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Background: Anastomotic leakage is a common complication after low anterior resection for rectal cancer, often resulting in a permanent stoma. This study aimed to evaluate the effectiveness of early detection, sepsis control, and transanal repair in managing anastomotic leakage. Methods: In this prospective cohort study conducted from January 2018 to June 2022 at a Norwegian university hospital, patients undergoing resectional surgery for rectal cancer were assessed for anastomotic leaks. Early detection involved CT with rectal contrast and flexible endoscopy. Repair eligibility required involvement of less than half the anastomotic circumference and no ischemia or retraction of the colon. The cavity outside the anastomotic defect was cleaned using a catheter for intermittent irrigation or endoluminal vacuum therapy. A diverting stoma was created, and a transabdominal pelvic drain was inserted if not already present. Once sepsis was controlled and the cavity was clean, the defect was sutured using a transanal minimally invasive surgery access platform or an open transanal technique, based on anastomosis level. Healing was confirmed via computed tomography (CT) with rectal contrast and rigid proctoscopy before reversing diverting stomas, and again at 12 months. A supplementary video demonstrates the technique. Results: Of 22 identified anastomotic leaks, 11 underwent transanal repair, resulting in healed anastomosis for nine patients and restored bowel continuity for eight. Among these, five reported major low anterior resection syndrome. Median hospital stay was 20 days, with no 90-day mortality. Conclusions: This anastomosis-preserving approach for treating anastomotic leakage shows promise, potentially preserving bowel function and reducing permanent stoma rates. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the effects of pelvic floor rehabilitation (PFR) after low anterior resection (LAR) at 1-year follow-up. Background: After LAR, with restoration of bowel continuity, up to 90% of patients develop anorectal dysfunction, significantly impacting their quality of life (QoL). However, standardized treatment is currently unavailable. The FORCE trial demonstrated the beneficial effects of PFR after 3 months regarding specific domains of the Fecal Incontinence QoL (FIQL) questionnaire and urgency compared with usual care. Methods: The FORCE trial is a multicenter, two-arm, randomized clinical trial. All patients undergoing LAR were randomly assigned to receive either usual care or a standardized PFR program. The primary outcome measure is the Wexner incontinence score, and the secondary endpoints included the low anterior resection syndrome score, the European Organization for Research and Treatment of Cancer colorectal-specific QoL questionnaire, and health and FIQL. Assessments were conducted at baseline before randomization, at 3 months and 1-year follow-ups. Results: A total of 86 patients were included (PFR: n = 40, control: n = 46). After 1 year, PFR did not significantly improve Wexner incontinence scores (PFR: -3.33, 95% CI: -4.41 to -2.26, control: -2.54, 95% CI: -3.54 to -1.54, P = 0.30). Similar to the 3-month follow-up, patients without near-complete incontinence at baseline showed a sustained improvement in fecal incontinence (PFR: -2.82, 95% CI: -3.86 to -1.76, control: -1.43, 95% CI: -2.36 to -0.50, P = 0.06). Significant improvement was reported in the FIQL domains Lifestyle (PFR: 0.51, control: -0.13, P = 0.03) and Coping and Behavior (PFR: 0.40, control: -0.24, P = 0.01). Trial registration: Netherlands Trial Registration, NTR5469, registered on September 3, 2015. Conclusions: At 1-year follow-up, no significant differences were found in fecal incontinence scores; however, PFR was associated with improved FIQL compared with usual care. [ABSTRACT FROM AUTHOR]

Abstract Aim The purpose of this study was to evaluate factors associated with surgical outcomes and postoperative complications (Grade ≥3 by Clavien–Dindo classification) of right hemicolectomy (RH) and low anterior resection (LAR) for colorectal cancer in patients ≥85 years old. Methods We retrospectively analyzed National Clinical Database (NCD) data on patients aged ≥85 years who underwent RH and LAR for colorectal cancer between 2017 and 2020. All possible preoperative factors were used to explore the risk factors for serious postoperative complication in these very elderly patients with colorectal cancer. Results For RH, the operative mortality rate was 1.1% (98 cases), and the rate of serious postoperative complications was 5.2% (480 cases). Similarly, the mortality rate was 1.1% (27 cases), and the rate of serious complications (Clavien–Dindo Grade ≥3) was 8.7% (206 cases) for LAR. Based on multivariate analysis, independent risk factors for serious postoperative complications were male sex, ADL (partially dependent), hypertension, platelets (1.1) for RH, and ASA‐PS (Grade ≥3), history of pneumonia, creatinine (>1.2 mg/day), and serum Na (

Abstract Background To evaluate the effect of stoma-related factors (stoma or no stoma, stoma type, and stoma reversal time) on the occurrence of low anterior resection syndrome (LARS), a highly prevalent condition that can develop after anal sphincter-sparing surgery for rectal cancer and impair quality of life, which includes fecal incontinence, fecal urgency and frequent defecation. Methods Patients who underwent radical rectal cancer surgery from July 2018 to July 2022 in a tertiary hospital were included. Baseline data, tumor condition, operation condition and postoperative recovery were obtained by clinical observation. Follow-up data were collected by telephone follow-up. The chi-square and Fisher exact tests were used to analyse differences, coefficient of contingency was used to determine correlations, and independent risk factors for the occurrence of LARS (Patients with a score of 21 or more points were defined as having LARS using the LARS score) were further determined by binary logistic regression. Results A total of 480 patients met the inclusion criteria, of which 267 used a defunctioning stoma and 213 did not use a defunctioning stoma. There was a positive correlation between defunctioning stoma (P 0.05). In binary logistic regression analysis, high BMI (Exp(B) = 1.072, P = 0.039), tumor closer to dentate line (Exp(B) = 0.910, P = 0.016), and ultra-low anterior resection (Exp(B) = 2.264, P = 0.011) increased the possibility of LARS at 3 months postoperatively; high BMI, proximity of the tumor to the dentate line, and ultra-low anterior resection were not independent risk factors for LARS at 6 months postoperatively (P > 0.05). However, proximity of the tumor to the dentate line (Exp(B) = 0.880, P = 0.035) increased the likelihood of LARS at 12 months postoperatively, while high BMI and ultra-low anterior resection remained non-significant as independent risk factors for LARS at 12 months postoperatively (P > 0.05). Conclusions Defunctioning stoma was not an independent risk factor for the occurrence of LARS, whereas high BMI, tumor closer to dentate line, and ultra-low anterior resection were independent risk factors for the occurrence of LARS. Trial registration Not applicable.

