w w w . j c o l . o r g . b r
Journal
of
Coloproctology
Review
Article
Functional
outcome
and
quality
of
life
following
treatment
for
rectal
cancer
夽
Pedro
Campelo
a,∗,
Elisabete
Barbosa
a,baUniversidadedoPorto,FaculdadedeMedicina,Porto,Portugal
bCentroHospitalarSãoJoão,DepartamentodeCirurgiaColorretal,Porto,Portugal
a
r
t
i
c
l
e
i
n
f
o
Articlehistory:
Received19April2016
Accepted7May2016
Availableonline30June2016
Keywords:
Rectalcancer
Qualityoflife
Functionaloutcome
Sphincterpreservation
Watchandwaitapproach
a
b
s
t
r
a
c
t
Introduction:Overthelastdecades,treatmentforrectalcancerhassubstantiallyimproved
withdevelopmentofnewsurgicaloptionsandtreatmentmodalities.Withtheimprovement
ofsurvival,functionaloutcomeandqualityoflifearegettingmoreattention.
Studyobjective:Toprovideanoverviewofcurrentmodalitiesinrectalcancertreatment,with
particularemphasisonfunctionaloutcomesandqualityoflife.
Results:Functionaloutcomesafterrectalcancertreatmentareinfluencedbypatientand
tumor characteristics,surgical technique,theuse ofpreoperativeradiotherapy andthe
methodandlevelofanastomosis.Sphincterpreservingsurgeryforlowrectalcanceroften
resultsinpoorfunctionaloutcomesthatimpairqualityoflife,referredtoaslowanterior
resectionsyndrome.Abdominoperinealresectionimposestheneedforapermanentstoma
butavoidstheriskofthissyndrome.Contrarytogeneralbelief,long-termqualityoflifein
patientswithapermanentstomaissimilartothoseaftersphincterpreservingsurgeryfor
lowrectalcancer.
Conclusion: Allpatientsshouldbeinformedabouttherisksoftreatmentmodalities.Decision
onrectalcancertreatmentshouldbeindividualizedsincenotallpatientsmaybenefitfrom
asphincterpreservingsurgery“atanyprice”.Non-resectiontreatmentshouldbethefuture
focustoavoidtheneedofapermanentstomaandboweldysfunction.
©2016SociedadeBrasileiradeColoproctologia.PublishedbyElsevierEditoraLtda.This
isanopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/
licenses/by-nc-nd/4.0/).
夽
StudyconductedatFacultyofMedicine,PortoUniversity,Porto,Portugal.
∗ Correspondingauthor.
E-mail:pedroncampelo@gmail.com(P.Campelo).
http://dx.doi.org/10.1016/j.jcol.2016.05.001
2237-9363/©2016SociedadeBrasileiradeColoproctologia.PublishedbyElsevierEditoraLtda.ThisisanopenaccessarticleundertheCC
Resultados
funcionais
e
qualidade
de
vida
após
tratamento
do
câncer
retal
Palavras-chave:
Cancrodoreto
Qualidadedevida
Resultadofuncional
Preservac¸ãodeesfíncter
Estratégiawatchandwait
r
e
s
u
m
o
Introduc¸ão: Aolongodasúltimasdécadas,otratamentodocâncerretalmelhorou
sub-stancialmentecomodesenvolvimentodenovasopc¸õesterapêuticas.Comamelhoriada
sobrevida, osresultados funcionaise a qualidadede vida sãocadavezmaistidos em
considerac¸ão.
Objetivosdoestudo: Reverasmodalidadesatuaisdetratamentodocâncerretal,comenfase
nosresultadosfuncionaisequalidadedevida.
Resultados: Osresultadosfuncionaisapóstratamentoparaocâncerretaléinfluenciado
pelas característicasdo doente,dotumor,da técnica cirúrgica,dousode radioterapia
pré-cirúrgicaedométodoenívelda anastomose.Acirurgiapoupadoradeesfíncterdo
câncerretalbaixoresultafrequentementeemmausresultadosfuncionaisqueprejudicam
a qualidadedevida,denominadossíndrome daressecc¸ãoanteriorbaixa.Aamputac¸ão
abdominoperitonealimpõeanecessidadedeumacolostomiadefinitivamasevitaosriscos
deresultadosfuncionaisdeficitários.Contrariamenteàcrenc¸ageral,aqualidadedevidaa
longo-prazoemdoentescomcolostomiadefinitivaésemelhanteàqualidadedevidaapós
cirurgiapoupadoradeesfíncterdocâncerretalbaixo.
Conclusão: Todososdoentesdevemserinformadossobreoriscodasopc¸õesterapêuticas.
Adecisãodotratamentodocâncerretaldeveserindividualizadaumavezquenemtodos
osdoentesbeneficiarãodeumacirurgiapoupadoradeesfíncter“aqualquerprec¸o”.A
pos-sibilidadedetratamentosemressecc¸ãodevemserofocofuturoparaevitaranecessidade
deumacolostomiadefinitivaedisfunc¸ãogastrointestinal.
©2016SociedadeBrasileiradeColoproctologia.PublicadoporElsevierEditoraLtda.Este
´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http://creativecommons.org/
licenses/by-nc-nd/4.0/).
Introduction
Colorectalcanceristhethirdmostcommonlydiagnosed
can-cerworldwide.Almost1.4millionnewcaseswerediagnosed
and693,900deathswereestimatedtooccurin2012,withabout
55%ofcasesoccurringindevelopedcountries.InEurope,it
countsasthesecondmostfrequentmalignancyandcauseof
cancerdeath,withanestimated447,000newcasesdiagnosed
and215,000deathsoccurringin2012.1
Approximately30%ofcolorectalcancerarediagnosedin
the rectum and aroundone thirdofrectal cancer (RC) are
locatedonitsthirddistalpart.2,3
Improvementsinearlierdetection ofRCfrom screening
programs,reductionofriskfactorsandenhancedtreatment
modalitiesresultedinincreasedsurvivalratesoverthelast
decades.4,5
Treatment of RC had been primarily focused on
onco-logicoutcome,withdetailedassessmentofsurvivalandlocal
recurrence.6Lessattentionhasbeinggiventofunctional
out-comesandqualityoflife(QoL).QoListhepersonalperception
oftheimpactofillnessortreatmentsonphysical,
psycholog-icalandsocialwell-being.7FunctionalandQoLimpairments
arefrequentamongpatientstreatedforRC,predominantlyin
patientswithlowRC.8Withtheincreasingnumberofpatients
livingwithtreatmenteffects,9thesefactorsgetamore
signif-icantroleindecisionmakingforRCtreatment.
Thepurposeofthisstudyistoreviewcurrentmodalities
inRC treatment, particularly its impacton functional
out-comesandQoL.Therefore,areviewofthemedicalliterature
wasperformedregardingtheseoutcomesafteroperativeand
non-operativemanagementofRC.
