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Background: Artificial intelligence (AI) has the potential to enhance surgical practice by predicting anatomical structures within the surgical field, thereby supporting surgeons' experiences and cognitive skills. Preserving and utilising nerves as critical guiding structures is paramount in rectal cancer surgery. Hence, we developed a deep learning model based on U-Net to automatically segment nerves. Methods: The model performance was evaluated using 60 randomly selected frames, and the Dice and Intersection over Union (IoU) scores were quantitatively assessed by comparing them with ground truth data. Additionally, a questionnaire was administered to five colorectal surgeons to gauge the extent of underdetection, overdetection, and the practical utility of the model in rectal cancer surgery. Furthermore, we conducted an educational assessment of non-colorectal surgeons, trainees, physicians, and medical students. We evaluated their ability to recognise nerves in mesorectal dissection scenes, scored them on a 12-point scale, and examined the score changes before and after exposure to the AI analysis videos. Results: The mean Dice and IoU scores for the 60 test frames were 0.442 (range 0.0465–0.639) and 0.292 (range 0.0238–0.469), respectively. The colorectal surgeons revealed an under-detection score of 0.80 (± 0.47), an over-detection score of 0.58 (± 0.41), and a usefulness evaluation score of 3.38 (± 0.43). The nerve recognition scores of non-colorectal surgeons, rotating residents, and medical students significantly improved by simply watching the AI nerve recognition videos for 1 min. Notably, medical students showed a more substantial increase in nerve recognition scores when exposed to AI nerve analysis videos than when exposed to traditional lectures on nerves. Conclusions: In laparoscopic and robot-assisted rectal cancer surgeries, the AI-based nerve recognition model achieved satisfactory recognition levels for expert surgeons and demonstrated effectiveness in educating junior surgeons and medical students on nerve recognition. [ABSTRACT FROM AUTHOR]

Background: Anastomotic stricture (AS) is a common complication following rectal cancer surgery with anastomosis, but its diagnosis and management pose significant challenges due to the lack of standardized diagnostic criteria. We present a case highlighting the complexities encountered in diagnosing and managing occult AS post-rectal cancer surgery. Case presentation: A 51-year-old male patient presented with symptoms suggestive of AS following robot-assisted laparoscopic low anterior resection for rectal adenocarcinoma. Despite conventional evaluations, including colonoscopy, digital rectal examination, and radiography, AS was not identified. Following prolonged and ineffective treatment for suspected conditions such as low anterior resection syndrome (LARS), the patient underwent anal dilatation, resulting in significant symptom improvement. Conclusions: This case underscores the challenges associated with diagnosing and managing occult AS following rectal cancer surgery. The absence of standardized diagnostic criteria and reliance on conventional modalities may lead to underdiagnosis and inadequate treatment. A comprehensive diagnostic approach considering intestinal diameter, elasticity, and symptoms related to difficult defecation may enhance diagnostic accuracy. Further research is needed to refine the diagnostic and therapeutic strategies for occult AS. [ABSTRACT FROM AUTHOR]

Background: In this study, we aimed to identify the risk factors in patients with rectal anastomotic re-leakage and develop a prediction model to predict the probability of rectal anastomotic re-leakage after stoma closure. Methods: This study was a single-center retrospective analysis of patients with rectal cancer who underwent surgery between January 2010 and December 2020. Among 3225 patients who underwent Total or Partial Mesorectal Excision (TME/PME) surgery for rectal cancer, 129 who experienced anastomotic leakage following stoma closure were enrolled. Risk factors for rectal anastomotic re-leakage were analyzed, and a prediction model was established for rectal anastomotic re-leakage. Results: Anastomotic re-leakage after stoma closure developed in 13.2% (17/129) of patients. Multivariable analysis revealed that neoadjuvant chemoradiotherapy (odds ratio, 4.07; 95% confidence interval, 1.17–14.21; p = 0.03), blood loss > 50 ml (odds ratio, 4.52; 95% confidence interval, 1.31–15.63; p = 0.02), and intersphincteric resection (intersphincteric resection vs. low anterior resection: odds ratio, 6.85; 95% confidence interval, 2.01–23.36; p = 0.002) were independent risk factors for anastomotic re-leakage. A nomogram was constructed to predict the probability of anastomotic re-leakage, with an area under the receiver operating characteristic curve of 0.828 in the cohort. Predictive results correlated with the actual results according to the calibration curve. Conclusions: Neoadjuvant chemoradiotherapy, blood loss > 50 ml, and intersphincteric resection are independent risk factors for anastomotic re-leakage following stoma closure. The nomogram can help surgeons identify patients at a higher risk of rectal anastomotic re-leakage. [ABSTRACT FROM AUTHOR]

Background: Bladder drainage is systematically used in rectal cancer surgery; however, the optimal type of drainage, transurethral catheterization (TUC) or suprapubic catheterization (SPC), is still controversial. The aim was to compare the rates of urinary tract infection on the fourth postoperative day (POD4) between TUC and SPC, after rectal cancer surgery regardless of the day of removal of the urinary drain. Methods: This randomized clinical trial in 19 expert colorectal surgery centers in France and Belgium was performed between October 2016 and October 2019 and included 240 men (with normal or subnormal voiding function) undergoing mesorectal excision with low anastomosis for rectal cancer. Patients were followed at postoperative days 4, 30, and 180. Results: In 208 patients (median age 66 years [IQR 58–71]) randomized to TUC (n = 99) or SPC (n = 109), the rate of urinary infection at POD4 was not significantly different whatever the type of drainage (11/99 (11.1%) vs. 8/109 (7.3%), 95% CI, − 4.2% to 11.7%; p = 0.35). There was significantly more pyuria in the TUC group (79/99 (79.0%) vs. (60/109 (60.9%), 95% CI, 5.7–30.0%; p = 0.004). No difference in bacteriuria was observed between the groups. Patients in the TUC group had a shorter duration of catheterization (median 4 [2–5] vs. 4 [3–5] days; p = 0.002). Drainage complications were more frequent in the SPC group at all followup visits. Conclusions: TUC should be preferred over SPC in male patients undergoing surgery for mid and/or lower rectal cancers, owing to the lower rate of complications and shorter duration of catheterization. Trial registration: ClinicalTrials.gov identifier NCT02922647. [ABSTRACT FROM AUTHOR]

