Outcomes of ultra-low anterior resection combined with or without intersphincteric resection in lower rectal cancer patients

Clinical efficacy and pathological outcomes of transanal endoscopic intersphincteric resection for low rectal cancer

BACKGROUND

Transanal endoscopic intersphincteric resection (ISR) surgery currently lacks sufficient clinical research and reporting.

AIM

To investigate the clinical effectiveness of transanal endoscopic ISR, in order to promote the clinical application and development of this technique.

METHODS

This study utilized a retrospective case series design. Clinical and pathological data of patients with lower rectal cancer who underwent transanal endoscopic ISR at the First Affiliated Hospital of Xiamen University between May 2018 and May 2023 were included. All patients underwent transanal endoscopic ISR as the surgical approach. We conducted this study to determine the perioperative recovery status, postoperative complications, and pathological specimen characteristics of this group of patients.

RESULTS

This study included 45 eligible patients, with no perioperative mortalities. The overall incidence of early complications was 22.22%, with a rate of 4.44% for Clavien-Dindo grade ≥ III events. Two patients (4.4%) developed anastomotic leakage after surgery, including one case of grade A and one case of grade B. Postoperative pathological examination confirmed negative circumferential resection margins and distal resection margins in all patients. The mean distance between the tumor lower margin and distal resection margin was found to be 2.30 ± 0.62 cm. The transanal endoscopic ISR procedure consistently yielded high quality pathological specimens.

CONCLUSION

Transanal endoscopic ISR is safe, feasible, and provides a clear anatomical view. It is associated with a low incidence of postoperative complications and favorable pathological outcomes, making it worth further research and application.

An anatomical study on intersphincteric space related to intersphincteric resection for ultra-low rectal cancer

BACKGROUND

Intersphincteric resection (ISR) has been proposed to offer sphincter-sparing solution for patients with ultra-low rectal cancer. However, complete and accurate concepts about the intersphincteric space (ISS) related anatomy are not demonstrated clearly. This study aimed to provide a comprehensive description about the anatomic structure of ISS related to ISR.

METHODS

This was a descriptive morphological study. 28 pelvic specimens were obtained from body donors. Macroscopic and microscopic observation of ISS was performed via gross anatomy, plastinated sections and histologic staining. The anatomical parameters of the anal canal were measured. Images of laparoscopic ISS dissection procedures were real-timely captured during ISR.

RESULTS

The hiatal ligament, microvessels on supra fascia of LAM and rectal longitudinal muscle at the level of anorectal ring, especially at 1, 5, 7, and 11o'clock, could be the preferred entrance of ISS. The conjoint longitudinal muscle (CLM), the major component of ISS, was the continuum of the rectal longitudinal muscle and got reinforcement from the elastic fibers from LAM and EAS. Microvessels and neuro tissues were also found in ISS. The ISS was split into two spaces by the CLM in the middle and might subjectively be divided into three segments according to its different compositions. The length and width of ISS varied from different segments and directions.

CONCLUSIONS

We provided a systemic description of boundaries, contents and topographic structure of ISS, which may help proper determination of surgical approaches and dissection planes during ISR.

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.

A Retrospective Study on the Feasibility of Completely Laparoscopic Transabdominal Approach Partial Intersphincteric Resection

Background: With the development of surgical techniques, gastrointestinal surgeons seek ways to improve the quality of life (QOL) for postoperative patients, while ensuring the tumor radical effect, such as reducing trauma, alleviating pain, and preserving the anus. This article discusses the postoperative outcomes of completely laparoscopic transabdominal approach partial intersphincteric resection (CLTPISR). Materials and Methods: The clinical data of 68 patients who underwent CLTPISR at the Affiliated Hospital of Chengde Medical College between May 2017 and June 2020, including procedure-related data, general postoperative conditions, and postoperative anal function data, were retrospectively analyzed to investigate the feasibility and safety of CLTPISR. Results: All 68 rectal cancer patients completed the CLTPISR. The average age was (60.47 ± 7.08) years, the average operative time was (196.22 ± 8.15) minutes, the mean operative bleeding was (49.12 ± 29.61) mL, and the average postoperative hospital stay was (13.46 ± 4.78) days. The postoperative pathology showed that the circumferential margins and distal margins were all negative, the maximum tumor diameter was (3.26 ± 1.11) cm, the distance from the anal verge was (3.92 ± 0.89) cm, and the average number of lymph nodes cleared was (11.06 ± 3.67). There were 28 stage I patients (41.18%), 21 stage II patients (30.88%), and 19 stage III patients (27.94%). The median follow-up time after surgery was 28 months, and the rates of distant metastasis, disease-free survival, and overall survival of the patients were 8.82%, 91.18%, and 95.59%, respectively. The patient's postoperative anal function gradually recovered as time increased. Conclusions: Under the premise of strictly grasping the indications, the CLTPISR is a safe and feasible surgery. It could achieve maximum anal preservation and improve patients' QOL, while maintaining the tumor radical effect, and had the advantages of the short operation time, low intraoperative bleeding, and quick recovery. The Clinical Trial Registration number is LL2020397.

