Surgery Today

, Volume 43, Issue 8, pp 838–847 | Cite as

Intersphincteric resection for very low rectal cancer: a systematic review

  • Yoshito AkagiEmail author
  • Tetsushi Kinugasa
  • Kazuo Shirouzu
Review Article


Radical surgical treatment for very low rectal cancer near the anus has generally involved abdominoperineal resection. Various sphincter-saving operations have been developed for such tumors to optimize the patients’ postoperative quality of life. Current protocols focus on intersphincteric resection (ISR), which differs from conventional hand-sewn coloanal anastomosis (CAA) after low anterior resection. However, the efficacy of ISR remains unclear. The surgical, oncologic, and functional outcomes after intersphincteric resection (ISR) were reviewed. This review of the current literature was conducted by searching the PubMed online database. Articles focusing specifically on conventional hand-sewn CAA were excluded from this study. The mean mortality rate is <2 %, and the mean morbidity rate ranges from 7.7 to 38.3 %. The mean local recurrence rate varies widely from 0 to 22.7 %, with a mean follow-up duration of 40–94 months. The mean disease-free and overall 5-year survival rates are 69–86 and 79–97 months, respectively. Functional outcomes are generally acceptable, but accurate evaluation is extremely difficult due to the absence of unified appraisal methods. ISR appears surgically, oncologically and functionally acceptable. However, more experience and better understanding of the oncology, anal physiology, and pelvic anatomy are necessary to achieve successful outcomes without complications, and to improve patient survival.


Rectal cancer Intersphincteric resection Local recurrence Survival 



Sponsorship or grants: this study was not performed under any commercial sponsorship or grant.

Conflict of interest

The authors declare that there is nothing to disclose.


