[Evolution of surgery for cancer of the anorectal junction].

Certain aspects of the epidemiology, classification and therapy of adenocarcinoma of the anorectal junction (< 5 cm from the anal verge) are not well standardised to date. To evaluate the recent advances in the surgical management we reviewed our database, focusing on the oncological and functional results of intersphincteric resection. From 1989 to 2005 we treated 183 adenocarcinomas of the anorectal junction with a curative intent by 106 total proctetomies (84 of which by intersphinteric resection), 54 abdominoperineal resections, 22 transanal local excision and 1 Hartmann procedure. Intersphincteric resections were performed in 51 males and 33 females, mean age 62, with the following clinical stages: 28 stage 1, 55 stages II and III, 1 stage IV; radiotherapy was administered preoperatively to 27 patients and postoperatively to 18. Fifty-five intersphinteric resections were performed by open surgery and 29 by laparoscopy (since 2001). All the procedures were R0 except for 2 R1 (readily converted to abdominoperineal resections). Perioperative mortality (30 days) was 1.1% and the overall morbidity was 27.7% (including a 6% leakage rate). Assessment of anal sphincter function recovery one year after restoration of bowel continuity showed good continence in 76% of the patients; 2 patients have a permanent ostomy. After an average 60-month follow-up (min. 30 months) the local recurrence rate was 2.4% and the actuarial 5-year survival rate 81.7%. Our experience shows a drop in abdominoperineal resections in the last 5 years from 56.5% to 17.8%, while the intersphincteric resection rate has increased from 32.6% to 66%. The oncological results of intersphincteric resection compare favourably with those of abdominoperineal resection and functional recovery appears satisfactory.