• Laparoscopic complete mesocolic excision
• Laparoscopic-assisted right hemicolectomy
• Right-sided colon cancer
• Short-term outcomes
• Total laparoscopic right hemicolectomy

• anal function
• intersphincteric resection
• intersphincteric space
• oncological outcome

• National Natural Science Foundation of China

• Humans
• Male
• Female
• Retrospective Studies
• Laparoscopy/methods
• Rectal Neoplasms/surgery
• Aged
• Anastomosis, Surgical/methods
• Middle Aged
• Surgical Stapling/methods
• Anal Canal/surgery
• Treatment Outcome
• Rectum/surgery
• Postoperative Complications
• Organ Sparing Treatments/methods
• Follow-Up Studies

• Anal preservation
• ISR
• Intersphincteric resection
• Ultra-low rectal cancer

• Humans
• Rectal Neoplasms/surgery
• Rectal Neoplasms/pathology
• Rectal Neoplasms/diagnosis
• Anal Canal/surgery
• Anal Canal/pathology
• Treatment Outcome
• Neoplasm Staging
• Proctectomy/methods
• Proctectomy/adverse effects
• Digestive System Surgical Procedures/methods
• Organ Sparing Treatments/methods
• Quality of Life

• circumferential tumor location
• local recurrence
• low rectal cancer
• total hiatal ligament excision

• Humans
• Rectal Neoplasms/surgery
• Rectal Neoplasms/pathology
• Rectal Neoplasms/mortality
• Male
• Female
• Middle Aged
• Neoplasm Recurrence, Local
• Aged
• Ligaments/surgery
• Prognosis
• Laparoscopy/methods
• Retrospective Studies
• Rectum/surgery
• Rectum/pathology
• Proctectomy/methods
• Propensity Score

• laparoscopic surgery
• meta‐analysis
• non‐inferiority
• open surgery
• rectal cancer

• Humans
• Laparoscopy/methods
• Laparoscopy/adverse effects
• Margins of Excision
• Postoperative Complications/epidemiology
• Postoperative Complications/etiology
• Proctectomy/methods
• Proctectomy/adverse effects
• Randomized Controlled Trials as Topic
• Rectal Neoplasms/surgery
• Rectal Neoplasms/mortality
• Rectal Neoplasms/pathology
• Treatment Outcome

• Beijing Shijitan Hospital Professionals Training Program (NO.2023LJRCDL)

• Humans
• Anal Canal
• Dissection
• Rectal Neoplasms/surgery
• Laparoscopy

Intersphincteric resection (ISR), the ultimate anus-preserving technique for ultralow rectal cancers, is an alternative to abdominoperineal resection (APR). The failure patterns and risk factors for local recurrence and distant metastasis remain controversial and require further investigation.

To investigate the long-term outcomes and failure patterns after laparoscopic ISR in ultralow rectal cancers.

Patients who underwent laparoscopic ISR (LsISR) at Peking University First Hospital between January 2012 and December 2020 were retrospectively reviewed. Correlation analysis was performed using the Chi-square or Pearson's correlation test. Prognostic factors for overall survival (OS), local recurrence-free survival (LRFS), and distant metastasis-free survival (DMFS) were analyzed using Cox regression.

We enrolled 368 patients with a median follow-up of 42 mo. Local recurrence and distant metastasis occurred in 13 (3.5%) and 42 (11.4%) cases, respectively. The 3-year OS, LRFS, and DMFS rates were 91.3%, 97.1%, and 90.1%, respectively. Multivariate analyses revealed that LRFS was associated with positive lymph node status [hazard ratio (HR) = 5.411, 95% confidence interval (CI) = 1.413-20.722, P = 0.014] and poor differentiation (HR = 3.739, 95%CI: 1.171-11.937, P = 0.026), whereas the independent prognostic factors for DMFS were positive lymph node status (HR = 2.445, 95%CI: 1.272-4.698, P = 0.007) and (y)pT3 stage (HR = 2.741, 95%CI: 1.225-6.137, P = 0.014).

