Long-term efficacy and short-term outcomes of intersphincteric resection vs abdominoperineal resection in patients with ultra-low rectal cancer

doi:10.3748/wjg.v31.i29.110004

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Aug 7, 2025 (publication date) through Aug 5, 2025

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World Journal of Gastroenterology

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1007-9327

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Baishideng Publishing Group Inc, 7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA

Retrospective Study

World J Gastroenterol. Aug 7, 2025; 31(29): 110004
Published online Aug 7, 2025. doi: 10.3748/wjg.v31.i29.110004

Table 1 Baseline characteristics of patients before and after propensity score matching, n (%)

Variables	Before PSM			After PSM
Variables	ISR group (n = 435)	APR group (n = 368)	P value	ISR group (n = 289)	APR group (n = 289)	P value
Sex			0.575			0.559
Female	245 (56.3)	200 (54.3)		160 (55.4)	153 (52.9)
Male	190 (43.7)	168 (45.7)		136 (47.1)	136 (47.1)
Age (years)			0.084			0.676
≤ 50	106 (24.4)	71 (19.3)		55 (19.0)	59 (20.4)
> 50	329 (75.6)	297 (80.7)		234 (81.0)	230 (79.6)
BMI (kg/m²)			0.435			0.400
≤ 25	350 (80.5)	304 (82.6)		237 (82.0)	229 (79.2)
> 25	85 (19.5)	64 (17.4)		52 (18.0)	60 (20.8)
ASA grade			0.025			0.970
I	41 (9.4)	27 (7.3)		22 (7.6)	22 (7.6)
II	350 (80.5)	281 (76.4)		228 (78.9)	230 (79.6)
III	44 (10.1)	60 (16.3)		39 (13.5)	37 (12.8)
Tumour diameter (cm)			< 0.001			0.491
≤ 3	225 (51.7)	119 (32.2)		103 (35.6)	111 (38.4)
> 3	210 (48.3)	249 (67.7)		186 (64.4)	178 (61.6)
CEA (ng/mL)			< 0.001			0.846
≤ 5	353 (81.1)	261 (70.9)		218 (75.4)	220 (76.1)
> 5	82 (18.9)	107 (29.1)		71 (24.6)	69 (23.9)
CA19-9 (U/mL)			< 0.001			0.883
≤ 37	410 (94.3)	316 (85.9)		264 (91.3)	263 (91.0)
> 37	25 (5.7)	52 (14.1)		25 (8.7)	26 (9.0)
pT stage			< 0.001			0.819
≤ T3	388 (89.2)	271 (73.6)		243 (84.1)	245 (84.8)
T4	47 (10.8)	97 (26.4)		46 (15.2)	44 (15.2)
pN stage			0.045			0.724
N0	300 (69.0)	229 (62.2)		191 (66.1)	195 (67.5)
N+	135 (31.0)	139 (37.8)		98 (33.9)	94 (32.5)
pTNM stage			< 0.001			0.705
0	36 (14.0)	36 (9.8)		31 (10.7)	31 (10.7)
I	135 (31.0)	77 (20.9)		86 (29.8)	77 (26.6)
II	104 (23.9)	116 (31.5)		74 (25.6)	85 (29.4)
III	135 (31.0)	139 (37.8)		98 (33.9)	94 (32.5)
Histopathology			0.719			0.761
Adenocarcinoma	426 (97.9)	359 (97.6)		283 (97.9)	284 (98.3)
Mucinous adenocarcinoma	9 (2.1)	9 (2.4)		6 (2.1)	5 (1.7)
nCRT			0.383			0.244
No	197 (45.3)	178 (48.4)		151 (52.2)	137 (47.4)
Yes	238 (54.7)	190 (51.6)		138 (47.8)	152 (52.6)
Surgical procedures			0.714			0.864
Laparoscopy	391 (89.9)	337 (91.6)		263 (91.7)	265 (91.7)
Open	34 (7.8)	24 (6.5)		18 (6.2)	18 (6.2)
Robotic	10 (2.3)	7 (1.9)		8 (2.8)	6 (2.1)
ISR approach			-¹			-¹
Complete trans-pelvic	372 (85.5)	0 (0.0)		249 (86.2)	0 (0.0)
Mixed	63 (14.5)	0 (0.0)		40 (13.8)	0 (0.0)
APR	0 (0.0)	368 (100.0)		0 (0.0)	289 (100.0)

¹Non-participation in propensity score matching.

PSM: Propensity score matching; ISR: Intersphincteric resection; APR: Abdomen perineal resection; BMI: Body mass index; ASA: American Society of Anesthesiologists; nCRT: Neoadjuvant chemoradiotherapy.

Table 2 Comparison of distant metastatic sites between the abdomen perineal resection and intersphincteric resection groups, n (%)

Metastatic site	APR group (n = 289)	ISR group (n = 289)	Total (n = 578)	P value
Total distant	66 (22.8)	52 (18.0)	118 (20.4)	0.149
Lung	33 (11.4)	28 (9.7)	61 (10.6)	0.498
Liver	15 (5.2)	14 (4.8)	29 (5.0)	0.849
Bone	12 (4.2)	13 (4.5)	25 (4.3)	0.838
Pelvis	15 (5.2)	7 (2.4)	22 (3.8)	0.082
Abdominal cavity	15 (5.2)	6 (2.1)	21 (3.6)	0.045
Lateral lymph nodes	14 (4.8)	5 (1.7)	19 (3.3)	0.036
Retroperitoneal	13 (4.5)	2 (0.7)	15 (2.6)	0.004
Brain	2 (0.7)	6 (2.1)	8 (1.4)	0.286
Inguinal	4 (1.4)	0 (0.0)	4 (0.7)	0.124
Perineum area	3 (1.0)	0 (0.0)	3 (0.2)	1.000
Adrenal	1 (0.3)	0 (0.0)	3 (0.5)	0.559
Not common sites¹	14 (4.8)	7 (2.4)	21 (3.6)	0.120

¹Includes bladder, uterus, penis, prostate, presacral, other unknown sites.

