• anal function
• intersphincteric resection
• intersphincteric space
• oncological outcome

• National Natural Science Foundation of China

• Anal function
• Fecal incontinence
• Intersphincteric resection
• Low rectal cancer
• Risk assessment form

• Humans
• Rectal Neoplasms/surgery
• Male
• Retrospective Studies
• Female
• Middle Aged
• Fecal Incontinence/etiology
• Anal Canal/surgery
• Risk Factors
• Aged
• Risk Assessment/methods
• Postoperative Complications/etiology
• Defecation/physiology
• Adult
• Neoplasm Staging
• Proctectomy/adverse effects
• Proctectomy/methods
• Preoperative Care/methods
• Age Factors
• Preoperative Period
• Treatment Outcome

• Anastomotic leakage
• Decision-making factor
• Defunctioning ileostomy
• Perioperative outcome
• Postoperative complication
• Rectal cancer

• Humans
• Male
• Rectal Neoplasms/surgery
• Retrospective Studies
• Ileostomy/methods
• Female
• Middle Aged
• Anastomotic Leak/etiology
• Anastomotic Leak/epidemiology
• Aged
• Case-Control Studies
• Length of Stay/statistics & numerical data
• Postoperative Complications/etiology
• Postoperative Complications/epidemiology
• Operative Time
• Risk Factors
• Adult
• Proctectomy/methods
• Proctectomy/adverse effects
• Clinical Decision-Making

• 20231148 Guangdong Provincial Administration of Traditional Chinese Medicine

• Intersphincteric resection
• Laparoscopy
• Rectal cancer
• Robot
• Total mesorectal excision

• Humans
• Rectal Neoplasms/surgery
• Rectal Neoplasms/pathology
• Laparoscopy/methods
• Laparoscopy/adverse effects
• Robotic Surgical Procedures/methods
• Robotic Surgical Procedures/adverse effects
• Anal Canal/surgery
• Multicenter Studies as Topic
• Treatment Outcome
• Proctectomy/methods
• Proctectomy/adverse effects
• Equivalence Trials as Topic
• Male
• Time Factors
• Female
• Postoperative Complications/etiology
• Adult
• Randomized Controlled Trials as Topic
• Middle Aged
• Rectum/surgery
• Quality of Life

• Rectal tumor
• anorectal manometry
• defecography
• dentate line
• endoscopic submucosal dissection

• Humans
• Male
• Female
• Aged
• Rectal Neoplasms/surgery
• Endoscopic Mucosal Resection/methods
• Endoscopic Mucosal Resection/adverse effects
• Prospective Studies
• Anal Canal/physiopathology
• Anal Canal/surgery
• Manometry
• Middle Aged
• Aged, 80 and over
• Defecation
• Proctoscopy/methods
• Defecography
• Rectum/surgery
• Rectum/physiopathology

• anatomy
• rectal neoplasm
• surgery

• Anastomosis
• Intersphincteric resection
• Low anterior resection syndrome
• Rectal cancer
• Transverse coloplasty pouch

• Humans
• Rectal Neoplasms/surgery
• Anastomosis, Surgical/adverse effects
• Anastomosis, Surgical/methods
• Male
• Female
• Retrospective Studies
• Anal Canal/surgery
• Middle Aged
• Treatment Outcome
• Aged
• Postoperative Complications/etiology
• Postoperative Complications/epidemiology
• Digestive System Surgical Procedures/methods
• Digestive System Surgical Procedures/adverse effects

• 2017Y9038 Joint Funds for the innovation of Science and Technology, Fujian province
• 2019Y9101 Joint Funds for the innovation of Science and Technology, Fujian province
• 2020Y9071 Joint Funds for the innovation of Science and Technology, Fujian province
• 2020GGB022 Fujian Provincial Health Technology Project
• 2020CXA025 Fujian Provincial Health Technology Project
• 2020J011030 Natural Science Foundation of Fujian Province
• 2022J01753 Natural Science Foundation of Fujian Province
• B20062DS Medical Science Research Foundation of Beijing Medical and Health Foundation
• X-J-2018-004 Bethune Charitable Foundation

