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Aim: Even if a defunctioning stoma mitigates the serious consequences of anastomotic leakage after total mesorectal excision (TME) for rectal cancer, the presence of a temporary stoma or having a stoma for a prolonged period of time may also be a determining factor for further morbidities and poor bowel function. The aim of this study was to evaluate the impact of diverting stomas on clinical and functional outcomes after TME, comparing ileostomy or colostomy effects. Methods: All consecutive patients who underwent TME for rectal cancer between March 2017 and December 2020 in three Italian referral centres were enrolled in the present study. For every patient sex, age, stage of the tumour, neoadjuvant therapy, surgical technique, anastomotic technique, the presence of a diverting stoma, perioperative complications and functional postoperative status were recorded. Considering the diverting stoma, the kind of stoma, length of time before closure and stoma related complications were evaluated. Results: During the study period 416 consecutive patients (63% men) were included. Preoperative neoadjuvant therapy was performed in 79%. A minimally invasive approach was performed in >95% of patients. Temporary stoma was performed during the operation in 387 patients (93%) (ileostomy 71%, colostomy 21%). The stoma was closed in 84% of patients. The median time from surgery to stoma closure was 145 days. No difference was found between ileostomy and colostomy in overall morbidity after stoma creation and closure. Moreover, increased postoperative functional disturbance seemed to be significantly proportional to the attending time for closure for ileostomy. Conclusion: The presence of a defunctioning stoma seems to have a negative impact on functional bowel activity, especially for delayed closure for ileostomy. This should be considered when the kind of stoma (ileostomy vs. colostomy) is selected for each patient. [ABSTRACT FROM AUTHOR]

Aim: Delayed closure of ileostomy following an anterior resection for rectal cancer in the UK is common. The aims of this study were (i) to investigate the variation in patient pathways between hospitals, (ii) to identify the key learning points from units with the shortest time to closure and (iii) to develop guidance for a pathway to minimize delay in ileostomy closure. Method: This was a mixed methods study. Thirty-eight colorectal units in the UK completed a short online survey. Nine colorectal units in Wales filled in an additional, expanded version of the survey. Semi-structured interviews were performed with clinicians from the six best performing units in terms of timely ileostomy closure. The optimal pathway suggested is based on the best evidence available and the Association of Coloproctology of Great Britain and Ireland guidelines. Results: Qualitative analysis revealed that 5% of units (n = 2) have a local target time for ileostomy closure. Of all units, 90% (n = 34) would consider implementing a pathway if guidelines were developed. In-depth interviews highlighted the importance of a multidisciplinary approach, a dedicated coordinator to facilitate timely booking, and consensus on whether closure should be performed before or after adjuvant chemotherapy. Conclusion: There is a lack of national guidance in timing of contrast studies and ileostomy closure. Key aspects to consider are better information at consent regarding stoma closure timing, a dedicated person to track patients and the planning of contrast studies at discharge from initial surgery. With a dedicated approach closure of ileostomy within 10–12 weeks is feasible for most units. [ABSTRACT FROM AUTHOR]

Aim: The aim of this study was to investigate changes in bowel function and anorectal physiology (ARP) after anterior resection for colorectal cancer. Method: Patients were recruited from November 2006 to September 2008. Cleveland Clinic Incontinence (CCI) scores and stool frequency were determined by patient questionnaires before surgery (t0) and at three (t3), six (t6), nine (t9) and 12 (t12) months after restoration of intestinal continuity. ARP measurements were recorded at T0, T3 and T12. Endoanal ultrasound was performed at T0 and T12. Results: Eighty‐nine patients were included. CCI score increased postoperatively then normalized, whereas stool frequency did not change. Patients who had neoadjuvant radiotherapy or a lower anastomosis had increased incontinence and stool frequency in the postoperative period, whereas those with defunctioning stomas or open surgery had increased stool frequency alone. Maximum resting pressure, volume at first urge and maximum rectal tolerance were reduced throughout the postoperative period. Radiotherapy, lower anastomosis and defunctioning stoma (but not operative approach) altered manometric parameters postoperatively. Maximum rectal tolerance correlated with incontinence and first urge with stool frequency. The length of the anterior internal anal sphincter decreased postoperatively. Conclusions: Incontinence recovers in the first year after anterior resection. Radiotherapy, lower anastomosis, defunctioning stoma and open surgery have a negative influence on bowel function. ARP may be useful if bowel dysfunction persists beyond 12 months. [ABSTRACT FROM AUTHOR]

Aim: Surgeons have concerns whether high ligation (HL) of the inferior mesenteric artery (IMA) increases the incidence of anastomotic leakage (AL). This meta‐analysis aimed to evaluate the influence of HL of the IMA on AL compared with low ligation (LL). Methods: PubMed, Embase, Web of Science, Cochrane Central Register of Controlled Trials and ClinicalTrials.gov databases were searched. Randomized controlled trial studies that compared HL with LL of the IMA in anterior resection for rectal cancer and reported AL outcomes were eligible for inclusion. The odds ratios and mean differences were analysed by a random‐effects model. Trial sequential analysis was performed to minimize the risk of random errors. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to evaluate the quality of evidence for outcomes. Results: Of the 531 records screened, five randomized controlled trials with 779 patients were selected for analysis. The pooled incidence of AL was 12.1% (95% Cl 7.77–18.26) in the HL group and 9.7% (95% Cl 5.79–15.82) in the LL group (OR 1.20, 95% CI 0.77–1.87, P = 0.42). In trial sequential analysis, the cumulative Z‐score curve exceeded the futility boundary, although the required information size of 1060 had not been reached. The quality of evidence was judged to be high according to the GRADE approach. Conclusions: This meta‐analysis shows that HL of the IMA does not increase the incidence of AL in anterior resection for rectal cancer. [ABSTRACT FROM AUTHOR]

