Intersphincteric resection in patients with very low rectal cancer: a review of the Japanese experience

Robot-assisted radical prostatectomy in patient with previous intersphincteric resection for rectal cancer

Introduction

There are often opportunities to consider treatment strategies for synchronous or metachronous prostate cancer with colorectal cancer. Performing robot-assisted radical prostatectomy for prostate cancer following previous rectal cancer surgery in cases involving anal-preserving surgeries such as low anterior resection or intersphincteric resection can be challenging because of the possibility of adhesions.

Case presentation

A 74-year-old man who had undergone laparoscopic intersphincteric resection for rectal cancer was diagnosed with prostate cancer. The patient desired to undergo robot-assisted radical prostatectomy. During surgery, we observed the absence of Denonvillier's fascia on the dorsal surface of the prostate, the intestinal anastomosis was distal to the vesicourethral anastomosis, and the rectum was replaced with a peristaltic sigmoid colon with minimal adhesions.

Conclusion

Periprostatic conditions vary depending on previous rectal surgical approaches. It is crucial to confirm the previous surgical approach for rectal cancer when performing robot-assisted radical prostatectomy following rectal cancer surgery.

Oncologic outcomes of intersphincteric resection versus abdominoperineal resection for lower rectal cancer: a systematic review and meta-analysis

BACKGROUND

The efficacy of intersphincteric resection (ISR) surgery for patients with lower rectal cancer remains unclear compared to abdominoperineal resection (APR). The aim of this study is to compare the oncologic outcomes for lower rectal cancer patients after ISR and APR through a systematic review and meta-analysis.

MATERIALS AND METHODS

A systematic electronic search of the Cochrane Library, PubMed, EMBASE, and MEDLINE was performed through January 12, 2022. The primary outcomes included 5-year disease-free survival (5y-DFS) and 5-year overall survival. Secondary outcomes included circumferential resection margin involvement, local recurrence, perioperative outcomes, and other long-term outcomes. The pooled odds ratios, mean difference, or hazard ratios (HRs) of each outcome measurement and their 95% CIs were calculated.

RESULTS

A total of 20 nonrandomized controlled studies were included in the qualitative analysis, with 1217 patients who underwent ISR and 1135 patients who underwent APR. There was no significant difference in 5y-DFS (HR: 0.84, 95% CI: 0.55-1.29; P =0.43) and 5-year overall survival (HR: 0.93, 95% CI: 0.60-1.46; P =0.76) between the two groups. Using the results of five studies that reported matched T stage and tumor distance, we performed another pooled analysis. Compared to APR, the ISR group had equal 5y-DFS (HR: 0.76, 95% CI: 0.45-1.30; P =0.31) and 5y-LRFS (local recurrence-free survival) (HR: 0.72, 95% CI: 0.29-1.78; P =0.48). Meanwhile, ISR had equivalent local control as well as perioperative outcomes while significantly reducing the operative time (mean difference: -24.89, 95% CI: -45.21 to -4.57; P =0.02) compared to APR.

CONCLUSIONS

Our results show that the long-term survival and safety of patients is not affected by ISR surgery, although this result needs to be carefully considered and requires further study due to the risk of bias and limited data.

Local Recurrence of Rectal Cancer After Transanal Total Mesorectal Excision and Risk Factors: A Nationwide Multicenter Cohort Study in Japan

Objective

To investigate the oncological outcomes after transanal total mesorectal excision (TaTME) for rectal cancer and risk factors for local recurrence (LR).

Background

A high LR rate with a multifocal pattern early after TaTME has been reported in Norway and the Netherlands, causing controversy over the oncological safety of this technique.

Methods

Twenty-six member institutions of the Japan Society of Laparoscopic Colorectal Surgery participated in this retrospective cohort study. A total of 706 patients with primary rectal cancer who underwent TaTME between January 2012 and December 2019 were included for analysis. The primary endpoint was the cumulative 3-year LR rate.

Results

A total of 253 patients had clinical stage III disease (35.8%) and 91 (12.9%) had stage IV. Intersphincteric resection was performed in 318 patients (45.0%) and abdominoperineal resection in 193 (27.3%). There was 1 urethral injury (0.1%). A positive resection margin (R1) was seen in 42 patients (5.9%). Median follow-up was 3.42 years, and the 2- and 3-year cumulative LR rates were 4.95% (95% confidence interval: 3.50-6.75) and 6.82% (95% confidence interval: 5.08-8.89), respectively. A multifocal pattern was observed in 14 (25%) of 56 patients with LR. Tumor height from the anal verge, pathological T4 disease, pathological stage III/IV, positive perineural invasion, and R1 resection were significant risk factors for LR in multivariable analysis.

Conclusions

In this selected cohort in which intersphincteric resection or abdominoperineal resection was performed in more than half of cases, oncological outcomes were acceptable during a median follow-up of more than 3 years.

Conformal sphincteric resection for ultra-low rectal cancer located below the dentate line: A pilot report

AIM

Sphincter-sparing surgery can be achieved in most cases of low rectal cancer with the development of intersphincteric resection. However, abdominoperineal resection is still inevitable for patients with tumours located below the dentate line. To address this, we have developed a procedure called conformal sphincteric resection (CSR) in which the corresponding part of the subcutaneous portion of the external anal sphincter and the perianal skin on the tumour side is removed to achieve a safe distal resection margin and lateral resection margin while the dentate line and the internal anal sphincter on the tumour-free side are preserved as much as possible, to achieve sphincter preservation without compromising oncological safety and functional acceptability, and to render tumour location no longer a contraindication for sphincter-sparing surgery. This is the first study to describe the concept, indication and surgical procedure of CSR and to report its preliminary surgical, oncological and functional results.

METHODS

This is a retrospective, single-centre, single-arm pilot study conducted at Huashan Hospital, Fudan University. Demographic, clinicopathological, oncological and functional follow-up data were collected from 20 consecutive patients with rectal tumours located below the dentate line who underwent laparoscopic CSR by the same surgical team from June 2018 to March 2022.

RESULTS

The mean distance of the tumour's lower edge from the anal verge was 13.1 ± 6.0 mm. The mean distal resection margin was 10.6 ± 4.3 mm. All circumferential resection margins were negative. There were no instances of perioperative mortality. The complication rate was 25% but all were Clavien-Dindo Grade I. Among the 20 cases, 17 were diagnosed with adenocarcinoma, one with squamous cell carcinoma and two with adenoma featuring high-grade intraepithelial neoplasia. Pathological TNM staging revealed two, seven, five, five and one case(s) in Stages 0, I, II, III and IV, respectively. The median follow-up period was 20 months (interquartile range 22 months), with no withdrawals. The overall and disease-free survival rates were both 95%. The mean Wexner incontinence score and low anterior resection syndrome score recorded 18 months following diverting ileostomy closure were 6.3 ± 3.8 and 27.3 ± 3.6, respectively.

CONCLUSIONS

This study has proposed the CSR procedure for the first time, which is a technically feasible, oncologically safe and functionally acceptable procedure for carefully selected patients with rectal tumours located below the dentate line.

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.