Preservation of the Arterial Arc Formed by Left Colic Artery, Proximal Inferior Mesenteric Artery, and the First Branch of Sigmoid Arteries in Anus Saving Treatment of Low Rectal Cancer

BACKGROUND

Low anterior, ultralow anterior, and intersphincteric resection are conventional, elective anus-sparing techniques for low rectal cancer, and good prognosis depends on a good blood supply and tension-free anastomosis.

AIM

The goal is to assess the effect of preserving the arc formed by the left colic and proximal inferior mesenteric arteries (IMAs), and first branch of the sigmoid arteries on the anastomotic blood supply, tension, and leakage rate in anus-sparing surgery for low rectal cancer.

METHOD

From 2011 to 2020, a patient with low rectal cancer resection was distributed into the ligation group (42 cases with inferior mesenteric artery ligation) and the preservation group (61 cases with preservation of the left colic and proximal IMAs and first branch of the sigmoid artery).

RESULTS

We evaluated patient characteristics, operative results, morbidity, and postoperative follow-up results. There were comparable outcomes between ligation and preservation groups in relations to the number of patients in each operative procedure, duration of surgery, operative blood loss, postoperative hospital stay, and the number of patients with protective stoma (P >.05). In postoperative morbidity, there were similar outcomes between ligation and preservation groups in terms of anastomotic subclinical dehiscence, bleeding and stricture, and urinary retention (P >.05). There were significant differences in anastomotic leakage and intra-abdominal abscess (P < .05).

CONCLUSION

Preservation of the arterial arc formed by left colic artery, proximal IMA, and the first branch of sigmoid arteries with apical lymph node dissection could increase anastomotic blood supply, reduce anastomotic tension, and leakage rate in anus-saving treatment of low rectal cancer.

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.

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.

Surgical specimen extraction via a prophylactic ileostomy procedure: A minimally invasive technique for laparoscopic rectal cancer surgery

AIM

To retrospectively evaluate the safety and feasibility of surgical specimen extraction via a prophylactic ileostomy procedure in patient with rectal cancer.

METHODS

We systematically reviewed 331 consecutive patients who underwent laparoscopic anterior resection for rectal cancer and prophylactic ileostomy in our institution from June 2010 to October 2016, including 155 patients who underwent specimen extraction via a prophylactic ileostomy procedure (experimental group), and 176 patients who underwent specimen extraction via a small lower abdominal incision (control group). Clinical data were collected from both groups and statistically analyzed.

RESULTS

The two groups were matched in clinical characteristics and pathological outcomes. However, mean operative time was significantly shorter in the experimental group compared to the control group (161.3 ± 21.5 min vs 168.8 ± 20.5 min; P = 0.001). Mean estimated blood loss was significantly less in the experimental group (77.4 ± 30.7 mL vs 85.9 ± 35.5 mL; P = 0.020). The pain reported by patients during the first two days after surgery was significantly less in the experimental group than in the control group. No wound infections occurred in the experimental group, but 4.0% of the controls developed wound infections (P = 0.016). The estimated 5-year disease-free survival and overall survival rate were similar between the two groups.

CONCLUSION

Surgical specimen extraction via a prophylactic ileostomy procedure represents a secure and feasible approach to laparoscopic rectal cancer surgery, and embodies the principle of minimally invasive surgery.

Outcomes of patients with abdominoperineal resection (APR) and low anterior resection (LAR) who had very low rectal cancer

We compared the oncological outcomes of sphincter-saving resection (SSR) and abdominoperineal resection (APR) in 409 consecutive patients with very low rectal cancer (i.e., tumors within 3 cm from the anal verge); 335 (81.9%) patients underwent APR and 74 (18.1%) underwent SSR. The APR group comprised higher proportions of men (67.5% vs 55.4%, P = .049) and advanced-stage patients (P < .001). Preoperative chemoradiotherapy (PCRT) was more frequently administered in the SSR group (83.8% vs 52.8%, P < .001). Overall, the systemic and local recurrence rates were 29.1% and 6.1%, respectively. On stratification according to PCRT and pathologic stage, the mode of surgery did not affect the recurrence type. Moreover, recurrence-free survival (RFS) did not differ according to the mode of surgery in different cancer stages. RFS was associated with ypT and ypN stages in patients who received PCRT, while pN stage, lymphovascular invasion (LVI), and circumferential resection margin (CRM) involvement were risk factors for RFS in those who did not receive PCRT. Notably, SSR was not found to be a risk factor for RFS in either subgroup. Patients who were stratified according to cancer stage and PCRT also showed no differences in RFS according to the mode of surgery. Our results demonstrate that, regardless of PCRT administration, SSR is an effective treatment for very low rectal cancer, while CRM is an important prognostic factor for patients who did not receive PCRT.

Interpretative Guidelines and Possible Indications for Indocyanine Green Fluorescence Imaging in Robot-Assisted Sphincter-Saving Operations

BACKGROUND

Since the introduction of indocyanine green angiography more than 25 years ago, few studies have presented interpretative guidelines for indocyanine green fluorescent imaging.

