title: Intersphincteric resection and hand-sewn coloanal anastomosis for low rectal cancer: Short-term outcomes in the Indian setting.
abstract: BACKGROUND
  The rectum remains a predominant subsite of colorectal cancer in the Indian population. Unique to the Indian setting are significant social repercussions associated with a permanent stoma. On account of this, many patients who are advised abdominal perineal excision of the rectum (APER) default treatment. Accurate demonstration of the intersphincteric plane with magnetic resonance imaging has made intersphincteric resection (ISR) a viable option. This study is aimed at determining the feasibility and oncological adequacy of ISR in the Indian scenario.
  
  
  METHODS
  All patients with low rectal cancer who underwent an ISR at the Tata Memorial Centre, from July 2013 to December 2013 were included. Patients with invasion of the external sphincter and suboptimal preoperative sphincter function were excluded. Following standard preoperative staging, patients with a threatened circumferential resection margin (CRM) and/or mesorectal nodes were given preoperative chemoradiotherapy. The oncological adequacy of the procedure was evaluated in terms of margin positivity (distal and CRMs) and lymph node yield. Short-term perioperative outcomes included 30-day mortality, postoperative morbidity, anastomotic leaks, and length of hospital stay.
  
  
  RESULTS
  Thirty-three patients with low rectal cancer and a median age of 38 years underwent ISR during the defined study period. Twenty-three patients (70 %) underwent open surgery whereas ten patients received a laparoscopic resection. The median blood loss and hospital stay was 300 mL and 7 days, respectively. Two patients had an involved CRM, but all distal margins were free of tumor. The quality of total mesorectal excision was satisfactory in all patients with a median lymph node yield of 9 nodes.
  
  
  CONCLUSIONS
  Intersphincteric resection is feasible and oncologically safe in selected patients with low rectal cancer. Long-term functional and oncological outcomes are essential before it can be considered a viable alternative to APER.
authors.affiliation: Department of Surgical Oncology, Tata Memorial Hospital, Ernest Borges Road, Parel, Mumbai, 400 012, India, vishpai88@gmail.com.
authors.forename: Vishwas D
authors.initials: VD
authors.lastname: Pai
authors.forename: Ashwin
authors.initials: A
authors.lastname: De Souza
authors.forename: Prachi
authors.initials: P
authors.lastname: Patil
authors.forename: Reena
authors.initials: R
authors.lastname: Engineer
authors.forename: Supreeta
authors.initials: S
authors.lastname: Arya
authors.forename: Avanish
authors.initials: A
authors.lastname: Saklani
mesh_terms: D000328:Adult; D000368:Aged; D001003:Anal Canal / Q000601:surgery*; D000714:Anastomosis, Surgical / Q000379:methods*; D003106:Colon / Q000601:surgery*; D016208:Databases, Factual; D013505:Digestive System Surgical Procedures / Q000379:methods*; D005260:Female; D006801:Humans; D007194:India; D010535:Laparoscopy; D008297:Male; D008875:Middle Aged; D011788:Quality of Life; D012004:Rectal Neoplasms / Q000601:surgery*; D012189:Retrospective Studies; D013536:Suture Techniques; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult