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Technical, functional, and oncological validity of robot-assisted total-intersphincteric resection (T-ISR) for lower rectal cancer

  • Jin Cheon Kim
    Correspondence
    Corresponding author. Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, 88, Olympic-ro-43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.
    Affiliations
    Division of Colorectal Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea
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  • Jong Lyul Lee
    Affiliations
    Division of Colorectal Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea
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  • Chan Wook Kim
    Affiliations
    Division of Colorectal Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea
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  • Jung Rang Kim
    Affiliations
    Division of Colorectal Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea
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  • Jihun Kim
    Affiliations
    Department of Pathology, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea
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  • Seong Ho Park
    Affiliations
    Department of Radiology, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea
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      Abstract

      Background

      Few studies fairly compared anorectal function and prognostic outcomes between patients undergoing abdominoperineal resection (APR) and anorectal-function-saving operations (ASO) under the equivalent conditions. By contrast, surgeons used to be somewhat hesitant to conduct total intersphincteric resection (T-ISR) as maximal ASO, due to its technical complexity and potential anorectal dysfunction.

      Methods

      Propensity-score matched cohorts undergoing robot-assisted R0 surgery [T-ISR vs APR vs partial-subtotal ISR (PS-ISR)/lower anterior resection (LAR)] for rectal cancer (n = 1361) were included. Operative outcomes, recurrence, and disease-free/overall survival (DFS/OS) were analyzed. Anorectal function was evaluated based on fecal incontinence score and high-resolution manometry between the T-ISR and other ASO groups.

      Results

      Few differences were detected between the T-ISR and APR groups. More patients undergoing APR had T4 stage disease, while the lowest tumor margin was the same in both groups (mean, 1.5 cm from anal verge). Prognostic outcomes did not differ between the T-ISR and APR groups, including local (5.1% vs 7.7%, p = 1) or systemic (15.4% vs 25.6%, p = 0.401) recurrence, and 5-year DFS (78.7% vs 61.5%, p = 0.1) and OS (89% vs 82.1%, p = 0.434) rates, nor were there differences between the T-ISR and PS-ISR/LAR groups. The PS-ISR group generally showed less anorectal dysfunction than the T-ISR group, but maximal tolerance volume did not differ between these two groups and was within the range for the healthy population.

      Conclusions

      T-ISR can replace most traditional APR, except for advanced T4 disease with aggressive infiltration into the levator-sphincters, and can provide tolerable anorectal dysfunction.

      Keywords

      Abbreviations:

      APR (abdominoperineal resection), ASO (anorectal-function saving operation), CI (confidence interval), CRM (circumferential resection margin), EAS (external anal sphincter), HR (hazard ratio), IAS (internal anal sphincter), ILM (intersphincteric longitudinal muscle), ISR (intersphincteric resection), LAM (levator ani muscle), LAR (lower anterior resection), MRP (mean resting pressure), MSP (maximal squeezing pressure), MTV (maximal tolerance volume), OR (odds ratio), PRM (puborectalis muscle), PS-ISR (partial and subtotal ISR), R0 (curative resection with microscopically margin-negative resection), TILME (total ILM excision), T-ISR (total ISR)
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