腹腔镜下经肛拖出直肠癌根治术超低位保肛的临床研究

目的探讨腹腔镜下经肛拖出直肠癌根治术超低位保肛的可行性、安全性、根治性及短期临床疗效。方法回顾我院收治的127例超低位直肠癌,运用腹腔镜经肛拖出直肠癌根治术行超低位保肛65例（腹腔镜组）、直肠癌超低位前切除术62例（开腹组）,比较两组术中、术后及愈后各项指标。结果腹腔镜组术中出血量及术后肠道功能恢复时间、止痛药物使用时间、住院时间均优于开腹组（P〈0.05）。两组手术时间、清扫淋巴结数量、术后吻合口漏、吻合口狭窄、复发、转移、大便失禁和总生存率各项差异无统计学意义（P〉0.05）。结论腹腔镜下经肛拖出直肠癌根治术超低位保肛符合肿瘤学根治性原则,安全可行,术后恢复快,适合用于超低位直肠癌保肛。     

Accuracy of digital rectal examination in the estimation of height of rectal lesions

BACKGROUND: To assess the accuracy of the digital rectal examination as a method of estimating the distance of a rectal lesion from the anal verge. METHODS: One hundred doctors of variable levels of experience and from different specialities performed digital rectal examination (DRE) on a pelvic model with two fixed buttons at different levels simulating lesions in the rectum. They were asked to estimate the distance of the lesions in centimetres from the anal verge and classify the lesion as mid or low rectal. RESULTS: Nearly half the doctors studied (45%) estimated the distance of the upper lesion accurately (7.5 cm, or within 1 cm of the correct distance), whereas 64% of the doctors estimated the distance to the lower lesion accurately (3 cm, or within 1 cm of correct distance). 93% of doctors classified the mid-rectal lesion correctly and 99% classified the lower rectal lesion correctly. CONCLUSIONS: Though less accurate in precisely estimating the distance of a lesion from the anal verge, DRE has high accuracy in classifying rectal lesions into lower and mid-rectal lesions, irrespective of experience and background of the clinicians. It is more accurate for lower rectal lesions than mid-rectal lesions.     

Ultrasonically activated scalpel versus monopolar electrocautery shovel in laparoscopic total mesorectal excision for rectal cancer

AIM： To investigate the feasibility and safety of monopolar electrocautery shovel （ES） in laparoscopic total mesorectal excision （TME） with anal sphincter preservation for rectal cancer in order to reduce the cost of the laparoscopic operation, and to compare ES with the ultrasonically activated scalpel （US）.
METHODS： Forty patients with rectal cancer, who underwent laparoscopic TME with anal sphincter preservation from June 2005 to June 2007, were randomly divided into ultrasonic scalpel group and monopolar ES group, prospectively. White blood cells （WBC） were measured before and after operation, operative time, blood loss, pelvic volume of drainage, time of anal exhaust, visual analogue scales （VAS） and surgery-related complications were recorded. RESULTS： All the operations were successful; no one was converted to open procedure. No significant differences were observed in terms of preoperative and postoperative d I and d 3 WBC counts （P = 0.493, P = 0.375, P = 0.559）, operation time （P = 0.235）, blood loss （P = 0.296）, anal exhaust time （P = 0.431）, pelvic drainage volume and VAS in postoperative d 1 （P = 0.431, P = 0.426） and d 3 （P = 0.844, P = 0.617） between ES group and US group. The occurrence of surgery-related complications such as anastomotic leakage and wound infection was the same in the two groups.
CONCLUSION： ES is a safe and feasible tool as same as US used in laparoscopic TME with anal sphincter preservation for rectal cancer on the basis of the skillful laparoscopic technique and the complete understanding of laparoscopic pelvic anatomy. Application of ES can not only reduce the operation costs but also benefit the popularization of laparoscopic operation for rectal cancer patients.     

