Ann Surg Treat Res.  2017 Oct;93(4):195-202. 10.4174/astr.2017.93.4.195.

Novel anal sphincter saving procedure with partial excision of levator-ani muscle in rectal cancer invading ipsilateral pelvic floor

• Noh GT
• Han J
• Cheong C
• Han YD
• Kim NK

• KMID: 2392369
• DOI: http://doi.org/10.4174/astr.2017.93.4.195

Abstract

PURPOSE
Tumors at the level of the anorectal junction had required total levator-ani muscle excision to achieve an adequate resection margin. However, in the cases of tumor invading ipsilateral levator-ani muscle and intact external sphincter, en bloc resection of rectum with levator-ani muscle including tumor would be possible. This hemilevator excision (HLE) technique enables preserving the anal sphincter function while obtaining oncologic clearance and avoiding permanent colostomy in those patients. This study aimed to evaluate the surgical outcomes and feasibility of HLE.
METHODS
Data on 13 consecutive patients who underwent HLE for pathologically proven low rectal cancer were retrospectively collected. All 13 patients presented low rectal cancer at the anorectal ring level that was suspected to invade or abut to the ipsilateral side of the levator-ani muscle.
RESULTS
A secure resection margin was achieved in all cases, and anastomotic leakage occurred in 2 patients. During follow-up, 3 patients experienced tumor recurrence (2 systemic and 1 local). Among 6 patients who underwent diverting ileostomy closure after the index operation, 2 complained of fecal incontinence. The other 4 patients without fecal incontinence showed <10 times of bowel movement per day. Accessing their incontinence scale, mean Wexner score was 9.4.
CONCLUSION
HLE is a novel sphincter-preserving technique that can be a treatment option for low rectal cancer invading ipsilateral levator-ani muscle, which has been an indication for abdominoperineal resection (APR) or extralevator APR. However, the long-term oncologic and functional outcomes of this procedure still need to be assessed to confirm its validity.

Keyword

Sphincter preservation; Rectal cancer; Levator ani

MeSH Terms

Anal Canal*
Anastomotic Leak
Colostomy
Fecal Incontinence
Follow-Up Studies
Humans
Ileostomy
Pelvic Floor*
Rectal Neoplasms*
Rectum
Recurrence
Retrospective Studies

Figure

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  Fig. 1 Comparison of colonoscopic and magnetic resonance imaging before and after chemoradiation. (A) Huge ulcerofungating lesion in the low rectum. (B) Partial regression of the tumor after chemoradiation. (C) Annular mass involving the low rectum with a positive circumferential resection margin at the left and right levator-ani muscle (white arrows). (D) Decreased extent of tumor with a still threatening circumferential resection margin at the right levator-ani muscle (white arrow).

• 

  Fig. 2 Schematic of hemilevator excision. (A) Axial view of the extent of resection for hemilevator excision including the rectum and the invaded levator-ani muscle. (B) Coronal view of the extent of resection for hemilevator excision through the intersphincter plane and sleeve-fashioned distal rectum resection. (C, D) Cadaveric model showing dissection plane for hemilevator excision between levator-ani muscle and external anal sphincter (posterior view after sacrum excision).

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  Fig. 3 Pelvic magnetic resonance imaging after hemilevator excision: obliterated defect of excised right levator-ani muscle by fibrotic tissue (white arrow). Axial (A) and coronal (B) view.

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  Fig. 4 Schematic of surgical options for advanced rectal cancer. (A) Intersphincteric resection for a tumor invading only the internal sphincter. (B) Abdominoperineal resection for a tumor invading beyond the internal sphincter. (C) Hemilevator excision for a tumor invading the levatorani muscle without external sphincter invasion. (D) Extralevator abdominoperineal resection for a tumor invading both the levator-ani muscle and external sphincter muscle.

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