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Colorectal surgery is one of the specialties that have significantly benefited from the adoption of robotic technology. Over 20 years since the first robotic rectal resection, the Intuitive Surgical Da Vinci system remains the predominant platform. The introduction of new robotic systems into the market has enabled the first documented total mesorectal excision (TME) using alternative platforms. This scoping review aimed to assess the role and adoption of these emerging robotic systems in performing TME for rectal cancer surgery. Methods: A comprehensive search of the Medline, Embase, and Cochrane databases was conducted up to August 2024, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines. Results: Thirty-six studies were included in the review. The majority of rectal surgical procedures were performed using eight different robotic platforms. Intraoperative, short-term, and functional outcomes were generally favorable. However, pathological results were frequently incomplete. Several studies identified the lack of advanced robotic instruments as a significant limitation. Conclusions: The quality of the resected specimen is critical in rectal cancer surgery. Although TME performed with new robotic platforms appears to be feasible and safe, the current body of literature is limited, particularly in the assessment of pathological and long-term survival outcomes. [ABSTRACT FROM AUTHOR]

Introduction: Robotic-assisted complete mesorectal excision (RATME) is increasingly being used by colorectal surgeons. Most surgeons consider RATME a safe method, and believe it can facilitate total mesorectal excision (TME) in rectal cancer, and may potentially have advantages over intersphincteric resection (ISR) and anus preservation. Therefore, this trial was designed to investigate whether RATME has technical advantages and can increase the ISR rate compared with laparoscopic-assisted TME (LATME) in patients with middle and low rectal cancer. Methods and analysis: This is a multicenter, superiority, randomized controlled trial designed to compare RATME and LATME in middle and low rectal cancer. The primary endpoint is the ISR rate. The secondary endpoints are coloanal anastomosis (CAA) rate, conversion to open surgery, conversion to transanal TME (TaTME), abdominoperineal resection (APR) rate, postoperative morbidity and mortality within 30 days, pathological outcomes, long-term survival outcomes, functional outcomes, and quality of life. In addition, certain measurements will be conducted to ensure quality and safety, including centralized photography review and semiannual assessment. Discussion: This trial will clarify if RATME improves ISR and promotes anus preservation in patients with mid- and low-rectal cancer. Furthermore, this trial will provide evidence on the optimal treatment strategies for RATME and LATME in patients with mid- and low-rectal cancer regarding improved operational safety. Trial registration: ClinicalTrials.gov NCT06105203. Registered on October 27, 2023. [ABSTRACT FROM AUTHOR]

Abstract Introduction Robotic-assisted complete mesorectal excision (RATME) is increasingly being used by colorectal surgeons. Most surgeons consider RATME a safe method, and believe it can facilitate total mesorectal excision (TME) in rectal cancer, and may potentially have advantages over intersphincteric resection (ISR) and anus preservation. Therefore, this trial was designed to investigate whether RATME has technical advantages and can increase the ISR rate compared with laparoscopic-assisted TME (LATME) in patients with middle and low rectal cancer. Methods and analysis This is a multicenter, superiority, randomized controlled trial designed to compare RATME and LATME in middle and low rectal cancer. The primary endpoint is the ISR rate. The secondary endpoints are coloanal anastomosis (CAA) rate, conversion to open surgery, conversion to transanal TME (TaTME), abdominoperineal resection (APR) rate, postoperative morbidity and mortality within 30 days, pathological outcomes, long-term survival outcomes, functional outcomes, and quality of life. In addition, certain measurements will be conducted to ensure quality and safety, including centralized photography review and semiannual assessment. Discussion This trial will clarify if RATME improves ISR and promotes anus preservation in patients with mid- and low-rectal cancer. Furthermore, this trial will provide evidence on the optimal treatment strategies for RATME and LATME in patients with mid- and low-rectal cancer regarding improved operational safety. Trial registration ClinicalTrials.gov NCT06105203. Registered on October 27, 2023.

Previous studies on successful anastomosis after intersphincteric resection (ISR) for low rectal cancer (LRC) primarily focused on anastomotic complications rather than functional outcomes. Here, we improved the anastomotic success criteria by considering surgical, oncological, and functional outcomes and proposed a new composite outcome, "textbook anastomotic success" (TASS). This retrospective single-center study included patients with LRC treated with ISR from January 2014 to April 2020. TASS was defined as (1) no anastomotic complications occurring after ISR; (2) ileostomy was closed and there was no severe intestinal dysfunction 2 years after ISR; and (3) no local recurrence within 2 years of surgery. TASS was achieved upon meeting all indicators. We analyzed 259 patients with LRC, with 125 (48.3%) achieving TASS. Multivariate analysis showed that male sex (OR 0.47; 95% CI 0.27–0.81; p = 0.007), hypertension (OR 0.48; 95% CI 0.24–0.97; p = 0.041), ASA score ≥ 3 (OR 0.28; 95% CI 0.10–0.81; p = 0.018), pre-treatment major low anterior resection syndrome (OR 0.37; 95% CI 0.15–0.94; p = 0.037), and preoperative neoadjuvant chemoradiotherapy (OR 0.41; 95% CI 0.22–0.77; p = 0.006) were independent risk factors for not achieving TASS. Conversely, transverse coloplasty pouch (OR 2.13; 95% CI 1.07–4.25; p = 0.032) and higher anastomosis level (OR 1.56; 95% CI 1.05–2.30; p = 0.026) were independent protective factors for achieving TASS. The nomogram constructed to evaluate the probability of achieving TASS demonstrated good accuracy in the dataset (area under curve, 0.737). TASS provides a comprehensive quality assessment for ISR in patients with LRC. The nomogram predicting TASS may assist surgeons in decision-making for managing LRC. [ABSTRACT FROM AUTHOR]

Background: Incontinence is not rare after rectal cancer surgery. Platelet-rich plasma may promote tissue repair and generation but has never been tested for the treatment of anal incontinence. This study evaluated the impact of platelet-rich plasma injection on the severity of incontinence and quality of life after low rectal cancer surgery. Methods: This is a prospective cohort proof of concept study in a colorectal cancer institution. Patients had undergone low anterior or intersphincteric resection for low rectal cancer and had a Wexner score > 4. Ten milliliters of platelet-rich plasma were injected into the internal and external sphincters under endoanal ultrasound (EAUS) guidance. Primary outcome measure was > 2 point improvement in Wexner score (improved group). The patients were assessed with endo-anal ultrasound examination, manometry, the Wexner Questionnaire and SF-36 Health Surveys, and patients were asked whether they used pads and antidiarrheal medications before and 6 months after PRP injection. Results: Of 20 patients included in the study, 14 (70%) were men, and the average age was 56.8 (SD = 9.5) years. No statistically significant difference was found in Wexner scores before and after PRP injection (p = 0.66). Seven (35%) patients experienced a > 2 point improvement in Wexner score. Rectal manometry demonstrated improved squeezing pressure (p = 0.0096). Furthermore, physical functioning scoring (p = 0.023), role limitation (p = 0.016), emotional well-being (p = 0.0057) and social functioning (p = 0.043) domains on the SF-36 questionnaire improved. One (5%) and three (15%) patients stopped using pads and antidiarrheal medications. Conclusion: Platelet-rich plasma injection does not restore Wexner scores, but more than one-third of patients may benefit from this application with an improvement of > 2 points in their scores. Platelet-rich plasma injection may improve squeezing pressure and certain life quality measures for incontinent patients after rectal cancer surgery. [ABSTRACT FROM AUTHOR]

