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 Table of Contents  
Year : 2019  |  Volume : 8  |  Issue : 3  |  Page : 84-88

Case-matched comparison of intersphincteric proctectomy versus proctectomy with stapled coloanal anastomosis for low rectal cancer

1 Digestive Disease Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
2 Digestive Disease Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates; Lerner School of Medicine at Case Western Reserve University, Cleveland, Ohio, United States of America
3 Dubai Colorectal and Digestive Clinic, Dubai, United Arab Emirates

Date of Submission13-Jun-2019
Date of Decision30-Jul-2019
Date of Acceptance15-Sep-2019
Date of Web Publication24-Oct-2019

Correspondence Address:
Dr. Maher A Abbas
Dubai Colorectal and Digestive Clinic, Al-Zahra Hospital, Dubai
United Arab Emirates
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/WJCS.WJCS_13_19

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Background: The role of intersphincteric proctectomy in low rectal cancer remains controversial. Objective: To compare the perioperative and oncologic outcomes of intersphincteric proctectomy to proctectomy with stapled coloanal anastomosis. Design: A retrospective case-matched review. Setting: A tertiary colorectal surgery unit. Patients and Methods: All intersphincteric proctectomy cases conducted by one surgeon over a 7-year period were matched for gender, race, age, and comorbidities with patients who underwent proctectomy with stapled coloanal anastomosis. Main Outcome Measures: Operative time, blood loss, postoperative complications, length of stay, margin status, lymph node harvest, and local recurrence rate. Sample Size: Thirty-four patients. Results: Group A (intersphincteric) 17 and Group B (stapled) 17 were compared. Mean age was 57.2 years (12 males and 5 females in each group). All patients received neoadjuvant chemoradiation and underwent diverting ileostomy. Estimated blood loss was higher in Group A (771 ml vs. 327 ml, P < 0.05). Similarly, operative time was longer in Group A (295 vs. 235 min, P < 0.05). No difference was noted in postoperative complication rate between Group A and B (29.4% vs. 17.6%, P = 0.688). Length of stay was similar in both groups (6.9 vs. 6.3 days, P = 0.565). There was no difference in radial or distal margin positivity (0%, both groups) or lymph node harvest. Distal margin was longer in Group B (3.7 vs. 1.6 cm, P = 0.007). During a mean follow-up of 22 months, the local recurrence rate was 0%. Conclusions: Intersphincteric proctectomy was associated with higher blood loss and longer operative time compared to stapled coloanal anastomosis. Immediate and long-term oncologic outcomes were comparable. Limitations: A single surgeon experience, retrospective study, and small number of patients. Conflict of Interest: None.

Keywords: Coloanal anastomosis, intersphincteric proctectomy, outcome, rectal cancer

How to cite this article:
Tabaja L, Akmal Y, Lackberg Z, Abbas MA. Case-matched comparison of intersphincteric proctectomy versus proctectomy with stapled coloanal anastomosis for low rectal cancer. World J Colorectal Surg 2019;8:84-8

How to cite this URL:
Tabaja L, Akmal Y, Lackberg Z, Abbas MA. Case-matched comparison of intersphincteric proctectomy versus proctectomy with stapled coloanal anastomosis for low rectal cancer. World J Colorectal Surg [serial online] 2019 [cited 2020 Oct 1];8:84-8. Available from: http://www.wjcs.us.com/text.asp?2019/8/3/84/269820

  Introduction Top

Surgical resection remains the standard of care for rectal cancer. Treatment goals include complete resection (R0) with complete tumor removal to minimize the risk of recurrence. Sir W Ernest Miles reported his initial experience with abdominoperineal resection (APR) for rectal cancer in the early twentieth century.[1] Mainly, the goal of radical resection was to cure the patient. In the last several decades, sphincter preservation for low rectal cancer has become an important topic and has been practiced frequently due to advances in surgical techniques.[2] A focus on the quality of life in patients with rectal cancer is the subject of ongoing research, especially for patients with low tumors located close to the anorectal sling and sphincter complex. The decision for sphincter preservation in such patients is driven first and foremost by oncologic considerations, followed by technical feasibility, and in the long-term, functional outcome.[2],[3]

