Skip to main content
Log in

Exfoliated cancer cells during intersphincteric resection for very low rectal cancer

  • Original Article
  • Published:
Surgery Today Aims and scope Submit manuscript

Abstract

Purpose

To investigate the frequency of exfoliated cancer cells and the efficacy of rectal washout during intersphincteric resection (ISR) in patients not receiving chemoradiotherapy (CRT) for very low rectal cancer.

Method

The subjects of this prospective study were 16 consecutive patients who underwent ISR without CRT for very low rectal cancer. Brushing cytology of the posterior anorectal wall was performed twice in each step of the ISR procedure and the samples were sent for blind cytological examination to identify exfoliated cancer cells.

Results

Exfoliated cancer cells were identified in 9 of 13 patients (69%) preoperatively. The number of cancer cells identified after abdominal total mesorectal dissection decreased significantly from 94% (15/16) to 25% (4/16) after transanal irrigation with 2000 mL saline (p < 0.001). No cancer cells were identified after swabbing the anal wall following transanal dissection with purse-string closure of the distal stump. No suture-line recurrence was found during a median follow-up duration of 6 years.

Conclusion

Exfoliated cancer cells, confirmed in 94% of patients after total mesorectal excision, could be eliminated by performing rectal irrigation after clamping the rectum proximal to the tumor and swabbing the anorectal wall during ISR.

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

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1

Similar content being viewed by others

References

  1. Kodela K, Holmberg E, Jorgren F, Nordgren S, Lindmark G. Rectal washout and local recurrence of cancer after anterior resection. Br J Surg. 2010;97:1589–97.

    Google Scholar 

  2. Rondelli F, Trastulli S, Cirocchi R, Avenia N, Marianti E, Sciannameo F, et al. Rectal washout and local recurrence in rectal resection for cancer: a meta-analysis. Colorectal Dis. 2011;14:1313–22.

    Google Scholar 

  3. Matsuda A, Kishi T, Musso G, Matsutani T, Yokoi K, Wang O, et al. The effect of intraoperative rectal washout on local recurrence after rectal cancer surgery: a meta-analysis. Ann Surg Oncol. 2013;20:856–63.

    PubMed  Google Scholar 

  4. Zhou C, Ren Y, Li J, Li X, He J, Liu P. Systemic review and meta-analysis of rectal washout on risk of local recurrence for cancer. J Surg Res. 2014;189:7–16.

    PubMed  Google Scholar 

  5. Maeda K, Maruta M, Hanai T, Sato H, Horibe Y. Irrigation volume determines the efficacy of “rectal washout”. Dis Colon Rectum. 2004;47:1706–10.

    PubMed  Google Scholar 

  6. Schiessel R, Karner-Hanusch J, Herbest F, Teleky B, Wundelich M. Intersphincteric resection for low rectal tumors. Br J Surg. 1994;81:1376–8.

    CAS  PubMed  Google Scholar 

  7. 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.

    CAS  PubMed  Google Scholar 

  8. 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.

    PubMed  Google Scholar 

  9. 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;49:1–10.

    Google Scholar 

  10. Tytherleigh MG, Mortensen HJ. Options for sphincter preservation in surgery for low rectal cancer. Br J Surg. 2003;90:922–33.

    CAS  PubMed  Google Scholar 

  11. Tsukamoto S, Miyake M, Shida D, Ochiai H, Yamada K, Kanemitsu Y. Intersphincteric resection has similar long-term oncological outcomes compared with abdominoperineal resection for low rectal cancer without preoperative therapy: results of propensity score analyses. Dis Colon Rectum. 2018;61:1035–42.

    PubMed  Google Scholar 

  12. Maeda K, Maruta M, Sato H, Masumori K, Aoyama H. “On table” positioning for optimal access for cancer excision in the lower rectum. World J Surg. 2004;28:416–9.

    PubMed  Google Scholar 

  13. Roberts PL, Shoetz DJ, Murray JJ, Coller JA, Veidenheimer MC. Use of new retractor to facilitate mucosal proctectomy. Dis Colon Rectum. 1990;33:1063–4.

