Intersphincteric resection with partial removal of external anal sphincter for low rectal cancer.

Abdominoperineal resection (APR) remains the standard procedure for rectal cancer located within 0.5 cm from dentate line (DL). In this study, we present a new type of restorative surgery: intersphincteric resection with partial removal of external anal sphincter (EAS) and anorectal reconstruction for-ultra low rectal cancer. Between March 2003 and May 2008 fifty patients (28 males, aged between 39 and 71) were operated on for ultra low rectal cancer uT2-3N0M0 with partial preservation of EAS and total anorectal reconstruction (smooth-muscle neosphincter and colonic pouch). A protective stoma was performed in all cases. Functional outcome and quality of life were recorded at 3, 6, 12, 18, 24 months after stoma closure using Wexner score and FIQL respectively. Anal manometry, vectrum volumetry and myography data were taken as well. Results. Postoperative complications developed in 2 patients, but no secondary surgery was required. Carcinomas were staged as pT2 (n = 14) and pT3 (n = 36). The distal clearance was 2.00.4 (range 1.5-2.8) cm, lateral clearance was 0.80.3 (range 0.2-1.4) cm. After a median follow-up of 24 (range 2-61) months, 2 local recurrences were occurred and salvaged by APR. Contractive activity of saved elements of EAS improved with a course of time and squeezing anal pressure increased as well. Perfect functional outcome was achieved in 25 of 34 patients at 12 months after stoma closure, and all the patients were satisfied with procedure. Good functional results of suggested surgery seems to be an acceptable alternative to APR with permanent stoma in selected patients.

Gasless transanal endoscopic surgery for rectal adenomas and early carcinomas.

Transansal endoscopic microsurgery (TEM) allows the excision of rectal tumors but is difficult and complex. A new TEM modification simplifying the procedure and reducing its cost is required. Between 1999 and 2004, 128 patients (78 women and 50 men) underwent gasless transanal endoscopic surgery (GTES) without use of a completely closed system by means of laparoscopic equipment. Histological examination revealed 112 adenomas, including 15 with neoplastic changes (6 cases of Tis and 9 cases of T1G1G2), 12 adenocarcinomas (1 case of Tis, 8 cases of T1G1G2, and 1 case of T2G1G2) and 3 carcinoid tumors. There was no operative mortality. One patient had postoperative bleeding. Adenomas recurred in 9 patients (8.3%). The adenocarcinomas demonstrated neither local recurrences nor distal spread. GTES may be considered a safe and effective minimally invasive treatment for patients with large adenomas and early carcinomas of the rectum.

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.

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.