Department of Colorectal Surgery, CHU Bordeaux, Haut-Leveque Hospital, University of Bordeaux, Pessac, France.
Department of Radiotherapy, CHU Bordeaux, Haut-Leveque Hospital, University of Bordeaux, Pessac, France.
Colorectal Dis. 2020 Nov;22(11):1603-1613. doi: 10.1111/codi.15258. Epub 2020 Sep 5.
There are few data evaluating the long-term outcomes of intersphincteric resection (ISR), especially the impact of inclusion of more juxtapositioned and intra-anal tumours on oncological and functional outcomes. We compared the oncological and functional results of patients treated by total mesorectal excision and ISR for low rectal cancer over a 25-year period.
This is a retrospective study from a single institution evaluating results of ISR over three periods: 1990-1998, 1999-2006 and 2007-2014. Patients treated by partial or total ISR, with or without neoadjuvant chemoradiotherapy, for low rectal cancer (≤ 6 cm from the anal verge) were included. We compared postoperative morbidity, quality of surgery and oncological and functional outcomes in the time periods studied.
Of 813 patients operated on for low rectal cancer, 303 had ISR. Tumour stage did not differ; however, the distance of the tumour from the anorectal junction decreased from 1 to 0 cm (P < 0.001) and the distal resection margin shortened from 25 to 10 mm (P < 0.001) from 1990 to 2014. The postoperative morbidity and quality of surgery did not change significantly over time. The 5-year local recurrence (4.3% vs 5.9% vs 3.5%; P = 0.741) and disease-free survival (72% vs 71% vs 75%; P = 0.918) did not differ between the three time periods. Functional results improved during the last period; however, overall 42% of patients experienced major bowel dysfunction.
Pushing the envelope of sphincter-saving resection in ultra-low rectal cancer reaching or invading the anal sphincter did not compromise oncological and functional outcomes. The main limitation of the ISR procedure appears to be functional rather than oncological, suggesting that bowel rehabilitation programmes should be developed.
评估经肛门内括约肌切除术（ISR）长期结果的相关数据很少，特别是纳入更多毗邻和肛内肿瘤对肿瘤学和功能结果的影响。我们比较了 25 年来接受直肠系膜全切除术和 ISR 治疗低位直肠癌患者的肿瘤学和功能结果。
这是一项来自单机构的回顾性研究，评估了 ISR 在三个时期的结果：1990-1998 年、1999-2006 年和 2007-2014 年。纳入接受部分或完全 ISR 治疗、接受或不接受新辅助放化疗的低位直肠癌（距肛门直肠交界处<6cm）患者。我们比较了研究期间术后发病率、手术质量以及肿瘤学和功能结果。
813 例低位直肠癌患者中，303 例行 ISR。肿瘤分期无差异；然而，肿瘤距肛直肠交界处的距离从 1cm 降至 0cm（P<0.001），远端切缘从 25mm 缩短至 10mm（P<0.001）。1990 年至 2014 年期间，术后发病率和手术质量无显著变化。5 年局部复发率（4.3%比 5.9%比 3.5%；P=0.741）和无病生存率（72%比 71%比 75%；P=0.918）在三个时期之间无差异。最后一个时期的功能结果有所改善；然而，总体上有 42%的患者出现严重的肠道功能障碍。
在超低位直肠癌中，不断推进肛门内括约肌保留切除术的极限，达到或侵犯肛门括约肌，并未影响肿瘤学和功能结果。ISR 手术的主要局限性似乎是功能性的，而不是肿瘤学方面的，这表明应该开发肠道康复计划。