Aim : To assess the effectiveness of transanal irrigation (TAI) compared with posterior tibial nerve stimulation (PTNS) in severe and chronic low anterior resection syndrome (LARS). Method : A two‐group parallel, open‐label randomized controlled trial carried out in a single university hospital. The study population included patients with a LARS scale score of more than 29 points who had undergone rectal surgery more than 1 year previously. These were randomly allocated, with a central randomization system, following a 1:1 sequence to TAI or PTNS. The main study outcome was to achieve a reduction of at least one LARS grade in at least 50% of the patients, for each intervention. Results : A total of 27 patients (TAI = 13, PTNS = 14) were randomized. Both groups were similar with regard to confounding factors. Four patients were excluded because of intercurrent disease or early dropout, leaving 23 (TAI, n = 10; PTNS, n = 13) for analysis. Eight out of 10 and 4 out of 13 patients were downgraded with TAI and PTNS, respectively. The median LARS score decreased from 35 [interquartile range (IQR) 32–39] to 12 (IQR 12–26) (P = 0.021) for the TAI group and from 35 (IQR 34–37) to 30 (IQR 25–33) (P = 0.045) for the PTNS group. The Vaizey score fell from 15 (IQR 11–18) to 6 (IQR 4–7) (P = 0.037) and from 14 (IQR 13–17) to 9 (IQR 7–10) (P = 0.007) with TAI and PTNS, respectively, with 80% and 38% of patients, respectively, showing decreases of more than 50%. Improvement in quality of life was observed in both groups. Conclusion : Both treatments improved the LARS score in this study but this was only significant in the TAI group. [ABSTRACT FROM AUTHOR]

Aim: Low anterior resection syndrome (LARS) can affect up to 70% of all patients with rectal cancer. In the last two decades, sacral nerve stimulation (SNS) has emerged as an effective treatment for faecal incontinence. There is some encouraging literature on the use of SNS in patients with LARS. The purpose of this review is to provide an up to date review on the utility of SNS on LARS. Method: A literature search was conducted using the MEDLINE, Embase and PubMed databases (January 1981–March 2019). Studies identified were appraised with standard selection criteria. Data points were extracted, and meta‐analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses. Results: Ten studies met the inclusion criteria and were included in this study. All studies used the Cleveland Clinic Incontinence Score (CCIS), whereas the low anterior resection syndrome score (LARS score) was used in three studies. Overall median improvement in the scoring system was 67.0% (range 35.5%–88.2%) after SNS implantation. There was a significant reduction in CCIS after SNS implantation (mean difference 11.23, 95% confidence interval 9.38–13.07, Z = 11.90, P < 0.00001). The LARS score was also significantly reduced after using SNS in patients with LARS (mean difference 17.87, 95% confidence interval 10.15–25.59, Z = 4.54, P < 0.00001). Conclusion: Use of SNS may provide symptomatic benefits for patients with LARS refractory to medical therapy. However, the current level of evidence remains limited. A large multicentre study of SNS for LARS using the validated LARS score is warranted. In addition, the cost‐effectiveness of SNS for patients with LARS needs further exploration. [ABSTRACT FROM AUTHOR]

Aim: This study investigates how often bowel continuity was restored after anastomotic leakage in anterior resection for rectal cancer and assesses the clinical factors associated with permanent stoma. Method: The Swedish Colorectal Cancer Registry was used to identify cases of anastomotic leakage registered in southern Sweden between January 2001 and December 2011. Patient characteristics, surgical details and clinical information about the anastomotic leakages were retrieved from medical records. Results: Of the 1442 patients operated on with anterior resection in 11 hospitals, 144 (10%) were diagnosed with anastomotic leakage after anterior resection for rectal cancer. After a median follow‐up of 87 months (range 21–165), the overall rate of permanent stoma among patients with anastomotic leakage was 65%. Age ≥ 70 years (P = 0.02) and re‐laparotomy (P < 0.001) were independently related to permanent stoma. Compared with nondefunctioned patients with anastomotic leakage, defunctioned patients with anastomotic leakage at the index procedure less often required re‐laparotomy at some point during the entire clinical course (P < 0.001), but nondefunctioned and defunctioned patients with anastomotic leakage both had permanent stoma to the same extent (67% and 62%, respectively). Conclusion: Anastomotic leakage is highly associated with permanent stoma after anterior resection, especially in patients aged ≥ 70 years. In this cohort of patients with anastomotic leakage, 65% had permanent stoma at long‐term follow‐up. A defunctioning stoma ameliorates the clinical course but does not affect the end result of bowel continuity in established anastomotic leakage after anterior resection. [ABSTRACT FROM AUTHOR]

Abstract: Aim: Anastomotic leakage (AL) is common after anterior resection (AR). Long term clinical outcomes of AL including late presenting leakage (LL) are not well studied. This study was undertaken to assess clinical features of LL with respect to incidence, association with predisposing factors and need for re‐intervention. Methods: The Swedish Colorectal Cancer Registry (SCRCR) was explored for AL cases after AR for rectal cancer in patients operated in the south of Sweden from 1 January 2001 to 31 December 2011. Demographic data, surgical technical details, number of postoperative days (POD) until diagnosis of AL, presenting symptoms, methods of diagnosis and treatment were retrieved from medical records. LL was defined according to different cut‐offs as leakages occurring after hospital discharge (LLAHD), after 30 POD (LL ≥ POD 30) and after 90 POD (LL ≥ POD 90). Results: In total, 1442 patients were operated on with AR of whom 144 cases of AL (10%) were identified. Median time from operation to follow‐up was 87 months (range 21–162). LLAHD, LL ≥ POD 30 and LL ≥ POD 90 were present in 51%, 24% and 9% respectively. All categories of LL were associated with a defunctioning stoma. Relaparotomy was significantly less often employed in LLAHD, but not in other categories of LL. Conclusion: LL constitutes a substantial portion of all AL after AR for rectal cancer. The large proportion of LLAHD calls for awareness in the outpatient setting. [ABSTRACT FROM AUTHOR]

Aims The objective of this study was to evaluate the surgical outcomes and feasibility of early loop defunctioning ileostomy closure, within 2 weeks of index surgery, in patients undergoing distal colorectal resection. Methods A systematic review of the literature on published randomized controlled trials reporting the feasibility and outcomes on early vs delayed closure of loop defunctioning ileostomy in patients undergoing distal colorectal resection using the principles of meta-analysis on RevMan 5.4 statistical software was undertaken. Results Four randomized, controlled trials on 446 patients evaluating the feasibility and outcomes on early vs delayed closure of loop defunctioning ileostomy in patients undergoing low colorectal resection were analysed. There were 176 patients in the early closure group and 270 patients in the delayed closure group. The risk of anastomotic leak [risk ratio 0.37 (CI: 0.10-1.42), P = 0.15], anastomotic stenosis [risk ratio 4.79 (CI: 0.23-98.47), P = 0.31] and postoperative complications [risk ratio 0.75 (CI: 0.48-1.16), P = 0.19] was similar in both groups. In addition, there was no significant difference between the groups with regard to the duration of operation [standardized mean difference −0.49 (CI: −01.09, −0.12), P = 0.12] and length of hospitalization [standardized mean difference −0.04 (CI: −0.25, −0.18), P = 0.75]. Conclusions Early closure of loop defunctioning ileostomy in patients undergoing distal colorectal resection is feasible with comparable outcomes to delayed closure. [ABSTRACT FROM AUTHOR]