This study confirmed the oncological safety of LsISR for ultralow rectal cancer. Poor differentiation, (y)pT3 stage, and lymph node metastasis are independent risk factors for treatment failure after LsISR, and thus patients with these factors should be carefully managed with optimal neoadjuvant therapy, and for patients with a high risk of local recurrence (N + or poor differentiation), extended radical resection (such as APR instead of ISR) may be more effective.

• Rectal cancer
• Intersphincteric resection
• Laparoscopic surgery
• Recurrence
• Risk factors

• Humans
• Robotic Surgical Procedures/methods
• Retrospective Studies
• Robotics/methods
• Rectal Neoplasms/surgery
• Rectal Neoplasms/pathology
• Pelvis

• Abdominoperineal resection (APR)
• Functional anatomy
• Oncological validity
• Rectal cancer
• Robot-assisted
• Total intersphincteric resection (T-ISR)

While laparoscopic colonoscopy was reported by several surgeons in the early 1990s, laparoscopic colorectal surgery has been attempted sporadically since 1992 in Korea. Then, in 2000, the Korean Laparoscopic Colorectal Surgery Study Group was established. Didactic lectures, videos, and live surgery by the early pioneers of this group inspired and helped many surgeons initiate the laparoscopic approach to the treatment of colorectal disease. As a result, the penetration rate of minimally invasive colorectal cancer surgery nationwide is increasing to 80% in 2018. As a witness on this journey, I would like to share my personal minimally invasive colorectal cancer surgery history and perspectives on future surgery in this field.

The operative results of different approaches for the laparoscopic intersphincteric resection (LAISR) of low rectal cancer vary, and the patient characteristics associated with the best outcomes for each procedure have not been reported. We compared the efficacy of different approaches for LAISR of low rectal cancer and discussed the surgical indications for each approach.

We retrospectively reviewed data from 235 patients with low rectal cancer treated via LAISR from October 2010 to September 2016. Patients underwent either the transabdominal approach for ISR (TAISR, n = 142), the transabdominal perineal approach for ISR (TPAISR, n = 57), or the transanal pull-through approach for ISR (PAISR, n = 36).

The PAISR and TAISR groups exhibited shorter operation times and less intraoperative blood loss than the TPAISR group. The anastomotic distance was shorter in the PAISR and TPAISR groups than in the TAISR group. No differences in the ability to perform radical resection, overall complications, postoperative recovery, Wexner score recorded 12 months after ostomy closure, 3-year disease-free survival, local recurrence-free survival, distant metastasis-free survival, or overall survival (OS) were observed among the three groups.

TAISR, TPAISR, and PAISR have unique advantages and do not differ in terms of operation safety, patient outcomes, or anal function. TPAISR requires a longer time to complete and is associated with more bleeding and a slower recovery of anal function. PAISR should be considered when TAISR cannot ensure a negative distal margin and the tumor and BMI are relatively small; otherwise, TPAISR is required.

• Anal function
• Intersphincteric resection
• Laparoscopy
• Low rectal cancer
• Operative approach

• Laparoscopic intersphincteric resection
• Nomogram
• Permanent stoma
• Prediction model
• Ultralow rectal adenocarcinoma

• abdominoperineal resection
• advanced rectal cancer
• anatomy
• anus-preserving surgery
• intersphincteric resection
• laparoscopic surgery
• minimally invasive surgery
• pelvic local recurrence
• robotic surgery
• sphincter-saving surgery

• B1901101 Korea University Internal Research Grant

• cancer
• minimal invasive surgery
• rectal cancer
• robotic surgery

• Laparoscopic surgery
• Long-term outcome
• Propensity score matching
• Rectal cancer
• Total mesorectal excision

• Cohort Studies
• Humans
• Laparoscopy
• Length of Stay
• Neoplasm Recurrence, Local
• Postoperative Complications/etiology
• Propensity Score
• Rectal Neoplasms/surgery
• Retrospective Studies
• Treatment Outcome

• cancer
• gastroenterology
• oncology

• Humans
• Rectal Neoplasms/therapy
• Rectal Neoplasms/surgery
• Rectal Neoplasms/pathology
• Rectal Neoplasms/mortality
• Male
• Female
• Middle Aged
• Neoadjuvant Therapy/methods
• Aged
• Minimally Invasive Surgical Procedures/methods
• Treatment Outcome
• Chemoradiotherapy/methods
• Adult
• Length of Stay
• Disease-Free Survival
• Retrospective Studies