Abstract Background In this study, we aimed to identify the risk factors in patients with rectal anastomotic re-leakage and develop a prediction model to predict the probability of rectal anastomotic re-leakage after stoma closure. Methods This study was a single-center retrospective analysis of patients with rectal cancer who underwent surgery between January 2010 and December 2020. Among 3225 patients who underwent Total or Partial Mesorectal Excision (TME/PME) surgery for rectal cancer, 129 who experienced anastomotic leakage following stoma closure were enrolled. Risk factors for rectal anastomotic re-leakage were analyzed, and a prediction model was established for rectal anastomotic re-leakage. Results Anastomotic re-leakage after stoma closure developed in 13.2% (17/129) of patients. Multivariable analysis revealed that neoadjuvant chemoradiotherapy (odds ratio, 4.07; 95% confidence interval, 1.17–14.21; p = 0.03), blood loss > 50 ml (odds ratio, 4.52; 95% confidence interval, 1.31–15.63; p = 0.02), and intersphincteric resection (intersphincteric resection vs. low anterior resection: odds ratio, 6.85; 95% confidence interval, 2.01–23.36; p = 0.002) were independent risk factors for anastomotic re-leakage. A nomogram was constructed to predict the probability of anastomotic re-leakage, with an area under the receiver operating characteristic curve of 0.828 in the cohort. Predictive results correlated with the actual results according to the calibration curve. Conclusions Neoadjuvant chemoradiotherapy, blood loss > 50 ml, and intersphincteric resection are independent risk factors for anastomotic re-leakage following stoma closure. The nomogram can help surgeons identify patients at a higher risk of rectal anastomotic re-leakage.

Background: Rectal cancer (RC) is a surgical challenge due to its technical complexity. The double-stapled (DS) technique, a standard for colorectal anastomosis, has been associated with notable drawbacks, including a high incidence of anastomotic leak (AL). Low anterior resection with transanal transection and single-stapled (TTSS) anastomosis has emerged to mitigate those drawbacks. Methods: Observational study in which it described the technical aspects and results of the initial group of patients with medium-low RC undergoing elective laparoscopic total mesorectal excision (TME) and TTSS. Results: Twenty-two patients were included in the series. Favourable postoperative outcomes with a median length of stay of 5 days and an AL incidence of 9.1%. Importantly, all patients achieved complete mesorectal excision with tumour-free margins, and no mortalities were reported. Conclusion: TTSS emerges as a promising alternative for patients with middle and lower rectal tumours, offering potential benefits in terms of morbidity reduction and oncological integrity compared with other techniques. [ABSTRACT FROM AUTHOR]

Purpose: To understand referral practices for rectal cancer surgical care and to secondarily determine differences in referral practices by two main hypothesized drivers of referral: the rurality of the community endoscopists' practice and their affiliation with a colorectal surgeon. Methods: Community gastroenterologists and general surgeons in Iowa completed a mailed questionnaire on practice demographics, volume, and referral practices for rectal cancer patients. Rurality was operationalized with RUCA codes. Results: Twenty-two of 53 gastroenterologists (42%) and 120 of 188 general surgeons (64%) (total 144/241, 60%) in Iowa responded. Most performed colonoscopies, including 22 gastroenterologists (100%) and 96 general surgeons (80%). Regular referral of rectal cancer patients to colorectal surgeons was reported for 57% of urban physicians affiliated with a colorectal surgeon, 33% of urban physicians not affiliated with a colorectal surgeon, and 57% and 72% of physicians in large and small rural areas, respectively, who were not affiliated with a colorectal surgeon. High surgeon volume, high hospital volume, and colorectal surgeon specialty were important factors in the referral decisions for over half the physicians. 69% of diagnosing urban general surgeons reported performing rectal cancer surgery about half the time or more, while 85% of small rural and 60% of large rural diagnosing general surgeons reported never or rarely performing rectal cancer surgery. Conclusions: Diagnosing physicians have variable rectal cancer referral practices, including consistency in referred to surgeon and prioritization of volume and specialization. Prioritizing specialized or high-volume rectal cancer surgical care would require changing existing referring patterns. [ABSTRACT FROM AUTHOR]

Abstract Aim The Coronavirus Disease 2019 (COVID‐19) pandemic affected the allocation of various medical resources to several areas, including intensive care units (ICUs). However, currently, its impact on the short‐term postoperative outcomes of gastrointestinal cancer surgeries remains unclear. We aimed to evaluate the impact of the pandemic on the incidence of complications occurring after low anterior resection in patients with rectal cancer in Japan. Methods Data from the Japanese National Clinical Database between 2018 and 2021 were retrospectively examined. The primary outcome of the study was the postoperative morbidity and mortality rates before and after COVID‐19 pandemic. Moreover, the postoperative ICU admission rate was assessed. Morbidity and mortality rates were also assessed using a standardized morbidity/mortality ratio (SMR, the ratio of the actual number of incidences to the expected number of incidences calculated by the risk calculator). Results This study included 74 181 patients, including 43 663 (58.9%) from COVID‐19 epidemic areas. The mean actual incidences of anastomotic leakage (AL) and pneumonia during the study period were 9.2% and 0.9%, respectively. The SMRs of these complications did not increase during the pandemic but those of AL declined gradually. The mean 30‐day mortality and operative mortality rates were 0.3% and 0.5%, respectively. Moreover, SMRs did not change significantly in the pandemic or regional epidemic status. The ICU admission rate temporarily decreased, especially in the epidemic areas. Conclusion Although the pandemic temporarily decreased the ICU admission rate, its impact on short‐term outcomes following low anterior resection in patients with rectal cancer was insignificant in Japan.

