Analysis of the clinical factors associated with anal function after intersphincteric resection for very low rectal cancer. World J Surg Oncol. 2013;11:24. [PMID: 23356424 DOI: 10.1186/1477-7819-11-24]

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.

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

Background

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

Methods

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

Results

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

Conclusions

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

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.

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 case of effective Delorme's procedure for colonic mucosal prolapse after intersphincteric resection

Recent surgical technical improvements, such as endoscopic surgery with intersphincteric resection (ISR), could help avoid a permanent colostomy for patients with low-lying rectal tumors. However, the problems associated with anal dysfunction following ISR remain unresolved. We performed ISR and temporary ileostomy in a patient with low-lying rectal cancer. After evaluating the stability of the anastomosis, we planned to close the ileostomy, but the patient developed post-operative colonic mucosal prolapse (CMP). Although there are treatment methods available for CMP, there is no consensus on the treatment for post-operative CMP. In this case, we performed Delorme’s procedure because the method has been reported to have advantages in terms of improving post-operative anal function. Post-operative anorectal manometry showed improvement in maximum squeeze pressure, and the patient’s anal function improved; subsequently, ileostomy closure was performed. Delorme’s procedure may be useful for patients with CMP after ISR to achieve good post-operative anal function.

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 intersphincteric resection with intraoperative radiotherapy using low-energy X-rays for locally advanced ultra-low rectal cancer

Background

In order to overcome the shortcomings of laparoscopic intersphincteric resection (Lap ISR), an alternative method of delivering intraoperative radiotherapy by Intrabeam X-rays radiotherapy system (XRS) is proposed in this paper. Intrabeam XRS is a device that uses low-energy X-rays source generated by a mobile controller unit, which is featured in accurate irradiation, reduced complications, and less exposure. The purpose of this study is to discuss the feasibility of Lap ISR with intra-operative radiotherapy using low-energy X-rays for locally advanced ultra-low rectal cancer in Asian woman. This novel proposed method will greatly increase the anus preserving probability and improved the quality of life.

Methods

A 53-year-old woman diagnosed with rectal adenocarcinoma had a strong desire to preserve the anal function and presented at the Jilin University Second Hospital, Jilin, China. The tumor’s size was 4 cm × 3 cm. It was located 2 cm from the anus merge and invaded the levator ani muscle. Preoperative clinical staging was T4N1M0 and could be reached R0 resection. After the consent form was signed by the patient, Lap ISR combined with the applicator put through the anus (natural orifice) to the tumor bed was performed and prophylactic ileostomy synchronized the anastomosis. Patient only received 1-cycle chemotherapy regimen of oxaliplatin with capecitabine postoperatively due to personal reasons. Pre- or postoperative radiotherapy was not given.

Results

After clinical follow-up, until now, there is not any sign of local recurrence. Anus function and short-term complications are acceptable. The short-term effect is satisfying and we look forward to further assess the long-term effect.

Conclusion

Laparoscopic intersphincteric resection with IORT using low-energy X-rays for the patients with late-stage ultra-low rectal cancer could provide an opportunity of preserving the anus function, and it is feasible for the selected patients.

Trial registration

Retrospectively registered; Trial registration: NCT03393234; Registered time: 05 January 2017.

Functional outcomes with handsewn versus stapled anastomoses in the treatment of ultralow rectal cancer

