Annals of Surgical Oncology

, Volume 21, Issue 11, pp 3608–3615 | Cite as

Long-term Outcomes after Intersphincteric Resection for Low-Lying Rectal Cancer

  • Norio Saito
  • Masaaki Ito
  • Akihiro Kobayashi
  • Yusuke Nishizawa
  • Motohiro Kojima
  • Yuji Nishizawa
  • Masanori Sugito
Colorectal Cancer



As an anus-preserving surgery for very low rectal cancer, intersphincteric resection (ISR), has advanced markedly over the last 20 years. We investigated long-term oncologic, functional, and quality of life (QOL) outcomes after ISR with or without partial external sphincter resection (PESR).


A series of 199 patients underwent curative ISR with or without PESR between 2000 and 2008, with 49 receiving preoperative chemoradiotherapy (CRT group) and 150 undergoing surgery first (surgery group). Overall survival (OS), disease-free survival (DFS), and local relapse-free survival (LFS) rates were calculated using Kaplan–Meier methods. Functional outcomes were assessed using the Wexner incontinence score. QOL was investigated using the Short-Form 36 questionnaire (SF-36) and modified fecal incontinence quality of life (mFIQL) scale.


After a median follow-up of 78 months (range 12–164 months), estimated 7-year OS, DFS, and LFS rates were 78, 67, and 80 %, respectively. LFS was better in the CRT group than in the surgery group (p = 0.045). Patients with PESR or positive circumferential resection margins showed significantly worse survival. The median Wexner incontinence score at >5 years was 8 in the surgery group and 10 in the CRT group (p = 0.01). QOL was improved in all physical and mental subscales of the SF-36 at >5 years. Although the mFIQL showed a relatively good score in all groups at >5 years, a significant difference existed between the CRT and surgery groups (p = 0.008).


With long-term follow-up, oncologic, functional, and QOL results after ISR appear acceptable, although CRT is associated with disturbance.


Circumferential Resection Margin Lateral Node Dissection Wexner Score Pelvic Lateral Node Dissection Fecal Incontinence Quality 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



This study was supported in part by a Grant-in-Aid from the National Cancer Center (NCC) Research and Development Fund (23-A-26) in Japan.

Conflict of interest

The authors declare no conflicts of interest.