• Abdominoperineal resection
• Low hartmann’s procedure
• Pelvic abscess
• Postoperative complication
• Rectal cancer

• Humans
• Rectal Neoplasms/surgery
• Propensity Score
• Male
• Female
• Middle Aged
• Retrospective Studies
• Proctectomy/methods
• Proctectomy/adverse effects
• Postoperative Complications/epidemiology
• Postoperative Complications/etiology
• Aged
• Colostomy/methods
• Colostomy/adverse effects
• Incidence

• abdominoperineal resection
• hazard ratio
• intersphincteric resection
• lower rectal cancer
• oncologic outcome

• Humans
• Rectal Neoplasms/surgery
• Rectal Neoplasms/mortality
• Rectal Neoplasms/pathology
• Proctectomy/methods
• Proctectomy/adverse effects
• Anal Canal/surgery
• Treatment Outcome
• Disease-Free Survival
• Neoplasm Recurrence, Local

• Adjuvant chemotherapy
• Adjuvant radiotherapy
• Distal rectal cancer
• Organ preservation
• Radical radiotherapy
• Watch and wait

• Humans
• Treatment Outcome
• Chemoradiotherapy
• Organ Preservation
• Quality of Life
• Rectal Neoplasms/surgery
• Neoadjuvant Therapy
• Neoplasm Recurrence, Local/prevention & control
• Watchful Waiting/methods

• U19A2064 National Natural Science Foundation of China
• 2020-I2M-C&T-B-036 Clinical and Translational Medicine Research Foundation of Chinese Academy of Medical Sciences

• Intersphincteric resection
• Low anterior resection syndrome
• Propensity score matching
• Quality of life
• Rectal cancer

• Male
• Female
• Humans
• Rectal Neoplasms/surgery
• Rectal Neoplasms/complications
• Low Anterior Resection Syndrome
• Postoperative Complications/epidemiology
• Postoperative Complications/etiology
• Postoperative Complications/diagnosis
• Retrospective Studies
• Quality of Life
• Propensity Score
• Fecal Incontinence
• Anal Canal/surgery
• Pain

• No. 2021YFS0025 Sichuan Province Science and Technology Support Program
• 20HXJS003 West China Hospital, Sichuan University
• 22HXFH001 West China Hospital, Sichuan University
• 2019HXFH031 West China Hospital, Sichuan University

• Delphi study
• abdominoperineal resection
• intersphincteric resection
• rectal cancer
• surgical anatomy
• ultra-low anterior resection

• Humans
• Consensus
• Delphi Technique
• Rectum/pathology
• Anal Canal
• Rectal Neoplasms/pathology
• Pelvic Floor
• Treatment Outcome

Intersphincteric resection (ISR), the ultimate anus-preserving technique for ultralow rectal cancers, is an alternative to abdominoperineal resection (APR). The failure patterns and risk factors for local recurrence and distant metastasis remain controversial and require further investigation.

To investigate the long-term outcomes and failure patterns after laparoscopic ISR in ultralow rectal cancers.

Patients who underwent laparoscopic ISR (LsISR) at Peking University First Hospital between January 2012 and December 2020 were retrospectively reviewed. Correlation analysis was performed using the Chi-square or Pearson's correlation test. Prognostic factors for overall survival (OS), local recurrence-free survival (LRFS), and distant metastasis-free survival (DMFS) were analyzed using Cox regression.

We enrolled 368 patients with a median follow-up of 42 mo. Local recurrence and distant metastasis occurred in 13 (3.5%) and 42 (11.4%) cases, respectively. The 3-year OS, LRFS, and DMFS rates were 91.3%, 97.1%, and 90.1%, respectively. Multivariate analyses revealed that LRFS was associated with positive lymph node status [hazard ratio (HR) = 5.411, 95% confidence interval (CI) = 1.413-20.722, P = 0.014] and poor differentiation (HR = 3.739, 95%CI: 1.171-11.937, P = 0.026), whereas the independent prognostic factors for DMFS were positive lymph node status (HR = 2.445, 95%CI: 1.272-4.698, P = 0.007) and (y)pT3 stage (HR = 2.741, 95%CI: 1.225-6.137, P = 0.014).

