A simple and effective evaluation method to determine the difficulty of total mesorectal excision for male patients with mid and lower rectal cancer

Rectal cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up.

High-level evidence on the long-term efficacy of postoperative TME quality in patients with low rectal cancer is lacking. The LASRE trial was used as background data to further explore the impact of TME quality on overall survival. We carried out a secondary analysis of the LASRE trial, which prospectively enrolled patients less than 5 cm from the dentate line from 22 hospitals in China who had undergone total mesorectal resection. TME quality was classified into 3 grades: grade A (complete), grade B (nearly complete), and grade C (incomplete), which were independently judged by the pathologist and surgeon, respectively, and if the results were inconsistent, then a third party finalized the grading based on photos of the specimen. 921 patients were included in the analysis, 787 (85.5%) in grade A, 108 (11.7%) in grade B, and 26 (2.8%) in grade C. The median follow-up was 36.0 months, and Kaplan-Meier curves showed that 3-year OS before PSM matching was 93.2% for grade A, 84.3% for grade B, 88.5% for grade C (P=0.0038), and 85.1% for grade B/C (P=0.0011). After PSM, it was 92.5% for grade A and 86.8% for grade B/C (P=0.044). TME quality was an independent influence on overall survival before PSM matching (HR=1.691, 95% CI: 1.133~2.522, p=0.010), and after PSM matching, TME quality remained an independent factor for OS (HR=1.881, 95% CI: 1.035~3.416, p=0.038). Excellent TME quality after surgery for low rectal cancer contributes to an improved prognosis and is an independent factor influencing long-term outcome.

Objective: To investigate the safety and efficacy of pelvic peritoneal reconstruction and its effect on anal function in laparoscopy-assisted anterior resection of low and middle rectal cancer. Methods: A prospective cohort study was conducted. Consecutive patients with low and middle rectal cancer who underwent laparoscopy-assisted transabdominal anterior resection at Naval Military Medical University Changhai Hospital from February 2020 to February 2021 were enrolled. Inclusion criteria: (1) the distance from tumor to the anal verge ≤10 cm; (2) laparoscopy-assisted transabdominal anterior resection of rectal cancer; (3) complete clinical data; (4) rectal adenocarcinoma diagnosed by postoperative pathology. Exclusion criteria: (1) emergency surgery; (2) patients with a history of anal dysfunction or anal surgery; (3) preoperative diagnosis of distant (liver, lung) metastasis; (4) intestinal obstruction; (5) conversion to open surgery for various reasons. The pelvic floor was reconstructed using SXMD1B405 (Stratafix helical PGA-PCL, Ethicon). The first needle was sutured from the left anterior wall of the neorectum to the right. Insertion of the needle was continued to suture the root of the sigmoid mesentery while the Hemo-lok was used to fix the suture. The second needle was started from the beginning of the first needle, after 3-4 needles, a drainage tube was inserted through the left lower abdominal trocar to the presacral space. Then, the left peritoneal incision of the descending colon was sutured, after which Hemo-lok fixation was performed. The operative time, perioperative complications, postoperative Wexner anal function score and low anterior resection syndrome (LARS) score were compared between the study group and the control group. Three to six months after the operation, pelvic MRI was performed to observe and compare the pelvic floor anatomical structure of the two groups. Results: A total of 230 patients were enrolled, including 58 who underwent pelvic floor peritoneum reconstruction as the study group and 172 who did not undergo pelvic floor peritoneum reconstruction as the control group. There were no significant differences in general data between the two groups (all P>0.05). The operation time of the study group was longer than that of control group [(177.5±33.0) minutes vs. (148.7±45.5) minutes, P<0.001]. There was no significant difference in the incidence of perioperative complications (including anastomotic leakage, anastomotic bleeding, postoperative pneumonia, urinary tract infection, deep vein thrombosis, and intestinal obstruction) between the two groups (all P>0.05). Eight cases had anastomotic leakage, of whom 2 cases (3.4%) in the study group were discharged after conservative treatment, 5 cases (2.9%) of other 6 cases (3.5%) in the control group were discharged after the secondary surgical treatment. The Wexner score and LARS score were 3.1±2.8 and 23.0 (16.0-28.0) in the study group, which were lower than those in the control group [4.7±3.4 and 27.0 (18.0-32.0)], and the differences were statistically significant (t=-3.018, P=0.003 and Z=-2.257, P=0.024). Severe LARS was 16.5% (7/45) in study group and 35.5% (50/141) in control group, and the difference was no significant differences (Z=4.373, P=0.373). Pelvic MRI examination 3 to 6 months after surgery showed that the incidence of intestinal accumulation in the pelvic floor was 9.1% (3/33) in study group and 46.4% (64/138) in control group (χ(2)=15.537, P<0.001). Conclusion: Pelvic peritoneal reconstruction using stratafix in laparoscopic anterior resection of middle and low rectal cancer is safe and feasible, which may reduce the probability of the secondary operation in patients with anastomotic leakage and significantly improve postoperative anal function.