Introduction: Despite spectacular visuals and the seemingly convincing rationale of using indocyanine-green-enhanced fluorescence in assessing bowel perfusion during colorectal resections, a lingering sense of subjectivity remains in the challenge of quantifying this fluorescence. This prospective study analyzed the application of O2C® spectrophotometry to quantify zones of fluorescence on the large bowel during low anterior resection. Materials and methods: Patients receiving a low anterior resection for cancer of the mid- and lower rectum were enrolled in this observational prospective study between February 2020 and December 2022. O2C® blood-flow measurement was performed at three different zones of fluorescence intensity (optimal [O], sufficient [S], and absent [A]), visualized at the designated and already skeletonized site of colon transection. The primary end point was to assess whether the O2C® flow value exceeds 164 arbitrary units (AU) at the zone of optimal fluorescence. The secondary objective was to assess whether there were statistically significant differences in flow parameters between the three zones, thus confirming reproducibility of measurements. Results: A total of 40 patients were enrolled in this study. Of these, 38 patients remained for statistical analysis with regard to O2C® measurement of the fluorescence zones. The O2C® flow parameter measured at the zone of optimal fluorescence was greater than 164 AU in all cases (100%, p < 0.0001). There were statistically significant differences in flow parameters measured at the three different zones of fluorescence (O-S: p < 0.0001; O-A: p < 0.0001; S-A: p = 0.0023). Conclusion: This study proves the feasibility and reproducibility of quantifying zones of indocyanine green (ICG)-enhanced fluorescence on the bowel. All O2C® flow measurements that were collected at the zone of optimal fluorescence exceeded 164 AU, thereby adding more evidence to this value as a suggested cut-off parameter in terms of bowel perfusion. [ABSTRACT FROM AUTHOR]

To explore the frequency and predictive factors of erectile dysfunction diagnosis after colorectal cancer surgery. The Surveillance, Epidemiology, and End Results—Medicare database was used to identify a national sample of men undergoing surgery for colorectal cancer from 2004 to 2015. Men aged > 65 years with any index surgery within 1 year of diagnosis of colorectal cancer were included. Men with a history of prior erectile dysfunction, metastatic cancer, or genitourinary cancer prior to their index procedure were excluded. The primary outcome was a new diagnosis of erectile dysfunction within 2 years of the index procedure. A total of 28,248 men aged > 65 years who underwent colorectal cancer surgery were identified. The rates of erectile dysfunction diagnosis 2 years after surgery were 3.6% for hemicolectomy, 5.3% for low anterior resection, and 6.4% for abdominoperineal resection. On multivariable analysis, low anterior resection (HR: 1.27, 95%CI 1.08 to 1.51, p < 0.01) and abdominoperineal resection (HR: 1.49, 95%CI 1.14 − 1.93, p < 0.01) were independently associated with increased risk of erectile dysfunction compared to hemicolectomy. Minimally invasive surgery was independently associated with an increased risk of erectile dysfunction compared to open surgery (HR: 1.44, 95% CI 1.25–1.65, p < 0.001). Compared to hemicolectomy, men treated with low anterior resection and abdominoperineal resection have a higher risk of being diagnosed with erectile dysfunction within 2 years of treatment. The absolute rate of erectile dysfunction diagnosis was low compared to rates reported in prior controlled trials, suggesting that patients are underdiagnosed in real-world settings. [ABSTRACT FROM AUTHOR]

Aim: This study aimed to investigate the utility of measuring amylase levels in drainage fluid (DFA) for early, non-invasive detection of anastomotic leakage (AL) in undergoing low anterior resection (LAR) for rectal cancer. Patients and Methods: This prospective observational cohort study analyzed drainage fluid samples from patients who underwent LAR for rectal cancer at two medical centers between February 2021 and December 2023. DFA levels were measured on postoperative days (PODs) 1, 3, and 5. AL was confirmed by clinical evidence and radiological imaging. Statistical analyses were performed to evaluate the diagnostic performance of DFA. Results: Of 120 LAR cases, AL occurred in five (4.16%). DFA levels on POD 3 and 5 were significantly higher in the AL than in the non-AL group (p<0.0001). DFA on POD 5 had the highest diagnostic accuracy for early AL detection, with an area under the curve of 0.99, achieving 100% sensitivity and 99.5% specificity at a cutoff of 846 U/l. A DFA >846 U/l predicted AL with negative predictive and positive predictive values of 83.3% and 100%, respectively, on POD 5. Conclusion: Measuring DFA is a non-invasive, simple and costeffective method for early AL detection in patients with rectal cancer undergoing LAR. Our findings also suggested that drain placement may be useful for the early detection of AL through DFA measurement. [ABSTRACT FROM AUTHOR]

Background: Low anterior resection (LAR) is the gold standard for curative cancer treatment in the middle and upper rectum. In radically operated patients, the local recurrence rates with total mesorectal excision (TME) after 5 and 10 years was < 10%, with 80% in 5 years survival. Anastomotic leakage (AL) affects 4%-20% of patients who underwent LAR. Based on some studies, there is a risk reduction of symptomatic AL after LAR and the need for reoperation in patients with a defunctioning stoma (DS), also known as diverting stoma. Ileostomy has many complications, such as skin irritation and leakage, dehydration, obstruction, and parastomal hernia. Considering the complications of defunctioning loop-ileostomy (DLI) we designed this study to evaluate non-inserting stoma in a particular group of patients. Methods: This retrospective cohort case series study utilized data of 20 patients with rectal adenocarcinoma with lesion > 7 cm from anal verge in rectoscopy who underwent LAR after 28 sessions of chemoradiotherapy (CRT) and 6 weeks of rehabilitation. All of the patients matched our criteria, so DLI was not performed on any of them. Results: Among our 20 patients, four AL were happened (20%). C-reactive protein (CRP) on post-operation day (POD) six was valuable. Computed tomography (CT) scan was not used as a reliable modality in our study. In all patients with positive AL, magnetic resonance imaging (MRI) was useful and reported correctly, and direct vision of the anastomosis site by rigid rectoscopy was not safe enough to make decisions about it. Conclusion: The leakage rate was not far from the average leakage rate in other studies. Then it seems it is possible to forget about defunctioning loop stoma (DLS) in safe cases to reduce the stoma complications. Due to our restricted case selection and our close observation protocol, we had no significant complications compared to other studies. According to this study, not inserting stoma in suitable cases with restricted protocol selection is possible, and the leakage rate is not higher in comparison with patients with stoma. [ABSTRACT FROM AUTHOR]

