The Impact of Anastomotic Leakage on Anal Function Following Intersphincteric Resection

Textbook anastomotic success in patients with low rectal cancer treated by intersphincteric resection: reappraising surgical, oncological, and functional outcomes

Previous studies on successful anastomosis after intersphincteric resection (ISR) for low rectal cancer (LRC) primarily focused on anastomotic complications rather than functional outcomes. Here, we improved the anastomotic success criteria by considering surgical, oncological, and functional outcomes and proposed a new composite outcome, "textbook anastomotic success" (TASS). This retrospective single-center study included patients with LRC treated with ISR from January 2014 to April 2020. TASS was defined as (1) no anastomotic complications occurring after ISR; (2) ileostomy was closed and there was no severe intestinal dysfunction 2 years after ISR; and (3) no local recurrence within 2 years of surgery. TASS was achieved upon meeting all indicators. We analyzed 259 patients with LRC, with 125 (48.3%) achieving TASS. Multivariate analysis showed that male sex (OR 0.47; 95% CI 0.27-0.81; p = 0.007), hypertension (OR 0.48; 95% CI 0.24-0.97; p = 0.041), ASA score ≥ 3 (OR 0.28; 95% CI 0.10-0.81; p = 0.018), pre-treatment major low anterior resection syndrome (OR 0.37; 95% CI 0.15-0.94; p = 0.037), and preoperative neoadjuvant chemoradiotherapy (OR 0.41; 95% CI 0.22-0.77; p = 0.006) were independent risk factors for not achieving TASS. Conversely, transverse coloplasty pouch (OR 2.13; 95% CI 1.07-4.25; p = 0.032) and higher anastomosis level (OR 1.56; 95% CI 1.05-2.30; p = 0.026) were independent protective factors for achieving TASS. The nomogram constructed to evaluate the probability of achieving TASS demonstrated good accuracy in the dataset (area under curve, 0.737). TASS provides a comprehensive quality assessment for ISR in patients with LRC. The nomogram predicting TASS may assist surgeons in decision-making for managing LRC.

Risk factors, quality of life, and oncological effects of refractory anastomotic leakage for laparoscopic intersphincteric resection

BACKGROUND AND AIM

Refractory anastomotic leakage (RAL) after intersphincteric resection (ISR) usually leads to failure of protective stoma reversal in ultralow rectal cancers. The aim of this study is to assess the risk factors and oncological outcomes of both anastomotic leakage (AL) and RAL, and quality of life (QoL) of RAL after laparoscopic ISR (LsISR).

METHODS

A total of 371 ultralow rectal cancer patients with LsISR were enrolled from a tertiary colorectal surgery referral center. Risk factors for AL and RAL were identified by logistic regression. Three-year disease-free survival (DFS) of AL and RAL was analyzed by the Cox regression. QoL of RAL group (compared with non-RAL group) was assessed using the European Organization for Research and Treatment of Cancer QLQ-C30 and QLQ-CR29 questionnaires.

RESULTS

The rates of AL and RAL after LsISR accounted for 8.4% (31/371) and 4.6% (17/371) in this cohort, respectively. Non-left colic artery preservation (odds ratio [OR] = 3.491, P = 0.009), neoadjuvant chemoradiotherapy (nCRT) (OR = 6.038, P < 0.001), and lower anastomosis height (OR = 5.271, P = 0.010) were independent risk factors for AL, while nCRT (OR = 11.602, P < 0.001) was the only independent risk factor for RAL. Male (hazard ratio [HR] = 1.989, P = 0.014), age > 60 years (HR = 1.877, P = 0.018), and lymph node metastasis (HR = 2.125, P = 0.005) were independent risk factors of poor 3-year DFS, but not RAL (P = 0.646). RAL patients have significantly worse global health status, worse emotional and social function scores at the late postoperative stage, and worse urinary and sexual function at the early postoperative stage (all P < 0.05).

CONCLUSIONS

Neoadjuvant chemoradiotherapy was an independent risk factor for RAL after LsISR. RAL shows similar oncological outcomes, but with poor QoL.

Can the Single-stapling Technique Following Intersphincteric Resection with Transanal Total Mesorectal Excision Become the New Standard Anastomosis?

For transanal total mesorectal excision (TaTME), the indication for single-stapling technique (SST) has been expanded to include lower anastomosis, even in intersphincteric resection (ISR). We focused on the anastomotic techniques following ISR with TaTME and examined the feasibility and safety of the SST below the anorectal junction (ARJ). Data on postoperative anastomosis-related complications and anorectal function was evaluated in comparison to conventional manual hand-sewn coloanal anastomosis in ISR with TaTME. We examined patients with 3-6 cm tumors from the anal verge who underwent ISR with TaTME between January 2018 and March 2020, and whose anastomotic line was located below the ARJ. Postoperative short-term outcomes and anorectal functions were compared. We also analyzed the effects of various factors on major low anterior resection syndrome (LARS) using multivariate logistic regression analysis. In total, 87 patients-48 in the hand-sewn anastomosis group and 39 in the SST group-were included in this study. SST below the ARJ in ISR with TaTME did not exacerbate surgical outcomes, including anastomosis-related complications. The SST group had a significantly lower LARS score as compared to the hand-sewn anastomosis group, and the proportion of major LARS was significantly lower. Only hand-sewn anastomosis was identified as a statistically significant independent risk factor for major LARS. In TaTME, SST below the ARJ was safe and feasible and had a lower negative impact on postoperative anastomosis-related complications and anorectal function as compared to hand-sewn anastomosis. Thus, SST is a promising anastomotic option for patients with low-lying rectal tumors.

Does anastomotic leakage after intersphincteric resection for ultralow rectal cancer influence long-term outcomes? A retrospective observational study

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.