This study aims to review the operative results and oncological outcomes of anterior resection for rectal and rectosigmoid cancer. Comparison was made between patients with total mesorectal excision (TME) for mid and distal cancer and partial mesorectal excision (PME) for proximal cancer, when a 4- to 5-cm mesorectal margin could be achieved. Risk factors for local recurrence and survival were also analyzed. Anterior resection has become the preferred treatment option rectal cancer. TME with sharp dissection has been shown to be associated with a low local recurrence rate. Controversies still exist as to the need for TME in more proximal tumor. Resection of primary rectal and rectosigmoid cancer was performed in 786 patients from August 1993 to July 2002. Of these, 622 patients (395 men and 227 women; median age, 67 years) underwent anterior resection. The technique of perimesorectal dissection was used. Patients with mid and distal rectal cancer were treated with TME while PME was performed for those with more proximal tumors. Prospective data on the postoperative results and oncological outcomes were reviewed. Risk factors for anastomotic leakage, local recurrence, and survival of the patients were analyzed with univariate and multivariate analysis. The median level of the tumor was 8 cm from the anal verge (range, 2.5-20 cm) and curative resection was performed in 563 patients (90.5%). TME was performed in 396 patients (63.7%). Significantly longer median operating time, more blood loss, and a longer hospital stay were found in patients with TME. The overall operative mortality and morbidity rates were 1.8% and 32.6%, respectively, and there were no significant differences between those of TME and PME. Anastomotic leak occurred in 8.1% and 1.3% of patients with TME and PME, respectively (P < 0.001). Independent factors for a higher anastomotic leakage rate were TME, the male gender, the absence of stoma, and the increased blood loss. The 5-year actuarial local recurrence rate was 9.7%. The advanced stage of the disease and the performance of coloanal anastomosis were independent factors for increased local recurrence. The 5-year cancer-specific survival was 74.5%. The independent factors for poor survival were the advanced stage of the disease and the presence of lymphovascular and perineural invasion. Anterior resection with mesorectal excision is a safe option and can be performed in the majority of patients with rectal cancer. The local recurrence rate was 9.7% and the cancer-specific survival was 74.5%. When the tumor requires a TME, this procedure is more complex and has a higher leakage rate than in those higher tumors where PME provides adequate mesorectal clearance. By performing TME in patients with mid and distal rectal cancer, the local control and survival of these patients are similar to those of patients with proximal cancers where adequate clearance can be achieved by PME.

