Intersphincteric resection (ISR) is the ultimate sphincter-preserving surgical technique for low rectal cancer. To promote the standardized implementation of ISR, this review discusses the important issues regarding the clinical application of ISR with reference to the latest Chinese expert consensus on ISR. In terms of ISR-related pelvic anatomy of the rectum/anal canal, hiatal ligament is not identical with the anococcygeal ligament. At the level where the rectourethralis muscle continuously extends to the posteroinferior area of the membranous urethra from the rectum, the neurovascular bundle is identified between the posterior edge of rectourethralis muscle and the anterior edge of the longitudinal muscle of the rectum. This knowledge is crucial to detect the anterior dissection plane during ISR at the levator hiatus level. The indication criteria for ISR included: (1) stage I early low rectal cancer; (2) stage II-III low rectal cancer undergoing neoadjuvant treatment, and supra-anal tumors and juxta-anal tumors of stage ycT3NxM0, or intra-anal tumors of stage ycT2NxM0. However, signet ring cell carcinoma, mucinous adenocarcinoma and undifferentiated carcinoma should be contraindicated to ISR. For locally advanced low rectal cancer (especially anteriorly located tumor), neoadjuvant treatment should be carried out in a standardized manner. However, it should be recognized that neoadjuvant chemoradiotherapy was a risk factor for poor anal function after ISR. For surgical approaches for ISR, including transanal, transabdominal, and transanal transabdominal approaches, the choice should be based on oncological safety and functional consequences. While ensuring the negative margin, maximal preservation of rectal walls and anal canal contributs to better postoperative anorectal function. Careful attention must be paid to complications regarding ISR, with special focus on the anastomotic complications. The incidence of low anterior resection syndrome (LARS) was higher than 40%. However, this issue is often neglected by clinicians. Thus, management and rehabilitation strategies for LARS with longer follow-ups were required.
Humans ; Rectal Neoplasms/pathology* ; Postoperative Complications ; Laparoscopy/methods* ; Anal Canal/pathology* ; Anus Neoplasms/pathology* ; Anus Diseases/surgery* ; Low Anterior Resection Syndrome ; Carcinoma, Signet Ring Cell/pathology* ; Treatment Outcome

Objective: To compare the long-term outcomes of intersphincteric (trans-internal and external) sphincter resection (ISR) and abdominoperineal proctocolectomy (APR) for low-grade rectal cancer. Methods: We used a meta-analytic approach to compare these procedures . Published reports comparing ISR and APR for low rectal cancer in Pubmed, Medline, EMBASE and Cochrane, China Knowledge Network (CNKI), China Biomedical Literature Database, and Vipers databases between January 2005 and January 2023 were searched and those meeting the eligibility criteria were selected for extraction of data for analysis. Inclusion criteria were as follows: (1) all reports comparing ISR and APR for low rectal cancer before January 2023; and (2) prospective randomized controlled studies or well-designed cohort studies. Exclusion criteria were as follows: (1) full text not available; (2) duplicate publications, missing primary outcome indicators, and unknown data; and (3) invalid statistical analysis. Results: Sixteen studies with 2498 patients were included in this study. Compared with the APR group, patients in the ISR group were relatively younger (weighted mean difference [WMD]=-1.82, 95%CI=-2.94 to -0.70, P=0.01), had tumors farther from the anal verge (WMD=0.43, 95%CI=0.18 to 0.67, P<0.01), and lower pathological T-stage (T3-4 stage: OR=0.54, 95%CI=0.36 to 0.81, P<0.01). In contrast, there were no statistically significant differences between the two groups in gender (P=0.78), body mass index (P=0.77), or pathological N stage (P=0.09). Compared with the APR group, patients in the ISR group had a lower rate of postoperative complications (OR=0.77, 95%CI=0.60 to 0.99, P=0.04), shorter hospital stay (WMD=-4.30, 95%CI=-7.07 to -1.53, P<0.01), higher 5-year overall survival (HR=0.54, 95%CI=0.33 to 0.88, P=0.01), and higher 5-year disease-free survival (HR=0.65, 95%CI=0.47 to 0.90, P<0.01). Five-year locoregional failure (HR=0.66, 95%CI=0.40 to 1.10, P=0.11) and time to surgery (WMD=-9.71, 95%CI=-41.89 to 22.47, P=0.55) did not differ significantly between the two groups. Conclusion: ISR is a safe and effective alternative to APR for early-stage low-grade rectal cancer.
Humans ; Prospective Studies ; Rectal Neoplasms/pathology* ; Rectum/surgery* ; Proctectomy ; Anal Canal/pathology* ; Treatment Outcome

