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Background: The aim of this meta-analysis was to assess the impact of operative blood loss on short and long-term outcomes following colorectal cancer surgery., Methods: A systematic literature review and meta-analysis were performed, from inception to the 10th of August 2020. A comprehensive literature search was performed on the 10th of August 2020 of PubMed MEDLINE, Embase, Science Citation Index Expanded, and Cochrane Central Register of Controlled Trials. Only studies reporting on operative blood loss and postoperative short term or long-term outcomes in colorectal cancer surgery were considered for inclusion., Results: Forty-three studies were included, reporting on 59,813 patients. Increased operative blood loss was associated with higher morbidity, for blood loss greater than 150-350 ml (odds ratio [OR] 2.09, p < 0.001) and > 500 ml (OR 2.29, p = 0.007). Anastomotic leak occurred more frequently for blood loss above a range of 50-100 ml (OR 1.14, p = 0.007), 250-300 ml (OR 2.06, p < 0.001), and 400-500 ml (OR 3.15, p < 0.001). Postoperative ileus rate was higher for blood loss > 100-200 ml (OR 1.90, p = 0.02). Surgical site infections were more frequent above 200-500 ml (OR 1.96, p = 0.04). Hospital stay was increased for blood loss > 150-200 ml (OR 1.63, p = 0.04). Operative blood loss was significantly higher in patients that suffered morbidity (mean difference [MD] 133.16 ml, p < 0.001) or anastomotic leak (MD 69.56 ml, p = 0.02). In the long term, increased operative blood loss was associated with worse overall survival above a range of 200-500 ml (hazard ratio [HR] 1.15, p < 0.001), and worse recurrence-free survival above 200-400 ml (HR 1.33, p = 0.01). Increased blood loss was associated with small bowel obstruction caused by colorectal cancer recurrence for blood loss higher than 400 ml (HR 1.97, p = 0.03) and 800 ml (HR 3.78, p = 0.02)., Conclusions: Increased operative blood loss may adversely impact short term and long-term postoperative outcomes. Measures should be taken to minimize operative blood loss during colorectal cancer surgery. Due to the uncertainty of evidence identified, further research, with standardised methodology, is required on this important subject., (© 2022. Springer Nature Switzerland AG.)

Background: The aim of this study was to compare energy devices used for intraoperative hemostasis during colorectal surgery., Methods: A systematic literature review and Bayesian network meta-analysis performed. MEDLINE, EMBASE, Science Citation Index Expanded, and Cochrane were searched from inception to August 11th 2021. Intraoperative outcomes were operative blood loss, operative time, conversion to open, conversion to another energy source. Postoperative outcomes were mortality, overall complications, minor complications and major complications, wound complications, postoperative ileus, anastomotic leak, time to first defecation, day 1 and 3 drainage volume, duration of hospital stay., Results: Seven randomized controlled trials (RCTs) were included, reporting on 680 participants, comparing conventional hemostasis, LigaSure™, Thunderbeat ® and Harmonic ® . Harmonic ® had fewer overall complications compared to conventional hemostasis. Operative blood loss was less with LigaSure™ (mean difference [MD] = 24.1 ml; 95% confidence interval [CI] - 46.54 to - 1.58 ml) or Harmonic ® (MD = 24.6 ml; 95% CI - 42.4 to - 6.7 ml) compared to conventional techniques. Conventional hemostasis ranked worst for operative blood loss with high probability (p = 0.98). LigaSure™, Harmonic ® or Thunderbeat ® resulted in a significantly shorter mean operative time by 42.8 min (95% CI - 53.9 to - 31.5 min), 28.3 min (95% CI - 33.6 to - 22.6 min) and 26.1 min (95% CI - 46 to - 6 min), respectively compared to conventional electrosurgery. LigaSure™ resulted in a significantly shorter mean operative time than Harmonic ® by 14.5 min (95% CI 1.9-27 min) and ranked first for operative time with high probability (p = 0.97). LigaSure™ and Harmonic ® resulted in a significantly shorter mean duration of hospital stay compared to conventional electrosurgery of 1.3 days (95% CI - 2.2 to - 0.4) and 0.5 days (95% CI - 1 to - 0.1), respectively. LigaSure™ ranked as best for hospital stay with high probability (p = 0.97). Conventional hemostasis was associated with more wound complications than Harmonic ® (odds ratio [OR] = 0.27; CI 0.08-0.92). Harmonic ® ranked best with highest probability (p = 0.99) for wound complications. No significant differences between energy devices were identified for the remaining outcomes., Conclusions: LigaSure™, Thunderbeat ® and Harmonic ® may be advantageous for reducing operative blood loss, operative time, overall complications, wound complications, and duration of hospital stay compared to conventional techniques. The energy devices result in comparable perioperative outcomes and no device is superior overall. However, included RCTs were limited in number and size, and data were not available to compare all energy devices for all outcomes of interest., (© 2022. Springer Nature Switzerland AG.)

