Intersphincteric Resection Research Articles

Laparoscopic intersphincteric resection and J-pouch reconstruction without laparotomy.

In some cases, a J-pouch is not created after laparoscopic intersphincteric resection (Lap-ISR), because this procedure usually does not involve laparotomy. This study aimed to develop a new technique for Lap-ISR and J-pouch reconstruction without laparotomy and to assess the short- and long-term outcomes of this technique. After a rectal specimen is excised using the transanal approach, the reconstructed intestine is reinserted into the intra-abdominal space. To create the J-shape, the reconstructed intestine is looped back using Allis forceps, and the septum of the J-shape is divided using a surgical stapler. We performed 20 surgeries using the new technique. Although three patients developed pelvic infections, no J-pouch-related complications were noted. Intestinal continuity could be maintained in all patients who received a diverting stoma.

Robotic-assisted lateral lymph node dissection for lower rectal cancer: short-term outcomes in 50 consecutive patients.

The goal of this study was to evaluate the short-term outcomes of robotic-assisted lateral lymph node dissection for patients with advanced lower rectal cancer. Between 2012 and 2013, 50 consecutive patients underwent robotic-assisted lateral lymph node dissection for rectal cancer in Shizuoka Cancer Center Hospital. Perioperative outcomes including operative time, operative blood loss, length of stay, postoperative complications, and histopathological data were collected prospectively. Median patient age was 62years (range 36-74years). Operative procedures included low anterior resections (n=27), intersphincteric resections (n=16), and abdominoperineal resections (n=7). Bilateral lymph node dissection was performed in 44 patients. The median operative time was 476min (range 320-683min), and the median time required for lateral lymph node dissection was 165min (range 85-257min). The median blood loss was 27mL (range 5-690mL). There were no cases of open surgery or laparoscopic conversion. The median duration of postoperative hospital stay was 8days (range 6-13days). Clavien-Dindo classification Grade III-IV complications occurred in only one patient (2.0%). There were no cases of anastomotic leak. There was no perioperative mortality. The median number of harvested lateral lymph nodes was 19 (range 5-47). Robotic-assisted lateral lymph node dissection is a safe, feasible, and useful approach for patients with advanced lower rectal cancer.

Risk factors for bowel dysfunction after sphincter-preserving rectal cancer surgery: a prospective study using the Memorial Sloan Kettering Cancer Center bowel function instrument.

Until recently, no studies have prospectively evaluated bowel function after sphincter-preserving surgery for rectal cancer with the use of a validated bowel function scoring system. The aim of this study was to investigate possible risk factors for altered bowel function after sphincter-preserving surgery. This was a prospective study. The study was conducted between January 2006 and May 2012 at the authors' institution. Patients who underwent sphincter-preserving rectal cancer surgery were recruited. Bowel function was assessed 1 day before (baseline) and at 1 year after sphincter-preserving surgery or temporary ileostomy takedown with the use of the Memorial Sloan Kettering Cancer Center questionnaire. Multivariable analysis was performed to identify the factors associated with altered bowel function after surgery. Overall, 266 patients were eligible for the analysis. The tumor was located in the upper, middle, and lower rectum in 68 (25.5%), 113 (42.5%), and 85 (32.0%) patients. Intersphincteric resection and temporary ileostomy were performed in 18 (6.8%) and 129 (48.5%) patients. The mean Memorial Sloan Kettering Cancer Center score was 64.5 ± 7.6 at 1 year after sphincter-preserving surgery or temporary ileostomy takedown. The Memorial Sloan Kettering Cancer Center score decreased in 163/266 patients (61.3%) between baseline and 1 year after surgery. Tumor location (p = 0.01), operative method (p = 0.03), anastomotic type (p = 0.01), and temporary ileostomy (p = 0.01) were associated with altered bowel function after sphincter-preserving surgery in univariate analyses. In multivariable analysis, only tumor location was independently associated with impaired bowel function after sphincter-preserving rectal cancer surgery. This study was limited by its nonrandomized design and the lack of measurement before preoperative chemoradiotherapy. We suggest that preoperative counseling should be implemented to inform patients of the risk of bowel dysfunction, especially in patients with lower rectal cancer, although this study cannot exclude the effect of chemoradiotherapy owing to the limitation of study.

