| Part one Intersphincteric resection versus abdominoperineal resection for lower rectal cancer:a retrospective controll studyObjective:The aim of this study was to compare the short-term safety and the oncologic results of intersphincteric resection(ISR)and abdominoperineal resection(APR).To assess the effective of intersphincteric resection for lower rectal cancer.Methods:This was a retrospective case controll study.Between April 2006 and June2016,patients of lower rectal cancer located within 5 cm from the anal verge underwent curative ISR and APR.A data collection and comparison was performed which included baseline characteristics of patients,operation,recovery,complication,pathological characteristics and oncological outcome.Results:There were 163 patients undergoing APR and 251 undergoing ISR.The ISR group had more patients with T1 tumor(16.3%vs.4.3%,p=0.000)and more with stage I(45.0%vs.25.2%,p=0.000)than APR group had.Meanwhile,the ISR group took more operation time than APR group did(260 min vs.200 min,p=0.000).The ISR group got distal margins with 1.8±0.5cm.There are 6 cases anastomotic fistula and 23 cases anastomotic stricture in ISR group.After 47.9±28.6 month follow-up,there are 66 and 50cases undergoing reccurence and metastasis,respectively in APR and ISR group.27 and 15cases underwent local reccurence in APR and ISR group,respectively.The 5-year cumulative survival rates,cumulative recurrence-free survival rates and cumulative local recurrence-free survival rates in patients who underwent ISR/APR were 75.6%/82.5%,56.2%/72.1%,80.7%/91.3%.There were no differences between 2 operation groups with stage I or III in 5-year cumulative survival rates,recurrence-free survival rates and local recurrence-free survival rates(p>0.05).In stage II cases,the rate of 5-year cumulative survival and recurrence-free survival were higher in the ISR group than in the APR group(p<0.05).The rates of 5-year cumulative survival,recurrence-free survival and local recurrence-free survival were higher in the ISR group than in the APR group for T3–4tumors(p<0.05).Conclusion:ISR is a safe surgical procedure for patients of lower rectal cancer located within 5 cm from the anal verge.It does not compromise oncologic results compared with abdominoperineal resection.This procedure may be an good alternative of sphincter preservation operation for low rectal cancer.Part two Influences of different types of Intersphincteric resection on anal functionObjective:To investigate influences of different types of intersphincteric resection on anal function.Methods:Between December 2006 and June 2016,199 cases of patients with rectal cancer were selected and respectively treated with low anterior resection(group A),partial ISR(group B),subtotal ISR(group C)and total ISR(group D).There were 31,71,58 and 39cases in group A,group B,group C and group D,respectively.Anorectal manometry and Wexner Score were used to trace dynamic changes of anal function of the four groups of patients in one year follow up after operations.Results:The anal function of the four groups of patients all decreased after operation,but the change trends of variables were different.Anal high-pressure zone(HPZ)length in A,B,C and D groups reduced to different extents after operations.With extend of postoperative time,HPZ length increased slightly.By the end of postoperative 12 months,they were(32.4±6.3)mm,(25.8±4.9)mm,(20.9±5.2)mm,(15.9±3.9)mm for A,B,C and D groups,respectively,and there were always significant differences between each other(p<0.05).For the maximum resting pressure of anal canal,the four groups significantly reduced.By the end of postoperative 12 months,they restored to different of levels:A group restored to(11.0±1.8)kPa,almost preoperative level;B group and C group rose to2/3 of preoperative level,(8.6±1.4)kpa and(8.3±1.9)kpa,respectively.D group rose to 1/3of preoperative level.For Wexner score,after operation,A,B,C and D groups increased,subsequently.Then,B group and C group maintained the same decrease trend.By the end of postoperative 12 months,the Wexner score of B group and C group were 3.2±2.6,5.2±2.6,respectively.There was no significant difference between two groups(p>0.05).Multiple regression analysis showed that by the end of postoperative 12 month,the postoperative HPZ length and maximum resting pressure were significantly and negatively associated with the subjective