External sphincter resection for lower rectal and anal canal adenocarcinoma: achieving anal preservation with oncological and functional satisfaction

Akagi, Yoshito; Kinugasa, Tetsushi; Oka, Yousuke; Mizobe, Tomoaki; Yoshida, Takefumi; Yuge, Kotaro; Shirouzu, Kazuo

doi:10.1007/s00595-014-0903-7

Cited by 5 publications

(5 citation statements)

References 10 publications

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“…To address these issues, we have developed CSR based on total ISR. This approach expands the resection scale beyond visceral structures on the tumour-affected side (similar to the approach in partial external sphincter resection for tumours invading the ISS to ensure a negative CRM [17]), distal to the Hilton white line (by removing a partial subcutaneous portion of the EAS and perianal skin) to ensure a safe after diverting stoma closure are comparable to those reported in the literature for partial intersphincteric resection or low anterior resection, suggesting that the CSR procedure yields better functional outcomes compared to conventional t-ISR, which is typically associated with a higher rate of postoperative bowel dysfunction [6][7][8]. Employing the CSR technique modifies the concept of decision-making for sphincter-preserving surgery, which is finally independent of the distance between the tumour's lower edge and the anal verge.…”

Section: Discussionmentioning

confidence: 99%

“…To address these issues, we have developed CSR based on total ISR. This approach expands the resection scale beyond visceral structures on the tumour‐affected side (similar to the approach in partial external sphincter resection for tumours invading the ISS to ensure a negative CRM [17]), distal to the Hilton white line (by removing a partial subcutaneous portion of the EAS and perianal skin) to ensure a safe DRM (confirmed negative by intra‐operative frozen section), while preserving the dentate line mucosa and IAS on the tumour‐free side to the greatest extent possible. The key to this technique is to ensure oncological safety through extensive excision of the anal canal on the tumour‐affected side while achieving acceptable functionality through compensation by preserving the dentate line mucosa and IAS on the contralateral side.…”

Section: Discussionmentioning

confidence: 99%

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Conformal sphincteric resection for ultra‐low rectal cancer located below the dentate line: A pilot report

Zhou,

Zang,

et al. 2023

Colorectal Disease

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AimSphincter‐sparing surgery can be achieved in most cases of low rectal cancer with the development of intersphincteric resection. However, abdominoperineal resection is still inevitable for patients with tumours located below the dentate line. To address this, we have developed a procedure called conformal sphincteric resection (CSR) in which the corresponding part of the subcutaneous portion of the external anal sphincter and the perianal skin on the tumour side is removed to achieve a safe distal resection margin and lateral resection margin while the dentate line and the internal anal sphincter on the tumour‐free side are preserved as much as possible, to achieve sphincter preservation without compromising oncological safety and functional acceptability, and to render tumour location no longer a contraindication for sphincter‐sparing surgery. This is the first study to describe the concept, indication and surgical procedure of CSR and to report its preliminary surgical, oncological and functional results.MethodsThis is a retrospective, single‐centre, single‐arm pilot study conducted at Huashan Hospital, Fudan University. Demographic, clinicopathological, oncological and functional follow‐up data were collected from 20 consecutive patients with rectal tumours located below the dentate line who underwent laparoscopic CSR by the same surgical team from June 2018 to March 2022.ResultsThe mean distance of the tumour's lower edge from the anal verge was 13.1 ± 6.0 mm. The mean distal resection margin was 10.6 ± 4.3 mm. All circumferential resection margins were negative. There were no instances of perioperative mortality. The complication rate was 25% but all were Clavien−Dindo Grade I. Among the 20 cases, 17 were diagnosed with adenocarcinoma, one with squamous cell carcinoma and two with adenoma featuring high‐grade intraepithelial neoplasia. Pathological TNM staging revealed two, seven, five, five and one case(s) in Stages 0, I, II, III and IV, respectively. The median follow‐up period was 20 months (interquartile range 22 months), with no withdrawals. The overall and disease‐free survival rates were both 95%. The mean Wexner incontinence score and low anterior resection syndrome score recorded 18 months following diverting ileostomy closure were 6.3 ± 3.8 and 27.3 ± 3.6, respectively.ConclusionsThis study has proposed the CSR procedure for the first time, which is a technically feasible, oncologically safe and functionally acceptable procedure for carefully selected patients with rectal tumours located below the dentate line.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Conformal sphincteric resection for ultra‐low rectal cancer located below the dentate line: A pilot report

