Background: The conventional double-stapling technique (DST) using a standard linear stapler horizontally is sometimes difficult to apply to an anastomosis where the pelvis is narrow or the anastomosis is ultralow. In this report, we review our experiences of a novel DST (IO-DST) that employs vertical division of the rectum using an endostapler. Materials and methods: One-hundred and five consecutive patients who underwent low anterior resection for rectal carcinoma below the peritoneal reflection were enrolled into this study. The clinical, oncological, and functional outcomes were studied retrospectively. Results: The median distance from the anal verge to the tumor was 5.0 cm in 'high risk' T1 tumors and 6.5 cm in more-advanced tumors. More than 2 cm of distal surgical margin was obtained in 80.6% of the patients with tumors deeper than T1. The median distance from the anal verge to the anastomosis was 4.2 cm in T1 tumors and 4.0 cm in more-advanced tumors. The median blood loss was 315 ml, and the median operative time was 262 min. There was no mortality in the IO-DST. Recurrence presented in 12 (13.0%) of the patients who underwent curative surgery, with local recurrence in four patients (4.3%) during a median follow-up of 46.2 months. However, no patients experienced suture-line recurrence. The early bowel frequency was four times/day after stoma closure in patients with transient covering colostomy and 3.5 times/day in patients without colostomy. The late bowel frequency was three times/day in patients with transient covering colostomy, and two times/day in patients without colostomy. Conclusions: The IO-DST is a feasible and safe procedure for facilitating lower anastomosis in rectal carcinoma below the peritoneal reflection.
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