Sphincter-Saving Resection for All Rectal Carcinomas

In Brief Objective: To assess oncologic outcome of patients treated by conservative radical surgery for tumors below 5 cm from the anal verge. Summary Background Data: Standard surgical treatment of low rectal cancer below 5 cm from the anal verge is abdominoperineal resection. Methods: From 1990 to 2003, patients with a nonfixed rectal carcinoma at 4.5 cm or less from the anal verge and without external sphincter infiltration underwent conservative surgery. Surgery included total mesorectal excision with intersphincteric resection, that is, removal of the internal sphincter, to achieve adequate distal margin. Patients with T3 disease or internal sphincter infiltration received preoperative radiotherapy. Results: Ninety-two patients with a tumor at 3 (range 1.5–4.5) cm from the anal verge underwent conservative surgery. There was no mortality and morbidity was 27%. The rate of complete microscopic resection (R0) was 89%, with 98% negative distal margin and 89% negative circumferential margin. In 58 patients with a follow-up of more than 24 months, the rate of local recurrence was 2% and the 5-year overall and disease-free survival were 81% and 70%, respectively. Conclusions: The technique of intersphincteric resection permits us to achieve conservative surgery in patients with a tumor close to or in the anal canal without compromising local control and survival. Tumor distance from the anal verge is no longer a limit for sphincter-saving resection. The concept of sphincter-saving resection for rectal cancer is historically and conventionally related to the tumor's lower edge. Ninety-two patients with advanced rectal carcinomas located at 3 cm from the anal verge were treated conservatively by intersphincteric resection without compromising local control and survival. Sphincter preservation can be extended to all rectal carcinomas, the limiting factor being external sphincter infiltration and not the tumor's lower edge.