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Safety and feasibility of sphincter preservation surgery in low lying rectal cancers

To the Editor, Sphincter preservation for low rectal cancers is desirable, if feasible with oncological adequacy. Rouanet et al. have attempted to establish the safety of sphincter preservation surgery in patients who were candidates for abdomino‐perineal resection (APR) at baseline in the GRECCAR‐1 trial. Feasibility of sphincter preservation in low rectal cancers was a subgroup analysis of this trial which mainly randomized patients to two different preoperative radiotherapy regimens. We feel that an improvised trial design in the future could increase the applicability of results. The study included patients of low rectal cancers with the distance of inferior edge of tumor from levator being less than 2 cm, nearly amounting to 4–6 cm distance of the tumor from the anal verge. Also, no extra‐levator resections were done as described in the study, indicating that the tumors were away from levator ani diaphragm. Inclusion of still lower rectal tumors at a higher risk of undergoing APR (below the levator diaphragm and abutting it) would have been desirable. In today's era, magnetic resonance imaging (MRI) serves as an unavoidable and a validated staging tool for the high risk low rectal cancers, more so with the use of diffusion weighted imaging sequences which have higher accuracy of differentiating postradiation fibrosis from viable tumor. The overall R‐0 resection rate was 81% for sphincter preservation surgery and 74% for APRs. These rates seem high against usual reported rates of less than 10% for total mesorectal excision following neoadjuvant radiation. This again raises the doubt over increased incidence of positive margins in the absence of MRI. Formulation of a more objective definition of criteria for choosing sphincter preservation surgery over APR for the high‐risk tumors rather than just subjective assessment by surgeons could lead to reproducible results. With an appreciable 84.6% sphincter preservation rate, increased sample size with more number of APRs (30/195) is required to make meaningful comparison with the sphincter preservation group, especially with respect to long term oncological outcomes. Sphincter preservation is more often sought in young patients, even in the ones with ultra‐low rectal cancers. Median age in the current study was around 60 years, thus questioning the generalizability of the results. Especially when the younger patient population is fraught with an increased predilection for poorly differentiated cancers especially signet ring cell histology. Recruitment of a younger patient cohort with a better definition of histology distribution could increase the applicability of the results. The safety of intersphincteric resections for low lying rectal tumors abutting or involving the puborectalis muscle at baseline with a good response post neoadjuvant radiation therapy remains to be established.