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Byline: Avanish. Saklani, Mufaddal. Kazi, Ashwin. Desouza, Ankit. Sharma, Reena. Engineer, Rahul. Krishnatry, Shivkumar. Gudi, Vikas. Ostwal, Anant. Ramaswamy, Aditya. Dhanwat, Prabhat. Bhargava, Shaesta. Mehta, Sridhar. Sundaram, Aditya. Kale, Mahesh. [...]

Background Methods Results Conclusions The objective of this systematic review and meta‐analysis was to pool randomized trials of patients undergoing left‐sided colorectal anastomosis, comparing the use of fluorescence perfusion imaging versus visual inspection in reducing anastomotic leaks.Databases searched included PubMed, Cochrane Library, Scopus, CINHAL (EBSCO), and Google Scholar based on the concepts: randomized, colorectal, anastomotic leak, and fluorescence imaging. The risk of bias was assessed using RoB2 and the certainty of the evidence with the GRADE Pro tool. The analysis used the log odds ratio for dichotomous data with 95% confidence intervals. Back‐transformation of the log odds to odds ratio was performed for the summary of findings. All syntheses used the Random‐effects model.Six randomized trials were included with 1949 patients and 204 events (leaks). Three trials included exclusively rectal cancer patients, while the other three involved benign and malignant pathologies of the sigmoid and rectum. The use of ostomy and preoperative radiation was variable. None of the studies had a high risk of bias. The pooled odds ratio for anastomotic leak reduction with Indocyanine Green (ICG) fluorescence was 0.586 (95% CI: 0.434–0.792). An absolute reduction of 4.7% in leak rates was observed, with no statistical heterogeneity (I2 = 0; p = 0.529). Due to clinical heterogeneity, the quality of evidence was rated moderate.The use of ICG is associated with reduced leak rates following left‐sided colorectal anastomosis with moderate confidence. ICG may be considered a standard of care given the clinically significant benefit in decreasing anastomotic leaks. [ABSTRACT FROM AUTHOR]

Anastomotic leak is a significant morbidity in colorectal surgeries. The risk factors for anastomotic leakage are multifactorial with vascularity of the bowel edge playing an important role. Indocyanine green (ICG) dye emits fluorescence and this principle is used to assess the bowel edge vascularity before anastomosis. The context of the study is that even though ICG dye has been used in colorectal cancer surgery for quite a while the evidence is not strong. Most of the data on the role of ICG dye in decreasing the anastomotic leak rate in colorectal cancer surgery comes from retrospective and few prospective trials. There are a few recently published randomized controlled trials (RCT) with contrasting outcomes in this regard. This study is a narrative review of randomized control trials and trial protocols published until 31st December 2023. PubMed, Embase, and Scopus were searched with the keywords ICG, AND Colorectal surgery, AND Anastomotic leak. Four completed RCTs were found and included in this review of all search results. Most of the included studies reported the beneficial effects of ICG on the incidence of anastomotic leak rate. To conclude, the role of ICG dye is not well established in reducing anastomotic leak rates following colorectal anastomosis, but there is growing evidence to support its use. [ABSTRACT FROM AUTHOR]

Background: Pelvic exenterations and cytoreduction are individually morbid procedures with oncological validity. The combination of these simultaneously in patients with rectal cancers has not been evaluated. The present study aimed to assess the surgical and survival outcomes of the combined procedure. Methods: Retrospective, single‐centre analysis of consecutive patients that underwent pelvic exenterations and cytoreductions for advanced or recurrent rectal cancers with peritoneal metastasis between 2013 and 2022. The primary outcome measure for safety was major complications (≥Grade IIIA). The threshold for considering the procedure unsafe was set at 50% for the upper confidence limit of major morbidity. Overall and recurrence‐free survival were also assessed. Results: Thirty‐nine patients underwent the combined procedure that included 24 total pelvic and 15 posterior pelvic exenterations. The median age of the cohort was 35 years, 18 (46.2%) had signet ring cell cancers, and eight patients (21%) had extraperitoneal disease as well. The median PCI was 4 and CC‐0 was achieved in 38 patients (97.4%). Hyperthermic intraperitoneal chemotherapy was delivered in 15 patients, and four had placement of an intraperitoneal chemo port. Major complications were experienced by 7 patients (18%; 95% confidence interval: 7.5%–33.5%). Median recurrence‐free and overall survivals were 9 and 17 months, respectively. Conclusion: Combined pelvic exenterations and cytoreductions are safe operations in terms of morbidity. Survival, however, remains poor for this group of patients despite aggressive surgery. [ABSTRACT FROM AUTHOR]