  1. 1.
    Schiessel R, Karner-Hanusch J, Herbst F, Teleky B, Wunderlich M. Intersphincteric resection for low rectal tumors. Br J Surg. 1994;81:1376–8.PubMedCrossRefGoogle Scholar
  2. 2.
    Rullier E, Zerbib F, Laurent C, Bonnel C, Caudry M, Saric J, et al. Intersphincteric resection with excision of internal anal sphincter for conservative treatment of very low rectal cancer. Dis Colon Rectum. 1999;42:1168–75.PubMedCrossRefGoogle Scholar
  3. 3.
    Shirouzu K, Ogata Y, Araki Y, Kishimoto Y, Sato Y. A new ultimate anus-preserving operation for extremely low rectal cancer and for anal canal cancer. Tech Coloproctol. 2003;7:203–6.PubMedCrossRefGoogle Scholar
  4. 4.
    Saito N, Ono M, Sugito M, Ito M, Morihiro M, Kosugi C, et al. Early results of intersphincteric resection for patients with very low rectal cancer: an active approach to avoid a permanent colostomy. Dis Colon Rectum. 2004;47:459–66.PubMedCrossRefGoogle Scholar
  5. 5.
    Köhler A, Athanasiadis S, Ommer A, Psarakis E. Long-term results of low anterior resection with intersphincteric anastomosis in carcinoma of the lower one-third of the rectum. Dis Colon Rectum. 2000;43:843–50.PubMedCrossRefGoogle Scholar
  6. 6.
    Vorobiev GI, Odaryuk TS, Tsarkov PV, Talalakin AI, Rybakov EG. Resection of the rectum and total excision of the internal anal sphincter with smooth muscle plasty and colonic pouch for treatment of ultralow rectal carcinoma. Br J Surg. 2004;91:1506–12.PubMedCrossRefGoogle Scholar
  7. 7.
    Schiessel R, Novi G, Holzer B, Rosen HR, Renner K, Hölbling N, et al. Technique and long-term results of intersphincteric resection for low rectal cancer. Dis Colon Rectum. 2005;48:1858–67.PubMedCrossRefGoogle Scholar
  8. 8.
    Rullier E, Laurent C, Bretagnol F, Rullier A, Vendrely V, Zerbib F. Sphincter-saving resection for all rectal carcinomas: the end of the 2 cm distal rule. Ann Surg. 2005;241:465–9.PubMedCrossRefGoogle Scholar
  9. 9.
    Hohenberger W, Merkel S, Matzel K, Bittorf B, Papadopoulos T, Gohl J. The influence of abdomino-perianal (intersphincteric) resection of lower third rectal carcinoma on the rates of sphincter preservation and locoregional recurrence. Colorectal Dis. 2006;8:23–33.PubMedCrossRefGoogle Scholar
  10. 10.
    Chin CC, Yeh CY, Huang WS, Wang JY. Clinical outcome of intersphincteric resection for ultra-low rectal cancer. World J Gastroenterol. 2006;12:640–3.PubMedGoogle Scholar
  11. 11.
    Saito N, Moriya Y, Shirouzu K, Maeda K, Mochizuki H, Koda K, et al. Intersphincteric resection in patients with very low rectal cancer: a review of the Japanese experience. Dis Colon Rectum. 2006;49:S13–22.PubMedCrossRefGoogle Scholar
  12. 12.
    Chamlou R, Parc Y, Simon T, Bennis M, Dehni N, Park R, et al. Long-term results of intersphincteric resection for low rectal cancer. Ann Surg. 2007;246:916–21.PubMedCrossRefGoogle Scholar
  13. 13.
    Portier G, Ghouti L, Kirzin S, Guimbaud R, Rives M, Lazorthes F. Oncological outcome of ultra-low coloanal anastomosis with and without intersphincteric resection for low rectal adenocarcinoma. Br J Surg. 2007;94:341–5.PubMedCrossRefGoogle Scholar
  14. 14.
    Krand O, Yalti T, Tellioglu G, Kara M, Berber I, Titiz MI. Use of smooth muscle plasty after intersphincteric rectal resection to replace a partially resected internal anal sphincter: long-term follow-up. Dis Colon Rectum. 2009;52:1895–901.PubMedCrossRefGoogle Scholar
  15. 15.
    Saito N, Sugito M, Ito M, Kobayashi A, Nishizawa Y, Yoneyama Y, et al. Oncologic outcome of intersphincteric resection for very low rectal cancer. World J Surg. 2009;33:1750–6.PubMedCrossRefGoogle Scholar
  16. 16.