Background: The efficacy of intersphincteric resection (ISR) surgery for patients with lower rectal cancer remains unclear compared to abdominoperineal resection (APR). The aim of this study is to compare the oncologic outcomes for lower rectal cancer patients after ISR and APR through a systematic review and meta-analysis. Materials and Methods: A systematic electronic search of the Cochrane Library, PubMed, EMBASE, and MEDLINE was performed through January 12, 2022. The primary outcomes included 5-year disease-free survival (5y-DFS) and 5-year overall survival. Secondary outcomes included circumferential resection margin involvement, local recurrence, perioperative outcomes, and other long-term outcomes. The pooled odds ratios, mean difference, or hazard ratios (HRs) of each outcome measurement and their 95% CIs were calculated. Results: A total of 20 nonrandomized controlled studies were included in the qualitative analysis, with 1217 patients who underwent ISR and 1135 patients who underwent APR. There was no significant difference in 5y-DFS (HR: 0.84, 95% CI: 0.55-1.29; P=0.43) and 5-year overall survival (HR: 0.93, 95% CI: 0.60-1.46; P=0.76) between the two groups. Using the results of five studies that reported matched T stage and tumor distance, we performed another pooled analysis. Compared to APR, the ISR group had equal 5y-DFS (HR: 0.76, 95% CI: 0.45-1.30; P= 0.31) and 5y-LRFS (local recurrence-free survival) (HR: 0.72, 95% CI: 0.29-1.78; P=0.48). Meanwhile, ISR had equivalent local control as well as perioperative outcomes while significantly reducing the operative time (mean difference: - 24.89, 95% CI: -45.21 to - 4.57; P=0.02) compared to APR. Conclusions: Our results show that the long-term survival and safety of patients is not affected by ISR surgery, although this result needs to be carefully considered and requires further study due to the risk of bias and limited data. [ABSTRACT FROM AUTHOR]

Background: Robotic-assisted total mesorectal excision (RaTME) may be associated with reduced conversion to an open approach and a higher rate of complete total mesorectal excision (TME); however, studies on its advantages in intersphincteric resection (ISR) are inadequate. Materials and methods: This retrospective multicenter cohort study enroled consecutive patients who underwent RaTME and laparoscopy-assisted total mesorectal excision (LaTME) at four medical centres between January 2020 and March 2023. Propensity score matching (PSM), inverse probability of treatment weight (IPTW), and multivariate logistic regression analyses were performed. The primary outcome was the ISR rate. Secondary outcomes were coloanal anastomosis (CAA), conversion to open surgery, conversion to transanal TME, abdominoperineal resection, postoperative morbidity and mortality within 30 days, and pathological outcomes. Results: Among the 1571 patients, 1211 and 450 underwent LaTME and RaTME, respectively, with corresponding ISR incidences of 5.3% and 8.4% (P=0.024). After PSM and IPTW, RaTME remained associated with higher ISR rates (4.5% versus 9.4%, P=0.022 after PSM; 4.9% versus 9.2, P=0.005 after IPTW). This association remained in multivariate analysis after adjusting for other confounding factors. RaTME was further associated with a higher CAA rate, longer operating time, and higher hospitalization expenses. Conclusions: RaTME may facilitate ISR in middle and low rectal cancers, showing an independent association with a higher ISR incidence, with pathological outcomes and complications comparable to those of LaTME. However, it may also require a longer operating time and incur higher hospitalization expenses. [ABSTRACT FROM AUTHOR]

Background: With the optimization of neoadjuvant treatment regimens, the indications for intersphincteric resection (ISR) have expanded. However, limitations such as unclear surgical field, impaired anal function, and failure of anal preservation still exist. Transanal total mesorectal excision can complement the drawbacks of ISR. Therefore, this study combined these two techniques and proposed transanal endoscopic intersphincteric resection (taE-ISR), aiming to explore the value of this novel technique in anal preservation for ultra-low rectal cancer. Material and methods: Four high-volume centres were involved. After 1:1 propensity score-matching, patients with ultra-low rectal cancer underwent taE-ISR (n =90) or ISR (n= 90) were included. Baseline characteristics, perioperative outcomes, pathological results, and follow-up were compared between the two groups. A nomogram model was established to assess the potential risks of anal preservation. Results: The incidence of adjacent organ injury (0.0% vs. 5.6%, P = 0.059), positive distal resection margin (1.1% vs. 8.9%, P = 0.034), and incomplete specimen (2.2% vs. 13.3%, P = 0.012) were lower in taE-ISR group. Moreover, the anal preservation rate was significantly higher in taE-ISR group (97.8% vs. 82.2%, P = 0.001). Patients in the taE-ISR group showed a better disease-free survival (P = 0.044) and lower cumulative recurrence (P = 0.022) compared to the ISR group. Surgery procedure, tumour distance, and adjacent organ injury were factors influencing anal preservation in patients with ultra-low rectal cancer. Conclusion: taE-ISR technique was safe, feasible, and improved surgical quality, anal preservation rate and survival outcomes in ultra-low rectal cancer patients. It held significant clinical value and showed promising application prospects for anal preservation. [ABSTRACT FROM AUTHOR]

Background The use of sphincter-saving resection without a permanent stoma in place of abdominoperineal resection (APR) has been one of the greatest advancements in the area of surgical therapy for low rectal cancer. Aim To assess the oncological and functional outcomes of inter-sphincteric resection of low rectal cancer in order to achieve radicality and a standard of living. Patients and methods At the hospitals affiliated with Menoufia University, a retrospective analysis was done. Forty patients with rectum cancer who were undergoing general surgery at Menoufia University Hospitals were the subject of this investigation. We comprised: older than 18 years old, sexes of both genders, low rectum and anal canal, with internal sphincter or rectal wall restriction on magnetic resonance imaging, differentiated tumour, tumour diameter of 1-5, and good continence. Results Mean operative time was 261.8 (±96.6 SD), the mean blood loss was 185.8 (±156.5 SD). Mean postoperative hospital stay was 11.2 (±4.1S D), the mean pain severity 1 h postoperatively was 5.5 (±1.0 SD), the mean 1 day postoperatively was 5.9 (±1.5 SD), the mean 5 day postoperatively was 3.3 (±1.2 SD), there were three with Anastomotic leakage, two with wound infection, two with hemorrhage, one with urinary tract infection, one with ileus. Regarding complications, mean score of micturition problems was 28.2 (±4.1 SD), the mean GIT symptoms was 32.2 (±3.1 SD), the mean weight loss was 5.5 (±1.0 SD), the mean CTX side effects was 13.9 (±1.5 SD), the mean body image was 70.3±6.2. Conclusion The intersphincteric resection approach improves the rate of sphincter preservation while maintaining oncological and functional results. Symptom-specific quality of life may be adversely affected by preoperative radiation. [ABSTRACT FROM AUTHOR]

Intersphincteric resection (ISR) with coloanal anastomosis is an oncologically safe anus-preserving technique for very low-lying rectal cancers. Most studies focused on oncological and functional outcomes of ISR with very few evaluating long-term postoperative anorectal complications. Full-thickness prolapse of the neorectum is a relatively rare complication. This report presents the case of a 70-year-old woman presenting with full-thickness prolapse of the side limb of the side-to-end coloanal anastomosis occurring 2 weeks after the stoma closure and 2 months after a robotic partial ISR performed with the Da Vinci single-port platform. The anastomosis was revised through resection of the side limb and conversion of the side-to-end anastomosis into an end-to-end handsewn anastomosis with interrupted stitches. This study describes the first case of full-thickness prolapse of the side limb of the side-to-end handsewn coloanal anastomosis following ISR. Moreover, a revision of all reported cases of post-ISR full-thickness and mucosal prolapse was performed.

