Search

Radical cystectomy after low anterior resection is rare, and no cases of robotic surgery have been reported. Cystectomy in patients who have undergone a previous pelvic surgery, whether open or endoscopic, requires caution to avoid damaging other organs due to anatomical changes caused by adhesions in a limited space. Additionally, the curative nature of the treatment must be maintained. We describe a 69‐year‐old man with a history of open low anterior resection for rectal cancer who underwent robot‐assisted radical cystectomy with extracorporeal ileal conduit construction. Although this procedure is challenging, it was performed safely with the collaboration of colorectal surgeons. The patient was discharged without perioperative complications and remained recurrence‐free for 5 years. [ABSTRACT FROM AUTHOR]

Aim: Although proximal faecal diversion is standard of care to protect patients with high‐risk colorectal anastomoses against septic complications of anastomotic leakage, it is associated with significant morbidity. The Colovac device (CD) is an intraluminal bypass device intended to avoid stoma creation in patients undergoing low anterior resection. A preliminary study (SAFE‐1) completed in three European centres demonstrated 100% protection of colorectal anastomoses in 15 patients, as evidenced by the absence of faeces below the CD. This phase III trial (SAFE‐2) aims to evaluate the safety and effectiveness of the CD in a larger cohort of patients undergoing curative rectal cancer resection. Methods: SAFE‐2 is a pivotal, multicentre, prospective, open‐label, randomized, controlled trial. Patients will be randomized in a 1:1 ratio to either the CD arm or the diverting loop ileostomy arm, with a recruitment target of 342 patients. The co‐primary endpoints are the occurrence of major postoperative complications within 12 months of index surgery and the effectiveness of the CD in reducing stoma creation rates. Data regarding quality of life and patient's acceptance and tolerance of the device will be collected. Discussion: SAFE‐2 is a multicentre randomized, control trial assessing the efficacy and the safety of the CD in protecting low colorectal anastomoses created during oncological resection relative to standard diverting loop ileostomy. Trial registration: NCT05010850. [ABSTRACT FROM AUTHOR]

Introduction: Total mesorectal excision (TME) is an established standard procedure for rectal surgery; however, it is technically challenging because of the deep and narrow pelvis. Minimally invasive surgeries have gained prominence for TME with favorable outcomes but come with limitations. Laparoscopic surgery often has dexterity restrictions because of the use of straight forceps, whereas robotic surgery is impeded by high costs and extended operative times. Articulating forceps aim to bridge the gap between these methods by offering enhanced dexterity at a lower cost. Patients and Surgical Technique: This video study involves two female patients diagnosed with lower rectal cancer. One patient underwent laparoscopic intersphincteric resection (Lap‐ISR) using the ArtiSential articulating forceps (LIVSMED Inc.), and the other underwent robot‐assisted low anterior resection (Rob‐LAR) using the da Vinci Xi System. Both operations involved similar mesorectal dissection steps, except for the anastomosis. The standard port placement was used, and dissection was performed circumferentially down to the perianal region. Discussion: The ArtiSential demonstrated effectiveness comparable with the da Vinci Xi system in TME surgery, with the potential advantage of improved cost‐effectiveness. [ABSTRACT FROM AUTHOR]

Colorectal cancer is a significant cause of cancer‐related deaths worldwide. Although advances in surgical technology and technique have decreased mortality rates, surviving patients often experience sexual dysfunction as a common complication. The development of the lower anterior resection has greatly decreased the use of the radical abdominoperineal resection surgery, but even the less radical surgery can result in sexual dysfunction, including erectile and ejaculatory dysfunction. Improving the knowledge of the underlying causes of sexual dysfunction in this context and developing effective strategies for preventing and treating these adverse effects are essential to improving the quality of life for postoperative rectal cancer patients. This article aims to provide a comprehensive evaluation of erectile and ejaculatory dysfunction in postoperative rectal cancer patients, including their pathophysiology and time course and strategies for prevention and treatment. [ABSTRACT FROM AUTHOR]

Introduction: Colorectal cancer (CRC) surgery complications are a major issue affecting morbidity and mortality rates. Anastomotic stricture, which occurs in almost 30% of patients after surgery for rectal cancer, is one of the most serious but underreported side effects. In this study, we tried to assess the effect of stapler size on anastomotic stricture rate. Materials and Methods: At our facility, all patients underwent low anterior resections (LAR) performed using an open laparotomy technique. A contour‐curved stapler and an end‐to‐end anastomosis (EEA) circular stapler were used in the double stapling technique (DST). All patients also underwent a protective loop ileostomy. Patients who developed stricture following leakage were excluded. Results: This study comprised a total of 173 rectal cancer patients. A 29‐mm circle stapler was used to anastomose 77 patients (44.5%), while a 31‐mm circular stapler was used to anastomose 96 patients (55.5%). Six individuals experienced strictures; two had a 29 mm stamper and four (4.4%) had a 31 mm one. There was no significant difference between the two groups (p:0.575). On aggregate, 8 patients experienced leakage; 3 (3.8%) of these patients received treatment with a 29 mm stapler, whereas 5 (5.2%) received treatment with a 31 mm stapler. Conclusion: this study found no statistically significant difference in the stricture rates and stapler size. The findings of this study provide credibility to the notion that in rectal cancer patients having LAR, strictures can be safely avoided by performing the anastomoses with both staplers. [ABSTRACT FROM AUTHOR]

Aim: After low anterior resection, the bowel can be anastomosed in different ways. It is not clear which configuration is optimal from a functional and complication point of view. The primary aim was to investigate the impact of the anastomotic configuration on bowel function evaluated by the low anterior resection syndrome (LARS) score. Secondarily, the impact on postoperative complications was evaluated. Method: All patients who had undergone low anterior resection from 2015 to 2017 were identified in the Swedish Colorectal Cancer Registry. Three years after surgery, patients were sent an extensive questionnaire and were analysed based on anastomotic configuration ('J‐pouch/side‐to‐end anastomosis' or 'straight anastomosis'). Inverse probability weighting by propensity score was used to adjust for confounding factors. Results: Among 892 patients, 574 (64%) responded, of whom 494 patients were analysed. After weighting, the anastomotic configuration had no significant impact on the LARS score (J‐pouch/side‐to‐end OR 1.05, 95% confidence interval [CI] 0.82–1.34). The J‐pouch/side‐to‐end anastomosis was significantly associated with overall postoperative complications (OR 1.43, 95% CI 1.06–1.95). No significant difference was seen regarding surgical complications (OR 1.14, 95% CI 0.78–1.66). Conclusion: This is the first study investigating the impact of the anastomotic configuration on long‐term bowel function, evaluated by the LARS score, in an unselected national cohort. Our results suggested no benefit for J‐pouch/side‐to‐end anastomosis on long‐term bowel function and postoperative complication rates. The anastomotic strategy may be based upon the anatomical conditions of the patient and surgical preference. [ABSTRACT FROM AUTHOR]

Aim: The best bowel preparation method for rectal surgery remains controversial. In this study we compared the efficacy and safety of mechanical bowel preparation (MBP) alone and MOABP (MBP combined with oral antibiotic bowel preparation [OABP]) for rectal cancer surgery. Methods: In this retrospective study we analyzed data from the Japanese Diagnosis Procedure Combination (DPC) database on 37 291 patients who had undergone low anterior resection for rectal cancer from 2014 to 2017. Propensity score matching analysis was used to compare postoperative outcomes between MBP alone and MOABP. Results: A total of 37 291 patients were divided into four groups: MBP alone: 77.7%, no bowel preparation (NBP): 16.9%, MOABP: 4.7%, and OABP alone: 0.7%. In propensity score matching analysis with 1756 pairs, anastomotic leakage (4.84% vs 7.86%, P < 0.001), small bowel obstruction (1.54% vs 3.08%, P = 0.002) and reoperation (3.76% vs 5.98%, P = 0.002) were less in the MOABP group than in the MBP group. The mean duration of postoperative antibiotics medication was shorter in the MOABP group (5.2 d vs 7.5 d, P < 0.001) than in the MBP group. There was no significant difference between the two groups in the incidence of Clostridium difficile (CD) colitis (0.40% vs 0.68%, P = 0.250) and methicillin‐resistant Staphylococcus aureus (MRSA) colitis (0.11% vs 0.17%, P = 0.654). There was no significant difference in in‐hospital mortality between the two groups (0.00% vs 0.11% respectively, P = 0.157). Conclusion: MOABP for rectal surgery is associated with a decreased incidence of postoperative complications without increasing the incidence of CD colitis and MRSA colitis. [ABSTRACT FROM AUTHOR]

