Intersphincteric Resection For Low Rectal Cancer Research Articles

Transverse Coloplasty Pouch versus Straight Coloanal Anastomosis Following Intersphincteric Resection for Low Rectal Cancer: the Functional Benefits May Emerge After Two Years

PurposeThis study aimed to compare the oncological and functional outcomes following intersphincteric resection (ISR) with transverse coloplasty pouch (TCP) or straight coloanal anastomosis (SCAA) for low rectal cancer. MethodsA single-center retrospective analysis was performed on patients with low rectal cancer who received ISR between January 2016 and June 2021. The primary endpoint was to compare the outcomes of bowel function within 1 year, 1 to 2 years, and 2 years after ileostomy closure in patients undergoing two different bowel reconstruction procedures (TCP or SCAA). The postoperative complications and oncological results were also compared between the two groups. ResultsA total of 235 patients were enrolled in this study (SCAA group: 166; TCP group: 69). There was no significant difference in complications, including grades A–C anastomotic leakage (9.6% vs 15.9%), 3-year local recurrence rates (6.1% vs 3.9%), disease-free survival (82.4%vs 83.8%), or overall survival (94.1% vs 94.7%) between the two groups. Two years after ileostomy closure, 52.7% of patients in the SCAA group were assessed as having major low anterior resection syndrome (LARS), which was significantly higher than the 25.9% of patients in the TCP group (P = 0.014), but no difference was found prior to 2 years. Similar differences were seen in Wexner scores 2 years after surgery (P = 0.032). Additionally, TCP was an independent protective factor for postoperative bowel function as measured by both the LARS (OR, 0.28; 95% CI, 0.10–0.82; p = 0.020) and Wexner scoring (OR, 0.28; 95% CI, 0.09–0.84; p = 0.023). ConclusionThis study suggests that TCP is a safe technique that may decrease bowel dysfunction after ISR for low rectal cancer compared with SCAA 2 years after ileostomy closure.

Sphincter-saving surgery versus abdominoperineal resection in low rectal cancer following neoadjuvant treatment with propensity score analysis.

Sphincter-saving operation is the treatment of choice in patients with lower rectal cancer, although abdominoperineal resection (APR) is necessary in some cases for adequate oncological outcomes. This study compared the oncologic outcomes of patients with low rectal cancer undergoing APR and intersphincteric resection (ISR) after neoadjuvant chemoradiotherapy (nCRT). We compared 104 patients who underwent ISR for lower rectal cancer between 2008 and 2014 with 79 patients who underwent APR during the same period. Cases in which tumors involved the levator ani muscle or the external anal sphincter, as well as those in which surgeons were unable to obtain a negative distal margin via sphincter-saving operation were excluded. Fifty-two patients who underwent ISR were matched via propensity scoring with 52 patients who underwent APR. The analyzed variables included patient and tumor characteristics and long-term outcomes before and after 1:1 propensity score matching (PSM). After matching, there were no significant differences between the two groups in clinical stage and tumor distance from anal verge. Short- and long-term outcomes were similar between the two groups. The 5-year disease-free survival rate was 76.3% in the ISR group and 57.8% in the APR group (p = 0.080). The 5-year cancer-specific survival rate was 89.5% in the ISR group and 85.4% in the APR group (p = 0.383). This reveals that ISR and APR have similar oncologic outcomes following nCRT in patients with advanced low rectal cancer adjusted for background variables.

Intersphincteric resection for low rectal cancer: the risk is functional rather than oncological. A 25-year experience from Bordeaux.

