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Anus-Preserving Surgery in Advanced Low-Lying Rectal Cancer: A Perspective on Oncological Safety of Intersphincteric Resection

Authors
Piozzi, Guglielmo NiccoloBaek, Se-JinKwak, Jung-MyunKim, JinKim, Seon Hahn
Issue Date
Oct-2021
Publisher
MDPI
Keywords
abdominoperineal resection; advanced rectal cancer; anatomy; anus-preserving surgery; intersphincteric resection; laparoscopic surgery; minimally invasive surgery; pelvic local recurrence; robotic surgery; sphincter-saving surgery
Citation
CANCERS, v.13, no.19
Indexed
SCIE
SCOPUS
Journal Title
CANCERS
Volume
13
Number
19
URI
https://scholar.korea.ac.kr/handle/2021.sw.korea/136198
DOI
10.3390/cancers13194793
ISSN
2072-6694
Abstract
Simple Summary</p> Intersphincteric resection (ISR) is the ultimate anus-preserving surgical technique for very low-lying rectal cancers. The oncological safety of ISR has been frequently discussed, especially relatively to abdominoperineal resection. This review critically discusses the oncological safety of ISR by evaluating the anatomical characteristics of the deep pelvis, the clinical indications, the role of distal and circumferential resection margins, the role of the neoadjuvant chemoradiotherapy, the outcomes between surgical approaches (open, laparoscopic, and robotic), the comparison with abdominoperineal resection, the risk factors for oncological outcomes and local recurrence, the patterns of local recurrences after ISR, considerations on functional outcomes after ISR, and learning curve and surgical education on ISR.</p> The surgical management of low-lying rectal cancer, within 5 cm from the anal verge (AV), is challenging due to the possibility, or not, to preserve the anus with its sphincter muscles maintaining oncological safety. The standardization of total mesorectal excision, the adoption of neoadjuvant chemoradiotherapy, the implementation of rectal magnetic resonance imaging, and the evolution of mechanical staplers have increased the rate of anus-preserving surgeries. Moreover, extensive anatomy and physiology studies have increased the understanding of the complexity of the deep pelvis. Intersphincteric resection (ISR) was introduced nearly three decades ago as the ultimate anus-preserving surgery. The definition and indication of ISR have changed over time. The adoption of the robotic platform provides excellent perioperative results with no differences in oncological outcomes. Pushing the boundaries of anus-preserving surgeries has risen doubts on oncological safety in order to preserve function. This review critically discusses the oncological safety of ISR by evaluating the anatomical characteristics of the deep pelvis, the clinical indications, the role of distal and circumferential resection margins, the role of the neoadjuvant chemoradiotherapy, the outcomes between surgical approaches (open, laparoscopic, and robotic), the comparison with abdominoperineal resection, the risk factors for oncological outcomes and local recurrence, the patterns of local recurrences after ISR, considerations on functional outcomes after ISR, and learning curve and surgical education on ISR.</p>
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