Introduction: Transanal intersphincteric resection (ISR) was introduced and has been increasingly performed as an ultimate surgical treatment for extremely low rectal cancer. Preoperative chemoradiation therapy (CRT) for rectal cancer reduces local recurrence and increases anal sphincter preservation rate. On the other hand, laparoscopic surgery is accepted as minimally invasive treatment for rectal cancer. We considered that high quality and less invasive surgery with preserving anal sphincter function could be achieved if ISR and preoperative CRT followed by laparoscopic surgery were combined.
Purpose: The aim of this study was to evaluate laparoscopic ISR with preoperative CRT for low rectal cancer.
Methods: This study included patients who performed laparoscopic ISR for rectal cancer after preoperative CRT. Preoperative CRT consists of 40Gy radiotherapy and chemotherapy by S-1. S-1 is a novel oral fluoropyrimidine inhibitory for dihydropyrimidine dehydrogenase and has potent radiosensitizing property. Surgical simulation consisted of 3-D CT including virtual colonography, MRI and PET-CT was performed. Tumor stages, operation time, intraoperative blood loss, complications and local recurrence were examined.
Results: Between December 2006 and July 2008, we performed laparoscopic ISR without lateral lymph node dissection after preoperative CRT for seven patients (male 5 and female 2) with very low rectal cancer. Mean age was 64 (41-77). Tumor size after CRT was 2.4 (0.5-5.5) cm in diameter and length between anal verge and tumor was 3.7 (3.0-5.0) cm in diameter. Tumor stages were as follows : T0,N0,M0(pathological complete response)=2, Tis,N0,M0=1, T1,N0,M0=1, T3,N0,M0=3. No patients converted open surgery. Median operation time was 374 min and median intraoperative blood loss was 220 ml. Complication was one anal fistula. Closure of covering stoma was performed in all patients. Median defecation time was 5 (2-10) and ejaculatory dysfunction occurred in one patient. Median follow-up was 20 months and no patients had local and distant recurrence.
Conclusions: Laparoscopic ISR with preoperative CRT is feasible and has favorable short-term results for the radical treatment of very low rectal disease, while preserving anal function. This operative procedure may be appropriate for locally advanced rectal cancers to avoid a permanent colostomy.
Program Number: P110