Retrospective Study
Copyright ©The Author(s) 2025. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Aug 7, 2025; 31(29): 110004
Published online Aug 7, 2025. doi: 10.3748/wjg.v31.i29.110004
Long-term efficacy and short-term outcomes of intersphincteric resection vs abdominoperineal resection in patients with ultra-low rectal cancer
Guan-Cong Wang, Jun-Xing Chen, Hong-Feng Pan, Kai Ye, Yin-Cong Guo, Ying Huang
Guan-Cong Wang, Yin-Cong Guo, Ying Huang, Department of Colorectal Surgery, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou 363000, Fujian Province, China
Guan-Cong Wang, Hong-Feng Pan, Ying Huang, Department of Colorectal Surgery, Fujian Medical University Union Hospital, Fuzhou 351000, Fujian Province, China
Jun-Xing Chen, Kai Ye, Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Fujian Medical University, Quanzhou 363000, Fujian Province, China
Co-first authors: Guan-Cong Wang and Jun-Xing Chen.
Co-corresponding authors: Yin-Cong Guo and Ying Huang.
Author contributions: Wang GC, Ye K, Guo YC and Huang Y were responsible for protocol/project development; Wang GC, Chen JX, and Pan HF were responsible for data collection/management; Wang GC was responsible for data analysis; Wang GC was responsible for manuscript writing/editing; Wang GC and Chen JX contributed equally to this article, they are the co-first authors of this manuscript; Guo YC and Huang Y contributed equally to this article, they are the co-corresponding authors of this manuscript; all authors have reviewed the manuscript.
Supported by Natural Science Foundation of Fujian Province, No. 2023J011819.
Institutional review board statement: This study was reviewed and approved by the Medical Ethics Committee of Zhangzhou Affiliated Hospital of Fujian Medical University (Approval No. 2024 LWB376), the Medical Ethics Committee of Union Hospital of Fujian Medical University (Approval No. 2025KY036), and the Medical Ethics Committee of the Second Affiliated Hospital of Fujian Medical University (Approval No. 2022492). All methods were performed in accordance with relevant guidelines and regulations, including the Declaration of Helsinki.
Informed consent statement: The informed consent was waived by the Institutional Review Board.
Conflict-of-interest statement: The authors declare no competing interests.
Data sharing statement: All data obtained or analyzed during this study are included in the article.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Yin-Cong Guo, Chief Physician, Professor, Department of Colorectal Surgery, Zhangzhou Affiliated Hospital of Fujian Medical University, No. 59 Shengli West Road, Zhangzhou 363000, Fujian Province, China. fjzzgyc@126.com
Received: May 28, 2025
Revised: June 13, 2025
Accepted: July 8, 2025
Published online: August 7, 2025
Processing time: 70 Days and 0.7 Hours
Abstract
BACKGROUND

Ultra-low rectal cancer (ULRC), defined as a lesion located within 5 cm of the anal verge, poses considerable clinical challenges because the treatment decision must balance oncological eradication with preservation of anal function. Historically, abdominoperineal resection (APR) has served as a standard approach for tumor eradication in these patients, but a permanent stoma significantly reduces patients' quality of life. In contrast, intersphincteric resection (ISR) can maintain anal function, thereby improving quality of life; however, the debate surrounding short-term postoperative complications and long-term prognosis has not been fully resolved. Therefore, large-scale multicenter retrospective cohort studies are crucial to address this issue and provide more reliable data.

AIM

To address a persistent debate in ULRC management, we compared ISR and APR outcomes through rigorous methodology.

METHODS

A retrospective analysis of patients undergoing surgery at three centers in China between 2012 and 2023 was performed with propensity score matching (PSM).

RESULTS

A total of 803 patients (435 in the ISR group and 368 in the APR group) met the inclusion criteria, with 289 comprising each of the two groups after PSM. Over a median follow-up of 47.2 months, the absolute 5-year overall survival (OS) improved by 6.7% with ISR (80.8% vs 74.1%, P = 0.032). Cox regression analysis confirmed ISR (HR = 0.554, 95%CI: 0.371-0.828, P = 0.004) as an independent protective factor for OS and reduced local recurrence (9.5% vs 12.9%, P = 0.019). With respect to short-term complications, despite higher anastomotic leakage rates (11.4% vs 1.0%), ISR significantly reduced total complications (29.4% vs 42.2%, P = 0.001) and hospitalization duration (9.8 days vs 12.9 days, P < 0.001). Moreover, incision infection, urinary retention, circumferential resection margins, and hospitalization time were greater in the APR group (P < 0.05).

CONCLUSION

The long-term prognosis of ULRC treated with ISR is excellent, with no increase in overall surgical complications or hospital stay duration, indicating that ISR is a feasible alternative to APR for managing ULRC.

Keywords: Intersphincteric resection; Abdominoperineal resection; Ultra-low rectal cancer; Propensity score matching; Surgical outcomes

Core Tip: As the largest propensity score-matched study comparing intersphincteric resection (ISR) and abdominoperineal resection (APR), we minimized selection bias by balancing 13 covariates across 803 patients (289 matched pairs). ISR demonstrated a 6.7% absolute improvement in 5-year overall survival (80.8% vs 74.1%, HR = 0.554, P = 0.004) and reduced local recurrence (9.5% vs 12.9%, P = 0.019), establishing its oncologic superiority. Despite higher anastomotic leakage rates (11.4% vs 1.0%), ISR significantly reduced total complications (29.4% vs 42.2%, P = 0.001) and hospitalization duration (9.8 days vs 12.9 days, P < 0.001), supporting its role as the preferred sphincter-preserving alternative to APR.