    Han JG, Wei GH, Gao ZG, Zheng Y, Wang ZJ. Intersphincteric resection with direct coloanal anastomosis for ultralow rectal cancer: the experience of People’s Republic of China. Dis Colon Rectum. 2009;52:950–7.PubMedCrossRefGoogle Scholar
  17. 17.
    Weiser MR, Quah HM, Shia J, Guillem JG, Paty PB, Temple LK, et al. Sphincter preservation in low rectal cancer is facilitated by preoperative chemoradiation and intersphincteric dissection. Ann Surg. 2009;249:236–42.PubMedCrossRefGoogle Scholar
  18. 18.
    Kuo LJ, Hung CS, Wu CH, Wang W, Tam KW, Liang HH, et al. Oncological and functional outcome of intersphincteric resection for low rectal cancer. J Surg Res. 2011;170:e93–8.PubMedCrossRefGoogle Scholar
  19. 19.
    Renner K, Rosen H, Novi G, Hölbling N, Schiessel R. Quality of life after surgery for rectal cancer. Dis Colon Rectum. 1999;42:1160–7.PubMedCrossRefGoogle Scholar
  20. 20.
    Barisic G, Markovic V, Popovic M, Dimitrijevic I, Gavrilovic P, Krivokapic Z. Function after intersphincteric resection for low rectal cancer and its influence on quality of life. Colorectal Dis. 2011;13:638–43.PubMedCrossRefGoogle Scholar
  21. 21.
    Matzel KE, Bittorf B, Günther K, Stadelmaier U, Hohenberger W. Rectal resection with low anastomosis: functional outcome. Colorectal Dis. 2003;5:458–64.PubMedCrossRefGoogle Scholar
  22. 22.
    Ito M, Saito N, Sugito M, Kobayashi A, Nishizawa Y, Tsunoda Y. Analysis of clinical factors associated with anal function after intersphincteric resection for very low rectal cancer. Dis Colon Rectum. 2009;52:64–70.PubMedCrossRefGoogle Scholar
  23. 23.
    Yamada K, Ogata S, Saiki Y, Fukunaga M, Tsuji Y, Takano M. Functional results of intersphincteric resection for low rectal cancer. Br J Surg. 2007;94:1272–7.PubMedCrossRefGoogle Scholar
  24. 24.
    Denost Q, Laurent C, Capdepont M, Zerbib F, Rullier E. Risk factors for fecal incontinence after intersphincteric resection for rectal cancer. Dis Colon Rectum. 2011;54:963–8.PubMedCrossRefGoogle Scholar
  25. 25.
    Parks AG. Transanal technique in low rectal anastomosis. Proc R Soc Med. 1972;65:975–6.PubMedGoogle Scholar
  26. 26.
    Lyttle JA, Parks AG. Intersphincteric excision of the rectum. Br J Surg. 1977;64:413–6.PubMedCrossRefGoogle Scholar
  27. 27.
    Shelygin YA, Vorobiev GI, Pikunov DY, Markova EV, Djhanaev YA, Fomenko OY. Intersphincteric resection with partial removal of external anal sphincter for low rectal cancer. Acta Chir Iugosl. 2008;55:45–53.PubMedCrossRefGoogle Scholar
  28. 28.
    Bretagnol F, Rullier E, Laurent C, Zerbib F, Gontier R, Saric J. Comparison of functional results and quality of life between intersphincteric resection and conventional coloanal anastomosis for low rectal cancer. Dis Colon Rectum. 2004;47:832–8.PubMedCrossRefGoogle Scholar
  29. 29.
    Heald RJ, Husband EM, Ryall RD. Mesorectum in rectal cancer surgery: the clue to pelvic recurrence. Br J Surg. 1982;69:613–6.PubMedCrossRefGoogle Scholar
  30. 30.
    Shirouzu K, Ogata Y. Histopathologic tumor spread in very low rectal cancer treated with abdominoperineal resection. Dis Colon Rectum. 2009;52:1887–94.PubMedCrossRefGoogle Scholar
  31. 31.
    Vernava AM 3rd, Moran M, Rothenberger DA, Wong WD. A prospective evaluation of distal margins in carcinoma of the rectum. Surg Gynecol Obstet. 1992;175:333–6.PubMedGoogle Scholar
  32. 32.
    Shirouzu K, lsomoto H, Kakegawa T. Distal spread of rectal cancer and optimal distal margin of resection for sphincter-preserving surgery. Cancer. 1995;76:388–92.PubMedCrossRefGoogle Scholar
  33. 33.
    Andreola S, Leo E, Belli F, Lavarino C, Bufalino R, Tomasic G, et al. Distal intramural spread in adenocarcinoma of the lower third of the rectum treated with total rectal resection and coloanal anastomosis. Dis Colon Rectum. 1997;40:25–9.PubMedCrossRefGoogle Scholar