Simple Summary: This research is dedicated to exploring the enduring discussion about the optimal level of ligation of the inferior mesenteric artery (IMA) during rectal cancer surgery, with an emphasis on historical, technical, and patient-centered dimensions. The study seeks to elucidate the unresolved issues by critically evaluating factors, such as the anastomotic leakage risk, genitourinary function implications, and oncological outcomes. The aim is to offer a nuanced perspective that transcends conventional paradigms, guiding surgeons and researchers toward a more individualized approach, mainly based on patient anatomy and surgeon preference. Efforts made by this research can lead to the refinement of surgical techniques and a better understanding of the intricate considerations involved in rectal cancer surgery, which can contribute to the ongoing evolution of medical practices in this area. Within the intricate field of rectal cancer surgery, the contentious debate over the optimal level of ligation of the inferior mesenteric artery (IMA) persists as an ongoing discussion, influencing surgical approaches and patient outcomes. This narrative review incorporates historical perspectives, technical considerations, and functional as well as oncological outcomes, addressing key questions related to anastomotic leakage risks, genitourinary function, and oncological concerns, providing a more critical understanding of the well-known inconclusive evidence. Beyond the dichotomy of high versus low tie, it navigates the complexities of colorectal cancer surgery with a fresh perspective, posing a transformative question: "Is low tie ligation truly reproducible?" Considering a multidimensional approach that enhances patient outcomes by integrating the surgeon, patient, technique, and technology, instead of a rigid and categorical statement, we argued that a balanced response to this challenging question may require compromise. [ABSTRACT FROM AUTHOR]

Aim: The Coronavirus Disease 2019 (COVID‐19) pandemic affected the allocation of various medical resources to several areas, including intensive care units (ICUs). However, currently, its impact on the short‐term postoperative outcomes of gastrointestinal cancer surgeries remains unclear. We aimed to evaluate the impact of the pandemic on the incidence of complications occurring after low anterior resection in patients with rectal cancer in Japan. Methods: Data from the Japanese National Clinical Database between 2018 and 2021 were retrospectively examined. The primary outcome of the study was the postoperative morbidity and mortality rates before and after COVID‐19 pandemic. Moreover, the postoperative ICU admission rate was assessed. Morbidity and mortality rates were also assessed using a standardized morbidity/mortality ratio (SMR, the ratio of the actual number of incidences to the expected number of incidences calculated by the risk calculator). Results: This study included 74 181 patients, including 43 663 (58.9%) from COVID‐19 epidemic areas. The mean actual incidences of anastomotic leakage (AL) and pneumonia during the study period were 9.2% and 0.9%, respectively. The SMRs of these complications did not increase during the pandemic but those of AL declined gradually. The mean 30‐day mortality and operative mortality rates were 0.3% and 0.5%, respectively. Moreover, SMRs did not change significantly in the pandemic or regional epidemic status. The ICU admission rate temporarily decreased, especially in the epidemic areas. Conclusion: Although the pandemic temporarily decreased the ICU admission rate, its impact on short‐term outcomes following low anterior resection in patients with rectal cancer was insignificant in Japan. [ABSTRACT FROM AUTHOR]

The narrow pelvis causes special challenges in surgery, and robotic-assisted surgery has been proven beneficial in these circumstances. While robotic surgery has some specific advantages in rectal cancer surgery, there is still limited evidence of the learning curve of the technique involved. The aim here was to study the transition from laparoscopic to robotic-assisted surgery among experienced laparoscopic surgeons. The data for this study were collected from a prospectively compiled register that includes patients operated on by the Da Vinci Xi robot in Tampere University Hospital. Each consecutive rectal cancer patient was included. The information on the surgical and oncological outcomes was analysed. The learning curve was assessed using cumulative sum (CUSUM) analysis. CUSUM already demonstrated an overall positively sloped curve at the beginning of the study, with neither the conversion rate nor morbidity reaching unacceptable thresholds. Conversions (4%) and postoperative complications (Clavien–Dindo III–IV 15%, no intraoperative complications) were rare. One patient died within one month and the death was not procedure-associated. While surgical and oncological outcomes were similar among all surgeons, the console times showed a decreasing trend and were shorter among those with more experience in laparoscopic rectal cancer surgery. Robotic-assisted rectal cancer surgery can be safely adapted by experienced laparoscopic colorectal surgeons. [ABSTRACT FROM AUTHOR]

Abstract Aim The best bowel preparation method for rectal surgery remains controversial. In this study we compared the efficacy and safety of mechanical bowel preparation (MBP) alone and MOABP (MBP combined with oral antibiotic bowel preparation [OABP]) for rectal cancer surgery. Methods In this retrospective study we analyzed data from the Japanese Diagnosis Procedure Combination (DPC) database on 37 291 patients who had undergone low anterior resection for rectal cancer from 2014 to 2017. Propensity score matching analysis was used to compare postoperative outcomes between MBP alone and MOABP. Results A total of 37 291 patients were divided into four groups: MBP alone: 77.7%, no bowel preparation (NBP): 16.9%, MOABP: 4.7%, and OABP alone: 0.7%. In propensity score matching analysis with 1756 pairs, anastomotic leakage (4.84% vs 7.86%, P

Abstract Background D3 lymph node dissection with left colic artery (LCA) preservation in rectal cancer surgery seems to have little effect on reducing postoperative anastomotic leakage. So we first propose D3 lymph node dissection with LCA and first sigmoid artery (SA) preservation. This novel procedure deserves further study. Methods Rectal cancer patients who underwent laparoscopic D3 lymph node dissection with LCA preservation or with LCA and first SA preservation between January 2017 and January 2020 were retrospectively assessed. The patients were categorized into two groups: the preservation of the LCA group and the preservation of the LCA and first SA group. A 1:1 propensity score-matched analysis was performed to decrease confounding. Results Propensity score matching yielded 56 patients in each group from the eligible patients. The rate of postoperative anastomotic leakage in the preservation of the LCA and first SA group was significantly lower than that in the LCA preservation group (7.1% vs. 0%, P=0.040). No significant differences were observed in operation time, length of hospital stay, estimated blood loss, length of distal margin, lymph node retrieval, apical lymph node retrieval, and complications. A survival analysis showed patients’ 3-year disease-free survival (DFS) rates of group 1 and group 2 were 81.8% and 83.5% (P=0.595), respectively. Conclusion D3 lymph node dissection with LCA and first SA preservation for rectal cancer may help reduce the incidence of anastomotic leakage without compromising oncological outcomes compare with D3 lymph node dissection with LCA preservation alone.

