Oncological and functional outcomes of intersphincteric resection for low rectal cancer

Analysis of risk factors for the sigmoid stoma complications in patients after abdominoperineal resection surgery: An observational study

To analyze the risk factors for intraperitoneal sigmoid stoma complications after abdominoperineal resection (APR) surgery to guide clinical practice. Patients who were diagnosed with rectal cancer and underwent APR surgery from June 2013 to June 2021 were retrospectively enrolled. The characteristics of the stoma complication group and the no stoma complication group were compared, and univariate and multivariate logistic analyses were employed to identify risk factors for sigmoid stoma-related complications. A total of 379 patients who were diagnosed with rectal cancer and underwent APR surgery were enrolled in this study. The average age of the patients was 61.7 ± 12.1 years, and 226 (59.6%) patients were males. Patients in the short-term stoma complication group were younger (55.7 vs 62.0, P < .05) and had a more advanced tumor stage (P < .05). However, there was no significant difference between the long-term stoma complication group and the no stoma complication group. Multivariate logistic regression analysis revealed that operation time was an independent risk factor (P < .05, OR = 1.005, 95% CI = 1.000-1.010) for short-term stoma complications. Both the short-term and long-term stoma complication rates in our institution were low. A longer operation time was an independent risk factor for short-term stoma complications after APR 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.

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.

Robotic Intersphincteric Resection for Low Rectal Cancer: Technical Controversies and a Systematic Review on the Perioperative, Oncological, and Functional Outcomes

Intersphincteric resection (ISR) is the ultimate anus-sparing technique for low rectal cancer and is considered an oncologically safe alternative to abdominoperineal resection. The application of the robotic approach to ISR (RISR) has been described by few specialized surgical teams with several differences regarding approach and technique. This review aims to discuss the technical aspects of RISR by evaluating point by point each surgical controversy. Moreover, a systematic review was performed to report the perioperative, oncological, and functional outcomes of RISR. Postoperative morbidities after RISR are acceptable. RISR allows adequate surgical margins and adequate oncological outcomes. RISR may result in severe bowel and genitourinary dysfunction affecting the quality of life in a portion of patients.

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.

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.

Delorme surgery for colonic mucosal prolapse after intersphincteric resection

PURPOSE

Mucosal prolapse at the site of anastomosis is a long-term complication unique to ISR. It reduces the QOL of patients due to a worsened anal function and local symptoms around the anus. We herein sought to assess the surgical outcomes after Delorme surgery for these patients.

METHODS

ISR was performed in 720 patients with low rectal cancer between January 2001 and March 2019 at the National Cancer Center Hospital East. Among these patients, the 33 (4.5%) who underwent initial Delorme surgery for postoperative colonic mucosal prolapse were identified from the medical records and then were analyzed retrospectively. We estimated the anal function using Wexner's incontinence score and assessed whether local anal symptoms due to the prolapse improved postoperatively.

RESULTS

Stoma closure was performed before Delorme surgery in 15 (45.5%) patients, and we compared the preoperative and postoperative anal function in these patients. The average Wexner's incontinence score changed from 15.1 before to 12.9 after Delorme surgery. Local symptoms around the anus improved in all 33 (100%) patients. Recurrence of colonic mucosal prolapse occurred in 5 patients (15%), and Delorme surgery was reperformed in these cases.

CONCLUSION

Delorme surgery for colonic mucosal prolapse following ISR has clinical benefits for both improving anal local symptoms and slightly improving the anal function.

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.

