Partial Intersphincteric Resection Research Articles

Defecography with water-soluble contrast enema: an alternative imaging method for detecting minor anastomotic fistula after partial intersphincteric resection.

Defecography with water-soluble contrast enema: an alternative imaging method for detecting minor anastomotic fistula after partial intersphincteric resection.

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.

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.

Risk Factors for Anorectal Dysfunction After Interspincteric Resection in Patients With Low Rectal Cancer.

Purpose: The objective of this study was to explore the risk factors for anorectal dysfunction after intersphincteric resection in patients with low rectal cancer.Methods: A total of 251 patients who underwent intersphincteric resection from July 2014 to June 2020 were included in this study, for which the Kirwan's grade, Wexner score, and anorectal manometric index were used to evaluate the anorectal function and other parameters including demographics, surgical features, and clinical and pathological characteristics. These parameters were analysed to explore the potential risk factors for anorectal function after intersphincteric resection.Results: In the 251 included patients, 98 patients underwent partial intersphincteric resection, 87 patients underwent subtotal intersphincteric resection, and 66 patients underwent total intersphincteric resection. There were 53 (21.1%) patients who had postoperative complications, while no significant difference was observed between the three groups. Furthermore, 30 patients (45.5%) in the total intersphincteric resection group were classified as having anorectal dysfunction (Kirwan's grade 3–5), which was significantly higher than that in the partial intersphincteric resection group (27.6%) and subtotal intersphincteric resection group (29.9%). The mean Wexner score of patients that underwent total intersphincteric resection was 7.9, which was higher than that of patients that had partial intersphincteric resection (5.9, p = 0.002) and subtotal intersphincteric resection (6.4, p = 0.027). The initial perceived volume was lower in the total intersphincteric resection group than in the partial and subtotal intersphincteric resection groups at 1, 3, and 6 months after intersphincteric resection. In addition, the resting pressure, maximum squeeze pressure, and maximum tolerated volume in the total intersphincteric resection group were worse than those in the partial and subtotal groups at 3 and 6 months after intersphincteric resection. Univariate and multivariate analyses suggested that an age ≥65, total intersphincteric resection, and preoperative chemoradiotherapy were independent risk factors for anorectal dysfunction (P = 0.023, P = 0.003, and P = 0.008, respectively). Among the 66 patients who underwent total intersphincteric resection, 17 patients received preoperative chemoradiotherapy, of which 12 patients (70.6%) were classified as having anorectal dysfunction.Conclusion: The current study concluded that age ≥65, total intersphincteric resection, and preoperative chemoradiotherapy were risk factors for anorectal dysfunction after intersphincteric resection. The morbidity of anorectal dysfunction after total intersphincteric resection for patients who received preoperative chemoradiotherapy was relatively high, and the indication should be carefully evaluated.

A Retrospective Study on the Feasibility of Completely Laparoscopic Transabdominal Approach Partial Intersphincteric Resection.

Background: With the development of surgical techniques, gastrointestinal surgeons seek ways to improve the quality of life (QOL) for postoperative patients, while ensuring the tumor radical effect, such as reducing trauma, alleviating pain, and preserving the anus. This article discusses the postoperative outcomes of completely laparoscopic transabdominal approach partial intersphincteric resection (CLTPISR). Materials and Methods: The clinical data of 68 patients who underwent CLTPISR at the Affiliated Hospital of Chengde Medical College between May 2017 and June 2020, including procedure-related data, general postoperative conditions, and postoperative anal function data, were retrospectively analyzed to investigate the feasibility and safety of CLTPISR. Results: All 68 rectal cancer patients completed the CLTPISR. The average age was (60.47 ± 7.08) years, the average operative time was (196.22 ± 8.15) minutes, the mean operative bleeding was (49.12 ± 29.61) mL, and the average postoperative hospital stay was (13.46 ± 4.78) days. The postoperative pathology showed that the circumferential margins and distal margins were all negative, the maximum tumor diameter was (3.26 ± 1.11) cm, the distance from the anal verge was (3.92 ± 0.89) cm, and the average number of lymph nodes cleared was (11.06 ± 3.67). There were 28 stage I patients (41.18%), 21 stage II patients (30.88%), and 19 stage III patients (27.94%). The median follow-up time after surgery was 28 months, and the rates of distant metastasis, disease-free survival, and overall survival of the patients were 8.82%, 91.18%, and 95.59%, respectively. The patient's postoperative anal function gradually recovered as time increased. Conclusions: Under the premise of strictly grasping the indications, the CLTPISR is a safe and feasible surgery. It could achieve maximum anal preservation and improve patients' QOL, while maintaining the tumor radical effect, and had the advantages of the short operation time, low intraoperative bleeding, and quick recovery. The Clinical Trial Registration number is LL2020397.