APR: Abdomen perineal resection; ISR: Intersphincteric resection.

Table 3 Univariate and multivariate Cox regression analyses for overall survival in ultra-low rectal cancer patients after propensity score matching (n = 578)

Variable	Group	n (%)	Univariate analysis HR (95%CI)	P value	Multivariate analysis HR (95%CI)	P value
Surgery	APR	289 (50.0)
Surgery	ISR	289 (50.0)	0.546 (0.363-0.820)	0.004	0.554 (0.371-0.828)	0.004
Sex	Female	313 (54.2)
Sex	Male	265 (45.8)	1.108 (0.742-1.656)	0.616
Age (years)	≤ 50	114 (19.7)
Age (years)	> 50	464 (80.3)	1.068 (0.614-1.859)	0.815
BMI (kg/m²)	≤ 25	466 (80.6)
BMI (kg/m²)	> 25	112 (19.4)	1.466 (0.909-2.365)	0.117
CEA (ng/mL)	≤ 5	438 (75.8)
CEA (ng/mL)	> 5	140 (24.2)	1.556 (0.990-2.444)	0.055
CA19-9 (U/mL)	≤ 37	527 (91.2)
CA19-9 (U/mL)	> 37	51 (8.8)	1.771 (1.007-3.113)	0.047	2.150 (1.194-3.679)	0.005
pT stage	≤ T3	488 (84.4)
pT stage	T4	90 (15.6)	1.109 (0.632-1.947)	0.718
pN stage	N0	386 (66.8)
pN stage	N+	192 (33.2)	2.450 (1.067-5.629)	0.035	3.621 (2.426-5.404)	< 0.001
pTNM stage	0-II	386 (66.8)
pTNM stage	III	192 (33.2)	1.292 (0.826-2.022)	0.261
Histopathology	Adenocarcinoma	567 (98.1)
Histopathology	Mucinous adenocarcinoma	11 (1.9)	1.414 (0.532-3.763)	0.487
nCRT	No	288 (49.8)
nCRT	Yes	190 (50.2)	1.687 (1.062-2.679)	0.027
Surgical Procedures	Laparoscopy and Open	564 (97.6)
Surgical Procedures	Robotic	14 (2.4)	0.765 (0.432-1.355)	0.359
ASA grade	I-II	502 (86.9)
ASA grade	III	76 (13.1)	1.839 (1.130-2.992)	0.014	1.804 (1.194-2.726)	0.005
Tumour diameter (cm)	≤ 3	214 (37.0)
Tumour diameter (cm)	> 3	364 (63.0)	0.929 (0.598-1.444)	0.743

ISR: Intersphincteric resection; APR: Abdomen perineal resection; BMI: Body mass index; ASA: American Society of Anesthesiologists; nCRT: Neoadjuvant chemoradiotherapy.

Table 4 Comparison of postoperative complications between the abdomen perineal resection and intersphincteric resection groups

Complications	APR group (n = 289)	ISR group (n = 289)	P value
Overall complications	122 (42.2)	85 (29.4)	0.001
Pelvic infection	42 (14.5)	42 (14.5)	1.000
Bowel obstruction	22 (7.6)	25 (8.7)	0.648
Incision infection	46 (15.9)	3 (1.0)	< 0.001
Urinary retention	29 (10.0)	8 (2.8)	< 0.001
Anastomotic leakage/bowel perforation	3 (1.0)	33 (11.4)	< 0.001¹
Anastomotic leak grade			< 0.001
Grade A	0 (0.0)	3 (1.0)
Grade B	1 (0.3)	29 (10.0)
Grade C	2 (0.7)	1 (0.3)
Pneumonia	10 (3.5)	15 (5.2)	0.307
Circumferential resection margin	12 (4.2)	3 (1.0)	0.019
Chylous leakage	4 (1.4)	8 (2.8)	0.243
Anastomotic bleeding	0 (0.0)	7 (2.4)	0.015
Distal margin positive	0 (0.0)	4 (1.4)	0.124
Other rare complications²	7 (2.4)	6 (2.1)	0.779
Surgical time (min)	205.1 ± 95.8	229.8 ± 95.4	0.001
Hospitalization time (days)	12.9 ± 8.8	9.8 ± 5.2	< 0.001

¹Abdomen perineal resection group with bowel perforation, intersphincteric resection group with anastomotic leakage.

²Including 2 bladder leakage, 2 sepsis, 4 abdominal bleeding, 1 stroke, 2 urinary infection, 1 deep venous tethering and 1 ureteral damage.

Data are presented as n (%) or mean ± SD. ISR: Intersphincteric resection; APR: Abdomen perineal resection.

Citation: Wang GC, Chen JX, Pan HF, Ye K, Guo YC, Huang Y. Long-term efficacy and short-term outcomes of intersphincteric resection vs abdominoperineal resection in patients with ultra-low rectal cancer. World J Gastroenterol 2025; 31(29): 110004
URL: https://www.wjgnet.com/1007-9327/full/v31/i29/110004.htm
DOI: https://dx.doi.org/10.3748/wjg.v31.i29.110004