To analyze the factors associated with anastomotic leakage after anterior resection in rectal cancer with the technique of total mesorectal excision (TME). From January 2005 and December 2007, 738 consecutive patients with rectal cancer underwent anterior resection. The data of those patients was collected and reviewed retrospectively. The associations between anastomotic leakage and 9 patient-related variables as well as 7 surgical-related variables were examined. Low rectal cancer (located 7 cm or less above the anal edge), non-specialized surgeon and transanal tube use were the risk factors associated with anastomotic leakage on univariate analysis. The anastomotic leakage rate of low-rectal cancer was significantly higher than that of high-rectal cancer (5.9% vs. 0.9%, P = 0.003). The anastomotic leakage rate of the cases operated by colorectal surgeon was significantly lower than that of the cases operated by non-specialized surgeon (3.9% vs. 11.3%, P = 0.031). There was a tendency for colorectal surgeons to operate on a greater proportion of low rectal cancer than non-specialized surgeons (72.1% vs. 52.8%, P = 0.003). The leakage rate of transanal tube group was unexpectedly higher than that in patients without transanal tube (14.5% vs. 3.6%, P < 0.001). On multivariate logistic regression analysis, diabetes mellitus (P = 0.027), distance less than 1 cm from tumor to distal resection margin (P = 0.009) and defunctioning stoma (P = 0.031) were also associated with anastomotic leakage rate besides low rectal cancer, non-specialized surgeon and transanal tube use. In a further analysis of 522 patients with low rectal cancer, the leakage rate of defunctioning stoma group was significantly lower than that of non-stoma group (2.9% vs. 8.5%, P = 0.007). By contract, the leakage rate of transanal tube group was still higher than that in patients without transanal tube (15.1% vs. 4.9%, P = 0.008) because of its poor protective effect as well as the selection bias. Low-rectal cancer, non-specialized surgeons and diabetes mellitus are risk factors of anastomotic leakage after rectal surgery. A defunctioning stoma was effective in preventing leakage after low-rectal cancer surgery.

Purpose. The most important surgical complication following rectal resection with anastomosis is symptomatic anastomotic leakage. This study investigated factors in anastomotic leakage and the effect of fecal diversion after resection of middle and low rectal cancers. Methods. Prospective data collection from patients with rectal cancer at 16 cm or less from anal verge was reviewed and risk factors of anastomosis investigated. The relationship between anastomotic leakage and clinicopathologic variables was determined using logistic regression analysis. Multivariate analysis with a logistic regression model was done to determine independent factors of anastomotic leakage. Results. From January 1993 to June 2003, 999 rectal cancer patients received elective radical resection and anastomosis. Fifty-three of these patients experienced anastomotic leakage. Univariable analysis revealed that age ＞70 years old (P=0.008), tumor location between 6-12 cm (P=0.026), and surgery with ultra-LAR (P=0.002) were significantly associated with increased anastomotic leakage. Multivariate analysis showed only older patients (P=0.009) and operation method (P=0.002) were independent factors for the development of anastomotic leakage; tumor of the middle rectum (6-12 cm) had borderline significance (P=0.078). Thirty percent (n=3/10) of patients with diverting stoma and 100% (n=43/43) of patients without diverting stoma needed reoperation to treat abdominal sepsis. Conclusion. Older rectal cancer patients, or those who have had anastomosis at the anorectal junction or dentate line, have increased risk of anastomotic leakage. A diverting stoma seems not to decrease incidence of anastomotic leakage, but may decrease the necessity of reoperation and provide a positive oncological impact if leakage occurs.

The aim of this study was to investigate the effect of body mass index (BMI) on local recurrence of primary rectal cancer after open curative sphincter-saving resection. Increasing BMI was reported to be associated with a higher likelihood of local recurrence in male patients with rectal cancer. However, it remained unclear whether BMI exerts the same effects on local recurrence of rectal cancer in the upper and lower rectum. Between January 1995 and December 2002, we investigated 1873 patients with well-documented body height and body weight who underwent curative anterior resection for primary rectal cancer in a single institution. The patients were assigned to 4 groups according to their BMI: underweight, normal, overweight, and obese. The frequency of local recurrence increased with an increase in the BMI in patients with lower rectal cancer. The local recurrence rates were 2.5% (2 of 79), 6.1% (48 of 782), 9.2% (39 of 424), and 13.8% (9 of 65) in underweight, normal, overweight, and obese patients with lower rectal cancer, respectively. These results were different from those of patients with upper rectal cancer. Independent risk factors for local recurrence in the lower rectal cancer group were BMI, resection margin, histologic grade of differentiation, depth of tumor invasion, and status of lymph node metastases. In the upper rectal cancer group, the depth of tumor invasion and histologic grade of differentiation reached statistical significance. BMI exerted different effects on local recurrence of rectal cancer in the upper and lower rectum. Further, more aggressive adjuvant and/or neoadjuvant treatments should be considered for patients with tumor in the lower rectum and with higher BMI.

