Nomogram to predict permanent stoma in rectal cancer patients after sphincter-saving surgery.

BACKGROUND: Approximately 20 percent of patients with a tumour localized in the low rectum still encounter the possibility of requiring permanent stoma (PS), which can cause drastic changes in lifestyle and physical perceptions. AIM: To determine the risk factors for PS and to develop a prediction model to predict the probability of PS in rectal cancer patients after sphincter-saving surgery. METHODS: A retrospective cohort of 421 rectal cancer patients who underwent radical surgery at Taipei Medical University Hospital between January 2012 and December 2020 was included in this study. Univariate and multivariate analyses were performed to identify the independent risk factors for PS. A nomogram was developed according to the independent risk factors obtained in the multivariate analysis. The performance of the nomogram was assessed using a receiver operating characteristic curve and a calibration curve. RESULTS: The PS rate after sphincter-saving surgery was 15.1% (59/391) in our study after a median follow-up of 47.3 mo (range 7-114 mo). Multivariate logistic regression analysis demonstrated that local recurrence, perirectal abscess, anastomosis site stenosis, perineural invasion, tumor size and operative time were independent risk factors for PS. These identified risk factors were incorporated into the nomogram, and the concordance index of this model was 0.903 (95%CI: 0.851-0.955). According to the calibration curves, the nomogram represents a perfect prediction model. CONCLUSION: Several risk factors for PS after sphincter-saving surgery were identified. Our nomogram exhibited perfect predictive ability and will improve a physician's ability to communicate the benefits and risks of various treatment options in shared decision making.

Comparative survival risks in patients undergoing abdominoperineal resection and sphincter-saving operation for rectal cancer: a 10-year cohort analysis using propensity score matching.

PURPOSE: Abdominoperineal resection (APR) has been considered to have a higher risk of local recurrence and poorer survival outcome than sphincter-saving operation (SSO) in patients with rectal cancer. This study compared long-term oncologic outcomes and prognostic parameters in propensity score-matched patients who underwent APR and SSO. METHODS: This study analyzed 958 consecutive patients with lower rectal cancer who underwent preoperative chemoradiotherapy followed by APR or SSO between 2005 and 2015. Propensity score matching analysis was performed to adjust baseline characteristics, including clinical stage, tumor distance from the anal verge, and tumor size. RESULTS: In the entire cohort, the APR group had larger and lower tumors and showed significantly shorter 5-year disease-free survival (DFS) than the SSO group (64.5% vs. 75.8%, p = 0.01). After propensity score matching, there were no significant between-group differences in local (9.5% vs. 8.0%, p = 0.59) and systemic (27.9% vs. 23.4%, p = 0.3) recurrence rates, and 5-year DFS (67.5% vs. 69.9%, p = 0.49) and overall survival (80.8% vs. 82.9%, p = 0.65) rates. A lower number of lymph nodes retrieved was independently associated with recurrence and survival outcomes in the APR group, whereas poorly differentiated histology was an independent associated parameter in the SSO group. Advanced stage and perineural invasion were identified as independent prognostic parameters in both groups. CONCLUSIONS: This study indicated that the long-term oncologic outcomes of APR were comparable to those of SSO. Because prognostic parameters associated with oncologic outcomes differed between the respective procedures, correctable parameters could be ameliorated through complete total mesorectal excision and personalized systemic treatment.

Sphincter-saving resection by cluneal arched skin incision for a gastrointestinal stromal tumor (GIST) of the lower rectum: a case report.

BACKGROUND: Planning the surgical strategy for a gastrointestinal stromal tumor (GIST) at the posterior wall of the lower rectum is difficult, as the procedures for the lower rectum are hampered by poor visualization and may cause anal dysfunction or discomfort. We report a novel procedure to resect a submucosal tumor of the rectum. CASE PRESENTATION: A 75-year-old woman presented with metrorrhagia. Endovaginal ultrasonography showed a low echoic tumor. Computed tomography showed an enhanced tumor, measuring 5.3 × 4.2 cm, behind the rectum. Magnetic resonance imaging revealed a submucosal tumor of the rectum, measuring 5.3 cm at its greatest dimension. Colonoscopy showed that the distal tumor margin was 1 cm above the dentate line. Core needle biopsy of the tumor revealed the rectal GIST. After receiving neoadjuvant imatinib treatment, the tumor size decreased to 3.5 cm. During the operation, we approached the rectum and resected the posterior rectal wall, including the 3.5 × 3.5 cm tumor with a safety margin, making an arched incision at the buttocks to form a skin flap with the patient in a jackknife position. The histopathological diagnosis was GIST of the rectum. Her anorectal sphincter function was well preserved. No recurrence was seen during the 2-year follow-up. CONCLUSIONS: This novel approach improves the operative field visibility in resecting a tumor with a safety margin and preserves a patient's anorectal sphincter function.

Management of Fistula-In-Ano with Special Reference to Ligation of Intersphincteric Fistula Tract.