Evaluation of sphincter-preserving surgery for rectal cancer

Background: Rectal carcinoma constitutes a health problem, previously managed with abdomino-perineal resection (APR) which has the impact of poor patient quality of life. With the introduction of the concept of total mesorectal excision (TME) and stapler technology, sphincter saving surgery (SSS) with its better local control and functional status is a better choice than APR. We tried to evaluate the operative safety, long-term oncologic andfunctional outcomes of SSS in rectal carcinoma. Patients and methods: Between October 2008 and October 2012, patients with rectal carcinoma who presented electively to Sohag University Hospital underwent SSSbased on sharp mesorectal excision in the form of anterior resection, low anterior resection and intersphincteric resection were evaluated. Patients were followed up for four years. Results: A total of 60 patients underwent SSS, regarding operative complications; there were 2 ureteric injuries and one bladder injury. Postoperatively, anastomotic leakage occurred in 6.7% of cases. Local recurrence and distant metastases were detected in 8.3% 13.3% respectively. During follow-up, disease-free survival rate was 66.9%, overall survival rate was 93%, 22% of patients had a degree ofincontinence. 21.66% had temporary bladder dysfunction. Sexual dysfunction became evident in 30% of male patients. Conclusion: SSS with TME provides a better alternative to APR in rectal carcinoma when feasible.

Robot-assisted rectal cancer surgery: short-term outcomes for 113 consecutive patients.

The purpose of this study was to assess the short-term outcome of robot-assisted laparoscopic surgery (RALS) for rectal cancer, including robotic, autonomic nerve-preserving, lateral lymph node dissection (RALLD), a new, technically challenging procedure. Between December 2011 and August 2013, 113 consecutive patients underwent RALS for rectal cancer. Surgical outcomes, pathological results, and postoperative complications were prospectively collected. There were 78 males and 35 females; 30 patients (26.5%) had cT1 tumor, 14 (12.4%) had cT2, 56 (49.6%) had cT3, and 12 (10.6%) had cT4 tumor. The types of procedures performed were 82 anterior resections, 23 intersphincteric resections, and 8 abdominoperineal resections. RALLD was performed in 38 patients (33.6%). The overall median operative time was 302 (135-683) min. In cases without RALLD, the median operative time was 242 (135-529) min, while median operative time was 486 (320-683) min with RALLD. None of the cases was converted to an open or laparoscopic procedure. There was no surgical mortality. The overall complication rate for Clavien-Dindo classification grade III-IV was 2.7%. Ten patients who developed urinary retention recovered completely within 30 days after the operation. RALS for rectal cancer is a technically feasible, less invasive procedure. This procedure can be performed with low morbidity and a low conversion rate, even for cases with advanced rectal cancer requiring complicated, robot-assisted, lateral lymph node dissection.

Long-term outcomes after intersphincteric resection for low-lying rectal cancer.

As an anus-preserving surgery for very low rectal cancer, intersphincteric resection (ISR), has advanced markedly over the last 20years. We investigated long-term oncologic, functional, and quality of life (QOL) outcomes after ISR with or without partial external sphincter resection (PESR). A series of 199 patients underwent curative ISR with or without PESR between 2000 and 2008, with 49 receiving preoperative chemoradiotherapy (CRT group) and 150 undergoing surgery first (surgery group). Overall survival (OS), disease-free survival (DFS), and local relapse-free survival (LFS) rates were calculated using Kaplan-Meier methods. Functional outcomes were assessed using the Wexner incontinence score. QOL was investigated using the Short-Form 36 questionnaire (SF-36) and modified fecal incontinence quality of life (mFIQL) scale. After a median follow-up of 78months (range 12-164months), estimated 7-year OS, DFS, and LFS rates were 78, 67, and 80%, respectively. LFS was better in the CRT group than in the surgery group (p=0.045). Patients with PESR or positive circumferential resection margins showed significantly worse survival. The median Wexner incontinence score at >5years was 8 in the surgery group and 10 in the CRT group (p=0.01). QOL was improved in all physical and mental subscales of the SF-36 at >5years. Although the mFIQL showed a relatively good score in all groups at >5years, a significant difference existed between the CRT and surgery groups (p=0.008). With long-term follow-up, oncologic, functional, and QOL results after ISR appear acceptable, although CRT is associated with disturbance.

