Skip to main content
SpringerLink
Log in

A concept of sphincter salvage in low rectal cancer

  • Chapter
Intersphincteric Resection for Low Rectal Tumors

Abstract

Standard surgery in low rectal cancer is moving to more conservative surgery, due to development of new techniques, newconcepts and specialization. The purpose of this article is to discuss the limits of the abdominoperineal resection (APR) procedure and the potential advantages of ultra low conservative surgery. A new surgical classification of low rectal cancer is also presented with the objective to standardize surgical management of low rectal cancer. The surgical technique of intersphincteric resection (ISR) is described, included the laparoscopic approach. Finally, personal results, in term of oncologic and functional outcome, as well as difficult cases are reported.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 129.00
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 169.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 169.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. Miles WE (1908) A method of performing abdomino perineal excision for carcinoma of the rectum and of the terminal portion of the pelvic colon. Lancet 2: 1812–1813

    Article  Google Scholar 

  2. Tytherleigh MG, McC Mortensen NJ (2003) Options for sphincter preservation in surgery for low rectal cancer. Br J Surg 90: 922–933

    Article  PubMed  CAS  Google Scholar 

  3. Morris E, Quirke P, Thomas JD, Fairley L, Cottier B, Forman D (2008) Unacceptable variation in abdominoperineal excision rates for rectal cancer: time to intervene? Gut 57: 1690–1697

    Article  PubMed  CAS  Google Scholar 

  4. Williams NS, Johnston D (1984) Survival and recurrence after sphincter saving resection and abdominoperineal resection for carcinoma of the middle third of the rectum. Br J Surg 71: 278–282

    Article  PubMed  CAS  Google Scholar 

  5. Marr R, Birbeck K, Garvican J, Macklin CP, Tiffin NJ, Parsons WJ, Dixon MF, Mapstone NP, Sebag-Montefiore D, Scott N, Johnston D, Sagar P, Finan P, Quirke P (2005) The modern abdominoperineal excision: the next challenge after total mesorectal excision. Ann Surg 242: 74–82

    Article  PubMed  Google Scholar 

  6. Nagtegaal ID, van de Velde C, Marijnen CAM, van Krieken J, Quirke P; Dutch Colorectal Cancer Group; Pathology Review Committee (2005) Low rectal cancer: a call for a change of approach in abdominoperineal resection. J Clin Oncol 23: 9257–9264

    Article  PubMed  Google Scholar 

  7. Wibe A, Syse A, Andersen E, Tretli S, Myrvold HE, Soreide O; Norwegian Rectal Cancer Group (2004) Oncological outcomes after total mesorectal excision for cure for cancer of the lower rectum: anterior vs. abdominoperineal resection. Dis Colon Rectum 47: 48–58

    Article  PubMed  Google Scholar 

  8. West NP, Finan PJ, Anderin C, Lindholm J, Holm T, Quirke P (2008) Evidence of the oncologic superiority of cylindrical abdominoperineal excision for low rectal cancer. J Clin Oncol 26: 3517–3522

    Article  PubMed  Google Scholar 

  9. West NP, Anderin C, Smith KJ, Holm T, Quirke P; European Extralevator Abdominoperineal Excision Study Group (2010) Multicentre experience with extralevator abdominoperineal excision for low rectal cancer. Br J Surg 97: 588–599

    Article  PubMed  CAS  Google Scholar 

  10. Kressner U, Graf W, Mahteme H, Pahlman L, Glimelius B (2002) Septic complications and prognosis after surgery for rectal cancer. Dis Colon Rectum 45: 316–321

    Article  PubMed  Google Scholar 

  11. Laurent C, Nobili S, Rullier A, Vendrely V, Saric J, Rullier E (2006) Efforts to improve local control in rectal cancer compromise survival by the potential morbidity of optimal mesorectal excision. J Am Coll Surg 203: 684–691

    Article  PubMed  Google Scholar 

  12. Yu JL, May L, Lhotak V, Shahrzad S, Shirasawa S, Weitz JI, Coomber BL, Mackman N, Rak JW (2005) Oncogenic events regulate tissue factor expression in colorectal cancer cells: implications for tumour progression and angiogenesis. Blood 105: 1734–1741

    Article  PubMed  CAS  Google Scholar 

  13. Rullier E, Sebag-Montefiore D (2006) Sphincter saving is the primary objective for local treatment of cancer of the lower rectum. Lancet Oncol 7: 775–777

    Article  PubMed  Google Scholar 

  14. Marijnen CAM, van de Velde CJH, Putter H, van den Brink M, Maas CP, Martijn H, Rutten HJ, Wiggers T, Kranenbarg EK, Leer JW, Stiggelbout AM (2005) Impact of short-term preoperative radiotherapy on health-related quality of life and sexual functioning in primary rectal cancer: report of a multicenter randomized trial. J Clin Oncol 23: 1847–1858