Neorectal prolapse following proctectomy: a novel application of mesh sacral pexy

Neorectal prolapse following proctectomy for cancer has seldom been reported and treatment has mostly consisted in the resection of the prolapse via a perineal approach. Management of a patient with neorectal J-pouch prolapse using mesh sacral pexy via an abdominal approach is reported. By analogy with native rectal prolapse due to pelvic static disorders, laparoscopic mesh sacral pexy is likely to afford the same advantages of low morbidity and durability when applied to neorectal prolapse following rectal cancer surgery.

International standardization and optimization group for intersphincteric resection (ISOG-ISR): modified Delphi consensus on anatomy, definition, indication, surgical technique, specimen description and functional outcome

AIM

Intersphincteric resection (ISR) is an oncologically complex operation for very low-lying rectal cancers. Yet, definition, anatomical description, operative indications and operative approaches to ISR are not standardized. The aim of this study was to standardize the definition of ISR by reaching international consensus from the experts in the field. This standardization will allow meaningful comparison in the literature in the future.

METHOD

A modified Delphi approach with three rounds of questionnaire was adopted. A total of 29 international experts from 11 countries were recruited for this study. Six domains with a total of 37 statements were examined, including anatomical definition; definition of intersphincteric dissection, intersphincteric resection (ISR) and ultra-low anterior resection (uLAR); indication for ISR; surgical technique of ISR; specimen description of ISR; and functional outcome assessment protocol.

RESULTS

Three rounds of questionnaire were performed (response rate 100%, 89.6%, 89.6%). Agreement (≥80%) reached standardization on 36 statements.

CONCLUSION

This study provides an international expert consensus-based definition and standardization of ISR. This is the first study standardizing terminology and definition of deep pelvis/anal canal anatomy from a surgical point of view. Intersphincteric dissection, ISR and uLAR were specifically defined for precise surgical description. Indication for ISR was determined by the rectal tumour's maximal radial infiltration (T stage) below the levator ani. A new surgical definition of T3isp was reached by consensus to define T3 low rectal tumours infiltrating the intersphincteric plane. A practical flowchart for surgical indication for uLAR/ISR/abdominoperineal resection was developed. A standardized ISR surgical technique and functional outcome assessment protocol was defined.

Transanal total mesorectal excision versus laparoscopic intersphincteric resection for low rectal cancer: a propensity score matching analysis

BACKGROUND

Anus-preserving surgery for low rectal cancer has always been a serious difficulty for surgeons. Transanal total mesorectal excision (TaTME) and laparoscopic intersphincteric resection (ISR) are commonly used Anus-preserving surgeries for low rectal cancer. The aim of this study was to compare the clinical use of two surgical methods.

METHODS

A total of 152 patients with low rectal cancer were treated with taTME in 75 cases and ISR in 77 cases. After propensity score matching, 46 patients in each group were included in the study. Perioperative outcomes, anal function scores (Wexner incontinence score) and quality of life scores (EORTC QLQ C30, EORTC QLQ CR38) at least 1 year after surgery were compared between the two groups.

RESULTS

There were no significant differences between the two groups in terms of surgical outcomes, pathological examination of surgical specimens, postoperative recovery, and postoperative complications, except for patients in the taTME group who had their indwelling catheters removed later. Anal Wexner incontinence score was lower in taTME group than ISR group (P < 0.05). On the EORTC QLQ-C30 scale, the physical function and role function scores in the ISR group were lower than those in the taTME group (P < 0.05), while the fatigue, pain symptoms, and constipation scores in the ISR group were higher than those in the taTME group (P < 0.05). On the EORTC QLQ-CR38 scale, the scores of gastrointestinal symptoms and defecation problems in the ISR group were higher than those in the taTME group (P < 0.05).

CONCLUSION

Compared with ISR surgery, taTME surgery is comparable in terms of surgical safety and short-term efficacy, and has better long-term anal function and quality of life. From the perspective of long-term anal function and quality of life, taTME surgery is a better surgical method for the treatment of low rectal cancer.

Surgical treatment of rectal cancer: prospective cohort study about good oncologic results and low rates of abdominoperineal excision

OBJECTIVES

the purpose of this study was to evaluate the outcome of rectal cancer surgery, in a unit adopting the principles of total mesorectal excision (TME) with a high restorative procedure rate and with a low rate of abdominoperineal excision (APE).

METHODS

we enrolles patients with extraperitoneal rectal cancer undergoing TME or TME+APE. Patients with mid rectal tumors underwent TME, and patients with tumors of the lower rectum and no criteria for APE underwent TME and intersphincteric resection. Those in which the intersphincteric space was invaded and in those with a free distal margin less than 1cm or a tumor free radial margin were unattainable underwent APE or extralevator abdominoperineal excision (ELAPE). We assessed local recurrence rates, overall survival and involvement of the radial margin.

RESULTS

sixty (89.6%) patients underwent TME and seven (10.4%) TME + APE, of which five underwent ELAPE. The local recurrence, in pacientes undergoing TME+LAR, was 3.3% and in patients undergoing APE, 14.3%. The local recurrence rate (p=0.286) or the distant recurrence rate (p=1.000) was similar between groups. There was no involvement of radial margins. Survival after 120 months was similar (p=0.239).

CONCLUSION

rectal malignancies, including those located in the low rectum, may be surgically treated with a low rate of APE without compromising oncological principles and with a low local recurrence rates.

The evaluation of postoperative bowel dysfunction in Japanese patients with rectal cancer

PURPOSE

The present study assessed postoperative bowel dysfunction in Japanese patients with rectal cancer, including patients who underwent preoperative radiotherapy (RT).

METHODS

A total of 277 rectal cancer patients who underwent primary resection were included in the analyses. A questionnaire survey was administered using the low anterior resection syndrome (LARS) score and Wexner score. Scores were determined one year after rectal surgery or diverting ileostomy closure. The LARS score was categorized as minor LARS (21-29) and major LARS (30-42).

RESULTS

The proportions of patients with minor and major LARS were significantly larger and Wexner scores significantly higher in patients with distal tumors and a lower anastomosis level than in those with proximal tumors and a higher anastomosis level. Among the patients with lower rectal cancer, the proportions with minor and major LARS were similar between those with and without preoperative RT. The Wexner scores in patients with preoperative RT were significantly higher than in patients without RT. A distal tumor location and lower anastomosis level were independent risk factors of major LARS in multivariate analyses.

CONCLUSION

A distal tumor location, low anastomosis level, and preoperative RT might be associated with postoperative bowel dysfunction in rectal cancer patients.

Comparison between robotic-assisted and laparoscopic sphincter-preserving operations for ultra-low rectal cancer

Aim

Sphincter-preserving operations for ultra-low rectal cancer include low anterior and intersphincteric resection. In low anterior resection, the distal rectum is divided by a transabdominal approach, which is technically demanding. In intersphincteric resection, a perineal approach is used. We aimed to evaluate whether robotic-assisted surgery is technically superior to laparoscopic surgery for ultra-low rectal cancer. We compared the frequency of low anterior resection in cases of sphincter-preserving operations.

