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Restorative low anterior resection (LAR) for rectal cancer carries a significant risk of anastomotic leak: One of the most feared complications in colorectal surgery. Operative management may include takedown of the anastomosis and end colostomy which, in some cases, is permanent. Other contemporary operative measures include over the scope clips and Endosponge. Recently, there have been case reports and a Society of American Endoscopic and Gastrointestinal Surgeons video on the novel use of transanal minimally invasive surgery (TAMIS) in the management of anastomotic leak. We present a 59-year-old female who underwent LAR after declining radiotherapy for a bulky 9 cm rectal tumour 9–10 cm from the anal verge. Following clinical deterioration, computed tomography demonstrated an anastomotic leak communicating with a 5-cm pelvic collection containing gas. At laparoscopy, pus and faeculent material were washed from the pelvic cavity and drains were placed. Intra-operative endoscopy demonstrated a 7–8 mm dehiscence at the anastomosis. The defect (approximately 7 cm from the anal verge) was successfully closed using TAMIS and a running V-lock suture. The patient recovered well and was discharged home on post-operative day 20. In this case, a low colorectal anastomotic leak was successfully rescued with TAMIS. This novel technique may be useful in the armamentarium of colorectal surgeons experienced in TAMIS.

Summary Background The optimal timing for ileostomy closure remains controversial, most of the surgeons are closing ileostomy after two to three months, although ileostomy closure considered a simple procedure, it can cause significant morbidity; this study aims to clarify any relation between the post-closure complications rate and the time from its creation to the repair. Method From January 2010 to December 2017, data retrieved for a 405 patients who had protective ileostomy closure after rectal cancer surgery, our sample has been enrolled into two arms, the first arm includes whose ileostomies closed at or before three months, and the second arm involved whose ileostomies closed after three months from the index surgery, statistical analysis was performed and compared in both arms, Result The overall post-closure complications in our hospital was 23.7%, there was no significant difference between the overall complications rate for both early and late closure groups (26.8% and 22.7%) respectively (P = 0.499), The majority of the complications were intestinal obstruction, and superficial surgical site infection, there was no significant association between the interval to ileostomy reversal and the intestinal obstruction although it was higher in the late closure group, in the other hand the surgical site infection complication found to be significantly higher in the early closure group than the late closure group (15.4% Vs 5.1%) with (P = 0.002). Conclusion The duration between the creation of protective ileostomy and its reversal was not a significant independent predictor of post-closure complications rate.

Background Anastomotic leakage (AL) is a severe complication of low anterior resection (LAR) for rectal cancer, and effective prevention is urgently needed. In the robotic era, this study aimed to explore the role of innovative techniques in preventing AL in rectal cancer patients undergoing robotic LAR. Methods From May 2012 to May 2017, a total of 601 patients underwent robotic LAR, with 191 patients participated as control subjects (non-PST group) and 410 patients are subjected to a trinity technique (PST group). The AL rate, short-term and long-term outcomes are analyzed and compared. Results The overall rate of AL was 6.8% out of 601 patients, with Grade B at 5.7% and Grade C at 1.1%, using the ISREC grading system. The PST group presented lower incidence of both overall AL (5.1% vs 10.5%, P = 0.015) and major AL (0.2% vs 3.2%, P = 0.005), when compared with the non-PST group, respectively. Furthermore, the PST group had similar surgical complications (17.3% vs 20.9%, P = 0.286), while with lower re-hospitalization rate (2.7% vs 6.3%, P = 0.038) and reoperation rate (0.2% vs 4.2%, P = 0.001), compared with the non-PST group, respectively. Short-term recovery and long-term oncological outcomes were not significant in the two groups. By multivariate logistic regression models, the risk factors of AL of robotic LAR are confirmed as non-PST technique, estimated blood loss ≥100 mL, anastomosis from anal verge Conclusions The innovative PST technique may shed light on an effective method for preventing occurrence of AL in robotic LAR.

Despite recent advances in perioperative chemoradiation for the treatment of rectal cancer, surgery remains the only curative therapy for most patients. Surgeries for rectal cancer are considered some of the most technically challenging operations for colorectal surgeons due to the anatomy of the pelvis, proximity to critical structures, and the widespread use of preoperative chemoradiation. This review will focus on the technical aspects of surgery for rectal cancer and appraise the current literature on select controversial topics.

