Anterior Resection Research Articles

Salvage robot‐assisted radical prostatectomy with pelvic lymph node dissection for radiorecurrent prostate cancer in a patient with a previous history of rectal cancer surgery

IntroductionSevere adhesions render salvage robot‐assisted radical prostatectomy challenging in the treatment of patients with prostate cancer who have previously undergone colorectal cancer surgery.Case presentationA 76‐year‐old Japanese man who had previously undergone low anterior resection for rectal cancer presented with an elevated prostate‐specific antigen level, indicating a recurrence of prostate cancer that had been treated with intensity‐modulated radiation and androgen deprivation therapies. During the salvage robot‐assisted radical prostatectomy with pelvic lymph node dissection, severe adhesions were noted between the posterior aspect of the prostate and the intestine. The adhesions were successfully dissected under digital rectal examination and transrectal ultrasound guidance.ConclusionSalvage robot‐assisted radical prostatectomy after rectal cancer can be challenging. The use of transrectal ultrasound and digital rectal examination can facilitate the procedure. Screening for prostate cancer prior to colorectal cancer surgery could potentially allow for simultaneous resections.

A novel technique for the construction of an end ileostomy to prevent stoma outlet obstruction after rectal resection and total colectomy: a single-center retrospective study.

Stoma outlet obstruction (SOO) is an early postoperative complication of rectal cancer. We devised a novel surgical technique: end-ileostomy, to reduce SOO. Here, we describe the surgical technique used for constructing an end ileostomy and assess its impact on SOO. The subjects of this retrospective study were 78 patients who underwent low anterior resection or total colectomy with a defunctioning ileostomy (DI) between 2018 and 2022. The surgical procedure for end ileostomy can be summarized as follows: First, the ileum was separated using a linear stapler, approximately 30cm from the Bauhin valve; then the opposite sides of the mesentery of the oral and anal ilea were sutured; and finally, end ileostomy was performed using standard techniques. End and loop ileostomies were performed in 34 and 44 patients, respectively. We assessed the independent risk factors for SOO. SOO occurred in 12 patients (15.3%): 1 (2.9%) with an end ileostomy and 11 (25%) with a loop ileostomy. Multivariate analysis identified loop ileostomy as an independent risk factor for SOO (p = 0.037). End ileostomy construction is a useful and safe technique for reducing the incidence of SOO in defunctioning ileostomies following rectal resection.

Enhancing support for patients with low anterior resection syndrome: insights and educational resources from the LARSCAT project

PurposeTo address the educational gaps and support needs of patients with low anterior resection syndrome (LARS) following rectal cancer surgery. The LARSCAT project aimed to develop comprehensive resources to better inform patients and enhance their quality of life.MethodsA qualitative study was conducted between November 2022 and March 2023. Seven focus groups were formed, including six patients, two surgeons, and three nurses. Patients had undergone rectal cancer surgery with stoma reversal 2 to 12 years earlier, and all experienced major LARS. The focus groups, held in-person and online, explored the impact on daily life, social and sexual health, mood, rest, and relationships. Thematic analysis was performed to identify key issues and support strategies following the COREQ guidelines.ResultsParticipants reported insufficient information regarding potential dysfunctions after rectal cancer surgery, and difficulties finding reliable information online. The timing of receiving information varied according to individual coping mechanisms. LARS symptoms significantly impacted daily life, social activities, sexual health, and mood. Patients emphasised the need for more tailored information and supplementary written materials to read at their own pace. Consequently, three comprehensive documents were created and made available online.ConclusionThis study highlights a significant gap in patient education on the long-term effects of rectal cancer surgery. The resources developed by the LARSCAT project aim to provide essential support to patients and healthcare professionals. Future research should focus on integrating these resources into routine care and evaluating their impact on patient outcomes and quality of life.