Introduction: In June 2023, our institution adopted the Medtronic Hugo RAS system for colorectal procedures. This system's independent robotic arms enable personalized docking configurations. This study presents our refined multi-docking strategy for robotic low anterior resection (LAR) and deep pelvic procedures, designed to maximize the Hugo RAS system's potential in rectal surgery, and evaluates the associated learning curve. Methods: This retrospective analysis included 31 robotic LAR procedures performed with the Hugo RAS system using our novel multi-docking strategy. Docking times were the primary outcome. The Mann–Kendall test, Spearman's correlation, and cumulative sum (CUSUM) analysis were used to assess the learning curve and efficiency gains associated with the strategy. Results: Docking times showed a significant negative trend (p < 0.01), indicating improved efficiency with experience. CUSUM analysis confirmed a distinct learning curve, with proficiency achieved around the 15th procedure. The median docking time was 6 min, comparable to other robotic platforms after proficiency. Conclusion: This study demonstrates the feasibility and effectiveness of a multi-docking strategy in robotic LAR using the Hugo RAS system. Our personalized approach, capitalizing on the system's unique features, resulted in efficient docking times and streamlined surgical workflow. This approach may be particularly beneficial for surgeons transitioning from laparoscopic to robotic surgery, facilitating a smoother adoption of the new technology. Further research is needed to validate the generalizability of these findings across different surgical settings and experience levels. [ABSTRACT FROM AUTHOR]

Rectal implantation cysts can occur at anastomotic sites after low anterior resection (LAR) for rectal cancer. Herein, we report a case of primary adenocarcinoma arising from a rectal implantation cyst after LAR for rectal cancer. A 70-year-old woman was referred to our hospital for diagnosis and treatment of a growing cystic lesion. She had LAR performed for rectal cancer 29 years previously and had a rectal implantation cyst detected 13 years previously. On the first visit to our hospital, serum CEA and CA19-9 levels were elevated, and computed tomography (CT) scans revealed a cystic lesion near the anastomosis. CT-guided biopsy revealed no cancer tissue in the cystic lesion. After that, the cystic lesion naturally shrank, and serum CEA and CA19-9 levels became normal. Follow-up included 3 monthly serum CEA and CA19-9 testing and 6 monthly CT scans. Two years later, serum CEA and CA19-9 levels were elevated again. Colonoscopy revealed an ulcerative lesion at the anastomotic site, in which adenocarcinoma was confirmed. Abdominoperineal resection with sacral resection was performed, and postoperative histopathological examination revealed a primary adenocarcinoma with mucinous component at the implantation cyst. Since rectal implantation cysts can become malignant after extended periods, clinicians need to be aware of this disease. [ABSTRACT FROM AUTHOR]

The article analyzes the features of treatment of cancer of the lower ampullary part of the rectum, one of the most common oncological pathologies of the digestive tract. It provides data on morbidity and mortality rates both globally and in Ukraine, highlighting the significance of the issue. The primary objective of the study was to assess the effectiveness of modern surgical methods, including transanal endoscopic microsurgery (TEM) resection, low anterior resection, intersphincteric resection and the use of lumbar bifold reservoirs according to the clinic’s methodology.

Background: Excessive tension at the anastomosis contributes to anastomotic leakage (AL) in low anterior resection (LAR). However, the specific tension has not been measured. We assessed whether "Bridging," characterized by the proximal colon resembling a suspension bridge above the pelvic floor, is a significant risk factor for AL following LAR for rectal cancer. Methods: This retrospective study reviewed the medical records and laparoscopic videos of 102 patients who underwent laparoscopic LAR using the double stapling technique at Yachiyo Hospital between January 2014 and December 2023. Patients were classified based on whether they had Bridging (tight or sagging) or were in a Resting state of the proximal colon, and the association between Bridging and AL was examined. Results: AL occurred in 31.3% of the Tight Bridging group, 20% of the Sagging Bridging group, and 2.2% of the Resting group (P = 0.002). The incidence of AL was significantly higher in patients with Bridging than in those without (23.2% vs. 2.2%, P = 0.003). Multivariate analysis revealed that Bridging is an independent risk factor for AL (odds ratio = 6.97; 95% confidence interval: 1.45–33.6; P = 0.016). Conclusions: The presence of Bridging is a significant risk factor for AL following LAR for rectal cancer, suggesting the need for implementing preventive measures in patients with this condition. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this study was to assess the effect of early stoma closure on bowel function after low anterior resection (LAR) for rectal cancer. Methods: Patients participating in the FORCE trial who underwent LAR with protective stoma were included in this study. Patients were subdivided into an early closure group (< 3 months) and late closure group (> 3 months). Endpoints of this study were the Wexner Incontinence, low anterior resection syndrome (LARS), EORTC QLQ-CR29, and fecal incontinence quality of life (FIQL) scores at 1 year. Results: Between 2017 and 2020, 38 patients had received a diverting stoma after LAR for rectal cancer and could be included. There was no significant difference in LARS (31 vs. 30, p = 0.63) and Wexner score (6.2 vs. 5.8, p = 0.77) between the early and late closure groups. Time to stoma closure in days was not a predictor for LARS (R2 = 0.001, F (1,36) = 0.049, p = 0.83) or Wexner score (R2 = 0.008, F (1,36) = 0.287, p = 0.60) after restored continuity. There was no significant difference between any of the FIQL domains of lifestyle, coping, depression, and embarrassment. In the EORTC QLQ-29, body image scored higher in the late closure group (21.3 vs. 1.6, p = 0.004). Conclusion: Timing of stoma closure does not appear to affect long-term bowel function and quality of life, except for body image. To improve functional outcome, attention should be focused on other contributing factors. [ABSTRACT FROM AUTHOR]

