Anterior Resection For Rectal Cancer Research Articles

Drainage Fluid Amylase as a Biomarker for the Detection of Anastomotic Leakage After Low Anterior Resection of Rectal Cancer: A Two-center Study.

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. 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. 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. Measuring DFA is a non-invasive, simple and cost-effective 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.

054. Loop Ileostomy Versus Loop Colostomy to Prevent Complications of Anterior Resection for Rectal Cancer: A Systematic Review and Meta-Analysis

Background: Anastomotic leaking constitutes a significant complication of colorectal cancer surgery, extending hospitalizations and adversely affecting patient prognosis. The preventative defunctioning stoma was created to diminish reoperation morbidity and death in high-risk anastomoses. Nonetheless, it is still uncertain if the often-employed loop colostomy (LC) or loop ileostomy (LI) can mitigate the risks associated with colorectal surgery. This study aims to evaluate the morbidities associated with LC and LI following anterior rectal cancer resection. Methods: We searched PubMed, Embase, WileyOnline Library, and the Cochrane Library to identify studies and trials published from 2019 to early 2024. The results of this investigation included stoma formation, stoma restriction, stoma stricture, and necrosis. We employed Revman 5.4.2 to do the meta-analysis. Results: Five studies were considered, comprising 1,011 patients, with 482 undergoing loop ileostomy and 529 undergoing loop colostomy. Our findings indicate that loop ileostomy was correlated with a reduction in the incidence of stoma formation, with a relative risk (RR) of 1.31 (95% CI [1.14; 1.49], p &lt; 0.0001), and a decrease in stoma stricture, with an RR of 0.45 (95% CI [0.28; 0.72], p = 0.0009). Our results reveal that loop ileostomy was associated with an increased incidence of stoma retraction (RR 0.50, 95% CI [0.18; 1.37], p = 0.17) and necrosis (RR 0.84, 95% CI [0.47; 1.49], p = 0.54). Conclusion: This study demonstrated that loop ileostomy was related to reducing the incidence of stoma formation and stoma restriction. Additional investigations are required to validate these findings.

Letter to editor: Optimized Machine Learning Model for Predicting Unplanned Reoperation After Rectal Cancer Anterior Resection.

Letter to editor: Optimized Machine Learning Model for Predicting Unplanned Reoperation After Rectal Cancer Anterior Resection.

Comment on “Optimized machine learning model for predicting unplanned reoperation after rectal cancer anterior resection”.

Comment on “Optimized machine learning model for predicting unplanned reoperation after rectal cancer anterior resection”.

Association Between Chemotherapy-Induced Peripheral Neuropathy and Low Anterior Resection Syndrome.

Low anterior resection syndrome (LARS) can be a debilitating condition that develops after undergoing sphincter-preserving surgery for rectal cancer. Chemotherapy-induced peripheral neuropathy is a common side effect of platinum-based chemotherapy agents used as systemic therapy for rectal cancer treatment. The purpose of this study was to determine the potential relationship between CIPN and LARS. This was a retrospective review of patients who underwent a low anterior resection for rectal cancer and received systemic therapy contacted at least six months from the most recent surgery. Eligible patients were called and completed the relevant surveys over the phone or email. There was a total of 42 patients who completed the surveys with 33 (79%) having major LARS. Presence of a diverting ileostomy was the only significantly differentcharacteristic in those with major LARS versus those without. CIPN was independently associated with LARS (p = 0.046) on linear regression when controlling for neoadjuvant chemoradiation, diverting ileostomy and tumor distance from the anal verge. Developing severe CIPN is associated with developing LARS. Further studies evaluating the etiology behind this relationship should be conducted.

A novel circumferential continuous reinforcing suture for anastomosis after laparoscopic resection for rectal cancer and sigmoid cancer: a retrospective case-controlled study.

