Symptom palliation with QUAD Shot radiation therapy to penile metastasis derived from descending colon cancer: a case report.

A 54-year-old man was diagnosed with descending colon cancer with metastases in the liver, para-aortic lymph nodes, and penis, and chemotherapy was introduced after construction of a colostomy. The patient reported only mild penile pain at the time of diagnosis; however, the pain gradually worsened and interfered with his daily life. Opioids did not provide sufficient analgesia, and the patient developed dysuria and priapism. Through construction of a cystostomy, palliative radiotherapy with QUAD Shot regimen (14 Gy in 4 fractions twice-daily on 2 days repeated every 4 weeks) to the penile metastasis was started for pain relief and tumor shrinkage. The radiation rapidly improved the penile symptoms, enabling opioid reduction and cystostomy removal. The patient remained pain-free and able to urinate on his own until his death. Metastatic penile tumors are rare, especially those derived from colon cancer. Penile metastases occur mainly in the late stages of cancer and may impair the patient's quality of life. In such cases, palliative radiotherapy, especially with QUAD Shot regimen, is useful with short treatment time, durable symptom control, and little adverse effect, maintaining quality of life.

Recent evidence for subcutaneous drains to prevent surgical site infections after abdominal surgery: A systematic review and meta-analysis.

BACKGROUND: Surgical site infections (SSIs) increase mortality, hospital stays, additional medical treatment, and medical costs. Subcutaneous drains prevent SSIs in gynecological and breast surgeries; however, their clinical impact in abdominal surgery remains unclear. AIM: To investigate whether subcutaneous drains were beneficial in abdominal surgery using a systematic review and meta-analysis. METHODS: The database search used PubMed, MEDLINE, and the Cochrane Library. The following inclusion criteria were set for the systematic review: (1) Randomized controlled trial studies comparing SSIs after abdominal surgery with or without subcutaneous drains; and (2) Studies that described clinical outcomes, such as SSIs, seroma formation, the length of hospital stays, and mortality. RESULTS: Eight studies were included in this meta-analysis. The rate of total SSIs was significantly lower in the drained group (54/771, 7.0%) than in the control group (89/759, 11.7%), particularly in gastrointestinal surgery. Furthermore, the rate of superficial SSIs was slightly lower in the drained group (31/517, 6.0%) than in the control group (49/521, 9.4%). No significant differences were observed in seroma formation between the groups. Hospital stays were shorter in the drained group than in the control group. CONCLUSION: Subcutaneous drains after abdominal surgery prevented SSIs and reduced hospital stays but did not significantly affect seroma formation. The timing of drain removal needs to be reconsidered in future studies.

The gut microbiota composition in patients with right- and left-sided colorectal cancer and after curative colectomy, as analyzed by 16S rRNA gene amplicon sequencing.

BACKGROUND: Gut pathological microbial imbalance or dysbiosis is closely associated with colorectal cancer. Although there are observable differences in molecular and clinical characteristics between patients with right- and left-sided colon cancer, differences in their gut microbiomes have not been thoroughly investigated. Furthermore, subsequent changes in microbiota status after partial colectomy remain unknown. We examined the human gut microbiota composition to determine its relationship with colon cancer and partial colon resection according to location. METHODS: Stool samples from forty-one subjects (10 in the control group, 10 in the right-sided colon cancer [RCC] group, 6 in the sigmoid colon cancer [SCC] group, 9 in the right colon resection [RCR] group and 6 in the sigmoid colon resection [SCR] group) were collected, and DNA was extracted. After terminal restriction fragment length polymorphism (T-RFLP) analysis, the samples were subjected to 16S rRNA gene amplicon sequencing, and the metabolic function of the microbiota was predicted using PICRUSt2. RESULTS: T-RFLP analysis showed a reduced ratio of clostridial cluster XIVa in the SCC patients and clostridial cluster IX in the RCC patients, although these changes were not evident in the RCR or SCR patients. 16S rRNA gene amplicon sequencing demonstrated that the diversity of the gut microbiota in the RCC group was higher than that in the control group, and the diversity in the SCR group was significantly higher than that in the RCR group. Principal coordinate analysis (PCoA) revealed significant differences according to the group. Analyses of the microbiota revealed that Firmicutes was significantly dominant in the RCC group and that the SCC group had a higher abundance of Verrucomicrobia. At the genus level, linear discriminant analysis effect size (LEfSe) revealed several bacteria, such as Ruminococcaceae, Streptococcaceae, Clostridiaceae, Gemellaceae, and Desulfovibrio, in the RCC group and several oral microbiomes in the SCC group. Metabolic function prediction revealed that cholesterol transport- and metabolism-related enzymes were specifically upregulated in the RCC group and that cobalamin metabolism-related enzymes were downregulated in the SCC group. CONCLUSION: Gut microbial properties differ between RCC and SCC patients and between right hemicolectomy and sigmoidectomy patients and may contribute to clinical manifestations.