The purpose of this study was to evaluate the risk factors for anastomotic leakage (AL) after anterior resection for middle and low rectal cancer in order to help surgeons to decide which patients could benefit from a diverting stoma. Data on 319 patients having a middle and low rectal cancer resection with anastomosis between May 2011 and October 2015 from two hospitals were included in the study. The analysis included the following variables: patient-related variables (gender, age, diabetes mellitus, ASA score, preoperative radiochemotherapy, body mass index, blood hemoglobin, and serum albumin level), tumor-related variables (K-ras status, distance of tumor from the anal verge, histopathologic grade, pathological T stage, pathological N stage, pathological M stage, TNM stage, and tumor size), and surgery-related variables (laparoscopic or open surgery, blood loss, and operative time). Univariate and multivariate regression analysis were carried out to identify risk factors for AL. The AL rate was 11.91% (38/319). Male (OR 2.898, 95% CI 1.265-6.637, p=0.012), diabetes mellitus (OR 2.482, 95% CI 1.004-6.134, p=0.049), K-ras mutation (OR 2.544, 95% CI 1.210-5.348, p=0.014), distance of tumor from the anal verge (OR 3.445, 95% CI 1.631-7.279, p=0.001), and preoperative radiochemotherapy (OR 2.790, 95% CI 1.056-7.372, p=0.039) were independent risk factors of AL. One (2.63%) in 38 patients with AL presented with no risk factor of AL, 6 (15.8%) in 38 patients with 1 risk factor, 16 (42.1%) in 38 patients with 2 risk factors, 9 (23.7%) in 38 patients with 3 risk factors, and 6 (15.7%) in 38 patients with 4 risk factors. No patient with 5 risk factors in our study. AL rate increased with the elevated number of risk factors clustering in individuals. K-ras mutation is first reported to be an independent risk factor for AL after sphincter-preserving surgery without diverting stoma. A diverting stoma should be performed in sphincter-preserving surgery for middle and low rectal cancer patients with 2 or more risk factors identified in this analysis.

Laparoscopic surgery for rectal cancer is thought to be a technically more difficult operation than laparoscopic colectomy. Data from the Conventional versus Laparoscopic-Assisted Surgery In Colorectal Cancer (CLASICC) trial showed that circumferential resection margin positivity was greater in the laparoscopic group (12%) than in the open surgery group (6%) undergoing anterior resection, although this difference was not significant [1]. In contrast, many nonrandomized studies, including ours, have suggested that laparoscopic surgery for rectal cancer is safe and feasible with careful case selection and expertise [2, 3]. The recent randomized Comparison of Open versus laparoscopic surgery for mid and low REctal cancer After Neoadjuvant chemoradiotherapy (COREAN) trial showed that laparoscopic surgery after preoperative chemoradiotherapy for mid and low rectal cancer is safe and that the quality of oncologic resection is similar to that of open surgery [4]. Because the future may see increasing demand for laparoscopic surgery to treat rectal cancer, a better understanding of the factors associated with the difficulty of laparoscopic surgery is important for surgeons, especially those learning these operations for proper case selection. In the December issue of Surgical Endoscopy, Killeen et al. [5] examined the influence of pelvic dimensions measured by magnetic resonance imaging (MRI) on difficulties in laparoscopic surgery for rectal cancer. Operative time was used as a measurement of operative difficulty. Univariate analysis showed that a less acutely curved sacrum and a larger sagittal pelvic outlet were significantly correlated with longer operative time, especially for a pelvis with a narrow intertuberous distance. Although Killeen et al. [5] introduced our study as supportive of their findings, indeed, we came to different conclusions [6]. We showed by multivariate analysis that narrower pelvic outlet together with higher body mass index, shorter tumor distance from the anal verge, and advanced tumor depth was independently predictive of longer operative time in laparoscopic total mesorectal excision (TME) with intracorporeal rectal transection and double-stapling technique (DST) anastomosis. There may be some reasons for the different conclusions. First, the total number of patients analyzed in the study of Killeen et al. [5] was small (n = 25). Second, multivariate analysis including patientand tumor-related factors other than pelvic dimensions was not performed in their study. Third, they evaluated the total operative time as dependent variable, and patients who underwent either laparoscopic anterior resection or abdominoperineal resection were included. However, excluding the procedures outside the pelvis might be necessary for accurate analysis of the influence that pelvic dimensions has on difficulties in laparoscopic surgery for rectal cancer because pelvic dimensions influence the procedures more directly after the pelvic cavity is reached. We also have reported that narrow pelvic dimensions were not associated with overall postoperative morbidity and anastomotic leakage [6]. On the contrary, larger pelvic outlet was independently predictive of anastomotic leakage [6]. Considering these results, we concluded in our T. Akiyoshi (&) M. Ueno Gastroenterological Center, Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo 135-8550, Japan e-mail: takashi.akiyoshi@jfcr.or.jp

