Intersphincteric resection for very low rectal cancer: A review of the updated literature

Abstract

Intersphincteric resection (ISR) has rapidly increased worldwide including laparoscopic surgery. However, there are some concerns for the definition of ISR, surgical technique, oncological outcome, anal function, and quality of life (QoL). The aim of the present study is to evaluate those issues. A review of this surgical technique was carried out by searching English language literature of the PubMed online database and appropriate articles were identified. With regard to open‐ISR, the morbidity rate ranged from 7.5% to 38.3%, with lower mortality rates. Local recurrence rates varied widely from 0% to 22.7%, with a mean follow‐up duration of 40–94 months. Disease‐free and overall 5‐year survival rates were 68–86% and 76–97%, respectively. Those outcomes were equivalent to laparoscopic‐ISR. Surgical and oncological outcomes of ISR were generally acceptable. However, accurate evaluation of anal function and QoL was difficult because of a lack of standard assessment of various patient‐related factors. The surgical and oncological outcomes after ISR seem to be acceptable. The ISR technique seems to be valid as an alternative to abdominoperineal resection in selected patients with a very low rectal cancer. However, both necessity for ISR and expectations of QoL impairment as a result of functional disorder should be fully discussed with patients before surgery.

Risk factor for permanent stoma and incontinence quality of life after sphincter‐preserving surgery for low rectal cancer without a diverting stoma

“…After transection of the inferior mesenteric artery and vein, total mesorectal excision (TME) was carried out as a standard surgical procedure, and bilateral LLND was done when the depth was T3 or deeper, as a rule . To secure a 2‐cm resection margin, ISR was selected for tumors located within 2 cm from the upper margin of the levator ani muscle attachment region . For anastomosis in LAR and ISR, double‐stapled and hand‐sewn coloanal anastomosis were carried out, respectively.…”

Intersphincteric Resection for Low Rectal Cancer: A Review of Anatomy and Surgical Techniques, Oncologic and Functional Outcomes and the Role of Robotics

“…Studies comparing open and laparoscopic ISR have reported long-term survival data with 5-year OS, DFS and LR rates ranging from 62% to 97%, 66.7% to 87% and 0 to 23%, respectively. 56,57,58,59,60,61,62,63,64 A recent review by Shirouzu et al 3 on a total of 22 studies evaluated oncological outcomes after ISR for both open and laparoscopic approaches. The results showed a radical resection (R0 resection) in over 90% of patients, but there was wide variation in the reported resection margins: the DRM was between 5 and 25 mm, and the CRM was ≤1 mm in 4% to 19.6% of cases.…”

“…The main concern for ISR is local recurrence in the pelvic cavity (including at the anastomotic site), which is reported to be between 0 and 22.7%. 3 Neoadjuvant CRT is used to both down-size the tumor and down-stage the disease and is a standard strategy to avoid positive CRM and reduce LR in locally advanced rectal cancer as per the NCCN guidelines. 65,66,67 However, in Japan, neoadjuvant CRT is not carried out for resectable cT1-3 tumors, regardless of the presence of lymph node metastasis within the TME 3 , with Akagi et al 68 reporting a low rate of LR (4.8%).…”

“…Laparoscopic ISR was introduced to improve post-operative short-term outcomes and recovery whilst providing as safe an oncological outcome as open surgery. 3 However, laparoscopic ISR is not a widespread technique due to its technically challenging nature, with only few specialized centers being able to offer such anal sparing resection. 4,5 Complex pelvic surgery benefits from the technical advantages offered by the robotic platform 5 , which results in similar oncological outcomes for ISR as with other conventional surgical approaches but with improved postoperative pelvic function.…”

Issue Information ‐ TOC

“…However, there is much concern about the functional outcome such as anal function and quality-of-life (QoL). They seem to deteriorate the more distal there section is performed, with signifi can differences between the conventional laparoscopic and the open approach [5]. Innovations in the transanal approach like TaTME claim to have a more nerve-preserving and nerve-oriented focus due to a better overview, but long-term data are still not yet available.…”