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Hindawi Publishing Corporation International Journal of Surgical Oncology Volume 2011, Article ID 901574, 6 pages doi:10.1155/2011/901574 Clinical Study Clinical Outcome of Laparoscopic Intersphincteric Resection Combined with Transanal Rectal Dissection for T3 Low Rectal Cancer in Patients with a Narrow Pelvis 1 1 2 1 Kimihiko Funahashi, Hiroyuki Shiokawa, Tatsuo Teramoto, Junichi Koike, and Hironori Kaneko Department of Gastroenterological Surgery, Toho University Medical Center, Omori Hospital, 6-11-1 Omorinishi Otaku, Tokyo 1438541, Japan Department of Surgery, JyuJyo Hospital, Chiba prefecture, Japan Correspondence should be addressed to Kimihiko Funahashi, email@example.com Received 30 April 2011; Accepted 14 September 2011 Academic Editor: Giuseppe Nigri Copyright © 2011 Kimihiko Funahashi et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Purpose. The purpose of this study was to analyze the safety and feasibility of laparoscopic intersphincteric resection (ISR) combined with transanal rectal dissection (TARD) for T3 low rectal cancer in a narrow pelvis. Methods. We studied 20 patients with a narrow pelvis of median body mass index 25.3 (16.9–31.2). Median observation period was 23.6 months (range 12.2– 56.7). Results. Partial, subtotal, and total ISR was performed in 15, 1, and 4 patients, respectively. Median duration of TARD was 83 min (range 43–135). There were no major complications perioperatively or postoperatively. Surgical margins were histologically free of tumor cells in all patients, and there was no local recurrence. Excluding urgency, frequency of bowel movements, and incontinence status improved gradually after stoma closure. Conclusion. Laparoscopic ISR combined with TARD is technically feasible for selective T3 low rectal cancer in patients with a narrow pelvis. 1. Introduction in laparoscopic surgery for rectal cancer . We have shown that transanal rectal dissection (TARD) performed prior to Intersphincteric resection (ISR) to preserve anal sphincter the abdominal phase of the operation is very useful for function for low rectal cancer extending into the anal canal an adequate oncologic resection in laparoscopic ISR for T3 was reported by Schiessel et al. in 1994 . The feasibility low rectal cancer in patients with a narrow pelvis . The of ISR has been demonstrated by surgeons since that time; purpose of this report is to evaluate the safety and feasibility it is now technically possible to use ISR to remove low of TARD to achieve laparoscopic ISR for T3 low rectal cancers rectal cancer with preservation of anal sphincter function in patients with a narrow pelvis. with a satisfactory oncologic outcome [2, 3]. Recently, the clinical outcome of ISR as a laparoscopic approach (laparo- 2. Patients scopic ISR) has been reported, but laparoscopic ISR for Preoperative staging evaluation included digital rectal exam- patients with bulky low rectal cancer remains challenging. Particularly for T3 tumors in patients with a narrow pelvis, ination, barium enema, colonoﬁberscope with biopsy, com- puted tomography (CT), magnetic resonance imaging it is important to achieve a low local recurrence. Total mesorectal excision (TME), negative circumferential margin (MRI), and transanal ultrasound (TAUS). The patients were excluded when preoperative examination showed the follow- (CFM), and tumor free surgical margin are prerequisites regardless of approach of ISR. Conversion to open operation ing ﬁndings: multiple metastases in distant organs, direct in laparoscopic ISR may inﬂuence prognosis, as is the case invasion into adjacent organs (clinical T4), involvement of 2 International Journal of Surgical Oncology lateral lymph nodes, and invasion into the external anal Table 1: Characteristics of patients. sphincter or/and levator ani. We studied 20 patients (5 Parameter N = 20 women, 15 men) with a median age of 66 years (range 42– Median age 66 (42–77) 77 years) between April 2006 and December 2009. In all Gender: male/female 15/5 patients the tumors were bulky in nature, and narrow pelvic Median body mass index (kg/m ) 25.3 (16.9–31.2) dimensions were expected for laparoscopically assisted pelvic ﬂoor dissection on the basis of radiographic ﬁndings of bar- Preoperative TNM staging ium enema, CT, and MRI. Preoperative CRT was performed T3N0M0 8 in 2 men out of the 20 patients. Finally, preoperative TNM T3N1M0 9 staging of the 20 patients wasT3N0M0in8,T3N1M0in T3N2M0 2 9, T3 N2 M0 in 2, and T3 N3 M1 in one. Median body mass T3N3M1 1 2 2 index was 25.3 kg/m (range 16.9–31.2 kg/m )(Table 1). The ISR patients were observed for a median of 23.6 months (range Partial/subtotal/total 15/1/4 12.2–56.7 months). Median duration of TARD (min) 83 (43–135) Male 89 (50–135) 3. Surgical Technique Female 81 (43–97) Postoperative TNM staging Surgical technique regarding TARD has been described pre- viously . The operation is performed in the Lloyd-Davies ypT2N0M0 1 position. Prior to the laparoscopically assisted abdominal ypT3N0M0 1 phase, the anal portion of the operation is initiated. First, pT2N0M0 4 TAUS is performed to conﬁrm the depth of invasion. If TAUS pT2N1M0 2 shows tumor invasion to the external sphincter and/or the pT3N0M0 7 levator ani, an abdominoperineal resection (APR) should be pT3N1M0 2 chosen as the surgical procedure. The anal canal is exposed pT3N2M0 2 with a self-holding retractor (Lone Star Retractor, Lone pT3N2M1 1 Star Medical Products Inc., Houston, TX, USA). The distal Median tumor size (mm) 42 (15–75) side at the lower margin of the tumor is then closed with Median circumferential rate of tumor (%) 66 (27.7–90) purse-string sutures under direct visualization, followed by irrigation of the anal canal with 5% povidone-iodine. This Median distal margin (mm) 22.5 (7–40) step is important for preventing cancer cell dissemination in ISR: intersphincteric resection. the surgical ﬁeld. The division of the rectum is then initiated posteriorly at least 2 cm distal to the tumor margin. A circu- lar incision of the rectum is performed by closing the cut end ensure that the subsequent coloanal anastomosis is free of the rectum with an interrupted suture, and mobilization of tension. The sigmoid colon and its mesentery are then of the rectum, including the tumor, is continued proximally removed, the lymph nodes around the inferior mesenteric by exposing the levator ani. Invasion of tumor cells on the artery are dissected with a harmonic scalpel, and the inferior dissected plane (the external sphincter or/and the levator ani) mesenteric artery is ligated at a high level with an endoclip. should be evaluated by microscopic examination of a frozen- It is relatively easy to dissect Denonvillier’s fascia and expose section specimen histologically whenever mobilization of the seminal vesicles and prostate gland or the posterior wall the rectum is not easy. If any ﬁndings of tumor invasion of the vagina on the anterior side and to mobilize the lower into the dissected plane are found, the procedure should rectum and mesorectum from the sacrum on the separated be immediately converted to abdominoperineal resection plane between the visceral and parietal endopelvic fascia (APR). Division and mobilization of the rectum, including through the anus. The lateral ligaments of the rectum are the mesorectum, is performed until the peritoneal reﬂection gradually divided with a harmonic scalpel from the inner on the anterior side, and up until the sacral promontory limit of the inferior hypogastric nerve ﬁbers, and the rectum, beyond the rectosacral ligament, is nearly reached poste- including the total mesorectum, is completely removed from riorly. Finally, a Lap disc mini (HAKKO Group, Japan) is the pelvic ﬂoor. The colon and rectum are pulled out of the adapted to the anal canal to maintain pressure during laparo- umbilical wound and are resected. A coloanal anastomosis is scopy (Figure 1). transanally performed by hand suturing. Finally, a diverting Regarding the laparoscopic procedure, a camera port is ileostomy is created. The diverting ileostomy is reversed three inserted in the paraumbilical zone with a trocar, and an to six months after surgery (Figure 2). operative port in the mid-lower abdominal region, and two additional operative ports in the left and right Mc Burney’s point are inserted. On routine intra-abdominal exploration, 3.1. Functional Assessment. Sphincter function was evaluated the gauze that is placed on the dissected plane as a landmark clinically in 3, 6, and 12 months after stoma closure. The can be identiﬁed through the peritoneum on the anterior patients were questioned about frequency of bowel move- side of the rectum. The sigmoid and descending colon are ments, ability to defer defecation for 15 minutes (urgency), mobilized completely from the subretroperitoneal fascia to and satisfaction of defecation status using visual analogue International Journal of Surgical Oncology 3 (a) (b) (c) Figure 1: Transanal rectal dissection for a male patient with T3 low rectal cancer. A circular incision of the rectum was performed by closing the cut end of the rectum (a). The rectum including the tumor was mobilized proximally by exposing the levator ani (b, c). scale (VAS). Continence status was determined according to 12.5 nodes. Distant organ metastasis developed in 2 patients, the classiﬁcation of Wexner incontinence score (WIS). but there was no local recurrence. Eighteen out of 20 patients received stoma closure excluding one with distant metastasis and one who did not 4. Results want stoma closure. In this study sphincter function was investigated