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Aim: Intersphincteric resection (ISR) is an oncologically complex operation for very low-lying rectal cancers. Yet, definition, anatomical description, operative indications and operative approaches to ISR are not standardized. The aim of this study was to standardize the definition of ISR by reaching international consensus from the experts in the field. This standardization will allow meaningful comparison in the literature in the future., Method: A modified Delphi approach with three rounds of questionnaire was adopted. A total of 29 international experts from 11 countries were recruited for this study. Six domains with a total of 37 statements were examined, including anatomical definition; definition of intersphincteric dissection, intersphincteric resection (ISR) and ultra-low anterior resection (uLAR); indication for ISR; surgical technique of ISR; specimen description of ISR; and functional outcome assessment protocol., Results: Three rounds of questionnaire were performed (response rate 100%, 89.6%, 89.6%). Agreement (≥80%) reached standardization on 36 statements., Conclusion: This study provides an international expert consensus-based definition and standardization of ISR. This is the first study standardizing terminology and definition of deep pelvis/anal canal anatomy from a surgical point of view. Intersphincteric dissection, ISR and uLAR were specifically defined for precise surgical description. Indication for ISR was determined by the rectal tumour's maximal radial infiltration (T stage) below the levator ani. A new surgical definition of T3isp was reached by consensus to define T3 low rectal tumours infiltrating the intersphincteric plane. A practical flowchart for surgical indication for uLAR/ISR/abdominoperineal resection was developed. A standardized ISR surgical technique and functional outcome assessment protocol was defined., (© 2023 Association of Coloproctology of Great Britain and Ireland.)

Background: The management of rectal cancer recognizes surgical resection as the most important step towards a permanent cure. Respecting the oncological principles, functional preservation represents a priority in achieving an acceptable quality of life for the patient. This study aimed to compare the results after low anterior resection (LAR) versus very low anterior resection (VLAR), in terms of postoperative outcome. Methods: We conducted a retrospective, observational study on a group of 147 patients with LAR or VLAR done for low rectal cancer in the 1st Department of General Surgery of the Emergency County Hospital of Targu Mures, between January 2015 and December 2019. We considered as low rectal cancer tumors located between 5-10 cm from the anal verge and very low those situated less than 5 cm from it. Patients were divided in two groups according to the type of operation. The postoperative evolution was followed. Results: The two groups, LAR with 81 and VLAR with 66 cases, had homogenous distribution regarding patients demographic and biological parameters and tumor pathological features. A significantly (p=0.0223) longer surgical intervention time was reported in VLAR than in LAR procedures. We found no statistically significant differences between LAR and VLAR in terms of associated postoperative morbidity or mortality, neither in hospitalization time. Conclusions: There was no statistical difference in terms of early postoperative outcomes among LAR and VLAR. The most important factor in achieving good oncologic and functional results in low rectal cancer is choosing the adequate, tailored to the case surgical management., (Celsius.)

Background and Objectives: The objective of this article is to evaluate the long-term oncological and functional outcomes following modified intersphincteric resections (ISR) for low rectal cancer. The modified technique consisted of the abandonment of colonic J-pouches, transverse coloplasty, or defunctioning temporary stoma in favor of a direct handsewn coloanal anastomosis (CAA)., Material and Methods: Sixty consecutive patients with type II and III (juxta-anal or intra-anal) low rectal tumors underwent modified ISR by the same surgical team and were followed for a period of five years. Functional outcomes using the Wexner Score, postoperative complications, recurrence rates, morbidity, and mortality rates were assessed., Results: The five-year survival rate was 93.3% with a disease-free interval at three years of 98%. Morbidity was 15% (n = 9) consisting of intestinal wall necrosis (n = 6), stenosis (n = 2), and sacral metastasis (n = 1). The Wexner score values were, at 1 year, 8.5 (range, 4-13); at three years 7.2 (range, 2-11); and at 5 years 6.7 (range, 2-12). A second surgery was needed in only one case that showed postoperative transmural necrosis of the colonic wall., Conclusions: In highly selected patients with type II or III low rectal tumors and proper preoperative imaging staging, ISR might be a viable alternative to other techniques such as abdominoperineal resection and low anterior resection, both from a functional and an oncological perspective., Competing Interests: The authors declare no conflict of interest

In patients with low rectal cancer, intersphincteric resection (ISR) technique is a better alternative of abdominoperineal resection (APR), but is recommended to be done in non-locally advanced stages (=T2) only. The aim of this study was to evaluate the long-term oncological outcome and survival rate in patients with early and locally advanced stages that underwent ISR, as compared to APR. In order to assess the quality of life and prognosis of patients with low rectal cancer, the 5-year follow-up was done in 72 consecutive cases diagnosed in pT1-T4 stage that underwent ISR or APR. Histopathological and clinical parameters were compared between the two included groups. Although the quality of life was better in patients which underwent ISR, the 5-year overall survival rate was not found to be influenced by the used surgical technique (71% for ISR and 58% for APR) either by the histological grade of differentiation (p=0.62), independently from the T stage (p=0.61). Regardless of the type of surgery, the independent prognostic factors proved to be lymph node status (p=0.001), lymph node ratio (p=0.001), and clinical stage (p=0.0001). Lymph node status remains the most important prognostic factor of patients with low rectal cancer. Independently from the histological subtype and depth of tumor infiltration, good oncological results can be obtained when performing ISR in selected cases.

