title: Push-back technique facilitates ultra-low anterior resection without nerve injury in total mesorectal excision for rectal cancer.
abstract: OBJECTIVE
  To describe our push-back approach to ultra-low anterior resection using the concept of the mucosal stump.
  
  
  METHODS
  We mobilize the rectum using an abdominal approach, and perform mucosal cutting circumferentially at the dentate line. The mucosal stump is closed, and the internal sphincteric muscle resected partially or totally according to tumor location. Perianal dissection is performed along the medial plane of the external sphincteric muscles, and the hiatal ligament is dissected posteriorly. To resect the entire rectum, the closed rectal stump is pushed back to the abdominal cavity using composed gauze. This prevents injury to the autonomic nerve.
  
  
  RESULTS
  We performed colonic J-pouch anal anastomosis using our mucosal stump approach in 58 patients with rectal cancer located <4 cm from the anal verge. According to the Wexner score, 7% of patients were fully continent, 71% had acceptable function with minor continence problems, and 22% were incontinent. No patients required intermittent self-catheterization during follow-up. After a median follow-up of 49 months, there was only 1 case of local recurrence after surgery.
  
  
  CONCLUSIONS
  Our push-back approach for internal sphincter resection produces satisfactory functional and oncological results in ultra-low anterior rectal cancer.
authors.affiliation: Department of Gastrointestinal and Pediatric Surgery, Division of Reparative Medicine, Institute of Life Sciences, Mie University Graduate School of Medicine, Mie, Japan.
authors.forename: Yasuhiro
authors.initials: Y
authors.lastname: Inoue
authors.forename: Junichiro
authors.initials: J
authors.lastname: Hiro
authors.forename: Yuji
authors.initials: Y
authors.lastname: Toiyama
authors.forename: Koji
authors.initials: K
authors.lastname: Tanaka
authors.forename: Keiichi
authors.initials: K
authors.lastname: Uchida
authors.forename: Chikao
authors.initials: C
authors.lastname: Miki
authors.forename: Masato
authors.initials: M
authors.lastname: Kusunoki
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001341:Autonomic Nervous System / Q000502:physiology*; D039021:Colonic Pouches; D007172:Erectile Dysfunction / Q000209:etiology; D005242:Fecal Incontinence / Q000209:etiology / Q000517:prevention & control; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D012004:Rectal Neoplasms / Q000601:surgery*; D012007:Rectum / Q000294:innervation* / Q000601:surgery; D016896:Treatment Outcome; D014549:Urinary Incontinence / Q000209:etiology / Q000517:prevention & control