Intersphincteric Resection Versus Abdominoperineal Resection for Low Rectal Cancer: A Meta-Analysis

Background. Abdominoperineal resection (APR) has been the standard surgery for ultra-low rectal cancer for a century. In recent years, intersphincteric resection (ISR) has been increasingly used to avoid the permanent colostomy. Up to now, there is no relevant meta-analysis comparing the clinical efficacy of ISR and APR. This meta-analysis aimed to compare the outcomes of these 2 procedures. Methods. A comprehensive search of online databases was performed on PubMed, EMBASE, and the Cochrane Library to obtain comparative studies of ISR and APR. Then the data from studies that met the inclusion criteria were extracted and analyzed. Results. A total of 12 studies covering 2438 patients were included. No significant differences were found between ISR and APR in gender, body mass index, distance from tumor to anal edge, operative time, and blood loss. In addition, hospital stay (weighted mean differences = -2.98 days; 95% confidence interval [CI] = -3.54 to -2.43; P < .00001) and postoperative morbidity (odds ratio [OR] = 0.76; 95% CI = 0.59 to 0.99; P = .04) were significantly lower in ISR group compared with APR group. However, patients who underwent ISR showed lower pathological T-stage (T3T4%, OR = 0.49; 95% CI = 0.28 to 0.86; P = .01) and lymph node metastasis rate (OR = 0.77; 95% CI = 0.59 to 1.01; P = .06) compared with those who underwent APR. Moreover, oncological outcomes were similar between the 2 groups. Conclusion. ISR may provide a safe alternative to APR, with shorter hospital stays, lower postoperative morbidity, and similar oncological outcomes. Well-designed randomized controlled trials are needed to confirm and update the findings of this analysis.

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.

Exploring bowel dysfunction of patients following colorectal surgery: A cohort study

AIMS AND OBJECTIVES

To examine changes in patients' bowel function and to compare patients' outcome among different operation and treatment after rectal resection.

BACKGROUND

Anal-preserving surgery is the trend of treatment of colorectal cancer and bowel function after surgery needs to be concerned.

DESIGN

Prospective cohort study.

METHODS

A total of 38 patients with convenience sampling were recruited from a teaching hospital. The low anterior resection syndrome (LARS) score was used to assess bowel function disturbances before discharge and at 1 week, 1 month and 3 months after discharge. We followed the STROBE checklist to ensure rigour in our study.

RESULTS

Approximately half of the patients experienced major LARS, including daily stool frequency of more than seven times and stool clustering at least once a week. The LARS scores observed at 1 month after discharge were significantly higher than those observed before discharge. Patients who received intersphincteric resection had higher LARS scores compared with those who received other surgeries. Furthermore, patients who underwent concurrent chemoradiotherapy, operation (OP) and chemotherapy had the highest LARS scores compared with those who underwent only an OP.

CONCLUSION

The patients experienced varied intestinal dysfunction after surgery based on their treatment plan and surgical method. Nurses should provide individualised health education for these patients.

RELEVANCE TO CLINICAL PRACTICE

A health education booklet is recommended to educate patients about LARS symptoms and the techniques to adapt in their daily lives after surgery.

Long-term assessment of anorectal function after extensive resection of the internal anal sphincter for treatment of low-lying rectal cancer near the anus

Objectives: Intersphincteric resection (ISR) for low-lying rectal cancer (LRC) may induce major problems associated with anorectal function. In this study, we assessed the severity of ISR-induced impairment in anorectal function. Methods: In total, 45 patients followed up regularly ≥2 years after diverting ileostoma closure were eligible. The patients underwent ISR (n=35) or conventional coloanal anastomosis without resection of the internal anal sphincter (IAS) (n=10) for treatment of LRC from January 2000 to December 2011. We retrospectively compared anorectal function [stool frequency, urgency, Wexner incontinence scale (WIS) score, and patient satisfaction with bowel movement habits on a visual analog scale (VAS) score] for ≥2 years after stoma closure between the two groups. Results: The median follow-up period was 4.0 years (range, 2.0-6.5 years). Of the total, 17 (48.6%) patients who underwent ISR had poor anorectal function, including two with complete incontinence. Significant differences were found between the groups in the incidence of urgency (p=0.042), WIS score (p=0.024), and defecation disorder with a WIS score of ≥10 (p=0.034) but not in stool frequency. Based on the VAS score, 45.7% of patients who underwent ISR were dissatisfied with their bowel movement habits (p=0.041). Conclusions: Extensive resection of the IAS has negative short- and long-term effects on anorectal function.

