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Outcomes of ultra-low anterior resection combined with or without intersphincteric resection in lower rectal cancer patients

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International Journal of Colorectal Disease Aims and scope Submit manuscript

Abstract

Purpose

We evaluated the current practice of ultra-low anterior resection (uLAR) in patients with lower rectal cancer and compared uLARs using mostly transabdominal approach with or without intersphincteric resection (ISR).

Methods

A total of 624 consecutive lower rectal cancer patients undergoing curative uLAR were prospectively enrolled as ISR+ vs. ISR− groups (329 vs. 295 patients) between 2005 and 2012. The ISR+ group additionally received levator-sphincter reinforcement after distal resection.

Results

The circumferential resection margin (CRM) + rate (≤1 mm) was 2.1 % in the two groups. Postoperative ileus occurred more in the ISR– group than in the ISR+ group (p = 0.02). Substantial erectile dysfunction occurred 1.8 times more frequently in the ISR– group than in the ISR+ group (32 vs. 18.1 %; p = 0.01) among male patients at 2 years postoperatively. The urge to defecate volume and maximal tolerance volume, closely correlated with maximal squeezing pressure and/or mean resting pressure, did not differ between patients with and without chemoradiotherapy until 24 months postoperatively. Nevertheless, the urge to defecate volume was lesser in the ISR− group than in the ISR+ group at 24 months postoperatively (p = 0.022). For 301 patients in which >5 years had elapsed postoperatively, the mean 5-year local recurrence rate was 4.3 %, and the 5-year disease-free and overall survival rates were 78.9 and 92 %, respectively, without differences between the two groups.

Conclusions

Compared with uLAR without ISR, the transabdominal ISR with levator-sphincter reinforcement provides a safe resection plane with competent CRM, concurrently reduces substantial complications, and marginally promotes recovery of neorectal function.

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Abbreviations

uLAR:

Ultra-low anterior resection

SSO:

Sphincter-saving operation

ISR:

Intersphincteric resection

CRT:

Chemoradiotherapy

AV:

Anal verge

ECOG:

Eastern Cooperative Oncology Group

CT:

Computed tomography

MRI:

Magnetic resonance imaging

EUS:

Endorectal ultrasonography

FL:

5-fluoroural and leucovorin

TME:

Total mesorectal excision

CRM:

Circumferential resection margin

OR:

Odds ratio

CI:

Confidence interval

LVI:

Lymphovascular invasion

PNI:

Perineural invasion

DFS:

Disease-free survival

OS:

Overall survival

s-CEA:

Serum carcinoembryonic antigen

APR:

Abdominoperineal resection

References

  1. Bokey EL (2013) Carcinoma of the rectum. In: Corman ML (ed) Colon and rectal surgery, 6th edn. Wolter Kluwer, Philadelphia, pp 864–990

    Google Scholar 

  2. Baik SH, Kim NK, Lee KY, Sohn SK, Cho CH (2005) Hand-sewn coloanal anastomosis for distal rectal cancer: long-term clinical outcomes. J Gastrointest Surg 9:775–780

    Article  PubMed  Google Scholar 

  3. Schiessel R, Karner-Hanusch J, Herbst F, Teleky B, Wunderlich M (1994) Intersphincteric resection for low rectal tumours. Br J Surg 81:1376–1378

    Article  CAS  PubMed  Google Scholar 

  4. Martin ST, Heneghan HM, Winter DC (2012) Systematic review of outcomes after intersphincteric resection for low rectal cancer. Br J Surg 99:603–612

    Article  CAS  PubMed  Google Scholar 

  5. Kim JC, Lim SB, Yoon YS, Park IJ, Kim CW, Kim CN (2014) Completely abdominal intersphincteric resection for lower rectal cancer: feasibility and comparison of robot-assisted and open surgery. Surg Endosc 28:2734–2744

    Article  PubMed  Google Scholar 

  6. Pucciani F (2013) A review on functional results of sphincter-saving surgery for rectal cancer: the anterior resection syndrome. Updates Surg 65:257–263

    Article  PubMed  Google Scholar 

  7. Kim JC, Yu CS, Lim SB, Kim CW, Kim JH, Kim TW (2013) Abdominoperineal resection and low anterior resection: comparison of long-term oncologic outcome in matched patients with lower rectal cancer. Int J Colorectal Dis 28:493–501

    Article  PubMed  Google Scholar 

  8. Kim JC, Kim CW, Yoon YS, Lee HO, Park IJ (2012) Levator-sphincter reinforcement after ultralow anterior resection in patients with low rectal cancer: the surgical method and evaluation of anorectal physiology. Surg Today 42:547–553

    Article  PubMed  Google Scholar 

  9. Jorge JM, Wexner SD (1993) Etiology and management of fecal incontinence. Dis Colon Rectum 36:77–97

    Article  CAS  PubMed  Google Scholar 

  10. Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240:205–213

    Article  PubMed Central  PubMed  Google Scholar 

  11. Goligher J, Duthie H (1984) Surgical anatomy and physiology of the anus, rectum and colon. In: Goligher J (ed) Surgery of the anus, rectum and colon, 5th edn. Ballière Tindall, London, pp 1–47

    Google Scholar 

  12. Stein E (2003) Anatomy of the anorectal region. In: Stein E (ed) Anorectal and colon disease, 1st edn. Springer, Berlin, pp 4–11

    Chapter  Google Scholar 

  13. Tiret E, Poupardin B, McNamara D, Dehni N, Parc R (2003) Ultralow anterior resection with intersphincteric dissection—what is the limit of safe sphincter preservation? Colorectal Dis 5:454–457

