Excision For Rectal Cancer Research Articles

Ghost-ileostomy versus conventional loop ileostomy in patients undergoing low anterior resection for rectal cancer: results of a randomised controlled multicentre pilot trial (DRKS00013997).

The objective of the current pilot trial was to evaluate whether ghost ileostomy is a safe alternative to the current standard of care in terms of a conventional loop ileostomy in patients undergoing low anterior resection with total mesorectal excision (LAR/TME) for rectal cancer. This randomized controlled pilot trial included patients undergoing LAR/TME, randomly assigning them to ghost ileostomy or conventional loop ileostomy intraoperatively. Follow-up spanned 6months, evaluating the following endpoints: comprehensive complication index (CCI), postoperative morbidity, transformation of ghost ileostomy, presence of ostomy at 6months, Wexner score, and quality of life (EORTC QLQ-C30 & CR29). Exploratory statistical analysis based on the intention-to-treat principle was conducted. Recruiting 30 patients from May 2018 to September 2022, the trial was prematurely stopped due to slow recruitment. The mean CCI was comparable between groups at any point of time (at 6months: 30.7 vs. 29.7, p = 0.889). There was no mortality and no need for creation of a terminal ostomy. Anastomotic leakage rates were similar in ghost ileostomy and loop ileostomy groups (p > 0.99). The ghost ileostomy was converted into a conventional loop ileostomy in 6 of 15 (40.0%) patients. Neither postoperative function, nor the overall quality of life showed significant differences. Ghost ileostomy appears as a viable and safe option for selectively deciding ileostomy creation in LAR/TME for rectal cancer. However, challenges in patient selection, excluding those at high risk for anastomotic leakage, limit widespread application and call for optimization in future research. German Clinical Trials Register ( https://drks.de/ ): DRKS00013997; date of registration: April 9th 2018.

Local excision of early rectal cancer: A multi-centre experience of transanal endoscopic microsurgery from the United Kingdom

Local excision of early rectal cancer: A multi-centre experience of transanal endoscopic microsurgery from the United Kingdom

A study of intersphincteric resection rate following robotic-assisted total mesorectal excision versus laparoscopic-assisted total mesorectal excision for patients with middle and low rectal cancer: study protocol for a multicenter randomized clinical trial

IntroductionRobotic-assisted complete mesorectal excision (RATME) is increasingly being used by colorectal surgeons. Most surgeons consider RATME a safe method, and believe it can facilitate total mesorectal excision (TME) in rectal cancer, and may potentially have advantages over intersphincteric resection (ISR) and anus preservation. Therefore, this trial was designed to investigate whether RATME has technical advantages and can increase the ISR rate compared with laparoscopic-assisted TME (LATME) in patients with middle and low rectal cancer.Methods and analysisThis is a multicenter, superiority, randomized controlled trial designed to compare RATME and LATME in middle and low rectal cancer. The primary endpoint is the ISR rate. The secondary endpoints are coloanal anastomosis (CAA) rate, conversion to open surgery, conversion to transanal TME (TaTME), abdominoperineal resection (APR) rate, postoperative morbidity and mortality within 30 days, pathological outcomes, long-term survival outcomes, functional outcomes, and quality of life. In addition, certain measurements will be conducted to ensure quality and safety, including centralized photography review and semiannual assessment.DiscussionThis trial will clarify if RATME improves ISR and promotes anus preservation in patients with mid- and low-rectal cancer. Furthermore, this trial will provide evidence on the optimal treatment strategies for RATME and LATME in patients with mid- and low-rectal cancer regarding improved operational safety.Trial registrationClinicalTrials.gov NCT06105203. Registered on October 27, 2023.

A New Approach to Ultra-Low Anterior Resection-Intersphincteric Dissection With Total Hiatal Ligament Excision for Very Low Rectal Cancer Located in the Posterior Wall of the Rectum: A More Satisfactory Technique for Local Recurrence Control.

