Outcomes of anterior and intersphincteric resection for rectal cancer: focus on the issue of permanent stoma

AIM: to assess early and long-term outcomes of interspincteric (ISR) and ultralow anterior resection (ULAR) for low rectal cancer, with a special focus on risk factors for a permanent stoma.

PATIENTS AND METHODS: seventy patients who underwent ISR/ULAR for rectal cancer from January 2019 to December 2023 were included in retrospective study. Patients who underwent ULAR during the same time period was selected after matching by the following parameters: gender, age, body mass index, comorbidities, type of surgical approach, pTNM, tumor stage, degree of differentiation, distance of the tumor from the anus, type of neoadjuvant radiation therapy (n = 58). The overall median follow-up of patients in both groups was 38 (95% CI: 31–41) months. Surgical complications, stoma formation rate, three-year overall (OS) and three-year recurrence-free survival (RFS) were assessed. Multivariate logistic regression analysis was used to identify predictors of permanent stoma. RESULTS: anastomotic leakage was higher after ULAR: 17/58 (29.3%) vs. 10/70 (14.3%) (p = 0.038). Late complications, predominantly functional disorders, occurred more often after AAR: 35/67 (52.2%) vs. 14/55 (25.5%) (p = 0.003). Despite higher odds of stoma reversal after ULAR (odds ratio (OR) 6.5; 95% confidence interval (CI) 1.7–23.9), by the end of follow-up, a greater proportion of patients in this group were living with a permanent stoma: 27/56 (48.2%) vs. 15/67 (22.4%) (p = 0.003). Independent predictors of a permanent stoma were the performance of ULAR (adjusted odds ratio (AOR) 3.54; 95 CI: 1.373–9.13), anastomotic leakage (AOR 11.76; 95 CI: 3.46–40), pN + stage (AOR 1.73; 95 CI: 1.06–2.82) and radiotherapy (AOR 3.92; 95 CI: 1.17–13.09). The prognostic model showed high discriminative ability (Area Under the Curve (AUC) = 0.851; 95% CI: 0.772–0.929). Three-year OS (63.9% (95% CI: 49.9–74.9) vs. 75.0%, (95% CI: 59.7–85.2), p = 0.503) and RFS (48.2% (95% CI: 33.9–61.2) vs. 50.3% (95% CI: 31.2–66.7), p = 0.646) after AAR and ULAR, respectively, were statistically comparable.

CONCLUSION: despite comparable oncological efficacy, ULAR is associated with a higher risk of anastomotic leakage, which is a key factor leading to a permanent stoma. AAR is associated with a higher rate of functional disorders. The choice of surgical technique should be based on an individual assessment of the risk of anastomotic leakage.

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