Historical
background
AlthoughmainenhancementsintreatmentmodalitiesofRC
were achieved over the last decades, surgery remains the
privilegedformoftreatment.3,10Abdominoperinealresection
(APR),primarilydescribedbyMilesin1908,wasthefirststep
giveninmoderneraofRCsurgery.Thisprocedureconsisted
ofanenblocrectaldissectionwithitslymphovascular
sup-plyinordertoobtainacylindricalspecimen.11Theanterior
resectionoftherectum,popularizedbyDixon40yearslater,
provedtobesuccessfulincancersofthemiddleandupper
rec-tumandwasthefirstsurgicalproceduretoavoidadefinitive
stoma.However,thecreationofasafety5cmresection
mar-ginfromthedentatelinedidnotallowresectionofthelower
rectum,whereAPRremainedtheonlyavailableoption.12
Several works began to re-evaluate the effect of distal
resectionmargins(DRM)ononcologicoutcome.Many
stud-ies reported that a DRM of 1cm or even smaller had no
negativeimpactononcologicoutcome.13Infact,distal
intra-mural disseminationofRCisrarelyobservedand probably
linked tohigh gradetumors, wheresurvivalismostly due
tometastaticspreadratherthanlocalrecurrence.14,15Onthe
otherside,theimportanceofcircumferentialresection
mar-gin (CRM) was confirmed in multiple works, with positive
CRM negativelyinfluencing localrecurrence andsurvival.16
mesorectalexcision(TME),asurgicaltechniqueinwhichRC
isremovedwithintactmesorectum,containingvasculature
andlymphaticdraining,enblock.Themesorectumconcept
wasdefinedbyHealdetal.in1980.6TMEadoptiondecreased
CRMpositivityandlocalrecurrence,improvingsurvivalrates
forRCpatients.17,18 Nowadays,TMEistheprimaryformof
treatmentforRC,withanoverall5-yearsurvivalupto80%.19
AnteriorresectionoftherectumbecamearealityinlowRC;
toleranceforsmallerDRM,implementationofTMEand
avail-abilityofcircularstaplingdeviceswasfollowedbyasignificant
decrease of APR rates.20–22 Aside from oncologic outcome,
sphincterpreservationisnowconsideredasign ofsurgical
qualityforRCpatients.11
Abdominoperineal
resection
and
anterior
resection
of
the
rectum
SeveralchangesinindicationsforAPRwereobservedafterits
firstdescription.ProgressesinAPRtechniquesinceitwas
orig-inallyintroducedandapplicationofTMEledtoadecreasein
localrecurrenceand mortalityrates.23 Nevertheless,recent
articles established that when comparing to low anterior
resectionoftherectum(LAR),APRdisplayedworseoncological
outcomes.A2009pooledanalysisof5Europeanrandomized
clinicaltrials24reportedthatAPRhadsignificantlyhigherCRM
positivity(10vs5%),higherrecurrencerates(20vs11%),and
worse5yearssurvival(59vs70%).Similarresultswere
con-sistentlyfoundinotherworks.25,26Thesereportshaveledto
thesuggestionthatoutcomesafterAPRwereinherentlyworse
comparedtoLAR.However,thesepoorestoutcomesfollowing
APRcouldbeduetotumorcharacteristics.Rectaltumorsin
patientswho undergoAPR appeartobeless differentiated,
morelocally advanced and with a lower response to
neo-adjuvantchemoradiotherapy(CRT).27,28Chenetal.20reported
higher rates ofCRM positivity following APR, nonetheless,
afteradjustmentforothercovariates,survivalrateswerenot
influencedbythetypeofsurgeryasanindependentrisk
fac-tor.ArecentstudyinNetherlandsreportednodifferencesin
CRMpositivitybetweenAPRandLAR.29Therefore,similar
out-comescouldbeobtainedwithbothsurgicaltechniques,even
forlocallyadvancedtumors.30
Selectionofsurgicalproceduredependsfundamentallyof
thesurgeonpreference,individualcharacteristicsandtumor
specifics.Ifradicalresectionisrequiredinlowrectumtumors,
thetwomaintreatmentoptionsareLARandAPR.Although
sphincterpreservation iscurrently animportant goal,APR
stillremainsthefirstchoiceincasesofverylowtumorswith
sphinctercomplexinvasion orimpairedpreoperativestate,
withapproximately24%ofpatientsrequiringAPRforprimary
tumoralresection.31
Low
anterior
resection
syndrome
Bowelfunctionisamajorissueafterasphincterpreserving
surgeryforlowRC. Bowel dysfunctionoccurs in30–70%of
patientsafterLARandmayreachupto90%insomeseries.32–34
Mostcommonsymptomsincludeabdominalpain,urgency,
fecalincontinence,frequentbowel movements,incomplete
evacuation,dolorous,irregularand/orobstructeddefecation,
andclustering.8,33,35Whenlowanastomosesareperformed,
patientsbecomemorepredisposetodeveloptheseunpleasant
symptoms.8Thisgroupofcomplaintsconstitutesamedical
conditionentitled“lowanteriorresectionsyndrome”(LARS).36
Patientswithpreviouslydamagedsphincters,compromised
continenceorchronicdiarrhealpathologiesaremoreprone
todevelopthissyndrome.37Frequently,LARSdevelopsshortly
aftersurgery,decreasinginafewmonths,withstabilitybeen
reachedinthefirst2years.32,35,38
Etiology of LARS is multifactorial. Causes may include
injury of pelvicfloor muscles, reduced rectal capacity and
compliance,diminishedinternalanalsphinctertoneandlack
of inhibitoryrecto-anal reflex. Posteriorly toLAR,lesion of
sphincterswithimpairmentofanalpressuresandlow
recov-eryofrecto-analreflexisfrequentlyobserved.39
While somepatients may recover almost normalbowel
function, others experience these disabilities permanently,
conditioning long-termQoL. Infact, LARS istightly
associ-atedwithQoL,withmajoreffectinglobalhealthstatus,social
functionandrolefunction.32
Living
with
a
stoma
Itisgenerallyassumedbymanysurgeonsandpatientsthata
permanentcolostomyresultsinworselong-termQoLwhen
comparedto asphincterpreservingsurgerythat canavoid
theadverse impactoflivingwithapermanentstoma.This
beliefwasamajorreasontoadoptLARasthefirstchoiceof
treatmentforlowRC.40,41
Duetothisassumption,thereisalackofrandomized
clin-icaltrialscomparingtheimpactinQoLofacolostomyafter
APRorafterasphincter-preservingtechnique.Nevertheless,
themostrecentreviewschallengethatconviction.42–45
In a 2005 Cochrane review42 of 2412 patients from 25
studies,nodifferenceswerefoundinQoLbetweenpatients
undergoingAPRorLAR.Theauthorsreferredthatprospective
studieswithlargersamplesandbetterdesignedwererequired
toclarifythisquestion.
In2007,ameta-analysisbyCornishetal.43of1443patients
also stated that, concerning QoL, no significant global
dif-ferenceswereidentifiedbetweenAPRandLARgroups,with
patientshavingsimilarperceptionofgeneralhealth. These
findings were consistently reported in larger, higher
qual-ity andwithself-administered questionnairesstudies.This
review also did not find significant differences regarding
impairedbodyimage.
Thesedataweresupportedbymorerecentstudiesusing
reliableandvalidatedinstrumentsforQOLassessment.44,46–48
Patients undergoing sphincter-saving ultra-low AR have
significantly more complications than APR. Fisher et al.49
reportedthat20%ofpatientshadtodealwithapermanent
stomaduetofailureofthesphincterpreservingtechnique,
leadingtoanegativeimpactinQOL.Thisoccurredmore
com-monlyinolderpatients.
Frequentlyimpairedgastrointestinalfunctionfollowinga
sphincter-preservingsurgerycouldequalizetheneedof
per-manentstoma.50 Boweldysfunctionfrequentlyexperienced
QoL,evenwhenpatientswerewelladvisedbytheirsurgeons.
These patients may haveraised preoperativeexpectations,
whichultimately resultsin agreatfrustration ifthey have
tolivewithsuchdisabilities.Oppositely,patientsundergoing
APRtypicallyhaveloweroutcomeprospects.However,when
theyrealizethatafairlynormallifeispossibledespiteliving
withastoma,thesepatientsmaybecomemoresatisfied.38
ThismaybethereasonwhypatientsundergoingARorAPR
havesimilaroverallQoL.
A possible explanation to the fact that patients with
markedlyimpairedbowelfunctionreportagoodQoLmaybe
duetothe“response-shiftphenomenon”:thegratefulnessfor
livingwithouta stomaallegedlyshiftspatient’s global QoL
expectations.51
APR should be viewed as a possibility to consider and
notonly an end-of-linetreatment option in behalfof QoL
alone. Thisseems tobeparticularly trueinolder patients,
patients with low life expectancy or with majoranorectal
dysfunction.49,52
Urogenital
function
InRCtreatment,pelvicorgansandnervesareverycloseto
theneoplasm.Damagetothesestructurescanresultnotonly
inbowel,butalsosexualandurinaryimpairment.Thelesion
severityonpelvicautonomicnervesmayvarydependingon
thesurgicalapproach.53,54Post-operatoryurogenitalfunction
wereimprovedbytheintroductionofTMEtechniqueandthe
increasingknowledgeofpelvicautonomicnervepathways.6,18
Currently,lessthan40%ofpatientspresenturinary
malfunc-tion,while10–70%ofpatientsdisplaysexualimpairment.53,55
Stress and overflow incontinence, urgency, incomplete
emptying of the bladder, increased frequency of
void-ing and lack of bladder fullness perception are the most
frequentcomplaintsofpatients.Malesexualdysfunction
fre-quentlyinvolvesimpairedejaculation(20–60%)andimpotence
(20–46%).Inabilitytoejaculateisoftennotreversible.54,55In
women,informationregardingsexualfunctionisrare;
how-ever, patients may complain of worsened sexual function,
includingproblemswithlubricationanddyspareunia.56,57
Sexualdysfunctionmaynotonlybeduetophysicalfactors
likenerveinjuryaftersurgeryorradiationtherapy.54,57,58In
fact,otherfactorslikepoorbodyimage,depression,fatigue
andlossofindependencemayalsoplayanimportantrolein
sexualdysfunction.57
Restorative
methods
InordertoovercomeLARSsymptoms,differentstrategiesfor
restorativemethodsfocusingontheproximalaspectofthe
anastomosishavebeendevelopedtoimproverectalvolume
andcompliance.36
Whencomparedtostraightcolorectalorcoloanal
anasto-mosis,colonicj-pouch,colonicside-to-endanastomosisand
coloplastyareassociatedwithlowerstoolfrequency,
incon-tinence,urgency,andfragmented stoolpattern.These data
aresupportedbyarecentmeta-analysis59reportingcolonicj
pouch,side-to-endcoloanalortransversecoloplastytohave
similar functional outcomes, that are superior when
com-paredtostraightanastomosisinthefirstpostoperatoryyear.