The hiatal ligament, as the anatomical landmark for the completion of total mesorectal excision (TME) for ultra-low rectal cancer, represents a continuation of the longitudinal muscle of the rectum. It receives vascular supply from the median sacral artery and contains lymphatic vessels. In cases where ultra-low rectal cancer is located in the posterior rectal wall, the hiatal ligament may theoretically serve as an anatomical region susceptible to direct tumor cell spread or distant metastasis. To evaluate the effect of circumferential tumor location (CTL) on postoperative survival of low rectal cancer and to determine the effect of total hiatal ligament excision (THLE) on the prognosis of patients with posterior rectal cancer. Patients with ultra-low rectal cancer who underwent laparoscopic surgery between March 2014 and October 2021 were enrolled in this study. Propensity score matching (PSM) analysis was used to compare the clinicopathological characteristics and prognosis of patients in the posterior group and the non-posterior group. Prognostic factors were identified using COX regression. PSM analysis was also used in the posterior tumor subgroup to compare the clinicopathological characteristics and prognosis of patients in the hiatal ligament traditional transection (HLTT) and THLE groups. After PSM, OS, and DFS were comparable between the posterior and non-posterior groups. Similarly, no difference was noted in the local recurrence rate between the two groups (p = 0.23). The prognosis of ultra-low rectal cancer was not affected by CTL. However, the local recurrence rate was significantly lower in the THLE group compared with the HLTT group (p = 0.023). Multivariate analysis of the posterior group identified CRM, TNM stage III, and HLTT as independent risk factors for local recurrence-free survival. CTL is not a prognostic risk factor for low rectal cancer. In posterior wall tumors, THLE significantly reduces the local recurrence rate for low rectal cancer.

Systematic review and meta-analysis comparing robotic total mesorectal excision versus transanal total mesorectal excision for rectal cancer

Introduction: The best approach for total mesorectal excision (TME) remains controversial. Two recently described approaches are robotic TME (RTME) and transanal TME (TaTME). This systematic review and meta-analysis aimed to compare the outcomes between robotic surgery and TaTME in patients undergoing rectal cancer resection. Methods: We structured this systematic review and meta-analysis according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines 2020 and Assessing the Methodological Quality of Systematic Reviews (AMSTAR) guidelines. An electronic search of relevant literature was conducted on 20 May 2023. The protocol was registered in PROSPERO (CRD42023435259). Results: Eleven eligible nonrandomised studies were included in this study. The study included 2796 patients (RTME = 1800; TaTME = 996). The RTME group had a higher rate of complete TME. However, no significant differences were observed in mortality, morbidity, severe complications, operative time, conversion rate, anastomotic leak, hospital stay, CRM-positive resection margin, distal resection margin, number of harvested lymph nodes, abdominoperineal resection (APR) rate, or local recurrence between the RTME and TaTME groups. Conclusion: The RTME technique may ensure a higher rate of complete TME than TaTME. However, no significant differences were observed in most postoperative outcomes and oncological safety between the RTME and TaTME groups. Evidence does not conclusively favor one technique over the other, highlighting the need for additional randomized controlled trials to better define their roles in rectal cancer surgery.

EP16 - Local Excision of Rectal Cancer by Transanal Endoscopic Microsurgery (TEM) – Review of outcomes and completeness of surveillance

