Clinicopathological Outcomes in Patients With Locally Advanced Rectal Cancer Undergoing Preoperative Short-Versus Long-course Chemoradiotherapy With Delayed Surgery.

BACKGROUND/AIM: We aimed to compare the clinicopathological outcomes in patients with locally advanced rectal cancer after short- or long-course concurrent chemoradiotherapy (CCRT) followed by delayed surgery. PATIENTS AND METHODS: The records of 94 patients with cT3-4N0-2M0 rectal cancer who received CCRT between 2010 and 2017 were reviewed. Short-course radiotherapy (RT) was delivered with a median total dose of 25 Gy in five fractions (n=27), and long-course RT was delivered with a median total dose of 50.4 Gy in 28 fractions (n=67). The following concurrent chemotherapy regimens were administered: 5-fluorouracil plus leucovorin in 58 and capecitabine in 24; in 12 cases agents were unknown. The median interval between CCRT and surgery was 8 weeks. Adjuvant chemotherapy was administered after surgery in 80 patients (5-fluorouracil plus leucovorin, n=54; capecitabine, n=9; other, n=14; and unknown, n=3). Propensity-score matching analysis was conducted. RESULTS: The median follow-up duration was 4.3 years. There were no statistically significant differences between the short- and long-course RT groups in sphincter preservation (85.2% vs. 92.5%, p=0.478), pathological complete remission (18.5% vs. 14.9%, p=0.905), downstaging (44.4% vs. 26.9%, p=0.159), and negative circumferential resection margin (92.6% vs. 89.6%, p=0.947) rates. No differences were found in survival outcomes between the short- and long-course groups at 3 years (overall survival: 91.8% vs. 88.1%, p=0.790; disease-free survival, 75.2% vs. 72.5%, p=0.420; locoregional relapse-free survival, 90.5% vs. 98.4%, p=0.180; and distant metastasis-free survival, 79.6% vs. 73.5%, p=0.490). Similar results were observed after PSM. CONCLUSION: Clinically, short-course CCRT may be a feasible alternative to long-course CCRT in patients with locally advanced rectal cancer.

The importance of compression time in stapled hemorrhoidopexy: is patience a virtue?

Purpose: The aim of this study was to evaluate whether longer compression time before firing the stapler reduced the postoperative complications related to staple line formation in stapled hemorrhoidopexy. Methods: This retrospective case-control study was conducted at a colorectal-anal specialty hospital. Consecutive patients with grade III and IV hemorrhoids who underwent stapled hemorrhoidopexy between January 2016 and November 2019 were included. According to the compression time, patients were assigned to the long compression time group (2 minutes) or the typical compression time group (30 seconds). The primary outcome measure was incidence of staple line complications such as dehiscence, bleeding, and stenosis. Results: A total of 348 patients treated with stapled hemorrhoidopexy were evaluated. Seventy-three and 275 patients were included in the long compression time group and the typical compression time group, respectively. No significant differences were observed in patient characteristics between the groups. However, additional procedures were performed more frequently in the typical compression time group (78.1% vs. 92.0%, P=0.001). Bleeding occurred more frequently in the typical compression time group (1.4% vs. 8.4%, P=0.030). The rates of dehiscence and stenosis were not significantly different between the groups. Fecal urgency developed more frequently in the typical compression time group (0% vs. 5.1%, P=0.040). In logistic regression analysis, typical compression time (30 seconds) was the only risk factor for bleeding (odds ratio, 8.496; P=0.040). Conclusion: Longer compression time was associated with a decreased incidence of postoperative bleeding after stapled hemorrhoidopexy.

Standardized Method of the Thiersch Operation for the Treatment of Fecal Incontinence.

