International standardization and optimization group for intersphincteric resection (ISOG-ISR): modified Delphi consensus on anatomy, definition, indication, surgical technique, specimen description and functional outcome

Piozzi GN 1 , Khobragade K 2 , Aliyev V 3 , Asoglu O 3 , Bianchi PP 4 , Butiurca VO 5 Show all authors , Chen WT 6 , Cheong JY 7 , Choi GS 8 , Coratti A 9 , Denost Q 10 , Fukunaga Y 11 , Gorgun E 7 , Guerra F 9 , Ito M 12 , Khan JS 13 , Kim HJ 8 , Kim JC 14 , Kinugasa Y 15 , Konishi T 16 , Kuo LJ 17 , Kuzu MA 18 , Lefevre JH 19 , Liang JT 20 , Marks J 21 , Molnar C 5 , Panis Y 22 , Rouanet P 23 , Rullier E 24 , Saklani A 25 , Spinelli A 26 , Tsarkov P 27 , Tsukamoto S 28 , Weiser M 29 , Kim SH 1

Affiliations 

  • 1 Korea University Anam Hospital, Seoul, Korea
  • 2 Alexis Multispecialty Hospital, Nagpur, India
  • 3 Bogazici Academy for Clinical Sciences, Istanbul, Turkey
  • 4 University of Milan, San Paolo Hospital, Milan, Italy
  • 5 University of Medicine, Pharmacy Science, and Technology 'G.E. Palade', Târgu-Mureș, Romania
  • 6 China Medical University Hsinchu Hospital, Zhubei City, Taiwan
  • 7 Cleveland Clinic, Cleveland, Ohio, USA
  • 8 Kyungpook National University Chilgok Hospital, Daegu, Korea
  • 9 Azienda USL Toscana Sud Est-Misericordia Hospital, Grosseto, Italy
  • 10 Bordeaux Colorectal Institute, Bordeaux, France
  • 11 Cancer Institution Hospital, Japanese Foundation of Cancer Research, Tokyo, Japan
  • 12 National Cancer Center Hospital East, Chiba, Japan
  • 13 University of Portsmouth, Portsmouth, UK
  • 14 University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea
  • 15 Tokyo Medical and Dental University, Tokyo, Japan
  • 16 M.D. Anderson Cancer Center, The University of Texas, Houston, Texas, USA
  • 17 Taipei Medical University Hospital, Taipei City, Taiwan
  • 18 Ankara University, Ankara, Turkey
  • 19 Department of Digestive Surgery, Sorbonne Université, AP-HP, Hôpital Saint Antoine, Paris, France
  • 20 National Taiwan University Hospital and College of Medicine, Taipei City, Taiwan
  • 21 Lankenau Medical Center, Wynnewood, USA
  • 22 Colorectal Surgery Center, Groupe Hospitalier Privé Ambroise Paré-Hartmann, Neuilly, Seine, France
  • 23 Montpellier Cancer Institute, Montpellier, France
  • 24 Bordeaux University Hospital, Haut-Leveque Hospital, Pessac, France
  • 25 Tata Memorial Hospital, Mumbai, India
  • 26 Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan, Italy
  • 27 Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
  • 28 National Cancer Center Hospital, Tokyo, Japan
  • 29 Memorial Sloan Kettering Cancer Center, New York City, New York, USA
Colorectal Dis, 2023 Sep;25(9):1896-1909.
PMID: 37563772 DOI: 10.1111/codi.16704

Abstract

AIM: Intersphincteric resection (ISR) is an oncologically complex operation for very low-lying rectal cancers. Yet, definition, anatomical description, operative indications and operative approaches to ISR are not standardized. The aim of this study was to standardize the definition of ISR by reaching international consensus from the experts in the field. This standardization will allow meaningful comparison in the literature in the future.

METHOD: A modified Delphi approach with three rounds of questionnaire was adopted. A total of 29 international experts from 11 countries were recruited for this study. Six domains with a total of 37 statements were examined, including anatomical definition; definition of intersphincteric dissection, intersphincteric resection (ISR) and ultra-low anterior resection (uLAR); indication for ISR; surgical technique of ISR; specimen description of ISR; and functional outcome assessment protocol.

RESULTS: Three rounds of questionnaire were performed (response rate 100%, 89.6%, 89.6%). Agreement (≥80%) reached standardization on 36 statements.

CONCLUSION: This study provides an international expert consensus-based definition and standardization of ISR. This is the first study standardizing terminology and definition of deep pelvis/anal canal anatomy from a surgical point of view. Intersphincteric dissection, ISR and uLAR were specifically defined for precise surgical description. Indication for ISR was determined by the rectal tumour's maximal radial infiltration (T stage) below the levator ani. A new surgical definition of T3isp was reached by consensus to define T3 low rectal tumours infiltrating the intersphincteric plane. A practical flowchart for surgical indication for uLAR/ISR/abdominoperineal resection was developed. A standardized ISR surgical technique and functional outcome assessment protocol was defined.

* Title and MeSH Headings from MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.

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