Extending the horizons of restorative rectal surgery: intersphincteric resection for low rectal cancer

Radical resection of tumours of the distal rectum has generally entailed an abdominoperineal excision, but the recognition of shorter safe distal resection margins, neoadjuvant chemoradiotherapy and the application of the technique of intersphincteric resection (ISR) have led to the prospect of restorative surgery for patients with distally situated tumours. The present study examines the indications, techniques and outcomes following ISR.

A literature search was performed to identify studies reporting outcomes following ISR for low rectal cancer. The outcomes of interest included short-term adverse events, functional and manometric results, postoperative quality of life and oncologic outcomes.

Twenty-one studies reflecting the experience of 13 units and 612 patients were included. Operative mortality following ISR was 1.6% (inter-unit range 0-5%) and anastomotic leak rate 10.5% (inter-unit range 0-48.4%). The pooled rate of local recurrence was 9.5% (range 0-31% between units) with an average 5-year survival of 81.5%. Most studies recorded a significant reduction in resting anal pressure but not squeeze pressure following surgery, but urgency was reported in up to 58.8% of patients. Functional outcomes and quality of life may be improved using colonic j-pouch reconstruction. The use of chemoradiotherapy can offer benefits in terms of oncologic result, but at the cost of worse functional outcomes.

Careful case selection and counselling is required if satisfactory results are to be achieved following ISR for low rectal cancers. In selected patients, however, the technique offers sphincter preserving surgery with acceptable oncologic and functional results.