• Korea Health Industry Development Institute

• Anal sparing surgery
• Intersphincteric resection
• Minimally invasive surgery
• Pelvic local recurrence
• Rectal cancer
• Robotic surgery

• Abdominoperineal resection
• Intersphincteric resection
• Needlescopic surgery
• Pain

• Laparoscopic surgery
• Low rectal cancer
• Mid/high rectal cancer
• Oncological outcomes
• Propensity score matching

• Prone jackknife position
• Prostatic enlargement
• Prostatic hypertrophy
• Rectal cancer
• Total mesorectal excision
• Transanal approach

• APR
• LARS
• LARS score
• nCRT
• very low rectal cancer

Laparoscopic surgery for rectal cancer is widely performed all over the world and several randomized controlled trials have been reported. However, the usefulness of laparoscopic surgery compared with open surgery has not been demonstrated sufficiently, especially for the low rectal area.

The aim of this study was to investigate the hypothesis that laparoscopic primary tumor resection is safe and effective when compared with the open approach for locally advanced low rectal cancer.

Data from patients with clinical stage II to III low rectal cancer below the peritoneal reflection were collected and analyzed. The operations were performed from 2010 to 2011. Short-term outcomes and long-term prognosis were analyzed with propensity score matching.

Of 1608 cases collated from 69 institutes, 1500 cases were eligible for analysis. The cases were matched into 482 laparoscopic and 482 open cases. The mean height of the tumor from the anal verge was 4.6 cm. Preoperative treatment was performed in 35% of the patients. The conversion rate from laparoscopic to open surgery was 5.2%. Estimated blood loss during laparoscopic surgery was significantly less than that during open surgery (90 vs 625 mL, P < 0.001). Overall, the occurrence of complications after laparoscopic surgeries was less than that after open surgeries (30.3% vs 39.2%, P = 0.005). Three-year overall survival rates were 89.9% [95% confidence interval (95% CI) 86.7–92.4] and 90.4% (95% CI 87.4–92.8) in the laparoscopic and open groups, respectively, and no significant difference was seen between the 2 groups. No significant difference was observed in recurrence-free survival (RFS) between the 2 groups (3-year RFS: 70.9%, 68.4 to 74.2 vs 71.8%, 67.5 to 75.7).

Laparoscopic surgery could be considered as a treatment option for advanced, low rectal cancer below the peritoneal reflection, based on the short-term and long-term results of this large cohort study (UMIN-ID: UMIN000013919).

Rectal cancer is frequent in Germany and worldwide. Several studies have assessed laparoscopic surgery as a treatment option and most have shown favorable results. However, long-term oncologic safety remains a controversial issue.

The current dataset derives from 30 clinical cancer registries in Germany and includes 16,378 patients diagnosed with rectal cancer between 2007 and 2016. Outcomes were 90-day mortality, overall survival (OS), local recurrence-free survival (RFS) and relative survival of patients treated with either open or laparoscopic surgery. Multivariable logistic regression was used to evaluate factors that affected the probability of a patient undergoing laparoscopic surgery as well as to evaluate short-term mortality. OS and RFS were analyzed by Kaplan–Meier plots and multivariable Cox regression conducted separately for UICC stages I–III, tumor location, and sex as well as by propensity score matching followed by univariable and multivariable survival analysis.

Of 16,378 patients, 4540 (27.7%) underwent laparoscopic surgery, a trend which increased during the observation period. Patients undergoing laparoscopy attained better results for 90-day mortality (odds ratio, OR 0.658, 95% confidence interval, CI 0.526–0.822). The 5-year OS rate in the laparoscopic group was 82.6%, vs. 76.6% in the open surgery group, with a hazard ratio (HR) of 0.819 in multivariable Cox regression (95% CI 0.747–0.899, p < 0.001). The laparoscopic group showed a better 5-year RFS, with 81.8 vs. 74.3% and HR 0.770 (95% CI 0.705–0.842, p < 0.001). The 5-year relative survival rates were also in favor of laparoscopy, with 93.1 vs. 88.4% (p = 0.012).

