Cáncer de recto del tercio inferior: resección anterior interesfintérica con anastomosis manual según técnicas de Parks o Turnbull-Cutait

doi:10.1016/S0009-739X(14)70004-1

Cirugía Española

Volume 92, Supplement 1, March 2014, Pages 13-20

https://doi.org/10.1016/S0009-739X(14)70004-1 Get rights and content

Resumen

La resección anterior ultrabaja interesfinteriana de recto puede utilizarse en casos seleccionados con la intención de mejorar la calidad de vida de los pacientes evitando una colostomía definitiva. La resección anterior ultrabaja interesfinteriana está indicada en tumores que se localizan desde 1-2 cm por encima del anillo anorrectal hasta la parte superior del esfínter anal interno sin afectación del suelo pélvico, del músculo puborrectalis o del esfínter anal externo, y su objetivo es obtener un margen distal libre de tumor no inferior a 1 cm. Es fundamental una correcta estadificación y localización anatómica preoperatoria del tumor respecto a las estructuras y órganos adyacentes. La reconstrucción del tránsito intestinal se puede realizar con una anastomosis coloanal manual según Parks más una ileostomía lateral o en alternativa, mediante anastomosis coloanal en 2 tiempos según técnica de Turnbull-Cutait evitando el estoma de protección.

La mortalidad y la morbilidad postoperatoria de la resección anterior ultrabaja interesfinteriana son comparables a las observadas en la resección anterior ultrabaja estándar, así como la tasa de recurrencia local y la supervivencia global libre de enfermedad a los 5 años. Las alteraciones funcionales postoperatorias de la resección anterior ultrabaja interesfinteriana pueden afectar la calidad de vida de los pacientes independientemente de la técnica reconstructiva utilizada. Los estudios existentes no aportan datos suficientes para establecer el método reconstructivo más eficiente en términos de resultados funcionales.

Abstract

Rectal ultralow, intersphincteric anterior resection (RIE) can be used in selected cases with the intention of improving the quality of life of patients avoiding permanent colostomy. RIE is indicated for tumors that are located from 1-2 cm above the anorectal ring to the top of the internal anal sphincter without involvement of the pelvic floor, puborrectalis muscle or external anal sphincter. RIE aims to get a free distal margin tumour not less than 1 cm. Correct preoperative staging and anatomical tumour location and relation with adjacent structures and organs is fundamental. Intestinal transit reconstruction can be performed manually with a coloanal anastomosis according with Parks and with a lateral ileostomy or, alternatively, by a two-stage coloanal anastomosis technique as Turnbull-Cutait avoiding the stoma protection.

Postoperative morbidity and mortality and the rate of local recurrence and overall disease-free survival at 5 years after RIE are comparable to those observed in standard ultra low anterior resection. Postoperative functional alterations of the RIE can affect the quality of life of patients regardless of reconstructive technique. Published studies do not provide sufficient data to establish the most efficient reconstruction method in terms of functional outcomes.

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Cited by (6)