BACKGROUND: Conventionally, the Thiersch operation has typically involved blind positioning of the sling, and sling tension is subjectively based on a rule-of-thumb estimate. The aim of this study was to describe standardized methods for performing the Thiersch operation. METHODS: Seventeen patients with fecal incontinence underwent the calibrated method of the Thiersch procedure. As an encircling sling, a 6-mm-wide silastic tube was used. Through 4 minimal perianal skin incisions, the sling was placed proximal to the anal skin 3 cm from the anal verge and 4 cm in depth. The circumference of the sling was 10 cm in length. Results were assessed by clinical responses and by comparing pre- and postoperative Wexner scores. The data were collected retrospectively. RESULTS: The median follow-up period was 9 months (range 6-19). In 16 out of 17 fecal incontinence patients (94.1%), the median Wexner incontinence score was 0 (range 0-3) postoperatively. Localized sepsis developed in three cases (17.7%, 3/17), which were controlled with drainage and antibiotics. Fecal impaction occurred in one case (5.9%, 1/17). There was no removal or breakage of the inserted sling. CONCLUSIONS: The elasticity of the silastic tube reduced the incidence of sling breakage. According to the standardized method, the sling was placed external to the external anal sphincter muscle and at the junction of the external anal sphincter muscle and puborectalis muscle. Fecal incontinence was controlled effectively, and the incidence of fecal impaction was negligible. High reproducibility was observed with this method.

High ligation of the anal fistula tract by lateral approach: A prospective cohort study on a modification of the ligation of the intersphincteric fistula tract (LIFT) technique.

BACKGROUND: Ligation of the intersphincteric fistula tract (LIFT) is a sphincter-preserving operation for anal fistulas. Although it has advantages in preserving continence after surgery, it is difficult to perform owing to the narrow field of view. We performed a modified surgical procedure based on the LIFT to overcome these drawbacks. MATERIALS AND METHODS: Twenty-eight patients who were scheduled to undergo high ligation of the anal fistula tract by the lateral approach for the treatment of transsphincteric anal fistulas were prospectively studied. Instead of making a new stab incision on the intersphincteric groove, we dissected along the fistula tract from the external opening until the intersphincteric space appeared. The fistula tract was then ligated close to the internal anal sphincter with absorbable sutures, and the distal part of the ligation was cut off. A cored-out wound was left open for drainage. RESULTS: The median follow-up was 16 months (range, 8-27 months). Of the 28 patients, 19 (68%) had simple transsphincteric fistulas and 9 (32%) had complex transsphincteric fistulas. Successful fistula closure was achieved in 21 patients (75%), with a median healing time of 4 weeks (range, 3-7 weeks). None of the patients complained of any incontinence symptoms after the procedure. Of the seven patients (25%) who failed to heal successfully, two (7%) did not heal up to 2 months after surgery and five (18%) experienced recurrence after complete healing. CONCLUSION: High ligation of the anal fistula tract by lateral approach may be a useful sphincter-sparing procedure for transsphincteric anal fistulas.

Early Removal of the Urinary Catheter After Total or Tumor-Specific Mesorectal Excision for Rectal Cancer Is Safe.

BACKGROUND: Total or tumor-specific mesorectal excision can preserve pelvic autonomic nerves during rectal cancer surgery and minimize urinary dysfunction. However, urinary catheterization several days in duration is a common practice after total or tumor-specific mesorectal excision. OBJECTIVE: This study aimed to evaluate the optimal duration of urinary catheterization after total or tumor-specific mesorectal excision for rectal cancer. DESIGN: This is a retrospective review of patients who underwent total or tumor-specific mesorectal excision for rectal cancer. SETTINGS: This study was performed in the colorectal division of a university-affiliated hospital. PATIENTS: Between March 2009 and February 2013, 236 patients fulfilled the inclusion criteria. Patients who underwent combined pelvic surgery and those who had postoperative complications with a Dindo grade III or more and a known urinary disease were excluded; the remaining 189 patients were evaluated. MAIN OUTCOME MEASURES: The primary outcome measure of this study was the incidence of postoperative urinary retention. RESULTS: The incidence of acute urinary retention was 4.8%. Urinary retention was not associated with the postoperative urinary catheterization duration (p = 0.99). Patients were assigned to 2 groups according to urinary catheterization duration (1 vs ≥ 2 days). No significant differences were observed between the 2 groups regarding urinary retention (4.8% for 1 day vs 4.7% for ≥ 2 days; p = 1.0). In a logistic regression analysis, age, sex, ASA classification, surgical procedure, surgical approach, stage, distance from the anal verge, rate of preoperative radiotherapy, duration of urinary catheterization, and time period of surgery were not associated with urinary retention. LIMITATIONS: This was a retrospective, single-center study. There is potential for selection bias. CONCLUSIONS: Our study showed that the urinary catheter could be safely removed on the first postoperative day after total or tumor-specific mesorectal excision.

