Laparoscopic Intersphincteric Resection Research Articles

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 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.

腹腔鏡下内肛門括約筋切除術後に下肢のAcute compartment syndromeをきたした進行下部直腸癌の1例

手術に関連するAcute compartment syndrome（ACS）は稀であり，早期の診断と加療が重要である．腹腔鏡下内肛門括約筋切除術後に下肢のACSをきたした症例を経験したので報告する．症例は進行下部直腸癌の40歳代男性．術前検査で側方リンパ節転移が疑われ，術前化学療法後に腹腔鏡下内肛門括約筋切除術および治療的両側側方リンパ節郭清術を施行した．体位は開脚頭低位を基本とし，会陰操作と側方リンパ節郭清時は頭低位かつ砕石位とした．手術時間は331分で出血は80mlであった．術後19時間に左下肢の激痛を認め，精査によりDVTは否定されACSの診断で発症後7時間に緊急減張切開術を施行した．primary sutureにより創部治癒し，その他の合併症を認めず術後13日で退院となった．術後14ヵ月現在，ACSの後遺症を認めず無再発経過観察中である．

Laparoscopic sphincter-preserving surgery (intersphincteric resection) after neoadjuvant imatinib treatment for gastrointestinal stromal tumor (GIST) of the rectum

Gastrointestinal stromal tumors (GISTs) of the rectum are rarely found, and radical surgery such as abdominoperineal resection would be necessary for large rectal GIST. On the other hand, therapy for GIST has changed significantly with the use of imatinib. Neoadjuvant imatinib therapy may reduce tumor size and may potentially prevent extended surgery. Moreover, when sphincter-preserving surgery is carried out laparoscopically, it can be performed as minimally invasive surgery with preservation of the anus. From 2008 to 2011, five patients with rectal GIST were treated in our hospital. All patients received preoperative imatinib treatment (400 mg/day) and underwent laparoscopic sphincter-preserving surgery after 4-12 months of this treatment. Initial median tumor size was 31 mm (range, 24-88). At the time of operation, the median tumor size was 24 mm (range, 11-52). Sphincter-preserving surgery was performed in all patients. Three patients underwent laparoscopic intersphincteric resection (ISR), and two patients underwent transanal full-thickness local resection and recto-anal anastomosis following laparoscopic ISR. Macroscopically complete resection was achieved, and microscopically, the resection margin was not involved of residual tumors. The median duration of postoperative hospital stay was 16 days (range, 13-30). No recurrence occurred in all patients during 1 to 4 years. The present study suggests that neoadjuvant imatinib therapy might be effective to prevent extended surgery for rectal GIST, and laparoscopic sphincter-preserving surgery is safe and technically feasible. We recommend a combination of neoadjuvant imatinib therapy and laparoscopic ISR for locally advanced rectal GIST.

Feasibility of Laparoscopic Intersphincteric Resection for Patients with cT1-T2 Low Rectal Cancer

Aims: The purpose of this study was to assess the feasibility of laparoscopic intersphincteric resection (LAP-ISR) for rectal cancer in terms of morbidity, oncological outcomes, and functional results. Methods: Thirty-seven patients with primary low rectal cancer cT1-T2 underwent LAP-ISR. Surgical outcomes, pathological results, postoperative complications, oncological outcomes, and functional results were analyzed retrospectively. Results: Three patients (8.1%) had carcinoma in situ, 22 (59.5%) had pT1 tumor, and 11 (29.7%) had pT2 tumor. Eleven patients (29.7%) were diagnosed as being node positive, while 26 (70.3%) had node-negative disease. The median operative time was 315 min (range: 195-502). The median blood loss was 37 ml (range: 0-745). One case was converted to open surgery. Pathological complete resection was achieved in all cases. There was no surgical mortality. Postoperative complications of grade III-IV on the Clavien-Dindo classification were observed in 16.2% of the patients. The median follow-up period was 2.8 years (range: 187-2,241 days), and 3-year disease-free survival was 93.1%. No patient developed local recurrence. The functional result was objectively good. Conclusion: LAP-ISR can be recommended as a feasible, ultimate sphincter-preserving procedure with acceptable functional and intermediate-term oncological outcomes in patients with cT1-T2 very low rectal cancer.