Laparoscopic surgery for rectal cancer can be performed safely and, according to this study, is associated with an oncological outcome superior to that of the open procedure. Therefore, in the absence of individual contraindications, it should be considered as a standard approach.

• Health services research
• Long-term survival
• Minimal invasive surgery
• Rectal cancer
• Retrospective analysis
• Short-term survival

• Adult
• Aged
• Datasets as Topic
• Female
• Germany
• Humans
• Laparoscopy
• Male
• Middle Aged
• Proctectomy/methods
• Propensity Score
• Rectal Neoplasms/mortality
• Rectal Neoplasms/surgery
• Rectum/surgery
• Regression Analysis
• Retrospective Studies
• Survival Analysis
• Survival Rate
• Treatment Outcome

• Deep venous thrombosis
• Pulmonary embolism
• Rectal surgery
• Surgical outcomes
• Venous thromboembolism

• Circumferential resection margin
• Preoperative chemoradiotherapy
• Prognosis
• Rectal cancer
• Stage
• Tumor regression grade

• Defecatory function
• Intersphincteric resection
• Low rectal cancer
• Oncological outcome

• Human epidermal growth factor receptor 2
• Preoperative chemoradiotherapy
• Prognosis
• Rectal cancer
• Silver in situ hybridization

• Adenocarcinoma/enzymology
• Adenocarcinoma/genetics
• Adenocarcinoma/pathology
• Adenocarcinoma/therapy
• Adult
• Aged
• Aged, 80 and over
• Biomarkers, Tumor/genetics
• Chemoradiotherapy, Adjuvant
• Disease-Free Survival
• Female
• Gene Amplification
• Genetic Predisposition to Disease
• Humans
• Immunohistochemistry
• In Situ Hybridization
• Male
• Microsatellite Instability
• Middle Aged
• Mutation
• Neoadjuvant Therapy
• Neoplasm Staging
• Neoplasm, Residual
• Phenotype
• Polymerase Chain Reaction
• Predictive Value of Tests
• Proto-Oncogene Proteins B-raf/genetics
• Proto-Oncogene Proteins p21(ras)/genetics
• Receptor, ErbB-2/genetics
• Rectal Neoplasms/enzymology
• Rectal Neoplasms/genetics
• Rectal Neoplasms/pathology
• Rectal Neoplasms/therapy
• Retrospective Studies
• Risk Factors
• Time Factors
• Treatment Outcome

The aim of this review is to evaluate the outcomes after an intersphincteric resection (ISR) for patients with low-lying rectal cancer. Reports published in the literature regarding surgical, oncological, and functional outcomes of an ISR were reviewed. The morbidity after an ISR was 7.7%–32%, and anastomotic leakage was the most common adverse event. Local recurrence rates ranged from 0% to 12%, 5-year overall survival rates ranged from 62% to 92%, and rates of major incontinence ranged from 0% to 25.8% after an ISR. An ISR is a safe procedure for sphincter-saving rectal surgery in patients with very low rectal cancer; it does not compromise the oncological outcomes of the resection and is a valuable alternative to an abdominoperineal resection. While the functional outcomes after an ISR were found to be acceptable, the long-term functional outcome and quality of life still require careful investigation. ISRs have been performed with surgical and oncologic safety on patients with low-lying rectal cancer. However, patients must be selected very carefully for an ISR, considering the associated functional derangement and the limited extent of the resection.

• Functional outcome
• Intersphincteric resection
• Low-lying rectal cancer
• Oncologic outcome

• Anorectal function
• Intersphincteric resection
• Low anterior resection
• Rectal cancer

• Intersphincteric resection
• Laparoscopic
• Meta-analysis
• Rectal cancer

• Laparoscopic resection
• Minimally invasive surgery
• Rectal cancer
• Robotic resection

• Intersphincteric resection
• Laparoscopic surgery
• Rectal carcinoma

• Intersphincteric resection
• Low rectal cancer
• Neoadjuvant chemoradiation
• Outcome
• Sphincter sparing surgery

• anastomotic leak
• anterior resection
• ileostomy
• rectal cancer
• spontaneously closing cannula ileostomy

Anastomotic leakage (AL) is one of the most dreadful postoperative complications because it can result in increased morbidity and mortality as well as poorer long-term prognosis. Although most studies of AL limited their investigation time to a period of 30 days postoperatively, only a few studies have shown that AL can occur after that period. Here, we report four patients of rectal cancer with delayed AL following laparoscopic intersphincteric resection (ISR) and conduct a literature review on delayed AL.

