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1007/s10151-003-0036-2 TECHNICAL NOTE
© Springer-Verlag 2003
K. Shirouzu • Y. Ogata • Y. Araki • Y. Kishimoto • Y. Sato
A new ultimate anus-preserving operation for extremely low rectal cancer and for anal canal cancer
Received: 10 July 2003 / Accepted: 18 August 2003
Abstract To avoid permanent colostomy, we perform a new ultimate anus preserving operation for extremely low rectal cancer or for anal canal cancer. According to our pathologic study, two different removal methods of anal canal were theoretically considered. One is internal sphincter resection (ISR method), and the other is both deep-superficial external sphincter and internal sphincter resection (ESR method). Six patients received ISR and ten patients ESR. No severe intraoperative complications occurred and the postoperative course was uneventful. All patients receiving ISR had excellent anal function without soiling. Some patients receiving ESR sometimes complained of night soiling but satisfied the anus preservation. The median follow-up was 15 months, (range, 3–28 months). We had recurrences in two female patients receiving ISR. One had para-aortic and lateral lymph node recurrences without anastomotic recurrence. She underwent lateral and para-aortic lymphadenectomy, but died of lung metastasis, regardless of intensive chemotherapy. Another had pelvic recurrence with abdominal dissemination. She underwent abdominoperineal resection and is alive with pelvic re-recurrence. ISR and ESR are excellent procedures for anus preservation, but ISR needs a strict indication. Key words Rectal cancer • Anus-preserving operation • Intersphincteric resection • External sphincter muscle resection
Introduction Abdominoperineal resection (APR) with the creation of a permanent stoma is commonly performed for low rectal cancer and anal canal cancer located extremely near the anus. These cancers may be associated with lymph node metastasis along the anal levator muscle or in the fatty tissue of the ischiorectal fossa . It is extremely difficult to technically preserve the anus, and anal function is destroyed by removing the sphincter muscle. Therefore APR accompanied with a permanent stoma was an established theory. Recently, however, internal sphincter muscle resection method has been performed for these cancers [2–5]. External sphincter muscle is only preserved to keep the anal function. Since 2001, we have tried to cut off anal levator muscle (puborectalis muscle), and then to remove deep and superficial external sphincter muscles and internal sphincter muscle including the dentate line . Anus preservation is accomplished by only keeping the subcutaneous external sphincter muscle. Anus reconstruction is performed by anastomosing among colonic J-pouch, anoderm and subcutaneous external sphincter muscle. We introduce the new operation method and describe the theoretical background based on the histological evidence.
Materials and methods
Anatomy of the anal canal The anal canal is classified into anatomical anal canal and surgical one. The former corresponds to the distance from the anal verge to dentate line, and the latter, from the anal verge to the highest part of the puborectal muscle. The circular muscle of rectum changes into the thick internal sphincter muscle in the anal canal. The terminal of the internal sphincter muscle exists under 1–2 cm lower parts from the dentate line. The longitudinal muscle of the rectum gradually becomes
K. Shirouzu ( ) • Y. Ogata • Y. Araki • Y. Kishimoto • Y. Sato Department of Surgery Faculty of Medicine Kurume University 67 Asahi-machi, Kurume City, 830-0011, Japan E-mail: firstname.lastname@example.org
204 thin several muscle fibers going through the subcutaneous external sphincter muscle, and finally, becomes an end at the subcutaneous tissue around the anal skin. The subcutaneous external sphincter muscle surrounds the anus at the lowest part of the anal canal. There is an intermuscular groove between the terminal of the internal sphincter muscle and the subcutaneous external sphincter muscle. We can identify the groove with a digital finger examination at about 1 cm above the anal verge. It is an important part, which becomes a key point of the ultimate anus preserving operation.
K. Shirouzu et al.: A new ultimate anus-preserving operation
Pathological and theoretical background Since 1982, in our department, the whole tumor mass was sliced at 5mm step sections including the oral and anal parts 5 cm from the tumor. The pathological findings of each case were sketched in detail. One surgical pathologist (K.S.) made the final pathological diagnosis . According to our pathological study of 213 surgical specimens receiving APR for a lower rectal cancer or an anal canal cancer (excluding anal cancer), neither direct invasion nor skip metastasis was observed in the subcutaneous external sphincter muscle or in the fatty tissue of ischiorectal fossa. However, spreading of cancer to the deep and superficial external sphincter muscles or puborectalis muscle was observed in 14%, (Table 1). Therefore, if the depth of invasion is within the muscle layer as in SM (submucosa invasion) or MP (proper muscle invasion) cancer, the radical operation can be accomplished by internal sphincter muscle resection (Fig. 1a). When the tumor invasion exceeds the internal sphincter muscle just like A1 (slight invasion) or A2 (marked invasion) cancer, safety surgical resection margin can be kept only by resection of deep and superficial external sphincter muscles including internal sphincter muscle (Fig. 1b). Even if subcutaneous external sphincter muscle is not resected, complete radical operation can be theoretically accomplished. With keeping subcutaneous external sphincter muscle, the ultimate anus preserving operation is possible by the lowest handsewn coloanal anastomosis.