Aim To determine the incidence of internal hernias after laparoscopic colorectal surgery and evaluate the risk factors and strategies in the management of this serious complication. Method Two databases ( MEDLINE from 1946 and Embase from 1949) were searched to mid-September 2015. The search terms included volvulus or internal hernia and laparoscopic colorectal surgery or colorectal surgery or anterior resection or laparoscopic colectomy. We found 49 and 124 articles on MEDLINE and Embase, respectively, an additional 15 articles were found on reviewing the references. After removal of duplicates, 176 abstracts were reviewed, with 33 full texts reviewed and 15 eligible for qualitative synthesis. Results The incidence of internal hernia after laparoscopic colorectal surgery is low (0.65%). Thirty-one patients were identified. Five cases were from two prospective studies (5/648, 0.8%), 20 cases were from seven retrospective studies (20/3165, 0.6%) and six patients were from case reports. Of the 31 identified cases, 21 were associated with left-sided resection, four with right sided resection, two with transverse colectomy, one with a subtotal colectomy and in three cases the operation was not specified. The majority of cases (64.3%) were associated with a restorative left sided resection. Nearly all cases occurred within 4 months of surgery. All patients required re-operation and reduction of the internal hernia and 35.7% of cases required a bowel resection. In 52.2% of cases, the mesenteric defect was closed at the second operation and 52.6% of cases were successfully managed laparoscopically. There were three deaths (0.08%). Conclusion Mesenteric hernias are a rare but important complication of laparoscopic colorectal surgery. The evidence does not support routine closure for all cases, but selective closure of the mesenteric defect during left-sided restorative procedures in high-risk patients at the initial surgery may be considered. [ABSTRACT FROM AUTHOR]

Aim It is controversial whether a high or low ligation of the inferior mesenteric artery ( IMA) is superior. The former allows an extended lymph node clearance whereas the latter preserves the distal vascular supply via the left colic artery ( LCA). Apical lymph node dissection of the IMA ( ALMA) harvests nodal tissue along the IMA proximal to the LCA whilst performing a low ligation. This anatomically replicates the oncological benefit of high ligation and the vascular preservation of low ligation. Our study evaluates the nodal yield of ALMA and the short-term outcome of this technique. Method We retrospectively studied 19 patients with sigmoid or rectal cancer who underwent curative surgical resection with ALMA. All ALMAs were performed with a standard technique previously described (Kobayashi et al., Surg Endosc 2005, 20:563-9; Sekimoto et al. Surg Endosc 2010, 25:861-6) . The lymph node yield from the dissection (the ALMA specimen) was compared with the total lymph node yield. Data on the LCA anatomy, time required to perform ALMA, complications and postoperative recovery were evaluated. Results ALMA was successful in 18 patients. Median postoperative hospitalization was 5 (2-26) days without ALMA-related morbidity or mortality. The median lymph node yield was 20 (9-41) and a median of 14.3 (0-80)% were harvested with ALMA. Two patients not having neoadjuvant chemoradiotherapy had fewer than 12 lymph nodes, excluding nodes harvested from ALMA. The average time required for ALMA was 18 min. Conclusion ALMA is a safe and feasible technique, allowing extended lymphadenectomy without sacrificing the LCA. In this small group of patients none were upstaged due to cancerous involvement of the proximal nodes. [ABSTRACT FROM AUTHOR]

Aim The rate of ileostomy reversal was estimated in patients undergoing an elective anterior resection for rectal cancer and factors associated with reversal were identified. Method The records of 4879 rectal patients who had an ileostomy created during anterior resection between 2009 and 2012 were identified in the National Bowel Cancer Audit database and linked to administrative records of the Hospital Episode Statistics. Patients were followed from surgery. Multivariable proportional hazards regression was used to estimate the impact of patient and cancer characteristics on ileostomy reversal with death as the competing risk. Results Within 18 months from anterior resection, 3536 (72.5%) patients had undergone ileostomy reversal. The reversal rate was lower in the following circumstances: older patients [hazard ratio (HR) 0.90; 95% CI 0.84-0.96, aged 80 vs 70 years], male gender (HR 0.90; 0.84-0.97), higher American Society of Anesthesiologists (ASA) grade (HR 0.64; 0.56-0.74, ASA 3+ vs 1), more advanced cancer (HR 0.77; 0.69-0.87, T3 vs T1), socioeconomic deprivation (HR 0.83; 0.74-0.93, most vs least deprived quintile), comorbidity (HR 0.92; 0.84-1.00, one vs no comorbidity) and open surgical procedure (HR 0.90; 0.84-0.97, open vs laparoscopic). Conclusion Overall, two-thirds of ileostomies were reversed within 18 months. Reversal rates were linked to patient and cancer characteristics (age, sex, fitness and stage), mode of surgical access and socioeconomic deprivation. Observed lower reversal rates in patients from poorer backgrounds may indicate inequity in access. [ABSTRACT FROM AUTHOR]

Aim Faecal incontinence may occur following rectal surgery and/or radiotherapy for rectal cancer. The aim of this paper was to review the evidence to support the use of sacral nerve stimulation ( SNS) for patients with incontinence who had undergone rectal surgery or received rectal radiotherapy. Method A search was performed of PubMed, Medline and Embase. All studies which reported the outcome of SNS in patients who had undergone a rectal resection or radiotherapy were reviewed. Results The first report of SNS following rectal surgery was in 2002. Since then seven further studies have described its effect in patients who have undergone anterior resection or pelvic radiotherapy. The total number of patients was 57. All studies were single group series, which ranged in size from one to 15 patients. The follow-up ranged from 1 to 36 months. The success of peripheral nerve evaluation ranged from 47% to 100%. Permanent SNS improved the symptoms and in some studies this was reflected in improved quality of life. The wide variation of patient factors, operations performed, the dose of radiotherapy given and time from operation makes interpretation of the results difficult. Conclusion Larger studies with better patient selection are needed to investigate the effect of SNS on incontinence following radiotherapy or rectal surgery. [ABSTRACT FROM AUTHOR]