The rate of unplanned reoperation for rectal cancer can provide information about surgical quality. We sought to determine factors associated with unplanned reoperation after low anterior resection and abdominoperineal resection for patients with rectal cancer and outcomes after these reoperations.The American College of Surgeons National Surgical Quality Improvement Program database was used to conduct this retrospective study. Patients who underwent elective low anterior resection and abdominoperineal resection for rectal cancer from 2012-2014 were identified. The primary outcomes were 30-day reoperation rates and postoperative complications.A total of 454 low anterior resection patients (5.9%) and 289 abdominoperineal resection patients (8.1%) required reoperation within 30 days of their index operation. The most common reasons for reoperation were infection, bleeding, and bowel obstruction. Multivariate analysis revealed that male sex (odds ratio: 1.5, P = .001), poor functional status (odds ratio: 2.2, P = .04), operative time (odds ratio: 1.001, P = .01), low preoperative albumin (odds ratio: 0.79, P = .04), and lack of ostomy (odds ratio, 0.66, P = .005) were independent risk factors for reoperation after low anterior resection. Smoking (odds ratio: 1.7, P = .001), chronic obstructive pulmonary disease (odds ratio: 1.8, P = .03), poor functional status (odds ratio: 2.1, P = .032), operative time (odds ratio: 1.003, P.001), low preoperative albumin (odds ratio: 0.69, P = .007), and open approach (odds ratio: 1.5, P = .02) were independent risk factors for reoperation after abdominoperineal resection. Postoperative complication rates are high for those undergoing reoperation, often leading to non-home discharge (P.001) after reoperation.Reoperation after low anterior resection and abdominoperineal resection for rectal cancer is not uncommon. This study highlights the indications for reoperation, potentially modifiable preoperative risk factors for reoperation, and the morbidity associated with such operations.

Robotic low anterior resection (RLAR) and transanal total mesorectal excision (TaTME) are novel surgical techniques for resection of rectal cancer. To our knowledge, no data exist on direct comparison of these procedures in terms of oncological or functional parameters.60 RLAR and 55 TaTME for rectal cancer were compared in respect to patient characteristics, clinicopathological parameters, intraoperative and perioperative results and anatomopathological outcome.62 surgeries addressed tumors of the lower third (53.9%). No intergroup differences in terms of patient characteristics and clinicopathological parameters were observed. Operating time did not differ between groups (p = 0.312), nor did the perioperative complication rate (p = 0.176). Circumferential resection margin was wider in the RLAR than in the TaTME group (p 0.001), while no differences were found in the remaining oncological parameters.Our study shows comparable results for RLAR and TaTME in rectal cancer treatment. Both procedures should be considered equally feasible for low rectal cancer cases and as an alternative to conventional anterior resections (open or laparoscopic). Furthermore, both techniques allow excellent oncological outcome especially in patients with anatomical limitations.

Introduction To reduce local recurrence rates when performing anterior resection in rectal cancer surgery Swedish national guidelines recommend rectal washout. This study aimed to describe current Swedish practice of rectal washout. Methods Questionnaires were sent to Swedish surgical departments performing rectal cancer surgery. Results Thirty-five units performed open rectal cancer surgery, and 91% (32/35) performed minimally invasive surgery. Forty percent (14/35) had a protocol on rectal washout. Rectal washout was most commonly performed using sterile water or an alcohol based solution and with a minimum volume of 100–499 ml. A catheter was used at most units, prior to transection of the rectum and with the bowel clamped. Routine use of rectal washout varied with the type of surgical procedure, with no differences between open and minimally invasive surgery: low anterior resection (97% (34/35) vs 94% (30/32); p = 0.60), high anterior resection (94% (33/35) vs 97% (31/32); p = 1.00), Hartmann's procedure (80% (28/35) vs 84% (27/32); p = 0.75), abdominoperineal resection (6% (2/35) vs 16% (5/32); p = 0.25). Conclusion Swedish colorectal units perform rectal washout routinely with no differences between open and minimally invasive procedures. A minority have a procedure protocol.