High Risk of Low Anterior Resection Syndrome in Long-term Follow-up After Anastomotic Leakage in Anterior Resection for Rectal Cancer

BACKGROUND

Low anterior resection syndrome is common after sphincter-sparing surgery, but it is unclear to what extent anastomotic leakage after anterior resection contributes to this condition.

OBJECTIVE

The aim of this study is to assess the long-term effect of anastomotic leakage on the occurrence of major low anterior resection syndrome.

DESIGN

This is a retrospective observational cohort study evaluating low anterior resection syndrome 4 to 11 years after index surgery. After propensity score-matching using the covariates sex, age, tumor stage, comorbidity, neoadjuvant treatment, extent of mesorectal excision, and defunctioning stoma at index surgery, the effect of anastomotic leakage on low anterior resection syndrome was investigated using relative risk and 95% CI.

SETTINGS

This multicenter study included patients from 15 Swedish hospitals between 2007 and 2013.

PATIENTS

Patients who underwent anterior resection for rectal cancer were included.

MAIN OUTCOME MEASURES

Outcome measures included patient-reported major low anterior resection syndrome, obtained via a postal questionnaire that included a question on stoma status.

RESULTS

Among 1099 patients, 653 (59.4%) responded in at a median of 83.5 (interquartile range 66 to 110) months postoperatively. After excluding patients with residual stoma or incomplete responses, 544 remained; of these, 42 had anastomotic leakage. Patients with anastomotic leakage were more likely to have major low anterior resection syndrome (66.7% [28/42]) than patients without leakage (45.8% [230/502]). After matching, anastomotic leakage was significantly related to major low anterior resection syndrome (relative risk 2.3; 95% CI 1.4-3.9) and the individual symptom of urgency (relative risk 2.1; 95% CI 1.1-4.1).

LIMITATIONS

This study was limited by its retrospective observational study design.

CONCLUSIONS

In long-term follow-up, major low anterior resection syndrome is common after anterior resection for rectal cancer. Anastomotic leakage appears to increase the risk of major low anterior resection syndrome, with urgency as a major contributing symptom. See Video Abstract at http://links.lww.com/DCR/B868 .

ALTO RIESGO DE SNDROME DE RESECCIN ANTERIOR BAJA EN EL SEGUIMIENTO A LARGO PLAZO TRAS FUGA ANASTOMTICA EN RESECCIN ANTERIOR POR CNCER DE RECTO

ANTECEDENTES:El síndrome de resección anterior baja es común después de una cirugía con preservación de esfínter pero no está claro hasta qué punto contribuye a esta condición la fuga anastomótica después de una resección anterior.OBJETIVO:El objetivo de este estudio es evaluar el efecto a largo plazo de la fuga anastomótica sobre la aparición de un síndrome de resección anterior baja mayor.DISEÑO:Se trata de un estudio de cohorte observacional retrospectivo que evalúa el síndrome de resección anterior baja 4-11 años después de la cirugía índice. Después del apareamiento por puntuación de propensión utilizando las covariables sexo, edad, estadio del tumor, comorbilidad, tratamiento neoadyuvante, extensión de la escisión mesorrectal y estoma de derivación en la cirugía índice, se investigó el efecto de la fuga anastomótica en el síndrome de resección anterior baja utilizando el riesgo relativo y intervalos de confianza de 95%.AJUSTES:Este estudio multicéntrico incluyó pacientes de 15 hospitales suecos entre 2007 y 2013.PACIENTES:Se incluyeron pacientes que fueron sometidos a resección anterior por cáncer de recto.PRINCIPALES MEDIDAS DE DESENLACE:Síndrome de resección anterior baja mayor informado por el paciente, obtenido a través de un cuestionario postal que incluye una pregunta sobre el estado de estomas.RESULTADOS:De 1099 pacientes, 653 (59,4%) respondieron una mediana de 83,5 meses después de la operación (rango intercuartílico 66-110).Después de excluir a los pacientes con estoma residual o respuestas incompletas, quedaron 544; de estos, 42 tuvieron fuga anastomótica. Los pacientes con fuga anastomótica tenían síndrome de resección anterior baja mayor en el 66,7% (28/42) en comparación con el 45,8% (230/502) de los pacientes sin fuga. Después del apareamiento, la fuga anastomótica se relacionó significativamente con el síndrome de resección anterior baja mayor (riesgo relativo 2,3; intervalo de confianza del 95%: 1,4-3,9) y con el síntoma individual de urgencia (riesgo relativo 2,1; intervalo de confianza del 95% 1,1-4,1).LIMITACIONES:Este estudio estuvo limitado por su diseño de estudio observacional retrospectivo.CONCLUSIONES:En el seguimiento a largo plazo, el síndrome de resección anterior baja mayor es común después de la resección anterior por cáncer de recto. La fuga anastomótica parece aumentar el riesgo de síndrome de resección anterior baja mayor, siendo la urgencia uno de los principales síntomas contribuyentes. Consulte Video Resumen en http://links.lww.com/DCR/B868 . (Traducción-Dr. Juan Carlos Reyes ).

Trans-Anastomotic Drainage Tube Placement After Hand-Sewn Anastomosis in Patients Undergoing Intersphincteric Resection for Low Rectal Cancer: An Alternative Drainage Method

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.

The effect of anastomotic leak on postoperative pelvic function and quality of life in rectal cancer patients

AIM

The aim of this review was to collect all available literature data analysing the effects of the anastomotic leak (AL) on post-sphincter preserving rectal cancer surgery bowel and urogenital function as well as to quality of life (QoL) dimensions.

METHODS

A literature search of the PubMed and Embase electronic databases was conducted by two independent investigators and all studies using either functional parameters or QoL as a primary or secondary endpoint after a rectal cancer surgery AL were included.