Introduction: This study was to compare the prevalence of stoma‐related complications and stoma reversal perioperative complications of patients with low‐lying rectal cancer who received preventative loop ileostomy and those who underwent loop transverse colostomy. Methods: This retrospective single‐center study analyzed the clinicopathologic and surgical data of 288 patients with pathologically proven primary rectal cancer who underwent anterior resection with either preventative loop ileostomy (n = 82) or loop transverse colostomy. To achieve comparability of a propensity score matching method was used to match patients from each group in a 1:2 ratio. Determinants of stoma‐related complications were analyzed by multivariate logistic regression analysis. Results: Forty‐nine (74.3%) patients in the loop ileostomy group experienced stoma‐related complications versus 48.7% in the loop transverse colostomy group (P < 0.01). Irritant dermatitis was the most frequent complication in both groups. The loop ileostomy group had a significantly higher rate (24.24%) of stoma reversal perioperative complications than the loop transverse colostomy group. Multivariate logistic regression analysis showed that ileostomy versus loop transverse colostomy was a significant independent risk for stoma‐related complications and stoma reversal perioperative complications. Furthermore, by Clavien–Dindo classification, patients receiving loop ileostomy had an overall higher rate of complications and stoma reversal perioperative complications versus those undergoing loop transverse colostomy (P < 0.01). The rate of grade II complications was significantly higher in the loop ileostomy group (43.9%) than that of loop transverse colostomy group (13.5%, P < 0.01), whereas the rate of grade I, and grade IIIa and IIIb complications and stoma reversal perioperative complications was comparable between the two groups. Conclusion: The study has demonstrated that loop transverse colostomy is associated with significantly lower rates of stoma‐related complications and stoma reversal perioperative complications compared to loop transverse colostomy. [ABSTRACT FROM AUTHOR]

Aim: Sphincter‐preserving operations for ultra‐low rectal cancer include low anterior and intersphincteric resection. In low anterior resection, the distal rectum is divided by a transabdominal approach, which is technically demanding. In intersphincteric resection, a perineal approach is used. We aimed to evaluate whether robotic‐assisted surgery is technically superior to laparoscopic surgery for ultra‐low rectal cancer. We compared the frequency of low anterior resection in cases of sphincter‐preserving operations. Method: We investigated 183 patients who underwent sphincter‐preserving robotic‐assisted or laparoscopic surgery for ultra‐low rectal cancer (lower border within 5 cm of the anal verge) between April 2010 and March 2020. The frequency of low anterior resection was compared between laparoscopic and robotic‐assisted surgeries. The clinicopathological factors associated with an increase in performing low anterior resection were analyzed by multivariate analyses. Results: Overall, 41 (22.4%) and 142 (77.6%) patients underwent laparoscopic and robotic‐assisted surgery, respectively. Patient characteristics were similar between the groups. Low anterior resection was done significantly more frequently in robotic‐assisted surgery (67.6%) than in laparoscopic surgery (48.8%) (P = 0.04). Multivariate analyses showed that tumor distance from the anal verge (P < 0.01) and robotic‐assisted surgery (P = 0.02) were significantly associated with an increase in the performance of low anterior resection. The rate of postoperative complications or pathological results was similar between the groups. Conclusion: Compared with laparoscopic surgery, robotic‐assisted surgery significantly increased the frequency of low anterior resection in sphincter‐preserving operations for ultra‐low rectal cancer. Robotic‐assisted surgery has technical superiority over laparoscopic surgery for ultra‐low rectal cancer treatment. [ABSTRACT FROM AUTHOR]

This article discusses the technique of rectal circular stapler anastomosis, which aims to reduce the occurrence of anastomotic leakage in rectal cancer surgery. The prevalent double-stapling technique has been associated with increased risk of leakage due to the formation of intersecting staple lines, known as 'dog-ears'. To address this issue, single-stapling techniques have been developed, including the transanal single-stapling technique. The authors propose a new approach that involves applying a purse-string suture to the distal rectal stump without the cutting staple line, which may reduce the incidence of anastomotic complications. [Extracted from the article]

Aim: The aim of the study was to investigate whether bowel symptoms related to low anterior resection for rectal cancer can be sufficiently well evaluated by the Low Anterior Resection Syndrome (LARS) questionnaire score or the ColoRectal Functional Outcome (COREFO) questionnaire compared with a stool diary. Method: All patients underwent low anterior resection for rectal cancer. They were asked to fill out a stool diary, the LARS questionnaire and the COREFO questionnaire, at 1, 4, 6 and 12 months after low anterior resection or stoma closure. The main outcome measure was the amount of association (calculated by means of canonical correlation analysis) between items on anal incontinence for faeces, frequency of bowel movements, clustering of bowel movements, urgency and soiling. Results: Ninety‐five patients were included. Items on anal incontinence for faeces and frequency of bowel movements were significantly correlated between the LARS questionnaire or the COREFO questionnaire, versus the stool diary, respectively. Items on soiling were significantly correlated between the COREFO questionnaire and the stool diary. Conclusion: Although the LARS questionnaire and the COREFO questionnaire are reliable and valid for measuring low anterior resection syndrome after rectal cancer, our results show that there are no strong associations with the stool diary. Therefore, we can conclude that there is additional clinical information to be obtained from the stool diary. In order to evaluate all aspects of low anterior resection syndrome, we suggest the addition of a stool diary or a combination of different measurement methods during patient follow‐up. [ABSTRACT FROM AUTHOR]

Aim: Recent reports have described the use and efficacy of several types of transanal tube (TAT) for preventing anastomotic leakage by reducing intraluminal pressure. The aim of this study was to evaluate the safety and efficacy of a newly developed TAT for the prevention of anastomotic leakage after low anterior resection (LAR) for rectal cancer. Method: A multicentre confirmatory single‐arm trial was designed to evaluate the safety and efficacy of a new TAT after LAR for rectal cancer. A total of 115 patients were registered in the trial at several cancer centres and other hospitals. All patients initially received reconstruction with a stapled anastomosis, but 18 then underwent creation of a diverting stoma. Of the remaining 97 patients, the first 96 were included in the protocol‐defined primary analysis set. The primary outcome was the incidence of symptomatic leakage and the secondary endpoint was the incidence of complications associated with use of the TAT. The TAT was placed during LAR without creating a covering stoma and the drain was removed 4 or 5 days postoperatively. Results: The rate of symptomatic leakage was 5.2% (95% confidence interval 1.7–11.7), which was significantly lower than the predetermined threshold value of 15.8% (one‐sided p‐value 0.0013). Only one patient had Grade 3 rectal bleeding that might have been related to use of the TAT. Conclusion: This nonrandomized study shows that the TAT appears to be safe and results in lower rates of anastomotic leakage in LAR compared with previous studies. [ABSTRACT FROM AUTHOR]

Introduction: Anastomotic leakage (AL) is a serious complication affecting short‐term and long‐term outcomes in rectal cancer surgery. While laparoscopic low anterior resection is a widespread procedure, the risk factors for AL are not well established. This study aimed to evaluate risk factors for AL after laparoscopic low anterior resection with double stapling technique (DST) anastomosis. Methods: We performed a retrospective cohort study of laparoscopic low anterior resection with DST anastomosis for rectal cancer between January 2010 and February 2019. Finally, a total of 1197 patients were eligible for the study. Twenty‐five variables were collected for univariate and multivariate analyses. Results: AL occurred in 49 patients (4.1%). In multivariate analysis, blood loss (≥70 mL) and no defunctioning stoma were independent risk factors (odds ratio [OR] 2.23; 95% confidence interval [CI] 1.08‐4.34; P =.030 and OR 3.15; 95% CI 1.66‐6.37; P =.0003, respectively). In addition, risk factors for AL were analyzed in 601 patients without defunctioning stoma. As a result, AL occurred in 36 patients (6.0%) and multivariate analysis demonstrated that blood loss (≥70 mL) and anastomotic level from anal verge (<5 cm) were independent risk factors (OR 3.11; 95% CI 1.24‐7.44; P =.016 and OR 2.33; 95% CI 1.14‐4.69; P =.020, respectively). Conclusion: Laparoscopic low anterior resection is feasible and safe with a low AL rate. Important factors associated with AL were blood loss and defunctioning stoma. Without defunctioning stoma, blood loss and distal anastomosis are also important factors. [ABSTRACT FROM AUTHOR]

