Intersphincteric Resection Research Articles

Reassessment of intersphincteric resection in the sphincter-preserving operation for ultra-low rectal cancer

Intersphincteric resection (ISR), as an ultra-low sphincter-preserving operation, is widely used in clinical practice at present. ISR can allow some patients with very low rectal cancer to avoid the pain of anal resection while ensuring oncological efficacy. However, the procedure of ISR requires wider intersphincteric dissection which may cause nerve damage, and the removal of partial or total internal anal sphincter as an "inherent defect" of ISR can result in poor anal function postoperatively. Based on the in-depth understanding of regional anatomy and physiological function, the author proposed a new functional sphincter preservation operation for very low rectal cancer-conformal sphincter preservation operation (CSPO) which has achieved good outcome in clinical practice. This article will revisit the brief history of rectal cancer surgery and discuss the main mechanisms underlining the poor anal function after ISR. Based on the anatomical study of the pelvic floor and anal canal, CSPO can improve the postoperative anal function of very low rectal cancer patients by reducing the damage of the autonomic nerves, receptor corpuscles and muscle fibers in the intersphincteric space, retaining more dentate line and internal sphincter with the design of resection line of tumor lower border under direct vision, and elevating the anastomosis height. At the same time, the future treatment prospect of low rectal cancer is envisioned.

Functional outcomes of intersphincteric resection in low rectal tumors.

Currently, sphincter-saving procedures are increasingly performed in the treatment of low rectal cancers. This study aimed to evaluate the outcomes of patients who underwent intersphincteric resection. This was a single-center, retrospective, cross-sectional study. We evaluated the electronic data files of 29 patients who had intersphincteric resections at our institute between 2008 and 2018. Bowel function outcomes were assessed prospectively using Wexner incontinence score. Histopathological, surgical and functional outcomes were analyzed. Mean age of nine female and 20 male patients included in the study was 55.8 ± 12.8 (30-76) years. A tumor-free surgical margin was achieved in all patients. Anastomotic leakage was detected in two patients. Mean Wexner incontinence score of 20 patients who still had functional anastomosis was 8.35, whereas 65% of the patients (n= 13) had a good continence status. There was no relationship between the continence status and sex, tumor distance from anal verge, T stage, distal surgical margin, and lymph node involvement. Twenty-one patients underwent primary coloanal anastomosis and eight patients underwent two-stage coloanal anastomosis. In the treatment of distal rectal cancer, adequate oncological surgery and relatively acceptable functional outcomes can be obtained with intersphincteric resection technique in suitable patients.

Trend of sphincter-preserving surgeries for resectable low rectal cancer: A 20-year experience in China.

3615 Background: Over the last decades, patients with low rectal cancer have realized better functional, morbidity, and quality-of-life outcomes from improvements in surgical techniques in sphincter preservation. We aimed to quantify the trend in sphincter-preserving surgeries for low rectal cancer over 20 years in China. Methods: Between November 1999 and October 2021, a cohort of patients with pathologically confirmed primary malignant rectal tumor ≤5cm from the anal verge and who received selective surgery at Changhai Hospital, was identified. Demographic and clinical data were extracted from electronic medical records. Survival data were collected from outpatient medical records and follow-up phone interviews. A Joinpoint Regression Model was used to analyze trends in surgical procedures by average annual percentage change (AAPC). A Cox proportional hazards regression model adjusting for demographic and clinicopathological confounders was used to assess the overall survival for patients with sphincter-preserving surgery vs. abdominoperineal resection (APR). Results: Among 19,276 patients with colorectal cancer, 4,072 (21.1%) had a tumor in the low rectum during the study period; 3,025 (74.2%) underwent a sphincter-preserving surgery and 1,047 (25.7%) received APR. Sphincter-preserving surgery increased 3.6% per year (AAPC 3.6, p=.006). Anterior resection was the most performed procedure (86.3%) and maintained a steady trend (AAPC 0.13, p=.49), while intersphincteric resection (including conformal sphincter preservation operation) increased 49.4% annually (AAPC 49.4, p=.003). Laparoscopic techniques increased 15.1% per year (AAPC 15.1, p=.035). Sphincter-preserving surgery increased annually for tumors ≤2cm, 2-3cm and 3-4cm from the anal verge (AAPC 7.08, p=.001; 4.69, p=.001; 2.66, p=.001, respectively). A total of 2,854 patients had sufficient vital status data for inclusion in the survival analysis. The characteristics of those with and without a follow-up encounter were comparable. Patients with sphincter-preserving surgery had a lower risk of death compared to APR (adjusted HR 0.78, 95% CI, 0.65-0.93, p=.01). Conclusions: Utilization of sphincter-preserving surgeries increased significantly over the last 20 years. Patients with low rectal cancer who underwent sphincter preservation had better survival than similar patients who underwent APR.[Table: see text]