Fig. 1a, b Resection line. a Internal sphincter resection line. The indication is applied for SM or MP cancer invading within the muscle layer. The dentate line is also excised and the anal canal is removed at the intermuscular groove. The puborectalis muscle and external sphincter muscles are preserved. b External-internal sphincter resection line. The indication is applied for A1 or A2 cancer invading beyond the muscle layer. Puborectal muscle is cut off. The dentate line is also excised and the anal canal is removed at the intermuscular groove. The subcutaneous external sphincter muscle is only preserved At the beginning of our operation, we had a large amount of hemorrhage because we dissected the posterior wall of prostate (or vagina) by looking from the intra-abdominal cavity. Since we hit on a good idea, i.e. the “pulling out method” (pulling rectum out from anus), it became easier to operate and the amount of hemorrhage decreased. The posterior wall of the rectum is carefully dissected so as not to damage the presacral vein. After Waldeyer’s fascia is dissected, the anal levator muscle appears clearly. The most inside part of the anal levator muscle surrounding the rectum is called the puborectalis muscle. At first, we cut off a 2-cm portion of the puborectalis muscle using an electric knife. If the puborectalis muscle is completely cut off the fatty tissue of the ischiorectal fossa appears clearly. The right, left and posterior parts of the puborectalis muscle are completely cut off, excluding the anterior part. The anterior part is cut off by trans-anal approach after pulling the rectum out from the anus.
Operation Cutting off puborectalis muscle The rectum is dissected based on an ordinary low anterior resection. The Denonvilliers fascia is excised while exposing the posterior wall of the seminal vesicle and prostate in men or the vagina in women. It is important to perform the dissection within a range under direct vision, because it is difficult to keep a good operative field by looking from the intra-abdominal cavity. The excessive dissection takes a long time to stop bleeding and causes a massive hemorrhage.
Table 1 Pathological findings in 213 cases of abdominoperineal resection. Values are n (%) of cases Neither direct invasion nor skip metastasis Puborectalis muscle or deep-superficial external sphincter muscles Subcutaneous external sphincter muscle Fatty tissue of the ischiorectal fossa 183 1(86) 211 1(99) 213 (100) Direct invasion or skip metastasis 30 (14) 2 1(1) 0 1(0)
Subcutaneous external sphincter muscle and fatty tissue of the ischiorectal fossa will be preserved in most patients
K. Shirouzu et al.: A new ultimate anus-preserving operation Transanal resection With the digital examination into the anus, the groove, which corresponds to the boundary between the terminal of the internal sphincter muscle and subcutaneous external one, is easily identified. The posterior mucosa of the anal canal is divided by cutting the groove open using an electric knife. Advancing the incision deeper, it reaches the fatty tissue of the ischiorectal fossa, which is dissected from the abdominal cavity side. Then, several strings are put on the proximal resection margin of the anal canal. It is important to pull those strings, because they prevent the rectum from withdrawing into the abdominal cavity. With advancing resection while pulling those strings, the posterior part of the anal canal is completely divided. After the right and left parts are completely divided, the distal resection margin of the anal canal is tightly closed by some string sutures to prevent cancer cells from implantating in the presacral space. Then, Parks’s proctoscope is inserted into the presacral space. The anterior part of the anal canal is not divided at this point. Next, with pulling up the strings which closed the distal resection margin and pushing up the anal canal and rectum, the presacral space appears clearly. So, the whole rectum and anal canal can be pulled out from the anus, as in an abdominoperineal resection, because the anal canal is excised for three-quarters of its circumference excluding the anterior part. We named the procedure “pulling out method” which means pulling the rectum out from the anus. It is an important procedure that makes this operation easy. Moreover, we can see clearly the space between the prostate (or vagina) and anal canal just under direct vision without blind spots. The puborectalis muscle connecting with the anterior part of the anal canal is dissected just as in abdominoperineal resection by pushing up the rectum using the left fingers. With dissecting the space between the prostate (or vagina) and anal canal, we completely remove the rectum and anal canal with preserving the anus. We might often see a small amount of bleeding from the posterior wall of the prostate while dissecting, but it is easy to stop it, because of the good vision. Transanal handsewn anastomosis The transanal colonic J-pouch-anus anastomosis is performed. After pulling the colonic J-pouch down to the anus, handsewn transfixion sutures are placed in order of the anal skin mucosa, subcutaneous external sphincter muscle and all layers of the colon. The mattress suture is used so that wound healing is smooth and beautiful. Another reason is that the anal skin is hypersensitive. So, it is important to suture as politely as possible. A total of 20 needles accomplish the anastomosis. Figure 2 shows the reconstructions for internal and external-internal sphincter resections. The anastomosis among colonic J-pouch, subcutaneous sphincter muscle and anoderm is performed. Follow-up Follow-up investigation was carried out at the outpatient clinic. The presence or absence of recurrence was determined by digital examination, barium enema, measurement of serum tumor marker levels, and by findings on chest radiography, ultrasound, CT, and MRI. The site of recurrence was recorded for each patient and defined as local (or pelvic) recurrence, distant metastasis (liver, lung, bone or cerebrum) or peritoneal dissemination. The median follow-up was 15 months, (range, 3–28 months). We had recurrences in two female patients receiving internal sphincter resection. The overall recurrence rate was 12.5% (2 of 16 patients). One had para-aortic and lateral lymph node recurrences without
