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

0.22 MB·English

by  Tokoro, Tadao

Tokoroetal.WorldJournalofSurgicalOncology2013,11:24
http://www.wjso.com/content/11/1/24 WORLD JOURNAL OF
SURGICAL ONCOLOGY
RESEARCH Open Access
Analysis of the clinical factors associated with
anal function after intersphincteric resection for
very low rectal cancer
Tadao Tokoro*, Kiyotaka Okuno, Jin-ichi Hida, Kazuki Ueda, Tahehito Yoshifuji, Koji Daito, Masako Takemoto
and Fumiaki Sugiura
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 patientswho underwent ISRwithout 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 theWexner score.
Results: The median distance between the distal margin of thedentate 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 circumferentialresection margin was positive in two cases. Morbidity was 33.3%:
anastomotic stricture in seven patients, colonic J-pouch prolapsein two patients, and ananovaginal fistula in one
patient. During the median, 56.2-month follow-upperiod, local, distant, and combined recurrences occurred infour,
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 with45.5%for those
withT3 tumors (P = 0.008). The mean Wexner scores and stool frequencies, 12 months after stoma closure in19
patients, were 11.5 and 6.6 per24 h, respectively. Significant differences were not seen in theWexner 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 inpatientswith anastomotic stricture thanin those without; there was
nosymptom improvement in patients withanastomotic stricture.
Conclusions: The anastomotic strictures in patients undergoing ISRmay have negatively affected anal function.For
total ISR patients, atleast,informed consentstating thepossibility ofa permanentcolostomy is necessary.
Keywords: Intersphincteric resection, Very low rectal cancer,Wexner score
Background preserve the sphincter without compromising on the
Over the last two decades, surgical treatment for patients oncologicalresults[3-5].
withverylow rectal cancerhasradicallyevolved,allowing However, when the tumor is located close to the den-
permanent colostomy to be avoided in these patients. tate line, conventional anterior resection using the inter-
Reappraisalofthedistalmarginhasallowedincreasedpo- peritoneal approach with DST may not allow a secure
tency of sphincter-preserving resections. Moreover, total distal resection margin. To resolve this problem, partial
mesorectal excision (TME) [1], coupled with techniques or total internal sphincteric resection (ISR) and coloanal
such as end-anal stapling and coloanal anastomosis using anastomosis peranuscanbeused for safesurgicalresec-
the double-stapling technique (DST) [2], can be used to tion of the tumor [6-11]. ISR has been proposed to
achieve distal clearance in selected patients with very
low rectal tumors extending to the upper part of the
*Correspondence:[email protected]
DepartmentofSurgery,KinkiUniversity,FacultyofMedicine,377-2, internal sphincter muscle. Furthermore, it has been
Ohno-Higashi,Osaka-Sayama,Osaka589-8511,Japan
©2013Tokoroetal.;licenseeBioMedCentralLtd.ThisisanOpenAccessarticledistributedunderthetermsoftheCreative
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proposed to restore the anal structure, preserve fecal criterionforISR,andtherefore,ISRwasperformedinone
continence, and reduce the numbers of patients requir- patientwithsynchronouslivermetastasis.
ingapermanent stoma. The histopathological findings and tumor stage clas-
ISR has been widely recognized to achieve a safe distal sification were based on the Union for International
resection margin, which can be as small as 1 to 2 cm Cancer Control (UICC) TNM classification (seventh
[12,13]. However, with this procedure, which involves edition) [22]. In Japan, preoperative chemoradiother-
dividing the rectum between the internal sphincter and apy (CRT) for resectable T3 rectal tumors, irrespective
the external sphincter or the levator ani, it remains un- oflymphnodeinvolvement,wasnot routinelyperformed,
clear whether a secure circumferential resection margin and none of the patients included in this study had
(CRM) of the tumor can be obtained. Further, partial or received preoperative CRT or pre or postoperative
total ISR procedures have been shown to possibly inter- radiotherapy.
ferewith fecalcontinence[7,8,14-16].