RESULTS

Amongst the 13 identified studies focusing on the post-AL neorecto-anal function, 3 case-matched studies,3 comparative studies and 1 population-based study supported the deleterious effects of the AL on bowel function, with disturbances of the types of high bowel movement frequency, urgency and increased incontinent episodes to predominate. At one case-matched study the Low Anterior Resection Syndrome (LARS) score was inferior in the AL patients. At limited under-powered studies, urinary frequency, reduced male sexual activity and female dyspareunia may be linked to a prior AL. According to two QoL-targeted detailed studies, QoL disturbances, such as physical and emotional function difficulties may persist up to 3 years after the AL occurrence.

CONCLUSIONS

AL may have adverse effects on postoperative pelvic function and QoL in rectal cancer patients. As evidenced by this literature review, the limited reports on this intriguing topic may trigger the initiative for planning and undertaking larger, multicentre studies on rectal cancer patients with varying degrees of AL severity.

Clinical effects of prophylactic transverse colostomy in patients undergoing completely laparoscopic transabdominal approach partial intersphincteric resection

Objective

To investigate the clinical effects of prophylactic transverse colostomy on gastrointestinal function recovery and complications in patients undergoing completely laparoscopic transabdominal approach partial intersphincteric resection (CLAPISR) of low rectal cancer.

Methods

We retrospectively analyzed the data of 74 patients with low rectal cancer who were treated with prophylactic transverse colostomy (Group A, n = 34) or without prophylactic transverse colostomy (Group B, n = 40). Surgery-related indicators, nutritional status indicators, systemic stress response indicators, and complications were compared between the two groups.

Results

On postoperative day 5, the C-reactive protein concentration and white blood cell count were not significantly different between the two groups; however, the serum concentrations of total protein and albumin were higher in Group A than in Group B. Within 26 months postoperatively, the total incidence rate of complications was not significantly different, but the incidence rate of anastomotic leakage was lower in Group A than in Group B.

Conclusion

Prophylactic transverse colostomy based on CLAPISR can lead to faster recovery of gastrointestinal function, better improvement of postoperative nutritional indicators, and a lower incidence of anastomotic leakage. These characteristics are conducive to the rapid recovery of patients, making this procedure worthy of clinical application.

Cumulative Incidence and Risk Factors of Permanent Stoma After Intersphincteric Resection for Ultralow Rectal Cancer

BACKGROUND

A permanent stoma is an unintended consequence that cannot be avoided completely after intersphincteric resection for ultralow rectal cancer. Unfortunately, its incidence and risk factors have been poorly defined.

OBJECTIVE

The objective was to determine the cumulative incidence and risk factors of permanent stoma after intersphincteric resection for ultralow rectal cancer.

DESIGN

This study was a retrospective analysis of prospectively collected data.

SETTINGS

This study was conducted at a colorectal surgery referral center.

PATIENTS

A total of 185 consecutive patients who underwent intersphincteric resection with diverting ileostomy from 2011 to 2019 were included.

MAIN OUTCOME MEASURES

The primary outcome was the incidence of and risk factors for the permanent stoma. The secondary outcome included differences in stoma formation between patients with partial, subtotal, and total intersphincteric resection.

RESULTS

After a median follow-up of 40 months (range, 6-107 months), 26 of 185 patients eventually required a permanent stoma, accounting for a 5-year cumulative incidence of 17.4%. The causes of permanent stoma were anastomotic morbidity (46.2%, 12/26), local recurrence (19.2%, 5/26), distant metastasis (19.2%, 5/26), fecal incontinence (3.8%, 1/26), perioperative mortality (3.8%, 1/26), patients' refusal (3.8%, 1/26), and poor general condition (3.8%, 1/26). Although the incidence of permanent stoma was significantly different between the intersphincteric resection groups (partial vs subtotal vs total: 8.3% vs 20% vs 25.8%, p = 0.02), it was not an independent predictor of stoma formation. Multivariate analysis demonstrated that anastomotic leakage (OR = 5.29; p = 0.001) and anastomotic stricture (OR = 5.13; p = 0.002) were independently predictive of permanent stoma.

LIMITATIONS

This study was limited by its retrospective nature and single-center data.

CONCLUSIONS

The 5-year cumulative incidence of permanent stoma was 17.4%. Anastomotic complications were identified as risk factors. Patients should be informed of the risks and benefits when contemplating the ultimate sphincter-sparing surgery. It might be preferable to decrease the probability of permanent stoma by further minimizing anastomotic complications. See Video Abstract at http://links.lww.com/DCR/B704.

INCIDENCIA ACUMULADA Y FACTORES DE RIESGO DE ESTOMA PERMANENTE DESPUS DE UNA RESECCIN INTERESFNTRICA EN CNCER RECTAL ULTRA BAJO