Schiessel and colleagues reported the intersphincteric resection (ISR) technique in 1950.[2] ISR entails the partial excision, and in some cases, complete excision of the internal anal sphincter muscle to obtain the necessary distal rectal margin. A handsewn coloanal anastomosis (HCAA) and a diverting ileostomy are created in the majority of patients.[4] The overall reported mortality of ISR is 1.6% (0%–5%), with a morbidity rate of approximately 25% (0%–48.4%).[5],[6],[7] While ISR has gained acceptability in European and Asian countries, it is infrequently performed in the United States with the majority of scientific data published from international centers.[5],[6],[7],[8] With current advances in neoadjuvant chemoradiation and an increased rate in clinical and pathologic responses, the potential for sphincter preservation has increased.[2],[8],[9] Furthermore, the increasing utilization of laparoscopic techniques and development of transanal extraction of specimen will undoubtedly provide many surgeons with the necessary technical skills and comfort to push the limit for patients with low rectal tumors.[10],[11],[12],[13]

This paper aims to compare the perioperative outcome and short and long-term oncologic results in patients with low rectal cancer treated with intersphincteric proctectomy to those who underwent proctectomy with stapled coloanal anastomosis.

  Patient and Methods Top

A retrospective case-matched study was conducted to surgeries performed for low rectal cancer at Kaiser Permanente, Los Angeles, California, a tertiary referral center for the 12 Kaiser Permanente hopsitals in Southern California. The study was approved by the Human Subject Committee of Kaiser Permanente in Southern California. All cases were operated by one surgeon (MAA, senior author) between January 2006 and December 2012. All patients who underwent ISR proctectomy (Group A) were identified through a comprehensive chart review and were matched to proctectomy with stapled coloanal anastomosis (Group B) for gender, race, and age. All patients in Group A had a portion of the internal sphincter removed, and none had the entire internal sphincter removed. All patients received neoadjuvant chemoradiotherapy and underwent sphincter preservation with a diverting loop ileostomy. Data collected included patient characteristics, perioperative and postoperative outcome variables, and immediate and long-term oncologic data. Malnutrition was defined with the albumin level <3.4 g/dL. Anemia was defined as hemoglobin level <13.5 g/dL in men and <12 g/dL in women. Statistical analysis was performed using the Fisher exact and unpaired Student's t-test. P < 0.05 was considered statistically significant. 95% confidence interval (CI) are reported.

  Results Top

Group A consisted of 17 patients who were case-matched to 17 patients in Group B. [Table 1] summarizes the patients' baseline characteristics. There were 12 males (70.6%) and 5 females (29.4%) in each group. The median age was similar (Group A 56.3 vs. Group B 58.1 years, P = 0.53). Body mass index (BMI) was 29.1 and 26.3 kg/m2, in Group A and Group B, respectively (P = 0.07). The median preoperative hemoglobin was higher in Group A (13.4 g/dL) than Group B (11.5 g/dL) (P = 0.001).
Table 1: Patient baseline characteristics

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The intraoperative outcomes are presented in [Table 2]. The operative time was longer in Group A (295 vs. 235 min, P = 0.012). The intraoperative blood loss in Group A was significantly higher than Group B (771 vs. 327 ml, P = 0.046) and intraoperative transfusion was needed in four patients in Group A (23.5%). There was only one intraoperative complication in Group A, which was an iliac vein injury with bleeding. The open approach was used in eight patients from Group A, and seven patients from Group B, whereas a minimally invasive approach (laparoscopic or robotic) was used in nine patients from Group A, and ten patients from Group B. Conversion to open surgery was needed in 1 patient in the robotic intersphincteric group.
Table 2: Intraoperative outcomes

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[Table 3] provides immediate oncologic data. The complete pathologic response rate was comparable in both groups (Group A 23.5% vs. Group B 17.6%, P = 1). As expected, the distal margin was longer in Group B (3.2 vs. 1.6 cm, P = 0.0007). No positive distal margins were detected in either group.
Table 3: Immediate oncologic outcomes