P-0168 - International Visibility of Research on Intersphincteric Resections for Rectal Cancer

Introduction: Recently, there is increasing science internationalization in the applications of the intersphincteric resections with rectal cancer patients. The purpose of this study was to analyze some features of the international popularization of research devoted to this relatively new topic of true medical significance. Methods: A retrospective problem-oriented search was carried out in February, 2014, in Web of Science (WoS) and MEDLINE (Thomson Reuters, USA) as well as in Scopus (Elsevier, the Netherlands). The period from 1988 till 2013 was assessed. The following scientometric parameters were comparatively studied: number of abstracted publications; names and countries of authors; languages and types of primary documents; titles of journals and number of articles in them, and nominations and countries of authors' institutions. Selected citation data in WoS were retrieved, too. Results: In WoS, there were 274 papers by authors from 32 countries, in Scopus - 201 papers by authors from 26 countries, and in MEDLINE - 183 papers. Most papers were abstracted in the last three years (109 in WoS, 75 in Scopus and 66 in MEDLINE). Between 1990 and 1999, only 17 papers were abstracted in WoS, 15 - in Scopus, and 18 - in MEDLINE. Primary publications were in 9 languages in WoS and in Scopus each in 8 languages - in MEDLINE. Original articles prevailed followed by reviews, letters-to-the-editor and conference papers. In MEDLINE, there were 176 original articles, 20 reviews, 11 evaluation studies, 10 case reports, three multicenter studies, two randomized controlled trials, one meta-analysis, six letters-to-the-editor, one editorial, etc. E. Rullier, N. Saito and M. Ito presented with most publications in this narrow field. The journal Dis. Colon Rectum contained most papers abstracted in these data-bases followed by Colorectal Dis. Next came some other prestigious journals such as Ann. Surg. and Ann. Surg. Oncol. in WOS as well as Br. J. Surg. and Surg. Endosc. - in Scopus. The authors from Japan occupied the leading position followed by those from France, Germany, South Korea and the USA. The scientists at the National Cancer Center Hospital East (Kashiwa, Japan) were most productive during this period. The papers abstracted in WoS received 3105 citations of which, 1911 were without self-citations. There were 1475 citing articles, of which 1276 were without self-citations. Average citations per item were 11.33, average citations per year were 147.86, and h-index was 29. Some 184 articles (out of 274) were cited at least once. The paper by E. Rullier et al. (Ann Surg., 241, 2005, No 3, 465-469) already received 158 citations in WoS. Of them, 526 citations were from papers published in 2013 and 55 ones - from those published between January 1 and February 28, 2014. Conclusion: Our results convincingly demonstrated a rising international visibility of scientists from smaller countries on the information market due to the fruitful international collaboration. The purposeful application of this constellation of scientometric indicators in rapidly advancing field could contribute to further improvement of this integration.

External sphincter resection for lower rectal and anal canal adenocarcinoma: achieving anal preservation with oncological and functional satisfaction.

Intersphincteric resection (ISR) has recently been performed for very low rectal cancer, whereas abdominoperineal resection (APR) is typically reserved for cancers extremely close to the anal verge and/or when the depth of tumor invasion is suspected to involve the intersphincteric space. This is because impairment of anal function is considered unavoidable if the external sphincter (ES) is excised. We describe our technique of ISR with ES resection and discuss its outcomes. This surgical technique may offer major clinical advantages to selected patients and should be considered as an alternative to APR, although careful consideration of anal function is required.

Perioperative nursing of laparoscopic intersphincteric resection

Objective To explore the effective perioperative nursing method of the treatment of ultralow rectal cancer through laparoscopic intersphincteric resection (ISR).Methods Sixteen patients with ultralow rectal cancer from June 2009 to June 2011 were chosen,and all patients received the laparoscopic ISR and the perioperative nursing,and the nursing effect was observed.Results All patients could actively cooperate with the operation through perioperative nursing,and the cases of death,anastomotic leakage and postoperative bleeding were not found.All patients had the different degree of anal discomfort symptoms including the bulge,fecal urgency,anal burning,endless defecate feeling after the recovery of the anus defecation.The cases of the perianal skin eczema or ulceration were 11 cases,and the clinical features included that the stool was watery and the number of stool was frequency (3-10 times/day) ; the number of stool was gradually reduced and the time of controlling stool was gradually increased through the perioperative nursing,and most patients obtained the satisfactory bowel control 1 years after operation.The assessment of anal sphincter function one year after operation showed that the cases of A,B,C,D grade were respectively 8,4,3,1 cases,and the good rate of function in patients was 93.75％.Conclusions Perioperative nursing is very important for the laparoscopic ISR,and the attention should be paid to the perioperative nursing so as to improve the clinical efficacy. Key words: Nursing; Laparoscopy; Intersphincteric resection

