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Background: Transanal total mesorectal excision (TaTME) is a minimally invasive surgical technique that tries to avoid conversion to open surgery. However, specific intraoperative complications and local recurrences have cast some doubt on the suitability of the technique. The primary endpoint of the present study was a composite outcome of conversion surgery. Secondary objectives were to assess postoperative recovery, and pathological and oncological outcomes., Methods: This was a prospective, multicentre, randomized, controlled open-label study of patients diagnosed with mid and low rectal adenocarcinoma who underwent laparoscopic TaTME or laparoscopic total mesorectal excision (LaTME). The TaTME technique comprised intracorporeal resection and anastomosis. Main outcomes were conversion to open surgery. Secondary outcomes were postoperative morbidity, mortality, pathological, oncological results, and survival. Modified intention-to-treat (mITT) and per-protocol analyses were performed., Results: The study was conducted between April 2015 and May 2021. Patients were randomized to the LaTME (57 patients) or TaTME (59) group. Fifty patients from the LaTME group and 55 from the TaTME group were eligible for mITT analysis. The procedure was converted to open surgery in 11 patients (11 per cent): 10 (20 per cent) in the LaTME group and 1 (2 per cent) in the laparoscopic TaTME group (difference 18.8, 95 per cent c.i. 30 to 7; P = 0.003). No significant differences were found in terms of postoperative recovery and morbidity at 30 days; nor were there significant differences in anastomotic leakage, although it was less common in laparoscopic TaTME. With a median follow-up of 39 months, there were three instances of local recurrence (6.1 per cent) in the LaTME group and one (1.8 per cent) in the laparoscopic TaTME group (95 per cent c.i. 60 to 69; P = 0.3). Registration number: NCT02550769 (http://www.clinicaltrials.gov)., Conclusion: The conversion rate was significantly lower in laparoscopic TaTME than in LaTME. At centres with experienced surgeons, laparoscopic TaTME can avoid conversion to open surgery., (© The Author(s) 2022. Published by Oxford University Press on behalf of BJS Society Ltd. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Aim: The aim was to describe the robot-assisted intracorporeal anastomosis technique in left colon surgery (rLCS) and report the initial results., Method: The rLCS was performed in 25 consecutive patients, starting with a Pfannenstiel incision and introducing a prepared anvil. The robot was docked and the affected segment resected. Colotomy was performed and the anvil was introduced in the proximal segment. End-to-end anastomosis was performed and reinforced. An air-leak test was performed., Results: The results varied in terms of patient's age, American Society of Anesthesiologists grade, weight and the technique performed. Most patients had cancer. There was no suture failure or mortality, and the mean hospital stay was 3 days., Conclusions: The rLCS is a safe, reproducible technique with good initial results. Prospective studies should be performed to demonstrate its advantages., (© 2022 Association of Coloproctology of Great Britain and Ireland.)