The objective is to investigate preoperative body mass index (BMI) in patients receiving beyond total mesorectal excision (bTME) surgery. The primary end point is length of postoperative stay. Secondary end points are length of intensive care stay, postoperative morbidity and overall survival. BMI is the most commonly used anthropometric measurement of nutrition and studies have shown that overweight and obese patients can have improved surgical outcomes. Patients who underwent a bTME operation for locally advanced or recurrent rectal cancer were put into three BMI (kg/m 2 ) groups of normal weight (18.5-24.9), overweight (25-29.9) and obese (≥ 30) for analysis. Included are 220 consecutive patients from a single centre. The overall length of stay, in days ± standard deviation (range), for normal weight, overweight and obese patients was 21.14 ± 16.4 (6-99), 15.24 ± 4.3 (7-32) and 19.10 ± 9.8 (8-62) respectively (p = 0.002). The mean ICU length of stay was 5.40 ± 9.1 (1-69), 3.37 ± 2.4 (0-19) and 3.60 ± 2.4 (1-14), respectively (p = 0.030). There was no significant difference between the three groups in terms of postoperative morbidity or overall survival. Patients with a normal weight BMI in this cohort have a significantly longer length of stay in ICU and in hospital than overweight or obese patients. This is seen with no significant difference in morbidity or overall survival.

Adequate oncological outcomes have been demonstrated with rectal resection and handsewn coloanal anastomosis (CAA) in tumours in close proximity to the internal anal sphincter. Our aim was to assess functional differences between handsewn CAA and ultralow stapled anastomosis. Participants were identified from a single-surgeon series. Included participants underwent anorectal physiology testing of anal sphincter function, in addition to completion of several questionnaires: Wexner Incontinence Score (WIS); Birmingham Bowel, Bladder and Urinary Symptom Questionnaire (BBUSQ); Low Anterior Resection Syndrome (LARS) Score; SF36. Non-parametric data compared using the Mann-Whitney U test. 20 participants were included; 11 stapled and 9 handsewn. Mean follow-up was 2.95 ± 1.97 years. The mean LARS score was 21.9 ± 1.97 years in the stapled group versus 29.4 ± 9.57 in the handsewn group (p = 0.133). The Wexner incontinence score was significantly higher in the handsewn group (p = 0.0076), with a mean score of 4.6 ± 3.69 versus 10.9 ± 4.76. The incontinence domain of the BBUSQ was also significantly worse in patients with a handsewn anastomosis (p = 0.001). With the exception of general health (p = 0.035) and social functioning (p = 0.035), which were worse in the handsewn groups, the other six domains of the SF-36 showed no statistical difference between groups. Anorectal physiology scores were not significantly different. Handsewn CAA anastomosis is known to be safe and oncologically feasible. Patient selection should be vigorous, with preoperative counseling regarding the likelihood of incontinence to manage patients' expectations and promote comparable quality of life in the long-term.