Aim Conventional teaching in surgical training programmes is constrained by time and cost, and has room for improvement. This study aimed to determine the effectiveness of a multimedia educational tool developed for an index colorectal surgical procedure (anterior resection) in teaching and assessment of cognitive skills and to evaluate its acceptability amongst general surgical trainees. Method Multimedia educational tools in open and laparoscopic anterior resection were developed by filming multiple operations which were edited into procedural steps and substeps and then integrated onto interactive navigational platforms using Adobe® Flash® Professional CS5 10.1. A randomized controlled trial was conducted on general surgical trainees to evaluate the effectiveness of online multimedia in comparison with conventional 'study day' teaching for the acquisition of cognitive skills. All trainees were assessed before and after the study period. Trainees in the multimedia group evaluated the tools by completing a survey. Results Fifty-nine trainees were randomized but 27% dropped out, leaving 43 trainees randomized to the multimedia group ( n = 25) and study day group ( n = 18) who were available for analysis. Posttest scores improved significantly in both groups ( P < 0.01). The change in scores (mean ± SD) in the multimedia group was not significantly different from the study day group (6.02 ± 5.12 and 5.31 ± 3.42, respectively; P = 0.61). Twenty-five trainees completed the evaluation survey and experienced an improvement in their decision making (67%) and in factual and anatomical knowledge (88%); 96% agreed that the multimedia tool was a useful additional educational resource. Conclusion Multimedia tools are effective for the acquisition of cognitive skills in colorectal surgery and are well accepted as an educational resource. [ABSTRACT FROM AUTHOR]

Aim The influence of the height of rectal cancer from the anal verge on the oncological outcome is controversial. This study aimed to determine the influence of the height of the tumour on the survival of patients treated in a specialized rectal cancer unit. Method Patients undergoing surgery for primary rectal cancer from 2006 to 2013 were identified from a prospectively maintained rectal cancer database. Those requiring total or multicompartmental pelvic exenteration were excluded. Low cancer was defined as tumour < 5 cm from the anal verge, as assessed by endoscopy and/or digital rectal examination. The primary outcome was 3-year disease-free survival ( DFS). Results Of 340 patients, 203 (59.7%) had low cancer. There were 302 (89%) restorative and 38 (11%) nonrestorative procedures. The rate of positive circumferential resection margin was similar for low compared with high cancer (3.4% vs 2.9%, P = 1.0) and for restorative compared with nonrestorative procedures in low cancer only (3.0% and 5.3%, P = 0.619). Low compared with high anterior resection was associated with increased anastomotic leakage (8.5% vs 2.2%, P = 0.023). Three-year DFS was similar for low and high resection (82% vs 86%, P = 0.305) and between restorative vs nonrestorative procedures in low cancer only (88% vs 77%, P = 0.215). In an adjusted model, low height did not lead to worse survival outcome (3-year DFS hazard ratio 0.54, 95% CI 0.24-1.24, P = 0.147). Conclusion With careful planning and a multidisciplinary approach, equivalent oncological outcome can be achieved for patients with rectal cancer who undergo curative surgery regardless of differences in tumour characteristics, location and operation performed. [ABSTRACT FROM AUTHOR]

Aim Postoperative mortality has traditionally been defined as death within 30 days of surgery. Such mortality after rectal cancer resection has declined significantly during the last decades. However, it is possible that this decline can be explained merely by a shift towards an increase in 90-day mortality. Method A nationwide cohort study was based on data from the Swedish Colorectal Cancer Registry and the Swedish Patient Registry concerning patients who had undergone surgical resection for rectal cancer in 2000-2011. Unconditional logistic regression was used to calculate ORs with 95% CIs regarding mortality in different calendar periods (2000-2003, 2004-2007 and 2008-2011) in two different postoperative time periods (0-30 days and 31-90 days). Results Some 15 437 patients were included in this surgical cohort. Mortality within 30 days of surgery decreased from 2.1% in 2000-2003 to 1.6% in 2008-2011, whilst the corresponding mortality within the 31- to 90-day time window decreased from 2.1% to 1.4%. The adjusted risk of 30-day mortality in 2008-2011 was statistically significantly decreased compared with that in 2000-2003 ( OR = 0.67; 95% CI: 0.48-0.93) and mortality in the 31- to 90-day time window was also reduced for 2008-2011 compared with 2000-2003 ( OR = 0.71; 95% CI: 0.51-0.99). Conclusion This population-based, nationwide Swedish study indicates that postoperative mortality, as measured within 30 days and 31-90 days after surgery, has decreased with time. However, no relevant shift from earlier to later postoperative mortality was discerned. [ABSTRACT FROM AUTHOR]

Aim A systematic analysis was conducted of trials comparing the effectiveness of transanal endoscopic microsurgery ( TEMS) with radical resection ( RR) for T1 and T2 rectal cancer. Method An electronic search was carried out of trials reporting the effectiveness of TEMS and RR in the treatment of T1 and T2 rectal cancers. Results Ten trials including 942 patients were retrieved. There was a trend toward a higher risk of local recurrence (odds ratio 2.78; 95% confidence interval 1.42, 5.44; z = 2.97; P < 0.003) and overall recurrence ( P < 0.01) following TEMS compared with RR. The risk of distant recurrence, overall survival (odds ratio 0.90; 95% confidence interval 0.49, 1.66; z = 0.33; P = 0.74) and mortality was similar. TEMS was associated with a shorter operation time and hospital stay and a reduced risk of postoperative complications ( P < 0.0001). The included studies, however, were significantly diverse in stage and grade of rectal cancer and the use of neoadjuvant chemoradiotherapy. Conclusion Transanal endoscopic microsurgery appears to have clinically measurable advantages in patients with early rectal cancer. The studies included in this review do not allow firm conclusions as to whether TEMS is superior to RR in the management of early rectal cancer. Larger, better designed and executed prospective studies are needed to answer this question. [ABSTRACT FROM AUTHOR]