Intersphincteric Resection for Low Rectal Cancer: Parameters Affecting Functional Outcomes and Survival Rates

Introduction: The development of new surgical techniques and devices, as well as the improvements in neoadjuvant chemoradiotherapy enabled intersphincteric resection (ISR), has reduced permanent colostomy usage. The aim of this study was to assess the long-term oncological and functional outcomes of patients who underwent partial ISR for rectal cancer located less than 5cm from the anal verge. Materials and Methods: A series of 106 consecutive patients with very low rectal cancer underwent curative partial ISR from January 2006 to September 2019 were retrospectively evaluated. One-hundred-three (97%) of 106 patients received neoadjuvant chemo-radiotherapy. Overall survival (OS), disease-free survival (DFS), and local recurrence (LR) rates were calculated using Kaplan–Meier methods. The Wexner incontinence score and Kirwan classification were used to evaluate patients’ functional results. Results: The median follow up was 60 months (range, 18–174). The estimated five-year overall and disease-free survival rates were 89% and 81.6%, respectively. Five-year local recurrence and distant metastasis rates were 6.6% and 10.4%, respectively. There was no in-hospital and 30-day mortality. The median Wexner score was 9 (range, 0–20) for 72 patients. Age (<65 years, p=0.027) and gender (male, p=0.019) had a positive effect on functional outcomes after surgery. One and five years colostomy-free survival rates were 96% and 89%, respectively. Conclusion: Intersphincteric resection techniques are feasible for patients with very low rectal cancer, providing good oncological and functional outcomes.

Transanterior obturator nerve gateway: a novel approach to achieving intracorporeal distal rectal transection for ultralow rectal cancer.

Intracorporeal rectal transection at the anorectal junction for ultralow rectal cancer is technically difficult due to pelvic width and limited roticulation, which might require a transanal transection or an oblique transection with multiple firings. These procedures were reported to be associated with the increased risk of morbidity. To address these problems, we presented a novel technique Transanterior Obturator Nerve Gateway (TANG) to transect rectum for ultralow rectal cancer and evaluated its safety and feasibility in this study. A total of 210 consecutive patients who underwent laparoscopic coloanal anastomosis with or without partial intersphincteric resection (CAA/pISR) for rectal cancers between January 2017 and January 2020 were included. Eighty of these patients were analyzed using propensity score matching (PSM). The perioperative characteristics, TANG-related variables, and genitourinary and anal function outcomes were analyzed. Among these enrolled patients, 170 patients underwent traditional transection, and 40 underwent TANG transection; the patients were matched to include 40 patients in each group by PSM. After PSM, there were no significant differences in the operating time (p = 0.351) or bleeding volume (p = 0.474) between the two groups. However, the TANG group had fewer cases of conversion to transanal transection (0 vs. 13, p < 0.001). Moreover, the patients in TANG group had a more desirable transection with longer distal resection margin (1.7 vs. 1.1cm, p < 0.001), shorter stapling line (6.6 vs. 10.3cm, p < 0.001) and fewer stapler firings (p < 0.001). The overall postoperative complication rates and genitourinary and anal function outcomes were not significantly different between the two groups. The TANG approach appears to be a safe, feasible and effective approach for intracorporeal ultralow rectal transection with more distal resection, more vertical transection and fewer stapler firings.

