Conformal sphincteric resection for ultra-low rectal cancer located below the dentate line: A pilot report.
Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland
AIM:Sphincter-sparing surgery can be achieved in most cases of low rectal cancer with the development of intersphincteric resection. However, abdominoperineal resection is still inevitable for patients with tumours located below the dentate line. To address this, we have developed a procedure called conformal sphincteric resection (CSR) in which the corresponding part of the subcutaneous portion of the external anal sphincter and the perianal skin on the tumour side is removed to achieve a safe distal resection margin and lateral resection margin while the dentate line and the internal anal sphincter on the tumour-free side are preserved as much as possible, to achieve sphincter preservation without compromising oncological safety and functional acceptability, and to render tumour location no longer a contraindication for sphincter-sparing surgery. This is the first study to describe the concept, indication and surgical procedure of CSR and to report its preliminary surgical, oncological and functional results. METHODS:This is a retrospective, single-centre, single-arm pilot study conducted at Huashan Hospital, Fudan University. Demographic, clinicopathological, oncological and functional follow-up data were collected from 20 consecutive patients with rectal tumours located below the dentate line who underwent laparoscopic CSR by the same surgical team from June 2018 to March 2022. RESULTS:The mean distance of the tumour's lower edge from the anal verge was 13.1 ± 6.0 mm. The mean distal resection margin was 10.6 ± 4.3 mm. All circumferential resection margins were negative. There were no instances of perioperative mortality. The complication rate was 25% but all were Clavien-Dindo Grade I. Among the 20 cases, 17 were diagnosed with adenocarcinoma, one with squamous cell carcinoma and two with adenoma featuring high-grade intraepithelial neoplasia. Pathological TNM staging revealed two, seven, five, five and one case(s) in Stages 0, I, II, III and IV, respectively. The median follow-up period was 20 months (interquartile range 22 months), with no withdrawals. The overall and disease-free survival rates were both 95%. The mean Wexner incontinence score and low anterior resection syndrome score recorded 18 months following diverting ileostomy closure were 6.3 ± 3.8 and 27.3 ± 3.6, respectively. CONCLUSIONS:This study has proposed the CSR procedure for the first time, which is a technically feasible, oncologically safe and functionally acceptable procedure for carefully selected patients with rectal tumours located below the dentate line.
10.1111/codi.16776
Comparison of functional and oncological outcome of conformal sphincter preservation operation, low anterior resection, and abdominoperineal resection in very low rectal cancer: a retrospective comparative cohort study with propensity score matching.
Langenbeck's archives of surgery
PURPOSE:Conformal sphincter preservation operation (CSPO) procedure is a sphincter preservation procedure for preserving the anal canal function for very low rectal cancers. This study investigated the functional and oncological outcome of conformal sphincter preservation operation by comparing with low anterior resection (LAR) and abdominoperineal resection (APR). METHODS:This is a retrospective comparative study. Patients who received conformal sphincter preservation operation (n = 52), low anterior resection (n = 54), or abdominoperineal resection (n = 69) were included between 2011 and 2016 in a tertiary referral hospital. Propensity score matching was applied to adjust the baseline characteristics which may influence the choice of the surgical procedure. RESULTS:Twenty-one pairs of conformal sphincter preservation operation vs. low anterior resection and 29 pairs of conformal sphincter preservation operation vs. abdominoperineal resection were selected. The first group had a higher tumor location than the second group. Compared with the low anterior resection group, the conformal sphincter preservation operation group had shorter distal resection margins; however, no significant differences were identified in daily stool frequency, Wexner incontinence score, local recurrence, distant metastasis, overall survival, and disease-free survival between both groups. Compared with the abdominoperineal resection group, the conformal sphincter preservation operation group had shorter operative time and shorter postoperative hospital stay. No significant differences were identified in local recurrence, distant metastasis, overall survival, and disease-free survival. CONCLUSION:Conformal sphincter preservation operation is oncologically safe compared to APR and LAR, and has similar functional findings to LAR. Studies comparing CSPO with intersphincteric resection should be performed.