There are few data evaluating the long-term outcomes of intersphincteric resection (ISR), especially the impact of inclusion of more juxtapositioned and intra-anal tumours on oncological and functional outcomes. We compared the oncological and functional results of patients treated by total mesorectal excision and ISR for low rectal cancer over a 25-year period. This is a retrospective study from a single institution evaluating results of ISR over three periods: 1990-1998, 1999-2006 and 2007-2014. Patients treated by partial or total ISR, with or without neoadjuvant chemoradiotherapy, for low rectal cancer (≤6cm from the anal verge) were included. We compared postoperative morbidity, quality of surgery and oncological and functional outcomes in the time periods studied. Of 813 patients operated on for low rectal cancer, 303 had ISR. Tumour stage did not differ; however, the distance of the tumour from the anorectal junction decreased from 1 to 0cm (P<0.001) and the distal resection margin shortened from 25 to 10mm (P<0.001) from 1990 to 2014. The postoperative morbidity and quality of surgery did not change significantly over time. The 5-year local recurrence (4.3% vs 5.9%vs 3.5%; P=0.741) and disease-free survival (72%vs 71%vs 75%; P=0.918) did not differ between the three time periods. Functional results improved during the last period; however, overall 42% of patients experienced major bowel dysfunction. Pushing the envelope of sphincter-saving resection in ultra-low rectal cancer reaching or invading the anal sphincter did not compromise oncological and functional outcomes. The main limitation of the ISR procedure appears to be functional rather than oncological, suggesting that bowel rehabilitation programmes should be developed.

Mesorectal fat area and mesorectal area affect the surgical difficulty of robotic‐assisted mesorectal excision and intersphincteric resection respectively in different ways

Many studies have demonstrated predictors of the difficulty of laparoscopic anterior resection for rectal cancer. Few studies focus on the influence of pelvic dimensions on robotic-assisted mesorectal excision (ME) and intersphincteric resection (ISR). This study aimed to evaluate the influences of the mesorectal fat area (MFA) and mesorectal area on the difficulty of robotic sphincter-saving surgery. We included 156 patients with middle and low rectal cancer who underwent robotic sphincter-saving surgery. Clinical and anatomical factors, including the pelvic dimensions, were collected. Linear regression was performed for variables associated with surgical duration. We also performed subgroup analyses for robotic-assisted ME and ISR. Logistic regression was used to find variables associated with transanal dissection. For patients with middle or low rectal cancer, the sacral length and tumour distance from the anal verge were independently associated with surgical duration. The pT stage, sacral length and the MFA were independent predictors for the surgical duration of robotic-assisted ME. By contrast, a small mesorectal area was independently related to a longer duration of robotic-assisted ISR. The pelvic outlet length was independently associated with the use of transanal dissection for ISR. It is suggested that a large MFA could affect the difficulty of ME in robotic-assisted ME, while a small mesorectal area could increase the surgical difficulty of robotic-assisted ISR for low rectal cancer. Besides, the pelvic outlet length was associated with the use of transanal dissection. Further studies are needed to validate the results and draw more scientific conclusions.

Oncologic safety and bowel function after ultralow anterior resection with or without intersphincteric resection for low lying rectal cancer: Comparative cross sectional study.

Despite acceptable oncologic outcomes of sphincter preserving surgeries for low rectal cancer, bowel dysfunction occurs. This study aimed to compare the oncologic and functional bowel outcomes between ultralow anterior resection (ULAR) and intersphincteric resection (ISR) for low rectal cancer. One hundred sixty-four patients who underwent ULAR with or without ISR for low rectal cancer between December 2010 and May 2018 were included. The Wexner and Memorial Sloan Kettering Cancer Center (MSKCC) scores were used to evaluate the bowel function of patients. Overall survival (OS) and disease-free survival (DFS) were compared between patients. The ISR group had higher incidence of major fecal incontinence than the ULAR group (75.9% vs 49.3%; P = .016). The median Wexner score decreased from 12 to 9 (P = .062) at 1-year follow-up. However, the frequency and urgency/soilage subscales of MSKCC score improved significantly in the ULAR group. ISR and follow-up interval less than 1-year significantly increased the major incontinence risk. The OS in the ULAR and ISR groups was 91.4% and 91.7%. Whereas the DFS in both groups was 79% and 79.2%, respectively. ULAR and ISR are comparable in oncologic outcomes. Severe bowel dysfunctions and major incontinence were noted in ISR group. Careful selection of patients is mandatory.