Locally advanced rectal cancer receiving total neoadjuvant therapy combined with nivolumab: a case report and literature review

BackgroundThe standard treatment for locally advanced rectal cancer (LARC) is preoperative chemoradiotherapy (CRT) followed by surgery and adjuvant chemotherapy. However, it has been suggested that intensification of neoadjuvant treatment with polychemotherapy in addition to CRT instead of as an adjuvant chemotherapy is better tolerated and associated with a higher pathological complete response (pCR) rate. This concept is known as total neoadjuvant therapy (TNT).Recently, the addition of immunotherapy to preoperative CRT has been reported to be useful in LARC patients with mismatch-repair-deficiency and high levels of microsatellite instability (MSI-H), but there are no reports showing the therapeutic effect of nivolumab in combination with TNT.Case presentationA 23-year-old man had frequent diarrhea. Preoperative examination revealed two adenocarcinomas in the rectum. His maternal grandmother had a rectal cancer patient who developed the disease at age 70s. The larger tumor was located at the peritoneal reflection, and its anterior border close to the prostate (<1 mm); there were eight enlarged pararectal lymph nodes. Considering the size and depth of the tumor, it was judged that radical resection with sufficient margins would be difficult. Therefore, it was decided that TNT would be performed. At first, CAPOX (capecitabine and L-OHP) was administered, followed by preoperative CRT (RT:50.4 Gy and capecitabine). During this period, genetic testing diagnosed this patient as MSI-H, so additional nivolumab was administered after CRT. Colonoscopy revealed that the larger tumor was no longer detectable, so robot-assisted intersphincteric resection and bilateral lateral lymph node dissection was performed. The diagnosis of pCR was made for the larger tumor and partial response was achieved for the smaller tumor, and no lymph node metastasis was found. Major complications were not observed and the patient was discharged on the 14th day after surgery. He was followed up without adjuvant chemotherapy and is alive and recurrence-free after 9 months.ConclusionA case of LARC with MSI-H was treated with TNT with nivolumab, resulting in pCR and complete radical resection. This result suggests that nivolumab in addition to TNT can be an option as a preoperative strategy for LARC with MSI-H.

Impact of near-infrared fluorescence imaging with indocyanine green on structural sequelae of anastomotic leakage after laparoscopic intersphincteric resection of malignant rectal tumors.