Anal incontinence is considered to influence various Surgicaltechnique
factors in patients receiving ISR, including preoperative The principle of the ISR procedure is based on an ana-
radiation therapy [17,18], reconstruction methods [9], ex- tomic dissection plane between the internal sphincter
tentofsphincterpreservation[19],tumorlevel,andheight muscle, which is an extension of the muscular layer of
of the anastomosis [20]. Moreover, fecal incontinence- the rectum, and the external sphincter muscle. Surgical
related quality of life (QOL) scores were poorer in ISR intervention was commenced with a high ligation of the
patientsthanthepatientswithlowanteriorresection[16]. inferior mesenteric artery using the abdominalapproach.
AlthoughISRwasproposedasanalternativeprocedureto The rectum was dissected to the levator ani with TME.
avoid abdominoperineal resection (APR), a colostomy is a Further, the intersphincteric plane was entered from the
viable option for patients who suffer from fecal incontin- nearest anorectal junction if possible. If this dissection
ence,whichoffersadefinitivecurealongwithanimproved was technically difficult to perform until a sufficient dis-
qualityoflife[21]. tal margin was obtained via the abdominal approach,
To evaluate the feasibility of ISR in very low rectal then the transanal approach of the operation was com-
cancer patients, it is necessary to clarify the oncologic menced after perineal exposure using a retractor (Lone
results and functional outcomes related to this proced- Star retractor, Lone Star Medical Products Inc, Houston,
ure. The aims of this study were to evaluate the surgical TX, USA). The distal margin was 1 cm for Tis-T2
safety of the procedure, to assess its oncologic and func- tumors, and 2 cm below the inferior extent of the tumor
tional outcomes, and to identify factors predictive of for T3 tumors. Total ISR involved complete excision of
anal dysfunctionintheabsence ofradiotherapy. the internal sphincter muscle, that is, the distal line of
resection was along the intersphincteric groove. For par-
Methods tial ISR, the distal resection line was along the dentate
Patients line, and for subtotal ISR, the distal resection line ran
We reviewed the medical charts of all 30 consecutive from the dentate line to intersphincteric groove [11,19].
patients who had undergone ISR for very low rectal If the tumor was close to the external sphincter or the
adenocarcinomabetween April 2001 and August 2010 at levator ani muscle, additional partial external sphincter
the Department of Surgery, Faculty of Medicine, Kinki resection(ESR) [11]wasperformed.
University. Written informed consent forms concerning The proximal rectal side of the cut edge was immedi-
this procedure were obtained for all patients in our ately closed and irrigated with 1,500 ml of a 5%
hospital. In all cases, tumor stage was evaluated before povidone-iodine solution to reduce the risk of tumor-
surgery by digital examination; colonoscopy; chest, ab- cell dissemination [7,23]. Then, the dissection was
dominal and pelvic computed tomography (CT); and carried out longitudinally along the plane between the
pelvic magnetic resonance imaging (MRI). Anorectal internal and external sphincters to reach the abdominal
manometry was not routinely performed. Preoperative excision. After the rectum was removed through the
criteria for the exclusion of patients for ISR were abdomen, colonic J-pouch and anal anastomosis proce-
clinical T4 tumors, poorly differentiated adenocarcin- dures with interrupted suture were performed. The
oma (revealedbybiopsyspecimens),infiltratinggrossap- anastomosis was protected with a diverting loop ileos-
pearance of the tumors, and some degree of preoperative tomy ortransverse colostomyinallthepatients.
incontinence.Amongpatients withT1tumorsconsidered
for transanal local excision, ISR was proposed for those Follow-upandlocalrecurrences
patients with a risk of lymph node metastases in the case All 30 patients were followed for a median of 56.2
of tumors with adverse pathologic features. Resectable months (range; 13.3 to 168.4 months), and 20 patients
distant metastases were not a preoperative exclusion were available for follow-up for more than 2 years. All
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patients were followed using a standardized protocol, in- Results
cluding a clinical examination with digital palpation, and Patientsandtumorcharacteristicsareshown inTable1.