This study aimed to investigate the effectiveness of a novel method for anastomosis reinforcement to minimize the occurrence of anastomotic complications after surgical resection of rectal and sigmoid cancer. We recruited 378 patients who underwent laparoscopic rectal anterior resection of rectal cancer and sigmoid cancer in SYSUCC. The occurrence rates of intraoperative bleeding, operation time, and postoperative anastomotic complications were compared between the treatment group receiving anastomotic reinforcement and the control group without anastomotic reinforcement. The incidence of anastomotic leakage in the treatment group was significantly lower than that in the control group (1.59% vs. 11.64%, p < 0.001). Following the application of inverse probability of treatment weighting (IPTW) to adjust for factors influencing the occurrence of anastomotic leakage, the incidence of anastomotic leakage remained significantly lower in the treatment group compared to the control group (2.54% vs. 12.08%, p < 0.001). The circumferential continuous anastomosis reinforcing suture method, recommended for laparoscopic surgery for rectal and sigmoid cancer, has the potential to effectively minimize the occurrence of anastomotic complications.

Economic burden of pelvic sepsis after anastomotic leakage following rectal cancer surgery: A retrospective cost-of-illness analysis.

Anastomotic leakage following rectal cancer surgery remains a challenging complication, with a nonhealing rate of approximately 50% at 1 year. Pelvic sepsis may require tertiary treatment that encompasses additional admissions, extensive surgery and other types of interventions. The aim of this study is to analyse the financial burden of pelvic sepsis in a tertiary hospital. From 2010 until 2020, all patients referred to a tertiary centre for pelvic sepsis after low anterior resection for rectal cancer were prospectively registered and retrospectively reviewed. The cost analysis adhered to Dutch National Healthcare Institute guidelines and covered hospital-imposed medical costs from salvage surgery to the last registered intervention, adjusted for inflation and priced in euros. This analysis included 126 patients, with an average total cost per patient of €31 131. Salvage surgery accounted for €21 326, with an additional €9805 for reinterventions and readmissions. Salvage surgery comprised nonrestorative surgery in 48% and restorative salvage surgery in the remaining cases. Length of hospital stay averaged 9.6 days on the general ward and 0.8 days in the intensive care unit. Common reinterventions included endoscopic vacuum sponge changes (n = 153), stoma closures (n = 59) and radiological abscess drainages (n = 51). Total costs did not differ significantly between nonrestorative surgery and restorative surgery (mean = €31 950 vs. €30 362, respectively; p = 0.893). Treating pelvic sepsis after rectal cancer resection in a tertiary hospital carries a substantial economic burden, averaging €31 131 per patient, and this work helps to quantify the potential economic impact of innovative care to reduce anastomotic leakage.

Optimized machine learning model for predicting unplanned reoperation after rectal cancer anterior resection

BackgroundUnplanned reoperation (URO) after surgery adversely affects the quality of life and prognosis of patients undergoing anterior resection for rectal cancer. This study aims to meet the urgent need for reliable predictive tools by developing an optimized machine learning model to estimate the risk of URO following anterior resection in rectal cancer patients. MethodsThis retrospective study collected multidimensional data from patients who underwent anterior resection for rectal cancer at Tongji Hospital of Huazhong University of Science and Technology from January 2012 to December 2022. Feature selection was conducted using both least absolute shrinkage and selection operator (LASSO) regression and the Boruta algorithm. Multiple machine learning models were developed, with parameter optimization via grid search and cross-validation. Performance metrics included accuracy, specificity, sensitivity, and area under curve (AUC). The optimal model was interpreted using SHapley Additive exPlanations (SHAP), and an online platform was created for real-time risk prediction. ResultsA total of 2384 patients who underwent anterior resection for rectal cancer were included in this study. Following rigorous selection, 14 variables were identified for constructing the machine learning model. The optimized model demonstrated high predictive accuracy, with the random forest (RF) model achieving the best overall performance. The model achieved an AUC of 0.889 and an accuracy of 0.842 on the test dataset. SHAP analysis revealed that the tumor location, previous abdominal surgery, and operative time were the most significant factors influencing the risk of URO. ConclusionThis study developed an optimized machine learning-based online predictive system to assess the risk of URO after anterior resection in rectal cancer patients. Accessible at https://yangsu2023.shinyapps.io/UROrisk/, this system improves prediction accuracy and offers real-time risk assessment, providing a valuable tool that may support clinical decision-making and potentially improve the prognosis of rectal cancer patients.

