Long-Term Functional and Oncological Outcomes Following Intersphincteric Resection for Low Rectal Cancers

Abstract

Surgery for low rectal cancer often involves a permanent stoma. Intersphincteric resection (ISR) with colo-anal anastomosis is a valuable sphincter sparing surgical procedure that avoids the need for permanent stoma in patients with low rectal cancer. The aim of this study was to analyze the long-term functional and oncological outcomes following ISR. This was a retrospective analysis of patients with low rectal cancer who underwent ISR with colo-anal anastomosis in our institution between 2007 and 2015. All patients had a diversion stoma. Bowel function outcomes were assessed prospectively using Wexner incontinence score, low anterior resection syndrome score (LARS), and the Cancer Institute Quality of Life (QoL) questionnaire. The histological reports were reviewed to assess the oncological adequacy of the surgery. Patterns of recurrence and survival were analyzed in this group of patients. Thirty-three patients who underwent an ISR were eligible for this study. Laparoscopic resection was performed in five patients. All the patients received neoadjuvant chemoradiation except the two who received short course radiation and one who did not receive any neoadjuvant treatment. The median distance from the anal verge to the distal edge of the tumor was 3 cm (range 1.5-5 cm). Distal resection margins and circumferential resection margins were negative in all the patients. The 30-day post-operative mortality rate was 3.03%. In 20 patients with a median follow-up of 48 months, the 3-year overall survival was 95%. One patient had recurrence in the para-aortic nodes. No patient had a local recurrence. Bowel function was assessed in 18 patients who had a minimum stoma free period of 1 year. After a median of 43 months following stoma closure, the median Wexner score was 3.56 (range 0-19), median LARS score was 4.78 (range 0-33), and the mean Cancer Institute QoL score was 151.56 ± 15.741. The QoL was average to very high with an overall acceptable quality of life. In this study, ISR was associated with acceptable long-term functional and oncological outcomes. It can be considered as a safe alternative to a permanent stoma in selected patients with low rectal cancer.

Predictors of Quality of Life and Social Support as a Mediator between Defecation Function and Quality of Life among Rectal Cancer Patients

“…Multiple regression analysis revealed that postoperative defecation function in rectal cancer patients significantly predicted QoL, which means that better defecation function was associated with higher QoL. This finding supports previous studies showing that rectal cancer patients with fecal incontinence and urgency after sphincter-saving resection surgery had significantly lower QoL than those without such problems [6,24]. In addition, this finding is consistent with the finding that defecation dysfunction is a major predictor of QoL following sphincter-preserving resection [25].…”

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

“…The high values of LARS and Wexner scores in both groups of sphincter-saving procedures in our study may result from the relatively short (6-month) follow-up period, as most authors agree that the bowel and preserved sphincter require more time for proper adaptation. Nonetheless, the functional outcomes seem to be promising with high QoL [ 44 ]. Kupsch et al also obtained good results regarding faecal continence; however, median time of evaluation was 6.5 years after stoma closure [ 45 ].…”

Critical and Challenging Issues in the Surgical Management of Low-Lying Rectal Cancer

“…They found that most patients had a satisfactory QoL after ISR, and good bowel function was correlated with good QoL. 78 …”

“…Mahalingam, et al 78 reported the long-term functional outcome of 33 patients who underwent ISR. After a median of 45 months from restoration of bowel continuity, a mean number of bowel movements of <3 per 24 h was seen in 40% and 3–7 per 24 h in 50%.…”