    CAS  PubMed  Google Scholar 

  14. Umpleby HC, Fermor B, Symes MO, Williamson RCN. Viability of exfoliated colorectal carcinoma cells. Br J Surg. 1984;71:659–63.

    CAS  PubMed  Google Scholar 

  15. Skipper D, Cooper AJ, Marston JE, Taylor I. Exfoliated cells and in vitro growth in colorectal cancer. Br J Surg. 1987;74:1049–52.

    CAS  PubMed  Google Scholar 

  16. Fermor B, Umpleby HC, Lever JV, Symes MO, Williamson RCN. Proliferative and metastatic potential of exfoliated colorectal cancer cells. J Natl Cancer Inst. 1985;76:347–9.

    Google Scholar 

  17. Gertsch P, Baer HU, Kraft R, Maddern GJ, Altermatt HJ. Malignant cells are collected on circular staplers. Dis Colon Rectum. 1992;35:238–41.

    CAS  PubMed  Google Scholar 

  18. Jenner DC, de Boer WB, Clarke G, Levitt MD. Rectal washout eliminates exfoliated malignant cells. Dis Colon Rectum. 1998;41:1432–4.

    CAS  PubMed  Google Scholar 

  19. Maeda K, Maruta M, Utsumi T, Toyama K, Sato H, Okumura Y, et al. Is intraoperative preparation like rectal washout needed on local excision for early rectal cancer? J Jap Coloproctol Soc. 1997;50:307–10 (in Japanese with English abstract).

    Google Scholar 

  20. Okada K, Sadahiro S, Kamei Y, Chan LF, Ogimi T, Miyakita H, et al. A prospective clinical study assessing the presence of exfoliated cancer cells and rectal washout including tumors in patients who receive neoadjuvant chemoradiotherapy for rectal cancer. Surg Today. 2020;50:352–9.

    CAS  PubMed  Google Scholar 

  21. Gafnis G, Nordstrom M. Evaluation of presence of intraluminal cancer cells following rectal washout in rectal cancer surgery. Tech Coloproctol. 2013;17:363–9.

    Google Scholar 

  22. Neufert RS, Teurneau-Hermansson K, Lydrup M, Jorgren F, Buchwald P. Rectal washout in rectal cancer surgery: a survey of Swedish practice-questionnaire; rectal washout in Swedish rectal cancer survey. Int J Surg Open. 2018;15:32–6.

    Google Scholar 

  23. Docherty JG, McGregor JR, Purdie CA, Galloway DJ, O’dwyer PJ. Efficacy of tumoricidal agents in vitro and in vivo. Br J Surg. 1995;82:1050–2.

    CAS  PubMed  Google Scholar 

  24. Umpleby HC, Williamson RCN. The efficacy of agents employed to prevent anastomotic recurrence in colorectal carcinoma. Ann R Coll Surg Engl. 1984;66:192–4.

    CAS  PubMed  PubMed Central  Google Scholar 

  25. Basha G, Penninckx F, Mebis J, Filez L, Geboes K, Yap P. Local and systemic effects of intraoperative whole-colon washout with 5 per cent povidone-iodine. Br J Surg. 1998;86:219–26.

    Google Scholar 

  26. Maeda K, Hanai T, Sato H, Masumoti K, Koide Y, Matsuoka H, et al. Intraluminal exfoliated cancer cells and effectiveness of bowel ligatures during sigmoidectomy for sigmoid colon cancer. Surg Today. 2014;44:297–301.

    PubMed  Google Scholar 

Download references

Funding

No funding.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Kotaro Maeda.

Ethics declarations

Conflict of interest

Yoshikazu Koide and the co-authors have no conflicts of interest.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Koide, Y., Maeda, K., Katsuno, H. et al. Exfoliated cancer cells during intersphincteric resection for very low rectal cancer. Surg Today 50, 1652–1656 (2020). https://doi.org/10.1007/s00595-020-02064-w

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00595-020-02064-w

Keywords

Navigation