Intersphincteric Resection Pushing the Envelope for Sphincter Preservation

Analysis of risk factors for the sigmoid stoma complications in patients after abdominoperineal resection surgery: An observational study

To analyze the risk factors for intraperitoneal sigmoid stoma complications after abdominoperineal resection (APR) surgery to guide clinical practice. Patients who were diagnosed with rectal cancer and underwent APR surgery from June 2013 to June 2021 were retrospectively enrolled. The characteristics of the stoma complication group and the no stoma complication group were compared, and univariate and multivariate logistic analyses were employed to identify risk factors for sigmoid stoma-related complications. A total of 379 patients who were diagnosed with rectal cancer and underwent APR surgery were enrolled in this study. The average age of the patients was 61.7 ± 12.1 years, and 226 (59.6%) patients were males. Patients in the short-term stoma complication group were younger (55.7 vs 62.0, P < .05) and had a more advanced tumor stage (P < .05). However, there was no significant difference between the long-term stoma complication group and the no stoma complication group. Multivariate logistic regression analysis revealed that operation time was an independent risk factor (P < .05, OR = 1.005, 95% CI = 1.000-1.010) for short-term stoma complications. Both the short-term and long-term stoma complication rates in our institution were low. A longer operation time was an independent risk factor for short-term stoma complications after APR surgery.

Treatment Options for Distal Rectal Cancer in the Era of Organ Preservation

OPINION STATEMENT

The introduction of total mesorectal excision into the radical surgery of rectal cancer has significantly improved the oncological outcome with longer survival and lower local recurrence. Traditional treatment modalities of distal rectal cancer, relying on radical surgery, while effective, take their own set of risks, including surgical complications, potential damage to the anus, and surrounding structure owing to the pursuit of thorough resection. The progress of operating methods as well as the integration of systemic therapies and radiotherapy into the peri-operative period, particularly the exciting clinical complete response of patients after neoadjuvant treatment, have paved the way for organ preservation strategy. The non-inferiority oncological outcome of "watch and wait" compared with radical surgery underscores the potential of organ preservation not only to control local recurrence but also to reduce the need for treatments followed by structure destruction, hopefully improving the long-term quality of life. Radical radiotherapy provides another treatment option for patients unwilling or unable to undergo surgery. Organ preservation points out the direction of treatment for distal rectal cancer, while additional researches are needed to answer remaining questions about its optimal use.

Transanal Total Mesorectal Excision for Rectal Cancer

Transanal total mesorectal excision (taTME) is a technique where rectal dissection is begun transanally in a "bottom-up" fashion. This technique facilitates dissection of the most distal part of the rectum and allows the establishment of the distal margin for rectal cancer. TaTME has proven its utility in facilitating low rectal dissection with significantly lower conversion rates and acceptable perioperative, oncological, and functional outcomes. However, taTME remains a challenging technique to learn and adopt. This article describes the technique, indications, and outcomes of taTME in rectal cancer during the last decade.

Functional outcomes of intersphincteric resection in low rectal tumors

OBJECTIVES

Currently, sphincter-saving procedures are increasingly performed in the treatment of low rectal cancers. This study aimed to evaluate the outcomes of patients who underwent intersphincteric resection.

MATERIAL AND METHODS

This was a single-center, retrospective, cross-sectional study. We evaluated the electronic data files of 29 patients who had intersphincteric resections at our institute between 2008 and 2018. Bowel function outcomes were assessed prospectively using Wexner incontinence score. Histopathological, surgical and functional outcomes were analyzed.

RESULTS

Mean age of nine female and 20 male patients included in the study was 55.8 ± 12.8 (30-76) years. A tumor-free surgical margin was achieved in all patients. Anastomotic leakage was detected in two patients. Mean Wexner incontinence score of 20 patients who still had functional anastomosis was 8.35, whereas 65% of the patients (n= 13) had a good continence status. There was no relationship between the continence status and sex, tumor distance from anal verge, T stage, distal surgical margin, and lymph node involvement. Twenty-one patients underwent primary coloanal anastomosis and eight patients underwent two-stage coloanal anastomosis.

CONCLUSION

In the treatment of distal rectal cancer, adequate oncological surgery and relatively acceptable functional outcomes can be obtained with intersphincteric resection technique in suitable patients.