Intersphincteric resection (ISR) was introduced recently as an alternative procedure for abdominoperineal resection and sparing the anal sphincter. Anastomosis stricture is a common complication after ISR. In this study, we attempted to maintain the dilatation longer using a stent in combination with dilatation during a single session on a patient who was suffering from anal stricture after an ISR procedure. Six weeks following neoadjuvant chemo-radiotherapy, a 52-year-old woman underwent ISR. She presented to the hospital with a rectal adenocarcinoma at a 3 cm distance from the anal verge. A complete diverting tube ileostomy was performed as a protective stoma instead of a conventional loop ileostomy. The patient reported hard defecation at 6 weeks after surgery. A severe anastomosis stricture was detected during the digital rectal exam. Dilatation was performed under general anesthesia. The lumen was dilated up to 1.5 cm with Hegar dilators, and colonic mucosa were confirmed by a rigid rectoscope. A polyvinyl chloride soft tube with a length of 20 cm and a diameter of 17 mm was used as a stent to maintain the dilatation. Instead of dilatation alone, we combined dilatation with a convenient anal stent. The patient was discharged on the postoperative third day. During the 2 weeks of follow up with the tube, the patient did not report any challenges in terms of mobilization and lifestyle. There was no bleeding. However, tenesmus was described during this 2-week period by the patient. After the removal of the tube on the fourteenth day, the stricture was resolved and defecation was within normal. After a follow-up period of 2 months, there were no reported problems regarding defecation. This treatment modality could be recommended as a first-line treatment instead of surgical revision procedures (e.g., flap or stricturoplasty) in the future because it is a minimally invasive procedure.

Objectives: This study aimed to compare the efficacy of local excision (LE) and intersphincteric resection (ISR) in patients with locally advanced rectal cancer who achieved a significant or complete pathological response following neoadjuvant chemoradiotherapy. Methods: We performed a retrospective analysis of data from patients with stage ypT0-1ycN0 low rectal cancer after neoadjuvant chemoradiotherapy who underwent LE or ISR between June 2016 and June 2021. Baseline characteristics, short-term outcomes, long-term oncological outcomes, and functional outcomes, were compared between the two groups. To reduce the selection bias, inverse probability of treatment weighting (IPTW) was performed. Results: This study included 106 patients (LE group: n = 51, ISR group: n = 55). There were significant differences in baseline characteristics between the two groups (P < 0.05). After IPTW, there were almost no significant differences in baseline data between the two groups. The LE group showed less postoperative complications and better function outcomes compared to the ISR group. The LE group had significantly lower rates of complications (13.7% vs. 36.4%, P = 0.014). There were no significant differences between the two groups in terms of long-term oncological outcomes. Conclusions: For patients with locally advanced low rectal cancer achieving significant or complete pathological response after neoadjuvant therapy, both LE and ISR present comparable oncological outcomes. Yet, LE seems to show more advantages in terms of postoperative complications and functional outcomes. These findings offer important insights for surgical decision-making, emphasizing the necessity to consider both oncological and functional outcomes in selecting the optimal surgical approach. [ABSTRACT FROM AUTHOR]

Aim: Sphincter‐sparing surgery can be achieved in most cases of low rectal cancer with the development of intersphincteric resection. However, abdominoperineal resection is still inevitable for patients with tumours located below the dentate line. To address this, we have developed a procedure called conformal sphincteric resection (CSR) in which the corresponding part of the subcutaneous portion of the external anal sphincter and the perianal skin on the tumour side is removed to achieve a safe distal resection margin and lateral resection margin while the dentate line and the internal anal sphincter on the tumour‐free side are preserved as much as possible, to achieve sphincter preservation without compromising oncological safety and functional acceptability, and to render tumour location no longer a contraindication for sphincter‐sparing surgery. This is the first study to describe the concept, indication and surgical procedure of CSR and to report its preliminary surgical, oncological and functional results. Methods: This is a retrospective, single‐centre, single‐arm pilot study conducted at Huashan Hospital, Fudan University. Demographic, clinicopathological, oncological and functional follow‐up data were collected from 20 consecutive patients with rectal tumours located below the dentate line who underwent laparoscopic CSR by the same surgical team from June 2018 to March 2022. Results: The mean distance of the tumour's lower edge from the anal verge was 13.1 ± 6.0 mm. The mean distal resection margin was 10.6 ± 4.3 mm. All circumferential resection margins were negative. There were no instances of perioperative mortality. The complication rate was 25% but all were Clavien−Dindo Grade I. Among the 20 cases, 17 were diagnosed with adenocarcinoma, one with squamous cell carcinoma and two with adenoma featuring high‐grade intraepithelial neoplasia. Pathological TNM staging revealed two, seven, five, five and one case(s) in Stages 0, I, II, III and IV, respectively. The median follow‐up period was 20 months (interquartile range 22 months), with no withdrawals. The overall and disease‐free survival rates were both 95%. The mean Wexner incontinence score and low anterior resection syndrome score recorded 18 months following diverting ileostomy closure were 6.3 ± 3.8 and 27.3 ± 3.6, respectively. Conclusions: This study has proposed the CSR procedure for the first time, which is a technically feasible, oncologically safe and functionally acceptable procedure for carefully selected patients with rectal tumours located below the dentate line. [ABSTRACT FROM AUTHOR]

Purpose: Our aim was to perform a propensity score-matched study to compare the long-term functional outcomes and quality of life following intersphincteric resection vs. low anterior resection (LAR) with very low anastomosis. Methods: Patients who underwent intersphincteric resection or low anterior resection with low anastomosis (≤ 4 cm from the anal verge) for rectal cancer between January 2017 and June 2020 were retrospectively included. A propensity score-matching process was performed. Functional outcomes and quality of life were assessed using the European Quality of Life 5 Dimensions 3 Level Version (EQ-5D-3L), EORC-QLQ C30, EORC-QLQ CR29, Low Anterior Resection Syndrome (LARS), Wexner, and International Prostate Symptom Score (IPSS) questionnaires. The primary outcome was the presence of LARS at least 12 months after surgery. The second outcome was the postoperative quality of life of included patients. Results: After propensity matching, 128 patients were included, including 58 males and 70 females with a median age of 59.5. Patients in the intersphincteric resection group showed a higher incidence of incontinence to flatus (32.8% versus 14.0%, p = 0.043) and stools (42.2% versus 21.9%, p = 0.046), pain/discomfort (25.0% versus 7.8%, p = 0.001), and bowel dysfunction, while the LARS scores (15.0 versus 13.2, p = 0.461) and major LARS rates (26.6% versus 14.1%, p = 0.078) were comparable in both groups. Conclusion: ISR leads to increased bowel incontinence rate and increased anal pain, without affecting the grade of low anterior resection syndrome, fecal urgency, and clustering. LAR might be the preferred sphincteric-preserving approach when negative resection margins and a safe anastomosis are guaranteed. Patients should be fully informed about potential functional impairment after sphincter-preservation procedures. [ABSTRACT FROM AUTHOR]

Purpose: Conformal sphincter preservation operation (CSPO) is a sphincter preservation operation for very low rectal cancers. Compared to intersphincteric resection (ISR), CSPO retains more dentate line and distal rectal wall, and also avoids damaging the nerves in the intersphincteric space. This study aimed to compare the postoperative anal function and quality of life between the CSPO and ISR. Method: Patients with low rectal cancer undergoing CSPO (n = 117) and ISR (n = 66) were included from Changhai and Huashan Hospital, respectively, between 2011 and 2020. A visual analog scale (range 0–10) was utilized to evaluate satisfaction with anal function and quality of life. The anal function was evaluated with Wexner scores and low anterior resection syndrome (LARS) score. Quality of life was evaluated with the EORTC QLQ-C30 and QLQ-CR38. Results: The CSPO group had more male patients (65.8% vs. 50%, p = 0.042), more preoperative chemoradiotherapy (33.3% vs. 10.6%, p < 0.001), lower tumor position (3.45 ± 1.13 vs. 4.24 ± 0.86 cm, p < 0.001), and more postoperative chemotherapy (65% vs. 13.6%, p < 0.001) compared to the ISR group. In addition, CSPO patients had shorter postoperative stay (6.63 ± 2.53 vs. 7.85 ± 4.73 days, p = 0.003) and comparable stoma reversal rates within 1 year after surgery (92.16% vs. 96.97%, p = 0.318). Multivariable analysis showed that CSPO significantly contributed to higher satisfaction with anal function (beta = 1.752, 95% CI 0.776–2.728) and with quality of life (beta = 1.219, 95% CI 0.374–2.064), but not to Wexner, LARS score, or EORTC QLQ-C30 and QLQ-CR38. Conclusion: CSPO improved the satisfaction with anal function and quality of life but utilized more preoperative chemoradiotherapy. CSPO may be an alternative choice for patients with very low rectal cancers in better physical health and with higher requirements for anal function and quality of life. [ABSTRACT FROM AUTHOR]