Wexner score of fecal incontinence(F=38.336,p=0.000,R~2=0.498).Conclusions:The postoperative anal fuction of the patients with low rectal cancer presented reversible dynamic changes.By the end of postoperative 12 months,the majority of the patients could restore a more satisfactory anal function.The postoperative HPZ length and maximum resting pressure were associated with the subjective Wexner score.Part three The feasibility study of intersphincteric resection with conformal incision at orthotopic anal canal for lower rectal cancerObjective:The aim of this study was to assess the safety and feasibility of intersphincteric resection(ISR)with conformal incision at orthotopic anal canal(CIOAC)for lower rectal cancer located within 2 cm from the dental line.Methods:Modified the incision of various ISR depended on Saito’s classification.Between December 2006 and June 2016,patients of lower rectal cancer located within 2cm from the dental line underwent classical ISR(A group)and ISR with conformal incision at orthotopic anal canal(B group).A data collection and comparison was performed which included baseline characteristics of patients,operation,complication,anal function and oncological outcome.Results:There were 46 patients in A group and 35 patients in B group.The patients’baseline characteristics were similar in two treatment groups(p>0.05).There were no differences between 2 operation groups in operation time,hospital stays and blood loss(p>0.05).The B group had higher rate of temporary stoma than A group(85.7%vs.61.7%,p<0.05).There was no positive of distal margin both in 2 groups,and there was no difference between 2 operation groups in the lenth of distal margin.Both one anastomotic fistula were in 2 groups,and there were 4 and 3cases of anastomotic stricture in A,B group,respectively.There were no differences between 2 operation groups in complications according to Clavien-Dindo grades(p>0.05).By the end of 1 year,the B group had higher anal maximum resting pressure,longer anal high-pressure zone length and lower Wexner score(all p<0.05).After 40.0±28.2 month follow-up,there were no differences between 2 groups in 3-year cumulative survival rates,recurrence-free survival rates and local recurrence-free survival rates(p<0.05).Conclusion:ISR with conformal incision at orthotopic anal canal could achieve better anal function than classical ISR,and we could get a safe distal margin and oncological outcome as similar to classical ISR for patients of lower rectal cancer located within 2 cm from the dentate line.Part four Simple instruments facilitating achievement of transanal total mesorectal excision through the extending intersphincteric plane in male patientsObjective:To assess the efficacy of a modified approach with transanal total mesorectal excision(taTME)through the extending intersphincteric plane using simple customized instruments when a giant tumor is encountered in patients with low rectal cancer.Methods:A total of 115 male patients with low rectal cancer from December 2006to August 2015 were retrospectively studied.All patients had a bulky tumor(tumor diameter≥40 mm).Forty-one patients(group A)underwent a classical approach of transabdominal TME and transanal intersphincteric resection(ISR),and the other 74patients(group B)underwent a modified approach with transabdominal TME,transanal ISR,and taTME through the extending intersphincteric plane.Some simple instruments including modified retractors and an anal dilator with a papilionaceous fixture were used to perform taTME.The operative time,quality of mesorectal excision,circumferential resection margin,local recurrence,and postoperative survival were evaluated.Results:All 115 patients had successful sphincter preservation.The operative time in group B(240 min,range:160–330 min)was significantly shorter than that in group A(280 min,range:200–360 min;p=0.000).Compared with group A,more complete distal mesorectum and total mesorectum were achieved in group B(100%vs.75.6%,p=0.000;90.5%vs.70.7%,p=0.008,respectively).After 46.1±25.6 mo follow-up,group B had a lower local recurrence rate and higher cumulative recurrence-free survival rate compared with group A,but these differences were not statistically significant(5.4%vs.14.6%,p=0.093;79.5%vs.65.1%,p=0.130).Conclusion:Retrograde taTME through the extending intersphincteric plane with simple customized instruments can achieve high-quality