Remote ischemic preconditioning versus sham-control for prevention of anastomotic leakage after resection for rectal cancer (RIPAL trial): a pilot randomized controlled, triple-blinded monocenter trial.

PURPOSE: Remote ischemic preconditioning (RIPC) reportedly reduces ischemia‒reperfusion injury (IRI) in various organ systems. In addition to tension and technical factors, ischemia is a common cause of anastomotic leakage (AL) after rectal resection. The aim of this pilot study was to investigate the potentially protective effect of RIPC on anastomotic healing and to determine the effect size to facilitate the development of a subsequent confirmatory trial. MATERIALS AND METHODS: Fifty-four patients with rectal cancer (RC) who underwent anterior resection were enrolled in this prospectively registered (DRKS0001894) pilot randomized controlled triple-blinded monocenter trial at the Department of Surgery, University Medicine Mannheim, Mannheim, Germany, between 10/12/2019 and 19/06/2022. The primary endpoint was AL within 30 days after surgery. The secondary endpoints were perioperative morbidity and mortality, reintervention, hospital stay, readmission and biomarkers of ischemia‒reperfusion injury (vascular endothelial growth factor, VEGF) and cell death (high mobility group box 1 protein, HMGB1). RIPC was induced through three 10-min cycles of alternating ischemia and reperfusion to the upper extremity. RESULTS: Of the 207 patients assessed, 153 were excluded, leaving 54 patients to be randomized to the RIPC or the sham-RIPC arm (27 each per arm). The mean age was 61 years, and the majority of patients were male (37:17 (68.5:31.5%)). Most of the patients underwent surgery after neoadjuvant therapy (29/54 (53.7%)) for adenocarcinoma (52/54 (96.3%)). The primary endpoint, AL, occurred almost equally frequently in both arms (RIPC arm: 4/25 (16%), sham arm: 4/26 (15.4%), p = 1.000). The secondary outcomes were comparable except for a greater rate of reintervention in the sham arm (9 (6-12) vs. 3 (1-5), p = 0.034). The median duration of endoscopic vacuum therapy was shorter in the RIPC arm (10.5 (10-11) vs. 38 (24-39) days, p = 0.083), although the difference was not statistically significant. CONCLUSION: A clinically relevant protective effect of RIPC on anastomotic healing after rectal resection cannot be assumed on the basis of these data.

Splenic flexure mobilization in left-sided colonic and rectal resections: A meta-analysis and meta-regression of factors associated with anastomotic leak and complications.

AIM: Splenic flexure mobilization (SFM) is commonly performed during left-sided colon and rectal resections. The aim of the present systematic review was to assess the outcomes of SFM in left-sided colon and rectal resections and the risk factors for complications and anastomotic leak (AL). METHOD: This study was a PRISMA-compliant systematic review. PubMed, Scopus and Web of Science were searched for studies that assessed the outcomes of sigmoid and rectal resections with or without SFM. The primary outcomes were AL and total complications, and the secondary outcomes were individual complications, operating time, conversion to open surgery, length of hospital stay (LOS) and pathological and oncological outcomes. RESULTS: Nineteen studies including data on 81 116 patients (49.1% male) were reviewed. SFM was undertaken in 40.7% of patients. SFM was associated with a longer operating time (weighted mean difference 24.50, 95% CI 14.47-34.52, p < 0.0001) and higher odds of AL (OR 1.19, 95% CI 1.06-1.33, p = 0.002). Both groups had similar odds of total complications, splenic injury, anastomotic stricture, conversion to open surgery, (LOS), local recurrence, and overall survival. A secondary analysis of rectal cancer cases only showed similar outcomes for SFM and the control group. CONCLUSIONS: SFM was associated with a longer operating time and higher odds of AL, yet a similar likelihood of total complications, splenic injury, anastomotic stricture, conversion to open surgery, LOS, local recurrence, and overall survival. These conclusions must be cautiously interpreted considering the numerous study limitations. SFM may have only been selectively undertaken in cases in which anastomotic tension was suspected. Therefore, the suboptimal anastomoses may have been the reason for SFM rather than the SFM being causative of the anastomotic insufficiencies.