Initial experience of robotic intersphincteric resection for rectal cancer

Purpose: Robotic systems (the da Vinci Surgical System) may offer considerable advantages, particularly in rectal surgery operated in the confined pelvis. This study was carried out on the assumption that a robotically naive, yet laparoscopically experienced surgeon successfully transferred to a robotic environment. We assessed immediate surgical outcomes of robotic intersphincteric resection (ISR) as an initial experience of a single surgeon. Methods: We analyzed the data of 19 consecutive patients with rectal cancer who underwent robot ISR between January 2009 and March 2012. Its immediate surgical outcomes were compared with those of 19 patients who underwent laparoscopic ISR as a control group of the same cohort. Results: There was no significant difference in the mean operating time between robotic and laparoscopic group (261.6±57.7 minutes, 222.37±68.2 minutes, P=0.064). Mean distal resection margin was 1.5±2.2 and 1.1±0.9 in robotic and laparoscopic groups, respectively (P=0.464). Three patients in each group had a circumferential margin clearance of less than 1 mm. Two patients in each group suffered from anastomotic leakeage. There were no significant differences in date of flatus passage and dietary intake, and the length of postoperative hospital stay between both groups. Conclusion: Robotic ISR is a safe and feasible procedure and its early short-term surgical outcomes are comparable to those of laparoscopic 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.

Feasibility and functional outcome of laparoscopic intersphincteric rectal resection for ultra-low rectal cancer

The Aim of this study is to evaluate the feasibility and analyze the functional outcome of laparoscopic intersphincteric resection (LISR) in ultra-low rectal cancer. The preservation of anal function following curative operations for low rectal cancer is becoming increasingly important. Laparoscopic intersphincteric resection of the rectum is the utmost sphincter saving operation for rectal cancer. The rectum is laparoscopically resected along with the internal anal sphincter, providing an adequate distal margin for even the ultra-low tumours of the rectum. Between 2008 and 2012, nine patients, 2 with a T3 tumour that received preoperative chemoradiotherapy and 7 patients with a non-fixed T2 rectal adenocarcinoma, underwent LISR by a single surgeon. Preoperative tumour staging included endorectal ultrasonography (ERUS) and pelvic MRI. Patients with multiple distant metastases, tumour invasion into adjacent organs and invasion into the external anal sphincter and/or levator ani, were excluded from LISR. Covering ileostomy in seven patients was reversed with a satisfactory functional outcome in each case. All patients underwent LISR with curative intent. There was no postoperative mortality. Complications included anal stenosis, prolapse of the neorectum and pelvic hematoma. The overall quality of life and functional outcome were deemed satisfactory. In selected patients, intersphincteric rectal resection may provide an acceptable functional outcome for ultra-low rectal cancer patients, without a permanent stoma.

Anorectal dynamics in low rectal carcinoma patients undergoing intersphincteric resection