Long-term results of intersphincteric resection for low rectal cancer in Japan.

Intersphincteric resection (ISR) is the ultimate sphincter-preserving procedure for low rectal cancer. A questionnaire about the standardization of ISR was given to 2125 patients who underwent curative ISR for low rectal cancer between 2005 and 2012at 127 affiliated institutions of the Japanese Society for Cancer of the Colon and Rectum (JSCCR), and the results were compared with the results of a systematic review. The findings revealed that although mortality and morbidity were relatively low and the survival rate after ISR was good, the rates of local recurrence and postoperative fecal incontinence were relatively high. The radicality of ISR was compared with that of abdominoperineal resection and low anterior resection using the propensity score matching prognosis analysis of patients in the JSCCR nationwide registry. The local recurrence rate was significantly higher after ISR, and especially high in patients with T3 (invasion into the external anal sphincter) and T4 disease. These results provide evidence about the factors related to fecal incontinence after ISR. As measures for the standardization of ISR, it is important to reconfirm that ISR is not indicated for patients with cT3 and cT4 disease and those with poor preoperative defecatory function, based on the ISR indication criteria.

Usefulness of Fecoflowgram for Assessment of Defecation after Intersphincteric Resection

Aim: We have developed an imaging functional assessment of defecation after partial intersphincteric resection (ISR) by fecoflowgram obtained by defecography. Patients and Methods: Between January 2012 and December 2014, 6 patients with temporary ileostomy who underwent partial ISR for lower rectal cancer at our hospital were enrolled in this study. Defecography was performed 2 weeks after closure of the ileostomy. The defecation of all patients was evaluated by defecography and a fecoflowgram calculated from defecography. During the same period, the control group was comprised of 2 male and 2 female healthy volunteers. Results: The descent of the perineum and linearization of the anorectal angle was observed relative to normal defecation in the healthy volunteers. All barium was discharged by a single abdominal pressure within 5 s in the controls. In patients after partial ISR, all barium could not be discharged by a single abdominal pressure. The time course of pressure distribution after ISR was lower than that of healthy volunteers, which could not be evaluated by defecography. Defecation time in patients following ISR was longer than that of healthy volunteers. Conclusion: Fecoflowgrams calculated from defecography seem to be useful for functional assessment of defecation after rectal resection.

Survival and functional and oncological outcomes following intersphincteric resection for low rectal cancer: short-term results.

ObjectiveThis study was performed to evaluate the 1-year survival rate and functional outcomes of 20 patients who underwent intersphincteric resection (ISR) for low rectal cancer.MethodsTwenty patients who underwent ISR for low rectal cancer were followed up for 1 year. Complications, functional outcomes objectified by the Wexner score, and oncological outcomes were assessed.ResultsThe short-term survival rate was 100%. The median Wexner score was ≤10 in all patients at 12 months after surgery. Signs of local recurrence were absent, and antigen levels remained within the reference ranges 1 year postoperatively.ConclusionsISR is a feasible alternative in highly selected patients who primarily refuse a colostomy bag and present with type II or III tumors. In the present study, patient-reported continence was satisfactory, and the absence of a colostomy bag increased patients’ quality of life. The oncological outcomes were satisfactory at 1 year postoperatively.

Safety and feasibility of laparoscopic intersphincteric resection for a lower rectal tumor.