Improvement of low anterior resection syndrome beyond 2 years after total mesorectal excision

AIM

Bowel dysfunction after sphincter-preserving proctectomy, also known as low anterior resection syndrome (LARS), has significant impact on survivors of rectal cancer. This study aimed to assess the temporal change of LARS beyond 2 years after proctectomy, which has not been fully studied.

METHODS

We longitudinally enrolled consecutive patients who had received total mesorectal excision in a tertiary academic medical center, with preoperative neoadjuvant therapy if indicated. LARS score was longitudinally assessed by two serial follow-ups, with a fixed interval of 18 months.

RESULTS

Overall, 107 patients responded for the first follow-up after a median of q20 months, 96 of whom responded for the second follow-up after a median of 38 months. At the first follow-up, 48 patients (44.9%) reported major LARS, compared with 23 (24.0%) at the second follow-up (p < 0.001). Mean LARS score improved from 27.3 to 18.6, mostly from "urgency" (12.2 vs. 6.2, p < 0.001) and "clustering of stools" (9.7 vs. 7.7, p = 0.001). Anastomosis less than 3 cm from the anal verge was independently associated with LARS improvement.

CONCLUSION

Bowel dysfunction continues to improve 2 years after total mesorectal excision, with most symptom relief in urgency and stool clustering, especially in patients with lower anastomosis.

Outcomes of robotic partial excision of the levator ani muscle for locally advanced low rectal cancer invading the ipsilateral pelvic floor at the anorectal ring level

PURPOSE

The purpose of this study is to evaluate partial excision of the levator ani muscle (PELM) enables preservation of anal sphincter function although levator ani muscle (LAM) was invaded.

METHODS

Functional outcomes and oncologic outcomes of 23 consecutive patients who underwent robotic PELM for low rectal cancer at the anorectal ring level invading or abutting the ipsilateral LAM are analysed.

RESULTS

Secured resection margins were achieved, especially for the circumferential resection margin. During a median follow-up of 44 months, the 3-year local recurrence rate was 14.4%. Among patients who underwent diverting ileostomy closure, mean Memorial Sloan Kettering Cancer Center Bowel Function Instrument and Wexner scores were 68.3 ± 11.9 and 10.7 ± 5.3, respectively, at 1 year after closure.

CONCLUSION

PELM is a sphincter-preserving alternative to abdominoperineal resection (APR) or extralevator APR for low rectal cancer invading the ipsilateral LAM at the level of the anorectal ring.

Comparison of Clinical Efficacy and Safety Between da Vinci Robotic and Laparoscopic Intersphincteric Resection for Low Rectal Cancer: A Meta-Analysis

Background and Aims: The intersphincteric resection (ISR) is beneficial for saving patients' anus to a large extent and restoring original bowel continuity. Laparoscopic ISR (L-ISR) has its drawbacks, such as two-dimensional images, low motion flexibility, and unstable lens. Recently, da Vinci robotic ISR (R-ISR) is increasingly used worldwide. The purpose of this article is to compare the feasibility, safety, oncological outcomes, and clinical efficacy of R-ISR vs. L-ISR for low rectal cancer. Methods: PubMed, EMBASE, Cochrane Library, and Web of Science were searched to identify comparative studies of R-ISR vs. L-ISR. Demographic, clinical, and outcome data were extracted. Mean difference (MD) and risk ratio (RR) with their corresponding confidence intervals (CIs) were calculated. Results: Five studies were included. In total, 510 patients were included, of whom 273 underwent R-ISR and 237 L-ISR. Compared with L-ISR, R-ISR has significantly lower estimated intraoperative blood loss (MD = -23.31, 95% CI [-41.98, -4.64], P = 0.01), longer operative time (MD = 51.77, 95% CI [25.68, 77.86], P = 0.0001), hospitalization days (MD = -1.52, 95% CI [-2.10, 0.94], P < 0.00001), and postoperative urinary complications (RR = 0.36, 95% CI [0.16, 0.82], P = 0.02). Conclusions: The potential benefits of R-ISR are considered as a safe and feasible alternative choice for the treatment of low rectal tumors.

Functional outcomes over time following perineal pseudocontinent colostomy reconstruction after abdominoperineal resection for ultralow rectal adenocarcinoma

BACKGROUND AND OBJECTIVES

Pseudocontinent-perineal colostomy (PCPC) following abdominoperineal resection (APR) is a promising technique associated with good quality of life. This study evaluates over time the functional results after PCPC using the Kirwan score.