Complete intersphincteric longitudinal muscle excision May Be key to reducing local recurrence during intersphincteric resection

BackgroundAlthough total mesorectal excision (TME) is regarded as a standard procedure for rectal cancer, technical definition and evaluation method have not yet been investigated for intersphincteric resection (ISR). This study was performed to introduce a complete ISR procedure, and to assess whether total intersphincteric longitudinal muscle excision (TILME) facilitated the completeness of ISR and reduced recurrence. MethodsA total of 1080 patients with rectal adenocarcinoma who underwent robot-assisted low anterior resection (LAR) over 10 years were consecutively enrolled. Propensity-score matching of the two LAR groups (ISR vs LAR group, 1:1) and three ISR subgroups (partial vs subtotal vs total ISR subgroup, 2:2:1) was performed by strict adjustment of baseline characteristics. Archived specimens and video-/photo-records were reevaluated to examine completeness of TILME. ResultsComplete-TILME was performed in 84.5% of patients who underwent ISR. Multivariate analysis showed that incomplete-TILME was the only parameter independently associated with increased 5-year cumulative local recurrence (odds ratio = 23.385; 95% confidence interval = 1.492–366.421; p = 0.03), and that incomplete-TILME was independently associated with adipose tissue surrounding the intersphincteric longitudinal muscle, coloanal anastomosis, and total ISR (p < 0.001–0.05). Although mean incontinence scores and anorectal manometry deteriorated to some degree 12–24 months after surgery in all patients, they remained acceptable. The 5-year cumulative DFS (74.1% vs 60%, p = 0.18) and OS (85.9% vs 70%, p = 0.10) rates tended to be higher in patients with complete than incomplete-TILME. ConclusionsThe completeness of TILME appears to be an independent indicator of complete ISR, reducing local recurrence following lower rectal cancer surgery.

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.

Da Vinci Single-Port robot-assisted transanal mesorectal excision: a promising preclinical experience

IntroductionRobotic single-port platforms represent a viable option for advanced surgical procedures. This preclinical study investigated the dual-field, single-port, robot-assisted transanal total mesorectal excision (taTME).TechniqueIn a male human cadaver, we employed the novel da Vinci® SP™ Surgical System, sequentially, to realize the transanal and abdominal parts of the taTME procedure. We evaluated the feasibility of the one-team approach.ResultsWe showed that single-port access for the taTME was technically feasible with the current da Vinci® SP™ Surgical System in both surgical fields. The total console times were 189 min for the juxta-anal purse-string suture placement, partial intersphincteric resection, and bottom-up mesorectal dissection to where it meets the peritoneal reflection and 43 min for the abdominal procedure. A good quality specimen was achieved. The surgeon comfort was high during simulated surgery. The task load was highly acceptable (NASA-TLX global score: 35), even though it was the surgeon’s first use of this platform.ConclusionThis preclinical study demonstrated that the robotic, single-port taTME was feasible and could be performed with the da Vinci® SP™ Surgical System, beginning at the level of the dentate line. Further simulations are necessary to confirm this promising approach.

Analysis on the technical characteristics and clinical efficacy of robotic-assisted intersphincteric resection for patients with low rectal cancer

