Between January 2010 and January 2015, we retrospectively collected data on 164 patients with pathologic-proven rectal cancer who underwent ISR at Surgical Oncology Department of South Egypt Cancer Institute, Assiut University, Egypt. A complete history and physical examination, CEA levels, full colonoscopy, Pelvi-abdominal MRI/CT and Chest X-Ray were performed. Patients with stage IV rectal cancer were excluded from this study along with those with proved positive surgical margin involved by the tumor and patients undergoing APR for tumors that reached to the DRMs.

Neoadjuvant chemoradiotherapy for T3 disease or above/presence of pathological nodes, short-course radiotherapy (25 Gy; administered as five daily fractions of 5 Gy) follow 1 week surgery, or, long-course CRT, patients received 4500 CGy/25 fractions 180 CGy per fraction over 5 weeks & boost 540 CGy/3 fractions on tumor + 1.5 cm margin to complete 50.4 Gy with concurrent chemotherapy concomitant capecitabine (825 mg/m² twice daily), volume included the entire rectum, mesorectum, and presacral space. Axially the volume covered internal iliac LN, perirectal LN, hypogastric LN, and presacral LN (Figure 1). MRI/Surgery performed 6 - 8 weeks after completion of chemoradiotherapy was performed eight weeks.

Abdominal part performed either open or laparoscopic technique; high ligation of the inferior mesenteric vein is performed at the level of the inferior border of the pancreas Figure 2(I). Mobilization of the splenic flexure colon, descending colon, Figure 2(J), ligation the inferior mesenteric artery after the emergence of the left colic artery (low tie) Figure 2(L).

TME, with sharp dissection along an anatomic plane between the mesorectal fascia and the fascia of the pelvic sidewall, identify and preserve the pelvic splanchnic nerves Figure 2(M). Denovilliers’ fascia is with the exposure of the seminal vesicles and the prostate or the vaginal wall. The dissection was performed as low as possible to the pelvic floor.

The first step of the perineal part of the operation is a good exposition of the anal canal; Saline adrenaline solution was injected sub-mucosally just distal to the dentate line. Figure 2(N) the mucosa and internal sphincter are circumferentially incised facilitates the exposure of the internal sphincter Figure 2(G), total-ISR The internal sphincter is completely removed, subtotal-ISR a two-third resection of the IAS and partial-ISR one-third resection of the upper part of the IAS, The anal orifice is then closed transanally with pursestring sutures Figure 2(P). Dissection was then carried out between internal and external sphincter till the level of pelvic floor. The distal rectal margin were examined with frozen sections, the rectum was removed transanally Figure 2(A).

Restoration of intestinal continuity is achieved with a handsewn coloanal anastomosis Figure 2(K). If enough length Colonic J-pouch about 6 cm is created, Figure 2(C) transverse coloplasty to create a neorectum Figure 2(D).

The side-to-end anastomosis Figure 2(B) preferable over a straight coloanal anastomosis. The temporary diverting ileostomy was performed in selected patients.

Patients with T3, T4, and/or node-positive disease received postoperative adjuvant chemotherapy; FOLFOX was repeated every two weeks for 24 weeks.

SPSS (Statistical Package for the Social Science) was used for data management. Mean and standard deviation described quantitative data and counted with percentages for qualitative data. For this retrospective cohort study, data were abstracted from patients’ records. Disease-free survival was calculated from the date of curative surgery up to first evidence of either local recurrence of distant metastasis or both. Overall survival was calculated from date of pathologic diagnostic confirmation to date of death or last followed up. For patients who lost follow with advanced state telephone calls were done to assess the occurrence of death. Kaplan Meier methods were used to estimate survival.

This study included a total number of 164 cases: 92 males and 72 females with a mean age of 54.5 years. Table 1 illustrates sociodemographic and clinical characteristics of the patients. Median follow-up time was of 48 months (range 21 to 120 months). Mean distance from the anal verge to the distal tumour edge was 4.1 cm (2.9 to 6 cm).

The median operation time was 230 minutes (range, 180 to 359 minutes). Median blood loss was 700 mL (290 - 1600 mL), mean postoperative hospital stay was 9 (range 6 - 18) days.

The surgical procedure was performed through a laparotomy in 119 patients (72.6%) and laparoscopically in 45 patients (27.4%) cases. Partial resection of the internal sphincter was performed in 60 patients (36.6%). Subtotal-ISR in 61 patients (37.2%) and Total-ISR in 43 patients (26.2%).

M = male, F = female, AV = anal verge, RTH = radiotherapy.