Relationship between symptoms and disordered continence mechanisms in women with idiopathic faecal incontinence

BACKGROUND AND AIMS: Anal sphincter weakness and rectal sensory disturbances contribute to faecal incontinence (FI). Our aims were to investigate the relationship between symptoms, risk factors, and disordered anorectal and pelvic floor functions in FI. METHODS: In 52 women with "idiopathic" FI and 21 age matched asymptomatic women, we assessed symptoms by standardised questionnaire, anal pressures by manometry, anal sphincter appearance by endoanal ultrasound and magnetic resonance imaging (MRI), pelvic floor motion by dynamic MRI, and rectal compliance and sensation by a barostat. RESULTS: The prevalence of anal sphincter injury (by imaging), reduced anal resting pressure (35% of FI), and reduced squeeze pressures (73% of FI) was higher in FI compared with controls. Puborectalis atrophy (by MRI) was associated (p<0.05) with FI and with impaired anorectal motion during pelvic floor contraction. Volume and pressure thresholds for the desire to defecate were lower, indicating rectal hypersensitivity, in FI. The rectal volume at maximum tolerated pressure (that is, rectal capacity) was reduced in 25% of FI; this volume was associated with the symptom of urge FI (p<0.01) and rectal hypersensitivity (p = 0.02). A combination of predictors (age, body mass index, symptoms, obstetric history, and anal sphincter appearance) explained a substantial proportion of the interindividual variation in anal squeeze pressure (45%) and rectal capacity (35%). CONCLUSIONS: Idiopathic FI in women is a multifactorial disorder resulting from one or more of the following: a disordered pelvic barrier (anal sphincters and puborectalis), or rectal capacity or sensation.     

低位直肠癌腹腔镜TME手术经直肠取出标本影响因素的分析

目的探讨低位直肠癌腹腔镜TME手术经直肠取出标本的限制因素。 方法回顾性分析经纳排标准筛选的于2018年6~12月在同济大学附属东方医院接受低位直肠癌腹腔镜保肛手术的有效病例，利用单因素和多因素logistic分析比较经直肠取标本组（LAR-NOSES）和腹部小切口取标本组（Mini-Lapar）在术前基线资料、经CT/MRI测得肿瘤及盆腔局部骨性及软组织参数和术后临床病理分期等特征的差异。 结果本研究最终共纳入有效患者89例，其中Mini-Lapar组48例，LAR-NOSES组41例，经直肠取标本成功率为46.1%。单因素分析结果显示LAR-NOSES与女性性别（χ²=9.0，P=0.003）、更小的BMI（t=-3.4，P=0.001）、肿瘤距肛缘位置（Z=-2.4，P=0.015）、肿瘤最大直径（t=-3.6，P=0.001）、肿瘤最大纵向长度（t=-3.9，P＜0.001）、直肠最大系膜厚度（t=-2.2，P=0.033）及更大的坐骨棘间径（t=3.0，P=0.004）和坐骨结节间径（t=2.6，P=0.011）显著相关。除pT分期外（χ²=6.6，P=0.038），两组在术后肿瘤病理大体、镜下分型分期及Wexner失禁评分方面差异均无统计学意义（P均＞0.05）。多因素logistic回归分析提示，BMI（OR=1.36，95%CI=1.09~1.70，P=0.006）、肿瘤距肛缘位置（OR=1.66，95%CI=1.03~2.70，P=0.039）、LTD（OR=2.99，95%CI=1.46~6.14，P=0.003）和坐骨棘间径（OR=0.44，95%CI=0.25~0.77，P=0.004）是限制腹腔镜低位直肠NOSES成功实施的独立预测因素。 结论直肠标本的尺寸越小、标本取出所经过的软组织通道越短、所经过的骨性通道尺寸越大越有利于LAR-NOSES的成功实现。     

Transanal natural orifice specimen extraction for laparoscopic anterior resection in rectal cancer

AIM:To investigate whether transanal natural orifice specimen extraction(NOSE)is a better technique for rectal cancer resection.METHODS:A prospectively designed database of a consecutive series of patients undergoing laparoscopic low anterior resection for rectal cancer with various tumor-node-metastasis classifcations from March 2011to February 2012 at the First Affliated Hospital of Sun Yat-Sen University was analyzed.Patient selection for transanal specimen extraction and intracorporeal anastomosis was made on the basis of tumor size and distance of rectal lesions from the anal verge.Demographic data,operative parameters,and postoperative outcomes were assessed.RESULTS:None of the patients was converted to laparotomy.Respectively,there were 16 cases in the low anastomosis and fve in the ultralow anastomosis groups.Mean age of the patients was 45.4 years,and mean body mass index was 23.1 kg/m2.Mean distance of the lower edge of the lesion from the anal verge was 8.3 cm.Mean operating time was 132 min,and mean intraoperative blood loss was 84 mL.According to the principle of rectal cancer surgery,we performed D2 lymph node dissection in 13 cases and D3 in eight.Mean lymph nodes harvest was 17.8,and the number of positive lymph nodes was 3.4.Median hospital stay was 6.7 d.No serious postoperative complication occurred except for one anastomotic leakage.All patients remained disease free.Mean Wexner score was 3.7 at11 mo after the operation.CONCLUSION:Transanal NOSE for total laparoscopic low/ultralow anterior resection is feasible,safe and oncologically sound.Further studies with long-term outcomes are needed to explore its potential advantages.     