laboratory tests, including tumors markers (carcinoem- During the study period, ISR covered 144 patients
bryonic antigen (CEA), CA-19-9), every 3 months for (26.3%) who underwent surgery for lower-third rectal
the first 3 years, and then every 6 months for 2 years, cancer,locatedbelow theperitoneal reflex,49 patientsof
and then once a year. Abdominal and pelvic computed conventional anterior resection with DST, 35 patients of
tomography and chest radiography were performed abdominoperineal resection, and 20 patients of local
every 6 months for the first 3 years. A colonoscopy was excision. The study population was made up of 30
performed 3 or 6 months after surgery for planning patients (16 men and 14 women) with a median age of
stoma closure, and then once every year for 3 years. 58.9 years (range, 31 to 75 years); 1 patient (3.3%) had a
Most patients with stage III rectal cancer received post- pTisofalarge villoustumor,8patientshadapT1tumor
operative chemotherapy with oral tegafur, uracil, and/or (26.7%), 10 patients had a pT2 tumor (33.3%) and 11
folic acid for 6 to 12 months. Local recurrence was patients had a pT3 tumor (36.7%). According to the
defined as the presence of any anastomotic, pelvic, or UICC TNM classification system, the tumors were clas-
lateral node recurrences documented either by clinical sified as stage 0 in 1 patient, stage I in 16 patients, stage
or pathologic exanimation, irrespective of the presence IIA in 5 patients, stage IIIB in 5 patients, and stage IVA
ofdistantmetastases. in1patient.
Table1Clinicopathologicalcharacteristicsofpatients
Analfunctionalassessments whoreceivedintersphinctericresection(n=30)
Functional outcomes were assessed using our functional
Characteristic Value
questionnaire. We prospectively collected questionnaires
Age,yearsa 60.5±9.9
regarding anal function from our patients every 3
Histopathologicalgradeb
months after closure of the diverting stoma. In this
questionnaire, patients were asked about stool frequency G1 12
(number of bowel movements per 24 h), fecal urgency G2 16
(ability to defer stool evacuation for >15 minutes), stool Muc 2
fragmentation (>2 evacuations in 1 h), dyschesia (taking
Tumorlocation
more than 15 minutes to defecate), nocturnal defecation,
Anteriorwall 14
use of intestinal transit regulators, and need to wear a
Posteriorwall 12
pad. Incontinence was assessed by the Wexner contin-
ence score [24], and we considered anal function to be Leftwall 1
poor if the Wexner score was 15 or more at 12 months Rightwall 2
[17,18]. Anastomotic stricture or occlusion was deter- Circ 1
mined when the surgeon’s forefinger could not pass Tumorsize,cma 3.8±1.5
throughtheanastomotic site3monthsaftersurgery.
<4cm 18
≥4cm 12
pTstage
Statisticalanalysis
Statistical analyses were performed using JMP10 soft- Tis 1(3.3%)
ware (SAS Institute Inc., Cary, NC, USA). Overall and T1 8(26.7%)
disease-free survival were analyzed using Kaplan-Meier T2 10(33.3%)
curves and the log rank test. For disease-free survival,
T3 11(36.7%)
patients who failed locally, systemically, or both were
TNMstage
censoredatthetimeofthefirstfailure.
0 1
Univariate and multivariate regression analyses were
used to evaluate the impact of age, gender, type of sur- I 16
gery, type of reconstruction, and anastomotic stricture. IIA 5
The changes in anal function between the different IIIA 2
groups of patients over time were compared using
IIIB 5
Wilcoxon signed-rank test, and comparisons between
IVA 1
the anastomotic stricture group and the non-stricture
groupswereperformedusingtheMann–WhitneyUtest. aValuesdenotemean±SD.
bDifferentiationofadenocarcinoma:G1=welldifferentiated;G2=moderately
Statisticalsignificancewasindicated attheP<0.05 level. differentiated;Muc=mucinouscarcinoma.Circ=circumferentialtumor.
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Surgical and histopathological findings are shown in patientsrequireddilationoftheanastomosisusing finger
Table2. bougie, endoscopic balloon dilation, or surgical stricture
In this study, partial ISR, subtotal ISR, and total ISR plasty before stoma closure. Two patients suffered com-
were performed in 12, 4, and 14 patients, respectively. plete occlusion oftheanastomosis.
Furthermore, 4 of 11 patients (36.4%) with T3 tumors
intraoperativelydecidedtoundergoadditionalpartialESR. Oncologicresults
The mean distance between the distal edge of the tumor Local, distant, and combined recurrence occurred in
and the dentate line was 8.9 ± 8.0 mm (range, -3 to 25 four, three, and two patients, respectively. Six patients
mm) in all the patients. Tumor location was significantly died of cancer recurrence. For all patients who received
different for each ISR procedure (partial ISR, 16.0 ± 4.6 ISR, the 5-year overall and disease-free survival rates
mm;subtotalISR,5.0±4.1mm;totalISR,3.5±5.1mm). were 76.5%and68.4%,respectively.
