Development and internal validation of a clinical prediction model for serious complications after emergency laparotomy.

PURPOSE: Emergency laparotomy (EL) is a common operation with high risk for postoperative complications, thereby requiring accurate risk stratification to manage vulnerable patients optimally. We developed and internally validated a predictive model of serious complications after EL. METHODS: Data for eleven carefully selected candidate predictors of 30-day postoperative complications (Clavien-Dindo grade > = 3) were extracted from the HELAS cohort of EL patients in 11 centres in Greece and Cyprus. Logistic regression with Least Absolute Shrinkage and Selection Operator (LASSO) was applied for model development. Discrimination and calibration measures were estimated and clinical utility was explored with decision curve analysis (DCA). Reproducibility and heterogeneity were examined with Bootstrap-based internal validation and Internal-External Cross-Validation. The American College of Surgeons National Surgical Quality Improvement Program's (ACS-NSQIP) model was applied to the same cohort to establish a benchmark for the new model. RESULTS: From data on 633 eligible patients (175 complication events), the SErious complications After Laparotomy (SEAL) model was developed with 6 predictors (preoperative albumin, blood urea nitrogen, American Society of Anaesthesiology score, sepsis or septic shock, dependent functional status, and ascites). SEAL had good discriminative ability (optimism-corrected c-statistic: 0.80, 95% confidence interval [CI] 0.79-0.81), calibration (optimism-corrected calibration slope: 1.01, 95% CI 0.99-1.03) and overall fit (scaled Brier score: 25.1%, 95% CI 24.1-26.1%). SEAL compared favourably with ACS-NSQIP in all metrics, including DCA across multiple risk thresholds. CONCLUSION: SEAL is a simple and promising model for individualized risk predictions of serious complications after EL. Future external validations should appraise SEAL's transportability across diverse settings.

Effect of the COVID-19 pandemic on surgery for indeterminate thyroid nodules (THYCOVID): a retrospective, international, multicentre, cross-sectional study.

BACKGROUND: Since its outbreak in early 2020, the COVID-19 pandemic has diverted resources from non-urgent and elective procedures, leading to diagnosis and treatment delays, with an increased number of neoplasms at advanced stages worldwide. The aims of this study were to quantify the reduction in surgical activity for indeterminate thyroid nodules during the COVID-19 pandemic; and to evaluate whether delays in surgery led to an increased occurrence of aggressive tumours. METHODS: In this retrospective, international, cross-sectional study, centres were invited to participate in June 22, 2022; each centre joining the study was asked to provide data from medical records on all surgical thyroidectomies consecutively performed from Jan 1, 2019, to Dec 31, 2021. Patients with indeterminate thyroid nodules were divided into three groups according to when they underwent surgery: from Jan 1, 2019, to Feb 29, 2020 (global prepandemic phase), from March 1, 2020, to May 31, 2021 (pandemic escalation phase), and from June 1 to Dec 31, 2021 (pandemic decrease phase). The main outcomes were, for each phase, the number of surgeries for indeterminate thyroid nodules, and in patients with a postoperative diagnosis of thyroid cancers, the occurrence of tumours larger than 10 mm, extrathyroidal extension, lymph node metastases, vascular invasion, distant metastases, and tumours at high risk of structural disease recurrence. Univariate analysis was used to compare the probability of aggressive thyroid features between the first and third study phases. The study was registered on ClinicalTrials.gov, NCT05178186. FINDINGS: Data from 157 centres (n=49 countries) on 87 467 patients who underwent surgery for benign and malignant thyroid disease were collected, of whom 22 974 patients (18 052 [78·6%] female patients and 4922 [21·4%] male patients) received surgery for indeterminate thyroid nodules. We observed a significant reduction in surgery for indeterminate thyroid nodules during the pandemic escalation phase (median monthly surgeries per centre, 1·4 [IQR 0·6-3·4]) compared with the prepandemic phase (2·0 [0·9-3·7]; p<0·0001) and pandemic decrease phase (2·3 [1·0-5·0]; p<0·0001). Compared with the prepandemic phase, in the pandemic decrease phase we observed an increased occurrence of thyroid tumours larger than 10 mm (2554 [69·0%] of 3704 vs 1515 [71·5%] of 2119; OR 1·1 [95% CI 1·0-1·3]; p=0·042), lymph node metastases (343 [9·3%] vs 264 [12·5%]; OR 1·4 [1·2-1·7]; p=0·0001), and tumours at high risk of structural disease recurrence (203 [5·7%] of 3584 vs 155 [7·7%] of 2006; OR 1·4 [1·1-1·7]; p=0·0039). INTERPRETATION: Our study suggests that the reduction in surgical activity for indeterminate thyroid nodules during the COVID-19 pandemic period could have led to an increased occurrence of aggressive thyroid tumours. However, other compelling hypotheses, including increased selection of patients with aggressive malignancies during this period, should be considered. We suggest that surgery for indeterminate thyroid nodules should no longer be postponed even in future instances of pandemic escalation. FUNDING: None.