Low anterior resection syndrome (LARS) is a constellation of symptoms that includes incontinence to flatus and/or feces, urgency, and frequency. LARS affects up to 80% of patients after low anterior resection. The pathophysiology of LARS is complex, and a variety of mechanisms have been proposed. These mechanisms include disruption of autonomic innervation and the rectoanal inhibitory reflex, internal anal sphincter dysfunction, decreased anal canal sensation, and decreased capacity and compliance of the neorectum. As the management of colorectal diseases such as rectal cancer continues to improve, there is a concomitant increase in organ preservation, survivorship, and attention to quality of life. Therefore, recognition and understanding of LARS is key to the diagnosis and treatment of this debilitating disease process.

Low Anterior Resection Syndrome (LARS) groups together bowel dysfunction symptoms which occur after rectal resection, such as fecal incontinence, urgency, frequent bowel movements and clustering of stool. For adequate surgical outcome reporting, as well as to encompass all aspects of the condition, optimal syndrome definition and clinical scoring are key. Herein, a narrative review of the literature published between 1993 and 2020 that reported on the definition of LARS and/or a LARS scoring system was undertaken. LARS was first defined and reported by non-targeted scores, such as scores for anal incontinence and/or quality of life. Recent years have seen the emergence of scores dedicated to LARS, such as the Memorial Sloan Kettering Cancer Center Bowel Function Instrument and the Low Anterior Resection Score. These scores, and their translations, have been validated on different cohorts of patients who underwent low anterior resection.To capture all aspects of LARS, the impact of all symptoms on the patient's quality of life should be considered.

Disorders of defecatory function are common after treatment for rectal cancer, especially following restorative proctectomy and radiotherapy, administered either in the neoadjuvant or postoperative adjuvant setting. The low anterior resection score (LARS) score is the most widely used questionnaire for assessing bowel function after restorative proctectomy. However, the LARS score, despite providing an effective means to pool data for meta-analyses and prediction modelling, has limitations because of the lack of a precise definition of LARS. An international consensus definition was only recently established, and further work is required to convert this into a scoring system that can hopefully more accurately quantify and discriminate changes that occur over time and with treatment. Only then will we be able to identify true and actionable risk factors for LARS.

There has been a recent increase in patient reported outcomes, specifically quality of life (QoL), following recovery from a restorative proctectomy. The constellation of post-operative bowel dysfunction symptoms has been collectively termed the Low Anterior Resection Syndrome (LARS). Research efforts have resulted in an international consensus statement on its definition and now establishes a foundation of future research on LARS incidence, significance and treatment options. Amidst the myriad of prior treatment options, all efforts by surgeons to provide organ (anus) preservation surgery have unfortunately resulted in an increasing number of patients who intensely suffer from LARS. Perhaps historically considered only for failure of symptom management by both surgeons and patients alike, use of a permanent colostomy may be an appropriate surgical outcome outright when patients are fully informed of what post-operative bowel “dysfunction” is likely to be expected. Still, the future of LARS treatments is just beginning to be investigated and increased physician awareness of those new management strategies may offer hope for patients who continually struggle with their QoL following a restorative proctectomy.

More than half of patients undergoing a low anterior resection with coloanal anastomosis will experience subsequent bowel dysfunction including symptoms of fecal incontinence and disordered evacuation. This cluster of symptoms is referred to as the low anterior resection syndrome (LARS). Several case series have demonstrated that sacral neuromodulation (SNM) improves various symptoms in individual with LARS, with the greatest degree of improvement in the symptoms of clustering and urgency. Although the mechanism by which SNM therapy was beneficial in a majority of patients with LARS is not clear, SNM warrants serious consideration in application to patients after anterior resection with bowel dysfunction that negatively affects their quality of life.

Introduction and importance Rectal prolapse is defined as herniation of mucosa or full-thickness of the rectal wall through the anal canal. It has a negative impact on the quality of life and therefore, it should be treated as soon as diagnosis is confirmed. Definitive treatment is surgical and it depends on the clinical characteristics of the patients. We aimed to present the one of the largest rectal prolapse case in the literature. Case presentation A 32- years- old male patient with a history of severe constipation was admitted to our institution with a giant rectal prolapse. The prolapsed segment was incarcerated, and a semi-emergent procedure was performed though a mid-line laparotomy. The sigmoid colon was redundant and therefore sigmoid colon and the upper two thirds of rectum were resected and end to end anastomosis was performed. The patient was discharged postoperative day 7 without any complication. Clinical discussion Rectal prolapse has a negative impact on quality of life and should be operated as soon as the diagnosis is reached. The surgical strategy depends on the compliance of the patient as well as the experience of the surgical team. Conclusion Clinicians should know that chronic constipation together with other factors may result in rectal prolapse which may become disproportionately large in size., Highlights • Rectal prolapse (RP) is herniation of mucosa or full-thickness of the rectal wall through the anal canal. RP is classified in to three clinical subtypes: mucosal invagination, partial; internal, and full-thickness; external. • Prolapsed segment of rectosigmoid larger than 10 cm in length are defined as giant RP

