Long-term outcome of per anum intersphincteric rectal dissection with direct coloanal anastomosis for lower rectal cancer

Latest Advances in Intersphincteric Resection for Low Rectal Cancer

Background

Intersphincteric resection (ISR) has been a preferable alternative to abdominoperineal resection (APR) for anal preservation in patients with low rectal cancer. Laparoscopic ISR and robotic ISR have been widely used with the proposal of 2 cm or even 1 cm rule of distal free margin and the development of minimally invasive technology. The aim of this review was to describe the newest advancements of ISR.

Methods

A comprehensive literature review was performed to identify studies on ISR techniques, preoperative chemoradiotherapy (PCRT), complications, oncological outcomes, and functional outcomes and thereby to summarize relevant information and controversies involved in ISR.

Results

Although PCRT is employed to avoid positive circumferential resection margin (CRM) and decrease local recurrence, it tends to engender damage of anorectal function and patients' quality of life (QoL). Common complications after ISR include anastomotic leakage (AL), anastomotic stricture (AS), urinary retention, fistula, pelvic sepsis, and prolapse. CRM involvement is the most important predictor for local recurrence. Preoperative assessment and particularly rectal endosonography are essential for selecting suitable patients. Anal dysfunction is associated with age, PCRT, location and growth of anastomotic stoma, tumour stage, and resection of internal sphincter.

Conclusions

The ISR technique seems feasible for selected patients with low rectal cancer. However, the postoperative QoL as a result of functional disorder should be fully discussed with patients before surgery.

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

INTRODUCTION

Abdomino-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.

AIM

Is 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 & METHODS

Between 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).

RESULTS

Among 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 1.5 years (range 1-4.6 years). The 3 year 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%.

CONCLUSION

Intersphincteric 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.

Analysis of the clinical factors associated with anal function after intersphincteric resection for very low rectal cancer

Background

Intersphincteric resection (ISR) has been used to avoid permanent colostomy in very low rectal cancer patients. This study aimed to assess the surgical safety and oncologic and functional outcomes of ISR.

Methods

The records of 30 consecutive very low rectal cancer patients who underwent ISR without neoadjuvant therapy were retrospectively analyzed; survival and locoregional recurrence rates were calculated by the Kaplan-Meier method. Incontinence was assessed by a functionality questionnaire and the Wexner score.

Results

The median distance between the distal margin of the dentate line was 10 mm. A total of 12, 4, and 14 patients underwent partial ISR, subtotal ISR, and total ISR, respectively. The mean distal resection margin was negative in all cases, and circumferential resection margin was positive in two cases. Morbidity was 33.3%: anastomotic stricture in seven patients, colonic J-pouch prolapse in two patients, and an anovaginal fistula in one patient. During the median, 56.2-month follow-up period, local, distant, and combined recurrences occurred in four, three, and two patients, respectively. The 5-year overall and disease-free survival rates were 76.5% and 68.4%, respectively. Local recurrence rates were 5.2% for the patients with Tis-T2 tumors as compared with 45.5% for those with T3 tumors (P = 0.008). The mean Wexner scores and stool frequencies, 12 months after stoma closure in 19 patients, were 11.5 and 6.6 per 24 h, respectively. Significant differences were not seen in the Wexner scores between partial ISR and subtotal/total ISR (11.8 ± 2.6 and 9.1 ± 5.6). Stool frequency (P = 0.02), urgency (P = 0.04), and fragmentation (P = 0.015) were worse in patients with anastomotic stricture than in those without; there was no symptom improvement in patients with anastomotic stricture.

Conclusions

The anastomotic strictures in patients undergoing ISR may have negatively affected anal function. For total ISR patients, at least, informed consent stating the possibility of a permanent colostomy is necessary.

Long-term results of intersphincteric resection for low rectal cancer

BACKGROUND

The aim of this study is to investigate the long-term therapeutic outcome of intersphincteric resection (ISR) as the treatment of ultra-low rectal cancer.

METHODS

During January 2004 and October 2010, ISR was performed in 60 patients with ultra-low rectal cancer and their survival, local recurrence, and functional outcome were evaluated retrospectively.

RESULTS

A total of 60 patients with tumors at a median distance of 42 (range 30-50) mm from the anal verge underwent ISR. Three cases developed anastomotic leakage and two cases developed anastomotic stenosis postoperatively. After a median follow-up of 49 (range 18-90) months, local and distant recurrence occurred in six and four patients, respectively. Five-year overall and disease-free survival rates were 90.0% and 83.3%. Among them, the functional results of 53 patients suggested the mean stool frequency were 3.8 ± 1.3 (range 3-10) per 24 hr. According to Kirwan classification, good continence was shown in 73.6% of the patients.

CONCLUSION

This preliminary study indicated that ISR might be a candidate technique in treating patients with ultra-low rectal cancer and achieved satisfactory long-term results in functional and oncologic respects.

Intersphincteric resection and coloanal anastomosis in treatment of distal rectal cancer

In the treatment of distal rectal cancer, abdominoperineal resection is traditionally performed. However, the recognition of shorter safe distal resection line, intersphincteric resection technique has given a chance of sphincter-saving surgery for patients with distal rectal cancer during last two decades and still is being performed as an alternative choice of abdominoperineal resection. The first aim of this study is to assess the morbidity, mortality, oncological, and functional outcomes of intersphincteric resection. The second aim is to compare outcomes of patients who underwent intersphincteric resection with the outcomes of patients who underwent abdominoperineal resection.

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.

Function after intersphincteric resection for low rectal cancer and its influence on quality of life

AIM

The aim of the study was to investigate function and quality of life after different types of intersphincteric resection (ISR).

METHOD

Between January 2006 and February 2008, 45 patients (34 men and 11 women) with distal third rectal cancer underwent curative ISR. Function was evaluated using the Memorial Sloan Kettering Cancer Center bowel function questionnaire and Wexner score, anal manometry and measurements of rectal capacity were also performed. Quality of life was assessed using the Serbian version of the European Organisation for Research and Treatment of Cancer, quality of life questionnaire (EORTC QLQ-C30) and the translated version of the fecal incontinence quality of life scale (FIQL).

RESULTS

There were no postoperative deaths. Partial ISR was performed in 22 (48.9%) patients, subtotal ISR was performed in 19 (42.2%) patients and total ISR was performed in four (8.9%) patients. Anastomotic leakage occurred in nine (20%) patients. Five (11.1%) of 45 patients had major (complete) incontinence and a further six (13.3%) patients had continuing frequent faecal leakage 12 months after ileostomy reversal. There was no significant difference in quality of life between the groups in the EORTC QLQ-C30 scale, but this was significantly altered by internal anal sphincter resection in two of the FIQL scales (coping/behaviour and depression/self-perception).

CONCLUSION

Although ISR does not affect quality of life in general, the extent of internal anal sphincter resection has a negative impact on symptom-specific quality of life owing to faecal incontinence.

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

OBJECTIVE

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.

METHOD

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.

RESULTS

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.

CONCLUSION

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.