Selective treatment of rectal cancer with single-stage coloanal or ultralow colorectal anastomosis does not adversely affect morbidity and mortality

Background and aims The surgical treatment of low rectal cancer commonly includes low pelvic anastomoses with coloanal or ultralow colorectal anastomoses. Anastomotic leak rates in low pelvic anastomoses range from 4 to 26%. Many surgeons opt to routinely create a diverting ostomy to reduce the extent of morbidity should an anastomotic leak occur. The intent of our study was to determine if our policy of selected diversion is safe. Materials and methods A retrospective chart review of 66 rectal cancer patients who underwent proctectomy and low pelvic anastomoses—less than 6 cm from anal verge, with or without a diverting ostomy—was undertaken. Temporary diverting stomas were utilized at the discretion of the attending surgeon primarily based on subjective criteria. The main outcome was postoperative complications. Results/findings Forty-nine patients (78% preoperatively irradiated) were treated with a one-stage operation, whereas 17 (53% preoperatively irradiated) underwent reconstruction with proximal diversion. The mean anastomotic height for patients with a single stage procedure was 3.8 cm above the anal verge versus 2.6 for patients with a two-stage procedure (p = 0.076). Complication rates were lower in patients who did not undergo diversion (29% vs 47%, p = 16). With regard to anastomotic-associated complications for single stage versus two stage, complication rates were 8% versus 18%, respectively (p = 0.27). Interpretation/conclusion Low pelvic anastomoses in rectal cancer patients can be safely performed as a single-stage procedure, reserving the use of diversion for select cases.     

Topography of the extrinsic internal anal sphincter nerve supply during laparoscopic-assisted TAMIS TME: five key zones of risk from the surgeons’ view

Purpose

Sparing the extrinsic autonomic innervation of the internal anal sphincter during total mesorectal excision is important for the preservation of anal sphincter function. This study electrophysiologically confirmed the topography of the internal anal sphincter nerve supply during laparoscopic-assisted transanal minimally invasive surgery for total mesorectal excision.

Methods

This prospective study was conducted at two large multispecialty referral centers. Six patients (five males and one female) aged between 45 and 65 years with low rectal cancer (≤5 cm from the anal verge) were enrolled. Surgery was performed under electric stimulation of the pelvic autonomic nerves with observation of the electromyographic signals of the internal anal sphincter.

Results

The minimally invasive transanal surgical approach enabled advantageous visualization of the pelvic autonomic nerves in all patients. In particular, extrinsic innervation to the internal anal sphincter near the levator muscle was consciously spared under electrophysiological confirmation. The evoked absolute electromyographic amplitudes of the internal anal sphincter during transanal minimally invasive surgery were significantly lower than the initial results of the laparoscopic approach [3.7 μV (interquartile range 2.4; 5.7) vs. 4.3 μV (interquartile range 3.1; 8.6); p?=?0.002]. Five key zones of risk for pelvic autonomic nerve damage were identified. No complications occurred.

Conclusions

The electromyographic results of this preliminary study indicate advantages for sparing the internal anal sphincter innervation during transanal minimally invasive mesorectal dissection considering the specific in situ neuroanatomical topography.

     

A new ultimate anus-preserving operation for extremely low rectal cancer and for anal canal cancer

Abstract. To avoid permanent colostomy, we perform a new ultimate anus preserving operation for extremely low rectal cancer or for anal canal cancer. According to our pathologic study, two different removal methods of anal canal were theoretically considered. One is internal sphincter resection (ISR method), and the other is both deep-superficial external sphincter and internal sphincter resection (ESR method). Six patients received ISR and ten patients ESR. No severe intraoperative complications occurred and the postoperative course was uneventful. All patients receiving ISR had excellent anal function without soiling. Some patients receiving ESR sometimes complained of night soiling but satisfied the anus preservation. The median follow-up was 15 months, (range, 3–28 months). We had recurrences in two female patients receiving ISR. One had para-aortic and lateral lymph node recurrences without anastomotic recurrence. She underwent lateral and para-aortic lymphadenectomy, but died of lung metastasis, regardless of intensive chemotherapy. Another had pelvic recurrence with abdominal dissemination. She underwent abdominoperineal resection and is alive with pelvic re-recurrence. ISR and ESR are excellent procedures for anus preservation, but ISR needs a strict indication.     