Objective To investigate the changes of anorectal dynamics in low rectal carcinomapatients subject to three different kinds of treatments undergoing intersphincteric resection (ISR),evaluatethe clinical effects on anorectal dynamics by three different kinds of treatments,and to discuss the mecha-nisms.Methods 113 low rectal carcinoma patients who received ISR were divided ioto three groups:neo-adjuvant chemotherapy with laparoscopic anterior resection ISR group (group A,n =32),laparoscopic an-terior resection ISR group (group B,n =43 ),open anterior resection ISR group ( group C,n =38 ).Theanorectal dynamics in the three groups was determined and compared before and 3,6,9,12 months afteroperation by an anorectal pressure detector.Results The level of anal resting pressure in the three groupsat 3rd month after operation [(33.53 ± 6.58),(24.69 ± 5.62),( 14.86 ± 5.54) mm Hg ( 1 mm Hg =0.133 kPa)] were remarkably lower than those before operation [(49.37 ± 14.32),(47.32 ± 7.87),(46.50±10.02) mmHg (P＜0.05)],but hada nilder decrease in group A (33.53±6.58) mmHgthan in group B (24.69 ± 5.62) mm Hg and group C (14.86 ± 5.54 )mm Hg ( P ＜ 0.05 ).The positiverate of rectoanal inhibitory reflex at 3rd month after operation was lower significantly than that before opera-tion ( P ＜ 0.05 ),but that in group A was higher than in group B and group C (P ＜ 0.05 ).As comparedwith group B,the levels of balloon-discharge test time,initial defecation capacity threshold and maximumtolerated volume in group A almost recovered to those before operation 3 months ahead of time ( P ＜ 0.05),and as compared with group C,6 months in advance recovery to preoperative levels (P ＜0.05).Conclu-sion Neoadjuvant chemotherapy with laparoscopic anterior resection is appropriate even more for low rectalcarcinoma ISR patients. Key words: Rectal neoplasms; Intersphincteric resection; Anorectal dynamics

A case of isolated lateral lymph node recurrence occurring after TME for T1 lower rectal cancer treated with lateral lymph node dissection: report of a case

We experienced a rare case of isolated lateral lymph node (LLN) recurrence after laparoscopic intersphincteric resection with total mesorectal excision for T1 lower rectal cancer that was successfully treated using LLN dissection with en bloc resection of the left superior vesical artery, the left ovary and the left obturator nerve, artery and vein. There are no guidelines for treating patients with isolated LLN recurrence because isolated LLN recurrence is rare, especially in patients with T1 rectal cancer. However, in patients with pT1N0 lower rectal cancer, follow-up examinations of the pelvis should be performed periodically. Patients with isolated LLN recurrence treated with surgery might have good long-term prognoses. Therefore, for such patients, surgical resection should be considered as a curative treatment only.

Short-term clinical outcome of robot-assisted intersphincteric resection for low rectal cancer: a retrospective comparison with conventional laparoscopy

A robotic system (da Vinci(®) Surgical System, Intuitive Surgical Inc., Sunnyvale, CA, USA) has technical advantages over conventional laparoscopic surgery because it increases the precision and accuracy of anatomical dissection. The present study aimed to compare the short-term outcomes between robot-assisted intersphincteric resection (ISR) and laparoscopic ISR for distal rectal cancer. Patients who underwent robot- or laparoscopy-assisted ISR for rectal cancer between March 2008 and July 2011 were included in this retrospective comparative study. Perioperative and postoperative data, including complications and early functional outcomes, were analyzed between the two groups. Functional outcomes were evaluated using the Wexner scoring system, the International Prostate Symptom Score, and the 5-item version of the International Index of Erectile Function. A total of 40 patients underwent robot-assisted and 40 underwent laparoscopic ISR. The mean operative time was significantly longer in the robotic group than in the laparoscopic group (235.5 vs. 185.4 min; p < 0.001). Transabdominal ISR, in which intersphincteric dissection is completed in the pelvic cavity, was performed more with robotic assistance than with laparoscopic surgery (8 vs. 2 cases; p = 0.043). No difference was observed between groups regarding postoperative morbidity and pathological outcomes. The robot-assisted group showed a trend toward less postoperative blood loss and early recovery of functional outcomes. Robot-assisted surgery was safe and effective for ISR of distal rectal cancer and showed surgical outcomes similar to those of the latest laparoscopic ISR. The favorable results of the robot-assisted ISR included reduced adaptation time, alleviated difficulty of perineal phase, and early recovery of functional outcomes in this analysis of short-term clinical outcomes.