Aim: Robotic surgery is increasingly being used for rectal resection, with short‐term benefits such as reduced hospital stay, faster bowel recovery and fewer complications. However, its utility for advanced rectal cancers requiring beyond total mesorectal excision has not been adequately evaluated. The aim of this study was to compare robotic and laparoscopic approaches for extended rectal resection, with postoperative and short‐term oncological outcomes as endpoints. Method: A retrospective, single‐centre study of patients with advanced rectal cancer requiring extended rectal resection between January 2017 and December 2022 was carried out. Beyond total mesorectal excisions included pelvic exenteration, en bloc soft tissue or partial organ resection with the rectum, and lateral pelvic node dissection. Propensity score matching in a 4:1 ratio of laparoscopic to robotic was performed with age, sex, comorbidities, body mass index, organs involved, clinical T stage and colonoscopic obstruction. Results: A total of 425 beyond total mesorectal excisions were performed by minimally invasive approaches during the study period, and after propensity matching 228 laparoscopic operations were compared with 57 robotic resections. All baseline characteristics were balanced. No difference in blood loss, postoperative complications, length of hospital stay, positive resection margin or nodal yield was found, but there was a somewhat longer operating duration in robotics. The 2‐year disease‐free and overall survival were also similar. Conclusions: No differences in postoperative or short‐term oncological outcomes were found between robotic and laparoscopic beyond total mesorectal excisions for advanced tumours when performed by teams experienced in both robotics and laparoscopy. [ABSTRACT FROM AUTHOR]

Aim: Although complete mesocolic excision (CME) for colon cancer is oncologically sound, to date, there has been no consensus on the extent of lymphadenectomy in radical right colectomy. This study essentially compared the perioperative and survival outcomes of CME with two templates of lymphadenectomy for right colon cancer. Method: This was a propensity matched, retrospective analysis of a single centre, prospectively maintained database of all patients undergoing elective right colectomy for nonmetastatic, biopsy‐proven adenocarcinoma from November 2013 to October 2018. CME + D3 was adopted selectively, documented prospectively, and compared with patients undergoing CME + central vascular ligation (CVL). The only technical difference between the groups was the excision of the surgical trunk of Gillot in the CME + D3 group. Postoperative, long‐term outcomes and patterns of recurrence were compared between the groups. Results: Of the 244 eligible patients, 88 (36.1%) and 156 (63.9%) underwent CME + D3 and CME + CVL, respectively. Matched groups (72 [CME + D3] vs. 108 [CME + CVL]) showed no difference in histology, tumour grade, postoperative complications, mortality, and hospital stay. CME + D3 was preferentially performed laparoscopically (35.2% vs. 9%), was associated with lower blood loss (215 mL vs. 297 mL, p = 0.001), higher nodal yield (31 vs. 25 nodes, p = 0.003) and a higher incidence of chyle leak (4 vs. 0, p = 0.013). At a median follow‐up of more than 57 months, there was no significant difference in local recurrence, disease‐free or overall survival. Conclusion: In this retrospective study, lymphadenectomy along the superior mesenteric vein, as a component of CME for right colon cancer, offered a higher nodal yield with no improvement in oncological outcome. Dissection of the SMV, over and above a D2 dissection, could therefore be restricted to specialized colorectal units until further studies establish the incremental oncological benefit of this extended lymphadenectomy or define a patient group in whom it is beneficial. [ABSTRACT FROM AUTHOR]

