Laparoscopic sphincter-preserving surgery for low rectal tumor using prolapsing technique

Authors

  • M.H. Zheng,

    1. Department of General Surgery, Ruijin Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai Minimally Invasive Surgery Center, Shanghai, China
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  • J.J. Ma,

    1. Department of General Surgery, Ruijin Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai Minimally Invasive Surgery Center, Shanghai, China
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  • T. Zhang,

    1. Department of General Surgery, Ruijin Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai Minimally Invasive Surgery Center, Shanghai, China
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  • Q.L. Zhu,

    1. Department of General Surgery, Ruijin Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai Minimally Invasive Surgery Center, Shanghai, China
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  • A.G. Lu,

    1. Department of General Surgery, Ruijin Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai Minimally Invasive Surgery Center, Shanghai, China
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  • Y.P. Zong,

    1. Department of General Surgery, Ruijin Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai Minimally Invasive Surgery Center, Shanghai, China
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  • M.L. Wang,

    1. Department of General Surgery, Ruijin Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai Minimally Invasive Surgery Center, Shanghai, China
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  • J.W. Li,

    1. Department of General Surgery, Ruijin Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai Minimally Invasive Surgery Center, Shanghai, China
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  • W.G. Hu,

    1. Department of General Surgery, Ruijin Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai Minimally Invasive Surgery Center, Shanghai, China
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  • Z.H. Mao,

    1. Department of General Surgery, Ruijin Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai Minimally Invasive Surgery Center, Shanghai, China
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  • F. Dong,

    1. Department of General Surgery, Ruijin Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai Minimally Invasive Surgery Center, Shanghai, China
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  • L. Zang

    1. Department of General Surgery, Ruijin Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai Minimally Invasive Surgery Center, Shanghai, China
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Correspondence
Jun-jun Ma. 197 Ruijin Er Road, Department of General Surgery, Ruijin Hospital, Shanghai 200025, China. Tel: +86 21 64458887
Fax: +86 21 64333548
Email: marsnew1997@163.com

Abstract

Introduction: With this study, we aimed to assess the feasibility and outcome of laparoscopy-assisted low anterior resection with a prolapsing technique for low rectal tumors.

Materials and Methods: We studied surgical techniques, recovery status, complications, oncological clearance and the results of short-term follow-up in 15 patients who had received laparoscopy-assisted low anterior resection with a prolapsing technique for low rectal tumors between October 2005 and January 2008.

Results: None of the cases was converted to open surgery. The mean operation time was 185  min (150–232 min), and the mean blood loss was 75 ml (25–105 ml). The mean time for passage of flatus, duration of urinary drainage, and postoperative hospital stay were 3 d (1–4 d), 6 d (5–10 d) and 11 d (7–20 d), respectively. The total amount of lymph nodes harvested was 15 (9–21), and the mean distal margin from the tumor was 2.5 cm (1.0–3.9 cm). No major complications were observed. The mean follow-up time was 13 months (4–27 months). Neither local recurrence nor metastasis was observed. Acceptable anal function results were obtained in most patients.

Discussion: Laparoscopy-assisted low anterior resection with a prolapsing technique can be successfully performed.

Introduction

In recent years, a series of randomized controlled trials have demonstrated the ability of laparoscopic surgery to cure colorectal cancer (1–4). Concomitant with this, there have been major developments in the use of laparoscopic low anterior resection (LLAR) for low rectal tumors. Despite these advancements, some major concerns remain when performing LLAR: fulfilling patients' desire to preserve the continuity of digestive tract after the operation, and the ability to determine intraoperatively the distal margin for bowel transection and to ensure a sufficient tumor. To resolve these issues, we have adopted a transanal prolapsing technique, or so-called everting technique, in selected patients. Previously, Dai et al. reported treating 43 patients by employing laparotomy with the prolapsing technique for ultra-low rectal cancer to preserve the anus (5,6). To the best of our knowledge, there have been very few reports on the application of transanal prolapsing technique in laparoscopic procedures and postoperative anal function. Thus, our experiences are shared as follows.