ANTECEDENTES:La necesidad de efectuar un estoma permanente es la consecuencia no intencional e inevitable por completo después de una resección interesfintérica en presencia de un cáncer rectal ultra bajo. Desafortunadamente, la incidencia y los factores de riesgo se han definido en una forma limitada.OBJETIVO:El objetivo fue determinar la incidencia acumulada y los factores de riesgo para la necesidad de efectuar un estoma permanente después de la resección intersfintérica de un cáncer rectal ultra bajo.DISEÑO:El presente estudio es un análisis retrospectivo de la información obtenida.ESCENARIO:Centro de referencia de cirugía colo-rectal.PACIENTES:Se incluyeron un total de 185 pacientes consecutivos que se sometieron a resección intersfintérica de un cáncer rectal ultra bajo con ileostomía de derivación de 2011 a 2019.MEDICION DE RESULTADOS:El resultado principal fue la identificación de la incidencia y los factores de riesgo para la presencia de un estoma permanente. En forma secundaria se describieron los resultados de las diferentes técnicas de la formación de un estoma entre los pacientes con resección interesfintérica parcial, subtotal o total.RESULTADOS:Posterior a una media de seguimiento de cuarenta meses (rango de 6 a 107), 26 de 185 pacientes requirieron en forma eventual un estoma permanente, lo que equivale a una incidencia acumulada a cinco años de 17.4 %. Las causas para dejar un estoma permanente fueron morbilidad de la anastomosis (46.2%, 12/26), recurrencia local (19.2%, 5/26), metástasis a distancia (19.2%, 5/26), incontinencia fecal (3.8%, 1/26), mortalidad perioperatoria (3.8%, 1/26), rechazo del paciente (3.8%, 1/26), y malas condiciones generales (3.8%, 1/26). Aunque la incidencia de un estoma permanente fue significativamente diferente entre los grupos de resección interesfintérica (parcial vs subtotal vs total: 8.3% vs 20% vs 25.8%, p = 0.02), no se consideró un factor predictor independiente para la formación de estoma. En el análisis multivariado se demostró que la fuga anatomótica (OR = 5.29; p = 0.001) y la estenosis anastomótica (OR = 5.13; p = 0.002) fueron factores independientes para predecir la necesidad de un estoma permanente.LIMITACIONES:La naturaleza retrospectiva del estudio y la información proveniente de un solo centro.CONCLUSIONES:La incidencia acumulada a cinco años de estoma permantente fue de 17.4%. Se consideran a las complicaciones anastomóticas como factores de riesgo. Los pacientes deberán ser informados de los riesgos y beneficios cuando se considere la posibilidad de efectuar una cirugía preservadora de esfínteres finalmente. Puede ser preferible disminuir la probabilidad de dejar un estoma permanente tratando de minimizar la posibilidad de complicaciones de la anastomosis. Consulte Video Resumen en http://links.lww.com/DCR/B704.

Nomogram for Predicting the Probability of Permanent Stoma after Laparoscopic Intersphincteric Resection

PURPOSE

The purpose of this study was to determine the risk factors for the development of a permanent stoma in laparoscopic intersphincteric resection (LS-ISR) for ultralow rectal adenocarcinoma and to develop and validate a prediction model to predict the probability of permanent stoma after surgery.

METHODS

A primary cohort consisting of 301 consecutive patients who underwent LS-ISR was enrolled in this study. Multivariable logistic regression analysis was used to identify risk factors and develop the nomogram. The performance of the nomogram was assessed with respect to its calibration, discrimination, and clinical usefulness. An independent validation cohort contained 91 consecutive patients from January 2012 to January 2019.

RESULTS

The permanent stoma rate was 11.3% (34/301) in the primary cohort and 18.7% (17/91) in the validation cohort. Multivariable analysis revealed that nCRT (OR, 3.195; 95% CI, 1.169-8.733; P=0.024), ASA score of 3 (OR, 5.062; 95% CI, 1.877-13.646; P=0.001), distant metastasis (OR, 14.645; 95% CI, 3.186-67.315; P=0.001), and anastomotic leakage (OR, 11.308; 95% CI, 3.650-35.035; P<0.001) were independent risk factors for permanent stoma, and a nomogram was established. The AUCs of the nomogram were 0.842 and 0.858 in the primary and validation cohorts, respectively. The calibration curves showed good calibration in both cohorts. Decision curve analysis demonstrated that the nomogram was clinically useful.

CONCLUSION

We developed and validated a nomogram for ultralow rectal adenocarcinoma patients who underwent LS-ISR, and the nomogram could help surgeons identify which patients are at a higher risk of a permanent stoma after surgery.

Risk Factors for Anorectal Dysfunction After Interspincteric Resection in Patients With Low Rectal Cancer

Purpose: The objective of this study was to explore the risk factors for anorectal dysfunction after intersphincteric resection in patients with low rectal cancer. Methods: A total of 251 patients who underwent intersphincteric resection from July 2014 to June 2020 were included in this study, for which the Kirwan's grade, Wexner score, and anorectal manometric index were used to evaluate the anorectal function and other parameters including demographics, surgical features, and clinical and pathological characteristics. These parameters were analysed to explore the potential risk factors for anorectal function after intersphincteric resection. Results: In the 251 included patients, 98 patients underwent partial intersphincteric resection, 87 patients underwent subtotal intersphincteric resection, and 66 patients underwent total intersphincteric resection. There were 53 (21.1%) patients who had postoperative complications, while no significant difference was observed between the three groups. Furthermore, 30 patients (45.5%) in the total intersphincteric resection group were classified as having anorectal dysfunction (Kirwan's grade 3-5), which was significantly higher than that in the partial intersphincteric resection group (27.6%) and subtotal intersphincteric resection group (29.9%). The mean Wexner score of patients that underwent total intersphincteric resection was 7.9, which was higher than that of patients that had partial intersphincteric resection (5.9, p = 0.002) and subtotal intersphincteric resection (6.4, p = 0.027). The initial perceived volume was lower in the total intersphincteric resection group than in the partial and subtotal intersphincteric resection groups at 1, 3, and 6 months after intersphincteric resection. In addition, the resting pressure, maximum squeeze pressure, and maximum tolerated volume in the total intersphincteric resection group were worse than those in the partial and subtotal groups at 3 and 6 months after intersphincteric resection. Univariate and multivariate analyses suggested that an age ≥65, total intersphincteric resection, and preoperative chemoradiotherapy were independent risk factors for anorectal dysfunction (P = 0.023, P = 0.003, and P = 0.008, respectively). Among the 66 patients who underwent total intersphincteric resection, 17 patients received preoperative chemoradiotherapy, of which 12 patients (70.6%) were classified as having anorectal dysfunction. Conclusion: The current study concluded that age ≥65, total intersphincteric resection, and preoperative chemoradiotherapy were risk factors for anorectal dysfunction after intersphincteric resection. The morbidity of anorectal dysfunction after total intersphincteric resection for patients who received preoperative chemoradiotherapy was relatively high, and the indication should be carefully evaluated.

