Clinical and functional results of laparoscopic intersphincteric resection for ultralow rectal cancer: is there a distinction between the three types of hand-sewn colo-anal anastomosis?

Clinical efficacy of different approaches for laparoscopic intersphincteric resection of low rectal cancer: a comparison study

Background

The operative results of different approaches for the laparoscopic intersphincteric resection (LAISR) of low rectal cancer vary, and the patient characteristics associated with the best outcomes for each procedure have not been reported. We compared the efficacy of different approaches for LAISR of low rectal cancer and discussed the surgical indications for each approach.

Methods

We retrospectively reviewed data from 235 patients with low rectal cancer treated via LAISR from October 2010 to September 2016. Patients underwent either the transabdominal approach for ISR (TAISR, n = 142), the transabdominal perineal approach for ISR (TPAISR, n = 57), or the transanal pull-through approach for ISR (PAISR, n = 36).

Results

The PAISR and TAISR groups exhibited shorter operation times and less intraoperative blood loss than the TPAISR group. The anastomotic distance was shorter in the PAISR and TPAISR groups than in the TAISR group. No differences in the ability to perform radical resection, overall complications, postoperative recovery, Wexner score recorded 12 months after ostomy closure, 3-year disease-free survival, local recurrence-free survival, distant metastasis-free survival, or overall survival (OS) were observed among the three groups.

Conclusions

TAISR, TPAISR, and PAISR have unique advantages and do not differ in terms of operation safety, patient outcomes, or anal function. TPAISR requires a longer time to complete and is associated with more bleeding and a slower recovery of anal function. PAISR should be considered when TAISR cannot ensure a negative distal margin and the tumor and BMI are relatively small; otherwise, TPAISR is required.

Anastomosis-Related Complications After Stapled Anastomosis With Reinforced Sutures in Transanal Total Mesorectal Excision for Low Rectal Cancer: A Retrospective Single-Center Study

BACKGROUND

The International Transanal Total Mesorectal Excision Registry group showed that transanal total mesorectal excision included clinical issues regarding anastomosis-related complications.

OBJECTIVE

This study evaluated anastomotic complications in patients whose anastomoses were created with the stapler plus reinforced sutures procedure after transanal total mesorectal excision for low rectal cancer.

DESIGN

This was a retrospective single-center study.

SETTING

The study was conducted at the National Cancer Center Hospital East, Japan.

PATIENTS

Between June 2016 and December 2019, 150 patients underwent transanal total mesorectal excision for low rectal cancer. Stapled anastomosis was performed for 55 patients, and coloanal handsewn anastomosis was performed for 95 patients. Blood perfusion of the colon was routinely evaluated with intraoperative indocyanine green fluorescence angiography. All patients who underwent stapled anastomosis received additional handsewn sutures on all rounds of the stapled line. Patients who underwent intersphincteric resection were excluded.

MAIN OUTCOME MEASURES

The anastomosis-related complications were compared between the groups.

RESULTS

Early anastomotic leakage was found in one (1.8%) and eight (8.4%) patients in the stapled group and handsewn group. Overall anastomosis-related complications, pelvic abscess, and anastomotic stenosis were significantly less frequent in the stapled group (p < 0.001, p < 0.048, and p < 0.032). Incomplete donuts after the stapled anastomosis were observed in 9 patients (16.4%); however, we reinforced all around the stapled line in these patients, and this reduced the subsequent occurrence of anastomotic leakage.

LIMITATIONS

First, this was a retrospective single-center study that was not randomized or controlled. Second, there were chronological differences regarding the anastomotic method between the two groups. Third, our study included a relatively small number of patients who received preoperative chemoradiotherapy.

CONCLUSIONS

Stapled anastomosis with reinforced handsewn sutures resulted in fewer anastomosis-related complications than did coloanal handsewn anastomosis after transanal total mesorectal excision for low rectal cancer; thus, the former may be superior and should be the preferred method, when technically possible. See Video Abstract at http://links.lww.com/DCR/B749.COMPLICACIONES RELACIONADAS CON LAS ANASTOMOSIS ENGRAMPADAS Y REFORZADAS CON SUTURAS EN LA EXCISIÓN TOTAL DEL MESORRECTO POR VÍA TRANSANAL EN CASOS DE CÁNCER DE RECTO BAJO: ESTUDIO RETROSPECTIVO UNICÉNTRICO.

ANTECEDENTES

El grupo del Registro Internacional de Excisión Total del Mesorrecto por vía Transanal mostró que la excisión total mesorrectal transanal incluía problemas clínicos relacionados a las complicaciones involucradas con la anastomosis.

OBJETIVO

Se evaluaron las complicaciones anastomóticas en pacientes cuyas anastomosis se realizaron con engrampadora reforzada de suturas después de la excisión total de l mesorrecto por vía transanal en casos de cáncer de recto bajo.

DISEO

Estudio retrospectivo unicéntrico.

AJUSTE

El Hospital del Centro Nacional del Cáncer del Este, Japón.

PACIENTES

Entre junio de 2016 y diciembre de 2019, 150 pacientes se sometieron a excisión total del mesorrecto por vía transanal en casos de cáncer de recto bajo. Se realizó anastomosis con engrampadora en 55 y anastomosis coloanal suturada a mano en 95 pacientes. La perfusión tisular sanguínea del colon operado se evaluó de forma rutinaria con angiografía de fluorescencia con verde de indocianina intraoperatoria. Todos los pacientes que se sometieron a anastomosis con grapas recibieron suturas realizadas a mano adicionales sobre la totalidad de la línea de grapas. Se excluyeron los pacientes sometidos a resección interesfintérica.

