Postoperative Hospital Stay After Laparoscopic Intersphincteric Resection for Lower Rectal Malignant Tumors

Seiichiro Yamamoto, PhD, Shin Fujita, PhD, Takayuki Akasu, MD, Masashi Takawa, Taihei Oshiro, MD

National Cancer Center Hospital

Introduction: For patients with lower rectal malignant tumor located within 4-5 cm from the anal verge, intersphincteric resection (ISR) was developed to avoid permanent colostomy; however, controversy still persists regarding the appropriateness of laparoscopic intersphincteric resection (Lap-ISR) because of concerns over the safety of the procedure and of the uncertainty of the long-term outcome. Lap-ISR involves many procedural complexities and technical difficulties, and Lap-ISR in patients with lower rectal malignant tumor is still technically demanding. It has been reported that postoperative hospital stay after Lap-ISR is around 9-18 days, much longer than that of other laparoscopic colorectal procedures. The aim of the present study was to report the reduced postoperative hospital stay after Lap ISR in our institution.

Patients and Methods: A review was performed of a prospective registry of 41 patients who underwent curative Lap-ISR for lower rectal carcinoma between December 2004 and August 2012. Candidate for Lap-ISR were basically patients who were preoperatively diagnosed with T1/2N0M0. After full mobilization of the left side colon and rectum, the intersphincteric plane between the puborectalis and the internal sphincter was dissected cautiously as caudally as possible under laparoscopic vision. Then, anal canal mucosa and the internal sphincter were circumferentially incised, and the intersphincteric plane was dissected by the anal approach. A per anum handsewn coloanal anastomosis was performed, and a temporary stoma was created. Patients were planned to be discharged within postoperative day 8 by the clinical pass. Patient demographics and outcomes were recorded prospectively.

Results: Operations were performed by three consultant surgeons, and all operations were completed laparoscopically in this series. There was no perioperative mortality. The median operative time was 338 minutes, and the median blood loss was 99 ml. Liquid and solid foods were started on median postoperative day 1 and 2, respectively. The median postoperative hospital stay was 8 days. Twenty postoperative complications occurred in 15 patients (36 percent), including subclinical anastomotic leakage in 2 and bowel obstruction in 2. Reoperation was not required in the present series. All the patients underwent ileostomy closure; however, one patient with a past history of esophagectomy for esophageal cancer hoped for a permanent stoma after ileostomy closure, because of diarrhea, and one patient required stoma after ileostomy closure because of late anastomotic leakage. The positive margin rate was 0 in the present series. At the end of the study period, cancer recurred in three patients (7.3%). One patient developed para-aortic and midiastinum lymph node metastasis 4 years after the initial operation, one patient developed local recurrence, and another patient developed pulmonary metastasis 2 years after the initial operation. The rate of patients discharged within postoperative day 8 was 4.8%(2/41).

Conclusion: The implementation of clinical pathway has led to the standardization of patient care and considerable decrease in length of postoperative hospital stay after Lap-ISR. It remains unclear, however, whether Lap-ISR is equivalent to conventional open surgery in terms of long-term oncological outcome and functional outcome, and this can only be answered through the accumulation of more patients prospectively.

Session: Poster Presentation

Program Number: P070

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