Early versus late closure of protective loop ileostomy: functional significant results in a preliminary analysis.

Protective loop ileostomy (PLI), commonly performed in rectal cancer surgery, is one of the most reliable methods to reduce the risk of sepsis associated with anastomotic complications. The correct timing of PLI closure is not well defined. Recently, most surgeons proposed to close early the PLI. The aim of this study was to evaluate the impact of the timing of stoma closure on postoperative outcomes. We analyzed prospectively data of patients who received PLI anterior resection for rectal cancer between January 2020 to June 2022. Patients were divided into 2 groups according to the timing of stoma closure, until four weeks (EC group) and more than four weeks (LC group). Outpatient clinic follow-up, perioperative data, postoperative complications and evidence of anterior resection syndrome with the Low-Anterior Resection Score (LARS) score were recorded. In the EC group 24 patients were included while 27 patients were considered for LC group. There were no differences between the groups with respect to all parameters, except for recourse to adjuvant therapy, higher for LC group. Perioperative analyzed characteristics were similar among groups. There was no statistically significant difference between the EC group and the LC group for complication rate. LARS score was higher in the LC group for score >20 and >30. Timing of PLI closure was not a significant independent predictor of post-closure complications rate. LARS incidence was significantly related to longer time of closure, with probably late recovery of motility function, but this should be confirmed by randomized studies.

Robot‐assisted radical cystectomy for bladder cancer after low anterior resection: A case report

AbstractRadical 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.

Robotic-assisted low anterior resection for rectal cancer shows similar clinical efficacy to laparoscopic surgery: A propensity score matched study.

Rectal cancer ranks as the second leading cause of cancer-related mortality worldwide, necessitating surgical resection as the sole treatment option. Over the years, there has been a growing adoption of minimally invasive surgical techniques such as robotic and laparoscopic approaches. Robotic surgery represents an innovative modality that effectively addresses the limitations associated with traditional laparoscopic techniques. While previous studies have reported favorable perioperative outcomes for robot-assisted radical resection in rectal cancer patients, further evidence regarding its oncological safety is still warranted. To conduct a comparative analysis of perioperative and oncological outcomes between robot-assisted and laparoscopic-assisted low anterior resection (LALAR) procedures. The clinical data of 125 patients who underwent robot-assisted low anterior resection (RALAR) and 279 patients who underwent LALAR resection at Shandong Provincial Hospital Affiliated to Shandong First Medical University from December 2019 to November 2022 were retrospectively analyzed. After performing a 1:1 propensity score matching, the patients were divided into two groups: The RALAR group and the LALAR group (111 cases in each group). Subsequently, a comparison was made between the short-term outcomes within 30 d after surgery and the 3-year survival outcomes of these two groups. Compared to the LALAR group, the RALAR group exhibited a significantly earlier time to first flatus [2 (2-2) d vs 3 (3-3) d, P = 0.000], as well as a shorter time to first fluid diet [4 (3-4) d vs 5 (4-6) d, P = 0.001]. Additionally, the RALAR group demonstrated reduced postoperative indwelling catheter time [2 (1-3) d vs 4 (3-5) d, P = 0.000] and decreased length of hospital stay after surgery [5 (5-7) d vs 7(6-8) d, P = 0.009]. Moreover, there was an observed increase in total cost of hospitalization for the RALAR group compared to the LALAR group [10777 (10780-11850) dollars vs 10550 (8766-11715) dollars, P = 0.012]. No significant differences were found in terms of conversion rate to laparotomy or incidence of postoperative complications between both groups. Furthermore, no significant disparities were noted regarding the 3-year overall survival rate and 3-year disease-free survival rate between both groups. Robotic surgery offers potential advantages in terms of accelerated recovery of gastrointestinal and urologic function compared to LALAR resection, while maintaining similar perioperative and 3-year oncological outcomes.