Aim: Nonrestorative low anterior resection (n‐rLAR) (also known as low Hartmann's) is performed for rectal cancer when a poor functional outcome is anticipated or there have been problems when constructing the anastomosis. Compared with restorative LAR (rLAR), little oncological outcome data are available for n‐rLAR. The aim of this study was to compare oncological outcomes between rLAR and n‐rLAR for primary rectal cancer. Method: This was a nationwide cross‐sectional comparative study including all elective sphincter‐saving LAR procedures for nonmetastatic primary rectal cancer performed in 2011 in 71 Dutch hospitals. Oncological outcomes of patients undergoing rLAR and n‐rLAR were collected in 2015; the data were evaluated using Kaplan–Meier survival analysis and the results compared using log‐rank testing. Uni‐ and multivariable Cox regression analysis was used to evaluate the association between the type of LAR and oncological outcome measures. Results: A total of 1197 patients were analysed, of whom 892 (75%) underwent rLAR and 305 (25%) underwent n‐rLAR. The 3‐year local recurrence (LR) rate was 3% after rLAR and 8% after n‐rLAR (P < 0.001). The 3‐year disease‐free survival and overall survival rates were 77% (rLAR) vs 62% (n‐rLAR) (P < 0.001) and 90% (rLAR) vs 75% (n‐rLAR) (P < 0.001), respectively. In multivariable Cox analysis, n‐rLAR was independently associated with a higher risk of LR (OR = 2.95) and worse overall survival (OR = 1.72). Conclusion: This nationwide study revealed that n‐rLAR for rectal cancer was associated with poorer oncological outcome than r‐LAR. This is probably a noncausal relationship, and might reflect technical difficulties during low pelvic dissection in a subset of those patients, with oncological implications. [ABSTRACT FROM AUTHOR]

Aim: Randomized controlled trials (RCT) are the gold standard in surgical research, and case‐matched studies, such as studies with propensity score matching, are expected to serve as an alternative to RCT. Both study designs have been used to investigate the potential superiority of laparoscopic surgery to open surgery for rectal cancer, but it remains unclear whether there are any differences in the findings obtained using these study designs. We aimed to examine similarities and differences between findings from different study designs regarding laparoscopic surgery for rectal cancer. Methods: Systematic review and meta‐analyses. A comprehensive literature search was conducted using PubMed, Scopus, and Cochrane. RCT, case‐matched studies, and cohort studies comparing laparoscopic low anterior resection and open low anterior resection for rectal cancer were included. In total, 8 short‐term outcomes and 3 long‐term outcomes were assessed. Meta‐analysis was conducted stratified by study design using a random‐effects model. Results: Thirty‐five studies were included in this review. Findings did not differ between RCT and case‐matched studies for most outcomes. However, the estimated treatment effect was largest in cohort studies, intermediate in case‐matched studies, and smallest in RCT for overall postoperative complications and 3‐year local recurrence. Conclusion: Findings from case‐matched studies were similar to those from RCT in laparoscopic low anterior resection for rectal cancer. However, findings from case‐matched studies were sometimes intermediate between those of RCT and unadjusted cohort studies, and case‐matched studies and cohort studies have a potential to overestimate the treatment effect compared with RCT. [ABSTRACT FROM AUTHOR]

Aim: Our aim was to study the implementation of the low anterior resection syndrome (LARS) score in a clinical setting and to evaluate a nurse‐led standardized intervention for bowel dysfunction following rectal cancer surgery. Method: All patients who underwent curatively intended, restorative rectal cancer resection in a single centre between 2012 and 2016 were screened using the LARS score. At clinical follow‐up, patients with major LARS were offered treatment in a nurse‐led clinic. Data were retrospectively collected from patients' electronic medical records. Results: In total, 190 out of 286 (66%) patients were screened with the LARS score of whom 89 had major LARS. A total of 86 patients requested treatment for their bowel dysfunction and the majority obtained acceptable function after nurse‐led optimized conservative treatment. Seventeen patients went on to transanal irrigation, and seven patients were treated with biofeedback. Five patients were referred for surgery, three for gastroenterological evaluation. After treatment in the clinic, patients achieved a statistically significant decrease in median LARS score from 37 (interquartile range 34–39) to 31 (interquartile range 23–34) (P < 0.001), and the prevalence of major LARS fell from 95% to 53% (P < 0.001). Conclusion: Screening for LARS was not optimal as one‐third of patients were not screened. The majority of patients with major LARS requested treatment for their symptoms and could be successfully treated with standardized interventions managed in a nurse‐led setting. [ABSTRACT FROM AUTHOR]

Aim: The aim was to develop and operationally define 'performance metrics' that characterize a reference approach to robotic‐assisted low anterior resection (RA‐LAR) and to obtain face and content validity through a consensus meeting. Method: Three senior colorectal surgeons with robotic experience and a senior behavioural scientist formed the Metrics Group. We used published guidelines, training materials, manufacturers' instructions and unedited videos of RA‐LAR to deconstruct the operation into defined, measurable components – performance metrics (i.e. procedure phases, steps, errors and critical errors). The performance metrics were then subjected to detailed critique by 18 expert colorectal surgeons in a modified Delphi process. Results: Performance metrics for RA‐LAR had 15 procedure phases, 128 steps, 89 errors and 117 critical errors in women, 88 errors and 118 critical errors in men. After the modified Delphi process the final performance metrics consisted of 14 procedure phases, 129 steps, 88 errors and 115 critical errors in women, 87 errors and 116 critical errors in men. After discussion by the Delphi panel, all procedure phases received unanimous consensus apart from phase I (patient positioning and preparation, 83%) and phase IV (docking, 94%). Conclusion: A robotic rectal operation can be broken down into procedure phases, steps, with errors and critical errors, known as performance metrics. The face and content of these metrics have been validated by a large group of expert robotic colorectal surgeons from Europe. We consider the metrics essential for the development of a structured training curriculum and standardized procedural assessment for RA‐LAR. [ABSTRACT FROM AUTHOR]

Background: Anastomotic leakage (AL) is one of the most dreadful complications after rectal cancer surgery. Indocyanine green fluorescence angiography (ICG FA) is now being used to evaluate blood supply at the anastomotic site. The aim of this study is to conduct a meta‐analysis of the available literature to evaluate whether ICG FA could prevent AL after low anterior resection (LAR) for rectal cancer. Methods: Databases including PubMed, Web of Science, Google Scholar databases, Cochrane Library and China National Knowledge Infrastructure were searched to find out potential comparative studies comparing AL rates after LAR between intraoperative use and non‐use of ICG FA. Results: A total of 1499 patients undergoing LAR in six studies were included. Intraoperative use of ICG FA was associated with lower AL rate (odds ratio (OR) 0.30; 95% confidence interval (CI) 0.19–0.49; P < 0.001; I2 = 0%), overall post‐operative complication rate (OR 0.46; 95% CI 0.30–0.70; P < 0.001; I2 = 0%) and reoperation rate (OR 0.21; 95% CI 0.06–0.75; P = 0.020; I2 = 0%). The initial transection line was changed in 7.62% (31/407) of patients in the ICG group and 19.35% (6/31) of patients suffered AL. In transection line unchanged patients (376/407), 5.05% (19/376) of patients suffered AL. Conclusion: Intraoperative use of ICG FA is associated with lower incidence of AL after LAR. The benefit of ICG FA may be that it could identify patients with high risk for AL. [ABSTRACT FROM AUTHOR]

