Purpose. The purpose of this study was to analyze the safety and feasibility of laparoscopic intersphincteric resection (ISR) combined with transanal rectal dissection (TARD) for T3 low rectal cancer in a narrow pelvis. Methods. We studied 20 patients with a narrow pelvis of median body mass index 25.3 (16.9–31.2). Median observation period was 23.6 months (range 12.2–56.7). Results. Partial, subtotal, and total ISR was performed in 15, 1, and 4 patients, respectively. Median duration of TARD was 83？min (range 43–135). There were no major complications perioperatively or postoperatively. Surgical margins were histologically free of tumor cells in all patients, and there was no local recurrence. Excluding urgency, frequency of bowel movements, and incontinence status improved gradually after stoma closure. Conclusion. Laparoscopic ISR combined with TARD is technically feasible for selective T3 low rectal cancer in patients with a narrow pelvis. 1. Introduction Intersphincteric resection (ISR) to preserve anal sphincter function for low rectal cancer extending into the anal canal was reported by Schiessel et al. in 1994 . The feasibility of ISR has been demonstrated by surgeons since that time; it is now technically possible to use ISR to remove low rectal cancer with preservation of anal sphincter function with a satisfactory oncologic outcome [2, 3]. Recently, the clinical outcome of ISR as a laparoscopic approach (laparoscopic ISR) has been reported, but laparoscopic ISR for patients with bulky low rectal cancer remains challenging. Particularly for T3 tumors in patients with a narrow pelvis, it is important to achieve a low local recurrence. Total mesorectal excision (TME), negative circumferential margin (CFM), and tumor free surgical margin are prerequisites regardless of approach of ISR. Conversion to open operation in laparoscopic ISR may influence prognosis, as is the case in laparoscopic surgery for rectal cancer . We have shown that transanal rectal dissection (TARD) performed prior to the abdominal phase of the operation is very useful for an adequate oncologic resection in laparoscopic ISR for T3 low rectal cancer in patients with a narrow pelvis . The purpose of this report is to evaluate the safety and feasibility of TARD to achieve laparoscopic ISR for T3 low rectal cancers in patients with a narrow pelvis. 2. Patients Preoperative staging evaluation included digital rectal examination, barium enema, colonofiberscope with biopsy, computed tomography (CT), magnetic resonance imaging (MRI), and transanal ultrasound (TAUS). The
D. G. Jayne, H. C. Thorpe, J. Copeland, P. Quirke, J. M. Brown, and P. J. Guillou, “Five-year follow-up of the medical research council CLASICC trial of laparoscopically assisted versus open surgery for colorectal cancer,” British journal of surgery, vol. 97, no. 11, pp. 1638–1645, 2010.
K. Funahashi, J. Koike, T. Teramoto et al., “Transanal rectal dissection: a procedure to assist achievement of laparoscopic total mesorectal excision for bulky tumor in the narrow pelvis,” American Journal of Surgery, vol. 197, no. 4, pp. e46–e50, 2009.
C. Laurent, T. Paumet, F. Leblanc, Q. Denost, and E. Rullier, “Intersphincteric resection for low rectal cancer: laparoscopic versus open surgery approach,” Colorectal Disease, vol. 14, no. 1, pp. 35–41, 2012.
Y. Fujimoto, T. Akiyoshi, H. Kuroyanagi et al., “Safety and feasibility of laparoscopic intersphincteric resection for very low rectal cancer,” Journal of Gastrointestinal Surgery, vol. 14, no. 4, pp. 645–650, 2010.
T. Akasu, M. Takawa, S. Yamamoto, S. Fujita, and Y. Moriya, “Incidence and patterns of recurrence after intersphincteric resection for very low rectal adenocarcinoma,” Journal of the American College of Surgeons, vol. 205, no. 5, pp. 642–647, 2007.
T. Akasu, M. Takawa, S. Yamamoto et al., “Intersphincteric resection for very low rectal adenocarcinoma: univariate and multivariate analyses of risk factors for recurrence,” Annals of Surgical Oncology, vol. 15, no. 10, pp. 2668–2676, 2008.
P. P. Tekkis, A. J. Senagore, and C. P. Delaney, “Conversion rates in laparoscopic colorectal surgery: a predictive model with 1253 patients,” Surgical Endoscopy and Other Interventional Techniques, vol. 19, no. 1, pp. 47–54, 2005.
