Collard Maxime, Lefevre Jérémie H
Sorbonne Université, Department of Digestive Surgery, AP-HP, Hôpital Saint Antoine, Paris, France.
Front Oncol. 2020 Mar 5;10:297. doi: 10.3389/fonc.2020.00297. eCollection 2020.
The proximity of the very low rectum rectal cancer to the anal sphincter raises a specific problem: how and until when can we preserve the anal continence without compromising the oncological result of the tumor resection? In this situation, intersphincteric resection (ISR) offers an excellent alternative to abdominoperineal resection (APR), but the selection of patients for this option must be extremely precise. This complex choice justifies the simultaneous consideration of an oncological approach with a functional approach in order to provide a full benefit to the patient. When a circumferential resection margin of at least 1 mm can be performed with a distal resection margin of at least 1 cm with or without preoperative radiotherapy, ISR ensures a safety choice. The oncological results of ISR reported in the literature when performed properly found a 5-year disease-free survival of 80.2% with a local recurrence rate of only 5.8%. In parallel to this oncological evaluation, the expected post-operative functional outcome and the resulting quality of life must be properly assessed pre-operatively, since partial or total resection of the internal sphincter impacts significantly on the functional outcome. Based on data from the literature, this work reports the essential anatomical considerations and then the oncological and functional elements indispensables when an anal continence preservation is evoked for a tumor of the very low rectum. Finally, the precise selection criteria and the major surgical principles are outlined in order to guarantee the safety of this modern choice for the patient.
极低位直肠癌距肛门括约肌很近，这引发了一个特殊问题：在不影响肿瘤切除的肿瘤学效果的前提下，我们如何以及能在何时保留肛门节制功能？在这种情况下，括约肌间切除术（ISR）为腹会阴联合切除术（APR）提供了一个极佳的替代方案，但必须极其精确地选择适合该方案的患者。这种复杂的选择使得在考虑肿瘤学方法的同时还要兼顾功能学方法，以便为患者带来最大益处。当在有或无术前放疗的情况下，能实现至少1毫米的环周切缘和至少1厘米的远端切缘时，ISR可确保是一种安全的选择。文献报道，正确实施ISR的肿瘤学结果显示，5年无病生存率为80.2%，局部复发率仅为5.8%。在进行这种肿瘤学评估的同时，术前必须正确评估预期的术后功能结果以及由此产生的生活质量，因为部分或全部切除内括约肌会对功能结果产生重大影响。基于文献数据，本研究报告了重要的解剖学考量因素，以及在考虑为极低位直肠癌保留肛门节制功能时必不可少的肿瘤学和功能学要素。最后，概述了精确的选择标准和主要手术原则，以确保这种现代选择对患者的安全性。