However,thereappearstobenosignificantdifferencesbeyond
2years.Thislong-termimprovementcouldbeexplainedby
thecontinuedincreaseinneorectalvolumeandrecoveryof
anorectalreflexesandsphincterfunctionfollowingstraight
anastomosis,thatprobablyallowscontinuedimprovementof
complianceandfunction.60
Better functional results are obtained shortly after RC
surgerywhenapouch isusediftheanastomosis iswithin
3and5cmfromtheanal verge.If apouch iscreated inan
upperlevel,evacuationproblemsaremorelikelytooccur.36,61
When itislocatedhigherthan7cmfrom theanalverge,a
straightanastomosisshouldbeperformedfromafunctional
perspective.36Sinceurgency,frequencyandincontinenceare
harder to manage than evacuation difficulties, the pouch
shouldalsonotbetoosmall.36,61
Thefewworksthataddressedpost-operativeQoLbetween
restorative methods did not report significant differences
betweenthesetechniques.59
Approach
techniques
Laparoscopicsurgery
LaparoscopictechniquehasbeenrecentlyappliedtoTMEfor
RC. Recentrandomized clinical trials indicated that, when
comparedtoopensurgery,thistechniquehasnocompromise
in oncologicoutcomes, hassimilar complication rates and
advantagesinearlierpostoperativerecoverywithlessblood
loss,rapidintestinalrecovery,shorterhospitalstayandlower
postoperativepain.62–66
With laparoscopic surgery allowing a better
visualiza-tion oftheoperativefield,this couldcontributetoabetter
preservationofpelvicautonomicnerves,thereforereducing
genitourinarydysfunctionfollowingRCsurgery.62
TheUnitedKingdom MedicalResearchCouncilCLASSIC
trial67,68 is the only randomized clinical trial that
com-paredgenitourinaryfunctionsbetweenopenandlaparoscopic
surgery forRC.While nodifference wasfound intermsof
bladderfunction,malepatientshadatendencyforworse
sex-ual functionsafterlaparoscopicsurgery.Thiswouldhavea
strongerimpactinsexuallyactivemalepatientswithlargeor
lowRC,andcouldhaveimplicationswhendecidingthebest
operativeapproach.67,68
However,morerecentprospectivestudiesstatedthat
nei-therlaparoscopicnoropensurgeryappearstohavesuperior
results regarding preservation of urinary or sexual
func-tion,althoughavailabledataislimited.69Theseresultscould
be explainedbythecontinued increase inexperiencewith
laparoscopicsurgery.
It isunclear whether laparoscopic approachcould offer
betterQoL. Whencomparing differentsurgicalapproaches,
studies evaluating QoL have obvious disagreements. While
some studies reported a better QoL in both short and
long-term after laparoscopic surgery,66,70 others did not
find any benefits in long-term QoL following this
surgi-calapproach.71–73 Inamulticenterrandomizedclinicaltrial
betweenthesesurgicalapproachesat1,6or12months.Both
laparoscopicandopensurgeryimpairedpostoperativeQoL,
recoveringgraduallytopreoperativelevelsovertime.
Since laparoscopic or open surgery might not present
differencesinQoL,thepreviouslydescribedbenefitsof
laparo-scopicsurgerylikelessbloodloss,rapidintestinalrecovery,
shorterhospitalstayandlowerpostoperativepain,couldbe
takenmoreintoaccountwhenselectingsurgicalapproachfor
RCtreatment.
Roboticsurgery
Robotic surgery has emerged during the last decade with
several studies reporting comparable safety and feasibility
tolaparoscopicsurgeryinRCsurgery.75 Whencomparedto
laparoscopicsurgery,roboticsurgeryhastheadvantagesof
providinghigh-resolution3Dview,physiologictremor
reduc-tionandarticulatinginstruments.76
Despite being rarely evaluated, some studies have
sug-gested thatrobotic surgery could achievebetter functional
outcomes,however,thisisstillunclear,asmoreinternational
multicenterrandomizedclinical trials are neededto
deter-minethesepossibleadvantages.75
New
sphincter
preserving
techniques
Intersphinctericresection(ISR)
ISRwasdescribed in1994bySchiessel etal.77 A transanal
divisionoftherectum,withremovalofentireorpartofthe
internalanalsphincter,isperformedafterTME.Thiswasonly
possibleduetoacceptablereductionofdistalsafetymargins
to1cm.13
Thisextremesphincterpreservingsurgeryhasbeenused
overthelastdecadesforpatientswithverylowRC,who
oth-erwisehadindicationforAPRwithpermanentcolostomy.77,78
InT1-3tumorslocatedbetween3and3.5cmfromtheanal
verge,oncologicoutcomes (bothoverall survivaland 5-year
disease-freesurvival)doesnotappeartobeadverselyaffected
byISR,whencomparedtoLARorAPR.79–81
FunctionaloutcomeisamajorconcerninISR.LARSis
fre-quentlyobservedafterthistechnique;a2012meta-analysis
of 8 studies stated that 11–63% of patients reported fecal
incontinenceand30–86%reportedtotalcontinence.However,
authors stated that functional outcomes are incompletely
reportedand,whenavailable,demonstratewidevariability.81
When compared to LAR, fecal continence is more
fre-quentlyimpairedafterISR.Thisisprobablyexplainedbya
significant decrease of the postoperative sphincter resting
pressure.82 Anestimated40–85%ofanalrestingpressure is
contributedbyinternalanalsphincter,playingamajorrolein
maintainingcontinence.83However,bothtechniquesappear
toresultincomparableurgencyandstoolfrequency.84
Performingonlyapartialexcision82andtheconstruction
of a colonic j-pouch85,86 improves functional results,
pre-dominantlyinthefirst yearaftersurgery.PreoperativeCRT
significantlyimpairsfunctionaloutcomes.87
Fewworks haveaddressed post-operativeQoL after ISR
anddataiscontradictory.81 Yongpatientswithearlystages
RC(T1-2),whodonotrequirepreoperativeradiotherapy(PRT)
andhavegoodpreoperativesphincterpressures,arethebest
candidatesforISR.37,78Patientsshouldbeinformedaboutthe
possibleimpairment offunctional outcomes afterISR,
par-ticularlystoolincontinence,anddecideifdealingwithsuch
conditionsispreferabletolivewithapermanentstoma.
AnteriorPerinealPlanEForultralowAnteriorResectionof therectum(APPEAR)
Williamsetal.88initiallydescribedAPPEARtechniquein2008
asanalternativemethodforverylowrectalresection. Itis
indicated forRCwithin2–5cm from theanal verge.89 This
technique uses an abdominaland a perineal approach, in
whichacrescentshapedincisionismadeintheperineum,
betweenthevaginaorthescrotumandtheanalverge.This
allowsabetteraccesstothedistalrectumformobilization
whencomparedtotheultra-lowARandabetterpreservation
ofthesphinctermusclewhencomparedtoISR.37
Thepilotstudy88included14patients,7withrectal
neo-plasia. Nolocalrecurrences werereported, but onepatient
developedsystemicdisease.Sevenpatients(50%)presented
anastomoticperinealfistulaeand,at1-yearfollow-up,5(36%)
patients were not considered forileostomyreversal. Three
patients(21%)developedtransientsexualdysfunctionbutno
urologicalimpairmentwasfound.Theauthorsalsoreported
thatafterperinealdissection,patientswithRChadamedian
Wexnercontinencescoreof5followingileostomyclosure.No
significantdifference wasobservedinanorectalphysiologic
testingorQOL.
Inamorerecentstudy,90nolocalrecurrencewasreported
and,afterostomy closure, the medianWexnerscore
docu-mentedwas5.5.
More studies are needed for evaluation of this recent
technique,sincethereisalackofstudiesononcologicand
functionaloutcomesandQOL.
TransanalTotalMesorectalExcision(TaTME)
TaTME is a rectal natural orifice transluminal endoscopic
surgery(NOTES).Itconsistsofatransanalapproach,usually
withtransabdominalassistance.TaTMEallowsabetter
mobi-lization ofthedistalrectumand sphincterpreservationfor
difficulttoreachdistalRC,particularlyinmalepatientswitha
narrowpelvisand/orobesitywheretheabdominalapproach
ischallenging.91,92 ContrarytoAPPERtechnique,thereisno
needtocreateaseparateperinealwound.
EvidencesuggeststhatTaTMEisfeasibleandsafe.Arecent
systematicreviewof26studiesreportedadequateand
repro-ducibleoncologicoutcomes,withCRMpositivitybeingequal
tothose achievedinlow ARand inferiortothoseachieved
inAPR.93Amorerecentmulticenterprospectivestudyof56
patients94reportedanaverageDRMof10mmandanaverage
CRMof8mm,withR0resectionachievedin53patients(94.6%).