C-reactive protein-to-albumin ratio as a risk factor for anastomotic leakage after anterior resection for rectal cancer with intraoperative use of indocyanine green fluorescence imaging.

Indocyanine green fluorescence imaging (ICG-FI) reduces anastomotic leakage (AL) in rectal cancer surgery. However, no studies investigating risk factors for anastomotic leakage specific to the group using ICG-FI have ever previously been conducted. The purpose of this retrospective multicenter study was to ascertain the risk factors for AL in the group using ICG-FI. A total of 638 patients who underwent laparoscopic or robotic anterior resection for rectal cancer between April 2018 and March 2023 were included in this study. Patients were divided into two groups: the ICG-FI group (n = 269) and the non-ICG-FI group (n = 369) for comparative analysis. The effects of clinicopathological and treatment-related factors on AL in the ICG-FI group were evaluated using both univariate and multivariate analyses. The incidence of AL in the ICG-FI group was 4.8%. Although there was no significant difference in the incidence of AL between the two groups, it was observed to be lower in the ICG-FI group. A multivariate analysis revealed a preoperative C-reactive protein-to-albumin ratio (CAR) ≥ 0.049 (odds ratio, 3.73; 95% confidence interval, 1.01-13.70; p = 0.048) as an independent risk factor for AL in the ICG-FI group. In this study, CAR was the only identified risk factor for AL in the ICG-FI group. It was suggested that CAR could be a criterion for early surgical intervention, prior to the escalation of risks, or for considering interventions such as diverting stoma creation.

A nomogram of anastomotic stricture after rectal cancer: a retrospective cohort analysis.

Anastomotic stricture significantly impacts patients' quality of life and long-term prognosis. However, current clinical practice lacks accurate tools for predicting anastomotic stricture. This study aimed to develop a nomogram to predict anastomotic stricture in patients with rectal cancer who have undergone anterior resection. A total of 1542 eligible patients were recruited for the study. Least absolute shrinkage selection operator (Lasso) analysis was used to preliminarily select predictors. A prediction model was constructed using multivariate logistic regression and presented as a nomogram. The performance of the nomogram was evaluated using receiver operating characteristic (ROC) curves, calibration diagrams, and decision curve analysis (DCA). Internal validation was conducted by assessing the model's performance on a validation cohort. 72 (4.7%) patients were diagnosed with anastomotic stricture. Participants were randomly divided into training (n = 1079) and validation (n = 463) sets. Predictors included in this nomogram were radiotherapy, diverting stoma, anastomotic leakage, and anastomotic distance. The area under the ROC curve (AUC) for the training set was 0.889 [95% confidence interval (CI) 0.840-0.937] and for the validation set, it was 0.930 (95%CI 0.879-0.981). The calibration curve demonstrated a strong correlation between predicted and observed outcomes. DCA results showed that the nomogram had clinical value in predicting anastomotic stricture in patients after anterior resection of rectal cancer. We developed a predictive model for anastomotic stricture following anterior resection of rectal cancer. This nomogram could assist clinicians in predicting the risk of anastomotic stricture, thus improving patients' quality of life and long-term prognosis.