The Japan Society for Surgical Infection: guidelines for the prevention, detection, and management of gastroenterological surgical site infection, 2018.

BACKGROUND: The guidelines for the prevention, detection, and management of gastroenterological surgical site infections (SSIs) were published in Japanese by the Japan Society for Surgical Infection in 2018. This is a summary of these guidelines for medical professionals worldwide. METHODS: We conducted a systematic review and comprehensive evaluation of the evidence for diagnosis and treatment of gastroenterological SSIs, based on the concepts of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. The strength of recommendations was graded and voted using the Delphi method and the nominal group technique. Modifications were made to the guidelines in response to feedback from the general public and relevant medical societies. RESULTS: There were 44 questions prepared in seven subject areas, for which 51 recommendations were made. The seven subject areas were: definition and etiology, diagnosis, preoperative management, prophylactic antibiotics, intraoperative management, perioperative management, and wound management. According to the GRADE system, we evaluated the body of evidence for each clinical question. Based on the results of the meta-analysis, recommendations were graded using the Delphi method to generate useful information. The final version of the recommendations was published in 2018, in Japanese. CONCLUSIONS: The Japanese Guidelines for the prevention, detection, and management of gastroenterological SSI were published in 2018 to provide useful information for clinicians and improve the clinical outcome of patients.

Association between preoperative tumor necrosis factor alpha inhibitor and surgical site infection after surgery for inflammatory bowel disease: a systematic review and meta-analysis.

Tumor necrosis factor-alpha inhibitor (TNFi) treatment is effective for ulcerative colitis (UC) and Crohn's disease (CD). Although several meta-analyses have been performed to evaluate the association between TNFi treatment and surgical morbidity, the results are controversial. We conducted a systematic review and meta-analysis of the prevention of surgical site infection (SSI) after surgery for UC and CD in patients on TNFis, based on literature published between January 2000 and May 2019 (registered on PROSPERO, No. CRD42019134156). Overall, 2175 UC patients in 13 observational studies (OBSs) and 7084 CD patients in 16 OBSs were included. The incidences of incisional (INC) SSI and organ/space (O/S) SSI after surgery for UC were 179/1985 (9.0%) and 176/2175 (8.1%), respectively. TNFi use was not associated with the incidences of INC SSI (odds ratio (OR) 1.04, 95% confidence interval (CI) (0.47-2.32) or O/S SSI (OR 1.85, 95% CI (0.82-4.20)) after surgery for UC. The INC SSI and O/S SSI incidences after surgery for CD were 289/3089 (9.4%) and 526/7,084 (7.4%), respectively. Preoperative TNFi use was not associated with INC SSI (OR 0.98, 95% CI (0.52-1.83)) or O/S SSI incidence (OR 1.09, 95% CI (0.78-1.52)) after surgery for CD. We did not find a significant association between preoperative TNFi use and SSI in surgery for UC or CD.

Preoperative heat shock protein 47 levels identify colorectal cancer patients with lymph node metastasis and poor prognosis.