Background: Oncological outcomes of self-expanding metallic stent used as a bridge to surgery in potential curative patients with left-sided colonic cancer obstruction remain unclear. The aim of this study was to investigate perioperative and mid-term oncological outcomes of 2 of the currently most commonly performed treatments in left-sided colonic cancer obstruction., Methods: This is a retrospective multicenter study including patients with left-sided colonic cancer obstruction treated with curative intent between 2013 and 2017. The presence of metastasis at diagnosis was an exclusion criterion. The primary outcome was to evaluate the noninferiority, in terms of overall survival, of bridge to surgery strategy compared with emergency colonic resection. The secondary outcomes were perioperative morbimortality, disease free survival, local recurrence, and distant recurrence., Results: A total of 564 patients were included, 320 in the emergency colonic resection group and 244 in the bridge to surgery group. Twenty-seven patients of the bridge-to-surgery group needed urgent operation. Postoperative morbidity rates were statistically higher in the emergency colonic resection group (odds ratio [95% confidence interval] 0.37 [0.24-0.55], P < .001). There was no difference in 90-day mortality between groups (odds ratio [95% confidence interval] 0.85 [0.36-1.99], P = .702). The median follow-up was 3.80 years (2.29-4.92). The results show the noninferiority of bridge to surgery versus emergency colonic resection in terms of overall survival (hazard ratio [95% confidence interval) 0.78 [0.56-1.07], P = .127). There were no differences in disease free survival, distant recurrence, and local recurrence rates between bridge to surgery and emergency colonic resection groups., Conclusion: Self-expanding metallic stent as bridge to surgery might not lead to a negative impact on the long-term prognosis of the tumor compared with emergency colonic resection in expert hands and selected patients., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Purpose: Combined endoscopic and laparoscopic surgery (CELS) has emerged as a promising method for managing complex benign lesions that would otherwise require major colonic resection. The aim of this study was to describe the different techniques and to evaluate the safety of CELS, assess its outcomes in a technique that is scarcely widespread in our environment., Method: Observational retrospective study, short-term outcomes of patients undergoing CELS for benign colon polyps from October 2018 to June 2020 were evaluated. Postoperative outcomes, length of hospital stay and pathological findings were evaluated., Results: Seventeen consecutive patients underwent CELS during the study period. The median size of the lesion was 3.5 cm (range 2.5-6.5 cm), the most frequent location was the cecum (10 from 17). Most patients treated with CELS underwent an endoscopic-assisted laparoscopic wedge resection (11 from 17). In four patients this resection was combined with another CELS technique, and two patients underwent an endoscopic-assisted laparoscopic segment resection. The success rate of CELS in our series was in 14 from 17 (82.4%). The median operative time was 85 min (range 50-225 min). The median hospital stay was 2 days (range 1-15 days). One patient experienced an organ/space surgical site infection which did not require further intervention. Four lesions were shown to be malignant by postoperative pathology study., Conclusion: CELS is a safe and multidisciplinar technique that requires collaboration between gastroenterologists and surgeons. It can be considered as an alternative to colonic resection for complex benign colonic polyps., (Copyright © 2020 AEC. Published by Elsevier España, S.L.U. All rights reserved.)

Transanal endoscopic microsurgery (TEM) allows the local excision of rectal tumors and achieves lower morbidity and mortality rates than total mesorectal excision. TEM can treat lesions up to 18 to 20 cm from the anal verge, obtaining good oncological results in T1 stage cancers and preserving sphincter function. TEM is technically demanding. Large lesions (>5 cm), those with high risk of perforation into the peritoneal cavity, those in the upper rectum or the rectosigmoid junction, and those in the anal canal are specially challenging. Primary suture after peritoneal perforation during TEM is safe and it does not necessarily require the creation of a protective stoma. We recommend closing the wall defect in all cases to avoid the risk of inadvertent perforation. It is important to identify these complex lesions promptly to transfer them to reference centers. This article summarizes complex procedures in TEM., Competing Interests: Conflict of Interest None declared., (Thieme. All rights reserved.)