Background The aim of this study was to evaluate the clinical utility and cost-effectiveness of routine histologic examination of the doughnuts from stapled anastomoses in patients undergoing a low anterior resection for rectal cancer. Methods We performed a retrospective review of 486 patients who underwent a low anterior resection with stapled anastomosis for rectal cancer between 2002 and 2015 at 3 institutions. Pathologic findings in the doughnuts and their impact on patient management were recorded. Tumor characteristics that may influence how often doughnuts were included in the pathology report were analyzed. An approximate cost of histologic examination of doughnuts was also calculated. Results A total of 412 patients (85%) had doughnuts included in their pathology reports. Two patients had cancer cells in their doughnuts, and both patients had a positive distal margin in their primary tumor specimen; 33 patients had benign findings in their doughnuts. Pathologic examination of the doughnut did not change clinical management in any patient. Patients with rectosigmoid tumors were less likely to have their doughnuts included in the pathology report compared to patients with low tumors ( P = .003). Doughnuts were not bundled with the primary tumor specimen in 374 (77%) of our patients; in these patients, pathologic analysis of the doughnut added an additional cost of approximately $643 per specimen. Conclusion This study demonstrates no clinical benefit in sending anastomotic doughnuts for histopathologic evaluation after performing a low anterior resection with a stapled anastomosis for rectal cancer. Overall cost may be decreased if doughnuts are not analyzed or if they are bundled with the primary tumor specimen.

Background Low anterior resection is associated with a relatively high incidence of postoperative morbidities, including anastomotic leakage and other operative site infections, which sometimes result in postoperative mortality. Therefore, recognition of the incidence and risk factors of postoperative complications following low anterior resection is essential. Methods Data from the National Clinical Database on patients who had undergone low anterior resection in 2011 and 2012 were retrospectively analyzed. Multiple logistic regression analyses were performed to generate predictive models of postoperative complications. Receiver-operator characteristic curves were generated, and the concordance index was used to assess the model's discriminatory ability. Results The number of patients who had undergone low anterior resection was 33,411. Seven complications, namely, overall operative site infections except for leakage, anastomotic leakage, urinary tract infection, pneumonia, renal failure, systemic sepsis, and cardiac events, were selected to construct statistical risk models. The concordance indices for the first 2 complications, which were dependent on the operative procedure, were relatively low (0.593–0.625), and the other 5, unrelated to operative procedures, showed high concordance indices (0.643–0.799). Conclusion This study created the world's second risk calculator to predict the complications of low anterior resection as a model based on mass nationwide data. In particular, this model is the first to predict anastomotic leakage.

Defunctioning stoma in low anterior resection (LAR) for rectal cancer can prevent major complications, but overall cost-effectiveness for the healthcare provider is unknown. This study compared inpatient healthcare resources and costs within 5 years of LAR between two randomized groups of patients undergoing LAR with and without defunctioning stoma.Five-year follow-up of a randomized, multicenter trial on LAR (NCT 00636948) with (stoma; n = 116) or without (no stoma; n = 118) defunctioning stoma comparing inpatient healthcare resources and costs. Unplanned stoma formation, days with stoma, length of hospital stay, reoperations, and total associated inpatient costs were analyzed.Average costs were € 21.663 per patient with defunctioning stoma and € 15.922 per patient without defunctioning stoma within 5 years of LAR, resulting in an average cost-saving of € 5.741. There was no difference between groups regarding the total number of days with any stoma (stoma = 33 398 vs. no stoma = 34 068). The total number of unplanned reoperations were 70 (no stoma) and 32 (stoma); p 0.001. In the group randomized to no stoma at LAR, 30.5% (36/118) required an unplanned stoma later.Randomization to defunctioning stoma in LAR was more expensive than no stoma, despite the cost-savings associated with a reduced frequency of anastomotic leakage. Both groups required the same total number of days with a stoma within five years of LAR.