Background: This report describes the oncologic outcomes for patients with advanced ovarian cancer who had bowel surgery performed by gynecologic oncologists (GOs) and compares the outcomes with those for bowel surgery performed by general surgeons (GSs) during maximal cytoreductive surgery. Methods: Patients from six academic institutions who had FIGO stage III or IV ovarian cancer and underwent any bowel surgeries during maximal cytoreductive surgery were eligible for the study. The patients were divided into two groups according to whether bowel surgery was performed by a GO or a GS. In both groups, the GOs were mainly involved in extra bowel debulking procedures. Perioperative and survival outcomes were compared between the two groups. Results: The 761 patients in this study included 113 patients who underwent bowel surgery by a GO and 648 who had bowel surgery by a GS. No discernible differences were observed in age, American Society of Anesthesiology (ASA) score, FIGO stage, histologic type, timing of cytoreductive surgery (primary or interval debulking surgery), or complications between the two groups. The GO group exhibited a shorter operation time than the GS group. Kaplan–Meier analysis showed no survival differences between the two groups. In the Cox analysis, non-serous cell types and gross residual diseases were associated with adverse effects on overall survival. However, performance of bowel surgery by a GO did not have an impact on survival. Conclusion: Performance of bowel surgery by a GO during maximal cytoreductive surgery is both feasible and safe. These results should be reflected in the training system for GOs regarding bowel surgery, and further research is needed to confirm that GOs can play a more leading role in performing extra-uterine procedures. [ABSTRACT FROM AUTHOR]

Background: Incontinence is not rare after rectal cancer surgery. Platelet-rich plasma may promote tissue repair and generation but has never been tested for the treatment of anal incontinence. This study evaluated the impact of platelet-rich plasma injection on the severity of incontinence and quality of life after low rectal cancer surgery. Methods: This is a prospective cohort proof of concept study in a colorectal cancer institution. Patients had undergone low anterior or intersphincteric resection for low rectal cancer and had a Wexner score > 4. Ten milliliters of platelet-rich plasma were injected into the internal and external sphincters under endoanal ultrasound (EAUS) guidance. Primary outcome measure was > 2 point improvement in Wexner score (improved group). The patients were assessed with endo-anal ultrasound examination, manometry, the Wexner Questionnaire and SF-36 Health Surveys, and patients were asked whether they used pads and antidiarrheal medications before and 6 months after PRP injection. Results: Of 20 patients included in the study, 14 (70%) were men, and the average age was 56.8 (SD = 9.5) years. No statistically significant difference was found in Wexner scores before and after PRP injection (p = 0.66). Seven (35%) patients experienced a > 2 point improvement in Wexner score. Rectal manometry demonstrated improved squeezing pressure (p = 0.0096). Furthermore, physical functioning scoring (p = 0.023), role limitation (p = 0.016), emotional well-being (p = 0.0057) and social functioning (p = 0.043) domains on the SF-36 questionnaire improved. One (5%) and three (15%) patients stopped using pads and antidiarrheal medications. Conclusion: Platelet-rich plasma injection does not restore Wexner scores, but more than one-third of patients may benefit from this application with an improvement of > 2 points in their scores. Platelet-rich plasma injection may improve squeezing pressure and certain life quality measures for incontinent patients after rectal cancer surgery. [ABSTRACT FROM AUTHOR]

Purpose: Increasing importance has been attributed in recent years to the preservation of the pelvic autonomic nerves during rectal resection to achieve better functional results. In addition to improved surgical techniques, intraoperative neuromonitoring may be useful. Methods: This single-arm prospective study included 30 patients who underwent rectal resection performed with intraoperative neuromonitoring by recording the change in the tissue impedance of the urinary bladder and rectum after stimulation of the pelvic autonomic nerves. The International Prostate Symptom Score, the post-void residual urine volume and the Low Anterior Resection Syndrome Score (LARS score) were assessed during the 12-month follow-up period. Results: A stimulation-induced change in tissue impedance was observed in 28/30 patients (93.3%). In the presence of risk factors such as low anastomosis, neoadjuvant radiotherapy and a deviation stoma, an average increase of the LARS score by 9 points was observed 12 months after surgery (p = 0,04). The function of the urinary bladder remained unaffected in the first week (p = 0,7) as well as 12 months after the procedure (p = 0,93). Conclusion: The clinical feasibility of the new method for pelvic intraoperative neuromonitoring could be verified. The benefits of intraoperative pelvic neuromonitoring were particularly evident in difficult intraoperative situations with challenging visualization of the pelvic nerves. [ABSTRACT FROM AUTHOR]

Purpose: We aimed to analyze the risk factors for anastomotic leakage (AL) after low anterior resection (LAR) in obese patients (body mass index [BMI] ≥ 25 kg/m2) with rectal cancer. Methods: Data were collected from four hundred two obese patients who underwent LAR for rectal cancer in 51 institutions. Results: Forty-six (11.4%) patients had clinical AL. The median BMI (27 kg/m2) did not differ between the AL and non-AL groups. In the AL group, comorbid respiratory disease was more common (p = 0.025), and the median tumor size was larger (p = 0.002). The incidence of AL was 11.5% in the open surgery subgroup and 11.4% in the laparoscopic surgery subgroup. Among the patients who underwent open surgery, the AL group showed a male predominance (p = 0.04) in the univariate analysis, but it was not statistically significant in the multivariate analysis. Among the patients who underwent laparoscopic surgery, the AL group included a higher proportion of patients with comorbid respiratory disease (p = 0.003) and larger tumors (p = 0.007). Conclusion: Comorbid respiratory disease and tumor size were risk factors for AL in obese patients with rectal cancer. Careful perioperative respiratory management and appropriate selection of surgical procedures are required for obese rectal cancer patients with respiratory diseases. [ABSTRACT FROM AUTHOR]

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]

BackgroundThe cornerstone of low anterior resection syndrome (LARS) treatment is self-management, which requires patient engagement. Colorectal surgeons and nurses may use patient-generated health data (PGHD) to help guide patients in their use of self-management strategies for LARS. However, the perspectives of LARS experts on the use of PGHD remain largely unexplored. The objective of this study was to explore the perspectives and experiences of LARS experts regarding the use of PGHD in the management of LARS.MethodsWe utilized purposive snowball sampling to identify international LARS experts, including surgeons, nurses, and LARS researchers with knowledge and expertise in LARS. We conducted individual semi-structured interviews with these experts between August 2022 and February 2024. We performed thematic analysis using the framework method to identify domains and associated themes.ResultsOur sample included 16 LARS experts from five countries. Thematic analysis identified four domains and associated themes. The domains included: data collection practices, data review practices, perceived usefulness, and future directions. Within the data collection practices domain, we found that most experts asked LARS patients to collect some form of PGHD, including bowel diaries, patient-reported outcome measures, or both. Within the data review practices domain, we found that both surgeons and nurses reviewed PGHD. Most participants described finding it difficult to interpret the data and identified time constraints, legibility, and completeness as the most common barriers to reviewing data in clinic. In terms of perceived usefulness, data collection was felt to help clinicians understand symptoms and their impact and assist patients with self-management. The future directions domain revealed that most experts felt that a clinical tool in the form of an online app or website to support data collection and enhance data visualization would be useful. Finally, some participants saw promise in leveraging PGHD to inform the creation of automated treatment algorithms for LARS management.ConclusionsThis study highlights many gaps in the processes of patient-generated LARS data collection and review. A clinical tool including various data collection templates and data visualization prototypes could help to address these gaps. Future research will focus on incorporating the patient perspective.

