Objective To investigate the safety and feasibility of the total mesorectal excision （TME） and intersphincteric resection （ISR） for ultra-low rectal cancer and anal sphincter preservation surgery for anorectal cancer， and to evaluate the short term efficacy and postoperative anal function. Methods A retrospective analysis of clinical and follow-up data of 86 cases with TME＋ISR for ultra-low rectal cancer and anorectal cancer from January 2009 to December 2010 in West China Hospital of Sichuan University were performed. Results Eighty-six patients were successfully performed the operation， the lower edge of tumor from the anus was 1-5 cm （average 1.63cm）； tumor diameter was 2-7 cm （average 3.4cm）. The tumors were high differentiation in 4 cases， moderately differentiation in 60 cases，and poorly differentiation in 22 cases. The pTNM stages were stageⅠin 12 cases， stageⅡA in 11 cases， stage ⅡB in 15 cases， stage ⅢA in 2 cases， stage ⅢB in 23 cases， stage ⅢC in 16 cases， and stage Ⅳ in 7 cases. There were postoperative anastomotic leakage in 3 cases， perianal infection in 2 cases （1 case received reoperation with permanent colostomy because of pelvic peritoneal infection caused by perianal severe infections）. Anastomotic bleeding and anastomotic stenosis were of 2 cases respectively. Rectovaginal fistula， inflammatory ileus， urinary retention， and abdominal infection were of 1 case respectively. Eighty-six patients were followed-up for 12-24 months， the mean time was 18 months. Liver metastases was found in 1 case in 7 months after operation， 2 cases dead in the 7th month and 12th month after operation respectively. Local recurrence were found in 3 cases （3.5%） in 1 year after operation. The survival rate of 1-year was 97.7% （84/86）. The times of defecation was 1-5 times a day. The Kirwan’s score level on function of control defecation was 1-2 grade. Conclusions TME＋ISR for low rectal cancer and anorectal cancer is a viable， safe， and radical operation type for preservation of anus. The short term efficacy is satisfactory.
Objective To summarize the assessment methods of anal function after low/ultralow rectal anastomosis in patients with rectal cancer. Methods Domestic and international publications on the study of evaluation of anal function after low/ultralow rectal anastomosis in patients with rectal cancer were collected and reviewed. Results Anal function of patients with rectal cancer was usually evaluated by feeling of discharge, continence, perceptual function of rectum, defecate frequency, and defecation time, anal manometry and three-dimensional vector manometry were used as well. Recovery of anal function in patients with rectal cancer after low/ultralow rectal anastomosis depended on the integrity of anal canal, length of remaining rectum, level of anastomosis, and integrity of mucosa. Conclusions Subjective assessment methods and auxiliary measuring instruments are the common means to evaluate the rectal-anal function. Subjective assessment method is simple and direct, but its accuracy is low; Auxiliary measuring instruments have high accuracy, while their examination costs are high and that of costs are not popular, the new assessment methods are needed for further research.
Objective To approach the curative effect of laparoscopic rectum resection combined with per anus intersphincteric rectal dissection and colo anal anastomosis for patients with ultra-low rectal cancer. Methods Thirteen patients were prospectively studied from June 2005 to December 2007. There were 8 male and 5 female patients, with a mean age of 53 (range, 41-69) years. All the tumors located less than 5 cm above the anal verge. All the patients were treated with general anaesthesia and then went through the following procedures: lied the reverse Trendelenburg reforming lithotomy position, the laparoscope went inside the abdomen through two apertures, the hylus aperture (observing aperture) and the McBurney point aperture (main performing aperture). After the resection through the laparoscope, the operation was translocated to the perineal region, the anus was enlarged to expose the operation area. Results The operation on all cases succeeded, there was no operative mortality, and no stomal leak in all patients. The follow-up duration ranged from 1 to 30 months (mean 17 months). Up to now, one patient developed recurrence in pelvic cavity, and one suffered hepatic metastasis, there was no port-site implantation metastasis， 9 patients had satisfactory functional recovery of anus in the sixth month after operation. Conclusion The therapy laparoscopic rectum resection combined with per anus intersphincteric rectal dissection and colo-anal anastomosis for patients with ultra-low rectal cancer is a safe, minimally invasive, anal-preserving technique with reliablity in curative effect and satisfaction in anal sphincter function.