It is thought that laparoscopic low anterior resection (LLAR) for lower rectal cancer improves quality of life (QOL) of these patients. However, it is a highly demanding surgical procedure. Despite an increasing surgical experience in high-volume hospitals, anastomotic leakage still remains a challenge [1, 2]. To reduce this leak rate, Fujii and colleagues [3] have developed and propose in the February issue of Surgical Endoscopy a new technique. The authors have tested the safety and efficiency of this method in 28 patients with low-lying rectal cancer and compared the results with those of 107 patients with similar tumor location treated by using multiple stapling for rectal transaction. Total mesorectal excision (TME) has been standard in the surgical treatment of rectal cancer. For the vast majority of patients, a sphincter-preserving treatment strategy is a primary desire. As a result of intensive research, low anterior resection (LAR) has been developed, and many patients benefit from this surgical approach. However, in many cases, decision-making between LAR and total rectal excision is currently too hard. Criteria for surgical decisions have not been standardized, and there is debate among surgeons about which is the optimal surgery for patients with low-lying rectal cancer. Standardized surgical quality is fundamental for improving outcomes of patients with gastrointestinal cancer [4–6], and the oncological principles of open surgery regarding R0 resection should also be met in laparoscopic surgery [7, 8]. Laparoscopic rectal resection has not been included in guidelines, even though evidence for the superiority of laparoscopic over open colectomy for colon cancer, and positive results from retrospective studies and small randomized controlled trials [9] suggest the safety and efficacy of laparoscopic approach. Moreover, a better view of the pelvis allows precision in performing safer and more effective TME by LLAR rather than by open surgery [1, 2]. There are expectations that not only will the underway randomized controlled trials provide positive results in favor of LLAR but also that the precision of laparoscopic or robotic surgery in TME may also improve local control and overall survival [10, 11]. Anastomotic leakage after laparoscopic TME (LTME), with a rate of approximately 10% despite rapid advances, still remains a substantial problem [1, 2]. Risk factors related to anastomotic failure have been reported to be TME and multiple anastomotic stapling, which may decrease blood supply to the remaining rectum stump and increase the risk of colorectal anastomosis leakage [1]. To reduce the clinical consequences of this anastomosis failure a protective temporal ileostoma is used, but there is still debate on its clinical utility [12]. Fujii and colleagues [3] looked at whether their technique, called the Y-Hood method, was safe and more effective in reducing anastomotic leak as compared with the double-stapling technique. The authors developed clamp forceps for intestinal lavage and a Y-shaped vinyl hood that can be operated under pneumoperitoneum for airproof surgery. According to authors, these devices enabled secure clamping and cleansing of the area and use of automatic suture instruments for open laparotomy through a minilaparotomy wound. Anastomotic leakage rates were 11.2% (12 patients) in the groups treated by using multiple stapling for rectal transaction and 7% (2 patients) in the group in which the authors used the Y-Hood technique. The number of times stapling for rectal C. Hottenrott (&) Chirurgische Klinik, St. Elisabethenkrankenhaus, Ginnheimer Strase 3, 60487 Frankfurt, Germany e-mail: info@gastricbreastcancer.com