The aim of the present study was to evaluate the short-term surgical outcomes of laparoscopic intersphincteric resection (ISR) for a lower rectal tumor in comparison with a case-control series of patients undergoing open ISR. Quality of life factors and anal function were also evaluated. Between July 2008 and April 2013, 103 patients with lower rectal cancer underwent laparoscopic surgery at the Surgical Oncology Department of Gifu University School of Medicine. A total of 25 patients with lower rectal cancer underwent ISR, and 19/25 patients who underwent laparoscopic ISR were compared with the control group of 6 patients who underwent open ISR. The technical feasibility and safety of ISR, and the short- and long-term outcomes following laparoscopic ISR were evaluated. Additional data associated with fecal incontinence conditions of the postoperative patients were evaluated using the Modified Fecal Incontinence Quality of Life scale. There was no recorded perioperative mortality, three complications were observed to occur in three patients and the morbidity rate was 15.8%. The postoperative complications detected included bleeding in one patient and ileus in two patients of the laparoscopic ISR group. The rate of severe complications of grade ≥3a was 15.8% and that of grade ≥3b was 5.3%. In the matched case-control study, blood loss was significantly lower in the laparoscopic ISR group. The median postoperative hospital stay was 14.1 days in the laparoscopic ISR group, which was significantly shorter compared with in the open ISR group (18.7 days). Cancer recurrence was detected in one (5%) patient in a single inguinal lymph node. No significant differences between the ISR and ultra-low anterior resection (ULAR) groups were observed in the maximum resting and maximum squeeze pressures; the outcomes for anal function and fecal incontinence were the same for ISR and ULAR. Thus, laparoscopic ISR for lower rectal cancer may provide a benefit in the early postoperative period without increasing morbidity or mortality.

The Impact of Anastomotic Leakage on Anal Function Following Intersphincteric Resection.

Data regarding anastomotic leakage (AL) following intersphincteric resection (ISR) are lacking. We aimed to evaluate the effect of AL on anal function in a retrospective review of patients who developed AL following ISR. We evaluated 341 consecutive patients who underwent ISR between 2000 and 2012. Patients were classified into three groups: anastomotic dehiscence (AD), major AL (Clavien-Dindo grade III+), or control (<grade III or no AL). Functional assessment was performed at 3, 6, 12, and 24months after defecation through the preserved anus, and the Wexner score was calculated. Among patients who underwent ISR for low rectal cancer (anal verge, 3.7±1.3cm), 59 (17%) developed AL. Of these, 13 patients were classified as AD and 36 as major AL. The rate of the 3-year stomal reversal was significantly lower in the major AL (78.6%) and AD groups (61.5%) than in the control group (88.7%; p<0.01). Furthermore, the anastomotic stricture rate was higher in the AL and AD groups than in the controls (16.7 and 38.5 vs. 1.8%, respectively; p<0.01). Wexner scores in the major AL group were poor during the early period, but were similar to the control group at the 2-year follow-up. In contrast, Wexner scores in the AD group remained high, even after 2years. Patients with major AL following ISR had poor anal function that recovered over 2years, as long as AD was not present. These findings suggest that patients with major AL require a long-term follow-up for anal function.

Functional results of robotic total intersphincteric resection with hand-sewn coloanal anastomosis

BackgroundIn recent decades there has been an increasing trend toward sphincter-preserving procedures for the treatment of low rectal cancer. Robotic surgery is considered to be particularly beneficial when operating in the deep pelvis, where laparoscopy presents technical limitations. The aim of this study was to prospectively evaluate the functional outcomes in patients affected by rectal cancer after robotic total intersphincteric resection (ISR) with hand-sewn coloanal anastomosis. Methods and proceduresFrom March 2008 to October 2012, 23 consecutive patients affected by distal rectal adenocarcinoma underwent robotic ISR. Operative, clinical, pathological and functional data regarding continence or presence of a low anterior resection syndrome (LARS) were prospectively collected in a database. ResultsTwenty-three consecutive patients were included in the study: 8 men and 15 women. The mean age was 60.2 years (range 28–73). Eighteen (78.3%) had neoadjuvant radiochemotherapy. Conversion rate was nil. The mean operative time was 296.01 min and the mean postoperative hospital stay was 7.43 ± 1.73 days. According to Kirwan's incontinence score, good fecal continence was shown in 85.7% of patients (Grade 1 and 2) and none required a colostomy (Grade 4). Concerning LARS score, the results were as follows: 57.1% patients had no LARS; 19% minor LARS and 23.8% major LARS. ConclusionsRobotic total ISR for low rectal cancer is an acceptable alternative to traditional procedures. Extensive discussion with the patient about the risk of poor functional outcomes or LARS syndrome is mandatory when considering an ISR for treatment of low rectal cancer.