Highlights • The effectiveness of a transanal decompression tube to prevent anastomotic leakage after rectal surgery is widely accepted. • A rare complication of colonic perforation due to a transanal decompression tube may occurred. • The relationship between the tip of the transanal decompression tube, the intestine and the sacrum might be important., Introduction The effectiveness of transanal decompression tube (TDT) to prevent anastomotic leakage after rectal surgery has been widely accepted in recent years. However, a rare complication of intestinal perforation due to TDT has been also reported. Presentation of case A 88-year-old woman underwent laparoscopic low anterior resection for rectal cancer. An abdominal drainage tube adjacent to the colorectal anastomosis and a TDT were placed. The patient experienced abdominal pain, nausea and elevated inflammatory markers on postoperative day 6. Enema and computed tomography demonstrated colonic perforation due to the TDT, and emergency laparotomy was performed. Perforation of the anterior sigmoid colon located at the proximal side of the colorectal anastomosis was seen, and the TDT was exposed to the abdominal cavity. Therefore, primary closure of the perforation site, peritoneal lavage, drainage tube placement and transverse colostomy was performed. Discussion In our case, TDT seemed to compress the anterior wall of the colon and lead to perforation. The looseness of the remaining oral intestinal tract depressed in the pelvis was compressed by the TDT. Conclusion TDTs should be very carefully placed to avoid complication. The length and looseness of the oral intestine and the relationship between the TDT to be inserted might be important.

Purpose The purpose of this study was to assess the relationship between the low anterior resection syndrome (LARS) and quality of life (QOL). Furthermore, in patients with major LARS, therapeutic management options were explored. Methods A cohort of surviving patients, who underwent a low anterior resection for rectal cancer after long course of radiochemotherapy, were identified. These patients were treated in Ghent University Hospital between 2006 and 2016. QOL was assessed using the European Organization for Research and Treatment of Cancer Quality Of Life questionnaire-C30 and the bowel function using the LARS-score. The relationship between LARS and QOL was analysed. Patients with major LARS (≥30 points) were contacted to explore their therapeutic management of LARS. Results 69% of the participants had major LARS. QOL was closely associated with LARS. Significant differences were found between those with and without LARS in the global health status (p ≤ 0.001) and in the following functional scales: physical (p ≤ 0.001), role (p ≤ 0.001), cognitive (p = 0.04) and social (p ≤ 0.001). Patients with major LARS experienced more diarrhea (p ≤ 0.001), fatigue (p = 0.002), insomnia (p ≤ 0.001) and pain (p = 0.02), compared to patient with no/minor LARS. Most patients tried dietary regimens (71%), medication (71%) and incontinence material (63.8%) in an attempt to manage their LARS and found some of them useful. The level of the anastomosis (low) was a significant risk factor for major LARS (p=0.03). Conclusion More than half of the patients in this cohort still suffered from major LARS. Patients confronted with major LARS had a lower QOL than patients with no/minor LARS. Currently, there is no gold standard for the management of LARS. Patients manage it through trial and error.

With an estimated 39,220 new diagnoses in 2016, rectal cancer continues to be a common disease within the United States [1]. Treatment of rectal cancer involves a multidisciplinary approach that often includes surgery, chemotherapy, and radiotherapy.

Background Anastomotic leakage (AL) is a severe complication after low anterior resection (LAR) in rectal cancer surgery. A diverting loop ileostomy has been reported to reduce early clinical AL and thereby decrease short-term morbidity. Less is known if long-term morbidity is affected by a loop ileostomy constructed at LAR. Methods At Ersta Hospital, Sweden, 287 consecutive patients were operated on with LAR, 2002–2011. Follow-up time was 3 years after LAR. Due to a shift in routines, 15% were diverted at LAR, 2002–2006 and 91%, 2007–2011. Data on long-term morbidity and permanent stoma in patients with or without a diversion at primary surgery were compared. Results During LAR, 139 patients were diverted (S+), 148 were not (S−). Total rate of AL, both early and late, was 26% in S+ and 30% in S−, p 0.25. Late AL (>30 days after LAR) was found in 6% and 15% were readmitted in the late postoperative period with no difference between the groups. Total length of hospital stay (30 days–3 years after LAR) was longer among S+ compared to S−, mean 7 vs. 4 days (p One out of six ended up with a permanent stoma (17% S+, 14% S−, p 0.47). Clinical AL was an independent risk factor and the most common cause for a permanent stoma in both groups. Conclusion A diverting loop ileostomy at LAR did not reduce long-term morbidity but was associated with a longer total length of hospital stay during a 3-year follow up.