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]

Anastomotic leakage (AL) following low anterior resection (LAR) for rectal cancer is a major complication. While most reports focus on the closure of AL using over-the-scope clip (OTSC), few reports are available on the use of through-the-scope clip (TTSC). This is because TTSC is not typically designed for full-thickness closure, unlike OTSC. However, a MANTIS clip, categorized as TTSC, is indicated for full-thickness closure. A 73-year-old man diagnosed with AL 7 days postoperatively following laparoscopic LAR underwent laparoscopic drainage and ileostomy the next day. Although the drainage led to the shrinkage of the fistula, it persisted even after 2 months. Consequently, the fistula orifice was closed using a MANTIS clip under colonoscopy and radiography. Two days later, the patient was discharged. The drain was withdrawn cautiously to prevent residual fistula and removed completely on day 29. This report highlights our experience in using a MANTIS clip for AL following LAR. [ABSTRACT FROM AUTHOR]

From November 2021 to February 2022, 15 patients underwent total abdominal mesorectal excision for rectal cancer using the da Vinci single port system. The clinical and pathological results were analyzed retrospectively. All surgeries were performed without conversion. The mean distance from the tumor to the anal verge was 10 cm (range, 2-15 cm). The mean operative time was 191 minutes, the median docking time was 4 minutes (range, 2-10 minutes), and the estimated blood loss was 20 mL (range, 20-50 mL). The mean number of lymph nodes harvested was 16.5, the mean distal resection margin was 3.52 cm, and all patients had circumferential and distal tumor-free resection margins. One patient had minor anastomotic leakage. The mean length of hospital stay was 5.8 ± 2.5 days. Abdominal total mesorectal excision using the da Vinci single port system for rectal cancer is technically feasible and safe, with acceptable pathological and short-term clinical outcomes.

Abstract Background Prolonged postoperative ileus (PPOI) is a common complication after colorectal surgery that increases patient discomfort, hospital stay, and financial burden. However, predictive tools to assess the risk of PPOI in patients undergoing laparoscopic low anterior resection have not been developed. Thus, the purpose of this study was to develop a nomogram to predict PPOI after laparoscopic low anterior resection for rectal cancer. Methods A total of 548 consecutive patients who underwent laparoscopic low anterior resection for mid­low rectal cancer at a single tertiary medical center were retrospectively enrolled between January 2019 and January 2023. Univariate and multivariate logistic regression analysis was performed to analyze potential predictors of PPOI. The nomogram was constructed using the filtered variables and internally verified by bootstrap resampling. Model performance was evaluated by receiver operating characteristic curve and calibration curve, and the clinical usefulness was evaluated by the decision curve. Results Among 548 consecutive patients, 72 patients (13.1%) presented with PPOI. Multivariate logistic analysis showed that advantage age, hypoalbuminemia, high surgical difficulty, and postoperative use of opioid analgesic were independent prognostic factors for PPOI. These variables were used to construct the nomogram model to predict PPOI. Internal validation, conducted through bootstrap resampling, confirmed the great discrimination of the nomogram with an area under the curve of 0.738 (95%CI 0.736–0.741). Conclusions We created a novel nomogram for predicting PPOI after laparoscopic low anterior resection. This nomogram can assist surgeons in identifying patients at a heightened risk of PPOI.

Objective: The aim of the study was to examine the efficacity and safety of ondansetron, a serotonin receptor antagonist, to treat patients with low anterior resection syndrome (LARS). Background: LARS after rectal resection is common and debilitating. Current management strategies include behavioral and dietary modifications, physiotherapy, antidiarrheal drugs, enemas, and neuromodulation, but the results are not always satisfactory. Methods: This is a randomized, multicentric, double-blinded, placebo-controlled, and cross-over study. Patients with LARS (LARS score >20) no longer than 2 years after rectal resection were randomized to receive either 4 weeks of ondansetron followed by 4 weeks of placebo (O-P group) or 4 weeks of placebo followed by 4 weeks of ondansetron (P-O group). The primary endpoint was LARS severity measured using the LARS score; secondary endpoints were incontinence (Vaizey score) and irritable bowel syndrome quality of life (IBS-QoL questionnaire). Patients' scores and questionnaires were completed at baseline and after each 4-week treatment period. Results: Of 46 randomized patients, 38 were included in the analysis. From baseline to the end of the first period, in the O-P group, the mean (SD) LARS score decreased by 25% [from 36.6 (5.6) to 27.3 (11.5)] and the proportion of patients with major LARS (score >30) went from 15/17 (88%) to 7/17 (41%), (P=0.001). In the P-O group, the mean (SD) LARS score decreased by 12% [from 37 (4.8) to 32.6 (9.1)], and the proportion of major LARS went from 19/21 (90%) to 16/21 (76%). After crossover, LARS scores deteriorated again in the O-P group receiving placebo, but further improved in the P-O group receiving ondansetron. Mean Vaizey scores and IBS QoL scores followed a similar pattern. Conclusions: Ondansetron is a safe and simple treatment that appears to improve both symptoms and QoL in LARS patients. [ABSTRACT FROM AUTHOR]