Does the Routine Skin-Only Closure in Ruptured Abdominal Aortic Aneurysm Repair Safely Diminish Abdominal Compartment Syndrome? A Hypothesis Generating Retrospective Study.

BACKGROUND: Abdominal compartment syndrome (ACS) often complicates ruptured abdominal aortic aneurysm (rAAA) repair. We report results with routine skin-only abdominal wound closure after rAAA surgical repair. METHODS: This was a single-center retrospective study including consecutive patients undergoing rAAA surgical repair for the duration of 7 years. Skin-only closure was routinely performed, and if possible, secondary abdominal closure was performed during the same admission. Demographic information, preoperative hemodynamic condition, and perioperative information (ACS, mortality, rate of abdominal closure, and postoperative outcomes) were collected. RESULTS: During the study period, 93 rAAAs were recorded. Ten patients were too frail to undergo repair or refused treatment. Eighty-three patients underwent immediate surgical repair. The mean age was 72.4 ± 10.5 years, and the vast majority were male (82:1). Preoperative systolic blood pressure <90 mm Hg was recorded in 31 patients. Intraoperative mortality was recorded in nine cases. Overall in-hospital mortality was 34.9% (29/83). Primary fascial closure was performed in five patients, while skin-only closure was performed in 69. ACS was recorded in two cases in whom skin sutures were removed and negative pressure wound treatment was applied. Secondary fascial closure was feasible in 30 patients during the same admission. Among 37 patients not undergoing fascial closure, 18 died and 19 survived and were discharged with a planned ventral hernia repair. Median length of intensive care unit and hospital stay were 5 (1-24) and 13 (8-35) days, respectively. After a mean follow-up of 21 months, telephone contact was possible with 14/19 patients who left the hospital with an abdominal hernia. Three reported hernia-related complications mandating surgical repair, while in 11, this was well tolerated. CONCLUSION: Routine skin-only closure during rAAA surgical repair results in low rates of ACS at the expense of a high rate of patients being discharged with a planned ventral hernia which, however, seems to be well tolerated by the majority of patients.

Prospective multicenter external validation of postoperative mortality prediction tools in patients undergoing emergency laparotomy.

BACKGROUND: Accurate preoperative risk assessment in emergency laparotomy (EL) is valuable for informed decision making and rational use of resources. Available risk prediction tools have not been validated adequately across diverse health care settings. Herein, we report a comparative external validation of four widely cited prognostic models. METHODS: A multicenter cohort was prospectively composed of consecutive patients undergoing EL in 11 Greek hospitals from January 2020 to May 2021 using the National Emergency Laparotomy Audit (NELA) inclusion criteria. Thirty-day mortality risk predictions were calculated using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), NELA, Portsmouth Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (P-POSSUM), and Predictive Optimal Trees in Emergency Surgery Risk tools. Surgeons' assessment of postoperative mortality using predefined cutoffs was recorded, and a surgeon-adjusted ACS-NSQIP prediction was calculated when the original model's prediction was relatively low. Predictive performances were compared using scaled Brier scores, discrimination and calibration measures and plots, and decision curve analysis. Heterogeneity across hospitals was assessed by random-effects meta-analysis. RESULTS: A total of 631 patients were included, and 30-day mortality was 16.3%. The ACS-NSQIP and its surgeon-adjusted version had the highest scaled Brier scores. All models presented high discriminative ability, with concordance statistics ranging from 0.79 for P-POSSUM to 0.85 for NELA. However, except the surgeon-adjusted ACS-NSQIP (Hosmer-Lemeshow test, p = 0.742), all other models were poorly calibrated ( p < 0.001). Decision curve analysis revealed superior clinical utility of the ACS-NSQIP. Following recalibrations, predictive accuracy improved for all models, but ACS-NSQIP retained the lead. Between-hospital heterogeneity was minimum for the ACS-NSQIP model and maximum for P-POSSUM. CONCLUSION: The ACS-NSQIP tool was most accurate for mortality predictions after EL in a broad external validation cohort, demonstrating utility for facilitating preoperative risk management in the Greek health care system. Subjective surgeon assessments of patient prognosis may optimize ACS-NSQIP predictions. LEVEL OF EVIDENCE: Diagnostic Test/Criteria; Level II.