Short-term outcomes of laparoscopic intersphincteric resection from a phase II trial to evaluate laparoscopic surgery for stage 0/I rectal cancer: Japan Society of Laparoscopic Colorectal Surgery Lap RC

Laparoscopic intersphincteric resection (Lap ISR) is not yet an established technique and its safety and feasibility are unclear. Our aim was to clarify the safety and feasibility of Lap ISR for clinical stage 0/I rectal cancer (Lap RC) in a prospective multicenter study of laparoscopic surgery in Japan. To examine the technical and oncological feasibility of laparoscopic surgery for rectal cancer, we conducted a confirmatory phase II trial to evaluate laparoscopic surgery for preoperative clinical stage 0/I rectal cancer. Eligibility criteria included histologically proven carcinoma, size ≤ 8 cm, age 20-75 years, no bowel obstruction, and no prior chemotherapy or radiotherapy. Between February 2008 and September 2010, 495 patients with rectal cancer underwent laparoscopic surgery at 43 institutions. Patients' background characteristics and operative and postoperative outcomes were recorded prospectively. Seventy-seven patients (15.6 %) underwent Lap ISR. A diverting stoma was created in 69 patients (89.6 %). Conversion to open surgery occurred in 4 patients (5.2 %): 2 patients were converted because of uncontrollable bleeding, and the other 2 patients because of the need for pelvic side wall lymphadenectomy. There was no mortality. Median operative time was 345 min (range = 198-565), median amount of blood loss was 100 ml (range = 0-1760), and three patients (3.9 %) were transfused intraoperatively. The median number of dissected lymph nodes was 14 (range = 3-33), and all (proximal, distal, and vertical) pathological cut margins were negative. Postoperative complications of grade 2 or more were detected in 17 patients (22.1 %), including anastomotic leakage in 5 (6.4 %), bowel obstruction in 5 (6.5 %), and surgical site infection in 2 (2.6 %). Abdominal drainage and diverting stoma were necessary in two patients (2.6 %) due to anastomotic leakage. Median length of postoperative hospital stay was 13 days (range = 7-167). Lap ISR was feasible and safe for clinical stage 0/I rectal cancer with favorable short-term outcome.

CLINICAL OUTCOME OF INTERSPHINCTERIC RESECTION FOR ULTRA-LOW RECTAL CANCER

BACKGROUND: Laparoscopic surgery has been reported to be one of the approaches for total mesorectal excision (TME) in rectal cancer surgery. Intersphincteric resection (ISR) has been reported as a promising method for sphincter-preserving operation in selected patients with very low rectal cancer. METHODS: We try to underline the important surgical issues surrounding the management of patients with low rectal cancer indicated to laparoscopic intersphincteric resection (ISR). From January 2007 till now, 35 patients with very low rectal cancer underwent laparoscopic TME with ISR. We report and analyze the results from them RESULTS: Conversion to open surgery was necessary in one (3%) patient. The median operation time was 293 min and median estimated blood loss was 40 ml. The pelvic plexus was completely preserved in 32 patients. There was no mortality. Postoperative complications occurred in three (9%) patients. The median length of postoperative hospital stay was 11 days. Macroscopic complete mesorectal excision was achieved in all cases. Complete resection (R0) was achieved in 21 (91%) patients. CONCLUSIONS: Laparoscopic TME with ISR is technically feasible and a safe alternative to laparotomy with favorable short-term postoperative outcomes. The literature research made by us found that the laparoscopic approach can be underwent in most patients with low rectal cancer in which laparoscopic ISR represents a feasible alternative to conventional open surgery.

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.

Intersphincteric resection for low rectal cancer: laparoscopic vs open surgery approach

Laparoscopic sphincter-saving surgery has been investigated for rectal cancer but not for tumours of the lower third. We evaluated the feasibility and efficacy of laparoscopic intersphincteric resection for low rectal cancer. From 1990 to 2007, patients with rectal tumour below 6 cm from the anal verge and treated by open or laparoscopic curative intersphincteric resection were included in a retrospective comparative study. Surgery included total mesorectal excision with internal sphincter excision and protected low coloanal anastomosis. Neoadjuvant treatment was given to patients with T3 or N+ tumours. Recurrence and survival were evaluated by the Kaplan-Meier method and compared using the Logrank test. Function was assessed using the Wexner continence score. Intersphincteric resection was performed in 175 patients with low rectal cancer: 110 had laparoscopy and 65 had open surgery. The two groups were similar according to age, sex, body mass index, ASA score, tumour stage and preoperative radiotherapy. Postoperative mortality (zero) and morbidity (23%vs 28%; P = 0.410) were similar in both groups. There was no difference in 5-year local recurrence (5%vs 2%; P = 0.349) and 5-year disease-free survival (70%vs 71%; P = 0.862). Function and continence scores (11 vs 12; P = 0.675) were similar in both groups. Intersphincteric resection did not alter long-term tumour control of low rectal cancer. The safety and efficacy of the laparoscopic approach for intersphincteric resection are suggested by a similar short- and long-term outcome as obtained by open surgery.