Objective: To explore the technical characteristics and short-term clinical efficacy of robotic-assisted intersphincteric resection (ISR) for patients with low rectal cancer. Methods: A retrospective cohort study was used. Inclusion criteria: (1) rigid colonoscopy showed lower margin of the tumor ≤5 cm from the anal verge; (2) preoperative rectal MRI or endorectal ultrasound revealed staging T1-2, or T3 patients receiving concurrent chemoradiotherapy; (3) patients less than 70 years old with good function of anal sphincter before surgery; (4) no synchronous multiple primary carcinoma, and no distant metastasis; (5) the method of operation was agreed by the patient. Exclusion criteria: (1) T4 stage tumors; (2) sphincter dysfunction before operation; (3) recurrent tumors; (4) lower edge of tumors beyond the dentate line; (5) death due to non-rectal cancer during follow-up and unsatisfactory follow-up data. The clinical data of 21 patients with low rectal cancer meeting inclusion criteria undergoing robotic-assisted ISR at our department from January 2015 to June 2018 were collected. Parameters during and after operation were observed. Anorectal manometry was performed at 3, 6, and 12 months after the operation, and anal function was evaluated at 3, 6, and 12 months after the closure of the stoma by Kirwan classification and Wexner fecal incontinence score. The key steps of the operation are as follows: according to the principle of total mesorectal excision, the robot continued to enter into the levator ani hiatusdistally, and dissectin the sphincter space; according to the scope of sphincter resection, ISRwas divided into partial ISR, subtotal ISR, and total ISR; subtotal and total ISR usually needed to be combined with transanal pathway. The reconstruction of digestive tract was performed by double stapler anastomosis under laparoscope orhand-sewnanastomosis under direct vision, and preventive ileostomy was completed in the right lower abdomen. Results: Of 21 patients, 13 were male and 8 were female with mean age of (57.5±16.3) years. All the patients successfully completed the operation without conversion to laparotomy. Fourteen cases (66.7%) adopted partial ISR through complete transabdominal approach, 6 cases (28.6%) adopted the subtotal ISR through combined transabdominal and transanal approachs, and 1 case (4.8%) adopted the total ISR through the combined transabdominal and transanal approachs. The total operation time was (213.1±56.3) minutes, including (27.3±5.4) minutes for mechanical arm installation and (175.7±51.6) minutes for robotic operation. The amount of intraoperative hemorrhage was (62.8±23.2) ml, and no blood transfusion was performed in any patient. All patients underwent prophylactic ileostomy, and the stoma was closed 3-6 months after the operation. Except one case of anastomotic leakage, all other stomas were closed successfully. The postoperative hospitalization time was (7.6±2.2) days, and time to fluid intake was (3.3±0.9) days. One case of anastomotic leakage, one case of anastomotic stenosis, one case of inflammatory external hemorrhoids and one case of urinary retention occurred after surgery,and all of them were cured by conservative treatment. The mean diameter of tumors was (2.9±1.2) cm, and the number of harvested lymph node was 12.8 ± 3.3. In the whole group, the circumcision margin was negative, the proximal margin was (12.2 ± 2.1) cm, the distal margin was (1.1 ± 0.4) with all negative, and the R0 resection rate was 100%. The results of anorectal manometry showed that the preoperative rest pressure, rectal maximum squeeze pressure, initial sensory volume and maximum tolerated volume were (45.19±8.46) mmHg, (128.18±18.80) mmHg, (44.33±10.11) ml and (119.00±19.28) ml, respectively;these parameters reduced significantly 3 months after operation and they were (23.44±5.54) mmHg, (93.72±12.15) mmHg, (17.72±5.32) ml and (70.44±10.9) ml, respectively. The differences were statistically significant (all P<0.001). The resting pressure and the rectal maximum squeeze pressure returned to preoperative levels 12 months after operation, which were (39.33±6.64) mmHg and (120.58±16.47) mmHg, respectively (both P>0.05), while the initial sensory volume and the maximum tolerated volume failed to reach the preoperative state, which were (30.67±7.45) ml and (92.25±10.32) ml, respectively (both P<0.05). The patients were followed up for (22.1±10.6) months without local recurrence and distant metastasis. Eighteen patients were evaluated for anal function: Kirwan classification was grade I for 6 cases, grade II for 7 cases, grade III for 4 cases, and grade IV for 1 case; Wexner incontinence score was 8.6±0.8; 14 cases had good defecation control. Conclusion: The clinical efficacy of ISR with Da Vinci robot in the treatment of low rectal cancer is satisfactory.

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.

Delayed anastomotic leakage following laparoscopic intersphincteric resection for lower rectal cancer: report of four cases and literature review