PRINCIPALES MEDIDAS DE RESULTADO

Las complicaciones relacionadas con la anastomosis se compararon entre los grupos.

RESULTADOS

Se encontró fuga anastomótica temprana en 1 (1.8%) y 8 (8.4%) pacientes en el grupo de engrampado y en el grupo suturado a mano, respectivamente. En general, las complicaciones relacionadas con la anastomosis, el absceso pélvico y la estenosis anastomótica fueron significativamente menos frecuentes en el grupo con grapas (p < 0.001, p < 0.048, p < 0.032, respectivamente). Se observaron donas incompletas después de la anastomosis grapada en 9 pacientes (16,4%); sin embargo, reforzamos todo alrededor de la línea de grapas en estos pacientes, y esto redujo la aparición posterior de fugas anastomóticas.

LIMITACIONES

Inicialmente, este fue un estudio retrospectivo de un solo centro que no fue aleatorizado ni controlado. En segundo lugar, hubo diferencias cronológicas con respecto al método anastomótico entre los dos grupos. En tercer lugar, nuestro estudio incluyó un número relativamente pequeño de pacientes que recibieron quimiorradioterapia preoperatoria.

CONCLUSIONES

La anastomosis engrapada reforzada con suturas realizadas a mano dio como resultado menos complicaciones relacionadas con la anastomosis que la anastomosis coloanal suturada a mano después de la excisión total del mesorrecto por vía transanal en casos de cáncer de recto bajo; por tanto, el primero puede ser superior y debería ser el método preferido, cuando sea técnicamente posible. Consulte Video Resumen en http://links.lww.com/DCR/B749. (Traducción-Dr. Xavier Delgadillo).

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.

Variation in rectoanal inhibitory reflex after laparoscopic intersphincteric resection for ultralow rectal cancer

AIM

The aim was to evaluate the physiological variation in rectoanal inhibitory reflex (RAIR) after laparoscopic intersphincteric resection (Lap-ISR) for ultralow rectal cancer.

METHOD

This was a retrospective study that included 56 patients who underwent Lap-ISR from a prospectively collected database. The RAIR was examined preoperatively and up to 12 months after ileostomy closure. The primary outcome included physiological variation in RAIR and its difference between partial, subtotal and total ISR. The secondary outcome was its correlation with functional outcome.

RESULTS

The reflex was present in 95% (53/56) of patients preoperatively, in 36% (20/56) before ileostomy closure, in 48% (27/56) at 3-6 months and in 61% (34/56) at 12 months after ileostomy closure. The elicited volume of RAIR was significantly increased at 12 months after ileostomy closure than at baseline (P = 0.005), but its duration and amplitude did not differ significantly. There was no significant difference in the reflex recovery between the ISR groups (partial vs. subtotal vs. total: 65% vs. 63% vs. 44%, P = 0.61). At 12 months after ileostomy closure, the RAIR-present group had favourable functional results and patient satisfaction (P < 0.05). Major faecal incontinence was found in 82% of patients in the RAIR-absent group.

CONCLUSION

The RAIR is abolished in the majority of patients after Lap-ISR, but a time-dependent recovery could be observed in more than half of the patients. The reflex recovery is not influenced by the resection grade of the internal sphincter. However, persistent loss of the RAIR correlates with worse continence.

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.

Postoperative Functional Management Contributes to Anal Functional Recovery in Patients With Low Rectal Cancer After Robotic Total Intersphincteric Resection

Purpose: To evaluate the effectiveness of the comprehensive post-operative management including low-frequency endo-anal electrical stimulation and daily suppository usage on post-operative anal functional recovery for low rectal cancer patients who underwent robotic total intersphincteric resection (ISR).

Methods: A retrospective analysis was performed on 42 low rectal cancer patients who underwent robotic total ISR, of which 23 patients received comprehensive post-operative management, including biofeedback low-frequency endo-anal electrical stimulation and daily suppository usage (management group). Wexner score and anorectal manometric values, including resting pressure (RP), maximum squeeze pressure (MSP), initial perceived volume (IPV), and maximum tolerated volume (MTV), were assessed and compared.

Results: A total of 42 low rectal cancer patients were included in our study. The RP at 6 months after ISR (40.95 ± 6.95 mmHg vs. 33.29 ± 5.40 mmHg, p = 0.002) and MSP at 3 and 6 months after ISR (72.05 ± 10.16 mmHg vs. 69.05 ± 8.67 mmHg, p = 0.031; 91.57 ± 15.47 mmHg vs. 84.05 ± 12.94 mmHg, p = 0.039, respectively) were significantly higher in the management group. The median IPV at 1 and 3 months after ISR (17.81 ± 3.61 ml vs. 15.43 ± 5.08 ml, p = 0.038; 20.19 ± 4.35 ml vs. 17.67 ± 5.16 ml, p = 0.044, respectively) and MTV at 3 months after ISR (83.71 ± 5.44 ml vs. 76.10 ± 8.42 ml, p = 0.012) were significantly higher in the management group. Wexner scores at 1 and 3 months after closure of stoma (COS) in the management group were significantly lower (11.3 ± 2.9 vs. 13.4 ± 3.0, p = 0.041; 8.9 ± 2.0 vs. 10.6 ± 2.4, p = 0.036, respectively).

Conclusions: Comprehensive post-operative management could accelerate the recovery of sphincteric function and anal sensitivity after robotic total ISR and could also contribute to treatment of fecal incontinence followed by COS.

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.