Background: Loop ileostomy (LI) formation is a common practice for patients undergoing low anterior resection or restorative ileo‐anal pouch surgery. Ileostomy closure can be performed using a stapled or hand‐sewn technique, with or without resection. If hand‐sewn, the closure can be one or two layers. Randomized controlled trials have not demonstrated one technique to be superior, and meta‐analyses are limited by the heterogeneity of published studies. Our primary aim is to compare stapled ileostomy closure with single‐ and two‐layer hand‐sewn closures. Methods: This retrospective, single‐centre cohort study included patients undergoing LI closure between January 1999 and April 2016. Patient demographics, anastomotic technique, operative time and patient outcomes were collected. Results: Our analysis included 244 patients (median age 67 years, 43.4% female). There were no significant differences in mean operative times (71.5, 73.1 and 88.5 min, for stapled, single‐ and two‐layer hand‐sewn closures, respectively, adjusted overall P = 0.262), or morbidity (21.5% versus 20.4% versus 17.6%, adjusted overall P = 0.934) between stapled or hand‐sewn anastomoses, and no mortality. Once adjusting for age, sex, American College of Anaesthesiology grade, and consultant surgeon, the length of stay was different (overall P = 0.034), being similar between stapled and single‐layer closures (4.2 versus 5.5 days, P = 0.105), but significantly different between stapled and two‐layer closures (4.2 versus 8.3 days, P = 0.026). Conclusion: Stapled and single‐layered hand‐sewn closures are similar in length of procedure, length of stay and complication rates. A two‐layer, hand‐sewn technique is associated with a significant increase in stay compared to a stapled ileostomy closure. [ABSTRACT FROM AUTHOR]

Introduction: Anastomotic leakage (AL) after low anterior resection for rectal cancer is a severe complication. Except for re‐operation, several endoscopic options have been proposed for the minimal invasive treatment of AL, including the endoluminal vacuum devices, tissue sealants and Over‐The‐Scope‐Clip (OTSC) technique. The aim of the present review is to evaluate the effect of alternative treatment options for AL repair, by means of endoscopy. Method: A bibliographic search was performed in the international literature. Ten case reports and series were finally included, reporting 75 cases of endoscopic repair of AL. A descriptive statistical analysis and a systematic review were performed. Results: The patients' mean age was 65.84 ± 9.92 years (95% CI: 61.70‐68.76), the male‐to‐female ratio being 1.5:1. The mean diameter of the cavity was 5.17 ± 3.32 cm (95% CI: 4.03‐6.31). The mean time until the diagnosis was 44.15 ± 105.91 days (95% CI: 13.39‐74.90). Vacuum‐assisted closure therapy was the most common technique (52%), followed by fibrin glue (25.3%) and OTSC (22.7%). As supplementary therapy, OTSC was applied in 8.3%, vacuum‐assisted closure in 25%, endoclips in 4.2%, while fibrin glue was the most frequently used (62.5%). Conclusion: Endoscopic management of AL after low anterior resection is considered as an alternative to surgical treatment with promising results. [ABSTRACT FROM AUTHOR]

Aim: Anastomotic leakage (AL) is a common and serious complication following sphincter‐preserving surgery for rectal cancer. Early detection and intervention can improve clinical outcomes. The aim of this prospective cohort study was to compare intraperitoneal microdialysis with a clinical scoring system for early detection of AL. Method: A microdialysis catheter was anchored near the anastomosis at low anterior resection (LAR) for rectal cancer. Peritoneal fluid samples were analysed (lactate, pyruvate, glucose and glycerol concentration) 4‐hourly and compared with a daily clinical leak score (DULK = Dutch leakage). At day 7 a pelvic CT with rectal contrast enema was performed to establish if there had been a radiological leak. Results: In this two‐centre study, 129 patients [median age 65 (26–82) years; 60.5% male] underwent LAR. The leak rate was 27% (grade A, n = 11; grade B, n = 12; grade C, n = 12). Receiver operator characteristic analysis demonstrated a lactate cut‐off value of 9.8 mm and had 77% sensitivity, 82% specificity, 78% accuracy, a positive predictive value (PPV) of 58, a negative predictive value (NPV) of 88 (CI 79–94) and an area under the curve (AUC) of 0.9 for AL. This compared with a clinical score ≥ 4, which had 57% sensitivity, 79% specificity, 71% accuracy, a PPV of 46, a NPV of 82 and an AUC of 0.7 for AL. The mean day for a positive test when using delta lactate ≥ 6.3 mm was 1.6 days and for leak score ≥ 4 it was 3.3 days (NS). Conclusion: When AL occurs, intraperitoneal lactate concentration increases over time, and at a certain cut‐off has a higher sensitivity, specificity, accuracy, PPV and NPV than a clinical scoring system. [ABSTRACT FROM AUTHOR]

Aim: Closure of a diverting ileostomy following restorative surgery is often associated with significant short‐term morbidity and variable long‐term bowel function. The aim of this systematic review was to investigate if preoperative stimulation of the defunctioned bowel restores bowel function more quickly after ileostomy closure and improves postoperative outcomes when compared with standard preoperative care. Method: MEDLINE, Embase, CENTRAL, Google Scholar and ClinicalTrials.gov were searched for studies evaluating preoperative bowel stimulation in patients with a temporary ileostomy after low anterior resection or ileal pouch–anal anastomosis, regardless of their design, publication type or language. Study selection, data extraction and study assessment were performed by one reviewer and verified by another. Study results were synthesized narratively. The GRADE approach was used to assess the quality of evidence. Results: Eight studies involving a total of 267 participants were included. The studies had a moderate to high risk of bias and were of varying methodological quality. Preoperative stimulation of the defunctioned bowel reduced the time to postoperative restoration of bowel function and the length of hospital stay when compared with standard preoperative care. Other functional outcomes and postoperative complication rates were similar to those of standard preoperative care. The overall quality of evidence was very low. Conclusion: Despite these promising early results, there is insufficient high‐quality evidence to recommend routine implementation of preoperative bowel stimulation in clinical practice. Nevertheless, there is no evidence suggesting that the intervention worsens outcomes or is unsafe, paving the way for rigorous assessment of effectiveness, acceptability and cost‐effectiveness within the context of well‐designed clinical trials. [ABSTRACT FROM AUTHOR]

Background: The aim was to assess factors influencing the timing of defunctioning stoma (DS) reversal following low anterior resection of rectum for cancer (LAR). Methods: All patients operated with LAR and a primary DS during a 9‐year period were included. Reversal later than 120 days after LAR was considered as delayed. A DS not reversed within 2 years was considered as permanent. Results: In the present study, median age at LAR was 67 years, 45% were females, median body mass index was 25, 87% had American Society of Anesthesiologists class I or II, 64% had pre‐operative radiotherapy, and 3% had cancer stage IV. A total of 79% (92/116) underwent stoma reversal, whereof 25% (23/92) were reversed within 120 days. The most common health‐related reasons for delayed stoma reversal were adjuvant chemotherapy in 38%, symptomatic anastomotic leakage in 16% and other post‐operative adverse events in 13%. In 35% delayed stoma reversal was because of low priority within the healthcare system. A total of 18% (20/110) never had their DS reversed (n = 11) or had their DS converted to a permanent end colostomy (n = 9). Major risk factors for permanent stoma were stage IV cancer in 55%, and symptomatic anastomotic leakage in 30%. Conclusion: One fourth of the patients had their defunctioning stoma reversed within 120 days. The most common identifiable medical reasons for delayed stoma reversal were adjuvant chemotherapy and symptomatic anastomotic leakage, while in one out of three patients it was because of low priority by the healthcare provider. We evaluate timing of stoma reversal and reasons of delayed stoma closure after low anterior resection of rectum for cancer in two different time frames in our institute. We find that in one fourth of the cases the temporary stoma was reversed within the scheduled 120 days after index surgery. In one third of cases delayed stoma reversal was due to low medical priority by healthcare provider. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic low anterior resection for rectal cancer has superior short‐term benefits compared to open surgery. When operative conditions do not favour a totally‐laparoscopic (TL) approach, a hybrid operation can be performed. In this laparoscopic‐assisted (LA) approach, mobilization and vessel ligation are performed laparoscopically, with total mesorectal excision and distal transection performed either partially or totally in an extra‐corporeal fashion. We compared short‐term post‐operative and oncological outcomes of both approaches. Methods: A prospectively collected database of patients who underwent laparoscopic low anterior resection for rectal cancer between January 2009 and December 2014 was retrospectively analysed. Demographics, post‐operative and oncological outcomes were compared. Results: Of 174 patients, 97 were completed by TL, 62 by LA and the remaining 15 were converted to open. Baseline demographics were similar. LA group compared to TL group had bulkier rectal cancers (6.75 cm3 versus 4.50 cm3, P = 0.04) which were lower (6 cm versus 7 cm from anal verge, P = 0.02). They were of a more advanced tumour grade and had greater incidence of lymphovascular invasion. Yet, post‐operative outcomes such as time to diet, pain scores, hospitalization duration, wound‐related and anastomotic complications, 30‐day morbidity and mortality were similar. There was no difference in oncological adequacy, including circumferential resection margins, distal margins, lymph node harvest and 2‐year local recurrence rates. Conclusion: Laparoscopic‐assisted low anterior resection enables minimally invasive rectal surgery to be performed despite unfavourable tumour factors and technical challenges; and compares favourably with TL approach in terms of short‐term outcomes and oncological safety. [ABSTRACT FROM AUTHOR]