METHODS

All PCPC patients operated on from January 2001 to January 2016 were followed with their functional results assessed at four checkpoints. A/B Kirwan scores and a 48 to 72 hours colonic irrigation rhythm were considered "good" and "convenient" and their overall variations over time were assessed by means of Cochran's Q test corrected by Bonferroni post hoc test.

RESULTS

Fifty-seven eligible patients were included in the study with 33 (58%) women. We noted a significant difference in both Kirwan score and colic irrigation rhythm during the four checkpoints in follow-up with Q(1) = 85.01 and Q(2) = 69. 86. By the fourth checkpoint, 86% of patients had a Kirwan score of A/B. Concerning the rhythm of colonic irrigation, there was a significant improvement between 6 months and other checkpoints. In the second year, 63% of patients reduced their colonic irrigation rhythm.

CONCLUSIONS

The functional results of PCPC after APR improve and stabilize from 6 months to 1 year after surgery thus making PCPC a good alternative that surgeons can present to their patients.

Ultimate Functional Preservation With Intersphincteric Resection for Rectal Cancer

The proximity of the very low rectum rectal cancer to the anal sphincter raises a specific problem: how and until when can we preserve the anal continence without compromising the oncological result of the tumor resection? In this situation, intersphincteric resection (ISR) offers an excellent alternative to abdominoperineal resection (APR), but the selection of patients for this option must be extremely precise. This complex choice justifies the simultaneous consideration of an oncological approach with a functional approach in order to provide a full benefit to the patient. When a circumferential resection margin of at least 1 mm can be performed with a distal resection margin of at least 1 cm with or without preoperative radiotherapy, ISR ensures a safety choice. The oncological results of ISR reported in the literature when performed properly found a 5-year disease-free survival of 80.2% with a local recurrence rate of only 5.8%. In parallel to this oncological evaluation, the expected post-operative functional outcome and the resulting quality of life must be properly assessed pre-operatively, since partial or total resection of the internal sphincter impacts significantly on the functional outcome. Based on data from the literature, this work reports the essential anatomical considerations and then the oncological and functional elements indispensables when an anal continence preservation is evoked for a tumor of the very low rectum. Finally, the precise selection criteria and the major surgical principles are outlined in order to guarantee the safety of this modern choice for the patient.

Rectal cancer lexicon: consensus statement from the society of abdominal radiology rectal & anal cancer disease-focused panel

Standardized terminology is critical to providing consistent reports to referring clinicians. This lexicon aims to provide a reference for terminology frequently used in rectal cancer and reflects the consensus of the Society of Abdominal Radiology Disease Focused Panel in Rectal cancer. This lexicon divided the terms into the following categories: primary tumor staging, nodal staging, treatment response, anal canal anatomy, general anatomy, and treatments.

Randomized clinical trial of prophylactic transanal irrigation versus supportive therapy to prevent symptoms of low anterior resection syndrome after rectal resection

Background

Low anterior resection syndrome (LARS) is a frequent problem after rectal resection. Transanal irrigation (TAI) has been suggested as an effective treatment in patients who have developed LARS. This prospective RCT was undertaken to evaluate the effect of TAI as a prophylactic treatment to prevent symptoms of LARS.

Methods

Patients who had undergone ultralow rectal resection were randomized to start TAI on a daily basis, or to serve as a control with supportive therapy only after ileostomy closure. All patients were seen after 1 week, 1 month and 3 months, and the maximum number of defaecation episodes per day and night documented during follow‐up. Wexner score, LARS score and Short Form 36 questionnaire responses were evaluated in both groups.

Results

Thirty‐seven patients could be evaluated according to protocol (TAI 18, control 19). The maximum number of stool episodes per day and per night was significantly lower among patients who underwent TAI at 1 month (median 3 versus 7 episodes/day in TAI versus control group, P = 0·003; 0 versus 3 episodes/night, P = 0·001) and 3 months (3 versus 5 episodes per day, P = 0·006; 0 versus 1 episodes/night, P = 0·002). LARS scores were significantly better in the TAI group after 1 month (median 16 versus 32 in control group; P = 0·044) and 3 months (9 versus 31; P = 0·001). A significantly better result in terms of Wexner score was seen in the TAI group after 3 months (median 2 versus 6 in controls; P = 0·046).

Conclusion

Prophylactic TAI led to a significantly better functional outcome compared with supportive therapy for up to 3 months. Registration number: DRKS00011752 ( http://apps.who.int/trialsearch/).