Objective: Mild AD can be treated safely and effectively on an outpatient basis without antibiotics., Summary of Background Data: In recent years, it has shown no benefit of antibiotics in the treatment of uncomplicated AD in hospitalized patients. Also, outpatient treatment of uncomplicated AD has been shown to be safe and effective., Methods: A Prospective, multicentre, open-label, noninferiority, randomized controlled trial, in 15 hospitals of patients consulting the emergency department with symptoms compatible with AD.The Participants were patients with mild AD diagnosed by Computed Tomography meeting the inclusion criteria were randomly assigned to control arm (ATB-Group): classical treatment (875/125 mg/8 h amoxicillin/clavulanic acid apart from anti-inflammatory and symptomatic treatment) or experimental arm (Non-ATB-Group): experimental treatment (antiinflammatory and symptomatic treatment). Clinical controls were performed at 2, 7, 30, and 90 days.The primary endpoint was hospital admission. Secondary endpoints included number of emergency department revisits, pain control and emergency surgery in the different arms., Results: Four hundred and eighty patients meeting the inclusion criteria were randomly assigned to Non-ATB-Group (n = 242) or ATB-Group (n = 238). Hospitalization rates were: ATB-Group 14/238 (5.8%) and Non-ATB-Group 8/242 (3.3%) [mean difference 2.58%, 95% confidence interval (CI) 6.32 to -1.17], confirming noninferiority margin. Revisits: ATB-Group 16/238 (6.7%) and Non-ATB-Group 17/242 (7%) (mean difference -0.3, 95% CI 4.22 to -4.83). Poor pain control at 2 days follow up: ATB-Group 13/230 (5.7%), Non-ATB-Group 5/221 (2.3%) (mean difference 3.39, 95% CI 6.96 to -0.18)., Conclusions: Nonantibiotic outpatient treatment of mild AD is safe and effective and is not inferior to current standard treatment., Trial Registration: ClinicalTrials.gov (NCT02785549); EU Clinical Trials Register (2016-001596-75)., Competing Interests: The authors declare no conflict of interests. The authors report no funding and conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Transanal endoscopic microsurgery (TEM) is a safe procedure and the rates of intra- and postoperative complications are low. The information in the literature on the management of these complications is limited, and so their importance may be either under- or overestimated (which may in turn lead to under- or overtreatment). The present article reviews the most relevant series of TEM procedures and their complications and describes various approaches to their management., Evidence Acquisition: A systematic review of the literature, including TEM series of more than 150 cases each. We analyzed the population characteristics, surgical variables and intraoperative and postoperative complications., Evidence Synthesis: A total of 1043 records were found. After review, 1031 were excluded. The review therefore includes 12 independent cohorts of TEM procedures with a total of 4395 patients. The rate of perforation into the peritoneal cavity was 5.1%, and conversion to abdominal approach was required in 0.8% of cases. The most frequent complications were acute urinary retention (AUR, 4.9%) and rectal bleeding (2.2%). Less common complications included abscesses (0.99%) and rectovaginal fistula (0.62%). Mortality rates were low, with a mean value of 0.29%., Conclusions: Awareness and knowledge of TEM complications and their management can play an important role in their treatment and patient safety. Here, we present a review of the most important TEM series and their complication rates and describe various approaches to their management.

Purpose: Laparoscopic ventral rectopexy is the most favored surgical treatment for rectal prolapse. Perineal approaches are recommended for frail patients and those with major comorbidities, and in young men to avoid genitourinary disorders. There are very few descriptions in the literature of transanal endoscopic surgery to treat complete rectal prolapse. The aim of this article is to describe our experience with this technique., Patients and Methods: Patients undergoing transanal endoscopic surgery for rectal prolapse repair between 2010 and 2019 were recruited for the study. Preoperative, surgical, and postoperative variables were recorded. Surgical technique, 30-day morbidity and follow-up are described., Results: Five patients have been included. The postoperative period was uneventful and all patients were discharged in 48 hours without complications. All showed improved symptoms at 1-year control, and none presented recurrence in a mean follow-up period of 6 years., Conclusions: The transanal endoscopic procedure allows improved endoscopic vision, and the reconstruction is performed transpelvically by fixing the anastomosis suture to the pelvic wall to prevent recurrence. Therefore, we think it is a valid alternative to other perineal procedures in patients in whom abdominal surgery is contraindicated., Competing Interests: The author declares no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Despite the publication of the guidelines for enhanced recovery after surgery (ERAS), attitudes to urinary catheter (UC) management vary widely in colorectal surgery. The aim of the present study was to define current practices in UC management in colorectal surgery., Methods: Cross-sectional observational study carried out in March-April 2019, based on the responses to a survey administered to public hospitals in Catalonia. Respondents were asked about their observance of ERAS programs, the percentage of laparoscopic procedures performed, and the time of UC withdrawal in surgery of the colon and rectum., Results: Forty-three of 45 hospitals contacted eventually responded (95.6%). As two hospitals reported that they did not perform colorectal surgery, the study is based on the results from 41 centers. Thirty-five (85.4%) reported following ERAS programs; 30 (73.2%) have coloproctology units, and 39 (95.1%) perform more than 70% of colorectal surgeries by laparoscopy. In colon surgery, 27 (65.9%) remove the UC at 24 h, and 12 (29.3%) on day 2 or day 3. In rectal surgery, 17 (58.6%) remove the UC on day 2-3., Conclusions: Management of UC in colon and rectal surgery varies widely. There is clearly room for improvement in UC management, but needs to be thoroughly assessed in randomized multicenter studies.