Background: Sphincter preserving surgery for the treatment of rectal cancer is very often feasible, avoiding a permanent colostomy. It is well recognized that a large proportion of patients will experience altered bowel habit following low anterior resection (LAR). Faecal incontinence is a common symptom associated with LAR syndrome. The aim of this study is to evaluate the long‐term improvement in continence and quality of life (QoL) in LAR patients treated with sacral nerve modulation. Methods: Patients with ongoing faecal incontinence for >1 year after reversal of diverting ileostomy post ultra‐LAR were selected for the study. Eligible patients underwent sacral nerve modulator implantation as a two‐stage procedure. Bowel diaries and the Cleveland Clinic Faecal Incontinence Score were used to measure faecal incontinence and QoL. Results: Twelve patients underwent permanent implantation of a sacral nerve stimulator. Median follow‐up was 34 months (interquartile range (IQR) 20.25–62.5 months). The median improvement in faecal incontinence was 90% (IQR 76.25–98.75%) and the median improvement in patient QoL was 80% (IQR 71.25–93.75%). Patients who had previously been treated with biofeedback showed a median improvement in incontinence of 75% compared to 90% which was found in patients who had not had prior biofeedback treatment. The mean percentage improvement in patients with an internal anal sphincter defect was 80% compared to 90% seen in patients with an intact sphincter. Conclusions: The results of this study suggest that sacral nerve modulation should be more widely considered as an effective treatment strategy for patients with faecal incontinence following LAR. [ABSTRACT FROM AUTHOR]

Abstract: Aim: The aim was to assess factors independently associated with low anterior resection syndrome (LARS) following resection for rectal cancer. Method: This was a cross‐sectional study carried out in two acute‐care teaching hospitals in Barcelona, Spain. Patients who had undergone sphincter‐preserving low anterior resection with curative intent with total or partial mesorectal excision (with and without protective ileostomy) between January 2001 and December 2009 completed a self‐administered questionnaire to assess bowel dysfunction after rectal cancer surgery. Predictors of LARS were assessed by univariate and multivariate analyses. Results: The questionnaire was sent to 329 patients (response rate 57.7%). Six cases of incomplete questionnaires were excluded. The study population included 184 patients (66.8% men) with a mean age of 63 years. There were 44 (23.9%) patients with no LARS, 36 (19.6%) with minor LARS and 104 (56.2%) with major LARS. In the univariate analysis, total mesorectal excision (P = 0.0008), protective ileostomy (P = 0.002), preoperative and postoperative radiotherapy (P = 0.0000), postoperative chemotherapy (P = 0.0046) and age (P = 0.035) were significantly associated with major LARS, whereas in the multivariate analysis total mesorectal excision (OR 2.18, 95% CI: 1.02–4.65), preoperative radiotherapy (OR 4.33, 95% CI: 2.03–9.27) and postoperative radiotherapy (OR 9.52, 95% CI: 1.74–52.24) were independent risk factors for major LARS. Conclusions: In this study, the risk of having major LARS increases with total mesorectal excision and both neoadjuvant and adjuvant radiotherapy. [ABSTRACT FROM AUTHOR]

Aim The construction of a new coloanal anastomosis ( CAA) following anastomotic leakage after low anterior resection ( LAR) is challenging. The available literature on this topic is scarce. The aim of this two-centre study was to determine the clinical success and morbidity after redo CAA. Method This retrospective cohort study included all patients with anastomotic leakage after LAR for rectal cancer who underwent a redo CAA between 2010 and 2014 in two tertiary referral centres. Short- and long-term morbidity were analysed, including both anastomotic leakage and permanent stoma rates on completion of follow-up. Results A total of 59 patients were included, of whom 45 (76%) were men, with a mean age of 59 years ( SD ± 9.4). The median interval between index and redo surgery was 14 months [interquartile range ( IQR) 8-27]. The median duration of follow-up was 27 months ( IQR 17-36). The most frequent complication was anastomotic leakage of the redo CAA occurring in 24 patients (41%), resulting in a median of three reinterventions ( IQR 2-4) per patient. At the end of follow-up, bowel continuity was restored in 39/59 (66%) patients. Fourteen (24%) patients received a definitive colostomy and six (10%) still had a diverting ileostomy. In a multivariable model, leakage of the redo CAA was the only risk factor for permanent stoma ( OR 0.022; 95% CI 0.004-0.122). Conclusion Redo CAA is a viable option in selected patients with persisting leakage after LAR for rectal cancer who want their bowel continuity restored. However, patients should be fully informed about the relatively high morbidity and reintervention rates. [ABSTRACT FROM AUTHOR]

Aim Postoperative ileus is the most commonly observed morbidity following ileostomy closure. Studies have demonstrated that the defunctionalized bowel of a loop ileostomy undergoes a series of functional and structural changes, such as atrophy of the intestinal villi and muscular layers, which may contribute to ileus. A single-centre study in Spain demonstrated that preoperative bowel stimulation via the distal limb of the loop ileostomy decreased postoperative ileus, length of stay and time to gastrointestinal function. Method A multicentre randomized controlled trial involving patients from Canadian institutions was designed to evaluate the effect of preoperative bowel stimulation before ileostomy closure on postoperative ileus. Stimulation will include canalizing the distal limb of the ileostomy loop with an 18Fr Foley catheter and infusing it with a solution of 500 ml of normal saline mixed with 30 g of a thickening agent (Nestle © Thicken-Up ©). This will be performed 10 times over the 3 weeks before ileostomy closure in an outpatient clinic setting by a trained Enterostomal Therapy nurse. Surgeons and the treating surgical team will be blinded to their patient's group allocation. Data regarding patient demographics, and operative and postoperative variables, will be collected prospectively. Primary outcome will be postoperative ileus, defined as an intolerance to oral food in the absence of clinical or radiological signs of obstruction, that either requires nasogastric tube insertion or is associated with two of the following on or after post-operative day 3: nausea/vomiting; abdominal distension; and the absence of flatus. Secondary outcomes will include length of stay, time to tolerating a regular diet, time to first passage of flatus or stool and overall morbidity. A cost analysis will be performed to compare the costs of conventional care with conventional care plus preoperative stimulation. Discussion This manuscript discusses the potential benefits of preoperative bowel stimulation in improving postoperative outcomes and outlines our protocol for the first multicenter study to evaluate preoperative bowel stimulation before ileostomy closure. The results of this study could have considerable implications for the care of patients undergoing ileostomy closure. [ABSTRACT FROM AUTHOR]

