surgery. Anastomotic leakage remains the most significant complication. Despite advancements in surgery, modern suturing tools, and preoperative patient optimization, complications are avoidable. Therefore, understanding the related factors and implementing preventive interventions is crucial.
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Affiliation(s)
- Ly Huu Phu
- Gastro-Intestinal Surgery Department, University Medical Center Ho Chi Minh City, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, VNM
| | - Ho Tat Bang
- Thoracic and Vascular Department, University Medical Center Ho Chi Minh City, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, VNM
- Department of Health Organization and Management, Faculty of Public Health, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, VNM
| | - Ung Van Viet
- Gastro-Intestinal Surgery Department, University Medical Center Ho Chi Minh City, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, VNM
- Department of General Surgery, Faculty of Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, VNM
| | - Hoang Danh Tan
- Gastro-Intestinal Surgery Department, University Medical Center Ho Chi Minh City, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, VNM
- Department of General Surgery, Faculty of Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, VNM
| | - Nguyen Trung Tin
- Department of General Surgery, Faculty of Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, VNM
- Proctology Department, University Medical Center Ho Chi Minh City, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, VNM
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Xu X, Zhong H, You J, Ren M, Fingerhut A, Zheng M, Li J, Yang X, Song H, Zhang S, Ding C, Abuduaini N, Yu M, Liu J, Zhang Y, Kang L, Cai Z, Feng B. Revolutionizing sphincter preservation in ultra-low rectal cancer: exploring the potential of transanal endoscopic intersphincteric resection (taE-ISR): a propensity score-matched cohort study. Int J Surg 2024; 110:709-720. [PMID: 38016136 PMCID: PMC10871607 DOI: 10.1097/js9.0000000000000945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 11/13/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND With the optimization of neoadjuvant treatment regimens, the indications for intersphincteric resection (ISR) have expanded. However, limitations such as unclear surgical field, impaired anal function, and failure of anal preservation still exist. Transanal total mesorectal excision can complement the drawbacks of ISR. Therefore, this study combined these two techniques and proposed transanal endoscopic intersphincteric resection (taE-ISR), aiming to explore the value of this novel technique in anal preservation for ultra-low rectal cancer. MATERIAL AND METHODS Four high-volume centres were involved. After 1:1 propensity score-matching, patients with ultra-low rectal cancer underwent taE-ISR ( n =90) or ISR ( n =90) were included. Baseline characteristics, perioperative outcomes, pathological results, and follow-up were compared between the two groups. A nomogram model was established to assess the potential risks of anal preservation. RESULTS The incidence of adjacent organ injury (0.0% vs. 5.6%, P =0.059), positive distal resection margin (1.1% vs. 8.9%, P =0.034), and incomplete specimen (2.2% vs. 13.3%, P =0.012) were lower in taE-ISR group. Moreover, the anal preservation rate was significantly higher in taE-ISR group (97.8% vs. 82.2%, P =0.001). Patients in the taE-ISR group showed a better disease-free survival ( P =0.044) and lower cumulative recurrence ( P =0.022) compared to the ISR group. Surgery procedure, tumour distance, and adjacent organ injury were factors influencing anal preservation in patients with ultra-low rectal cancer. CONCLUSION taE-ISR technique was safe, feasible, and improved surgical quality, anal preservation rate and survival outcomes in ultra-low rectal cancer patients. It held significant clinical value and showed promising application prospects for anal preservation.
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Affiliation(s)
- Ximo Xu
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of General Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai
| | - Hao Zhong
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jun You
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Xiamen University, Teaching Hospital of Fujian Medical University, Xiamen
| | - Mingyang Ren
- Department of Gastrointestinal Surgery, The Affiliated Nanchong Central Hospital of North Sichuan Medical College, Nanchong
| | - Abe Fingerhut
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Section for Surgical Research, Department of Surgery, Medical University of Graz, Auenbruggerplatz 29, Graz, Austria
| | - Minhua Zheng
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jianwen Li
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiao Yang
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Haiqin Song
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Sen Zhang
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chengsheng Ding
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Naijipu Abuduaini
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Mengqin Yu
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jingyi Liu
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yi Zhang
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Liang Kang
- Department of General Surgery (Colorectal Surgery)
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Zhenghao Cai
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Bo Feng
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Pan H, Zhao Z, Deng Y, Zheng Z, Huang Y, Chi P, Huang S. Transverse Coloplasty Pouch versus Straight Coloanal Anastomosis Following Intersphincteric Resection for Low Rectal Cancer: the Functional Benefits May Emerge After Two Years. J Gastrointest Surg 2023; 27:2526-2537. [PMID: 37848684 DOI: 10.1007/s11605-022-05565-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 12/06/2022] [Indexed: 10/19/2023]
Abstract
PURPOSE This study aimed to compare the oncological and functional outcomes following intersphincteric resection (ISR) with transverse coloplasty pouch (TCP) or straight coloanal anastomosis (SCAA) for low rectal cancer. METHODS A single-center retrospective analysis was performed on patients with low rectal cancer who received ISR between January 2016 and June 2021. The primary endpoint was to compare the outcomes of bowel function within 1 year, 1 to 2 years, and 2 years after ileostomy closure in patients undergoing two different bowel reconstruction procedures (TCP or SCAA). The postoperative complications and oncological results were also compared between the two groups. RESULTS A total of 235 patients were enrolled in this study (SCAA group: 166; TCP group: 69). There was no significant difference in complications, including grades A-C anastomotic leakage (9.6% vs 15.9%), 3-year local recurrence rates (6.1% vs 3.9%), disease-free survival (82.4%vs 83.8%), or overall survival (94.1% vs 94.7%) between the two groups. Two years after ileostomy closure, 52.7% of patients in the SCAA group were assessed as having major low anterior resection syndrome (LARS), which was significantly higher than the 25.9% of patients in the TCP group (P = 0.014), but no difference was found prior to 2 years. Similar differences were seen in Wexner scores 2 years after surgery (P = 0.032). Additionally, TCP was an independent protective factor for postoperative bowel function as measured by both the LARS (OR, 0.28; 95% CI, 0.10-0.82; p = 0.020) and Wexner scoring (OR, 0.28; 95% CI, 0.09-0.84; p = 0.023). CONCLUSION This study suggests that TCP is a safe technique that may decrease bowel dysfunction after ISR for low rectal cancer compared with SCAA 2 years after ileostomy closure.
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Affiliation(s)
- Hongfeng Pan
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou, 350001, Fujian Province, China
- Training center of minimally invasive surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Zeyi Zhao
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou, 350001, Fujian Province, China
- Training center of minimally invasive surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Yu Deng
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou, 350001, Fujian Province, China
- Training center of minimally invasive surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Zhifang Zheng
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou, 350001, Fujian Province, China
- Training center of minimally invasive surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Ying Huang
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou, 350001, Fujian Province, China.
- Training center of minimally invasive surgery, Fujian Medical University Union Hospital, Fuzhou, China.
| | - Pan Chi
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou, 350001, Fujian Province, China.
- Training center of minimally invasive surgery, Fujian Medical University Union Hospital, Fuzhou, China.
| | - Shenghui Huang
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou, 350001, Fujian Province, China.
- Training center of minimally invasive surgery, Fujian Medical University Union Hospital, Fuzhou, China.
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Liu F, Zhang B, Xiang J, Zhuo G, Zhao Y, Zhou Y, Ding J. Does anastomotic leakage after intersphincteric resection for ultralow rectal cancer influence long-term outcomes? A retrospective observational study. Langenbecks Arch Surg 2023; 408:394. [PMID: 37816844 DOI: 10.1007/s00423-023-03131-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 10/02/2023] [Indexed: 10/12/2023]
Abstract
PURPOSE To determine whether anastomotic leakage (AL) following intersphincteric resection (ISR) for ultralow rectal cancer (uLRC) is associated with long-term negative outcomes. METHODS Between June 2011 and January 2022, 236 consecutive patients who underwent ISR with diverting ileostomy for uLRC were included. The primary outcome was long-term clinical consequences of AL, including chronic stricture, stoma reversal, and oncological and functional results. RESULTS Forty-one (17.4%) patients developed symptomatic AL, whereas only two (0.8%) required re-laparotomy due to severe leakage. Patients with leaks had a significantly increased incidence of chronic stricture (29.3% vs. 8.7%, P = 0.001) and stoma non-reversal (34.1% vs. 4.6%, P < 0.0001) than controls. The severe consequences were particularly common in patients with anastomotic separation, resulting in 60% of those presenting with chronic stricture and 50% ending up with stoma non-reversal. After a median follow-up of 59 (range, 7-139) months, AL did not compromise long-term oncological outcomes, including tumor recurrence (9.8% vs. 5.6%, P = 0.3), 5-year disease-free, and overall survival (73.4% vs. 74.8% and 85.1% vs. 85.4%, P = 0.56 and P = 0.55). A total of 149 patients with bowel continuity who completed self-assessment questionnaires were enrolled for functional evaluation. The median follow-up was 24 (range, 12-94) months after ileostomy reversal, and functional results were comparable between patients with and without leaks. CONCLUSION AL is an unfortunate reality for patients who underwent ISR for uLRC, but the rate of severe leakage is limited. Leaks contribute to possible adverse impacts on chronic stricture and stoma non-reversal, especially for patients with anastomotic separation. However, long-term oncological and functional results may not be compromised. TRIAL REGISTRATION Chictr.org.cn identifier: ChiCTR-ONC-15007506 and ChiCTR2100051614.