Quality of life and anterior resection syndrome after surgery for mid to low rectal cancer: A cross-sectional study
2018, European Journal of Surgical Oncology
Citation Excerpt :
Patients were divided in three groups: patients that underwent APR or ultralow Hartman procedure (Group I), and patients with sphincter saving procedure (SSP), with low mechanical colorectal anastomosis (CRA) (Group II) and with manual coloanal anastomosis (CAA) (Group III). In this last group, coloanal anastomosis was performed after rectal resection in one-stage procedure associated with diverting ileostomy, or in a second stage according to Turnbull-Cutait procedure without ileostomy [27,28]. All patients with a tumor that did not involve the external sphincter or the lower two-thirds of the internal sphincter were recommended for SSP with low colorectal or coloanal anastomosis associated with partial or total intersphincteric resection if necessary [11].
The aim of this study was to analyze the quality of life (QoL), low anterior resection syndrome (LARS) and fecal incontinence after surgery for mid to low rectal cancer and its relationship with the type of surgical procedure performed.
A cross-sectional cohort survey study of 358 patients operated on for mid to low rectal cancer. Patients were included in three groups: abdominoperineal resection (APR), low mechanical colorectal anastomosis (CRA) and hand-sewn coloanal anastomosis (CAA). The QLQ-C30/CR29 questionnaires, LARS and Vaizey scores were used to study QoL and defecatory dysfunction. Multivariable analysis was used to estimate the prognostic effect of the variables on QoL and LARS scores.
62.6% of the patients answered the survey. The global QoL score was similar among APR, CRA and CAA. Patients' body image perception was significantly worse after APR than after CRA or CAA. LARS score was better in CRA group (p = 0.002). A major LARS was observed in 83.3% of the patients who underwent CAA and in 56.6% of the patients who underwent CRA. No relationship between surgical procedures and the global QoL score was observed. Neoadjuvant radiotherapy (p = 0.048) and CAA (p = 0.005) were associated with a major LARS. The Vaizey score was higher for CAA than for CRA (p = 0.036).
Though CAA group presents worse LARS and higher faecal incontinence scores respect CRA patients, and APR is related with a worse body image, global QoL was similar in the three groups.
Turnbull-cutait technique in low rectal cancer: Case report
2016, Cirugia y Cirujanos
El tratamiento quirúrgico para el cáncer de recto del tercio inferior implica la realización de una resección anterior ultrabaja de recto con resección total de mesorrecto y una anastomosis coloanal. La anastomosis coloanal en 2 tiempos según Turnbull-Cutait podría ser una opción en pacientes con cáncer de recto del tercio inferior.
Paciente femenina de 69 años de edad con diagnóstico de adenocarcinoma (T2N1), localizado a 4 cm de margen anal. Recibe radioterapia neoadyuvante. Se realiza una resección anterior ultrabaja y la resección total del mesorrecto. El tránsito intestinal se reconstruye mediante una anastomosis coloanal de tipo Turnbull-Cutait.
La anastomosis coloanal en 2 tiempos según Turnbull-Cuatit podría ser una opción primaria en pacientes con cáncer de recto del tercio inferior para evitar la realización de ileostomía de protección y su impacto económico y en la calidad de vida.
The surgical treatment for low rectal cancer involves an ultra-low anterior resection with complete mesorectal resection and coloanal anastomosis. Two-stage coloanal anastomosis such as the Turnbull-Cutait technique represents an option for patients with low rectal cancer.
A 69 year-old female patient with a diagnosis of adenocarcinoma (T2N1), located 4 cm from the anal margin. She received neoadjuvant radiotherapy. An ultra-low anterior resection and total resection of the mesorectum were performed. The intestinal transit was reconstructed by coloanal anastomosis using the Turnbull-Cutait technique.
Coloanal anastomosis with the Turnbull-Cutait technique represents a primary option for patients with low rectal cancer, avoiding a loop ileostomy, its economic impact and on their quality of life.
Specialized referral centers for rectal cancer
2015, Cirugia Espanola
«The paradigm of surgical treatment of distal rectal cancer: What to remove vs. what to leave behind»
2015, Cirugia Espanola
Two-Stage Turnbull-Cutait Pull-Through Coloanal Anastomosis for Low Rectal Cancer: A Randomized Clinical Trial
2020, JAMA Surgery
Two-stage Turnbull-Cutait pull-through coloanal anastomosis versus coloanal anastomosis with protective loop ileostomy for low rectal cancer. Protocol for a randomized controlled trial (Turnbull-BCN)
2017, International Journal of Colorectal Disease

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Cáncer de recto del tercio inferior: resección anterior interesfintérica con anastomosis manual según técnicas de Parks o Turnbull-CutaitDistal third rectal cancer: intersphincteric anterior resection with manual anastomosis using the techniques of Parks or Turnbull-Cutait

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