A comparative study of transanal endoscopic approach and completely transabdominal approach in intersphincteric resection_CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Authors：

NAIJIPU Abuduaini , XU Ximo , SONG Haiqin , CHENG Xi , ZHANG Sen , LI Jianwen , ZHENG Minhua ,  CAI Zhenghao ,  FENG Bo

Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine; Shanghai Minimally Invasive Surgery Center, Shanghai 200025, P. R. China;

Corresponding author：

CAI Zhenghao, Email: c3z2h1@alumni.sjtu.edu.cn; FENG Bo, Email: fengbo2022@163.com

Keywords：

ultra-low rectal cancer; intersphincteric resection; completely transabdominal approach; transanal endoscopic surgery

DOI：

10.7507/1007-9424.202403106

Video：

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Objective To compare the perioperative safety and oncologic efficacy of transanal endoscopic intersphincteric resection (TaE-ISR) and the completely transabdominal approach intersphincteric resection (CTA-ISR) for the treatment of ultra-low rectal cancer. Methods Clinical data of patients who underwent TaE-ISR or CTA-ISR at Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, from June 2022 to June 2023, were retrospectively analyzed. A total of 38 cases of TaE-ISR and 16 cases of CTA-ISR were included. Comparison of surgery-related indexes (including operation time, injury of adjacent organs, protective stoma, and placement of anal tube), postoperative recovery and complications, and oncological results (including positive rate of circumferential resection margin, positive rate of distal resection margin, and number of lymph nodes) were compared between the 2 groups. Results The distance of the lower edge of the tumor from the anal verge was lower in the TaE-ISR group than that in the CTA-ISR group [4.0 (3.4, 4.5) cm vs. 4.9 (4.1, 5.9) cm, P<0.001]. A longer duration of the surgery [(177.18±37.24) min vs (146.25±38.86) min], a higher rate of the anal tube [97.4% (37/38) vs 56.3% (7/16)], a higher rate of protective stoma [94.7% (36/38) vs 12.5% (2/16)], and a higher rate of transanal specimen extraction [92.1% (35/38) vs 0% (0/16)] were observed in the TaE-ISR group (P<0.05). No adjacent organ injuries occurred in the TaE-ISR group, whereas 2 patients in the CTA-ISR group had intraoperative adjacent organ injuries (0% vs 12.5%), the difference was statistically significant (P=0.026). There was no statistically significant difference between the 2 groups in terms of postoperative hospitalization, postoperative time to first flatus, Clavien-Dindo grading of postoperative complications, the incidence of anastomotic leakage and anastomotic stenosis, distal margin distance, the total number of lymph nodes cleared, and the number of positive lymph nodes (P>0.05). Postoperative specimens in all cases were adequate for distal margins and negative for circumferential margins.Conclusion TaE-ISR and CTA-ISR can both be applied to anus-preserving surgery for ultra-low rectal cancer, but TaE-ISR may be a more reasonable approach than CTA-ISR when the lower edge of the tumor is closer to the anal verge.