Materials and Methods

Patients

From October 2005 to January 2008, 15 patients (9 men; 6 women) who were treated in our hospital with LLAR using a prolapsing technique were included in our database. The mean age was 58 years (ranged 40–75 years). All the patients were preoperatively diagnosed by colonoscopy as rectal adenoma or adenocarcinoma, which awaslocated 5.5 cm (ranged. 4–7 cm) above anal verge. The inclusion criteria for this study was as follows: a preoperative diagnosis of adenoma; T1, T2 or T3; N0 carcinoma in the low rectum below the peritoneal reflection with a distance from the anal verge to the tumor of 4 cm or more; and cases where limited space in the pelvic cavity increased the difficulty of endoscopic stapling. Patients were excluded if their tumor's circumference was larger than half a lumen, their pelvis was narrow; or the mesentery of the rectum was too thick. The postoperative pathological stage and the differentiation degree of tumor cell are described in detail in Table 1.

Table 1.   Clinical data
Age (years)GenderTumor
staging
Tumor
differentiation
MaleFemaleAdenomaIIIIIIIIIIV
  1. Patients' general characteristics and pathological tumor staging.

58 (40–75)96211 23800
T1T2T3
382

Surgical technique

All patients were given general anesthesia intravenously. The patients laid in an anti-Tredelenburg modified lithotomy position, with both the surgeon and camera holder standing on the right side of the patient, and the assistant standing on the left side of the patient. The video monitor, the laparoscopy and the pneumoperitoneum system were placed between the patient's legs.

The pneumoperitoneum was established using the Veress needle method, usually at the umbilical port, with an average of 15 mmHg intraperitoneal pressure of CO2. (See Figure 1 for trocar placement.) During the abdominal phase, the procedure was similar to that of general laparoscopic total mesorectal excision. Only one aspect of the procedure is different: after the total mobilization of the bowel, an Endo-GIA endoscopic linear stapler (Covidien, Mansfield, USA) was used to transect the proximal bowel segment, but not the distal segment, in the pelvic extremities. The perineal phase then started with the distension of the anus. Grasping forceps were inserted into the anus and tenderly grasped the stump of the distal rectum, allowing the rectum to be gradually everted transanally out of the body. The distal rectum with its mucosal layer can be observed after the eversion of the bowel (Figure 2), exposing the location, size and the appearance of the lesion. A second linear stapler was applied extracorporally for transection of the distal rectum (Figure 3). The distal rectum was then pushed back through the anus into the pelvis. The proximal colon was delivered from a 4–5 cm small incision. The anastomosis of the two bowel segments was performed either by a double-stapling technique with a circular 31 or 33 mm stapler or by transanal manual sutures.

Figure 1.

 Trocar placement. One 10 mm trocar is placed through umbilicus to insert camera, a 12 mm trocar is inserted in the right lower abdominal quadrant as a major operative site, and three 5 mm assistant trocars were also required.

Figure 2.

 Eversion of the rectum through anus. The distal rectum is everted through anus with its mucosal layer observed.

Figure 3.

 Transection of distal rectum using a linear stapler. A linear stapler is applied extracorporally for transection of the distal rectum in the straight view.

Observation parameter

The observation parameter included: (1) intraoperative status: operative time, blood loss and conversion rate; (2) postoperative recovery: pass of flatus and postoperative hospital stay; (3) pathological outcome; (4) intra/postoperative complications; and (5) follow-up results of local recurrence, metastasis and defecation function. Postoperative defecation was evaluated at 3, 6 and 12 months by an independent observer using a standardized questionnaire, including defecation frequency, fecal incontinence, and discrimination between gas and stool.

Results

All operations were performed laparoscopically, and all rectal eversions were performed successfully, five of which received a protective ileostomy. No conversions to open surgery or major intraoperative complications occurred. The mean operative time was 185 min (150–232 min), and the mean blood loss was 75 ml (25–105 ml). The mean time for passage of flatus, duration of urinary drainage, and length of postoperative hospital stay were 3 d (1–4 d), 6 d (5–10 d) and 11 d (7–20 d), respectively. The TNM classification for adenocarcinoma of the rectum was stage I in 11 patients (T1N0 in three and T2N0 in eight) and stage II (T3N0) in two patient; the two other patients had rectal adenomas. The mean size of tumor is 2.8 cm (2.0–3.5 cm) in diameter. The total amount of lymph nodes harvested was 15 (9–21), and the mean distal margin from the tumor was 2.5 cm (1.0–3.9 cm). No major complications were observed. The mean follow-up time was 13 months (4–27 months). Neither local recurrence nor distal metastasis was observed. The postoperative defecation was evaluated at 3, 6, and 12 months; however, those who received ileostomy were evaluated at the same intervals, but only after the closure of their stoma. Acceptable anal function results were obtained in most patients (see details in Tables 2a and 2b).