  1. 1.
    Heald RJ, Ryall RD. Recurrence and survival after total mesorectal excision for rectal cancer. Lancet. 1986;1:1479–82.PubMedCrossRefGoogle Scholar
  2. 2.
    Schiessel R, Karner-Hanusch J, Herbst F, et al. Intersphincteric resection for low rectal tumours. Br J Surg. 1994;81:1376–8.PubMedCrossRefGoogle Scholar
  3. 3.
    Bannon JP, Marks GJ, Mohiuddin M, et al. Radical and local excisional methods of sphincter-sparing surgery after high-dose radiation for cancer of the distal 3 cm of the rectum. Ann Surg Oncol. 1995;2:221–7.PubMedCrossRefGoogle Scholar
  4. 4.
    Braun J, Treutner KH, Winkeltau G, et al. Results of intersphincteric resection of the rectum with direct coloanal anastomosis for rectal carcinoma. Am J Surg. 1992;163:407–12.PubMedCrossRefGoogle Scholar
  5. 5.
    Rullier E, Laurent C, Bretagnol F, et al. Sphincter-saving resection for all rectal carcinomas: the end of the 2-cm distal rule. Ann Surg. 2005;241:465–9.PubMedCrossRefPubMedCentralGoogle Scholar
  6. 6.
    Saito N, Moriya Y, Shirouzu K, et al. Intersphincteric resection in patients with very low rectal cancer: a review of the Japanese experience. Dis Colon Rectum. 2006;49(10 Suppl.):S13–22.PubMedCrossRefGoogle Scholar
  7. 7.
    Chamlou R, Parc Y, Simon T, et al. Long-term results of intersphincteric resection for low rectal cancer. Ann Surg. 2007;246:916–21.PubMedCrossRefGoogle Scholar
  8. 8.
    Akasu T, Takawa M, Yamamoto S, et al. Intersphincteric resection for very low rectal adenocarcinoma: univariate and multivariate analyses of risk factors for recurrence. Ann Surg Oncol. 2008;15:2668–76.PubMedCrossRefGoogle Scholar
  9. 9.
    Schiessel R, Novi G, Holzer B, et al. Technique and long-term results of intersphincteric resection for low rectal cancer. Dis Colon Rectum. 2005;48:1858–65.PubMedCrossRefGoogle Scholar
  10. 10.
    Hohenberger W, Merkel S, Matzel K, et al. The influence of abdomino-peranal (intersphincteric) resection of lower third rectal carcinoma on the rates of sphincter preservation and locoregional recurrence. Colorectal Dis. 2006;8:23–33.PubMedCrossRefGoogle Scholar
  11. 11.
    Yamada K, Ogata S, Saiki Y, et al. Long-term results of intersphincteric resection for low rectal cancer. Dis Colon Rectum. 2009;52:1065–71.PubMedCrossRefGoogle Scholar
  12. 12.
    Saito N, Sugito M, Ito M, et al. Oncologic outcome of intersphincteric resection for very low rectal cancer. World J Surg. 2009;33:1750–6.PubMedCrossRefGoogle Scholar
  13. 13.
    Weiser MR, Quah HM, Shia J, et al. Sphincter preservation in low rectal cancer is facilitated by preoperative chemoradiation and intersphincteric dissection. Ann Surg. 2009;249:236–42.PubMedCrossRefGoogle Scholar
  14. 14.
    Krand O, Yalti T, Tellioglu G, et al. 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.
    Jorge JM, Wexner SD. Etiology and management of fecal incontinence. Dis Colon Rectum. 1993;36:77–97.PubMedCrossRefGoogle Scholar
  16. 16.
    Sobin LH, Wittekind Ch. International Union Against Cancer TMN classification of malignant tumours, 6th ed. New York: Wiley-Liss; 2002.Google Scholar
  17. 17.
    Denost Q, Laurent C, Capdepont MCRA, et al. Risk factors for fecal incontinence after intersphincteric resection for rectal cancer. Dis Colon Rectum. 2011;54:963–8.PubMedCrossRefGoogle Scholar
  18. 18.
    Hashimoto H, Green J, Iwao Y, et al. Reliability, validity, and responsiveness of the Japanese version of the Inflammatory Bowel Disease Questionnaire. J Gastroenterol. 2003;38:1138–43.PubMedCrossRefGoogle Scholar
  19. 19.
    Fukuhara S, Bito S, Green J, et al. Translation, adaptation, and validation of the SF-36 Health Survey for use in Japan. J Clin Epidemiol. 1998;51:1037–44.PubMedCrossRefGoogle Scholar
  20. 20.
    Hashimoto H, Shiokawa H, Funahashi 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
  21. 21.
    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
  22. 22.
    Quirke P, Steele R, Monson J, et al. Effect of the plane of surgery achieved on local recurrence in patients with operable rectal cancer: a prospective study using data from the MRC CR07 and NCIC-CTG CO16 randomised clinical trial. Lancet. 2009;373:821–28.PubMedCrossRefPubMedCentralGoogle Scholar
  23. 23.
    Taylor FGM, Quirke P, Heald RJ, et al. One millimetre is the safe cut-off for magnetic resonance imaging prediction of surgical margin status in rectal cancer. Br J Surg. 2011;98:872–9.PubMedCrossRefGoogle Scholar
  24. 24.
    Martin ST, Heneghan HM, Winter DC. Systematic review of outcomes after intersphincteric resection for low rectal cancer. Br J Surg. 2012;99:603–12.PubMedCrossRefGoogle Scholar
  25. 25.
    Ito M, Saito N, Sugito M, et al. 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
  26. 26.
    Nishizawa Y, Fujii S, Saito N, et al. The association between anal function and neural degeneration after preoperative chemoradiotherapy followed by intersphincteric resection. Dis Colon Rectum. 2011;54:1423–9.PubMedCrossRefGoogle Scholar
  27. 27.
    Sprangers MA, Taal BG, Aaronson NK, et al. Quality of life in colorectal cancer. Stoma vs. nonstoma patients. Dis Colon Rectum. 1995;38:361–9.PubMedCrossRefGoogle Scholar
  28. 28.
    Renner K, Rosen HR, Novi G, et al. Quality of life after surgery for rectal cancer: do we still need a permanent colostomy? Dis Colon Rectum. 1999;42:1160–7.PubMedCrossRefGoogle Scholar
  29. 29.
    Rockwood TH, Church JM, Fleshman JW, et al. Fecal incontinence quality of life scale: quality of life instrument for patients with fecal incontinence. Dis Colon Rectum. 2000;43:9–16.PubMedCrossRefGoogle Scholar

Copyright information

© Society of Surgical Oncology 2014

Authors and Affiliations

  • Norio Saito
    • 1
  • Masaaki Ito
    • 1
  • Akihiro Kobayashi
    • 1
  • Yusuke Nishizawa
    • 1
  • Motohiro Kojima
    • 2
  • Yuji Nishizawa
    • 1
  • Masanori Sugito
    • 1
  1. 1.Department of Colorectal SurgeryNational Cancer Center Hospital EastChibaJapan
  2. 2.Pathology Division, Research Center for Innovative OncologyNational Cancer Center Hospital EastChibaJapan

Personalised recommendations