Sa1606 Efficacy and Safety of Endoscopic Radial Incision and Cutting (RIC) Method for Benign Anastomotic Severe Stricture After Surgery of Lower Rectal Cancer

Intersphincteric resection (ISR) and low anterior resection (LAR) can preserve anal function, however, anastomotic stricture sometimes occurs as complications after surgery. Endoscopic balloon dilation (EBD) or bougie is generally performed in the anastomotic stricture of the lower rectum with a high frequency of restenosis. Although it has been reported that radial incision and cutting (RIC) using electrosurgical insulated tip (IT) knife is effective for refractory anastomotic stricture after esophagectomy, little is known regarding RIC for anastomotic stricture after ISR or LSR.

Laparoscopic intersphincteric resection for low rectal cancer: comparison of stapled and manual coloanal anastomosis

The study aim was to analyse the safety and feasibility of laparoscopic intersphincteric resection with stapled coloanal anastomosis for low rectal cancer. Between March 2009 and August 2010, 22 patients underwent laparoscopic intersphincteric resection with a stapled coloanal anastomosis without a diverting ileostomy. The results were compared retrospectively with hand-sewn coloanal anastomoses performed between January 2001 and May 2009, which included 55 open and 38 laparoscopic intersphincteric resections. The morbidity comparison only included data relevant to the anastomosis. Function was compared using the Saito function questionnaire and the Wexner score and only involved data relevant to the laparoscopy. The anastomotic complication rates were similar for fistula, bleeding and neorectal mucosal prolapse (P=0.526, P=0.653 and P=0.411, respectively). Anastomotic leakage and stricture formation of the stapled coloanal anastomosis were significantly lower than those of the hand-sewn coloanal anastomosis (P=0.037 and P=0.028, respectively). There were no significant differences in the Saito function questionnaire and the Wexner score between the stapled and hand-sewn coloanal anastomotic groups (all P>0.05). Laparoscopic intersphincteric resection with a stapled coloanal anastomosis is technically feasible and is less likely to result in anastomotic leakage and stricture formation than a hand-sewn anastomosis.

Completely abdominal intersphincteric resection for lower rectal cancer: feasibility and comparison of robot-assisted and open surgery

Most previous studies of intersphincteric resection (ISR) adopted a two-stage procedure involving abdominal and transanal approaches. We performed completely abdominal ISR via open and a robot-assisted (RA) approaches as treatments for lower rectal cancer (LRC). The RA approach might enable deep dissection and facilitate ISR in patients with restrictive pelvic anatomy. A consecutive cohort of 222 LRC patients who underwent completely abdominal ISR (RA ISR, n=108; open ISR, n=114) was enrolled prospectively, and their short-term outcomes were evaluated. In a multivariate analysis, ISR was performed more frequently in the RA than in the open group (82.6vs. 67.9%, p=0.008). The number of harvested lymph nodes was>12 in both groups. A positive distal resection margin was not observed in either group, and a positive circumferential resection margin was found in one patient in the RA group. Overall morbidity did not differ between the groups. Moderate to severe sexual dysfunction occurred 2.7-fold more frequently in the open group (p=0.023) among male patients≤65years. Mean Wexner's fecal incontinence scores at postoperative months 6 and 12 were greater in the open group than in the RA group (p<0.05). Completely abdominal ISR may be feasible in the treatment of LRC, based on a short-term study. Furthermore, RA ISR had equivalent oncological outcomes and slightly improved functional recovery relative to open ISR.