Laparoscopic intersphincteric resection versus an open approach for low rectal cancer: a meta-analysis

AIM

The aim of this study was to compare the short-term and mid-term effects of laparoscopic intersphincteric resection with the conventional open approach for patients with low rectal cancer through a meta-analysis.

METHODS

The PubMed, EMBASE, Cochrane, and Ovid databases were searched for eligible studies until March 2017. Operation time, blood loss, circumferential resection margin-positive rate, distal margin length, number of resected lymph nodes, diverting stoma rate, postoperative overall morbidity, anastomotic leakage, and hospital stay were the main short-term effect endpoints. We also examined disease-free survival, overall survival, local recurrence, and post-operational anal function as secondary outcomes to evaluate the mid-term effects of laparoscopic surgery.

RESULTS

Five studies involving 620 patients were included in the analyses. Compared with the open approach, the laparoscopic ISR had less blood loss (weighted mean difference [WMD] = - 214.65 ml, 95% CI [- 370.44, - 196.13], p < 0.01), less postoperative overall morbidity (OR = 0.58, 95% CI [0.40, 0.86], p < 0.01), and shorter duration of hospital stay (WMD = - 5.87 days, 95% CI [- 11.35, - 0.40], p < 0.05); however, the operation time was significantly longer in the laparoscopic group (WMD = 47.34 min, 95% CI [4.10, 90.58], p < 0.05). No other significant differences were observed.

CONCLUSION

Laparoscopic ISR for low rectal cancer offers fewer complications and faster recovery, with similar operation quality and mid-term oncological results than the conventional approach. Although this technique is comparatively more complex than the conventional approach and requires practice, laparoscopic ISR shows great potential as a surgical option and deserves further clinical study.

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.

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.

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.

Anorectal complications after robotic intersphincteric resection for low rectal cancer

BACKGROUND

Robotic intersphincteric resection (ISR) has been introduced for sphincter-preservation in the treatment of low rectal cancer. However, many patients experience anorectal symptoms and defecatory dysfunction after ISR. This study aims to evaluate the anorectal complications that develop after ISR.

METHODS

The medical records of 108 patients who underwent robotic ISR at Taipei Medical University Hospital, Taipei, Taiwan between December 2011 and June 2016 were retrospectively reviewed. Photographic records of perineal conditions were documented at the following time intervals after surgery: 1 day, 2 weeks, 1, 2, 3 and 6 months. Clinical outcomes and treatment results were analysed.

RESULTS

Eighty-five patients (78.7%) developed edematous hemorrhoids after surgery. These subsided at a median of 56 days after operation (range 23-89 days). Forty-six patients (42.6%) were found to have anal stenosis requiring anal dilatation. Sixteen patients (14.8%) had neorectal mucosal prolapse, which was noted to occur at an average of 98 days after surgery (range 41-162 days). Multivariate analysis showed that the occurrence of edematous hemorrhoids was associated with operating time (P = 0.043), and male gender was a significant risk factor for anal stenosis (P = 0.007).

CONCLUSIONS

This is the first study reporting on the clinical outcomes of anorectal status after robotic ISR. Further studies are needed to assess the long-term effects of these anorectal complications.

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.

Intersphincteric resection and hand-sewn coloanal anastomosis for low rectal cancer: Short-term outcomes in the Indian setting

INTRODUCTION

The rectum remains a predominant subsite of colorectal cancer in the Indian population. Unique to the Indian setting are significant social repercussions associated with a permanent stoma. On account of this, many patients who are advised abdominal perineal excision of the rectum (APER) default treatment. Accurate demonstration of the intersphincteric plane with magnetic resonance imaging has made intersphincteric resection (ISR) a viable option. This study is aimed at determining the feasibility and oncological adequacy of ISR in the Indian scenario.

