Abstract
Purpose: Abdominoperineal resection has been the standard surgery for very low rectal cancer located within 5 cm of the anal verge. However, permanent colostomy exerts serious limitations on quality of life. The present study aimed to investigate curability and functional results of intersphincteric resection and additional partial external sphincteric resection for carcinoma of the anorectal junction. Methods: Thirty-five patients were prospectively studied from November 1999 to September 2002. All patients displayed adenocarcinoma (T3: n = 26; T2: n = 7; T1: n = 2) located between 0 and 2 cm above the dentate line. Abdominotransanal rectal resection with total mesorectal excision was performed in all patients (total intersphincteric resection: n = 14; subtotal intersphincteric resection: n = 5; additional partial external sphincteric resection: n = 6). All patients underwent diverting colostomy, which was closed at a median of six months postoperatively. Twenty patients received preoperative radiochemotherapy. Results: All patients had curative intent with microscopic safety margins (mean surgical cut end: 4 mm; mean distal cut end: 10 mm). No postoperative mortality was encountered. Morbidity was identified in 13 patients (perianastomotic abscess: n = 4; anastomotic leakage and fistula: n = 4; postoperative bleeding: n = 2; wound infection: n = 1; anastomotic stenosis: n = 1; anovaginal fistula: n = 1). One of these patients received a permanent colostomy. Five patients developed recurrence (liver: n = 1; lung: n = 2; local and lung: n = 1; abdominal wall: n = 1) during the median observation period (23 months). Two of these patients underwent curative resection of liver or lung metastases. Twenty-one patients have received stoma closure, and although continence was satisfactory in all, 5 displayed occasional minor soiling 12 months after stoma closure. Anal canal manometry demonstrated significant reduction in maximum resting pressure (median: 50 cmH2O at 12 months after stoma closure), but acceptable function results were obtained. Conclusion: Curability and anal function were achieved by means of intersphincteric resection without or with additional partial external sphincteric resection. These procedures can be recommended for low rectal cancer patients who are candidates for abdominoperineal resection.
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References
Williams NS, Johnston D. The quality of life after rectal excision for low rectal cancer. Br J Surg 1983; 70: 460–2
Sprangers MA, Taal BG, Aaronson NK, te te Velde A. Quality of life in colorectal cancer patients: stoma vs. nonstoma patients. Dis Colon Rectum 1995; 38: 361–9
Schiessel R, Karner-Hanusch J, Herbst F, Teleky B, Wunderlich M. Intersphincteric resection for low rectal tumors. Br J Surg 1994; 81: 1376–8
Rullier E, Zerbib F, Laurent C, 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
Renner K, Rosen HR, Novi G, Hölbling N, Schiessel R. Quality of life after surgery for rectal cancer: do we still need a permanent colostomy? Dis Colon Rectum 1999; 42: 1160–7
Braun J, Treutner ICH, Winkeltau G, Heidenreich U, Lerck MM, Schumpelik N. Results of intersphincteric resection of the rectum with direct coloanal anastomosis for rectal carcinoma. Am J Surg 1992; 163: 407–12
Sobin LH, Wittekind C. International Union Against Cancer (eds) TNM classification of malignant tumours. 6th ed. New York, Wiley-Liss, 2002
Heald RJ, Ryall RD. Recurrence and survival after total mesorectal excision for rectal cancer. Lancet 1986; 2: 1479–82
Enker WE, Thaler HT, Cranor ML, Polyak T. Total mesorectal excision in the operative treatment of carcinoma of the rectum. J Am Coll Surg 1995; 181: 335–46