This study aimed to identify risk factors for circumferential R1 resection (R1c) after neoadjuvant radiochemotherapy (RCT) and laparoscopic total mesorectal excision (TME) for mid or low rectal cancer. Better knowledge of pre- or intraoperative risk factors could possibly help for the management of these patients. Between 2005 and 2013, 233 consecutive patients undergoing laparoscopic TME for low or mid rectal cancer after RCT were included. R1c resection was defined as a circumferential margin ≤ 1 mm. Univariate and multivariate analyses were performed to identify independent risk factors for R1c. Twenty-five patients had R1c resection (11%). In univariate analysis, low rectal cancer, anterior tumour, T4 on pretherapeutic magnetic resonance imaging (MRI), T4 and/or N+ on post-RCT MRI and operative time > 240 min were associated with a significantly increased risk of R1c resection. In multivariate analysis, only T4 on post-RCT MRI (odds ratio (OR) = 6.02 [1.06-33]; p = 0.043) and operative time >240 min. (OR = 5.4 [1.01-28.9]; p = 0.049) were identified as independent risk factors for R1c resection. The risk of R1c resection was 3% (n = 3/88), 10% (n = 5/51) or 38% (n = 3/8) when 0, 1 or 2 risk factors were present in the same patient, respectively. Patients with T4 on MRI after RCT and/or operative time >240 min. seems to be at higher risk for R1c resection. In a pragmatic approach, we consider that systematic second MRI after RCT could help the surgeon, especially in area where circumferential margin is too short, in order to reduce this risk of R1 resection.

This free journal suppl. entitled: Special Issue: RCSEd/CSHK Conjoint Scientific Congress 2016, Making Wise Choices in Surgery, 17–18 September 2016, Aberdeen, Hong Kong

To investigate the factors associated with the anastomotic leakage after anterior resection in rectal cancer. From January 2014 to January 2017 471 patients underwent Dixon procedure for rectal cancer in The Affiliated Hospital of Qingdao University. The data of those patients was collected and reviewed retrospectively. Inclusion criteria included: 1) rectal cancer confirmed by preoperative electron colonoscopy; 2) the standard of total mesorectal excision followed by the surgeon during the surgery; and 3) elective surgery. Exclusion criteria included multi-primary rectal cancer, secondary surgery for tumor recurrence, palliative surgery, Miles procedure, Hartmann procedure, hormone drugs used, presence of rheumatic and immune diseases, and distant metastasis of rectal cancer. The variables, including demograpic characteristics, ASA score, diabetes mellitus, preoperative radiochemotherapy, histopathologic grade, pathological T stage, laparoscopic or open surgery, distance of the tumor from the anal verge ≤5 cm, were analyzed to identify the risk factors for anastomotic leakage. Of 471 patients, 285 and 186 were men and women, respectively, with a mean age of 61 years (range, 31-92) years. Symptomatic clinically anastomotic leakage occurred in 31 patients (6.6%, 31/471) after Dixon procedure for rectal cancer. On univariate analysis, the occurrence of anastomotic leakage was associated with diabetes (χ2=10.972, P=0.001), serum albumin level <35 g/L (χ2=9.784, P=0.002), neoadjuvant chemoradiotherapy (χ2=6.867, P=0.009), distance ≤5 cm between the tumor and anal edge (χ2=5.993, P=0.014), preventive colostomy (χ2=5.630, P=0.018), and the use of double-perfusion cannula for abdominal flushing (χ2=4.232, P=0.040). Multivariate analysis revealed that diabetes (OR=3.632, 95%CI: 1.620-8.145, P=0.002), neoadjuvant chemoradiotherapy (OR=3.177, 95%CI: 1.283-7.867, P=0.012) and distance ≤5 cm between the tumor and anal edge(OR=2.444, 95%CI: 1.172-5.059, P=0.017) were independent risk factors for anastomotic leakage, while preventive colostomy (OR=0.138, 95%CI: 0.056-0.345, P=0.000) and the use of double-perfusion cannula for abdominal flushing (OR=0.223, 95%CI: 0.086-0.575, P=0.002) were independent protective factors for anastomotic leakage. For patients with rectal cancer with diabetes, undergoing neoadjuvant chemoradiotherapy, or distance ≤5 cm between the tumor and anal edge, anastomotic leakage after anterior resection of rectal cancer must be paid attention. When necessary, preventive colostomy or use of double-perfusion cannula for abdominal flushing should be considered.