Method

We investigated 183 patients who underwent sphincter-preserving robotic-assisted or laparoscopic surgery for ultra-low rectal cancer (lower border within 5 cm of the anal verge) between April 2010 and March 2020. The frequency of low anterior resection was compared between laparoscopic and robotic-assisted surgeries. The clinicopathological factors associated with an increase in performing low anterior resection were analyzed by multivariate analyses.

Results

Overall, 41 (22.4%) and 142 (77.6%) patients underwent laparoscopic and robotic-assisted surgery, respectively. Patient characteristics were similar between the groups. Low anterior resection was done significantly more frequently in robotic-assisted surgery (67.6%) than in laparoscopic surgery (48.8%) (P = 0.04). Multivariate analyses showed that tumor distance from the anal verge (P < 0.01) and robotic-assisted surgery (P = 0.02) were significantly associated with an increase in the performance of low anterior resection. The rate of postoperative complications or pathological results was similar between the groups.

Conclusion

Compared with laparoscopic surgery, robotic-assisted surgery significantly increased the frequency of low anterior resection in sphincter-preserving operations for ultra-low rectal cancer. Robotic-assisted surgery has technical superiority over laparoscopic surgery for ultra-low rectal cancer treatment.

Comparative survival risks in patients undergoing abdominoperineal resection and sphincter-saving operation for rectal cancer: a 10-year cohort analysis using propensity score matching

PURPOSE

Abdominoperineal resection (APR) has been considered to have a higher risk of local recurrence and poorer survival outcome than sphincter-saving operation (SSO) in patients with rectal cancer. This study compared long-term oncologic outcomes and prognostic parameters in propensity score-matched patients who underwent APR and SSO.

METHODS

This study analyzed 958 consecutive patients with lower rectal cancer who underwent preoperative chemoradiotherapy followed by APR or SSO between 2005 and 2015. Propensity score matching analysis was performed to adjust baseline characteristics, including clinical stage, tumor distance from the anal verge, and tumor size.

RESULTS

In the entire cohort, the APR group had larger and lower tumors and showed significantly shorter 5-year disease-free survival (DFS) than the SSO group (64.5% vs. 75.8%, p = 0.01). After propensity score matching, there were no significant between-group differences in local (9.5% vs. 8.0%, p = 0.59) and systemic (27.9% vs. 23.4%, p = 0.3) recurrence rates, and 5-year DFS (67.5% vs. 69.9%, p = 0.49) and overall survival (80.8% vs. 82.9%, p = 0.65) rates. A lower number of lymph nodes retrieved was independently associated with recurrence and survival outcomes in the APR group, whereas poorly differentiated histology was an independent associated parameter in the SSO group. Advanced stage and perineural invasion were identified as independent prognostic parameters in both groups.

CONCLUSIONS

This study indicated that the long-term oncologic outcomes of APR were comparable to those of SSO. Because prognostic parameters associated with oncologic outcomes differed between the respective procedures, correctable parameters could be ameliorated through complete total mesorectal excision and personalized systemic treatment.

Clinical Efficacy of Intersphincteric Resection for Low Rectal Cancer Compared With Abdominoperineal Resection: A Single-Center Retrospective Study

BACKGROUND

In recent years, intersphincteric resection (ISR) has been increasingly used to replace abdominoperineal resection (APR) in the surgical treatment of ultra-low rectal cancer.

AIM

This study was to compare the clinical efficacy of ISR and APR.

METHODS

Between 2012 and 2018, 74 consecutive patients with ultra-low rectal cancer underwent ISR or APR in our medical center. A retrospective comparison of these 2 procedures was performed.

RESULTS

A total of 43 patients underwent ISR and 31 underwent APR were included in the study. No significant differences were found between 2 groups in gender, age, BMI, and ASA score. Intersphincteric resection group showed shorter operative time (P = .02) and less blood loss (P = .001). Hospital stays, time to soft diet, and postoperative 30-day complications were not significantly different between the 2 groups. R0 resection achieved 100% in both the groups. As for the long-term outcomes, the survival and recurrence rate were similar between 2 groups. Moreover, the LARS and Wexner score showed that the postoperative anal function after ISR were satisfactory.

CONCLUSION

This study suggested that ISR was feasible and safe for selected patients with ultra-low rectal cancer, with clinically superior outcomes in select patients (small tumors/further from the anal verge) and similar oncological outcomes to APR, and the anal functional outcomes after ISR were acceptable.

Transanal Anastomosis Method and Prolapsing Technique in Totally Laparoscopic Low Anterior Resection for Lower Rectal Cancer

There are some reports of totally laparoscopic surgery performed by intracorporeal anastomosis without abdominal incision. However, intracorporeal anastomosis with prolapsing technique is difficult and complicated via laparoscopic surgery alone. We found it easier to achieve totally laparoscopic low anterior resection (LAR) by anastomosis anally. Our procedure was performed in 32 patients. After the prolapsed rectum with the tumor was transected, reconstruction was performed by using a double-stapling technique (DST) or a hand-sewn technique (HST). In the DST, the proximal colon was pulled outside transanally, and the anvil head was inserted into the colon and returned to the abdominal cavity. The anal-side rectum was closed using a linear stapling device, and DST was performed. The HST was modified from intersphincteric resection anastomosis. No patient experienced complications associated with this procedure. Cosmetic satisfaction was achieved. All patients obtained disease-free margins pathologically, and none experienced local recurrence. Intracorporeal anastomosis of totally laparoscopic low anterior resection is difficult via laparoscopic ports only. It can be simplified by operating with anastomosis via the anus.

Anus-Preserving Surgery in Advanced Low-Lying Rectal Cancer: A Perspective on Oncological Safety of Intersphincteric Resection

The surgical management of low-lying rectal cancer, within 5 cm from the anal verge (AV), is challenging due to the possibility, or not, to preserve the anus with its sphincter muscles maintaining oncological safety. The standardization of total mesorectal excision, the adoption of neoadjuvant chemoradiotherapy, the implementation of rectal magnetic resonance imaging, and the evolution of mechanical staplers have increased the rate of anus-preserving surgeries. Moreover, extensive anatomy and physiology studies have increased the understanding of the complexity of the deep pelvis. Intersphincteric resection (ISR) was introduced nearly three decades ago as the ultimate anus-preserving surgery. The definition and indication of ISR have changed over time. The adoption of the robotic platform provides excellent perioperative results with no differences in oncological outcomes. Pushing the boundaries of anus-preserving surgeries has risen doubts on oncological safety in order to preserve function. This review critically discusses the oncological safety of ISR by evaluating the anatomical characteristics of the deep pelvis, the clinical indications, the role of distal and circumferential resection margins, the role of the neoadjuvant chemoradiotherapy, the outcomes between surgical approaches (open, laparoscopic, and robotic), the comparison with abdominoperineal resection, the risk factors for oncological outcomes and local recurrence, the patterns of local recurrences after ISR, considerations on functional outcomes after ISR, and learning curve and surgical education on ISR.

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.

Outcomes of robotic partial excision of the levator ani muscle for locally advanced low rectal cancer invading the ipsilateral pelvic floor at the anorectal ring level

PURPOSE

The purpose of this study is to evaluate partial excision of the levator ani muscle (PELM) enables preservation of anal sphincter function although levator ani muscle (LAM) was invaded.