Zhou,

Zang,

et al. 2023

Colorectal Disease

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“…Vascular insufficiency is the major complication of TPP with delayed CAA, in the present study shown in four patients, due to the compression of the anal canal on the exteriorized colonic stump. This adverse effect can be solved using the posterior incision of halfthickness anal sphincter 18 and concomitant scar debridement, without any clinically significant effect on anal contraction.…”

Section: Discussionmentioning

confidence: 99%

Transanal Pull-Through Procedure with Delayed versus Immediate Coloanal Anastomosis for Anus-Preserving Curative Resection of Lower Rectal Cancer: A Case-Control Study

Xiong

Huang

Ren

2016

The American Surgeon

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This case-control study compared the effectiveness and safety of transanal pull-through procedure (TPP) with delayed or immediate coloanal anastomosis (CAA) for anus-preserving curative resection of lower rectal cancer. Lower rectal cancer patients (n = 128) were hospitalized between January 2003 and December 2013 for elective anus-preserving curative resection through a TPP with delayed (n = 72) or immediate (n = 56) CAA. Main outcome measures including surgical safety, resection radicality, and defecation function were assessed. The two groups were comparable in age, sex, gross pathology, histology, and tumor-node-metastasis staging. Both the delayed and immediate CAA TPPs had similar resection radicality and safety profiles. The immediate CAA was associated with a significantly higher risk of anastomotic leakage and defecation impairment. None of patients in the delayed CAA group experienced anastomotic leakage. In conclusion, TPP with delayed CAA may be superior to immediate CAA in minimizing the risk of anastomotic leakage and relevant surgical morbidities, and does not require a temporary ileostomy and second-look restoration of ostomy.

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“… 36 With its acceptable oncologic outcome and preservation of anal function, adaptation of ISR with CAA has increased and has largely replaced APR; nevertheless, APR is still indicated when there is infiltration of the intersphincteric space to avoid leaving tumor cells at the resection margin. 37 …”

Section: Sphincter Preservationmentioning

confidence: 99%

“…Partial removal of the external sphincter is also performed if there is invasion into the intersphincteric space and/or external sphincter muscles. 37 38 A Japanese study group defined three types of ISRs: Total ISR is performed when the tumor has spread beyond the dentate line, and involves complete removal of the internal sphincter. Subtotal ISR is performed when the distal edge of the tumor is >2 cm from the dentate line, and involves resection of two-thirds of the internal sphincter.…”

Section: Sphincter Preservationmentioning

confidence: 99%

Critical and Challenging Issues in the Surgical Management of Low-Lying Rectal Cancer

Nacion¹,

Park

Yang

et al. 2018

Yonsei Med J

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Despite innovative advancements, the management of distally located rectal cancer (RC) remains a formidable endeavor. The critical location of the tumor predisposes it to a circumferential resection margin that tends to involve the sphincters and surrounding organs, pelvic lymph node metastasis, and anastomotic complications. In this regard, colorectal surgeons should be aware of issues beyond the performance of total mesorectal excision (TME). For decades, abdominoperineal resection had been the standard of care for low-lying RC; however, its association with high rates of tumor recurrence, tumor perforation, and poorer survival has stimulated the development of novel surgical techniques and modifications, such as extralevator abdominoperineal excision. Similarly, difficult dissections and poor visualization, especially in obese patients with low-lying tumors, have led to the development of transanal TME or the “bottom-to-up” approach. Additionally, while neoadjuvant chemoradiotherapy has allowed for the execution of more sphincter-saving procedures without oncologic compromise, functional outcomes remain an issue. Nevertheless, neoadjuvant treatment can lead to significant tumor regression and complete pathological response, permitting the utilization of organ-preserving strategies. At present, an East and West dualism pervades the management of lateral lymph node metastasis, thereby calling for a more global and united approach. Moreover, with the increasing importance of quality of life, a tailored, individualized treatment approach is of utmost importance when taking into account oncologic and anticipated functional outcomes.

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External sphincter resection for lower rectal and anal canal adenocarcinoma: achieving anal preservation with oncological and functional satisfaction

Cited by 5 publications

References 10 publications

Conformal sphincteric resection for ultra‐low rectal cancer located below the dentate line: A pilot report

Conformal sphincteric resection for ultra‐low rectal cancer located below the dentate line: A pilot report

Transanal Pull-Through Procedure with Delayed versus Immediate Coloanal Anastomosis for Anus-Preserving Curative Resection of Lower Rectal Cancer: A Case-Control Study

Critical and Challenging Issues in the Surgical Management of Low-Lying Rectal Cancer

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