This study confirmed the oncological safety of LsISR for ultralow rectal cancer. Poor differentiation, (y)pT3 stage, and lymph node metastasis are independent risk factors for treatment failure after LsISR, and thus patients with these factors should be carefully managed with optimal neoadjuvant therapy, and for patients with a high risk of local recurrence (N + or poor differentiation), extended radical resection (such as APR instead of ISR) may be more effective.

• Rectal cancer
• Intersphincteric resection
• Laparoscopic surgery
• Recurrence
• Risk factors

• Humans
• Robotic Surgical Procedures/methods
• Retrospective Studies
• Robotics/methods
• Rectal Neoplasms/surgery
• Rectal Neoplasms/pathology
• Pelvis

• Anastomotic leak
• Inferior mesenteric artery ligation
• Randomized controlled trial
• Rectal cancer

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.

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.

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.

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.

• Defecation-related muscles
• Low anterior resection syndrome
• Magnetic resonance imaging

• Minimally invasive surgical procedures
• Proctectomy
• Rectal neoplasms
• Transanal endoscopic surgery

Despite innovative advancements, distally located rectal cancer remains a critical disease of challenging management. The crucial location of the tumor predisposes it to a circumferential resection margin (CRM) that tends to involve the anal sphincter complex and surrounding organs, with a high incidence of delayed anastomotic complications and the risk of the pelvic sidewall or rarely inguinal lymph node metastases. In this regard, colorectal surgeons should be aware of other issues beyond total mesorectal excision (TME) performance. For decades, the concept of extralevator abdominoperineal resection to avoid compromised CRM has been introduced. However, the complexity of deep pelvic dissection with poor visualization in low-lying rectal cancer has led to transanal TME. In contrast, neoadjuvant chemoradiotherapy (NCRT) has allowed for the execution of more sphincter-saving procedures without oncologic compromise. Significant tumor regression after NCRT and complete pathologic response also permit applying the watch-and-wait protocol in some cases, now with more solid evidence. This review article will introduce the current surgical treatment options, their indication and technical details, and recent oncologic and functional outcomes. Lastly, the novel characteristics of distal rectal cancer, such as pelvic sidewall and inguinal lymph node metastases, will be discussed along with its tailored and individualized treatment approach.

• Lymph node excision
• Proctectomy
• Rectal neoplasms
• Surgical procedures

• anorectal dysfunction
• intersphincteric resection
• low rectal cancer
• preoperative chemoradiation
• risk factors

• TpAPE
• abdominoperineal excision
• pelvic floor muscle

• abdominoperineal resection
• advanced rectal cancer
• anatomy
• anus-preserving surgery
• intersphincteric resection
• laparoscopic surgery
• minimally invasive surgery
• pelvic local recurrence
• robotic surgery
• sphincter-saving surgery

• B1901101 Korea University Internal Research Grant

This article expresses the viewpoint of the authors’ management of low rectal cancer in ulcerative colitis (UC). This subject suffers from a paucity of literature and therefore management decision is very difficult to take. The aim of this paper is to provide a structured approach to a challenging situation. It is subdivided into two parts: a first part where the existing literature is reviewed critically, and a second part in which, on the basis of the literature review and their extensive clinical experience, a management algorithm is proposed by the authors to offer guidance to surgical and oncological practices. This text adds to the literature a useful guide for the treatment of these complex clinical scenarios.

Low rectal Carcinoma arising at the background of Ulcerative Colitis poses significant management challenges to the clinicians. The complex decision-making requires discussion at the multidisciplinary team meeting. The published literature is scarce, and there are significant variations in the management of such patients. We reviewed treatment protocols and operative strategies; with the aim of providing a practical framework for the management of low rectal cancer complicating UC. A practical treatment algorithm is proposed.

• inflammatory bowel diseases
• rectal cancer
• surgical management
• treatment algorithm
• ulcerative colitis

• Intersphincteric resection
• Oncological outcome
• Rectal cancer
• Robot-assisted
• Total intersphincteric longitudinal muscle excision (TILME)

Intersphincteric resection (ISR) has been increasingly used as the ultimate sphincter-preserving procedure in extremely low rectal cancer. The most critical complication of this technique is anastomotic leakage. The incidence rate of anastomotic leakage after ISR has been reported to range from 5.1% to 20%.