MATERIAL AND METHODS

All patients with low rectal cancer who underwent an ISR at the Tata Memorial Centre, from July 2013 to December 2013 were included. Patients with invasion of the external sphincter and suboptimal preoperative sphincter function were excluded. Following standard preoperative staging, patients with a threatened circumferential resection margin (CRM) and/or mesorectal nodes were given preoperative chemoradiotherapy. The oncological adequacy of the procedure was evaluated in terms of margin positivity (distal and CRMs) and lymph node yield. Short-term perioperative outcomes included 30-day mortality, postoperative morbidity, anastomotic leaks, and length of hospital stay.

RESULTS

Thirty-three patients with low rectal cancer and a median age of 38 years underwent ISR during the defined study period. Twenty-three patients (70 %) underwent open surgery whereas ten patients received a laparoscopic resection. The median blood loss and hospital stay was 300 mL and 7 days, respectively. Two patients had an involved CRM, but all distal margins were free of tumor. The quality of total mesorectal excision was satisfactory in all patients with a median lymph node yield of 9 nodes.

CONCLUSIONS

Intersphincteric resection is feasible and oncologically safe in selected patients with low rectal cancer. Long-term functional and oncological outcomes are essential before it can be considered a viable alternative to APER.

Clinical outcomes of robot-assisted intersphincteric resection for low rectal cancer: comparison with conventional laparoscopy and multifactorial analysis of the learning curve for robotic surgery

BACKGROUND

This study evaluated the feasibility of robot-assisted intersphincteric resection (ISR) for low rectal cancer. Further, we attempted to analyze the learning curve for robotic surgery.

METHODS

A total of 64 patients were retrospectively chart-reviewed. Patients were classified into a laparoscopic procedure (n = 28) group and a robot-assisted (n = 36) group. Comparisons of age, gender, clinical staging, operating time, complications, and pathologic status were analyzed. Besides, we used a seventh-order moving average method for the construction of a learning curve in robotic surgery.

RESULTS

Operating time was 374.3 min (range, 210-570 min) in the laparoscopic group and 485.8 min (range, 315-720 min) in the robotic group, with statistical difference between these two groups (P < 0.001). Thirteen patients (46.4 %) received diverting stoma in the laparoscopic group and seven patients (19.4 %) in the robotic group, with statistical difference between these two groups (P = 0.021). Operative experience of robotic ISR showed that the mean operating time was 519.5 min (range, 360-720 min) in the first stage and 448.2 min (range, 315-585 min) in the second stage, with statistical difference between these two stages (P = 0.02). Multifactorial analysis showed that protective diverting stoma creation or neorectum necrosis was not associated with age, sex, pretreatment T stage, or surgeons' experience.

CONCLUSIONS

Our data shows that robot-assisted ISR for low rectal cancer is feasible and safe with no compromising oncological outcomes. The surgeons' experience improves operating time in robotic surgery.

Evaluation of the frequency and pattern of local recurrence following intersphincteric resection for ultra-low rectal cancer

INTRODUCTION

Abdomino-perineal resection has been the standard treatment for rectal tumors located ≤5cm from the anal verge. Recently, intersphincteric resection became a valid option which preserves the bowel continuity with better functional outcome.

AIM

Is to evaluate the oncological and functional outcome alongside the associated surgical morbidity in patients with T1-3 rectal cancer, who underwent intersphincteric resection (ISR).

PATIENTS & METHODS

Between the years 2006 and 2011, 55 patients with invasive rectal adenocarcinoma, T1-3 lesions, located 2-5cm from the anal verge underwent ISR with total mesorectal excision. When inevitable, complete. ISR was performed, otherwise partial ISR was done. All T3 patients underwent total meso-rectal excision (TME) while some had lateral lymph node dissection (LND) with concomitant pelvic autonomic nerve preservation (PANP).