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The postoperative outcomes are highlighted in [Table 4]. Overall, there was no statistically significant difference in postoperative complications (Group A 29.4% vs. Group B 17.6%, P = 0.69). The length of stay was similar (Group A 6.9 days vs. Group B 6.3 days, P = 0.57). Three patients (17.6%) in Group A and 5 patients (29.4%) in Group B required readmission within 90 days (P = 0.69).
Table 4: Postoperative outcome

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[Table 5] reports the long-term oncologic outcome and rate of temporary stoma closure. During a median follow-up of 22 months, there was no local recurrence in either group. Three distant recurrences (17.6%) were noted in Group A, with 1 noted within the first postoperative year. During the study period, there were three deaths in Group A (17.6%) and one in group B (5.9%). However, none were related to operative intervention. Two patients in Group A had a permanent stoma due to a strictured anastomosis.
Table 5: Long-term outcome

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  Discussion Top

APR remains one of the most commonly performed operations for low rectal cancer.[14] However, sphincter preservation, when feasible, is often chosen by patients. For low rectal tumors, sphincter preservation with stapled anastomosis is the preferred method of establishing intestinal continuity. For very low tumors at or just above the anorectal junction, clearance of the distal margin often requires partial, or in some cases, complete resection of the internal sphincter muscle. ISR is part of the surgical armamentarium for low rectal tumors, but most of the currently available data stems from international centers outside the United States.[5],[6],[7],[8],[15] Thus, this technique has not gained wide acceptance. However, with the recent introduction of transanal total mesorectal excision (taTME), ISR may play a future role in patients with very low rectal tumors.[13]

In this study, we aimed at comparing the perioperative outcome and oncologic results in patients with low rectal cancer treated with ISR proctectomy to those who underwent proctectomy with stapled coloanal anastomosis. We hoped to provide additional US data in support of the selective use of ISR in patients with low rectal tumors. Proper selection of patients in our study demonstrated comparable short and long-term oncologic results. The main differences between patients who underwent ISR and stapled coloanal anastomosis were intraoperative differences in operative time, blood loss, and need for transfusion. There was no difference in postoperative complications, length of stay, or re-admission rate. During a median follow-up of 22 months, the local recurrence rate was 0%. All the patients in our study had received neoadjuvant chemoradiation. Previous studies reported a mean local recurrence rate of 6.7% (0%–23%).[15] The differences in recurrence rates can be accounted for by the variable rate of neoadjuvant chemoradiation use and patient selection. The decision to proceed with ISR over proctectomy with stapled coloanal anastomosis is complex. There are four levels of decision making listed here by order of importance: oncologic adequacy, patient fitness to undergo a prolonged procedure, technical considerations related to body habitus and tumor location, and long-term functional outcome. Oncologic factors include the distal margin, radial margin, and involvement of the sphincter complex. Traditionally, a 2-cm distal margin was recommended for nonirradiated patients to optimize the oncologic clearance.[16],[17] However, recent studies have shown that, after neoadjuvant chemoradiotherapy, tumor extension beyond the gross mucosal margin is uncommon (appearing in only 1.8% of patients) and is generally less than 1 cm.[18] In general, a 1-cm distal margin is often desirable for very low rectal tumors although a shorter margin can be acceptable in a select group of patients such as those with the complete or near-complete pathologic response following neoadjuvant chemoradiation.[19]

In our study, there was no difference in overall complications when comparing patients with ISR to patients who underwent a stapled coloanal anastomosis. Our overall rate of complications was similar to previously reported large studies looking at ISR.[20] Previously reported anastomotic complications pertinent to ISR encompass leakage with or without fistula formation, pelvic abscess with infection, hemorrhage, bowel blockage, and wound-related complications.[20],[21] Anastomotic leakage remains a serious complication and is characterized by pelvic abscess infection, which can be diagnosed by an imaging study, such as CT scan, or by physical examination if abdominal peritonitis is present. Akasu and colleagues reported the outcome of 120 patients who underwent ISR and noted the risk factors associated with anastomotic complications such as a leak.[21] Preoperative factors like pulmonary disease and intraoperative factors like the need for transfusing blood or creating a colonic J-pouch reconstruction were reported as independent risk factors for leakage of the anastomosis. In our study, we noted anastomotic leak in two patients (11.8%), both of whom underwent ISR. Both patients ended up with a permanent stoma.