ObjectiveTo investigate the effect of suprapubic catheterization(SPC) by using central venous catheter (CVC) on the perioperative complications in middle and low rectal cancer surgery. MethodsThe clinical data of 141 patients with middle and low rectal cancer underwent operation in Shengjing Hospital of China Medical University from April 2012 to January 2015 were collected. There were 65 patients performed SPC by using CVC, 76 patients performed routine transurethral catheterization(TUC). The incidences of bacteriuria and urinary retention, recatheterization rate, duration of catheterization, and catheter-related pain were analyzed and compared between these two groups. Results①Compared with the TUC, the SPC by using CVC could significantly reduce the incidence of bacteriuria(P=0.002), espe-cially in female(P=0.006), ≥60 years old(P=0.001), low rectal cancer(P=0.003), open surgery(P=0.018), Miles(P=0.016), and Dixon(P=0.032).②There was no significant difference in the incidence of urinary retention(P=0.464) between the SPC by using CVC and the TUC.③Compared with the TUC, the SPC by using CVC could significantly reduce the inci-dence of recatheterization rate(P=0.001), especially in the patients with male(P=0.016), ≥60 years old(P=0.008), low rectal cancer(P=0.019), laparoscopic surgery(P=0.013), and Miles(P=0.037).④Compared with the TUC, the point of catheter-related pain was significantly lower in the SPC by using CVC(P=0.001), no matter males(P=0.005) or females(P=0.010), aged 60 years and older(P=0.023) or younger(P=0.034), middle rectal cancer(P=0.017) or low rectal cancer(P=0.046), open surgery(P=0.033) or laparoscopic surgery(P=0.021), Dixon(P=0.019) or Miles(P=0.035).⑤The duration of catheterization was similar between the SPC by using CVC and the TUC(P=0.597). ConclusionSPC by using CVC is a safer, more effective and more acceptable method of bladder drainage in middle and low rectal cancer surgery as compared with routine TUC.
ObjectiveTo investigate risk factors of anastomotic fistula after total mesorectum excision (TME) in middle and low rectal cancer. MethodsThe clinical data of 446 patients with middle and low rectal cancer received TME surgery from June 2004 to June 2014 were retrospectively analyzed.Single-factor analysis of risk factors was used by χ2 test,multiple-factor analysis was used by logistic regression analysis. ResultsThere were 36 patients with anastomotic fistula in these 446 patients,which of 22 patients were recovered after conservative treatment,of 14 patients were recovered after colostomy.The results of single-factor analysis showed that the age>60 years,preoperative hemoglobin<110 g/L,preoperative albumin<35 g/L,accompanied with diabetes mellitus,neoadjuvant chemoradiation,distance from anasto-mosis to anus<5 cm,non-strengthen suture by hand were the risk factors of anastomotic fistula after TME in the middle and low rectal cancer (P<0.05).The results of multiple-factor analysis showed that the preoperative hemoglobin<110 g/L,preoperative albumin<35 g/L,accompanied with diabetes mellitus,neoadjuvant chemoradiation,and distance from anastomosis to anus<5 cm were the independent risk factors of anastomotic fistula after TME in the middle and low rectal cancer (P<0.05). ConclusionsRisk of anastomotic fistula after TME in middle and low rectal cancer is higher.Basic complications of patient and local conditions of anastomosis,and intraoperative factors could affect incidence of anastomotic fistula,it should be paid enough attention.In general,most of anastomotic fistula could be cured with conservative treatment,in case of conservative treatment is invalid,colostomy is feasible.
Objective To evaluate the effects of neoadjuvant long-course chemoradiotherapy (CRT), neoadjuvant short-course radiotherapy (SCRT), and total neoadjuvant treatment (TNT) on chemoradiotherapy related complications and perioperative safety in mid-low rectal cancer patients. Methods The clinical data of 63 rectal cancer patients who received neoadjuvant (chemo) radiotherapies and surgery treatment in West China Hospital from Jul. 2014 to Feb. 2016 were retrospectively analyzed. According to the neoadjuvant regimen, the patients were divided into CRT group (n=15), SCRT group (n=30), and TNT group (n=18), and then the effects of these 3 kinds of neoadjuvant regimen on chemoradiotherapy related complications and perioperative safety were compared. Results ① Chemoradiotherapy related complications: among all the included 63 patients, 29 patients (46.0%) occurred chemoradiotherapy related complications, including radiation enteritis in 9 patients and bone marrow suppression in 25 patients. There were significant differences in the overall incidence of chemoradiotherapy related complications, incidence of radiation enteritis and bone marrow suppression (P≤0.001). The overall incidence of chemoradiotherapy related complications and incidence of bone marrow suppression of SCRT group were lower. ② Perioperative safety: no significant differences were found in the incidence of surgical complications, incidence of specific surgical complication, operation duration, intraoperative blood loss, and postoperative flatus time (P<0.05), but there was significant difference in the postoperative hospital stay among 3 groups (P=0.033), the postoperative hospital stay of SCRT group was shorter. Conclusion CRT, SCRT, and TNT have similar effect on the safety in the mid-low rectal cancer patients, which suggests that SCRT is worthy of further research and promotion.