  34. 34.
    Moore HG, Riedel E, Minsky BD, Saltz L, Paty P, Wong D, et al. Adequacy of 1-cm distal margin after restorative rectal cancer resection with sharp mesorectal excision and preoperative combined-modality therapy. Ann Surg Oncol. 2003;10:80–5.PubMedCrossRefGoogle Scholar
  35. 35.
    Kuvshinoff B, Maghfoor I, Miedema B, Bryer M, Westgate S, Wilkes J, et al. Distal margin requirements after preoperative chemoradiotherapy for distal rectal carcinomas: are < or = 1 cm distal margins sufficient? Ann Surg Oncol. 2001;8:163–9.PubMedGoogle Scholar
  36. 36.
    Guillem JG, Chessin DB, Shia J, Suriawinata A, Riedel E, Moore HG, et al. A Prospective pathologic analysis using whole-mount sections of rectal cancer following preoperative combined modality therapy: implications for sphincter preservation. Ann Surg. 2007;245:88–93.PubMedCrossRefGoogle Scholar
  37. 37.
    Nagtegaal ID, Quirke P. What is the role for the circumferential margin in the modern treatment of rectal cancer? J Clin Oncol. 2008;26:303–12.PubMedCrossRefGoogle Scholar
  38. 38.
    Holzer B, Urban M, Hölbling N, Feil W, Novi G, Hruby W, et al. Magnetic resonance imaging predicts sphincter invasion of low rectal cancer and influences selection of operation. Surgery. 2003;133:656–61.PubMedCrossRefGoogle Scholar
  39. 39.
    Urban M, Rosen HR, Hölbling N, Feil W, Hochwarther G, Hruby W, et al. MR imaging for the preoperative planning of sphincter-saving surgery for tumors of the lower third of the rectum: use of intravenous and endorectal contrast materials. Radiology. 2000;214:503–8.PubMedGoogle Scholar
  40. 40.
    Beets-Tan RG, Lettinga T, Beets GL. Pre-operative imaging of rectal cancer and its impact on surgical performance and treatment outcome. Eur J Surg Oncol. 2005;31:681–8.PubMedCrossRefGoogle Scholar
  41. 41.
    Dent OF, Chapuis PH, Haboubi N, Bokey L. Magnetic resonance imaging cannot predict histological tumour involvement of a circumferential surgical margin in rectal cancer. Colorectal Dis. 2011;13:974–81.PubMedCrossRefGoogle Scholar
  42. 42.
    Bamba Y, Itabashi M, Kameoka S. Preoperative evaluation of the depth of anal canal invasion in very low rectal cancer by magnetic resonance imaging and surgical indications for intersphincteric resection. Surg Today. 2012;42:328–33.PubMedCrossRefGoogle Scholar
  43. 43.
    Rullier E, Laurent C, Carles J, Saric J, Michel P, Parneix M. Local recurrence of low rectal cancer after abdominoperineal and anterior resection. Br J Surg. 1997;84:525–8.PubMedCrossRefGoogle Scholar
  44. 44.
    Kapiteijn E, Marijnen CA, Nagtegaal ID, Putter H, Steup WH, Wiggers T, et al. Dutch Colorectal Cancer Group. Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. N Engl J Med. 2001;345:638–46.PubMedCrossRefGoogle Scholar
  45. 45.
    Hassan I, Larson DW, Wolff BG, Cima RR, Chua HK, Hahnloser D, et al. Impact of pelvic radiotherapy on morbidity and durability of sphincter preservation after coloanal anastomosis for rectal cancers. Dis Colon Rectum. 2008;51:32–7.PubMedCrossRefGoogle Scholar
  46. 46.
    Bonnel C, Parc YR, Pocard M, Dehni N, Caplin S, Parc R, et al. Effects of preoperative radiotherapy for primary resectable rectal adenocarcinoma on male sexual and urinary function. Dis Colon Rectum. 2002;45:934–9.PubMedCrossRefGoogle Scholar
  47. 47.
    Peeters KC, Marijnen CA, Nagtegaal ID, Kranenbarg EK, Putter H, Wiggers T, et al. Dutch Colorectal Cancer Group. The TME trial after a median follow-up of 6 years: increased local control but no survival benefit in irradiated patients with resectable rectal carcinoma. Ann Surg. 2007;246:693–701.PubMedCrossRefGoogle Scholar
  48. 48.