Background: Magnetic resonance defecography (MRD) allows for dynamic visualisation of the pelvic floor compartments when assessing for pelvic floor dysfunction. Additional benefits over traditional techniques are largely unknown. The aim of this study was to compare detection and miss rates of pelvic floor abnormalities with MRD versus clinical examination and traditional fluoroscopic techniques., Methods: A systematic review and meta-analysis was conducted in accordance with recommendations from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. MEDLINE, Embase and the Cochrane Central Register of Controlled Trials were accessed. Studies were included if they reported detection rates of at least one outcome of interest with MRD versus EITHER clinical examination AND/OR fluoroscopic techniques within the same cohort of patients., Results: Twenty-eight studies were included: 14 studies compared clinical examination to MRD, and 16 compared fluoroscopic techniques to MRD. Detection and miss rates with MRD were not significantly different from clinical examination findings for any outcome except enterocele, where MRD had a higher detection rate (37.16% with MRD vs 25.08%; OR 2.23, 95% CI 1.21-4.11, p = 0.010) and lower miss rates (1.20 vs 37.35%; OR 0.05, 95% CI 0.01-0.20, p = 0.0001) compared to clinical examination. However, compared to fluoroscopy, MRD had a lower detection rate for rectoceles (61.84 vs 73.68%; OR 0.48 95% CI 0.30-0.76, p = 0.002) rectoanal intussusception (37.91 vs 57.14%; OR 0.32, 95% CI 0.16-0.66, p = 0.002) and perineal descent (52.29 vs 74.51%; OR 0.36, 95% CI 0.17-0.74, p = 0.006). Miss rates of MRD were also higher compared to fluoroscopy for rectoceles (15.96 vs 0%; OR 15.74, 95% CI 5.34-46.40, p < 0.00001), intussusception (36.11 vs 3.70%; OR 10.52, 95% CI 3.25-34.03, p = 0.0001) and perineal descent (32.11 vs 0.92%; OR 12.30, 95% CI 3.38-44.76, p = 0.0001)., Conclusions: MRD has a role in the assessment of pelvic floor dysfunction. However, clinicians need to be mindful of the risk of underdiagnosis and consider the use of additional imaging.

There is an ever-growing need, with the ongoing developments in research and the progress towards patient centered care, to delineate standardized protocols of management of anal cancer. However, guidelines from different societies show some degree of disagreement. This is a systematic review of the literature to identify similarities and discrepancies between the guidelines for the management of anal cancer drafted by the European Society for Medical Oncology (ESMO) and by the National Comprehensive Cancer Network (NCCN). We found essentially similar management for investigation, diagnosis, chemotherapy regimens, and radiotherapy doses in both ESMO and NCCN recommendations in the management of anal cancer. There were few differences, which included the levels of evidence and grades of recommendations, the delineation of radiotherapy fields, and the treatment of the elderly and personalized medicine based on genetics. The follow-up regime is also marginally different in the first 2 years. Even if the observed differences may be justified by a different implementation of evidence-based medicine among different countries for particular management modalities of anal cancer, we identified the grey areas which need further study. In addition, these facets should be assessed more carefully when planning future guidelines.

Background: The aim of the present study was to evaluate the surgical technique, short-term oncological and perioperative outcomes for the transabdominal division of the levator ani muscles during abdominoperineal excision of the rectum (APER)., Methods: A systematic review was performed to identify studies reporting on transabdominal division of the levator ani during APER. A comprehensive literature search was performed using a combination of free-text terms and controlled vocabulary when applicable on the following databases: MEDLINE, EMBASE, Science Citation Index Expanded and Cochrane Central Register of Controlled Trials in the Cochrane Library. The search period was from January 1945 to December 2015. The following search headings were used: "transabdominal", "transpelvic", "abdominal" or "pelvic" combined with either "levator" or "extralevator" and with "abdominoperineal"., Results: Nine publications were identified reporting on 99 participants. The male/female distribution was 1.44:1, respectively, and the mean age was 56.6 (30-77) years. All tumours were less than 5 cm from the anal verge. The preoperative radiological staging was T2 in 18% of cases, T3 in 53.5% and T4 in 28.5%. Transabdominal division of the levators was performed laparoscopically in 55 cases, robotically in 34 and open in 10. The mean operating time was 255 (177-640) min. Mean intraoperative blood loss was 140 (92-500) ml. There were no conversions to open. Circumferential resection margins were positive in two cases, and there was one intraoperative perforation. Mean post-operative length of stay was 9.3 (3-67) days. Follow-up (from 0 to 31 months) revealed 19 perineal wound infections, 15 cases of sexual dysfunction and 7 cases of urinary retention. There was no mortality and 1 readmission., Conclusions: Transabdominal division of the levators during APER is feasible and reproducible, with acceptable perioperative and good early oncological outcomes. Further comparative studies are needed.