Transanal gauze packing to manage massive presacral bleeding secondary to prescral abscess caused by rectal anastomotic leakage: a novel approach.

Anastomotic leakage following rectal resection is a serious and fearful complication, and may cause presacral abscess and/or peritonitis. To our knowledge, massive hematochezia secondary to presacral abscess caused by anastomotic leakage has not yet been reported in the literature. We observed this rare and life-threatening complication in three patients who were successfully treated with a simple but effective transanal gauze packing technique.

Impact of laparoscopic experience on virtual robotic simulator dexterity.

BACKGROUND: Different skills are required for robotic surgery and laparoscopic surgery. We hypothesized that the laparoscopic experience would not affect the performance with the da Vinci(®) system. A virtual robotic simulator was used to estimate the operator's robotic dexterity. MATERIALS AND METHODS: The performance of 11 surgical fellows with laparoscopic experience and 14 medical students were compared using the dV-trainer(®). Each subject completed three virtual endo-wrist modules ("Pick and Place," "Peg Board," and "Match Board"). Performance was recorded using a built-in scoring algorithm. RESULTS: In the Peg Board module, the performance of surgical fellows was better in terms of the number of instrument collisions and number of drops (P < 0.05). However, no significant differences were found in the percentage scores of the three endo-wrist modules between the groups. CONCLUSION: Robotic dexterity was not significantly affected by laparoscopic experience in this study. Laparoscopic experience is not an important factor for learning robotic skills.

Robotic versus laparoscopic intersphincteric resection for low rectal cancer: comparison of the operative, oncological, and functional outcomes.

BACKGROUND: Robotic surgery was developed to overcome the limitations of laparoscopic surgery and is increasingly used to treat low rectal cancer. In this study, we compared the operative, oncological, and functional outcomes of low rectal cancer patients who underwent robotic or laparoscopic intersphincteric resection (ISR). METHODS: Prospectively collected data from low rectal cancer patients who underwent laparoscopic or robotic ISR between September 2006 and August 2011 were retrospectively compared. The functional outcomes of patients followed up for ≥ 12 months after ileostomy closure were evaluated via questionnaire. RESULTS: Forty-four and 26 patients underwent robotic and laparoscopic ISR, respectively. The robotic group patients had a higher body mass index (BMI; 21.42 ± 3.13 vs. 24.13 ± 3.33 kg/m(2); p = 0.001), more advanced clinical N stage (p = 0.029), lower cancer location (3.71 ± 0.89 vs. 3.24 ± 0.78 cm; p = 0.023), more frequent chemoradiotherapy (26.9 vs. 54.5 %; p = 0.025), and longer operation time (286.77 ± 51.46 vs. 316.43 ± 65.11 min; p = 0.038). However, no intergroup differences were observed in the pathological details (except the number of retrieved lymph nodes), postoperative morbidity, 3-year overall survival, recurrence-free survival (RFS), local RFS, and functional outcomes. CONCLUSIONS: Robotic and laparoscopic ISR yielded similar operative, oncological, and functional outcomes in patients with low rectal cancer, despite differences in unfavorable outcome-affecting factors, including BMI, clinical N stage, cancer location, and chemoradiotherapy frequency. A randomized trial will provide more solid methodology for investigating the potential benefits of robotic ISR.