Impact of the endoscopic surgical skill qualification system on conversion to laparotomy after low anterior resection for rectal cancer in Japan (a secondary analysis of the EnSSURE study).

BACKGROUND AND AIMS: Conversion to laparotomy is among the serious intraoperative complications and carries an increased risk of postoperative complications. In this cohort study, we investigated whether or not the Endoscopic Surgical Skill Qualification System (ESSQS) affects the conversion rate among patients undergoing laparoscopic surgery for rectal cancer. METHODS: We performed a retrospective secondary analysis of data collected from patients undergoing laparoscopic surgery for cStage II and III rectal cancer from 2014 to 2016 across 56 institutions affiliated with the Japan Society of Laparoscopic Colorectal Surgery. Data from the original EnSSURE study were analyzed to investigate risk factors for conversion to laparotomy by performing univariate and multivariate analyses based on the reason for conversion. RESULTS: Data were collected for 3,168 cases, including 65 (2.1%) involving conversion to laparotomy. Indicated conversion accounted for 27 cases (0.9%), while technical conversion accounted for 35 cases (1.1%). The multivariate analysis identified the following independent risk factors for indicated conversion to laparotomy: tumor diameter [mm] (odds ratio [OR] 1.01, 95% confidence interval [CI] 1.01-1.05, p = 0.0002), combined resection of adjacent organs [+/-] (OR 7.92, 95% CI 3.14-19.97, p < 0.0001), and surgical participation of an ESSQS-certified physician [-/+] (OR 4.46, 95% CI 2.01-9.90, p = 0.0002). The multivariate analysis identified the following risk factors for technical conversion to laparotomy: registered case number of institution (OR 0.99, 95% CI 0.99-1.00, p = 0.0029), institution type [non-university/university hospital] (OR 3.52, 95% CI 1.54-8.04, p = 0.0028), combined resection of adjacent organs [+/-] (OR 5.96, 95% CI 2.15-16.53, p = 0.0006), and surgical participation of an ESSQS-certified physician [-/+] (OR 6.26, 95% CI 3.01-13.05, p < 0.0001). CONCLUSIONS: Participation of ESSQS-certified physicians may reduce the risk of both indicated and technical conversion. Referral to specialized institutions, such as high-volume centers and university hospitals, especially for patients exhibiting relevant background risk factors, may reduce the risk of conversion to laparotomy and lead to better outcomes for patients. TRIAL REGISTRATION: This study was registered with the Japanese Clinical Trials Registry as UMIN000040645.

A novel circumferential continuous reinforcing suture for anastomosis after laparoscopic resection for rectal cancer and sigmoid cancer: a retrospective case-controlled study.

INTRODUCTION: This study aimed to investigate the effectiveness of a novel method for anastomosis reinforcement to minimize the occurrence of anastomotic complications after surgical resection of rectal and sigmoid cancer. METHODS: We recruited 378 patients who underwent laparoscopic rectal anterior resection of rectal cancer and sigmoid cancer in SYSUCC. The occurrence rates of intraoperative bleeding, operation time, and postoperative anastomotic complications were compared between the treatment group receiving anastomotic reinforcement and the control group without anastomotic reinforcement. RESULTS: The incidence of anastomotic leakage in the treatment group was significantly lower than that in the control group (1.59% vs. 11.64%, p < 0.001). Following the application of inverse probability of treatment weighting (IPTW) to adjust for factors influencing the occurrence of anastomotic leakage, the incidence of anastomotic leakage remained significantly lower in the treatment group compared to the control group (2.54% vs. 12.08%, p < 0.001). CONCLUSION: The circumferential continuous anastomosis reinforcing suture method, recommended for laparoscopic surgery for rectal and sigmoid cancer, has the potential to effectively minimize the occurrence of anastomotic complications.

Enhanced recovery and reduced conversion rates in robotic rectal cancer surgery: a single-center retrospective cohort study.