Assessment of the fixed surgical specimens revealed The median disease-free interval for six patients with
that the median distal edge of the tumor was 7 mm local recurrence was 13 months (range, 8 to 14 months)
(range, 3 to 22 mm), and it was negative in all cases. (Table 3). All of the four isolated local recurrence epi-
The median circumferential margin of the tumor was 3 sodes developed within the first 2 years. All the patients
mm (range, 0.5 to 9 mm). The circumferential resection who experienced local recurrence had pT3 tumors, ex-
margin was positive (<1 mm) in two patients with T3 cept one patient who had a pT2 tumor. The local recur-
tumor without partial ESR. Reconstruction of the co- rence rates were significantly lower in patients with Tis
lonic J-pouch was performed in 26 patients, and straight to T2 tumors (5.2%) than in those with T3 tumors
coloanal anastomosis wasperformed in 4patients due to (45.5%;P=0.008;Figure 1).
narrow pelvis orbulky mesocolic fattissue.
Aspectsofstomaclosure
Mortalityandmorbidity Of the 29 ISR patients, excluding 1 with stage IVA dis-
There was no mortality. Complications were encoun- ease, 19 (65.5%) underwent stoma closure by February
tered in ten patients (33.3%). Anastomotic leakage oc- 2010, including 3 patients who had undergone straight
curred in seven patients, who were treated with perianal anastomosis. The median interval between ISR and
drainage. The colonic J-pouch prolapsed in two patients stoma closure was 7 months (range, 3 to 14 months).
who underwent total ISR. One patient had ananovaginal The median follow-up interval after stoma closure was
fistula,requiring repair offistula using perineal muscular 35 months (range, 4 to 68 months). Nine, two, and eight
rotation flap, and subsequent stoma closure. Anasto- patients received stoma closure in the partial ISR, sub-
motic stricture or complete occlusion of an anastomosis total ISR,andtotal ISR groups,respectively(Table 2).
occurred in seven patients. Of these seven patients, five Definitive stoma closure could not be performed in 11
patients. Of the 11 patients, 5 had insufficient anal con-
Table2Differencesinclinicopathologicalcharacteristics dition (complete anastomotic occlusions in 2, prolapse
betweenintersphinctericresection(ISR)procedures
of colonic J-pouch in 2, obvious loose anastomosis in 1).
PartialISR, SubtotalISR, TotalISR, The patients who developed colonic J-pouch prolapse or
(n=11) (n=4) (n=14)
obvious loose anastomosis had received total ISR. Four
Sex
patients were diagnosed with distant metastases or local
Male 6 2 6 relapse ofthedisease before stomaclosure.Two patients
Female 6 2 8 did not undergo stoma closure for social reasons. Three
Typeofreconstruction out of four patients with additional partial ESR did not
achieve stoma closure because of a colonic J-pouch pro-
ColonicJ-pouch 9 4 13
lapse orlocalrecurrence.
Straight 3 0 1
CombinedwithpartialESR 0 2 2
Evaluationofanalfunction
Distancebetweenthedistal 16.0±4.6 5.0±4.1 3.5±5.1 Anal function was evaluated in 19 patients who under-
edgeofthetumorandthe
went stoma closure. At 12 months after stoma closure,
dentateline,mma
the mean Wexner score for all patients was 11.5 (range,
Distalresectionmargin,mma 8.7±6.0 9.5±10.5 7.2±5.4
1 to 19). In the patients with partial ISR, the Wexner
CRM,mma 3.2±2.7 4.8±3.1 3.6±2.1
scores were improved from 13.0 ± 3.1 at 3 months to
No.ofstomaclosuresb 9(81.8) 2(50) 8(57.1) 12.1 ± 3.0 at 6 months (P = 0.04). In contrast, in the
aValuesindicatemean±SD. patients with subtotal or total ISR, no significant differ-
bDatainparenthesesrepresentpercentagevaluesineachgroup.