BackgroundAnastomotic leakage (AL) is one of the most dreadful postoperative complications because it can result in increased morbidity and mortality as well as poorer long-term prognosis. Although most studies of AL limited their investigation time to a period of 30 days postoperatively, only a few studies have shown that AL can occur after that period. Here, we report four patients of rectal cancer with delayed AL following laparoscopic intersphincteric resection (ISR) and conduct a literature review on delayed AL.Case presentationCase 1 was a 67-year-old male who underwent laparoscopic partial ISR in July 2009. Although the patient was asymptomatic, an anastomotic-urethral fistula was observed 57 months after ISR. Case 2 was a 44-year-old female who underwent laparoscopic partial ISR in July 2008. She presented with discharge of gas and feces from her vagina, and an anastomotic-vaginal fistula was observed 14 months after ISR. Case 3 was a 74-year-old man who underwent laparoscopic partial ISR in August 2007. He presented with pneumaturia and fecaluria, and an anastomotic-urethral fistula was observed 4 months after ISR. Case 4 was a 68-year-old woman who underwent laparoscopic subtotal ISR for rectal cancer in February 2013 and partial hepatic resection for liver metastases in March 2013. She presented with anal pain and purulent perineal discharge, and an anastomotic-perineal fistula was observed 9 months after ISR. All four cases presented with fistula formation and required reoperation (establishment of a diverting ileostomy).ConclusionsSince delayed AL is not a rare postoperative complication, surgeons need to provide long-term follow-up and remain alert to the possible development of delayed AL.

Combined NOTES total mesorectal excision and single-incision laparoscopy principles for conservative proctectomy: a single-centre study.

Surgery for low rectal cancer remains a challenge when a standard laparoscopic approach is used. Transanal endoscopic total mesorectal excision (TME) has been shown to be feasible and to be associated with a low conversion rate. Combining the transanal and transabdominal single-port approaches (with an abdominal single port implanted in the future stoma and extraction site) could allow TME with minimal wound trauma, low morbidity, and faster recovery. The aim of the current study was to assess the short- and mid-term results of this technique. We conducted a prospective single-centre study of consecutive patients presenting with low rectal cancer requiring a conservative proctectomy with a manual coloanal anastomosis between January 2012 and April 2015. During the study period, 41 patients were recruited. Conversion to open surgery was required in only one patient (2.4%). The median operating time was 358.5min (range 300-600min). Partial intersphincteric resection was necessary for 15 patients (36.6%). The specimens were mostly extracted via the abdominal access (n=34) without wound complications. The mean number of lymph nodes harvested was 12.7 (range 6-24lymph nodes). Specimens were graded as complete (n=31) or nearly complete (n=10) in all of the patients, and the circumferential resection margin positivity was 4.9%. Intraoperative morbidity rate was 4.9%, and the 30-day morbidity rate was 24.4% (n=10). Sixty per cent (n=6) of the patients with 30-day morbidity were Dindo I-II. At a median follow-up of 29months, overall and disease-free survival rates were 97.5 and 80.5%, respectively. The stoma-free survival rate was 95.1%. Combining an endoscopic transanal TME and a single laparoscopic ileostomy-site proctectomy is a promising minimally invasive approach for the treatment of low rectal cancer.

The risk of definitive stoma formation at 10years after low and ultralow anterior resection for rectal cancer.

The long-term risk of definitive stoma after sphincter-saving resection (SSR) for rectal cancer is underestimated and has never been reported for ultralow conservative surgery. We report the 10-year risk of definitive stoma after SSR for low rectal cancer. From 1994 to 2008, patients with low rectal cancer who were suitable for SSR were analysed retrospectively. Patients were divided into the following four groups: low colorectal anastomosis (LCRA); coloanal anastomosis (CAA); partial intersphincteric resection (pISR); and total intersphincteric resection (tISR). The end-point was the risk of a definitive stoma according to the type of anastomosis. During the study period, 297 patients had SSR for low rectal cancer. The incidence of definitive stoma increased from 11% at 1year to 22% at 10years. The reasons were no closure of the loop ileostomy (4.7%), anastomotic morbidity (6.5%), anal incontinence (8%) and local recurrence (5.2%). The risk of definitive stoma was not influenced by type of surgery: 26% vs 18% vs 18% vs 19% (P=0.578) for LCRA, CAA, pISR and tISR, respectively. Independent risk factors for definitive stoma were age >65years and surgical morbidity. The risk of a definitive stoma after SSR increased two-fold between 1 and 10years after surgery, from 11% to 22%. Ultralow conservative surgery (pISR and tISR) did not increase the risk of definitive stoma compared with conventional CAA or LCRA.

Hand-sewn coloanal anastomosis for low rectal cancer: technique and long-term outcome.

