Laparoscopic Intersphincteric Resection: A Feasible Technique or the Treatment of Choice for Patients with Low Rectal Cancer?

Abstract

an unacceptable functional result. They might even have a better QoL than patients with colorectal or coloanal anastomoses as the latter patient group often suffers from fecal incontinence due to the lack of filling capacity of the neorectum [1] . Not only medical considerations but also the cultural mindset in the heads of both patients and their doctors determine whether a stoma is constructed or not. Yamamoto et al. [2] describe in a single-center report their results of laparoscopic intersphincteric resection (ISR) for patients with distal rectal cancer. Only 29 patients were described in a study period of almost 10 years, suggesting a certain selection bias. Of these, 7 patients were excluded as matched cases could not be identified in the control group. ISR in rectal cancer is based on several facts and assumptions: through meticulous dissection it has become a feasible technique, it is safe in certain oncological stages, and it results in a superior QoL for the patients. However, the exact place of this technique, performed open or laparoscopically, is not completely clear. The surgeon’s expertise and the will of both surgeons and patients to preserve the anus certainly influences the likelihood that this technique will be used. As the authors describe, in order to make it a safe procedure a skilled surgical team and adequate postoperative care are prerequisites. With acceptable morbidity and absent mortality, the Japanese colleagues seem to have fulfilled this demand. Of course, the oncological outcome after (laparoscopic) ISR is of key importance. When a safe distal margin of 1–2 cm can be achieved most authors consider For many years rectal cancer has posed a challenge to oncologists, with locoregional recurrences of up to 30% being an important cause of debilitating death in the past. Since Miles introduced his abdominoperineal resection more than 100 years ago, techniques have been refined substantially, inflicting less trauma on the patient. Stapling techniques have made very distal anastomoses possible and meticulous dissection in the right anatomical planes has reduced the necessity of a wide distal resection margin. As such, the number of patients undergoing sphincter-saving surgery has increased. Transanal endoscopic microsurgery for early rectal cancers and the introduction of laparoscopy have further contributed in this respect. Apart from these major surgical advances, novel (neo)adjuvant treatment regimens have further increased both local control and survival. Preoperative radiotherapy has reduced the likelihood of local failure, and chemoradiotherapy may even induce a complete clinical response. Although this occurs only in a minority of patients, the impact is significant: wait-and-see protocols omitting surgery are currently being explored in several parts of the world. Parallel to these advances in rectal cancer treatment, more attention is being paid to the impact of several treatment options on quality of life (QoL). In general, a stoma is considered to have a negative impact on QoL. Nevertheless, major improvements have been made in stoma care and surgeons are increasingly aware of the necessity of creating a stoma that has optimal function. Patients with a permanent stoma do not necessarily end up with Published online: December 20, 2011