Adequate oncological outcomes have been demonstrated with rectal resection and handsewn coloanal anastomosis (CAA) in tumours in close proximity to the internal anal sphincter. Our aim was to assess functional differences between handsewn CAA and ultralow stapled anastomosis. Participants were identified from a single-surgeon series. Included participants underwent anorectal physiology testing of anal sphincter function, in addition to completion of several questionnaires: Wexner Incontinence Score (WIS); Birmingham Bowel, Bladder and Urinary Symptom Questionnaire (BBUSQ); Low Anterior Resection Syndrome (LARS) Score; SF36. Non-parametric data compared using the Mann–Whitney U test. 20 participants were included; 11 stapled and 9 handsewn. Mean follow-up was 2.95 ± 1.97 years. The mean LARS score was 21.9 ± 1.97 years in the stapled group versus 29.4 ± 9.57 in the handsewn group (p = 0.133). The Wexner incontinence score was significantly higher in the handsewn group (p = 0.0076), with a mean score of 4.6 ± 3.69 versus 10.9 ± 4.76. The incontinence domain of the BBUSQ was also significantly worse in patients with a handsewn anastomosis (p = 0.001). With the exception of general health (p = 0.035) and social functioning (p = 0.035), which were worse in the handsewn groups, the other six domains of the SF-36 showed no statistical difference between groups. Anorectal physiology scores were not significantly different. Handsewn CAA anastomosis is known to be safe and oncologically feasible. Patient selection should be vigorous, with preoperative counseling regarding the likelihood of incontinence to manage patients’ expectations and promote comparable quality of life in the long-term.

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.

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.

The transrectal single port laparoscopic radical prostatectomy in a cadaver model

OBJECTIVE

To explore the feasibility of laparoscopic trans-rectal Natural Orifice Transluminal Endoscopic Surgery (NOTES) radical prostatectomy in a cadaveric model and to define anatomical landmarks of this surgical route.

MATERIALS AND METHODS

After the ethical clearance, the study was conducted in Turkish Council of Forensic Medicine. With the cadaver in an exaggerated lithotomy position, a full thickness incision was made on the anterior wall of the rectum. The anteriorly visible Denonvilliers' fascia was incised sharply, exposing the posterior surface of the prostate. A single-port device (GelPOINT(®)Path) was inserted transanally passing the incision on the anterior wall of the rectum, into the bluntly created space between rectum and prostate. Three, 10 mm ports were placed through the GelPOINT(®)Path, at 3, 6, and 9 o'clock positions. A 5 mm, 0° degree lens was introduced at 6 o'clock position; followed by laparoscopic scissors and laparoscopic grasper. Prostatic and periprostatic anatomy was defined as encountered during each step of the procedure.

RESULTS

Exposure of the posterior surface of the prostate and seminal vesicles was easily achieved. No additional openings of the rectal wall were made. Surgical specimen was extracted keeping its integrity.

CONCLUSION

Transrectal radical prostatectomy is technically feasible in the cadaver model, being facilitated by previous experience with perineal surgery. Anatomical observations during the present experimental study suggest that the transrectal NOTES route provides good exposure of the operative field and easy access to the posterior surface of prostate, Future experimental endeavors should focus on reproducibility of this approach and feasibility of lymph node dissection using trans-rectal route.

Effects of pelvic floor muscle exercise on faecal incontinence in rectal cancer patients after stoma closure

The purpose of this study was to examine the effects of pelvic floor muscle exercise (PFME) on the faecal incontinence (FI) of rectal cancer patients following stoma closure. Participants were randomly distributed into an exercise group (n = 27) and non-exercise group (n = 26). An experimental design and longitudinal approach were implemented for data collection. Baseline data were collected at 1 day before discharge, and then PFME was taught before the patients were discharged from the hospital. We collected data and followed up with the patients at their pre-discharge visit and at 1, 2, 3, 6 and 9 months after discharge. The Cleveland Clinic Faecal Incontinence (CCI) score was used to measure patient outcome. PFME proved to effectively decrease the degree of FI in stoma closure recipients. The FI score of the exercise group significantly decreased from 8.37 to 2.27 after PFME compared with that of the non-exercise group (from 8.54 to 2.58). The generalised estimation equation tests showed that both group and time were significantly different. The tests also indicated that although PFME appeared to hasten the decline of incontinence, this effect was no longer detectable at 9 months; thus, it may be an effective intervention for FI when implemented up to half a year after discharge.

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.