Intersphincteric resection with partial removal of external anal sphincter for low rectal cancer

Abstract

Abdominoperineal resection (APR) remains the standard procedure for rectal cancer located within 0.5 cm from dentate line (DL). In this study, we present a new type of restorative surgery: intersphincteric resection with partial removal of external anal sphincter (EAS) and anorectal reconstruction for-ultra low rectal cancer. Between March 2003 and May 2008 fifty patients (28 males, aged between 39 and 71) were operated on for ultra low rectal cancer uT2-3N0M0 with partial preservation of EAS and total anorectal reconstruction (smooth-muscle neosphincter and colonic pouch). A protective stoma was performed in all cases. Functional outcome and quality of life were recorded at 3, 6, 12, 18, 24 months after stoma closure using Wexner score and FIQL respectively. Anal manometry, vectrum volumetry and myography data were taken as well. Results. Postoperative complications developed in 2 patients, but no secondary surgery was required. Carcinomas were staged as pT2 (n = 14) and pT3 (n = 36). The distal clearance was 2.00.4 (range 1.5-2.8) cm, lateral clearance was 0.80.3 (range 0.2-1.4) cm. After a median follow-up of 24 (range 2-61) months, 2 local recurrences were occurred and salvaged by APR. Contractive activity of saved elements of EAS improved with a course of time and squeezing anal pressure increased as well. Perfect functional outcome was achieved in 25 of 34 patients at 12 months after stoma closure, and all the patients were satisfied with procedure. Good functional results of suggested surgery seems to be an acceptable alternative to APR with permanent stoma in selected patients.

Intersphincteric resection for very low rectal cancer: A review of the updated literature

“…The same strategy appears in Russian and Korean studies,44, 53 and the concept is supported by a histopathological investigation 61. However, the ESR showed a higher positive CRM rate (36.7%) 37.…”

“…Smooth muscle plasty was devised as a neo‐sphincter to improve anal function 22, 30. Combined EAS resection (ESR) is sometimes carried out for tumors with suspected invasion into the intersphincteric space and/or EAS 17, 44, 53. Finally, protective diverting ileostomy or colostomy is commonly created.…”

“…Some authors reported that colonic J‐pouch anastomosis offered superiority in bowel frequency, urgency control, tolerable volume, Wexner score, and fecal incontinence severity index (FISI)77 compared with the straight anastomosis 20, 43, 78. Moreover, the C‐pouch and smooth muscle plasty procedures improved anal function following ISR 30, 44. However, these procedures may be difficult in obese patients and/or in male patients with a narrow pelvis.…”

“…ISR is the ultimate anal preservation surgery by both abdominal and anal approaches which consists of TME and excision of the internal anal sphincter. The surgical technique changed the concept of anal preservation and, since 2000, has rapidly expanded not only in Europe, but also in Japan and other Asian countries 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53. Also, laparoscopic‐ISR has come to be aggressively carried out 38, 39, 40, 41, 42.…”

Low rectal cancer: Sphincter preserving techniques-selection of patients, techniques and outcomes

“…Therefore, partial ISR is defined as a one-third resection of the upper part of the IAS, subtotal ISR as a two-third resection of the IAS, and total ISR as a complete resection of the IAS [21] . Combined resection of the EAS (external sphincter resection, ESR) is sometimes performed for tumors with suspected invasion into the intersphincteric space and/or external sphincter muscles [33,34] . ISR differs from conventional coloanal anastomosis performed after ultra low anterior resection, because it's characterized by resection of internal sphincter by dissection in the intersphincteric plane [35] .…”