Recent studies have indicated the potential benefit of intraoperative near-infrared fluorescence imaging (NIR-FI) with indocyanine green in reducing early anastomotic leakage in colorectal surgery. Nonetheless, whether NIR-FI is effective in reducing structural sequelae of anastomotic leakage (SSAL) remains unclear. The aim of the present study was to investigate the impact of NIR-FI on SSAL after laparoscopic intersphincteric resection (ISR) of malignant rectal tumors. This study was a retrospective single-center cohort study. A total of 293 consecutive patients who underwent elective laparoscopic ISR from May 2010 to August 2017 were included. Patients were divided into 2 groups; those who underwent elective laparoscopic ISR with lymphadenectomy for malignant rectal tumors using NIR-F (NIR-FI group) and those who underwent elective laparoscopic ISR with lymphadenectomy for malignant rectal tumors without using NIR-FI (control group). Thirty were excluded from the analyses (13 died, 7 had pelvic recurrence, and 10 were lost to follow-up). The primary endpoint was the rate of SSAL within 2years after the primary resection, whereas the secondary endpoint was the rate of natural defecation via the anus at 2years after the primary resection. Using various statistical analyses, such as propensity score matching, the rate of SSAL was compared between groups. A total of 263 patients were analyzed [177 males and 86 females, median age 61 (27-84) years]. Prior to propensity score matching (n = 263), NIR-FI was performed in 70 patients (26.6%) The rates of SSAL were 1.4% (1/70) in the NIR-FI group and 10.4% (20/193) in the control group (p = 0.02). After propensity score matching (n = 163), the rates of SSAL were 1.5% (1/66) in the NIR-FI group and 11.7% (12/103) in the control group (p = 0.02). Propensity score analyses, as well as simple regression analyses, revealed that NIR-FI was associated with a significantly lower risk of SSAL (OR 0.10-0.13; p = 0.03-0.05). NIR-FI is useful in reducing the rate of SSAL after laparoscopic ISR.

Clinical effects of prophylactic transverse colostomy in patients undergoing completely laparoscopic transabdominal approach partial intersphincteric resection.

ObjectiveTo investigate the clinical effects of prophylactic transverse colostomy on gastrointestinal function recovery and complications in patients undergoing completely laparoscopic transabdominal approach partial intersphincteric resection (CLAPISR) of low rectal cancer.MethodsWe retrospectively analyzed the data of 74 patients with low rectal cancer who were treated with prophylactic transverse colostomy (Group A, n = 34) or without prophylactic transverse colostomy (Group B, n = 40). Surgery-related indicators, nutritional status indicators, systemic stress response indicators, and complications were compared between the two groups.ResultsOn postoperative day 5, the C-reactive protein concentration and white blood cell count were not significantly different between the two groups; however, the serum concentrations of total protein and albumin were higher in Group A than in Group B. Within 26 months postoperatively, the total incidence rate of complications was not significantly different, but the incidence rate of anastomotic leakage was lower in Group A than in Group B.ConclusionProphylactic transverse colostomy based on CLAPISR can lead to faster recovery of gastrointestinal function, better improvement of postoperative nutritional indicators, and a lower incidence of anastomotic leakage. These characteristics are conducive to the rapid recovery of patients, making this procedure worthy of clinical application.

Impact of Modern Management Strategies on the Clinical Outcome of Patients With Low Rectal Cancer - A Retrospective, Monocentric Cohort Study.

The aim of this study was to retrospectively investigate the impact of intersphincteric resection (ISR) and Enhanced Recovery After Surgery (ERAS) protocols for rectal cancer. Since we implemented rectal ERAS protocol and ISR in 2016, we retrospectively assessed and compared clinical, pathological and survival outcomes of two groups of patients: group 1, treated 2000-2015 (n=242); and group 2, treated 2016-2020 (n=108). Propensity score matching using nearest-neighbor method was used to match each patient of group 1 to a patient of group 2. Before and after matching, the American Society of Anesthesiology score for patients in group 1 was significantly lower than in group 2 (score of 3: 9.9% vs. 25.9%, p<0.0001) as were grade I-II complications (27.7% vs. 45.4% p<0.001). Before and after matching, the quality of the mesorectum excision was significantly lower in group 1 (complete in 31% vs. 59.2% p<0.0001). After matching, 3-year overall survival for groups 1 and 2 were similar (88.2% vs. 92.6%; p=0.988). ERAS and ISR had no negative impact on the oncological outcome of our patients and increased the preservation of bowel continuity.

Comparison of Anorectal Functional Outcome Following Low Anterior Resection Versus Intersphincteric Resection for Rectal Cancer

Comparison of Anorectal Functional Outcome Following Low Anterior Resection Versus Intersphincteric Resection for Rectal Cancer

Comparison between robotic-assisted and laparoscopic sphincter-preserving operations for ultra-low rectal cancer.