A delayed-onset rectourethral fistula after intersphincteric resection for very low rectal cancer: a case report and literature review.

Rectourethral fistula is one of the complications that can occur after prostatectomy in the urologic discipline. However, a delayed-onset rectourethral fistula after intersphincteric resection (ISR) for low rectal cancer is extremely rare. Here, we report one such case in a 57-year-old man. After ISR for low rectal cancer with a diverting stoma (DS), the DS was closed. After approximately 1 year, frequent pneumaturia and right orchitis were observed. Results of contrast enemas and abdominal computed tomography examinations revealed a rectourethral fistula from an anastomosis to the urethra. The colonoscopic appearance revealed a pinhole fistula on the anastomotic line, with thick pus. We performed a transverse colostomy, and the pneumaturia and right orchitis were no longer observed. Two months later, colonoscopy, contrast enemas, and cystoscopy revealed no rectourethral fistula. To the best of our knowledge, our case is the first report of a delayed-onset rectourethral fistula after ISR.

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.

Intersphincteric resection for very low rectal cancer: clinical outcomes of open versus laparoscopic approach and multidimensional analysis of the learning curve for laparoscopic surgery

BackgroundLaparoscopic rectal cancer surgery is regarded as more complex because of its technical difficulties in pelvic exposure, dissection, and sphincter preservation. This study therefore aimed to investigate the feasibility of laparoscopic resection for low rectal cancer using intersphincteric resection (ISR) and to assess its short-term oncological outcomes. Further, we intended to analyze the learning curve for laparoscopic surgery and identify the factors influencing the learning curve. MethodsPatients with low rectal cancer who received open or laparoscopic ISR were retrospectively chart reviewed. The surgical and oncological outcomes were evaluated. Comparisons of operating time, estimated blood loss, surgical outcomes, and histopathologic status were analyzed. Also, operating time was used as a technical indicator for learning curve analysis. ResultsThe mean estimated blood loss was 265 mL (range, 100–800 mL) in the open group and 104 mL (range, 30–250 mL) in the laparoscopic group. There was a significant difference between these two groups (P < 0.001). Operative experience analysis showed that the mean operating time was 402.1 min (range, 210–570 min) in the first stage and 331.4 min (range, 210–450 min) in the second stage, and on pathologic examination the mean number of lymph nodes harvested was 11.1 (range, 5–21) in the first stage and 18.3 (range, 11–31) in the second stage, with statistical differences between these two stages (P = 0.034 and P = 0.004, respectively). Multifactorial analysis showed that operating time was associated with surgeons’ experience (<18 or ≥18 cases) (odds ratio = 2.918, 95% CI 1.078–7.902). Protective stoma creation was also associated with surgeons’ experience (odds ratio = 3.999, 95% CI 1.153–13.86). ConclusionsOur data show that laparoscopic ISR for low rectal cancer is feasible and safe. Surgeons’ experience improved operating time and postoperative complications.