Randomised Controlled Pilot Trial on GHOST Ileostomy versus Conventional Loop Ileostomy in Patients Undergoing low Anterior Resection for Rectal Cancer

Abstract Background Anastomotic leakage is the most important complication after colorectal surgery. In patients undergoing low anterior resection with total mesorectal excision (LAR/TME) a loop ileostomy is fashioned to protect the low anastomosis. Ghost ileostomy is a pre-stage ileostomy, which can be converted to a diverting ileostomy, if anastomotic leakage is suspected. If there are no signs of anastomotic leakage an actual ileostomy can be avoided. Aims The objective was to evaluate whether ghost ileostomy is a safe alternative to a conventional loop ileostomy. Methods GHOST was a randomised controlled pilot trial without formal hypothesis. Patients undergoing LAR/TME for rectal cancer were intraoperatively randomised to receive a ghost ileostomy or loop ileostomy. Patients were followed prospectively for 6 months. Comprehensive complication index, transformation of ghost ileostomy into loop ileostomy, presence of an ostomy at 6 months, Wexner score and quality of life were assessed. Results Thirty patients were equally randomised. The CCI was 30.7 (± 17.7) in the ghost ileostomy group compared to 29.7 (± 18.6) in the loop ileostomy group at 6 months (p=0.889). The ghost ileostomy was converted into a loop ileostomy in 6 of 15 (40.0%) patients. At 6 months after low anterior resection, 6 (40.0%) patients in the ghost ileostomy group and 7 (46.7%) patients in the ileostomy group still had an ileostomy. There was no mortality and no need for creation of a terminal ostomy within the trial. Neither postoperative function assessed by the Wexner score, nor the overall quality of life showed significant differences. Conclusion Ghost ileostomy seems to be a viable and safe option to a more selective approach regarding creation of an ileostomy in patients undergoing LAR/TME. However, the difficult patient selection with exclusion of patients at high risk of anastomotic leakage limits its widespread application and should be optimised in future trials.

Machine learning model for prediction of permanent stoma after anterior resection of rectal cancer: A multicenter study

BackgroundThe conversion from a temporary to a permanent stoma (PS) following rectal cancer surgery significantly impacts the quality of life of patients. However, there is currently a lack of practical preoperative tools to predict PS formation. The purpose of this study is to establish a preoperative predictive model for PS using machine learning algorithms to guide clinical practice. MethodsIn this retrospective study, we analyzed clinical data from a total of 655 patients who underwent anterior resection for rectal cancer, with 552 patients from one medical center and 103 from another. Through machine learning algorithms, five predictive models were developed, and each was thoroughly evaluated for predictive performance. The model with superior predictive accuracy underwent additional validation using both an independent testing cohort and the external validation cohort. The Shapley Additive exPlanations (SHAP) approach was employed to elucidate the predictive factors influencing the model, providing an in-depth visual analysis of its decision-making process. ResultsEight variables were selected for the construction of the model. The support vector machine (SVM) model exhibited superior predictive performance in the training set, evidenced by an AUC of 0.854 (95 % CI:0.803–0.904). This performance was corroborated in both the testing set and external validation set, where the model demonstrated an AUC of 0.851 (95%CI:0.748–0.954) and 0.815 (95%CI:0.710–0.919), respectively, indicating its efficacy in identifying the PS. ConclusionsThe model(https://yangsu2023.shinyapps.io/psrisk/) indicated robust predictive performance in identifying PS after anterior resection for rectal cancer, potentially guiding surgeons in the preoperative stratification of patients, thus informing individualized treatment plans and improving patient outcomes.

Minor impact of anastomotic leakage in anterior resection for rectal cancer on long-term male urinary and sexual function