METHODS

Functional outcomes and oncologic outcomes of 23 consecutive patients who underwent robotic PELM for low rectal cancer at the anorectal ring level invading or abutting the ipsilateral LAM are analysed.

RESULTS

Secured resection margins were achieved, especially for the circumferential resection margin. During a median follow-up of 44 months, the 3-year local recurrence rate was 14.4%. Among patients who underwent diverting ileostomy closure, mean Memorial Sloan Kettering Cancer Center Bowel Function Instrument and Wexner scores were 68.3 ± 11.9 and 10.7 ± 5.3, respectively, at 1 year after closure.

CONCLUSION

PELM is a sphincter-preserving alternative to abdominoperineal resection (APR) or extralevator APR for low rectal cancer invading the ipsilateral LAM at the level of the anorectal ring.

Sphincter-saving surgery after neoadjuvant therapy for ultra-low rectal cancer where abdominoperineal resection was indicated: 10-year results of the GRECCAR 1 trial

This phase III trial included patients with ultra-low rectal adenocarcinoma that initially required abdominoperineal resection. The surgical decision was based on clinical tumour status after preoperative treatment. The overall sphincter-saving resection rate was 85 per cent, with 72 per cent rate of intersphincteric resection. Long-term results showed that changing the initial abdominoperineal resection indication into a sphincter-saving resection according to tumoral response is oncologically safe.

Saving the sphincter

Risk factors for local recurrence and long term survival after minimally invasive intersphincteric resection for very low rectal cancer: Multivariate analysis in 161 patients

INTRODUCTION

Intersphincteric resection (ISR) is the ultimate anal-sparing technique as an alternative to abdominoperineal resection in selected patients. Oncological safety is still debated. This study analyses long-term oncological results and evaluates risk factors for local recurrence (LR) and overall survival (OS) after minimally-invasive ISR.

MATERIALS AND METHODS

Retrospective single-center data were collected from a prospectively maintained colorectal database. A total of 161 patients underwent ISR between 2008 and 2018. OS and local recurrence-free survival (LRFS) were assessed using Kaplan-Meier analysis (log-rank test). Risk factors for OS and LRFS were assessed with Cox-regression analysis.

RESULTS

Median follow-up was 55 months. LR occurred in 18 patients. OS and LRFS rates at 1, 3, and 5 years were 96%, 91%, and 80% and 96%, 89%, and 87%, respectively. Tumor size (p = 0.035) and clinical T-stage (p = 0.029) were risk factors for LRFS on univariate analysis. On multivariate analysis, tumor size (HR 2.546 (95% CI: 0.976-6.637); p = 0.056) and clinical T-stage (HR 3.296 (95% CI: 0.941-11.549); p = 0.062) were not significant. Preoperative CEA (p < 0.001), pathological T-stage (p = 0.033), pathological N-stage (p = 0.016) and adjuvant treatment (p = 0.008) were prognostic factors for OS on univariate analysis. Preoperative CEA (HR 4.453 (95% CI: 2.015-9.838); p < 0.001) was a prognostic factor on multivariate analysis.

CONCLUSIONS

This study confirms the oncological safety of minimally-invasive ISR for locally advanced low-lying rectal tumors when performed in experienced centers. Despite not a risk factor for LR, tumor size and, locally advanced T-stage with anterior involvement should be carefully evaluated for optimal surgical strategy. Preoperative CEA is a prognostic factor for OS.

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.

Comparison of Clinical Efficacy and Safety Between da Vinci Robotic and Laparoscopic Intersphincteric Resection for Low Rectal Cancer: A Meta-Analysis

Background and Aims: The intersphincteric resection (ISR) is beneficial for saving patients' anus to a large extent and restoring original bowel continuity. Laparoscopic ISR (L-ISR) has its drawbacks, such as two-dimensional images, low motion flexibility, and unstable lens. Recently, da Vinci robotic ISR (R-ISR) is increasingly used worldwide. The purpose of this article is to compare the feasibility, safety, oncological outcomes, and clinical efficacy of R-ISR vs. L-ISR for low rectal cancer. Methods: PubMed, EMBASE, Cochrane Library, and Web of Science were searched to identify comparative studies of R-ISR vs. L-ISR. Demographic, clinical, and outcome data were extracted. Mean difference (MD) and risk ratio (RR) with their corresponding confidence intervals (CIs) were calculated. Results: Five studies were included. In total, 510 patients were included, of whom 273 underwent R-ISR and 237 L-ISR. Compared with L-ISR, R-ISR has significantly lower estimated intraoperative blood loss (MD = -23.31, 95% CI [-41.98, -4.64], P = 0.01), longer operative time (MD = 51.77, 95% CI [25.68, 77.86], P = 0.0001), hospitalization days (MD = -1.52, 95% CI [-2.10, 0.94], P < 0.00001), and postoperative urinary complications (RR = 0.36, 95% CI [0.16, 0.82], P = 0.02). Conclusions: The potential benefits of R-ISR are considered as a safe and feasible alternative choice for the treatment of low rectal tumors.

ISR for T1-2 Low Rectal Cancer: A Japanese Approach

The evolution over the past 20 years of anal preservation in rectal cancer surgery has been truly remarkable. Intersphincteric resection (ISR) reported by Schiessel in 1994 in Australia has been shown to enable anal preservation even for cancers quite close to the anus. In Japan, ISR via the detachment of the anal canal between the internal and external sphincters and excision of the internal sphincter first began to be practiced in the latter half of 1990. A multicenter Phase II trial of ISR in Japan suggested that 70% of the cases had relatively good function with less than 10 points of Wexner score but around 10% had severe incontinence that would not be improved for long term. The primary end point of the clinical study, 3-year local recurrence rate, was 13.2% across the overall cohort (T1, 0%; T2, 6.9%; and T3, 21.6%). When ISR is performed on T1/T2 rectal cancers, sufficient circumferential resection margin can be obtained even without preoperative chemoradiotherapy, and local recurrence rate was acceptably low. Based on these evidences, ISR is a currently important, standard treatment option among anal-preserving surgeries for T1/T2 low-lying rectal cancers. In Japan, a feasibility study (LapRC trial) of laparoscopic ISR on Stage 0 and Stage 1 low rectal cancer showed excellent outcomes. A prospective Phase II clinical trial targeting low rectal cancers within 5 cm from the anal verge (ultimate trial) is being performed and awaiting the results in near future.

Narrow pelvic inlet plane area and obesity as risk factors for anastomotic leakage after intersphincteric resection

BACKGROUND

Intersphincteric resection (ISR) has been increasingly used as the ultimate sphincter-preserving procedure in extremely low rectal cancer. The most critical complication of this technique is anastomotic leakage. The incidence rate of anastomotic leakage after ISR has been reported to range from 5.1% to 20%.

AIM

To investigate risk factors for anastomotic leakage after ISR based on clinicopathological variables and pelvimetry.