AimSphincter‐preserving operations for ultra‐low rectal cancer include low anterior and intersphincteric resection. In low anterior resection, the distal rectum is divided by a transabdominal approach, which is technically demanding. In intersphincteric resection, a perineal approach is used. We aimed to evaluate whether robotic‐assisted surgery is technically superior to laparoscopic surgery for ultra‐low rectal cancer. We compared the frequency of low anterior resection in cases of sphincter‐preserving operations.MethodWe investigated 183 patients who underwent sphincter‐preserving robotic‐assisted or laparoscopic surgery for ultra‐low rectal cancer (lower border within 5 cm of the anal verge) between April 2010 and March 2020. The frequency of low anterior resection was compared between laparoscopic and robotic‐assisted surgeries. The clinicopathological factors associated with an increase in performing low anterior resection were analyzed by multivariate analyses.ResultsOverall, 41 (22.4%) and 142 (77.6%) patients underwent laparoscopic and robotic‐assisted surgery, respectively. Patient characteristics were similar between the groups. Low anterior resection was done significantly more frequently in robotic‐assisted surgery (67.6%) than in laparoscopic surgery (48.8%) (P = 0.04). Multivariate analyses showed that tumor distance from the anal verge (P < 0.01) and robotic‐assisted surgery (P = 0.02) were significantly associated with an increase in the performance of low anterior resection. The rate of postoperative complications or pathological results was similar between the groups.ConclusionCompared with laparoscopic surgery, robotic‐assisted surgery significantly increased the frequency of low anterior resection in sphincter‐preserving operations for ultra‐low rectal cancer. Robotic‐assisted surgery has technical superiority over laparoscopic surgery for ultra‐low rectal cancer treatment.

Non-operative management after chemoradiotherapy plus consolidation or sandwich (induction with bevacizumab and consolidation) chemotherapy in patients with locally advanced rectal cancer: a multicentre, randomised phase II trial (NOMINATE trial)

IntroductionTotal mesorectal excision (TME) and postoperative adjuvant chemotherapy following neoadjuvant chemoradiotherapy (CRT) is the standard treatment for locally advanced rectal cancer (LARC). However, neoadjuvant CRT has no recognised impact on...

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

BackgroundThe 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.MethodsWe 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).ResultsThe 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.ConclusionsTAISR, 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.

Da Vinci SP robotic approach to colorectal surgery: two specific indications and short-term results.

Da Vinci® Single Port (dvSP) was recently developed. Its application in colorectal surgery is under investigation. The aim of this study was to explore the safety and feasibility of dvSP for intersphincteric (dvSP-ISR), right colectomy (dvSP-RC), and transverse colectomy (dvSP-TC). Surgical indication and short-term results were analyzed. All consecutive patients from a prospective database of patients who underwent dvSP-ISR, dvSP-RC, and dvSP-TC at Korea University Anam Hospital from November 2020 to December 2021, were analyzed. Perioperative, pathological, and oncological short-term outcomes were analyzed. A total of 7 dvSP-ISR, 5 dvSP-RC, and 1 dvSP-TC were performed. Median age was 56.0 (55.0-61.0) years for the dvSP-ISR and 54.0 (44.7-63.5) years for the dvSP-RC/TC. Median body mass index was 22.8 (17.1-24.8) kg/m2 for the dvSP-ISR and 23.6 (20.8-26.9) kg/m2 for the dvSP-RC/TC. All dvSP-ISR patients received neoadjuvant long-course chemoradiotherapy, including one patient with squamocellular carcinoma who was treated with 5-fluorouracil (5-FU)/mitomycin. All other patients, excluding one dvSP-RC patient with Crohn's disease, had an adenocarcinoma. Median operation time was 280 (240-370) minutes for the dvSP-ISR and 220 (201-270) minutes for the dvSP-RC/TC. Estimated blood loss was insignificant. No intraoperative complications or conversions to multiport/open surgery was reported. Median post-operative stay was 7.0 (6.0-10.0) days for the dvSP-ISR and 5.0 (4.0-6.7) days for the dvSP-RC/TC. Quality of mesorectum was complete for six patients, and nearly complete for one. Median number of retrieved lymph nodes were 21 (17-25) for the dvSP-ISR and 28 (24-49) for the dvSP-RC/TC. Proximal and distal resection margins were tumor free. Four patients experienced post-operative complications not related to the platform which were: ileus, voiding dysfunction, infected pelvic hematoma, and wound infection. Median follow-up was 9 (6-11) months and 11 (7-17) months for the dvSP-ISR and dvSP-RC/TC, respectively. Two patients had systemic recurrence; all others were tumor free. The dvSP platform is safe and feasible for intersphincteric resection with right lower quadrant access, and right/transverse colectomy with suprapubic access. Further studies are needed to evaluate benefit differences compared to multiport robotic platform.

