Journal of Surgery Concepts & Practice >

2026 , Vol. 31 >Issue 02: 114 - 120

DOI: https://doi.org/10.16139/j.1007-9610.2026.02.04

Experts forum

Theoretical and practical breakthroughs in functional sphincter preservation for low rectal cancer

  • WEN Dihao ,
  • ZHOU Leqi ,
  • ZHANG Wei
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  • 1 Department of Colorectal Surgery, the First Affiliated Hospital of Naval Medical University, Shanghai 200433, China
    2 Department of Colorectal Surgery， Bethune International Peace Hospital of PLA， Hebei Shijiazhuang 050011, China

Received date: 2026-01-20

  Online published: 2026-06-23

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Abstract

The management of low rectal cancer has evolved from a radical "life-saving" paradigm through an era of sphincter preservation into a new epoch prioritizing function preservation, representing a transformative leap rooted in systematic innovations across surgical philosophy, technological capabilities, and therapeutic procedures. This evolution is epitomized by the revolutionary refinement of safe distal resection margins from the traditional "5-cm principle" to the contemporary "1-cm principle", which has catalyzed the development of sphincter-preserving procedures while fundamentally elevating the decision-making paradigm from "anatomic sphincter preservation" to the more sophisticated concept of "functional sphincter preservation". Technically, laparoscopic and robotic surgeries have achieved minimally invasive and precise operations, and the advancement of surgical instruments has ensured the reliability of deep pelvic anastomosis. The neoadjuvant therapy model has evolved from traditional radiotherapy and chemotherapy to total neoadjuvant therapy (TNT) and immunotherapy, significantly improving the rate of pathological complete response (pCR), laying a scientific foundation for the "watch-and-wait" strategy. Radiomics contribute to the precise preoperative assessment. The ultimate aim is to comprehensively integrate the latest theoretical advancements, smoothly applies them to practice, builds a standardized diagnosis and treatment system. Ultimately, while ensuring the safety of oncology, this initiative will customize individualized treatment plans for each patient of low rectal cancer, shifting the paradigm from merely "curing the disease" to "healing the patient".

Key words： Low rectal cancer; Functional sphincter preservation; Surgical treatment; Neoadjuvant therapy; "Watch-and-wait" strategy

Cite this article

WEN Dihao , ZHOU Leqi , ZHANG Wei . Theoretical and practical breakthroughs in functional sphincter preservation for low rectal cancer[J]. Journal of Surgery Concepts & Practice, 2026 , 31(02) : 114 -120 . DOI: 10.16139/j.1007-9610.2026.02.04