Case 1 was a 67-year-old male who underwent laparoscopic partial ISR in July 2009. Although the patient was asymptomatic, an anastomotic-urethral fistula was observed 57 months after ISR. Case 2 was a 44-year-old female who underwent laparoscopic partial ISR in July 2008. She presented with discharge of gas and feces from her vagina, and an anastomotic-vaginal fistula was observed 14 months after ISR. Case 3 was a 74-year-old man who underwent laparoscopic partial ISR in August 2007. He presented with pneumaturia and fecaluria, and an anastomotic-urethral fistula was observed 4 months after ISR. Case 4 was a 68-year-old woman who underwent laparoscopic subtotal ISR for rectal cancer in February 2013 and partial hepatic resection for liver metastases in March 2013. She presented with anal pain and purulent perineal discharge, and an anastomotic-perineal fistula was observed 9 months after ISR. All four cases presented with fistula formation and required reoperation (establishment of a diverting ileostomy).

Since delayed AL is not a rare postoperative complication, surgeons need to provide long-term follow-up and remain alert to the possible development of delayed AL.

• Delayed anastomotic leakage
• Intersphincteric resection
• Rectal cancer
• Surgery

• Abdominoperineal resection
• Intersphincteric resection
• Open
• Rectal cancer
• Robot

• Anal Canal/pathology
• Anal Canal/surgery
• Fecal Incontinence/etiology
• Female
• Humans
• Male
• Middle Aged
• Neoplasm Recurrence, Local/pathology
• Organ Sparing Treatments
• Postoperative Care
• Rectal Neoplasms/pathology
• Rectal Neoplasms/surgery
• Robotics/methods
• Survival Analysis
• Treatment Outcome

Intersphincteric resection (ISR) has rapidly increased worldwide including laparoscopic surgery. However, there are some concerns for the definition of ISR, surgical technique, oncological outcome, anal function, and quality of life (QoL). The aim of the present study is to evaluate those issues. A review of this surgical technique was carried out by searching English language literature of the PubMed online database and appropriate articles were identified. With regard to open‐ISR, the morbidity rate ranged from 7.5% to 38.3%, with lower mortality rates. Local recurrence rates varied widely from 0% to 22.7%, with a mean follow‐up duration of 40–94 months. Disease‐free and overall 5‐year survival rates were 68–86% and 76–97%, respectively. Those outcomes were equivalent to laparoscopic‐ISR. Surgical and oncological outcomes of ISR were generally acceptable. However, accurate evaluation of anal function and QoL was difficult because of a lack of standard assessment of various patient‐related factors. The surgical and oncological outcomes after ISR seem to be acceptable. The ISR technique seems to be valid as an alternative to abdominoperineal resection in selected patients with a very low rectal cancer. However, both necessity for ISR and expectations of QoL impairment as a result of functional disorder should be fully discussed with patients before surgery.

• functional outcome
• intersphincteric resection
• local recurrence
• oncological outcome
• rectal cancer
• survival

For low rectal cancer located < 5 cm from the anal verge, abdominoperineal resection (APR) with permanent sigmoid colostomy is usually used to ensure the R0 resection. Sphincter saving surgery has emerged in the last 20 years, and the introduction of intersphincteric resection (ISR) can successfully preserve the anal function and guarantee a radical tumor resection for patients with ultra-low lying tumors. Therefore, the use of APR has been consistently declining worldwide. Recently, a growing body of research on ISR has been reported. However, more evidence based results are needed to clarify some issues about ISR. In the current review, we discuss the indications for ISR and the oncological and functional outcomes following the procedure. Some technique issues of ISR are also discussed.

• Intersphincteric resection
• Low rectal cancer
• Abdominoperineal resection