CONTEXT: The surgical management of fistula-in-ano is still debatable and no clear recommendations have been made available until now. The present study analyses the results of ligation of intersphincteric fistula tract (LIFT) technique in treating fistula-in-ano in particular with recurrence, healing time, and continence status. AIMS: LIFT in the management of patients of fistula-in-ano of cryptoglandular origin. SETTINGS AND DESIGN: Prospective study. MATERIALS AND METHODS: This is a prospective study of 52 patients admitted from September 2012 to August 2014. Patients were managed with LIFT technique and results of LIFT technique were compared with other studies in terms of recurrence rate, incontinence rate, and other postoperative complications. RESULTS: A total of 52 patients were studied. Median follow-up was 24 weeks. Primary healing was achieved in 32 (71.11%) patients. Thirteen patients (28.88%) had a recurrence. No patient reported any subjective decrease incontinence after the procedure. CONCLUSIONS: LIFT technique is simple and easy to learn. With this method fistula-in-ano could be easily treated even at primary health care level. LIFT technique is a simple and novel modified approach for the treatment of fistula-in-ano with rapid healing rate and without any resultant incontinence.

Utility of indocyanine-green fluorescent imaging during robot-assisted sphincter-saving surgery on rectal cancer patients.

BACKGROUND: There have been few studies describing the use of indocyanine green (ICG) fluorescent imaging during robot-assisted (RA) sphincter-saving operations (SSOs) and assessing its potential role in reducing anastomotic leak (AL). METHODS: A consecutive cohort of 436 rectal cancer patients who underwent curative RA SSOs were prospectively enrolled during 2010-2014, including 123 patients with ICG imaging (ICG+ group) and 313 patients without ICG imaging (ICG- group). RESULTS: ICG imaging appeared to be helpful in identifying competent perfusion of the bowel adjacent to the anastomosis in 13 patients (10.6%) who might be susceptible to bowel ischaemia, including restrictive mesocolon. AL was remarkably greater in the ICG- group compared with the ICG+ group (5.4% vs 0.8%; p = 0.031). CONCLUSIONS: ICG imaging during RA SSO provides accurate real-time knowledge of the perfusion status at or near the anastomosis, specifically reducing AL in patients who may incur bowel ischaemia. Copyright © 2015 John Wiley & Sons, Ltd.

Tratamiento de la fístula anal mediante ligadura del trayecto fistuloso en el espacio interesfintérico con poliglactina 2-0: Estudio piloto / Treatment of anal fistula by ligation of intersphincteric fistula tract with 2-0 polyglactin: Pilot study

Objetivo: Determinar el porcentaje de curación y de continencia fecal (CF) con la ligadura interesfintérica del trayecto fistuloso (LIFT, por sus siglas en inglés: ligation of intersphinteric fistula tract) con poliglactina 2-0. Diseño: Estudio piloto, experimental, descriptivo y no comparativo. Sede: Unidad de Coloproctología del Hospital General de México (UCHGM). Análisis estadístico: Los resultados se presentan en tablas de frecuencia y porcentaje de acuerdo con cada variable estudiada. Material y métodos: De forma no probabilística y por conveniencia, se eligieron 14 pacientes con fístula anal (FA) compleja para tratamiento con la técnica de LIFT con poliglactina 2-0. Sólo a 10 pacientes se les pudo realizar LIFT. Se les dio seguimiento postoperatorio por 3 meses. Resultados: Sólo a 10 pacientes se les pudo realizar LIFT (71%), de los cuales el 50%, a los 3 meses, no presentó orificio fistuloso secundario (OFS) ni exudado; el 80% no tuvo dolor después de la cirugía y el 100% se integró a sus actividades laborales a las 2 semanas. Después de 3 meses, 5 pacientes continuaron con FA. De los 10 pacientes a los que se les realizó LIFT ninguno presentó incontinencia fecal (IF). Conclusión: La LIFT con poliglactina 2-0 es un procedimiento seguro, se logró realizar en el 71% de los candidatos seleccionados y con buena efectividad para la curación del 50%.

Objective: To determine the percentage of healing and fecal continence (FC) with the technique of ligation of intersphinteric fistula tract (LIFT) with 2-0 polyglactin. Design: Experimental, descriptive non-comparative pilot study. Setting: Coloproctology Unit of the General Hospital of Mexico. Statistical analysis: Results are presented in frequency and percentage tables according to each studied variable. Patients and methods: We chose randomly and by convenience 14 patients with complex anal fistula (AF) to be treated with the LIFT technique with 2-0 polyglactin. LIFT could only be performed in 10 patients. They were followed for 3 months after surgery. Results: LIFT could only be performed in 10 (71%) of the patients; of these, 50% did not present secondary fistulous orifice nor exudates; 80% had no pain after surgery, and 100% returned to their working activities after 2 weeks. After 3 months, five patients continued with AF. Of the 10 patients subjected to LIFT, none presented fecal incontinence. Conclusion: LIFT with 2-0 polyglactin is a safe procedure; it was possible to performe the procedure in 71% of the chosen candidates, with a good healing efficacy in 50% of the patients.