Aim Anastomotic leakage is the most serious complication following low anterior resection for rectal cancer and is a major cause of postoperative morbidity and mortality. The object of the present study was to investigate whether rectal tube drainage can reduce anastomotic leakage after minimally invasive rectal cancer surgery. Method Three hundred and seventy-four patients who underwent laparoscopic or robotic LAR for tumours located ≤ 15 cm above the anal verge between 1 April 2012 and 31 October 2014 were assessed retrospectively. Of these, 107 with intermediate risk of anastomotic leakage received transanal rectal tube drainage. The rectal tube group was matched by propensity score analysis with patients not having rectal tube drainage, giving 204 patients in the study. Covariates for propensity score analysis included age, sex, body mass index, tumour height from the anal verge and preoperative chemoradiation. Results Patient demographics, tumour location, preoperative chemoradiation and operative results were similar between the two groups. The overall leakage rate was 10.8% (22/204), with no significant difference between the rectal tube group (9.8%) and the nonrectal tube group (11.8%, P = 0.652). Of the patients with anastomotic leakage, major leakage requiring reoperation developed in 11.8% of those without and 3.9% of those with a rectal tube. On multivariate analysis, age over 65 years and nonuse of a rectal tube were found to be independent risk factors for major anastomotic leakage. Conclusion Rectal tube placement may be a safe and effective method of reducing the rate of major anastomotic leakage, alleviating the clinical course of leakage following minimally invasive rectal cancer surgery. [ABSTRACT FROM AUTHOR]

Aim Outcomes following treatment for low rectal cancer still remain inferior to those for upper rectal cancer. A clear definition of 'low' rectal cancer is lacking and consensus is more likely using a definition based on MRI criteria. This study aimed to determine disease presentation and treatment outcome of low rectal cancer based on a strict anatomical definition. Method A low rectal cancer was defined as one with a lower border below the pelvic attachment of the levator muscles on sagittal MRI. One hundred and eighty consecutive patients with tumours defined by this criterion between 2006 and 2011 were identified from a prospectively managed departmental database. Results One hundred and eighteen patients (66%) underwent curative resection and 12 (7%) palliative resection. Eleven patients (6%) were entered into a 'watch and wait' (W&W) protocol; 10 others (5%) were not fit to undergo any operation. Some 26 patients (14%) had nonresectable local or metastatic disease. An R0 resection was the most important factor influencing survival after curative surgery. R+ resections occurred in 12% of non-abdominoperineal excisions, 11% of abdominoperineal excisions and 47% of extended resections. Overall survival was similar in the curative resections compared with the W&W patients. In 23 of the 96 (24%) treated with neoadjuvant chemoradiotherapy there was a persistent clinical or a pathological complete response. Conclusion In curative resections, a clear margin is the most important determinant of survival. In 24% of the patients treated with neoadjuvant chemoradiotherapy, surgery could potentially have been avoided. There is scope for improvement in the treatment of locally advanced rectal cancers. [ABSTRACT FROM AUTHOR]

Aim This study used a national registry to compare the outcome after a low Hartmann's procedure ( LHP), defined as removal of most of the rectum to leave a short anorectal stump and an end colostomy, and low anterior resection (LA) with or without a diverting ileostomy ( DI) in rectal cancer patients all of whom had received preoperative neoadjuvant radiotherapy ( RT). Method Patients who underwent LHP or LA with or without DI for rectal cancer after RT between 2009 and 2013 were identified from the Dutch Surgical Colorectal Audit. The postoperative outcome was compared between the three groups and risk of complications, reoperation and mortality were analysed in a multivariable model. Results The study included 4288 patients were included, of whom 27.8% underwent LHP, 20.2% LA and 52.0% LA with DI. Thirty-day mortality was higher after LHP (3.2% vs 1.3% and 1.3% for LA with or without DI, P < 0.001), but LHP was not an independent predictor of mortality in multivariable analysis. LHP and LA with DI were associated with a lower rate of abdominal infective complications (6.5% and 10.1% vs 16.2%, P < 0.001) and reoperation (7.3% and 8.1% vs 16.5%, P < 0.001). In multivariable analysis, LHP ( OR 0.35, 95% CI 0.26-0.47) and LA with DI ( OR 0.43, 95% CI 0.33-0.54) were associated with a lower risk of reoperation than LA alone. LHP was associated with a lower risk of any postoperative complication than LA with or without DI ( OR 0.81, 95% CI 0.66-0.98). Conclusion LHP and LA with DI were associated with fewer infective complications and reoperations than LA alone. The rate of any complication was less after LHR than LA with or without DI. [ABSTRACT FROM AUTHOR]

Aim Several procedures have been described for rectovaginal fistula with a wide range of success, but there is little information on the long-term outcome. The aim of the present study was to investigate the long-term outcome after transvaginal anterior levatorplasty ( ALP) for intractable rectovaginal fistula. Method Data of 16 consecutive patients undergoing transvaginal ALP with fistulectomy and closure of the rectum and vagina between 1998 and 2011 were prospectively recorded and retrospectively investigated to study the long-term outcome. Results Birth injury ( n = 7), low anterior resection for rectal cancer ( n = 3), pouch surgery for ulcerative colitis ( n = 2) and a procedure for prolapse and haemorrhoids ( n = 2) were the main causes of the fistula. Nine patients had a covering stoma before surgery. All patients underwent ALP, with a covering stoma in two patients. Infection occurred in one patient and wound rupture after surgery in another patient. These patients underwent reoperation by ALP. All fistulae had healed at a median follow-up of 84 (8-193) months after initial surgery or stoma closure. Conclusion Transvaginal ALP is effective for the treatment of mid or low rectovaginal fistula. The results show that a graft is not necessary regardless of whether or not previous surgery has been performed. [ABSTRACT FROM AUTHOR]

Background and aims Anastomotic dehiscence is one of the most feared complications in colorectal surgery leading to significant morbidity and mortality. Progressively lower anastomoses are associated with a greater leak rate. One of the key factors is the perfusion of the bowel to be joined. Presently, surgeons rely on a variety subjective measures to determine anastomotic perfusion and mechanical integrity however these have shortcomings. The aim of this paper is to appraise the literature on the use of fluorescence angiography ( FA) in laparoscopic rectal surgery. Materials and methods A Pubmed search was undertaken using terms 'fluorescence angiography' and 'rectal surgery'. The search was expanded using the related articles function. Studies were included if they used FA specifically for rectal surgery. Outcomes of interest including anastomotic leak rate, change of operative strategy and time taken for FA were recorded. Results Eleven papers detailing the use of FA in rectal surgery are outlined demonstrating that this technique may change operative strategy and lead to a reduction in anastomotic leak rate. Conclusion In this paper, we discuss assessment of colorectal blood supply using FA and how this technique holds great potential to detect insufficiently perfused bowel. In so doing, the operator can adjust their operative strategy to mitigate these affects with the aim of reducing the complications of anastomotic leak and stenosis. However, it is highlighted that there is a clear need for randomised controlled trials in order to determine this definitively. [ABSTRACT FROM AUTHOR]

Aim Many patients having anterior resection for rectal cancer suffer from severe long-term bowel dysfunction, known as low anterior resection syndrome ( LARS). The LARS score was developed in Denmark, and Swedish, Spanish and German versions have been validated. The aim of this study was to validate the English translation of the LARS score in British rectal cancer patients. Method Rectal cancer patients who underwent an anterior resection in 12 UK centres received the LARS score questionnaire, the EORTC QLQ-C30 and a single ad hoc quality of life question. A subgroup of patients received the LARS score questionnaire twice. Results The response rate was 80% and 451 patients were included in the analyses. A strong association between LARS score and quality of life (convergent validity) was found ( P < 0.01), discriminative validity was good ( P < 0.02) and the test-retest reliability was high (intraclass correlation coefficient 0.83). Conclusion The English translation of the LARS score has shown good psychometric properties comparable with recently published results from an international multicentre study. Thus, the English translation of the LARS score can be considered a valid and reliable tool for measuring LARS. [ABSTRACT FROM AUTHOR]