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Affiliation(s)
- Feifan Liu
- Postgraduate Training Base of Jinzhou Medical University, the Characteristic Medical Center of PLA Rocket Force, Beijing, 100088, China
- Department of Colorectal Surgery, the Characteristic Medical Center of PLA Rocket Force, Beijing, 100088, China
| | - Bin Zhang
- Department of Colorectal Surgery, the Characteristic Medical Center of PLA Rocket Force, Beijing, 100088, China
| | - Jianbin Xiang
- Department of General Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Guangzuan Zhuo
- Department of Colorectal Surgery, the Characteristic Medical Center of PLA Rocket Force, Beijing, 100088, China
| | - Yujuan Zhao
- Department of Colorectal Surgery, the Characteristic Medical Center of PLA Rocket Force, Beijing, 100088, China
| | - Yiming Zhou
- Department of General Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Jianhua Ding
- Department of Colorectal Surgery, the Characteristic Medical Center of PLA Rocket Force, Beijing, 100088, China.
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Kim HJ, Choi GS, Song SH, Park JS, Park SY, Lee SM, Na DH, Jeong MH. Single-Port Robotic Intersphincteric Resection for the Treatment of Rectal Cancer. Surg Laparosc Endosc Percutan Tech 2023; 33:249-255. [PMID: 37172021 DOI: 10.1097/sle.0000000000001179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 03/20/2023] [Indexed: 05/14/2023]
Abstract
BACKGROUND The da Vinci Single-port (SP) system is designed to facilitate single-incision robotic surgery in a narrow space. We developed a new procedure of intersphincteric resection (ISR) using the SP platform and evaluated the technical safety and feasibility of this procedure for the treatment of very low rectal cancer. MATERIALS AND METHODS Eleven rectal cancer patients who underwent SP robotic ISR between August 2020 and July 2021 were included. Patients' clinical characteristics, operative and pathologic findings of the patients were retrospectively analyzed. RESULTS The median tumor height was 3 cm (range, 2-4 cm). A single docking was performed, and the median docking time was 3 min 10 sec (range, 2 min 50 sec-3 min 30 sec). The median total operation time was 210 min (range, 150-280 min), and the median time of pelvic dissection was 57 min (range, 45-68 min). All patients presented with negative distal resection margins [median 1 cm (range, 0.5-2.0 cm)], and only one patient had less than 1mm of circumferential resection margin (0.9 mm). CONCLUSIONS Our initial experience suggests that SP robotic ISR is safe and feasible.
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Affiliation(s)
- Hye Jin Kim
- Colorectal Cancer Center, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
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Bediako-Bowan AAA, Naalane N, Dakubo JCB. Morbidity and oncological outcomes after intersphincteric resection of the rectum for low-lying rectal cancer: experience of a single center in a lower-middle-income country. BMC Surg 2023; 23:39. [PMID: 36805711 PMCID: PMC9938915 DOI: 10.1186/s12893-023-01940-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 02/16/2023] [Indexed: 02/21/2023] Open
Abstract
BACKGROUND Intersphincteric resection (ISR) of the rectum for low-lying rectal cancer with colo-anal anastomosis was introduced years ago, allowing for bowel continuity, and avoiding permanent stomas. The colorectal unit of Korle Bu Teaching Hospital adopted this procedure in 2014 when indicated, for the management of rectal cancers, where hitherto, abdominoperineal resection of the rectum with a permanent stoma was indicated. This study aimed to assess morbidity, mortality, and oncological outcomes associated with ISR of the rectum and determine the factors contributing to these. METHODS This was an observational study from prospectively stored data. All patients who underwent intersphincteric resection of the rectum due to low-lying rectal cancer from July 2014 to June 2021 were included in the study, and their records were assessed for intra-operative and 30-day postoperative complications, as well as mortality and their related risk factors and their oncological outcomes in terms of local recurrence at one year. RESULTS 102 patients were included in this analysis. Six percent (6/102) of patients had intra-operative complications, including bleeding, and 41% (42/102) had 30-day postoperative complications, which were associated with pelvic side wall attachment of tumor and intra-op complications. Mortality risk was 12.7% (13/102) in the early postoperative period, and nine patients had a local recurrence within the first year of surgery. CONCLUSION There is a high risk of early postoperative morbidity and mortality after intersphincteric resection of the rectum in our setting. The oncological outcomes are favorable in a population that abhors a permanent colostomy.
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Affiliation(s)
- Antoinette Afua Asiedua Bediako-Bowan
- Department of Surgery, University of Ghana Medical School, University of Ghana, P. O. Box 4236, Accra, Ghana. .,Department of Surgery, Korle Bu Teaching Hospital, Accra, Ghana. .,Mwin Tuba Hospital and Coloproctology Centre, Accra, Ghana.
| | - Narious Naalane
- grid.415489.50000 0004 0546 3805Department of Surgery, Korle Bu Teaching Hospital, Accra, Ghana
| | - Jonathan C. B. Dakubo
- grid.8652.90000 0004 1937 1485Department of Surgery, University of Ghana Medical School, University of Ghana, P. O. Box 4236, Accra, Ghana ,grid.415489.50000 0004 0546 3805Department of Surgery, Korle Bu Teaching Hospital, Accra, Ghana ,Mwin Tuba Hospital and Coloproctology Centre, Accra, Ghana
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Wang J, Ye X, Zhou Q, Xu C, Fan Y, Luan N, Zhu X. Parachute-like pull-through anastomosis for low rectal cancer: a new method for preservation of anal function. Langenbecks Arch Surg 2023; 408:86. [PMID: 36781494 PMCID: PMC9925529 DOI: 10.1007/s00423-023-02768-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 11/29/2022] [Indexed: 02/15/2023]
Abstract
BACKGROUND With recent improvements in surgical technique, oncological outcomes of low rectal cancer have improved over time. But the QoL impairment as a result of anal functional disorder cannot be ignored. And the incidence of anastomosis-related complications cannot be ignored. To address these problems, a personal technique for pull-through coloanal anastomosis (parachute-like intussuscept pull-through anastomosis) was introduced and evaluated. This technique can relatively reduce surgical complications, minimize the impact of anal function, and obviate a colostomy creation. METHODS Between June 2020 and April 2021, 14 consecutive patients with rectal cancer underwent laparoscopic-assisted resection of rectal cancer in our hospital. Parachute-like pull-through anastomosis method was performed in all patients. Anal function, perioperative details, and postoperative outcomes were analyzed. RESULTS The mean (SD) operative time of first stage was 282.1 min (range 220-370) with an average estimated blood loss of 90.3 mL (range 33-200). And the mean (SD) operative time of second was 46 min (range 25-76) with an average estimated blood loss of 16.1 mL (range 5-50). Wexner scores declined significantly during the median follow-up of 18 months. Four postoperative anastomosis-related complications occurred in 14 patients, including perianastomotic abscess: 1 case (7%), anastomotic stricture: 1 case (7%), and colonic ischemia of the exteriorized colonic segment: 2 cases (14%). CONCLUSION The results suggest that the method can facilitate safe and easy completion of coloanal anastomosis, using parachute-like pull-through anastomosis, with acceptable anal function.
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Affiliation(s)
- JianWei Wang
- Department of Colorectal Surgery and Oncology, Key Laboratory of Cancer Prevention and Intervention, Ministry of Education, 2nd Affiliated Hospital, Zhejiang University School of Medicine, Jiefang Road 88th, Hangzhou, China.
