Partial resection of rectum for rectal GIST by posterior approach

Partial resection of rectum for rectal GIST by posterior approach | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Partial resection of rectum for rectal GIST by posterior approach Makoto Hasegawa, Wataru Sakamoto, Hiroki Yago, Takahiro Sato, and 8 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6557613/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 29 Aug, 2025 Read the published version in Langenbeck's Archives of Surgery → Version 1 posted 9 You are reading this latest preprint version Abstract Objective The standard surgical treatment for gastrointestinal stromal tumor (GIST) is local resection. Colorectal GIST, which accounts for 5–10% of all GIST tends to develop in the lower rectum, making intra-abdominal approaches difficult and invasive. We perform partial resection of rectum with posterior approach for rectal GIST. We herein presented our procedure of posterior approach and retrospectively analysed the efficacy and safety of the posterior approach. Methods In a retrospective analysis from 2018 to 2023, data were collected from patients who underwent partial resection of rectum with posterior approach for rectal GIST. Patient characteristics, surgical outcomes, complications, prognosis and presence/absence of low anterior resection syndrome (LARS) were collected. Results Four patients with rectal GIST were included in this study. The median age was 50.5 years and all patients were male. The median operation time was 203.5 minutes, the median interoperative blood loss was 30 g, and the median initial tumour diameter was 29.5 mm. One patient underwent diverting ileostomy, and the ileostomy was closed one year after surgery. Complete pathological resection was achieved in all cases. Postoperative complications were observed in one patient: outlet obstruction of the diverting ileostomy and LARS and there were no other postoperative complications including anastomotic leakage. No recurrence was observed in the median follow-up of 33.5 months. Conclusions This study demonstrated that posterior approach is safe, low incidence of LARS, and facilitates complete resection, making it a valuable surgical option for rectal GIST. Rectal GIST posterior approach rectal cancer pelvic recurrence Figures Figure 1 Figure 2 Background Posterior approach had been previously used for lower rectal cancer ( 1 , 2 ). However, since this method alone did not allow for lymph node dissection or extensive rectal resection, currently, low anterior resection (LAR) or abdomino-perineal resection (APR) of the rectum with lymph node dissection are the standard of treatment for rectal cancer ( 3 ). However, the advantages of the posterior approach are relatively less postoperative pain, low incidence of LARS, and cosmetic benefits ( 4 , 5 ). In addition, it has the technical advantage in rectal manipulation, since it might be easier to recognize anatomy of sphincter directly. Therefore, posterior approach can be an effective approach for lower rectal surgery that does not require lymph node dissection. Considering the oncological characteristics, rectal gastrointestinal stromal tumor (GIST) which tends to develop in the lower rectum and do not require lymph node dissection is a possible indication for this posterior approach ( 3 , 6 ). However, there are no consensus about the procedure of partial resection of rectum ( 7 ), and LAR or APR have been performed mainly for lower rectal GIST ( 8 , 9 ). In our institution, the rectal GIST is considered to be a good indication for the local resection of rectum without lymph node dissection through posterior approach and we herein summarized the outcome of 4 cases. Methods Patients In this retrospective study, we analysed patients who underwent partial resection of rectum for rectal GIST using a posterior approach in Fukushima Medical University hospital from January 2018 to December 2023. The enrolment criteria for this study were: (i) diagnosis of rectal GIST based on histopathology and immunohistochemical study; (ii) resection of rectal GIST by the posterior approach. This study was approved by the Institutional Ethics Committee of Fukushima Medical University (approval number 30148) for a retrospective analysis of the collected data in accordance with the ethical standards of the Declaration of Helsinki of the World Medical Association. Surgical producer for rectal GIST The surgery was performed with the patient in the jackknife position. An approximately 10-cm skin incision was made at a point 3 cm proximal to the anal verge and 1 cm lateral to either the left or right border of the sacrum. The subcutaneous fat and part of the gluteus maximus muscle were separated. The iliococcygeus muscle was separated then presacral space, rectum and mesorectum could be seen. In cases where an optimal surgical view was not obtained, the excision of the coccyx was performed additionally. After sufficient dissection around the rectal GIST, it was resected in full thickness while confirming the border of the tumor using digital rectal examination. Defects in the rectal wall are closed by suturing using 4 − 0 PDS® (Johnson & Johnson, New