Safety of Small Circular Staplers in Double Stapling Technique Anastomosis for Sigmoid Colon and Rectal Cancer

BACKGROUND

Although smaller circular staplers are easier to insert and less likely to involve the vagina and levator ani muscles when performing double stapling technique anastomosis, surgeons often consider that larger circular staplers would be safer in reducing the risk of postoperative anastomotic strictures.

OBJECTIVE

This study aimed to investigate the safety of using 25-mm circular staplers compared with 28/29-mm staplers in the double stapling technique anastomosis regarding the development of anastomotic strictures and other complications.

DESIGN

This is a retrospective observational study.

SETTING

This study was conducted at a single comprehensive cancer center.

PATIENTS

Consecutive patients undergoing curative colorectal resection with double stapling technique anastomosis for stage I to III sigmoid colon and rectal cancer between 2013 and 2016 were included.

MAIN OUTCOME MEASURES

The incidence of anastomotic complications (strictures, leakage, and bleeding) was compared between the 25- and 28/29-mm circular staplers. Predictors for anastomotic strictures were investigated with multivariable logistic regression.

RESULTS

Small (25-mm) staplers were used in 186 (22.8%) of 815 eligible patients. The 25-mm staplers were associated with use in female patients, splenic flexure take down, high tie of the inferior mesenteric artery, and low anastomosis. Overall anastomotic complications (11.8% vs 13.7%, p = 0.51), strictures (5.9% vs 3.3%, p = 0.11), leakage (2.7% vs 3.8%, p = 0.47), and bleeding (4.8% vs 7.6%, p = 0.19) were not different between the 25- and 28/29-mm staplers. From multivariable logistic regression, independent predictors of anastomotic strictures included diverting ostomy and anastomotic leakage, but not small circular stapler use. Most of the 32 anastomotic strictures were successfully treated without surgical intervention (finger dilation, n = 25; endoscopic intervention, n = 5).

LIMITATIONS

This was a single-center retrospective study.

CONCLUSIONS

Use of 25-mm circular staplers for double stapling technique anastomosis is safe and does not increase the risk of anastomotic strictures and other anastomotic complications in comparison with larger staplers. See Video Abstract at http://links.lww.com/DCR/B576.

SEGURIDAD DE ENGRAPADORAS CIRCULARES PEQUEAS EN ANASTOMOSIS, CON TCNICA DE DOBLE ENGRAPADO PARA CNCER DE RECTO Y COLON SIGMOIDE

ANTECEDENTES:Aunque las engrapadoras circulares más pequeñas son más fáciles de insertar y menos probable que involucren a la vagina y los músculos elevadores del ano, cuando se realiza una anastomosis con técnica de doble engrapado, frecuentemente los cirujanos consideran que las engrapadoras circulares más grandes, serían más seguras para disminuir los riesgos de estenosis anastomóticas postoperatorias.OBJETIVO:El estudio se dirigió para investigar la seguridad en el uso de engrapadoras circulares de 25 mm, en comparación con engrapadoras de 28/29 mm, en anastomosis con técnica de doble engrapado, en relación al desarrollo de estenosis anastomóticas y otras complicaciones.DISEÑO:Estudio observacional retrospectivo.AJUSTE:Centro oncológico integral único.PACIENTES:Se incluyeron pacientes consecutivos sometidos a resección colorrectal curativa, con anastomosis y técnica de doble engrapado, para cáncer de recto y colon sigmoide en estadios I-III entre 2013 y 2016.PRINCIPALES MEDIDAS DE RESULTADO:Se compararon las incidencias de complicaciones anastomóticas (estenosis, fugas y sangrados) entre las engrapadoras circulares de 25 y 28/29 mm. Los predictores para estenosis anastomóticas se investigaron con regresión logística multivariable.RESULTADOS:Entre un total de 815 pacientes elegibles, se utilizaron engrapadoras de 25 mm en 186 (22,8%). Las engrapadoras de 25 mm se asociaron con el uso en pacientes femeninas, descenso del ángulo esplénico, ligadura alta de arteria mesentérica inferior y anastomosis baja. Complicaciones anastomóticas generales (11,8% vs. 13,7%, p = 0,51), estenosis (5,9% vs. 3,3%, p = 0,11), fugas (2,7% vs. 3,8%, p = 0,47) y sangrado (4,8% vs. 7,6%, p = 0,19). No hubo diferencia entre las engrapadoras de 25 y 28/29 mm. En la regresión logística multivariable, predictores independientes de estenosis anastomóticas incluyeron ostomía derivativa y fuga anastomótica, pero no incluyeron el uso de engrapadoras circulares pequeñas. La mayoría de las 32 estenosis anastomóticas se trataron con éxito sin intervención quirúrgica (dilatación del dedo, n = 25; intervención endoscópica, n = 5).LIMITACIONES:Fue un estudio retrospectivo de un solo centro.CONCLUSIONES:El uso de engrapadoras circulares de 25 mm para la anastomosis con técnica de doble engrapado, es seguro y no aumenta el riesgo de estenosis anastomóticas y de otras complicaciones anastomóticas, cuando son comparadas con engrapadoras más grandes. Consulte Video Resumen en http://links.lww.com/DCR/B576. (Traducción-Dr. Fidel Ruiz-Healy).

Multicenter investigation of bowel evacuation function after transanal total mesorectal excision for mid-low rectal cancer

PURPOSE

To determine the effect of transanal total mesorectal excision (taTME) procedure on the postoperative bowel evacuation function of patients with low rectal cancer.