Accumulating evidence suggests that overexpression of heat shock protein 47 (HSP47) increases cancer progression, and that HSP47 level in the tumor-associated stroma may serve as a diagnostic marker in various cancers. The present study aimed to evaluate whether HSP47 gene expression in colorectal cancer (CRC) tissues could be used to identify lymph node (LN) metastasis status preoperatively in patients with CRC. To do so, HSP47 gene expression was determined and its association with the clinicopathological characteristics of patients with CRC was analyzed. A total of 139 surgical specimens from patients with CRC and 36 patients with benign colonic disease undergoing surgery at Mie University Hospital were analyzed. HSP47 gene expression was determined by reverse transcription quantitative PCR using Power SYBR Green PCR methods. Expression level of HSP47 was significantly higher in CRC tissues compared with normal tissue from patients with benign colonic disease. Furthermore, high HSP47 expression was significantly associated with tumor progression, including high T stage, lymph node metastasis and venous invasion, and high TNM stage. High HSP47 expression may therefore serve as a novel predictive biomarker for determining patients with CRC and LN metastasis. According to Kaplan-Meier analysis, patients with high HSP47 expression level had significantly poorer overall survival than those with low HSP47 expression level. Furthermore, multivariate analyses identified HSP47 expression as an independent predictive marker for LN metastasis and poor overall survival in patients with CRC. In summary, the present study demonstrated that HSP47 expression may be considered as a novel biomarker for predicting LN metastasis status and prognosis in patients with CRC.

Downregulation of trefoil factor-3 expression in the rectum is associated with the development of ulcerative colitis-associated cancer.

Diagnostic markers facilitate more selective screening and treatment strategies for ulcerative colitis (UC)-associated cancer (UCAC). The expression of trefoil factor-3 (TFF3), which is involved in mucosal protection and repair in the gastrointestinal tract, was analyzed and its significance for UCAC was evaluated. A total of 145 patients with UC who underwent proctocolectomies were enrolled, including 15 patients (10.8%) with UCAC. TFF3 expression in the rectal mucosa and in cancer cells was assessed using immunohistochemistry, and the expression in UCAC and sporadic colorectal cancer was compared. Analyzing the mucinous granules of goblet cells located in crypts revealed that the non-cancerous rectal mucosa of patients with UCAC had significantly lower mean TFF3 staining scores compared with patients with UC without UCAC or patients with sporadic cancer. TFF3 staining score was revealed to be an independent predictor of UCAC development. These results indicated that low TFF3 expression in the rectal mucosa was associated with the development of UCAC. Thus, TFF3 expression in the rectal mucosa may be a useful biomarker for monitoring patients with UC.

The Efficacy of Antimicrobial-Coated Sutures for Preventing Incisional Surgical Site Infections in Digestive Surgery: a Systematic Review and Meta-analysis.

BACKGROUND: Antimicrobial-coated sutures have recently become well known for preventing surgical site infections (SSIs). However, the evidence and recommendations from some organizations remain controversial. Therefore, we conducted a systematic review and meta-analysis to analyze the efficacy of antimicrobial-coated sutures for preventing SSIs in digestive surgery. METHODS: We performed a systematic review of literature published from 2000 to 2017 (registered on PROSPERO, No. CRD42017076780). We included studies defined as randomized controlled trials (RCTs) and observational studies (OBSs) for the prevention of SSIs and the reduction in hospital stay length associated with digestive surgery. RESULTS: In the 10 RCTs, the incidence rates of incisional SSIs were 160/1798 (8.9%) with coated sutures and 205/1690 (12.1%) with non-coated sutures. Overall, antimicrobial-coated sutures were superior for reducing the incidence of incisional SSI (risk ratio (RR) 0.67, 95% confidence intervals (CI) 0.48-0.94, p = 0.02) in RCTs for digestive surgery with the mixed wound class and surgeries limited to a clean-contaminated wound (RR 0.66, 95% CI 0.44-0.98, p = 0.04). A superior effect of antimicrobial-coated sutures was found in 9 RCTs that involved only colorectal surgeries (RR 0.69, 95% CI 0.49-0.98, p = 0.04). The mean hospital stay length was similar with coated or uncoated sutures in 5 RCTs involving colorectal surgery (mean difference (MD) - 5.00, 95% CI 16.68-6.69, p = 0.4). CONCLUSION: Antimicrobial-coated sutures are significantly more efficacious for preventing SSIs during digestive and colorectal surgery, even when restricted to clean-contaminated wounds. However, the hospital stay length was not affected.

Monitoring perioperative serum albumin can identify anastomotic leakage in colorectal cancer patients with curative intent.