    Article  PubMed  Google Scholar 

  15. Williams NS, Dixon MF, Johnston D (1983) Reappraisal of the 5 centimetre rule of distal excision for carcinoma of the rectum: a study of distal intramural spread and of patients’ survival. Br J Surg 70: 150–154

    Article  PubMed  CAS  Google Scholar 

  16. Ueno H, Mochizuki H, Hashiguchi Y, Ishikawa K, Fujimoto H, Shinto E, Hase K (2004) Preoperative parameters expanding the indication of sphincter preserving surgery in patients with advanced low rectal cancer. Ann Surg 239: 34–42

    Article  PubMed  Google Scholar 

  17. Shirouzu K, Isomoto H, Kakegawa T (1995) Distal spread of rectal cancerand optimal distalmargin of resectionfor sphincterpreserving surgery. Cancer 76: 388–392

    Article  PubMed  CAS  Google Scholar 

  18. Rullier A, Laurent C (2007) Recommendations for clinical practice. Therapeutic choices for rectal cancer. What quality criteria are important for surgical excision of rectal cancer? Gastroenterol Clin Biol 31: 1S34–1S51

    Article  PubMed  Google Scholar 

  19. Engstrom PF, Arnoletti JP, Benson AB 3rd, Chen YJ, Choti MA, Cooper HS, Covey A, Dilawari RA, Early DS, Enzinger PC, Fakih MG, Fleshman J Jr, Fuchs C, Grem JL, Kiel K, Knol JA, Leong LA, Lin E, Mulcahy MF, Rao S, Ryan DP, Saltz L, Shibata D, Skibber JM, Sofocleous C, Thomas J, Venook AP, Willett C; National Comprehensive Cancer Network (2009) NCCN Clinical Practice Guidelines in Oncology: rectal cancer. J Natl Compr Canc Netw 7: 838–881

    PubMed  Google Scholar 

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

    Article  PubMed  CAS  Google Scholar 

  21. Schiessel R, Novi G, Holzer B, Rosen HR, Renner K, Hölbling N, Feil W, Urban M (2005) Technique and long-term results of intersphincteric resection for low rectal cancer. Dis Colon Rectum 48: 1858–1867

    Article  PubMed  Google Scholar 

  22. Braun J, Treutner KH, Winkeltau G, Heidenreich U, Lerch MM, Schumpelick V (1992) Results of intersphincteric resection of the rectum with direct coloanal anastomosis for rectal carcinoma. Am J Surg 163: 407–412

    Article  PubMed  CAS  Google Scholar 

  23. Rullier E, Zerbib F, Laurent C, Bonnel C, Caudry M, Saric J, Parneix M (1999) Intersphincteric resection with excision of internal anal sphincter for conservative treatment of very low rectal cancer. Dis Colon Rectum 42: 1168–1175

    Article  PubMed  CAS  Google Scholar 

  24. Köhler A, Athanasiadis S, Ommer A, Psarakis E (2000) Long term results of low anterior resection with intersphincteric an astomosis in carcinoma of the lower one-third of the rectum: analysis of 31 patients. Dis Colon Rectum 43: 843–850

    Article  PubMed  Google Scholar 

  25. Teramoto T, Watanabe M, Kitajima M (1997) Per anum intersphincteric rectal dissection with direct coloanal anastomosis for lower rectal cancer: the ultimate sphincter-preserving operation. Dis Colon Rectum 40: S43–S47

    Article  PubMed  CAS  Google Scholar 

  26. Saito N, Ono M, Sugito M, Ito M, Morihiro M, Kosugi C, Sato K, Kotaka M, Nomura S, Arai M, Kobatake T (2004) Early results of intersphincteric resection for patients with very low rectal cancer: an active approach to avoid a permanent colostomy. Dis Colon Rectum 47: 459–466

    Article  PubMed  Google Scholar 

  27. Rullier E, Laurent C, Bretagnol F, Rullier A, Vendrely V, Zerbib F (2005) Sphincter-saving resection for all rectal carcinomas: the end of the 2-cm distal rule. Ann Surg 241: 465–469

    Article  PubMed  Google Scholar 

  28. Quirke P, Durdey P, Dixon MF, Williams NS (1986) Local recurrence of rectal adenocarcinoma due to inadequate surgical resection: histopathological study of lateral tumour spread and surgical excision. Lancet 38: 996–999

    Article  Google Scholar 

  29. Birbeck KF, Macklin CP, Tiffin N, Parsons W, Dixon MF, Mapstone NP, Abbott CR, Scott N, Finan PJ, Johnston D, Quirke P (2002) Rates of circumferential resection margin involvement vary between surgeons and predict outcomes in rectal cancer surgery. Ann Surg 235: 449–457