Aim Preclinical studies have suggested that nitinol-based compression anastomosis might be a viable solution to anastomotic leak following low anterior resection. A prospective multicentre open label study was therefore designed to evaluate the performance of the ColonRing™ in (low) colorectal anastomosis. Method The primary outcome measure was anastomotic leakage. Patients were recruited at 13 different colorectal surgical units in Europe, the United States and Israel. Institutional review board approval was obtained. Results Between 21 March 2010 and 3 August 2011, 266 patients completed the study protocol. The overall anastomotic leakage rate was 5.3% for all anastomoses, including a rate of 3.1% for low anastomoses. Septic anastomotic complications occurred in 8.3% of all anastomoses and 8.2% of low anastomoses. Conclusion Nitinol compression anastomosis is safe, effective and easy to use and may offer an advantage for low colorectal anastomosis. A prospective randomized trial comparing ColonRing™ with conventional stapling is needed. [ABSTRACT FROM AUTHOR]

Aim Preclinical studies have suggested that nitinol-based compression anastomosis might be a viable solution to anastomotic leak following low anterior resection. A prospective multicentre open label study was therefore designed to evaluate the performance of the ColonRing™ in (low) colorectal anastomosis. Method The primary outcome measure was anastomotic leakage. Patients were recruited at 13 different colorectal surgical units in Europe, the United States and Israel. Institutional review board approval was obtained. Results Between 21 March 2010 and 3 August 2011, 266 patients completed the study protocol. The overall anastomotic leakage rate was 5.3% for all anastomoses, including a rate of 3.1% for low anastomoses. Septic anastomotic complications occurred in 8.3% of all anastomoses and 8.2% of low anastomoses. Conclusion Nitinol compression anastomosis is safe, effective and easy to use and may offer an advantage for low colorectal anastomosis. A prospective randomized trial comparing ColonRing™ with conventional stapling is needed. [ABSTRACT FROM AUTHOR]

Aim Knowledge of urinary and sexual dysfunction in women after rectal cancer treatment is limited. This study addresses this in relation to the use of preoperative radiotherapy, type of surgery and the presence of bowel dysfunction. Method All living female patients who underwent abdominoperineal excision ( APE) or low anterior resection ( LAR) for rectal cancer in Denmark between 2001 and 2007 were identified. Validated questionnaires (the ICIQ- FLUTS and the SVQ) on urinary and sexual function were completed by 516 (75%) and 482 (72%) recurrence-free patients in 2009. Results Urgency and incontinence were reported by 77 and 63% of respondents, respectively. Vaginal dryness, dyspareunia and reduced vaginal dimensions occurred in 72, 53 and 29%, respectively, and 69% reported that they had little/no sexual desire. Preoperative radiotherapy was associated with voiding difficulties ( OR = 1.63, 95% CI 1.09-2.44), reduced vaginal dimensions ( OR = 4.77, 95% CI 1.97-11.55), dyspareunia ( OR = 2.76, 95% CI 1.12-6.79), lack of desire ( OR = 2.22, 95% CI 1.09-4.53) and reduced sexual activity ( OR = 0.55, 95% CI 0.30-0.98). Patients undergoing APE had a higher risk of dyspareunia ( OR = 2.61, 95% CI 1.00-6.85). Bowel dysfunction after LAR was associated with bladder storage difficulties ( OR = 1.64, 95% CI 1.01-2.65), symptoms of incontinence ( OR = 2.17, 95% CI 1.35-3.50), lack of sexual desire ( OR = 2.69, 95% CI 1.21-5.98), sexual inactivity ( OR = 0.48, 95% CI 0.24-0.96) and sexual dissatisfaction ( OR = 0.40, 95% CI 0.20-0.82). Conclusion Urinary and sexual problems are common in women after treatment for rectal cancer. Preoperative radiotherapy interferes with several aspects of urinary and sexual functioning. Bowel dysfunction after LAR is associated with urinary dysfunction and a reduction in sexual desire, activity and satisfaction. [ABSTRACT FROM AUTHOR]

Aim This study evaluated the efficacy and safety of ileal diversion, using a tracheal cannula, to protect from a low colorectal anastomosis in patients treated with neoadjuvant chemoradiotherapy. Method Fifty patients who presented with rectal cancer and who had accepted neoadjuvant chemoradiotherapy were included. All underwent a low anterior resection with ileal diversion by either tracheal cannula ileostomy ( n = 28) or conventional loop ileostomy ( n = 22). Demographics, clinical features and operation data were recorded. Results Two patients developed anastomotic dehiscence after completion of the cannula ileostomy but neither patient required any further operation. There was no difference in anastomotic dehiscence, peritonitis or requirement for further surgery in patients treated with cannula ileostomy and loop ileostomy. Conclusion Cannula ileostomy is a safe, quick, effective and convenient means of intestinal diversion after low anterior resection. Its obvious advantage over loop ileostomy is a reduced overall hospital stay and avoidance of the need to close the stoma. [ABSTRACT FROM AUTHOR]

Introduction Anastomotic leakage remains a devastating complication following low anterior resection of the rectum. Our aim was to retrospectively assess the efficacy of transanal drainage. Methods Twenty-five patients with anastomotic leakage after laparoscopic low anterior resection (using the double-stapling technique) were reviewed. Transanal drainage was performed when an abscess was localized within the pelvic cavity, and any leakage was detected through radiological study and digital examination. In each patient, the fistula was dilated with a forefinger, and the abscess was drained into the rectum. A suction drain tube was indwelled transanally when the abscess cavity was large or unstable. Clinical outcomes of patients after transanal drainage were then analyzed. Results Nine of the 25 patients required an emergency operation. The remaining 16 cases with localized disease were treated conservatively as an initial treatment. This included 12 patients treated by transanal drainage, 10 of whom were successfully cured. Two eventually required a defunctioning ileostomy because of fistula formation with other organs (treatment success rate: 83.3%). The median duration of drain placement, fasting and postoperative hospitalization were 10, 10 and 45 days, respectively. Conclusions Transanal drainage may be a viable option for the treatment of anastomotic leakage after low anterior resection of the rectum. [ABSTRACT FROM AUTHOR]

Aim Reported incidence rates of colorectal anastomotic leakage ( AL) vary between 2.5 and 20%. There is little information on late anastomotic leakage ( LAL). The aim of this study was to determine the incidence of LAL after colorectal resection. Method All patients undergoing colorectal resection with primary anastomosis between January 2004 and October 2009 at the University Medical Center Groningen were included. LAL was defined as anastomotic leakage diagnosed more than 30 days after surgery. Results One hundred and forty-one patients were analysed. Indications for surgery included both benign and malignant conditions. The incidence of early anastomotic leakage ( EAL) within 30 days after surgery was 13%. The LAL rate was 6%. Eighty-nine per cent of patients with EAL underwent relaparotomy compared with 44% for LAL ( P = 0.02). Conclusion One-third of all anastomotic leakages were diagnosed more than 30 days after surgery. Of these, 44% underwent relaparotomy. Patients with leakage diagnosed within 30 days after surgery were more likely to undergo relaparotomy. LAL is a significant problem after colorectal surgery. [ABSTRACT FROM AUTHOR]

Aim Abdominoperineal excision (APR) has been associated with higher circumferential resection margin (CRM) involvement and local recurrence rates than extralevator APR for low rectal cancer. This study aimed to evaluate the CRMs in APR and low anterior resection (LAR) specimens and to identify factors influencing CRM involvement. Method All pathological specimens from consecutive patients with rectal cancer who underwent curative resection at the Cleveland Clinic Florida, from January 2000 to July 2010, were reviewed by two pathologists. Demographics, tumour characteristics, operative data, postoperative pathology and Dworak's tumour regression grade were compared between specimens with positive and negative CRMs. Results One-hundred and fifty-four patients underwent curative APR ( n = 65) or LAR ( n = 69). Mean tumour size was 3.6 cm, and mean distance from the dentate line was 5.4 cm. Nine (6.8%) patients had a positive CRM ( n = 6 APR, n = 3 LAR), which was associated with tumour size > 5.9 cm ( P = 0.002), a distance of ≤ 2.6 cm from the dentate line ( P = 0.013), microvascular invasion ( P = 0.009), perineural invasion ( P < 0.001), number of positive lymph nodes ( P = 0.046) and incomplete total mesorectal excision (TME) ( P < 0.001). APR specimens were three times more likely than LAR specimens to have an incomplete mesorectum (9.8% vs 2.9%, P = 0.322). Conclusions Factors associated with a positive CRM were tumour size > 5.9 cm, a distance of ≤ 2.6 cm from the dentate line, incomplete TME, number of positive nodes and microvascular and perineural invasion. The incidence of a positive CRM was not significantly different between LAR and APR ( n = 3 LAR and n = 6 APR). [ABSTRACT FROM AUTHOR]