BACKGROUND: Preoperative hypoalbuminemia is a well-known risk factor for anastomotic leakage after colorectal surgery, but the association between perioperative albumin level and anastomotic leakage has not been fully investigated in curative colorectal cancer (CRC) patients. METHODS: In total, 200 CRC patients (Stage I-III) undergoing curative laparoscopic surgery between January 2004 and December 2013 were enrolled in this study. We collected data on surgical factors, perioperative levels of serum albumin and inflammatory markers, and perioperative factors affecting hypoalbuminemia from 196 CRC patients to assess the relation to anastomotic leakage. RESULTS: Anastomotic leakage occurred in 11 cases (5.6%) and the frequency was higher in rectal cancer patients (p = 0.0044). There was no significant difference of preoperative serum albumin level between the anastomotic leakage group (AL) and the nonanastomotic leakage group (NAL). Postoperative serum albumin levels in AL were significantly lower than in NAL [postoperative day (POD) 0, p = 0.0004; POD1, p = 0.0001; POD3, p = 0.0004; and POD7, p = 0.0021]. On multivariate analysis, lower average level of serum albumin on POD1 and POD3 {odds ratio (OR) [95% confidence interval (CI)] = 7.53 (1.60-55.80), p = 0.0095}, higher average level of serum white blood cells on POD1 and POD3 [OR (95% CI) = 7.24 (1.40-59.25), p = 0.0165], and surgery for rectal cancer [OR (95% CI) = 15.18 (3.26-93.99), p = 0.0004] were independent risk factors for anastomotic leakage. CONCLUSION: Lower early postoperative serum albumin levels are a potentially valuable indicator of anastomotic leakage in CRC patients undergoing curative surgery.

Colonic Histological Criteria Predict Development of Pouchitis after Ileal Pouch: Anal Anastomosis for Patients with Ulcerative Colitis.

BACKGROUND/AIMS: Pouchitis is one of the main complications after ileal pouch-anal anastomosis in patients with ulcerative colitis. The aim of this study was to determine whether the use of colonic histological criteria can predict the development of pouchitis. METHODOLOGY: We retrospectively reviewed 147 patients' clinical data and performed a histological evaluation of the resected total colon using Tanaka's criteria, which comprise the following 6 factors: ulceration (H1), crypt abscesses (H2), degree of mononuclear cell infiltration (MNCI) (H3), segmental distribution of MNCI (H4), eosinophil infiltration (H5), and extent of disease of resected colon (H6). RESULTS: The development of pouchitis and chronic pouchitis within 3 years after restoration of gastrointestinal continuity was recognized in 52 (35.4%) and 26 (17.7%) of the 147 patients, respectively. Using various combinations of each score, the H3 + H4 - H5 scores of patients with pouchitis or chronic pouchitis were significantly higher than those of patients without. A H3 + H4 - H5 score of >0.4 was a statistically significant risk factor for the development of both pouchitis and chronic pouchitis. CONCLUSIONS: The combination of the degree of MNCI, segmental distribution of MNCI, and eosinophil infiltration from histological criteria has utility in predicting the future development of pouchitis, especially chronic pouchitis.

Prevalence of anastomotic leak and the impact of indocyanine green fluorescein imaging for evaluating blood flow in the gastric conduit following esophageal cancer surgery.

BACKGROUNDS AND AIM: Anastomotic leak (AL) following esophagectomy for esophageal cancer (EC) remains an important cause of prolonged hospitalization and impaired quality of life. Recently, indocyanine green (ICG) fluorescein imaging has been used to evaluate the gastric conduit blood supply during EC surgery. Although several factors have been reported to be associated with AL, no studies have evaluated the relationships between risk factors for AL, including ICG fluorescein imaging. The purpose of this study was to investigate the risk factors associated with AL following esophagectomy and to evaluate the impact of ICG fluorescein imaging of the gastric conduit during EC surgery. METHODS: One hundred and twenty patients undergoing esophagectomy with esophagogastric anastomosis for EC were enrolled in this retrospective study. Clinicopathological factors, preoperative laboratory variables, and surgical factors, including ICG fluorescence imaging, were analyzed to determine their association with AL. Univariate and multivariate logistic regression analysis was used to evaluate the impact of each of these factors on the incidence of AL. RESULTS: Among the 120 patients enrolled in the study, 10 (8.3%) developed AL. Univariate analysis demonstrated an increased risk of AL in patients with a high-neutrophil-to-lymphocyte ratio (p = 0.0500) and in patients who did not undergo ICG fluorescein imaging (p = 0.0057). Multivariate analysis revealed that the absence of ICG imaging was an independent risk factor for AL (p = 0.0098). CONCLUSIONS: Using ICG fluorescein imaging to evaluate blood flow in the gastric conduit might decrease the incidence of AL following EC surgery.