Aim While the use of robotic assistance in the management of rectal cancer has gradually increased in popularity over the years, the optimal technique is still under debate. The authors' preferred technique is a robotic low anterior resection that requires a hybrid approach with laparoscopic hand-assisted mobilization of the left colon and robotic assistance for rectal dissection. The aim of this study was to determine the efficacy of this approach as it relates to intra-operative and short-term outcomes. Method Between August 2005 and July 2011, consecutive patients undergoing rectal dissection for cancer via the hybrid robotic technique were included in our study. Demographics, margin positivity, intra-operative and short-term outcomes were evaluated. Results The preferred approach was performed in 77 patients with rectal adenocarcinoma. Of these, 68 underwent low anterior resection and nine had a coloanal pull-through procedure (mean age 60.1 years; mean body mass index 28.0 kg/m2; mean operative time 327 min; conversion rate 3.9%). Three patients (3.9%) had positive resection margins (one circumferential, two distal). Five patients had an anastomotic leak (6.4%). No robot-specific complications were observed. Conclusion The hybrid approach involving hand-assisted left colon mobilization and robotic rectal dissection is a safe and feasible technique for minimally invasive low anterior resection. This approach can be considered an viable option for surgeons new to robotic rectal dissection. [ABSTRACT FROM AUTHOR]

Aim Good functional outcome following anterior resection (AR) for rectal cancer is an important clinical goal, but its prediction has proven difficult. Assessments such as anal manometry have been advocated as a potential tool but functional anatomy as depicted on MRI has not been investigated. This study looked at whether sphincter complex measurements recorded from preoperative staging MRIs and preoperative anal manometry have any correlation with functional outcome. Method Consecutive patients with rectal adenocarcinoma underwent preoperative manometric assessment and MRI staging. MRIs were assessed with regard to anorectal angle, puborectalis thickness, canal length and external and internal anal sphincter thickness. Functional outcome was categorized into three groups according to the number of adverse postoperative symptoms (frequency, urgency, leakage, diarrhoea, use of pads, use of antidiarrhoeal medication): 0, 1 and ≥2. This was evaluated 1 year following surgery and 6 months following stoma reversal where applicable. Univariate analysis of an ordinal regression model was performed with significance at the 5% level. Results Thirty patients were assessed. No single preoperative manometric parameter proved significant ( P > 0.05). Only puborectalis thickness showed a significant ( P = 0.01) relationship with the number of adverse symptoms suffered postoperatively. On receiver operating characteristics analysis, a cut-off value of 3.5 mm gave an optimal sensitivity of 0.5 (95% CI, 0.17-0.83) and specificity of 0.86 (95% CI, 0.64-0.96). Conclusions Measurements of the puborectalis thickness on preoperative staging MRIs for rectal cancer may help predict functional outcome following AR. Prospective assessment of larger numbers with a fully validated continence score are required to evaluate these findings further. [ABSTRACT FROM AUTHOR]

Anastomotic leakage after low anterior resection may incompletely resolve, resulting in sinus tracts that persist on repeated contrast studies. This case series evaluated the factors that may contribute to sinus healing or to safe reversal of the defunctioning ileostomy. All patients ( n = 8) who developed an anastomotic sinus after low anterior resection over an 8-year period were identified from a prospective database. All patients had been treated with low anterior resections with defunctioning stomas for rectal carcinoma [median follow up 43.5 (13-84) months]. Two patients with an unhealed subclinical leak had the stoma reversed successfully. Of the six patients with clinical leakage, two healed spontaneously, one healed after application of fibrin glue, one developed an anastomotic stricture that was successfully treated by dilatation with subsequent stoma reversal, and one developed recurrent cancer and was not reversed. One patient underwent reversal, despite persistence of the sinus, followed by rectal perforation requiring laparotomy and faecal diversion. Bowel function was satisfactory where the sinus healed spontaneously, but poor where reversal was carried out without sinus healing. Tracks that persist for longer than 1 year are unlikely to heal, but the stoma can be reversed if there had been a subclinical leak previously. A persistent anastomotic sinus leading to a cavity may not be suitable for stoma closure. [ABSTRACT FROM AUTHOR]

The impact of anastomic leakage (AL) on the oncological outcome after anterior resection (AR) for rectal cancer is still controversial. We explored the impact of AL regarding local recurrence (LR), distant metastasis and overall recurrence (OAR). Overall and cancer-specific survival was analysed. Patients undergoing AR for rectal cancer with a registered AL between 1995 and 1997 and a control group were identified in the Swedish Rectal Cancer Registry. The medical records were retrieved for additional data and validation. Differences in the oncological outcome at 5-year follow-up were analysed with multivariate methods. After validation, 114 patients with AL and 136 control patients with locally radical surgery for tumours in tumour-node-metastasis stages I-III were analysed. There was no difference detected between patients with AL and control patients regarding rates of LR [8% (9 of 114) vs 9% (12 of 136); P = 0.97], distant metastasis [18% (20 of 114) vs 23% (31 of 136); P = 0.37] and OAR [19% (22 of 114) vs 28% (38 of 136); P = 0.15]. The 5-year cancer-specific survival was almost 80% in both groups. In multivariate analysis, AL was not a risk factor of LR, distant metastasis or OAR and had no impact on 5-year overall or 5-year cancer-specific survival. Irrespective of the occurrence of AL, preoperative radiotherapy ( P = 0.055) and rectal washout ( P = 0.046) reduced the LR rate, but did not influence survival. Anastomotic leakage was not proved to be a risk factor of worse oncological outcome. Hence, additional adjuvant treatment or extended follow-up on the basis of the occurrence of AL after AR might not be justified. [ABSTRACT FROM AUTHOR]

Abdominoperineal resection (APR) has been shown to have poor outcomes compared with anterior resection (AR) in the treatment of rectal cancer. We compared APR outcomes with those for low AR. Lower third rectal cancers treated at the John Radcliffe Hospital with APR and low AR were examined using a prospectively collected database augmented with review of patient records. For all cases (APR and low AR), a range of patient, cancer and outcome data were collected. A selected group was created on the basis of exclusions. Outcomes for the global and selected APR and low AR groups were compared using the Kaplan-Meier method. CRM+ve and CRM−ve APR cases were compared. Between 1994 and 2003, 70 APR and 93 low AR were performed. After exclusions, 42 APR and 81 low AR remained. Median follow-up was 4.8 years. Five year survival for the APR group was significantly worse than for the low AR group. The APR group showed significantly fewer T0 cancers and significantly more T3 cancers. CRM R1 involvement was significantly higher for the APR group. The CRM+ve APR group contained significantly more later stage cancers, more defective resection specimens, more abscesses and fistulas and was associated with more local recurrence. These data showed that APR led to worse results than low AR in terms of overall survival and circumferential margin involvement, but that the cancers treated with APR tended to be more locally advanced. [ABSTRACT FROM AUTHOR]