Aim: The best bowel preparation method for rectal surgery remains controversial. In this study we compared the efficacy and safety of mechanical bowel preparation (MBP) alone and MOABP (MBP combined with oral antibiotic bowel preparation [OABP]) for rectal cancer surgery. Methods: In this retrospective study we analyzed data from the Japanese Diagnosis Procedure Combination (DPC) database on 37 291 patients who had undergone low anterior resection for rectal cancer from 2014 to 2017. Propensity score matching analysis was used to compare postoperative outcomes between MBP alone and MOABP. Results: A total of 37 291 patients were divided into four groups: MBP alone: 77.7%, no bowel preparation (NBP): 16.9%, MOABP: 4.7%, and OABP alone: 0.7%. In propensity score matching analysis with 1756 pairs, anastomotic leakage (4.84% vs 7.86%, P < 0.001), small bowel obstruction (1.54% vs 3.08%, P = 0.002) and reoperation (3.76% vs 5.98%, P = 0.002) were less in the MOABP group than in the MBP group. The mean duration of postoperative antibiotics medication was shorter in the MOABP group (5.2 d vs 7.5 d, P < 0.001) than in the MBP group. There was no significant difference between the two groups in the incidence of Clostridium difficile (CD) colitis (0.40% vs 0.68%, P = 0.250) and methicillin‐resistant Staphylococcus aureus (MRSA) colitis (0.11% vs 0.17%, P = 0.654). There was no significant difference in in‐hospital mortality between the two groups (0.00% vs 0.11% respectively, P = 0.157). Conclusion: MOABP for rectal surgery is associated with a decreased incidence of postoperative complications without increasing the incidence of CD colitis and MRSA colitis. [ABSTRACT FROM AUTHOR]

Background: D3 lymph node dissection with left colic artery (LCA) preservation in rectal cancer surgery seems to have little effect on reducing postoperative anastomotic leakage. So we first propose D3 lymph node dissection with LCA and first sigmoid artery (SA) preservation. This novel procedure deserves further study. Methods: Rectal cancer patients who underwent laparoscopic D3 lymph node dissection with LCA preservation or with LCA and first SA preservation between January 2017 and January 2020 were retrospectively assessed. The patients were categorized into two groups: the preservation of the LCA group and the preservation of the LCA and first SA group. A 1:1 propensity score-matched analysis was performed to decrease confounding. Results: Propensity score matching yielded 56 patients in each group from the eligible patients. The rate of postoperative anastomotic leakage in the preservation of the LCA and first SA group was significantly lower than that in the LCA preservation group (7.1% vs. 0%, P=0.040). No significant differences were observed in operation time, length of hospital stay, estimated blood loss, length of distal margin, lymph node retrieval, apical lymph node retrieval, and complications. A survival analysis showed patients' 3-year disease-free survival (DFS) rates of group 1 and group 2 were 81.8% and 83.5% (P=0.595), respectively. Conclusion: D3 lymph node dissection with LCA and first SA preservation for rectal cancer may help reduce the incidence of anastomotic leakage without compromising oncological outcomes compare with D3 lymph node dissection with LCA preservation alone. [ABSTRACT FROM AUTHOR]

Background: Several pivotal studies and international guidelines on the perioperative management of rectal cancer have been published. However, little is known about the current state of perioperative management of rectal cancer patients in clinical practice worldwide. Methods: An online survey including 13 questions focusing on key topics related to the perioperative management of patients with rectal cancer was conducted among colorectal surgeons registered within the database of the Research Institute Against Digestive Cancer (IRCAD). Results: A total of 535 respondents from 89 countries participated in the survey. Most surgeons worked in the European region (40.9%). Two hundred and fifty-four respondents (47.5%) performed less than 25% of surgical procedures laparoscopically. The most commonly used definition of the upper limit of the rectum was a fixed distance from the anal verge (23.4%). Magnetic resonance imaging was used to define the upper limit of the rectum by 258 respondents (48.2%). During total mesorectal excision (TME), 301 respondents (56.3%) used a high-tie technique. The most commonly constructed anastomosis was an end-to-end anastomosis (68.2%) with the majority of surgeons performing a leak test intraoperatively (88.9%). A total of 355 respondents (66.4%) constructed a diverting ostomy, and the majority of these surgeons constructed an enterostomy (82%). A total of 208 respondents (39.3%) closed a stoma within 8 weeks. Lastly, 135 respondents (25.2%) introduced a solid diet on postoperative day 1. Conclusion: There is considerable heterogeneity in the perioperative management of rectal cancer patients worldwide with several discrepancies between current international practice and recommendations from international guidelines. To achieve worldwide standardization in rectal cancer care, further research is needed to elucidate the cause of this heterogeneity and find ways of improved implementation of best practice recommendations. [ABSTRACT FROM AUTHOR]

Keywords: "Hands" teaching methods; Inferior mesenteric artery; Rectal cancer surgery; Medical education EN "Hands" teaching methods Inferior mesenteric artery Rectal cancer surgery Medical education 251 255 5 02/07/23 20230301 NES 230301 The anatomy of the inferior mesenteric artery (IMA) is very important in rectal cancer surgery, especially for a D3 lymph node dissection with low tie of the IMA, which has become very popular recently [[1]]. IMA inferior mesenteric artery, LCA left colic artery, SA sigmoid artery, SRA superior rectal artery Graph: Fig. [Extracted from the article]