- Department of Surgery, 4th Affiliated Hospital, School of Medicine, International Institutes of Medicine, Zhejiang University, Yiwu, China.
| | - Xun Ye
- Department of Colorectal Surgery and Oncology, Key Laboratory of Cancer Prevention and Intervention, Ministry of Education, 2nd Affiliated Hospital, Zhejiang University School of Medicine, Jiefang Road 88th, Hangzhou, China
| | - Qin Zhou
- Department of Colorectal Surgery and Oncology, Key Laboratory of Cancer Prevention and Intervention, Ministry of Education, 2nd Affiliated Hospital, Zhejiang University School of Medicine, Jiefang Road 88th, Hangzhou, China
| | - ChengCai Xu
- Department of Surgery, 4th Affiliated Hospital, School of Medicine, International Institutes of Medicine, Zhejiang University, Yiwu, China
| | - YiQun Fan
- Department of Surgery, 4th Affiliated Hospital, School of Medicine, International Institutes of Medicine, Zhejiang University, Yiwu, China
| | - Na Luan
- Department of Colorectal Surgery and Oncology, Key Laboratory of Cancer Prevention and Intervention, Ministry of Education, 2nd Affiliated Hospital, Zhejiang University School of Medicine, Jiefang Road 88th, Hangzhou, China
| | - XiaoLing Zhu
- Department of Surgery, 4th Affiliated Hospital, School of Medicine, International Institutes of Medicine, Zhejiang University, Yiwu, China
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Kim JC, Lee JL, Kim CW, Kim JR, Kim J, Park SH. Technical, functional, and oncological validity of robot-assisted total-intersphincteric resection (T-ISR) for lower rectal cancer. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:188-195. [PMID: 35864011 DOI: 10.1016/j.ejso.2022.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 06/14/2022] [Accepted: 07/08/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND Few studies fairly compared anorectal function and prognostic outcomes between patients undergoing abdominoperineal resection (APR) and anorectal-function-saving operations (ASO) under the equivalent conditions. By contrast, surgeons used to be somewhat hesitant to conduct total intersphincteric resection (T-ISR) as maximal ASO, due to its technical complexity and potential anorectal dysfunction. METHODS Propensity-score matched cohorts undergoing robot-assisted R0 surgery [T-ISR vs APR vs partial-subtotal ISR (PS-ISR)/lower anterior resection (LAR)] for rectal cancer (n = 1361) were included. Operative outcomes, recurrence, and disease-free/overall survival (DFS/OS) were analyzed. Anorectal function was evaluated based on fecal incontinence score and high-resolution manometry between the T-ISR and other ASO groups. RESULTS Few differences were detected between the T-ISR and APR groups. More patients undergoing APR had T4 stage disease, while the lowest tumor margin was the same in both groups (mean, 1.5 cm from anal verge). Prognostic outcomes did not differ between the T-ISR and APR groups, including local (5.1% vs 7.7%, p = 1) or systemic (15.4% vs 25.6%, p = 0.401) recurrence, and 5-year DFS (78.7% vs 61.5%, p = 0.1) and OS (89% vs 82.1%, p = 0.434) rates, nor were there differences between the T-ISR and PS-ISR/LAR groups. The PS-ISR group generally showed less anorectal dysfunction than the T-ISR group, but maximal tolerance volume did not differ between these two groups and was within the range for the healthy population. CONCLUSIONS T-ISR can replace most traditional APR, except for advanced T4 disease with aggressive infiltration into the levator-sphincters, and can provide tolerable anorectal dysfunction.
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Affiliation(s)
- Jin Cheon Kim
- Division of Colorectal Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea.
| | - Jong Lyul Lee
- Division of Colorectal Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea
| | - Chan Wook Kim
- Division of Colorectal Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea
| | - Jung Rang Kim
- Division of Colorectal Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea
| | - Jihun Kim
- Department of Pathology, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea
| | - Seong Ho Park
- Department of Radiology, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea
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Takemasa I, Hamabe A, Miyo M, Akizuki E, Okuya K. Essential updates 2020/2021: Advancing precision medicine for comprehensive rectal cancer treatment. Ann Gastroenterol Surg 2022; 7:198-215. [PMID: 36998300 PMCID: PMC10043777 DOI: 10.1002/ags3.12646] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 11/16/2022] [Accepted: 11/23/2022] [Indexed: 12/28/2022] Open
Abstract
In the paradigm shift related to rectal cancer treatment, we have to understand a variety of new emerging topics to provide appropriate treatment for individual patients as precision medicine. However, information on surgery, genomic medicine, and pharmacotherapy is highly specialized and subdivided, creating a barrier to achieving thorough knowledge. In this review, we summarize the perspective for rectal cancer treatment and management from the current standard-of-care to the latest findings to help optimize treatment strategy.
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Affiliation(s)
- Ichiro Takemasa
- Department of Surgery, Surgical Oncology and ScienceSapporo Medical UniversitySapporoJapan
| | - Atsushi Hamabe
- Department of Surgery, Surgical Oncology and ScienceSapporo Medical UniversitySapporoJapan
- Department of Gastroenterological Surgery, Graduate School of MedicineOsaka UniversityOsakaJapan
| | - Masaaki Miyo
- Department of Surgery, Surgical Oncology and ScienceSapporo Medical UniversitySapporoJapan
| | - Emi Akizuki
- Department of Surgery, Surgical Oncology and ScienceSapporo Medical UniversitySapporoJapan
| | - Koichi Okuya
- Department of Surgery, Surgical Oncology and ScienceSapporo Medical UniversitySapporoJapan
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Zheng K, Hu Q, Yu G, Zhou L, Yao Y, Zhou Y, Wang H, Hao L, Yu E, Lou Z, Zhang Y, Qiu H, Meng R, Zhang W. Trends of sphincter-preserving surgeries for low lying rectal cancer: A 20-year experience in China. Front Oncol 2022; 12:996866. [PMID: 36568186 PMCID: PMC9773833 DOI: 10.3389/fonc.2022.996866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 11/14/2022] [Indexed: 12/13/2022] Open
Abstract
Background Over the last 2 decades, patients with low rectal cancer have had better outcomes from improvements in surgical techniques in sphincter preservation. We aimed to quantify the trends in sphincter-preserving surgeries for low rectal cancer over 20 years in a top tertiary hospital in China. Methods Between 1999 and 2021, a cohort of patients with primary malignant rectal tumor ≤5cm from the anal verge and who received elective surgeries at Changhai Hospital, Shanghai, China, was identified. Data were extracted from electronic medical records. A Joinpoint Regression Model was used to analyze trends in surgical procedures by average annual percentage change (AAPC). Adjusted Cox proportional hazards regression model was used to assess overall survival. Results Among a total of 4,172 patients during the study period, 3,111 (74.6%) underwent a sphincter-preserving surgery and 1,061 (25.4%) received APR. Sphincter-preserving surgery increased 3.6% per year (95%CI, 2.3-4.9). Low anterior resection was the most performed procedure (86.3%) and maintained a steady trend, while intersphincteric resection increased 49.4% annually (95%CI, 19.5-86.7) after initiation. Laparoscopic techniques increased 15.1% per year (95%CI, 8.4-43.4) after initiation. Sphincter-preserving surgery increased annually for tumors ≤2cm, 2-≤3cm and 3-≤4cm from the anal verge (AAPC 7.1, 4.5-9.8; 4.7, 3.1-6.3; 2.7, 1.7-3.6, respectively). Furthermore, patients with sphincter-preserving surgery had a better overall survival than abdominoperineal resection (APR) patients (adjusted HR 0.78, 95% CI, 0.65-0.93, p=.01). Conclusions Utilization of sphincter-preserving surgeries increased significantly over the last 20 years. Patients with low rectal cancer who underwent sphincter preservation had better survival than similar patients who underwent APR.
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Affiliation(s)
- Kuo Zheng
- Department of Colorectal Surgery, Changhai Hospital, Shanghai, China
| | - Qingqing Hu
- Global Epidemiology, Office of Chief Medical Officer, Johnson & Johnson, Shanghai, China
| | - Guanyu Yu
- Department of Colorectal Surgery, Changhai Hospital, Shanghai, China
| | - Leqi Zhou
- Department of Colorectal Surgery, Changhai Hospital, Shanghai, China
| | - Yuting Yao
- Department of Professional Education, Johnson & Johnson Medical (Shanghai) LTD, Shanghai, China
| | - Yuan Zhou
- Department of Professional Education, Johnson & Johnson Medical (Shanghai) LTD, Shanghai, China
| | - Hao Wang
- Department of Colorectal Surgery, Changhai Hospital, Shanghai, China
| | - Liqiang Hao
- Department of Colorectal Surgery, Changhai Hospital, Shanghai, China
| | - Enda Yu
- Department of Colorectal Surgery, Changhai Hospital, Shanghai, China
| | - Zheng Lou
- Department of Colorectal Surgery, Changhai Hospital, Shanghai, China
| | - Yongjing Zhang
- Global Epidemiology, Office of Chief Medical Officer, Johnson & Johnson, Shanghai, China
| | - Hong Qiu
- Global Epidemiology, Office of Chief Medical Officer, Johnson & Johnson, Shanghai, China
| | - Ronggui Meng
- Department of Colorectal Surgery, Changhai Hospital, Shanghai, China
| | - Wei Zhang
- Department of Colorectal Surgery, Changhai Hospital, Shanghai, China,*Correspondence: Wei Zhang,
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11
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Zhong X, Xie X, Hu H, Li Y, Tian S, Qian Q, Jiang C, Ren X. Trans-Anastomotic Drainage Tube Placement After Hand-Sewn Anastomosis in Patients Undergoing Intersphincteric Resection for Low Rectal Cancer: An Alternative Drainage Method. Front Oncol 2022; 12:872120. [PMID: 35965574 PMCID: PMC9365931 DOI: 10.3389/fonc.2022.872120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 05/13/2022] [Indexed: 11/30/2022] Open
Abstract
Anastomotic leakage (AL) is a common complication after intersphincteric resection (ISR). It significantly reduces quality of life and causes great distress to patients. Although traditional drainage (e.g., anal and pelvic catheters) may reduce the impact of AL to some extent, their role in reducing the incidence of AL remains controversial. In this study, we developed a novel drainage technique involving the placement of drainage tubes through the gap between sutures during handsewn anastomosis, to reduce the occurrence of anastomotic leakage. We retrospectively analyzed 34 consecutive patients who underwent intersphincteric resection requiring handsewn anastomosis between February 1, 2017, and January 1, 2021. Patients were classified into the trans-anastomotic drainage tube group (TADT, n = 14) and the non-TADT group (n = 20) based on whether trans-anastomotic tube placement was performed. The incidence of postoperative complications, such as AL, was compared between the two groups, and anal function of patients at 1-year post-ISR was evaluated. Six cases of AL occurred in the non-TADT group, while none occurred in the TADT group; this difference was statistically significant (p=0.031). The TADT group also had a shorter hospital stay (p=0.007). There were no other significant intergroup differences in operation time, blood loss, pain score, anastomotic stenosis, intestinal obstruction, or incidence of wound infection. In the 30 patients (88.2%) evaluated for anal function, there were no significant intergroup differences in stool frequency, urgency, daytime/nocturnal soiling, Wexner incontinence score, or Kirwan grading. Taken together, trans-anastomotic tube placement is a novel drainage method that may reduce AL after ISR requiring handsewn anastomosis and without adversely affecting anal function.