    Nagamatsu Y, Shirouzu K, Isomoto H, Ogata Y, Tsuchida I, Akagi Y. Surgical treatment of lower rectal cancer with sphincter preservation using handsewn coloanal anastomosis. Surg Today. 1998;28:696–700.PubMedCrossRefGoogle Scholar
  49. 49.
    Ortiz H, Armendariz P. Anterior resection: do the patients perceive any clinical benefit? Int J Colorectal Dis. 1996;11:191–5.PubMedCrossRefGoogle Scholar
  50. 50.
    Kakodkar R, Gupta S, Nundy S. Low anterior resection with total mesorectal excision for rectal cancer: functional assessment and factors affecting outcome. Colorectal Dis. 2006;8:650–6.PubMedCrossRefGoogle Scholar
  51. 51.
    Kirwan WO, Turnbull RB Jr, Fazio VW, Weakley FL. Pullthrough operation with delayed anastomosis for rectal cancer. Br J Surg. 1978;65:695–8.PubMedCrossRefGoogle Scholar
  52. 52.
    Jorge JM, Wexner SD. Etiology and management of fecal incontinence. Dis Colon Rectum. 1993;36:77–9.PubMedCrossRefGoogle Scholar
  53. 53.
    Beersiek F, Parks AG, Swash M. Pathogenesis of ano-rectal incontinence. A histometric study of the anal sphincter musculature. J Neurol Sci. 1979;42:111–27.PubMedCrossRefGoogle Scholar
  54. 54.
    Lewis WG, Holdsworth PJ, Stephenson BM, Finan PJ, Johnston D. Role of the rectum in the physiological and clinical results of coloanal and colorectal anastomosis after anterior resection for rectal carcinoma. Br J Surg. 1992;79:1082–6.PubMedCrossRefGoogle Scholar
  55. 55.
    Nicholls RJ, Lubowski DZ, Donaldson DR. Comparison of colonic reservoir and straight colo-anal reconstruction after rectal excision. Br J Surg. 1988;75:318–20.PubMedCrossRefGoogle Scholar
  56. 56.
    Parks AG, et al. Resection and sutured colo-anal anastomosis for rectal carcinoma. Br J Surg. 1982;69:301–4.PubMedCrossRefGoogle Scholar
  57. 57.
    Hallböök O, Påhlman L, Krog M, Wexner SD, Sjödahl R. Randomized comparison of straight and colonic J pouch anastomosis after low anterior resection. Ann Surg 996; 224:58–65.Google Scholar
  58. 58.
    Tilney HS, Tekkis PP. Extending the horizons of restorative rectal surgery: intersphincteric resection for low rectal cancer. Colorectal Dis. 2008;10:3–15.PubMedCrossRefGoogle Scholar
  59. 59.
    Hashimoto H, Shiokawa H, Funahashi K, Saito N, Sawada T, Shirouzu K, et al. Development and validation of a modified fecal incontinence quality of life scale for Japanese patients after intersphincteric resection for very low rectal cancer. J Gastroenterol. 2010;45:928–35.PubMedCrossRefGoogle Scholar
  60. 60.
    Araki Y, Momosaki K, Nozoe Y, Hayashi K, Yamada K, Kanazawa M, et al. Graciloplasty for internal and external sphincteric resection of lower rectal cancer. Kurume Med J. 2004;51:287–9.PubMedCrossRefGoogle Scholar
  61. 61.
    Sauer R, Becker H, Hohenberger W, Rödel C, Wittekind C, Fietkau R, et al. German Rectal Cancer Study Group. Preoperative versus postoperative chemotherapy for rectal cancer. N Engl J Med. 2004;351:1731–40.PubMedCrossRefGoogle Scholar
  62. 62.
    Lange MM, den Dulk M, Bossema ER, Maas CP, Peeters KC, Rutten HJ, et al. Cooperative Clinical Investigators of the Dutch Total Mesorectal Excision Trial. Risk factors for fecal incontinence after rectal cancer treatment. Br J Surg. 2007;94:1278–84.PubMedCrossRefGoogle Scholar
  63. 63.
    Tsukasa H, Hiroki Y. Laparoscopic surgery for rectal cancer: review of published literature 2000–2009. Surg Today. 2011;41:1583–91.CrossRefGoogle Scholar

Copyright information

© Springer Japan 2012

Authors and Affiliations

  • Yoshito Akagi
    • 1
    Email author
  • Tetsushi Kinugasa
    • 1
  • Kazuo Shirouzu
    • 1
  1. 1.Department of SurgeryKurume University School of MedicineKurumeJapan

Personalised recommendations