The oncological outcomes of low ligation (LL) compared to high ligation (HL) of the inferior mesenteric artery (IMA) during low-anterior rectal resection (LAR) with total mesorectal excision are still debated. The aim of this study is to report the 5 year oncologic outcomes of patients undergoing laparoscopic LAR with either HL vs. LL of the IMA Between June 2014 and December 2016, patients who underwent elective laparoscopic LAR + TME in 6 Italian non-academic hospitals were randomized to HL or LL of IMA after meeting the inclusion criteria (HighLow trial; ClinicalTrials.gov Identifier NCT02153801). We analyzed the rate of local recurrence, distant metastasis, overall survival, disease-specific survival, and disease-free survival at 5 years of patients previously enrolled. Five-year follow up data were available for 196 patients. Recurrence happened in 42 (21.4%) of patients. There was no statistically significant difference in the distant recurrence rate (15.8% HL vs. 18.9% LL; P = 0.970) and pelvic recurrence rate (4,9% HL vs 3,2% LL; P = 0.843). No statistically significant difference was found in 5-year OS (p = 0.545), DSS (p = 0.732) or DFS (p = 0.985) between HL and LL. Low vs medium and upper rectum site of tumor, conversion rate, Clavien-Dindo post-operative grade ≥3 complications and tumor stage were found statistically significantly associated to poor oncological outcomes in univariate analysis; in multivariate analysis, however, only conversion rate and stage 3 cancer were found to be independent risk factors for poor DFS at 5 years. We confirmed the results found in the previous 3-year survival analysis, the level of inferior mesenteric artery ligation does not affect OS, DSS and DFS at 5-year follow-up. • Oncological outcomes do not differ according to the level of vascular ligation in rectal resection for cancer. • Cancer stage and conversion rate are associated with poor oncological outcomes in rectal cancer • Low IMA ligation does not affect survival in laparoscopic TME since the level of the vascular ligation is not one of the risk factors for local or distant disease recurrence [ABSTRACT FROM AUTHOR]

Purpose: This study aimed to investigate the effect of placement of double-lumen irrigation-suction tubes (DLIST) on the closure of anastomotic defect (AD) after rectal cancer surgery. Methods: The study was carried out at two centers managed by one surgeon, both adopted the same treatments. Patients with postoperative AD after rectal cancer surgery from January 2011 to June 2020 were eligible and were divided into a passive drainage (PD) group and a DLIST group according to whether the PD, placed in the rectal cancer surgery, had been replaced with the DLIST. The effect of DLIST on the AL was evaluated. Result: There distributed 76 patients in the DLIST group and 52 in the PD group. A higher closure rate was reported in the DLIST group (46 patients in DLIST group, for a closure rate of 60.5%, and 21 patients in PD group, for a closure rate of 40.4%. HR = 3.05; 95% CI: 1.79–5.19; P < 0.001). Both length of stay and costs of the treatment in the DLIST group were lower (54 days [interquartile range, IQR: 41–17] days vs. 112 days [IQR: 66–27] days, P = 0.005; and $18,721 [IQR: $14,982–4,960] vs. $40,840 [IQR: $20,932–50,529], P < 0.001). Conclusion: Placement of DLIST might serve as an effective method for treating AD following rectal cancer surgery. In comparison with PD, it costs lower to apply DLIST in the treatment of AD and the length of stay is shorter. [ABSTRACT FROM AUTHOR]

Within the intricate field of rectal cancer surgery, the contentious debate over the optimal level of ligation of the inferior mesenteric artery (IMA) persists as an ongoing discussion, influencing surgical approaches and patient outcomes. This narrative review incorporates historical perspectives, technical considerations, and functional as well as oncological outcomes, addressing key questions related to anastomotic leakage risks, genitourinary function, and oncological concerns, providing a more critical understanding of the well-known inconclusive evidence. Beyond the dichotomy of high versus low tie, it navigates the complexities of colorectal cancer surgery with a fresh perspective, posing a transformative question: “Is low tie ligation truly reproducible?” Considering a multidimensional approach that enhances patient outcomes by integrating the surgeon, patient, technique, and technology, instead of a rigid and categorical statement, we argued that a balanced response to this challenging question may require compromise.

In rectal cancer surgery the formation of a defunctioning stoma is common in order to reduce the consequences of an anastomotic leakage. The role of a defunctioning stoma and time to stoma reversal, in relation to major Low Anterior Resection Syndrome (LARS) in the long-term perspective, is still unclear. The aim of the study was to investigate the association between a defunctioning stoma and long-term bowel function. Patients who underwent curative rectal cancer surgery between 2007 and 2013 in Stockholm county, Sweden, who had no history of anastomotic leakage, without a remaining stoma, free of cancer and alive in April 2017 were eligible for the study. The exposures were (i) use of defunctioning stoma at cancer surgery and (ii) time to stoma reversal. Main outcome was major LARS with information retrieved from the LARS score questionnaire. Multivariable logistic regression model was used to calculate odds ratios (OR) primary comparing major LARS to no LARS. A total of 430 patients were included in analysis. The mean follow-up time was 6.7 years after surgery (range 3.4–10.7 years). The use of a defunctioning stoma was associated to major LARS with an adjusted OR of 2.43 (95% CI 1.14–5.20) when compared to no stoma. There were no evident associations between time to stoma reversal and the risk of major LARS. This study indicates that the presence of a defunctioning stoma is associated with impaired bowel function in the long-term perspective, while failing to show any clear association to time to stoma reversal. [ABSTRACT FROM AUTHOR]

This study aims to develop a robust preoperative prediction model for anastomotic leakage (AL) after surgical resection for rectal cancer, based on established risk factors and with the power of a large prospective nation-wide population-based study cohort. A development cohort was formed by using the DCRA (Dutch ColoRectal Audit), a mandatory population-based repository of all patients who undergo colorectal cancer resection in the Netherlands. Patients aged 18 years or older were included who underwent surgical resection for rectal cancer with primary anastomosis (with or without deviating ileostomy) between 2011 and 2019. Anastomotic leakage was defined as clinically relevant leakage requiring reintervention. Multivariable logistic regression was used to build a prediction model and cross-validation was used to validate the model. A total of 13.175 patients were included for analysis. AL was diagnosed in 1319 patients (10%). A deviating stoma was constructed in 6853 patients (52%). The following variables were identified as significant risk factors and included in the prediction model: gender, age, BMI, ASA classification, neo-adjuvant (chemo)radiotherapy, cT stage, distance of the tumor from anal verge, and deviating ileostomy. The model had a concordance-index of 0.664, which remained 0.658 after cross-validation. In addition, a nomogram was developed. The present study generated a discriminative prediction model based on preoperatively available variables. The proposed score can be used for patient counselling and risk-stratification before undergoing rectal resection for cancer. - This study aims to develop a robust preoperative prediction model for anastomotic leakage (AL) after surgical resection for rectal cancer, based on established risk factors and with the power of a large prospective nation-wide population-based study cohort. - A total of 13.175 patients were included for analysis. - The following variables were identified as significant risk factors and included in the prediction model: gender, age, BMI, ASA classification, deviating ileostomy, neo-adjuvant (chemo)radiotherapy, cT stage, and distance of the tumor from anal verge. - The model had a concordance-index of 0.664, which remained 0.658 after cross-validation. - The proposed score can be used for patient counselling and risk-stratification before undergoing rectal resection for cancer. [ABSTRACT FROM AUTHOR]

