Perineal or Abdominal Approach First During Intersphincteric Resection for Low Rectal Cancer: Which Is the Best Strategy?

Abstract

Intersphincteric resection during total mesorectal excision for low rectal cancer can be performed through a primary abdominal or a primary perineal approach. The purpose of this study was to compare the results of a primary perineal approach with those of a primary abdominal approach in patients undergoing laparoscopic total mesorectal excision for low rectal cancer. This was a case-matched retrospective study from a prospectively maintained database. The study was conducted at a tertiary colorectal surgery referral center. From 2005 to 2013, among 138 patients with low rectal cancer who underwent total mesorectal excision with intersphincteric resection, 34 patients with a primary abdominal approach (abdominal group) were matched with 51 identical patients with a primary perineal approach (6-cm perineal dissection along the mesorectal plane; perineal group), according to TNM stage, sex, BMI, and age. Postoperative morbidity, oncologic outcomes, and 3-year overall and disease-free survivals were measured. The operative time was significantly shorter in the perineal group (269 minutes in perineal vs 240 minutes in abdominal group; p = 0.01). Overall morbidity (47% vs 47%; p = 1.00), severe morbidity (16% vs 15%; p = 0.90), and clinical anastomotic leakage (24% vs 12%; p = 0.17) rates showed no differences when comparing the 2 groups. The overall R1 resection rate was similar in the 2 groups (16% vs 9%; p = 0.36), including a 10% vs 9% positive circumferential margin (p = 0.88) and a 8% vs 0% positive distal margin (p = 0.15). After a median follow-up of 39 months, 3-year overall (100% vs 93% (95% CI, 88%-98%); p = 0.26) and disease-free (63% (95% CI, 56%-71%) vs 62% (95% CI, 53%-71%); p = 0.58) survival rates showed no differences between the 2 groups. The study was limited by its nonrandomized nature and limited sample size. In cases of laparoscopic total mesorectal excision with intersphincteric resection for low rectal cancer, the primary perineal approach appears to reduce operative time and is associated with similar short- and long-term outcomes as compared with the primary abdominal approach. The primary perineal approach should thus be considered as the standard strategy.