PurposeAnastomotic leakage after anterior resection for rectal cancer induces bowel dysfunction, but the influence on urinary and sexual function is largely unknown. This cross-sectional cohort study evaluated long-term effect of anastomotic leakage on urinary and sexual function in male patients.MethodsPatients operated with anterior resection for rectal cancer in 15 Swedish hospitals 2007–2013 were identified. Anastomotic leakage and other clinical variables were retrieved from the Swedish Colorectal Cancer Registry and medical records. Urinary and sexual dysfunction were evaluated at 4 to 11 years after surgery using the International Prostate Symptom Score, International Index of Erectile Function, and European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire CR29. The effect of anastomotic leakage on average scores of urinary and sexual dysfunction was evaluated as a primary outcome, and the single items permanent urinary catheter and sexual inactivity as secondary outcomes. The association of anastomotic leakage and functional outcomes was analyzed using regression models with adjustment for confounders.ResultsAfter a median follow-up of 84 months (interquartile range: 67–110), 379 out of 864 eligible men were included. Fifty-nine (16%) patients had anastomotic leakage. Urinary incontinence was more common in the leakage group, with an adjusted mean score difference measured by EORTC QLQ ColoRectal–29 of 8.69 (95% confidence interval: 0.72–16.67). The higher risks of urinary frequency, permanent urinary catheter, and sexual inactivity did not reach significance.ConclusionAnastomotic leakage after anterior resection had a minor negative impact on urinary and sexual function in men.

Simple pelvimetry predicts the pelvic manipulation time in robot-assisted low and ultra-low anterior resection for rectal cancer.

This study explored the difficulty factors in robot-assisted low and ultra-low anterior resection, focusing on simple measurements of the pelvic anatomy. This was a retrospective analysis of the clinical data of 61 patients who underwent robot-assisted low and ultra-low anterior resection for rectal cancer between October 2018 and April 2023. The relationship between the operative time in the pelvic phase and clinicopathological data, especially pelvic anatomical parameters measured on X-ray and computed tomography (CT), was evaluated. The operative time in the pelvic phase was defined as the time between mobilization from the sacral promontory and rectal resection. Robot-assisted low and ultra-low anterior resections were performed in 32 and 29 patients, respectively. The median operative time in the pelvic phase was 126 (range, 31-332)min. A multiple linear regression analysis showed that a short distance from the anal verge to the lower edge of the cancer, a narrow area comprising the iliopectineal line, short anteroposterior and transverse pelvic diameters, and a small angle of the pelvic mesorectum were associated with a prolonged operative time in the pelvic phase. Simple pelvic anatomical measurements using abdominal radiography and CT may predict the pelvic manipulation time in robot-assisted surgery for rectal cancer.

Preoperative beta blockers and other drugs in relation to anastomotic leakage after anterior resection for rectal cancer.

Previous research has indicated that preoperative beta blocker therapy is associated with a decreased risk of complications after surgery for rectal cancer. This is thought to arise because of the anti-inflammatory activity of the drug. These results need to be reproduced and analyses extended to other drugs with such properties, as this information might be useful in clinical decision-making. The main aim of this work was to replicate previous findings of beta blocker use as a prognostic marker for postoperative leakage. We also investigated whether drug exposure might induce anastomotic leaks. This is a retrospective multicentre cohort study, comprising 1126 patients who underwent anterior resection for rectal cancer between 2014 and 2018. The use of any preoperative beta blocker was treated as the primary exposure, while anastomotic leakage within 12 months of surgery was the outcome. Secondary exposures comprised angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, statins and metformin. Using multivariable regression, we performed a replication analysis with a predictive aim for beta blockers only, while adjustment for confounding was done in more causally oriented analyses for all drugs. We estimated incidence rate ratio (IRR) and relative risk (RR) with 95% confidence intervals (CIs). Anastomotic leakage occurred in 20.6% of patients. Preoperative beta blockers were used by 22.7% of the cohort, while the leak distribution was almost identical between exposure groups. In the main replication analysis, no association could be detected (IRR 0.95, 95% CI 0.68-1.33). In the causally oriented analyses, only metformin affected the risk of leakage (RR 1.59, 95% Cl 1.31-1.92). While previous research has suggested that preoperative beta blocker use could be prognostic of anastomotic leakage, this study could not detect any such association. On the contrary, our results indicate that preoperative beta blocker use neither predicts nor causes anastomotic leakage after anterior resection for rectal cancer.