PURPOSE: This study aimed to compare the outcomes of robotic-assisted rectal resection with conventional laparoscopic and open approaches, focusing on complication rates, conversion rates, length of hospital stay, and oncologic outcomes. METHODS: A retrospective single-center cohort study included 106 patients with non-metastatic rectal cancer (UICC stages I-III) who underwent rectal resection from January 2013 to December 2023. Patients were assigned to open surgery (n = 23), conventional laparoscopic surgery (n = 55), or robotic-assisted surgery (n = 28). RESULTS: Robotic surgery demonstrated significantly lower conversion rates compared to minimal-invasive surgeries (p = 0.047) and shorter hospital stays (11.5 ± 8 days) compared to open (17.91 ± 12 days) and laparoscopic (17.2 ± 14 days) surgeries (p = 0.001). The quality of the specimen was significantly better (Score 1) in robotic (85.71%) and open (89.09%) cases compared to laparoscopic approaches (47.83%) (p < 0.001). Laparoscopic surgery was identified as a risk factor for worse specimen quality (p < 0.001). Older patients (> 63 years) had a higher risk for conversion in univariate analysis (p = 0.049). Morbidity was comparable between the groups (p = 0.131), and the anastomotic leakage rate did not differ significantly (laparoscopic: 18.18%, open: 13.04%, robotic: 17.86%). Kaplan-Meier survival curves showed no significant differences in overall survival probabilities among the groups. CONCLUSION: Robotic-assisted rectal resection provides significant advantages in terms of lower conversion rates, better specimen quality, and shorter hospital stays while maintaining comparable complication rates and oncologic outcomes to conventional laparoscopic and open approaches. These findings support robotic surgery as a standard treatment option for rectal cancer.

A modified method for precise anastomosis during laparoscopic low anterior resection for rectal cancer: the first clinical experience and application.

BACKGROUND: There is no criterion to guide and evaluate the anastomosis of laparoscopic low anterior resection (LAR). We developed a new technique for precise anastomosis. This study endeavored to evaluate the effectiveness and safety of this new technology. METHODS: Patients with mid-low rectal cancer who underwent laparoscopic LAR in our department were enrolled retrospectively between January 1, 2021 and July 1, 2023. During the LAR, the distance between the sacral promontory and the rectal stump was measured and used to determine the length of the sigmoid colon, which was preserved for anastomose. The demographic characteristics and short-term outcomes were analyzed. RESULTS: Forty-nine patients (26 men, 23 women) with low and middle rectal cancer were retrospectively enrolled in the study. The distance of the tumor from the anal verge was 6.4 ± 2.7 cm. The operative time was 193 ± 42 min. All patients underwent precise anastomosis, among which 12 patients underwent freeing of the splenic flexure of the colon. According to our criteria, there was no redundant or tense state of the colon anterior to the sacrum after the anastomosis. Only one patient had a postoperative anastomotic leak (Grade B). All 15 patients receiving neoadjuvant chemoradiotherapy underwent terminal ileostomy. No postoperative death occurred within 30 days of the surgery. The median follow-up time in our study was 12 months. One patient developed a single metastasis in the right lobe of the liver in the eighth month after surgery and underwent microwave radiofrequency ablation, which did not recur in the four months of postoperative follow-up, and the rest of the patients survived disease-free without recurrence of metastasis. CONCLUSIONS: Precise measurement of the proximal colon of the anastomosis can ensure accurate and convenient colorectal anastomosis and this may be a technique worthy of clinical application. However, its effectiveness needs to be further verified in a multicenter clinical trial.

Treatment techniques for rectovaginal fistulas after low rectal resection for deep endometriosis.

Endometriosis is a benign gynecologic affection that may lead to major surgeries, such as colorectal resections. Rectovaginal fistulas (RVF) are among the possible complications. When they occur, it is necessary to adapt the repair surgery as best as possible to limit their functional consequences. This video shows three different techniques for correcting RVF after rectal resection for endometriosis, with a combination of perineal surgery and laparoscopy: a mucosal flap, a transanal transection and single stapled anastomosis (TTSS) and a pull through. Supplementary file1 (MP4 469658 KB).