Objective The influence of symptomatic anastomotic leakage (AL) after anterior resection (AR) for rectal cancer on short and long-term mortality and local and distant recurrence was analysed. Method All patients with a first diagnosis of rectal carcinoma were prospectively registered in a national database. This comprised 1494 Danish citizens who had had a curative AR between May 2001 and December 2004. Data on survival and recurrence were obtained from the National Patient Register. Multivariate analyses were performed. Results Anastomotic leakage increased the 30-day mortality [odds ratio (OR) 4.01 (95% CI 2.24-7.17)]. Of other possible risk factors, only age had a significant interaction with leakage, as the risk of death within 30 days of AR decreased with increasing age. Long-term survival decreased significantly after AL [hazard ratio (HR) of 1.63, CI 1.21-2.19]. A total of 97 (6.7%) and 258 (18.0%) patients had local and distant recurrence respectively in the follow-up period. The risk of local and distant recurrence after AL was not different with HR of 1.50 (CI 0.84-2.69) and 1.13 (CI 0.76-1.69) respectively. No other factors influenced the risk of recurrence due to AL. Conclusion Anastomotic leakage after AR for rectal cancer increases the 30-day and long-term mortality, but AL did not increase the risk of local and distant recurrence. [ABSTRACT FROM AUTHOR]

Introduction A temporary loop ileostomy is often created to minimize the impact of peritoneal sepsis if anastomotic dehiscence occurs following low colorectal anastomosis. Although it has been suggested that a loop ileostomy should be reversed within 12 weeks of formation, this is often not the case. We set out to analyse the use of loop ileostomy following elective anterior resection in England and to identify factors associated with non and delayed reversal. Method Hospital episode statistics for the years 2001–2006 were obtained from the Department of Health. Patients undergoing elective anterior resection with a loop ileostomy for a primary diagnosis of rectal or recto-sigmoid cancer between April 2001 and March 2003 were identified as the study cohort. This cohort was followed until March 2006 to identify patients undergoing reversal of an ileostomy in an English NHS Hospital. Results A total of 6582 patients had an elective anterior resection between April 2001 and March 2003, of which 964 (14.6%) also had an ileostomy. Seven hundred and two (75.1%) patients were reversed before March 2006. Advancing age and comorbidity were statistically related to nonreversal. Median time to reversal was 207 days (Interquartile range 119–321.5 days). Postoperative chemotherapy and comorbidity significantly delayed reversal. Conclusions One in four loop ileostomies performed to defunction an elective anterior resection is not reversed, and in the presence of significant comorbidity one in three is not reversed. Only 12% is reversed within 12 weeks. [ABSTRACT FROM AUTHOR]

Purpose Anastomotic leaks in colorectal surgery are associated with significant morbidity and mortality and may result in poor functional and oncological outcomes. Diagnostic difficulties may delay identification and appropriate management of leaks. The aim of this study was to look at the diagnosis, clinical management and outcomes of anastamotic leaks in our department. Method A retrospective audit and case note review of all patients who underwent the formation of a colorectal anastomosis between January 1996 and December 2002 ( n = 1421) was performed. An anastomotic leak was defined as sepsis identified to have arisen from an anastomosis that subsequently required surgery, radiological drainage or intravenous antibiotics. Forty-one patients (25 male, 16 female) with a median age of 60 years (range 7–89 years) were identified as having suffered an anastomotic leak. Results The median time to diagnosis of an anastomotic leak following surgery was 7 days (range 3–29). At re-operation, 21 patients (51%) underwent formation of a stoma, and any who required the anastomosis to be formally taken down have been left with a ‘permanent’ stoma. Currently only four of 12 patients (33%) who required a stoma for an anastomotic leak following anterior resection have undergone stoma reversal. Eleven of 16 patients (69%) who had received a stoma following another colorectal procedure had undergone stoma reversal. The mortality associated with an anastamotic leak in this series was 5% ( n = 2). Conclusion Although anastomotic leaks following colorectal surgery are associated with significant morbidity and stoma formation, early and aggressive management should result in a low overall mortality. If an anastomosis is taken down following an anastomotic leak after anterior resection, this will usually result in a ‘permanent’ stoma. [ABSTRACT FROM AUTHOR]

Objective High anterior resection (HAR) for colorectal cancer is traditionally performed with routine mobilization of the splenic flexure. This is a retrospective review of mortality and morbidity following HAR in which the splenic flexure has been preserved. Method From a prospective database, all patients who had undergone elective HAR for colorectal cancer between 1999 and 2005 were identified. Morbidity, mortality, pathology and survival data for patients having HAR with and without splenic flexure mobilization were analysed. Results A total of 707 patients were identified. Five hundred and thirty-one had HAR with preservation of the splenic flexure. In these patients outcome was: anastomotic leak (0.4%), wound infection (3.6%), anastomotic stricture (0.4%) and 30-day mortality (0.9%). No statistical significant difference was found for postoperative morbidity ( P = 0.1926), 30-day mortality ( P =0.3285), lymph node harvest ( P = 0.2127) or survival ( P = 0.1457) compared with patients in whom the splenic flexure was mobilized. Longitudinal resection margins were greater following HAR with splenic flexure mobilization ( P < 0.0001). Conclusion No morbidity, oncological or survival disadvantage in performing splenic flexure preserving HAR was found. [ABSTRACT FROM AUTHOR]

Objective Anastomotic complications following sphincter saving rectal surgery remains a significant clinical problem in rectal cancer surgery. Preoperative combined modality therapy followed by anterior resection with total mesorectal excision (TME) has become the preferred treatment paradigm for locally advanced rectal cancer. However, its impact on anastomotic complications has not been adequately evaluated. This study aimed to assess the relationship between the response of the primary tumour to neo-adjuvant therapy with anastomotic complications and to evaluate the effect of other clinico-pathological factors previously implicated, in this patient cohort. Method A total of 119 consecutive patients with primary rectal cancer were assessed of which there were 87 anterior resections. A prospectively collected database was queried to determine the incidence of anastomotic complications, association with response to neo-adjuvant therapy and other clinico-pathological factors. Data were analysed withspss 14.0. Results Anterior resection was performed in 87/111 (78.4%) patients of which 46/84 (56%) were low resections, with an abdominoperineal excision of rectum rate of 11/111 (9.9%). Anastomotic complications were seen as clinical leaks in 10/87 (11.5%) and late colo-visceral fistulae in 2/87 (2.2%) patients. Subclinical/ radiological ‘leaks’ were quantified as 4/87 (4.5%). A good pathological response to neo-adjuvant therapy was found to be strongly associated with anastomotic complications ( P = 0.006). Presence of a perioperative cardiac event was the only other clinical factor associated with anastomotic complications ( P = 0.004) in our study. Conclusion Rectal cancer treated with neo-adjuvant therapy and radical resection with TME for better local control may be associated with greater anastomotic complications particularly when a good pathological response is seen. [ABSTRACT FROM AUTHOR]