Topographie der extrinsischen Nervenversorgung des inneren Analsphinkters während der laparoskopisch assistierten TAMIS TME

Purpose

Sparing the extrinsic autonomic innervation of the internal anal sphincter during total mesorectal excision is important for the preservation of anal sphincter function. This study electrophysiologically confirmed the topography of the internal anal sphincter nerve supply during laparoscopicassisted transanal minimally invasive surgery for total mesorectal excision.

Methods

This prospective study was conducted at two large multispecialty referral centers. Six patients (five males and one female) aged between 45 and 65 years with low rectal cancer (≤5 cm from the anal verge) were enrolled. Surgery was performed under electric stimulation of the pelvic autonomic nerves with observation of the electromyographic signals of the internal anal sphincter.

Results

The minimally invasive transanal surgical approach enabled advantageous visualization of the pelvic autonomic nerves in all patients. In particular, extrinsic innervation to the internal anal sphincter near the levator muscle was consciously spared under electrophysiological confirmation. The evoked absolute electromyographic amplitudes of the internal anal sphincter during transanal minimally invasive surgery were significantly lower than the initial results of the laparoscopic approach (3.7 μV (interquartile range 2.4; 5.7) vs. 4.3 μV (interquartile range 3.1; 8.6); p = 0.002). Five key zones of risk for pelvic autonomic nerve damage were identified. No complications occurred.

Conclusions

The electromyographic results of this preliminary study indicate advantages for sparing the internal anal sphincter innervation during transanal minimally invasive mesorectal dissection considering the specific in situ neuroanatomical topography.

     

Laparoscopic total mesorectal excision of low rectal cancer with preservation of anal sphincter： A report of 82 cases

AIM: To assess the feasibility and efficacy of laparoscopic total mesorectal excision (LTME) of low rectal cancer with preservation of anal sphincter. METHODS: From June 2001 to June 2003, 82 patients with low rectal cancer underwent laparoscopic total mesorectal excision with preservation of anal sphincter. The lowest edge of tumors was below peritoneal reflection and 1.5-7 cm from the dentate line (1.5-5 cm in 48 cases, 5-7 cm in 34 cases). RESULTS: LTME with anal sphincter preservation was performed on 82 randomized patients with low rectal cancer, and 100 % sphincter preservation rate was achieved. There were 30 patients with laparoscopic low anterior resection (LLAR) at the level of the anastomosis below peritoneal reflection and 2 cm above from the dentate line; 27 patients with laparoscopic ultralow anterior resection (LULAR) at the level of anastomoses 2 cm below from the dentate line; and 25 patients with laparoscopic coloanal anastomoses (LCAA) at the level of the anastomoses at or below the dentate line. No defunctioning ileostomy was created in any case. The mean operating time was 120 minutes (ranged from 110-220 min), and the mean operative blood loss was 20 mL (ranged from 5-120 mL). Bowel function was restored and diet was resumed on day 1 or 2 after operation. The mean hospital stay was 8 days (ranged from 5-14). Postoperative analgesics were used in 45 patients. After surgery, 2 patients had urinary retention, one had anastomotic leakage, and another 2 patients had local recurrence one year later. No interoperative complication was observed. CONCLUSION: LTME with preservation of anal sphincter is a feasible, safe and minimally invasive technique with less postoperative pain and rapid recovery, and importantly, it has preserved the function of the sphincter.     

