Laparoscopic intersphincteric resection with intraoperative radiotherapy using low-energy X-rays for locally advanced ultra-low rectal cancer

Abstract

Background: In order to overcome the shortcomings of laparoscopic intersphincteric resection (Lap ISR), an alternative method of delivering intraoperative radiotherapy by Intrabeam X-rays radiotherapy system (XRS) is proposed in this paper. Intrabeam XRS is a device that uses low-energy X-rays source generated by a mobile controller unit, which is featured in accurate irradiation, reduced complications, and less exposure. The purpose of this study is to discuss the feasibility of Lap ISR with intra-operative radiotherapy using low-energy X-rays for locally advanced ultra-low rectal cancer in Asian woman. This novel proposed method will greatly increase the anus preserving probability and improved the quality of life.

Methods: A 53-year-old woman diagnosed with rectal adenocarcinoma had a strong desire to preserve the anal function and presented at the Jilin University Second Hospital, Jilin, China. The tumor's size was 4 cm × 3 cm. It was located 2 cm from the anus merge and invaded the levator ani muscle. Preoperative clinical staging was T4N1M0 and could be reached R0 resection. After the consent form was signed by the patient, Lap ISR combined with the applicator put through the anus (natural orifice) to the tumor bed was performed and prophylactic ileostomy synchronized the anastomosis. Patient only received 1-cycle chemotherapy regimen of oxaliplatin with capecitabine postoperatively due to personal reasons. Pre- or postoperative radiotherapy was not given.

Results: After clinical follow-up, until now, there is not any sign of local recurrence. Anus function and short-term complications are acceptable. The short-term effect is satisfying and we look forward to further assess the long-term effect.

Conclusion: Laparoscopic intersphincteric resection with IORT using low-energy X-rays for the patients with late-stage ultra-low rectal cancer could provide an opportunity of preserving the anus function, and it is feasible for the selected patients.

Trial registration: Retrospectively registered; Trial registration: NCT03393234 ; Registered time: 05 January 2017.

Keywords: Anus preservation; IORT; Intrabeam X-rays radiotherapy system; Lap ISR; Low-energy X-rays.

Conflict of interest statement

Ethics approval and consent to participate

This study conforms to the Declaration of Helsinki. The ethics committee of the Second Affiliated Hospital of Jilin University obtained the consent of the patient who participates in this study.

Consent for publication

Written consent was obtained from the patient for publication of this study and accompanying images.

Competing interests

The authors declare that they have no competing interests.

Figures

Fig. 1

The introduction of Intrabeam System. The Zeiss Intrabeam System (Carl Zeiss Meditec AG, Germany). a The console. b XRS. c Spherical plastic applicators for IORT. d The X-rays source (XRS) with a spherical applicator mounted on the floor stand

Fig. 2

Tumor markers value (CEA: Carcinoembryonic antigen; CA19-9: Carbohydrate antigen19-9)

Fig. 3

The procedure of surgery. a The ligation and excision of the inferior mesenteric artery. b Dissection to levator ani muscle. c The exposed anal canal by sutures. d The applicator was input trans-anally. e The applicator put in tumor bed under the surveillance of laparoscopy. f The prophylactic ileostomy

Fig. 4

The excision. The excision including the tumor

Fig. 5

The Pelvic MRI images. a Preoperative image. b Postoperative 9th month image. c Postoperative 24th month image