Purpose: Combined endoscopic and laparoscopic surgery (CELS) has emerged as a promising method for managing complex benign lesions that would otherwise require major colonic resection. The aim of this study was to describe the different techniques and to evaluate the safety of CELS, assess its outcomes in a technique that is scarcely widespread in our environment., Method: Observational retrospective study, short-term outcomes of patients undergoing CELS for benign colon polyps from October 2018 to June 2020 were evaluated. Postoperative outcomes, length of hospital stay and pathological findings were evaluated., Results: Seventeen consecutive patients underwent CELS during the study period. The median size of the lesion was 3.5 cm (range 2.5 - 6.5 cm), the most frequent location was the cecum (10 from 17). Most patients treated with CELS underwent an endoscopic-assisted laparoscopic wedge resection (11 from 17). In four patients this resection was combined with another CELS technique, and two patients underwent an endoscopic-assisted laparoscopic segment resection. The success rate of CELS in our series was in 14 from 17 (82,4%). The median operative time was 85 min (range 50-225 min). The median hospital stay was 2 days (range 1-15 days). One patient experienced an organ/space surgical site infection which did not require further intervention. Four lesions were shown to be malignant by postoperative pathology study., Conclusion: CELS is a safe and multidisciplinar technique that requires collaboration between gastroenterologists and surgeons. It can be considered as an alternative to colonic resection for complex benign colonic polyps., (Copyright © 2020 AEC. Publicado por Elsevier España, S.L.U. All rights reserved.)

Background: The aim of this study is to assess the feasibility of transanal endoscopic surgery (TES) in obese patients., Methods: Observational descriptive study evaluating the feasibility of TES in obese rectal tumors between June 2004 and January 2019. Patients were assigned to two groups: body mass index (BMI) < 30 kg/m 2 and BMI ≥30 kg/m 2 , the latter defined as obese., Results: From 775 patients, 681 were enrolled in the study, 145 (21.3%) of them obese. No statistically significant differences between groups were found with respect to overall morbidity (27, 18.6%).The obese patients presented trends towards shorter mean surgical time (65 min, IQR 48 min), less perforation in the peritoneal cavity (eight, 5.5%), and 133 (91.7%) presented a lower rate of lesion fragmentation., Conclusion: There were no significant differences in postoperative outcomes in obese patients (BMI ≥30 kg/m 2 ). TES in those obese patients does not represent a factor of surgical difficulty., Competing Interests: Declaration of competing interest The authors have no competing interests to declare., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Introduction: Frailty is associated with greater postoperative morbidity and mortality. Individualized multidisciplinary management of these patients can improve the quality of care. The objectives of this study are to determine the percentage of frail patients with colorectal cancer in our population, and to describe the morbidity and mortality associated with surgery and the evolution of palliative treatment., Methods: A prospective, observational study of patients with surgical colorectal cancer (February 1, 2018-April 30, 2019). Frail patients were screened and classified according to degrees of frailty. Therapeutic decision-making (surgery or palliative treatment) was determined by the degree of fragility and explicit will of the patient. Postoperative comorbidities were analyzed (according to Clavien-Dindo and Comprehensive Complication Index), as were mortality and oncological follow-up., Results: The study included 193 patients with surgical colorectal cancer, with a mean age of 74 years (44-92). Screening identified 46 frail patients (24%), with a mean age of 80 years (57-92). Twenty-two patients were optimized and underwent surgery (48%), with a mean age of 78 years (57-89). Relevant adverse effect rate was 27.7% (4 grade iva adverse effects, one ivb and one v, according to Clavien-Dindo). Comprehensive Complication Index was 17.5. Palliative treatment was administered in 24 patients (52%), with a mean age of 82 years (59-92). Mean follow-up was 7.8 months. There were 2 deaths due to disease progression (8.3%), 5 re-consultations due to complications of colorectal cancer (20.1%)., Conclusions: The multidisciplinary and individualized management of frail patients with colorectal cancer is key to improve the quality of care in the treatment of this patient group., (Copyright © 2020 AEC. Publicado por Elsevier España, S.L.U. All rights reserved.)