Surgical management of rectovaginal fistula after stapled transanal rectal resection for prolapsed hemorrhoids.

INTRODUCTION AND HYPOTHESIS: Rectovaginal fistula is an epithelium-lined direct communication route between the vagina and the rectum. The gold standard of fistula management is surgical treatment. Rectovaginal fistula after stapled transanal rectal resection (STARR) may be challenging to treat, due to the extensive scarring, the local ischemia, and the risk of rectal stenosis. We aimed to present a case of iatrogenic rectovaginal fistula after STARR that was successfully treated with a transvaginal primary layered repair and bowel diversion. METHODS: A 38-year-old woman was referred to our division for continuous fecal discharge through her vagina that developed a few days after she had a STARR for prolapsed hemorrhoids. Clinical examination revealed a 2.5 cm-wide direct communication between the vagina and rectum. After proper counseling, the patient was admitted to transvaginal layered repair and temporary laparoscopic bowel diversion RESULTS: No surgical complications were observed. The patient was successfully discharged home on postoperative day 3. Bowel diversion was reversed after 2 months. At the current follow-up (6 months), the patient is asymptomatic and without recurrence. CONCLUSIONS: The procedure was successful in obtaining anatomical repair and relieving symptoms. This approach represents a valid procedure for the surgical management of this severe condition.

Predictive factors associated with anastomotic leakage after resection of rectal cancer: a multicenter study with the Hiroshima Surgical study group of Clinical Oncology.

PURPOSE: Several factors have been reported as risk factors for anastomotic leakage after resection of rectal cancer. This study aimed to evaluate the risk factors for anastomotic leakage, including nutritional and immunological indices, following rectal cancer resection. METHODS: This study used a multicenter database of 803 patients from the Hiroshima Surgical study group of Clinical Oncology who underwent rectal resection with stapled anastomosis for rectal cancer between October 2016 and April 2020. RESULTS: In total, 64 patients (8.0%) developed postoperative anastomotic leakage. Five factors were significantly associated with the development of anastomotic leakage after rectal cancer resection with stapled anastomosis: male sex, diabetes mellitus, C-reactive protein/albumin ratio ≥ 0.07, prognostic nutritional index < 40, and low anastomosis under peritoneal reflection. The incidence of anastomotic leakage was correlated with the number of risk factors. The novel predictive formula based on odds ratios in the multivariate analysis was useful for identifying patients at high risk for anastomotic leakage. Diverting ileostomy reduced the ratio of anastomotic leakage ≥ grade III after rectal cancer resection. CONCLUSIONS: Male sex, diabetes mellitus, C-reactive protein/albumin ratio ≥ 0.07, prognostic nutritional index < 40, and low anastomosis under peritoneal reflection are possible risk factors for developing anastomotic leakage after rectal cancer resection with the stapled anastomosis. Patients at high risk of anastomotic leakage should be assessed for the potential benefits of diverting stoma.

Efficacy of a transanal drainage tube versus diverting stoma in protecting colorectal anastomosis: a systematic review and meta-analysis.

Anastomotic leakage (AL) is the most fearsome complication in low rectal resection. The temporary diverting stoma (DS) is recommended to prevent AL, but it may cause relevant morbidity and needs a second surgical procedure to be closed. Therefore, the use of a transanal drainage tube (TDT) has been proposed as an alternative. We performed a systematic review and meta-analysis concerning the peri-operative outcomes in patients undergoing elective anterior rectal resection (ARR) with TDT alone or DS alone. Six studies were meta-analyzed, including a total of 735 patients. The meta-analysis showed that the incidences of AL, surgery-related complications, infective complications, and 30-day reoperation after ARR with low colorectal or coloanal anastomosis did not differ significantly between patients undergoing positioning of TDT and those undergoing DS. Furthermore, overall complications were significantly rarer in patients undergoing TDT. A meta-analysis of the randomized control trial (RCT) and no-RCT subgroups did not detect any statistically significant differences in any outcomes. These results suggest that it might be reasonable to employ a TDT in place of a DS to protect low colorectal and coloanal anastomosis, with consequent considerable advantages in terms of the short- and long-term post-operative outcomes. However, more well-designed RCTs are needed to definitively assess this issue.