Table 2a.   Postoperative defecation function
Evaluation timenDefecation frequency
n (%)
≤34–56–89
  1. The postoperative defecation frequency of those who were followed up were evaluated at 3, 6 and 12 months.

3 months152 (13.3)6 (40.0)5 (33.3)2 (13.3)
6 months147 (50.0)5 (35.7)2 (14.3)0 (0)
12 months85 (62.5)3 (27.5)0 (0)0 (0)
Table 2b.   Postoperative defecation function
Evaluation timenFecal incontinence n (%)Discrimination between
gas and stool
  1. The postoperative fecal description of those who were followed up were evaluated at 3, 6 and 12 months.

3 months157 (46.7)8 (53.3)
6 months144 (28.6)10 (71.4)
12 months80 (0)6 (75)

Discussion

Patients' selection and operative feasibility

Fukunaga et al. considered the prolapsing technique more suitable for patients with low rectal cancer staging T1-2N0, but patients with possible local invasion may need a more extensive lymph node dissection, which could result in an enlargement of rectal mesenterectomy and difficulty in prolapsing from anus (7). Fukunaga also reported a series of 10 cases in which patients received LLAR using the prolapsing technique. No cases were converted or encountered complications intraoperatively. In our study, all 15 patients successfully underwent the operation with prolapsing technique. Based on our experience, this technique should keep its indications at least in early stage of surgical practice, because patients may have a greater difficulty with prolapsing manipulation if their tumor is larger than 2 cm in diameter or its circumference is larger than half a lumen, their pelvis was narrow; or the mesentery of the rectum was too thick.

In normal LLAR, there is usually difficulty in determining the distal margin for bowel transection, especially in cases with a small or impalpable tumor mass, Moreover, the limited space in pelvic cavity increases the difficulty of endoscopic stapling. In such conditions, anal sphincter preserving is sometimes practical only in theory. However, when the rectum is everted from the anus, the tumor located on the mucosal layer is completely exposed so that the transection margin may be determined under the surgeon's direct view, guaranteeing a distal margin for tumor. Additionally, a total extracorporal maneuver allows the bowel to be transected despite the limitation of space. With regard operative time, blood loss and postoperative recovery, our data corresponds with that of previous literatures on similar LLAR (8). In this study, no major operative complications were observed, which implies the feasibility of this technique.

Oncological outcome

Fukunaga et al. reported a mean distal tumor margin of 15.9 mm (10–35 mm), a mean 14.3 (8–25) dissected lymph nodes, and no local recurrence during the short-term follow-up (7). Prete et al. demonstrated a similar result from a study of 10 cases who received a standard prolapsing technique and a comparative group who underwent common LLAR (9). In our previously published study on common LLAR, we concluded that the lymph node obtained from the specimens was 12.2±4.3 in general, and the distal tumor margin was 2.68±1.16 cm (8). The oncological outcome was similar in our current group using the prolapsing technique.

Another advantage of this technique is that the rectal washout and wiping off can be performed extracorporally, which may prevent the dissemination or micrometastasis of tumor cells and thus improve the oncological safety. Although there was no local recurrence or distal metastasis after our short-term follow-up, a long-term follow-up and accumulation of data should be carried out to demonstrate the feasibility of this technique in treating low rectal cancer.

Postoperative defecation

The postoperative anal function is always one of the major concerns after low anterior resection. During our postoperative follow-up at 3, 6 and 12 months, we discovered that most patients had decreasing defecation frequency, stool incontinence, and stool fragmentation, which implies that the ability to store stool and defecate gradually improve. Some literature reported using a colonic J-pouch or a transverse coloplasty method to improve the ability to store stool (10,11). All the patients in our study received either a colorectal or coloanal anastomosis, which functioned satisfactorily during the postoperative follow-up. To improve the postoperative function, we believe that the following points are essential: (1) the sufficient mobilization of rectum in pelvis should be performed using the classic total mesorectal excision principle to protect the pelvic nerve and anal sphincter, and (2) the rectum should be everted tenderly to avoid any possible injury to the sphincter tissue.

Ultimately, we recommend a selective application of rectal prolapsing technique in LLAR to ensure its feasibility and safety. This technique can improve the determination of the distal margin and the transection of bowel, as well as preserve postoperative anal function. In conclusion, this technique is practical and worthy of further research and promotion.

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