This study compared the operative outcome and long-term survival of three types of hand-sewn coloanal anastomosis (CAA) for low rectal cancer. Patients presenting with low rectal cancer at a single centre between 2006 and 2014 were classified into three types of hand-sewn CAA: type 1 (supra-anal tumours undergoing transabdominal division of the rectum with transanal mucosectomy); type 2 (juxta-anal tumours, undergoing partial intersphincteric resection); and type 3 (intra-anal tumours, undergoing near-total intersphincteric resection with transanal mesorectal excision). Seventy-one patients with low rectal cancer underwent CAA: 17 type 1; 39 type 2; and 15 type 3. The median age of patients was 61.6 years, with a male/female ratio of 2:1. Neoadjuvant therapy was given to 56 (79%) patients. R0 resection was achieved in 69 (97.2%) patients. Adverse events occurred in 25 (35.2%) of the 71 patients with a higher complication rate in type 1 vs type 2 vs type 3 (47.1% vs 38.5% vs 13.3%, respectively; P = 0.035). Anastomotic separation was identified in six (8.5%) patients and pelvic haematoma/seroma in five (7%); two (8.3%) female patients developed a recto-vaginal fistula. Ten (14.1%) patients were indefinitely diverted, with a trend towards higher long-term anastomotic failure in type 1 vs type 2 vs type 3 (17.6% vs 15.5% vs 6.7%). The type of anastomosis did not influence the overall or disease-free survival. CAA is a safe technique in which anorectal continuity can be preserved either as a primary restorative option in elective cases of low rectal cancer or as a salvage procedure following a failed stapled anastomosis with a less successful outcome in the latter. CAA has acceptable morbidity with good long-term survival in carefully selected patients.

Risk Factors for Anastomotic Leakage After Intersphincteric Resection Without a Protective Defunctioning Stoma for Lower Rectal Cancer.

Intersphincteric resection (ISR) is performed as an alternative to abdominoperineal resection for super-low rectal cancer. The purpose of this study was to evaluate risk factors for anastomotic leakage (AL) after ISR without a defunctioning stoma for lower rectal cancer. Between 1995 and 2012, 135 consecutive patients with lower rectal cancer underwent curative ISR without a protective defunctioning stoma. Univariate and multivariate analyses were performed to determine the risk factors for AL. The radiological and symptomatic AL rate was 17.0 % (23/135). Univariate analysis demonstrated that male sex (P = 0.030), preoperative chemotherapy (P = 0.016), partial ISR (P < 0.001), lateral lymph-node dissection (P = 0.042), distal tumor distance from the dentate line (P = 0.007), and straight reconstruction (P < 0.001) were significantly associated with AL. Severe AL requiring re-laparotomy developed in 13 (9.6 %) patients. Univariate analysis demonstrated that male sex (P = 0.006), partial ISR (P < 0.001), distal tumor distance from the dentate line (P = 0.002), and straight reconstruction (P < 0.001) were significantly associated with AL requiring relaparotomy. Multivariate analysis demonstrated that partial ISR [odds ratio (OR) 6.701; P = 0.001] and straight reconstruction (OR 5.552; P = 0.002) were independently predictive of AL. Partial ISR and straight reconstruction increased the risk of AL after ISR without a protective defunctioning stoma. A defunctioning stoma might be mandatory in patients with the risk factors identified in this analysis.

Toward the end of abdominoperineal resection for rectal cancer? An 8-year experience in 189 consecutive patients with low rectal cancer.

To assess whether recent advances, such as intersphincteric resection (ISR) or local excision (LE) if a suspicion of complete tumor response after radiochemotherapy (RCT), could have modified the rate of end stoma (ES) in low rectal cancer treatment. ES rate remains around 30% to 50% in patients with low rectal cancer. From 2005 to 2013, all patients with low rectal cancer undergoing laparoscopic total mesorectal excision, with or without neoadjuvant RCT, and patients undergoing LE after RCT were included. A total of 189 patients presented a low rectal cancer; 162 (86%) underwent RCT; total mesorectal excision was performed in 172 (90%), followed by stapled colorectal anastomosis (n=26; 15%), manual coloanal anastomosis with partial (n=92; 53%) or total ISR (n=32; 19%), or ES that included abdominoperineal resection (n=21; 12%) and low Hartmann procedure (n=1; 1%). LE after RCT was performed in 19 of 189 (10%) patients with a suspicion of complete tumor response. Among them 2 of 19 (11%) underwent immediate secondary total mesorectal excision (1 abdominoperineal resection and 1 coloanal anastomosis with total ISR) because of poor pathological criteria. Management of rectal cancer with colorectal anastomosis and coloanal anastomosis with partial ISR allowed to obtain a 38% ES rate (71/189); the additional use of total ISR decreased this rate to 22% (39/189). Selective use of LE reduced this rate to only 12% (22/189). Nowadays, recent advances lead to a paradigm shift, with only 12% ES rate in low rectal cancer.