Abstract Aim To review outcomes and completeness of follow-up for patients undergoing TEM for rectal cancer. Method Retrospective review of outcomes of all TEM cancer operations performed by a single surgeon. Where completion surgery was not indicated, adherence to local surveillance protocol was assessed. Results 20 Patients underwent TEM for cancer from January 2014-March 2022. 55.0% (n=11) Had submucosal excision and 45.0% (n=9) full-thickness excision. 35.0% (n=7) Went on to have completion surgery, 40.0%(n=8) had surveillance only, 10.0% (n=2) received adjuvant treatment then underwent surveillance and 15.0% (n=3) declined further treatment/follow-up or were unfit. Histology was T1 in 75.0%(n=15), T2 in 20.0% (n=4) and T3 in 5.0% (n=1). Of T1 cancers 40.0% (n=6) received completion surgery, 46.7% (n=7) surveillance only and 13.3% (n=2) declined further treatment or were too unwell. Of T2 cancers 25.0% (n=1) received completion surgery, 50.0% (n=2) were considered high risk for surgery and underwent adjuvant treatment then surveillance and 25.0% (n=1) surveillance only. The patient with T3 cancer declined anything further. Overall recurrence during TEM surveillance was 30.0% (n=3). For T1 and T2 recurrence was 14.3% (n=1) and 66.7% (n=2) respectively. Two patients underwent salvage surgery, and one underwent palliative chemotherapy. Of 10 patients in surveillance after TEM, 80.0% (n=8) have currently received up to date follow-up 20.0% (n=2) have not, due to patient choice. Conclusion All patients undergoing surveillance have been offered time appropriate follow-up tests. In this sample all patients received timely and appropriate treatment.

What To Do With Suspected Nodal Regrowth on Magnetic Resonance Imaging During Follow-up in an Organ Preservation Approach for Rectal Cancer?

BACKGROUND: For nodal regrowth in patients with rectal cancer following watch-and-wait standardized protocols on diagnostic procedures and subsequent treatment are lacking. OBJECTIVE: Evaluate the diagnosis and treatment of suspected nodal regrowth following an organ preservation approach. SETTINGS: Patients were included from national and institutional watch-and-wait -databases. DESIGN: Thirty-five rectal cancer patients with suspected nodal regrowth on magnetic resonance imaging were retrospectively identified during watch-and-wait follow-up. PATIENTS: Twenty-seven of 35 patients followed watch-and-wait after neoadjuvant (chemo)radiotherapy and 8/35 followed watch-and-wait schedule after local excision for early rectal cancer. MAIN OUTCOME MEASURES: Diagnostic procedures, treatment and histopathological outcome. RESULTS: Median follow-up was 34 months. Median time from end of (chemo)radiotherapy or local excision to first detection of suspected nodal regrowth on magnetic resonance imaging following watch-and-wait was 9 and 10 months. After first detection, 17 of 35 patients underwent immediate treatment without further diagnostics, of whom 7 also had luminal regrowth. In 18 of 35 patients, additional diagnostic procedures were performed. In 4 of 18 patients, positron emission tomography-computed tomography or endorectal ultrasound-guided biopsy was performed and treatment was initiated based on increased nodal regrowth suspicion. In 14 of 18 patients, MRI was repeated after 8-12 weeks: growth of suspected lymph nodes was the most decisive factor to proceed to treatment. In 8 patients, repeated magnetic resonance imaging was combined with positron emission tomography-computed tomography and/or endorectal ultrasound-guided biopsy: in half of them it contributed to treatment initiation. In total, 34/35 patients were treated: 9 received (re-)irradiation and 33 underwent total mesorectal excision. In 27 of 33 patients, nodal regrowth was pathologically confirmed in the total mesorectal excision-resection specimen; 5 of 6 patients without nodal involvement had pathologically confirmed luminal regrowth. LIMITATIONS: Highly selected study population. CONCLUSIONS: During watch-and-wait follow-up of patients with rectal cancer in an organ preservation strategy, magnetic resonance imaging plays an important role in diagnosis of nodal regrowth. Repeated magnetic resonance imaging after an interval can be helpful in making treatment decisions, and the role of positron emission tomography-computed tomography and endorectal ultrasound-guided biopsy appears limited. See Video Abstract.

