A study investigating the perfusion of colorectal anastomoses using fluorescence angiography: results of the FLAG randomized trial.

AIM: Our aim was to evaluate the efficacy of indocyanine green (ICG) fluorescence angiography (FA) in reducing the incidence of anastomotic leakage (AL) following colorectal anastomosis. METHOD: A single-centre randomized trial was undertaken between 2018 and 2019. Those patients who underwent a stapled colorectal anastomosis were randomized 1:1 for ICG FA versus visual clinical assessment of blood perfusion of the anastomosed colon and rectal stump (non-ICG FA group). The primary end-point was to assess whether ICG FA was associated with a reduction in the incidence of AL. Secondary outcomes were the rate of postoperative complications and change in the level of bowel resection. RESULTS: A total of 380 patients undergoing sigmoid and rectal resection were enrolled. After randomization, three patients were excluded. The results of 377 cases were available for analysis; 187 had ICG FA and 190 were in the non-ICG FA group. ICG FA identified impaired blood perfusion of the colon in 36 (19%) cases. An AL (grade A, B or C) developed in 48 patients: 17 (9.1%) in the ICG FA group and 31 (16.3%) in the non-ICG FA group (P = 0.04). ICG FA did not decrease the rate of AL of high anastomoses (9-15 cm from the anal verge), at 1.3% vs 4.6% in the non-ICG FA group (P = 0.37). In contrast, a decrease in AL rate was found for low (4-8 cm) colorectal anastomoses (14.4% in ICG FA vs 25.7% in the non-ICG FA group; P = 0.04). CONCLUSION: ICG FA is associated with a reduction in AL following low anterior resection.

[Early Rectal Cancer: Can Transanal Endoscopic Microsurgery (TEM) Become the Standard Treatment?]

Aim: Transanal endoscopic microsurgery (TEM) is a main treatment technique for rectal adenomas, but can also be used for selected malignant tumors. This study presents TEM experience. Methods: The study enrolled patients with rectal adenomas, and selected adenocarcinomas. Preoperative work-up included: digital rectal examination, rectoscopy with biopsy, colonoscopy, EUS, pelvic MRI. Results: Three hundred and thirty patients [mean age of 61,4±10 (33­88)] underwent TEM. The mean size ± SD of tumors was 3.2±1.2 cm (0.6­10.0). Mean distance from anal verge was 6.7±2.6 cm (2.0­14.0). Preoperative biopsy revealed: adenoma ­ 263/330 (79,7%), adenocarcinoma ­ 67/330 (20,3%). The median operating time was 40 (15­220) min. Tumor-free margins were obtained in all operative specimens. In 5/330 (1.5%) cases tumors were fragmented. The morbidity rate was 19/330 (5.7%). Pathological investigation revealed: adenoma in 192/330 (58.1%) cases, adenocarcinoma stage Tis, T1, T2 and T3 in 138/330 (41.9%). Median follow-up lasted for 24 (1­57) months. Five patients (2.0%) with adenoma and four patients (5.2%) with adenocarcinoma had local recurrence. Conclusion: Transanal endoscopic microsurgery for rectal adenomas and selected malignant tumors is associated with low morbidity and low recurrents rates.