1.	Marks GJ, Marks JH, Mohiuddin M, et al. Radical Sphincter preservation surgery with coloanal anastomosis following high-dose external irradiation for the very low lying rectal cancer. Recent Results Cancer Res, 1998, 146: 161-174.
2.	Piozzi GN, Khobragade K, Aliyev V, et al. International standardization and optimization group for intersphincteric resection (ISOG-ISR): modified Delphi consensus on anatomy, definition, indication, surgical technique, specimen description and functional outcome. Colorectal Dis, 2023, 25(9): 1896-1909.
3.	Schiessel R, Karner-Hanusch J, Herbst F, et al. Intersphincteric resection for low rectal tumours. Br J Surg, 1994, 81(9): 1376-1378.
4.	Teramoto T, Watanabe M, Kitajima M. Per anum intersphincteric rectal dissection with direct coloanal anastomosis for lower rectal cancer: the ultimate sphincter-preserving operation. Dis Colon Rectum, 1997, 40(10 Suppl): S43-S47.
5.	Köhler A, Athanasiadis S, Ommer A, et al. 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(6): 843-850.
6.	Saito N, Ono M, Sugito M, et al. 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(4): 459-466.
7.	Chamlou R, Parc Y, Simon T, et al. Long-term results of intersphincteric resection for low rectal cancer. Ann Surg, 2007, 246(6): 916-921, 921-922.
8.	Saito N, Sugito M, Ito M, et al. Oncologic outcome of intersphincteric resection for very low rectal cancer. World J Surg, 2009, 33(8): 1750-1756.
9.	Yamada K, Ogata S, Saiki Y, et al. Long-term results of intersphincteric resection for low rectal cancer. Dis Colon Rectum, 2009, 52(6): 1065-1071.
10.	Martin ST, Heneghan HM, Winter DC. Systematic review of outcomes after intersphincteric resection for low rectal cancer. Br J Surg, 2012, 99(5): 603-612.
11.	Akagi Y, Kinugasa T, Shirouzu K. Intersphincteric resection for very low rectal cancer: a systematic review. Surg Today, 2013, 43(8): 838-847.
12.	池畔, 林惠铭, 卢星榕, 等. 腹腔镜经盆腔入路括约肌间超低位直肠前切除术治疗直肠癌可行性研究. 中国实用外科杂志, 2010, 30(3): 203-205.
13.	Chi P, Huang SH, Lin HM, et al. Laparoscopic transabdominal approach partial intersphincteric resection for low rectal cancer: surgical feasibility and intermediate-term outcome. Ann Surg Oncol, 2015, 22(3): 944-951.
14.	中华医学会外科学分会结直肠外科学组. 低位直肠癌经括约肌间切除术中国专家共识 (2023版). 中华胃肠外科杂志, 2023, 26(6): 536-547.
15.	Xu X, Zhong H, You J, et al. Revolutionizing sphincter preservation in ultra-low rectal cancer: exploring the potential of transanal endoscopic intersphincteric resection (taE-ISR): a propensity score-matched cohort study. Int J Surg, 2024, 110(2): 709-720.
16.	Clavien PA, Barkun J, de Oliveira ML, et al. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg, 2009, 250(2): 187-196.
17.	Modarai B, Forshaw M, Parker MC, et al. Self-expanding metallic stents in the treatment of benign colorectal anastomotic strictures: a word of caution. Tech Coloproctol, 2008, 12(2): 127-129.
18.	Manisundaram N, DiBrito SR, Hu CY, et al. Reporting of circumferential resection margin in rectal cancer surgery. JAMA Surg, 2023, 158(11): 1195-1202.
19.	Laurent C, Paumet T, Leblanc F, et al. Intersphincteric resection for low rectal cancer: laparoscopic vs open surgery approach. Colorectal Dis, 2012, 14(1): 35-41, 42-43.
20.	Park SY, Choi GS, Park JS, et al. Short-term clinical outcome of robot-assisted intersphincteric resection for low rectal cancer: a retrospective comparison with conventional laparoscopy. Surg Endosc, 2013, 27(1): 48-55.