    Article  PubMed  Google Scholar 

  30. Taylor FG, Quirke P, Heald RJ, Moran B, Blomgvist L, Swift I, St Rose S, Sebag-Montefiore DJ, Tekkis P, Brown G; MERCURY study group (2011) One millimeter is the safe cut-off for magnetic resonance imaging prediction of surgical margin status in rectal cancer. Br J Surg 98: 872–879

    Article  PubMed  CAS  Google Scholar 

  31. Tilney HS, Tekkis PP (2007) Extending the horizons of restorative rectal surgery: intersphincteric resection for low rectal cancer. Colorectal Dis 10: 3–16

    PubMed  Google Scholar 

  32. Rullier E, Goffre B, Bonnel C, Zerbib F, Caudry M, Saric J (2001) Preoperative radiochemotherapy and sphincter-saving resection for T3 carcinomas of the lower third of the rectum. Ann Surg 234: 633–640

    Article  PubMed  CAS  Google Scholar 

  33. Bretagnol F, Rullier E, Laurent C, Zerbib F, Gontier R, Saric J (2004) Comparison of functional results and quality of life between intersphincteric resection and conventional coloanal anastomosis for low rectal cancer. Dis Colon Rectum 47: 832–838

    Article  PubMed  Google Scholar 

  34. Denost Q, Laurent C, Capdepont M, Zerbib F, Rullier E (2011) Risk factors for fecal incontinence after intersphincteric resection for rectal cancer. Dis Colon Rectum 54: 963–968

    Article  PubMed  Google Scholar 

  35. 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  PubMed  CAS  Google Scholar 

  36. Matzel KE, Bittorf B, Günther K, Stadelmaier U, Hohenberger W (2002) Rectal resection with low anastomosis: functional outcome. Colorectal Dis 5: 458–464

    Article  Google Scholar 

  37. Chamlou R, Parc Y, Simon T, Bennis M, Dehni N, Parc R, Tiret E (2007) Long-term results of intersphincteric resection for low rectal cancer. Ann Surg 246: 916–922

    Article  PubMed  Google Scholar 

  38. Rullier E, Sa-Cunha A, Couderc P, Rullier A, Gontier R, Saric J (2003) Laparoscopic intersphincteric resection with coloplasty and coloanal anastomosis for mid and low rectal cancer. Br J Surg 90: 445–451

    Article  PubMed  CAS  Google Scholar 

  39. Laurent C, Leblanc F, Bretagnol F, Capdepont M, Rullier E (2008) Long-term wound adavantages of the laparoscopic approach in rectal cancer. Br J Surg 95: 903–908

    Article  PubMed  CAS  Google Scholar 

  40. Laurent C, Paumet T, Leblanc F, Denost Q, Rullier E (2011) Intersphincteric resection for low rectal cancer: laparoscopic versus open approach. Colorectal Dis (in press)

    Google Scholar 

  41. Laurent C, Leblanc F, Wütrich P, Scheffler M, Rullier E (2009) Laparoscopic versus open surgery for rectal cancer: long-term oncologic results. Ann Surg 250: 54–61

    Article  PubMed  Google Scholar 

  42. Fucini C, Elbetti C, Petrolo A, Casella D (2002) Excision of the levator muscles with external sphincter preservation in the treatment of selected low T4 rectal cancers. Dis Colon Rectum 45: 1697–1705

    Article  PubMed  Google Scholar 

  43. Laurent C, Coueffe X, Denost Q, Adam JP, Martenot M, Rullier E (2011) Does R1 resection compromise local control after anterior resection for lowrectal cancer? Colorectal Dis 13 [Suppl 6]: 1

    Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Surgery, Saint-Andre Hospital, University of Bordeaux, 1 rue Jean Burguet, 33075, Bordeaux, France

    Prof. Eric Rullier, Quentin Denost MD & Christophe Laurent MD (Professor of Surgery)

Authors
  1. Prof. Eric Rullier
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Quentin Denost MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Christophe Laurent MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Eric Rullier .

Editor information

Editors and Affiliations

  1. Ludwig Boltzmann Institute for Surgical Oncology, Vienna, Austria

    Rudolf Schiessel MD

  2. Surgical Department, Danube Hospital, Vienna, Austria

    Peter Metzger MD, PhD

Rights and permissions

Reprints and permissions

Copyright information

© 2012 Springer-Verlag/Wien

About this chapter

Cite this chapter

Rullier, E., Denost, Q., Laurent, C. (2012). A concept of sphincter salvage in low rectal cancer. In: Schiessel, R., Metzger, P. (eds) Intersphincteric Resection for Low Rectal Tumors. Springer, Vienna. https://doi.org/10.1007/978-3-7091-0929-8_10

Download citation

  • DOI: https://doi.org/10.1007/978-3-7091-0929-8_10

  • Publisher Name: Springer, Vienna

  • Print ISBN: 978-3-7091-0928-1

  • Online ISBN: 978-3-7091-0929-8

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation