TY - JOUR
AU - Rybakov, E G
AB - Abstract Background Intersphincteric resection can provide tumour-free margins for rectal tumours located 0–1 cm above the dentate line. However, the internal anal sphincter (IAS) is partially or totally resected and some degree of anal incontinence may develop. A novel technique of smooth muscle plasty of the IAS and colonic pouch construction is described, along with an assessment of morbidity, oncological results and functional outcome. Patients and methods Between 1997 and 2002, 27 patients (16 men; median age 55 (range 26–75) years) were operated on for T2–3 N0–1 M0 rectal carcinoma located a median of 1·0 (range 0·5–1·5) cm from the dentate line. Resection of the IAS was performed transanally. A smooth muscle cuff, fashioned from the muscular layer of colon, and a colonic pouch were used for anorectal reconstruction. Results There were no perioperative deaths. Anastomotic leakage developed in two patients. After a median follow-up of 38 (range 14–66) months no local recurrence was detected. Distant metastases occurred in three patients, two of whom died. Perfect functional outcome was achieved in 22 of 26 patients. At 6 months after surgery the mean(s.d.) resting anal pressure was 49(8) mmHg. Conclusion In selected patients intersphincteric resection does not compromise the oncological result. The suggested anorectal reconstruction may improve the functional outcome. Introduction Although sphincter-saving procedures are widely used in rectal cancer surgery, abdominoperineal resection (APR) remains the treatment of choice for rectal carcinoma located 1–2 cm above the dentate line. Low anterior resection for tumours at the anorectal junction is associated with the risk of ‘close-shave’ distal margins, because it is difficult to obtain both 2 cm distal tumour clearance1 and anal sphincter conservation. In selected patients distal clearance can be achieved by intersphincteric resection2–4, in which the plane of resection passes between the external and internal (IAS) anal sphincters (Fig. 1). With this approach the IAS is partially or totally resected, and some degree of anal incontinence and soiling occurs in up to 50 per cent of patients2,5,6. In addition, the loss of rectal capacity leads to frequent defaecation and urgency. Fig. 1 Open in new tabDownload slide a Anatomic specimen showing anal canal and lower rectum. The metal probe passed between the internal and the external anal sphincters. b The slide obtained from the same specimen (haematoxylin-eosin). c Scheme illustrating the anatomic structures seen on the slide. The blue line is the intersphincteric plane of suggested resection Use of a colonic pouch7,8 reduces the undesirable consequences of ‘low anterior resection syndrome’. On the other hand, loss of function of the IAS, which is responsible for involuntary continence, probably remains an underestimated problem. Smooth muscle plasty, as proposed Schmidt9,10 and modified by others11–14, has been developed as a treatment option for anal incontinence and used to create a neosphincter after APR. This paper reports the results of anorectal reconstruction after intersphincteric resection with total resection of the IAS. The reconstruction incorporated a colonic pouch, and smooth muscle cuff as a substitute for the IAS. The aims of the study were to assess the morbidity of intersphincteric resection with substitution of the IAS, and to evaluate the oncological and functional results. Patients and methods Between 1997 and 2002, 27 patients (16 men; median age 55 (range 26–75) years) underwent intersphincteric resection with total resection of the IAS and subsequent anorectal reconstruction for well or moderately differentiated carcinoma of the low rectum. According to the Union Internacional Contra la Cancrum tumour node metastasis (TNM) classification (5th edition, 1997), there were eight uT2 N0 M0 and 19 uT3 N0 M0 carcinomas located between 0·5 and 1·5 (median 1·0) cm from the dentate line. The institutional board ethics committee approved the study protocol and informed consent was obtained from all patients. Patients were informed about total IAS resection and the possibility of poor anal function after surgery. Preoperative tumour staging was carried out by endorectal ultrasonography (EUS). EUS was performed using a rigid 7·5-MHz transrectal electronic linear probe (UST-657; Aloka, Tokyo, Japan) connected to an echo camera (SSD-630; Aloka). Only patients with no infiltration of the external anal sphincter and/or puborectalis muscle and no positive (hypoechoic) perirectal lymph nodes were selected for surgery. All patients were in good general health and were fully continent before operation. Liver ultrasonography and chest radiography demonstrated no evidence of distant metastasis at time of diagnosis. Two patients (uT3 N0 M0) had neoadjuvant radiotherapy (40 Gy). Operative technique The patient was placed in the lithotomy position and the operation was conducted through a midline incision. Total mobilization of the sigmoid and descending colon was accomplished with mobilization of the splenic flexure if necessary. The inferior mesenteric artery was ligated at its origin from the aorta and the inferior mesenteric vein was divided just beneath the pancreas. The sigmoid was divided with a linear stapling device 15 cm proximal to the proximal palpable border of the rectal tumour. A smooth muscle neosphincter was formed as described by Fedorov et al.13 (Fig. 2). Approximately 3–4 cm of distal colon was freed from the pericolic fat. The seromuscular layer was sharply dissected from the mucosa and the resulting smooth muscle sleeve was incised spirally to create a pedunculated muscular flap 1–1·5 cm wide and 5–7 cm long. The flap was then turned around the bowel and fixed to its wall turn-by-turn by means of interrupted absorbable 3/0 Vicryl® (Ethicon, Edinburgh, UK) sutures. Thus a cone-shaped smooth muscle cuff 3–4 cm long was formed at the terminal part of the colon. The C-shaped or lateral pouch15 technique was used to create a colonic pouch (Fig. 2). Both handsewn and stapling techniques were used. A loop of colon (5–6 cm) was formed into a C shape. A stapling device was introduced through a colotomy at the top of the pouch. After creation of the pouch the colotomy opening was closed by means of a purse-string suture (3/0 Vicryl®). The integrity of the colonic pouch was checked by insufflation of saline through the open end of the bowel. Fig. 2 Open in new tabDownload slide Phases of smooth muscle cuff and colonic pouch creation The rectal dissection always included total mesorectal excision. Intersphincteric resection was conducted transanally. For prevention of bleeding adrenaline solution (1 : 100 000) was injected into the anal canal. A circular incision of anal canal was made at the distal end of the IAS, at the intersphincteric groove. Mobilization proceeded in the intersphincteric plane, that is between the IAS and the external anal sphincter (Figs 1 and 3). After 1–1·5 cm of anal mucosa and IAS had been mobilized, the rectal lumen was closed by means of a purse-string suture applied at the edge of the resected anal mucosa. The anus was thoroughly washed out with povidone–iodine (Betadine®; EGIS, Budapest, Hungary) to avoid tumour cell implantation. Mobilization along the intersphincteric plane was continued until the pelvic dissection was reached and the resected rectum was removed. The colon with its smooth muscle cuff was placed into the bed of the excised IAS and an anastomosis created between the anal verge and the bowel wall with absorbable interrupted 3/0 Vicryl® sutures (Fig. 3). The faecal stream was diverted in all cases by means of an ileostomy. Contrast enema examination of pouch and anastomosis was performed between 4 and 6 weeks after intersphincteric resection (Fig. 4) and, if integrity was confirmed, the ileostomy was closed. Fig. 3 Open in new tabDownload slide Scheme for intersphincteric resection and anorectal reconstruction Fig. 4 Open in new tabDownload slide Contrast enema examination 3 months after intersphincteric resection and anorectal reconstruction Follow-up Postoperative chemotherapy was administered to one patient in whom histopathological examination of the resected specimen upstaged the disease from uT3 N0 M0 to pT3 N1 M0. Clinical follow-up was performed at 3-month intervals for first 2 years and then twice each year. Liver and rectal ultrasonography, and chest radiography were performed at 6-month intervals to detect any recurrence. Postoperative bowel function was assessed at 3, 6 and 12 months after ileostomy closure. Data on frequency of bowel movements over 24 h, fragmentation (multiple defaecations in a short time), continence (Kirwan scale), stool and flatus discrimination, urgency (the ability to defer defaecation for 15 min), use of laxatives or antidiarrhoeal medication, and diet were obtained from responses to a questionnaire. Physiological assessment included measurement of mean resting and squeeze anal pressures, threshold volume and maximum tolerated volume. Manometry was undertaken at the same intervals as the interviews. A six-channel water-perfused flexible catheter, 5·5 mm in external diameter (Zinetics 9012 P2461; Medtronic Synectics®, Stockholm, Sweden), was used as a pressure probe. Anal sphincter manometry and