Sphincter-preserving surgical techniques in low rectal cancer management: A systematic review of contemporary evidence

Abstract

Rectal cancer ranks as the third most prevalent malignancy globally, with an estimated 1.9 million incident cases reported in 2020. The management of low rectal cancer presents significant therapeutic challenges due to its anatomical complexity, and substantially impacts patients' quality of life. While abdominoperineal resection (Miles procedure) ensures oncological radicality, the morbidity associated with permanent colostomy has driven innovations in sphincter-preserving surgical techniques. This review synthesizes current evidence on sphincter-preserving surgical approaches for low rectal cancer. The implementation of total mesorectal excision (TME) principles and enhanced understanding of circumferential resection margin have facilitated the evolution of diverse sphincter-preserving surgical modalities. These include local excision, low anterior resection (Dixon procedure), intersphincteric resection, pull-through procedures, transanal TME, and conventional sphincter-preserving operation. Minimally invasive approaches, particularly laparoscopic and robotic platforms, alongside natural orifice transluminal endoscopic surgery, have demonstrated improved surgical precision and enhanced postoperative recovery outcomes. Novel functional perineal reconstruction techniques offer promising alternatives for patients requiring posterior pelvic exenteration. Nevertheless, the high incidence of low anterior resection syndrome (LARS) and its chronic sequelae remain clinically notable. Evidence indicates that long-course neoadjuvant radiotherapy and TME constitute significant risk factors for LARS development. Contemporary sphincter-preserving surgery for low rectal cancer is advancing toward minimally invasive, personalized, and precision-based approaches. The increasing incidence of early-onset rectal cancer necessitates individualized treatment strategies that balance oncological efficacy with functional preservation. Future directions should focus on standardizing surgical indications, optimizing postoperative rehabilitation protocols, and enhancing treatment outcomes through multidisciplinary integration and technological innovation.

Keywords: Low rectal cancer; Sphincter-preserving surgery; Minimally invasive techniques; Functional reconstruction; Quality of life

Core Tip: The adoption of total mesorectal excision (TME) principle and better understanding of circumferential resection margin have led to the development of various sphincter-preserving surgeries, such as local excision, Dixon surgery, intersphincteric resection, etc. Minimally invasive methods such as laparoscopic, robotic and natural orifice transluminal endoscopic surgery improve operational precision and postoperative recovery. New perineal reconstruction techniques also benefit some patients. However, the high incidence of low anterior resection syndrome (LARS) and its sequelae are notable. Long-course neoadjuvant radiotherapy and TME are key risk factors for LARS.