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Open Access 01-12-2013 | Research

Analysis of the clinical factors associated with anal function after intersphincteric resection for very low rectal cancer

Authors: Tadao Tokoro, Kiyotaka Okuno, Jin-ichi Hida, Kazuki Ueda, Tahehito Yoshifuji, Koji Daito, Masako Takemoto, Fumiaki Sugiura

Published in: World Journal of Surgical Oncology | Issue 1/2013

Abstract

Background

Intersphincteric resection (ISR) has been used to avoid permanent colostomy in very low rectal cancer patients. This study aimed to assess the surgical safety and oncologic and functional outcomes of ISR.

Methods

The records of 30 consecutive very low rectal cancer patients who underwent ISR without neoadjuvant therapy were retrospectively analyzed; survival and locoregional recurrence rates were calculated by the Kaplan-Meier method. Incontinence was assessed by a functionality questionnaire and the Wexner score.

Results

The median distance between the distal margin of the dentate line was 10 mm. A total of 12, 4, and 14 patients underwent partial ISR, subtotal ISR, and total ISR, respectively. The mean distal resection margin was negative in all cases, and circumferential resection margin was positive in two cases. Morbidity was 33.3%: anastomotic stricture in seven patients, colonic J-pouch prolapse in two patients, and an anovaginal fistula in one patient. During the median, 56.2-month follow-up period, local, distant, and combined recurrences occurred in four, three, and two patients, respectively. The 5-year overall and disease-free survival rates were 76.5% and 68.4%, respectively. Local recurrence rates were 5.2% for the patients with Tis-T2 tumors as compared with 45.5% for those with T3 tumors (P = 0.008). The mean Wexner scores and stool frequencies, 12 months after stoma closure in 19 patients, were 11.5 and 6.6 per 24 h, respectively. Significant differences were not seen in the Wexner scores between partial ISR and subtotal/total ISR (11.8 ± 2.6 and 9.1 ± 5.6). Stool frequency (P = 0.02), urgency (P = 0.04), and fragmentation (P = 0.015) were worse in patients with anastomotic stricture than in those without; there was no symptom improvement in patients with anastomotic stricture.

Conclusions

The anastomotic strictures in patients undergoing ISR may have negatively affected anal function. For total ISR patients, at least, informed consent stating the possibility of a permanent colostomy is necessary.

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Heald RJ, Ryall RD: Recurrence and survival after total mesorectal excision for rectal cancer. Lancet. 1986, 1: 1479-1482.CrossRefPubMed

Cohen Z, Myers E, Langer B, Taylor B, Railton RH, Jamieson C: Double stapling technique for low anterior resection. Dis Colon Rectum. 1983, 26: 231-235.CrossRefPubMed

Lavery IC, Lopez-Kostner F, Fazio VW, Fernandez-Martin M, Milsom JW, Church JM: Chances of cure are not compromised with sphincter-saving procedures for cancer of the lower third of the rectum. Surgery. 1997, 122: 779-785.CrossRefPubMed

Gamagami RA, Liagre A, Chiotasso P, Istvan G, Lazorthes F: Coloanal anastomosis for distal third rectal cancer: prospective study of oncologic results. Dis Colon Rectum. 1999, 42: 1272-1275.CrossRefPubMed

Berge A, Tiret E, Cunningham C, Dehni N, Parc R: Rectal excision and colonic pouch-anal anastomosis for rectal cancer: oncologic results at five years. Dis Colon Rectum. 1999, 42: 1265-1271.CrossRef

Schiessel R, Kamer-Hanusch J, Herbst F, Teleky B, Wunderlich M: Intersphincteric resection for low rectal tumours. Br J Surg. 1994, 81: 1376-1378.CrossRefPubMed

Teramoto T, Watanabe M, Kitajima M: Per anum intersphinctric rectal dissection with direct coloanal anastomosis for lower rectal cancer: the ultimate sphincter-preserving operation. Dis Colon Rectum. 1997, 40: S43-S47.CrossRefPubMed

Köhler A, Athanasiadis S, Ommer A, Psarakis E: Long-term results of low anterior resection with intersphincteric anastomosis in carcinoma of the lower one-third of the rectum: analysis of 31 patients. Dis Colon Rectum. 2000, 43: 843-850.CrossRefPubMed

Tilney HS, Tekkis PP: Extending the horizons of restorative rectal surgery: intersphincteric resection for low rectal cancer. Colorectal Dis. 2008, 10: 3-16.CrossRefPubMed

10.