METHODS

This study was conducted at Department of Colorectal Surgery, Japanese Red Cross Medical Center, Tokyo, Japan, with a total of 117 patients. We enrolled 117 patients with extremely low rectal cancer who underwent laparotomic and laparoscopic ISRs at our hospital. We conducted retrospective univariate and multivariate regression analyses on 33 items to elucidate the risk factors for anastomotic leakage after ISR. Pelvic dimensions were measured using three-dimensional reconstruction of computed tomography images. The optimal cutoff value of the pelvic inlet plane area that predicts anastomotic leakage was determined using a receiver operating characteristic (ROC) curve.

RESULTS

We observed anastomotic leakage in 10 (8.5%) of the 117 patients. In the multivariate analysis, we identified high body mass index (odds ratio 1.674; 95% confidence interval: 1.087-2.58; P = 0.019) and smaller pelvic inlet plane area (odds ratio 0.998; 95% confidence interval: 0.997-0.999; P = 0.012) as statistically significant risk factors for anastomotic leakage. According to the receiver operating characteristic curves, the optimal cutoff value of the pelvic inlet plane area was 10074 mm². Narrow pelvic inlet plane area (≤ 10074 mm²) predicted anastomotic leakage with a sensitivity of 90%, a specificity of 85.9%, and an accuracy of 86.3%.

CONCLUSION

Narrow pelvic inlet and obesity were independent risk factors for anastomotic leakage after ISR. Anastomotic leakage after ISR may be predicted from a narrow pelvic inlet plane area (≤ 10074 mm²).

Sphincter-saving surgery for ultra-low rectal carcinoma initially indicated for abdominoperineal resection: Is it safe on a long-term follow-up?

BACKGROUND

Rate of abdominoperineal resection (APR) varies from countries and surgeons. Surgical impact of preoperative treatment for ultra-low rectal carcinoma (ULRC) initially indicated for APR is debated. We report the 10-year oncological results from a prospective controlled trial (GRECCAR 1) which evaluate the sphincter saving surgery (SSR).

METHODS

ULRC indicated for APR were included (n = 207). Randomization was between high-dose radiation (HDR, 45 + 18 Gy) and radiochemotherapy (RCT, 45 Gy + 5FU infusion). Surgical decision was based on tumour volume regression at surgery. SSR technique was standardized as mucosectomy (M) or partial (PISR)/complete (CISR) intersphincteric resection.

RESULTS

Overall SSR rate was 85% (72% ISR), postoperative morbidity 27%, with no mortality. There were no significant differences between the HDR and RCT groups: 10-year overall survival (OS10) 70.1% versus 69.4%, respectively, 10.2% local recurrence (9.2%/14.5%) and 27.6% metastases (32.4%/27.7%). OS and disease-free survival were significantly longer for SSR (72.2% and 60.1%, respectively) versus APR (54.7% and 38.3%). No difference in OS10 between surgical approaches (M 78.9%, PISR 75.5%, CISR 65.5%) or tumour location (low 64.8%, ultralow 76.7%).

CONCLUSION

GRECCAR 1 demonstrates the feasibility of safely changing an initial APR indication into an SSR procedure according to the preoperative treatment tumour response. Long-term oncologic follow-up validates this attitude.

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.

Exfoliated cancer cells during intersphincteric resection for very low rectal cancer

PURPOSE

To investigate the frequency of exfoliated cancer cells and the efficacy of rectal washout during intersphincteric resection (ISR) in patients not receiving chemoradiotherapy (CRT) for very low rectal cancer.

METHOD

The subjects of this prospective study were 16 consecutive patients who underwent ISR without CRT for very low rectal cancer. Brushing cytology of the posterior anorectal wall was performed twice in each step of the ISR procedure and the samples were sent for blind cytological examination to identify exfoliated cancer cells.

RESULTS

Exfoliated cancer cells were identified in 9 of 13 patients (69%) preoperatively. The number of cancer cells identified after abdominal total mesorectal dissection decreased significantly from 94% (15/16) to 25% (4/16) after transanal irrigation with 2000 mL saline (p < 0.001). No cancer cells were identified after swabbing the anal wall following transanal dissection with purse-string closure of the distal stump. No suture-line recurrence was found during a median follow-up duration of 6 years.

CONCLUSION

Exfoliated cancer cells, confirmed in 94% of patients after total mesorectal excision, could be eliminated by performing rectal irrigation after clamping the rectum proximal to the tumor and swabbing the anorectal wall during ISR.

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.

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.

Long Term Results of Modified Intersphincteric Resections for Low Rectal Cancer: A Single Center Experience

BACKGROUND AND OBJECTIVES

The objective of this article is to evaluate the long-term oncological and functional outcomes following modified intersphincteric resections (ISR) for low rectal cancer. The modified technique consisted of the abandonment of colonic J-pouches, transverse coloplasty, or defunctioning temporary stoma in favor of a direct handsewn coloanal anastomosis (CAA).

MATERIAL AND METHODS

Sixty consecutive patients with type II and III (juxta-anal or intra-anal) low rectal tumors underwent modified ISR by the same surgical team and were followed for a period of five years. Functional outcomes using the Wexner Score, postoperative complications, recurrence rates, morbidity, and mortality rates were assessed.

RESULTS

The five-year survival rate was 93.3% with a disease-free interval at three years of 98%. Morbidity was 15% (n = 9) consisting of intestinal wall necrosis (n = 6), stenosis (n = 2), and sacral metastasis (n = 1). The Wexner score values were, at 1 year, 8.5 (range, 4-13); at three years 7.2 (range, 2-11); and at 5 years 6.7 (range, 2-12). A second surgery was needed in only one case that showed postoperative transmural necrosis of the colonic wall.

CONCLUSIONS

In highly selected patients with type II or III low rectal tumors and proper preoperative imaging staging, ISR might be a viable alternative to other techniques such as abdominoperineal resection and low anterior resection, both from a functional and an oncological perspective.

Long-term results of intersphincteric resection for low rectal cancer in Japan

Intersphincteric resection (ISR) is the ultimate sphincter-preserving procedure for low rectal cancer. A questionnaire about the standardization of ISR was given to 2125 patients who underwent curative ISR for low rectal cancer between 2005 and 2012 at 127 affiliated institutions of the Japanese Society for Cancer of the Colon and Rectum (JSCCR), and the results were compared with the results of a systematic review. The findings revealed that although mortality and morbidity were relatively low and the survival rate after ISR was good, the rates of local recurrence and postoperative fecal incontinence were relatively high. The radicality of ISR was compared with that of abdominoperineal resection and low anterior resection using the propensity score matching prognosis analysis of patients in the JSCCR nationwide registry. The local recurrence rate was significantly higher after ISR, and especially high in patients with T3 (invasion into the external anal sphincter) and T4 disease. These results provide evidence about the factors related to fecal incontinence after ISR. As measures for the standardization of ISR, it is important to reconfirm that ISR is not indicated for patients with cT3 and cT4 disease and those with poor preoperative defecatory function, based on the ISR indication criteria.

Usefulness of Fecoflowgram for Assessment of Defecation after Intersphincteric Resection

AIM

We have developed an imaging functional assessment of defecation after partial intersphincteric resection (ISR) by fecoflowgram obtained by defecography.