Jersey, U.S.). A Blake® Silicon Drain (Johnson & Johnson, New Jersey, U.S.) was inserted into the suture site and SILASCON® Duple Drain (Kaneka Medix Corporation, Osaka City, Osaka) was inserted as transanal drainage tube. The iliococcygeus muscle was sutured with 4 − 0 PDS®, and the gluteus maximus muscle was sutured with 0 Vicryl® (Johnson & Johnson New Jersey, U.S.). Finally, the skin was closed by dermal buried suture. Indications for covering ileostomies were considered when the defect area was large and suturing tension was high. (Fig. 1 A, B). Outcome measurement The surgical outcome was assessed by the following factors: operative time (min), operative blood loss (g), date of first post-operative meal (post operative days (POD)), duration of urinary catheter placement (days), urinary catheter reinsertion, duration of pelvic floor drainage tube placement (days), postoperative hospital stay (days), and LARS (evaluated by the LARS Scoring Instructions ( 10 ) at 2 year after surgery). Results Patient characteristics Four patients with rectal GIST were included in this study. The median age was 50.5 years old (range: 36–71), and all patients were men. The median operation time was 203.5 min (121–257) and the median interoperative blood loss was 30g (10–50) (Table 1). The median duration of urinary catheter insertion was 2 days ( 2 – 2 ), and no patients reinserted urinary catheter. The median duration of drainage tube placement was 6 days ( 5 – 14 ). The tumour size ranged from 20 to 61 mm, with a median diameter of 29.5 mm. Representative sagittal T2 weighted image and colonoscopy image of each patient were shown in Fig. 2 . Two patients underwent excision of the coccyx. Two patients have received preoperative imatinib chemotherapy, and one patient has received postoperative imatinib chemotherapy. One patient was performed diverting ileostomy, and the ileostomy was closed after one year of the surgery. A pathological complete resection was achieved in all cases. Postoperative complications were observed in one patient: outlet obstruction of the diverting ileostomy and major LARS (the LARS score was 39 points 2 years after the closure of the diverting ileostomy). There was no other postoperative complication including anastomotic leakage. No recurrence was observed in a median follow-up of 33.5 months (13–71). The patient (Case 3) who experienced LARS had a Rb tumor extended partially to anal canal, and the diameter was 61 mm (Fig. 2 ). Most of the puborectalis and rectococcygeus muscles had already been extremely stretched by the tumor, and only a very thin muscle layer could be seen on the surface of the tumor at the time of surgery. Part of the rectococcygeus muscle was resected to complete the tumor resection. Discussion The posterior approach was a useful procedure that was able to provide complete resection of rectal GIST safely in our institution. The posterior approach to the rectum was first reported in 1873 by Verneuil, and in 1885 Kraske described in detail a posterior approach to the rectum with partial sacral resection ( 1 , 2 ). However, resection with lymph node dissection has become the standard treatment for colorectal cancer ( 3 ), the opportunities for posterior approaches to malignant diseases have become much rarer. GIST is a malignant disease that does not require lymph node dissection. GIST develops most often in the stomach (50–70%), followed by duodenum and small intestine (20–30%), colorectum (5–10%, most in the rectum), and rarely in the esophagus, mesentery, or omentum ( 6 ). Since lymph node metastasis is extremely rare, local resection without lymph node dissection is recommended as a standard surgical procedure for primary GIST ( 6 ). Rectal GIST tends to develop in the lower rectum ( 11 ), which makes it difficult to approach intra-abdominally. In many cases of rectal GIST, it has been reported that LAR, super low anterior resection, inter-sphincter rectal resection, or sometime APR are performed ( 8 , 9 ), and the patients experienced various postoperative complications such as low anterior resection syndrome (LARS) ( 12 , 13 ) and permanent stoma. LARS is characterized by frequent defecation and feeling of urgent need to defecate and fecal incontinence ( 10 , 13 ) affecting 42–48% of patients underwent LAR ( 12 , 13 ). Therefore, intra-abdominal resection of the rectum with mesorectal resection for rectal GIST may be too invasive and potentially avoidable ( 4 ). There is no unified and well-established method for the posterior approach. Qin et al ( 14 ) and Qiu et al ( 15 ) have used a {Citation}posterior approach involving the excision of the coccyx in all cases. The excision of coccyx may provide a better view of surgical field. However, since we could perform direct manipulation with optimal surgical view without the removal of coccyx in our two cases, the removal of coccyx resection should be considered case-by-case. Regarding LARS, particular care is needed in cases in which the puborectalis and/or rectococcygeal muscle have been stretched by a giant tumor in the anal canal. Qin et al reported that maximum LARS score of 17 patients after posterior approach was only 9, they, therefore, reported