Anastomotic leakage after resection for rectal cancer and recurrence-free survival in relation to postoperative C-reactive protein levels

BackgroundAnastomotic leakage after rectal cancer surgery is linked to reduced survival and higher recurrence rates. While an aggravated inflammatory response may worsen outcomes, few studies have explored the combined effects of leakage and inflammation.MethodsThis is a retrospective multicenter cohort study including patients operated with anterior resection for rectal cancer in Sweden during 2014–2018. Anastomotic leakage within 12 months was exposure and primary outcome was recurrence-free survival. Mediation analysis was performed to evaluate the potential effect of systemic inflammatory response, as measured by the highest postoperative C-reactive protein (CRP) level within 14 days of surgery. Confounders were chosen using a causal diagram.ResultsSome 1036 patients were eligible for analysis, of whom 218 (21%) experienced an anastomotic leakage. At the end of follow-up at a median of 61 months after surgery, recurrence-free survival amounted to 82.6% and 77.8% in the group with and without leakage, respectively. The median highest postoperative CRP value after surgery was higher in the leakage group (219 mg/l), compared with the group without leakage (108 mg/l). Leakage did not lead to worse recurrence-free survival (HR 0.66; 95% CI 0.43–0.94), and there was no apparent effect through postoperative highest CRP (HR 1.12; 95% CI 0.93–1.29).ConclusionsIn conclusion, anastomotic leakage, with its accompanying CRP increase, was not found to be associated with recurrence-free survival after anterior resection for rectal cancer in this patient cohort. Larger, even more detailed studies are needed to further investigate this topic.

Learning Curve of Robotic-Assisted Low Anterior Resection for Low and Mid Rectal Cancer.

Objective: The aim of our study was to assess the learning curve of robotic assisted low anterior resection with diverting loop ileostomy (LARDLI) for low and mid rectal cancer performed by novice in robotic-assisted surgery colorectal surgeon in a public hospital with limited access to the robotic platform. Methods: A retrospective analysis of all low and mid rectal cancer robotic-assisted operations was conducted. All procedures were performed by a single surgeon with a once per week access to the Da Vinci® Si™ Surgical System, Intuitive Surgical Inc. Demographic, clinical, and pathological data were reviewed. The cumulative sum (CUSUM) analysis was utilized to analyze learning curve for operative time. Results: A total of 107 consecutive patients who underwent LARDLI for lower and mid rectal cancer between November 2011 and July 2020 were included in the analysis. The median patients' age was 65 (range, 32-85) years, 72% were males (n = 77), and 91% (n = 97) received neoadjuvant therapy. Median operative time was 295.5 (range, 180-551) minutes. The conversion rate was 3.7% (n = 4). Median length of hospital stay was 6 (range, 1-41) days. There were 35 (32.7%) postoperative complications, of these 7 (6.5%) were major complications (≥Grade 3, according to the Clavien-Dindo classification). There was only one intraoperative complication (.9%). CUSUM analysis showed that the learning curve was 49 cases to achieve a plateau. Conclusions: The learning curve of robotic assisted low anterior resection for lower and mid rectal cancer for a novice in robotic surgery colorectal surgeon with limited access to the robotic platform is 49 cases. Surgeon and operative team dedication, alongside sufficient hospital support, may lower the number of cases of the learning curve.

Rectal Cancer Surgery in a District Hospital: Our Experience.

Introduction Rectal cancer forms a significant proportion of newly diagnosed colorectal cancer. Treatment of rectal cancer is multi-modal, but surgery remains the cornerstone of treatment of rectal cancer and has undergone significant changes in the last three decades. The advent of minimally invasive techniques has revolutionised the landscape of surgery of the rectum. There is now a growing push to centralise rectal cancer surgery to tertiary centres only. We present the results of rectal cancer surgery from our district hospital. Methods This is a single-centre retrospective review of patients undergoing rectal cancer surgery from January 2018 to December 2019 at Northern Lincolnshire and Goole Trust. Results A total of 104 patients were included, with a mean age of 69.13 years (median 70, range 45-98 years). Of the patients, 65 (62.5%) patients were male and 39 (37.5%) patients were female. Neoadjuvant therapy was given to 34% of patients, while 66% of patients underwent surgery first. Anterior resection was performed in 64% of patients, abdomino-perineal resection was performed in 24% of patients, and Hartmann's type operations were performed in 9% of patients. Median length of stay was 9 days (range 2-78 days). Morbidity was 24%, and five patients had anastomotic leaks, of whom three had radiological drain insertion and two required re-operation. Mortality was 2.,8% and re-operations were performed in 2% of patients. Conclusion Rectal cancer surgery can be safely undertaken in district hospitals with adequately trained surgeons using a multi-disciplinary approach.