Robotic-assisted surgery for rectal adenocarcinoma: short-term and midterm outcomes from 200 consecutive cases at a single institution.

BACKGROUND: Although robotic surgery is increasingly used in the management of rectal cancer, its oncologic safety remains uncertain. OBJECTIVE: We aimed to evaluate the feasibility and safety of robotic-assisted rectal cancer resection in terms of short-term and midterm outcomes. DESIGN: A prospectively collected set of samples was retrospectively evaluated. SETTINGS: Data included in this study were collected at a single institution from 2007 to 2011. PATIENTS: The study included 200 consecutive rectal cancer patients. INTERVENTION: The patients underwent robotic-assisted resection surgery performed by a single surgeon. MAIN OUTCOME MEASURES: The short-term (surgical outcome and pathologic data) and midterm outcomes (local pelvic control and overall and disease-free survival) were evaluated and compared with those in the published literature. RESULTS: The median patient age was 60 years, and the male:female ratio was 2:1. The median distance of rectal tumors from the anal verge was 6 cm. Preoperative radiotherapy was performed in 55 patients. The median operation time was 270 minutes, and the median blood loss was 190 mL. Grade 3 to 5 complications, according to the Clavien-Dindo classification, were observed in 15 patients (7.5%). The circumferential resection margin was positive in 5 patients (2.5%). During the median follow-up period of 29.8 months, recurrence occurred in 27 patients (distant metastasis, 18 patients; local recurrence, 7 patients; and both local recurrence and distant metastases, 2 patients). The local pelvic control and overall and disease-free survival rates of stage III patients at 5 years were 93.0%, 88.6%, and 76.6%. LIMITATIONS: This was a retrospective, uncontrolled study of selected patients by a single surgeon. CONCLUSIONS: Our results demonstrated an acceptable morbidity and a low rate of positive circumferential resection margin with effective local control. We also achieved excellent survival data. The midterm oncologic safety justifies the practice of robotic rectal cancer resection to further investigate its role on long-term outcomes.

The multiphasic learning curve for robot-assisted rectal surgery.

BACKGROUND: Robotic rectal surgery is gaining in popularity. We aimed to define the learning curve of an experienced laparoscopic colorectal surgeon in performing robot-assisted rectal surgery. We hypothesized that there are multiple phases in this learning process. METHODS: We performed a retrospective analysis. Consecutive patients who underwent robot-assisted rectal surgery between July 2007 and August 2011 were identified. Operating times were analyzed using the CUSUM (cumulative sum) technique. CUSUMs were model fitted as a fourth-order polynomial. χ(2), Fisher's exact, two independent samples t test, one-way ANOVA, Kruskal-Wallis, and Mann-Whitney tests were used. A p value of <0.05 was considered statistically significant. RESULTS: We identified 197 patients. The median (range) total operative, robot, console, and docking times (min) were 265 (145-515), 140 (59-367), 135 (50-360), and 5 (3-40), respectively. CUSUM analysis of docking time showed a learning curve of 35 cases. CUSUM analysis of total operative, robot, and console times demonstrated three phases. The first phase (35 patients) represented the initial learning curve. The second phase (93 patients) involved more challenging cases with increased operative time. The third phase (69 patients) represented the concluding phase in the learning curve. There was increased complexity of cases in the latter two phases. Of phase 1 patients, 45.7% had tumors ≤7 cm from the anal verge compared to 64.2% in phases 2 and 3 (p = 0.042). Of phase 1 patients, 2.9% had neoadjuvant chemoradiotherapy compared to 32.7% of patients in phases 2 and 3 (p < 0.001). Splenic flexure was mobilized in 8.6% of phase 1 patients compared to 56.8% of patients in phases 2 and 3 (p < 0.001). Median blood loss was <50 ml in all three phases. The patients in phases 2 and 3 had a longer hospital stay compared to those in phase 1 (9 vs. 8 days, p = 0.002). There were no conversions. CONCLUSION: At least three phases in the learning curve for robot-assisted rectal surgery are defined in our study.