Anastomotic leak and stricture formation are recognised complications of colorectal anastomoses. Surgical technique has been implicated in its aetiology. The use of innovative anastomotic techniques and technical standardisation may facilitate risk modification. Early detection of complications using novel diagnostic tests can lead to reduction in delay of diagnosis as long as a standard system is used. We review our practice for creation a safe anastomosis for minimal invasive rectal cancer resection. Several technical points discussed and evaluated based on the evidence. We propose several recommendations aiming to standardize the technique and to minimize anastomotic complications.

The surgical management of rectal cancer has evolved as techniques have improved and the use of preoperative multimodality therapy has gained acceptance as the standard of care. One of the most dynamic areas regarding surgical resection of rectal cancer has been the issue of an oncologically safe distal resection margin. Despite recommendations for the minimum acceptable distal margin shrinking from 5 cm to 2 cm and now to 1 cm over the past several decades, this question remains a topic of intense debate. Such discussion centering on the impact distal margins of resection can critically affect the ability to preserve the anal sphincter complex during rectal resection for cancer. In the present era of the surgical treatment of locally advanced rectal cancers with neoadjuvant chemoradiation, the literature has supported the potential safety of a 1-cm margin for sphincter preservation without a significant risk for unresected microscopic distal intramural spread. More recently, data has emerged demonstrating no statistical difference in oncologic outcomes in terms of local recurrence or overall survival when comparing shorter distal margins to those greater than 1 cm. This review examines the data in support of the 1-cm rule and discusses its validity in light of more recent reports in the modern multidisciplinary treatment era.

Introduction This study aimed to investigate local control and survival rates following abdominoperineal resection (APR) compared with low anterior resection (LAR) in lower and middle rectal cancer. Methods In this retrospective study, 153 patients with newly histologically proven rectal adenocarcinoma located at low and middle third that were treated between 2004 and 2010 at a tertiary hospital. The tumors were pathologically staged according to the 7th edition of the American Joint Committee on Cancer (AJCC) staging system. Surgery was applied for 138 (90%) of the patients, of which 96 (70%) underwent LAR and 42 were (30%) treated with APR. Total mesorectal excision was performed for all patients. In addition, 125 patients (82%) received concurrent (neoadjuvant, adjuvant or palliative) pelvic chemoradiation, and 134 patients (88%) received neoadjuvant, adjuvant or concurrent chemotherapy. Patients’ follow-up ranged from 4 to 156 (median 37) months. Results Of 153 patients, 89 were men and 64 were women with a median age of 57 years. One patient (0.7%) was stage 0, 15 (9.8%) stage I, 63 (41.2%) stage II, 51 (33.3%) stage III and 23 (15%) stage IV. There was a significant difference between LAR and APR in terms of tumor distance from anal verge, disease stage and combined modality therapy used. However, there was no significant difference regarding 5-year local control, disease free and overall survival rates between LAR and APR. Conclusion LAR can provide comparable local control, disease free and overall survival rates compared with APR in eligible patients with lower and middle rectal cancer.