Stenosis is a serious complication associated with stomas. The initial treatment for stoma stenosis is mainly the finger-bougie technique or balloon dilatation, and recurrence requires stomal reconstruction. However, the use of local triamcinolone injections for treating stoma stenosis has not been reported. Herein, we reported a case of repeated stoma stenosis in a high-risk patient in whom balloon dilatation combined with local triamcinolone injection effectively avoided stomal reconstruction. A woman in her 70s was admitted to our hospital with the chief complaint of a positive fecal occult blood test and was diagnosed with Ra advanced rectal cancer. Owing to the presence of multiple comorbidities, a laparoscopic Hartmann procedure with D3 dissection was performed. The operative time was 165 min and the intraoperative blood loss was 5 mL. On postoperative day 2, the colostomy stump became discolored, and stoma necrosis was diagnosed, which was successfully treated conservatively, with no findings of stoma falling or peritonitis. Six months after surgery, late stoma stenosis causing colonic obstruction was diagnosed, and the finger-bougie technique and balloon dilatation were ineffective. To avoid reoperation under general anesthesia, balloon dilatation using a CRE™ PRO GI Wireguided (Boston Scientific) at 19 mm for 3 min combined with a 40 mg injection of local triamcinolone into the stoma orifice scar was successfully performed. No restenosis was observed after treatment. Balloon dilatation combined with local triamcinolone injections may be effective for recurrent stoma stenosis in patients with high-risk comorbidities after rectal cancer surgery. • Stenosis is a serious complication associated with stomas. • The recurrent stoma stenosis requires stomal reconstruction. • Balloon dilatation combined with local triamcinolone injections was effective for recurrent stoma stenosis. [ABSTRACT FROM AUTHOR]

Background: Anastomotic stricture (AS) is a common complication following rectal cancer surgery with anastomosis, but its diagnosis and management pose significant challenges due to the lack of standardized diagnostic criteria. We present a case highlighting the complexities encountered in diagnosing and managing occult AS post-rectal cancer surgery., Case Presentation: A 51-year-old male patient presented with symptoms suggestive of AS following robot-assisted laparoscopic low anterior resection for rectal adenocarcinoma. Despite conventional evaluations, including colonoscopy, digital rectal examination, and radiography, AS was not identified. Following prolonged and ineffective treatment for suspected conditions such as low anterior resection syndrome (LARS), the patient underwent anal dilatation, resulting in significant symptom improvement., Conclusions: This case underscores the challenges associated with diagnosing and managing occult AS following rectal cancer surgery. The absence of standardized diagnostic criteria and reliance on conventional modalities may lead to underdiagnosis and inadequate treatment. A comprehensive diagnostic approach considering intestinal diameter, elasticity, and symptoms related to difficult defecation may enhance diagnostic accuracy. Further research is needed to refine the diagnostic and therapeutic strategies for occult AS., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Cao, Zhang, Wu and Zhou.)

Background: Variations of the vasculature at splenic flexure by left colic artery (LCA) and middle colic artery (MCA) remain ambiguous. Objectives: This study aim to investigate the anatomical variations of the branches from LCA and MCA at splenic flexure area. Methods: Using ultra-thin CT images (0.5-mm thickness), we traced LCA and MCA till their merging site with paracolic marginal arteries through maximum intensity projection (MIP) reconstruction and computed tomography angiography (3D-CTA). Results: A total of 229 cases were retrospectively enrolled. LCA ascending branch approached upwards till the distal third of the transverse colon in 37.6%, reached the splenic flexure in 37.6%, and reached the lower descending colon in 23.1%, and absent in 1.7% of the cases. Areas supplied by MCA left branch and aMCA were 33.2%, 44.5% and 22.3% in the proximal, middle and distal third of transverse colon of the cases, respectively. The accessory MCA separately originated from the superior mesenteric artery was found in 17.9% of the cases. Mutual correlation was found that, when the LCA ascending branch supplied the distal transverse colon, MCA left branch tended to feed the proximal transverse colon; when the LCA ascending branch supplied the lower part of descending colon, MCA left branch was more likely to feed the distal third of transverse colon. Conclusions: Vasculature at splenic flexure by LCA and MCA varied at specific pattern. This study could add more anatomical details for vessel management in surgeries for left-sided colon cancer. [ABSTRACT FROM AUTHOR]

in the literature on rectal cancer (RC) surgery many studies have focused on the quality of total mesorectal excision (TME) dissection, while there is a scarcity of comparative data on transection and anastomosis. No anastomosis has so far proved to be superior to any other. The aim of this study was to compare anastomotic leak (AL) rates between conventional laparoscopic double-stapled (DS), transanal total mesorectal excision (TaTME) and Transanal Transection and Single-Stapled anastomosis (TTSS) techniques. consecutive mid-low RC patients undergoing elective laparoscopic TME with stapled anastomosis and protective stoma, by either DS, TaTME or TTSS techniques were retrieved from a prospectively collected database. 127 DS; 100 TaTME and 50 TTSS were included. Demographics, distance of the tumor from anal verge and neoadjuvant therapy were comparable. Operative time was longer in TaTME over DS and TTSS (p < 0.0001). More 90-days complications occurred in DS group vs TTSS (p = 0.029). The AL rate was 17.5% in DS, 6% in TaTME and 2% in TTSS group (p = 0.005). AL grade was: one B (2%) in TTSS; 2 grade B (2%) and 4 grade C (4%) in TaTME; 6 grade A (4.7%), 7 grade B (5.5%) and 9 grade C (7.1%) in DS group. Reintervention rate after AL was higher in DS group over TTSS (12.6% vs 2%; p = 0.003). The rate of stoma closure, pathology data and margin positivity did not differ. TTSS strategy is feasible, safe and leads to very low AL rates after TME for RC. [ABSTRACT FROM AUTHOR]