that no LARS was observed in posterior approach ( 14 ). In our study, LARS was observed in one case whose puborectalis and rectococcygeal muscle had already overstretched extremely due to the giant GIST and had to be resected along with the tumor in the anal canal. It is likely that the overstretch was considered as the main reason for LARS in the case. The posterior approach can be applied potentially for other surgeries. In our institution, we applied it for two cases of local recurrence of rectal cancer. Approaching the presacral space was performed in the same way as the procedure for rectal GIST. The two patients had previously undergone APR. In the same way as GIST surgery, posterior side of pelvic space could be manipulated easily with good surgical view. A pathological complete resection was achieved in all cases. No recurrence was observed at a median follow-up of 24.5 months (24–25) (Table 2). Therefore, posterior approach may be a promising option not only for rectal GIST surgery but also for other malignancies. This study has several limitations. First, being a single-center retrospective study, it may have potential biases. Second, the small sample size may not be sufficient to draw solid conclusions regarding short-term and long-term outcome. Future research, including multicenter and prospective studies, is needed to address these limitations. Conclusions The posterior approach may be a useful procedure for rectal GIST, which is safe, enables direct manipulation with optimal surgical view and the prevalence of LARS may be low. Abbreviations GIST: gastrointestinal stromal tumor, LARS: low anterior resection syndrome, LAR: low anterior resection, APR: abdomino-perineal resection, POD: postoperative day Declarations Ethics approval: This study was approved by the Institutional Ethics Committee of Fukushima Medical University (approval number 30148) for a retrospective analysis of the collected data in accordance with the ethical standards of the Declaration of Helsinki of the World Medical Association. Consent for publication: Written informed consent was obtained from the patient for publication. Availability of data and materials: All data generated or analysed during this study are included in this published article. Competing interests: The authors declare that they have no competing interests in this case. Funding: This research did not receive any specific grants from funding agencies in the public, commercial, or not-for-profit sectors. Authors’ contributions: MH conceived the case presentation and wrote the manuscript. WS, HO, TM and KK have revised the manuscript. All authors participated in the treatment of the patient and read and approved the final manuscript. Acknowledgements: We would like to thank the secretaries of Department of Gastrointestinal Tract Surgery, Fukushima Medical University School of Medicine for their cooperation in literature collection. References Kraske P, Perry EG, Hinrichs B. A new translation of professor Dr P. Kraske’s Zur Exstirpation Hochsitzender Mastdarmkrebse. 1885. Aust N Z J Surg. 1989 May;59(5):421–4. Arnaud A, Fretes IR, Joly A, Sarles JC. Posterior approach to the rectum for treatment of selected benign lesions. Int J Colorectal Dis. 1991 May;6(2):100–2. Hashiguchi Y, Muro K, Saito Y, Ito Y, Ajioka Y, Hamaguchi T, et al. Japanese Society for Cancer of the Colon and Rectum (JSCCR) guidelines 2019 for the treatment of colorectal cancer. Int J Clin Oncol. 2020 Jan;25(1):1–42. Tazawa H, Hirata Y, Kuga Y, Nishida T, Sakimoto H. Sphincter-saving resection by cluneal arched skin incision for a gastrointestinal stromal tumor (GIST) of the lower rectum: a case report. Surg Case Rep. 2017 Dec;3(1):8. Asare EA, Vreeland TJ, Feig BW. Resection of a Perirectal Leiomyosarcoma via a Posterior Transcoccygeal Approach. Ann Surg Oncol. 2018 Sep;25(9):2641. Hirota S, Tateishi U, Nakamoto Y, Yamamoto H, Sakurai S, Kikuchi H, et al. English version of Japanese Clinical Practice Guidelines 2022 for gastrointestinal stromal tumor (GIST) issued by the Japan Society of Clinical Oncology. Int J Clin Oncol. 2024 Jun;29(6):647–80. Hawkins AT, Wells KO, Krishnamurty DM, Hunt SR, Mutch MG, Glasgow SC, et al. Preoperative Chemotherapy and Survival for Large Anorectal Gastrointestinal Stromal Tumors: A National Analysis of 333 Cases. Ann Surg Oncol. 2017 May;24(5):1195–201. IJzerman NS, Mohammadi M, Tzanis D, Gelderblom H, Fiore M, Fumagalli E, et al. Quality of treatment and surgical approach for rectal gastrointestinal stromal tumour (GIST) in a large European cohort. Eur J Surg Oncol. 2020 Jun;46(6):1124–30. Miettinen M, Furlong M, Sarlomo-Rikala M, Burke A, Sobin LH, Lasota J. Gastrointestinal stromal tumors, intramural leiomyomas, and leiomyosarcomas in the rectum and anus: a clinicopathologic, immunohistochemical, and molecular genetic study of 144 cases. Am J Surg Pathol. 2001 Sep;25(9):1121–33. Emmertsen KJ, 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. Ann Surg. 2012 May;255(5):922–8. Yeo HL, Paty PB. Management of recurrent rectal cancer: practical insights in planning and surgical intervention. J Surg Oncol. 