Background: An important drawback of local surgery for lesions in the anal canal is the difficulty of achieving en bloc full-thickness resections. The aim of this study is to evaluate TEM/TEO in lesions of this type from the point of view of morbidity, mortality and the quality of the pathology specimen., Methods: This is an observational study with prospective data collection from June 2004 to July 2018. Two groups are defined: group A (rectal tumors with proximal margin between 0 and ≤4 cm from anal verge) and group B (distal margin > 4 cm from anal verge). A technical description is provided; resections and postoperative complications in both groups are compared., Results: During the study period, 757 patients underwent TEM/TEO. Finally, 692 patients were included, 192 patients in group A and 500 patients in group B. An en bloc surgical specimen was obtained in 176/192 patients (91.7%), although the defect was completely sutured in 132 (68.8%). In the comparative analysis, group A did not present significantly greater fragmentation of the resected piece [16/192 (8.3%) vs. 36/500 (7.2%), p = 0.630], although group A was associated with greater involvement of the surgical margin [28/192 (14.6%), 32/500 (6.4%), p = 0.001] and clinically relevant morbidity [16/192 (8.3%), 20/500 (4%), p = 0.034]. There was no mortality., Conclusions: The use of TEM/TEO to remove lesions originating in the anal canal is feasible. But we have to take into account that there is an increase in complications, technical difficulties and affected margins resection.

Colorectal cancer is the second most frequent cancer in the Western world. A third of colorectal tumors are located in the right colon, and right hemicolectomy is the treatment in nondisseminated right colon cancer. The most serious complication of this procedure is anastomotic leak, which occurs in 8.4% of cases. At present, there is no standardized technique for laparoscopic ileo-colic anastomosis. In previous observational studies, intracorporeal side-to-side ileo-colic laparoscopic anastomosis has shown better results than extracorporeal anastomosis in terms of morbidity and mortality. It is known that randomized studies provide higher levels of evidence, but multicenter randomized controlled studies may imply a learning curve bias due to the differences in technical experience acquired at each hospital. As a result, we propose to carry out a prospective, controlled, nonrandomized TREND-study design (Transparent Reporting of Evaluations with Non-randomized Designs-TREND) in a large sample of 416 patients (208 per group) in order to assess the use of intracorporeal side-to-side ileo-colic laparoscopic anastomosis as the gold standard in right hemicolectomy., (© 2019 S. Karger AG, Basel.)

Purpose: Completion proctectomy is the traditional approach in the rectal stump remaining after subtotal colectomy for benign disease. It is associated with high morbidity and urinary and sexual dysfunction. To reduce this risk, a minimally invasive approach is presented, intersphincteric intramesorectal proctosigmoidectomy by transanal endoscopic operation and laparoscopy., Patients and Methods: Patients who had undergone total or subtotal colectomy for benign disease, those with a rectosigmoid stump who had rejected intestinal reconstruction and with refractory symptoms or risk of degeneration were selected. The technique proposed and the morbidity outcomes are described., Results: Three patients underwent this minimally invasive approach, operative time was 130 to 150 minutes. The median postoperative hospital stay was 6.6 days. Genitourinary and sexual tests performed in the male patient showed no dysfunction., Conclusions: This minimally invasive technique, with intersphincteric resection and dissection close to the rectal wall, theoretically reduces morbidity and the damage to the autonomic pelvic nerves.