Purpose: This study aimed to compare the oncological and functional outcomes following intersphincteric resection (ISR) with transverse coloplasty pouch (TCP) or straight coloanal anastomosis (SCAA) for low rectal cancer. Methods: A single-center retrospective analysis was performed on patients with low rectal cancer who received ISR between January 2016 and June 2021. The primary endpoint was to compare the outcomes of bowel function within 1 year, 1 to 2 years, and 2 years after ileostomy closure in patients undergoing two different bowel reconstruction procedures (TCP or SCAA). The postoperative complications and oncological results were also compared between the two groups. Results: A total of 235 patients were enrolled in this study (SCAA group: 166; TCP group: 69). There was no significant difference in complications, including grades A–C anastomotic leakage (9.6% vs 15.9%), 3-year local recurrence rates (6.1% vs 3.9%), disease-free survival (82.4%vs 83.8%), or overall survival (94.1% vs 94.7%) between the two groups. Two years after ileostomy closure, 52.7% of patients in the SCAA group were assessed as having major low anterior resection syndrome (LARS), which was significantly higher than the 25.9% of patients in the TCP group (P = 0.014), but no difference was found prior to 2 years. Similar differences were seen in Wexner scores 2 years after surgery (P = 0.032). Additionally, TCP was an independent protective factor for postoperative bowel function as measured by both the LARS (OR, 0.28; 95% CI, 0.10–0.82; p = 0.020) and Wexner scoring (OR, 0.28; 95% CI, 0.09–0.84; p = 0.023). Conclusion: This study suggests that TCP is a safe technique that may decrease bowel dysfunction after ISR for low rectal cancer compared with SCAA 2 years after ileostomy closure. [ABSTRACT FROM AUTHOR]

Background and Aim: Refractory anastomotic leakage (RAL) after intersphincteric resection (ISR) usually leads to failure of protective stoma reversal in ultralow rectal cancers. The aim of this study is to assess the risk factors and oncological outcomes of both anastomotic leakage (AL) and RAL, and quality of life (QoL) of RAL after laparoscopic ISR (LsISR). Methods: A total of 371 ultralow rectal cancer patients with LsISR were enrolled from a tertiary colorectal surgery referral center. Risk factors for AL and RAL were identified by logistic regression. Three‐year disease‐free survival (DFS) of AL and RAL was analyzed by the Cox regression. QoL of RAL group (compared with non‐RAL group) was assessed using the European Organization for Research and Treatment of Cancer QLQ‐C30 and QLQ‐CR29 questionnaires. Results: The rates of AL and RAL after LsISR accounted for 8.4% (31/371) and 4.6% (17/371) in this cohort, respectively. Non‐left colic artery preservation (odds ratio [OR] = 3.491, P = 0.009), neoadjuvant chemoradiotherapy (nCRT) (OR = 6.038, P < 0.001), and lower anastomosis height (OR = 5.271, P = 0.010) were independent risk factors for AL, while nCRT (OR = 11.602, P < 0.001) was the only independent risk factor for RAL. Male (hazard ratio [HR] = 1.989, P = 0.014), age > 60 years (HR = 1.877, P = 0.018), and lymph node metastasis (HR = 2.125, P = 0.005) were independent risk factors of poor 3‐year DFS, but not RAL (P = 0.646). RAL patients have significantly worse global health status, worse emotional and social function scores at the late postoperative stage, and worse urinary and sexual function at the early postoperative stage (all P < 0.05). Conclusions: Neoadjuvant chemoradiotherapy was an independent risk factor for RAL after LsISR. RAL shows similar oncological outcomes, but with poor QoL. [ABSTRACT FROM AUTHOR]

Purpose: To determine whether anastomotic leakage (AL) following intersphincteric resection (ISR) for ultralow rectal cancer (uLRC) is associated with long-term negative outcomes. Methods: Between June 2011 and January 2022, 236 consecutive patients who underwent ISR with diverting ileostomy for uLRC were included. The primary outcome was long-term clinical consequences of AL, including chronic stricture, stoma reversal, and oncological and functional results. Results: Forty-one (17.4%) patients developed symptomatic AL, whereas only two (0.8%) required re-laparotomy due to severe leakage. Patients with leaks had a significantly increased incidence of chronic stricture (29.3% vs. 8.7%, P = 0.001) and stoma non-reversal (34.1% vs. 4.6%, P < 0.0001) than controls. The severe consequences were particularly common in patients with anastomotic separation, resulting in 60% of those presenting with chronic stricture and 50% ending up with stoma non-reversal. After a median follow-up of 59 (range, 7–139) months, AL did not compromise long-term oncological outcomes, including tumor recurrence (9.8% vs. 5.6%, P = 0.3), 5-year disease-free, and overall survival (73.4% vs. 74.8% and 85.1% vs. 85.4%, P = 0.56 and P = 0.55). A total of 149 patients with bowel continuity who completed self-assessment questionnaires were enrolled for functional evaluation. The median follow-up was 24 (range, 12–94) months after ileostomy reversal, and functional results were comparable between patients with and without leaks. Conclusion: AL is an unfortunate reality for patients who underwent ISR for uLRC, but the rate of severe leakage is limited. Leaks contribute to possible adverse impacts on chronic stricture and stoma non-reversal, especially for patients with anastomotic separation. However, long-term oncological and functional results may not be compromised. Trial registration: Chictr.org.cn identifier: ChiCTR-ONC-15007506 and ChiCTR2100051614. [ABSTRACT FROM AUTHOR]

Objective: In the evolving era of minimal access surgery, low rectal cancers still pose a challenge to laparoscopic or robotic surgeons. Hence, at our institute we intended to demonstrate the oncological efficacy of intersphincteric resection and coloanal anastomosis in the treatment of distal rectal cancers, performing the abdominal part of the procedure which includes rectal mobilization, laparoscopically. Methods: From February 2017 to March 2021, 125 patients who had undergone intersphincteric resection and coloanal anastomosis via the perineal approach at Galaxy Care Laparoscopic Institute, Pune, were included in this study. Transabdominal mobilization of the rectum was performed laparoscopically. All patients had a diversion ileostomy and a pelvic drain. Patients were followed-up for a period of 18 months post-surgery. Data on clinical and oncological outcomes were collected and analysed. The pre-operative and post-operative Wexner incontinence scores were compared. Results: The mean time taken for surgery was 181.57 ± 30.00 min. The mean blood loss was 119.76 ± 42.53 mL. Most patients (103, 82.4%) had their tumour at a distance of 1–2 cm from the anal verge. A loco-regional recurrence rate of 12.8% (16/125) was noted in our study. For the post-surgery Wexner score, 74.4% of patients (93/125) had a score of 5 or less, depicting that three-quarters of the study population had satisfactory continence. Overall, 81.6% of patients were satisfied with the functional results of surgery. Conclusion: Intersphincteric resection and coloanal anastomosis, with a 12.8% recurrence rate, can now be considered an oncological and technically feasible procedure with sphincter salvage and good continence.