METHODS

Bowel evacuation function was investigated in 316 patients with rectal cancer after taTME in 18 hospitals in China. Low anterior resection syndrome (LARS) score, Wexner score, and EORTC QLQ-C30 were used for functional evaluation. The association between perioperative risk factors and LARS score was determined by univariate and multivariate analyses.

RESULTS

The prevalence rate of no LARS, minor LARS, and major LARS in patients after taTME was 39.9%, 28.2%, and 31.9%, respectively. The two most frequently reported symptoms of LARS after taTME were bowel clustering (72.8%) and fecal urgency (63.3%). Patients with major LARS had significantly higher Wexner score and worse global health status and financial difficulties according to the EORTC QLQ-C30 questionnaire than those without major LARS. Preoperative chemoradiotherapy was an independent risk factor of major LARS occurrence after taTME (OR: 3.503, P = 0.044); existing preoperative constipation (OR: 0.082, P = 0.040) and manual anastomosis (OR: 4.536, P = 0.021) were favorable factors affecting bowel evacuatory function within 12 months after taTME, but for patients whose follow-up time was longer than 12 months, postoperative chemoradiotherapy (OR: 8.790, P = 0.001) and defunctioning stoma (OR: 3.962, P = 0.010) were independent risk factors.

CONCLUSIONS

The bowel evacuation function after taTME is acceptable. Perioperative chemoradiotherapy, anastomotic method, and preoperative constipation are factors associated with bowel dysfunction after taTME.

Sacral neuromodulation for the prevention of a permanent stoma in patients with severe defecation disorder following intersphincteric resection

PURPOSE

Severe defecation disorder occurs frequently in coloanal anastomosis for low rectal cancer, and may affect quality of life. Sacral neuromodulation (SNM) has been reported to be successful after rectal resection, but there are no results for patients treated with intersphincteric resection (ISR).

METHODS

A retrospective single-center study of SNM was performed for patient with defecation disorder following ISR. Pre- and post-treatment bowel frequencies, fecal incontinence episodes, and Wexner, LARS and FIQL scores were assessed to evaluate the efficacy. A good response was defined as ≥ 50% reduction of bowel frequency per day or fecal incontinence episodes per week.

RESULTS

10 patients (7 males, mean age 67.5 years) underwent SNM. All patients had severe fecal incontinence with a median Wexner score of 15 (13-20) and a median LARS score of 41 (36-41). The Wexner score improved after SNM, but not significantly (p = 0.06). LARS and FIQL scores significantly improved after SNM (p = 0.02, p = 0.01). At the end of follow-up, the good response rate was 40%. Three cases without a good response required creation of a permanent stoma.

CONCLUSION

Seven out of 10 patients did not require a permanent colostomy after SNM. SNM should be considered before performing a permanent colostomy.

Management guidelines for low anterior resection syndrome - the MANUEL project

AIM

Little is known about the pathophysiology of low anterior resection syndrome (LARS), and evidence concerning the management of patients diagnosed with this condition is scarce. The aim of the LARS Expert Advisory Panel was to develop practical guidance for healthcare professionals dealing with LARS.

METHOD

The 'Management guidelines for low anterior resection syndrome' (MANUEL) project was promoted by a team of eight experts in the assessment and management of patients with LARS. After a face-to-face meeting, a strategy was agreed to create a comprehensive, practical guide covering all aspects that were felt to be clinically relevant. Eight themes were decided upon and working groups established. Each working group generated a draft; these were collated by another collaborator into a manuscript, after a conference call. This was circulated among the collaborators, and it was revised following the comments received. A lay patient revised the manuscript, and contributed to a section containing a patient's perspective. The manuscript was again circulated and finalized. A final teleconference was held at the end of the project.

RESULTS

The guidance covers all aspects of LARS management, from pathophysiology, to assessment and management. Given the lack of sound evidence and the often poor quality of the studies, most of the recommendations and conclusions are based on the opinions of the experts.

CONCLUSIONS

The MANUEL project provides an up-to-date practical summary of the available evidence concerning LARS, with useful directions for healthcare professional and patients suffering from this debilitating condition.

Latest Advances in Intersphincteric Resection for Low Rectal Cancer

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.

Risk factors for parastomal hernia of loop stoma and relationships with other stoma complications in laparoscopic surgery era

Background

Laparoscopic approach is now a widespread technique used worldwide, but there are few recent studies on risk factors for parastomal hernia. Therefore, this study was performed to analyze the incidence of parastomal hernia in laparoscopic and open surgery in which a loop stoma was created and was intended to be temporary, and to determine risk factors for parastomal hernia formation. Associations between parastomal hernia and other stoma-related complications were also analyzed.

Methods

A retrospective analysis of patient and surgical characteristics was performed in 153 consecutive patients who underwent a temporary diverting loop ileostomy or colostomy after surgery related to malignant diseases at our hospital from January to December 2016.

Results

Parastomal hernia developed in 77 cases (50.3%), including 39 (25.5%) diagnosed by physical examination and 38 (24.8%) detected by CT alone. On multivariate analysis, a stoma not passing through the middle of the rectus abdominis muscle was the only independent risk factor for parastomal hernia formation (p = 0.005) during the median follow-up of 245.0 days. When we analyzed the factors that were associated with a stoma not passing through the middle of the rectus abdominis muscle, the only independent factor associated with this misplacement of the stoma was a laparoscopic approach (p = 0.012). An analysis of stoma-related complications showed that peristomal skin disorders were significantly associated with parastomal hernia (p = 0.049).

Conclusions

This study showed that a stoma that is not formed through the middle of the rectus abdominis muscle is a risk factor for parastomal hernia formation, and that a laparoscopic approach is associated with this risk factor. Moreover, parastomal hernia is significantly associated with peristomal skin disorders.

