Objective To assess the anal sphincteric function after intersphincteric resection for low rectal cancer by vectorial manometry. Methods Maximal anal pressure, vector volume, vector symmetric index and rectal anal inhibitory reflex were assessed in 16 patients underwent intersphincteric resection for low rectal cancer from 1999 to 2006. Thirty patients with low anterior resection for rectal cancer and another 30 healthy individuals were selected as control. Results The patients in intersphincteric resection group were subdivided into soiling group and defecation function good group. Maximal pressure, vector volume and vector symmetric index of the patients in soiling group and defecation function good group were significantly lower than those of the healthy and low anterior resection controls (P＜0.001). The maximal systole pressure, systole vector volume and vector symmetric index in soiling group were significantly lower than those in function good group (P＜0.001). The 25.0% patients in intersphincteric resection group had rectal anal inhibitory reflex， was significantly lower than that of the low anterior resection control group (93.3%, P＜0.001). Conclusion The maximal pressure and vector volume are compromised in patients underwent intersphincteric resection . The vectorial manometry can be an objective comprehensive tool for the evaluation of anal sphincter function in patients with intersphincteric resection.
ObjectiveTo study the risk factors affecting anterior resection syndrome of rectal cancer. MethodsSixty-seven patients with low rectal cancer who performed anus preserving operation in Second Artillery General Hospital from August 2013 to October 2014 were screened out based on inclusion and exclusion criteria. Forty-two cases received low anterior resection (LAR), 25 cases received intersphincter resection (ISR). Patients were followed-up for 1 year. The severity of anterior resection syndrome was evaluated by using score system for anterior resection syndrome. The patients' age, gender, body mass index (BMI), TNM stage, surgical mode, surgical approach, anastomotic height, prophylactic colostomy, adjuvant chemotherapy, and radiotherapy were used as research indicators, and to evaluate the impact to anterior resection syndrome. ResultsThe single factor analysis showed that the surgical mode, preventive stoma, radiotherapy, anastomotic height, and age were related to the severity of anterior resection syndrome (P < 0.05). Logistic regression showed that the surgical mode (OR=4.506, 95% CI: 1.220, 16.640, P=0.024) and radiotherapy (OR=14. 688, 95% CI: 3.200, 67.429, P=0.001) were related to the severity of anterior resection syndrome. ConclusionSurgical mode and radiotherapy are the independent risk factors of anterior resection syndrome.
ObjectiveTo evaluate the efficacy of robotic intersphincteric resection (ISR) for rectal cancer.MethodsA literature search was performed using the China biomedical literature database, Chinese CNKI, Wanfang, PubMed, Embase, and the Cochrane library. The retrieval time was from the establishment of databases to April 1, 2019. Related interest indicators were brought into meta-analysis by Review Manager 5.2 software.ResultsA total of 510 patients were included in 5 studies, including 273 patients in the robot group and 237 patients in the laparoscopic group. As compared to the laparoscopic group, the robot group had significantly longer operative time [MD=43.27, 95%CI (16.48, 70.07), P=0.002], less blood loss [MD=–19.98.27, 95%CI (–33.14, –6.81), P=0.003], lower conversion rate [MD=0.20, 95%CI (0.04, –0.95), P=0.04], less lymph node harvest [MD=–1.71, 95%CI (–3.21, –0.21), P=0.03] and shorter hospital stay [MD=–1.61, 95%CI (–2.26, –0.97), P<0.000 01]. However, there were no statistically significant differences in the first flatus [MD=–0.01, 95%CI (–0.48, 0.46), P=0.96], time to diet [MD=–0.20, 95%CI (–0.67, 0.27), P=0.41], incidence of complications [OR=0.76, 95%CI (0.50, 1.14), P=0.18], distal resection margin [MD=0.00, 95%CI (–0.17, 0.17), P=0.98] and positive rate of circumferential resection margin [OR=0.61, 95%CI (0.27, 1.37), P=0.23].ConclusionsRobotic and laparoscopic ISR for rectal cancer shows comparable perioperative outcomes. Compared with laparoscopic ISR, robotic ISR has the advantages of less blood loss, lower conversion rate, and longer operation times. These findings suggest that robotic ISR is a safe and effective technique for treating low rectal cancer.