Aim The aim of this retrospective study of laparoscopic low anterior resection was to compare splenic flexure mobilization ( SFM) carried out by an extended medial to lateral approach with that by a lateral approach. Method Records of patients with rectal cancer on a prospectively maintained database undergoing laparoscopic low anterior resection performed between January 2009 and November 2011 by a single surgeon were analysed. The extended medial to lateral approach involved continuing the medial to lateral approach upwards to enter the lesser sac over the pancreas, thus permitting detachment of the splenic flexure. Results Two hundred and thirty-seven patients, including 164 undergoing a lateral SFM and 73 an extended medial to lateral SFM, were evaluated. Both patient groups had similar characteristics except for operative time (152.7 ± 32.7 min extended medial to lateral; 171.5 ± 40.8 min lateral; P < 0.001), postoperatively the interval to oral intake (3.1 ± 0.8 days extended medial to lateral; 3.7 ± 0.9 lateral; P < 0.001) and duration of hospital stay (8.2 ± 2.8 days extended medial to lateral; 10.3 ± 7.5 days lateral; P = 0.002) favoured the extended medial to lateral group. Conclusion An extended medial to lateral approach for SFM during laparoscopic low anterior resection of rectal cancer appears to be an improvement over the previously used lateral approach, because it may provide a shorter operation time and shorter hospital stay. [ABSTRACT FROM AUTHOR]

The aim of this study was to assess the effectiveness of sacral nerve stimulation (SNS) in the management of faecal incontinence following neoadjuvant therapy and low anterior resection (LAR) for rectal cancer. In a prospective single-centre study, 15 patients (12 men, median age 72 years) were enrolled between 2005 and 2008. All had severe incontinence after total mesorectal excision, and 14 had received preoperative full-course chemoradiotherapy. The patients were followed up for a median of 50 (range: 24-144) months. There was no recurrence (local or distal). Incontinence was evaluated using the Cleveland Clinic Florida Fecal Incontinence (CCF-FI) scoring system. Quality of life (QoL) was evaluated using the Fecal Incontinence Quality of Life (FIQL) questionnaire. SNS was performed in three stages. During percutaneous nerve evaluation (PNE), a good response was observed in seven patients, all of whom received a permanent implant. The median follow up was 12 (range: 1-44) months. The mean CCF-FI score was reduced from 19.2 [standard deviation (SD) 1.2] to 6.2 (SD 1.7) ( P < 0.01). The mean number of days per week with an incontinent episode decreased from 7 (SD 0) to 0.2 (SD 0.3) ( P < 0.01), and the mean number of defaecations per week decreased from 42.5 (SD 13.7) to 13.2 (SD 7.4) ( P < 0.01). In the five patients with a permanent implant who were followed up for longer than 6 months, all FIQL scores improved. An increase in the mean resting and squeeze pressures was seen in four patients with a permanent implant. SNS is a treatment option for faecal incontinence after LAR for rectal cancer. [ABSTRACT FROM AUTHOR]

Objective The creation of a loop ileostomy is considered suitable to protect a distal anastomosis in colorectal surgery. This technique is, however, associated with failure, complications and even mortality. The aim of this study was to quantify retrospectively the morbidity associated with an ileostomy and its subsequent closure. Method One hundred and nineteen patients with a temporary loop ileostomy, created between January 2000 and July 2007 were retrospectively analysed from a review of patient records. Results All ileostomies were closed after a median period of 106 days (interquartile range: 69–174 days). Stoma-related morbidity occurred in 23 (19%) patients. After ileostomy closure, 16 major complications were seen in 14 (12%) patients and 43 minor complications occurred in 25 (21%) patients. Sixty-three patients (53%) had neither stoma-related morbidity or peri- or postoperative complications after stoma closure. Conclusion Protective loop ileostomy was found to be associated with a high morbidity. This raises the question of the mode of identifying the specific patients with a low anastomosis who should be provided an ileostomy for protection, set against the potential complications of the formation and closure of the ileostomy. [ABSTRACT FROM AUTHOR]

Objective Many patients experience disordered defaecation after low anterior resection of the rectum (LARR). We analysed the anorectal function of these patients to determine which factors might contribute to this problem. Patients and methods Between November 2002 and January 2004, 18 consecutive patients (11 males and 7 females) who underwent LARR with total mesorectal excision (TME) for rectal cancer were assessed by anorectal manometry, balloon proctometry and the Wexner continence questionnaire before operation and at 6 months and 1 year following stoma closure. Sixteen volunteers (11 males and 5 females) were evaluated for comparison. Stepwise logistic regression was performed for variables that were highly significant at univariate analysis. Results The mean daily preoperative stool frequency was 2, mean basal pressure (MBP) 43.12 cm H2O, maximum threshold volume (MTV) 181.8 ml, length of high-pressure zone (HPZ) 3.11 cm and the rectoanal inhibitory reflex (RAIR) was present in all the patients. Twelve months after stoma closure, the stool frequency was 3.3, MBP 37.7 cm H2O, MTV 146.3 ml, length of HPZ 2.88 cm and Wexner score 4.37. Comparing patients having a good anorectal function (Wexner score ≥ 5) with those having an unsatisfactory function, we found that, on multivariate analysis, the factors that independently contributed to a poor outcome at 12 months after operation were the absence of RAIR as well as an MTV and HPZ below the fifth percentile of normal individuals. Conclusions Many patients undergoing LARR with TME for rectal cancer experience an anterior resection syndrome that persists for at least 1 year. Those with no RAIR and subnormal MTV and HPZ lengths can be predicted to have an unsatisfactory outcome. [ABSTRACT FROM AUTHOR]

Irrigation of the distal part of the large bowel is a nonsurgical alternative for patients with defaecation disturbances. In our institution, all patients with defaecation disturbances, not responding to medical treatment and biofeedback therapy, were offered retrograde colonic irrigation (RCI). This study is aimed at evaluating the long-term feasibility and outcome of RCI.Between 1989 and 2001, a consecutive series of 267 patients was offered RCI. All patients received instructions about RCI by one of our enterostomal therapists. Twenty-eight patients were lost to follow-up. A detailed questionnaire was sent by mail to 239 patients. The total response rate was 79% (190 patients). Based on the returned questionnaires it became clear that 21 (11%) patients never started RCI. The long-term feasibility and outcome of RCI was therefore assessed in the remaining group of 169 patients. Thirty-two patients were admitted with soiling, 71 patients with faecal incontinence, 37 patients with obstructed defaecation and 29 had defaecation disturbances after low anterior resection or pouch surgery.According to the returned questionnaires, RCI was considered effective by 91 (54%) patients. Among patients with soling and faecal incontinence, RCI was found to be effective in, respectively, 47 and 41% of the subjects. Despite of the reported effectiveness, 10 (67%) patients with soiling and 5 (17%) patients with faecal incontinence decided to stop. Among patients with obstructed defaecation and those with defaecation disturbances after low anterior resection or pouch surgery the effectiveness of RCI was found to be 65 and 79%, respectively. None of these patients ceased their therapy. The overall success-rate of long-term RCI was therefore 45%.Long-term RCI is beneficial for 45% of patients with defaecation disturbances. In the group of patients who considered RCI effective and beneficial, discontinuation of therapy was only observed among those with soiling and faecal incontinence. [ABSTRACT FROM AUTHOR]

While still debated, it was advised to perform a protective temporary ileostomy after a low anterior resection (LAR). This might help to decrease the leak rate and therefore offers the patient better outcomes. Anastomotic leak can occur in many situations after a LAR and the control of the risk factors helps to adapt the need of an ileostomy. Near infrared technology allows assessing the microvascularisation of the anastomosis at the time of surgery and therefore might be an important tool to avoid a stoma in given situation. This article reviews the evidences with the use of this technology. [ABSTRACT FROM AUTHOR]