Smooth Muscle Enfoldment Internal Sphincter Construction after Intersphincteric Resection for Rectal Cancer

ObjectiveTo assess smooth muscle enfoldment and internal sphincter construction (SMESC) for improvement of continence after intersphincteric resection (ISR) for rectal cancer.MethodsTwenty-four Bama miniature pigs were randomly divided into a conventional ISR group and experimental SMESC group, with 12 pigs in each group. The proximal sigmoid colon was anastomosed directly to the anus in the ISR group. In the SMESC group, internal sphincter construction was performed. At 12 weeks before and after surgery, rectal resting pressure and anal canal length were assessed. Three-dimensional ultrasound was used to determine the thickness of the internal sphincter. After the animals were sacrificed, the rectum and anus were resected and pathological examinations were performed to evaluate the differences in sphincter thickness and muscle fibers.ResultsAll 24 animals in the SMESC group and the ISR group survived the surgery. Twelve weeks post-surgery, the rectal resting pressure, length of the anal high-pressure zone and the postoperative internal sphincter thickness for the ISR group were significantly lower than for the SMESC group. There was a thickened area (about 2 cm) above the anastomotic stoma among animals from the SMESC group; in addition, the smooth muscles were significantly enlarged and enfolded when compared to the ISR group.ConclusionThis animal model study shows that the SMESC procedure achieved acceptable reconstruction of the internal anal neo-sphincter (IAN/S), without increasing surgical risk. However, the findings in this experimental animal model must be confirmed by clinical trials to determine the safety and efficacy of this procedure in clinical practice.

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

IntroductionAbdomino-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. AimIs 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 & methodsBetween 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). ResultsAmong 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 1.5years (range 1–4.6years). The 3year 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%. ConclusionIntersphincteric 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.

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

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. 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. Operating time was 374.3min (range, 210-570min) in the laparoscopic group and 485.8min (range, 315-720min) 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 519.5min (range, 360-720min) in the first stage and 448.2min (range, 315-585min) 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. 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.

Long-Term Clinical and Functional Results of Intersphincteric Resection for Lower Rectal Cancer

Intersphincteric resection (ISR) is an alternative to abdominoperineal resection (APR) for super-low rectal cancer. The aim of this study was to evaluate the long-term curability after ISR over an average 6-year observational period, to compare the postoperative functional outcomes for ISR with those for low anterior resection (LAR), and to determine whether ISR is a function-preserving surgery. Between 2000 and 2007, a total of 77 consecutive patients with low rectal cancer underwent curative ISR. The curability outcomes for ISR, LAR, and APR were compared. We evaluated the postoperative defecation functions, Wexner incontinence score (WIS), and defecation quality of life (QOL) for a between-groups comparison (ISR/LAR). The 5-year survival rate after ISR was 76.4 %, and the outcome was better than for APR (APR 51.2 %, LAR 80.7 %). Local recurrence after ISR occurred in 7.8 % of patients (APR 12.1 %, LAR 11.7 %). The average daily frequency of defecation was 3.7 times for the ISR patients and 3.2 times for the LAR patients, indicating no significant difference between the groups. Moreover, there were no significant differences between the groups for defecation functions. The WIS was 8.1 for ISR and 4.9 for LAR, and the defecation QOL for ISR and LAR was not significantly different (modified fecal incontinence QOL score: ISR 34.3, LAR 26.5). The long-term clinical and functional results suggest that ISR may be the optimal sphincter-preserving surgery for patients with lower rectal cancers who cannot be treated with a double-stapling technique.

Acceptance of sphincter-preserving surgery for T3 lower rectal cancer after short-course radiotherapy with delayed surgery.

620 Background: One of the reasons for avoiding sphincter-preserving surgery for lower rectal cancer is difficulty in obtaining a sufficient distal margin. Short-course radiotherapy (SRT) with immediate surgery is not expected to reduce tumor volume, and currently available evidence suggests that it does not increase the sphincter-preservation rate. However, SRT with delayed surgery has been linked to downsizing of the primary tumor during the waiting period. We evaluated the feasibility of sphincter-preserving surgery for T3 lower rectal cancer after SRT with delayed surgery and examined whether a distal margin of ≤ 5 mm has an impact on oncologic outcomes. Methods: We retrospectively studied 161 consecutive patients with lower rectal cancer located below the peritoneum reflection who underwent radical surgery with total mesorectum resection (TME) 3 to 4 weeks after the completion of SRT. The median follow-up was 53.5 months. Results: Sphincter-preserving surgery was performed in 149 (92.5%) of the 161 patients. The procedures were as follows: double-stapling technique, 58 patients; intersphincteric resection, 91; abdominoperineal resection, 10; and Hartmann operation, 2. Among the patients who underwent sphincter-preserving surgery, the distal margin was ≤ 5 mm in 41 patients and &gt; 5 mm in 108. The local recurrence rate was respectively 5.8% vs. 10.4% (p = 0.606), the recurrence-free survival 83.4% vs. 82.8% (p = 0.682), and the overall survival at 5 years 82.3% vs. 87.6% (p = 0.418). Our results suggested that there is no difference in long-term outcomes between a distal margin of ≤ 5 mm and &gt; 5 mm. Conclusions: Sphincter-preserving surgery was performed in 92.5% of patients with T3 lower rectal cancer who received SRT with delayed surgery. Our results confirmed the long-term oncologic feasibility of sphincter-preserving surgery with a distal margin of ≤ 5 mm; there was no negative impact on long-term outcomes such as local recurrence, recurrence-free survival, and overall survival.