To investigate risk factors for anastomotic leakage after ISR based on clinicopathological variables and pelvimetry.

This study was conducted at Department of Colorectal Surgery, Japanese Red Cross Medical Center, Tokyo, Japan, with a total of 117 patients. We enrolled 117 patients with extremely low rectal cancer who underwent laparotomic and laparoscopic ISRs at our hospital. We conducted retrospective univariate and multivariate regression analyses on 33 items to elucidate the risk factors for anastomotic leakage after ISR. Pelvic dimensions were measured using three-dimensional reconstruction of computed tomography images. The optimal cutoff value of the pelvic inlet plane area that predicts anastomotic leakage was determined using a receiver operating characteristic (ROC) curve.

We observed anastomotic leakage in 10 (8.5%) of the 117 patients. In the multivariate analysis, we identified high body mass index (odds ratio 1.674; 95% confidence interval: 1.087-2.58; P = 0.019) and smaller pelvic inlet plane area (odds ratio 0.998; 95% confidence interval: 0.997-0.999; P = 0.012) as statistically significant risk factors for anastomotic leakage. According to the receiver operating characteristic curves, the optimal cutoff value of the pelvic inlet plane area was 10074 mm². Narrow pelvic inlet plane area (≤ 10074 mm²) predicted anastomotic leakage with a sensitivity of 90%, a specificity of 85.9%, and an accuracy of 86.3%.

Narrow pelvic inlet and obesity were independent risk factors for anastomotic leakage after ISR. Anastomotic leakage after ISR may be predicted from a narrow pelvic inlet plane area (≤ 10074 mm²).

• Intersphincteric resection
• Anastomotic leakage
• Pelvimetry
• Pelvic dimensions
• Pelvic inlet plane area
• Rectal cancer

Purpose: To evaluate the effectiveness of the comprehensive post-operative management including low-frequency endo-anal electrical stimulation and daily suppository usage on post-operative anal functional recovery for low rectal cancer patients who underwent robotic total intersphincteric resection (ISR).

Methods: A retrospective analysis was performed on 42 low rectal cancer patients who underwent robotic total ISR, of which 23 patients received comprehensive post-operative management, including biofeedback low-frequency endo-anal electrical stimulation and daily suppository usage (management group). Wexner score and anorectal manometric values, including resting pressure (RP), maximum squeeze pressure (MSP), initial perceived volume (IPV), and maximum tolerated volume (MTV), were assessed and compared.

Results: A total of 42 low rectal cancer patients were included in our study. The RP at 6 months after ISR (40.95 ± 6.95 mmHg vs. 33.29 ± 5.40 mmHg, p = 0.002) and MSP at 3 and 6 months after ISR (72.05 ± 10.16 mmHg vs. 69.05 ± 8.67 mmHg, p = 0.031; 91.57 ± 15.47 mmHg vs. 84.05 ± 12.94 mmHg, p = 0.039, respectively) were significantly higher in the management group. The median IPV at 1 and 3 months after ISR (17.81 ± 3.61 ml vs. 15.43 ± 5.08 ml, p = 0.038; 20.19 ± 4.35 ml vs. 17.67 ± 5.16 ml, p = 0.044, respectively) and MTV at 3 months after ISR (83.71 ± 5.44 ml vs. 76.10 ± 8.42 ml, p = 0.012) were significantly higher in the management group. Wexner scores at 1 and 3 months after closure of stoma (COS) in the management group were significantly lower (11.3 ± 2.9 vs. 13.4 ± 3.0, p = 0.041; 8.9 ± 2.0 vs. 10.6 ± 2.4, p = 0.036, respectively).

Conclusions: Comprehensive post-operative management could accelerate the recovery of sphincteric function and anal sensitivity after robotic total ISR and could also contribute to treatment of fecal incontinence followed by COS.