Objective Local recurrence after abdomino-perineal excision of the rectum for tumours has been reported to occur in up to a third of patients in contrast to 4% after restorative anterior resection. Method Low rectal tumours were defined as tumours within 8 cm of the anal verge and were treated by either stapled low anterior resection (SLAR) or abdomino-perineal excision of the rectum (APER). One hundred and seventy-eight patients with tumours in the lower third of the rectum (30% of 591 rectal cancers) underwent surgical resection between 1980 and 2001. Data were collected prospectively; 68 (38%) had SLAR and 110 (62%) had APER with median follow up of approximately 12 years; 54 SLAR (79%) and 76 APER (69%) had curative procedures on clinical and pathological criteria. Results Local and distant recurrence occurred in seven (13%) and eight (15%) patients in the SLAR group and six (8%) and 14 (18%) patients in the APER group, respectively. Overall 5-year survival was 63% and 60% in the SLAR and APER groups, respectively Conclusion For rectal cancers within 8 cm of the anal verge, both procedures achieved equivalent results measured by low local recurrence rates and overall survival. [ABSTRACT FROM AUTHOR]

Optimal surgery remains the mainstay of best outcome for rectal cancer. The demonstration, during the 3rd Annual Pelican Surgical Workshop Symposium, of an abdomino-perineal excision (APE) performed in the ‘Berlin position’, further added to the debate on optimal surgical technique. Much interest was created at the 1st Pelican symposium with the demonstration, by the Swedish surgeon Dr Torbjorn Holm, of a prone APE and the delivery of a ‘cylindrical’ specimen and the potential to reduce local recurrence using this approach. The high rates of local recurrence following APE and the discussions as to optimal technique have led to the development of a proposed MERCURY Study Group study to assess the benefit of a radical APE, with careful assessment of the impact that this operation may have on morbidity. A German study has also been proposed adopting the UK's multidisciplinary team approach. It aims at targeting preoperative chemoradiotherapy at those patients in whom a radical APE or total mesorectal excision is likely to result in an involved surgical resection margin. In this article we review the evidence for improving the surgical technique for low rectal cancer. We believe improvements may be best achieved through continued European prospective, multi-centre, multidisciplinary studies. [ABSTRACT FROM AUTHOR]

Abstract Aims Defunctioning stomas are used following anterior resection to guard against the serious consequences of anastomotic leak such as pelvic sepsis and generalized peritonitis. This study aims to determine what proportion of patients undergoing anterior resection have a defunctioning stoma, how many of these patients do not have their stoma closed, and the reasons for this. Methods All patients undergoing a resection for rectal cancer in our institution in a five year period (January 1995 to December 1999) are included in the study. Anterior resection was performed on 154 patients, divided into 76 anterior resections (AR) and 78 low anterior resections (defined as the anastomosis within 6 cm of the anal verge). The data from these patients were analysed retrospectively. Results Of the total of 154 patients undergoing anterior resection, 59 (38%) were defunctioned, divided into 33 with loop ileostomy and 26 with loop colostomy. Five of these patients had not had their stoma closed at a median follow up of four years (range 1.5–6.5 years). The reasons for non closure were anastomotic stricture (2), metastatic disease (2), and patient choice (1). When comparing AR and LAR, 16% of patients had a defunctioning stoma after AR, compared with 60% after LAR (P < 0.01). Conclusion Anterior resection is being performed for very low rectal tumours in order to avoid a permanent stoma. However we have found that 8% of patients who are defunctioned with a stoma at anterior resection will not have their stoma closed, and conclude that patients should be warned of this pre-operatively. [ABSTRACT FROM AUTHOR]

Abstract Objective To evaluate the complications of the temporary loop ileostomy. Method A retrospective study of 222 consecutive patients with low anterior resection, ileal pouch-anal anastomosis or continent ileostomy and a diverting loop ileostomy routinely fashioned during the primary operation. The loop ileostomy was closed in 213 patients (96%) during the minimum follow-up period of 15 months. Results Four patients (2%) required preterm closure of the ostomy due to stomal retraction (n = 3) or bowel obstruction (n = 1). Four patients were readmitted due to transient bowel obstruction that resolved without surgery. After closure of the loop ileostomy a total of 27 patients (13%) had complications. In 7 patients emergency re-operation was done due to small bowel obstruction (n = 5) or intra-abdominal abscess (n = 2). Elective re-operation was done in 5 patients for hernia at the site of the previous stoma. Despite the use of a loop ileostomy there was 1 postoperative death after the initial operation in consequence of anastomotic leakage. There was 1 death in consequence of closure of the loop ileostomy after 3 weeks due to intra-abdominal sepsis and heart failure. Conclusion In this series closure of the ostomy wasassociated with one death (0.5%) and overall ostomy-related morbidity included the need to re-operate in 6%. [ABSTRACT FROM AUTHOR]

Objective To measure changes in patients' quality of life following reversal of a defunctioning ileostomy in patients who had a curative anterior resection for rectal cancer. Patients and methods Twenty consecutive patients undergoing reversal of a loop ileostomy following low anterior resection for primary rectal cancer participated. They answered three quality of life questionnaires: the European Organization for the Research and Treatment of Cancer (EORTC) QLQ-C30 and QLQ-CR38, and the SF-36. Questionnaires were answered before reversal, on discharge home, and at 3 and 6 months postoperatively. Results Reversal of the defunctioning ileostomy resulted in significant improvements in global quality of life, physical function, social function, role-physical and energy-vitality scores. Post-operative diarrhoea and frequency improved over six months, but one third of patients had mild incontinence of faeces which did not improve with time. Emotional function, mental health, future perspective, perception of body image and general health perception did not change significantly after reversal. There was a significant negative correlation between defaecation-related problems, global quality of life and body image. Conclusion Reversal of a defunctioning loop ileostomy improves most patients' overall quality of life. Therefore, once it is considered safe to reverse a stoma, an early operation may give the patient a longer time with an improved quality of life. [ABSTRACT FROM AUTHOR]