HTA80 Health Technology Assessment of Robot-Assisted Versus Laparoscopic Low Anterior Resection for Middle and Low Rectal Cancer: A Prospective Cohort Study

HTA80 Health Technology Assessment of Robot-Assisted Versus Laparoscopic Low Anterior Resection for Middle and Low Rectal Cancer: A Prospective Cohort Study

Cardiopulmonary exercise testing parameters associated with postoperative outcomes in colorectal cancer patients undergoing anterior resection.

Cardiopulmonary exercise testing parameters associated with postoperative outcomes in colorectal cancer patients undergoing anterior resection.

A COMPARATIVE STUDY ON THE OUTCOME OF ILEOSTOMY VERSUS COLOSTOMY FOR TEMPORARY DIVERSION OF RECTAL ANASTOMOSIS

Temporary diversion with a stoma is often required in patients undergoing rectal resection for rectal cancer to minimize anastomotic complications. Loop ileostomy and loop colostomy are the two common options for fecal diversion. Despite their widespread use, the comparative outcomes regarding morbidity and complications of these procedures, especially in the context of temporary diversion, remain debatable. Objective: To compare the outcomes of loop ileostomy and loop colostomy for temporary rectal diversion in cancer patients undergoing rectal resection. Methods: A prospective study was conducted in the General Surgery Department of Nishtar Hospital, Multan from June 2024 to November 2024. A total of 150 rectal cancer patients undergoing anterior resection were included in the study. Patients were divided into two groups; Group A included 75 patients undergoing loop ileostomy and Group B included 75 patients undergoing loop colostomy. The primary outcome was to perform a comparison between morbidity outcomes after stoma formation and closure between both procedures. Patients were followed up after every 2-4 weeks in OPD after stomal construction and reversal. Results: After stomal construction, the incidence of complications between both groups was similar. Overall morbidity occurred in 23 patients (30.6%) in group A and 21 patients (28%) in group B. The parastomal hernia was the most common complication in the study population in 31 patients (20.6%), the difference in both groups was insignificant (20% vs 21.3%) (p=0.78). After the stomal reversal, 4 (8%) in group A and 1 (1.9%) in group B had anastomotic leaks, however, the difference was insignificant (p=0.19). 50 (66.7%) patients in the ileostomy group and 51 (68%) patients in the colostomy group underwent stoma reversal. Complications after reversal were similar with the most common complication being wound infection (14 vs 7.9%) (p=0.53%). Conclusion: The outcomes of loop ileostomy and loop colostomy for temporary diversion of rectal anastomosis in patients with rectal cancer were comparable. Larger, randomized studies are needed to verify our findings.

Our experience at Bangabandhu Sheikh Mujib Medical University on laparoscopic assisted surgery for rectal cancer

Background: Rectal cancer is a leading cause of mortality worldwide, with laparoscopic surgery emerging as a viable alternative to open surgery due to its benefits in postoperative recovery, pain management and survival rates. Despite its advantages, laparoscopic colorectal resection faces scrutiny over oncologic safety and technical demands, limiting its widespread adoption. Methods: This retrospective descriptive study analyzed 60 patients with colorectal adenocarcinoma treated at the Department of Colorectal Surgery, BSMMU, from January 2018 to December 2018. Inclusion criteria encompassed clinically diagnosed colorectal cancer with histological confirmation. Data on demographics, tumor characteristics, surgical details and postoperative outcomes were collected and analyzed with SPSS software. Results: Among the 60 patients, 32 were male, with a mean age of 52 years. Tumors within 5 cm of the anal verge necessitated abdominoperineal resections (n=44), while anterior resections were performed for the remaining (n=16). All patients achieved adequate proximal margins (>5 cm) and most (90%) had distal margins >2 cm. The average operative time ranged from 190 to 270 minutes, with no intraoperative complications and a postoperative stay of 3-5 days. Patients reported less postoperative pain and faster recovery. Conclusions: Laparoscopic colorectal surgery demonstrated similar oncologic outcomes to open surgery but involved a longer operative time and required advanced surgical skills. The benefits included reduced blood loss, lower postoperative pain and a shorter hospital stay, although costs were higher. A need for expert surgeons in selected patients is emphasized for optimal outcomes. Laparoscopic resection for rectal cancer aligns with oncologic principles and offers a safe, effective approach, yielding improved recovery metrics compared to traditional surgery. Further analysis on cost-effectiveness, especially for lower socioeconomic populations, is warranted to enhance accessibility.