10.1007/s00423-023-02925-1
[Techniques and classification of intersphincteric resection for ultra-low rectal cancer].
Zhonghua wei chang wai ke za zhi = Chinese journal of gastrointestinal surgery
ISR is the most widely used anal-preserving operation for ultra-low rectal cancer. It can be divided into total ISR, subtotal ISR and partial ISR according to the resection range of internal sphincter. The advantage of ISR is that it can preserve the sphincter while ensuring the safety of oncology for ultra-low rectal cancer, representing the state of the art. However, it still needs to face the problem that the quality of life will decline due to poor postoperative anal function. The conformal sphincter-preserving operation (CSPO) is a functional anal-preserving surgery improved on the basis of ISR. It is superior to ISR in the postoperative anal function and patients' quality of life. So it can be a new choice for ultra-low rectal cancer.
10.3760/cma.j.cn441530-20230603-00191
[Transanal conformal resection for super low rectal cancer].
Lou Zheng,Zhang Wei
Zhonghua wei chang wai ke za zhi = Chinese journal of gastrointestinal surgery
Intersphincteric resection(ISR) is a valuable anus-preserving operation that avoids the need for permanent stoma in patients with super low rectal cancer. Recently, with the application and promotion of ISR, the rate of anus-preservation has been greatly elevated, however, some patients following ISR had poor anal function. Based on the knowledge of anal canal anatomical features for better anal function, we propose conformal sphincter-preserving operation (CSPO) for super low rectal cancer, which is a new integrated anus-preservation procedure with total mesorectal excision (TME), coloanal anastomosis, pull through resection, anal canal dissection, local resection and natural orifice transluminal endoscopic surgery technology. CSPO includes pull through conformal resection (PTCR) and transanal conformal resection (TaCR). This article focuses on the problems about TaCR for very low rectal cancer and introduces TaCR combined with our practical experience. The indications for the TaCR operation should be according to the conventional laparoscopic surgery. In addition, the TaCR operation has its special indications: the tumor location is within 2 cm of the dental line; the tumor is well differentiation (moderately to well differentiation); the diameter of the tumor is not more than 3 cm or no more than the 1/3 circle of intestinal wall; and the depth of invasion is T1-T2. Patients with a clinical complete remission after neoadjuvant radiochemotherapy can receive TaCR. The laparoscopic five hole method is used to carry out the abdominal operation with TME technique. It is unnecessary to dissection intersphincter space. The incisional line is made according to the tumor location and shape to preserve the opposite normal rectal wall, internal sphincter and dentate line as more as possible via transanal resection. After closing the rectal stump by interrupted sutures, a circular stapler or hand suture is use to perform the anastomosis as far from the dentate line as possible. Protective loop ileostomy is performed. Postoperative complications, including anastomotic leakage, abdominal infection, and anastomotic bleeding, should be remembered. If there is any signs of these complications, intervention should be done as soon as possible.
Retrospective study of the functional and oncological outcomes of conformal sphincter preservation operation in the treatment of very low rectal cancer.
Techniques in coloproctology
BACKGROUND:Conformal sphincter preservation operation (CSPO) is a new surgical procedure for very low rectal cancers (within 4-5 cm from the anal verge). CSPO preserves more of the dentate line and distal rectal wall and also avoids injuring nerves in the intersphincteric space, resulting in satisfactory anal function after resection. The aim of this study was to analyze the short-term surgical results and long-term oncological and functional outcomes of CSPO. METHODS:Consecutive patients with very low rectal cancer, who had CSPO between January 2011 and October 2018 at Changhai Hospital, Shanghai were included. Patient demographics, clinicopathological features, oncological outcomes and anal function were analyzed. RESULTS:A total of 102 patients (67 men) with a mean age of 56.9 ± 10.8 years were included. The median distance of the tumor from the anal verge was 3 (IQR, 3-4) cm. Thirty-five patients received neoadjuvant chemoradiation (nCRT). The median distal resection margin (DRM) was 0.5 (IQR, 0.3-0.8) cm. One patient had a positive DRM. All circumferential margins were negative. There was no perioperative mortality. The postoperative complication rate was 19.6%. The median duration of follow-up was 28 (IQR, 12-45.5) months. The local recurrence rate was 2% and distant metastasis rate was 10.8%. The 3-year overall survival and disease-free survival rates were 100% and 83.9%, respectively. The mean Wexner incontinence and low anterior resection syndrome scores 12 months after ileostomy reversal were 5.9 ± 4.3, and 29.2 ± 6.9, respectively. CONCLUSIONS:For patients with very low rectal cancers, fecal continence can be preserved with CSPO without compromising oncological results.