Fig. 2a, b Anus reconstruction. a Reconstruction for internal sphincter resection. An anastomosis among colonic J-pouch, subcutaneous external sphincter muscle and anoderm is made. b Reconstruction for external-internal sphincter resection. The anastomosis is the same as above anastomotic recurrence. She underwent lateral and para-aortic lymphadenectomy, but died of lung metastasis, regardless of intensive chemotherapy. Another had pelvic recurrence with abdominal dissemination. She underwent abdominoperineal resection and is alive with pelvic re-recurrence.
Results Six patients received internal sphincter resection and ten patients received external-internal sphincter resection. No severe intraoperative complications occurred and the postoperative course was uneventful. All patients receiving internal sphincter resection had excellent anal function without soiling. Some patients receiving external-internal sphincter resection sometimes complained of night soiling but satisfied the anus preservation. One patient had para-aortic and lateral lymph node recurrences without anastomotic recurrence, and finally died of lung metastasis. Another patient had pelvic recurrence and abdominal dissemination. In one patient who underwent external-internal sphincter resection, the preoperative barium enema showed an extremely low rectal cancer (Fig. 3a). The surgical specimen showed an ulcerated tumor of which the lowest part was located at the dentate line (Fig. 3b). The dentate line was excised by total circumference, and the distal resection margin was resected
K. Shirouzu et al.: A new ultimate anus-preserving operation
external sphincter muscle puborectalis muscle
Fig. 3a-c A case of external-internal sphincter resection. a The barium enema shows an extremely low rectal cancer spreading to the anal canal. b The surgical specimen shows an ulcerated tumor spreading to the dentate line. c The puborectalis muscle is cut off and the external sphincter muscle is also resected. The tumor slightly invades the external sphincter muscle beyond the internal sphincter muscle
sufficiently. The tumor penetrated beyond the internal sphincter muscle and slightly invaded the external sphincter muscle (Fig. 3c). The deep and superficial external sphincter muscles and puborectalis muscle were sufficiently excised. Neither direct invasion nor skip metastasis was found at the site of the surgical margin.
Discussion The method of ordinary transanal resection and anastomosis for a low rectal cancer is to partially remove the internal sphincter muscle to preserve the dentate line. On the other hand, this operation is a total or subtotal resection of the internal sphincter muscle including the dentate line, and is a new procedure for preserving anus. Recently, we developed the method further and modified it. We widely remove the external and internal sphincter muscles for an extremely low rectal cancer or for an anal canal cancer. However, there are some important problems about the new operation. These are indication, anal function and recurrence. The internal sphincter resection or external-internal sphincter resection is carried out for low rectal cancer or anal canal cancer within 2 cm from the dentate line. It is not performed for anal canal cancer invading the groove or anal cancer invading the anal skin. Moreover, anal canal cancer derived from the anal gland is also not an indication because perianal pagetoid disease usually accompanies it. If the depth of invasion is correctly diagnosed as within the submucosal layer or muscle layer before operation, internal sphincter muscle resection is a good option. However, when the preoperative diagnosis is uncertain, only internal sphincter muscle resection may have a high risk of residual cancer cells. We had pelvic recurrences in two patients receiving internal sphincter resection. Therefore, this procedure needs a strict indication. Both internal and external sphincter muscle
resection seems to be better and safer. In another way, when the tumor is confined to one side, both internal and external sphincter muscle resection is applied on the same side of the tumor, but internal sphincter muscle resection is optionally performed on the contralateral side of the tumor. It is necessary to consider the appropriate operation for each patient because there are a lot of options. The prognosis and anal function are not sufficiently evaluated yet, because of the short follow-up. However, an anus should be in the original place. So, the internal sphincter resection and external-internal sphincter resection are excellent procedures for anus preservation. These methods may substitute abdominoperineal resection in future.
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