The Hellenic Emergency Laparotomy Study (HELAS): A Prospective Multicentre Study on the Outcomes of Emergency Laparotomy in Greece.

BACKGROUND: Emergency laparotomy (EL) is accompanied by high post-operative morbidity and mortality which varies significantly between countries and populations. The aim of this study is to report outcomes of emergency laparotomy in Greece and to compare them with the results of the National Emergency Laparotomy Audit (NELA). METHODS: This is a multicentre prospective cohort study undertaken between 01.2019 and 05.2020 including consecutive patients subjected to EL in 11 Greek hospitals. EL was defined according to NELA criteria. Demographics, clinical variables, and post-operative outcomes were prospectively registered in an online database. Multivariable logistic regression analysis was used to identify independent predictors of post-operative mortality. RESULTS: There were 633 patients, 53.9% males, ASA class III/IV 43.6%, older than 65 years 58.6%. The most common operations were small bowel resection (20.5%), peptic ulcer repair (12.0%), adhesiolysis (11.8%) and Hartmann's procedure (11.5%). 30-day post-operative mortality reached 16.3% and serious complications occurred in 10.9%. Factors associated with post-operative mortality were increasing age and ASA class, dependent functional status, ascites, severe sepsis, septic shock, and diabetes. HELAS cohort showed similarities with NELA patients in terms of demographics and preoperative risk. Post-operative utilisation of ICU was significantly lower in the Greek cohort (25.8% vs 56.8%) whereas 30-day post-operative mortality was significantly higher (16.3% vs 8.7%). CONCLUSION: In this study, Greek patients experienced markedly worse mortality after emergency laparotomy compared with their British counterparts. This can be at least partly explained by underutilisation of critical care by surgical patients who are at high risk for death.

Correction: Daskalaki et al. Early Postoperative Parathormone and Calcium as Prognostic Factors for Postoperative Hypocalcemia. J. Clin. Med. 2022, 11, 2389.

In the published article [...].

External Validation of the American College of Surgeons Surgical Risk Calculator in Elderly Patients Undergoing General Surgery Operations.

Preoperative risk stratification in the elderly surgical patient is an essential part of contemporary perioperative care and can be done with the use of the American College of Surgeons Surgical Risk Calculator (ACS-SRC). However, data on the generalizability of the ACS-SRC in the elderly is scarce. In this study, we report an external validation of the ACS-RC in a geriatric cohort. A retrospective analysis of a prospectively maintained database was performed including patients aged > 65 who underwent general surgery procedures during 2012−2017 in a Greek academic centre. The predictive ability of the ACS-SRC for post-operative outcomes was tested with the use of Brier scores, discrimination, and calibration metrics. 471 patients were included in the analysis. 30-day postoperative mortality was 3.2%. Overall, Brier scores were lower than cut-off values for almost all outcomes. Discrimination was good for serious complications (c-statistic: 0.816; 95% CI: 0.762−0.869) and death (c-statistic: 0.824; 95% CI: 0.719−0.929). The Hosmer-Lemeshow test showed good calibration for all outcomes examined. Predicted and observed length of stay (LOS) presented significant differences for emergency and for elective cases. The ACS-SRC demonstrated good predictive performance in our sample and can aid preoperative estimation of multiple outcomes except for the prediction of post-operative LOS.

Medicinal plants in the treatment of urinary tract malignancies during the Araboislamic period (7th- 14th century AD).

