title: Sphincter-saving resection for all rectal carcinomas: the end of the 2-cm distal rule.
abstract: OBJECTIVE
  To assess oncologic outcome of patients treated by conservative radical surgery for tumors below 5 cm from the anal verge.
  
  
  BACKGROUND
  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.
authors.affiliation: Department of Surgery, Saint-André Hospital, Bordeaux, France. eric.rullier@chu-bordeaux.fr
authors.forename: Eric
authors.initials: E
authors.lastname: Rullier
authors.forename: Christophe
authors.initials: C
authors.lastname: Laurent
authors.forename: Frédéric
authors.initials: F
authors.lastname: Bretagnol
authors.forename: Anne
authors.initials: A
authors.lastname: Rullier
authors.forename: Véronique
authors.initials: V
authors.lastname: Vendrely
authors.forename: Frank
authors.initials: F
authors.lastname: Zerbib
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002277:Carcinoma / Q000401:mortality / Q000556:secondary / Q000601:surgery*; D013505:Digestive System Surgical Procedures / Q000379:methods; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local; D011183:Postoperative Complications; D012004:Rectal Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D012007:Rectum / Q000601:surgery*; D015996:Survival Rate
references.citation: Int J Radiat Oncol Biol Phys. 2003 Apr 1;55(5):1311-20
references.pmid: 12654443
references.citation: Br J Surg. 1951 Nov;39(155):199-211
references.pmid: 14895939
references.citation: Br J Surg. 2003 Aug;90(8):922-33
references.pmid: 12905543
references.citation: Dis Colon Rectum. 2004 Jun;47(6):832-8
references.pmid: 15108027
references.citation: Br J Surg. 1977 Jun;64(6):413-6
references.pmid: 871615
references.citation: N Engl J Med. 1979 May 3;300(18):1028-30
references.pmid: 431596
references.citation: Dis Colon Rectum. 1981 Nov-Dec;24(8):600-1
references.pmid: 7318624
references.citation: Br J Surg. 1983 Mar;70(3):150-4
references.pmid: 6831156
references.citation: Ann Surg. 1983 Aug;198(2):159-63
references.pmid: 6870373
references.citation: Lancet. 1986 Nov 1;2(8514):996-9
references.pmid: 2430152
references.citation: Semin Surg Oncol. 1994 Jan-Feb;10(1):12-20
references.pmid: 8115781
references.citation: Br J Surg. 2003 Apr;90(4):445-51
references.pmid: 12673746
references.citation: Surgery. 2000 Mar;127(3):291-5
references.pmid: 10715984
references.citation: Dis Colon Rectum. 2000 Jun;43(6):843-50
references.pmid: 10859087
references.citation: Ann Surg Oncol. 2001 Aug;8(7):611-5
references.pmid: 11508624
references.citation: Ann Surg. 2001 Nov;234(5):633-40
references.pmid: 11685026
references.citation: Br J Surg. 2001 Dec;88(12):1607-12
references.pmid: 11736973
references.citation: Ann Surg. 2002 Apr;235(4):449-57
references.pmid: 11923599
references.citation: Br J Surg. 1994 Sep;81(9):1376-8
references.pmid: 7953423
references.citation: Ann Surg. 1995 Jan;221(1):67-73
references.pmid: 7826163
references.citation: Br J Surg. 1995 Apr;82(4):465-8
references.pmid: 7542142
references.citation: Br J Surg. 1995 Aug;82(8):1054-6
references.pmid: 7648152
references.citation: Br J Surg. 1996 Jan;83(1):15-8
references.pmid: 8653351
references.citation: Dis Colon Rectum. 1997 Oct;40(10 Suppl):S43-7
references.pmid: 9378011
references.citation: Obstet Gynecol. 1998 Mar;91(3):369-74
references.pmid: 9491862
references.citation: Br J Surg. 1998 May;85(5):596-603
references.pmid: 9635802
references.citation: Arch Surg. 1998 Aug;133(8):894-9
references.pmid: 9711965
references.citation: Int J Radiat Oncol Biol Phys. 1998 Aug 1;42(1):51-7
references.pmid: 9747819
references.citation: Dis Colon Rectum. 1999 Sep;42(9):1168-75
references.pmid: 10496557