Intersphincteric resection for low rectal cancer: the risk is functional rather than oncological. A 25‐year experience from Bordeaux

Denost, Quentin; Moreau, J L; Vendrely, V.; Célérier, Bertrand; Rullier, Anne; Assénat, Vincent

doi:10.1111/codi.15258

Cited by 34 publications

(45 citation statements)

References 39 publications

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“…Third, although this study focused on the technical aspects, it was unclear whether LAR or ISR is better in terms of postoperative anorectal function. Previous studies have reported that patients who have undergone ISR have a higher risk of fecal incontinence and bowel dysfunction than those who have undergone LAR [39,40]. However, the characteristics of patients in previous studies were different from those in this study, and these results could not be extrapolated to the present study.…”

Section: Discussioncontrasting

confidence: 79%

Comparison between robotic-assisted and laparoscopic sphincter-preserving operations for ultra-low rectal cancer: a single institutional retrospective study

Kojima

Hino

Shiomi

et al. 2021

Preprint

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Background Sphincter-preserving operations for ultra-low rectal cancer include low anterior resection and intersphincteric resection. In low anterior resection, the distal rectum is divided by a transabdominal approach, which is technically demanding. In intersphincteric resection, a perineal approach is performed. We aimed to evaluate whether robotic-assisted surgery is technically superior to laparoscopic surgery for ultra-low rectal cancer. The frequency of conducting low anterior resection by a specific procedure can indicate the technical superiority of that procedure for ultra-low rectal cancer. Thus, we compared the frequency of low anterior resection between robotic-assisted and laparoscopic surgery in cases of sphincter-preserving operations. Methods We investigated 183 patients who underwent sphincter-preserving robotic-assisted or laparoscopic surgery for ultra-low rectal cancer (lower border within 5 cm of the anal verge) between April 2010 and March 2020. The frequency of low anterior resection was compared between laparoscopic and robotic-assisted surgeries. The clinicopathological factors associated with an increase in performing low anterior resection were analyzed by multivariate analyses. Results Overall, 41 (22.4%) and 142 (77.6%) patients underwent laparoscopic and robotic-assisted surgery, respectively. Patient characteristics were similar between the groups. Low anterior resection was performed significantly more frequently in robotic-assisted surgery (67.6%) than in laparoscopic surgery (48.8%) (p = 0.04). Multivariate analyses showed that tumor distance from the anal verge (p < 0.01) and robotic-assisted surgery (p = 0.02) were significantly associated with an increase in the performance of low anterior resection. The rate of postoperative complications or pathological results was similar between the groups. Conclusions Compared with laparoscopic surgery, robotic-assisted surgery significantly increased the frequency of low anterior resection in sphincter-preserving operations for ultra-low rectal cancer. Robotic-assisted surgery has technical superiority over laparoscopic surgery for ultra-low rectal cancer treatment.

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Section: Discussioncontrasting

confidence: 79%

Comparison between robotic-assisted and laparoscopic sphincter-preserving operations for ultra-low rectal cancer: a single institutional retrospective study

Kojima

Hino

Shiomi

et al. 2021

Preprint

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“…Therefore, ISR is characterized by a certain degree of sphincter function impairment [ 48 , 158 ]. Denost et al performed a long-term retrospective study evaluating the functional outcomes of 171 patients (56%) with a median follow-up of 4.6 years (range 1.0–15.6) [ 159 ]. The authors reported a median Low Anterior Resection Syndrome (LARS) score of 30 months (range 0–42) with 44% no LARS, 14% minor LARS, and 42% major LARS.…”

Section: Considerations On Functional Outcomes After Isrmentioning

confidence: 99%

Anus-Preserving Surgery in Advanced Low-Lying Rectal Cancer: A Perspective on Oncological Safety of Intersphincteric Resection

