Mesorectal reconstruction with pedicled greater omental transplantation to relieve low anterior resection syndrome following total intersphincteric resection in patients with ultra-low rectal cancer

BACKGROUND

Total intersphincteric resection (ISR) is the ultimate anus-preserving surgery for patients with ultra-low rectal cancer (ULRC), which can result in various degrees of anorectal dysfunction. Known as low anterior resection syndrome (LARS), it seriously affects the postoperative quality of life of patients. The aim of this study was to discuss the value of mesorectal reconstruction with pedicled greater omental transplantation (PGOT) to relieve LARS following total ISR in patients with ULRC, hoping to provide new ideas and strategies for the prevention and improvement of LARS.

METHODS

We retrospectively analyzed hospitalization data and postoperative anorectal function of 26 ULRC patients, who were met inclusion and exclusion criteria in our center from January 2015 to February 2022. And combined with the results of anorectal manometry and rectal magnetic resonance imaging (MRI) defecography of some patients, we assessed comprehensively anorectal physiological and morphological changes of the patients after surgery, and their correlation with LARS.

RESULTS

In this study, 26 patients with ULRC were enrolled and divided into observation group (n = 15) and control group (n = 11) according to whether PGOT was performed. There were no significant differences in surgical results such as operative time, intraoperative blood loss and postoperative complications between the two groups (P > 0.05). Postoperative follow-up showed that patients in both groups showed severe LARS within 3 months after surgery, but from the 3rd month after surgery, LARS in both groups gradually began to decrease, especially in the observation group, which showed faster recovery and better recovery, with statistically significant difference (P < 0.001). Through anorectal manometry, the mean rectal resting pressure in the observation group was significantly lower than that in the control group (P = 0.010). In addition, the postoperative thickness of the posterior rectal mesenterium in the observation group was significantly higher than that in the control group (P = 0.001), and also higher than the preoperative level (P = 0.018). Moreover, rectal MRI defecography showed that the neo-rectum had good compliance under the matting of greater omentum, and its intestinal peristalsis was coordinated.

CONCLUSIONS

ULRC patients, with the help of greater omentum, coordinated their neo-rectum peristalsis after total ISR and recovery of LARS was faster and better. PGOT is expected to be an effective strategy for LARS prevention and treatment of ULRC patients after surgery and is worthy of clinical promotion.

Application of the Xi robotic platform for familial adenomatous polyposis with ultra-low rectal cancer: exploration of minimally invasive and refined therapies

When a familial adenomatous polyposis (FAP) patient's rectal polyp undergoes malignant transformation, the surgeon needs to consider how to balance the quality of surgery with the patient's quality of life. Here, we present a case of robotic surgery in a patient with familial adenomatous polyposis and ultra-low rectal cancer. Fiberoptic colonoscopy found that hundreds of polyp-like bulges were diffusely distributed throughout the colon, and a malignant mass was found at the end of the rectum. The patient underwent total colectomy with abdominoperineal extended radical resection for rectal cancer using the Xi robotic platform. The patient recovered well in the postoperative period. The ileostomy was well used. And the patient was in good health and metastasis free at 9 months postoperatively. We identified total colectomy combined with extended radical rectal resection under the assistance of the da Vinci robot platform is of great benefit to the patient.

Two-stage Turnbull-Cutait pull-through coloanal anastomosis versus coloanal anastomosis with protective loop ileostomy for low rectal cancer. Protocol for a randomized controlled trial (Turnbull-BCN)

PURPOSE

The aim of this study was to determine whether patients that underwent ultra-low rectal resection for cancer can benefit from the recently reintroduced two-stage Turnbull-Cutait abdominoperineal pull-through procedure.

METHODS

Patients with low rectal tumors undergoing radical sphincter-sparing resection are eligible for inclusion in a randomized multicenter study. Whether two-stage Turnbull-Cutait coloanal anastomosis provides significant benefits over hand-sewn coloanal anastomosis and associated lateral ileostomy in terms of postoperative morbidity is the primary endpoint. In addition, the study aims to assess secondary endpoints such as quality of life, fecal incontinence, and locoregional recurrence of the neoplasm. Patients with adenocarcinoma of the lower rectum diagnosed by rigid proctoscopy, with histological confirmation of malignancy, and who are candidates of rectal removal and coloanal anastomosis will be included in a randomized controlled and multicenter trial. Postoperative morbidity is defined as complications that occur within 30 days of the data of the second surgical procedure of the last patient included in the trial. Patients will be followed for a minimum period of 3 years.

CONCLUSIONS

The two-stage Turnbull-Cutait coloanal anastomosis may constitute an effective surgical alternative in the current approach to the treatment of low rectal cancer without the need of a temporary loop colostomy, preventing the wide range of complications related to stoma surgery.

TRIAL REGISTRATION

This trial is registered at clinicaltrials.gov (trial number: NCT01766661). This trial is registered in January 10, 2013.

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.

Clinical outcome of intersphincteric resection for ultra-low rectal cancer

AIM: To analyze oncological outcome of intersphincteric resection (ISR) in ultra-low rectal cancer with intent to spare colostoma.

METHODS: From 1995 to 1998, patients with a non-fixed rectal adenocarcinoma (tumor stage T2) preserving the lower margin at 1-3 cm above the dentate line without distant metastasis was enrolled (period I). ISR was practiced in eight patients, and their postoperative follow-up was at least 5 years. In addition, from 1999 to 2003, another 10 patients having the same tumor location as period I underwent ISR (period II). Among those, 6 patients with T3-4-staged tumor received preoperative chemoradiotherapy.

RESULTS: All patients received ISR with curative intention and no postoperative mortality. In these case series at period I, local recurrence rate was 12.5% and metastasis rate 25.0%; the 5-year survival rate was 87.5% and disease-free survival rate 75.0%. There was no local recurrence or distant metastases in 10 patients with a median follow-up of 30 (range, 18-47) mo at period II.

CONCLUSION: As to ultra-low rectal cancer, intersphincteric resection could provide acceptable local control and cancer-related survival with no permanent stoma in early-staged tumor (tumor stage T2); moreover, preoperative concurrent chemoradiotherapy would make ISR feasible with surgical curative intent in more advanced tumors (tumor stages T3-4).