Twentysixpercentofpatientshadpostoperative
complica-tions.Functionaloutcomewasonlyaccessedbythisstudy,
with28%(13)ofpatientsreportingafragmentedstoolpattern
andevacuationdifficulty.ThereportedmedianWexnerscore
The transanal approach can be performed with either
transanalendoscopicmicrosurgery(TEM)ortransanal
min-imally invasivemicrosurgery (TAMIS). Itappears that both
techniquesoffersimilarresectionquality.95,96
TaTMEtechniquemaybeapromisingalternativeto
con-ventionallowAR,butthereisanecessityoffurtherstudiesto
betterevaluateoncologicalandfunctionaloutcomes,aswell
astheimpactonQoL.
Local
excision
Inrecent years,withimprovementsofscreening programs
leadingtoearlydiagnosisofRC,moreattentionisbeingpaid
tolocalexcisionasanattractivealternativetoradical
trans-abdominalresection.Localexcisioncanbeperformedusing
conventional transanalexcision,TEM or the morerecently
describedTAMIS.
Comparedtothenewertechniques,conventionaltransanal
excision hasa reportedlower resection qualityand higher
localrecurrenceandmortality.96,97
In1980,Buessetal.98developedTEM,aminimallyinvasive
techniqueinitiallydescribed forremovalofadenomasthat
wereendoscopicallyunresectable,usingspecificinstruments
andarectoscopethatofferedhighprecisionfortransanallocal
excision.
TEMcanachieverectalpreservationforbenignpolypsand
earlyRC.Iteliminatestheneedforapermanentcolostomy
andisassociatedwithlowermorbidityandimpacton
func-tional outcome and QoL than TME.99–101 The safety and
effectiveness of this technique is well documented, with
severalstudiesreportingsurvivalandlocalrecurrence
com-parable to radical surgery in well selected cases.99,102–105
Nevertheless, oncologic outcomes of this technique still
remainamatterofstudyanddebate.
TEMisanoptiontoconsiderinpatientswithadenomas
notmanageablethroughendoscopyorwithfavorableearly
stage RC who want to avoid radical resection of the
rec-tumandarewillingtoacceptapossiblehigherriskoflocal
recurrence.89,106,107Itcanalsoberecommendedforpatients
withadvancedtumorunabletoundergoradicalsurgery,asa
palliativetreatment.89,106,107Presently,theeligibleproportion
ofRCthatcouldundergolocalexcisionissmall.This
propor-tionmayincreasewiththecombineduseofCRTincarefully
selectedcases.106
Thereisaconcernthataprolongeduseofa40mm
diam-eter operating scope could overstretch the anal sphincters
andcausepostoperativeimpairmentinfecalcontinence.In
fact,restinganal pressureisfrequentlyreduced
postopera-tively,howeverthisreductionisonlytemporary(likelytohave
resolvedby3months)anditdoesnotappeartochange
con-tinencescores.100,108–110
SeveralstudiesreportedthatTEMhasanegativeimpacton
anorectalfunctionandQoL,withpatientscomplainingoffecal
incontinence,increasedstoolfrequency,pain,flatulence,sore
skinandembarrassment.111,112Theseeffectsarealsoreported
tobetemporary.Hompsetal.112analyzed102patientsafter
TEMforRCandreported thatfunctionaloutcome and QoL
deteriorationwasworseafter6weeksbut returnedto
nor-mallevelsat12weeks.SimilarresultswerefoundbyLezoche
etal.,111withbowelfunctionreturningtonormallevelsat26
weeks.
Allaixetal.113analyzed93patientswhounderwentTEM
after5yearsfollow-upandreportedthatanorectalfunction
declinedinthefirst3months,returningtopreoperativelevels
12monthsaftersurgery.Therewasnodifferenceinlong-term
continenceandQoLscoresbeforeandaftersurgery.
Ina41patientsprospectivestudybyCataldoetal.,108no
differences were found in FISI(fecal incontinence severity
index)andFIOL (fecalincontinenceQoL)scores,numberof
bowermovementsper24handurgencybetweenpreoperative
and6weeksaftersurgery.
Doornebushet al.100 andPlanting et al.101 reportedthat
fecalincontinenceQoLwasimprovedaftersurgeryinpatients
with preoperativefecal incontinence.Thiscould be dueto
improved fecalcontinenceaftertumorexcision inpatients
thathaddiarrheacausedbyamucousproducingtumor.
Inthelimitedexistingliterature,itappearsthatQoLand
anorectalfunctionmaybeimpairedafterTEMsurgery,with
nolong-termeffect.
TEMhasthedisadvantageofasteeplearningcurveand
ele-vatedcostsofspecializedinstrumentation.114In2009,TAMIS
wasdevelopedasafeasibleandlow-costalternativetoTEM
forlocalexcisionofrectallesions.Thisnewtechniqueuses
familiarlaparoscopicinstrumentsthroughatransanal
multi-channelsingle-port,asimpleandeasytousedevicewithlow
equipmentcostsandminimalsetuptime.115
Both TEM and TAMIS have the same indications,95,116
howeverthereisalackofstudies reportingfunctional and
oncologic outcomes of TAMIS for early RC and adenomas
resection. One study evaluating TAMISfunctional outcome
afterresectionofrectalpolypsreportedfunctionaloutcomes
tobecomparabletothoseobtainedwithTEM.117
Neoadjuvant
therapy
Regardless ofthe increasingdevelopment ofsurgical
tech-niques,itisnowgenerallyacceptedasstandardpracticetouse
amultimodalapproachinRCtreatmentinordertoachieve
optimal results. PRT significantly reduces local recurrence
rates,improveslocalcontrolandenablessphincter
preserva-tioninselectedcases,howeveritdoesnotappeartochange
overallsurvival.118–120
Nevertheless, inaddition tosurgery,PRT isrelatedwith
an increased incidence and severity of bowel dysfunction,
withpatientsreportingmorefecalincontinence,urgency,and
higher stool frequencyand evacuation disorders.56,118,121 It
is also associated with a diminished resting and squeeze
pressuresinanorectalmanometry.122
Chenetal.123investigatedhealth-relatedQOLintheDutch
TMEtrialandreportedthatadditionofPRTtoTMEincreases
theriskofmajorLARSscorefrom35to56%,withmajorLARS
beingassociatedwithreducedhealthrelatedQoL.Ithasalso
beenshownthatPRTincreasestheriskofsexualandurinary
dysfunction,124furthercompromisingQoL.118,121
Whenassociatedtolocalexcisiontechniques,PRTtherapy
significantlyincreasespostoperativemorbidity.125InaPolish
multicenter trial,126 patients that undergone local excision
to those observed in patients undergoing AR alone. The
authorsconcludedthatbetterfunctionaloutcomesachieved
bylocalexcisioncouldbecompromisedbyPRT.
The mechanisms that could contribute to the adverse
impactofradiotherapyonanorectalfunctionarenotyet
com-pletely understood. Da Silva et al.127 observed that pelvic
irradiationincreasescollagendepositionandcausesdamage
to internal anal sphincter myenteric plexus. These effects
couldberesponsibletothedecreaseofmaximumanalresting
andsqueezepressuresandreductionofneorectumcapacity,
contributingtoanorectaldysfunction.128,129
Presently, thereis fewavailable dataon functional
out-comesafterpreoperativeCRT forRCtreatment, howeverit
appearsthat both PRC and preoperative CRT have similar
anorectalfunctionalresults130andlongtermQoL.131
Bothpotentialbenefitsandriskofincreasedanorectal
dys-functionalafterPRTshouldbeconsideredwhenchoosingthe
mostadequatetreatmentoption.
“Wait-and-see
policy”,
the
next
step
in
rectal
cancer
treatment?
InselectpatientswithcompletetumorregressionafterCRT,
adoptionofanon-operativestrategycouldavoidamutilating
surgeryand itssequelae,resultinginbetterfunctional
out-comesandQoL.132
Approximately15–20%ofpatientswithlocallyadvanced
RChaveapathologicalcompleteresponse(pCR)after
neoad-juvantCRT,withnoresidualtumorobservedintheresected
specimen.133 pCR is found in a subgroup ofpatients with
clinicalcompleteresponse(cCP),inwhichresidualtumoris
notclinicallydetectable.However,thereisapoorcorrelation
betweenclinicalandpathologicalresponses,makingit
diffi-culttodeterminewhichpatientswithcCPalsohaspCR.134
Habr-Gamaetal.135wasthefirsttosystematically
evalu-atetheoutcomesofanon-operativestrategyinpatientswho
achievedcCRafterCRT.Theresultsobtainedinthisserieswere
impressive,withnocancer-relateddeathreportedinamean
57monthsfollow-up,suggestingthatthesepatientshad
sim-ilarsurvivalratestopatientswho hadradicalsurgeryafter
CRTandhadpCRconfirmation.Otherstudieshavesupported
theseresults.136,137
AmorerecentstudybyHabr-Gammaetal.138reporteda
sustainedcompleteresponseat1yearin57%ofpatients
man-agednon-operativelyafterCRTand,afteramean56months
follow-up,51%ofpatientswerefreeofrecurrence.