Inferior mesenteric artery ligation was done at the root in 44 patients (26.8%) and after left colic artery in 120 patients (73.2%). Inferior mesenteric vein ligation: High in 160 patients (97.6%) and Low in 4 patients (2.4%). The median number of lymph nodes removed at surgery was 17 (range, 9 - 36).

A colonic J-pouch was performed in 27 patients (16.5%), transverse coloplasty 26 patients (15.9%), a side-to-end anastomosis 44 patients (26.8%) and straight coloanal anastomosis 67 patients (40.9%). Protective ileostomy was performed for 11 patients (6.7%).

Two deaths (1.2%) occurred, one due to myocardial infarction, one patient who had anastomotic leakage and sepsis Figure 2(E).

Surgical Morbidity were observed in 24 patients (14.6%). Anastomotic leakage occurred in 6 patients (3.7%) {Four patients (2.4%) were treated conservatively and two patients (1.2%) were managed by abdominal drainage and diverting stoma}. Pelvic abscess occurred in 6 patients (3.7%) who were treated by percutaneous drainage.

Anastomotic stenosis were observed 3 patients (1.8%) {One need a Hegar dilator, second underwent endoscopic balloon dilatation, third underwent surgery (colostomy)}.

Wound infection and hernia in 5 patients (3%) and respiratory tract infection in 2 patients (1.2%).

Ileus (bowel obstruction) was observed in 5 patients (3%) who were managed conservatively. Anal irritation occurred in 23 patients (14%). Four female patients (2.4%) developed a recto-vaginal fistula: {one was managed conservatively and the other 3 had a defunctioning ileostomy, a revisional coloanal anastomosis repair and omental flap} (Figure 3).

Transient voiding difficulty 6 patients (3.7%), erectile dysfunction 24 patients (14.6%), ejaculatory dysfunction 25 patients (15.2%).

Pathologic complete response 18 patients (11%). The median tumor size was 34 mm (range 28 - 56 mm).

Neoadjuvant radiotherapy provided to 147 patients (89.6%) {long-course radiotherapy 122 patient (74.4%), short-course radiotherapy 25 patients (15.2%)}, neoadjuvant chemotherapy 47 patients (28.7%). Adjuvant Chemotherapy in 115 patients (70.1%).

Median circumferential margin was 7 mm (1 - 19 mm). Positive in four patients (2.4%). The distal margin median 20 mm (8 - 40 mm), complete resection (R0) was achieved for 156 patients (95.1%).

Local recurrence rate was observed in 13 patients (7.9%), in {pelvic wall 3 patients (1.8%) treated by pelvic lymphadenectomy, anastomoticin 4 patients (2.4%) (managed with abdominoperineal resection), urinary bladder in 3

patients (1.8%), seminal vesicle in 1 patient (0.6%) and presacral area in 2 patients (1.2%). Recurrence was treated by curative pelvic exenteration}.

Distant metastasis 25 patients (15.2%); {peritoneal dissemination in 2 patients (1.2%) cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal carcinosis Figure 2(N), oxaliplatin given bidirectionally with 5-FU intravenously and oxaliplatin in the peritoneum, 460 mg/m² for 30 min at 42˚C - 43˚C + I.V. 5-FU 400 mg/m² & leucovorin 20 mg/m² for peritoneal carcinosis (liver, 10 (6%)); 6 (3.6%) partial hepatic resection for liver metastases, non-regional nodes 3 (1.8%), lung 5 (3%), ovary 1 patient (0.6%), bone 4 patients (2.4%), whereas the other patients were treated by palliative chemotherapy (2nd line FOLFIRI)}.

The 5-year overall and disease-free survival rates were 79.8% and 75.8%, respectively.

Incontinence was assessed by calculating the Wexner score, where 0 reflected perfect continence and 20 reflected the worst possible level of incontinence the median Wexner score 6 (1 - 18). Incontinence {for flatus 18 patients (11%), to liquid in 8 patients (4.9%), to solid in 7 patients (4.3%)}. Median number of bowel motions in a 24-h period was 3 (1 - 10). Faecal urgency was present (< 15 min) 29 patients (17.7%). Stool fragmentation 31 patients (18.9%). Difficult evacuation occurred in 29 patients (17.7%). Lifestyle alteration 24 patients (14.6%). Difficulty feces/flatus discrimination 71 patients (43.3%). Nocturnal soiling in 28 patients (17.1%). Daytime soiling 18 patients (11%). Pad wearing 39 Patients (23.8%). Anti-diarrhea medication loperamide 23 patients (14%) (Figure 4).