Background: Signet-ring cell colorectal carcinoma (SRCC) is an extremely aggressive yet uncommon histologic subtype of colorectal cancer (CRC) with an unknown etiology. There is a stark difference in the prevalence of signet cancers between Western countries and the Indian subcontinent; however, India itself is a vast and diverse country with variable cancer incidence. Objective: To study the spatial epidemiology of SRCC in India for identifying regions with high prevalence. Methods: This retrospective study included all patients diagnosed with colorectal adenocarcinoma at Tata Memorial Hospital, the largest colorectal cancer referral unit in India, between January 2020 and December 2022. Geocoding based on the location of the residence was done to map the incidences. Comparisons were performed between the proportion of signet cell and non-signet colorectal cancers. Results: A total of 4100 patients with colon or rectal adenocarcinomas were included, of which signet cell histology was found in 624 (15%) patients. SRCC accounted for the highest proportions of CRCs in the Central (19%) and Northern (19%) regions, and the lowest in the North-Eastern (10%) and Western (12%) regions of India (P < 0.001), with non-overlapping confidence intervals. Compared with patients with non-signet CRCs, those with SRCC more commonly had colon cancers (22% vs. 17%; P = 0.003) and belonged to a lower socioeconomic background (67% vs. 59%; P < 0.001). Conclusions: This study found that SRCCs accounted for a significant proportion of CRC cases in India, but there was no substantial disparity in distribution across regions. [ABSTRACT FROM AUTHOR]

Introduction: Anorectal manometry (ARM) is sometimes performed before ostomy reversal in patients with an intersphincteric resection (ISR) to predict bowel function. However, no clinical predictive data exist regarding its utility. Methods: The single‐centre, retrospective data of ISR patients who had an ARM prior to ostomy reversal, and bowel functional assessment with the low anterior resection syndrome (LARS) and Wexner incontinence scores at least 6 months after reversal, were considered. Correlation statistics were performed with each of the manometric parameters and functional outcome categories. Results: Eighty‐nine patients were included. The median basal and squeeze pressures were 41 and 100 mmHg, respectively. Any LARS (score ≥20) and major incontinence (score ≥11) was observed in 51.7% and 16.9%, respectively. None of the manometric parameters (median basal or maximum squeeze pressure, anal canal length, volume at urge and the ability to expel) correlated with LARS or incontinence. Conclusions: Anorectal manometry (ARM) before ostomy reversal to predict bowel function at 6 months or beyond was not helpful in patients with an ISR and diverting stoma. No manometric parameter correlated with the LARS or Wexner incontinence scores. [ABSTRACT FROM AUTHOR]

Aim: Extended total mesorectal excision (eTME) is a complex procedure involving en bloc resection of the structures surrounding the various quadrants of the rectum. This study, presenting the largest series so far of patients undergoing eTME, aimed to assess the surgical and survival outcomes of patients following treatment with eTME and to compare these outcomes with historical data on pelvic exenteration. Method: The study is a retrospective review of all patients with locally advanced rectal cancer requiring an eTME (2014–2020). The database includes the demographic profile, operative details, histopathological features and follow‐up. Results: One hundred and sixty three patients who underwent eTME were analysed. The overall Clavien–Dindo complication rate of > IIIa was 21.1%. The anterior quadrant was the most common anatomical site resected (68.5%). The R1 resection rate was 10.4%. After a median follow‐up of 28 months, there were 51 recurrences in the study and twenty two deaths were recorded. The local recurrence rate was 7.3% among the study population. The disease‐free survival (DFS) and overall survival were 66.7% and 80.4%, respectively, at 3 years. The majority of the recurrences were distant metastasis (84.3%). In univariate analysis, the quadrant involved did not affect survival. In multivariate analysis, signet ring histology, metastatic presentation, inadequate tumour response and R1 resection affected DFS. Conclusion: The recurrence pattern, R1 resection rate and survival outcomes of patients in the present study were comparable with those for patients undergoing an exenteration. Therefore, eTME is probably a safe alternative to pelvic exenterations when R0 resection is achievable and when the procedure is performed in high‐volume specialist tertiary care centres. [ABSTRACT FROM AUTHOR]