    Article  CAS  PubMed  Google Scholar 

  14. Williams NS, Murphy J, Knowles CH (2008) Anterior perineal plane for ultra-low anterior resection of the rectum (the APPEAR technique): a prospective clinical trial of a new procedure. Ann Surg 247:750–758

    Article  PubMed  Google Scholar 

  15. Nagtegaal ID, Quirke P (2008) What is the role for the circumferential margin in the modern treatment of rectal cancer? J Clin Oncol 26:303–312

    Article  PubMed  Google Scholar 

  16. Trakarnsanga A, Gonen M, Shia J, Goodman KA et al (2013) What is the significance of the circumferential margin in locally advanced rectal cancer after neoadjuvant chemoradiotherapy? Ann Surg Oncol 20:1179–1184

    Article  PubMed Central  PubMed  Google Scholar 

  17. Park JS, Huh JW, Park YA et al (2014) A circumferential resection margin of 1 mm is a negative prognostic factor in rectal cancer patients with and without neoadjuvant chemoradiotherapy. Dis Colon Rectum 57:933–940

    Article  PubMed  Google Scholar 

  18. Bown EJ, Lloyd GM, Boyle KM, Miller AS (2014) Rectal cancer: prognostic indicators of long-term outcome in patients considered for surgery. Int J Colorectal Dis 29:147–155

    Article  CAS  PubMed  Google Scholar 

  19. Akagi Y, Kinugasa T, Shirouzu K (2013) Intersphincteric resection for very low rectal cancer: a systematic review. Surg Today 43:838–847

    Article  PubMed  Google Scholar 

  20. Chang JS, Lee Y, Lim JS et al (2014) Preoperative chemoradiotherapy effects on anastomotic leakage after rectal cancer resection: a propensity score matching analysis. Ann Surg 259:516–521

    Article  PubMed  Google Scholar 

  21. Mirnezami A, Mirnezami R, Chandrakumaran K, Sasapu K, Sagar P, Finan P (2011) Increased local recurrence and reduced survival from colorectal cancer following anastomotic leak: systematic review and meta-analysis. Ann Surg 253:890–899

    Article  PubMed  Google Scholar 

  22. Kinugasa Y, Sugihara K (2009) Why does levator ani nerve damage occur during rectal surgery? J Clin Oncol 27:999–1000

    Article  PubMed  Google Scholar 

  23. Lange MM, van de Velde CJ (2011) Urinary and sexual dysfunction after rectal cancer treatment. Nat Rev Urol 8:51–57

    Article  PubMed  Google Scholar 

  24. Keating JP (2004) Sexual function after rectal excision. ANZ J Surg 74:248–259

    Article  PubMed  Google Scholar 

  25. Timmcke AE (1990) Objectives and methodology of manometry. In Smith LE (ed) Practical guideline to anorectal testing. 1st edn. Igaku-shoin, New York · Tokyo, pp 23-30

  26. Loos M, Quentmeier P, Schuster T et al (2013) Effect of preoperative radio(chemo)therapy on long-term functional outcome in rectal cancer patients: a systematic review and meta-analysis. Ann Surg Oncol 20:1816–1828

    Article  PubMed  Google Scholar 

  27. Gamagami R, Istvan G, Cabarrot P, Liagre A, Chiotasso P, Lazorthes F (2000) Fecal continence following partial resection of the anal canal in distal rectal cancer: long-term results after coloanal anastomoses. Surgery 127:291–295

    Article  CAS  PubMed  Google Scholar 

  28. Saito N, Ito M, Kobayashi A et al (2014) Long-term outcomes after intersphincteric resection for low-lying rectal cancer. Ann Surg Oncol 21:3608–3615

    Article  PubMed  Google Scholar 

  29. Peng J, Sheng W, Huang D et al (2011) Perineural invasion in pT3N0 rectal cancer: the incidence and its prognostic effect. Cancer 117:1415–1421

    Article  PubMed  Google Scholar 

  30. Fujita S, Nakanisi Y, Taniguchi H et al (2007) Cancer invasion to Auerbach’s plexus is an important prognostic factor in patients with pT3-pT4 colorectal cancer. Dis Colon Rectum 50:1860–1866

    Article  PubMed  Google Scholar 

  31. Jessup JM, Thomas P (1998) CEA and metastasis: a facilitator or site-specific metastasis. In: Stanners CP (ed) Cell adhesion and communication mediated by the CEA family, 1st edn. Harwood Academic, Amsterdam, pp 195–223

    Google Scholar 

  32. Gastinger I, Marusch F, Steinert R et al (2005) Protective defunctioning stoma in low anterior resection for rectal carcinoma. Br J Surg 92:1137–1142

    Article  CAS  PubMed  Google Scholar 

Download references

Acknowledgement

This work was supported by the Grants (to J. C. Kim) from the Korea Research Foundation (2013R1A2A1A03070986); Ministry of Science, ICT, and Future Planning; the Korea Health 21 R&D Project (HI06C0868 and HI13C1750), and the Center for Development and Commercialization of Anti-Cancer Therapeutics (HI10C2014), Ministry of Health and Welfare, Republic of Korea.

Conflict of interest

The authors declare that they have no competing interests.

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Authors and Affiliations

  1. Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, South Korea

    Jin C. Kim, Chang S. Yu, Seok-B Lim, Chan W. Kim, In J. Park & Yong S. Yoon

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  1. Jin C. Kim
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  2. Chang S. Yu
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  3. Seok-B Lim
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Correspondence to Jin C. Kim.

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Kim, J.C., Yu, C.S., Lim, SB. et al. Outcomes of ultra-low anterior resection combined with or without intersphincteric resection in lower rectal cancer patients. Int J Colorectal Dis 30, 1311–1321 (2015). https://doi.org/10.1007/s00384-015-2303-x

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  • DOI: https://doi.org/10.1007/s00384-015-2303-x

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