2014 Jan;109(1):47–52. Homma Y, Mimura T, Koinuma K, Horie H, Sata N. Incidence of low anterior resection syndrome and its association with the quality of life in patients with lower rectal tumors. Surg Today. 2024 Aug 1;54(8):857–65. Croese AD, Lonie JM, Trollope AF, Vangaveti VN, Ho YH. A meta-analysis of the prevalence of Low Anterior Resection Syndrome and systematic review of risk factors. Int J Surg. 2018 Aug;56:234–41. Qin X, Li C, Yang Z, Guo W, Guo H, Chen C, et al. Transsacrococcygeal approach in rectal gastrointestinal stromal tumour resection: 10-year experience at a single centre. Ann Transl Med. 2021 Feb;9(4):341. Qiu HZ, Lin GL, Xiao Y, Wu B. The use of posterior trans-sphincteric approach in surgery of the rectum: a Chinese 16-year experience. World J Surg. 2008 Aug;32(8):1776–82. Tables Tables 1 and 2 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files 20250324table.xlsx Table 1. Patient characteristics of rectal GIST. Table 2. Patient characteristics of recurrence of rectal cancer patients. Cite Share Download PDF Status: Published Journal Publication published 29 Aug, 2025 Read the published version in Langenbeck's Archives of Surgery → Version 1 posted Editorial decision: Revision requested 17 Jun, 2025 Reviews received at journal 17 Jun, 2025 Reviews received at journal 28 May, 2025 Reviewers agreed at journal 15 May, 2025 Reviewers agreed at journal 15 May, 2025 Reviewers invited by journal 13 May, 2025 Editor assigned by journal 05 May, 2025 Submission checks completed at journal 05 May, 2025 First submitted to journal 29 Apr, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6557613","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":455699354,"identity":"3231c73b-f6ab-46f0-81ef-de4ce83c8dd7","order_by":0,"name":"Makoto Hasegawa","email":"","orcid":"","institution":"Fukushima Medical University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Makoto","middleName":"","lastName":"Hasegawa","suffix":""},{"id":455699355,"identity":"d9ed58d3-2069-46dd-a6f5-c88845008453","order_by":1,"name":"Wataru 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Medicine","correspondingAuthor":false,"prefix":"","firstName":"Koji","middleName":"","lastName":"Kono","suffix":""}],"badges":[],"createdAt":"2025-04-29 14:53:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6557613/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6557613/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00423-025-03845-y","type":"published","date":"2025-08-29T15:58:15+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":82798257,"identity":"ab794728-81ee-449b-b138-61ae240e8590","added_by":"auto","created_at":"2025-05-15 10:48:33","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":13880336,"visible":true,"origin":"","legend":"\u003cp\u003eA: Schema of partial resection of rectum by posterior approach for rectal gastrointestinal stromal tumor. Skin and iliococcygeus muscle are shown as translucent to illustrate underlying structures. 1B: Intraoperative image of partial resection of rectum by posterior approach for rectal gastrointestinal stromal tumor.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-6557613/v1/f891fd255cd08fed0c37c3b3.png"},{"id":82798253,"identity":"bb2010af-4148-4ead-9428-4a2094507c37","added_by":"auto","created_at":"2025-05-15 10:48:32","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":3021474,"visible":true,"origin":"","legend":"\u003cp\u003eThe images presented herein depict magnetic resonance imaging and colonoscopy images of the patients in this study. The presence of a tumor is indicated by the yellow arrows. In the third case, the tumor demonstrates extension into the anal canal (indicated by the white arrow).\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-6557613/v1/c6deda0638d68c7d1a746d21.png"},{"id":90345032,"identity":"08ae6589-3327-4f7a-8ef8-9779535a3db6","added_by":"auto","created_at":"2025-09-01 16:09:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":27178029,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6557613/v1/55c0870a-9927-483a-9309-3c9452d2538d.pdf"},{"id":82798240,"identity":"214006ff-71b2-47e8-938f-f70a752dffd1","added_by":"auto","created_at":"2025-05-15 10:48:32","extension":"xlsx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":12968,"visible":true,"origin":"","legend":"\u003cp\u003eTable 1. Patient characteristics of rectal GIST.\u003c/p\u003e\n\u003cp\u003eTable 2. Patient characteristics of recurrence of rectal cancer patients.\u003c/p\u003e","description":"","filename":"20250324table.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-6557613/v1/1891560bdd345694fa259bd1.xlsx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Partial resection of rectum for rectal GIST by posterior approach","fulltext":[{"header":"Background","content":"\u003cp\u003ePosterior approach had been previously used for lower rectal cancer (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). However, since this method alone did not allow for lymph node dissection or extensive rectal resection, currently, low anterior resection (LAR) or abdomino-perineal resection (APR) of the rectum with lymph node dissection are the standard of treatment for rectal cancer (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). However, the advantages of the posterior approach are relatively less postoperative pain, low incidence of LARS, and cosmetic benefits (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). In addition, it has the technical advantage in rectal manipulation, since it might be easier to recognize anatomy of sphincter directly. Therefore, posterior approach can be an effective approach for lower rectal surgery that does not require lymph node dissection.