Aim: Empty pelvis syndrome (EPS) is a source of considerable morbidity following total pelvic exenteration. None of the available methods have been universally successful in mitigating this problem. The aim of this work was to evaluate the safety and efficacy of the obstetric Bakri balloon in preventing empty pelvis syndrome. Method: This study was a combined prospective and retrospective study of all total pelvic exenterations for rectal cancers from a single institution performed between October 2013 and May 2022. Since December 2019 the Bakri balloon was used in all patients who provided consent. EPS within 90 days was the primary end point, and included bowel obstruction, pelvic collection and entero‐perineal fistula. Comparison with those patients who did not have a Bakri balloon was performed. Results: Seventy‐five patients with a Bakri balloon were compared with 96 patients without a balloon placed after pelvic exenteration. No patient experienced an untoward complication from balloon deployment. The incidence of EPS was 13.3% and 22.9% in the Bakri and no Bakri cohorts, respectively (p = 0.110). Every component of EPS was proportionally lower, without statistical significance. Based on point estimates, the number needed to treat to prevent EPS using the Bakri balloon was 10. Conclusions: Use of the Bakri balloon was safe without serious adverse events. The incidence of EPS after total pelvic exenteration was not statistically different with the use of the Bakri balloon despite a 9.6% reduction. A larger comparative study is needed to evaluate the efficacy of the balloon. [ABSTRACT FROM AUTHOR]

Segmental inflow control prior to parenchymal transection is a daunting task. Prior descriptions of the Glissonian approach to inflow control are limited to secondary pedicles that have constant landmarks. However, it is possible with the understanding that the Glissonian sheath surrounding the portal structures is separable from the Laennec capsule surrounding the liver parenchyma. The image depicts segmental inflow control to the right hemiliver using this concept, and the technique is described in the accompanying text. The Glissonian approach avoids injuries to bile ducts that are fragile structures and circumvents all biliary and vascular variations since these occur below the hilar plate. Moreover, the described technique does not require an expert sonologist to identify the segmental pedicles. With the described technique, segmental control is possible at the hilum prior to proceeding with parenchymal division with relative ease which is difficult with any other method allowing smaller yet anatomical resections. [ABSTRACT FROM AUTHOR]

This article discusses a case of laparoscopic abdominoperineal resection with obturator internus fascia excision for a patient with low rectal cancer. The patient had received neoadjuvant therapy but still had involvement of the mesorectal fascia. The surgical procedure involved a stepwise approach to ensure margin-negative resection. The patient had a successful recovery and was discharged after 10 days. The authors highlight that this technique provides a safe and replicable method for excising rectal cancer in cases with persistent spread after neoadjuvant therapy. [Extracted from the article]

Aim: The learning curve of total mesorectal excision (TME) by minimally invasive surgery (MIS) beyond the competency phase has not been adequately reported with large numbers or using a statistical control limit. The aim of this work was to study the learning curve of MIS TME in the proficiency phase. Method: Risk‐adjusted (RA) cumulative sum (CUSUM) and RA Bernoulli CUSUM charts were plotted for sequential MIS TME performed by a surgical team over 1000 cases. Surgical failure, a composite endpoint of conversions, complications of grade IIIA or above, R1 resections and inadequate nodal yield were used to monitor the performance. Results: The RA CUSUM detected an inflection point around the 600th operation. Two peaks were identified that could be traced back to probable causes of surgical failure. Similar inflection points were detected at the 450th case for laparoscopic TME and the 367th case for sphincter preservation. No single definite threshold point was noticed for robotic or abdominoperineal operations. At no point did the curves cross the safety threshold. The probability of surgical failure reduced with increasing experience in the multivariate regression (OR 0.899, p = 0.000). This association persisted irrespective of the surgical approach (laparoscopic versus robotic) or the type of operation (sphincter preservation versus abdominoperineal resection). Conclusion: The learning curves for MIS TME did not cross the safety threshold beyond the competency phase. However, a 10% reduction of relative risk in surgical failure was observed for every 100 cases operated on. [ABSTRACT FROM AUTHOR]

Locoregional failure during and after short-course radiotherapy followed by chemotherapy and surgery compared to long-course chemoradiotherapy and surgery: a five-year follow-up of the RAPIDO trial. Keywords: radiation; rectal cancer; short-course radiation; total neoadjuvant therapy EN radiation rectal cancer short-course radiation total neoadjuvant therapy 1542 1544 3 07/25/23 20230701 NES 230701 Total neoadjuvant therapy (TNT) is gaining widespread popularity in the treatment of rectal cancers. Is it the end of the road for short-course radiation in total neoadjuvant therapy for rectal cancers? Radiation, rectal cancer, total neoadjuvant therapy, short-course radiation. [Extracted from the article]