Background: Polypectomy is the gold standard for treating colorectal adenomas up to 2 cm in size. For larger lesions, various procedures ranging from endoscopy to transanal surgery can be performed and achieve varying results for en bloc resection and recurrence. There are no clear guidelines for dealing with involved resection margins. We assess the recurrence of rectal adenomas operated using TEM with full-thickness wall excision with or without free resection margins and define optimal endoscopic follow-up., Method: Observational study with prospective data collection, including patients undergoing TEM between 6/2004 and 11/2017, with definitive diagnosis of rectal adenoma. Data on epidemiological, preoperative, surgical, postoperative, pathological, and follow-up variables were recorded. Univariate analysis, follow-up risk function, and multivariate logistic regression analysis were performed to detect risk factors for recurrence., Results: TEM was indicated in 736 patients; 481 adenomas were identified in the preoperative biopsy, of which 95 were infiltrating adenocarcinomas (19.8%) in the definitive pathology study. With a minimum follow-up of 1 year, 372 patients were included. Pathology study showed free margins in 324 (87%). Recurrences were recorded in 15 patients (4%), up to 18 months in the free margins group and up to 24 months in the involved margins group. Thirteen patients with recurrence (86.6%) were treated with TEM. No predictors of recurrence were found in the multivariate analysis., Conclusion: TEM is the technique of choice for treating rectal adenomas and recurrences, achieving a low relapse rate. Follow-up must be adapted to resection margins and should be extended to 24 months.

Background: Total Mesorectal Excision (TME) is the standard surgical technique for the treatment of rectal cancer. However, rates of sexual dysfunction ofup to 50% have been described after TME, and rates of urinary dysfunction of up to 30%. Although other factors are involved, the main cause of postoperative genitourinary dysfunction is intraoperative injury to the pelvic autonomic nerves. The risk is particularly high in the inferior mesenteric artery (IMA). The aim of this study is to compare pre- and post-TME sexual dysfunction, depending on the surgical approach usedin the inferior mesenteric vessels: either directly on the IMA, or from the inferior mesenteric vein (IMV) to the IMA., Methods: Prospective, randomized,controlled study of patients with rectal adenocarcinoma with neoadjuvant chemoradiotherapy, who will be randomly assigned to one of two groups depending on the surgical approach to the inferior mesenteric vessels. The main variable is pre- and postoperative sexual dysfunction; secondary variables are visualization and preservation of the pelvic autonomic nerves, pre- and postoperative urinary dysfunction, and pre- and postoperative quality of life. The sample will comprise 90 patients, 45 per group., Discussion: The aim is to demonstrate that the dissection route from the IMV towards the IMA favors the preservation of the pelvic autonomic nerves and thus reducesrates of sexual dysfunction post-surgery., Trial Registration: Ethical and Clinical Research Committee, Parc Taulí University Hospital: ID 017/315. ClinicalTrials.gov TAU-RECTALNERV-PRESERV-2018 (TRN: NCT03520088 ) (Date of registration 04/03/2018).

Background: Loop ileostomy reduces the rates of morbidity due to colorectal anastomotic dehiscence. For its part, ileostomy closure is associated with low mortality (0-4%) but substantial morbidity (11-37%). Incisional surgical site infection (SSI) is one of the most frequent complications (2-40%)., Methods: A single-center, prospective, randomized controlled clinical trial of two study groups: control (conventional primary skin closure) and experimental (primary skin closure with a contralateral Penrose ® drain)., Results: Seventy patients undergoing loop ileostomy closure between April 2013 and June 2017 were included (35 per branch). Four were later removed from the study. Six of the remaining 66 patients (per protocol analysis) were diagnosed with incisional SSI (9.1%); there were no statistically significant differences between the two groups (control group: 9.7%; experimental group: 8.6%) or between the risk factors associated with incisional SSI. Rates of overall and relevant morbidity (Clavien ≥ III) were considerable (28.1% and 9.1%, respectively), and there were no statistically significant differences between the two groups. No patients died., Conclusion: Contralateral drainage does not significantly affect the results of primary ileostomy closure. The rate of incisional SSI was similar in the drainage and non-drainage groups, and the overall rate of 9.1% was in the low range of those reported in the literature. The absence of mortality (0%) and the non-negligible rates of overall and relevant morbidity (28.1% and 9.1%, respectively) in our series suggest that loop ileostomy is a safe procedure. However, the bowel reconstruction involves risks that must be borne in mind., Clinical Trial Registration: The study was registered and approved by the clinical research ethics committee of the study center (reference number 2012076). Clinical trial was registered in ClinicalTrial.gov (identification number NCT02574702 and reference: ILEOS-ISS&#95;2013).