Objective: In this study, we aimed to investigate the prevalence of low anterior resection syndrome (LARS) in patients who had survived for more than 5 years after sphincter-preserving surgery for rectal cancer and to analyze its relationship with postoperative time. Methods: This was a single-center, retrospective, cross-sectional study. The study cohort comprised patients who had survived for at least 5 years (60 months) after undergoing sphincter- preserving radical resection of pathologically diagnosed rectal adenocarcinoma within 15 cm of the anal verge in the Department of Gastrointestinal Surgery, Peking University People's Hospital from January 2005 to May 2016. Patients who had undergone local resection, had permanent stomas, recurrent intestinal infection, local recurrence, history of previous anorectal surgery, or long- term preoperative defecation disorders were excluded. A LARS questionnaire was administered by telephone interview, points being allocated for incontinence for flatus (0-7 points), incontinence for liquid stools (0-3 points), frequency of bowel movements (0-5 points), clustering of stools (0-11 points), and urgency (0-16 points). The patients were allocated to three groups based on these scores: no LARS (0-20 points), minor LARS (21-29 points), and major LARS (30-42 points). The prevalence of LARS and major LARS in patients who had survived more than 5 years after surgery, correlation between postoperative time and LARS score, and whether postoperative time was a risk factor for major LARS and LARS symptoms were analyzed. Results: The median follow-up time of the 160 patients who completed the telephone interview was 97 (60-193) months; 81 (50.6%) of them had LARS, comprising 34 (21.3%) with minor LARS and 47 (29.4%) with major LARS. Spearman correlation analysis showed no significant correlation between LARS score and postoperative time (correlation coefficient α=-0.016, P=0.832). Multivariate analysis identified anastomotic height (RR=0.850, P=0.022) and radiotherapy (RR=5.760, P<0.001) as independent risk factors for major LARS; whereas the postoperative time was not a significant risk factor (RR=1.003, P=0.598). The postoperative time was also not associated with LARS score rank and frequency of bowel movements, clustering, or urgency (P>0.05). However, the rates of incontinence for flatus (3/31, P=0.003) and incontinence for liquid stools (8/31, P=0.005) were lower in patients who had survived more than 10 years after surgery. Conclusions: Patients with rectal cancer who have survived more than 5 years after sphincter-preserving surgery still have a high prevalence of LARS. We found no evidence of major LARS symptoms resolving over time.
Humans ; Rectal Neoplasms/pathology* ; Cross-Sectional Studies ; Low Anterior Resection Syndrome ; Postoperative Complications/etiology* ; Retrospective Studies ; Flatulence/complications* ; Anal Canal/pathology* ; Diarrhea ; Quality of Life

