A quest for sphincter-saving surgery in ultralow rectal tumours—a single-centre cohort study

Abstract

IntroductionDespite the progress in the treatment of colorectal cancer, there is still no optimal strategy for tumours located adjacent to the anal sphincter. This study aims to evaluate oncological and functional results of surgery for rectal cancer in unfavourable locations in proximity to anal sphincters.Materials and methodsPatients with rectal cancer, which was either initially infiltrating the anal sphincter or located in the close proximity of the sphincter, were included in the study. Patients were submitted to extralevator abdominoperineal resection (APR), intersphincteric resection, or transanal total mesorectal excision (TaTME). Primary outcomes were perioperative data: operative time, blood loss, complications, length of stay (LOS), and 30-day mortality. Secondary outcomes were pathological quality of the specimens and functional outcome 6 months after defunctioning ileostomy closure.ResultsAmong patients with cancer adjacent to the anal sphincter, 13 (25%) underwent APR, 14 (27%) patients were submitted to intersphincteric resection, and 25 (48%) patients were treated with the TaTME approach. Operative time was 240 (210–270 IQR) for APR, 212.5 (170–260 IQR) for intersphincteric resection, and 270 (240–330 IQR) for TaTME (p = 0.018). Perioperative morbidity was 31% for APR, 36% for intersphincteric resections, and 12% for the TaTME group (p = 0.181). Complete mesorectal excision was achieved in 92% of specimens in the TaTME group, 93% in intersphincteric resections, and 78% in the APR group (p = 0.72). Median circumferential resection margin in APR was 6 mm (4–7 IQR), in intersphincteric resections 7.5 mm (2.5–10 IQR), and in the TaTME group 4 mm (2.8–8 IQR). All patients after intersphincteric resections developed major low anterior resection syndrome (LARS). Four patients in the TaTME group developed minor LARS, and 21 had major LARS.ConclusionSphincter-saving rectal resections are a feasible alternative to APR with good clinical, pathological, and oncological outcomes. Intersphincteric resections and TaTME seem to be equal in terms of clinicopathological results. The functional outcome is yet to be investigated.Trial registrationThe study was retrospectively registered in Thai Clinical Trials Registry (23-07-2018, ID TCTR20180724001).

Long Term Results of Modified Intersphincteric Resections for Low Rectal Cancer: A Single Center Experience

“…Morbidity and mortality rates found in our study are similar to those reported by other authors, as well as to overall survival [23][24][25][26][27][29][30][31]36].…”

“…There is no consensus concerning the indication of this procedure in regard to tumor distance from the anal verge. Various authors reported different indications in both cohort studies and review studies ranging from > 4cm to > 6cm from the anal verge [23,29,30].…”

“…Histopathology report quality parameters were reviewed to assess the completeness of mesorectal excision: completeness of mesorectal fascia, circumferential resection margin (CRM), and distal resection margin (DMR). DRM and CRM > 1 mm were considered to be negative [23]. Local recurrence was defined as any recurrence at the pelvic level.…”

Functional complaints and quality of life after transanal total mesorectal excision: a meta-analysis

“…Eleven studies used the Wexner score to assess the level of continence ( Table 2); two others 36,44 used the Vaizey or Kirwin score. All studies that performed a preoperative assessment of function 32,39,41 confirmed that no major preoperative deviations in Wexner score were present. Summarizing data that reported Wexner scores at specific times (3, 6, 9, 12, 18, 24 months) showed a median Wexner score at 3 months of 9 (range 1-20) 38,41,43 .…”

“…and †median (range). The International Prostate Symptom Score (IPSS) ranges from 0 to 35, with categories no/mild (0-7), moderate (8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19) and severe (20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35) complaints. IIEF, International Index of Erectile Function; TaTME, transanal total mesorectal excision; n.r., not reported/not reported correctly; LapTME, laparoscopic total mesorectal excision.…”