Arabic medicine, or Arab-Islamic, mainly refers to all developments achieved in the Age of Khalifs, or the Golden Age of the Arab-Islamic civilization (ca 7th-14th centuries AD). Arab scholars adopted ancient Greek medicine and soon understood the essence of the fatal disease known as cancer. They introduced various new types of cancer, distinguishing other entities like infection and proposed new methods of treatment, both surgical and non-invasive. Herbal medicine after Dioscurides and Galen bloomed in the Arabic world. Malignancy of the urinary tract was identified and a plethora of herbs were used to slow down its expansion. Moreover, herbal drugs were introduced to alleviate cancerous symptomatology. Avicenna introduced Hindiba, while known scholars like Abulcasis and Rhazes noted the benefits of garlic, onion, black seeds, pomegranate, olive oil as well as leaf and bread wheat. Arabian herbal medicine may still be beneficial in anticancer fight and mainly in the palliative medicine. It should be emphasized that almost 50% of the drugs administered today have their point of origin in the plants used in antiquity.

Early Postoperative Parathormone and Calcium as Prognostic Factors for Postoperative Hypocalcemia.

BACKGROUND: Postoperative hypocalcemia is one of the most common complications after total thyroidectomy. Parathormone (PTH) and calcium levels, measured several hours after surgery, have been suggested as valuable markers for detecting patients at risk for post-thyroidectomy hypocalcemia. We aimed to determine if early post-surgery PTH and calcium levels can be used for the early identification of patients at risk for symptomatic hypocalcemia. METHODS: PTH and calcium were measured before surgery and at 10 min and 4 h post-thyroidectomy, in 77 patients. Performance characteristics of PTH and calcium levels and their post/pre-surgery ratios were calculated. RESULTS: Four-hour calcium was a sensitive (93.75%) but not specific (67.61%) indicator of patients at risk for symptomatic hypocalcemia. The 4-h/pre-surgery PTH ratio was the most accurate (90.81%) and the most specific (94.37%) test to identify patients at risk. Serum calcium at 4-h, 4-h/pre-surgery PTH ratio, and PTH at 10 min post-surgery had the higher diagnostic odds ratios (50.86, 32.85, and 29.04, respectively). The 4-h/pre-surgery PTH ratio also had the highest (0.694) Youden's J statistic. CONCLUSIONS: Low serum calcium levels 4 h after thyroidectomy and the 4-h/pre-surgery PTH ratio could be valuable additions to everyday clinical practice in post-thyroidectomy patients.

Complications of modern pancreaticoduodenectomy: A systematic review and meta-analysis.

BACKGROUND: In the past decades, the perioperative management of patients undergoing pancreaticoduodenectomy (PD) has undergone major changes worldwide. This review aimed to systematically determine the burden of complications of PD performed in the last 10 years. DATA SOURCES: A systematic review was conducted in PubMed for randomized controlled trials and observational studies reporting postoperative complications in at least 100 PDs from January 2010 to April 2020. Risk of bias was assessed using the Cochrane RoB2 tool for randomized studies and the methodological index for non-randomized studies (MINORS). Pooled complication rates were estimated using random-effects meta-analysis. Heterogeneity was investigated by subgroup analysis and meta-regression. RESULTS: A total of 20 randomized and 49 observational studies reporting 63 229 PDs were reviewed. Mean MINORS score showed a high risk of bias in non-randomized studies, while one quarter of the randomized studies were assessed to have high risk of bias. Pooled incidences of 30-day mortality, overall complications and serious complications were 1.7% (95% CI: 0.9%-2.9%; I2 = 95.4%), 54.7% (95% CI: 46.4%-62.8%; I2 = 99.4%) and 25.5% (95% CI: 21.8%-29.4%; I2= 92.9%), respectively. Clinically-relevant postoperative pancreatic fistula risk was 14.3% (95% CI: 12.4%-16.3%; I2 = 92.0%) and mean length of stay was 14.8 days (95% CI: 13.6-16.1; I2 = 99.3%). Meta-regression partially attributed the observed heterogeneity to the country of origin of the study, the study design and the American Society of Anesthesiologists class. CONCLUSIONS: Pooled complication rates estimated in this study may be used to counsel patients scheduled to undergo a PD and to set benchmarks against which centers can audit their practice. However, cautious interpretation is necessary due to substantial heterogeneity.

Urine 8-Hydroxyguanine (8-OHG) in Patients Undergoing Surgery for Colorectal Cancer.