References

[1] SIEGEL R L, WAGLE N S, CERCEK A, et al. Colorectal cancer statistics, 2023[J]. CA Cancer J Clin, 2023, 73(3):233-254.
[2] FANG C, YANG L, YU Y, et al. Rectal cancer in West China: younger onset, poor survival, and poor compliance[J]. Dis Colon Rectum, 2021, 64(6):639-641.
[3] CHEN W, ZHENG R, BAADE P D, et al. Cancer statistics in China, 2015[J]. CA Cancer J Clin, 2016, 66(2):115-132.
[4] 郑荣寿, 陈茹, 韩冰峰, 等. 2022年中国恶性肿瘤流行情况分析[J]. 中华肿瘤杂志, 2024, 46(3):221-231.
  ZHENG R S, CHEN R, HAN B F, et al. Cancer incidence and mortality in China, 2022[J]. Chin J Oncol, 2024, 46(3):221-231.
[5] VAN DER VALK M, HILLING D E, BASTIAANNET E, et al. Long-term outcomes of clinical complete responders after neoadjuvant treatment for rectal cancer in the International Watch & Wait Database (IWWD): an international multicentre registry study[J]. Lancet, 2018, 391(10139):2537-2545.
[6] DIXON C F. Anterior resection for malignant lesions of the upper part of the rectum and lower part of the sigmoid[J]. Ann Surg, 1948, 128(3):425-442.
[7] GRINNELL R S. Distal intramural spread of carcinoma of the rectum and rectosigmoid[J]. Surg Gynecol Obstet, 1954, 99(4):421-430.
[8] HEALD R J, KARANJIA N D. Results of radical surgery for rectal cancer[J]. World J Surg, 1992, 16(5):848-857.
[9] BUJKO K, RUTKOWSKI A, CHANG G J, et al. Is the 1-cm rule of distal bowel resection margin in rectal cancer based on clinical evidence? A systematic review[J]. Ann Surg Oncol, 2012, 19(3):801-808.
[10] SCHIESSEL R, KARNER-HANUSCH J, HERBST F, et al. Intersphincteric resection for low rectal tumours[J]. Br J Surg, 1994, 81(9):1376-1378.
[11] EMMERTSEN K J, LAURBERG S. Low anterior resection syndrome score: development and validation of a symptom-based scoring system for bowel dysfunction after low anterior resection for rectal cancer[J]. Ann Surg, 2012, 255(5):922-928.
[12] AKAGI Y, KINUGASA T, SHIROUZU K. Intersphincteric resection for very low rectal cancer: a systematic review[J]. Surg Today, 2013, 43(8):838-847.
[13] KEANE C, FEARNHEAD N S, BORDEIANOU L G, et al. International consensus definition of low anterior resection syndrome[J]. Colorectal Dis, 2020, 23(3):331-341.
[14] 楼征, 张卫. 超低位直肠癌适形保肛手术之经肛适形切除术[J]. 中华胃肠外科杂志, 2018, 21(3):246-249.
  LOU Z, ZHANG W. Transanal conformal resection for super low rectal cancer[J]. Chin J Gastrointest Surg, 2018, 21(3):246-249.
[15] JACOBS M, VERDEJA J C, GOLDSTEIN H S. Minimally invasive colon resection (laparoscopic colectomy)[J]. Surg Laparosc Endosc, 1991, 1(3):144-150.
[16] 马君俊, 陆爱国. 我国腹腔镜结直肠手术现状与展望[J]. 上海医药, 2017, 38(2):3-6.
  MA J J, LU A G. Current status and prospects of laparoscopic colorectal surgery in China[J]. Shanghai Med Pharm J, 2017, 38(2):3-6.
[17] 曾冬竹, 张超, 唐波, 等. 达芬奇机器人在超低位直肠癌保肛手术中的应用[J]. 中华结直肠疾病电子杂志, 2015,3:48-50.
  ZENG D Z, ZHANG C, TANG B, et al. The application of Da Vinci robotic surgical system in anus preserving operation of ultra low rectal cancers[J]. Chin J Colorec Dis (Electronic Edition), 2015,3:48-50.
[18] FENG Q, YUAN W, LI T, et al. Robotic vs. laparoscopic surgery for middle and low rectal cancer: the REAL randomized clinical trial[J]. JAMA, 2025, 334(2):136-148.
[19] ZENG Z, LUO S, ZHANG H, et al. Transanal vs. laparoscopic total mesorectal excision and 3-year disease-free survival in rectal cancer: the TaLaR randomized clinical trial[J]. JAMA, 2025, 333(9):774-783.