ObjectiveTo investigate current status of anal sphincter preservation in low rectal cancer.MethodThe recent literatures on the progress of anal sphincter preservation in the low rectal cancer were reviewed.ResultsIn the past, the surgical treatment of the low rectal cancer was mainly based on the Miles. With the deepening of the anatomical understanding, the improvement of surgical concepts, and the development of minimally invasive techniques, the treatment concept of the low rectal cancer had gradually entered the era of retaining anal and anal function. At present, many surgical methods including the transanal local excision, intersphincteric resection, transanal total mesorectal excision, etc. could be applied to the anal sphincter preservation of the lower rectal cancer, but the advantages and disadvantages of each surgical procedure and the scope of application were slightly different.ConclusionsAlthough there are many surgical procedures that can be applied to patients with low rectal cancer, none of them can achieve perfection in terms of retaining anal and anal function, reducing complications and recurrence rates, and improving survival. It is believed that with continuous understanding of rectal anatomy by surgeons, emergence of various neoadjuvant chemoradiation and new devices, and more anal sphincter preservation procedures and even artificial anal surgery, treatment of low rectal cancer will also be more good care for anal and maintenance function, so that patients can obtain a higher quality and a long-term survival opportunity.
ObjectiveTo evaluate the efficacy of robotic intersphincteric resection (ISR) for rectal cancer.MethodsA literature search was performed using the China biomedical literature database, Chinese CNKI, Wanfang, PubMed, Embase, and the Cochrane library. The retrieval time was from the establishment of databases to April 1, 2019. Related interest indicators were brought into meta-analysis by Review Manager 5.2 software.ResultsA total of 510 patients were included in 5 studies, including 273 patients in the robot group and 237 patients in the laparoscopic group. As compared to the laparoscopic group, the robot group had significantly longer operative time [MD=43.27, 95%CI (16.48, 70.07), P=0.002], less blood loss [MD=–19.98.27, 95%CI (–33.14, –6.81), P=0.003], lower conversion rate [MD=0.20, 95%CI (0.04, –0.95), P=0.04], less lymph node harvest [MD=–1.71, 95%CI (–3.21, –0.21), P=0.03] and shorter hospital stay [MD=–1.61, 95%CI (–2.26, –0.97), P<0.000 01]. However, there were no statistically significant differences in the first flatus [MD=–0.01, 95%CI (–0.48, 0.46), P=0.96], time to diet [MD=–0.20, 95%CI (–0.67, 0.27), P=0.41], incidence of complications [OR=0.76, 95%CI (0.50, 1.14), P=0.18], distal resection margin [MD=0.00, 95%CI (–0.17, 0.17), P=0.98] and positive rate of circumferential resection margin [OR=0.61, 95%CI (0.27, 1.37), P=0.23].ConclusionsRobotic and laparoscopic ISR for rectal cancer shows comparable perioperative outcomes. Compared with laparoscopic ISR, robotic ISR has the advantages of less blood loss, lower conversion rate, and longer operation times. These findings suggest that robotic ISR is a safe and effective technique for treating low rectal cancer.
ObjectiveTo evaluate the efficacy, safety, and feasibility of fecal drainage technique on rectal anastomosis for preventing anastomotic leakage after operation for middle-low rectal cancer.MethodsThe retrospective analysis was used to collect the middle-low rectal cancer which completed operation in this hospital from 2014 to 2019. According to the way of preventing annstomotic leakage, the patients were divided into two groups: fecal drainage on rectal anastomosis group (Abbreviation: fecal drainage group) and end ileum prophylactic stoma group (Abbreviation: ileostomy group). The incidence of anastomotic leakage after operation and the different treatment methods following leakage were compared between the two groups.ResultsA total of 231 cases were recorded, including 84 cases in the fecal drainage group, 147 cases in the ileostomy group. There were no significant differences in the baseline data such as the gender, age, preoperative complications, operation mode, etc. between the two groups (P>0.050). There were no significant differences in the operation time, intraoperative blood loss, incision infection, postoperative intestinal obstruction, total hospitalization cost, death, anastomotic leakage (overall, each grade, treatment, and outcome) between the two groups (P>0.050). Although the length of hospital stay except the patients with anastomotic leakage in the fecal drainage group was significantly longer than that in the ileostomy group (P<0.001), there was no significant difference in the total length of hospital stay between the two groups (P>0.050), and the incidence of anastomotic stenosis in the fecal drainage group was significantly lower than that in the ileostomy group (P=0.029).ConclusionAccording to the results of this study, fecal drainage technique on rectal anastomosis is effective, safe, and feasible in preventing anastomotic leakage after operation for middle-low rectal cancer.
ObjectiveTo 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. MethodsClinical 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. ResultsThe 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)], faster time to first postoperative semi-liquid diet [4 (3, 5) d vs 6 (5, 6) d] 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.ConclusionTaE-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.