Despiteremainingcontroversialand inanexperimental
phase, results from the Habr-Gama series suggests that a
groupofselectedpatientswithcompleteresponseafterCRT
couldbemanagedwiththewait-and-seeapproach,after
eval-uationofrisksandbenefitswiththepatient.
Conclusion
Overthelast decades treatmentforRChasimproved with
developmentofnewsurgicaloptionsandtreatment
modal-ities.Whileoncologicoutcomeremainstheprimarygoalin
RCtreatment,functionaloutcomesandQoLaregettingmore
attention.IfsimilaroncologicaloutcomesareachievedforRC
treatmentoptions,functionaloutcomesandQoLplayamajor
partwhendecidingforthemostadequatetreatmentoption
foreachpatient.
FunctionaloutcomesafterlowRCtreatmentareinfluenced
bymultiplefactors,includingpatientandtumor
characteris-tics,surgicaltechnique,theuseofradioorchemotherapyand
themethodandlevelofanastomosis.
Sphincterpreservingsurgeryremainsapriorityandamark
ofsurgicalqualityRCtreatment,inpartduethegeneralbelief
by both patients and surgeons that avoiding a permanent
colostomy would result inbetter long term QoL. However,
thereisenough evidencetosupportthatlong-termQoLin
patientswithapermanentstomaaresimilartothoseafter
sphincterpreservingsurgeryforlowRC.Patientsshouldbe
awarethatsphincterpreservingsurgeryforlowRCoftenresult
in poor functional outcomes that impairs QoL. Therefore,
depending onpatient’s characteristics and personal
prefer-ences,decisionshouldbeindividualizedsincenotallpatients
maybenefitfromasphincterpreservingsurgery“atanyprice”.
Postoperativeboweldisabilitiesshouldalwaysbetakeninto
accountwhensurgerytechniqueisselectedandpatientswho
arenotwillingtolivewithsuchpotentiallimitationsshould
considerundergoinganon-sphincterpreservingsurgery.
Localexcisionandnon-operativetreatmentsarestarting
togetmoreattentionincarefullyselectedpatients,inwhich
theneedofapermanentstomaandboweldysfunctioncould
beavoided,achievingbetterQoL.However,the“wait-and-see
policy”stillremainsinanexperimentalphase,requiringmore
studiestobetterevaluatethisapproach.
Patientsneedtobeclearlyinformed aboutall the
treat-mentoptionsforlowRCanditspotentialoutcomes,including
the possibility ofanon-surgicalapproach, sothat patients
couldhavemorerealisticexpectationsandbeinvolvedinthe
decisionmakingprocess.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
r
e
f
e
r
e
n
c
e
s
1.FerlayJ,SoerjomataramI,DikshitR,EserS,MathersC, RebeloM,etal.Cancerincidenceandmortalityworldwide: sources,methodsandmajorpatternsinGLOBOCAN2012. IntJCancer.2015;136:E359–86.
2.ValentiniV,Beets-TanR,BorrasJM,KrivokapicZ,LeerJW, PahlmanL,etal.Evidenceandresearchinrectalcancer. RadiotherOncol.2008;87:449–74.
3.LindsetmoRO,JohYG,DelaneyCP.Surgicaltreatmentfor rectalcancer:aninternationalperspectiveonwhatthe medicalgastroenterologistneedstoknow.WorldJ Gastroenterol.2008;14:3281–9.
4.TorreLA,BrayF,SiegelRL,FerlayJ,Lortet-TieulentJ,JemalA. Globalcancerstatistics:2012.CA:CancerJClin.
2015;65:87–108.
6. HealdRJ,RyallRD.Recurrenceandsurvivalaftertotal mesorectalexcisionforrectalcancer.Lancet.1986;1:1479–82.
7. FerransCE,ZerwicJJ,WilburJE,LarsonJL.Conceptualmodel ofhealth-relatedqualityoflife.JNursScholarsh.
2005;37:336–42.
8. RasmussenOO,PetersenIK,ChristiansenJ.Anorectal functionfollowinglowanteriorresection.ColorectalDis. 2003;5:258–61.
9. DeSantisCE,LinCC,MariottoAB,SiegelRL,SteinKD, KramerJL,etal.Cancertreatmentandsurvivorship statistics:2014.CA:CancerJClin.2014;64:252–71.
10.vanderVoortvanZijpJ,HoekstraHJ,BassonMD.Evolving managementofcolorectalcancer.WorldJGastroenterol. 2008;14:3956–67.
11.LangeMM,RuttenHJ,vandeVeldeCJ.Onehundredyearsof curativesurgeryforrectalcancer:1908–2008.EurJSurg Oncol.2009;35:456–63.
12.DixonCF.Anteriorresectionformalignantlesionsofthe upperpartoftherectumandlowerpartofthesigmoid.Ann Surg.1948;128:425–42.
13.BujkoK,RutkowskiA,ChangGJ,MichalskiW,ChmielikE, KusnierzJ.Isthe1-cmruleofdistalbowelresectionmargin inrectalcancerbasedonclinicalevidence?Asystematic review.AnnSurgOncol.2012;19:801–8.
14.ShirouzuK,IsomotoH,KakegawaT.Distalspreadofrectal cancerandoptimaldistalmarginofresectionfor
sphincter-preservingsurgery.Cancer.1995;76:388–92.
15.LeoE,BelliF,MiceliR,MarianiL,GallinoG,BattagliaL,etal. Distalclearancemarginof1cmorless:asafedistancein lowerrectumcancersurgery.IntJColorectalDis. 2009;24:317–22.
16.AdamIJ,MohamdeeMO,MartinIG,ScottN,FinanPJ, JohnstonD,etal.Roleofcircumferentialmargin
involvementinthelocalrecurrenceofrectalcancer.Lancet. 1994;344:707–11.
17.MaurerCA,RenzulliP,KullC,KaserSA,MazzucchelliL, UlrichA,etal.Theimpactoftheintroductionoftotal mesorectalexcisiononlocalrecurrencerateandsurvivalin rectalcancer:long-termresults.AnnSurgOncol.
2011;18:1899–906.
18.MacFarlaneJK,RyallRD,HealdRJ.Mesorectalexcisionfor rectalcancer.Lancet.1993;341:457–60.
19.BalchGC,DeMeoA,GuillemJG.Modernmanagementof rectalcancer:a2006update.WorldJGastroenterol. 2006;12:3186–95.
20.ChenZH,SongXM,ChenSC,LiMZ,LiXX,ZhanWH,etal.
Riskfactorsforadverseoutcomeinlowrectalcancer.World JGastroenterol.2012;18:64–9.
21.CohenZ,MyersE,LangerB,TaylorB,RailtonRH,JamiesonC. Doublestaplingtechniqueforlowanteriorresection.Dis ColonRectum.1983;26:231–5.
22.ParksAG,PercyJP.Resectionandsuturedcolo-anal anastomosisforrectalcarcinoma.BrJSurg.1982;69: 301–4.
23.WestNP,FinanPJ,AnderinC,LindholmJ,HolmT,QuirkeP. Evidenceoftheoncologicsuperiorityofcylindrical abdominoperinealexcisionforlowrectalcancer.JClin Oncol.2008;26:3517–22.
24.denDulkM,PutterH,ColletteL,MarijnenCA,FolkessonJ, BossetJF,etal.Theabdominoperinealresectionitselfis associatedwithanadverseoutcome:theEuropean experiencebasedonapooledanalysisoffiveEuropean randomisedclinicaltrialsonrectalcancer.EurJCancer. 2009;45:1175–83.
25.YangZ,XuH,ZhangW,XuY,XuZ.Aretrospectiveanalysis ofultralowanteriorresectionvs.abdomino-perineal resectionforlowerrectalcancer.Hepatogastroenterology. 2012;59:1780–3.
26.WestNP,AnderinC,SmithKJ,HolmT,QuirkeP.Multicentre experiencewithextralevatorabdominoperinealexcisionfor lowrectalcancer.BrJSurg.2010;97:588–99.
27.WeiserMR,QuahHM,ShiaJ,GuillemJG,PatyPB,TempleLK, etal.Sphincterpreservationinlowrectalcanceris
facilitatedbypreoperativechemoradiationand intersphinctericdissection.AnnSurg.2009;249:236–42.
28.HowP,ShihabO,TekkisP,BrownG,QuirkeP,HealdR,etal. Asystematicreviewofcancerrelatedpatientoutcomes afteranteriorresectionandabdominoperinealexcisionfor rectalcancerinthetotalmesorectalexcisionera.Surg Oncol.2011;20:e149–55.