\u003c/p\u003e \u003cp\u003eConsidering the oncological characteristics, rectal gastrointestinal stromal tumor (GIST) which tends to develop in the lower rectum and do not require lymph node dissection is a possible indication for this posterior approach (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). However, there are no consensus about the procedure of partial resection of rectum (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e), and LAR or APR have been performed mainly for lower rectal GIST (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn our institution, the rectal GIST is considered to be a good indication for the local resection of rectum without lymph node dissection through posterior approach and we herein summarized the outcome of 4 cases.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u003c/h2\u003e \u003cp\u003eIn this retrospective study, we analysed patients who underwent partial resection of rectum for rectal GIST using a posterior approach in Fukushima Medical University hospital from January 2018 to December 2023. The enrolment criteria for this study were: (i) diagnosis of rectal GIST based on histopathology and immunohistochemical study; (ii) resection of rectal GIST by the posterior approach.\u003c/p\u003e \u003cp\u003e This study was approved by the Institutional Ethics Committee of Fukushima Medical University (approval number 30148) for a retrospective analysis of the collected data in accordance with the ethical standards of the Declaration of Helsinki of the World Medical Association.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSurgical producer for rectal GIST\u003c/h3\u003e\n\u003cp\u003eThe surgery was performed with the patient in the jackknife position. An approximately 10-cm skin incision was made at a point 3 cm proximal to the anal verge and 1 cm lateral to either the left or right border of the sacrum. The subcutaneous fat and part of the gluteus maximus muscle were separated. The iliococcygeus muscle was separated then presacral space, rectum and mesorectum could be seen. In cases where an optimal surgical view was not obtained, the excision of the coccyx was performed additionally. After sufficient dissection around the rectal GIST, it was resected in full thickness while confirming the border of the tumor using digital rectal examination. Defects in the rectal wall are closed by suturing using 4\u0026thinsp;\u0026minus;\u0026thinsp;0 PDS\u0026reg; (Johnson \u0026amp; Johnson, New Jersey, U.S.). A Blake\u0026reg; Silicon Drain (Johnson \u0026amp; Johnson, New Jersey, U.S.) was inserted into the suture site and SILASCON\u0026reg; Duple Drain (Kaneka Medix Corporation, Osaka City, Osaka) was inserted as transanal drainage tube. The iliococcygeus muscle was sutured with 4\u0026thinsp;\u0026minus;\u0026thinsp;0 PDS\u0026reg;, and the gluteus maximus muscle was sutured with 0 Vicryl\u0026reg; (Johnson \u0026amp; Johnson New Jersey, U.S.). Finally, the skin was closed by dermal buried suture. Indications for covering ileostomies were considered when the defect area was large and suturing tension was high. (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA, B).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eOutcome measurement\u003c/h3\u003e\n\u003cp\u003eThe surgical outcome was assessed by the following factors: operative time (min), operative blood loss (g), date of first post-operative meal (post operative days (POD)), duration of urinary catheter placement (days), urinary catheter reinsertion, duration of pelvic floor drainage tube placement (days), postoperative hospital stay (days), and LARS (evaluated by the LARS Scoring Instructions (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) at 2 year after surgery).\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003ePatient characteristics\u003c/h2\u003e \u003cp\u003eFour patients with rectal GIST were included in this study. The median age was 50.5 years old (range: 36\u0026ndash;71), and all patients were men. The median operation time was 203.5 min (121\u0026ndash;257) and the median interoperative blood loss was 30g (10\u0026ndash;50) (Table\u0026nbsp;1). The median duration of urinary catheter insertion was 2 days (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e), and no patients reinserted urinary catheter. The median duration of drainage tube placement was 6 days (\u003cspan additionalcitationids=\"CR6 CR7 CR8 CR9 CR10 CR11 CR12 CR13\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). The tumour size ranged from 20 to 61 mm, with a median diameter of 29.5 mm. Representative sagittal T2 weighted image and colonoscopy image of each patient were shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Two patients underwent excision of the coccyx. Two patients have received preoperative imatinib chemotherapy, and one patient has received postoperative imatinib chemotherapy. One patient was performed diverting ileostomy, and the ileostomy was closed after one year of the surgery. A pathological complete resection was achieved in all cases. Postoperative complications were observed in one patient: outlet obstruction of the diverting ileostomy and major LARS (the LARS score was 39 points 2 years after the closure of the diverting ileostomy). There was no other postoperative complication including anastomotic leakage. No recurrence was observed in a median follow-up of 33.5 months (13\u0026ndash;71).