Aim: Laparoscopic rectal cancer surgery has several limitations. Transanal total mesorectal excision (TaTME) can potentially overcome these limitations. The aim of this study was to compare the rates of non‐radical surgery and anastomotic leakage after TaTME, open TME (OpTME), laparoscopic TME (LaTME) and robotic TME (RoTME) procedures in a nationwide cohort. Methods: We extracted the demographic, perioperative and pathological data of patients who underwent a curative OpTME, LaTME, RoTME or TaTME procedure between January 2014 and December 2018 from the national database of the Danish Colorectal Cancer Group (DCCG). We conducted multiple group‐comparisons, uni‐ and multivariate analyses to determine the factors associated with positive resection margin (+RM) and anastomotic leakage. Results: We included 2393 patients (OpTME = 205, LaTME = 1163, RoTME = 713 and TaTME = 312). The rate of +RM was 5.7% after TaTME. The lowest rate of +RM was achieved after RoTME (8.2%, 4.7%, 2.52%, and 5.7%, after OpTME, LaTME, RoTME and TaTME respectively, p < 0.001). In multivariate analysis, having a T4 tumour and intraoperative bowel perforation were associated with the risk of +RM (p < 0.001, p < 0.001, respectively). The factors associated with anastomotic leakage in multivariate analysis were male gender, high BMI and intraoperative bowel perforation (p < 0.001, p = 0.049, p = 0.002, respectively). TaTME was associated with the highest rate of sphincter‐saving procedures (79.8%, p < 0.001), the lowest rate of bowel perforation (2.9%, p = 0.028) and the lowest rate of conversion to open surgery (1.3%, p < 0.001). Conclusions: In a nationwide audit of TME approaches, the rate of +RM was lowest after RoTME. No differences were found between the four approaches regarding the risk of anastomotic leakage. TaTME offered advantages related to sphincter‐saving, perforation and conversion. [ABSTRACT FROM AUTHOR]

Abstract Background The influence of anastomotic leakage (AL) on local recurrence rates and survival in rectal cancer remains controversial. The aim of this study was to analyze the effect of asymptomatic anastomotic leakage (AAL) and symptomatic anastomotic leakage (SAL) on short- and long-term outcome after curative rectal cancer resection. Methods All patients who underwent surgical resection of non-metastatic rectal cancer with curative intent from January 2005 to December 2017 were retrospectively analyzed. Short-term morbidity, long-term functional and oncological outcomes were compared between patients with SAL, AAL and without AL (WAL). Results Overall, 200 patients were included and AL was observed in 39 (19.5%) patients (10 AAL and 29 SAL) with a median follow-up of 38.5 months. Rectal cancer location and preoperative neoadjuvant treatment was similar between the three groups. Postoperative 30-day mortality rate was nil. The permanent stoma rate was higher in patients with SAL or AAL compared to WAL patients (44.8 and 30% vs 9.3%, p

Abstract Background Across Ontario, since the year 2006 various knowledge translation (KT) interventions designed to improve the quality of rectal cancer surgery have been implemented by the provincial cancer agency or by individual researchers. Ontario is divided administratively into 14 health regions. We piloted a method to audit and score for each region of the province the KT interventions implemented to improve the quality of rectal cancer surgery. Methods We interviewed stakeholders to audit KT interventions used in respective regions over years 2006 to 2014. Results were summarized into narrative and visual forms. Using a modified Delphi approach, KT experts reviewed these data and then, for each region, scored implementation of KT interventions using a 20-item KT Signature Assessment Tool. Scores could range from 20 to 100 with higher scores commensurate with greater KT intervention implementation. Results There were thirty interviews. KT experts produced scores for each region that were bimodally distributed, with an average score for 2 regions of 78 (range 73–83) and for 12 regions of 30.5 (range 22–38). Conclusion Our methods efficiently identified two groups with similar KT Signature scores. Two regions had relatively high scores reflecting numerous KT interventions and the use of sustained iterative approaches in addition to those encouraged by the provincial cancer agency, while 12 regions had relatively low scores reflecting minimal activities outside of those encouraged by the provincial cancer agency. These groupings will be used for future comparative quantitative analyses to help determine if higher KT signature scores correlate with improved measures for quality of rectal cancer surgery.

Aim: This study aimed to investigate the use of defunctioning stomas after rectal cancer surgery in Australia and New Zealand, as current practice is unknown. Methods: From the Binational Colorectal Cancer Audit database, data on rectal cancer patients who underwent a resection between 2007 and 2019 with the formation of an anastomosis were extracted and analysed. The primary outcome was the rate of defunctioning stoma formation. Secondary outcomes were anastomotic leakage (AL) rates and other postoperative complications, length of hospital stay (LOS), readmissions and 30‐day mortality rates between stoma and no‐stoma groups. Propensity score matching was performed to correct for differences in baseline characteristics between stoma and no‐stoma groups. Results: In total, 2581 (89%) received a defunctioning stoma and 319 (11%) did not. There were more male patients in the stoma group (65.5% vs. 57.7% for the no‐stoma group; P = 0.006). The median age was 64 years in both groups. The stoma group underwent more ultra‐low anterior resections (79.9% vs. 30.1%; P < 0.0001), included more American Joint Committee on Cancer Stage III patients (53.7% vs. 29.2%; P < 0.0001) and received more neoadjuvant therapy (66.9% vs. 16.3%; P < 0.0001). The AL rate was similar in both groups (5.1% vs. 6.0%; P = 0.52). LOS was longer in the stoma group (8 vs. 6 days; P < 0.0001) with higher 30‐day readmission rates (14.9% vs. 8.3%; P = 0.003). After propensity score matching (n = 208 in both groups), AL rates remained similar (2.9% for stoma vs. 5.8% for no‐stoma group; P = 0.15), but stoma patients required less reoperations (0% vs. 8%; P = 0.016). The stoma group had higher postoperative ileus rates and an increased LOS. Conclusion: In Australia and New Zealand, most patients who underwent rectal cancer resections with the formation of an anastomosis received a defunctioning stoma. A defunctioning stoma does not prevent AL from occurring but is mostly associated with a lower reoperation rate. Patients with a defunctioning stoma experienced a higher postoperative ileus rate and had an increased LOS. [ABSTRACT FROM AUTHOR]