for twelve out of 18 patients in 3, 6, and 12 The numbers of patients undergoing partial, subtotal, and months after stoma closure. Half ten patients, experienced total ISR were 15, 1, and 4, respectively. There was no nine and more bowel movements a day, 8 (80%) complained conversion to an open operation. The median duration of urgency, and 8 (80%) reported ﬁve or less VAS in three TARD procedure was 83 min (range 43–135 min) and was months after stoma closure. In twelve months after stoma longer in males than in females (81 min versus 89 min). closure, the rate of the patients who experienced nine and Although there were no major complications perioperatively more bowel movements a day and reported ﬁve or less VAS or postoperatively, anastomotic stenosis in two male patients, decreased to 20% and 17%, respectively, but nine (75%) bowel obstruction in one male patient, and pelvic abscess complained urgency. Regarding continence status, the rate formation in one female patient occurred postoperatively. of the patients answered ten and more WIS in three months Morphologically, the median maximum tumor size was and twelve months after stoma closure were 50% and 33%, 42 mm (15–75 mm), and the median circumferential rate respectively (Table 2). of tumor was 66% (27.7–90.0%). The average distance from the rectal stump was 16 mm (range 7–40 mm), and circumferential and distal margins were histologically free 5. Discussion of tumor cells in all patients. Pathological response grading ISR has been shown to preserve anal sphincter function following preoperative CRT performed for two patients was and provide an adequate oncologic resection for low rectal grade 2 and grade 1b, respectively. Finally, postoperative cancers since Schiessel’s ﬁrst report in 1994. The pooled pathological staging was ypT2N0M0 in one, ypT3N0M0 in one, pT2N0M0 in 4, pT2N1M0 in 2, pT3N0M0 in 7, rate of local recurrence was 0–31%, with an average 5- year survival of 81.5%, in an evaluation of the experience pT3N1M0 in 2, pT3N2M0 in 2, and pT3N2M1 in one patient. The median number of evaluated lymph nodes was of 13 centers and 612 patients by Tilney and Tekkis . 4 International Journal of Surgical Oncology (a) (b) (c) (d) Figure 2: Laparoscopic procedure combined with transanal rectal dissection. The gauze that was placed on the dissected plane as a landmark was able to be identiﬁed through the peritoneum on the anterior side on the rectum. It was relatively easy to dissect Denonvillier’s fascia and expose the seminal vesicles and prostate gland (a). On the posterior side of the rectum, it was possible to mobilize the lower rectum and mesorectum from the sacrum on the separated plane between the visceral and parietal endopelvic fascia through the anus (b). The lateral ligaments of the rectum were gradually divided with a harmonic scalpel from the inner limit of the inferior hypogastric nerve ﬁbers. The rectum, including the total mesorectum, was completely removed from the pelvic ﬂoor (c, d). Table 2: Sphincter function after stoma closure. 3months(n = 10) 6months(n = 10) 12 months (n = 12) No. of patients (%) No. of patients (%) No. of patients (%) Urgency 8 (80) 8 (80) 9 (75) ≤3 1 (10) 3 (30) 3 (30) 4-5 3 (30) 3 (30) 6 (60) Frequency of bowel movements 6–8 0 1 (10) 1 (10) ≥9 5 (50) 3 (30) 2 (20) <5 8 (80) 4 (40) 2 (17) VAS 5–7 1 (10) 3 (30) 3 (25) ≥7 1 (10) 3 (30) 7 (58) <10 5 (50) 6 (60) 8 (67) WIS ≥10 5 (50) 4 (40) 4 (33) VAS: visual analogue scale, WIS: Wexners’ incontinence score. Recently, clinical outcomes of ISR as a laparoscopic approach laparoscopic approach and 65 patients undergoing an open have been reported, but laparoscopic ISR for bulky low approach and reported a satisfactory outcome of laparo- rectal cancer is challenging, especially for T3 low rectal scopic ISR, with a 5-year disease-free survival of 70% and a cancer in patients with a narrow pelvis. Laurent et al.  5-year local recurrence of 5%. Fujimoto et al.  also noted made a comparison between 110 patients undergoing the the advantages of laparoscopic ISR in their evaluation of International Journal of Surgical Oncology 5 35 patients with low rectal cancer. However, in these reports with ulcerative colitis complicated by T1 colorectal cancer; the inﬂuence of narrow pelvic dimensions on outcomes of feasibility for T3 low rectal cancer could not be evaluated laparoscopic ISR was not described. Also, Akasu et al.  due to the small number of patients. We also consider reported thatlocal controlfor T3 tumors wasdiﬃcult as that TARD as the transanal procedure performed prior compared with T1-T2 tumors. In our study, only patients to the laparoscopically assisted abdominal phase is very with T3 low rectal cancer and a narrow pelvis were included useful to achieve a good oncologic result with a low local in the analysis. With