Sphincter-saving surgery for failed organ preservation after a neoadjuvant therapy and radiation boost: A surgeon's perspective

Abstract

Abstract Purpose This study investigates the functional outcomes of patients with low rectal cancer undergoing inter-sphincteric resection (ISR) following brachytherapy boost radiotherapy (BoRT), compared to those who underwent ISR after standard chemoradiotherapy. BoRT is an alternative to total neoadjuvant therapy for increasing organ preservation rates in low rectal cancers. However, its impact on sphincter function following stoma reversal remains unclear. Method The study involved a retrospective analysis of 145 patients treated at a single institution between 2013 and 2021. Eighteen patients received pre-operative BoRT and were compared with 127 patients who did not, using propensity score matching based on age, sex, body mass index, and tumor distance from the anal verge with match ratio 1:4. Functional outcomes were assessed six months post-stoma reversal using the Low Anterior Resection Syndrome (LARS) Score, Wexner Score, and Kirwan Grade. Results The results revealed that patients in the boost RT group had significantly worse functional outcomes, with a median LARS score of 36 (very high) compared to 10 in the no boost group (p < 0.001). Similarly, the median Wexner score was higher in the boost RT group (17 vs. 8, p < 0.001). The Kirwan Grade was consistent across both groups. Conclusion This study highlights the detrimental impact of BoRT on functional status, underscoring the importance of comprehensive patient counselling before initiating BoRT in candidates eligible for sphincter preservation. If optimal outcomes are not achieved following brachytherapy boost, surgical options like ISR or APR should be thoroughly discussed with patients to ensure informed decision-making.

Keywords

• Brachytherapy boost radiotherapy
• Contact X ray brachytherapy
• Intersphincteric resection
• Salvage surgery
• Sphincter preservation