Transanal total mesorectal excision combined with intersphincteric resection has similar long-term oncological outcomes to laparoscopic abdominoperineal resection in low rectal cancer: a propensity score-matched cohort study.

BackgroundTransanal total mesorectal excision (taTME) or intersphincteric resection (ISR) has recently proven to be a valid and safe surgical procedure for low rectal cancer. However, studies focusing on the combination of these two technologies are limited. This study aimed to evaluate perioperative results, long-term oncologic outcomes, and anorectal functions of patients with low rectal cancer undergoing taTME combined with ISR, by comparing with those of patients undergoing laparoscopic abdominoperineal resection (laAPR).MethodsAfter 1:1 propensity score matching, 200 patients with low rectal cancer who underwent laAPR (n = 100) or taTME combined with ISR (n = 100) between September 2013 and November 2019 were included. Patient demographics, clinicopathological characteristics, oncological outcomes, and anal functional results were analysed.ResultsPatients in the taTME-combined-with-ISR group had less intraoperative blood loss (79.6 ± 72.6 vs 107.3 ± 65.1 mL, P = 0.005) and a lower rate of post-operative complications (22.0% vs 44.0%, P < 0.001) than those in the laAPR group. The overall local recurrence rates were 7.0% in both groups within 3 years after surgery. The 3-year disease-free survival rates were 86.3% in the taTME-combined-with-ISR group and 75.1% in the laAPR group (P = 0.056), while the 3-year overall survival rates were 96.7% and 94.2%, respectively (P = 0.319). There were 39 patients (45.3%) in the taTME-combined-with-ISR group who developed major low anterior resection syndrome, whereas 61 patients (70.9%) had good post-operative anal function (Wexner incontinence score ≤ 10).ConclusionWe found similar long-term oncological outcomes for patients with low rectal cancer undergoing laAPR and those undergoing taTME combined with ISR. Patients receiving taTME combined with ISR had acceptable post-operative anorectal function.

An anatomical study on intersphincteric space related to intersphincteric resection for ultra-low rectal cancer.

Intersphincteric resection (ISR) has been proposed to offer sphincter-sparing solution for patients with ultra-low rectal cancer. However, complete and accurate concepts about the intersphincteric space (ISS) related anatomy are not demonstrated clearly. This study aimed to provide a comprehensive description about the anatomic structure of ISS related to ISR. This was a descriptive morphological study. 28 pelvic specimens were obtained from body donors. Macroscopic and microscopic observation of ISS was performed via gross anatomy, plastinated sections and histologic staining. The anatomical parameters of the anal canal were measured. Images of laparoscopic ISS dissection procedures were real-timely captured during ISR. The hiatal ligament, microvessels on supra fascia of LAM and rectal longitudinal muscle at the level of anorectal ring, especially at 1, 5, 7, and 11o'clock, could be the preferred entrance of ISS. The conjoint longitudinal muscle (CLM), the major component of ISS, was the continuum of the rectal longitudinal muscle and got reinforcement from the elastic fibers from LAM and EAS. Microvessels and neuro tissues were also found in ISS. The ISS was split into two spaces by the CLM in the middle and might subjectively be divided into three segments according to its different compositions. The length and width of ISS varied from different segments and directions. We provided a systemic description of boundaries, contents and topographic structure of ISS, which may help proper determination of surgical approaches and dissection planes during ISR.