Early Experience of Undertaking Robotic Assisted Total Mesorectal Excision in Rectal Resections, Avoiding a Diverting Stoma: Key eHancement of the Anastomosis for No Stoma Technique - A Case Series.

Background. Anastomotic leak is a feared complication in rectal cancer surgery, and a proximal diverting stoma to protect the rectal anastomosis is used to minimize its impact. We evaluated a novel technique that uses the da Vinci® robotic platform (Intuitive Surgical) to reinforce the colorectal anastomosis and rectal staple line with sutures, and rectal resection and assessment of the anastomotic perfusion, using our Portsmouth protocol. Methods. During robotic rectal cancer surgery, we used indocyanine green to determine the level of transection and check the vascularity of the circular anastomosis. The distal transverse staple line and circular staple line of the colorectal anastomosis were reinforced with absorbable interrupted stitches (KHANS technique - Key enHancement of the Anastomosis for No Stoma). The integrity of the colorectal/anal anastomosis was also checked using the underwater air-water leak test, with concomitant flexible sigmoidoscopy to visualize the circular staple line. Results. Fifty patients underwent total mesorectal excision for cancer. Using the KHANS technique, we avoided a diverting stoma in all cases. One patient had a radiological leak, leading to a pelvic abscess. In 56% of cases, the anastomosis was within 5 cm of the anal verge. Median length of stay was 5 (3-34) days, with two 30-day readmissions. No 90-day mortality or 30-day reoperations were observed. Conclusion. The KHANS technique appears feasible, successful, and safe in decreasing the incidence of diverting stomas in rectal resections.

Ileus conditions after rectal and Hartmann's resections.

INTRODUCTION: Bowel obstruction is one of the most common postoperative complications in pelvic surgery. In most cases, adhesive mechanical ileus of the small bowel is the cause. In procedures such as Hartmann's resection or abdominoperineal rectal resection, it seems that the large wound area on the pelvic walls and pelvic floor and the dead space after the removed rectum with mesorectum contribute to the ileus condition. The aim of this paper was to identify the risk factors for ileus after selected pelvic procedures and to map the possible ways of prevention and treatment of these complications. METHODS: We performed retrospective simple analysis of a set of 98 patients who underwent elective abdominoperineal resection of the rectum, pelvic exenteration or Hartmann's resection for rectal cancer between 2017-2022. Postoperative complications were recorded, especially bowel obstruction, and perineal wound or rectal stump healing complications. In all 9 patients, who needed reoperation, we searched for risk factors for ileus known from the literature. We also described the management of ileus. RESULTS: In the group of 9 patients subjected to detailed analysis, 8 risk factors were most common: male gender, obesity, history of radiotherapy, open surgery, requirement of adhesiolysis in primary surgery, large blood loss, difficult dissection, and impaired healing of the rectal stump/perineum. A total of 8 (88.9%) patients had a combination of 4 or more of the mentioned risk factors. CONCLUSION: Our results confirm the impact of risk factors known from the literature; furthermore, they indicate a connection with the formation of a dead space in the pelvis and with complications of the rectal stump or perineal wound healing. Some of the risk factors cannot be changed, and current preventive measures cannot completely prevent the formation of adhesions. It is therefore advisable to look for other materials and methods that would ideally limit the formation of adhesions and at the same time fill the dead space and thus separate it from the perineal wound.

Anastomotic leakage following restorative rectal cancer resection: treatment and impact on stoma presence 1 year after surgery-a population-based study.