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

IntroductionAbdomino-perineal resection has been the standard treatment for rectal tumors located ⩽5cm from the anal verge. Recently, intersphincteric resection became a valid option which preserves the bowel continuity with better functional outcome. AimIs to evaluate the oncological and functional outcome alongside the associated surgical morbidity in patients with T1-3 rectal cancer, who underwent intersphincteric resection (ISR). Patients & methodsBetween the years 2006 and 2011, 55 patients with invasive rectal adenocarcinoma, T1-3 lesions, located 2–5cm from the anal verge underwent ISR with total mesorectal excision. When inevitable, complete. ISR was performed, otherwise partial ISR was done. All T3 patients underwent total meso-rectal excision (TME) while some had lateral lymph node dissection (LND) with concomitant pelvic autonomic nerve preservation (PANP). ResultsAmong the 55 patients, 21 (38.1%) patients were T1-2 and 34 (61.9%) patients were T3. The tumor location range was 0–5cm from the anal verge (median 2.3cm). Partial or complete ISR was done for 35 (63.6%) and 20 (36.4%), respectively. Patients were followed for a median of 1.5years (range 1–4.6years). The 3year local recurrence and distant metastasis free rates were 85.2% and 85.6%, respectively. All the 3 local recurrences occurred in T3 patients group, and had positive circumferential resection margins. Overall 3-year disease-free survival was 82.6%; while the overall 3-year survival was 88.7%. ConclusionIntersphincteric resection with TME does not affect the local recurrence or overall survival rate in early rectal cancer T1-2 & 3, with preservation of bowel continuity and better life quality.

A pilot study of natural orifice transanal endoscopic total mesorectal excision with laparoscopic assistance for rectal cancer

The objective of this pilot study was to evaluate the feasibility and safety of natural orifice endoscopic transanal total mesorectal excision (TME) with laparoscopic assistance in a cohort study of five patients with stage I and IIA rectal cancer. Five eligible patients with node-negative rectal cancer located 4-12 cm from the anal verge were enrolled in an IRB-approved pilot study. All patients underwent transanal endoscopic TME with laparoscopic assistance, hand-sewn coloanal anastomosis, and a diverting loop ileostomy. Primary and secondary end points included adequacy of the mesorectal excision and 30-day postoperative complications, respectively. Between November 2011 and May 2012, three males and two females underwent transanal endoscopic TME with laparoscopic assistance. Patient mean age and BMI were 48.6 ± 9.8 years and 25.7 ± 2.3 kg/m(2), respectively. Tumors were located an average of 5.7 ± 2.4 cm from the anal verge and preoperatively staged as T1N0M0 (2), T2N0M0 (1), and T3N0M0 (2). Mean operative time was 274.6 ± 85.4 min with no intraoperative complications. Partial intersphincteric resection was performed in conjunction with transanal endoscopic TME in three patients. Pathologic examination of TME specimens demonstrated complete mesorectal excision in all cases with negative proximal, distal, and radial margins. Mean length of hospital stay was 5.2 ± 2.6 days and three minor complications occurred, including one ileus and two cases of transient urinary dysfunction. At a mean early follow-up of 5.4 ± 2.3 months, all patients remain disease-free. In this pilot study of five patients with rectal cancer, transanal endoscopic TME with laparoscopic assistance is feasible and safe, and is a promising alternative to open and laparoscopic TME. Evaluation of long-term functional and oncologic outcomes of this approach is needed before widespread adoption can be recommended.