Sphincter-Sparing Surgery in Patients with Low-Lying Rectal Cancer: Techniques, Oncologic Outcomes, and Functional Results

Abstract

Background Rectal cancer management has evolved into a complex multimodality approach with survival, local recurrence, and quality of life parameters being the relevant endpoints. Surgical treatment for low rectal cancer has changed dramatically over the past 100 years. Discussion Abdominoperineal resection, once the standard of care for all rectal cancers, has become much less frequently utilized as surgeons devise and test new techniques for preserving the sphincters, maintaining continuity, and performing oncologically sound ultra-low anterior or local resections. Progress in rectal cancer surgery has been driven by improved understanding of the anatomy and pathophysiology of the disease, innovative surgical technique, improved technology, multimodality approaches, and increased appreciation of the patient's quality of life. The patient with a low rectal cancer, once almost universally destined for impotence and a colostomy, now has the real potential for improved survival, avoidance of a permanent stoma, and preservation of the normal route of defecation.Keywords Rectal cancer . Sphincter preservation . Total mesorectal excision . Anterior resection . Intersphincteric resection . Local excision rectal cancer Historical BackgroundThe modern era of rectal cancer surgery began with the description of the abdominoperineal resection (APR) by Miles in 1908. Prior perineal and sacral approaches (e.g., Kraske approach) to rectal cancer resection produced high rates of complications, cancer recurrence, poor quality of life (QOL), and poor overall survival. Miles' operation reflected greater understanding of the natural history of rectal cancer that was based on postmortem examination of his patients after perineal resection. He observed cancerous implants in the pelvic peritoneum, mesorectum, and affected nodes of the left common iliac bifurcation. These findings led him to develop a "cylindrical concept" of the spread of rectal cancer to upward, downward, and lateral zones. 1 The original operation included resection of the rectum, sigmoid, mesorectum, nodes of the iliac bifurcation, and a perineal component to include the anus and levator ani muscles. Postoperative mortality was high initially, but local recurrence decreased

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

“…Under direct vision, the dissection is continued cephalad through the intersphincteric space to be connected with the TME plane developed transabdominally [3] . The specimen is usually delivered per anus.…”

“…A positive CRM (< 1 mm), places the patient at great risk for local failure and distant metastases, thus reducing the overall survival [13] . Adoption of TME resulted in decreased CRM positivity [3] . Another change in the rectal cancer surgical management was the re-evaluation of the length of distal resection margin (DRM).…”

“…For more than twenty years, the most fundamental advance in rectal cancer surgery was the advent of total mesorectal excision (TME), proposed by Heald et al [2] in 1982. Although TME never compared to the traditional surgical approaches in a prospective randomized fashion, TME demonstrates clear superiority in terms of local recurrence and survival as compared to historical controls [3] . Properly conducted TME reduces the recurrence rate to < 10% and increases overall 5-year survival to over 80% [4] .…”

Local control of sphincter‐preserving procedures and abdominoperineal resection for locally advanced low rectal cancer: Propensity score matched analysis

“…However, sphincter‐preserving procedures (SPPs) have increasingly been carried out in the last two decades and have recently been improved by more detailed anatomical understanding, improvements in surgical devices and techniques, accurate preoperative staging, and neoadjuvant therapy 1, 2. SPPs are now technically possible even for advanced or considerably low‐lying tumors.…”

“…Moreover, many previous studies compared newer SPPs cases with older APR cases, or included many cases operated in the 1990s. The techniques and devices for rectal resection, preoperative accurate diagnosis, and preoperative treatment have advanced, especially in the last 10 years 1. Hence, we thought that the justification of oncological safety of SPPs would still be unclear and thus warranted a further well‐designed study to adjust for these confounders.…”