J Korean Surg Soc.  2009 Jan;76(1):28-35. 10.4174/jkss.2009.76.1.28.

Intersphincteric Resection and Coloanal Anstomosis for Very Low Lying Rectal Cancer

• Kim JS
• Lee CR
• Kim NK
• Hur H
• Min BS
• Ahn JB
• Keum KC

• KMID: 2040601
• DOI: http://doi.org/10.4174/jkss.2009.76.1.28

Abstract

PURPOSE
Ultralow anterior resection and coloanal anastomosis (hand-sewn) has commonly been used for preserving the anal sphincter in patients with low-lying distal rectal cancer. Preoperative chemoradiation therapy is a contributing factor to preserve the anal sphincter. Intersphincteric resection has been introduced and has begun to be applied to distal rectal cancer for anal sphincter preservation. The aim of this study was to report on patients who underwent intersphincteric resection and coloanal anastomosis for very low-lying rectal cancer.
METHODS
Intersphincteric resection was performed in 21 patients with very low-lying rectal cancer (within 4 cm from the anal verge) between December 2004 and May 2008. All patients received colonic J pouch anal anastomosis and loop ileostomy. The patients were selected prospectively and followed up for the function of bowel movement and recurrence.
RESULTS
Mean tumor distance from anal verge was 2.8 cm (range 2~4 cm). No postoperative mortality was encountered. One patient developed ischemic colitis of colonic J-pouch after high doses of tomotherapy. Subsequently he received abdominoperineal resection and permanent colostomy. One patient underwent diverting colostomy for severe incontinence after ileostomy takedown. The other cases reported good anorectal function such as frequency of bowel movement and fecal incontinence. There were two local recurrences during a mean follow-up period of 11.6 months.
CONCLUSION
Based on a single surgeon's experiences, postoperative morbidity and anorectal function after intersphincteric resection with coloanal anastomosis seems acceptable.

Keyword

Rectal cancer; Intersphincteric resection; Coloanal anastomosis; Chemoradiotherapy

MeSH Terms

Anal Canal
Chemoradiotherapy
Colitis, Ischemic
Colon
Colonic Pouches
Colostomy
Deception
Fecal Incontinence
Follow-Up Studies
Humans
Ileostomy
Prospective Studies
Rectal Neoplasms
Recurrence

Figure

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  Fig. 1 Scheme of intersphincteric resection for distal rectal cancer using concurrenct chemoradiotherapy. (a) Rectal tumor before chemoradiation presenting as an infiltrative lesion. (b) Rectal tumor after chemoradiation showing decreased tumor size. (c) Fibrotic change of previous tumor infiltrative lesion. (d) Surgical plane of intersphincteric resection allowing adequate distal margin. IS = internal anal sphincter; ES = external anal sphincter; PR = puborectalis; CRT = chemoradiation therapy.

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  Fig. 2 Surgical technique of intersphincteric resection. (A) Circumferential incision of the anal mucosa. (B) Dissection of intersphincteric space between internal and external anal sphincter. (C) Hand-sewn anastomosis among colonic J pouch, external anal sphincter, and anoderm made at the level of dentate line.

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  Fig. 3 Colonoscopic findings of rectal cancer before (A) and after (B) preoperative chemoradiotherapy. Ulcerofungating mass shrinked into small ulcerative lesion.

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  Fig. 4 Surgical specimen of intersphincteric resectioin. Previous tumor was changed to fibrous scar after preoperative chemoradiotherapy (white arrow). Internal sphincter was completely resected with the specimen (black arrow).

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