ences were found between the Wexner scores at 3
CRM=circumferentialresectionmargin;ESR=externalsphinctericresection;
ISR=intersphinctericresection. months and 6 months (13.0 ± 3.8 and 11.5 ± 4.9,
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Table3Characteristicsofsixpatientswithlocalrecurrenceafterintersphinctericresection(ISR)
Patient TNM Tstage Histological Surgical Distal Circumferential Localization Distant Treatment Outcome
type procedure resection resectionmargin, metastases
margin,mm mm
1 IIA T3 G2 tISR+pESR 7 2 Pelvicwall NS CRT 45months,O
2 IIIB T3 G2 sISR+pESR 25 2 Pelvicwall NS CRT 70months,S
3 IIIB T3 G2 pISR 12 5 Pelvicwall Bone,lung Cx 31months,P
4 IIA T3 G2 pISR 10 0.5 Lateralnode Adrenalgland Cx 36months,P
5 I T2 G1 pISR 3 6 Anastomosis NS APR 22months,S
6 IIB T3 G1 pISR 3 0.5 Lateralnode NS CRT 17months,S
Distalresectionmarginsandcircumferentialresectionmarginsweremeasuredonthehistologicalslides.
APR=abdominoperinealresection;CRT=chemoradiotherapy;Cx=chemotherapy;ESR=externalintersphinctericresection;ISR=intersphinctericresection;
NS=notstated;O=otheroriginofdeath;P=primarydeath;S=survived.
respectively; P = 0.14), but an upward trend was regardtostoolfrequency(5.1±2.9vs9.0±5.3;P=0.02),
observed in the Wexner scores at 6 months and 12 urgency(3/12vs4/5;P=0.04),andfragmentation(4/12vs
months (11.5 ± 4.9 vs 9.1 ± 5.6, respectively, P = 0.06). 5/5;P=0.015)at12months.
At 3,6,and 12 months,the Wexner scores were not sig- The results of the univariate analysis revealed that poor
nificantlydifferentbetween patientswho underwent par- anal function, as assessed by the Wexner score, was sig-
tial and subtotal or total ISR (Table 4). In the patients nificantlyassociatedwithgender(male;P=0.047)andthe
without anastomotic stricture, the Wexner scores were presence of anastomotic stricture (P = 0.018) at 12
significantly improved at 6 months and 12 months com- months. The surgical procedure (partial or subtotal/total
pared with those at 3months. However, five patients, in- ISR), type of reconstruction (straight or colonic J-pouch),
cluding the one with subtotal ISR and an additional andage(<70or≥70)werenotsignificantlyassociatedwith
partial ESR, required finger bougie, endoscopic balloon anal function. The results of the multivariate analysis also
dilation, or stricture plasty for anastomotic stricture, no showedthatgender(P=0.283)wasnotsignificantlyasso-
improvement intheWexnerscorewasobserved. ciatedwithanalfunctionand thatthepresenceofanasto-
Table 5 shows the anal function based on the ques- motic stricture (P = 0.093) only demonstrated a trend
tionnaires answered at 3, 6, and 12 months after stoma towards being significantly associated with anal function
closure, with or without anastomotic stricture. At 12 (datanotshown).
months after stoma closure, patients without anasto-
motic stricture were showed improved urgency (from Discussion
12/14to3/12;P=0.008) andnocturnaldefecation(from Although ISR is the sphincter-preserving procedure for
9/14 to 5/12; P = 0.014). However, patients with anasto- verylow rectalcancer,there are concerns regarding local
motic stricture did not report improvement in any symp- control and defecatory function. In this study, we report
tom. Compared to patients with anastomotic stricture, the the outcomes of ISR of very low rectal cancer, less than
non-stricturegroupshowedsignificantlybetterresultswith 2.5 cm from the dentate line, with a median follow-up
period of 56 months. Our data show that this operation
is feasible, with no postoperative mortality found in the
study group. Moreover, it is associated with favorable
Table4Wexnerscoresat3,6,and12monthsinpatients
whounderwentintersphinctericresection(ISR)followed
bystomaclosure
Procedure/findings 3months 6months 12months
Surgicalprocedure
PartialISR(n=9) 13.3±3.1 12.1±3.0* 11.8±2.6
SubtotalortotalISR(n=10) 13.0±3.8 11.5±4.9 9.1±5.6
Anastomoticstricture
Yes(n=5) 15.4±2.9 13.4±4.5 13.6±3.9
No(n=14) 12.4±3.3 11.2±3.9* 9.0±4.5*
Figure1Ratesoflocalrecurrenceamong30patients
undergoingintersphinctericresectionaccordingtothe Dataareshownasmean±SD.Dataat6and12monthswerestatistically
pathologicdepthofthetumors(Tstage). comparedwiththoseat3monthsusingtheWilcoxonsigned-ranktest.