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Affiliation(s)
- Xinjian Zhong
- Department of Colorectal and Anal Surgery, Zhongnan Hospital of Wuhan University, Wuhan, China
- Clinical Center of Intestinal and Colorectal Diseases of Hubei Province, Wuhan, China
- Key Laboratory of Intestinal and Colorectal Diseases of Hubei Province, Wuhan, China
- Colorectal and Anal Disease Research Center, Medical School of Wuhan University, Wuhan, China
- Quality Control Center of Colorectal and Anal Surgery, Health Commission of Hubei Province, Wuhan, China
| | - Xiaoyu Xie
- Department of Colorectal and Anal Surgery, Zhongnan Hospital of Wuhan University, Wuhan, China
- Clinical Center of Intestinal and Colorectal Diseases of Hubei Province, Wuhan, China
- Key Laboratory of Intestinal and Colorectal Diseases of Hubei Province, Wuhan, China
- Colorectal and Anal Disease Research Center, Medical School of Wuhan University, Wuhan, China
- Quality Control Center of Colorectal and Anal Surgery, Health Commission of Hubei Province, Wuhan, China
| | - Hang Hu
- Department of Colorectal and Anal Surgery, Zhongnan Hospital of Wuhan University, Wuhan, China
- Clinical Center of Intestinal and Colorectal Diseases of Hubei Province, Wuhan, China
- Key Laboratory of Intestinal and Colorectal Diseases of Hubei Province, Wuhan, China
- Colorectal and Anal Disease Research Center, Medical School of Wuhan University, Wuhan, China
- Quality Control Center of Colorectal and Anal Surgery, Health Commission of Hubei Province, Wuhan, China
| | - Yi Li
- Department of Colorectal and Anal Surgery, Zhongnan Hospital of Wuhan University, Wuhan, China
- Clinical Center of Intestinal and Colorectal Diseases of Hubei Province, Wuhan, China
- Key Laboratory of Intestinal and Colorectal Diseases of Hubei Province, Wuhan, China
- Colorectal and Anal Disease Research Center, Medical School of Wuhan University, Wuhan, China
- Quality Control Center of Colorectal and Anal Surgery, Health Commission of Hubei Province, Wuhan, China
| | - Shunhua Tian
- Department of Colorectal and Anal Surgery, Zhongnan Hospital of Wuhan University, Wuhan, China
- Clinical Center of Intestinal and Colorectal Diseases of Hubei Province, Wuhan, China
- Key Laboratory of Intestinal and Colorectal Diseases of Hubei Province, Wuhan, China
- Colorectal and Anal Disease Research Center, Medical School of Wuhan University, Wuhan, China
- Quality Control Center of Colorectal and Anal Surgery, Health Commission of Hubei Province, Wuhan, China
| | - Qun Qian
- Department of Colorectal and Anal Surgery, Zhongnan Hospital of Wuhan University, Wuhan, China
- Clinical Center of Intestinal and Colorectal Diseases of Hubei Province, Wuhan, China
- Key Laboratory of Intestinal and Colorectal Diseases of Hubei Province, Wuhan, China
- Colorectal and Anal Disease Research Center, Medical School of Wuhan University, Wuhan, China
- Quality Control Center of Colorectal and Anal Surgery, Health Commission of Hubei Province, Wuhan, China
| | - Congqing Jiang
- Department of Colorectal and Anal Surgery, Zhongnan Hospital of Wuhan University, Wuhan, China
- Clinical Center of Intestinal and Colorectal Diseases of Hubei Province, Wuhan, China
- Key Laboratory of Intestinal and Colorectal Diseases of Hubei Province, Wuhan, China
- Colorectal and Anal Disease Research Center, Medical School of Wuhan University, Wuhan, China
- Quality Control Center of Colorectal and Anal Surgery, Health Commission of Hubei Province, Wuhan, China
- *Correspondence: Congqing Jiang, ; Xianghai Ren,
| | - Xianghai Ren
- Department of Colorectal and Anal Surgery, Zhongnan Hospital of Wuhan University, Wuhan, China
- Clinical Center of Intestinal and Colorectal Diseases of Hubei Province, Wuhan, China
- Key Laboratory of Intestinal and Colorectal Diseases of Hubei Province, Wuhan, China
- Colorectal and Anal Disease Research Center, Medical School of Wuhan University, Wuhan, China
- Quality Control Center of Colorectal and Anal Surgery, Health Commission of Hubei Province, Wuhan, China
- *Correspondence: Congqing Jiang, ; Xianghai Ren,
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12
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Bozbıyık O, Çalışkan C, Köse Ö, Verendağ O, Göktepe B, Yoldaş T, Akgün E, Korkut MA. Functional outcomes of intersphincteric resection in low rectal tumors. Turk J Surg 2022; 38:180-186. [PMID: 36483164 PMCID: PMC9714657 DOI: 10.47717/turkjsurg.2022.5556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 03/16/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVES Currently, sphincter-saving procedures are increasingly performed in the treatment of low rectal cancers. This study aimed to evaluate the outcomes of patients who underwent intersphincteric resection. MATERIAL AND METHODS This was a single-center, retrospective, cross-sectional study. We evaluated the electronic data files of 29 patients who had intersphincteric resections at our institute between 2008 and 2018. Bowel function outcomes were assessed prospectively using Wexner incontinence score. Histopathological, surgical and functional outcomes were analyzed. RESULTS Mean age of nine female and 20 male patients included in the study was 55.8 ± 12.8 (30-76) years. A tumor-free surgical margin was achieved in all patients. Anastomotic leakage was detected in two patients. Mean Wexner incontinence score of 20 patients who still had functional anastomosis was 8.35, whereas 65% of the patients (n= 13) had a good continence status. There was no relationship between the continence status and sex, tumor distance from anal verge, T stage, distal surgical margin, and lymph node involvement. Twenty-one patients underwent primary coloanal anastomosis and eight patients underwent two-stage coloanal anastomosis. CONCLUSION In the treatment of distal rectal cancer, adequate oncological surgery and relatively acceptable functional outcomes can be obtained with intersphincteric resection technique in suitable patients.