The Impact of Anastomotic Leakage on Long-term Function After Anterior Resection for Rectal Cancer

BACKGROUND

It is still not clear whether anastomotic leakage after anterior resection for rectal cancer affects long-term functional outcome.

OBJECTIVE

This study aimed to evaluate how anastomotic leakage following anterior resection for rectal cancer influences defecatory, urinary, and sexual function.

DESIGN

In this retrospective population-based cohort study, patients were identified through the Swedish Colorectal Cancer Registry, which was also used for information on the exposure variable anastomotic leakage and covariates.

SETTINGS

A nationwide register was used for including patients.

PATIENTS

All patients undergoing anterior resection for rectal cancer in Sweden from April 2011 to June 2013 were included.

MAIN OUTCOME MEASURES

Outcome was any defecatory, sexual, or urinary dysfunction, assessed 2 years after surgery by a postal questionnaire. The association between anastomotic leakage and function was assessed in multivariable logistic and linear regression models, with adjustment for confounding.

RESULTS

Response rate was 82%, resulting in 1180 included patients. Anastomotic leakage occurred in 7.5%. A permanent stoma was more common among patients with leakage (44% vs 9%; p < 0.001). Patients with leakage had an increased risk of aid use for fecal incontinence (OR, 2.27; 95% CI, 1.20-4.30) and reduced sexual activity (90% vs 82%; p = 0.003), whereas the risk of urinary incontinence was decreased (OR, 0.53; 95% CI, 0.31-0.90). A sensitivity analysis assuming that a permanent stoma was created because of anorectal dysfunction strengthened the negative impact of leakage on defecatory dysfunction.

LIMITATIONS

Limitations include the use of a questionnaire that had not been previously validated, underreporting of anastomotic leakage in the register, and small patient numbers in the analysis of sexual symptoms.

CONCLUSIONS

Anastomotic leakage was found to statistically significantly increase the risk of aid use due to fecal incontinence and reduced sexual activity, although the impact on defecatory dysfunction might be underestimated, because permanent stomas are sometimes fashioned because of anorectal dysfunction. Further research is warranted, especially regarding urogenital function. See Video Abstract at http://links.lww.com/DCR/B157. EL IMPACTO DE LA FUGA ANASTOMÓTICA EN LA FUNCIÓN A LARGO PLAZO DESPUÉS DE LA RESECCIÓN ANTERIOR POR CÁNCER RECTAL: Todavía no está claro si la fuga anastomótica después de la resección anterior por cáncer rectal afecta el resultado funcional a largo plazo.Evaluar cómo la fuga anastomótica después de la resección anterior para el cáncer rectal influye en la función defecatoria, urinaria y sexual.En este estudio de cohorte retrospectivo basado en la población, los pacientes fueron identificados a través del Registro Sueco de cáncer colorrectal, que también se utilizó para obtener información sobre la variable de exposición de fuga anastomótica y las covariables.Se utilizó un registro nacional para incluir pacientes.Se incluyeron todos los pacientes sometidos a resección anterior por cáncer de recto en Suecia desde abril de 2011 hasta junio de 2013.El resultado fue cualquier disfunción defecatoria, sexual o urinaria, evaluada dos años después de la cirugía mediante un cuestionario postal. La asociación entre la fuga anastomótica y la función se evaluó en modelos logísticos multivariables y de regresión lineal, con ajuste por confusión.La tasa de respuesta fue del 82%, lo que resultó en 1180 pacientes incluidos. La fuga anastomótica ocurrió en el 7,5%. Un estoma permanente fue más común entre los pacientes con fugas (44% vs. 9%; p <0.001). Los pacientes con fugas tenían un mayor riesgo de uso de ayuda para la incontinencia fecal (OR 2.27; IC 95% 1.20-4.30) y una menor actividad sexual (90% vs. 82%; p = 0.003), mientras que el riesgo de incontinencia urinaria disminuyó (OR 0.53; IC 95% 0.31-0.90). Un análisis de sensibilidad que supone que se creaba un estoma permanente debido a una disfunción anorrectal fortaleció el impacto negativo de la fuga en la disfunción defecatoria.Las limitaciones incluyen el cuestionario utilizado que no ha sido validado previamente, el subregistro de fugas anastomóticas en el registro y el pequeño número de pacientes en el análisis de síntomas sexuales.Se descubrió que la fuga anastomótica aumentaba estadísticamente de manera significativa el riesgo de uso de ayuda debido a la incontinencia fecal y la actividad sexual reducida, aunque el impacto en la disfunción defecatoria podría estar subestimada, ya que a veces los estomas permanentes se forman debido a la disfunción anorrectal. Se justifica la investigación adicional, especialmente con respecto a la función urogenital. Consulte Video Resumen en http://links.lww.com/DCR/B157. (Traducción-Dr. Gonzalo Hagerman).

Ultimate Functional Preservation With Intersphincteric Resection for Rectal Cancer

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.

Short-term outcomes of laparoscopic intersphincteric resection with intraoperative radiotherapy using low-energy X-rays for primary locally advanced low rectal cancer: a single center experience

Background

Even with the augmentative application of anal-preservation surgery in low rectal cancer, the role and indications of laparoscopic intersphincteric resection (Lap ISR) are still under debate, especially for T3 or node-positive (T3N0M0, T1–3N+M0) cancer, mainly due to the oncological safety and functional outcomes. INTRABEAM (Carl Zeiss, Germany) intraoperative radiotherapy (IORT) using low-energy X-rays features in accurate irradiation, less exposure, and reduced complications. Taking advantages of Lap ISR and INTRABEAM IORT, this innovative approach aims to increase the probability of the anal preservation with acceptable postoperative outcomes.

