Comparative analysis of laparoscopic low rectal resections

Abstract

Objective: to study the immediate results of laparoscopic intersphincteric resection (ISR) and ultralow anterior resection (ULAR) of the rectum. Subjects and methods. The results of surgical treatment in 42 patients operated on in the Saint Petersburg Clinical Research-Practical Center for Specialized Medical (Oncology) Cares in March 2014 to January 2015 are given. The inclusion criteria were the lower edge of cT1–3N0 adenocarcinoma 2-5 cm above the dentate line and no signs of invasion into the sphincter and levators. All the patients were divided into 2 groups: 1) 24 patients who had undergone laparoscopic ISR; 2) 18 patients who had laparoscopic ULAR. Both groups were matched for gender, age, body mass index, and CR-POSSUM predicted mortality scores. Thirty-two patients received neoadjuvant chemoradiotherapy. Results. The mean duration of operations did not differ significantly in the groups: 206 ± 46 and 216 ± 24 min (р = 0.72). The differences in the mean volume of blood loss were also insignificant: 85 and 113 ml (р = 0.93). Circular and distal resection margins were intact in all the cases. In 18 (75 %) patients in Group 1 and in 14 (77.8 %) patients in Group 2, the quality of total mesorectumectomy (TME) was rated as grade 3 according to the Quirk criteria (p = 0.83). In Group 1, complications requiring no reoperation occurred in 5 (20.8 %) cases: anastomotic incompetence in 3 (12.5 %) cases, anastomotic stricture with further bougienage in 1 (4.2 %), and urinary retention in 1 (4.2 %). In Group 2, postoperative coтplications were also observed in 5 (27.8 %) cases: necrosis of the brought-out bowel in 2 (11.1 %) patients and coloanal incompetence in 1 (5.6 %) required reoperation; 2 (11.1 %) patients underwent bougienage due to established anastomotic stricture. One month postoperatively, the Wexner constipation scoring system was used to rate the degree of encopresis: anal incontinence turned out to be significantly higher in Group 2 and amounted to 9.3 versus 6.2 in Group1. ULAR required consumables costing an average of 45 000 rubles more than did ISR. Conclusion. Both surgical procedures are comparable in the duration of a surgical intervention, the volume of intraoperative blood loss, and the quality of TME. ULAR with a reservoir is functionally more preferential.