Fish oil-enriched nutrition combined with systemic chemotherapy for gastrointestinal cancer patients with cancer cachexia.

Despite recent advances in chemotherapy for gastrointestinal cancer, a crucial factor related to poor prognosis is reduced tolerance to chemotherapy induced by cancer cachexia. Fish oil (FO)-derived eicosapentaenoic acid (EPA) modulates inflammation in patients with various malignancies; however, the impact of FO-enriched nutrition as a combined modality therapy on clinical outcomes remains controversial. We systemically analysed chronological changes in biochemical and physiological status using bioelectrical impedance analysis in 128 gastrointestinal cancer patients provided with or without FO-enriched nutrition during chemotherapy. Furthermore, we evaluated the clinical significance of FO-enriched nutrition and clarified appropriate patient groups that receive prognostic benefits from FO-enriched nutrition during treatment of gastrointestinal cancer. The control group showed significant up-regulation of serum CRP) levels and no significant difference in both skeletal muscle mass and lean body mass. In contrast, the FO-enriched nutrition group showed no changes in serum CRP concentration and significantly increased skeletal muscle mass and lean body mass over time. Furthermore, high CRP levels significantly correlated with reduced tolerance to chemotherapy, and FO-enriched nutrition improved chemotherapy tolerance and prognosis, particularly in gastrointestinal cancer patients with a modified Glasgow prognostic score (mGPS) of 1 or 2. We conclude that FO-enriched nutrition may improve the prognosis of patients with cancer cachexia and systemic inflammation (i.e., those with a mGPS of 1 or 2).

Laparoscopic ileopexy for afferent limb syndrome after ileal pouch-anal anastomosis.

Afferent limb syndrome (ALS) is caused by an obstruction of the afferent intestinal limb after ileal pouch-anal anastomosis. Here, we describe the first case of ALS to be successfully treated by a laparoscopic approach. A 27-year-old man underwent ileal pouch-anal anastomosis for ulcerative colitis. He was subsequently diagnosed with ALS and underwent ileopexy with laparotomy at 33 years old. Then, 21 months after the first ileopexy, he underwent laparoscopic ileopexy for ALS recurrence. The operative findings revealed a shortened fixed portion of the afferent limb adhering to the right pelvic retroperitoneum, which was regarded as the cause of the acute angulation. The portion of the afferent limb fixed to the abdominal wall was extended under laparoscopic visualization by suturing above the level of the iliac crest. At the 12-month follow-up, the patient remained free of symptoms of obstruction. Laparoscopic ileopexy should be the procedure of choice for patients with ALS.

Clinical burden of preoperative albumin-globulin ratio in esophageal cancer patients.

BACKGROUND: Lower albumin-globulin ratio (AGR) is associated with increased mortality in several cancers. However, no studies have evaluated the relationship between the AGR and prognostic outcome in esophageal cancer (EC) patients. METHODS: To identify indicators of early recurrence and poor prognosis, we assessed the clinicopathological findings and preoperative laboratory data (carcinoembryonic antigen [CEA], squamous cell carcinoma antigen, total protein, and albumin) of 112 EC patients who underwent surgery. The AGR was calculated as albumin/(total protein-albumin). RESULTS: A lower AGR was significantly associated with tumor progression. The CEA level was an independent predictor for overall survival (OS) and disease-free survival (DFS). The AGR and CEA combination was identified as a feasible indicator of poor prognosis and early recurrence. Among EC patients without lymph node metastasis, those with lower AGR had poorer DFS and OS than those with higher AGR. CONCLUSION: AGR was identified as a significant predictor of OS and DFS in EC patients. Among EC patients without lymph node metastasis, AGR may help identify candidates who might benefit from more intensive adjuvant therapy.

Prognostic Impact of Preoperative Albumin-to-Globulin Ratio in Patients with Colon Cancer Undergoing Surgery with Curative Intent.