To investigate the feasibility and therapeutic effect of laparoscopy combined with total intersphincteric resection (Total-ISR) for extremely low rectal cancer.
 Methods: We performed laparoscopy combined with Total-ISR in 45 patients with extremely low rectal cancer (1.0 cm≤the lower edge of tumor to the anal edge≤3.0 cm) from January 2014 to December 2016. The operation time, blood loss, resection margin and overall incidence of postoperative complications were observed. The rate of local recurrence and distant metastasis after surgery during the median following-up time of 20.5 months were observed. Anal function at 3, 6, and 12 months after operation were compared.
 Results: The operation for 45 cases were successful without perioperative death. The operation time was (220±33) min and blood loss was (110±31) mL. The surgical margins were all negative. The incidence of postoperative complication was 6.7% (3/45) and no one suffered anastomotic leakage. After a median follow-up of 20.5 (6-30) months, 2 cases developed local recurrence and 1 case developed distant metastasis. According to Kirwan grade, the grade II was 24.4% (11/45), grade III was 57.8% (26/45) in 3 months after operation, and the grade II increased to 51.1% (23/45), the grade III decreased to 35.5% (16/45) after 6 months. Seven out of 40 patients in 12 months after operation reached the grade I, and 25 patients reached the grade II. There were significant differences between 3 months and 6 months, 6 months and 12 months after operation (P<0.05) in the anal function situation.
 Conclusion: It is feasible, for appropriate patients, to perform laparoscopic combined with total-ISR, especially for the patients with extremely low rectal cancer that were in early stage without invasion to the extemal sphincter. The procedure has the advantages of radical sphincter-saving, minimal invasion and economy.
Anal Canal ; pathology ; surgery ; Humans ; Laparoscopy ; Postoperative Complications ; Rectal Neoplasms ; surgery ; Treatment Outcome

OBJECTIVETo investigate the risk factors of low anterior resection syndrome (LARS) after anal sphincter preserving surgery (SPS) for rectal cancer patients.

METHODSClinicopathological and follow-up data of rectal cancer patients who underwent SPS from January 2010 to June 2014 in Department of Gastroenterological Surgery, Peking University People's Hospital, were retrospectively analyzed. Patients receiving permanent colostomy and local resection were excluded. Meanwhile, during October 2014 and March 2015, the enrolled patients were asked to fill out a specially designed questionnaire for LARS through face-to-face interview or telephone inquiry, according to the chronological order of operation. Based on the score of questionnaire, patients were divided into three groups: 0-20 points: non LARS; 21-29: minor LARS; 30-42: major LARS. The demographic and clinicopathologic features were compared among groups and the risk factors of major LARS were tested by logistic regression analysis.

RESULTSA total of 100 patients (61 males, 39 females) completed the bowel function survey, with an average age of 66.2(41-86) years, 33 patients <60 years versus 67 patients ≥60 years. No significant difference was observed in age distribution (P=0.204). Interval from operation to first follow-up was more than 1 year in 70 patients, and the median follow-up was 23 months. Thirty-seven patients were non LARS, 18 were minor LARS and 45 were major LARS. No significant differences in clinicopathological data (all P>0.05) were observed among three groups except radiotherapy history (P=0.025), tumor location(P=0.000) and distance from anastomotic site to anal verge(P=0.008). After comparison of non LARS group combined with minor LARS group versus major LARS, re-analysis of risk factors showed that radiotherapy history (RR=5.608, 95%CI:1.457 to 21.584, P=0.006), distance from tumor lower margin to anal verge (RR=0.125, 95%CI:0.042 to 0.372, P=0.000), distance from anastomotic site to anal verge (RR=0.255, 95%CI:0.098 to 0.665, P=0.004) and preventive ileostomy history(RR=3.643, 95%CI:1.058 to 12.548, P=0.032) were associated with major LARS. One potential risk factor detected in combined analysis was female (RR=2.138, 95%CI: 0.944 to 4.844, P=0.078). Multivariate analysis revealed that female (RR=2.654, 95%CI: 1.005 to 7.014, P=0.049), radiotherapy history (RR=10.422, 95%CI:2.394 to 45.368, P=0.002) and distance from tumor lower margin to anal verge ≤7 cm (RR=8.935, 95%CI:2.827 to 28.243, P=0.000) were independent risk factors of major LARS.