Systematic review of outcomes after intersphincteric resection for low rectal cancer

For a select group of patients proctectomy with intersphincteric resection (ISR) for low rectal cancer may be a viable alternative to abdominoperineal resection, with good oncological outcomes while preserving sphincter function. The purpose of this systematic review was to evaluate the current evidence regarding oncological outcomes, morbidity and mortality, and functional outcomes after ISR for low rectal cancer. A systematic review of the literature was undertaken to evaluate evidence regarding oncological outcomes, morbidity and mortality after ISR for low rectal cancer. Three major databases (PubMed, MEDLINE and the Cochrane Library) were searched. The review included all original articles reporting outcomes after ISR, published in English, from January 1950 to March 2011. Eighty-four studies were identified. After applying inclusion and exclusion criteria, 14 studies involving 1289 patients were included (mean age 59.5 years, 67.0 per cent men). R0 resection was achieved by ISR in 97.0 per cent. The operative mortality rate was 0.8 per cent and the cumulative morbidity rate 25.8 per cent. Median follow-up was 56 (range 1-227) months. The mean local recurrence rate was 6.7 (range 0-23) per cent. Mean 5-year overall and disease-free survival rates were 86.3 and 78.6 per cent respectively. Functional outcome was reported in eight studies; among these, the mean number of bowel motions in a 24-h period was 2.7. Oncological outcomes after ISR for low rectal cancer are acceptable, with diverse, often imperfect functional results. These data will aid the clinician when counselling patients considering an ISR for management of low rectal cancer.

Short-Term Outcomes of Laparoscopic Intersphincteric Resection for Lower Rectal Cancer and Comparison with Open Approach

Background/Aims: To evaluate the short-term surgical outcomes of laparoscopic intersphincteric resection (ISR) for lower rectal cancer, and to compare them with a case-control series of open ISR. Methods: Between July 2002 and March 2011, 29 patients with lower rectal cancer underwent laparoscopic ISR, and 22 of 29 patients who underwent laparoscopic ISR were compared with the control open ISR group of patients matched for age, gender, operative procedure and pathological stage. Results: There was no perioperative mortality, 8 complications occurred in 7 patients, and the morbidity rate was 24.1% (7/29). Leakage occurred in 1 patient (3.4%) in the laparoscopic ISR group. Regarding the matched case-control study, the operative time was significantly longer (p = 0.0007), but blood loss was significantly lower (p = 0.0003) in the laparoscopic ISR group. The median postoperative hospital stay was 8 days in the laparoscopic ISR group, which was significantly shorter than in the open ISR group (14 days). Postoperative complication rates were similar. In the laparoscopic ISR group, the levels of C-reactive protein on postoperative days 1–3 were significantly lower than in the open ISR group. Conclusions: Laparoscopic ISR for lower rectal cancer provides benefits in the early postoperative period without increasing morbidity or mortality.

Extending the horizons of restorative rectal surgery: intersphincteric resection for low rectal cancer

Radical resection of tumours of the distal rectum has generally entailed an abdominoperineal excision, but the recognition of shorter safe distal resection margins, neoadjuvant chemoradiotherapy and the application of the technique of intersphincteric resection (ISR) have led to the prospect of restorative surgery for patients with distally situated tumours. The present study examines the indications, techniques and outcomes following ISR. A literature search was performed to identify studies reporting outcomes following ISR for low rectal cancer. The outcomes of interest included short-term adverse events, functional and manometric results, postoperative quality of life and oncologic outcomes. Twenty-one studies reflecting the experience of 13 units and 612 patients were included. Operative mortality following ISR was 1.6% (inter-unit range 0-5%) and anastomotic leak rate 10.5% (inter-unit range 0-48.4%). The pooled rate of local recurrence was 9.5% (range 0-31% between units) with an average 5-year survival of 81.5%. Most studies recorded a significant reduction in resting anal pressure but not squeeze pressure following surgery, but urgency was reported in up to 58.8% of patients. Functional outcomes and quality of life may be improved using colonic j-pouch reconstruction. The use of chemoradiotherapy can offer benefits in terms of oncologic result, but at the cost of worse functional outcomes. Careful case selection and counselling is required if satisfactory results are to be achieved following ISR for low rectal cancers. In selected patients, however, the technique offers sphincter preserving surgery with acceptable oncologic and functional results.