Trajectory of change of low anterior resection syndrome over time after restorative proctectomy for rectal adenocarcinoma.

Restorative proctectomy for rectal cancer is associated with a high incidence of low anterior resection syndrome (LARS), but few studies report longitudinal results for bowel function. The aim of our study was to examine the trajectory of change of LARS over the first 18months after restorative proctectomy for rectal cancer. A prospective database measuring functional outcomes in rectal cancer patients from a single university-affiliated specialist colorectal referral center from 10/2018 to 03/2020 was queried. Patients were included in this study if they underwent restorative proctectomy for rectal cancer and had at least three assessments in the first 18months after primary surgery or after closure of proximal diversion. Bowel function was assessed using the LARS score, administered at every surveillance follow-up after restoration of bowel continuity. Latent-class growth curve (trajectory) analysis was used to identify different trajectories of LARS changes over the first 18months and group patients into these trajectory groups. These groups were then compared to identify predictors for each trajectory. A total of 95 patients were included (63 males, mean age. 61.3 ± 12.5years). Trajectory analysis identified three distinct trajectory groups. Group 1 had stable minimal LARS over time (26%). Group 2 had early LARS scores consistent with the minor LARS category and improved with time (28%). Group 3 had persistently high LARS scores (45%). Neoadjuvant therapy, intersphincteric resection, and proximal diversion were more common in group 3. We identified three main trajectories of change of LARS in the 18months after restorative proctectomy. These data may be used to better inform patients of their expected postoperative bowel function.

Outcomes of rectal cancer patients with a positive pathological circumferential resection margin.

Evidence-based management of positive pathological circumferential resection margin (pCRM) following preoperative radiation and an adequate rectal resection for rectal cancers is lacking. Retrospective analysis of prospectively maintained single-centre institutional database was done to study the patterns of failure and management strategies after a rectal cancer surgery with a positive pCRM. A total of 86 patients with rectal adenocarcinoma with a positive pCRM were identified over 8years (2011-2018). Majority had low-lying rectal cancers (90.7%) and were operated after preoperative radiotherapy (95.3%). Operative procedures included abdomino-perineal resections, inter-sphincteric resections, low anterior resections and pelvic exenteration in 61 (70.9%), 9 (10.5%), 11(12.8%) and 5 (5.8%) patients respectively. A total of 83 (96.5%) received chemotherapy as the sole adjuvant treatment modality while 2 patients (2.3%) were given post-operative radiotherapy and 1 patient underwent revision surgery. A total of 53 patients (61.6%) had recurrence, with 16 (18.6%), 20 (23.2%), 8(9.3%) and 9 (10.5%) patients having locoregional, systemic, peritoneal and simultaneous local-systemic relapse. Systemic recurrences were more often detected either by surveillance in an asymptomatic patient (20.1%) while local (13.1%) and peritoneal (13.2%) recurrences were more often symptomatic (p = 0.000). The 2-year overall survival (OS) and disease-free survival (DFS) of the cohort was 82.4% and 74.0%. Median local recurrence-free survival (LRFS) was 10.3months. Patients with a positive pCRM have high local and distal relapse rates. Systemic relapses are more often asymptomatic as compared to peritoneal or locoregional relapse and detected on follow-up surveillance. Hence, identification of such recurrences while still salvageable via an intensive surveillance protocol is desirable.

Inter sphincter rectal resection with and without Malone ante grade continence enema in cases with low rectal cancer: A randomized, prospective, single-blind, clinical trial.