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Affiliation(s)
- Osman Bozbıyık
- Department of Surgery, Ege University Faculty of Medicine, İzmir, Türkiye
| | - Cemil Çalışkan
- Department of Surgery, Ege University Faculty of Medicine, İzmir, Türkiye
| | - Özgün Köse
- Department of Surgery, Ege University Faculty of Medicine, İzmir, Türkiye
| | - Ozan Verendağ
- Department of Surgery, Ege University Faculty of Medicine, İzmir, Türkiye
| | - Berk Göktepe
- Department of Surgery, Ege University Faculty of Medicine, İzmir, Türkiye
| | - Tayfun Yoldaş
- Department of Surgery, Ege University Faculty of Medicine, İzmir, Türkiye
| | - Erhan Akgün
- Department of Surgery, Ege University Faculty of Medicine, İzmir, Türkiye
| | - Mustafa Ali Korkut
- Department of Surgery, Ege University Faculty of Medicine, İzmir, Türkiye
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13
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Korai T, Akizuki E, Okita K, Nishidate T, Okuya K, Sato Y, Hamabe A, Ishii M, Nobuoka T, Takemasa I. Defecation disorder and anal function after surgery for lower rectal cancer in elderly patients. Ann Gastroenterol Surg 2022; 6:101-108. [PMID: 35106420 PMCID: PMC8786691 DOI: 10.1002/ags3.12505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 08/24/2021] [Accepted: 08/29/2021] [Indexed: 11/23/2022] Open
Abstract
AIM This study aims to investigate the association of patient age with defecation disorders and anal function after lower rectal cancer surgery. METHODS We retrospectively reviewed the data of 141 consecutive patients with lower rectal cancer who underwent sphincter-preserving operation. The patients were classified into five categories by age thresholds at 65, 70, 75, 80, and 85 years, for disaggregate analysis. Anal manometry was used for measuring the maximum resting pressure, high-pressure zone, and maximum squeeze pressure. Anal manometry was performed preoperatively and at 3, 6, 9, and 12 months postoperatively. The Wexner and low anterior resection syndrome scores were assessed at 1, 3, 6, 9, and 12 months after rectal surgery or stoma closure for patients with ileostomy. RESULTS The data of 117 patients were reviewed. No significant differences were found between the younger and elderly groups in any characteristics across the six age groups. The preoperative intra-anal pressures of the elderly patients were slightly lower than those of the younger patients; however, there was no significant difference in the course of postoperative intra-anal pressures. Defecation disorder, as measured by the Wexner and low anterior resection syndrome scores, improved significantly in elderly patients compared to younger patients. CONCLUSION There was no significant difference in the course of postoperative intra-anal pressures between the elderly and younger patients. However, defecation disorders in elderly patients significantly improved compared with younger patients. Sphincter-preserving operation can be a viable treatment option for active elderly patients.
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Affiliation(s)
- Takahiro Korai
- Department of SurgerySurgical Oncology and ScienceSapporo Medical UniversitySapporoJapan
| | - Emi Akizuki
- Department of SurgerySurgical Oncology and ScienceSapporo Medical UniversitySapporoJapan
| | - Kenji Okita
- Department of SurgerySurgical Oncology and ScienceSapporo Medical UniversitySapporoJapan
| | - Toshihiko Nishidate
- Department of SurgerySurgical Oncology and ScienceSapporo Medical UniversitySapporoJapan
| | - Koichi Okuya
- Department of SurgerySurgical Oncology and ScienceSapporo Medical UniversitySapporoJapan
| | - Yu Sato
- Department of SurgerySurgical Oncology and ScienceSapporo Medical UniversitySapporoJapan
| | - Atsushi Hamabe
- Department of SurgerySurgical Oncology and ScienceSapporo Medical UniversitySapporoJapan
| | - Masayuki Ishii
- Department of SurgerySurgical Oncology and ScienceSapporo Medical UniversitySapporoJapan
| | - Takayuki Nobuoka
- Department of SurgerySurgical Oncology and ScienceSapporo Medical UniversitySapporoJapan
| | - Ichiro Takemasa
- Department of SurgerySurgical Oncology and ScienceSapporo Medical UniversitySapporoJapan
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14
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Piozzi GN, Kim SH. Robotic Intersphincteric Resection for Low Rectal Cancer: Technical Controversies and a Systematic Review on the Perioperative, Oncological, and Functional Outcomes. Ann Coloproctol 2021; 37:351-367. [PMID: 34784706 PMCID: PMC8717069 DOI: 10.3393/ac.2021.00836.0119] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 10/13/2021] [Accepted: 10/13/2021] [Indexed: 11/10/2022] Open
Abstract
Intersphincteric resection (ISR) is the ultimate anus-sparing technique for low rectal cancer and is considered an oncologically safe alternative to abdominoperineal resection. The application of the robotic approach to ISR (RISR) has been described by few specialized surgical teams with several differences regarding approach and technique. This review aims to discuss the technical aspects of RISR by evaluating point by point each surgical controversy. Moreover, a systematic review was performed to report the perioperative, oncological, and functional outcomes of RISR. Postoperative morbidities after RISR are acceptable. RISR allows adequate surgical margins and adequate oncological outcomes. RISR may result in severe bowel and genitourinary dysfunction affecting the quality of life in a portion of patients.
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Affiliation(s)
- Guglielmo Niccolò Piozzi
- Division of Colon and Rectal Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Seon Hahn Kim
- Division of Colon and Rectal Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
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15
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Piozzi GN, Baek SJ, Kwak JM, Kim J, Kim SH. Anus-Preserving Surgery in Advanced Low-Lying Rectal Cancer: A Perspective on Oncological Safety of Intersphincteric Resection. Cancers (Basel) 2021; 13:4793. [PMID: 34638278 PMCID: PMC8507715 DOI: 10.3390/cancers13194793] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 09/17/2021] [Accepted: 09/21/2021] [Indexed: 12/15/2022] Open
Abstract
The surgical management of low-lying rectal cancer, within 5 cm from the anal verge (AV), is challenging due to the possibility, or not, to preserve the anus with its sphincter muscles maintaining oncological safety. The standardization of total mesorectal excision, the adoption of neoadjuvant chemoradiotherapy, the implementation of rectal magnetic resonance imaging, and the evolution of mechanical staplers have increased the rate of anus-preserving surgeries. Moreover, extensive anatomy and physiology studies have increased the understanding of the complexity of the deep pelvis. Intersphincteric resection (ISR) was introduced nearly three decades ago as the ultimate anus-preserving surgery. The definition and indication of ISR have changed over time. The adoption of the robotic platform provides excellent perioperative results with no differences in oncological outcomes. Pushing the boundaries of anus-preserving surgeries has risen doubts on oncological safety in order to preserve function. This review critically discusses the oncological safety of ISR by evaluating the anatomical characteristics of the deep pelvis, the clinical indications, the role of distal and circumferential resection margins, the role of the neoadjuvant chemoradiotherapy, the outcomes between surgical approaches (open, laparoscopic, and robotic), the comparison with abdominoperineal resection, the risk factors for oncological outcomes and local recurrence, the patterns of local recurrences after ISR, considerations on functional outcomes after ISR, and learning curve and surgical education on ISR.
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Affiliation(s)
| | | | | | | | - Seon Hahn Kim
- Division of Colon and Rectal Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul 02841, Korea; (G.N.P.); (S.-J.B.); (J.-M.K.); (J.K.)
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16
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Kohata A, Shimizu W, Kochi M, Takakura Y, Ohdan H. A case of effective Delorme's procedure for colonic mucosal prolapse after intersphincteric resection. J Surg Case Rep 2021; 2021:rjab359. [PMID: 34531972 PMCID: PMC8440137 DOI: 10.1093/jscr/rjab359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 07/27/2021] [Indexed: 11/13/2022] Open
Abstract
Recent surgical technical improvements, such as endoscopic surgery with intersphincteric resection (ISR), could help avoid a permanent colostomy for patients with low-lying rectal tumors. However, the problems associated with anal dysfunction following ISR remain unresolved. We performed ISR and temporary ileostomy in a patient with low-lying rectal cancer. After evaluating the stability of the anastomosis, we planned to close the ileostomy, but the patient developed post-operative colonic mucosal prolapse (CMP). Although there are treatment methods available for CMP, there is no consensus on the treatment for post-operative CMP. In this case, we performed Delorme’s procedure because the method has been reported to have advantages in terms of improving post-operative anal function. Post-operative anorectal manometry showed improvement in maximum squeeze pressure, and the patient’s anal function improved; subsequently, ileostomy closure was performed. Delorme’s procedure may be useful for patients with CMP after ISR to achieve good post-operative anal function.
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Affiliation(s)
- Akihiro Kohata
- Department of Surgery, National Hospital Organization Higashi Hiroshima Medical Center, Higashihiroshima, Japan
| | - Wataru Shimizu
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University Hospital, Hiroshima, Japan
| | - Masatoshi Kochi
- Department of Surgery, National Hospital Organization Higashi Hiroshima Medical Center, Higashihiroshima, Japan
| | - Yuji Takakura
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University Hospital, Hiroshima, Japan
| | - Hideki Ohdan
- Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical & Health Sciences, Hiroshima University Hospital, Hiroshima, Japan
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17
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Desouza AL, Kazi M, Verma K, Sugoor P, Mahendra BK, Saklani AP. Local recurrence with intersphincteric resection in adverse histology rectal cancers. A retrospective study with competing risk analysis. ANZ J Surg 2021; 91:2475-2481. [PMID: 34427027 DOI: 10.1111/ans.17155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 07/16/2021] [Accepted: 08/07/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND The safety of inter-sphincteric resection (ISR) for low rectal cancer with adverse histologic subtypes has been incompletely studied. The present study aims at determining the risk of local recurrence with this procedure in poorly differentiated and signet ring cell (PDSR) adenocarcinoma. METHODS Retrospective analysis from a single tertiary cancer centre of non-metastatic primary rectal cancer <6 cm from the anal verge that underwent ISR. Competing risk analysis and sub-distribution hazard ratios for local recurrence free survivals were calculated to determine factors that influenced local recurrence with the competing risk of death from any cause to overcome the exceeding risk of distant metastasis associated with adverse histologic types. RESULTS One hundred forty-two patients underwent ISR and 22.6% has PDSR histology. At a median follow up of 61 months, 15.6% of the PDSR cohort developed local recurrence (five patients) compared to 11.7% in the non-PDSR group. PDSR histology influenced overall and disease free survival but not local recurrence on cox regression. On competing risk analysis, only ypT stage ≥3 predicted worse local recurrence free survival and not histology. CONCLUSIONS The presence of PDSR histology did not increase the risk of local recurrence after ISR in this retrospective competing risk analysis.