Aim: Intersphincteric resection (ISR) is an oncologically complex operation for very low‐lying rectal cancers. Yet, definition, anatomical description, operative indications and operative approaches to ISR are not standardized. The aim of this study was to standardize the definition of ISR by reaching international consensus from the experts in the field. This standardization will allow meaningful comparison in the literature in the future. Method: A modified Delphi approach with three rounds of questionnaire was adopted. A total of 29 international experts from 11 countries were recruited for this study. Six domains with a total of 37 statements were examined, including anatomical definition; definition of intersphincteric dissection, intersphincteric resection (ISR) and ultra‐low anterior resection (uLAR); indication for ISR; surgical technique of ISR; specimen description of ISR; and functional outcome assessment protocol. Results: Three rounds of questionnaire were performed (response rate 100%, 89.6%, 89.6%). Agreement (≥80%) reached standardization on 36 statements. Conclusion: This study provides an international expert consensus‐based definition and standardization of ISR. This is the first study standardizing terminology and definition of deep pelvis/anal canal anatomy from a surgical point of view. Intersphincteric dissection, ISR and uLAR were specifically defined for precise surgical description. Indication for ISR was determined by the rectal tumour's maximal radial infiltration (T stage) below the levator ani. A new surgical definition of T3isp was reached by consensus to define T3 low rectal tumours infiltrating the intersphincteric plane. A practical flowchart for surgical indication for uLAR/ISR/abdominoperineal resection was developed. A standardized ISR surgical technique and functional outcome assessment protocol was defined. [ABSTRACT FROM AUTHOR]

Background: Anus-preserving surgery for low rectal cancer has always been a serious difficulty for surgeons. Transanal total mesorectal excision (TaTME) and laparoscopic intersphincteric resection (ISR) are commonly used Anus-preserving surgeries for low rectal cancer. The aim of this study was to compare the clinical use of two surgical methods. Methods: A total of 152 patients with low rectal cancer were treated with taTME in 75 cases and ISR in 77 cases. After propensity score matching, 46 patients in each group were included in the study. Perioperative outcomes, anal function scores (Wexner incontinence score) and quality of life scores (EORTC QLQ C30, EORTC QLQ CR38) at least 1 year after surgery were compared between the two groups. Results: There were no significant differences between the two groups in terms of surgical outcomes, pathological examination of surgical specimens, postoperative recovery, and postoperative complications, except for patients in the taTME group who had their indwelling catheters removed later. Anal Wexner incontinence score was lower in taTME group than ISR group (P < 0.05). On the EORTC QLQ-C30 scale, the physical function and role function scores in the ISR group were lower than those in the taTME group (P < 0.05), while the fatigue, pain symptoms, and constipation scores in the ISR group were higher than those in the taTME group (P < 0.05). On the EORTC QLQ-CR38 scale, the scores of gastrointestinal symptoms and defecation problems in the ISR group were higher than those in the taTME group (P < 0.05). Conclusion: Compared with ISR surgery, taTME surgery is comparable in terms of surgical safety and short-term efficacy, and has better long-term anal function and quality of life. From the perspective of long-term anal function and quality of life, taTME surgery is a better surgical method for the treatment of low rectal cancer. [ABSTRACT FROM AUTHOR]

Introduction: Anorectal manometry (ARM) is sometimes performed before ostomy reversal in patients with an intersphincteric resection (ISR) to predict bowel function. However, no clinical predictive data exist regarding its utility. Methods: The single‐centre, retrospective data of ISR patients who had an ARM prior to ostomy reversal, and bowel functional assessment with the low anterior resection syndrome (LARS) and Wexner incontinence scores at least 6 months after reversal, were considered. Correlation statistics were performed with each of the manometric parameters and functional outcome categories. Results: Eighty‐nine patients were included. The median basal and squeeze pressures were 41 and 100 mmHg, respectively. Any LARS (score ≥20) and major incontinence (score ≥11) was observed in 51.7% and 16.9%, respectively. None of the manometric parameters (median basal or maximum squeeze pressure, anal canal length, volume at urge and the ability to expel) correlated with LARS or incontinence. Conclusions: Anorectal manometry (ARM) before ostomy reversal to predict bowel function at 6 months or beyond was not helpful in patients with an ISR and diverting stoma. No manometric parameter correlated with the LARS or Wexner incontinence scores. [ABSTRACT FROM AUTHOR]

Background: In recent years, intersphincteric resection (ISR) has been increasingly used to replace abdominoperineal resection (APR) in the surgical treatment of ultra-low rectal cancer. Aim: This study was to compare the clinical efficacy of ISR and APR. Methods: Between 2012 and 2018, 74 consecutive patients with ultra-low rectal cancer underwent ISR or APR in our medical center. A retrospective comparison of these 2 procedures was performed. Results: A total of 43 patients underwent ISR and 31 underwent APR were included in the study. No significant differences were found between 2 groups in gender, age, BMI, and ASA score. Intersphincteric resection group showed shorter operative time (P =.02) and less blood loss (P =.001). Hospital stays, time to soft diet, and postoperative 30-day complications were not significantly different between the 2 groups. R0 resection achieved 100% in both the groups. As for the long-term outcomes, the survival and recurrence rate were similar between 2 groups. Moreover, the LARS and Wexner score showed that the postoperative anal function after ISR were satisfactory. Conclusion: This study suggested that ISR was feasible and safe for selected patients with ultra-low rectal cancer, with clinically superior outcomes in select patients (small tumors/further from the anal verge) and similar oncological outcomes to APR, and the anal functional outcomes after ISR were acceptable. [ABSTRACT FROM AUTHOR]

Objectives: Abdominoperineal resection (APR) is considered the gold standard surgical treatment for ultra-low rectal cancer. Anus-preserving alternative procedures have been tested to avoid the need for a permanent colostomy. The present study compares the functional and oncological outcomes of the traditional APR methods with inter-sphincteric resection (ISR). Methods: Sixty patients with ultra-low rectal cancers that underwent tumor resection using the ISR and APR methods were compared retrospectively. Patients' demographic information as well as tumor characteristics were evaluated. All patients were followed after the operation every three months for two years, and then every six months for at least three years. Results: Thirty-four (56.6%) patients were male, and 26 (43.3%) were females, which showed no statistical significance between the two groups. The mean tumor distance from the anal verge in the APR group was 5.11±0.06 cm and in the ISR group was 5.22±1.1 cm. In the APR group, 9 (30%) patients developed primary tumor recurrence, while in the ISR group, 10 (33.3%) patients had relapses. The observed difference was not statistically significant. However, the study showed that patients with a T stage of T2 or higher had a higher probability of tumor recurrence. Conclusion: There is no significant difference in the efficacy of the ISR method compared with the conventional APR for the treatment of ultra-low rectal cancer.