AIM: To identify predictors of poor prognosis of patients with colon cancer (CC) who underwent surgery with curative intent, we investigated the association between the albumin to globulin ratio (AGR) with clinicopathological findings such as overall (OS) and disease-free (DFS) survival. PATIENTS AND METHODS: We conducted a retrospective study of clinicopathological findings, including preoperative laboratory data, for 248 patients with stage I-III CC. RESULTS: Patients with low AGR had shorter DFS and OS compared to those with high AGR. Multivariate analyses identified low AGR as an independent variable independently associated with recurrence and poor prognosis of patients with CC who underwent surgery with curative intent regardless of lymphnode metastasis. CONCLUSION: The preoperative AGR was an independent predictor of recurrence and poor prognosis of patients with CC who underwent surgery with curative intent. The AGR indicates that these patients may benefit from intensive adjuvant therapy.

Inflammation-based prognostic scores as indicators to select candidates for primary site resection followed by multimodal therapy among colorectal cancer patients with multiple metastases.

BACKGROUND: Although patients with metastatic colorectal cancer (CRC) are often unable to undergo treatment after resection of primary tumors, identifying such patients before surgery is not easy. In this study, we evaluated the association among clinicopathological findings, survival outcomes, and ability to undergo multimodal therapy after primary tumor resection in patients with Stage IV CRC. METHODS: We collected clinicopathological findings and preoperative laboratory data, including carcinoembryonic antigen (CEA) and systemic inflammatory response markers for 92 patients who were treated for Stage IV CRC between 2005 and 2014. We used multivariate analysis on factors that affect prognosis and ability to undergo postoperative treatment. RESULTS: Postoperative multimodal therapy improved overall survival (OS) significantly. Among serum markers, elevated CEA, neutrophil-to-lymphocyte ratio, and modified Glasgow prognosis score (mGPS) were significant indicators of shorter OS. In multivariate analysis, low performance status (P = 0.003), undifferentiated histology type (P = 0.019), and elevated mGPS (P = 0.042) were independent predictors of worse prognosis; and older age (P = 0.016), right-sided colon cancer (P = 0.043), and elevated mGPS (P = 0.031) were independent risk factors for difficulty of introducing postoperative multimodal therapy. CONCLUSIONS: Preoperative mGPS is a useful objective indicator for CRC patients with multiple metastases who are able to undergo primary site resection followed by postoperative multimodal therapy.

Risk factors for recurrence of Crohn's disease requiring surgery in patients receiving post-operative anti-tumor necrosis factor maintenance therapy.

OBJECTIVES: Anti-tumor necrosis factor (TNF) antibodies have shown efficacy in the prevention of recurrence of Crohn's disease after intestinal resection. However, some patients develop surgical recurrence despite this therapy. We aimed to evaluate the risk factors for recurrence of Crohn's disease requiring surgery while receiving post-operative anti-TNF therapy. METHODS: We performed a retrospective evaluation of 164 patients who had received post-operative anti-TNF maintenance therapy between 2002 and 2016. We classified Crohn's disease-related re-operation as surgical recurrence and analyzed its risk factors using the Cox proportional hazard model. RESULTS: Of the 164 participants, 128 had received infliximab and 36 had received adalimumab maintenance therapy. We obtained follow-up data over a mean of 60.2 months. The proportion of patients with surgical recurrence at 5 years was 14.9%. The only independent risk factor for surgical recurrence, which we identified was post-operative smoking habit (odds ratio, 5.03; 95% CI, 1.14-12.8; P=0.033). CONCLUSIONS: Post-operative smoking may be a significant risk factor for post-operative surgical recurrence of Crohn's disease while receiving anti-TNF maintenance therapy.

Complete laparoscopic total mesorectal excision with an intersphincteric resection and coloplasty pouch anal anastomosis for lower rectal cancer.

This pilot study aimed to develop a new technique, complete laparoscopic total mesorectal excision (TME) with an intersphincteric resection (ISR) and coloplasty pouch anal anastomosis to avoid any further abdominal incision other than laparoscopic port sites, and to assess the impact on short-quality of life and oncological outcomes of this technique. After laparoscopic TME, large bowel was dissected at the level of the promontory. Then, laparoscopic construction of the coloplasty pouch was performed. Simultaneously, a rectal specimen with ISR was excised using the transanal approach. Coloplasty pouch was gently pulled from pelvic thorough anal and a hand-sewn coloplasty pouch anal anastomosis was created. We had performed 8 surgeries using the new technique. Though one patient developed pelvic infections, but intestinal continuity could be maintained and no local and distant recurrence was recognized in other patients. We foresee this novel approach to have significant clinical potential for lower rectal cancer patients with ISR.