Rullier E, Zerbib F, Laurent C, Bonnel C, Caudry M, Saric J, Parneix M: Intersphincteric resection with excision of internal anal sphincter for conservative treatment of very low rectal cancer. Dis Colon Rectum. 1999, 42: 1168-1175.CrossRefPubMed

11.

Saito N, Ono M, Sugito M, Ito M, Morihiro M, Kosugi C, Sato K, Kotaka M, Nomura S, Arai M, Kobatake T: Early results of intersphincteric resection for patients with very low rectal cancer: An active approach to avoid a permanent colostomy. Dis Colon Rectum. 2004, 47: 459-466.CrossRefPubMed

12.

Ueno H, Mochizuki H, Hashiguchi Y, Ishikawa K, Fujimoto H, Shinto E, Hase K: Preoperative parameters expanding the indication of sphincter preserving surgery in patients with advanced low rectal cancer. Ann Surg. 2004, 239: 34-42.PubMedCentralCrossRefPubMed

13.

Rullier E, Laurent C, Bretagnol F, Rullier A, Vendrely V, Zerbib F: Sphincter-saving resection for all rectal carcinomas -The end of the 2-cm distal rule. Ann Surg. 2005, 241: 465-469.PubMedCentralCrossRefPubMed

14.

Rullier E, Goffre B, Bonnel C, Zerbib F, Caudry M, Saric J: Preoperative radiochemotherapy and sphincter-saving resection for T3 carcinomas of the lower third of the rectum. Ann Surg. 2001, 234: 633-640.PubMedCentralCrossRefPubMed

15.

Tiret E, Poupardin B, McNamara D, Dehni N, Parc R: Ultralow anterior resection with intersphincteric dissection-what is the limit of safe sphincter preservation?. Colorectal Dis. 2003, 5: 454-457.CrossRefPubMed

16.

Bretagnol F, Rullier E, Laurent C, Laurent C, Zerbib F, Gontier R, Saric J: Comparison of functional results and quality of life between intersphincteric resection and conventional coloanal anastomosis for low rectal cancer. Dis Colon Rectum. 2004, 47: 832-838.CrossRefPubMed

17.

Ito M, Saito N, Sugito M, Kobayashi A, Nishizawa Y, Tsunoda Y: Analysis of clinical factors associated with anal function after intersphincteric resection for very low rectal cancer. Dis Colon Rectum. 2009, 52: 64-70.CrossRefPubMed

18.

Chamlou R, Parc Y, Simon T, Bennis M, Dehni N, Parc R, Tiret E: Long-term results of intersphincteric resection for low rectal cancer. Ann Surg. 2007, 246: 916-922.CrossRefPubMed

19.

Yamada K, Ogata S, Saiki Y, Fukunaga M, Tsuji Y, Takano M: Functional results of intersphincteric resection for low rectal cancer. Br J Surg. 2007, 94: 1272-1277.CrossRefPubMed

20.

Denost Q, Laurent C, Capdepont M, Zerbib F, Rullier E: Risk factor for fecal incontinence after intersphincteric resection for rectal cancer. Dis Colon Rectum. 2011, 54: 963-968.CrossRefPubMed

21.

Colquhoun P, Kaizer R, Efron J, Weiss EG, Nogueras JJ, Vernava AM, Vernava AM, Wexner SD: Is the quality of life better in patients with colostomy than patients with fecal incontinence?. World J Surg. 2006, 30: 1925-1928.CrossRefPubMed

22.