The major limitations of our study were as follows: it is a retrospective review of highly selected cases at a tertiary center with all cases performed by one surgeon. Despite a study period of 7 years, the number of patients who underwent ISR was limited (on average, 70 cases of rectal carcinoma were treated per year by the senior author, but only 17 cases of ISR were done over 7 years). Despite collecting short-term and some long-term oncologic parameters, due to a median follow-up of 22 months, no 5-year oncologic data such as cancer-specific or overall survival could be provided. Finally, no functional or quality of life data was available for group comparison. Despite these limitations, collected data provided some valuable information on perioperative and postoperative outcomes demonstrating longer operative time and higher blood loss in patients who underwent ISR but no overall difference in short-term complications, length of stay, or re-admission rate.

  Conclusions Top

The main goal of rectal cancer therapy is to find a cure. Surgical resection remains critical to achieving this goal. Sphincter preservation is desirable when feasible. The ISR technique provides an opportunity to perform sphincter-saving surgery in a highly select group of patients, as demonstrated by this study. From an oncologic perspective, it appears safe following neoadjuvant chemoradiation. The postoperative complications were comparable to patients undergoing a stapled coloanal anastomosis, and no mortality was observed in this study. The alternative to ISR in patients with very low rectal tumor is the APR. While our group and others advocate this technique as a viable alternative to the abdominoperineal resection in some patients, prospective clinical trials are needed to provide a comprehensive assessment of the oncologic results in addition to functional outcome and quality of life.

This study was a poster presentation at the 2016 American Society of Colon Rectal Surgeons Annual Meeting, Los Angeles, California (2016).

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Zbar AP. Sir W. Ernest miles. Tech Coloproctol 2007;11:71-4.  Back to cited text no. 1
Abbas MA. Sphincter preservation for distal rectal cancer: How far is too far? Am J Clin Oncol 2008;31:195-8.  Back to cited text no. 2
Abbas MA, Chang GJ, Read TE, Rothenberger DA, Garcia-Aguilar J, Peters W, et al. Optimizing rectal cancer management: Analysis of current evidence. Dis Colon Rectum 2014;57:252-9.  Back to cited text no. 3
Martin ST, Heneghan HM, Winter DC. Systematic review of outcomes after intersphincteric resection for low rectal cancer. Br J Surg 2012;99:603-2.  Back to cited text no. 4
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Kim JS, Hur H, Kim NK, Kim YW, Cho SY, Kim JY, et al. Oncologic outcomes after radical surgery following preoperative chemoradiotherapy for locally advanced lower rectal cancer: Abdominoperineal resection versus sphincter-preserving procedure. Ann Surg Oncol 2009;16:1266-73.  Back to cited text no. 9
Fuji S, Yamamoto S, Ito M, Yamaguchi S, Sakamoto K, Kinugasa Y, et al. Short-term outcomes of laparoscopic intersphincteric resection from a phase II trial to evaluate laparoscopic surgery for stage 0/I rectal cancer: Japan Society of Laparoscopic Colorectal Surgery Lap RC. Surg Endosc 2012;26:3067-76.  Back to cited text no. 10
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de Lacy FB, van Laarhoven JJEM, Pena R, Arroyave MC, Bravo R, Cuatrecasas M, et al. Transanal total mesorectal excision: Pathological results of 186 patients with mid and low rectal cancer. Surg Endosc 2018;32:2442-7.  Back to cited text no. 13
Monson JR, Probst CP, Wexner SD, Remzi FH, Fleshman JW, Garcia-Aguilar J, et al. Failure of evidence-based cancer care in the United States: The association between rectal cancer treatment, cancer center volume, and geography. Ann Surg 2014;260:625-31.  Back to cited text no. 14
Martin ST, Heneghan HM, Winter DC. Systematic review of outcomes after intersphincteric resection for low rectal cancer. Br J Surg 2012;99:603-12.  Back to cited text no. 15
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Andreola S, Leo E, Belli F, Lavarino C, Bufalino R, Tomasic G, et al. Distal intramural spread in adenocarcinoma of the lower third of the rectum treated with total rectal resection and coloanal anastomosis. Dis Colon Rectum 1997;40:25-29.  Back to cited text no. 17
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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