Laparoscopic Versus Open Intersphincteric Resection and Coloanal Anastomosis for Low Rectal Cancer

To compare the surgical outcome and intermediate oncological outcomes for laparoscopic versus open intersphincteric resection (ISR). Intersphincteric resection has been proposed as an alternative to abdominoperineal resection for selected low rectal cancer cases, but the oncological adequacy of laparoscopic ISR has not been established. A total of 210 consecutive patients with low rectal cancer who underwent ISR between 1997 and 2009 in 2 institutions were evaluated retrospectively. Patients were classified into an open surgery (OS, n = 80) group and a laparoscopy (LAP, n = 130) group. The primary endpoint was 3-year disease-free survival. The major complication rates were similar in the LAP and OS groups (5.4% vs 3.8%, respectively; P = 0.428). However, the LAP group had a shorter hospital stay and time to bowel movement compared with the OS group. In the LAP group, operating time was 16 minutes shorter (P = 0.230) and intraoperative blood loss was less (P = 0.002). Median follow-up was 34 months (interquartile range: 20.0-42.5 months). The local recurrence rates were similar in the 2 groups (LAP, 2.6% vs OS, 7.7%; P = 0.184). The combined 3-year disease-free survival for all stages was 82.1% (95% CI: 73.7-90.2%) in the LAP group and 77.0% (95% CI: 66.9%-86.9%) in the OS group (P = 0.523). Laparoscopic ISR can be performed safely and offers a minimally invasive sphincter-sparing alternative. The oncological adequacy of laparoscopic ISR requires long-term follow-up data, but the intermediate-term outcomes seem equivalent to those achieved with OS.

Laparoscopic Intersphincteric Resection for Low Rectal Cancer

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, the functional outcome, and the short-term oncologic outcomes of laparoscopic ISR for low rectal adenocarcinoma at our institution. We retrospectively reviewed the data of 111 consecutive patients who underwent laparoscopic ISR for low rectal adenocarcinoma between July 2005 and December 2009. Demographic status, surgical outcomes, functional outcome data, and oncologic outcome data were collected. The mean distance of the tumor from the anal verge was 3.4 cm (range: 1-5 cm). The mean operative time was 214.7 min (range, 150-450 min). The mean distal resection margin was 1.3 ± 1.1 cm. Morbidity occurred in 24 patients (21.6%), including anastomotic leakage in 2 patients (1.8%). The mean Wexner continence score after stoma repair was 7.5 ± 2.7 (range: 2 ~ 19), and 9.8 in total ISR, 7.3 in partial ISR (P = 0.071). The 3-year overall survival rate was 92.8%, and the 3-year disease-free survival rate was 73.0%. Local recurrence was noted in 6 of the 111 patients with TNM stage I to III (5.4%). The patients with lesions at 2 cm to the dentate line had a 7.07-fold greater risk of local recurrence, including a 13.42-fold greater risk of lateral pelvic wall recurrence and perineal recurrence (95% Confidence interval [CI], 1.141-158.006; P = 0.009) than in those who had lesions more than 2 cm from the anal verge (95% CI, 1.290-38.832; P = 0.011). Laparoscopic ISR after neoadjuvant chemoradiation can be recommended as a technically feasible, minimally invasive, and a sphincter-saving procedure with acceptable functional and short-term oncologic outcomes in patients with very low rectal cancer.