Usefulness of participation of endoscopic surgical skill qualification system-qualified surgeons in laparoscopic high anterior resection.

A technical qualification system was established by the Japanese Society of Endoscopic Surgery in 2004, and its effectiveness in low anterior resection (LAR) has been reported. We herein performed a subgroup analysis of the effectiveness of the participation of technically qualified surgeons in laparoscopy-assisted high anterior resection (HAR), a procedure used for the technical qualification of surgeons. The EnSSURE study enrolled 3188 patients who underwent laparoscopic rectal resection for rectal cancer between January 2014 and December 2016 at 56 Japanese hospitals. The outcomes of HAR were compared between groups with and without the participation of technically qualified surgeons. The background of the two groups were equalized by propensity score matching. In the group with the participation of qualified surgeons, the operative time was significantly shorter (p = .0427), more lymph nodes were dissected (p = .0207), and the conversion rate to open surgery was lower (p = .0016); however, no significant difference was observed in blood loss (p = .0616), the R0 resection rate (p = 1.00), intraoperative complication rate (p = .160), postoperative complication rate (p = 1.00), or reoperation rate (p = .6999) between the two groups. Furthermore, no significant difference was noted in long-term outcomes (recurrence-free survival (p = .275) or overall survival (p = .941)). In HAR, the technical benefits of the participation of qualified surgeons was limited to a shorter operative time and lower conversion rate. Nevertheless, the qualification is unique in that it predicts the usefulness of reducing complications in more technically challenging procedures when its effectiveness in LAR is considered.

Oncological and Clinical Impacts of Routine Splenic Flexure Mobilization in Anterior Resection

Oncological and Clinical Impacts of Routine Splenic Flexure Mobilization in Anterior Resection

Comparative Outcomes of End-to-End versus Side-to-End Colorectal Anastomosis Following Low Anterior Resection for Rectal Cancer

Comparative Outcomes of End-to-End versus Side-to-End Colorectal Anastomosis Following Low Anterior Resection for Rectal Cancer

Erectile dysfunction is an underdiagnosed consequence of low anterior resection and abdominoperineal resection for colorectal cancer.

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 > 65years with any index surgery within 1year 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 2years 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 2years 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 2years 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.

Safety and Feasibility of Umbilical Stoma After Low Anterior Resection Using Propensity Score Matching

Safety and Feasibility of Umbilical Stoma After Low Anterior Resection Using Propensity Score Matching

Coding the issue: low anterior resection syndrome following rectal cancer treatment.

Coding the issue: low anterior resection syndrome following rectal cancer treatment.

Risk factors of the low anterior resection syndrome (LARS) after ileostomy reversal in rectal cancer patient

This study is aimed at identifying risk factors of Low Anterior Resection Syndrome following ileostomy reversal in rectal cancer patients who had undergone preventive ileostomy. This retrospective analysis was conducted on a cohort of 605 patients treated at the Fourth Hospital of Hebei Medical University between January 2018 and December 2021. These patients were grouped based on LARS score, and Clinical and follow-up data were collected to conduct univariate analyses of potential factors influencing LARS occurrence based on variable type. Variables with statistical significance were included in a logistic regression model to analyze potential influences on the occurrence of LARS. Univariate and Multivariate logistic regression analysis showed that N2 stage (OR = 2.290 95%CI: 1.076–4.873, P = 0.031), chemoradiotherapy (OR = 2.271, 95%CI: 1.246–4.138, P = 0.007), and anastomosis height (OR = 0.836, 95%CI: 0.717–0.975, P = 0.022) were independent influences on the occurrence of LARS. In model 3 (adjusting for all covariates), the relationship between anastomotic height and patient LARS status showed a negative correlation. In subgroup analyses, there were significant differences in the effect of anastomotic height on LARS in subgroups with different hemoglobin concentrations. A high occurrence rate of LARS is observed in rectal cancer patients with preventive ileostomy reversal. N2 stage, history of chemoradiotherapy, and anastomotic height are independent influence factors for the occurrence of major LARS after ileostomy reversal.

Defunctioning Ileostomy After Low Anterior Resection of Rectum: Morbidity Related to Fashioning and Closure.