Background: Total mesorectal excision using conventional straight fixed devices may be technically difficult because of the narrow and concave pelvis. Several laparoscopic articulating tools have been introduced as an alternative to robotic systems. The aim of this study was to compare perioperative outcomes between laparoscopic low anterior resection using ArtiSential® and robot-assisted surgery for rectal cancer. Methods: This retrospective study included 682 patients who underwent laparoscopic or robotic low anterior resection for rectal cancer from September 2018 to December 2021. Among them, 82 underwent laparoscopic surgery using ArtiSential® (group A) and 201 underwent robotic surgery (group B). A total of 73 [group A; 66.37 ± 11.62; group B 65.79 ± 11.34] patients were selected for each group using a propensity score matching analysis. Results: There was no significant difference in the baseline characteristics between group A and B. Mean operative time was longer in group B than A (163.5 ± 61.9 vs 250.1 ± 77.6 min, p < 0.001). Mean length of hospital stay was not significantly different between the two groups (6.2 ± 4.7 vs 6.7 ± 6.1 days, p = 0.617). Postoperative complications, reoperation, and readmission within 30 days after surgery were similar between the two groups. Pathological findings revealed that the circumferential resection margins were above 10 mm in both groups (11.00 ± 7.47 vs 10.17 ± 6.25 mm, p = 0.960). At least 12 lymph nodes were sufficiently harvested, with no significant difference in the number harvested between the groups (20.5 ± 9.9 vs 19.7 ± 7.3, p = 0.753). Conclusions: Laparoscopic low anterior resection using ArtiSential® can achieve acceptable clinical and oncologic outcomes. ArtiSential®, a multi-joint and articulating device, may serve a feasible alternative approach to robotic surgery in rectal cancer. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Anastomotic leakage is a complication that creates significant concern in terms of postoperative morbidity and mortality after colorectal surgery. This study aimed to identify variables for detecting anastomotic leakage in those who had open, laparoscopic, or robotic low anterior resection for cancer and to explore their relationships. PATIENTS AND METHODS: A total of 283 patients who were diagnosed with rectal cancer and underwent low anterior resection were divided into two groups: those with and without anastomotic leakage. Demographic and clinical data were analyzed. Anastomotic leakage was detected in 23 of 283 patients who underwent low anterior resection. RESULTS: The postoperative analysis of the biochemical data of the patients showed statistically significant differences between the two groups in terms of C-reactive protein (Crp), albumin, lymphocytes, leukocytes, neutrophils, and their ratio. The performance of these parameters in predicting anastomotic leakage was statistically analyzed in the patient group with anastomotic leakage, and nomogram results were acquired. Immune system components and biomarkers were statistically tested, and nomogram results were obtained in rectal cancer patients. CONCLUSIONS: These parameters can be used together as a potential marker in anastomotic leakage. Further development of these variables has the potential to facilitate the timely detection and treatment of anastomotic leakage. [ABSTRACT FROM AUTHOR]

Many patients undergo small bowel and colon surgery for reasons related to malignancy, inflammatory bowel disease (IBD), mesenteric ischemia, and other benign conditions, including post-operative adhesions, hernias, trauma, volvulus, or diverticula. Some patients arrive in the operating theatre severely malnourished due to an underlying disease, while others develop complications (e.g., anastomotic leaks, abscesses, or strictures) that induce a systemic inflammatory response that can increase their energy and protein requirements. Finally, anatomical and functional changes resulting from surgery can affect either nutritional status due to malabsorption or nutritional support (NS) pathways. The dietitian providing NS to these patients needs to understand the pathophysiology underlying these sequelae and collaborate with other professionals, including surgeons, internists, nurses, and pharmacists. The aim of this review is to provide an overview of the nutritional and metabolic consequences of different types of lower gastrointestinal surgery and the role of the dietitian in providing comprehensive patient care. This article reviews the effects of small bowel resection on macronutrient and micronutrient absorption, the effects of colectomies (e.g., ileocolectomy, low anterior resection, abdominoperineal resection, and proctocolectomy) that require special dietary considerations, nutritional considerations specific to ostomized patients, and clinical practice guidelines for caregivers of patients who have undergone a surgery for local and systemic complications of IBD. Finally, we highlight the valuable contribution of the dietitian in the challenging management of short bowel syndrome and intestinal failure. [ABSTRACT FROM AUTHOR]

Abstract Background The hinotori™ Surgical Robot System was approved for use in colorectal cancer surgery in Japan in 2022. This robot has advantages, such as an operation arm with eight axes, an adjustable arm base, and a flexible three-dimensional viewer, and is expected to be utilized in rectal cancer surgery. Herein, we report the world's first surgery for rectal cancer using the hinotori™ Surgical Robot System. Case presentation A 71-year-old woman presented to our hospital with bloody stools. A colonoscopy revealed type 2 advanced cancer in the rectum, and a histological examination exposed a well-differentiated adenocarcinoma. Abdominal enhanced computed tomography divulged rectal wall thickening without significant swelling of the lymph nodes or distant metastasis. Pelvic magnetic resonance imaging showed tumor invasion beyond the intrinsic rectal muscle layer. The patient was diagnosed with cStage IIa (cT3N0M0) rectal cancer and underwent low anterior resection using the hinotori™ Surgical Robot System. Based on an adequate simulation, surgery was safely performed with appropriate port placement and arm base-angle adjustment. The operating time was 262 min, with a cockpit time of 134 min. Subsequently, the patient was discharged 10 days postoperatively without complications. The pathological diagnosis was pStage IIA (cT3N0M0) and the circumferential resection margin was 6 mm. Conclusions We report the first case of low anterior resection for rectal cancer using the hinotori™ Surgical Robot System, in which a safe and appropriate oncological surgery was performed.

Background: Prolonged postoperative ileus (PPOI) is a common complication after colorectal surgery that increases patient discomfort, hospital stay, and financial burden. However, predictive tools to assess the risk of PPOI in patients undergoing laparoscopic low anterior resection have not been developed. Thus, the purpose of this study was to develop a nomogram to predict PPOI after laparoscopic low anterior resection for rectal cancer. Methods: A total of 548 consecutive patients who underwent laparoscopic low anterior resection for mid-low rectal cancer at a single tertiary medical center were retrospectively enrolled between January 2019 and January 2023. Univariate and multivariate logistic regression analysis was performed to analyze potential predictors of PPOI. The nomogram was constructed using the filtered variables and internally verified by bootstrap resampling. Model performance was evaluated by receiver operating characteristic curve and calibration curve, and the clinical usefulness was evaluated by the decision curve. Results: Among 548 consecutive patients, 72 patients (13.1%) presented with PPOI. Multivariate logistic analysis showed that advantage age, hypoalbuminemia, high surgical difficulty, and postoperative use of opioid analgesic were independent prognostic factors for PPOI. These variables were used to construct the nomogram model to predict PPOI. Internal validation, conducted through bootstrap resampling, confirmed the great discrimination of the nomogram with an area under the curve of 0.738 (95%CI 0.736–0.741). Conclusions: We created a novel nomogram for predicting PPOI after laparoscopic low anterior resection. This nomogram can assist surgeons in identifying patients at a heightened risk of PPOI. [ABSTRACT FROM AUTHOR]