10.1007/s10151-020-02229-2
[Reassessment of intersphincteric resection in the sphincter-preserving operation for ultra-low rectal cancer].
Zhonghua wei chang wai ke za zhi = Chinese journal of gastrointestinal surgery
Intersphincteric resection (ISR), as an ultra-low sphincter-preserving operation, is widely used in clinical practice at present. ISR can allow some patients with very low rectal cancer to avoid the pain of anal resection while ensuring oncological efficacy. However, the procedure of ISR requires wider intersphincteric dissection which may cause nerve damage, and the removal of partial or total internal anal sphincter as an "inherent defect" of ISR can result in poor anal function postoperatively. Based on the in-depth understanding of regional anatomy and physiological function, the author proposed a new functional sphincter preservation operation for very low rectal cancer-conformal sphincter preservation operation (CSPO) which has achieved good outcome in clinical practice. This article will revisit the brief history of rectal cancer surgery and discuss the main mechanisms underlining the poor anal function after ISR. Based on the anatomical study of the pelvic floor and anal canal, CSPO can improve the postoperative anal function of very low rectal cancer patients by reducing the damage of the autonomic nerves, receptor corpuscles and muscle fibers in the intersphincteric space, retaining more dentate line and internal sphincter with the design of resection line of tumor lower border under direct vision, and elevating the anastomosis height. At the same time, the future treatment prospect of low rectal cancer is envisioned.
10.3760/cma.j.cn441530-20220321-00107
[Standardized surgical procedure of conformal sphincter-preservation operation for low rectal cancer (2023 edition)].
Zhonghua wei chang wai ke za zhi = Chinese journal of gastrointestinal surgery
Conformal sphincter-preservation operation (CSPO) is considered the effective surgical technique for preserving the sphincter in cases of low rectal cancer. Accurate preoperative diagnosis and staging, reasonable selection of surgical approaches and technique, standardized perioperative management, and postoperative rehabilitation are the keys to ensuring the oncological clearance and functional preservation of CSPO. However, there is currently a lack of standardized surgical procedure for implementing CSPO in China. Therefore, the Colorectal Surgery Group of Surgery Branch of the Chinese Medical Association,along with the Colorectal Cancer Committee of the Chinese Medical Doctor Association and the Anorectal Branch of Chinese Medical Doctor Association, gathered experts in colorectal surgery to discuss and establish this standardized surgical procedure of CSPO. This standard, based on the latest evidence from literature, expert experiences, and China national condition, focuses on the definition, classification, pelvic anatomy, surgical techniques, postoperative complications, and perioperative care of CSPO. It aims to guide the standardized clinical practice of CSPO in China.
10.3760/cma.j.cn441530-20230829-00073
Evaluation of the learning curve for conformal sphincter preservation operation in the treatment of ultralow rectal cancer.