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Affiliation(s)
- Ashwin L Desouza
- Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India.,Homi Bhabha National Institute, Mumbai, India
| | - Mufaddal Kazi
- Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India.,Homi Bhabha National Institute, Mumbai, India
| | - Kamlesh Verma
- Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India.,Homi Bhabha National Institute, Mumbai, India
| | - Pavan Sugoor
- Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India.,Homi Bhabha National Institute, Mumbai, India
| | - Balu K Mahendra
- Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India.,Homi Bhabha National Institute, Mumbai, India
| | - Avanish P Saklani
- Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India.,Homi Bhabha National Institute, Mumbai, India
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18
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Pallan A, Dedelaite M, Mirajkar N, Newman PA, Plowright J, Ashraf S. Postoperative complications of colorectal cancer. Clin Radiol 2021; 76:896-907. [PMID: 34281707 DOI: 10.1016/j.crad.2021.06.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 06/09/2021] [Indexed: 12/12/2022]
Abstract
Colorectal cancer is the third most common cancer, and surgery is the most common treatment. Several surgical options are available, but each is associated with a range of potential complications. The timely and efficient identification of these complications is vital for effective clinical management of these patients in order to minimise their morbidity and mortality. This review aims to describe the range of commonly performed surgical treatments for colorectal surgery. In addition, frequent post-surgical complications are explored with investigative options explained and illustrated.
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Affiliation(s)
- A Pallan
- Department of Radiology, University Hospitals Birmingham NHS FT, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham, B15 2GW, UK.
| | - M Dedelaite
- Department of Radiology, University Hospitals Birmingham NHS FT, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham, B15 2GW, UK
| | - N Mirajkar
- Department of Radiology, University Hospitals Birmingham NHS FT, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham, B15 2GW, UK
| | - P A Newman
- Department of Radiology, University Hospitals Birmingham NHS FT, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham, B15 2GW, UK
| | - J Plowright
- Department of Radiology, University Hospitals Birmingham NHS FT, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham, B15 2GW, UK
| | - S Ashraf
- Department of Colorectal Surgery, University Hospitals Birmingham NHS FT, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham, B15 2GW, UK
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19
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Piozzi GN, Park H, Lee TH, Kim JS, Choi HB, Baek SJ, Kwak JM, Kim J, Kim SH. Risk factors for local recurrence and long term survival after minimally invasive intersphincteric resection for very low rectal cancer: Multivariate analysis in 161 patients. Eur J Surg Oncol 2021; 47:2069-2077. [PMID: 33781627 DOI: 10.1016/j.ejso.2021.03.246] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 01/23/2021] [Accepted: 03/17/2021] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Intersphincteric resection (ISR) is the ultimate anal-sparing technique as an alternative to abdominoperineal resection in selected patients. Oncological safety is still debated. This study analyses long-term oncological results and evaluates risk factors for local recurrence (LR) and overall survival (OS) after minimally-invasive ISR. MATERIALS AND METHODS Retrospective single-center data were collected from a prospectively maintained colorectal database. A total of 161 patients underwent ISR between 2008 and 2018. OS and local recurrence-free survival (LRFS) were assessed using Kaplan-Meier analysis (log-rank test). Risk factors for OS and LRFS were assessed with Cox-regression analysis. RESULTS Median follow-up was 55 months. LR occurred in 18 patients. OS and LRFS rates at 1, 3, and 5 years were 96%, 91%, and 80% and 96%, 89%, and 87%, respectively. Tumor size (p = 0.035) and clinical T-stage (p = 0.029) were risk factors for LRFS on univariate analysis. On multivariate analysis, tumor size (HR 2.546 (95% CI: 0.976-6.637); p = 0.056) and clinical T-stage (HR 3.296 (95% CI: 0.941-11.549); p = 0.062) were not significant. Preoperative CEA (p < 0.001), pathological T-stage (p = 0.033), pathological N-stage (p = 0.016) and adjuvant treatment (p = 0.008) were prognostic factors for OS on univariate analysis. Preoperative CEA (HR 4.453 (95% CI: 2.015-9.838); p < 0.001) was a prognostic factor on multivariate analysis. CONCLUSIONS This study confirms the oncological safety of minimally-invasive ISR for locally advanced low-lying rectal tumors when performed in experienced centers. Despite not a risk factor for LR, tumor size and, locally advanced T-stage with anterior involvement should be carefully evaluated for optimal surgical strategy. Preoperative CEA is a prognostic factor for OS.
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Affiliation(s)
- G N Piozzi
- Colorectal Surgery Unit, Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milano, Italy; Division of Colorectal Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, South Korea
| | - H Park
- Division of Colorectal Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, South Korea
| | - T H Lee
- Division of Colorectal Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, South Korea
| | - J S Kim
- Division of Colorectal Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, South Korea
| | - H B Choi
- Division of Colorectal Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, South Korea
| | - S J Baek
- Division of Colorectal Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, South Korea
| | - J M Kwak
- Division of Colorectal Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, South Korea
| | - J Kim
- Division of Colorectal Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, South Korea
| | - S H Kim
- Division of Colorectal Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, South Korea.
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Laparoscopic intersphincteric resection with hand-sewn coloanal anastomosis in the treatment of low rectal cancer: 10-year experience. Eur Surg 2021. [DOI: 10.1007/s10353-021-00694-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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21
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Fung TLD, Tsukada Y, Ito M. Essential anatomy for total mesorectal excision and lateral lymph node dissection, in both trans-abdominal and trans-anal perspective. Surgeon 2020; 19:e462-e474. [PMID: 33248924 DOI: 10.1016/j.surge.2020.09.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 08/10/2020] [Accepted: 09/02/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND PURPOSE Total Mesorectal Excisions (TME) is the standard treatment of rectal cancer. It can be performed under laparoscopic, robotic or transanal approach. Inadvertent injury to surrounding structure like autonomic nerves is avoidable, no matter which approach is adopted. Lateral lymph node dissection (LLND) is a less commonly performed pelvic operation involving dissection in an unfamiliar area to most general surgeons. This article aims to clarify all the essential anatomy related to these procedures. METHODS We performed thorough literature search and revision on the pelvic anatomy. Our cases of TME and LLND, under either laparoscopic or transanal approach, were reviewed. We integrated the knowledge from literatures and our own experience. The result was presented in details, together with original figures and intra-operative photos. MAIN FINDINGS Anatomy of pelvic fascia, autonomic nerve system, anal canal and sphincter complex are core knowledge in performing TME and LLND. CONCLUSIONS Thorough understanding of the pelvic anatomy enables colorectal surgeons to master these procedures, avoid complication and perform extended resection. On the other hand, surgeons can appreciate the complex pelvic anatomy easier by seeing the pelvis in opposite angles (transabdominal and transaanal view).
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Affiliation(s)
| | - Yuichiro Tsukada
- Department of Colorectal Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | - Masaaki Ito
- Department of Colorectal Surgery, National Cancer Center Hospital East, Kashiwa, Japan
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22
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Denost Q, Moreau JB, Vendrely V, Celerier B, Rullier A, Assenat V, Rullier E. Intersphincteric resection for low rectal cancer: the risk is functional rather than oncological. A 25-year experience from Bordeaux. Colorectal Dis 2020; 22:1603-1613. [PMID: 32649005 DOI: 10.1111/codi.15258] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 04/03/2020] [Indexed: 02/07/2023]
Abstract
AIM There are few data evaluating the long-term outcomes of intersphincteric resection (ISR), especially the impact of inclusion of more juxtapositioned and intra-anal tumours on oncological and functional outcomes. We compared the oncological and functional results of patients treated by total mesorectal excision and ISR for low rectal cancer over a 25-year period. METHOD This is a retrospective study from a single institution evaluating results of ISR over three periods: 1990-1998, 1999-2006 and 2007-2014. Patients treated by partial or total ISR, with or without neoadjuvant chemoradiotherapy, for low rectal cancer (≤ 6 cm from the anal verge) were included. We compared postoperative morbidity, quality of surgery and oncological and functional outcomes in the time periods studied. RESULTS Of 813 patients operated on for low rectal cancer, 303 had ISR. Tumour stage did not differ; however, the distance of the tumour from the anorectal junction decreased from 1 to 0 cm (P < 0.001) and the distal resection margin shortened from 25 to 10 mm (P < 0.001) from 1990 to 2014. The postoperative morbidity and quality of surgery did not change significantly over time. The 5-year local recurrence (4.3% vs 5.9% vs 3.5%; P = 0.741) and disease-free survival (72% vs 71% vs 75%; P = 0.918) did not differ between the three time periods. Functional results improved during the last period; however, overall 42% of patients experienced major bowel dysfunction. CONCLUSION Pushing the envelope of sphincter-saving resection in ultra-low rectal cancer reaching or invading the anal sphincter did not compromise oncological and functional outcomes. The main limitation of the ISR procedure appears to be functional rather than oncological, suggesting that bowel rehabilitation programmes should be developed.
