Early Results of Intersphincteric Resection for Patients with Very Low Rectal Cancer: An Active Approach to Avoid a Permanent Colostomy

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Abstract
Abdominoperineal resection has been the standard surgery for very low rectal cancer located within 5 cm of the anal verge. However, permanent colostomy exerts serious limitations on quality of life. The present study aimed to investigate curability and functional results of intersphincteric resection and additional partial external sphincteric resection for carcinoma of the anorectal junction. Thirty-five patients were prospectively studied from November 1999 to September 2002. All patients displayed adenocarcinoma (T3: n = 26; T2: n = 7; T1: n = 2) located between 0 and 2 cm above the dentate line. Abdominotransanal rectal resection with total mesorectal excision was performed in all patients (total intersphincteric resection: n = 14; subtotal intersphincteric resection: n = 5; additional partial external sphincteric resection: n = 6). All patients underwent diverting colostomy, which was closed at a median of six months postoperatively. Twenty patients received preoperative radiochemotherapy. All patients had curative intent with microscopic safety margins (mean surgical cut end: 4 mm; mean distal cut end: 10 mm). No postoperative mortality was encountered. Morbidity was identified in 13 patients (perianastomotic abscess: n = 4; anastomotic leakage and fistula: n = 4; postoperative bleeding: n = 2; wound infection: n = 1; anastomotic stenosis: n = 1; anovaginal fistula: n = 1). One of these patients received a permanent colostomy. Five patients developed recurrence (liver: n = 1; lung: n = 2; local and lung: n = 1; abdominal wall: n = 1) during the median observation period (23 months). Two of these patients underwent curative resection of liver or lung metastases. Twenty-one patients have received stoma closure, and although continence was satisfactory in all, 5 displayed occasional minor soiling 12 months after stoma closure. Anal canal manometry demonstrated significant reduction in maximum resting pressure (median: 50 cmH(2)O at 12 months after stoma closure), but acceptable function results were obtained. Curability and anal function were achieved by means of intersphincteric resection without or with additional partial external sphincteric resection. These procedures can be recommended for low rectal cancer patients who are candidates for abdominoperineal resection.

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