consideration of a good oncologic recurrence, when performed with laparoscopic ISR for bulky outcome with a low recurrence rate after surgery for T3 low rectal cancer, especially T3 low rectal cancer in patients low rectal cancer, some prerequisites are necessary regardless with a narrow pelvis. In fact, we experienced neither major of the ISR approach:TME,negativeCFM,and tumor-free complication nor conversion to open operation in this study. surgical margins. In most prior studies, pathological TNM For T3 tumors, a high local recurrence rate in patients stage and T stage were reported as important risk factors without radiotherapy was reported by Tekkis et al. , for prognosis. In addition, Akasu et al.  reported that but there was no local recurrence in selective patients the resection margin, focal diﬀerentiation, and serum CA with a narrow pelvis. However, this study was retrospective 19-9 level were important risk factors of local recurrence and limited by a short postoperative observation period in an evaluation of 120 patients with very low rectal cancer (median 23.6 months). Exclusion of patients with T4 tumors including 46 patients with stage III disease. In this study, with TAUS preoperatively may decrease local recurrence. In preoperative radiographic examination demonstrated bulky addition, TARD was able to dissect with adequate radial tumor occupying the pelvis in all patients. Although preop- margins around the tumor under direct vision even if the erative CRT in order to decrease the volume of tumor and tumor invaded near the levator ani and was considered to prevent local recurrence was performed only for two patients be eﬀective for a good oncologic outcome. In this study, secondary to preference, the resection margin including the preoperative CRT decreased the volume of the primary radial margin was histologically free of tumor in all patients tumor in one patient allowing for laparoscopic ISR. However, including patients without preoperative CRT. Conversion to the other patient had Grade 1b cancer, and preoperative open operation impacted signiﬁcantly on overall survival CRT was not considered to be eﬀective for laparoscopically except when considering long-term disease-free survival with assisted pelvic ﬂoor dissection. While some researchers have laparoscopic surgery for colorectal cancer . This subject reported a good correlation between the volume reduction deserves more than a passing notice, and conversion to open rate of primary tumor and pathologic tumor response of operation should be avoided to prevent local recurrence preoperative CRT [18, 19], complete pathological response in laparoscopic ISR as well. In general, the following risk rate wasreportedtobeonlyfrom7%to34.7% [20–22]. For factors for conversion to open operation from traditional some of the nonresponders, a histological reaction (ﬁbrosis laparoscopic surgery for rectal cancer were reported: obesity, and/or edema) may have occurred in the rectum itself, and bulky tumor, and bony pelvis. In laparoscopic ISR, these adjacent organs may have made pelvic dissection around the factors may make laparoscopically assisted pelvic dissection tumor more diﬃcult. even more challenging because these factors further conﬁne Sphincter function after ISR impacts on quality of life the surgical ﬁeld, hindering visualization and retraction in of patients signiﬁcantly. In this study, sphincter function a deep and narrow pelvis. Tekkis et al.  and Scheidbach was investigated for limited patients in 3, 6, and 12 months et al.  reported a direct correlation between increasing after stoma closure. Frequency of bowel movements and WIS body mass index and higher conversion rates for laparoscopic improved gradually, but the fact that 75% of the patients colorectal surgery. Bege ` et al.  and Yamamoto et al. complained urgency in 12 months after stoma closure can  conﬁrmed the correlation between body mass index hardly be ignored. Although preoperative radiation therapy, and conversion rate. In this study, laparoscopic ISR without volume of resected internal sphincter muscle, or gender was conversion to open operation was achieved for all patients, reported as poor risk factors of sphincteric dysfunction, these with a median body mass index of 25.3 kg/m and a median results could not be explained by these factors in this study tumor circumferential rate of 66%. [23–26]. In general, transanal manipulation for dissection of In conclusion laparoscopic ISR will be widely adopted as the tumor from the levator ani and external sphincter is an acceptable procedure to preserve anal sphincter function performed after the abdominal phase of ISR, including for low rectal cancer extending to the anal canal. Laparo- the procedure described by Schiesel. 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