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Affiliation(s)
- Q Denost
- Department of Colorectal Surgery, CHU Bordeaux, Haut-Leveque Hospital, University of Bordeaux, Pessac, France
| | - J-B Moreau
- Department of Colorectal Surgery, CHU Bordeaux, Haut-Leveque Hospital, University of Bordeaux, Pessac, France
| | - V Vendrely
- Department of Radiotherapy, CHU Bordeaux, Haut-Leveque Hospital, University of Bordeaux, Pessac, France
| | - B Celerier
- Department of Colorectal Surgery, CHU Bordeaux, Haut-Leveque Hospital, University of Bordeaux, Pessac, France
| | - A Rullier
- Department of Pathology, CHU Bordeaux, Pellegrin Hospital, University of Bordeaux, Bordeaux, France
| | - V Assenat
- Department of Colorectal Surgery, CHU Bordeaux, Haut-Leveque Hospital, University of Bordeaux, Pessac, France
| | - E Rullier
- Department of Colorectal Surgery, CHU Bordeaux, Haut-Leveque Hospital, University of Bordeaux, Pessac, France
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23
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Latest Advances in Intersphincteric Resection for Low Rectal Cancer. Gastroenterol Res Pract 2020; 2020:8928109. [PMID: 32765603 PMCID: PMC7387965 DOI: 10.1155/2020/8928109] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 06/19/2020] [Accepted: 06/20/2020] [Indexed: 02/06/2023] Open
Abstract
Background Intersphincteric resection (ISR) has been a preferable alternative to abdominoperineal resection (APR) for anal preservation in patients with low rectal cancer. Laparoscopic ISR and robotic ISR have been widely used with the proposal of 2 cm or even 1 cm rule of distal free margin and the development of minimally invasive technology. The aim of this review was to describe the newest advancements of ISR. Methods A comprehensive literature review was performed to identify studies on ISR techniques, preoperative chemoradiotherapy (PCRT), complications, oncological outcomes, and functional outcomes and thereby to summarize relevant information and controversies involved in ISR. Results Although PCRT is employed to avoid positive circumferential resection margin (CRM) and decrease local recurrence, it tends to engender damage of anorectal function and patients' quality of life (QoL). Common complications after ISR include anastomotic leakage (AL), anastomotic stricture (AS), urinary retention, fistula, pelvic sepsis, and prolapse. CRM involvement is the most important predictor for local recurrence. Preoperative assessment and particularly rectal endosonography are essential for selecting suitable patients. Anal dysfunction is associated with age, PCRT, location and growth of anastomotic stoma, tumour stage, and resection of internal sphincter. Conclusions The ISR technique seems feasible for selected patients with low rectal cancer. However, the postoperative QoL as a result of functional disorder should be fully discussed with patients before surgery.
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24
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Clinical Relevance and Practical Approach for Challenging Rectal Cancer MRI Findings. CURRENT RADIOLOGY REPORTS 2020. [DOI: 10.1007/s40134-020-00359-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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25
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Maldonado Marcos E, Planellas Giné P, Gil Garcia J, Farrés Coll R, Codina Cazador A. Altemeier procedure for rectal prolapse after intersphincteric low anterior resection with transanal total mesorrectal excision. Cir Esp 2020; 99:389-391. [PMID: 32564876 DOI: 10.1016/j.ciresp.2020.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 05/17/2020] [Accepted: 05/21/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Eloy Maldonado Marcos
- Cirugía General y Digestiva, Unidad de Cirugía Colorrectal, Servicio de Cirugía General y del Aparato Digestivo, Universidad de Girona, Instituto de Investigación Biomédica de Girona (IdIBGi), Girona, España.
| | - Pere Planellas Giné
- Cirugía General y Digestiva, Unidad de Cirugía Colorrectal, Servicio de Cirugía General y del Aparato Digestivo, Universidad de Girona, Instituto de Investigación Biomédica de Girona (IdIBGi), Girona, España
| | - Júlia Gil Garcia
- Cirugía General y Digestiva, Unidad de Cirugía Colorrectal, Servicio de Cirugía General y del Aparato Digestivo, Universidad de Girona, Instituto de Investigación Biomédica de Girona (IdIBGi), Girona, España
| | - Ramon Farrés Coll
- Cirugía General y Digestiva, Unidad de Cirugía Colorrectal, Servicio de Cirugía General y del Aparato Digestivo, Universidad de Girona, Instituto de Investigación Biomédica de Girona (IdIBGi), Girona, España
| | - Antoni Codina Cazador
- Cirugía General y Digestiva, Unidad de Cirugía Colorrectal, Servicio de Cirugía General y del Aparato Digestivo, Universidad de Girona, Instituto de Investigación Biomédica de Girona (IdIBGi), Girona, España
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26
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Robotic Surgery for Rectal Cancer: Hype or Hope? (Indian Experience). Indian J Surg Oncol 2020; 11:604-612. [PMID: 33281402 DOI: 10.1007/s13193-020-01113-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 05/28/2020] [Indexed: 12/16/2022] Open
Abstract
The primary goal to achieve cure in oncology is to reduce recurrence, maximize disease-free survival, maintain function, and optimize quality of life. Surgery remains the mainstay treatment modality in rectal cancer. The current trend is to perform least invasive method of doing complex surgeries while not compromising in the oncological of functional outcomes of patients. Total mesorectal excision (TME) for rectal cancer surgery entails removal of the rectum with its fascia as an intact unit while preserving surrounding vital structures. The procedure is technically challenging because of the narrow and deep pelvic cavity housing the rectum encased by fatty lymph vascular tissue within the perirectal fascia, distally the anal sphincter complex, and an intimate surrounded by vital structures like ureter, vessels, and nerves. Robotic technology enables overcoming these difficulties caused by complex pelvic anatomy. This system can facilitate better preservation of the pelvic autonomic nerve and thereby achieve favorable postoperative sexual and voiding functions after rectal cancer surgery. The nerve-preserving TME technique includes identification and preservation of the superior hypogastric plexus nerve, bilateral hypogastric nerves, pelvic plexus, and neurovascular bundles.
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Collard M, Lefevre JH. Ultimate Functional Preservation With Intersphincteric Resection for Rectal Cancer. Front Oncol 2020; 10:297. [PMID: 32195192 PMCID: PMC7066078 DOI: 10.3389/fonc.2020.00297] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 02/20/2020] [Indexed: 12/11/2022] Open
Abstract
The proximity of the very low rectum rectal cancer to the anal sphincter raises a specific problem: how and until when can we preserve the anal continence without compromising the oncological result of the tumor resection? In this situation, intersphincteric resection (ISR) offers an excellent alternative to abdominoperineal resection (APR), but the selection of patients for this option must be extremely precise. This complex choice justifies the simultaneous consideration of an oncological approach with a functional approach in order to provide a full benefit to the patient. When a circumferential resection margin of at least 1 mm can be performed with a distal resection margin of at least 1 cm with or without preoperative radiotherapy, ISR ensures a safety choice. The oncological results of ISR reported in the literature when performed properly found a 5-year disease-free survival of 80.2% with a local recurrence rate of only 5.8%. In parallel to this oncological evaluation, the expected post-operative functional outcome and the resulting quality of life must be properly assessed pre-operatively, since partial or total resection of the internal sphincter impacts significantly on the functional outcome. Based on data from the literature, this work reports the essential anatomical considerations and then the oncological and functional elements indispensables when an anal continence preservation is evoked for a tumor of the very low rectum. Finally, the precise selection criteria and the major surgical principles are outlined in order to guarantee the safety of this modern choice for the patient.