[20] KNIGHT C D, GRIFFEN F D. An improved technique for low anterior resection of the rectum using the EEA stapler[J]. Surgery, 1980, 88(5):710-714.
[21] COHEN Z, MYERS E, LANGER B, et al. Double stapling technique for low anterior resection[J]. Dis Colon Rectum, 1983, 26(4):231-235.
[22] SAUER R, LIERSCH T, MERKEL S, et al. Preoperative versus postoperative chemoradiotherapy for locally advanced rectal cancer: results of the German CAO/ARO/AIO-94 randomized phase Ⅲ trial after a median follow-up of 11 years[J]. J Clin Oncol, 2012, 30(16):1926-1933.
[23] VAN GIJN W, MARIJNEN C A, NAGTEGAAL I D, et al. Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer: 12-year follow-up of the multicentre, randomised controlled TME trial[J]. Lancet Oncol, 2011, 12(6):575-582.
[24] GLYNNE-JONES R, WYRWICZ L, TIRET E, et al. Rectal cancer: ESMO clinical practice guidelines for diagnosis, treatment and follow-up[J]. Ann Oncol, 2017, 28(suppl_4):iv22-iv40.
[25] DENG Y, CHI P, LAN P, et al. Modified FOLFOX6 with or without radiation versus fluorouracil and leucovorin with radiation in neoadjuvant treatment of locally advanced rectal cancer: initial results of the Chinese FOWARC multicenter, open-label, randomized three-arm phase Ⅲ trial[J]. J Clin Oncol, 2016, 34(27):3300-3307.
[26] 中华医学会放射肿瘤治疗学分会, 中国医师协会放射肿瘤治疗医师分会, 中国抗癌协会肿瘤放射治疗专业委员会. 局部晚期直肠癌新辅助治疗中国专家共识(2025版)[J]. 中华放射肿瘤学杂志, 2026, 35(2):121-134.
  China Society for Radiation Oncology, Chinese Medical Association, Radiation Oncology Physician Branch, Chinese Medical Doctor Association, Professional Committee of Radiation Oncology, China Anti-Cancer Association. Chinese expert consensus on neoadjuvant therapy for locally advanced rectal cancer (2025 edition)[J]. Chin J Radiat Oncol, 2026, 35(2):121-134.
[27] BAHADOER R R, DIJKSTRA E A, VAN ETTEN B, et al. Short-course radiotherapy followed by chemotherapy before total mesorectal excision (TME) versus preoperative chemoradiotherapy, TME, and optional adjuvant chemotherapy in locally advanced rectal cancer (RAPIDO): a randomised, open-label, phase 3 trial[J]. Lancet Oncol, 2021, 22(1):29-42.
[28] CERCEK A, LUMISH M, SINOPOLI J, et al. PD-1 blockade in mismatch repair-deficient, locally advanced rectal cancer[J]. N Engl J Med, 2022, 386(25):2363-2376.
[29] CERCEK A, ROXBURGH C S D, STROMBOM P, et al. Adoption of total neoadjuvant therapy for locally advanced rectal cancer[J]. JAMA Oncol, 2018, 4(6):e180071.
[30] CHALABI M, FANCHI L F, DIJKSTRA K K, et al. Neoadjuvant immunotherapy leads to pathological responses in MMR-proficient and MMR-deficient early-stage colon cancers[J]. Nat Med, 2020, 26(4):566-576.
[31] CHEN G, JIN Y, GUAN W L, et al. Neoadjuvant PD-1 blockade with sintilimab in mismatch-repair deficient, locally advanced rectal cancer: an open-label, single-centre phase 2 study[J]. Lancet Gastroenterol Hepatol, 2023, 8(5):422-431.
[32] RAHMA O E, YOTHERS G, HONG T S, et al. Use of total neoadjuvant therapy for locally advanced rectal cancer: initial results from the pembrolizumab arm of a phase 2 randomized clinical trial[J]. JAMA Oncol, 2021, 7(8):1225-1230.
[33] FORMENTI S C, DEMARIA S. Combining radiotherapy and cancer immunotherapy: a paradigm shift[J]. J Natl Cancer Inst, 2013, 105(4):256-265.
[34] XIA F, WANG Y, WANG H, et al. Randomized phase Ⅱ trial of immunotherapy-based total neoadjuvant therapy for proficient mismatch repair or microsatellite stable locally advanced rectal cancer (TORCH)[J]. J Clin Oncol, 2024, 42(28):3308-3318.