CONCLUSIONSLARS is a significant problem in most rectal cancer patients after SPS. The risk of major LARS increases on condition of radiotherapy, low tumor position and female. When dealing with these patients, preventive measures should be taken into consideration during SPS.

Adult ; Aged ; Aged, 80 and over ; Anal Canal ; pathology ; surgery ; Anastomosis, Surgical ; adverse effects ; Colon ; surgery ; Defecation ; physiology ; Factor Analysis, Statistical ; Female ; Follow-Up Studies ; Humans ; Long Term Adverse Effects ; epidemiology ; Male ; Middle Aged ; Radiotherapy ; adverse effects ; Rectal Neoplasms ; complications ; pathology ; surgery ; Rectum ; physiopathology ; surgery ; Retrospective Studies ; Risk Assessment ; methods ; Risk Factors ; Sex Factors ; Surveys and Questionnaires ; Syndrome

OBJECTIVETo summarize the perioperative and postoperative complications follow laparoscopic intersphincteric resection (LapISR) in the treatment of low rectal cancer and their management.

METHODSAn observational study was conducted in 73 consecutive patients who underwent LapISR for low rectal cancer between June 2011 and February 2016 in our hospital. The clinicopathological parameters, perioperative and postoperative complications, and clinical outcomes were collected from a prospectively maintained database. Perioperative and postoperative complications were defined as any complication occurring within or more than 3 months after the primary operation, respectively.

RESULTSForty-nine(67.1%) cases were male and 24(32.9%) were female with a median age of 61(25 to 79) years. The median distance from distal tumor margin to anal verge was 4.0(1.0 to 5.5) cm. The median operative time was 195 (120 to 360) min, median intra operative blood loss was 100 (20 to 300) ml, median number of harvested lymph nodes was 14(3 to 31) per case. All the patients underwent preventive terminal ileum loop stoma. No conversion or hospital mortality was presented. The R0 resection rate was 98.6% with totally negative distal resection margin. A total of 34 complication episodes were recorded in 21(28.8%) patients during perioperative period, and among which 20.6%(7/34) was grade III(-IIII( according to Dindo system. Anastomosis-associated morbidity (16.4%,12/73) was the most common after LapISR, including mucosa ischemia in 9 cases(12.3%), stricture in 7 cases (9.6%, 4 cases secondary to mucosa necrosis receiving anal dilation), grade A fistula in 3 cases (4.1%) receiving conservative treatment and necrosis in 1 case (1.4%) receiving permanent stoma. After a median follow up of 21(3 to 60) months, postoperative complications were recorded in 12 patients (16.4%) with 16 episodes, including anastomotic stenosis (8.2%), rectum segmental stricture (5.5%), ileus (2.7%), partial anastomotic dehiscence (1.4%), anastomotic fistula (1.4%), rectovaginal fistula (1.4%) and mucosal prolapse (1.4%). These patients received corresponding treatments, such as endoscopic transanal resection, anal dilation, enema, purgative, permanent stoma, etc. according to the lesions. Six patients (8.2%) required re-operation intervention due to postoperative complications.

CONCLUSIONAnastomosis-associated morbidity is the most common after LapISR in the treatment of low rectal cancer in perioperative and postoperative periods, which must be strictly managed with suitable methods.

Adult ; Aged ; Anal Canal ; surgery ; Anastomosis, Surgical ; adverse effects ; Blood Loss, Surgical ; statistics & numerical data ; Colectomy ; adverse effects ; Constriction, Pathologic ; etiology ; therapy ; Digestive System Surgical Procedures ; adverse effects ; Female ; Humans ; Ileostomy ; adverse effects ; Intestinal Mucosa ; pathology ; Ischemia ; etiology ; Laparoscopy ; adverse effects ; Lymph Node Excision ; statistics & numerical data ; Male ; Margins of Excision ; Middle Aged ; Necrosis ; etiology ; Operative Time ; Postoperative Complications ; etiology ; therapy ; Rectal Neoplasms ; complications ; surgery ; Rectovaginal Fistula ; etiology ; therapy ; Surgical Stomas ; Treatment Outcome

OBJECTIVETo explore the risk factors and clinical features of delayed anastomotic fistula (DAF) following sphincter-preserving operation for rectal cancer.