Intersphincteric resection with excision of internal anal sphincter for conservative treatment of very low rectal cancer

PURPOSE: Standard surgical treatment for low rectal cancer situated below 5 cm from the anal verge or at less than 1 cm from the anal ring is abdominoperineal resection. This is because of the necessity both to achieve a sufficient distal margin and to preserve the whole of the anal sphincter. The aim of this study was to evaluate morbidity, oncologic, and functional results of intersphincteric resection with excision of the internal anal sphincter and low coloanal anastomosis for carcinomas of the anorectal junction. METHODS: From January 1990 to December 1996, 16 patients were studied prospectively. All patients had an infiltrating adenocarcinoma (5 T2 and 11 T3), located between 2.5 and 4.5 (mean, 3.6) cm from the anal verge. Rectal resection with a minimum distal margin of 2 (mean, 2.4) cm was performed in all cases; six patients underwent partial resection of the internal sphincter, and ten patients had a subtotal resection. A colonic J-pouch was associated with coloanal anastomoses in eight cases. Twelve patients had preoperative radiotherapy, 3 with concomitant chemotherapy; 5 patients had postoperative chemotherapy. RESULTS: There was no postoperative mortality. Morbidity occurred in four patients, of whom two underwent permanent colostomy after pelvic hemorrhage or anovaginal fistula. After a median follow-up of 44 (range, 11-92) months, no local recurrence was observed, and two patients died of distal metastases. The five-year actuarial survival rate was 75 percent. Continence was normal in one-half of patients and was altered in the other patients who suffered from occasional minor leaks. The median resting pressure was lower after subtotal than after partial resection of the internal sphincter (40 vs. 70 cm H2O; P = 0.02), but functional results were similar in the two groups. CONCLUSION: These preliminary results suggest that intersphincteric resection can be an alternative to abdominoperineal resection for selected rectal tumors situated at the anorectal junction, without compromising chance of cure. Functional results and continence were not altered by subtotal resection of the internal anal sphincter.     

Transvaginal low anterior resection for rectal cancer

Adenocarcinoma of the lower rectum can be resected with a sphincter-sparing procedure but exposure of the lower pelvis may be difficult and sphincter function may be compromised. We have performed a low anterior resection for rectal cancer in a 69-year-old woman with mobilisation of the tumour and anastomosis performed transvaginally without a covering stoma. This way we could get good exposure of the lower rectum and anal sphincters. The patient made an uneventful recovery and was fully continent after surgery. Transvaginal low anterior resection is an alternative route which may be useful in cases of difficult exposure of low rectal cancer.     

低位直肠癌精准功能保肛（PPS）时代真的来了吗?——PPS在低位直肠癌保肛中的应用与研究

直肠癌是目前较为常见的恶性肿瘤,其中低位直肠癌占50%以上,根治性手术是目前最有效的治疗方式。低位直肠癌保肛一直是结直肠外科领域的热点与难点,近年来在保肛率和保肛质量上一直未取得突破性进展,其根本原因是没有良好的手术视野和创新性的手术器械。通过特制器械辅助,精准功能保肛手术可在直视下完成低位直肠癌病灶的精准切除和肠管断端的确切缝合,为低位直肠癌的保肛治疗提供了新方法。     

Experimental Models of Neuropathic Fecal Incontinence: An Animal Model of Childbirth Injury to the Pudendal Nerve and External Anal Sphincter

Purpose  Childbirth is the most common cause of fecal incontinence and damage to the pudendal nerve is a major component of childbirth injury. This study was designed to develop an acute animal model of injury to the innervation of the external anal sphincter. Methods  Forty-eight female virgin wistar rats were studied. Two models of neuropathic injury were developed. Bilateral inferior rectal nerve crush (Group A) acted as a positive control. Prolonged intrapelvic retrouterine balloon inflation (Group B) simulated the pelvic compressive forces of labor. Quantitative analysis of external anal sphincter muscle function was performed by using electromyography, external anal sphincter specific force production, and stereologic calculation of external anal sphincter mass. Results  Injury in both groups caused significant atrophy of the external anal sphincter (P = 0.002, ANOVA) and electromyographic evidence of reinnervation at one week. Specific force (mN force per mg mass) was not altered. External anal sphincter muscle mass recovered after four weeks in Group B. Conclusions  Balloon dilation within the boney pelvis results in denervation of the external anal sphincter and offers an experimental model of the effects of childbirth on the continence mechanism in humans. Supported by a grant from The Health Research Board, Ireland. Presented at the meeting of The American Society of Colon and Rectal Surgeons, St. Louis, Missouri, June 2 to 6, 2007, and was the winner of the Research Forum Prize.     