Objective Self-expanding metal stents have been developed to treat acute left-sided large bowel obstruction, either for palliation or for bowel decompression prior to subsequent abdominal surgery. The cost effectiveness of stenting vs surgical decompression has been analysed. Patients and methods Between April 1997 and April 1998, 16 patients with acute large bowel obstruction were managed by self-expanding metal stents. This group was compared with 10 unselected patients previously managed by surgical decompression. The cost-effectiveness of stenting was compared with surgical decompression by analysis of total hospital stay, running costs, and operating theatre/radiology suite utility. This was extended to include stented patients who proceeded to elective anterior resection (n=5) and patients managed by Hartmann’s operation who proceeded to reversal (n=6). Results The results showed significant reduction in the total hospital stay in the stent group, with a mean hospital stay of 2.5 days compared with 13.5 days in the surgical decompression group. There was also a mean net saving of £1760 per stented patient, with a cumulative annual saving of £26 400 on an average of 15 cases stented per year. In patients who proceeded either to post-stenting anterior resection, or reversal of Hartmann’s operation, the mean hospital stay was 17 days and 23.5 days (including hospital stay for decompression procedure), respectively, with a mean net saving of £685 per stented patient. Conclusion Stenting of acute large bowel obstruction is a cost-effective procedure with a reduction in total hospital stay and expenditure compared with surgical decompression. [ABSTRACT FROM AUTHOR]

Objective A defunctioning transanal stent may theoretically reduce the leakage rate after anterior rectal resection. We present a randomized open study with the aim of comparing the leakage rate after anterior resection with a loop ileostomy, a transanal stent, both or neither. Patients and methods Randomized open trial of 194 patients operated in 11 hospitals during September 2000 to September 2003 with anterior resection for a mobile rectal tumour, 115 men and 79 women, median age 68 years (range 37–90 years). The surgeon decided upon the use of a protective ileostomy, and after completion of the operation the patients were randomized in two groups with and without a transanal stent. Results A clinically significant leakage was diagnosed in 25 patients (13%). No significant difference was found 17 of 98 patients with a stent and 8 of 96 without ( P = 0.09), or in 9 of 44 ileostomy patients with a stent and in 3 of 45 without ( P = 0.07). Several leaks over a short time led to an interim analysis after inclusion of 194 of 448 planned patients. The analysis showed no significant protective effect of the stent, and more leakages in the stent group, although not statistically significant. On this basis it was decided to discontinue the study prematurely for ethical reasons. Conclusion Decompression of the anastomosis with a transanal stent does not reduce the risk of anastomotic leakage after anterior resection. [ABSTRACT FROM AUTHOR]

Background Colonic pouch formation with pouchanal anastomosis is now regarded as the procedure of choice for restoration of intestinal continuity following anterior resection for low rectal cancers. The aim of this study was to review the necessity for routine colonic pouchography prior to closure of a diverting loop stoma. Methods This was a prospective study of 52 consecutive patients who underwent colonic pouch formation between 1 June 1999 and 31 May 2002, four of whom have subsequently died. Each pouch was assessed clinically and radiologically prior to stoma closure. Results There were no clinical anastomotic leaks. Forty-six of 48 surviving patients have had a colonic pouchogram and in no case was either a pouch or pouchanal anastomotic defect identified. To date 40 patients have undergone stoma closure without an anastomosis- related complication. Conclusion Following successful colonic pouch formation, routine study of the pouch by contrast radiology does not add to clinical assessment. As a consequence radiological imaging is unnecessary and can be omitted. [ABSTRACT FROM AUTHOR]

The uterus continues to be a source of difficulty in mobilization of the rectum. These difficulties are compounded in laparoscopic operations, particularly anterior resection, proctectomy and vaginal sacrocolpopexy. Techniques to overcome this have in general proved unsatisfactory. We have adopted a technique of using an extended Vesellum forceps from gynaecological practice and recommend its use by all. The technique is described. [ABSTRACT FROM AUTHOR]

Aim The effectiveness of rectal washout was compared with no washout for the prevention of local recurrence after anterior rectal resection for rectal cancer. Method The following electronic databases were searched: PubMed, OVID Medline, Cochrane Database of Systematic Reviews, EBM Reviews, CINAHL and EMBASE. Results Five nonrandomized studies including a total of 5012 patients were identified. Meta-analysis suggested that rectal washout significantly reduced the local recurrence rate ( P < 0.0001; OR 0.57; 95% CI 0.43-0.74). It was also significantly lower after washout in patients having radical resection only ( P = 0.0004; OR 0.54; 95% CI 0.39-0.76), patients treated by a curative resection ( P < 0.0001; OR 0.55; 95% CI 0.42-0.72) and those undergoing preoperative radiotherapy ( P = 0.04; OR 0.62; 95% CI 0.39-0.98). Conclusion Taking into account the limitations of the design of the included studies the meta-analysis showed that rectal washout is associated with reduced local recurrence and therefore should be routine during anterior resection for rectal cancer. [ABSTRACT FROM AUTHOR]

Aim Splenic flexure mobilization (SFM) is standard practice in anterior resections. No previous studies have compared outcomes with and without SFM in laparoscopic and open colorectal cancer surgery. This study aimed to determine whether routine or selective SFM should be advised. Method Data were collected prospectively on all elective anterior resections for cancer in our unit between October 2006 and November 2009. Results Of 263 resections, SFM data were recorded in 216; 138 were laparoscopic (32% with SFM, 3.6% converted) and 78 open (68% with SFM). Eighty-eight were low anterior resections (LARs) for mid-low rectal cancers, with 54 laparoscopic (50% with SFM) and 34 open (91% with SFM). Comparing laparoscopic with SFM to without, differences were found in the proportion of LARs (61% vs 29%, P < 0.001), defunctioning ileostomy rates (75% vs 46%, P = 0.001) and operative time (median 255 vs 185 min, P < 0.001), with no differences in age, gender, body mass index, American Society of Anesthesiology score, preoperative treatment, length of stay, lymph node yield, conversion rate, mortality, anastomotic leakage, reoperation, readmission and R0 resection. No differences in outcomes were seen between laparoscopic LARs with and without SFM or between open resections with and without SFM. Conclusion Our results show no disadvantage in short-term clinical or oncological outcomes when SFM was avoided. Laparoscopic anterior resections with SFM take longer. A selective approach to SFM is safe during anterior resection (open or laparoscopic), including mid-low rectal cancers. [ABSTRACT FROM AUTHOR]