measurement of neorectal volume was performed with the patient in the left lateral position by means of a Puller Synectics URO (Medtronic Synectics) at a speed of 5 mm/min, and recording on a polygraph (PC Polygraph HR; Medtronic Synectics). Statistical analysis was performed by means of SPSS® 10.0 for Windows® (SPSS, Chicago, Illinois, USA). Results There was no postoperative death, pelvic abscess or wound infection. Temporary urinary retention developed in two patients. The median postoperative hospital stay was 14 (range 12–16) days. Two patients had asymptomatic anastomotic leakage revealed by contrast enema at 1 month after operation. The leaks resolved spontaneously and the ileostomy in these two patients was closed at 13 and 16 weeks after the initial surgery. Lateral and distal tumour-free margins of resection were confirmed by histopathological examination. No tumour with intramural distal spread was found. The median distance from the lowest border of the tumour to the distal margin of resection measured on the unfixed specimen was 1·9 (range 1·5–2·6) cm and the median distance from the point of deepest tumour penetration into the bowel wall to the radial margin of resection was 0·8 (range 0·6–1·5) cm. No patient was lost from medical observation and the median follow-up was 38 (range 14–66) months. No local recurrence was detected. Distant metastases (pulmonary in two patients and hepatic in one) were detected at 10, 18 and 30 months after operation. Two patients had resection of a solitary hepatic and lung metastasis (left hepatectomy and resection of the middle lobe of right lung respectively) followed by chemotherapy. Both patients died within 6 months of resection from disease progression with no evidence of local recurrence. The third patient had multiple pulmonary metastases and received chemotherapy, and at the time of writing has local control and stable distant disease. Functional outcome Functional results and manometric assessment were available for all but one patient, who died from cancer progression and for whom functional results at 12 months after surgery are missing (Table 1). At 3 months after surgery two-thirds of patients had two or fewer bowel movements per day. Only one patient suffered from frequent defaecation. The same patient and four others experienced fragmentation of stools. The frequency of bowel movements decreased with time and this was correlated strongly with an increase in threshold and maximum tolerated volumes. One year after ileostomy closure only one patient defaecated more than five times daily. This patient suffered severe low anterior resection syndrome, fragmentation and frequent major soiling. He was offered a defunctioning stoma, but refused further treatment. Table 1 Functional outcome and physiological findings after intersphincteric resection with total resection of the internal anal sphincter and anorectal reconstruction . Time after surgery (months) . . 3 (n = 27) . 6 (n = 27) . 12 (n = 26) . Daily stool frequency  < 2  18  20  22  3–4   8   6   3  > 5   1   1   1 Fragmentation   5   5   6 Urgency (< 15 min)   4   3   1 Flatus and faeces discrimination   6   5   3 Use of medication and diet   4   1   1 Continence  Perfect  19  22  22  Incontinence to flatus   4   3   2  Occasional minor soiling   3   1   1  Frequent major soiling   1   1   1  Incontinent   0   0   0 Physiological findings*  Resting anal pressure (mmHg)  39(9)  49(8)  54(4)  Squeeze anal pressure (mmHg) 117(42) 124(31) 143(28)  Threshold volume (ml)  38(7)  46(6)  56(4)  Maximum tolerated volume (ml) 170(56) 180(44) 210(26) . Time after surgery (months) . . 3 (n = 27) . 6 (n = 27) . 12 (n = 26) . Daily stool frequency  < 2  18  20  22  3–4   8   6   3  > 5   1   1   1 Fragmentation   5   5   6 Urgency (< 15 min)   4   3   1 Flatus and faeces discrimination   6   5   3 Use of medication and diet   4   1   1 Continence  Perfect  19  22  22  Incontinence to flatus   4   3   2  Occasional minor soiling   3   1   1  Frequent major soiling   1   1   1  Incontinent   0   0   0 Physiological findings*  Resting anal pressure (mmHg)  39(9)  49(8)  54(4)  Squeeze anal pressure (mmHg) 117(42) 124(31) 143(28)  Threshold volume (ml)  38(7)  46(6)  56(4)  Maximum tolerated volume (ml) 170(56) 180(44) 210(26) * Values are mean(s.d.). Open in new tab Table 1 Functional outcome and physiological findings after intersphincteric resection with total resection of the internal anal sphincter and anorectal reconstruction . Time after surgery (months) . . 3 (n = 27) . 6 (n = 27) . 