Multimedia article. Laparoscopic abdominoanal pull-through procedure for male patients with lower rectal cancer after chemoradiation therapy.

INTRODUCTION: Abdominoanal pull-through procedure is an alternative procedure for lower rectal cancer in which double-stapling technique is difficult to apply and/or the adequate distal safety margin (>2 cm) cannot be achieved in a very narrow male pelvis. The present study is to examine if the pull-through procedure can be effectively performed by laparoscopic approach for male lower rectal cancer downstaged by concurrent chemoradiation therapy.

METHODS: A total of 14 male patients with advanced lower rectal cancer (Stage II: n=6; Stage III: n=8, by tumor, node, and metastasis staging system of International Union Against Cancer) and successfully downstaged by preoperative concurrent chemoradiation therapy were accrued for this study. All patients underwent three-staged operation including: transverse-colostomy creation before concurrent chemoradiation therapy, laparoscopic pull-through procedure and closure of colostomy. The details of laparoscopic pull-through procedure were shown in the video including: total mobilization for rectum in the fashion of total mesorectal excision, retrieval and transection of bowel through an incision over dentate line, and coloanal anastomosis. The surgical outcome of the patients were prospectively evaluated.

RESULTS: Although the dissection plane is a little blurred by preoperative concurrent chemoradiation therapy, the laparoscopic pull-through procedure was preformed with acceptable operation time (274.6+/-52.4 minutes, mean+/-standard deviation) and little blood loss (104.5+/-32.0 ml) through 5 small wounds of abdominal ports. The number of dissected lymph node was 17.0+/-3.0. The distal safety margin of all patients was more than 2 cm. The patients have quick functional recovery, as evaluated by the length of postoperative ileus (48.0+/-8.0 hours), hospitalization (9.0+/-1.0 days), and degree of postoperative pain (3.5+/-0.5, visual analog scale). There were no major postoperative complications yet postoperative fever developed in one patient and wound infection in the other one. Besides the expenses covered by the National Bureau of Health Insurance in Taiwan, the patient had to pay extra expenses of NT$25000.0+/-3500.0 (1.0 US dollars=32.0 NT$). During the follow-up periods (median: 10 months, range, 4 to 16 months), one patient developed a recurrent lung metastasis.

CONCLUSION: In view of the good functional recovery and fine short-term oncologic results, laparoscopic pull-through procedure was thus a good choice for downstaged male lower rectal cancer in terms of sphincter-preservation and enough distal section margin of tumor.