H. Scheidbach, F. Benedix, O. Hügel, D. Kose, F. K？ckerling, and H. Lippert, “Laparoscopic approach to colorectal procedures in the obese patient: risk factor or benefit?” Obesity Surgery, vol. 18, no. 1, pp. 66–70, 2008.
T. Bège, B. Lelong, D. Francon, O. Turrini, J. Guiramand, and J. R. Delpero, “Impact of obesity on short-term results of laparoscopic rectal cancer resection,” Surgical Endoscopy and Other Interventional Techniques, vol. 23, no. 7, pp. 1460–1464, 2009.
S. Yamamoto, M. Fukunaga, N. Miyajima, J. Okuda, F. Konishi, and M. Watanabe, “Impact of conversion on surgical outcomes after laparoscopic operation for rectal carcinoma: a retrospective study of 1,073 patients,” Journal of the American College of Surgeons, vol. 208, no. 3, pp. 383–389, 2009.
T. Teramoto, M. Watanabe, and M. Kitajima, “Per anum intersphincteric rectal dissection with direct coloanal anastomosis for lower rectal cancer,” Diseases of the Colon and Rectum, vol. 40, 10, pp. S43–S47, 1997.
M. Watanabe, T. Teramoto, H. Hasegawa, and M. Kitajima, “Laproscopic ultralow anterior resection combined with per anum intersphincteric rectal dissection for lower rectal cancer,” Diseases of the Colon and Rectum, vol. 43, 1, pp. s94–s97, 2000.
J. H. Yoo, H. Hasegawa, Y. Ishii, H. Nishibori, M. Watanabe, and M. Kitajima, “Long-term outcome of per anum intersphincteric rectal dissection with direct coloanal anastomosis for lower rectal cancer,” Colorectal Disease, vol. 7, no. 5, pp. 434–440, 2005.
F. Uchikoshi, T. Nishida, S. Ueshima, M. Nakahara, and H. Matsuda, “Laparoscope-assisted anal sphincter-preserving operation preceded by transanal procedure,” Techniques in Coloproctology, vol. 10, no. 1, pp. 5–9, 2006.
S. G. Yeo, D. Y. Kim, T. H. Kim et al., “Tumor volume reduction rate measured by magnetic resonance volumetry correlated with pathological tumor response of preoperative chemoradiatiotherapy for rectal cancer,” International Journal of Radiation Oncology Biology Physics, vol. 78, no. 1, pp. 164–171, 2010.
J. H. Kang, Y. C. Kim, H. Kim et al., “Tumor volume changes assessed by three-dimensional magnetic resonace volumetry in rectal cancer patients after preoperative chemoradiation: the impact of volume reduction ration on the prediction of pathologic complete response,” International Journal of Radiation Oncology Biology Physics, vol. 76, no. 4, pp. 1018–1025, 2010.
T. Sato, H. Ozawa, K. Hatate et al., “A phase II trial of neoadjuvant preoperative chemoradiotherapy with S-1 plus irinotecan and radiation in patients with locally advanced rectal cancer: clinical feasibility and response rate,” International Journal of Radiation Oncology, Biology, Physics, vol. 79, no. 3, pp. 677–683, 2011.
S. J. Shin, N. K. Kim, K. C. Keum et al., “Phase II study of preoperative chemoradiotherapy(CRT) with irinitecan plus S-1 in locally advanced rectal cancer,” Radiotherapy and Oncology, vol. 95, no. 3, pp. 303–307, 2010.
M. Ito, N. Saito, M. Sugito, A. Kobayashi, Y. Nishizawa, and Y. Tsunoda, “Analysis of clinical factors associated with anal function after intersphincteric resection for very low rectal cancer,” Diseases of the Colon and Rectum, vol. 52, no. 1, pp. 64–70, 2009.
K. Yamada, S. Ogata, Y. Saiki, M. Fukunaga, Y. Tsuji, and M. Takano, “Functional results of intersphincteric resection for low rectal cancer,” British Journal of Surgery, vol. 94, no. 10, pp. 1272–1277, 2007.
A. P. Pietsch, R. Fietkau, G. Klautke, T. Foitzik, and E. Klar, “Effect of neoadjuvant chemoradiation on postoperative fecal continence and anal sphincter function in rectal cancer patients,” International Journal of Colorectal Disease, vol. 22, no. 11, pp. 1311–1317, 2007.