Purpose: A protective loop ileostomy is the most useful method to reduce sequelae in the event of an anastomotic leakage (AL) after rectal cancer surgery. However, it requires an additional stoma reversal surgery with its own potential complications. Postoperative ileus (POI) remains the most common complication after ileostomy reversal, which leads to an increase in morbidity, length of hospital stay (LOS) and overall healthcare costs. Several retrospective studies carried out in this field have concluded that there are insufficient evidence-based recommendations about the routine application of preoperative bowel stimulation in clinical practice. Here we discuss whether stimulation of the efferent limb before ileostomy reversal might reduce POI and improve postoperative outcomes. Methods: This is a multicentre randomised controlled trial to determine whether mechanical stimulation of the efferent limb during the 2 weeks before the ileostomy reversal would help to reduce the development of POI after surgery. This study was registered on Clinicaltrials.gov (NCT05302557). Stimulation will consist of infusing a solution of 500 ml of saline chloride solution mixed with a thickening agent (Resource©, Nestlé Health Science; 6.4 g sachet) into the distal limb of the ileostomy loop. This will be performed within the 2 weeks before ileostomy reversal, in an outpatient clinic under the supervision of a trained stoma nurse. Conclusion: The results of this study could provide some insights into the preoperative management of these patients. [ABSTRACT FROM AUTHOR]

Introduction: Symptomatic anastomotic stricture is a rare but major complication after left-sided colorectal surgery. Hydraulic balloon dilatation is the first-line treatment in cases where the complication occurs, but 20% of patients present with refractory strictures after multiple sessions. Endoscopic stricturoplasty with the use of a linear stapler is a novel therapeutic alternative for those difficult cases. Materials and Methods: We identified all patients in our department who underwent endoscopic stricturoplasty with a linear stapler between 2004 and 2022. The technical, periinterventional, and follow-up data of the patients were retrospectively analyzed. Results: We identified nine patients who fulfilled our inclusion criteria. The procedure was technically possible in eight cases, whereas in one case, the anatomy of the anastomosis did not allow for a correct placement of the stapler. All patients with a technically successful procedure were relieved from their symptoms and could have their ostomy reversed. There was no periprocedural morbidity and mortality. Two patients presented with a recurrent stricture eight and 26 months after the initial stricturoplasty, and the procedure was successfully repeated in both cases. Conclusions: Endoscopic stricturoplasty is a feasible, safe, and minimally invasive alternative for the treatment of refractory anastomotic strictures in the distal colon and rectum for patients with a suitable anatomy. [ABSTRACT FROM AUTHOR]

Purpose: Comparative studies on efficacy of treatment strategies for anastomotic leakage (AL) after low anterior resection (LAR) are almost non-existent. This study aimed to compare different proactive and conservative treatment approaches for AL after LAR. Methods: This retrospective cohort study included all patients with AL after LAR in three university hospitals. Different treatment approaches were compared, including a pairwise comparison of conventional treatment and endoscopic vacuum-assisted surgical closure (EVASC). Primary outcomes were healed and functional anastomosis rates at end of follow-up. Results: Overall, 103 patients were included, of which 59 underwent conventional treatment and 23 EVASC. Median number of reinterventions was 1 after conventional treatment, compared to 7 after EVASC (p < 0.01). Median follow-up was 39 and 25 months, respectively. Healed anastomosis rate was 61% after conventional treatment, compared to 78% after EVASC (p = 0.139). Functional anastomosis rate was higher after EVASC, compared to conventional treatment (78% vs. 54%, p = 0.045). Early initiation of EVASC in the first week after primary surgery resulted in better functional anastomosis rate compared to later initiation (100% vs. 55%, p = 0.008). Conclusion: Proactive treatment of AL consisting of EVASC resulted in improved healed and functional anastomosis rates for AL after LAR for rectal cancer, compared to conventional treatment. If EVASC was initiated within the first week after index surgery, a 100% functional anastomosis rate was achievable. [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]

Background Many publications describe the advantages of the creation of ghost ileostomy (GI) to prevent the need for formal covering ileostomy in more than 80% of carcinoma rectum patients. However, none of the papers describes exactly how to ultimately remove the GI in these 80% of patients in whom it doesn't need formal maturation. Aim To describe and evaluate the ghost ileostomy release down (GIRD) technique in terms of feasibility, complications, hospital stay, procedure time etc. in patients with low anterior resection/ultra-low anterior resection (LAR/uLAR) with GI for carcinoma rectum. Method The present was a prospective cohort study of patients with restorative colorectal resections with GI for carcinoma rectum, Postoperatively the patients were studied with respect to ease and feasibility of the release down of GI and its complications. The data was collected, analyzed and inference drawn. Results A total of 26 patients needed the GIRD and were included in the final statistical analysis of the study. The procedure was done between 7th to 16th postoperative days (POD) and was successful in all patients without the need of any additional surgical procedure. None of the patients required any local anesthetic injection or any extra analgesics. The average time taken for procedure was 5-minutes and none of the patients had any significant difficulty in GI release. There were no immediate postprocedure complications. Conclusion The GIRD technique is a simple, safe, and quick procedure done around the 10th POD that can easily be performed by the bedside of patient without the need of any anesthesia or additional analgesics.

Abstract 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

Gastrointestinal arteriovenous malformations (AVMs) are a rare disease. Sigmoid-anorectal AVM has only been reported in a few cases. The condition is usually detected when patients have gastrointestinal bleeding complications. The diagnosis and treatment of colorectal AVMs are still challenging. This paper presents a case of an Asian 32-year-old female patient admitted to hospital because of lower gastrointestinal bleeding lasting 17 years. The patient was diagnosed with sigmoid-rectal arteriovenous malformation and failed with other medical treatments. The damaged gastrointestinal tract was removed by a laparoscopic low anterior resection. The results were positive after a three-month follow-up; the bleeding was resolved, and the anal sphincter function was intact. Laparoscopic low anterior resection is a safe, less invasive, and effective approach for managing patients with digestive tract bleeding due to extensive colorectal AVM and preservation of the anal sphincter.

Abstract Background Rectovaginal fistula (RVF) is a troublesome and refractory complication after low anterior resection (LAR) for rectal cancer. An omental flap repair was performed for the RVF caused due to Crohn’s disease and childbirth trauma. However, there are few cases of an omental flap repair for RVF after LAR. Herein, we present a successfully repaired case of RVF by omental flap coverage after LAR for rectal cancer. Case presentation A 50-year-old female patient with advanced rectal cancer underwent laparoscopic LAR with double-stapling technique anastomosis and achieved curative resection. She complained of a stool from the vagina and was diagnosed with RVF on the postoperative day (POD) 18. Conservative therapy was ineffective. We performed laparoscopic fistula resection and direct closure of the vagina and rectum, designed the omentum that could reach the pelvis, repaired RVF by omental flap coverage, and performed transverse colostomy on POD 25. She was discharged on initial POD 48. Seven months after the initial operation, colostomy closure was administered. There was no recurrence of RVF found 1 year after the initial operation. Conclusions The patient achieved an omental flap coverage for RVF. We successfully performed the omental flap coverage repair in patients with RVF after the leakage of LAR. An omental flap may become an alternative treatment for muscle flap or an effective treatment for RVF.