Neorectal prolapse following proctectomy for cancer has seldom been reported and treatment has mostly consisted in the resection of the prolapse via a perineal approach. Management of a patient with neorectal J-pouch prolapse using mesh sacral pexy via an abdominal approach is reported. By analogy with native rectal prolapse due to pelvic static disorders, laparoscopic mesh sacral pexy is likely to afford the same advantages of low morbidity and durability when applied to neorectal prolapse following rectal cancer surgery. [ABSTRACT FROM AUTHOR]

Abstract Aim Sphincter‐preserving operations for ultra‐low rectal cancer include low anterior and intersphincteric resection. In low anterior resection, the distal rectum is divided by a transabdominal approach, which is technically demanding. In intersphincteric resection, a perineal approach is used. We aimed to evaluate whether robotic‐assisted surgery is technically superior to laparoscopic surgery for ultra‐low rectal cancer. We compared the frequency of low anterior resection in cases of sphincter‐preserving operations. Method We investigated 183 patients who underwent sphincter‐preserving robotic‐assisted or laparoscopic surgery for ultra‐low rectal cancer (lower border within 5 cm of the anal verge) between April 2010 and March 2020. The frequency of low anterior resection was compared between laparoscopic and robotic‐assisted surgeries. The clinicopathological factors associated with an increase in performing low anterior resection were analyzed by multivariate analyses. Results Overall, 41 (22.4%) and 142 (77.6%) patients underwent laparoscopic and robotic‐assisted surgery, respectively. Patient characteristics were similar between the groups. Low anterior resection was done significantly more frequently in robotic‐assisted surgery (67.6%) than in laparoscopic surgery (48.8%) (P = 0.04). Multivariate analyses showed that tumor distance from the anal verge (P

Abstract Background The operative results of different approaches for the laparoscopic intersphincteric resection (LAISR) of low rectal cancer vary, and the patient characteristics associated with the best outcomes for each procedure have not been reported. We compared the efficacy of different approaches for LAISR of low rectal cancer and discussed the surgical indications for each approach. Methods We retrospectively reviewed data from 235 patients with low rectal cancer treated via LAISR from October 2010 to September 2016. Patients underwent either the transabdominal approach for ISR (TAISR, n = 142), the transabdominal perineal approach for ISR (TPAISR, n = 57), or the transanal pull-through approach for ISR (PAISR, n = 36). Results The PAISR and TAISR groups exhibited shorter operation times and less intraoperative blood loss than the TPAISR group. The anastomotic distance was shorter in the PAISR and TPAISR groups than in the TAISR group. No differences in the ability to perform radical resection, overall complications, postoperative recovery, Wexner score recorded 12 months after ostomy closure, 3-year disease-free survival, local recurrence-free survival, distant metastasis-free survival, or overall survival (OS) were observed among the three groups. Conclusions TAISR, TPAISR, and PAISR have unique advantages and do not differ in terms of operation safety, patient outcomes, or anal function. TPAISR requires a longer time to complete and is associated with more bleeding and a slower recovery of anal function. PAISR should be considered when TAISR cannot ensure a negative distal margin and the tumor and BMI are relatively small; otherwise, TPAISR is required.

Aim of this study was to compare operative, long-term oncological and functional outcomes of laparoscopic (LISR) and robotic (RISR) intersphincteric resection in low-lying rectal cancer. Retrospective analysis of prospectively maintained database was performed. 115 cases (LISR, n = 55; RISR, n = 60) were performed by a single surgeon (January 2011–January 2020). Clinical characteristics did not differ between the groups. Operating time was longer in RISR (160.0 ± 45.7 vs. 205.0 ± 36.5 min, p = 0.035). There was no conversion in RISR, whereas in LISR, two patients (3.6%) converted to open surgery. Complete mesorectum was 61.8% and 83.3% for LISR and RISR (p = 0.046), respectively. Circumferential radial margin involvement was 10.9% and 8.3% in LISR and RISR (p = 0.365), respectively. Median follow-up was 82.8 (30–138) months for LISR and 83.6 (30–138) months for RISR. Three-, five-, and seven-year overall survival rates (OS) for LISR and RISR were: 88.6%, 80.4%, 73.4% and 90.4%, 86.3%, 76.9%, respectively. Three-, five-, and seven-year disease-free survival (DFS) rates for LISR and RISR were 80.5%, 75.2%, 70.4% and 84.4%, 81.4%, 79.8% (p = 0.328), respectively. Three-, five-, and seven-year local recurrence-free survival rates in LISR and RISR were: 96.1%, 92.6%, 88.4% and 96.7%, 94.2%, 90.4% (p = 0.573), respectively. Mean Wexner score for LISR (n = 32) and RISR (n = 40) was: 10.5 ± 4.7 and 9.8 ± 4.2 (p = 0.782), respectively. Colostomy-free survival in LISR and RISR was: 3 years 94.5%/95.2%, 5 years 89.1%/91.7%, and 7 years 83.6%/85.0%. RISR is associated with better mesorectal integrity, no conversion, and lower postoperative complication rate. RISR has longer operation time. Oncological and anorectal functional outcomes are similar in both groups. [ABSTRACT FROM AUTHOR]

Intersphincteric resection (ISR) is the ultimate anus-sparing technique for low rectal cancer and is considered an oncologically safe alternative to abdominoperineal resection. The application of the robotic approach to ISR (RISR) has been described by few specialized surgical teams with several differences regarding approach and technique. This review aims to discuss the technical aspects of RISR by evaluating point by point each surgical controversy. Moreover, a systematic review was performed to report the perioperative, oncological, and functional outcomes of RISR. Postoperative morbidities after RISR are acceptable. RISR allows adequate surgical margins and adequate oncological outcomes. RISR may result in severe bowel and genitourinary dysfunction affecting the quality of life in a portion of patients.

ObjectiveAnus-preserving surgery in overweight patients with low rectal cancer has been a challenge due to the narrow operating space. Intersphincteric resection (ISR) was once a standard therapeutic option for low rectal cancer. The effectiveness of transanal total mesorectal excision (taTME) in treating this group of patients remains uncertain as a new surgical strategy. The aim of this study was to evaluate the short-term effects of taTME with ISR in overweight patients with low rectal cancer.MethodsA total of 53 patients with low rectal cancer were treated with taTME in 31 cases and ISR in 22 cases. The surgery-related data, pathological manifestations of surgical specimens, postoperative recovery, and postoperative complications were compared.ResultsPatients in both groups completed the surgery successfully. There were no significant differences in operative time, blood loss, anastomotic distance from the anal verge and ileostomy between the two groups (P > 0.05). TaTME group performed or virtually finished resection of the rectal mesentery, and no positive cases of Circumferential Resection Margin (CRM) or Distal Resection Margin (DRM) were detected in either group. The number of lymph nodes found in surgical specimens did not change significantly between the two groups (P = 0.391). In the subgroup analysis, however, more lymph nodes were detected in female patients undergoing taTME than in male patients (P = 0.028). The ISR group took less time to remove the drainage tubes (P = 0.013) and the same results were obtained in both groups of male patients in the subgroup analysis (P = 0.011). There were no statistically significant differences in time to start liquid diet, time to remove catheters, time to start flatus, time to begin ambulation, postoperative hospital stay, and readmission within 30 days after surgery between the two groups (P > 0.05). However, female patients in the taTME group were initiated ambulation earlier than males in the subgroup analysis (P = 0.034). The difference was insignificant in the occurrence of postoperative complications between the two groups (P > 0.05).ConclusiontaTME is safe and feasible for the treatment of overweight patients with low rectal cancer.

Aim: Sphincter‐preserving operations for ultra‐low rectal cancer include low anterior and intersphincteric resection. In low anterior resection, the distal rectum is divided by a transabdominal approach, which is technically demanding. In intersphincteric resection, a perineal approach is used. We aimed to evaluate whether robotic‐assisted surgery is technically superior to laparoscopic surgery for ultra‐low rectal cancer. We compared the frequency of low anterior resection in cases of sphincter‐preserving operations. Method: We investigated 183 patients who underwent sphincter‐preserving robotic‐assisted or laparoscopic surgery for ultra‐low rectal cancer (lower border within 5 cm of the anal verge) between April 2010 and March 2020. The frequency of low anterior resection was compared between laparoscopic and robotic‐assisted surgeries. The clinicopathological factors associated with an increase in performing low anterior resection were analyzed by multivariate analyses. Results: Overall, 41 (22.4%) and 142 (77.6%) patients underwent laparoscopic and robotic‐assisted surgery, respectively. Patient characteristics were similar between the groups. Low anterior resection was done significantly more frequently in robotic‐assisted surgery (67.6%) than in laparoscopic surgery (48.8%) (P = 0.04). Multivariate analyses showed that tumor distance from the anal verge (P < 0.01) and robotic‐assisted surgery (P = 0.02) were significantly associated with an increase in the performance of low anterior resection. The rate of postoperative complications or pathological results was similar between the groups. Conclusion: Compared with laparoscopic surgery, robotic‐assisted surgery significantly increased the frequency of low anterior resection in sphincter‐preserving operations for ultra‐low rectal cancer. Robotic‐assisted surgery has technical superiority over laparoscopic surgery for ultra‐low rectal cancer treatment. [ABSTRACT FROM AUTHOR]

