**2. Material and method**

#### **2.1. Case series**

We performed a prospective study on a group of 40 patients admitted in the First Surgical Clinic of the Tîrgu-Mureș Emergency County Hospital between 2015 and 2017. All patients were diagnosed with low rectal cancer. One of our main inclusion criteria was the flat denial of patients to have a permanent colostomy bag, even a temporary one. Patient's refusal was registered in the written informed consent. Tumor localization, tumor type, and the preoperative Wexner score were also considered alongside with preoperative antigen levels.

Most of the patients were from an urban background, 75% were males and none of them had a previous personal oncological background. Median age of the group was 66 years old.

**2.4. Preoperative sphincter function**

cases, full laparoscopic surgery was performed.

illustrated below (**Figures 3**–**9**).

**Figure 2.** Wexner score system.

radiotherapy) was **4.9**.

**2.5. Surgery**

We chose case series to evaluate the sphincter function using the Wexner score (**Figure 2**). There are numerous ways to evaluate the continence (FIQL, RAFST etc.), but we consider the Wexner score to be the easiest to accomplish and having the best correlation between the

Quality of Life Following Intersphincteric Resections for Low Rectal Cancer: Early Results

http://dx.doi.org/10.5772/intechopen.79727

115

In our case series, we performed preoperative evaluation of the Wexner score in all patients followed by postradiotherapy evaluation. The Wexner score was calculated again at 3, 6 and 12 months following surgery to assess the continence. The medium value of the preradiotherapy Wexner score was **7.65** and the median value for the preoperative (post neoadjuvant

All surgical procedures were performed by the same surgeon, 33 partial intersphincteric resections and 7 total intersphincteric resections for type II and III rectal tumors following the technique described above. In five cases, a partial laparoscopic approach was used, and in two

Restoration of bowel continuity was achieved by performing a hand-sewn coloanal anastomosis with absorbable threads in all cases, without a protection ileostomy or colostomy. We did not perform a colonic J pouch in any patient. The technique consists of some key points

patient's perception of continence and the clinical assessment of the surgeon [22–24].

#### **2.2. ISR technique**

Intersphincteric resections can be performed for type II (juxta-anal) or type III (intra-anal) low rectal tumors (<6 cm from the anal verge), cases in which partial intersphincteric resection is performed, respectively total intersphincteric resection [21].

The first part of the surgery starts with the primary vascular approach of the inferior mesenteric artery in all cases followed by left colon mobilization and ligation of the inferior mesenteric vein and TME (total mesorectal excision). This first aspect of the surgery can be done either by conventional surgery or using a laparoscopic or robotic approach, each with its own pros and cons. Conventional surgery in low volume centers has a smaller operative time as compared to laparoscopic approach, and it allows the surgeon direct mobilization and approximation of local tumor spread. Laparoscopic surgery, however, seems to be superior to conventional surgery regarding nerve identification and the use of nerve sparing techniques. Both the laparoscopic and robotic approaches require specialized instruments and have a long learning curve for the surgeon [20].

The intersphincteric groove is entered from the abdomen whenever possible to assess tumor invasion. The perineal part begins with digital and instrumental dilatation followed by the exposure of the anal canal using four to six traction threads (in the absence of a designated retractor). Following exposure, a circular incision is made on the anal mucosa distal to the dentate line—in the event of a total ISR—or at the level of it—for partial ISR. A minimum distance of 1 cm distally was maintained in all cases. The perineal phase continues with intersphincteric circumferential cranial preparation to meet the dissection plane from the abdomen. Following the completion of the dissection, the rectum is delivered through the anus with the transection of the sigmoid colon at the appropriate level. The final part of the surgery consists of a hand-sewn coloanal anastomosis.

#### **2.3. Preoperative staging and preparation**

Preoperative investigations consisted of a standard rectal touch, tumor biopsy with a malignant histopathology report. Preoperative imaging consisted of MR in most of cases and computed tomography in some of them and showed stage T2 tumors in all patients (tumor confinement to the rectal wall). Abdominal ultrasound and standard chest X-ray was also routinely performed to further asses the presence of distant metastatic disease.

All patients received long-term pelvic neoadjuvant radiotherapy with a total dose of 50 Gy for 5 weeks according to NCCN Guidelines, V2 and none of them received preoperative chemotherapy. From the entire series, 10 patients showed a type III inferior rectal tumor (intra-anal) and 30 had type II tumors (juxta-anal). From an antigen point of view, CEA and CA 19-9 levels were elevated in all cases and no signs of distant metastatic disease were found on preoperative imaging.

#### **2.4. Preoperative sphincter function**

We chose case series to evaluate the sphincter function using the Wexner score (**Figure 2**). There are numerous ways to evaluate the continence (FIQL, RAFST etc.), but we consider the Wexner score to be the easiest to accomplish and having the best correlation between the patient's perception of continence and the clinical assessment of the surgeon [22–24].