For low-lying rectal cancers, proximal diversion can reduce anastomotic leak after sphincter-preserving surgery; however, evidence suggests that such temporary diversions are often not reversed. We aimed to evaluate nonreversal and delayed stoma reversal in elderly patients undergoing low anterior resection (LAR).SEER-Medicare-linked analysis from 1991-2007.A total of 1179 primary stage I-III rectal cancer patients over age 66 who underwent LAR with synchronous diverting stoma.(1) Stoma creation and reversal rates; (2) time to reversal; (3) characteristics associated with reversal and shorter time to reversal.Within 18 mo of LAR, 51% of patients (603/1179) underwent stoma reversal. Stoma reversal was associated with age80 y (P0.0001), male sex (P = 0.018), fewer comorbidities (P = 0.017), higher income (quartile 4 versus 1; P = 0.002), early tumor stage (1 versus 3; P0.001), neoadjuvant radiation (P0.0001), rectal tumor location (versus rectosigmoid; P = 0.001), more recent diagnosis (P = 0.021), and shorter length of stay on LAR admission (P = 0.021). Median time to reversal was 126 d (interquartile range: 79-249). Longer time to reversal was associated with older age (P = 0.031), presence of comorbidities (P = 0.014), more advanced tumor stage (P = 0.007), positive lymph nodes (P = 0.009), receipt of adjuvant radiation therapy (P = 0.008), more recent diagnosis (P = 0.004), and longer length of stay on LAR admission (P0.0001).Half of elderly rectal cancer patients who undergo LAR with temporary stoma have not undergone stoma reversal by 18 mo. Identifiable risk factors predict both nonreversal and longer time to reversal. These results help inform preoperative discussions and promote realistic expectations for elderly rectal cancer patients.

Background Availability of anastomotic leakage rates and mortality rates following anastomotic leakage is essential when informing patients with rectal cancer preoperatively. We performed a meta-analysis of studies describing anastomotic leakage and the subsequent postoperative mortality in relation to the overall postoperative mortality after low anterior resection for rectal cancer. Methods A systematic search was performed of the published literature. Data on the definition and incidence rate of AL, postoperative mortality caused by AL, and overall postoperative mortality were extracted. Data were pooled and a meta-analysis was performed. Results Twenty-two studies with 10,343 patients in total were analyzed. Meta-analysis of the data showed an average AL rate of 9%, postoperative mortality caused by leakage of 0.7% and overall postoperative mortality of 2%. The studies showed variation in incidence, definition and measurement of all outcomes. Conclusion We found a considerable overall AL rate and a large contribution of AL to the overall postoperative mortality. The variability of definitions and measurement of AL, postoperative mortality caused by leakage and overall postoperative mortality may hinder providing reliable risk information. Large-scale audit programs may provide accurate and valid risk information which can be used for preoperative decision making.

We present a case of a child with ongoing lower gastrointestinal bleeding caused by a rectosigmoid arteriovenous malformation. To reduce perioperative bleeding, we performed preoperative angioembolization followed by subsequent resection by low anterior resection. Here we present the case and review the literature regarding neoadjuvent embolization for gastrointestinal and pelvic arteriovenous malformations.

Robotic surgery has many features that make it superior to traditional laparoscopic surgery. However, the use of the robot is limited by the need to reposition the robot during colon and rectal operations encompassing more than one abdominal quadrant. A "hybrid" technique has been developed which combines traditional laparoscopy with a robotic pelvic dissection. With this combined approach, the benefits of the 2 techniques can be maximized, while minimizing their limitations.

Background In many patients with rectal cancer, defunctioning stomas are created to limit the consequences of anastomotic leakage. Although intended to be temporary, a substantial proportion of these stomas might never be reversed for various reasons. We aimed to describe stoma policy by use of data from the total mesorectal excision (IME) trial in patients with rectal cancer and to identify factors that limit stoma reversal.Methods 924 Dutch patients with rectal cancer who underwent a low anterior resection were selected from the TME trial, a prospective, randomised multicentre trial studying the effects of short-term preoperative radiotherapy in 1861 patients who underwent TME. Creation of stomas and time to stoma reversal were analysed retrospectively by use of multivariate analysis.Findings In 523 of 924 (57%) patients, a primary stoma (defined as a stoma created at the time of TME) was constructed. after a low anterior resection. Geographical differences in the number of primary stomas constructed were reported throughout the Netherlands. 19% of stomas that were created were never reversed. Postoperative complications and secondary constructed stomas (defined as a stoma created during a second or subsequent procedure after TME) were associated with a high likelihood of a permanent stoma. However, perioperative complications were not a limiting factor for stoma closure.Interpretation Postoperative complications are an important limiting factor for stoma reversal because, after occurrence of these complications, patients and surgeons might be reluctant to reverse the stoma, so a substantial proportion of these stomas are never dosed. Future guidelines for stoma creation and closure should consider these factors.