ObjectiveTo compare the perioperative safety and oncologic efficacy of transanal endoscopic intersphincteric resection (TaE-ISR) and the completely transabdominal approach intersphincteric resection (CTA-ISR) for the treatment of ultra-low rectal cancer. MethodsClinical data of patients who underwent TaE-ISR or CTA-ISR at Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, from June 2022 to June 2023, were retrospectively analyzed. A total of 38 cases of TaE-ISR and 16 cases of CTA-ISR were included. Comparison of surgery-related indexes (including operation time, injury of adjacent organs, protective stoma, and placement of anal tube), postoperative recovery and complications, and oncological results (including positive rate of circumferential resection margin, positive rate of distal resection margin, and number of lymph nodes) were compared between the 2 groups. ResultsThe distance of the lower edge of the tumor from the anal verge was lower in the TaE-ISR group than that in the CTA-ISR group [4.0 (3.4, 4.5) cm vs. 4.9 (4.1, 5.9) cm, P<0.001]. A longer duration of the surgery [(177.18±37.24) min vs (146.25±38.86) min], a higher rate of the anal tube [97.4% (37/38) vs 56.3% (7/16)], a higher rate of protective stoma [94.7% (36/38) vs 12.5% (2/16)], and a higher rate of transanal specimen extraction [92.1% (35/38) vs 0% (0/16)], faster time to first postoperative semi-liquid diet [4 (3, 5) d vs 6 (5, 6) d] were observed in the TaE-ISR group (P<0.05). No adjacent organ injuries occurred in the TaE-ISR group, whereas 2 patients in the CTA-ISR group had intraoperative adjacent organ injuries (0% vs 12.5%), the difference was statistically significant (P=0.026). There was no statistically significant difference between the 2 groups in terms of postoperative hospitalization, postoperative time to first flatus, Clavien-Dindo grading of postoperative complications, the incidence of anastomotic leakage and anastomotic stenosis, distal margin distance, the total number of lymph nodes cleared, and the number of positive lymph nodes (P>0.05). Postoperative specimens in all cases were adequate for distal margins and negative for circumferential margins.ConclusionTaE-ISR and CTA-ISR can both be applied to anus-preserving surgery for ultra-low rectal cancer, but TaE-ISR may be a more reasonable approach than CTA-ISR when the lower edge of the tumor is closer to the anal verge.
ObjectiveThe low anterior resection syndrome (LARS) score is a simple and visual instrument assessing sphincter preserving surgery for low rectal cancer. The purpose of this study is to analyze the feasibility of using LARS score to assess the function after intersphincteric resection for low rectal cancer. MethodsBetween March 2013 and June 2015, 76 patients underwent sphincter preserving surgery for low rectal cancer, 23 cases underwent intersphincteric resection set as ISR group, the other 53 cases received low anterior resection set as LAR group. LARS score, Saito function questionnaire, Wexner score, and European organization for research and treatment of cancer (EORTC) quality of life questionnaire core 30 (QLQ-C30), questionnaire module for colorectal cancer (QLQ-CR29) were compared for the two groups. ResultsThere were 63.2 percent patients (48/76) appeared major LARS, 27.6 percent (21/76) minor LARS and 9.2 percent (7/76) no LARS, there were no statistically difference between the ISR and LAR groups (P=0.727), but the item of incontinence due to liquid stools appeared more obvious in ISR group (P=0.009). The items of faecel incontinence and sore skin for EORTC QLQ-CR29 were serious in ISR group (P < 0.05), the other item of EORTC QLQ-CR29 and EORTC QLQ-C30, Saito function questionnaire, Wexner score were similar between the two groups (all P > 0.05). ConclusionThe anal function after intersphincteric resection is non-inferior to the low anterior resection for low rectal cancer, but both can appear serious low anterior resection syndrome.
Objective To determine the oncological outcomes following the intersphincteric resection (ISR) for lower rectal cancer and influencing factors. Methods Reviewed the reports on ISR for lower rectal cancer, and summarized the oncological outcomes and influencing factors. The oncological outcomes included local and distant recurrence rates, postoperative survival, and mortality rates. Tumor indicators, surgical techniques, and perioperative radiochemotherapy were included in the influencing factors. Results The recurrence, survival, and mortality rates following ISR resemble traditional operations. Higher stages, metastasis, and non-standard operations affect the oncological outcomes significantly. Preoperative radiochemotherapy could improve the efficacy, but probably at the cost of postoperative anal function. Conclusions The oncological outcomes following ISR are acceptable. The careful case selection and rational arrangements of radiochemotherapy will allow better outcomes.
