Hu G, Ma J, Qiu WL, Mei SW, Zhuang M, Xue J, Liu JG, Tang JQ. Patient selection and operative strategies for laparoscopic intersphincteric resection without diverting stoma. World J Gastrointest Surg 2025; 17(3): 95983 [DOI: 10.4240/wjgs.v17.i3.95983]
Corresponding Author of This Article
Jian-Qiang Tang, MD, Chief Doctor, Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 17 Panjiayuan Nanli, Chaoyang District, Beijing 100021, China. doc_tjq@hotmail.com
Research Domain of This Article
Surgery
Article-Type of This Article
Observational Study
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
World J Gastrointest Surg. Mar 27, 2025; 17(3): 95983 Published online Mar 27, 2025. doi: 10.4240/wjgs.v17.i3.95983
Patient selection and operative strategies for laparoscopic intersphincteric resection without diverting stoma
Gang Hu, Ji Ma, Wen-Long Qiu, Shi-Wen Mei, Meng Zhuang, Jun Xue, Jun-Guang Liu, Jian-Qiang Tang
Gang Hu, Wen-Long Qiu, Shi-Wen Mei, Meng Zhuang, Jian-Qiang Tang, Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
Ji Ma, Department of General Surgery, Datong Third People’s Hospital, Datong 037008, Shanxi Province, China
Jun Xue, Department of General Surgery, The First Affiliated Hospital of Hebei North University, Zhangjiakou 075000, Hebei Province, China
Jun-Guang Liu, Department of General Surgery, Peking University First Hospital, Beijing 100034, China
Co-first authors: Gang Hu and Wen-Long Qiu.
Author contributions: Hu G and Ma J contributed to data acquisition, data analysis and follow-up, and drafting the manuscript; Qiu WL contributed to data analysis and follow-up and drafting the manuscript; Mei SW and Zhuang M contributed to data acquisition; Xue J and Liu JG provided critical revision of the manuscript; Tang JQ contributed to research design and critical revision of manuscript; All authors contributed to the conception and design of the study. Hu G and Qiu WL contributed equally to this work as co-first authors.
Supported by Beijing Natural Science Foundation, No. L222054 and No. 4232058.
Institutional review board statement: This study was reviewed and approved by the Ethics Committee of National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences.
Informed consent statement: All study participants, or their legal guardian, provided informed written consent prior to study enrollment.
Conflict-of-interest statement: The authors declare that they have no conflicts of interest.
STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.
Data sharing statement: There are no conflicts of interest to report.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Jian-Qiang Tang, MD, Chief Doctor, Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 17 Panjiayuan Nanli, Chaoyang District, Beijing 100021, China. doc_tjq@hotmail.com
Received: April 23, 2024 Revised: August 2, 2024 Accepted: October 30, 2024 Published online: March 27, 2025 Processing time: 306 Days and 16.8 Hours
Abstract
BACKGROUND
Diverting stoma (DS) is routinely proposed in intersphincteric resection for ultralow rectal cancer, but it is associated with increased stoma-related complications and economic burden. Appropriate patient selection and operative strategies to avoid stoma formation need further elucidation.
AIM
To select patients who may not require DS.
METHODS
This study enrolled 505 consecutive patients, including 84 who underwent stoma-free (SF) intersphincteric resection. After matching, patients were divided into SF (n = 78) and DS (n = 78) groups. The primary endpoint was the anastomotic leakage (AL) rate within 6 months and its protective factors for both the total and SF cohorts. The secondary endpoints included overall survival and disease-free survival.
RESULTS
The AL rate was greater in the SF group than in the DS group (12.8% vs 2.6%, P = 0.035). Male sex [(odds ratio (OR) = 2.644, P = 0.021], neoadjuvant chemoradiotherapy (nCRT) (OR = 6.024, P < 0.001), and tumor height from the anal verge ≤ 4 cm (OR = 4.160, P = 0.007) were identified as independent risk factors. Preservation of the left colic artery (LCA) was protective in both the total cohort (OR = 0.417, P = 0.013) and the SF cohort (OR = 0.312, P = 0.027). The female patients who did not undergo nCRT and had preservation of the LCA experienced a significantly lower incidence of AL (2/97, 2.1%). The 3-year overall survival or disease-free survival did not significantly differ between the groups.
CONCLUSION
Female patients who do not receive nCRT may avoid the need for DS by preserving the LCA without increasing the risk of AL or compromising oncological outcomes.
Core Tip: This study aimed to investigate suitable patient selection and operative strategies by comparing the surgical results and oncological outcomes between stoma-free and diverting stoma intersphincteric resection. Our study makes a significant contribution to the literature because we found female patients without neoadjuvant chemoradiotherapy could be exempted from diverting stomas by preserving the left colic artery without compromising anastomotic leakage risk and oncological outcomes.