PURPOSE: Anastomotic leakage (AL) continues to be a challenge after restorative rectal resection (RRR). Various treatment options of AL are available; however, their long-term outcomes are uncertain. We explored the impact of AL on the risk of stoma presence 1 year after RRR for rectal cancer and described treatment of AL after RRR including impact on the probability of receiving adjuvant chemotherapy and stoma presence following different treatment options of AL. METHODS: We included 859 patients undergoing RRR in Central Denmark Region between 2013 and 2019. Stoma presence was calculated as the proportion of patients with stoma 1 year after RRR. Multivariable logistic regression was conducted to estimate the impact of AL on stoma presence adjusting for potential predictors. Descriptive data of outcomes were stratified for various treatment options of AL. RESULTS: The risk of stoma presence 1 year after surgery was 9.8% (95% CI 7.98-12.0). Predictors for having stoma 1 year after RRR were AL (OR 8.43 (95% CI 4.87-14.59)) and low tumour height (OR 3.85 (95% CI 1.22-13.21)). For patients eligible for adjuvant chemotherapy, the probability of receiving it was 42.9% (95% CI 21.8-66.0) if treated with endo-SPONGE and 71.4% (95% CI 47.8-88.7) if treated with other anastomosis preserving treatment options. The risk of having stoma 1 year after RRR was 33.9% (95% CI 21.8-47.8) for patients treated with endo-SPONGE and 13.5% (95% CI 5.6-25.8) for patients treated with other anastomosis preserving treatment options (p = 0.013). CONCLUSION: AL is a strong predictor for stoma presence 1 year after RRR. Patients treated with endo-SPONGE seem to have worse outcomes compared to other anastomosis preserving treatment options.

Robotic beyond total mesorectal excision surgery for primary and recurrent pelvic malignancy: Feasibility and short-term outcomes.

AIM: To explore the feasibility and safety of robotic beyond total mesorectal excision (TME) surgery for primary and recurrent pelvic malignancy. METHODS: Patients undergoing robotic beyond TME resections for primary or recurrent pelvic malignancy between July 2015 and July 2021 in a public quaternary and a private tertiary centre were included. Demographic and clinical data were recorded and outcomes analysed. RESULTS: Twenty-four patients (50% males) were included, with a median age of 58 (45-70.8) years, and a BMI of 26 (24.3-28.1) kg/m2 . Indication for surgery was rectal adenocarcinoma in nineteen, leiomyosarcoma in two, anal squamous cell carcinoma in one and combined rectal and prostatic adenocarcinoma in two patients. All patients required resection of at least one adjacent pelvic organ including genitourinary structures (n = 23), internal iliac vessels (n = 3) and/or bone (n = 2). Eleven patients had a restorative procedure. Of the 13 nonrestorative cases, nine needed perineal reconstruction with a flap. There was one conversion due to bleeding. The mean operating time was 370 (285-424) min, and the median blood loss was 400 (200-2,000) ml. The median length of stay was 16 (9.3-23.8) days. Fourteen patients (58.3%) had postoperative complications; eight of them (33.3%) were Clavien-Dindo III or more complication. Twenty-three (95.8%) patients had an R0 resection. During a median follow-up of 10 (7-23.5) months, five patients (20.8%) had systemic recurrences. No local recurrences were identified during the study period. CONCLUSION: Implementation of robotic beyond TME surgery for primary and recurrent pelvic malignancy is feasible within a highly specialised setting.

The impact of prolonged delay to loop ileostomy closure on postoperative morbidity and hospital stay: A retrospective cohort study.

AIM: There is increasing evidence that delayed loop ileostomy closure is associated with an increase in postoperative morbidity. In the context of a publicly funded health service with constrained theatre access, we review the impact of delay in loop ileostomy closure. METHOD: A retrospective cohort study of patients undergoing loop ileostomy closure at the Dunedin Public Hospital between 2000-2017 was performed. Cases and complications were identified from the prospectively maintained Otago Clinical Audit database. Patient demographics, ASA score, indications for ileostomy, reasons for delay in closure, length of stay (LOS) after ileostomy closure and complications were collected. LOS and overall complication rate were assessed using univariable and multivariable analyses. RESULTS: A total of 292 patients were included in the study, of whom 74 (25.3%) were waiting for longer than 12 months for ileostomy closure. The overall complication rate was 21.5%. This was 8% up to 90 days, 20% between 90-360 days, 28% between 360-720 days and 54% after 720 days. Delay was associated with an increased risk of any complication (RR 1.06 for every 30 days with stoma, p < 0.001), including Ileus (OR [95% CI] 1.06 [1.00-1.11], p = 0.024). Overall mean LOS was 5.9 days (range 1-63), being 4.6 days up to 180 days, 5.6 between 180-720 days and 8.7 after 720 days. LOS significantly increased with increasing stoma duration (p = 0.04). CONCLUSION: Increasing time with loop ileostomy is detrimental for patients, being associated with an increase in complication rates, and is detrimental for hospitals due to increased length of stay. Resources should be allocated for timely closure of loop ileostomies.