12 (n = 26) . Daily stool frequency  < 2  18  20  22  3–4   8   6   3  > 5   1   1   1 Fragmentation   5   5   6 Urgency (< 15 min)   4   3   1 Flatus and faeces discrimination   6   5   3 Use of medication and diet   4   1   1 Continence  Perfect  19  22  22  Incontinence to flatus   4   3   2  Occasional minor soiling   3   1   1  Frequent major soiling   1   1   1  Incontinent   0   0   0 Physiological findings*  Resting anal pressure (mmHg)  39(9)  49(8)  54(4)  Squeeze anal pressure (mmHg) 117(42) 124(31) 143(28)  Threshold volume (ml)  38(7)  46(6)  56(4)  Maximum tolerated volume (ml) 170(56) 180(44) 210(26) . Time after surgery (months) . . 3 (n = 27) . 6 (n = 27) . 12 (n = 26) . Daily stool frequency  < 2  18  20  22  3–4   8   6   3  > 5   1   1   1 Fragmentation   5   5   6 Urgency (< 15 min)   4   3   1 Flatus and faeces discrimination   6   5   3 Use of medication and diet   4   1   1 Continence  Perfect  19  22  22  Incontinence to flatus   4   3   2  Occasional minor soiling   3   1   1  Frequent major soiling   1   1   1  Incontinent   0   0   0 Physiological findings*  Resting anal pressure (mmHg)  39(9)  49(8)  54(4)  Squeeze anal pressure (mmHg) 117(42) 124(31) 143(28)  Threshold volume (ml)  38(7)  46(6)  56(4)  Maximum tolerated volume (ml) 170(56) 180(44) 210(26) * Values are mean(s.d.). Open in new tab According to the Kirwan scale, more than two-thirds of patients had perfect continence by 3 months after surgery. Excluding the patient with a poor overall result, 1 year after ileostomy closure only three of 25 patients were incontinent to gas or had occasional (once or twice weekly) minor soiling. At 3 months after surgery four patients were unable to defer defaecation for more than 15 min, but by 1 year only one patient suffered from urgency. Fragmentation developed in six patients by 1 year. They had a sense of incomplete evacuation and needed two or three attempts to attain complete evacuation, but only one used enemas and required a special diet. Loss of ability to discriminate between stool and flatus was a problem for six patients at 3 months after surgery and persisted at 1 year in three. This was probably associated with extended resection of the anal mucosa, particularly the transitional zone. Further observation showed that these patients permanently lost sensitivity and the ability to discriminate the components of bowel discharge. These patients regularly used pads but, nevertheless, were satisfied with the results of surgery. The mean anal canal resting pressure was 39 mmHg at 3 months and increased by 1 year after operation. Similar increases were seen in the threshold and maximum tolerated volumes of ‘neorectal’ distension. The rectoanal inhibitory reflex or, more correctly, relaxation of the ‘neo-IAS’ due to ‘neorectal’ distension was not detected in any patient. Discussion Rectal carcinoma located at the anorectal junction poses a dilemma for the colorectal surgeon. The proximity of the tumour to the anal sphincters makes preservation difficult from an oncological point of view. Although local excision may be used for non-invasive carcinomas, APR is the surgery of choice for more advanced low rectal tumours. Neoadjuvant treatment, either radiotherapy alone or combined with chemotherapy, increases the chances of sphincter-saving surgery owing to tumour shrinkage and downstaging. On the other hand, radiotherapy may impair functional outcome after sphincter-saving surgery16. The concept of intersphincteric resection is based on anatomoembryological differences between the rectum, the proximal and distal parts of anal canal, and the pelvic floor17,18. Published results of intersphincteric resection3–5 have demonstrated acceptable local control and survival in selected patients. Rullier et al.2 reported perfect local control and a 5-year survival rate of 75 per cent after intersphincteric resection for T2–T3 rectal carcinomas located between 2·5 and 4·5 cm from the anal verge. The selection criteria are of great importance. In the present study, only patients with well and moderately differentiated carcinomas and no evidence of tumour infiltration to the puborectalis muscle or the external anal sphincter were recommended for intersphincteric resection. Histopathological investigation confirmed that the intersphincteric approach enabled adequate distal and radial margins of resection to be achieved in these selected patients. The postoperative mortality rate was lower than that reported previously after intersphincteric resection2–4. Although anastomotic leakage occurred in two patients, no additional surgery was required and the ileostomy was reversed in all patients. The most controversial aspect of intersphincteric resection is functional outcome. Between a third and half of patients have been reported to