METHODSClinical data of 1 594 patients with rectal cancer undergoing sphincter-preserving operation in our department from January 2008 to May 2015 based on the prospective database of Dpartment of Colorectal Surgery, Fujian Medical University Union Hospital were retrospectively analyzed. Sixty patients(3.8%) developed anastomotic fistula. Forty-one patients (2.6%) developed early anastomotic fistula (EAF) within 30 days after surgery while 19(1.2%) were DAF that occurred beyond 30 days. Univariate analyses were performed to compare the clinical features between EAF and DAF group.

RESULTSDAF was diagnosed at a median time of 194(30-327) days after anastomosis. As compared to EAF group, DAF group had lower tumor site [(6.1±2.3) cm vs. (7.8±2.8) cm, P=0.023], lower anastomosis site [(3.6±1.8) cm vs. (4.8±1.6) cm, P=0.008], higher ratio of patients receiving neoadjuvant chemoradiotherapy (84.2% vs. 34.1%, P=0.000), and receiving preventive stoma (73.7% vs. 14.6%, P=0.000). According to ISREC grading system for anastomotic fistula, DAF patients were grade A and B, while EAF cases were grade B and C(P=0.000). During the first hospital stay for anastomosis, DAF group did not have abdominal pain, general malaise, drainage abnormalities, peritonitis but 8 cases(42.1%) had fever more than 38centi-degree. In EAF group, 29 patients(70.7%) had abdominal pain and general malaise, and 29(70.7%) had drainage abnormalities. General or circumscribed peritonitis were developed in 25(61.0%) EAF patients, and fever occurred in 39(95.1%) EAF cases. There were 13(68.4%) cases with sinus or fistula formation and 9(47.4%) with rectovaginal fistula in DAF group, in contrast to 5 (12.2%) and 5 (12.2%) in EAF group respectively. In DAF group, 5 (26.3%) patients received follow-up due to stoma (no closure), 5 (26.3%) received bedside surgical drainage, while 9(47.4%) patients underwent operation, including diverting stoma in 3 patients, Hartmann procedure in 1 case, intersphincteric resection, coloanal anastomosis plus ileostomy in 1case because of pelvic fibrosis and stenosis of neorectum after radiotherapy, mucosal advancement flap repair with a cellular matrix interposition in 3 rectovaginal fistula cases, incision of sinus via the anus in 1 case. During a median follow-up of 28 months, 14(73.7%) DAF patients were cured.

CONCLUSIONSIt is advisable to be cautious that patients with lower site of tumor and anastomosis, neoadjuvant chemoradiotherapy and preventive stoma are at risk of DAF. DAF is clinically silent and most patients can be cured by effective surgical treatment.

Anal Canal ; Anastomosis, Surgical ; Anastomotic Leak ; diagnosis ; pathology ; Colostomy ; Digestive System Surgical Procedures ; adverse effects ; Female ; Humans ; Ileostomy ; Length of Stay ; Neoadjuvant Therapy ; Organ Sparing Treatments ; Postoperative Complications ; diagnosis ; Rectal Neoplasms ; surgery ; Rectovaginal Fistula ; Rectum ; surgery ; Retrospective Studies ; Risk Factors ; Surgical Flaps ; Surgical Stomas ; Treatment Outcome

OBJECTIVETo compare the effect of An's Shaobei Injection ([symbols; see text]) with Xiaozhiling Injection ([symbols; see text]) in patients with internal hemorrhoids of grade I-III.

METHODSThis cohort study included 1,520 internal hemorrhoids patients with grade I-III who were scheduled for liquid injection treatment from July 2003 to July 2009. The cohort included patients who underwent either An's Shaobei Injection treatment (the treatment group, 760 cases) or Xiaozhiling Injection treatment (the control group, 760 cases). All patients were followed up regularly for 3 years; the observing indices included anal function recovery and clinical response after operation.