PATIENTS AND METHODS

Between January 2012 and December 2014, 6 patients with temporary ileostomy who underwent partial ISR for lower rectal cancer at our hospital were enrolled in this study. Defecography was performed 2 weeks after closure of the ileostomy. The defecation of all patients was evaluated by defecography and a fecoflowgram calculated from defecography. During the same period, the control group was comprised of 2 male and 2 female healthy volunteers.

RESULTS

The descent of the perineum and linearization of the anorectal angle was observed relative to normal defecation in the healthy volunteers. All barium was discharged by a single abdominal pressure within 5 s in the controls. In patients after partial ISR, all barium could not be discharged by a single abdominal pressure. The time course of pressure distribution after ISR was lower than that of healthy volunteers, which could not be evaluated by defecography. Defecation time in patients following ISR was longer than that of healthy volunteers.

CONCLUSION

Fecoflowgrams calculated from defecography seem to be useful for functional assessment of defecation after rectal resection.

Intersphincteric Resection Has Similar Long-term Oncologic Outcomes Compared With Abdominoperineal Resection for Low Rectal Cancer Without Preoperative Therapy: Results of Propensity Score Analyses

BACKGROUND

Intersphincteric resection has been performed for very low rectal cancer in place of abdominoperineal resection to avoid permanent colostomy.

OBJECTIVE

This study aimed to evaluate long-term oncologic outcomes of intersphincteric resection compared with abdominoperineal resection.

DESIGN

In this retrospective study, propensity score matching and stratification analyses were performed to reduce the effects of confounding factors between groups, including age, sex, BMI, CEA value, tumor height, tumor depth, lymph node enlargement, and circumferential resection margin measured by MRI.

SETTING

A database maintained at our institute was used to identify patients during the period between 2000 and 2014.

PATIENTS

A total of 285 patients who underwent curative intersphincteric resection (n = 112) or abdominoperineal resection (n = 173) for stage I to III low rectal cancer without preoperative chemoradiotherapy were enrolled in this study.

MAIN OUTCOME MEASURE

The main outcome was recurrence-free survival.

RESULTS

Patients in the abdominoperineal resection group were more likely to have a preoperative diagnosis of advanced cancer before case matching. After case matching, clinical outcomes were similar between intersphincteric resection and abdominoperineal resection groups. Five-year relapse-free survival rates were 69.9% for the intersphincteric resection group and 67.9% for abdominoperineal resection group (p = 0.64), and were similar in the propensity score-matched cohorts (89 matched pairs). Three-year cumulative local recurrence rates were 7.3% for intersphincteric resection and 3.9% for abdominoperineal resection (p = 0.13). In the propensity score-matched model, the hazard ratio for recurrence after intersphincteric resection in comparison with abdominoperineal resection was 0.90. Stratification analysis revealed similar recurrence rates (HR, 0.75-1.68) for intersphincteric resection in comparison with abdominoperineal resection.

LIMITATION

Eight covariates were incorporated into the model, but other covariates were not included.

CONCLUSIONS

Our findings suggest similar oncologic outcomes for intersphincteric resection and abdominoperineal resection without preoperative chemoradiotherapy in patients with low rectal cancer adjusted for background variables. See Video Abstract at http://links.lww.com/DCR/A661.

Intersphincteric Resection for Patients With Low-Lying Rectal Cancer: Oncological and Functional Outcomes

The aim of this review is to evaluate the outcomes after an intersphincteric resection (ISR) for patients with low-lying rectal cancer. Reports published in the literature regarding surgical, oncological, and functional outcomes of an ISR were reviewed. The morbidity after an ISR was 7.7%–32%, and anastomotic leakage was the most common adverse event. Local recurrence rates ranged from 0% to 12%, 5-year overall survival rates ranged from 62% to 92%, and rates of major incontinence ranged from 0% to 25.8% after an ISR. An ISR is a safe procedure for sphincter-saving rectal surgery in patients with very low rectal cancer; it does not compromise the oncological outcomes of the resection and is a valuable alternative to an abdominoperineal resection. While the functional outcomes after an ISR were found to be acceptable, the long-term functional outcome and quality of life still require careful investigation. ISRs have been performed with surgical and oncologic safety on patients with low-lying rectal cancer. However, patients must be selected very carefully for an ISR, considering the associated functional derangement and the limited extent of the resection.

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.

Full-thickness neorectal prolapse after transanal transabdominal proctosigmoidectomy for low rectal cancer: a cohort study

AIM

Transanal transabdominal proctosigmoidectomy (TATA) with a coloanal anastomosis is an alternative to abdominoperineal excision of the rectum (APR) for low rectal cancer. Neorectal prolapse is an unusual complication following TATA. This study aimed to determine the incidence of neorectal prolapse after TATA for low rectal cancer.

METHOD

This cohort study was conducted in a tertiary referral colorectal centre. From a prospectively maintained database including 1093 patients treated for rectal cancer between 1984 and 2016 we identified those who underwent sphincter-preserving surgery. Data regarding the incidence, management and outcomes of neorectal prolapse were analysed.

RESULTS

A total of 409 patients were identified, of whom 185 underwent open surgery and 224 a minimally invasive surgical procedure (MIS). All received neoadjuvant chemoradiation. Neorectal prolapse occurred in 4.6% (n = 19) with an incidence of 2.2% in the open and 6.7% in the MIS group (P = 0.023), with no difference between MIS techniques. There was one recurrence of neorectal prolapse (5.9%). The incidence of neorectal prolapse was higher in women (9.5%) than men (2.5%) (P = 0.011). There were no differences in local recurrence rates between the neorectal prolapse group (5.3%) and our population without prolapse (3.4%) (P = 0.79).

CONCLUSION

Neorectal prolapse is a rare occurrence following minimally invasive sphincter-saving surgical procedures performed for rectal cancer. It appears to be more frequent in patients who undergo MIS procedures and in women.

The Impact of Anastomotic Leakage on Anal Function Following Intersphincteric Resection

BACKGROUND

Data regarding anastomotic leakage (AL) following intersphincteric resection (ISR) are lacking. We aimed to evaluate the effect of AL on anal function in a retrospective review of patients who developed AL following ISR.

METHODS

We evaluated 341 consecutive patients who underwent ISR between 2000 and 2012. Patients were classified into three groups: anastomotic dehiscence (AD), major AL (Clavien-Dindo grade III+), or control (<grade III or no AL). Functional assessment was performed at 3, 6, 12, and 24 months after defecation through the preserved anus, and the Wexner score was calculated.

RESULTS

Among patients who underwent ISR for low rectal cancer (anal verge, 3.7 ± 1.3 cm), 59 (17%) developed AL. Of these, 13 patients were classified as AD and 36 as major AL. The rate of the 3-year stomal reversal was significantly lower in the major AL (78.6%) and AD groups (61.5%) than in the control group (88.7%; p < 0.01). Furthermore, the anastomotic stricture rate was higher in the AL and AD groups than in the controls (16.7 and 38.5 vs. 1.8%, respectively; p < 0.01). Wexner scores in the major AL group were poor during the early period, but were similar to the control group at the 2-year follow-up. In contrast, Wexner scores in the AD group remained high, even after 2 years.