Background:Fecal incontinence is the main morbidity of inter-sphincteric resection (ISR) in ultra-low rectal cancer. Malone Ante grade Continence Enema (MACE) has been proposed for these patients. We aimed to compare the quality of life outcomes in cases with ultra-low rectal cancer who had undergone ISR±MACE.Methods:The current randomized clinical study was accomplished for two years from December 2016 to February 2018 in Imam Khomeini Hospital (Sari City, I.R.Iran) on 30 patients (15 in each group) with rectal cancer. The inclusion criteria of the study were stage 1 and 2a of low rectal cancer with type 2 and 3 of Rullier's classification, those who received neoadjuvant chemo radiotherapy. The exclusion criteria were comorbidity diseases, immune deficiency, poor follow-up. The follow-up period was one year. The Quality of Life (Qol) was reported as primary endpoint. The EORTC QLQ-C30 score and Wexner questionnaires were used. SPSS Version 22 was used. A p-value less than 0.05 was considered statistically significant.Results:The mean age of patients was 56.23±years. The overall Qol score was better in the ISR-MACE (P=0.023). The overall Qol was lower in women than in men in both groups. Low anterior resection syndrome score was lower in the ISR plus MACE group than the ISR group (P=0.030). The Wexner score revealed better scores in the ISR with MACE group than the ISR without MACE group (p<0.0001).Conclusion:Patients who underwent ISR plus MACE surgery had better defecation control and better quality of life than patients without MACE.

Comparative study of functional outcomes between ultra-low anterior resection and inter-sphincteric resection: a propensity matched analysis.

Comparative bowel functional outcomes between ultralow anterior resections (ULAR) and inter-sphincteric resection (ISR) for similar tumour and patient characteristics is not known. Single centre study of low rectal caners (<5cm from anal verge) with 1:1 propensity matching of age, sex, body mass index, prior radiation, and surgical approach (open vs. minimally invasive) was performed for the ULAR and ISR groups. Primary outcome measure was Wexner Incontinence scores and Low Anterior Resection Syndrome (LARS) score at a single time point after stoma reversal. Seventy-two matched patients were included. Median Wexner scores were five and eight for the ULAR and ISR cohorts (p = 0.006). Major incontinence (Wexner >11) was found in 5.6% versus 33% after ULAR and ISR, respectively. Major LARS (score > 29) was demonstrated in 11% versus 25% in ULAR versus ISR (p = 0.293). Majority in both groups has no LARS (score < 20), that is, 72.2% versus 63.9% in ULAR against ISR. Besides these, stool fragmentation (p < 0.001), nocturnal defecation (p < 0.001) and use of anti-diarrhoeal medications (p = 0.023) were significantly more after ISR. Bowel continence was relatively inferior after ISR as compared to an ULAR for low rectal cancers in matched cohorts. Major LARS in ISR was twice as prevalent without statistical differences.

Lateral pelvic node dissection after neoadjuvant chemoradiation in rectal cancer with right internal iliac node metastasis but without regional node metastasis: A case report.

Introduction and importanceTotal mesorectal excision (TME) with lateral pelvic node dissection was routinely done in low clinical T3 rectal tumors below the peritoneal reflection as stated in the Japanese guidelines for colorectal cancer. Our institution follows the same practice in selected patients. This is our first reported case wherein a patient with rectal cancer underwent total mesorectal excision with lateral lymphadenectomy after neoadjuvant treatment with a positive lateral node on histopathology.Case presentationA 49 year old female rectal had rectal adenocarcinoma 4 cm FAV. Pelvic MRI revealed a low rectal tumor abutting the mesorectal fascia anteriorly, anal sphincters not involved, and confluent enlarged right iliac nodes. After neoadjuvant treatment, interval decrease in size of the rectal lesion and the right iliac nodes were noted. Patient underwent partial intersphincteric resection, lateral pelvic node dissection and protective loop ileostomy.Clinical discussionHistopathology revealed a rectal adenocarcinoma with one right internal iliac lymph node was positive for tumor involvement. Circumferential resection margin was 4.0 mm. Patient is currently on 4th cycle of adjuvant chemotherapy. Preoperative chemoradiation could not completely eradicate lateral pelvic node metastasis. Therefore, lateral pelvic node dissection should be considered if lateral pelvic lymph node metastasis is suspected even after neoadjuvant therapy.ConclusionUnlike TME, performance of a routine lateral lymphadenectomy in rectal cancer surgery varies by geographic location. Reports from Asian countries and our practice in our institution shows that it can be performed safely. This could improve the oncologic outcomes of patients especially if combined with neoadjuvant chemoradiotherapy.

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.