Piozzi

Baek

Kwak

et al. 2021

Cancers

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The surgical management of low-lying rectal cancer, within 5 cm from the anal verge (AV), is challenging due to the possibility, or not, to preserve the anus with its sphincter muscles maintaining oncological safety. The standardization of total mesorectal excision, the adoption of neoadjuvant chemoradiotherapy, the implementation of rectal magnetic resonance imaging, and the evolution of mechanical staplers have increased the rate of anus-preserving surgeries. Moreover, extensive anatomy and physiology studies have increased the understanding of the complexity of the deep pelvis. Intersphincteric resection (ISR) was introduced nearly three decades ago as the ultimate anus-preserving surgery. The definition and indication of ISR have changed over time. The adoption of the robotic platform provides excellent perioperative results with no differences in oncological outcomes. Pushing the boundaries of anus-preserving surgeries has risen doubts on oncological safety in order to preserve function. This review critically discusses the oncological safety of ISR by evaluating the anatomical characteristics of the deep pelvis, the clinical indications, the role of distal and circumferential resection margins, the role of the neoadjuvant chemoradiotherapy, the outcomes between surgical approaches (open, laparoscopic, and robotic), the comparison with abdominoperineal resection, the risk factors for oncological outcomes and local recurrence, the patterns of local recurrences after ISR, considerations on functional outcomes after ISR, and learning curve and surgical education on ISR.

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“…However, many patients suffer from anorectal dysfunction after ISR, especially total ISR, resulting in a conversion to a permanent colostomy and a reduction in the quality of daily life ( 6 ). Previous studies have shown that ~42% of patients experience major bowel dysfunction after ISR, indicating that the functional outcomes may be the main risk of undergoing ISR rather than oncological outcomes ( 7 ). Furthermore, ISR can be classified as partial ISR, subtotal ISR, and total ISR according to the resected grade of the internal sphincter.…”

Section: Introductionmentioning

confidence: 99%

Risk Factors for Anorectal Dysfunction After Interspincteric Resection in Patients With Low Rectal Cancer

Zhang

Wang

et al. 2021

Front. Surg.

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Purpose: The objective of this study was to explore the risk factors for anorectal dysfunction after intersphincteric resection in patients with low rectal cancer.Methods: A total of 251 patients who underwent intersphincteric resection from July 2014 to June 2020 were included in this study, for which the Kirwan's grade, Wexner score, and anorectal manometric index were used to evaluate the anorectal function and other parameters including demographics, surgical features, and clinical and pathological characteristics. These parameters were analysed to explore the potential risk factors for anorectal function after intersphincteric resection.Results: In the 251 included patients, 98 patients underwent partial intersphincteric resection, 87 patients underwent subtotal intersphincteric resection, and 66 patients underwent total intersphincteric resection. There were 53 (21.1%) patients who had postoperative complications, while no significant difference was observed between the three groups. Furthermore, 30 patients (45.5%) in the total intersphincteric resection group were classified as having anorectal dysfunction (Kirwan's grade 3–5), which was significantly higher than that in the partial intersphincteric resection group (27.6%) and subtotal intersphincteric resection group (29.9%). The mean Wexner score of patients that underwent total intersphincteric resection was 7.9, which was higher than that of patients that had partial intersphincteric resection (5.9, p = 0.002) and subtotal intersphincteric resection (6.4, p = 0.027). The initial perceived volume was lower in the total intersphincteric resection group than in the partial and subtotal intersphincteric resection groups at 1, 3, and 6 months after intersphincteric resection. In addition, the resting pressure, maximum squeeze pressure, and maximum tolerated volume in the total intersphincteric resection group were worse than those in the partial and subtotal groups at 3 and 6 months after intersphincteric resection. Univariate and multivariate analyses suggested that an age ≥65, total intersphincteric resection, and preoperative chemoradiotherapy were independent risk factors for anorectal dysfunction (P = 0.023, P = 0.003, and P = 0.008, respectively). Among the 66 patients who underwent total intersphincteric resection, 17 patients received preoperative chemoradiotherapy, of which 12 patients (70.6%) were classified as having anorectal dysfunction.Conclusion: The current study concluded that age ≥65, total intersphincteric resection, and preoperative chemoradiotherapy were risk factors for anorectal dysfunction after intersphincteric resection. The morbidity of anorectal dysfunction after total intersphincteric resection for patients who received preoperative chemoradiotherapy was relatively high, and the indication should be carefully evaluated.

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Intersphincteric resection for low rectal cancer: the risk is functional rather than oncological. A 25‐year experience from Bordeaux

Cited by 34 publications

References 39 publications

Comparison between robotic-assisted and laparoscopic sphincter-preserving operations for ultra-low rectal cancer: a single institutional retrospective study

Comparison between robotic-assisted and laparoscopic sphincter-preserving operations for ultra-low rectal cancer: a single institutional retrospective study

Anus-Preserving Surgery in Advanced Low-Lying Rectal Cancer: A Perspective on Oncological Safety of Intersphincteric Resection

Risk Factors for Anorectal Dysfunction After Interspincteric Resection in Patients With Low Rectal Cancer

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