RESULTS

Among the 55 patients, 21 (38.1%) patients were T1-2 and 34 (61.9%) patients were T3. The tumor location range was 0-5cm from the anal verge (median 2.3cm). Partial or complete ISR was done for 35 (63.6%) and 20 (36.4%), respectively. Patients were followed for a median of 1.5 years (range 1-4.6 years). The 3 year local recurrence and distant metastasis free rates were 85.2% and 85.6%, respectively. All the 3 local recurrences occurred in T3 patients group, and had positive circumferential resection margins. Overall 3-year disease-free survival was 82.6%; while the overall 3-year survival was 88.7%.

CONCLUSION

Intersphincteric resection with TME does not affect the local recurrence or overall survival rate in early rectal cancer T1-2 & 3, with preservation of bowel continuity and better life quality.

Intersphincteric resection for treatment of ultra-low rectal cancer

Traditional treatment for ultra-low rectal cancer is abdominal perineal resection, but it is associated with poor quality of life. With the continued development of surgical techniques, intersphincteric resection has been greatly improved. Its unique advantages include improvement of sphincter preservation and anal function after surgery and no requirement of a permanent stoma. Although the ability of defecation control needs to be gradually restored, intersphincteric resection has similar postoperative survival rate, relapse rate and oncology results to abdominal perineal resection. Thus, intersphincteric resection should be the preferred treatment for ultra-low rectal cancer.

Quality of life of patients after low anterior, intersphincteric, and abdominoperineal resection for rectal cancer--a matched-pair analysis

PURPOSE

Limits for sphincter preservation in rectal cancer have been expanded under the assumption that patients with a permanent colostomy have worse quality of life (QoL). Incontinence and painful defecation are common problems; therefore, this study compares functional outcome and QoL after sphincter-sparing intersphincteric resection (ISR), low anterior resection (LAR), and abdominoperineal resection (APR) for rectal cancer.

METHODS

From a prospective database, three matched groups of patients after surgery for rectal cancer between 1999 and 2009 were extracted. Median follow-up was 59 months. Of 131 patients receiving a questionnaire, 95 % could be analyzed further. Generic and disease-specific validated QoL (European Organization for Research and Treatment in Cancer QLQ-C30, CR38) and Wexner incontinence score were used.

RESULTS

Global QoL was comparable between the groups. Physical functioning was significantly better after sphincter preservation surgery than APR (p < 0.05). Symptom scores for diarrhea (DIA) and constipation (CON) were higher after sphincter-preserving surgery (ISR: DIA 45.4, CON 20.2; LAR: DIA 34.1, CON 25.2) compared to APR (DIA 16.6, CON 12.0) (p < 0.05 and <0.01, respectively). Disease-specific QoL assessment showed significantly worse QoL regarding to male sexual function after APR (80.8) than after ISR (53.6) (p < 0.005). Regarding defecation, the ISR group showed significantly higher symptom scores than patients after LAR (p < 0.05). Wexner scores were significantly higher after ISR (12.9) than after LAR (9.5) (p < 0.005).

A novel animal model of long-term sustainable anal sphincter dysfunction

BACKGROUND

Although intersphincteric resection can avoid the need for permanent colostomy in patients with lower rectal cancer, it sometimes causes anal sphincter dysfunction, thus resulting in a lifelong, debilitating disorder due to incontinence of solid and liquid stool. The development of regenerative medicine could improve this condition by regenerating impaired anal muscle. In order to prove this hypothesis, preliminary experiments in animals will be indispensable; however, an adequate animal model is currently lacking. The purpose of this study was to establish a novel animal model with long-term sustainable anal sphincter dysfunction.

MATERIALS AND METHODS

Twenty male Sprague-Dawley rats were allocated into sham operation (n = 10) and anal sphincter resection (ASR) (n = 10) groups. The ASR group underwent removal of the left half of both the internal and external anal sphincters. Both groups were evaluated for anal function by measuring their resting pressure before surgery and on postoperative day (POD) 1, 7, 14, and 28.