Impact of the endoscopic surgical skill qualification system on conversion to laparotomy after low anterior resection for rectal cancer in Japan (a secondary analysis of the EnSSURE study)

Background and aimsConversion to laparotomy is among the serious intraoperative complications and carries an increased risk of postoperative complications. In this cohort study, we investigated whether or not the Endoscopic Surgical Skill Qualification System (ESSQS) affects the conversion rate among patients undergoing laparoscopic surgery for rectal cancer.MethodsWe performed a retrospective secondary analysis of data collected from patients undergoing laparoscopic surgery for cStage II and III rectal cancer from 2014 to 2016 across 56 institutions affiliated with the Japan Society of Laparoscopic Colorectal Surgery. Data from the original EnSSURE study were analyzed to investigate risk factors for conversion to laparotomy by performing univariate and multivariate analyses based on the reason for conversion.ResultsData were collected for 3,168 cases, including 65 (2.1%) involving conversion to laparotomy. Indicated conversion accounted for 27 cases (0.9%), while technical conversion accounted for 35 cases (1.1%). The multivariate analysis identified the following independent risk factors for indicated conversion to laparotomy: tumor diameter [mm] (odds ratio [OR] 1.01, 95% confidence interval [CI] 1.01–1.05, p = 0.0002), combined resection of adjacent organs [+/−] (OR 7.92, 95% CI 3.14–19.97, p < 0.0001), and surgical participation of an ESSQS-certified physician [−/+] (OR 4.46, 95% CI 2.01–9.90, p = 0.0002). The multivariate analysis identified the following risk factors for technical conversion to laparotomy: registered case number of institution (OR 0.99, 95% CI 0.99–1.00, p = 0.0029), institution type [non-university/university hospital] (OR 3.52, 95% CI 1.54–8.04, p = 0.0028), combined resection of adjacent organs [+/−] (OR 5.96, 95% CI 2.15–16.53, p = 0.0006), and surgical participation of an ESSQS-certified physician [−/+] (OR 6.26, 95% CI 3.01–13.05, p < 0.0001).ConclusionsParticipation of ESSQS-certified physicians may reduce the risk of both indicated and technical conversion. Referral to specialized institutions, such as high-volume centers and university hospitals, especially for patients exhibiting relevant background risk factors, may reduce the risk of conversion to laparotomy and lead to better outcomes for patients.Trial RegistrationThis study was registered with the Japanese Clinical Trials Registry as UMIN000040645.

Long-term bowel functional outcomes following anal sphincter-preserving surgery for upper and middle rectal cancer: a single-center longitudinal study.

Despite advances in neoadjuvant chemoradiotherapy and anal sphincter-preserving surgery for rectal cancer, bowel dysfunction is still unavoidable and negatively affects patients' quality of life. In this longitudinal study, we aimed to investigate the changes in bowel function with follow-up time and the effect of neoadjuvant chemoradiotherapy on bowel function following low anterior resection for rectal cancer. In this study, 171 patients with upper or middle rectal cancer who underwent low anterior resection between 2012 and 2018 were included. Bowel function was assessed longitudinally with Memorial Sloan Kettering Cancer Center Bowel Function Instrument and Wexner scores every 6 months after restoration of bowel continuity. Patients with at least 2 follow-up visits were included. Overall, 100 patients received neoadjuvant chemoradiotherapy. Urgency, soilage, and fecal incontinence were noted within 24 months in the patients treated with neoadjuvant chemoradiotherapy. After 2 years of follow-up, significant bowel dysfunction and fecal incontinence were observed in the neoadjuvant chemoradiotherapy group. Low tumor level and neoadjuvant chemoradiotherapy were associated with delayed bowel dysfunction. Neoadjuvant chemoradiotherapy in combination with low tumor level was significantly associated with delayed bowel dysfunction even after 2 years of follow-up. Therefore, careful selection and discussion with patients are paramount.