Robot-assisted intersphincteric resection for low rectal cancer: technique and short-term outcome for 29 consecutive patients

Intersphincteric resection (ISR) for low rectal cancer has been described as the ultimate sphincter-saving procedure. Laparoscopic ISR has been proved safe with early postoperative benefits. Recently, some colorectal surgeons have begun to perform robot-assisted ISR to harness the advantages of the da Vinci robotic system. The authors present their short-term results for a robotic technique of ISR. Data from 29 consecutive patients at a single institution with very low rectal cancer (<4cm) from the anal verge who underwent robot-assisted ISR were prospectively collected between December 2007 and March 2010. The study enrolled 23 men and 6 women with a median age of 61.5years (range, 36-82years). Their median body mass index (BMI) was 23.3kg/m(2) (range, 17.9-32.5kg/m(2)). The median distance of the tumor from the anal verge was 3cm (range, 1-4cm). The median operative time was 325min (range, 235-435min), with a console time of 130min (range, 110-210min). There were no conversions to open surgery. A protecting ileostomy was performed for all the patients. The median blood loss was less than 50ml (range,<50-1,000ml). The median size of the tumor was 3cm (range, 0-6.9cm), and the median number of lymph nodes harvested was 16 (range, 1-44). The median distal margin was 0.8cm (range, 0-4cm), and one margin was positive. The circumferential margin was negative (>2mm) for 27 patients. Therefore, complete resection (R0) was achieved for 26 (90%) of the 29 patients. The median hospital stay was 9days (range, 5-15days). Nine patients experienced complications, including three anastomotic leaks (10%). All the leaks were managed conservatively. No surgical mortalities occurred. Robot-assisted intersphincteric resection for very low rectal cancer is feasible, and its short-term outcome is acceptable.

Clinical Outcome of Laparoscopic Intersphincteric Resection Combined with Transanal Rectal Dissection for T3 Low Rectal Cancer in Patients with a Narrow Pelvis

Purpose. The purpose of this study was to analyze the safety and feasibility of laparoscopic intersphincteric resection (ISR) combined with transanal rectal dissection (TARD) for T3 low rectal cancer in a narrow pelvis. Methods. We studied 20 patients with a narrow pelvis of median body mass index 25.3 (16.9–31.2). Median observation period was 23.6 months (range 12.2–56.7). Results. Partial, subtotal, and total ISR was performed in 15, 1, and 4 patients, respectively. Median duration of TARD was 83 min (range 43–135). There were no major complications perioperatively or postoperatively. Surgical margins were histologically free of tumor cells in all patients, and there was no local recurrence. Excluding urgency, frequency of bowel movements, and incontinence status improved gradually after stoma closure. Conclusion. Laparoscopic ISR combined with TARD is technically feasible for selective T3 low rectal cancer in patients with a narrow pelvis.

A large cystic gastrointestinal stromal tumor of the rectum in the retrorectal space

A 54-year-old man presented with pain on defecation and rectal bleeding. Colonoscopy revealed a submucosal tumor extending from the lower rectum to the upper rim of the anal canal, which compressed the rectal wall inward by two thirds of its circumference. Magnetic resonance images demonstrated a 70×80-mm unilocular cystic mass with a solid portion in the periphery in the retrorectal space, which displaced the rectum anterolaterally. The peripheral solid portion was hypointense on T2-weighted images and not hyperintense on diffusion-weighted images, suggesting low cellularity of the lesion. Cytological examination of the clear and serous fluid obtained by transrectal biopsy showed the presence of normal columnar and squamous epithelial cells and the absence of malignant cells. Therefore, the cystic retrorectal mass was presumed to be tailgut cysts rather than gastrointestinal stromal tumors (GISTs). The mass and rectum were extirpated en bloc with an adequate surgical margin by laparoscopic intersphincteric resection. Pathologically, spindle tumor cells proliferated with nuclear palisading and were strongly immunopositive for c-kit, leading to a final diagnosis of rectal GIST. There are no reports describing a huge, cystic rectal GIST arising in the retrorectal space, which should be considered in the differential diagnosis of cystic retrorectal lesions.