PURPOSE: Cellular RNA is less compact than DNA, more easily accessible to ROS and therefore could be more susceptible to oxidative damage. This study was conceived in order to analyze the RNA oxidative damage in the urine of patients undergoing operation for colorectal cancer (CRC), to compare with healthy controls, and correlate with the stage. MATERIALS AND METHODS: The study population was constituted by a group of 147 patients and a group of 128 healthy controls. Urine and blood samples were collected before the colonoscopy in all participants and 24 hours post-operatively for those who underwent surgery. Urine 8-hydroxyguanine (8-OHG) was determined as marker of RNA oxidation, and serum uric acid (UA) as antioxidant marker. RESULTS: Preoperatively, 8-OHG (ng/ml) values of CRC patients were found to be significantly higher than those of controls (p = 0.001). More specifically, stages II/III had significantly higher 8-OHG values (p < 0.001 and p = 0.007) than stages 0/I. Post-operatively, 8-OHG values were similar to controls (p = 0.053). Preoperatively, UA values (mg/dl) were significantly lower (p = 0.001), while postoperatively were similar to controls (p = 0.069). CONCLUSION: Oxidative RNA damage occurs in CRC patients. Stages II/III are associated with higher values of 8-OHG than stages 0/I. 8-OHG could act as a marker for the identification of patients with advanced disease.

A Comparison of the Malnutrition Universal Screening Tool (MUST) and the Mini Nutritional Assessment-Short Form (MNA-SF) Tool for Older Patients Undergoing General Surgery.

The optimal malnutrition screening tool in geriatric surgery has yet to be determined. Herein, we compare two main tools in older patients undergoing general surgery operations. Older patients (>65 years old) who underwent general surgery operations between 2012 and 2017 in a tertiary centre were included. The Malnutrition Universal Screening Tool (MUST) and the Mini Nutritional Assessment Short Form (MNA-SF) were used for nutritional risk assessment. Preoperative variables as well as postoperative outcomes were recorded prospectively. Agreement between tools was determined with the weighted kappa (κ) statistic. Multiple regression analysis was used to assess the association of the screening tools with postoperative outcomes. A total of 302 patients (median age 74 years, range: 65-92) were included. A similar number of patients were classified as medium/high risk for malnutrition with the MNA-SF and MUST (26% vs. 36%, p = 0.126). Agreement between the two tools was moderate (weighted κ: 0.474; 95%CI: 0.381-0.568). In the multivariate analysis, MNA-SF was associated significantly with postoperative mortality (p = 0.038) and with postoperative length of stay (p = 0.001). MUST was associated with postoperative length of stay (p = 0.048). The MNA-SF seems to be more consistently associated with postoperative outcomes in elderly patients undergoing general surgery compared with the MUST tool.

Primary Repair of Traumatic Complete Pancreatic Rupture.

Isolated pancreatic injury with transection of the pancreatic duct is generally treated with pancreatic resection, but the optimal management is not based on high-level evidence. Herein, we report a case of primary repair of complete rupture of the pancreas and pancreatic duct after a blunt abdominal trauma and a review of the literature. A 33-year-old patient had an isolated pancreatic injury after blunt abdominal trauma. At laparotomy, an even transection was found with minimal necrosis and tissue loss and an end-to-end anastomosis of the duct and the parenchyma with omental patch was performed. Patient's postoperative course was complicated by a 6 cm pseudocyst and a low output pancreatic fistula which did not require any intervention and were self-limited. In the literature, 17 cases with primary repair of similar grade IV pancreatic injuries have been reported. Postoperative complications included mostly fistulas and pseudocysts.

Factors Associated with Malnutrition and Its Impact on Postoperative Outcomes in Older Patients.

Malnutrition is associated with dismal treatment outcomes in older patients but its impact in geriatric surgery has not been studied extensively. Herein, we report the prevalence of malnutrition risk, its risk factors and its association with postoperative outcomes in older patients undergoing operations of general surgery. This is a retrospective analysis of a prospectively maintained database including patients older than 65 years who were to undergo general surgery operations between 2012 and 2017. The Malnutrition Universal Screening Tool (MUST) was used for nutritional risk. Demographics, socioeconomic data, site and magnitude of the operation, various measures of comorbidity and functional dependence as well as postoperative complications based on Clavien-Dindo classification and length of stay were recorded. There were 501 patients. A total of 28.6% of them were at intermediate malnutrition risk (MUST = 1) and 14.6% were at high malnutrition risk (MUST ≥ 2). Variables independently associated with malnutrition risk (MUST ≥ 1) were smoking (Odds Ratio, OR:1.6, p = 0.041), upper gastrointestinal (GI) tract surgery (OR:20.4, p < 0.001), hepatobiliary-pancreatic surgery (OR:3.7, p = 0.001), lower GI surgery (OR:5.2, p < 0.001) and American Society of Anesthesiologists (ASA) class III/IV (OR:2.8, p = 0.001). In the multiple regression analysis adjusted for several confounding variables, the MUST score was significantly associated with postoperative death (OR:9.1, p = 0.047 for MUST = 1 and OR:11.9, p = 0.035 for MUST score ≥ 2) and postoperative hospital stay (adjusted incidence rate ratio, 1.3, p = 0.041 for MUST = 1 and 1.7, p < 0.001 for MUST ≥ 2). Malnutrition risk was highly prevalent in this sample, particularly in patients with operations of the gastrointestinal tract, in patients with poor physical status and it was associated with postoperative mortality and length of stay.

