Intersphincteric Resection Pushing the Envelope for Sphincter Preservation

Abstract

During the last 15 years, a significant evolution has emerged in the surgical treatment of rectal cancer and restoration of bowel continuity has been one of the main goals. For many years the treatment of distal rectal cancer would necessarily require an abdominoperineal resection and end colostomy. The surgical procedure of intersphincteric resection has been proposed to offer sphincter preservation in patients with low rectal cancer and has been legitimized if executed according to adequate oncologic criteria. This article will discuss the best indications, technical aspects, functional, and oncological outcomes of intersphicteric resection in the management of rectal cancer.

Keywords: intersphincteric resection; radiochemotherapy; rectal cancer.

Fig. 1

Anatomy of the low rectum. (Reprinted with permission from Shihab OC, Heald RJ, Rullier E, et al. Defining the surgical plane on MRI improves surgery for cancer of the low rectum. Lancet Oncol. 2009;10(12):1207–1211.)

Fig. 2

Classification of low rectal cancer. Type I are treated by conventional coloanal anastomosis, type II by partial intersphincteric resection (ISR), type III by total ISR, and type IV by APE. APE: Abdominoperineal excision, AR: anal ring, DL: dentate line; AV: anal verge. (Reprinted with permission from Rullier E, Denost Q, Vendrely V, Rullier A, Laurent C. Low rectal cancer: classification and standardization of surgery. Dis Colon Rectum. 2013;56(5):560–567.)

Fig. 3

Exposition and circular incision of the anal canal. (Reprinted with permission from Laurent C, Rullier E. Intersphincteric rectal resection [in French]. J Chir (Paris) 2007;144(3):225–230.)

Fig. 4

Dissection of the intersphincteric bloodless plane by scissors. (Reprinted with permission from Laurent C, Rullier E. Intersphincteric rectal resection [in French]. J Chir (Paris) 2007;144(3):225–230.)

Fig. 5

Posterior dissection. The plane between the internal and the external sphincters is initially behind the presacral facia and becomes in front to find the mesorectal plane.

Fig. 6

Evolution of Wexner's score after ISR. (Reprinted with permission from Denost Q, Laurent C, Capdepont M, Zerbib F, Rullier E. Risk factors for fecal incontinence after intersphincteric resection for rectal cancer. Dis Colon Rectum 2011;54(8):963–968.)

Fig. 7

Male urogenital function after rectal surgery for cancer. (Reprinted with permission from Adam JP, Denost Q, Capdepont M, van Geluwe B, Rullier E. Prospective and longitudinal study of urogenital dysfunction after proctectomy for rectal cancer. Dis Colon Rectum 2016;59(9):822–830.)

Fig. 8

Female sexual function after rectal surgery for cancer. (Reprinted with permission from Adam JP, Denost Q, Capdepont M, van Geluwe B, Rullier E. Prospective and longitudinal study of urogenital dysfunction after proctectomy for rectal cancer. Dis Colon Rectum 2016;59(9):822–830.)

Fig. 9

Plane of dissection of the low rectum accordingly to the abdominal (plane A) or transanal approach (plane B). (Reprinted with permission from Denost Q, Adam JP, Rullier A, Buscail E, Laurent C, Rullier E. Perineal transanal approach: a new standard for laparoscopic sphincter-saving resection in low rectal cancer, a randomized trial. Ann Surg 2014;260(6):993–999.)