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Perineal Transanal Approach: A New Standard for Laparoscopic Sphincter-Saving Resection in Low Rectal Cancer, a Randomized Trial

Denost, Quentin MD*,‡; Adam, Jean-Philippe MD*,‡; Rullier, Anne MD, PhD†,‡; Buscail, Etienne MD*,‡; Laurent, Christophe MD, PhD*,‡; Rullier, Eric MD*,‡

doi: 10.1097/SLA.0000000000000766
Randomized Controlled Trials

Background: Laparoscopic sphincter preservation for low rectal cancer is challenging because of the high risk of positive circumferential resection margin. We hypothesized that perineal dissection of the distal rectum may improve quality of surgery, compared with the conventional abdominal dissection.

Methods: Between 2008 and 2012, 100 patients with low rectal cancer (< 6 cm from the anal verge) suitable for sphincter preservation were randomized between perineal and abdominal low rectal dissection. Surgery included laparoscopic mobilization of the left colon with high rectal dissection. Distal rectal dissection was performed laparoscopically in the abdominal group and transanally in the perineal group. The primary endpoint was quality of surgery (circumferential resection margin, mesorectum grade, and lymph nodes). Secondary end points were morbidity and conversion.

Results: The rate of positive circumferential resection margin decreased significantly after perineal compared with abdominal low rectal dissection, 4% versus 18% (P = 0.025). The mesorectum grade and the number of lymph nodes analyzed did not differ between the 2 groups. There was no difference in surgical morbidity (12% vs 14%; P = 0.766) and conversion (4% vs 10%; P = 0.436) between perineal and abdominal rectal dissection. Multivariate analysis showed that abdominal rectal dissection was the only independent factor of positive circumferential resection margin (odds ratio = 5.25; 95% confidence interval: 1.03–26.70; P = 0.046).

Conclusions: Perineal rectal dissection reduces the risk of positive circumferential resection margin, as compared with the conventional abdominal dissection in low rectal cancer. This suggests the perineal rectal dissection as a new standard in laparoscopic sphincter-saving resection for low rectal cancer.

Laparoscopic sphincter-saving resection for low rectal cancer is technically challenging and exposes to a high risk of positive circumferential resection margin. We compared perineal transanal dissection of the distal rectum with the conventional abdominal dissection and observed a significantly lower rate of positive circumferential resection margin in the perineal group with a trend to a lower rate of conversion. We therefore recommend the perineal approach in patients treated by laparoscopic sphincter-saving resection for low rectal cancer.

*CHU Bordeaux, Saint André Hospital, Department of Surgery

CHU Bordeaux, Pellegrin Hospital, Department of Pathology

University Segalen Bordeaux 2, Bordeaux, France.

Reprints: Eric Rullier, MD, Service de Chirurgie Digestive, Hôpital Saint-André, 33075 Bordeaux, France. E-mail: eric.rullier@chu-bordeaux.fr.

Disclosure: The authors report no financial or other conflict of interest relevant to the subject of this article.

Presented as oral communication at the congress of Société Française de Chirurgie Digestive (SFCD), Paris, France, November 28–30, 2012.

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