Lower conversion rate with robotic assisted rectal resections compared with conventional laparoscopy; a national cohort study.

BACKGROUND: Conversion from laparoscopic to open access colorectal surgery is associated with a poorer postoperative outcome. The aim of this study was to assess conversion rates and outcomes after standard laparoscopic rectal resection (LR) and robotic laparoscopic rectal resection (RR). METHODS: A national 5-year cohort study utilizing prospectively recorded data on patients who underwent elective major laparoscopic resection for rectal cancer. Data were retrieved from the Norwegian Registry for Gastrointestinal Surgery and from the Norwegian Colorectal Cancer Registry. Primary end point was conversion rate. Secondary end points were postoperative complications within 30 days and histopathological results. Chi-square test, two-sided T test, and Mann-Whitney U test were used for univariable analyses. Both univariable and multivariable logistic regression analyses were used to analyze the relations between different predictors and outcomes, and propensity score matching was performed to address potential treatment assignment bias. RESULTS: A total of 1284 patients were included, of whom 375 underwent RR and 909 LR. Conversion rate was 8 out of 375 (2.1%) for RR compared with 87 out of 909 (9.6%) for LR (p < 0.001). RR was associated with reduced risk for conversion compared with LR (aOR 0.22, 95% CI 0.10-0.46). There were no other outcome differences between RR and LR. Factors associated with increased risk for conversion were male gender, severe cardiac disease and BMI > 30. Conversion was associated with higher rates of major complications (20 out of 95 (21.2%) vs 135 out of 1189 (11.4%) p = 0.005), reoperations (13 out of 95 (13.7%) vs 93 out of 1189 (7.1%) p = 0.020), and longer hospital stay (median 8 days vs 6 days, p = 0.001). CONCLUSION: Conversion rate was lower with robotic assisted rectal resections compared with conventional laparoscopy. Conversions were associated with higher rates of postoperative complications.

Anastomotic occlusion after laparoscopic low anterior rectal resection: a rare case study and literature review.

BACKGROUND: With the development of laparoscopic techniques and the broad clinical application of various anastomotic types, anal-preserving low anterior rectal resection and ultra-low anterior rectal resection have been popularized. Some patients with rectal cancer have retained their anus and improved their quality of life. Nevertheless, the incidence of postoperative anastomotic stenosis remains high, and anastomotic occlusion is even rarer. CASE PRESENTATION: We report a case of anastomotic occlusion in a patient with rectal cancer, which occurred after undergoing laparoscopic low anterior rectal resection + prophylactic terminal ileal fistulation at our department. Under endoscopy, we used a small guidewire to break through the occluded anastomosis, thereby finding the lacuna. After endoscopic balloon dilation, digital anal dilatation, and continuous dilator-assisted dilation, the desired efficacy was achieved, ultimately recovering ileal stoma. Postoperative follow-up condition was generally acceptable, without symptoms like abdominal pain, bloating, or difficulty in defecation. CONCLUSION: Numerous factors cause postoperative anastomotic stenosis in patients with rectal cancer. Complete occlusion of anastomosis occurs relatively rare in clinical practice, and is challenging to treat. This case was our first attempt to remove the anastomotic occlusion successfully, which avoided re-operation or pain from the permanent fistula.

Surgery for deep infiltrating rectal endometriosis-Selecting the right approach.

Endometriosis involving the bowel is a form of deep infiltrating endometriosis (DIE). The endometriotic lesions can infiltrate the bowel layers mimicking a malignancy. The majority of bowel involvement happens in the colon and rectum. We report our experience in surgically managing rectal endometriosis in two patients, one via a conservative approach and the other with a more radical approach and their associated short-term and long-term outcomes are observed. In principle, surgery remains the mainstay of treatment in managing rectal DIE with adjuvant hormonal therapy. The selection of surgical approach should be based on disease factors such as the size of the lesions and extent of the disease, patient factors including fitness for surgery and expectations as well as logistics and resource limitations.

MRI diagnose post-operative anastomotic leak in patients with rectal cancer: preliminary experience.

BACKGROUND: Anastomotic leakage (AL) is one of the most serious postoperative complications after colorectal anastomosis. This study aims to evaluate the feasibility and diagnostic accuracy of magnetic resonance imaging (MRI) in the early detection of AL in patients with clinically suspected AL after rectal anterior resection. METHODS: This was a prospective study including patients who underwent anterior resection and postoperative MRI examination. AL was diagnosed by comprehensive indictors, which were mainly confirmed by clinical signs, symptoms, and retrograde contrast enema (RCE) radiography. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of diagnosing AL with MRI were calculated. RESULTS: In total, 347 patients received anterior resection for rectal cancer, and 28 patients were suspected to have AL. Finally, 23 patients were included and received MRI examination. The median time interval from surgery to MRI was 10 days (3-21 days). The median distance from anastomosis to anal verge was 4.0 cm (2.0-10 cm), and 11 patients underwent diverted ileostomy. Eighteen patients had an anastomotic leak, including one patient who had a pelvic abscess and five patients who had no evidence of AL in the MRI examination. The overall sensitivity and specificity were 94.4% (95% CI 70.6% to 99.7%) and 80% (95% CI 29.8% to 98.9%), respectively. The PPV was 0.94 (95% CI 0.71 to 0.99) and the NPV was 0.80 (95% CI 0.29 to 0.99). For patients who had anastomosis less than 5 cm, the diagnostic accuracy of MRI was 93.7% (15/16). T2-weighted imaging with fat suppression can effectively reveal the leak track. CONCLUSIONS: The accuracy of plain MRI examination in diagnosing AL was favorable for patients with a suspected AL. T2-weighted imaging with fat suppression was the best imaging modality to diagnose AL. A multicenter prospective study with more samples is needed to further determine the safety and feasibility of MRI in the diagnosis of AL.

[Transanal endoscopic rectal resection: immediate and long-term results]. / Transanal'naya endoskopicheskaya rezektsiya pryamoi kishki: neposredstvennye i otdalennye rezul'taty.

OBJECTIVE: To analyze the results of transanal endoscopic microsurgery in patients with rectal tumors. MATERIAL AND METHODS: We analyzed 87 transanal endoscopic resections of rectal benign tumors (35 patients) and rectal cancer cT1N0M0 (52 patients) for the period since 2012. RESULTS: There were 2 (3.8%) intraoperative intestinal wall perforations into abdominal cavity and 2 (3.8%) postoperative bleedings among patients with rectal cancer. Four (7.7%) patients developed recurrent rectal cancer (pT1N0M0 - 1 patient, pT2N0M0 - 3 patients; by tumor grades: G1 - 2 patients, G2 - 2 patients) within 1.6-5.2 years. All recurrent tumors were located on anterior rectal wall. In patients with rectal cancer, cumulative relapse-free survival was 0.923 (standard error 0.037), cumulative overall survival - 0.926 (standard error 0.043). There was 1 (4.3%) intraoperative intestinal wall perforation among patients with benign rectal tumors. Postoperative anastomotic leakage occurred in 1 (4.3%) patient. Recurrent benign tumors occurred in 2 (8.7%) patients with villous rectal tumors. No relapses were observed in patients with rectal adenomas (p=1.0). CONCLUSION: Transanal endoscopic rectal resection is effective for benign rectal tumors and rectal cancer pT1N0M0 with high relapse-free and overall survival and low complication rate. Risk factors of recurrence are tumor stage pT2N0M0, tumor location on anterior wall and distance from the anus over 10 cm.