Intersphincteric resection for rectal cancer with pull through delayed anastomosis. An alternative to coloanal anastomos
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Hellenic Journal of Surgery (2016) 88:6, 417-421
Intersphincteric Resection for Rectal Cancer with Pull Through Delayed Anastomosis. An Alternative to Coloanal Anastomosis with Covering Ileostomy I. Bolanis, S. Bassioukas, D. Psilopoulos, D. Gialvalis, G. Filippou, R. Galanopoulou, M. Oikonomou, N. Spourlis
Abstract Standard surgical treatment for low rectal cancer below 5 cm from the anal verge used to be abdominoperineal resection (APR). In recent years sphincter saving techniques, like intersphincteric resection (ISR) proved to be an ongologically accepted alternative. Operations for ultra low rectal cancer are challenging and coloanal anastomosis is probably the source of most postoperative complications. We present ISR with pull-through delayed anastomosis (PTDA) as a surgical option for the management of elective cases, when standard coloanal anastomosis (CAA) is at greater risk of dehiscence or a covering stoma is refused or dangerous. Key words: Rectal cancer; intersphincteric resection (ISR); pull-through delayed anastomosis (PTDA); anastomotic salvage
Introduction Rectal cancer accounts for one third (28%) of colon cancer incidence. When dealing with a patient diagnosed with rectal cancer there are three goals to be achieved; treatment under strict oncological principles, optimal functional outcome and no permanent stoma. The establishment of total mesorectal excision [1] in combination with preoperative radio-chemotherapy [2] (RT/CHT) improved local control and survival for patients with rectal cancer. For lower third rectal cancer, located less than 5 cm from the anal verge (AV) or less than 2 cm from the dentate line (DL), abdominoperineal resection (APR) was considered the standard surgical procedure. Patients undergoing APR usually have problems with their quality of life due to the permanent colostomy [3,4]. Low anterior resection (LAR) with stapling techniques [5] and intersphincteric resection (ISR) [6] with sutured coloanal anastomosis (CAA) proved equal to APR in terms of oncological results [7-9], with better functional outcomes. In ISR the use of a diverting ileostomy is mandatory to minimize the risk of anastomotic leak or dehiscence, still total complication rate is 7.3 to 17%. In these cases, the I. Bolanis, D. Gialvalis, G. Filippou, R. Galanopoulou Clinic of General, Laparoscopic and Digestive Surgery, Athens Medical Center, Greece S. Bassioukas, D. Psilopoulos, M. Oikonomou, N. Spourlis 2nd Department of Gastroenterology, Athens Medical Center, Greece Corresponding author: Ioannis Bolanis Director Clinic of General, Laparoscopic and Digestive Surgery, Athens Medical Center, Greece, Tel.:+30 6945 588 540 e-mail: [email protected] Received 13 Sept 2016; Accepted 15 Oct 2016 Hellenic Journal of Surgery 88
reintervention to salvage the anastomosis may be extremely difficult and often a permanent colostomy is necessitated. We use a modified ISR with pull-through delayed anastomosis (ISR-PTDA), with or without diverting ileostomy, to minimize the risk of dehiscence in elective cases.
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