RESULTS

The rats in the sham operation group recovered their anal pressure up to baseline on POD 7. The rats in the ASR group showed a significant decrease in anal pressure on POD 1 (P < 0.0001) compared with the baseline, and kept this low pressure until POD 28 (P < 0.0001). The defect of the anal sphincter muscle was confirmed histologically in the ASR group on POD 28.

CONCLUSIONS

The present novel model exhibits continuous anal sphincter dysfunction for at least 1 mo and may contribute to further studies evaluating the efficacy of therapies such as regenerative medicine.

Intersphincteric resection for very low rectal cancer: clinical outcomes of open versus laparoscopic approach and multidimensional analysis of the learning curve for laparoscopic surgery

BACKGROUND

Laparoscopic rectal cancer surgery is regarded as more complex because of its technical difficulties in pelvic exposure, dissection, and sphincter preservation. This study therefore aimed to investigate the feasibility of laparoscopic resection for low rectal cancer using intersphincteric resection (ISR) and to assess its short-term oncological outcomes. Further, we intended to analyze the learning curve for laparoscopic surgery and identify the factors influencing the learning curve.

METHODS

Patients with low rectal cancer who received open or laparoscopic ISR were retrospectively chart reviewed. The surgical and oncological outcomes were evaluated. Comparisons of operating time, estimated blood loss, surgical outcomes, and histopathologic status were analyzed. Also, operating time was used as a technical indicator for learning curve analysis.

RESULTS

The mean estimated blood loss was 265 mL (range, 100-800 mL) in the open group and 104 mL (range, 30-250 mL) in the laparoscopic group. There was a significant difference between these two groups (P < 0.001). Operative experience analysis showed that the mean operating time was 402.1 min (range, 210-570 min) in the first stage and 331.4 min (range, 210-450 min) in the second stage, and on pathologic examination the mean number of lymph nodes harvested was 11.1 (range, 5-21) in the first stage and 18.3 (range, 11-31) in the second stage, with statistical differences between these two stages (P = 0.034 and P = 0.004, respectively). Multifactorial analysis showed that operating time was associated with surgeons' experience (<18 or ≥18 cases) (odds ratio = 2.918, 95% CI 1.078-7.902). Protective stoma creation was also associated with surgeons' experience (odds ratio = 3.999, 95% CI 1.153-13.86).

CONCLUSIONS

Our data show that laparoscopic ISR for low rectal cancer is feasible and safe. Surgeons' experience improved operating time and postoperative complications.

Analysis of the clinical factors associated with anal function after intersphincteric resection for very low rectal cancer

Background

Intersphincteric resection (ISR) has been used to avoid permanent colostomy in very low rectal cancer patients. This study aimed to assess the surgical safety and oncologic and functional outcomes of ISR.

Methods

The records of 30 consecutive very low rectal cancer patients who underwent ISR without neoadjuvant therapy were retrospectively analyzed; survival and locoregional recurrence rates were calculated by the Kaplan-Meier method. Incontinence was assessed by a functionality questionnaire and the Wexner score.

Results

The median distance between the distal margin of the dentate line was 10 mm. A total of 12, 4, and 14 patients underwent partial ISR, subtotal ISR, and total ISR, respectively. The mean distal resection margin was negative in all cases, and circumferential resection margin was positive in two cases. Morbidity was 33.3%: anastomotic stricture in seven patients, colonic J-pouch prolapse in two patients, and an anovaginal fistula in one patient. During the median, 56.2-month follow-up period, local, distant, and combined recurrences occurred in four, three, and two patients, respectively. The 5-year overall and disease-free survival rates were 76.5% and 68.4%, respectively. Local recurrence rates were 5.2% for the patients with Tis-T2 tumors as compared with 45.5% for those with T3 tumors (P = 0.008). The mean Wexner scores and stool frequencies, 12 months after stoma closure in 19 patients, were 11.5 and 6.6 per 24 h, respectively. Significant differences were not seen in the Wexner scores between partial ISR and subtotal/total ISR (11.8 ± 2.6 and 9.1 ± 5.6). Stool frequency (P = 0.02), urgency (P = 0.04), and fragmentation (P = 0.015) were worse in patients with anastomotic stricture than in those without; there was no symptom improvement in patients with anastomotic stricture.