CONCLUSIONS

Patients with major AL following ISR had poor anal function that recovered over 2 years, as long as AD was not present. These findings suggest that patients with major AL require a long-term follow-up for anal function.

Long-Term Functional and Oncological Outcomes Following Intersphincteric Resection for Low Rectal Cancers

Surgery for low rectal cancer often involves a permanent stoma. Intersphincteric resection (ISR) with colo-anal anastomosis is a valuable sphincter sparing surgical procedure that avoids the need for permanent stoma in patients with low rectal cancer. The aim of this study was to analyze the long-term functional and oncological outcomes following ISR. This was a retrospective analysis of patients with low rectal cancer who underwent ISR with colo-anal anastomosis in our institution between 2007 and 2015. All patients had a diversion stoma. Bowel function outcomes were assessed prospectively using Wexner incontinence score, low anterior resection syndrome score (LARS), and the Cancer Institute Quality of Life (QoL) questionnaire. The histological reports were reviewed to assess the oncological adequacy of the surgery. Patterns of recurrence and survival were analyzed in this group of patients. Thirty-three patients who underwent an ISR were eligible for this study. Laparoscopic resection was performed in five patients. All the patients received neoadjuvant chemoradiation except the two who received short course radiation and one who did not receive any neoadjuvant treatment. The median distance from the anal verge to the distal edge of the tumor was 3 cm (range 1.5-5 cm). Distal resection margins and circumferential resection margins were negative in all the patients. The 30-day post-operative mortality rate was 3.03%. In 20 patients with a median follow-up of 48 months, the 3-year overall survival was 95%. One patient had recurrence in the para-aortic nodes. No patient had a local recurrence. Bowel function was assessed in 18 patients who had a minimum stoma free period of 1 year. After a median of 43 months following stoma closure, the median Wexner score was 3.56 (range 0-19), median LARS score was 4.78 (range 0-33), and the mean Cancer Institute QoL score was 151.56 ± 15.741. The QoL was average to very high with an overall acceptable quality of life. In this study, ISR was associated with acceptable long-term functional and oncological outcomes. It can be considered as a safe alternative to a permanent stoma in selected patients with low rectal cancer.

Intersphincteric Resection Pushing the Envelope for Sphincter Preservation

During the last 15 years, a significant evolution has emerged in the surgical treatment of rectal cancer and restoration of bowel continuity has been one of the main goals. For many years the treatment of distal rectal cancer would necessarily require an abdominoperineal resection and end colostomy. The surgical procedure of intersphincteric resection has been proposed to offer sphincter preservation in patients with low rectal cancer and has been legitimized if executed according to adequate oncologic criteria. This article will discuss the best indications, technical aspects, functional, and oncological outcomes of intersphicteric resection in the management of rectal cancer.

Sphincter-Preserving Surgery for Low Rectal Cancer: Do We Overshoot the Mark?

PURPOSE

Intersphincteric resection (ISR) is an alternative to abdominoperineal resection (APR) for a selected subset of patients with low rectal cancer, combining equivalent oncological outcome and sphincter preservation. However, functional results are heterogeneous and often imperfect. The aim of the present investigation was to determine the long-term functional results and quality of life after ISR.

METHODS

One hundred forty-three consecutive patients who underwent surgery for low rectal cancer were analysed. Sixty patients received ISR and 83 patients APR, respectively. Kaplan-Meier estimate was used to analyse patients' survival. The EORTC QLQ-C30, -C29 and the Wexner score were used to determine functional outcome and quality of life.

RESULTS

ISR and APR were both associated with comparable morbidity and no mortality. Patients' disease- and recurrence-free survival after ISR and APR were similar (p = 0.2872 and p = 0.4635). Closure of ileostomy was performed in 73% of all patients after ISR. Long-term outcome showed a rate of incontinence (Wexner score ≥10) in 66% of the patients. Despite this, patients' quality of life was significantly better after ISR compared to APR in terms of abdominal complaints and psycho-emotional functioning.

CONCLUSIONS

ISR is technically feasible with acceptable postoperative morbidity rates. Functional results following ISR are compromised by incontinence as the most important complication. However, long-term quality of life is superior to APR, which should be considered when selecting patients for ISR.

Intersphincteric resection for very low rectal cancer: A review of the updated literature

Intersphincteric resection (ISR) has rapidly increased worldwide including laparoscopic surgery. However, there are some concerns for the definition of ISR, surgical technique, oncological outcome, anal function, and quality of life (QoL). The aim of the present study is to evaluate those issues. A review of this surgical technique was carried out by searching English language literature of the PubMed online database and appropriate articles were identified. With regard to open‐ISR, the morbidity rate ranged from 7.5% to 38.3%, with lower mortality rates. Local recurrence rates varied widely from 0% to 22.7%, with a mean follow‐up duration of 40–94 months. Disease‐free and overall 5‐year survival rates were 68–86% and 76–97%, respectively. Those outcomes were equivalent to laparoscopic‐ISR. Surgical and oncological outcomes of ISR were generally acceptable. However, accurate evaluation of anal function and QoL was difficult because of a lack of standard assessment of various patient‐related factors. The surgical and oncological outcomes after ISR seem to be acceptable. The ISR technique seems to be valid as an alternative to abdominoperineal resection in selected patients with a very low rectal cancer. However, both necessity for ISR and expectations of QoL impairment as a result of functional disorder should be fully discussed with patients before surgery.

Efficacy of an additional flap operation in bladder-preserving surgery with radical prostatectomy and cystourethral anastomosis for rectal cancer involving the prostate

Purpose

Sphincter-preserving operations performed with bladder-preserving surgery and a cystourethral anastomosis (CUA) do not require a urinary stoma, but leakage from the CUA may develop. The aim of this study was to evaluate the efficacy of performing an additional flap operation.

Methods

The subjects were 39 patients who underwent bladder-preserving surgery for advanced rectal cancer involving the prostate, between 2001 and 2015.32 of whom had a CUA and one of whom had a neobladder. Five of these 32 patients underwent an ileal flap operation, 2 underwent an omental flap operation, and 3 underwent an operation using both flaps.

Results

Leakage developed in 3 (30%) of the 10 patients who underwent additional flap operations, but in 14 (60.9%) of the 23 patients who did not undergo a flap operation. The mean periods of catheterization for the patients who suffered leakage were 31 weeks (8–108 weeks) in those without a flap and 16 weeks (8–20 weeks) in those with a flap. Four (33.3%) of the 12 patients with leakage after surgery without a flap had a period of urinary catheterization >30 weeks, and 2 (16.7%) had leakage of CTCAE grade 3. There were no cases of leakage after flap surgery.

Conclusion

An additional flap operation may decrease the risk of leakage from a CUA.