suffer from anal incontinence, soiling, frequent bowel movements and urgency2,4. Colonic pouches mitigate the undesirable consequence of removal of the rectal ampulla7,8 but some impairment of anal continence is inevitable after intersphincteric resection. The role of the IAS in anal continence is uncertain21, but it is well known that tonic contraction of the internal sphincter provides about 70 per cent of the anal canal resting pressure19,20. A decrease in anal resting pressure occurs after coloanal anastomosis21,22; nevertheless, some reports of intersphincteric resection2,3 have suggested that partial or even total resection of the IAS does not seriously impair continence and that patients' quality of life after resection is satisfactory. Obviously there is bias in the selection of candidates for intersphincteric resection in that some patients are not prepared to live with a permanent stoma but will consent to an operation that carries a risk of anal incontinence. The problem of incontinence associated with intraoperative trauma of the IAS has received less attention, but should not be underestimated23. The concept of the IAS smooth muscle plasty came from Schmidt10 and others11,12,14. A smooth muscle cuff overlapped around the distal colon at the site of iliac or perineal colostomy13 was proposed, and early studies confirmed the viability of a free autologous smooth muscle graft and the possibility of creating a high-pressure zone9,13. The present technique for creation of a smooth muscle cuff differs from Schmidt's original free autograft sphincteroplasty9 and the reverse smooth muscle plasty described by Holschneider et al.12. Theoretically, the pedunculated flap technique is safer in terms of the risk of fibrosis and necrosis of the muscle flap, owing to better vascularity of the smooth muscle flap due to its continuity with the neorectal wall. The present study may be criticized because preoperative manometry was not carried out and there was no control group. However, the authors believe that assessment of resting and squeeze anal pressure in patients with rectal carcinoma located at the anorectal junction, and in some cases the upper third of the anal canal, is of little value. Nonetheless all patients included in the study assessed themselves as fully continent before surgery. Postoperative evaluation of resting pressure demonstrated values close to normal and there was a tendency for it to improve with time. The observed functional outcome appeared to be better than that after intersphincteric resection with a straight coloanal anastomosis, even though other authors used subtotal or partial excision of the IAS2–4. However, further investigation is necessary to elucidate the role and function of a ‘neo-IAS’, and controlled studies are necessary to define the advantages of the present operation over more common current surgical procedures. Intersphincteric resection was feasible in selected patients very low rectal malignancy and appeared to meet with current oncological standards. Smooth muscle substitution of the IAS in combination with a colonic pouch produced encouraging functional results, and further trials are warranted to evaluate the potential benefits of this operation. References 1 Williams NS , Dixon MF, Johnston D. Reappraisal of the 5 centimetre rule of distal excision for carcinoma of the rectum: a study of distal intramural spread and of patients' survival . Br J Surg 1983 ; 70 : 150 – 154 . Google Scholar Crossref Search ADS PubMed WorldCat 2 Rullier E , Zerbib F, Laurent C, Bonnel C, Caudry M, Saric J et al. Intersphincteric resection with excision of internal anal sphincter for conservative treatment of very low rectal cancer . Dis Colon Rectum 1999 ; 42 : 1168 – 1175 . Google Scholar Crossref Search ADS PubMed WorldCat 3 Schiessel R , Karner-Hanusch J, Herbst F, Teleky B, Wunderlich M. 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Google Scholar PubMed OpenURL Placeholder Text WorldCat Author notes Presented to the Eighth Biennial Congress of the European Council of Coloproctology, Prague, Czech Republic, April–May 2001 Copyright © 2004 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) Copyright © 2004 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.
TI - Resection of the rectum and total excision of the internal anal sphincter with smooth muscle plasty and colonic pouch for treatment of ultralow rectal carcinoma
JF - British Journal of Surgery
DO - 10.1002/bjs.4330
DA - 2004-10-21
UR - https://www.deepdyve.com/lp/oxford-university-press/resection-of-the-rectum-and-total-excision-of-the-internal-anal-lN12Fq6sd5
SP - 1506
EP - 1512
VL - 91
IS - 11
DP - DeepDyve
ER -