Anastomotic leakage (AL) is a common complication after intersphincteric resection (ISR). It significantly reduces quality of life and causes great distress to patients. Although traditional drainage (e.g., anal and pelvic catheters) may reduce the impact of AL to some extent, their role in reducing the incidence of AL remains controversial. In this study, we developed a novel drainage technique involving the placement of drainage tubes through the gap between sutures during handsewn anastomosis, to reduce the occurrence of anastomotic leakage. We retrospectively analyzed 34 consecutive patients who underwent intersphincteric resection requiring handsewn anastomosis between February 1, 2017, and January 1, 2021. Patients were classified into the transanastomotic drainage tube group (TADT, n = 14) and the non-TADT group (n = 20) based on whether trans-anastomotic tube placement was performed. The incidence of postoperative complications, such as AL, was compared between the two groups, and anal function of patients at 1-year post-ISR was evaluated. Six cases of AL occurred in the non-TADT group, while none occurred in the TADT group; this difference was statistically significant (p=0.031). The TADT group also had a shorter hospital stay (p=0.007). There were no other significant intergroup differences in operation time, blood loss, pain score, anastomotic stenosis, intestinal obstruction, or incidence of wound infection. In the 30 patients (88.2%) evaluated for anal function, there were no significant intergroup differences in stool frequency, urgency, daytime/nocturnal soiling, Wexner incontinence score, or Kirwan grading. Taken together, trans-anastomotic tube placement is a novel drainage method that may reduce AL after ISR requiring handsewn anastomosis and without adversely affecting anal function. [ABSTRACT FROM AUTHOR]

Background: Da Vinci® Single Port (dvSP) was recently developed. Its application in colorectal surgery is under investigation. The aim of this study was to explore the safety and feasibility of dvSP for intersphincteric (dvSP-ISR), right colectomy (dvSP-RC), and transverse colectomy (dvSP-TC). Surgical indication and short-term results were analyzed. Methods: All consecutive patients from a prospective database of patients who underwent dvSP-ISR, dvSP-RC, and dvSP-TC at Korea University Anam Hospital from November 2020 to December 2021, were analyzed. Perioperative, pathological, and oncological short-term outcomes were analyzed. Results: A total of 7 dvSP-ISR, 5 dvSP-RC, and 1 dvSP-TC were performed. Median age was 56.0 (55.0–61.0) years for the dvSP-ISR and 54.0 (44.7–63.5) years for the dvSP-RC/TC. Median body mass index was 22.8 (17.1–24.8) kg/m2 for the dvSP-ISR and 23.6 (20.8–26.9) kg/m2 for the dvSP-RC/TC. All dvSP-ISR patients received neoadjuvant long-course chemoradiotherapy, including one patient with squamocellular carcinoma who was treated with 5-fluorouracil (5-FU)/mitomycin. All other patients, excluding one dvSP-RC patient with Crohn's disease, had an adenocarcinoma. Median operation time was 280 (240–370) minutes for the dvSP-ISR and 220 (201–270) minutes for the dvSP-RC/TC. Estimated blood loss was insignificant. No intraoperative complications or conversions to multiport/open surgery was reported. Median post-operative stay was 7.0 (6.0–10.0) days for the dvSP-ISR and 5.0 (4.0–6.7) days for the dvSP-RC/TC. Quality of mesorectum was complete for six patients, and nearly complete for one. Median number of retrieved lymph nodes were 21 (17–25) for the dvSP-ISR and 28 (24–49) for the dvSP-RC/TC. Proximal and distal resection margins were tumor free. Four patients experienced post-operative complications not related to the platform which were: ileus, voiding dysfunction, infected pelvic hematoma, and wound infection. Median follow-up was 9 (6–11) months and 11 (7–17) months for the dvSP-ISR and dvSP-RC/TC, respectively. Two patients had systemic recurrence; all others were tumor free. Conclusions: The dvSP platform is safe and feasible for intersphincteric resection with right lower quadrant access, and right/transverse colectomy with suprapubic access. Further studies are needed to evaluate benefit differences compared to multiport robotic platform. [ABSTRACT FROM AUTHOR]

Background: Intersphincteric resection (ISR) has been proposed to offer sphincter-sparing solution for patients with ultra-low rectal cancer. However, complete and accurate concepts about the intersphincteric space (ISS) related anatomy are not demonstrated clearly. This study aimed to provide a comprehensive description about the anatomic structure of ISS related to ISR. Methods: This was a descriptive morphological study. 28 pelvic specimens were obtained from body donors. Macroscopic and microscopic observation of ISS was performed via gross anatomy, plastinated sections and histologic staining. The anatomical parameters of the anal canal were measured. Images of laparoscopic ISS dissection procedures were real-timely captured during ISR. Results: The hiatal ligament, microvessels on supra fascia of LAM and rectal longitudinal muscle at the level of anorectal ring, especially at 1, 5, 7, and 11o'clock, could be the preferred entrance of ISS. The conjoint longitudinal muscle (CLM), the major component of ISS, was the continuum of the rectal longitudinal muscle and got reinforcement from the elastic fibers from LAM and EAS. Microvessels and neuro tissues were also found in ISS. The ISS was split into two spaces by the CLM in the middle and might subjectively be divided into three segments according to its different compositions. The length and width of ISS varied from different segments and directions. Conclusions: We provided a systemic description of boundaries, contents and topographic structure of ISS, which may help proper determination of surgical approaches and dissection planes during ISR. [ABSTRACT FROM AUTHOR]

Background: The operative results of different approaches for the laparoscopic intersphincteric resection (LAISR) of low rectal cancer vary, and the patient characteristics associated with the best outcomes for each procedure have not been reported. We compared the efficacy of different approaches for LAISR of low rectal cancer and discussed the surgical indications for each approach. Methods: We retrospectively reviewed data from 235 patients with low rectal cancer treated via LAISR from October 2010 to September 2016. Patients underwent either the transabdominal approach for ISR (TAISR, n = 142), the transabdominal perineal approach for ISR (TPAISR, n = 57), or the transanal pull-through approach for ISR (PAISR, n = 36). Results: The PAISR and TAISR groups exhibited shorter operation times and less intraoperative blood loss than the TPAISR group. The anastomotic distance was shorter in the PAISR and TPAISR groups than in the TAISR group. No differences in the ability to perform radical resection, overall complications, postoperative recovery, Wexner score recorded 12 months after ostomy closure, 3-year disease-free survival, local recurrence-free survival, distant metastasis-free survival, or overall survival (OS) were observed among the three groups. Conclusions: TAISR, TPAISR, and PAISR have unique advantages and do not differ in terms of operation safety, patient outcomes, or anal function. TPAISR requires a longer time to complete and is associated with more bleeding and a slower recovery of anal function. PAISR should be considered when TAISR cannot ensure a negative distal margin and the tumor and BMI are relatively small; otherwise, TPAISR is required. [ABSTRACT FROM AUTHOR]

Successful resection of intra‐abdominal tumors using indocyanine green (ICG) fluorescence imaging has not been reported. Here, we report a rare case of an intra‐abdominal desmoid‐type fibromatosis successfully resected using this technique after intersphincteric resection (ISR) for rectal cancer. One year after ISR for rectal cancer in a 47‐year‐old man, computed tomography showed a 50‐mm intra‐abdominal tumor near the left common iliac vein. Surgical resection was performed. The tumor was located in the mesentery of the remnant rectum after ISR. ICG fluorescence imaging confirmed the blood supply to the mesentery of the distal remnant rectum after tumor excision. The anal canal was successfully preserved without creating a permanent colostomy. The tumor was safely resected with resection margins, diagnosed as desmoid‐type fibromatosis. No tumor recurrence was observed 6 months post‐resection. This was the first case report to demonstrate the utility of this technique for an intra‐abdominal tumor resection. [ABSTRACT FROM AUTHOR]

Intersphincteric resection (ISR) for low rectal cancer is a relatively novel anal-sparing technique that requires a thorough knowledge of the anatomy of the deep pelvic space and advanced surgical skills. The development of laparoscopic intersphincteric resection, through magnification of the surgical field, has renewed the interest in the anatomical description of the anal canal and deep pelvis, which has been historically fraught with inconsistencies. Introduction of the robotic platform has made the deep pelvis technically accessible to a greater number of colorectal surgeons. The literature describes ISR as an oncologically safe technique with good functional outcomes; however, there is often confusion regarding its definition, indications and technical aspects of this challenging procedure. This review aims to evaluate the current state of robotic ISR through the discussion of novel detailed anatomical descriptions, surgical techniques and indications, together with oncological and functional results.

