Long-term results of low anterior resection with intersphincteric anastomosis in carcinoma of the lower one-third of the rectum - Analysis of 31 patients

INTRODUCTION: Between 1985 and 1996, 190 patients underwent a low anterior rectal resection with coloanal anastomosis for adenocarcinoma of the lower one-third of the rectum. METHODS: This article reports on 31 (17 males) of these patients with a very low localization of the tumor (distal tumor marg in 1.3 +/- 0.9 cm above the dentate line). If the function of the sphincter was acceptable and we could exclude tumor infiltration into the sphincter through endosonography, we relocated the resection plane distally into the intersphincteric region to attain an acceptable margin of safety. In all of these cases, it was impossible for us to perform the usual surgical proced ure of a mechanical anastomosis by means of a circular stapler. After inter sphincteric rectal resection, the anastomosis was handsewn, using interrupt ed sutures from the perineal approach, 2.5 to 3 cm above the anal verge, im plementing Parks' retractor. A protective stoma was performed in all cases. All data were documented prospectively. RESULTS: Complications: Postoperat ive mortality was 0 percent. Postoperatively, none of the patients showed a n indication for relaparotomy. The leakage rate was 48 percent. Only 16 per cent later needed additional surgery for anastomotic strictures or for rect ovaginal fistulas. Long-term observations showed that the anastomosis heale d well in 27 patients (87.1 percent). Four patients (12.9 percent) decided to have a terminal colostomy performed (anastomotic stricture, 3 patients; anorectal incontinence, 1 patient). Followup: During the follow-up period o f 6.8 +/- 3.7 years, six patients (19.4 percent) developed a tumor progress ion 9.7 percent local recurrences and 12.9 percent distant spread). The fiv e;year survival rate was 79 percent (Dukes A, 100 percent (n = 18); Dukes B , 67 percent (n = 4); and Dukes C, 44 percent (n = 9)). Continence: One-thi rd of patients developed anorectal incontinence for liquid (29.6 percent) o r solid stool (3.7 percent). Average stool frequency was 3.3 times per day. Resting pressure decreased significantly by 29 percent (preoperative, 105 +/- 37 cm H2O and postoperative, 75 +/- 19 cm H2O; P < 0.05), whereas squee ze pressure did not change. CONCLUSION: In selected patients with tumors cl ose to the dentate line, an intersphincteric resection of the rectum may he lp to avoid an abdominoperineal excision of the rectum with a terminal stom a, without any curtailment of oncologic standards. A protective stoma for t hree months is advantageous.