• anal function
• biofeedback
• intersphincteric resection (ISR)
• low rectal cancer
• robotic

• Adolescent
• Adult
• Aged
• Female
• Humans
• Male
• Middle Aged
• Young Adult
• Chemoradiotherapy
• Disease-Free Survival
• Laparoscopy/adverse effects
• Margins of Excision
• Neoadjuvant Therapy
• Neoplasm Recurrence, Local
• Postoperative Complications
• Proctectomy/adverse effects
• Prospective Studies
• Quality of Life
• Rectal Neoplasms/surgery
• Rectal Neoplasms/therapy
• Survival Analysis
• Treatment Outcome
• Clinical Trials, Phase I as Topic
• Clinical Trials, Phase II as Topic
• Non-Randomized Controlled Trials as Topic

• LARS—low anterior resection syndrome
• functional results
• intersphincteric resection (ISR)
• neoadjucant chemoradiation
• rectal cancer

• Local excision
• Neoadjuvant chemoradiotherapy
• Rectal cancer
• TEM
• Total mesorectal excision
• Transanal endoscopic microsurgery

• Chemoradiotherapy, Adjuvant
• Digestive System Surgical Procedures/methods
• Humans
• Margins of Excision
• Neoplasm Staging
• Organ Sparing Treatments/methods
• Patient Selection
• Quality of Life
• Rectal Neoplasms/pathology
• Rectal Neoplasms/therapy
• Treatment Outcome

To assess postoperative anal function and quality of life of ultra-low rectal cancer patients treated by laparoscopic modified Parks surgery.

From February 2017 to March 2019, 114 patients with ultra-low rectal cancer above T2 were treated respectively with ultra-low anterior resection (Dixon), modified coloanal anastomosis (modified Parks), and Miles according to the preoperative stage and anastomotic position. The postoperative anal function and Fecal Incontinence Quality of Life Scale (FIQL) of each patient were collected and synthetically analyzed.

Compared with the Dixon group, the postoperative anal function and FIQL in the Parks group were poor at the early stage. However, from 6 to 12 months after surgery, the scores of anal function and FIQL in the Parks group were similar to those in the Dixon group (P > 0.05). Compared with the Miles group, the FIQL of the two groups were similar in the early postoperative stage. However, with the passage of time, from 3 to 9 months after surgery, the four domains of FIQL in the Parks group were higher than those in the Miles group successively (P < 0.05).

Laparoscopic modified Parks is a safe, effective, and economical anus-preserving surgery. Although its early anal function and FIQL were poor, it could gradually recover to the similar level as Dixon. Moreover, it can save the anus and obtain a better postoperative quality of life for some patients who previously could only undergo Miles.

• Anal function
• Anus-preserving surgery
• FIQL
• Modified transanal coloanal anastomosis (Parks surgery)
• Rectal cancer
• Ultra-low position

Rectal amputation (RA) remains an important surgical procedure for salvage despite advances in sphincter-preserving resection, including intersphincteric resection. The aim of this study was to compare short- and long-term outcomes of RA with an initial perineal approach to those of RA with an initial abdominal approach (conventional abdominoperineal resection (APR)) for primary anorectal cancer.

We retrospectively analyzed the short- and long-term outcomes of 48 patients who underwent RA with an initial perineal approach (perineal group) and 21 patients who underwent RA with an initial abdominal approach (conventional group).

For the perineal group, the operation time was shorter than that for the conventional group (313 vs. 388 min, p = 0.027). The postoperative complication rate was similar between the two groups (43.8 vs. 47.6%, p = 0.766). Perineal wound complications (PWCs) were significantly fewer in the perineal group than in the conventional group (22.9 vs. 57.1%, p = 0.006). All 69 patients underwent complete TME, but positive CRM was significantly higher in the conventional group than in the perineal group (0 vs. 19.0%, p = 0.011). There were no significant differences in the recurrence (43.8 vs. 47.6%, p = 0.689), 5-year disease-free survival (63.7% vs. 56.7%, p = 0.665) and 5-year overall survival rates (82.5% vs. 66.2%, p = 0.323) between the two groups.

These data suggest that RA with an initial perineal approach for selective primary anorectal carcinoma is advantageous in minimizing PWCs and positive CRMs. Further investigations on the advantages of this approach are necessary.

• Low-lying rectal cancer near the anus
• Rectal amputation with an initial perineal approach
• Sphincter-preserving resection