29.vanLeersumN,MartijnseI,denDulkM,KolfschotenN,Le CessieS,vandeVeldeC,etal.Differencesincircumferential resectionmargininvolvementafterabdominoperineal excisionandlowanteriorresectionnolongersignificant. AnnSurg.2014;259:1150–5.
30.WibeA,SyseA,AndersenE,TretliS,MyrvoldHE,SoreideO. Oncologicaloutcomesaftertotalmesorectalexcisionfor cureforcancerofthelowerrectum:anteriorvs. abdominoperinealresection.DisColonRectum. 2004;47:48–58.
31.BurkeJP,CoffeyJC,BoyleE,KeaneF,McNamaraDA.Early outcomesforrectalcancersurgeryintherepublicofIreland followinganationalcentralizationprogram.AnnSurg Oncol.2013;20:3414–21.
32.EmmertsenKJ,LaurbergS.Impactofboweldysfunctionon qualityoflifeaftersphincter-preservingresectionforrectal cancer.BrJSurg.2013;100:1377–87.
33.BryantCL,LunnissPJ,KnowlesCH,ThahaMA,ChanCL. Anteriorresectionsyndrome.LancetOncol.2012;13: e403–8.
34.EmmertsenKJ,LaurbergS.Boweldysfunctionafter treatmentforrectalcancer.ActaOncol.2008;47:994–1003.
35.OrtizH,ArmendarizP.Anteriorresection:dothepatients perceiveanyclinicalbenefit?IntJColorectalDis. 1996;11:191–5.
36.HallbookO,SjodahlR.Surgicalapproachestoobtaining optimalbowelfunction.SeminSurgOncol.2000;18:249–58.
37.BordeianouL,MaguireLH,AlaviK,SudanR,WisePE,Kaiser AM.Sphincter-sparingsurgeryinpatientswithlow-lying rectalcancer:techniques,oncologicoutcomes,and functionalresults.JGastrointestSurg.2014;18:1358–72.
38.Campos-LobatoLF,Alves-FerreiraPC,LaveryIC,KiranRP. Abdominoperinealresectiondoesnotdecreasequalityof lifeinpatientswithlowrectalcancer.Clinics(SaoPaulo). 2011;66:1035–40.
39.LeeSJ,ParkYS.Serialevaluationofanorectalfunction followinglowanteriorresectionoftherectum.IntJ ColorectalDis.1998;13:241–6.
40.DiBettaE,D’HooreA,FilezL,PenninckxF.Sphinctersaving rectumresectionisthestandardprocedureforlowrectal cancer.IntJColorectalDis.2003;18:463–9.
41.EngelJ,KerrJ,Schlesinger-RaabA,EckelR,SauerH,HolzelD. Qualityoflifeinrectalcancerpatients:afour-year
prospectivestudy.AnnSurg.2003;238:203–13.
42.PachlerJ,Wille-JorgensenP.Qualityoflifeafterrectal resectionforcancer,withorwithoutpermanentcolostomy. CochraneDatabaseSystRev.2005:Cd004323.
43.CornishJA,TilneyHS,HeriotAG,LaveryIC,FazioVW,Tekkis PP.Ameta-analysisofqualityoflifeforabdominoperineal excisionofrectumversusanteriorresectionforrectal cancer.AnnSurgOncol.2007;14:2056–68.
45.VarpeP,HuhtinenH,RantalaA,SalminenP,RautavaP, HurmeS,etal.Qualityoflifeaftersurgeryforrectalcancer withspecialreferencetopelvicfloordysfunction.Colorectal Dis.2011;13:399–405.
46.OrsiniRG,ThongMS,vandePoll-FranseLV,SlooterGD, NieuwenhuijzenGA,RuttenHJ,etal.Qualityoflifeofolder rectalcancerpatientsisnotimpairedbyapermanent stoma.EurJSurgOncol.2013;39:164–70.
47.BossemaER,SeuntiensMW,MarijnenCA,Baas-Thijssen MC,vandeVeldeCJ,StiggelboutAM.Therelationbetween illnesscognitionsandqualityoflifeinpeoplewithand withoutastomafollowingrectalcancertreatment. Psychooncology.2011;20:428–34.
48.HowP,StelznerS,BranaganG,BundyK,ChandrakumaranK, HealdRJ,etal.Comparativequalityoflifeinpatients followingabdominoperinealexcisionandlowanterior resectionforlowrectalcancer.DisColonRectum. 2012;55:400–6.
49.FischerA,TarantinoI,WarschkowR,LangeJ,ZerzA,Hetzer FH.Issphincterpreservationreasonableinallpatientswith rectalcancer?IntJColorectalDis.2010;25:425–32.
50.ScheeleJ,LemkeJ,MeierM,SanderS,Henne-BrunsD, KornmannM.Qualityoflifeaftersphincter-preservingrectal cancerresection.ClinColorectalCancer.2015;14:e33–40.
51.SchwartzCE,BodeR,RepucciN,BeckerJ,SprangersMA, FayersPM.Theclinicalsignificanceofadaptationto changinghealth:ameta-analysisofresponseshift.QualLife Res.2006;15:1533–50.
52.FuciniC,GattaiR,UrenaC,BandettiniL,ElbettiC.Qualityof lifeamongfive-yearsurvivorsaftertreatmentforverylow rectalcancerwithorwithoutapermanentabdominal stoma.AnnSurgOncol.2008;15:1099–106.
53.NesbakkenA,NygaardK,Bull-NjaaT,CarlsenE,EriLM. Bladderandsexualdysfunctionaftermesorectalexcision forrectalcancer.BrJSurg.2000;87:206–10.
54.MaasCP,MoriyaY,SteupWH,KiebertGM,KranenbargWM, vandeVeldeCJ.Radicalandnerve-preservingsurgeryfor rectalcancerinTheNetherlands:aprospectivestudyon morbidityandfunctionaloutcome.BrJSurg.1998;85:92–7.
55.MoriyaY.Functionpreservationinrectalcancersurgery.Int JClinOncol.2006;11:339–43.
56.WiltinkLM,ChenTY,NoutRA,KranenbargEM,FioccoM, LaurbergS,etal.Health-relatedqualityoflife14yearsafter preoperativeshort-termradiotherapyandtotalmesorectal excisionforrectalcancer:reportofamulticenter
randomisedtrial.EurJCancer.2014;50:2390–8.
57.LangeMM,MarijnenCA,MaasCP,PutterH,RuttenHJ, StiggelboutAM,etal.Riskfactorsforsexualdysfunction afterrectalcancertreatment.EurJCancer.2009;45:1578–88.
58.HavengaK,MaasCP,DeRuiterMC,WelvaartK,TrimbosJB. Avoidinglong-termdisturbancetobladderandsexual functioninpelvicsurgery:particularlywithrectalcancer. SeminSurgOncol.2000;18:235–43.
59.HuttnerFJ,TenckhoffS,JensenK,UhlmannL,KuluY, BuchlerMW,etal.Meta-analysisofreconstruction
techniquesafterlowanteriorresectionforrectalcancer.BrJ Surg.2015;102:735–45.
60.PedersenIK,ChristiansenJ,HintK,JensenP,OlsenJ, MortensenPE.Anorectalfunctionafterlowanterior resectionforcarcinoma.AnnSurg.1986;204:133–5.
61.HidaJ,OkunoK.Pouchoperationforrectalcancer.Surg Today.2010;40:307–14.
62.LujanJ,ValeroG,HernandezQ,SanchezA,FrutosMD, ParrillaP.Randomizedclinicaltrialcomparinglaparoscopic andopensurgeryinpatientswithrectalcancer.BrJSurg. 2009;96:982–9.
63.BonjerHJ,DeijenCL,AbisGA,CuestaMA,vanderPasMH, deLange-deKlerkES,etal.Arandomizedtrialof
laparoscopicversusopensurgeryforrectalcancer.NEnglJ Med.2015;372:1324–32.
64.ZhaoJK,ChenNZ,ZhengJB,HeS,SunXJ.Laparoscopic versusopensurgeryforrectalcancer:resultsofasystematic reviewandmeta-analysisonclinicalefficacy.MolClin Oncol.2014;2:1097–102.
65.ZhangFW,ZhouZY,WangHL,ZhangJX,DiBS,HuangWH, etal.Laparoscopicversusopensurgeryforrectalcancer:a systematicreviewandmeta-analysisofrandomized controlledtrials.AsianPacJCancerPrev.2014;15:9985–96.
66.BragaM,FrassonM,VignaliA,ZulianiW,CaprettiG,DiCarlo V.Laparoscopicresectioninrectalcancerpatients:outcome andcost-benefitanalysis.DisColonRectum.2007;50:464–71.
67.JayneDG,BrownJM,ThorpeH,WalkerJ,QuirkeP,GuillouPJ. Bladderandsexualfunctionfollowingresectionforrectal cancerinarandomizedclinicaltrialoflaparoscopicversus opentechnique.BrJSurg.2005;92:1124–32.