Background and Objectives: The aim of this study was to assess any predisposing factors to the morbidity of fashioning and reversal of diverting ileostomy in a prospective cohort of patients who have undergone TME and low colo-rectal or colo-anal anastomosis for rectal cancer. Materials and Methods: Consecutive patients with rectal cancer undergoing low anterior resection and a defunctioning loop ileostomy in three surgical units from 2016 to 2020 were included in the study and retrospectively analyzed. Results: One hundred eighty-two patients from three centres were included. Ileostomy-related mortality was 0.5%, attributed to renal failure.. Ileostomy-related morbidity was 46%. Postoperative ileus was seen in 37.4%, and dehydration in 18.8% of the patients. The readmission rate for ileostomy-related reasons was 15.4%. Stoma care was problematic in 15.7% or poor in 7% of the cases. Advanced age, male gender and obesity were independent risk factors for ileostomy-related morbidity. Ileostomy was reversed in 165 patients. The morbidity in 165 patients was 16%. Ileus was seen in 10.3%, anastomotic leak in 4.8% and wound infection in 12.7% of the cases. One patient died because of an anastomotic leak. No predisposing factors that affect the outcomes of ileostomy closure were identified. Conclusions: Diverting ileostomy-related morbidity is high. Life threatening dehydration and renal failure from ileus is more commonly seen in elderly, male and obese patients and should be anticipated. Ileostomy closure-related morbidity is low.

Use of transanal irrigation (TAI) in the treatment of persistent bowel disorders in patients with endometriosis: A retrospective study

PurposeEndometriosis has a strong impact on women’s quality of life (QoL). Pain is the main symptom of the disease, but bowel dysfunctions such as fecal incontinence, constipation and voiding difficulties are also reported. Patients could suffer from a Low Anterior Resection Syndrome (LARS)-like syndrome. Transanal irrigation (TAI), known to alleviate LARS-related symptoms, has been suggested to aid bowel dysfunction in endometriosis patients, potentially facilitating pelvic floor rehabilitation.MethodsWe retrospectively collected data from 60 patients with endometriosis and bowel dysfunction who had been prescribed with the Peristeen® Plus TAI system. Patient satisfaction, pain, QoL and LARS score were evaluated before (baseline) and after TAI treatment (follow-up of approximately 12 months).ResultsOf the 60 patients meeting the inclusion criteria, 12 patients did not complete the questionnaires at follow-up and 16 patients discontinued treatment. Data analysis performed on 32 patients showed a mean increase of 3.6 points in patient satisfaction after TAI treatment and a mean pain reduction of 1.8 points (both, p-value < 0.001). LARS score decreased from a mean of 21.9 at baseline to a mean of 12.7 (p-value < 0.001). Accordingly, there was a notable improvement in patients’ QoL.ConclusionTAI is a useful treatment for bowel dysfunctions in patients with endometriosis. When offered to these patients, TAI seems to represent a valuable strategy to reduce pelvic floor stress. This study confirms that TAI was associated to a significantly higher patients’ satisfaction, as well as to a reduction of pain and LARS-like symptoms.

Preventive Strategies in Anesthetizing a High-Risk Patient for Robotic Surgery: A Case Report

The physiologic consequences of intraabdominal insufflation and extreme positioning in robotic surgery predispose a patient with heart failure to complications. Reports on anesthetic strategies to prevent adverse events in patients with heart failure undergoing these types of surgeries are sparse. A 65-year-old male, who was a known case of heart failure with reduced ejection fraction (EF), was scheduled for robot-assisted low anterior resection for rectal adenocarcinoma. Preoperative diagnostic tools such as echocardiography, 12-lead electrocardiography, and blood tests guided preoperative risk assessment, and anesthesia-related planning and interventions. A balanced anesthetic technique using sevoflurane, atracurium, and fentanyl, with postoperative bilateral rectus sheath and subcostal block was used. In addition to standard monitors, arterial pulse pressure variation (PPV) was utilized for goal-directed fluid therapy to prevent complications. Patient tolerated surgery and anesthesia well with no report of any complication during the perioperative course. Patient was eventually discharged and scheduled for follow-up. The physiologic consequences of robotic surgery compound the already elevated risk for complications of a patient with heart failure. Anesthetic strategies to actively prevent adverse events are of paramount importance.