Laparoscopic intersphincteric resection using needlescopic instruments.

Intersphincteric resection (ISR) is a procedure designed to preserve anal function in cases with very low rectal cancer. We report our clinical experience with laparoscopic ISR (Lap ISR) performed using needlescopic instruments. First, a camera port is created at the umbilicus. Two 5-mm ports are then inserted at the right upper and lower quadrants. Two needlescopic forceps (Endo-Relief™ Hope Denshi Co., Chiba, Japan) are inserted at the left upper and lower quadrants. We then perform the following procedures; ligation of the inferior mesenteric artery and vein, total mesorectal excision and dissection of the intersphincteric space. After the transanal intersphincteric dissection, the specimen is extracted through the anus and a hand —sewn coloanal anastomosis is performed. The covering ileostomy is finally created at the right upper port. We performed Lap ISR using needlescopic forceps in two patients with very low rectal cancer. In both cases, we were able to perform this procedure without insertion of an additional port or to change the needlescopic forceps to conventional 5-mm forceps. Lap ISR with needlescopic instruments is a feasible procedure for minimally invasive surgery.

Laparoscopic Total Mesorectal Excision for Ultralow Rectal Cancer with Transanal Intersphincteric Dissection as a First Step: A Single-surgeon Experience

Laparoscopic intersphincteric resection (ISR) after neoadjuvant chemoradiation is helpful in the management of patients with low rectal cancer. With the advent of this technique, the need for performance of abdominoperineal resection seems to have decreased in patients with very low rectal tumors. The aim of the present study was to evaluate the feasibility of laparoscopic ISR preceded by transanal rectal dissection low rectal cancer. Between December 2009 and June 2011, we performed laparoscopic ISR for 30 patients with very low rectal cancer. Patients received preoperative concurrent chemoradiation (5 days a week for 5 weeks). The surgical procedure was performed 6 weeks after radiotherapy and included total mesorectal excision, ISR, transanal coloanal anastomosis with coloplasty and loop ileostomy. Clinical data of 30 patients were analyzed retrospectively. Thirty patients (21 men, nine women) had a median age of 65 years (range, 37 to 75 years), a median body weight of 67 kg (range, 43 to 96 kg), and body mass index of 24 kg/m(2) (range, 19 to 33 kg/m(2)). The distance of the tumor from the anal verge was 5 cm (range, 2 to 11 cm). The operative time was from 240 to 360 minutes, and estimated blood loss was 100 to 520 mL. There were no conversions and no postoperative mortality. This procedure is feasible and has favorable short-term results for radical treatment of very low rectal disease while preserving anal function.

Laparoscopic Partial or Subtotal Intersphincteric Resection for Lower Rectal Cancer

Objective to investigate the treatment probability of laparoscopic partial or subtotal intersphincteric resection for ultra-low rectal cancer. Clinical data of 14 patients with ultra-low rectal cancer who have underwent laparoscopic partial or subtotal intersphincteric resection between January 2013 and February 2014 in gastrointestinal surgery was collected. Clinical application effect of laparoscopic partial or subtotal intersphincteric resection for ultra-low rectal cancer was analyzed.Results: Among all the cases, nobody got peri-operative death, one patient got partial anastomotic crack a week after operation and another patient got 12 days postoperative anastomotic fistula, both of whom cured through conservative treatment. During the 6- 54-month follow-up, there was 1 case of local recurrence after 6 months of operation. The anal functions of all patients turned out to be in Kirwan class 1 or 2 and 1 patient got anastomotic stenosis, who required regular expansion treatment. Conclusion Laparoscopic partial or subtotal intersphincteric resection for ultra-low rectal cancer was a safe and possible operational method. Keywords: Intersphincteric resection; Laparoscopic surgery; Rectal cancer.