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe patient (Case 3) who experienced LARS had a Rb tumor extended partially to anal canal, and the diameter was 61 mm (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Most of the puborectalis and rectococcygeus muscles had already been extremely stretched by the tumor, and only a very thin muscle layer could be seen on the surface of the tumor at the time of surgery. Part of the rectococcygeus muscle was resected to complete the tumor resection.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe posterior approach was a useful procedure that was able to provide complete resection of rectal GIST safely in our institution.\u003c/p\u003e \u003cp\u003eThe posterior approach to the rectum was first reported in 1873 by Verneuil, and in 1885 Kraske described in detail a posterior approach to the rectum with partial sacral resection (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). However, resection with lymph node dissection has become the standard treatment for colorectal cancer (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e), the opportunities for posterior approaches to malignant diseases have become much rarer.\u003c/p\u003e \u003cp\u003eGIST is a malignant disease that does not require lymph node dissection. GIST develops most often in the stomach (50\u0026ndash;70%), followed by duodenum and small intestine (20\u0026ndash;30%), colorectum (5\u0026ndash;10%, most in the rectum), and rarely in the esophagus, mesentery, or omentum (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Since lymph node metastasis is extremely rare, local resection without lymph node dissection is recommended as a standard surgical procedure for primary GIST (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Rectal GIST tends to develop in the lower rectum (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e), which makes it difficult to approach intra-abdominally. In many cases of rectal GIST, it has been reported that LAR, super low anterior resection, inter-sphincter rectal resection, or sometime APR are performed (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e), and the patients experienced various postoperative complications such as low anterior resection syndrome (LARS) (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) and permanent stoma. LARS is characterized by frequent defecation and feeling of urgent need to defecate and fecal incontinence (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) affecting 42\u0026ndash;48% of patients underwent LAR (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Therefore, intra-abdominal resection of the rectum with mesorectal resection for rectal GIST may be too invasive and potentially avoidable (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThere is no unified and well-established method for the posterior approach. Qin et al (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) and Qiu et al (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) have used a {Citation}posterior approach involving the excision of the coccyx in all cases. The excision of coccyx may provide a better view of surgical field. However, since we could perform direct manipulation with optimal surgical view without the removal of coccyx in our two cases, the removal of coccyx resection should be considered case-by-case.\u003c/p\u003e \u003cp\u003eRegarding LARS, particular care is needed in cases in which the puborectalis and/or rectococcygeal muscle have been stretched by a giant tumor in the anal canal. Qin et al reported that maximum LARS score of 17 patients after posterior approach was only 9, they, therefore, reported that no LARS was observed in posterior approach (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). In our study, LARS was observed in one case whose puborectalis and rectococcygeal muscle had already overstretched extremely due to the giant GIST and had to be resected along with the tumor in the anal canal. It is likely that the overstretch was considered as the main reason for LARS in the case.\u003c/p\u003e \u003cp\u003eThe posterior approach can be applied potentially for other surgeries. In our institution, we applied it for two cases of local recurrence of rectal cancer. Approaching the presacral space was performed in the same way as the procedure for rectal GIST. The two patients had previously undergone APR. In the same way as GIST surgery, posterior side of pelvic space could be manipulated easily with good surgical view. A pathological complete resection was achieved in all cases. No recurrence was observed at a median follow-up of 24.5 months (24\u0026ndash;25) (Table\u0026nbsp;2). Therefore, posterior approach may be a promising option not only for rectal GIST surgery but also for other malignancies.