Objective This study was performed to evaluate the 1-year survival rate and functional outcomes of 20 patients who underwent intersphincteric resection (ISR) for low rectal cancer. Methods Twenty patients who underwent ISR for low rectal cancer were followed up for 1 year. Complications, functional outcomes objectified by the Wexner score, and oncological outcomes were assessed. Results The short-term survival rate was 100%. The median Wexner score was ≤10 in all patients at 12 months after surgery. Signs of local recurrence were absent, and antigen levels remained within the reference ranges 1 year postoperatively. Conclusions ISR is a feasible alternative in highly selected patients who primarily refuse a colostomy bag and present with type II or III tumors. In the present study, patient-reported continence was satisfactory, and the absence of a colostomy bag increased patients' quality of life. The oncological outcomes were satisfactory at 1 year postoperatively.

The main target in rectal cancer management is an individualized therapeutic strategy, based on tumor and patient characteristics. The assessment of clinical and pathological factors is important because they represent powerful predictors of the postoperative outcome and have to be considered in the decision making regarding the appropriate surgical technique. The aim of the study was to analyze how the tumor clinical and pathological features correlate with the chosen type of surgical intervention in influencing survival of rectal cancer patients. We ran a retrospective study on 289 patients (N=289) surgically treated for rectal cancer. We analyzed the individual influence of the studied parameter on survival rate in multivariate analysis and we also grouped them in associations of parameter variations and performed a survival analysis for prognostic univariate analysis. For patients with vascular and lymphatic invasion and without perineural invasion, choosing a sphincter function preserving technique brought a better long-term outcome. The TNM stages showed the strongest statistically significant effect upon survival. Patients in T3 or T4 stage benefited best from a performed sphincter saving technique and the positive effect was even higher for those in N1 stage. Assessment of pathological parameters, in association with the type of the surgical procedure, has a strong predictive value upon survival. Sphincter function preserving techniques are followed by good long-term outcome. Accurate preoperative staging can help in choosing the best individualized therapeutic management improving the life expectancy of patients with rectal cancer.

In this paper, we present the successful therapeutic approach of unresectable liver metastases in a patient with rectal cancer.A 63-year-old male underwent endoscopic polypectomy followed by rectosigmoid resection for an adenocarcinoma of the rectum diagnosed in pT2N0 stage. The angio-computed tomography (CT) revealed four metastatic hepatic nodules ranging from 12 to 130 mm in diameter. After one cure of trans-arterial chemoembolization (TACE) with lipiodol and 5-fluorouracil, combined with FOLFOX4 + capecitabine systemic chemotherapy, the diameter of all hepatic nodules decreased to half size, at 6 months after TACE. Further curative surgical hepatic metastasectomy was done and complete pathologic response was obtained. The patient is free of recurrences and metastases after 26 months of follow-up.This representative case shows that an efficient trans-disciplinary approach could lead to successful therapeutic management even in patients with advanced-staged colorectal carcinomas.

Introduction: Although several studies have shown that the presence of acellular mucin pools in surgical specimens with rectal carcinomas examined after preoperative chemoradiotherapy indicated complete response to therapy, the proper meaning of these pools has yet to be elucidated. The aims of this study were to analyze the immunoprofile of acellular mucin pools and to review the relevant literature., Methods: In 30 consecutive rectal cancers that were preoperatively treated with chemoradiotherapy, the clinicopathologic features were correlated with the immunoexpression of AE1/AE3 keratin and carcinoembryonic antigen (CEA)., Results: Acellular mucin pools were present in all the cases, independently by their preoperative histological aspect. In remnant tumors (n=20), they were present at the invasion front and were marked by CEA. In cases without remnant tumor cells (n=10), they also displayed CEA positivity. In 2 of the 10 cases, isolated tumor cells were identified after multilevel sectioning of paraffin-embedded blocks., Conclusions: The presence of acellular mucin pools in surgical specimens of rectal cancers cannot be interpreted as an indicator of complete response to radiotherapy if at least 10 multilevel sections are performed in at least three tumor blocks per case, and CEA negativity is not proved.