21.	Kim JC, Lim SB, Yoon YS, et al. Completely abdominal intersphincteric resection for lower rectal cancer: feasibility and comparison of robot-assisted and open surgery. Surg Endosc, 2014, 28(9): 2734-2744.
22.	Ou W, Wu X, Zhuang J, et al. Clinical efficacy of different approaches for laparoscopic intersphincteric resection of low rectal cancer: a comparison study. World J Surg Oncol, 2022, 20(1): 43. doi: 10.1186/s12957-022-02521-5.
23.	Kawada K, Hida K, Hasegawa S, et al. A comparison of the long-term anorectal function between laparoscopic intersphincteric resection and low anterior resection for low rectal cancer. Surg Today, 2018, 48(10): 921-927.
24.	Molnar C, Nicolescu C, Grigorescu BL, et al. Comparative oncological outcomes and survival following surgery for low rectal cancer - a single center experience. Rom J Morphol Embryol, 2019, 60(3): 847-852.
25.	Tsukamoto S, Kanemitsu Y, Shida D, et al. Comparison of the clinical results of abdominoperanal intersphincteric resection and abdominoperineal resection for lower rectal cancer. Int J Colorectal Dis, 2017, 32(5): 683-689.
26.	Li Y, Wang J, Ma X, et al. A review of neoadjuvant chemoradiotherapy for locally advanced rectal cancer. Int J Biol Sci, 2016, 12(8): 1022-1031.
27.	Moore HG, Riedel E, Minsky BD, et al. Adequacy of 1-cm distal margin after restorative rectal cancer resection with sharp mesorectal excision and preoperative combined-modality therapy. Ann Surg Oncol, 2003, 10(1): 80-85.
28.	黄胜辉, 池畔, 林惠铭, 等. 低位直肠癌经腹括约肌间切除术后患者肛门功能的影响因素分析. 中华胃肠外科杂志, 2014, 17(10): 1014-1017.
29.	Guan X, Hu X, Jiang Z, et al. Short-term and oncological outcomes of natural orifice specimen extraction surgery (NOSES) for colorectal cancer in China: a national database study of 5 055 patients. Sci Bull (Beijing), 2022, 67(13): 1331-1334.
30.	Rullier E, Laurent C, Bretagnol F, et al. Sphincter-saving resection for all rectal carcinomas: the end of the 2-cm distal rule. Ann Surg, 2005, 241(3): 465-469.
31.	Baek SJ, Al-Asari S, Jeong DH, et al. Robotic versus laparoscopic coloanal anastomosis with or without intersphincteric resection for rectal cancer. Surg Endosc, 2013, 27(11): 4157-4163.
32.	Kanso F, Maggiori L, Debove C, et al. Perineal or abdominal approach first during intersphincteric resection for low rectal cancer: which is the best strategy? Dis Colon Rectum, 2015, 58(7): 637-644.
33.	Katsuno H, Shiomi A, Ito M, et al. Comparison of symptomatic anastomotic leakage following laparoscopic and open low anterior resection for rectal cancer: a propensity score matching analysis of 1 014 consecutive patients. Surg Endosc, 2016, 30(7): 2848-2856.
34.	Kawada K, Hasegawa S, Hida K, et al. Risk factors for anastomotic leakage after laparoscopic low anterior resection with DST anastomosis. Surg Endosc, 2014, 28(10): 2988-2995.
35.	Kuo LJ, Lin YK, Chang CC, et al. Clinical outcomes of robot-assisted intersphincteric resection for low rectal cancer: comparison with conventional laparoscopy and multifactorial analysis of the learning curve for robotic surgery. Int J Colorectal Dis, 2014, 29(5): 555-562.
36.	Park JS, Kim NK, Kim SH, et al. Multicentre study of robotic intersphincteric resection for low rectal cancer. Br J Surg, 2015, 102(12): 1567-1573.