\u003c/p\u003e \u003cp\u003eThis study has several limitations. First, being a single-center retrospective study, it may have potential biases. Second, the small sample size may not be sufficient to draw solid conclusions regarding short-term and long-term outcome. Future research, including multicenter and prospective studies, is needed to address these limitations.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe posterior approach may be a useful procedure for rectal GIST, which is safe, enables direct manipulation with optimal surgical view and the prevalence of LARS may be low.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eGIST: gastrointestinal stromal tumor, LARS: low anterior resection syndrome, LAR: low anterior resection, APR: abdomino-perineal resection, POD: postoperative day\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Institutional Ethics Committee of Fukushima Medical University (approval number 30148) for a retrospective analysis of the collected data in accordance with the ethical standards of the Declaration of Helsinki of the World Medical Association.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll data generated or analysed during this study are included in this published article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests in this case.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grants from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMH conceived the case presentation and wrote the manuscript. WS, HO, TM and KK have revised the manuscript. All authors participated in the treatment of the patient and read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank the secretaries of Department of Gastrointestinal Tract Surgery, Fukushima Medical University School of Medicine for their cooperation in literature collection.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKraske P, Perry EG, Hinrichs B. A new translation of professor Dr P. Kraske\u0026rsquo;s Zur Exstirpation Hochsitzender Mastdarmkrebse. 1885. Aust N Z J Surg. 1989 May;59(5):421\u0026ndash;4. \u003c/li\u003e\n\u003cli\u003eArnaud A, Fretes IR, Joly A, Sarles JC. Posterior approach to the rectum for treatment of selected benign lesions. Int J Colorectal Dis. 1991 May;6(2):100\u0026ndash;2. \u003c/li\u003e\n\u003cli\u003eHashiguchi Y, Muro K, Saito Y, Ito Y, Ajioka Y, Hamaguchi T, et al. Japanese Society for Cancer of the Colon and Rectum (JSCCR) guidelines 2019 for the treatment of colorectal cancer. Int J Clin Oncol. 2020 Jan;25(1):1\u0026ndash;42. \u003c/li\u003e\n\u003cli\u003eTazawa H, Hirata Y, Kuga Y, Nishida T, Sakimoto H. Sphincter-saving resection by cluneal arched skin incision for a gastrointestinal stromal tumor (GIST) of the lower rectum: a case report. Surg Case Rep. 2017 Dec;3(1):8. \u003c/li\u003e\n\u003cli\u003eAsare EA, Vreeland TJ, Feig BW. Resection of a Perirectal Leiomyosarcoma via a Posterior Transcoccygeal Approach. Ann Surg Oncol. 2018 Sep;25(9):2641. \u003c/li\u003e\n\u003cli\u003eHirota S, Tateishi U, Nakamoto Y, Yamamoto H, Sakurai S, Kikuchi H, et al. English version of Japanese Clinical Practice Guidelines 2022 for gastrointestinal stromal tumor (GIST) issued by the Japan Society of Clinical Oncology. Int J Clin Oncol. 2024 Jun;29(6):647\u0026ndash;80. \u003c/li\u003e\n\u003cli\u003eHawkins AT, Wells KO, Krishnamurty DM, Hunt SR, Mutch MG, Glasgow SC, et al. Preoperative Chemotherapy and Survival for Large Anorectal Gastrointestinal Stromal Tumors: A National Analysis of 333 Cases. Ann Surg Oncol. 2017 May;24(5):1195\u0026ndash;201. \u003c/li\u003e\n\u003cli\u003eIJzerman NS, Mohammadi M, Tzanis D, Gelderblom H, Fiore M, Fumagalli E, et al. Quality of treatment and surgical approach for rectal gastrointestinal stromal tumour (GIST) in a large European cohort. Eur J Surg Oncol. 2020 Jun;46(6):1124\u0026ndash;30. \u003c/li\u003e\n\u003cli\u003eMiettinen M, Furlong M, Sarlomo-Rikala M, Burke A, Sobin LH, Lasota J. Gastrointestinal stromal tumors, intramural leiomyomas, and leiomyosarcomas in the rectum and anus: a clinicopathologic, immunohistochemical, and molecular genetic study of 144 cases. Am J Surg Pathol. 2001 Sep;25(9):1121\u0026ndash;33. \u003c/li\u003e\n\u003cli\u003eEmmertsen KJ, 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. Ann Surg. 2012 May;255(5):922\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eYeo HL, Paty PB. Management of recurrent rectal cancer: practical insights in planning and surgical intervention. J Surg Oncol. 2014 Jan;109(1):47\u0026ndash;52. \u003c/li\u003e\n\u003cli\u003eHomma Y, Mimura T, Koinuma K, Horie H, Sata N. Incidence of low anterior resection syndrome and its association with the quality of life in patients with lower rectal tumors. Surg Today. 