Conclusions

The anastomotic strictures in patients undergoing ISR may have negatively affected anal function. For total ISR patients, at least, informed consent stating the possibility of a permanent colostomy is necessary.

Intersphincteric resection for very low rectal cancer: a systematic review

Radical surgical treatment for very low rectal cancer near the anus has generally involved abdominoperineal resection. Various sphincter-saving operations have been developed for such tumors to optimize the patients' postoperative quality of life. Current protocols focus on intersphincteric resection (ISR), which differs from conventional hand-sewn coloanal anastomosis (CAA) after low anterior resection. However, the efficacy of ISR remains unclear. The surgical, oncologic, and functional outcomes after intersphincteric resection (ISR) were reviewed. This review of the current literature was conducted by searching the PubMed online database. Articles focusing specifically on conventional hand-sewn CAA were excluded from this study. The mean mortality rate is <2 %, and the mean morbidity rate ranges from 7.7 to 38.3 %. The mean local recurrence rate varies widely from 0 to 22.7 %, with a mean follow-up duration of 40-94 months. The mean disease-free and overall 5-year survival rates are 69-86 and 79-97 months, respectively. Functional outcomes are generally acceptable, but accurate evaluation is extremely difficult due to the absence of unified appraisal methods. ISR appears surgically, oncologically and functionally acceptable. However, more experience and better understanding of the oncology, anal physiology, and pelvic anatomy are necessary to achieve successful outcomes without complications, and to improve patient survival.

Intersphincteric resection and coloanal anastomosis in treatment of distal rectal cancer

In the treatment of distal rectal cancer, abdominoperineal resection is traditionally performed. However, the recognition of shorter safe distal resection line, intersphincteric resection technique has given a chance of sphincter-saving surgery for patients with distal rectal cancer during last two decades and still is being performed as an alternative choice of abdominoperineal resection. The first aim of this study is to assess the morbidity, mortality, oncological, and functional outcomes of intersphincteric resection. The second aim is to compare outcomes of patients who underwent intersphincteric resection with the outcomes of patients who underwent abdominoperineal resection.

Systematic review of outcomes after intersphincteric resection for low rectal cancer

BACKGROUND

For a select group of patients proctectomy with intersphincteric resection (ISR) for low rectal cancer may be a viable alternative to abdominoperineal resection, with good oncological outcomes while preserving sphincter function. The purpose of this systematic review was to evaluate the current evidence regarding oncological outcomes, morbidity and mortality, and functional outcomes after ISR for low rectal cancer.

METHODS

A systematic review of the literature was undertaken to evaluate evidence regarding oncological outcomes, morbidity and mortality after ISR for low rectal cancer. Three major databases (PubMed, MEDLINE and the Cochrane Library) were searched. The review included all original articles reporting outcomes after ISR, published in English, from January 1950 to March 2011.

RESULTS

Eighty-four studies were identified. After applying inclusion and exclusion criteria, 14 studies involving 1289 patients were included (mean age 59.5 years, 67.0 per cent men). R0 resection was achieved by ISR in 97.0 per cent. The operative mortality rate was 0.8 per cent and the cumulative morbidity rate 25.8 per cent. Median follow-up was 56 (range 1-227) months. The mean local recurrence rate was 6.7 (range 0-23) per cent. Mean 5-year overall and disease-free survival rates were 86.3 and 78.6 per cent respectively. Functional outcome was reported in eight studies; among these, the mean number of bowel motions in a 24-h period was 2.7.

CONCLUSION

Oncological outcomes after ISR for low rectal cancer are acceptable, with diverse, often imperfect functional results. These data will aid the clinician when counselling patients considering an ISR for management of low rectal cancer.