*P<0.05.
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Table5Analdysfunctionafterstomaclosureinpatientswithanastomoticstrictureandthosewithnoanastomotic
stricture
Symptomsrelatedto 3months 6months 12months
analfunction
Non-stricture Stricture Non-stricture Stricture Non-stricture Stricture
Stoolfrequency,times/day 6.4±3.6 11.4±3.0** 6.8±2.8 7.0±2.1 5.1±2.9 9.0±5.3**
Urgency 12/14 4/5 8/13 2/5 3/12* 4/5**
Fragmentation 10/14 5/5 7/13 4/5 4/12 5/5**
Dyschesia 2/14 3/5 2/13 0/5 2/12 0/5
Medicationuse 4/14 4/5 3/13 4/5** 2/12 3/5
Nocturnaldefecation 9/14 5/5 5/13* 5/5 5/12* 4/5
Dataassociatedwitheachanaldysfunctionat6and12monthswerestatisticallycomparedwiththoseat3monthsforeachconditionofanastomoticsitesusing
Wilcoxonsigned-ranktest.*P<0.05.
Dataassociatedwitheachanaldysfunctionofthestricturegroupwerestatisticallycomparedwiththoseofthenon-stricturegroupat3,6,and12monthsusing
theMann–WhitneyUtest.**P<0.05.
oncological outcomes for Tis-T2 tumors. With regard to the external sphincter muscles, during surgical resection,
the Wexner score, total ISR did not produce worse there is a considerable risk of cutting into the tumor or
outcomes than partial ISR did, with the exception that achievingaveryshortdistanceofafewmillimeterstothe
permanent stomawerenecessitatedbyunfavorableanas- CRM. Thus, for a group of patients withT3 tumors, ISR
tomosis. However, anastomotic stricture, which occurred wasappliedtoattaingoodresponsestoneoadjuvantCRT,
as a postoperative complication, was found to negatively leadingtosecureCRM.
affectanal function. Partial or total resection of the internal sphincter
From an oncological point of view, local control of the muscle resulted in defecatory dysfunction with frequent
disease remains the most important objective in rectal defecation, urgency, and fecal incontinence [16,18,29].
cancer surgery. The local recurrence rate of very low Moreover, preoperative radiotherapy against T3 tumors
rectal cancer for ISR varied widely, ranging between 0% or lymph node involvement was found to have a nega-
[23] to 31% [25]. With ISR, the rate of secure distal re- tive impact on anal function after ISR [17,18,26]. In the
section margin was in the range of 95% [23] to 100% studybyItoetal.[17],ofallthepatientswhounderwent
[18],and ourresultsshowed amedian distance of7mm, ISR, 40% received radiotherapy and were found to have
and a definite negative distal margin in all patients. a mean Wexner score of 10 at 12 months. Moreover,
Therefore, ISR was found to provide an optimal distal Denostet al. [20] reported amedianWexnerscoreof 11
resection margin, which is difficult to attain by using inmostofthepatientswho received radiotherapy.
only the abdominal approach for very low rectal cancer. IthasbeenshownthatcolonicJ-pouchreconstructionin
RateofpositiveCRMoftherectalcanceralsoinfluenced conjunction with ISR can minimize the anal dysfunction-
factor of local recurrence. Inour study group,6.7%ofall relatedsideeffectsofasphinctericresection[9].Hidaetal.