68.QuahHM,JayneDG,EuKW,Seow-ChoenF.Bladderand sexualdysfunctionfollowinglaparoscopicallyassistedand conventionalopenmesorectalresectionforcancer.BrJSurg. 2002;89:1551–6.
69.LimRS,YangTX,ChuaTC.Postoperativebladderandsexual functioninpatientsundergoingsurgeryforrectalcancer:a systematicreviewandmeta-analysisoflaparoscopicversus openresectionofrectalcancer.TechColoproctol.
2014;18:993–1002.
70.YangL,YuYY,ZhouZG,LiY,XuB,SongJM,etal.Qualityof lifeoutcomesfollowinglaparoscopictotalmesorectal excisionforlowrectalcancers:aclinicalcontrolstudy.EurJ SurgOncol.2007;33:575–9.
71.StaudacherC,VignaliA,SaverioDP,ElenaO,AndreaT. Laparoscopicvs.opentotalmesorectalexcisionin unselectedpatientswithrectalcancer:impactonearly outcome.DisColonRectum.2007;50:1324–31.
72.BartelsSA,VlugMS,UbbinkDT,BemelmanWA.Qualityof lifeafterlaparoscopicandopencolorectalsurgery:a systematicreview.WorldJGastroenterol.2010;16:5035–41.
73.LiJ,ChenR,XuYQ,WangXC,ZhengS,ZhangSZ,etal. Impactofalaparoscopicresectiononthequalityoflifein rectalcancerpatients:resultsof135patients.SurgToday. 2010;40:917–22.
74.AnderssonJ,AngeneteE,GellerstedtM,AngerasU,JessP, RosenbergJ,etal.Health-relatedqualityoflifeafter laparoscopicandopensurgeryforrectalcancerina randomizedtrial.BrJSurg.2013;100:941–9.
75.XiongB,MaL,HuangW,ZhaoQ,ChengY,LiuJ.Robotic versuslaparoscopictotalmesorectalexcisionforrectal cancer:ameta-analysisofeightstudies.JGastrointestSurg. 2015;19:516–26.
76.D’AnnibaleA,MorpurgoE,FisconV,TrevisanP,SovernigoG, OrsiniC,etal.Roboticandlaparoscopicsurgeryfor treatmentofcolorectaldiseases.DisColonRectum. 2004;47:2162–8.
77.SchiesselR,Karner-HanuschJ,HerbstF,TelekyB, WunderlichM.Intersphinctericresectionforlowrectal tumours.BrJSurg.1994;81:1376–8.
78.KoyamaM,MurataA,SakamotoY,MorohashiH,Takahashi S,YoshidaE,etal.Long-termclinicalandfunctionalresults ofintersphinctericresectionforlowerrectalcancer.Ann SurgOncol.2014;21Suppl3:S422–8.
79.PortierG,GhoutiL,KirzinS,GuimbaudR,RivesM,Lazorthes F.Oncologicaloutcomeofultra-lowcoloanalanastomosis withandwithoutintersphinctericresectionforlowrectal adenocarcinoma.BrJSurg.2007;94:341–5.
81.MartinST,HeneghanHM,WinterDC.Systematicreviewof outcomesafterintersphinctericresectionforlowrectal cancer.BrJSurg.2012;99:603–12.
82.TilneyHS,TekkisPP.Extendingthehorizonsofrestorative rectalsurgery:intersphinctericresectionforlowrectal cancer.ColorectalDis.2008;10:3–15,discussion15–16.
83.FrencknerB,EulerCV.Influenceofpudendalblockon thefunctionoftheanalsphincters.Gut.1975;16: 482–9.
84.BretagnolF,RullierE,LaurentC,ZerbibF,GontierR,SaricJ. Comparisonoffunctionalresultsandqualityoflifebetween intersphinctericresectionandconventionalcoloanal anastomosisforlowrectalcancer.DisColonRectum. 2004;47:832–8.
85.ParkJG,LeeMR,LimSB,HongCW,YoonSN,KangSB,etal.
ColonicJ-pouchanalanastomosisafterultralowanterior resectionwithuppersphincterexcisionforlow-lyingrectal cancer.WorldJGastroenterol.2005;11:2570–3.
86.BittorfB,StadelmaierU,GohlJ,HohenbergerW,MatzelKE. Functionaloutcomeafterintersphinctericresectionofthe rectumwithcoloanalanastomosisinlowrectalcancer.EurJ SurgOncol.2004;30:260–5.
87.NishizawaY,FujiiS,SaitoN,ItoM,OchiaiA,SugitoM,etal. Theassociationbetweenanalfunctionandneural
degenerationafterpreoperativechemoradiotherapy followedbyintersphinctericresection.DisColonRectum. 2011;54:1423–9.
88.WilliamsNS,MurphyJ,KnowlesCH.AnteriorPerinealPlanE forUltra-lowAnteriorResectionoftheRectum(theAPPEAR technique):aprospectiveclinicaltrialofanewprocedure. AnnSurg.2008;247:750–8.
89.DimitriouN,MichailO,MorisD,GriniatsosJ.Lowrectal cancer:sphincterpreservingtechniques-selectionof patients,techniquesandoutcomes.WorldJGastrointest Oncol.2015;7:55–70.
90.QiuHZ,XiaoY,LinGL,WuB,NiuBZ,ZhouJL.Clinical applicationofanteriorperinealplaneforultra-lowanterior resectionoftherectum.ZhonghuaWeiChangWaiKeZa Zhi.2012;15:47–50.
91.AtallahS,AlbertM,DeBeche-AdamsT,NassifG,Polavarapu H,LarachS.Transanalminimallyinvasivesurgeryfortotal mesorectalexcision(TAMIS-TME):astepwisedescriptionof thesurgicaltechniquewithvideodemonstration.Tech Coloproctol.2013;17:321–5.
92.AtallahS.Transanalminimallyinvasivesurgeryfortotal mesorectalexcision.MinimInvasiveTherAlliedTechnol. 2014;23:10–6.
93.AraujoSE,CrawshawB,MendesCR,DelaneyCP.Transanal totalmesorectalexcision:asystematicreviewofthe experimentalandclinicalevidence.TechColoproctol. 2015;19:69–82.
94.TuechJJ,KarouiM,LelongB,DeChaisemartinC,BridouxV, ManceauG,etal.AsteptowardNOTEStotalmesorectal excisionforrectalcancer:endoscopictransanal proctectomy.AnnSurg.2015;261:228–33.
95.AlbertMR,AtallahSB,deBeche-AdamsTC,IzfarS,Larach SW.Transanalminimallyinvasivesurgery(TAMIS)forlocal excisionofbenignneoplasmsandearly-stagerectalcancer: efficacyandoutcomesinthefirst50patients.DisColon Rectum.2013;56:301–7.
96.MooreJS,CataldoPA,OslerT,HymanNH.Transanal endoscopicmicrosurgeryismoreeffectivethantraditional transanalexcisionforresectionofrectalmasses.DisColon Rectum.2008;51:1026–30,discussion1030–1031.
97.ChristoforidisD,ChoHM,DixonMR,MellgrenAF,Madoff RD,FinneCO.Transanalendoscopicmicrosurgeryversus conventionaltransanalexcisionforpatientswithearly rectalcancer.AnnSurg.2009;249:776–82.
98.BuessG,TheissR,HuttererF,PichlmaierH,PelzC,HolfeldT, etal.Transanalendoscopicsurgeryoftherectum–testinga newmethodinanimalexperiments.LeberMagenDarm. 1983;13:73–7.
99.DeGraafEJ,DoorneboschPG,TollenaarRA,Meershoek-Klein KranenbargE,deBoerAC,BekkeringFC,etal.Transanal endoscopicmicrosurgeryversustotalmesorectalexcisionof T1rectaladenocarcinomaswithcurativeintention.EurJ SurgOncol.2009;35:1280–5.
100.DoorneboschPG,TollenaarRA,GosselinkMP,StassenLP, DijkhuisCM,SchoutenWR,etal.Qualityoflifeafter transanalendoscopicmicrosurgeryandtotalmesorectal excisioninearlyrectalcancer.ColorectalDis.2007;9:553–8.
101.PlantingA,PhangPT,RavalMJ,BrownCJ.Transanal endoscopicmicrosurgery:impactonfecalincontinenceand qualityoflife.CanJSurg.2013;56:243–8.
102.CallenderGG,DasP,Rodriguez-BigasMA,SkibberJM,Crane CH,KrishnanS,etal.Localexcisionafterpreoperative chemoradiationresultsinanequivalentoutcometototal mesorectalexcisioninselectedpatientswithT3rectal cancer.AnnSurgOncol.2010;17:441–7.