[35] TANG Y, LI H Y, WEI L C, et al. Short-course-based TNT with or without PD-1 inhibitor for pMMR locally advanced rectal cancer: phase 2 results of a randomized trial (STELLAR II)[J]. Med, 2025, 6(11):100807.
[36] ZHOU L, YU G, SHEN Y, et al. Safety and clinical efficacy of neoadjuvant chemoradiation therapy with immunotherapy for organ preservation in ultra-low rectal cancer: preliminary results of the CHOICE-Ⅰ trial: a prospective cohort study[J]. Int J Surg, 2025, 111(3):2487-2494.
[37] BEETS-TAN R G H, LAMBREGTS D M J, MAAS M, et al. Magnetic resonance imaging for clinical management of rectal cancer: Updated recommendations from the 2016 European Society of Gastrointestinal and Abdominal Radiology (ESGAR) consensus meeting[J]. Eur Radiol, 2018, 28(4):1465-1475.
[38] HORVAT N, CARLOS T R C, CLEMENTE O B, et al. MRI of rectal cancer: tumor staging, imaging techniques, and management[J]. Radiographics, 2019, 39(2):367-387.
[39] LAMBIN P, LEIJENAAR R T H, DEIST T M, et al. Radiomics: the bridge between medical imaging and persona-lized medicine[J]. Nat Rev Clin Oncol, 2017, 14(12):749-762.
[40] BERA K, BRAMAN N, GUPTA A, et al. Predicting cancer outcomes with radiomics and artificial intelligence in radiology[J]. Nat Rev Clin Oncol, 2022, 19(2):132-146.
[41] CUI Y, YANG X, SHI Z, et al. Radiomics analysis of multiparametric MRI for prediction of pathological complete response to neoadjuvant chemoradiotherapy in locally advanced rectal cancer[J]. Eur Radiol, 2019, 29(3):1211-1220.
[42] LAMBIN P, RIOS-VELAZQUEZ E, LEIJENAAR R, et al. Radiomics: extracting more information from medical images using advanced feature analysis[J]. Eur J Cancer, 2012, 48(4):441-446.
[43] 中华医学会外科学分会结直肠外科学组. 低位直肠癌经括约肌间切除术中国专家共识(2023版)[J]. 中华胃肠外科杂志, 2023, 26(6):536-547.
  Chinese Society of Colorectal Surgery. Chinese expert consensus on intersphincteric resection for low rectal cancer (2023 edition)[J]. Chin J Gastrointest Surg, 2023, 26(6):536-547.
[44] NAGTEGAAL I D, QUIRKE P. What is the role for the circumferential margin in the modern treatment of rectal cancer?[J]. J Clin Oncol, 2008, 26(2):303-312.
[45] HEALD R J, HUSBAND E M, RYALL R D. The mesorectum in rectal cancer surgery-the clue to pelvic recurrence?[J]. Br J Surg, 1982, 69(10):613-616.
[46] KIM Y S, KIM M J, PARK S C, et al. Robotic versus laparoscopic surgery for rectal cancer after preoperative chemoradiotherapy: case-matched study of short-term outcomes[J]. Cancer Res Treat, 2016, 48(1):225-231.
[47] HABR-GAMA A, OLIVA P R. The strategy "wait and watch" in patients with a cancer of bottom stocking rectum with a complete clinical answer after neoadjuvant radiochemotherapy[J]. J Chir (Paris), 2009, 146(3):237-239.
[48] HABR-GAMA A, PEREZ R O, S?O J G, et al. Nonoperative approaches to rectal cancer: a critical evaluation[J]. Semin Radiat Oncol, 2011, 21(3):234-239.
[49] LIU J, LEE J, BEDRIKOVETSKI S, et al. Clinical predictors of rectal cancer response after neo-adjuvant (Chemo)radiotherapy in Australia and New Zealand: analysis of the Bi-National Colorectal Cancer Audit (BCCA)[J]. Eur J Surg Oncol, 2023, 49(11):107070.
[50] TIE J, WANG Y, TOMASETTI C, et al. Circulating tumor DNA analysis detects minimal residual disease and predicts recurrence in patients with stage Ⅱ colon cancer[J]. Sci Transl Med, 2016, 8(346):346ra92.
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