1. Marks GJ, Marks JH, Mohiuddin M, et al. Radical Sphincter preservation surgery with coloanal anastomosis following high-dose external irradiation for the very low lying rectal cancer. Recent Results Cancer Res, 1998, 146: 161-174.
2. Piozzi GN, Khobragade K, Aliyev V, et al. International standardization and optimization group for intersphincteric resection (ISOG-ISR): modified Delphi consensus on anatomy, definition, indication, surgical technique, specimen description and functional outcome. Colorectal Dis, 2023, 25(9): 1896-1909.
3. Schiessel R, Karner-Hanusch J, Herbst F, et al. Intersphincteric resection for low rectal tumours. Br J Surg, 1994, 81(9): 1376-1378.
4. Teramoto T, Watanabe M, Kitajima M. Per anum intersphincteric rectal dissection with direct coloanal anastomosis for lower rectal cancer: the ultimate sphincter-preserving operation. Dis Colon Rectum, 1997, 40(10 Suppl): S43-S47.
5. Köhler A, Athanasiadis S, Ommer A, et al. 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(6): 843-850.
6. Saito N, Ono M, Sugito M, et al. 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(4): 459-466.
7. Chamlou R, Parc Y, Simon T, et al. Long-term results of intersphincteric resection for low rectal cancer. Ann Surg, 2007, 246(6): 916-921, 921-922.
8. Saito N, Sugito M, Ito M, et al. Oncologic outcome of intersphincteric resection for very low rectal cancer. World J Surg, 2009, 33(8): 1750-1756.
9. Yamada K, Ogata S, Saiki Y, et al. Long-term results of intersphincteric resection for low rectal cancer. Dis Colon Rectum, 2009, 52(6): 1065-1071.
10. Martin ST, Heneghan HM, Winter DC. Systematic review of outcomes after intersphincteric resection for low rectal cancer. Br J Surg, 2012, 99(5): 603-612.
11. Akagi Y, Kinugasa T, Shirouzu K. Intersphincteric resection for very low rectal cancer: a systematic review. Surg Today, 2013, 43(8): 838-847.
12. 池畔, 林惠铭, 卢星榕, 等. 腹腔镜经盆腔入路括约肌间超低位直肠前切除术治疗直肠癌可行性研究. 中国实用外科杂志, 2010, 30(3): 203-205.
13. Chi P, Huang SH, Lin HM, et al. Laparoscopic transabdominal approach partial intersphincteric resection for low rectal cancer: surgical feasibility and intermediate-term outcome. Ann Surg Oncol, 2015, 22(3): 944-951.
14. 中华医学会外科学分会结直肠外科学组. 低位直肠癌经括约肌间切除术中国专家共识 (2023版). 中华胃肠外科杂志, 2023, 26(6): 536-547.
15. Xu X, Zhong H, You J, et al. Revolutionizing sphincter preservation in ultra-low rectal cancer: exploring the potential of transanal endoscopic intersphincteric resection (taE-ISR): a propensity score-matched cohort study. Int J Surg, 2024, 110(2): 709-720.
16. Clavien PA, Barkun J, de Oliveira ML, et al. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg, 2009, 250(2): 187-196.
17. Modarai B, Forshaw M, Parker MC, et al. Self-expanding metallic stents in the treatment of benign colorectal anastomotic strictures: a word of caution. Tech Coloproctol, 2008, 12(2): 127-129.
18. Manisundaram N, DiBrito SR, Hu CY, et al. Reporting of circumferential resection margin in rectal cancer surgery. JAMA Surg, 2023, 158(11): 1195-1202.
19. Laurent C, Paumet T, Leblanc F, et al. Intersphincteric resection for low rectal cancer: laparoscopic vs open surgery approach. Colorectal Dis, 2012, 14(1): 35-41, 42-43.
20. Park SY, Choi GS, Park JS, et al. Short-term clinical outcome of robot-assisted intersphincteric resection for low rectal cancer: a retrospective comparison with conventional laparoscopy. Surg Endosc, 2013, 27(1): 48-55.
21. Kim JC, Lim SB, Yoon YS, et al. Completely abdominal intersphincteric resection for lower rectal cancer: feasibility and comparison of robot-assisted and open surgery. Surg Endosc, 2014, 28(9): 2734-2744.
22. Ou W, Wu X, Zhuang J, et al. Clinical efficacy of different approaches for laparoscopic intersphincteric resection of low rectal cancer: a comparison study. World J Surg Oncol, 2022, 20(1): 43. doi: 10.1186/s12957-022-02521-5.
23. Kawada K, Hida K, Hasegawa S, et al. A comparison of the long-term anorectal function between laparoscopic intersphincteric resection and low anterior resection for low rectal cancer. Surg Today, 2018, 48(10): 921-927.
24. Molnar C, Nicolescu C, Grigorescu BL, et al. Comparative oncological outcomes and survival following surgery for low rectal cancer - a single center experience. Rom J Morphol Embryol, 2019, 60(3): 847-852.
25. Tsukamoto S, Kanemitsu Y, Shida D, et al. Comparison of the clinical results of abdominoperanal intersphincteric resection and abdominoperineal resection for lower rectal cancer. Int J Colorectal Dis, 2017, 32(5): 683-689.
26. Li Y, Wang J, Ma X, et al. A review of neoadjuvant chemoradiotherapy for locally advanced rectal cancer. Int J Biol Sci, 2016, 12(8): 1022-1031.
27. Moore HG, Riedel E, Minsky BD, et al. Adequacy of 1-cm distal margin after restorative rectal cancer resection with sharp mesorectal excision and preoperative combined-modality therapy. Ann Surg Oncol, 2003, 10(1): 80-85.
28. 黄胜辉, 池畔, 林惠铭, 等. 低位直肠癌经腹括约肌间切除术后患者肛门功能的影响因素分析. 中华胃肠外科杂志, 2014, 17(10): 1014-1017.
29. Guan X, Hu X, Jiang Z, et al. Short-term and oncological outcomes of natural orifice specimen extraction surgery (NOSES) for colorectal cancer in China: a national database study of 5 055 patients. Sci Bull (Beijing), 2022, 67(13): 1331-1334.
30. Rullier E, Laurent C, Bretagnol F, et al. Sphincter-saving resection for all rectal carcinomas: the end of the 2-cm distal rule. Ann Surg, 2005, 241(3): 465-469.
31. Baek SJ, Al-Asari S, Jeong DH, et al. Robotic versus laparoscopic coloanal anastomosis with or without intersphincteric resection for rectal cancer. Surg Endosc, 2013, 27(11): 4157-4163.
32. Kanso F, Maggiori L, Debove C, et al. Perineal or abdominal approach first during intersphincteric resection for low rectal cancer: which is the best strategy? Dis Colon Rectum, 2015, 58(7): 637-644.
33. Katsuno H, Shiomi A, Ito M, et al. Comparison of symptomatic anastomotic leakage following laparoscopic and open low anterior resection for rectal cancer: a propensity score matching analysis of 1 014 consecutive patients. Surg Endosc, 2016, 30(7): 2848-2856.
34. Kawada K, Hasegawa S, Hida K, et al. Risk factors for anastomotic leakage after laparoscopic low anterior resection with DST anastomosis. Surg Endosc, 2014, 28(10): 2988-2995.
35. Kuo LJ, Lin YK, Chang CC, et al. Clinical outcomes of robot-assisted intersphincteric resection for low rectal cancer: comparison with conventional laparoscopy and multifactorial analysis of the learning curve for robotic surgery. Int J Colorectal Dis, 2014, 29(5): 555-562.
36. Park JS, Kim NK, Kim SH, et al. Multicentre study of robotic intersphincteric resection for low rectal cancer. Br J Surg, 2015, 102(12): 1567-1573.

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