Materials and methods

From December 2015 to August 2019, we retrospectively analyzed the short-term outcomes of 12 patients evaluated preoperatively with T3 or node-positive (T3N0M0, T1–3N+M0) primary locally advanced low rectal cancer. They all had received Lap ISR and INTRABEAM IORT with a dose of 16–18 Gy applied by an applicator through the anus (natural orifice). Then, with no pre- or postoperative radiotherapy given, the patients were suggested to receive 6–8 cycles of the XELOX chemotherapy regimen (oxaliplatin, 130 mg/m² and capecitabine, 1000 mg/m²).

Results

All patients achieved R0 resection. The median radiation time was 27 min and 15 s, and the mean radiative dose was 17.3 Gy (range 16–18 Gy). The median follow-up time was 18.5 months (range 3–45 months). Two patients experienced local recurrence. Two male patients experienced anastomotic stenosis. Furthermore, one of them experienced perianal abscess and the other one experienced pulmonary metastasis after refusing to receive chemotherapy. One female patient with internal anal sphincter invasion experienced distant metastases to the liver and gluteus maximus muscle 35 months after IORT. No acute radiation injuries or symptoms were observed. Although they experienced a reduction in anal function, every patient was satisfied with the postoperative outcomes.

Conclusions

For patients evaluated preoperatively with T3 or node-positive (T3N0M0, T1–3N+M0) primary locally advanced low rectal cancer, Lap ISR with INTRABEAM IORT may be a safe and feasible approach for anal preservation without compromising oncological outcomes.

Laparoscopic Ultra Low Anterior Resection: Single Center, 6-Year Study

Background: This study represents a prospective analysis of a series of laparoscopic ultra low anterior resection (ULAR) done at a laparoscopic surgical center to assess the surgical outcome, oncological efficacy, and quality of life after surgery. Methods: Over a period of 6 years (2013-2018), 43 patients aged between 40 and 68 years, with very low rectal cancers (3-6 cm from the anal verge), within T3N1M0 stage, assessed by positron emission tomography-computed tomography and pelvic magnetic resonance imaging, underwent neoadjuvant chemoradiotherapy (nCRT) followed by laparoscopic ULAR and simultaneous diversion ileostomy. Results: The overall complication rate was low and there was an overall leak rate of 9.3% with a radiological leak (Grade A) in 3 of the 43 patients (7%), but only 1 (2.3%) patient required a local lavage and a resuturing for secondary hemorrhage. Recurrence was seen in 2/43 (4.7%), one of whom had a conversion to abdominoperineal resection. The other had distant metastasis and refused further treatment. The functional outcome is assessed in 41 (95.3%) patients by low anterior resection syndrome (LARS) score and a reasonable quality of life with major LARS was seen in only 7.3% of the patients at a follow-up ranging from 1 to 6 years. Conclusion: The nCRT followed by laparoscopic ULAR is a feasible option for operable very low rectal cancers and is associated with minimal postoperative events, a low local recurrence and less incidence of LARS.

[Influence of anastomotic leakage on the long-term outcomes in patients with colorectal cancer]

Anastomotic leakage after surgery for colorectal cancer is a widely known factor aggravating immediate outcomes. At the same time, deterioration of oncological results is under much less attention. Long-term consequences of anastomotic leakage and possible mechanism of negative effect of this complication on long-term results are reviewed in the article.

Validation of the Japanese Version of the Low Anterior Resection Syndrome Score

BACKGROUND

The low anterior resection syndrome (LARS) score is a patient-reported outcome measure to evaluate the severity of bowel dysfunction after rectal cancer surgery by scoring the major symptoms of LARS. The aim of this study was to translate the English version of the LARS score into Japanese and to investigate the validity and reliability of the LARS score.

METHODS

The LARS score was translated in Japanese following current international recommendations. A total of 149 rectal cancer patients completed the LARS score questionnaire and were also asked a single question assessing the impact of bowel function on quality of life (QoL). A total of 136 patients answered the LARS score questionnaire twice.

RESULTS

The Japanese LARS score showed high convergent validity, based on its good correlation between the LARS score and QoL (p < 0.001). The LARS score was able to discriminate between patients according to the tumor distance to anal verge (p < 0.001), type of surgery (p < 0.001), and time since surgery (p = 0.001). Patients after ultra-low anterior resection and intersphincteric resection showed especially high scores. The score also had high test-retest reliability (intraclass correlation coefficient: 0.87).

CONCLUSION

The Japanese LARS score is a valid and reliable tool for measuring LARS. The LARS score is appropriate for assessments in postoperative bowel function and international comparison. Using this score, patient-reported outcome measures of LARS in Japanese patients can be shared internationally. Additional validation reports from non-English speaking countries can support the LARS score as a worldwide assessment tool for postoperative bowel dysfunction.

Alterations of anal physiological features after surgery for low rectal cancer and management strategies

The sphincter preserving operation has improved the quality of life (QOL) of patients with low rectal cancer. However, some patients complain of having postoperative fecal incontinence and low QOL due to sphincter injury, nerve injure, and decreased rectal capacity. Therefore, anal physiology evaluation must be done preoperatively, the sphincter muscle and nerve should be preserved in operation, and biofeedback treatment should be administered postoperatively.

Functional outcomes after intersphincteric resection for ultralow rectal cancer

Anal function is one of the most important parameters for evaluating the efficacy of intersphincteric resection (ISR) for the treatment of ultralow rectal cancer (< 1 cm from the anal sphincter). Although there have been no results hitherto from randomized controlled trials to verify the clinical benefits of the ultimate sphincter-sparing technique, increasing evidence demonstrates that ISR significantly decreases the rate of permanent stoma and patients could acquire satisfied functional results after surgery. This review discusses the short-term and long-term functional outcomes, risk factors for anal incontinence, and surgical method and approach of ISR.