2024 Aug 1;54(8):857\u0026ndash;65. \u003c/li\u003e\n\u003cli\u003eCroese AD, Lonie JM, Trollope AF, Vangaveti VN, Ho YH. A meta-analysis of the prevalence of Low Anterior Resection Syndrome and systematic review of risk factors. Int J Surg. 2018 Aug;56:234\u0026ndash;41. \u003c/li\u003e\n\u003cli\u003eQin X, Li C, Yang Z, Guo W, Guo H, Chen C, et al. Transsacrococcygeal approach in rectal gastrointestinal stromal tumour resection: 10-year experience at a single centre. Ann Transl Med. 2021 Feb;9(4):341. \u003c/li\u003e\n\u003cli\u003eQiu HZ, Lin GL, Xiao Y, Wu B. The use of posterior trans-sphincteric approach in surgery of the rectum: a Chinese 16-year experience. World J Surg. 2008 Aug;32(8):1776\u0026ndash;82. \u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 and 2 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"langenbecks-archives-of-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"laos","sideBox":"Learn more about [Langenbeck's Archives of Surgery](http://link.springer.com/journal/423)","snPcode":"423","submissionUrl":"https://submission.nature.com/new-submission/423/3","title":"Langenbeck's Archives of Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Rectal GIST, posterior approach, rectal cancer, pelvic recurrence","lastPublishedDoi":"10.21203/rs.3.rs-6557613/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6557613/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eThe standard surgical treatment for gastrointestinal stromal tumor (GIST) is local resection. Colorectal GIST, which accounts for 5\u0026ndash;10% of all GIST tends to develop in the lower rectum, making intra-abdominal approaches difficult and invasive. We perform partial resection of rectum with posterior approach for rectal GIST. We herein presented our procedure of posterior approach and retrospectively analysed the efficacy and safety of the posterior approach.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eIn a retrospective analysis from 2018 to 2023, data were collected from patients who underwent partial resection of rectum with posterior approach for rectal GIST. Patient characteristics, surgical outcomes, complications, prognosis and presence/absence of low anterior resection syndrome (LARS) were collected.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eFour patients with rectal GIST were included in this study. The median age was 50.5 years and all patients were male. The median operation time was 203.5 minutes, the median interoperative blood loss was 30 g, and the median initial tumour diameter was 29.5 mm. One patient underwent diverting ileostomy, and the ileostomy was closed one year after surgery. Complete pathological resection was achieved in all cases. Postoperative complications were observed in one patient: outlet obstruction of the diverting ileostomy and LARS and there were no other postoperative complications including anastomotic leakage. No recurrence was observed in the median follow-up of 33.5 months.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThis study demonstrated that posterior approach is safe, low incidence of LARS, and facilitates complete resection, making it a valuable surgical option for rectal GIST.\u003c/p\u003e","manuscriptTitle":"Partial resection of rectum for rectal GIST by posterior approach","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-15 10:48:27","doi":"10.21203/rs.3.rs-6557613/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-06-17T21:13:53+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-17T07:46:13+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-28T20:24:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"199115547070117730230264592859675026234","date":"2025-05-15T17:17:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"120845868675388795285053030576450635690","date":"2025-05-15T10:30:27+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-05-13T04:50:34+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-05T14:19:32+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-05T06:46:01+00:00","index":"","fulltext":""},{"type":"submitted","content":"Langenbeck's Archives of Surgery","date":"2025-04-29T14:42:15+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"langenbecks-archives-of-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"laos","sideBox":"Learn more about [Langenbeck's Archives of Surgery](http://link.springer.com/journal/423)","snPcode":"423","submissionUrl":"https://submission.nature.com/new-submission/423/3","title":"Langenbeck's Archives of Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"67d33254-fd4a-4361-8e8c-d3c0a1db1079","owner":[],"postedDate":"May 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-09-01T16:06:21+00:00","versionOfRecord":{"articleIdentity":"rs-6557613","link":"https://doi.org/10.1007/s00423-025-03845-y","journal":{"identity":"langenbecks-archives-of-surgery","isVorOnly":false,"title":"Langenbeck's Archives of Surgery"},"publishedOn":"2025-08-29 15:58:15","publishedOnDateReadable":"August 29th, 2025"},"versionCreatedAt":"2025-05-15 10:48:27","video":"","vorDoi":"10.1007/s00423-025-03845-y","vorDoiUrl":"https://doi.org/10.1007/s00423-025-03845-y","workflowStages":[]},"version":"v1","identity":"rs-6557613","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6557613","identity":"rs-6557613","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}