ObjectiveTo investigate current status of anal sphincter preservation in low rectal cancer.MethodThe recent literatures on the progress of anal sphincter preservation in the low rectal cancer were reviewed.ResultsIn the past, the surgical treatment of the low rectal cancer was mainly based on the Miles. With the deepening of the anatomical understanding, the improvement of surgical concepts, and the development of minimally invasive techniques, the treatment concept of the low rectal cancer had gradually entered the era of retaining anal and anal function. At present, many surgical methods including the transanal local excision, intersphincteric resection, transanal total mesorectal excision, etc. could be applied to the anal sphincter preservation of the lower rectal cancer, but the advantages and disadvantages of each surgical procedure and the scope of application were slightly different.ConclusionsAlthough there are many surgical procedures that can be applied to patients with low rectal cancer, none of them can achieve perfection in terms of retaining anal and anal function, reducing complications and recurrence rates, and improving survival. It is believed that with continuous understanding of rectal anatomy by surgeons, emergence of various neoadjuvant chemoradiation and new devices, and more anal sphincter preservation procedures and even artificial anal surgery, treatment of low rectal cancer will also be more good care for anal and maintenance function, so that patients can obtain a higher quality and a long-term survival opportunity.
ObjectiveTo analyze the relation between preoperative staging and surgical decision-making in rectal cancer patients from the West China Colorectal Cancer Database (DACCA) and to identify key factors influencing the selection of surgical approach. MethodsBased on the updated DACCA dataset as of April 24, 2024, the patients with rectal cancer were included. Chi-square tests and logistic regression analyses were performed to evaluate the correlation between preoperative staging [(y)cTNM stage] and the selection of sphincter-preserving surgery or intersphincteric resection (ISR). Additional factors, including age, body mass index (BMI), tumor location, and nutritional score, were assessed for their impact on surgical choices. ResultsA total of 2 733 rectal cancer patients were included. Preoperative (y)cTNM staging distribution was as follows: 23 (0.8%) at stage 0, 388 (14.2%) at stage Ⅰ, 760 (27.8%) at stage Ⅱ, 873 (31.9%) at stage Ⅲ, and 689 (25.2%) at stage Ⅳ. The preoperative stage Ⅱ–Ⅳ were the independent risk factors for both the choices of sphincter-preserving surgery and ISR [stage Ⅱ: sphincter-preserving surgery: OR(95%CI)=13.634 (4.952, 37.540), P<0.001; ISR: OR (95%CI)=3.097 (2.108, 4.551), P<0.001. stage Ⅲ: sphincter-preserving surgery: OR (95%CI)=14.677 (5.339, 40.345), P<0.001; ISR: OR (95%CI)=2.985 (2.042, 4.363), P<0.001. stage Ⅳ: OR (95%CI)=25.653 (9.320, 70.610), P<0.001; ISR: OR (95%CI)=4.445 (3.015, 6.555), P<0.001]. The low/ultra-low tumor location was an independent risk factor for choice of sphincter-preserving surgery [OR (95%CI)=2.038 (1.489, 2.791), P<0.001], but which was an independent protective factor for the choice of ISR [OR (95%CI)=0.013 (0.009, 0.019), P<0.001]. ConclusionsResults of this study are consistent with clinical practice, indicating that preoperative staging is the core basis for surgical decision-making in rectal cancer. With the progression of staging, patients are more inclined to choose non-sphincter-preserving and non-ISR procedures. Although low/ultralow tumors pose great challenges for anal preservation, the proportion of ISR selection remains relatively high. The anatomical location of the tumor and nutritional status also significantly affect surgical selection, necessitating comprehensive preoperative evaluation.
ObjectiveTo analyze the safety and feasibility of laparoscopic intersphincteric resection with stapled colo-anal anastomosis under direct vision for low rectal cancer. MethodsFrom January 2001 to March 2012, 138 patients were underwent intersphincteric resection for low rectal cancer, 45 cases of whom were received laparoscopic surgery and stapled colo-anal anastomosis (SCAA group), and the other 93 cases (55 open and 38 laparoscopic) of whom were received hand-sewn colo-anal anastomosis (HCAA group). The morbidity comparison only involed the data of relevant to the anastomosis. The anus functional outcomes, including those from the Saito function questionnaire and Wexner score, were compared and only involved the data of relevant to the laparoscope. Results①The anastomotic complications rates were similar for the fistula, bleeding, and rectal mucosal prolapse (P > 0.05); the rate of anastomosis leakage and the degree of anastomotic stricture in the SCAA group were significantly lower (or milder) than those in the HCAA group (P=0.001 and P=0.022, respectively).②As for the functional results, the incidence of dyschesia in the SCAA group was significantly lower than that in the HCAA group (P=0.016), and the other 7 items of Saito function questionnaire and Wexner score were similar between these two groups (P > 0.05). ConclusionsCompared with traditional intersphincteric resection for low rectal cancer, laparoscopic surgery with stapled colo-anal anastomosis could reduce the morbidity and the anus function is non-inferior to the former.