Law WL, Chu W. Impact of total mesorectal excision on the results of surgery of distal rectal cancer. Br J Surg 2001; 88: 1607–12
Parks AG. Transanal technique in low rectal anastomosis. Proc R Soc Med 1972; 65: 925–6
Williams NS, Patel J, George RD, Hallan RI, Watkins ES. Development of an electrically stimulated neoanal sphincter. Lancet 1991; 338: 1166–9
Paty PB, Enker WE, Cohen AM, Lauwers GY. Treatment of rectal cancer by low anterior resection with coloanal anastomosis. Ann Surg 1994; 219: 365–73
Lazorthes F, Fages P, Chiotasso P, Bugat R. Synchronous abdominotrans-sphincter resection of low rectal cancer: new technique for direct colo-anal anastomosis. Br J Surg 1986; 73: 573–5
McAnema OJ, Heald R, Lockhart-Mummery HE. Operative and functional results of total mesorectal excision with ultra-low anterior resection in the management of carcinoma of the lower one-third of the rectum. Surg Gynecol Obstet 1990; 170: 517–21
Leo E, Belli F, Baldini MT, et al. New perspective in the treatment of low rectal cancer: total rectal resection and coloendoanal anastomosis. Dis Colon Rectum 1994; 37: S62–8
Rouanet P, Fabre JM, Dubois JB, et al. Conservative surgery for low rectal carcinoma after high dose radiation: functional and oncologic results. Ann Surg 1995; 221: 67–73
Cavalière F, Pemberton JH, Cosimelli M, Fazio VW, Beart RW. Coloanal anastomosis for rectal cancer: long-term results at the Mayo and Cleveland Clinics. Dis Colon Rectum 1995; 38: 807–12
Marks G, Mohiuddin M, Masoni L, Montori A. High-dose preoperative radiation therapy as the key to extending sphincter-preservation surgery for cancer of the distal rectum. Surg Oncol Clin N Am 1992; 1: 71–86
Teramoto T, Watanabe M, Kitajima M. Per anum intersphincteric rectal dissection with direct coloanal anastomosis for lower rectal cancer: the ultimate sphincter-preserving operation. Dis Colon Rectum 1997; 40: 43–7
Batignani G, Monaci I, Ficari F, Tonelli F. What affects continence after anterior resection of the rectum? Dis Colon Rectum 1991; 34: 329–35
Lewis WG, Martin IG, Williamson ME, et al. Why do some patients experience poor functional results after anterior resection of the rectum for carcinoma? Dis Colon Rectum 1995; 38: 259–63
Karanjia ND, Schache DJ, Heald RJ. Function of the distal rectum after low anterior resection for cancer. Br J Surg 1992; 79: 114–6
Williamson ME, Lewis WG, Finan PJ, Miller AS, Holdsworth PJ, Johnston D. Recovery of physiologic and clinical function after low anterior resection of the rectum for carcinoma: myth or reality? Dis Colon Rectum 1995; 38: 411–8
Paty PB, Enker WE, Cohen AM, Minsky BD, Friedlander-Klar H. Long-term functional results of coloanal anastomosis for rectal cancer. Am J Surg 1994; 167: 90–5
Graf W, Ekström K, Glimelius B, Pahlman L. A pilot study of factors influencing bowel function after colorectal anastomosis. Dis Colon Rectum 1996; 39: 744–9
Milsom JW, Ludwig KA. Surgical management of rectal cancer. In: Wanebo HJ (ed) Surgery for gastrointestinal cancer: a multidisciplinary approach. Philadelphia, Lippincott-Raven, 1997: 639–55
Grumann MM, Nack EM, Hoffmann RN, Schlag PM. Comparison of quality of life in patients undergoing abdominoperineal extirpation or anterior resection for rectal cancer. Ann Surg 2001; 233: 149–56
Mantyh CR, Hull TL, Fazio VW. Coloplasty in low colorectal anastomosis: manometric and functional comparison with straight and colonic J-pouch anastomosis. Dis Colon Rectum 2001; 44: 37–42
Schmidt E. Surgery for anal incontinence. Coloproctology 1986; 8: 218–22
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Saito, N., Ono, M., Sugito, M. 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 47, 459–466 (2004). https://doi.org/10.1007/s10350-003-0088-4
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DOI: https://doi.org/10.1007/s10350-003-0088-4