Sobin LH, Gospodarowicz M, Wittekind C: UICC: TNM classification of malignant tumors. 2009, New York, NY: Wiley-Liss, 100-109. 7

23.

Weiser MR, Quah HM, Shia J, Guillem JG, Paty PB, Temple LK, Goodman KA, Minsky BD, Wong WD: Sphincter preservation in low rectal cancer is facilitated by preoperative chemoradiation and intersphincteric dissection. Ann Surg. 2009, 249: 236-242.CrossRefPubMed

24.

Jorge JM, Wexner SD: Etiology and management of fecal incontinence. Dis Colon Rectum. 1993, 36: 77-97.CrossRefPubMed

25.

Yoo JH, Hasegawa H, Ishii Y, Nishibori H, Watanabe M, Kitajima M: Long-term outcome of per anum intersphincteric rectal dissection with direct coloanal anastomosis for lower rectal cancer. Colorectal Dis. 2005, 7: 434-440.CrossRefPubMed

26.

Kuo LJ, Hung CS, Wu CH, Wang W, Tam KW, Liang HH, Chang YJ, Wei PL: Oncological and functional outcomes of intersphincteric resection for low rectal cancer. J Surg Res. 2011, 170: e93-e98.CrossRefPubMed

27.

Hohenberger W, Merkel S, Matzel K, Bittorf B, Papadopoulos T, Göhl J: The influence of abdomino-peranal (intersphincteric) resection of lower third rectal carcinoma on the rates of sphincter preservation and locoregional recurrence. Colorectal Dis. 2006, 8: 23-33.CrossRefPubMed

28.

Akasu T, Takawa M, Yamamoto S, Fujita S, Moriya Y: Incidence and patterns of recurrence after intersphincteric resection for very low rectal adenocarcinoma. J Am Coll Surg. 2007, 205: 642-647.CrossRefPubMed

29.

Barisic G, Markovic M, Popovic M, Dimitrijevic I, Gavrilovic P, Krivokapic Z: Function after intersphincteric resection for low rectal cancer and its influence on quality of life. Colorectal Dis. 2011, 13: 638-643.CrossRefPubMed

30.

Hida J, Yoshifuji T, Tokoro T, Inoue K, Matsuzaki T, Okuno K, Shiozaki H, Yasutomi M: Comparison of long-term functional results of colonic J-pouch and straight anastomosis after low anterior resection for rectal cancer: a five-year follow-up. Dis Colon Rectum. 2004, 47: 1578-1585.CrossRefPubMed

31.

Dennett ER, Parry BR: Misconceptions about the colonic J-pouch: what the accumulating data show. Dis Colon Rectum. 1999, 42: 804-811.CrossRefPubMed

32.

Martin ST, Heneghan HM, Winter DC: Systematic review of outcomes after intersphincteric resection for low rectal cancer. British J Surg. 2012, 99: 603-612.CrossRef

33.

Tuson JR, Everett WG: A retrospective study of colostomies, leaks and strictures after colorectal anastomosis. Int J Colorectal Dis. 1990, 5: 44-48.CrossRefPubMed

34.

Nesbakken A, Nygaard K, Lunde OC: Outcome and late functional results after anastomotic leakage following mesorectal excision for rectal cancer. Br J Surg. 2001, 88: 400-404.CrossRefPubMed

Title: Analysis of the clinical factors associated with anal function after intersphincteric resection for very low rectal cancer
Authors: Tadao Tokoro
Kiyotaka Okuno
Jin-ichi Hida
Kazuki Ueda
Tahehito Yoshifuji
Koji Daito
Masako Takemoto
Fumiaki Sugiura
Publication date: 01-12-2013
Publisher: BioMed Central
Published in: World Journal of Surgical Oncology / Issue 1/2013
Electronic ISSN: 1477-7819
DOI: https://doi.org/10.1186/1477-7819-11-24

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Analysis of the clinical factors associated with anal function after intersphincteric resection for very low rectal cancer

Abstract

Background

Methods

Results

Conclusions

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

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