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Letter in response to colorectal disease article on intersphincteric resection

Dear Sir, We were interested to read the review paper on intersphincteric resection (ISR) by Tilney and Tekkis [1] along with the associated commentary and editorial. We fully endorse efforts to retain gastrointestinal continuity both for benign and malignant disease provided that this is compatible with reasonable function and acceptable recurrence rates, which appears to be the case. In addition, we agree that patient selection and preference are essential when making the decision to proceed to ultra low sphincter saving resection. However, we were surprised that no mention was made by this review concerning postoperative sexual function after the technique was performed. Although ISR may represent a step forward with regard to such procedures, there are several problems associated with this approach. In all cases, ISR requires that the internal anal sphincter is excised to some extent, and that dissection of the most distal anorectal segment is undertaken in a relatively blind fashion. Furthermore, when this technique is performed, no rectum can remain and a coloanal anastomosis must be constructed transanally. For most patients, these limitations can be avoided by the recently reported APPEAR technique (Anterior Perineal PlanE for ultra-low Anterior Resection) [2], which via a transperineal incision gains access to that part of the distal rectum enveloped by the pelvic musculature. This segment of the anorectum has been termed the ‘rectal no-man’s land’, and can vary in length from 2 to 12 cm depending on sex and body habitus [2,3]. Nevertheless, the access afforded by the APPEAR procedure allows total mesenteric excision to be performed precisely under direct vision, and all or part of the rectum within the ‘no-man’s land’ to be excised as necessary. Furthermore, if tumour is found to invade the surrounding pelvic muscles, this can be excised en bloc with a macroscopically clear margin. In our experience, most low rectal cancers can be dealt with by this technique, whilst the entire sphincter complex and its nerve supply can be preserved. Indeed, the patients recruited by studies assessed within the review of Tilney and Tekkis [1] had tumours situated at 1.5–3.0 cm from the dentate line, which could be dealt with relatively easily by the APPEAR procedure provided the most distal sited tumour did not invade through the anterior rectal wall. While the APPEAR technique is not suitable for those rare tumours that invade the sphincter mechanism, most studies cited by Tilney and Tekkis also regarded this finding as a contraindication to ISR. It should be stated that, in comparison with ISR, the APPEAR procedure may not be as technically demanding, especially for those colorectal surgeons who have experience in transperineal rectocele repair. The APPEAR technique also facilitates laparoscopic anterior resection as after abdominal mobilization is performed as low in the pelvis as deemed appropriate, the distal anorectal segment can be mobilized and removed via the perineal incision. This combination of procedures avoids an abdominal incision entirely and allows the anastomosis to be constructed at any height that is deemed appropriate, either manually or by stapler under direct vision. In particular, this strategy aids low anterior resection in men for whom this approach may be associated with considerable morbidity, or may not be possible at all [4]. In conclusion, the APPEAR technique like ISR should reduce the rate of permanent stoma construction for rectal cancer. However, the APPEAR technique also has the propensity to extend the horizons for ultra low sphincter preservation further than ISR, and may ultimately produce a better functional result. In addition, it should make laparoscopic low anterior resection a more realistic procedure.