Low rectal cancer: Sphincter preserving techniques-selection of patients, techniques and outcomes

Abstract

Low rectal cancer is traditionally treated by abdominoperineal resection. In recent years, several new techniques for the treatment of very low rectal cancer patients aiming to preserve the gastrointestinal continuity and to improve both the oncological as well as the functional outcomes, have been emerged. Literature suggest that when the intersphincteric resection is applied in T1-3 tumors located within 30-35 mm from the anal verge, is technically feasible, safe, with equal oncological outcomes compared to conventional surgery and acceptable quality of life. The Anterior Perineal PlanE for Ultra-low Anterior Resection technique, is not disrupting the sphincters, but carries a high complication rate, while the reports on the oncological and functional outcomes are limited. Transanal Endoscopic MicroSurgery (TEM) and TransAnal Minimally Invasive Surgery (TAMIS) should represent the treatment of choice for T1 rectal tumors, with specific criteria according to the NCCN guidelines and favorable pathologic features. Alternatively to the standard conventional surgery, neoadjuvant chemo-radiotherapy followed by TEM or TAMIS seems promising for tumors of a local stage T1sm2-3 or T2. Transanal Total Mesorectal Excision should be performed only when a board approved protocol is available by colorectal surgeons with extensive experience in minimally invasive and transanal endoscopic surgery. Core tip: The present review presents the most recent advances in the field of sphincter preserving surgery for the treatment of low rectal cancer patients, providing indications, patients' selection, surgical techniques, multimodality approaches, postoperative course and oncological and functional outcomes. In particular, the review focuses on data deriving from prospective EDITORIAL

The potential predictive value of DEK expression for neoadjuvant chemoradiotherapy response in locally advanced rectal cancer

“…Chemoradiotherapy improves survival rates and local recurrence by reducing tumour size and stage, and also has the ability to achieve pathologic downstaging [ 11 , 12 ]. For these reasons, neoadjuvant chemotherapy is the standard of care for stage II–III rectal tumours, not only to increase the effectiveness of radiotherapy but also to attain negative surgical margins [ 13 ] and enhance the possibility for sphincter-preserving surgery [ 14 ]. As described by Ryan et al, tumour regression grade is a useful method of scoring pathologic response to chemoradiotherapy in rectal carcinomas [ 15 ].…”

Intersphincteric Resection Is the Optimal Procedure for Very Low Rectal Cancer: Techniques, Morbidity, Oncologic and Functional Outcomes

“…Martin et al the 5-year disease-free survival rate was 78.6% and the 5-year overall survival was 86.3% [15]. Oncological outcomes after ISR were not markedly different from those after APR with ranges of 68% -86% and 76% -97%, respectively.…”

“…Kuo et al reported functional outcomes of ISR 38% had stool fragmentation, 23.8% had nocturnal defecation Saito et al mean Wexner score was 7.8. Kohler et al: Incontinence to flatus 23.8%, incontinence for liquid 29% and for solid stool 3.7%, Schiessel et al the mean stool frequency per 24 h was 2.6, Martin's et al [15] use of antidiarrheal medications (30%), Denost 7 urgency in 38%, Yoo et al use of hygiene pads (20%) [2]…”

The usefulness of an 18F-FDG-PET/MR examination in a patient with rectal and breast cancer. A case report

“…emphasise that in order to assess the distance between the rectal tumour and the sphincter an MRI examination should be performed [9]. Proper evaluation of the stage of the disease and the location of the rectal tumour in respect to the anal sphincter is crucial for the possibility of surgical intervention that could spare that sphincter, thus preserving of the continuity of digestive tract and consequently the quality of life of the patient after the treatment is finished [10]. Owing to precise, effective MRI imaging in PET/MRI in the reported case, it was possible to pinpoint with better precision the depth of the intestinal wall infiltration by the rectal carcinoma.…”