TME,and it might be an effective and economical alternative for male patients with bulky tumors.Part five The feasibility study of intersphincteric resection with anterior sagittal incision for lower anterior rectal cancerChapter One Clinical prognosis of lower anterior rectal cancerObjective:The aim of this study was to oberserve the oncologic outcome of lower rectal cancer located within 5 cm from the anal verge with or without anterior wall invaded.Methods:This was a retrospective case controll study.Between April 2006 and June2016,patients of lower rectal cancer located within 5 cm from the anal verge were included.A data collection and comparison was performed which included baseline characteristics of patients,operation,pathological characteristics,TNM stage,adjuvant therapy and oncological outcome.Results:There were 238 patients with anterior wall invaded(A group)and 176without anterior wall invaded(B group).There were no differences between 2 operation groups in age,sex,ASA grade,BMI,the length from tumor to anal verge,diameter of tumor,TNM stage,adjuvant chemotherapy(p>0.05).The A group had higher rate of poor pathologic differentiation and T4 than A group had(p<0.05).And The A group had higher rate of neoadjuvant chemoradiotherapy and APR operation than B group,however,there were no differences between 2 operation groups in these(p>0.05).After 47.9±28.6month follow-up,the rate of 5-year cumulative survival and recurrence-free survival were higher in the A group than in B group(p<0.05).Conclusion:The patients with anterior wall invaded in lower rectal cancer located have a worse oncologic outcome than those without anterior wall invaded.Chapter two The feasibility study of intersphincteric resection with anterior sagittal incision for lower anterior rectal cancerObjective:The aim of this study was to assess the safety and feasibility of intersphincteric resection(ISR)with anterior sagittal incision for lower anterior rectal cancer.Methods:Wedesignedanteriorsagittalincisionatperineumto achieve radical resection for lower anterior rectal cancer by exposuring the anterior of anorectum.Between December 2006 and June 2016,patients of lower anterior rectal cancer located within 4 cm from the anal verge underwent classical ISR(A group)and ISR with anterior sagittal incision(B group).A data collection and comparison was performed which included baseline characteristics of patients,operation,complication,anal function and oncological outcome.Results:There were 19 patients in A group and 16 patients in B group.There were no differences between 2 operation groups in age,ASA grades,BMI,diameter of tumor,intertuberal diameter,tumor differentiation,T-stage,TNM stage and adjuvant therapy(p>0.05).The B group had more male patients than A group(93.7%vs.57.9%,p<0.05).There was no difference between 2 operation groups in operation time,blood loss and hospital stays(p>0.05).All patients in B group underwent temporary stoma,but 63.2%in A group.There was no positive of distal margin both in 2 groups,and there was no difference between 2 operation groups in the lenth of distal margin.Status of circumferential resection margin was positive on 2 patients in A group,however,none in B group.There were one anastomotic fistula in A group,and there are 2 and 1cases in A,B group,respectively.Three and one patients underwent urinary retention in A and B group,respectively.There was no urinary tract infection.There were no differences between 2operation groups in complications according to Clavien-Dindo grades(p>0.05).At the end of 1 year,there were no differences between 2 operation groups in anal maximum resting pressure,anal high-pressure zone length and Wexner score(all p>0.05).After 39.8±25.3month follow-up,there were one patients underwent local reccurence in A group.no anastomotic recurrence.5 patients underwent metastasis.There were no differences between A,B group in 5-year cumulative survival rates,recurrence-free survival rates and local recurrence-free survival rates(85.7%vs.100%,62.2%vs.72.7%,94.7%vs.100%,all p>0.05).Conclusion:ISR with anterior sagittal incision could achieve accurate dissection of anterior rectal cancer without compromising on operation time,blood loss,complication and anal function.This procedure may be an safe and effective alternative for patients with low anterior rectal cancer. |
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