This study explored postoperative outcomes for patients with lower rectal cancer who underwent low anterior resection (LAR) or intersphincteric resection (ISR). A total of 49 patients (33 LAR, 16 ISR) were followed using anorectal manometry and quality of life (QOL) questionnaires over a year, pre- and post surgery. The primary aim of this study is to clarify differences in anal manometry, sphincter function, fecal incontinence, and QOL between the two surgical arms. The secondary aim was to identify indicators suitable for assessing relationships between anorectal manometry measurements, fecal incontinence, and QOL. Anorectal manometry elements (AMEs), such as atmospheric maximum mean squeeze pressure (aMSP), maximum tolerable volume (MTV), and incremental maximum mean squeeze pressure (iMSP), showed no significant differences during the observation period. However, maximum resting pressure (MRP), high-pressure zone length (HPZ), and threshold volume (TV) were significantly worse in the ISR group. Fecal incontinence, measured by Wexner and Kirwan scores, was significantly better in the LAR group. We observed no differences in SF36 between the two groups. Multi-correlation analysis revealed positive and negative correlations among these factors, with inverse correlations between anorectal manometry measurements and incontinence assessments decreasing post-surgery. We found no correlation between SF36 and anorectal manometry at any time. The findings indicate that surgical technique affects postoperative anal function, fecal incontinence, and SF36. However, combined assessment methods should be used with caution when deriving relationships between anal function and SF36.

Background: Low anterior, ultralow anterior, and intersphincteric resection are conventional, elective anus-sparing techniques for low rectal cancer, and good prognosis depends on a good blood supply and tension-free anastomosis.Aim: The goal is to assess the effect of preserving the arc formed by the left colic and proximal inferior mesenteric arteries (IMAs), and first branch of the sigmoid arteries on the anastomotic blood supply, tension, and leakage rate in anus-sparing surgery for low rectal cancer.Method: From 2011 to 2020, a patient with low rectal cancer resection was distributed into the ligation group (42 cases with inferior mesenteric artery ligation) and the preservation group (61 cases with preservation of the left colic and proximal IMAs and first branch of the sigmoid artery).Results: We evaluated patient characteristics, operative results, morbidity, and postoperative follow-up results. There were comparable outcomes between ligation and preservation groups in relations to the number of patients in each operative procedure, duration of surgery, operative blood loss, postoperative hospital stay, and the number of patients with protective stoma (P >.05). In postoperative morbidity, there were similar outcomes between ligation and preservation groups in terms of anastomotic subclinical dehiscence, bleeding and stricture, and urinary retention (P >.05). There were significant differences in anastomotic leakage and intra-abdominal abscess (P < .05).Conclusion: Preservation of the arterial arc formed by left colic artery, proximal IMA, and the first branch of sigmoid arteries with apical lymph node dissection could increase anastomotic blood supply, reduce anastomotic tension, and leakage rate in anus-saving treatment of low rectal cancer. [ABSTRACT FROM AUTHOR]

Background and Aims: The intersphincteric resection (ISR) is beneficial for saving patients' anus to a large extent and restoring original bowel continuity. Laparoscopic ISR (L-ISR) has its drawbacks, such as two-dimensional images, low motion flexibility, and unstable lens. Recently, da Vinci robotic ISR (R-ISR) is increasingly used worldwide. The purpose of this article is to compare the feasibility, safety, oncological outcomes, and clinical efficacy of R-ISR vs. L-ISR for low rectal cancer.Methods: PubMed, EMBASE, Cochrane Library, and Web of Science were searched to identify comparative studies of R-ISR vs. L-ISR. Demographic, clinical, and outcome data were extracted. Mean difference (MD) and risk ratio (RR) with their corresponding confidence intervals (CIs) were calculated.Results: Five studies were included. In total, 510 patients were included, of whom 273 underwent R-ISR and 237 L-ISR. Compared with L-ISR, R-ISR has significantly lower estimated intraoperative blood loss (MD = −23.31, 95% CI [−41.98, −4.64], P = 0.01), longer operative time (MD = 51.77, 95% CI [25.68, 77.86], P = 0.0001), hospitalization days (MD = −1.52, 95% CI [−2.10, 0.94], P < 0.00001), and postoperative urinary complications (RR = 0.36, 95% CI [0.16, 0.82], P = 0.02).Conclusions: The potential benefits of R-ISR are considered as a safe and feasible alternative choice for the treatment of low rectal tumors.

Purpose: The objective of this study was to explore the risk factors for anorectal dysfunction after intersphincteric resection in patients with low rectal cancer.Methods: A total of 251 patients who underwent intersphincteric resection from July 2014 to June 2020 were included in this study, for which the Kirwan's grade, Wexner score, and anorectal manometric index were used to evaluate the anorectal function and other parameters including demographics, surgical features, and clinical and pathological characteristics. These parameters were analysed to explore the potential risk factors for anorectal function after intersphincteric resection.Results: In the 251 included patients, 98 patients underwent partial intersphincteric resection, 87 patients underwent subtotal intersphincteric resection, and 66 patients underwent total intersphincteric resection. There were 53 (21.1%) patients who had postoperative complications, while no significant difference was observed between the three groups. Furthermore, 30 patients (45.5%) in the total intersphincteric resection group were classified as having anorectal dysfunction (Kirwan's grade 3–5), which was significantly higher than that in the partial intersphincteric resection group (27.6%) and subtotal intersphincteric resection group (29.9%). The mean Wexner score of patients that underwent total intersphincteric resection was 7.9, which was higher than that of patients that had partial intersphincteric resection (5.9, p = 0.002) and subtotal intersphincteric resection (6.4, p = 0.027). The initial perceived volume was lower in the total intersphincteric resection group than in the partial and subtotal intersphincteric resection groups at 1, 3, and 6 months after intersphincteric resection. In addition, the resting pressure, maximum squeeze pressure, and maximum tolerated volume in the total intersphincteric resection group were worse than those in the partial and subtotal groups at 3 and 6 months after intersphincteric resection. Univariate and multivariate analyses suggested that an age ≥65, total intersphincteric resection, and preoperative chemoradiotherapy were independent risk factors for anorectal dysfunction (P = 0.023, P = 0.003, and P = 0.008, respectively). Among the 66 patients who underwent total intersphincteric resection, 17 patients received preoperative chemoradiotherapy, of which 12 patients (70.6%) were classified as having anorectal dysfunction.Conclusion: The current study concluded that age ≥65, total intersphincteric resection, and preoperative chemoradiotherapy were risk factors for anorectal dysfunction after intersphincteric resection. The morbidity of anorectal dysfunction after total intersphincteric resection for patients who received preoperative chemoradiotherapy was relatively high, and the indication should be carefully evaluated.