To investigate the feasibility and application value of improved anvil placement in laparoscopic resection of low rectal cancer with resection of anal eversion. A retrospective study was performed on 17 patients who were operated by improved extracorporeal anvil placement in laparoscopic resection of low rectal cancer with resection of anal eversion at Huaihe Hospital of Henan University during June 2015 and June 2017. (1) distance from tumor low margin to anal edge was 4 to 6 cm; (2) protrusive type tumor with a circumferential diameter of less than 3 cm; (3) ulcer type tumor with circumferential bowel infiltration of less than 1/2; (4) no distant metastasis(M0) and preoperative MRI of pelvic floor indicating T1-3N0. Patients with BMI>35 kg/m2, or insufficient length of sigmoid and mesentery, or thickening sigmoid and mesentery were excluded. According to total mesorectal excision(TME) principle, rectum and its mesentery was resected completely; the sigmoid colon was cut off at the superior margin of tumor; the oval forceps was placed through anus to clamp and evert the rectum out of the anus; the rectum was transected at 1-2 cm from the lower edge of the tumor; the distal sigmoid colon was pulled out through anus; purse string suture was made after insertion of anvil and was restored to the abdominal cavity; end-to-end anastomosis of the rectum and sigmoid colon was performed after closing rectal stump. Of 17 low rectal cancer patients, 10 were male and 7 were female with age of 42 to 71 (median 58) years old and BMI of 20.6 to 33.5(median 26) kg/m2. Preoperative staging indicated 2 cases of stage I, 15 cases of stage II. Distance from tumor low margin to anal edge was 4 to 6(median 5.0) cm and diameter of tumor was 3.4 to 4.8 (median 4.2) cm. All the patients completed operations successfully without conversion to laparotomy. The operation time was 124 to 182 (median 136) minutes. Distal sigmoid colon was difficult to pull out in 1 patient due to the insufficient free of the mesosigmoid, which was then successful after the mesosigmoid was dissociated with laparoscopy thoroughly again. The intraoperative blood loss was 10 to 50 (median 20) ml. Postoperative pathology reveled 2 cases of stage I, 12 cases of stageII and 3 cases of stage III; 1 case of poorly differentiated adenocarcinoma, 15 cases of moderately differentiated adenocarcinoma and 1 case of highly differentiated adenocarcinoma. The postoperative exhaust time was 24 to 128 (median 36) hours and hospital stay was 5 to 15 (median 8) days. No anastomotic leakage and intra-abdominal infection was found. Fifteen patients were followed up for 5 to 24 months without local recurrence or distant metastasis. The improved anvil placement in laparoscopic resection of low rectal cancer with resection of anal eversion without abdominal incision is safe and feasible.

Achieving complete total mesorectal excision (TME) is considered an important indicator of surgical quality in rectal cancer surgery. However, the impact of TME quality on overall survival (OS) remains controversial. This study aimed to evaluate the association between TME quality and OS in patients undergoing rectal cancer surgery. A retrospective analysis was conducted on 171 patients who underwent elective low anterior resection or abdominoperineal resection for rectal cancer between 2021 and 2022. OS was compared between patients with incomplete TME and those with near-complete or complete TME. In addition, clinical and pathological factors associated with TME quality were assessed. Incomplete TME was independently associated with worse OS [hazard ratio (HR)=2.53, 95% confidence interval (CI) 1.15-5.59, p=0.021], while undergoing a Hartmann procedure showed the strongest negative impact on OS (HR=4.60, 95% CI 2.04-10.38, p<0.001). At 36 months, OS was 86.3% in the near-complete/complete TME group versus 68.3% in the incomplete group (log-rank p=0.008). Factors associated with incomplete TME included lower preoperative albumin levels, larger tumor size, previous abdominal surgery, tumors located closer to the anal verge, lymphovascular invasion, and positive circumferential resection margins. Incomplete TME was associated with significantly worse OS in patients undergoing rectal cancer surgery. These findings highlight the importance of achieving optimal TME quality. Larger prospective studies are warranted to validate these results.