Identification of hiatal ligament for laparoscopic total mesorectal excision

Total mesorectal excision (TME) based operation is now established as a standard procedure for patients with lower or middle third rectal cancer. Laparoscopic surgery has a great advantage in colorectal surgery, with good operative views, as well as benefit to the patients owing to less invasiveness, early recovery and shorter hospitalization. From April 2001 through March 2002, we assessed the laparoscopic TME for eight consecutive patients with rectal cancer in Kobe University Hospital (median age: 65.3). The procedure included sharp mesorectal dissection with high vascular ligation and preservation of autonomic pelvic nerves. During the laparoscopic TME, the hiatal ligament that is the sequence of anococcygeal raphe body can be identified with the traction of the rectum upward, and this fixes the posterior wall of the rectum to the levator hiatus. Resection of the hiatal ligament enables us to isolate the recto-anal canal up to the level of the internal anal sphincter. We conclude that identification of the hiatus ligament is essential to achieve the appropriate laparoscopic TME.     

MRI检查在直肠癌诊断与术前分期的应用研究

目的探讨3.0T MRI对直肠癌患者术前判断T、N分期以及测量直肠肿瘤下缘与肛缘间曲线距离的准确性。 方法经术前肠镜活检病理证实为直肠癌的患者53例,于术前行MRI扫描,进行T、N分期并测量肿瘤下缘与肛缘间的距离。以术后病理结果为标准,验证3.0T MRI评价肿瘤T、N分期的准确性;用MRI测量出的肿瘤下缘与肛缘曲线的距离与手术标本测量的结果相比较,找出两种结果的相关性。 结果MRI对直肠癌患者T、N分期判定的准确率分别为83.1%、67.9%,统计学分析显示与病理结果有较好的一致性。MRI测量肿瘤下缘与肛缘的曲线距离与手术标本测得的数值无明显统计学差异。 结论MRI对直肠癌患者术前T、N分期的判定以及测量肿瘤下缘与肛缘间的曲线距离有较高的准确性,对术前治疗及手术方式的选择有很好的指导意义。     

Recent progress in diagnosis and treatment of rectal cancer]

Rectal cancer is an emerging health issue in Korea because its incidence is rapidly increasing with changes in life styles and diets. The optimal treatment of rectal cancer is based on multimodality. Among them, surgical treatment is the corner-stone. In the past, local recurrence rate has been reported as high as 30-40%, but the concept of total mesorectal excision (TME) lowered the rate of local recurrence down to less than 10%. TME focuses on sharp pelvic dissection and complete removal of rectal cancer with surrounding mesorectum inside the rectal proper fascia. TME is now considered as a standard procedure for surgical treatment of mid and low rectal cancer. With the introduction of pelvic magnetic resonance imaging (MRI) for preoperative staging of rectal cancer, risk factors for local recurrence can be predicted before surgery to distinguish patients who are in high risk for recurrence that requires preoperative neoadjuvant chemoradiation therapy. Early rectal cancer was assessed by transrectal ultrasonography (TRUS) and endorectal MRI with coil. Transanal local excision can be applied with anal sphincter preservation safely. Neoadjuvant chemoradiation therapy was performed in patients with locally advanced rectal cancer, and this resulted in tumor size reductions and histopathologic downstaging effect. As far as the quality of life is concerned, sexual and voiding function are much improved by techniques preserving nerve. Many experts have dealt with challenging practical problems of managing rectal cancer from diagnosis to quality of life. This issue contains recent progresses in the diagnosis and treatment of rectal cancer which will serve as a comprehensive reference for those who manage rectal cancer in their medical practice.     

Outcome of patients with clinical stage II or III rectal cancer treated without adjuvant radiotherapy

Background  To clarify the indications for preoperative adjuvant radiotherapy for rectal cancer, the outcome of patients who underwent curative surgery without adjuvant radiotherapy was investigated. Methods  A total of 817 consecutive patients who underwent curative surgery for clinical stage II or III rectal cancer without preoperative adjuvant radiotherapy between 1988 and 2002 were reviewed. Results  The actuarial 5-year local recurrence rate in the examined patients was 6.2%. Univariate analysis showed that sex, pathological T classification (pT), clinical N classification (cN), pathological N classification (pN), tumor site, distance from the anal verge, type of surgery, pathological stage, a positive radical margin, lymphatic invasion, and venous invasion were significantly correlated with local recurrence. Multivariate analysis of preoperative factors identified cN, distance from the anal verge, and sex as statistically significant risk factors for local recurrence. In patients with rectal cancer located less than 5 cm from the anal verge and with positive cN, the local recurrence rate was more than 10%. Conclusions  Patients with rectal cancer located less than 5 cm from the anal verge and with clinically positive lymph nodes should be given preoperative adjuvant radiotherapy.