Objectives: Preventing anastomotic complications during rectal cancer surgery is important. Compared with a manual circular stapler, a powered circular stapler is expected to reduce undesirable tension during anastomosis. However, whether a powered circular stapler can reduce anastomotic complications during robotic low anterior resection (Ro-LAR) remains unclear. We aimed to investigate whether the use of a powered circular stapler contributes to safe anastomosis in Ro-LAR. Methods: A total of 271 patients who underwent Ro-LAR for rectal cancer between April 2019 and April 2022 were included. Depending on the type of device employed, patients were divided into a powered circular stapler group (PCSG) and a manual circular stapler group (MCSG). Clinicopathological features and surgical outcomes were compared between the two groups. Results: There were no differences in clinicopathological characteristics and surgical outcomes, except for anastomotic outcomes, between the two groups. Patients with positive air leak tests were significantly more in the MCSG (p=0.026; PCSG, 1.5%; MCSG, 8.0%). Frequencies of anastomotic leakage (p=0.486; PCSG, 6.1%; MCSG, 8.9%) and anastomotic bleeding (p=1.000; PCSG, 0.7%; MCSG, 0.8%) were similar between the two groups. Multivariate analysis showed that the use of a powered circular stapler significantly increased the negative leak tests (p=0.020, odds ratio 6.74, 95% confidence interval 1.35-33.56). Conclusions: Use of a powered circular stapler in Ro-LAR for rectal cancer was significantly associated with a negative air leak test, suggesting that it contributes to stable and safe anastomosis.

Background: Pain has a wide spectrum of effects on the body and inadequate management of postoperative pain outcomes in multiple physiological and psychological consequences; and increases morbidity. The use of opioid-based analgesia in high doses can have multiple adverse effects including respiratory depression, nausea, and vomiting. Objectives: Our aim was to evaluate the efficacy of analgesic and safety of both techniques (transversus abdominis plane block [TAPB] and erector spinae plane block [ESPB]) in cases having lower abdominal surgery through laparotomy. Materials and Methods: This randomized trial was performed on 62 cases who underwent laparotomy for lower abdominal surgery under general anesthesia were recruited. Subjects were equally distributed into either TAPB or ESPB. The primary outcome was total morphine intake postoperatively for 24 h. Other variables were intraoperative fentanyl consumption, delay to first morphine demand, and intraoperative morphine consumption, the number of patients who needed rescue analgesia by morphine, perioperative heart rate and mean blood pressure, numerical rating score (NRS), postoperative nausea and vomiting, and block-related complications. Results: ESPB patients consumed less total postoperative morphine than the TAPB group (5.35 ± 2.65 vs. 8.52 ± 3.35 mg; P < 0.001). Patients who received ESPB showed less postoperative pain scores and, thus, needed rescue medication after a longer period than the TAPB group (12.50 ± 7.31 h vs. 7.72 ± 5.69 h; P = 0.008). In addition, ESPB patients needed less intraoperative fentanyl doses than TAPB (138.71 ± 35.85 vs. 203.23 ± 34.00 mcg; P < 0.001). ESPB group demonstrated statistically significant lower scores of NRS at rest and at movement. Conclusions: Ultrasound (US)-guided ESPB provides more safe and effective analgesia in lower abdominal surgeries compared with US-guided TAPB.

Background: The hinotori™ Surgical Robot System was approved for use in colorectal cancer surgery in Japan in 2022. This robot has advantages, such as an operation arm with eight axes, an adjustable arm base, and a flexible three-dimensional viewer, and is expected to be utilized in rectal cancer surgery. Herein, we report the world's first surgery for rectal cancer using the hinotori™ Surgical Robot System. Case presentation: A 71-year-old woman presented to our hospital with bloody stools. A colonoscopy revealed type 2 advanced cancer in the rectum, and a histological examination exposed a well-differentiated adenocarcinoma. Abdominal enhanced computed tomography divulged rectal wall thickening without significant swelling of the lymph nodes or distant metastasis. Pelvic magnetic resonance imaging showed tumor invasion beyond the intrinsic rectal muscle layer. The patient was diagnosed with cStage IIa (cT3N0M0) rectal cancer and underwent low anterior resection using the hinotori™ Surgical Robot System. Based on an adequate simulation, surgery was safely performed with appropriate port placement and arm base-angle adjustment. The operating time was 262 min, with a cockpit time of 134 min. Subsequently, the patient was discharged 10 days postoperatively without complications. The pathological diagnosis was pStage IIA (cT3N0M0) and the circumferential resection margin was 6 mm. Conclusions: We report the first case of low anterior resection for rectal cancer using the hinotori™ Surgical Robot System, in which a safe and appropriate oncological surgery was performed. [ABSTRACT FROM AUTHOR]

Introduction: We previously developed risk models for mortality and morbidity after low anterior resection using a nationwide Japanese database. However, the milieu of low anterior resection in Japan has undergone drastic changes since then. This study aimed to construct risk models for 6 short-term postoperative outcomes after low anterior resection, i.e., in-hospital mortality, 30-day mortality, anastomotic leakage, surgical site infection except for anastomotic leakage, overall postoperative complication rate, and 30-day reoperation rate. Methods: This study enrolled 120,912 patients registered with the National Clinical Database, who underwent low anterior resection between 2014 and 2019. Multiple logistic regression analyses were performed to generate predictive models of mortality and morbidity using preoperative information, including the TNM stage. Results: We developed new risk prediction models for the overall postoperative complication and 30-day reoperation rates for low anterior resection, which were absent from the previous version. The concordance indices for each endpoint were 0.82 for in-hospital mortality, 0.79 for 30-day mortality, 0.64 for anastomotic leakage, 0.62 for surgical site infection besides anastomotic leakage, 0.63 for complications, and 0.62 for reoperation. The concordance indices of all four models included in the previous version showed improvement. Conclusion: This study successfully updated the risk calculators for predicting mortality and morbidity after low anterior resection using a model based on vast nationwide Japanese data. [ABSTRACT FROM AUTHOR]