patients had a CRM ≤1 mm, and similar results were [30]reportedthelong-termbenefitsofcolonicJ-pouchre-
reportedintherangeof0%to13.3%[18,26].Preoperative construction suggesting that it improves reservoir func-
CRT was considered useful for preventing local recur- tion to a greater extent than straight anastomosis does,
rence in low rectal cancer patients requiring ISR [14,23]. especiallyinpatientsinwhomtheanastomosisislessthan
Kuoetal.[26]reportedapositiveCRMrateof13.3%,but 4 cm from the anal verge. In addition, Dennett et al. [31]
a local recurrence rate of 7.7% in their ISR series of 26 reportedthatcolonicJ-pouchiseffectiveinverylowrectal
patients;88.5%ofthesepatientshadundergonepreopera- cancer surgery, causing apparent reduction in the inci-
tive CRT. Paradoxically, Hohenberger and colleagues [27] denceofanastomoticleaksandinbowelfrequency.Inour
reported that in ISR patients with lower-third rectal study, the mean Wexner score was 11.5 in most patients
cancerwithoutradiotherapy,thelocalrecurrenceratewas with colonic J-pouch reconstruction, and none of the
high, at 46.5%. In our study, local recurrence was signifi- patients had received radiation therapy. In previous
cantly higher in patients with T3 tumors than in those studies, total ISR was performed in 8.9% [29] to 33.7%
withTis-T2 tumors. Akasu et al. [28] reported that both [20] of all the ISR patients. A possible reason for the
T3tumorsandapositivemicroscopicresectionmarginin poorer outcomes about Wexner score in our study was
patients who underwent ISR were significantly associated that the number of patients who required total ISR
with local recurrence. Because ISR involves dissection of accountedforapproximatelyhalftheISRpatients(42.1%),
therectumbetweentheinternalsphinctermuscleandthe because coloanal anastomosis using conventional DST
externalsphinctermuscle,inpatientswithT3tumorswith was technically possible in a few patients who required
expandingmicroscopictumorcellsnearthelevatoranior partialISRduringourstudyperiod.
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The outcome for continence is reported to be worse stomaclosure,thiswasnottakenintoconsiderationwhile
after total ISR than after subtotal or partial ISR [19,20]. estimatinganalfunction.
In our results for Wexner scores, anal function between
total or subtotal ISR and partial ISR were not different, Conclusions
but patients of partial ISR had earlier recovery than In summary, ISR is an oncologically safe procedure for
those of subtotal or total ISR. Our functional results are pTis or pT2 tumors among very low rectal cancer
limited because of the differences in stoma closure rates patients. Also, total ISR, that is, complete removal of the
between partial ISR and subtotal/total ISR patients. The internal sphincter muscles, carried risks of worse anal
rates of stoma closure in patients with subtotal or total function or possibility of a permanent stoma. The com-
ISR were lower than those in patients undergoing partial plications associated with anastomosis, especially sten-
ISR.Thisresultinitselfindicatespooranalfunctionout- osis, resulted in poorer anal function. Larger studies are
comes for subtotal/total ISR. Especially with respect to needed to evaluate functional results in ISR patients
the three patients with total ISR, stoma closure was not who suffer fromanastomotic stricture.
possible because ofthehighriskofmajorincontinence.
Postoperative complication rates varied between Abbreviations
reported series from 18% to 64% [15]. Common compli- CRM:circumferentialresectionmargin;DST:double-staplingtechnique;
ESR:externalsphincterresection;ISR:intersphinctericresection;TME:total
cations included leakage, anastomotic stricture, fistula,
mesorectalexcision.
pelvic sepsis, and prolapse. In a previous literature re-
view, anastomotic leakage rates of 5% to 48% [32] were Competinginterests
reportedly associated with ISR, and they varied depend- Theauthorsdeclaretheyhavenocompetinginterests.
ing on whether asymptomatic leaks were radiologically
Authors’contributions
detected. Also,Tilney and Tekkis [9]reviewed21 studies TT,KO,JH,KU,TY,KD,MT,FS:madesubstantialcontributionstoconception
and reported an overall anastomotic leak rate of 10.5% anddesign,and/oracquisitionofdata,and/oranalysisandinterpretationof
data.TT,KO,JH:draftedthearticleandreviseditcriticallyforimportant
and anastomotic stricture rate of 5.8%. Similar rates
intellectualcontent.TT,KO,JH,KU,TY,KD,MK,FS:responsibleforfinal
were reported in the current series: anastomotic leakage approvalofthemanuscript.Allauthorsreadandapprovedthefinal
occurred in 7 of 30 patients (23.3%) and anastomotic manuscript.
stricture in 12% of the patients. Anastomotic leakage is
Acknowledgements
an important feature since it has been found to lead to
WethankallthemembersoftheDepartmentofPathologyatourinstitute
postoperative anastomotic stricture [33] and poor post- forconductingthepathologicalinvestigationsforthisstudy.
operative anorectal function [34]. However, in our study,
Received:5September2012Accepted:14January2013
there were no independent factors associated with anal
Published:28January2013
dysfunction in the multivariate analysis, but patients
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