Intestinal Microbiota in Colorectal Cancer Surgery.

The intestinal microbiota consists of numerous microbial species that collectively interact with the host, playing a crucial role in health and disease. Colorectal cancer is well-known to be related to dysbiotic alterations in intestinal microbiota. It is evident that the microbiota is significantly affected by colorectal surgery in combination with the various perioperative interventions, mainly mechanical bowel preparation and antibiotic prophylaxis. The altered postoperative composition of intestinal microbiota could lead to an enhanced virulence, proliferation of pathogens, and diminishment of beneficial microorganisms resulting in severe complications including anastomotic leakage and surgical site infections. Moreover, the intestinal microbiota could be utilized as a possible biomarker in predicting long-term outcomes after surgical CRC treatment. Understanding the underlying mechanisms of these interactions will further support the establishment of genomic mapping of intestinal microbiota in the management of patients undergoing CRC surgery.

Current and Future Trends in Molecular Biomarkers for Diagnostic, Prognostic, and Predictive Purposes in Non-Melanoma Skin Cancer.

Skin cancer represents the most common type of cancer among Caucasians and presents in two main forms: melanoma and non-melanoma skin cancer (NMSC). NMSC is an umbrella term, under which basal cell carcinoma (BCC), squamous cell carcinoma (SCC), and Merkel cell carcinoma (MCC) are found along with the pre-neoplastic lesions, Bowen disease (BD) and actinic keratosis (AK). Due to the mild nature of the majority of NMSC cases, research regarding their biology has attracted much less attention. Nonetheless, NMSC can bear unfavorable characteristics for the patient, such as invasiveness, local recurrence and distant metastases. In addition, late diagnosis is relatively common for a number of cases of NMSC due to the inability to recognize such cases. Recognizing the need for clinically and economically efficient modes of diagnosis, staging, and prognosis, the present review discusses the main etiological and pathological features of NMSC as well as the new and promising molecular biomarkers available including telomere length (TL), telomerase activity (TA), CpG island methylation (CIM), histone methylation and acetylation, microRNAs (miRNAs), and micronuclei frequency (MNf). The evaluation of all these aspects is important for the correct management of NMSC; therefore, the current review aims to assist future studies interested in exploring the diagnostic and prognostic potential of molecular biomarkers for these entities.

A case of solitary rectal diverticulum presenting with a large retrorectal abscess.

Colonic diverticular disease is a common condition, affecting 50% of the population aged above 80. In contrast, rectal diverticular disease is a rare condition with very few cases reported, while symptomatic rectal diverticular disease is even rarer. We present a case of a symptomatic large rectal diverticulum presenting with a retrorectal abscess. A 49-year-old Caucasian female was brought to the emergency department complaining of abdominal pain and weakness in the lower limbs. She was found to have obstructive uropathy and unilateral sciatic neuropathy. She rapidly developed acute abdomen and emergency laparotomy revealed a giant purulent rectal diverticulum. The patient underwent exploratory laparotomy and a loop colostomy was made to decompress the colon.

Detailed and applied anatomy for improved rectal cancer treatment.

Rectal anatomy is one of the most challenging concepts of visceral anatomy, even though currently there are more than 23,000 papers indexed in PubMed regarding this topic. Nonetheless, even though there is a plethora of information meant to assist clinicians to achieve a better practice, there is no universal understanding of its complexity. This in turn increases the morbidity rates due to iatrogenic causes, as mistakes that could be avoided are repeated. For this reason, this review attempts to gather current knowledge regarding the detailed anatomy of the rectum and to organize and present it in a manner that focuses on its clinical implications, not only for the colorectal surgeon, but most importantly for all colorectal cancer-related specialties.