In our case series, we performed preoperative evaluation of the Wexner score in all patients followed by postradiotherapy evaluation. The Wexner score was calculated again at 3, 6 and 12 months following surgery to assess the continence. The medium value of the preradiotherapy Wexner score was **7.65** and the median value for the preoperative (post neoadjuvant radiotherapy) was **4.9**.

#### **2.5. Surgery**

Most of the patients were from an urban background, 75% were males and none of them had a previous personal oncological background. Median age of the group was 66 years

Intersphincteric resections can be performed for type II (juxta-anal) or type III (intra-anal) low rectal tumors (<6 cm from the anal verge), cases in which partial intersphincteric resection is

The first part of the surgery starts with the primary vascular approach of the inferior mesenteric artery in all cases followed by left colon mobilization and ligation of the inferior mesenteric vein and TME (total mesorectal excision). This first aspect of the surgery can be done either by conventional surgery or using a laparoscopic or robotic approach, each with its own pros and cons. Conventional surgery in low volume centers has a smaller operative time as compared to laparoscopic approach, and it allows the surgeon direct mobilization and approximation of local tumor spread. Laparoscopic surgery, however, seems to be superior to conventional surgery regarding nerve identification and the use of nerve sparing techniques. Both the laparoscopic and robotic approaches require specialized instruments and have a

The intersphincteric groove is entered from the abdomen whenever possible to assess tumor invasion. The perineal part begins with digital and instrumental dilatation followed by the exposure of the anal canal using four to six traction threads (in the absence of a designated retractor). Following exposure, a circular incision is made on the anal mucosa distal to the dentate line—in the event of a total ISR—or at the level of it—for partial ISR. A minimum distance of 1 cm distally was maintained in all cases. The perineal phase continues with intersphincteric circumferential cranial preparation to meet the dissection plane from the abdomen. Following the completion of the dissection, the rectum is delivered through the anus with the transection of the sigmoid colon at the appropriate level. The final part of the surgery

Preoperative investigations consisted of a standard rectal touch, tumor biopsy with a malignant histopathology report. Preoperative imaging consisted of MR in most of cases and computed tomography in some of them and showed stage T2 tumors in all patients (tumor confinement to the rectal wall). Abdominal ultrasound and standard chest X-ray was also

All patients received long-term pelvic neoadjuvant radiotherapy with a total dose of 50 Gy for 5 weeks according to NCCN Guidelines, V2 and none of them received preoperative chemotherapy. From the entire series, 10 patients showed a type III inferior rectal tumor (intra-anal) and 30 had type II tumors (juxta-anal). From an antigen point of view, CEA and CA 19-9 levels were elevated in all cases and no signs of distant metastatic disease were found on preopera-

routinely performed to further asses the presence of distant metastatic disease.

performed, respectively total intersphincteric resection [21].

long learning curve for the surgeon [20].

consists of a hand-sewn coloanal anastomosis.

**2.3. Preoperative staging and preparation**

tive imaging.

old.

114 Cancer Survivorship

**2.2. ISR technique**

All surgical procedures were performed by the same surgeon, 33 partial intersphincteric resections and 7 total intersphincteric resections for type II and III rectal tumors following the technique described above. In five cases, a partial laparoscopic approach was used, and in two cases, full laparoscopic surgery was performed.

Restoration of bowel continuity was achieved by performing a hand-sewn coloanal anastomosis with absorbable threads in all cases, without a protection ileostomy or colostomy. We did not perform a colonic J pouch in any patient. The technique consists of some key points illustrated below (**Figures 3**–**9**).


**Figure 2.** Wexner score system.

**Figure 3.** Mobilization of the sigmoid and rectum during the abdominal time.

**Figure 6.** Intersphincteric removal of the anal canal.

Quality of Life Following Intersphincteric Resections for Low Rectal Cancer: Early Results

http://dx.doi.org/10.5772/intechopen.79727

117

**Figure 7.** Advancement with the removal of the anal canal.

**Figure 8.** Anal sphincter—final aspect.

**Figure 4.** Exposure of the anal canal for the perineal time.

**Figure 5.** Demarcation of the anal resection line.

Quality of Life Following Intersphincteric Resections for Low Rectal Cancer: Early Results http://dx.doi.org/10.5772/intechopen.79727 117

**Figure 6.** Intersphincteric removal of the anal canal.

**Figure 3.** Mobilization of the sigmoid and rectum during the abdominal time.

116 Cancer Survivorship

**Figure 4.** Exposure of the anal canal for the perineal time.

**Figure 5.** Demarcation of the anal resection line.

**Figure 7.** Advancement with the removal of the anal canal.

**Figure 8.** Anal sphincter—final aspect.

**Figure 9.** Colo-cutaneous hand-sewn anastomosis.