Ding Hai-Bo,Wang Lin-Hui,Sun Ge,Yu Guan-Yu,Gao Xian-Hua,Zheng Kuo,Gong Hai-Feng,Sui Jin-Ke,Zhu Xiao-Ming,Zhang Wei
World journal of surgical oncology
BACKGROUND:To investigate the learning curve of conformal sphincter preservation operation (CSPO) in the treatment of ultralow rectal cancer and to further explore the influencing factors of operation time. METHODS:From August 2011 to April 2020, 108 consecutive patients with ultralow rectal cancer underwent CSPO by the same surgeon in the Department of Colorectal Surgery of Changhai Hospital. The moving average and cumulative sum control chart (CUSUM) curve were used to analyze the learning curve. The preoperative clinical baseline data, postoperative pathological data, postoperative complications, and survival data were compared before and after the completion of learning curve. The influencing factors of CSPO operation time were analyzed by univariate and multivariate analysis. RESULTS:According to the results of moving average and CUSUM method, CSPO learning curve was divided into learning period (1-45 cases) and learning completion period (46-108 cases). There was no significant difference in preoperative clinical baseline data, postoperative pathological data, postoperative complications, and survival data between the two stages. Compared with the learning period, the operation time (P < 0.05), blood loss (P < 0.05), postoperative flatus and defecation time (P < 0.05), liquid diet time (P < 0.05), and postoperative hospital stay (P < 0.05) in the learning completion period were significantly reduced, and the difference was statistically significant. Univariate and multivariate analysis showed that distance of tumor from anal verge (≥ 4cm vs. < 4cm, P = 0.039) and T stage (T3 vs. T1-2, P = 0.022) was independent risk factors for prolonging the operation time of CSPO. CONCLUSIONS:For surgeons with laparoscopic surgery experience, about 45 cases of CSPO are needed to cross the learning curve. At the initial stage of CSPO, beginners are recommended to select patients with ultralow rectal cancer whose distance of tumor from anal verge is less than 4 cm and tumor stage is less than T3 for practice, which can enable beginners to reduce the operation time, accumulate experience, build self-confidence, and shorten the learning curve on the premise of safety.
10.1186/s12957-022-02541-1
Comparison of anal function and quality of life after conformal sphincter preservation operation and intersphincteric resection of very low rectal cancer: a multicenter, retrospective, case-control analysis.
Techniques in coloproctology
PURPOSE:Conformal sphincter preservation operation (CSPO) is a sphincter preservation operation for very low rectal cancers. Compared to intersphincteric resection (ISR), CSPO retains more dentate line and distal rectal wall, and also avoids damaging the nerves in the intersphincteric space. This study aimed to compare the postoperative anal function and quality of life between the CSPO and ISR. METHOD:Patients with low rectal cancer undergoing CSPO (n = 117) and ISR (n = 66) were included from Changhai and Huashan Hospital, respectively, between 2011 and 2020. A visual analog scale (range 0-10) was utilized to evaluate satisfaction with anal function and quality of life. The anal function was evaluated with Wexner scores and low anterior resection syndrome (LARS) score. Quality of life was evaluated with the EORTC QLQ-C30 and QLQ-CR38. RESULTS:The CSPO group had more male patients (65.8% vs. 50%, p = 0.042), more preoperative chemoradiotherapy (33.3% vs. 10.6%, p < 0.001), lower tumor position (3.45 ± 1.13 vs. 4.24 ± 0.86 cm, p < 0.001), and more postoperative chemotherapy (65% vs. 13.6%, p < 0.001) compared to the ISR group. In addition, CSPO patients had shorter postoperative stay (6.63 ± 2.53 vs. 7.85 ± 4.73 days, p = 0.003) and comparable stoma reversal rates within 1 year after surgery (92.16% vs. 96.97%, p = 0.318). Multivariable analysis showed that CSPO significantly contributed to higher satisfaction with anal function (beta = 1.752, 95% CI 0.776-2.728) and with quality of life (beta = 1.219, 95% CI 0.374-2.064), but not to Wexner, LARS score, or EORTC QLQ-C30 and QLQ-CR38. CONCLUSION:CSPO improved the satisfaction with anal function and quality of life but utilized more preoperative chemoradiotherapy. CSPO may be an alternative choice for patients with very low rectal cancers in better physical health and with higher requirements for anal function and quality of life.
10.1007/s10151-023-02819-w