RESULTSAmong the 1,520 patients, 1,508 (99.2%) completed the 3-year follow-up. The efficacy rate was 97.5% in the treatment group, significantly higher than the control group (91.8%, P<0.01). The recurrence rate in the treatment group was 0.5%, significantly lower than that of the control group (1.3%, P<0.01). In addition, perianal callosity occurred in 8 cases (1.1%) and anorectal stricture in 26 cases (3.5%) after operation in the control group. There was no perianal callosity and anorectal stricture in the treatment group.

CONCLUSIONThe treatment with An's Shaobei Injection demonstrated superior clinical effect to Xiaozhiling Injection with fewer adverse effects.

Adult ; Anal Canal ; drug effects ; pathology ; Drugs, Chinese Herbal ; administration & dosage ; adverse effects ; Female ; Follow-Up Studies ; Hemorrhoids ; drug therapy ; pathology ; Humans ; Injections, Intralesional ; Male ; Middle Aged ; Mucous Membrane ; drug effects ; pathology ; Prospective Studies ; Recurrence ; Sclerosing Solutions ; administration & dosage ; adverse effects ; Severity of Illness Index ; Treatment Outcome

OBJECTIVETo investigate the clinical value of MRI examination in congenital anorectal malformation (CARM).

METHODForty-four cases with operatively proved anorectal malformation from May 2008 to May 2012 in the authors' hospital were reviewed. Of the 44 cases, 25 were males and 19 females, their age ranged from 1 day to 2 years. MRI was performed in all patients.

RESULTOf all 44 cases, 15 cases had high imperforate anus (34%), rectum blind end were above PC line, the distance of rectum blind end and anus nest was (29.12 ± 2.35) mm; 8 cases had median imperforate anus (18%), rectum blind ends were near PC line, the distance of rectum blind end and anus nest was (18.98 ± 2.21) mm; 21 cases had low imperforate anus (48%), rectum blind ends were below PC line, the distance of rectum blind end and anus nest was (7.54 ± 1.08) mm. Twenty-five cases with fistula in 44 cases were confirmed by rectal angiography and surgery, accounting for 57%. In 13 cases with fistula, the lesion could be clearly demonstrated on MRI, in the remaining 12 cases with fistula, the lesion could not be visualized clearly or no image development occurred on MRI. Of all 44 cases, 1 case had tethered cord with filum terminale lipoma, 1 case had tethered cord, 2 cases had syringomyelia, 1 case had right kidney agenesis, 1 case had hydrocele. In 44 cases of multi-planar MRI imaging could clearly show the perianal muscles developmental situation, 36 cases had perianal muscles dysplasia, amd showed levator ani muscle, puborectalis and anal sphincter asymmetry, muscle belly slim.

CONCLUSIONMRI examination has a high clinical value in CARM diagnosis, can help accurately judge the anal atresia type, display the presence and running of most of the fistula, and diagnose perianal muscle development and other systems malformations, finally provide a reliable diagnostic basis for surgical program and prognostic assessment.

Abnormalities, Multiple ; Anal Canal ; abnormalities ; surgery ; Anus, Imperforate ; complications ; diagnosis ; surgery ; Child, Preschool ; Female ; Fistula ; epidemiology ; etiology ; Humans ; Infant ; Infant, Newborn ; Magnetic Resonance Imaging ; Male ; Perineum ; pathology ; Rectum ; abnormalities ; surgery ; Retrospective Studies ; Urinary Fistula ; epidemiology ; etiology

Acupuncture Therapy ; Anal Canal ; pathology ; Female ; Humans ; Intervertebral Disc Displacement ; complications ; Middle Aged ; Pain ; etiology ; Rectal Diseases ; etiology ; pathology ; therapy