Controversial surgical anatomical landmarks in the deep pelvis can be visualized and identified using current technologies. Performing the gate approach technique during deep lateral dissection for total mesorectal excision facilitates visualization of the pelvic neurovascular structures following simple dissection steps to preserve the pelvic autonomic nerves and avoid accidental vascular injuries. Here, we discuss laparoscopic exposure of an infrequent disposition of the middle rectal artery anterior to the lateral ligament of the rectum while performing the gate approach. [ABSTRACT FROM AUTHOR]

Objective: To describe outcomes after transanal total mesorectal excision (TaTME) 5 years from implementation at a large-volume colorectal unit, including local recurrence, distant metastasis, and survival. Background: Transanal total mesorectal excision (TaTME) is a relatively new procedure for mid- and low-rectal cancer, with well-documented safety and feasibility. However, data on long-term results are limited. Methods: This study was based on a prospective data collection via a maintained database in a large colorectal unit. The database included patients who underwent TaTME from December 2013 through July 2019. We have updated the database through a review of patient charts, including radiology and pathology reports. Data collection included operative details, intraoperative findings, postoperative complications, pathologic results, and oncologic results. Results: During the study period, two hundred patients underwent TaTME in the study period (men = 147). The mean BMI was 26.7%, and the mean tumor height from the anal verge was 7.86 cm. Neoadjuvant treatment was given to 22% of patients. Anastomotic leakage occurred in 9.3% of patients, and the overall rate of postoperative complications was 24.5%. The TME specimen was incomplete in 11% of patients, and the CRM was positive in 5.5% of patients. Local recurrence (LR) occurred in seven patients with a follow-up of at least 2 years (4.7%). Distant metastasis (DM) occurred in 12% of patients. The overall survival was 90% and disease-free survival was 81%. The operating time was reduced in the later period of our experience. Conclusions: This study showed that TaTME is feasible, safe, and had acceptable short-term outcomes and an acceptable rate of LR. The study included, however, one group that was non-randomized, and the follow-up was not long enough for most patients. Studies with longer follow-up data are awaited. [ABSTRACT FROM AUTHOR]

• Transanal total mesorectum excision is feasible for mid and low rectal cancer. • Good quality of the mesorectum specimen is obtain after TaTME surgery. • TaTME with intersphincteric resection is a feasible option for selected cases of very low rectal cancer. • Surgical complication rates after intersphincteric TaTME with hand-sewn coloanal anastomosis could be higher. Describe and demonstrate the feasibility and safety of TaTME in short term outcomes in the Instituto Nacional de Enfermedades Neoplásicas (INEN) in Peru. Case series with retrospective and prospective data collection of patients with middle and inferior rectal cancer who underwent TaTME between January 2015 and March 2020. Patients and tumor characteristics, operative details, postoperative complications and pathological results were analyzed. Nineteen patients were included. The median age was 56 years old (range 40–69). Ten were female. The median distance from the anal verge was 4 cm (range 3–6) and 17 cases were located in the inferior rectum. Eleven patients with clinical stage III. Thirteen (68.4%) patients received neoadjuvant treatment. There was no conversion to open surgery reported. Ten (52.6%) cases had intersphincteric resection and 18 (94.7%) had primary coloanal anastomosis, 13 (72.2%) of them with hand-sewn. All patients had a diversion with ileostomy. The median operative time was 330 min (range 270–480). Median postoperative hospital stay of 5 days (range 3–18). The overall rate of postoperative complication was 21.1%, two cases (10.5%) had anastomotic leakage and mortality was present in one (5.3%) patient. 94.5% had an optimal TME specimen, only one case (5.3%) had positive circumferential resection margin and positive distal margin. The median tumor size in the specimen was 4 cm (range 2–11) and nine (47.4%) patients had ypT3 on pathology. TaTME is a safe and feasible technique with good pathological results. [ABSTRACT FROM AUTHOR]

Background: Extralevator abdominoperineal excision (ELAPE), abdominoperineal excision (APE) or pelvic exenteration (PE) with or without sacral resection (SR) for locally advanced rectal cancer leaves a significant defect in the pelvic floor. At first, this defect was closed primarily. To prevent perineal hernias, the use of a biological mesh to restore the pelvic floor has been increasing. The aim of this study, was to evaluate the outcome of the use of a biological mesh after ELAPE, APE or PE with/without SR. Methods: A retrospective study was conducted on patients who had ELAPE, APE or PE with/without SR with a biological mesh (Permacol™) for pelvic reconstruction in rectal cancer in our center between January 2012 and April 2015. The endpoints were the incidence of perineal herniation and wound healing complications. Results: Data of 35 consecutive patients [22 men, 13 women; mean age 62 years (range 31–77 years)] were reviewed. Median follow-up was 24 months (range 0.4–64 months). Perineal hernia was reported in 3 patients (8.6%), and was asymptomatic in 2 of them. The perineal wound healed within 3 months in 37.1% (n = 13), within 6 months in 51.4% (n = 18) and within 1 year in 62.9% (n = 22). In 17.1% (n = 6), the wound healed after 1 year. It was not possible to confirm perineal wound healing in the remaining 7 patients (20.0%) due to death or loss to follow-up. Wound dehiscence was reported in 18 patients (51.4%), 9 of whom needed vacuum-assisted closure therapy, surgical closure or a flap reconstruction. Conclusions: Closure of the perineal wound after (EL)APE with a biological mesh is associated with a low incidence of perineal hernia. Wound healing complications in this high-risk group of patients are comparable to those reported in the literature. [ABSTRACT FROM AUTHOR]