Intersphincteric Resection and Coloanal Anastomosis
Radical resection for low rectal cancer is the mainstay among the treatment modalities. Intersphincteric resection (ISR) is considered a relatively new but effective surgical treatment for low-lying rectal tumor. With the advance of treatment modality, pa
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Min Soo Cho and Nam Kyu Kim
Abstract
Radical resection for low rectal cancer is the mainstay among the treatment modalities. Intersphincteric resection (ISR) is considered a relatively new but effective surgical treatment for low-lying rectal tumor. With the advance of treatment modality, patients who have undergone abdominoperineal resection in the past can be treated with ISR. Furthermore, preoperative chemoradiation induces tumor downstaging and facilitates anal sphincter- preserving surgery. To achieve good oncologic outcomes, appropriate patient selection based on magnetic resonance imaging (MRI) is also important because MRI provides accurate information on the extent of tumor invasion and the anal canal structures. On top of all, meticulous surgical technique based on anatomical dissection is essential. Future investigations should be directed in improving functional outcomes after ISR. Keywords
Rectal neoplasm · Intersphincteric resection Coloanal anastomosis · Operative technique Operative outcome
M. S. Cho • N. K. Kim (*) Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea e-mail: [email protected]
Abbreviations 3-D Three-dimensional APR Abdominoperineal resection CAA Coloanal anastomosis CRM Circumferential resection margin CRT Chemoradiation therapy ISR Intersphincteric resection MRI Magnetic resonance imaging TME Total mesorectal excision TRUS Transrectal ultrasonography uLAR Ultralow anterior resection
17.1 Introduction The primary goal for the surgical treatment of rectal cancer is to achieve an oncologic cure while preserving function. Total mesorectal excision (TME) is the standard surgical procedure for rectal cancer. The concept of TME is the elimination of potential sources of local recurrence by completely excising the mesorectum through sharp pelvic dissection [1]. TME has evolved to include the tailored removal of the mesorectum with adequate mucosal margins that are determined according to the distance of the tumor from the anal verge [2]. However, surgical treatment for low rectal cancer remains challenging, particularly with regard to the preservation of the anal sphincter. Anatomically, the mesorectum
© Springer Nature Singapore Pte Ltd. 2018 N. K. Kim et al. (eds.), Surgical Treatment of Colorectal Cancer, https://doi.org/10.1007/978-981-10-5143-2_17
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disappears at a distance of 1–2 cm above the anorectal sling, and only the rectal wall remains to the anal hiatus. Thus, there are greater risks of direct tumor invasion of the adjacent structures and of a positive circumferential resection margin (CRM) in low rectal lesions. In 1977, Lyttle and Parks [3] used the term “intersphincteric excision” in the context of surgical treatment for inflammatory bowel disease, and the authors described the dissection of the anal canal and rectum via the intersphincteric plane. In 1981, Shafix [4] also described a technique for anorectal mobilization through the intersphincteric plane for the treatment of benign and malignant rectal diseases. In 1982, Par
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