Intersphincteric resection and coloanal anastomosis in the treatment of distal rectal cancers

Objective:In the evolving era of minimal access surgery,low rectal cancers still pose a challenge to laparoscopic or robotic surgeons.Hence,at our institute we intended to demonstrate the oncological efficacy of intersphincteric resection and coloanal anastomosis in the treatment of distal rectal cancers,performing the abdominal part of the procedure which includes rectal mobilization,laparoscopically.Methods:From February 2017 to March 2021,125 patients who had undergone intersphincteric resection and coloanal anastomosis via the perineal approach at Galaxy Care Laparoscopic Institute,Pune,were included in this study.Transabdominal mobilization of the rectum was performed laparoscopically.All patients had a diversion ileostomy and a pelvic drain.Patients were followed-up for a period of 18 months post-surgery.Data on clinical and oncological outcomes were collected and analysed.The pre-operative and post-operative Wexner incontinence scores were compared.Results:The mean time taken for surgery was 181.57±30.00 min.The mean blood loss was 119.76±42.53 mL.Most patients(103,82.4%)had their tumour at a distance of 1e2 cm from the anal verge.A loco-regional recurrence rate of 12.8%(16/125)was noted in our study.For the post-surgery Wexner score,74.4% of patients(93/125)had a score of 5 or less,depicting that three-quarters of the study population had satisfactory continence.Overall,81.6%of patients were satisfied with the functional results of surgery.Conclusion:Intersphincteric resection and coloanal anastomosis,with a 12.8%recurrence rate,can now be considered an oncological and technically feasible procedure with sphincter salvage and good continence.

EVALUATION OF PHYSIOLOGIC FUNCTION OF COLONIC POUCHANASTOMOSES AFTER EXCISION FOR RECTAL CANCER

Objective: To study the physiology value of colonic pouch anastomosis after rectal cancer excision. Methods: Forty-six patients with total mesonectal excision for carcinoma were randomized to either a straight (Group A, n=23) or a colonic pouch anastomosis (Group B, n=23). The neorectal physiologic function of patients in both groups was evaluated, which included laboratory studies. Results: Sphincter pressures in both groups were similar. Preoperative compliance of the rectum was restored after surgery in the Group B, 0.296 (0.224–0.347) L/Kpa, but there was a significant decrease after surgery in the Group A, 0.194 (0.112–0.235) L/Kpa P<0.001. By a multiple regression analysis, neo-rectal complicance was associated with favorable clinical function, and hypermotility of the canal was associated with adverse clinical function. Conclusion: Colonic pouch-anastomosis restores neorectal compliance, which is important for good function after low anterior resection.

Mechanical intestinal obstruction due to isolated diffuse venous malformations in the gastrointestinal tract: A case report and review of literature

BACKGROUND Isolated gastrointestinal venous malformations(GIVMs)are extremely rare congenital developmental abnormalities of the venous vasculature.Because of their asymptomatic nature,the diagnosis is often quite challenging.However,as symptomatic GIVMs have nonspecific clinical manifestations,misdiagnosis is very common.Here,we report a case of isolated diffuse GIVMs inducing mechanical intestinal obstruction.A literature review was also conducted to summarize clinical features,diagnostic points,treatment selections and differential diagnosis in order that doctors may have a comprehensive understanding of this disease.CASE SUMMARY A 50-year-old man presented with recurrent painless gastrointestinal bleeding for two months and failure to pass flatus and defecate with nausea and vomiting for ten days.Digital rectal examination found bright red blood and soft nodular masses 3 cm above the anal verge.Computed tomography showed that part of the descending colon and rectosigmoid colon was thickened with phleboliths in the intestinal wall.Colonoscopy exhibited bluish and reddish multinodular submucosal masses and flat submucosal serpentine vessels.Endoscopic ultrasonography showed anechoic cystic spaces within intestinal wall.The lesions were initially thought to be isolated VMs involving part of the descending colon and rectosigmoid colon.Laparoscopic subtotal proctocolectomy,pullthrough transection and coloanal anastomosis and ileostomy were performed.Histopathology revealed intact mucosa and dilated,thin-walled blood vessels in the submucosa,muscularis,and serosa involving the entire colorectum.The patient recovered with complete symptomatic relief during the 52-mo follow-up period.CONCLUSION The diagnosis of isolated GIVMs is challenging.The information presented here is significant for the diagnosis and management of symptoms.

Sphincter Saving Surgeries for Locally Advanced Low Rectal Cancer after Neoadjuvant Chemoradiation

Background: Rectal cancer accounts for the largest distribution within one anatomical region of the large bowel, with approximately one third of all CRC located within the rectum. The Golden standard treatment of primary rectal cancer is curative surgical resection;however, a fine balance remains between disease cure and restoration of gastrointestinal continuity. Combined modality has proven efficacy in many malignant tumors with advantage of organ preservation. Methods: Forty nine (49) patients with low rectal carcinoma were included in a prospective study, between Jan 2007 and Jan 2012. Preoperative chemoradiation was administrated to all patients and subjected to different techniques of sphincter saving surgery. Stage I and Stage IV disease at diagnosis were excluded from the study. Results: Forty nine patients were included in the study. 27 (55%) patients were male and 22 (45%) were female;the age ranges from 23 years to 70 years with the median age 46 years. The main presenting symptoms were bleeding per rectum and tenesmus, Stage II 18 patients (36.7%), stage III 31 patients (63.3%). Complete clinical and pathological response in 3 patients (6%), and complete clinical response with only microscopically residual carcinoma in 20 patients (41%), partial response in 18 patients (36.7%), and no significant response in 8 patients (16%) 7 from 8 were mucoid carcinoma. Low anterior resection (LAR) in 22 patients (44.9%), Hartman’s procedure in 4 patients (8.1%), Coloanal pull-through (COP) was done in 19 patients (38.9%) and perineal colostomy in 4 patients (8.1%). For patients with colo-anal pull-through technique complete dehiscent and retraction observed in 2 cases, Major leakage in one case, stenosis in 4 cases. Conclusion: There is tendency of colorectal cancers to affect younger groups. Most patients presented in advanced stage. Neadjuvant chemo radiation is an excellent tool in sphincter saving surgery. Coloanal pull-through technique is not a widely spread technique for low rectal cancer with good oncological safety and acceptable functional outcome.