Intersphincteric resection for low rectal cancer

For low rectal cancer located < 5 cm from the anal verge, abdominoperineal resection (APR) with permanent sigmoid colostomy is usually used to ensure the R0 resection. Sphincter saving surgery has emerged in the last 20 years, and the introduction of intersphincteric resection (ISR) can successfully preserve the anal function and guarantee a radical tumor resection for patients with ultra-low lying tumors. Therefore, the use of APR has been consistently declining worldwide. Recently, a growing body of research on ISR has been reported. However, more evidence based results are needed to clarify some issues about ISR. In the current review, we discuss the indications for ISR and the oncological and functional outcomes following the procedure. Some technique issues of ISR are also discussed.

Colonic prolapse after intersphincteric resection for very low rectal cancer: a report of 12 cases

BACKGROUND

There are no published data concerning management of patients with exteriorized colonic prolapse (CP) after intersphincteric rectal resection (ISR) and side-to-end coloanal manual anastomosis (CAA) for very low rectal cancer. The aim of the present study was to report our experience in 12 consecutive cases of CP following ISR with CAA.

METHODS

From 2006 to 2014, all patients with very low rectal cancer who developed CP after ISR and CAA were reviewed. Demographic and surgical data, prolapse symptoms and treatment were recorded. Postoperative morbidity, functional outcomes and results after prolapse surgery were recorded.

RESULTS

Twelve out of 143 patients (8 %) who underwent ISR with side-to-end CAA for low rectal cancer presented CP: 7/107 ISR (7 %) with partial resection of the internal anal sphincter (IAS) and 5/36 ISR (14 %) with subtotal or total resection of the IAS (NS). CP was diagnosed after a median of 6 months (range 2-72 months) after ISR. All patients with CP suffered from pain and fecal incontinence. Median Wexner fecal incontinence score before surgery was 16.5 (range 12-20). Three patients refused reoperation. Nine patients underwent transanal surgery with prolapse resection (including colonic stump and side-to-end anastomosis) and new end-to-end CAA (with posterior myorraphy in 4 cases). After a median follow-up of 30 months (range 8-87 months), 3/9 patients (33 %) had CP recurrence: One with very poor function was treated by abdominoperineal resection and definitive stoma. The 2 others were successfully reoperated on transanally. Median Wexner fecal incontinence score after CP surgery was 9 (range 0-20). No CP recurrence was noted for the 6 other patients, and function improved in all cases. Thus, at the end of follow-up, 8/9 patients (89 %) had no recurrence after surgery.

CONCLUSIONS

We believe surgery must be attempted in these patients who develop CP after ISR with CAA for very low rectal cancer in order to improve function and symptoms. A transanal approach with CP resection and new end-to-end anastomosis appeared to be safe and effective. Larger studies are needed to confirm our results.

Long-term results of extended intersphincteric resection for very low rectal cancer: a retrospective study

Background

Intersphincteric resection (ISR) has become an increasingly popular optional surgical tool for the treatment of very low rectal cancer. The purpose of this study was to assess the long-term oncological and functional outcomes of intersphincteric resection for T2 and T3 rectal cancer situated below 4 cm from the anal verge.

Methods

A total of 62 consecutive patients with very low rectal cancer who underwent ISR from 2001 to 2010 were classified into standard ISR for T2 lesions (Group I, n = 24) and extended ISR for T3 lesions (Group II, n = 38).

Results

The 5-year overall survival rates were 95.8 % for group I and 94.7 % for group II. The 5-year recurrence-free survival rates were 87.5 % for group I and 86.8 % for group II. Bowel functions were evaluated at the 12^th and 24^th months after ileostomy closure in both groups. The frequency of bowel evacuation was higher in patients who underwent extended ISR than in those who underwent standard ISR at the 12^th month (p < 0.05). However, at the 24^th month, the frequencies decreased in both groups, exhibiting no significant difference. In the comparison based on the Kirwan classification, group I showed better continence status than group II but no significant difference. The Wexner scores of both groups revealed that the average score was 7.33 ± 2.8 in group I and 8.18 ± 2.9 in group II at the 12^th month, and at the 24^th month, the average score was 5.21 ± 1.7 in group I and 5.82 ± 1.9 in group II. There were no statistically significant differences between the two groups.

Conclusions

Extended ISR with quadrant resection of the upper external sphincter achieved good post-operative continence status, OS and RFS. Extended ISR can thus be an alternative to abdominoperineal resection for very low rectal cancer without compromising the chance of cure and improving quality of life.

Functional results of robotic total intersphincteric resection with hand-sewn coloanal anastomosis

BACKGROUND

In recent decades there has been an increasing trend toward sphincter-preserving procedures for the treatment of low rectal cancer. Robotic surgery is considered to be particularly beneficial when operating in the deep pelvis, where laparoscopy presents technical limitations. The aim of this study was to prospectively evaluate the functional outcomes in patients affected by rectal cancer after robotic total intersphincteric resection (ISR) with hand-sewn coloanal anastomosis.

METHODS AND PROCEDURES

From March 2008 to October 2012, 23 consecutive patients affected by distal rectal adenocarcinoma underwent robotic ISR. Operative, clinical, pathological and functional data regarding continence or presence of a low anterior resection syndrome (LARS) were prospectively collected in a database.

RESULTS

Twenty-three consecutive patients were included in the study: 8 men and 15 women. The mean age was 60.2 years (range 28-73). Eighteen (78.3%) had neoadjuvant radiochemotherapy. Conversion rate was nil. The mean operative time was 296.01 min and the mean postoperative hospital stay was 7.43 ± 1.73 days. According to Kirwan's incontinence score, good fecal continence was shown in 85.7% of patients (Grade 1 and 2) and none required a colostomy (Grade 4). Concerning LARS score, the results were as follows: 57.1% patients had no LARS; 19% minor LARS and 23.8% major LARS.

CONCLUSIONS

Robotic total ISR for low rectal cancer is an acceptable alternative to traditional procedures. Extensive discussion with the patient about the risk of poor functional outcomes or LARS syndrome is mandatory when considering an ISR for treatment of low rectal cancer.

Necessary circumferential resection margins to prevent rectal cancer relapse after abdomino-peranal (intersphincteric) resection

PURPOSE

The purpose of this study was to determine the adequate circumferential resection margin (CRM) for abdomino-peranal (intersphincteric) resection (ISR) that would prevent the relapse of rectal cancers.

METHODS

The records of 41 cases that underwent curative ISR for rectal cancer were retrospectively reviewed. The relapse-free survival rates and overall survival rates were evaluated and correlated with the maximum depth of the inner muscularis layer reached during ISR (i.e., the radial margin [RM] and distal margin [DM]). Cases were divided into three groups based on the sizes of the RM and DM: (1) group A (RM >2 mm and DM >1.5 cm), (2) group B (RM >2 mm or DM >1.5 cm but not both), and (3) group C (RM <2 mm and DM <1.5 cm).

RESULTS

The relapse-free survival rates of the cases in group C were lower than those in the cases of group A or group B (p = 0.002 and 0.037, respectively). The resection margins required to prevent rectal cancer relapse were >2 mm for the RM and >1.5 cm for the DM. For these margins, the intersphincteric space had to be entered (i.e., between the internal and external anal sphincters).

CONCLUSION

It is critical to enter the intersphincteric space to ensure an adequate CRM (RM >2 mm and DM >1.5 cm) for preventing rectal cancer recurrence after ISR.