Reply:
The functional outcome of the technique of intersphincteric resection (ISR) for rectal cancer has been reported previously.1,2 At least 50% of the patients had a spontaneous good continence.2 Medical treatment and biofeedback were able to improve continence in a further 25% of patients.3 Finally, 75% of good continence can be expected following ISR. Results are better after partial than after total internal sphincter excision: 73% versus 50%.4 This is due to the decreased resting anal canal pressure according to internal sphincter excision: 70 cm H2O after partial ISR and 40 cm H2O after total ISR.1 Paradoxically, the ability of the patients to distinguish feces from flatus was not significantly different between ISR and a conventional coloanal anastomosis preserving all the internal sphincter: 62% versus 73% (P = 0.34).2 Functional results of ISR are improved by adding a colonic pouch compared with a straight coloanal anastomosis.5
We agree with Dr. Ramesh that our series of ISR (median follow-up, 40 months) needs further follow-up because some local recurrences may occur at 5 years after neoadjuvant treatment.
The criteria of exclusion for sphincter preservation in our experience was exclusively related to the infiltration of the tumor to the external sphincter. Neither the lymph node status nor the differentiation of the tumor was a contraindication.6 In the present series of 92 ISRs, there were 52 N1 and 5 poorly differentiated tumors. The good local control (2% of local recurrence) after sphincter-saving resection for very low rectal cancer, including N1 and poorly differentiated tumors, suggests that since the introduction of the technique of total mesorectal excision, N1 and poorly differentiated tumors are related to a risk of metastases rather than local recurrence.
In our experience, contraindication for sphincter preservation because of previous impaired fecal incontinence was exceptional. It was diagnosed exclusively clinically, ie, presence of significant solid or liquid fecal incontinence more than 6 months before the diagnosis of the tumor.
Eric Rullier, MD
Christophe Laurent, MD
Frédéric Bretagnol, MD
Anne Rullier, MD
Véronique Vendrely, MD
Frank Zerbib MD, PhD
Saint André Hospital, Bordeaux, France, eric.rullier@chu-bordeaux.fr
REFERENCES
- 1.Rullier E, Zerbib F, Laurent C, et al. Intersphincteric resection with excision of internal anal sphincter for conservative treatment of very low rectal cancer. Dis Colon Rectum. 1999;42:1168–1175. [DOI] [PubMed] [Google Scholar]
- 2.Bretagnol F, Rullier E, Laurent C, et al. Comparison of functional results and quality of life between intersphincteric resection and conventional coloanal anastomosis for low rectal cancer. Dis Colon Rectum. 2004;47:832–838. [DOI] [PubMed] [Google Scholar]
- 3.Laurent C, Benajah D, Bretagnol F, et al. Management of defecatory function disorders following rectal resection with coloanal anastomosis for low rectal cancer: can fecal incontinence and quality of life improve? [Abstract]. Gastroenterology. 2005;128:A267. [Google Scholar]
- 4.Gamagami R, Istvan G, Cabarrot P, et al. Fecal continence following partial resection of the anal canal in distal rectal cancer: long-term results after coloanal anastomoses. Surgery. 2000;127:291–295. [DOI] [PubMed] [Google Scholar]
- 5.Bittorf B, Stadelmaier U, Gohl J, et al. Functional outcome after intersphincteric resection of the rectum with coloanal anastomosis in low rectal cancer. Eur J Surg Oncol. 2004;30:260–265. [DOI] [PubMed] [Google Scholar]
- 6.Rullier E, Goffre B, Bonnel C, et al. Preoperative radiochemotherapy and sphincter-saving resection for T3 carcinomas of the lower third of the rectum. Ann Surg. 2001;234:633–640. [DOI] [PMC free article] [PubMed] [Google Scholar]