OBJECTIVE

We aimed to provide interpretative guidelines for indocyanine green fluorescent imaging through quantitative analysis and to suggest possible indications for indocyanine green fluorescent imaging during robot-assisted sphincter-saving operations.

DESIGN

This is a retrospective observational study.

SETTINGS

This study was conducted at a single center.

PATIENTS

A cohort of 657 patients with rectal cancer who consecutively underwent curative robot-assisted sphincter-saving operations was enrolled between 2010 and 2016, including 310 patients with indocyanine green imaging (indocyanine green fluorescent imaging+ group) and 347 patients without indocyanine green imaging (indocyanine green fluorescent imaging- group).

MAIN OUTCOME MEASURES

We tried to quantitatively define the indocyanine green fluorescent imaging findings based on perfusion (mesocolic and colic) time and perfusion intensity (5 grades) to provide probable indications.

RESULTS

The anastomotic leakage rate was significantly lower in the indocyanine green fluorescent imaging+ group than in the indocyanine green fluorescent imaging- group (0.6% vs 5.2%) (OR, 0.123; 95% CI, 0.028-0.544; p = 0.006). Anastomotic stricture was closely correlated with anastomotic leakage (p = 0.002) and a short descending mesocolon (p = 0.003). Delayed perfusion (>60 s) and low perfusion intensity (1-2) were more frequently detected in patients with anastomotic stricture and marginal artery defects than in those without these factors (p ≤ 0.001). In addition, perfusion times greater than the mean were more frequently observed in patients aged >58 years, whereas low perfusion intensity was seen more in patients with short descending mesocolon and high ASA classes (≥3).

LIMITATIONS

The 300 patients in the indocyanine green fluorescent imaging- group underwent operations 3 years before indocyanine green fluorescent imaging.

CONCLUSIONS

Quantitative analysis of indocyanine green fluorescent imaging may help prevent anastomotic complications during robot-assisted sphincter-saving operations, and may be of particular value in high-class ASA patients, older patients, and patients with a short descending mesocolon.

Risk calculators-methods, development, implementation, and validation

INTRODUCTION

A surgical risk calculator (SRC) estimates the probabilities of unfavorable outcomes such as complications or death after a specific surgery. The risk estimates are based on information regarding the patient's medical history and his current status. They are calculated using risk models derived from the analysis of data from a large number of previous patients in a similar clinical situation.

METHODS

This paper discusses several aspects of the SRC development and its implementation into clinical practice: the development of the statistical risk models, their validation and software implementation, the use of the SRC output for shared decision making in clinical settings, and the evaluation of the SRC's impact on individual patient outcomes as well as on the institution's quality of care of the clinical institution.

RESULTS

Probably the most elaborate SRC is the ACS NSQIP SRC. A comparable project was started by the German Society for Visceral and General Surgery (DGAV) in the framework of its Study, Documentation, and Quality Center (StuDoQ). It is relevant to consider that the transportability of a SRC from a US American to a German setting is not straightforward.

CONCLUSIONS

Risk calculators are important instruments for shared decision making between patients and doctor. Their implementation into clinical practice has to solve technical issues, and it is related to appropriate training of clinicians. There are specific study designs to evaluate the clinical impact of a SCR.

Comparative analysis focusing on surgical and early oncological outcomes of open, laparoscopy-assisted, and robot-assisted approaches in rectal cancer patients

PURPOSE

Because there are few comparative studies of open, laparoscopy-assisted (LA), and robot-assisted (RA) total mesorectal excision (TME) for rectal cancer, we aimed to compare these three procedures in terms of sphincter-saving operation (SSO) achievement, surgical complications, and early oncological outcomes.

METHODS

The short-term outcomes of 2114 patients with rectal cancer consecutively enrolled between July 2010 and February 2015 at Asan Medical Center (Seoul, Korea) were retrospectively evaluated. Patients underwent either open, LA, or RA TME (n = 1095, 486, and 533, respectively) performed by experienced surgeons.

RESULTS

RA TME was a significant determinant of SSO in multivariate analysis that included potential variables such as tumor location and T4 category (odds ratio, 2.458; 95 % confidence interval, 1.497-4.036; p < 0.001). The cumulative rates of 3-year local recurrence, overall survival, and disease-free survival did not differ among the three groups: 2.5-3.4, 91.9-94.6, and 82.2-83.1 % (p = 0.85, 0.352, and 0.944, respectively). Early general surgical complications occurred more frequently in the open group than in the LA and RA groups (19.3 versus 13.0 versus 12.2 %, p < 0.001), specifically ileus and wound infection.

CONCLUSIONS

There were no significant differences in 3-year survival outcomes and local recurrence among open, LA, and RA TME. RA TME is useful for SSO achievement, regardless of advanced stage and location of rectal cancer. The open procedure had a slightly but significantly higher incidence of postoperative complications than LA and RA.