103.HeintzA,MorschelM,JungingerT.Comparisonofresults aftertransanalendoscopicmicrosurgeryandradical resectionforT1carcinomaoftherectum.SurgEndosc. 1998;12:1145–8.
104.AllaixME,ArezzoA,CaldartM,FestaF,MorinoM.Transanal endoscopicmicrosurgeryforrectalneoplasms:experience of300consecutivecases.DisColonRectum.2009;52:1831–6.
105.LezocheG,BaldarelliM,GuerrieriM,PaganiniAM,De SanctisA,BartolacciS,etal.Aprospectiverandomized studywitha5-yearminimumfollow-upevaluationof transanalendoscopicmicrosurgeryversuslaparoscopic totalmesorectalexcisionafterneoadjuvanttherapy.Surg Endosc.2008;22:352–8.
106.FisherSE,DanielsIR.Qualityoflifeandsexualfunction followingsurgeryforrectalcancer.ColorectalDis.2006;8 Suppl3:40–2.
107.HakimanH,PendolaM,FleshmanJW.Replacingtransanal excisionwithtransanalendoscopicmicrosurgeryand/or transanalminimallyinvasivesurgeryforearlyrectalcancer. ClinColonRectalSurg.2015;28:38–42.
108.CataldoPA,O’BrienS,OslerT.Transanalendoscopic microsurgery:aprospectiveevaluationoffunctionalresults. DisColonRectum.2005;48:1366–71.
109.KennedyML,LubowskiDZ,KingDW.Transanalendoscopic microsurgeryexcision:isanorectalfunctioncompromised? DisColonRectum.2002;45:601–4.
110.HermanRM,RichterP,WalegaP,PopielaT.Anorectal sphincterfunctionandrectalbarostatstudyinpatients followingtransanalendoscopicmicrosurgery.IntJ ColorectalDis.2001;16:370–6.
111.LezocheE,PaganiniAM,FabianiB,BallaA,VestriA, PescatoriL,etal.Quality-of-lifeimpairmentafter endoluminallocoregionalresectionandlaparoscopictotal mesorectalexcision.SurgEndosc.2014;28:227–34.
112.HompesR,AshrafSQ,GosselinkMP.Evaluationofqualityof lifeandfunctionat1yearaftertransanalendoscopic microsurgery.ColorectalDis.2015;17:O54–61.
113.AllaixME,RebecchiF,GiacconeC,MistrangeloM,MorinoM. Long-termfunctionalresultsandqualityoflifeafter transanalendoscopicmicrosurgery.BrJSurg. 2011;98:1635–43.
114.PapagrigoriadisS.Transanalendoscopicmicro-surgery (TEMS)forthemanagementoflargeorsessilerectal adenomas:areviewofthetechniqueandindications.Int SeminSurgOncol.2006;3:13.
116.BarendseRM,DoorneboschPG,BemelmanWA,FockensP, DekkerE,deGraafEJ.Transanalemploymentofsingle accessportsisfeasibleforrectalsurgery.AnnSurg. 2012;256:1030–3.
117.SchiphorstAH,LangenhoffBS,MaringJ,PronkA, ZimmermanDD.Transanalminimallyinvasivesurgery: initialexperienceandshort-termfunctionalresults.Dis ColonRectum.2014;57:927–32.
118.vanGijnW,MarijnenCA,NagtegaalID,KranenbargEM, PutterH,WiggersT,etal.Preoperativeradiotherapy combinedwithtotalmesorectalexcisionforresectable rectalcancer:12-yearfollow-upofthemulticentre, randomisedcontrolledTMEtrial.LancetOncol. 2011;12:575–82.
119.KapiteijnE,MarijnenCA,NagtegaalID,PutterH,SteupWH, WiggersT,etal.Preoperativeradiotherapycombinedwith totalmesorectalexcisionforresectablerectalcancer.NEngl JMed.2001;345:638–46.
120.SauerR,BeckerH,HohenbergerW,RodelC,WittekindC, FietkauR,etal.Preoperativeversuspostoperative chemoradiotherapyforrectalcancer.NEnglJMed. 2004;351:1731–40.
121.ContinP,KuluY,BrucknerT,SturmM,WelschT, Muller-StichBP,etal.Comparativeanalysisoflate functionaloutcomefollowingpreoperativeradiation therapyorchemoradiotherapyandsurgeryorsurgeryalone inrectalcancer.IntJColorectalDis.2014;29:165–75.
122.PollackJ,HolmT,CedermarkB,HolmstromB,MellgrenA. Long-termeffectofpreoperativeradiationtherapyon anorectalfunction.DisColonRectum.2006;49:345–52.
123.ChenTY,WiltinkLM,NoutRA,Meershoek-KleinKranenbarg E,LaurbergS,MarijnenCA,etal.Bowelfunction14years afterpreoperativeshort-courseradiotherapyandtotal mesorectalexcisionforrectalcancer:reportofamulticenter randomizedtrial.ClinColorectalCancer.2015;14:106–14.
124.PollackJ,HolmT,CedermarkB,AltmanD,HolmstromB, GlimeliusB,etal.Lateadverseeffectsofshort-course preoperativeradiotherapyinrectalcancer.BrJSurg. 2006;93:1519–25.
125.MarksJH,ValsdottirEB,DeNittisA,YarandiSS,NewmanDA, NwezeI,etal.Transanalendoscopicmicrosurgeryforthe treatmentofrectalcancer:comparisonofwound
complicationrateswithandwithoutneoadjuvantradiation therapy.SurgEndosc.2009;23:1081–7.
126.GornickiA,RichterP,PolkowskiW,SzczepkowskiM,Pietrzak L,KepkaL,etal.Anorectalandsexualfunctionsafter preoperativeradiotherapyandfull-thicknesslocalexcision ofrectalcancer.EurJSurgOncol.2014;40:723–30.
127.DaSilvaGM,BerhoM,WexnerSD,EfronJ,WeissEG, NoguerasJJ,etal.Histologicanalysisoftheirradiatedanal sphincter.DisColonRectum.1998;46:543–9,discussion 549–551.
128.AmmannK,KirchmayrW,KlausA,MuhlmannG,KafkaR, OberwalderM,etal.Impactofneoadjuvantchemoradiation onanalsphincterfunctioninpatientswithcarcinomaof themidrectumandlowrectum.ArchSurg.2003;138: 257–61.
129.DahlbergM,GlimeliusB,GrafW,PahlmanL.Preoperative irradiationaffectsfunctionalresultsaftersurgeryforrectal cancer:resultsfromarandomizedstudy.DisColonRectum. 1998;41:543–9,discussion549–551.
130.BujkoK,NowackiMP,Nasierowska-GuttmejerA,Michalski W,BebenekM,PudelkoM,etal.Sphincterpreservation followingpreoperativeradiotherapyforrectalcancer:report ofarandomisedtrialcomparingshort-termradiotherapyvs. conventionallyfractionatedradiochemotherapy.Radiother Oncol.2004;72:15–24.
131.BraendengenM,TveitKM,HjermstadMJ,JohanssonH, BerglundA,BrandbergY,etal.Health-relatedqualityoflife (HRQoL)aftermultimodaltreatmentforprimarily
non-resectablerectalcancer.Long-termresultsfroma phaseIIIstudy.EurJCancer.2012;48:813–9.
132.Glynne-JonesR,HughesR.Criticalappraisalofthe‘waitand see’approachinrectalcancerforclinicalcomplete
respondersafterchemoradiation.BrJSurg.2012;99: 897–909.
133.MaasM,NelemansPJ,ValentiniV,DasP,RodelC,KuoLJ, etal.Long-termoutcomeinpatientswithapathological completeresponseafterchemoradiationforrectalcancer:a pooledanalysisofindividualpatientdata.LancetOncol. 2010;11:835–44.
134.HiotisSP,WeberSM,CohenAM,MinskyBD,PatyPB,Guillem JG,etal.Assessingthepredictivevalueofclinicalcomplete responsetoneoadjuvanttherapyforrectalcancer:an analysisof488patients.JAmCollSurg.2002;194:131–5, discussion135–136.
135.Habr-GamaA,PerezRO,NadalinW,SabbagaJ,RibeiroUJr, SilvaeSousaAHJr,etal.Operativeversusnonoperative treatmentforstage0distalrectalcancerfollowing chemoradiationtherapy:long-termresults.AnnSurg. 2004;240:711–7,discussion717–718.
136.MaasM,Beets-TanRG,LambregtsDM,LammeringG, NelemansPJ,EngelenSM,etal.Wait-and-seepolicyfor clinicalcompleterespondersafterchemoradiationforrectal cancer.JClinOncol.2011;29:4633–40.
137.DaltonRS,VelineniR,OsborneME,ThomasR,HarriesS,Gee AS,etal.Asingle-centreexperienceofchemoradiotherapy forrectalcancer:istherepotentialfornonoperative management?ColorectalDis.2012;14:567–71.