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Affiliation(s)
- Maxime Collard
- Sorbonne Université, Department of Digestive Surgery, AP-HP, Hôpital Saint Antoine, Paris, France
| | - Jérémie H Lefevre
- Sorbonne Université, Department of Digestive Surgery, AP-HP, Hôpital Saint Antoine, Paris, France
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28
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Butiurca VO, Molnar C, Constantin C, Botoncea M, Bud TI, Kovacs Z, Satala C, Gurzu S. Long Term Results of Modified Intersphincteric Resections for Low Rectal Cancer: A Single Center Experience. MEDICINA (KAUNAS, LITHUANIA) 2019; 55:medicina55120764. [PMID: 31795439 PMCID: PMC6955682 DOI: 10.3390/medicina55120764] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Revised: 11/25/2019] [Accepted: 11/27/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND OBJECTIVES The objective of this article is to evaluate the long-term oncological and functional outcomes following modified intersphincteric resections (ISR) for low rectal cancer. The modified technique consisted of the abandonment of colonic J-pouches, transverse coloplasty, or defunctioning temporary stoma in favor of a direct handsewn coloanal anastomosis (CAA). MATERIAL AND METHODS Sixty consecutive patients with type II and III (juxta-anal or intra-anal) low rectal tumors underwent modified ISR by the same surgical team and were followed for a period of five years. Functional outcomes using the Wexner Score, postoperative complications, recurrence rates, morbidity, and mortality rates were assessed. RESULTS The five-year survival rate was 93.3% with a disease-free interval at three years of 98%. Morbidity was 15% (n = 9) consisting of intestinal wall necrosis (n = 6), stenosis (n = 2), and sacral metastasis (n = 1). The Wexner score values were, at 1 year, 8.5 (range, 4-13); at three years 7.2 (range, 2-11); and at 5 years 6.7 (range, 2-12). A second surgery was needed in only one case that showed postoperative transmural necrosis of the colonic wall. CONCLUSIONS In highly selected patients with type II or III low rectal tumors and proper preoperative imaging staging, ISR might be a viable alternative to other techniques such as abdominoperineal resection and low anterior resection, both from a functional and an oncological perspective.
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Affiliation(s)
- Vlad-Olimpiu Butiurca
- First Department of Surgery, University of Medicine, Pharmacy, Science and Technology ‘George Emil Palade’, 540139 Târgu-Mureș, Romania; (V.-O.B.); (C.C.); (M.B.)
- Clinic of Vascular Surgery, Emergency County Hospital, 540139 Târgu-Mureș, Romania;
| | - Călin Molnar
- First Department of Surgery, University of Medicine, Pharmacy, Science and Technology ‘George Emil Palade’, 540139 Târgu-Mureș, Romania; (V.-O.B.); (C.C.); (M.B.)
- Correspondence: ; Tel.: +40-07-2224-1281
| | - Copotoiu Constantin
- First Department of Surgery, University of Medicine, Pharmacy, Science and Technology ‘George Emil Palade’, 540139 Târgu-Mureș, Romania; (V.-O.B.); (C.C.); (M.B.)
| | - Marian Botoncea
- First Department of Surgery, University of Medicine, Pharmacy, Science and Technology ‘George Emil Palade’, 540139 Târgu-Mureș, Romania; (V.-O.B.); (C.C.); (M.B.)
| | - Teodor Ioan Bud
- Clinic of Vascular Surgery, Emergency County Hospital, 540139 Târgu-Mureș, Romania;
| | - Zsolt Kovacs
- Department of Pathology, Emergency County Hospital, 540136 Târgu-Mureș, Romania; (Z.K.); (C.S.)
| | - Cătălin Satala
- Department of Pathology, Emergency County Hospital, 540136 Târgu-Mureș, Romania; (Z.K.); (C.S.)
| | - Simona Gurzu
- Department of Pathology, University of Medicine, Pharmacy, Science and Technology, 540139 Târgu-Mureș, Romania;
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Hope TA, Gollub MJ, Arya S, Bates DDB, Ganeshan D, Harisinghani M, Jhaveri KS, Kassam Z, Kim DH, Korngold E, Lalwani N, Moreno CC, Nougaret S, Paroder V, Paspulati RM, Golia Pernicka JS, Petkovska I, Pickhardt PJ, Rauch GM, Rosenthal MH, Sheedy SP, Horvat N. Rectal cancer lexicon: consensus statement from the society of abdominal radiology rectal & anal cancer disease-focused panel. Abdom Radiol (NY) 2019; 44:3508-3517. [PMID: 31388697 DOI: 10.1007/s00261-019-02170-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Standardized terminology is critical to providing consistent reports to referring clinicians. This lexicon aims to provide a reference for terminology frequently used in rectal cancer and reflects the consensus of the Society of Abdominal Radiology Disease Focused Panel in Rectal cancer. This lexicon divided the terms into the following categories: primary tumor staging, nodal staging, treatment response, anal canal anatomy, general anatomy, and treatments.
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Affiliation(s)
- Thomas A Hope
- Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Avenue, M-391, San Francisco, CA, 94143, USA.
- Department of Radiology, San Francisco VA Medical Center, San Francisco, CA, USA.
- UCSF Helen, Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA, USA.
| | - Marc J Gollub
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - David D B Bates
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | | | - Kartik S Jhaveri
- University of Toronto University Health Network, Toronto, ON, Canada
| | - Zahra Kassam
- Schulich School of Medicine, Western University, London, ON, Canada
| | - David H Kim
- School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | | | - Neeraj Lalwani
- Department of Radiology, Section of Abdominal Imaging, Wake Forest University and Baptist Medical Center, Winston-Salem, NC, USA
| | | | - Stephanie Nougaret
- Montpellier Cancer Research Institute, Montpellier, France
- Department of Radiology, Montpellier Cancer Institute, INSERM, U1194, University of Montpellier, Montpellier, France
| | - Viktoriya Paroder
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Raj M Paspulati
- Department of Radiology, University Hospitals, Case Western Reserve University, Cleveland, OH, USA
| | | | - Iva Petkovska
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Perry J Pickhardt
- School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Gaiane M Rauch
- Department of Radiology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Michael H Rosenthal
- Harvard Medical School, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Boston, MA, USA
| | | | - Natally Horvat
- Department of Radiology, Hospital Sirio-Libanes, São Paulo, São Paulo, Brazil
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30
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Kim JC, Lee JL, Bong JW, Seo JH, Kim CW, Park SH, Kim J. Oncological and anorectal functional outcomes of robot-assisted intersphincteric resection in lower rectal cancer, particularly the extent of sphincter resection and sphincter saving. Surg Endosc 2019; 34:2082-2094. [DOI: 10.1007/s00464-019-06989-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 07/15/2019] [Indexed: 01/06/2023]
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31
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Miura T, Sakamoto Y, Morohashi H, Yoshida T, Sato K, Hakamada K. Risk factor for permanent stoma and incontinence quality of life after sphincter-preserving surgery for low rectal cancer without a diverting stoma. Ann Gastroenterol Surg 2017; 2:79-86. [PMID: 29863122 PMCID: PMC5868869 DOI: 10.1002/ags3.12033] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 07/13/2017] [Indexed: 12/13/2022] Open
Abstract
The goal of the present study was to evaluate permanent stoma formation and defecation function in long-term follow up after surgery for low rectal cancer without a diverting stoma. Subjects were 275 patients who underwent sphincter-preserving surgery for low rectal cancer between 2000 and 2012. Clinical outcomes were evaluated and defecation function was assessed based on a questionnaire survey, using Wexner and modified fecal incontinence quality of life (mFIQL) scores. Incidence of anastomotic leakage was 21.8%, and surgery-related death as a result of anastomotic leakage occurred in one male patient. Median follow-up period was 4.9 years and permanent stoma formation rate was 16.7%. Anastomotic leakage was an independent predictor of permanent stoma formation (odds ratio [OR] 5.86, P<0.001). Age <65 years (OR 1.99, P=0.001) and male gender (OR 4.36, P=0.026) were independent predictors of anastomotic leakage. A permanent stoma was formed as a result of poor healing of anastomotic leakage in 29.6% of males, but in no females. Defecation function was surveyed in 27 and 116 patients with and without anastomotic leakage, respectively. These groups had no significant differences in median follow-up period (63.5 vs 63 months), Wexner scores (quartile) (6 (2.5-9) vs 6 (3-11)), and mFIQL scores (26.1 (4.8-64.2) vs 23.8 (5.9-60.7). Defecation function associated with anastomotic leakage showed no significant dependence on gender or resection procedure. Sphincter-preserving surgery without a diverting stoma may be indicated for females with low rectal cancer. In this procedure, male gender is a risk factor for anastomotic leakage and subsequent formation of a permanent stoma in one in three patients.
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Affiliation(s)
- Takuya Miura
- Department of Gastroenterological Surgery Hirosaki University Graduate School of Medicine Hirosaki Japan
| | - Yoshiyuki Sakamoto
- Department of Gastroenterological Surgery Hirosaki University Graduate School of Medicine Hirosaki Japan
| | - Hajime Morohashi
- Department of Gastroenterological Surgery Hirosaki University Graduate School of Medicine Hirosaki Japan
| | - Tatsuya Yoshida
- Department of Gastroenterological Surgery Hirosaki University Graduate School of Medicine Hirosaki Japan
| | - Kentaro Sato
- Department of Gastroenterological Surgery Hirosaki University Graduate School of Medicine Hirosaki Japan
| | - Kenichi Hakamada
- Department of Gastroenterological Surgery Hirosaki University Graduate School of Medicine Hirosaki Japan
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