Survival after surgery beyond total mesorectal excision for primary locally advanced rectal cancer, a population-based study

BackgroundThe aim of this study was to compare relative survival in non-metastatic rectal cancer clinically staged as T3-T4 requiring beyond total mesorectal excision (TME) to that after standard TME. MethodsThis population-based study included all patients operated with anterior resection, abdominoperineal excision or Hartmann's procedure for non-metastatic rectal cancer clinically staged as T3-T4 in Sweden between 2009 and 2018. Relative survival was analysed in relation to surgery beyond TME (bTME), which was subcategorized as bTME- and bTME + to account for extent of resection. In all survival analyses, follow-up started at 90 days after surgery. Based on a causal model defined a priori excess mortality rate ratios (EMRR) were estimated using Poisson regression. ResultsOf 8272 included patients 1220 (14.7 %) were operated bTME. In a model adjusted for age and sex bTME was associated with higher excess mortality compared to standard TME (EMRR: 1.76, 95%CI:1.52–2.04). This association persisted after additional adjustment for tumour characteristics, neoadjuvant therapy and hospital volume (EMRR: 1.32, 95%CI:1.11–1.56) and was mainly attributable to restricted relative survival after bTME- (EMRR: 1.42, 95%CI:1.18–1.72) as EMRR after bTME+ was 1.07 (95%CI:0.80–1.44). ConclusionThis national population-based study showed inferior relative survival after bTME compared to standard TME in non-metastasized rectal cancer cT3-cT4. Unexpectedly this difference was mainly seen after bTME of limited extent.

565P Neoadjuvant chemotherapy, excision, and observation for early rectal cancer: The phase II NEO trial (CCTG CO.28) results after minimum 3 years follow up

565P Neoadjuvant chemotherapy, excision, and observation for early rectal cancer: The phase II NEO trial (CCTG CO.28) results after minimum 3 years follow up

Initial case series experience with robotic-assisted transanal minimally invasive surgery performed with da Vinci single-port system for the excision of rectal cancer.

Transanal minimally invasive surgery (TAMIS) is widely used for rectal lesion excision. Robot-assisted TA TAMIS (R-TAMIS) may improve surgical ergonomics. The introduction of the da Vinci Single-Port (SP) robot, designed for endoluminal surgery, has brought new possibilities. Our primary objective herein was to assess the technical and oncological feasibility and efficacy of Single-port robotic TAMIS (SPR-TAMIS) in rectal cancer excision. The secondary objective was to analyze the perioperative outcomes. We included 14 consecutive patients with rectal cancer who underwent SPR-TAMIS between April 2021 and February 2023. Patient data, surgical details, and clinical outcome data were collected to assess the safety and feasibility of SPR-TAMIS. The median participant age was 72years, and full-thickness excision was performed without specimen fragmentation in all cases. The median tumor diameter was 2.7cm, positioned between 10cm proximally and 7cm distally from the anal verge. Negative margins were achieved in 93% of cases, with one case requiring further resection. The median operative time was 175min, and the median hospital stay was 5days. No intraoperative conversion from SPR-TAMIS to laparoscopic or conventional transanal excision was required. No mortalities or major postoperative complications occurred; however, one patient (7.1%) experienced minor morbidity manifesting as wound dehiscence (Clavien-Dindo grade I). No recurrence was observed during the 24-month follow-up. In our early experience, SPR-TAMIS is a safe and feasible surgery for selected early stage rectal cancers, offering enhanced visualization and stable maneuverability transanally. This platform may have potential advantages for the excision of larger or more proximal lesions.

Prediction of postoperative complications following transanal total mesorectal excision in middle and low rectal cancer: development and internal validation of a clinical prediction model

PurposeThe objective of this study is to develop a nomogram for the personalized prediction of postoperative complication risks in patients with middle and low rectal cancer who are undergoing transanal total mesorectal excision (taTME). This tool aims to assist clinicians in early identification of high-risk patients and in addressing preoperative risk factors to enhance surgical safety.MethodsIn this case–control study, 207 patients diagnosed with middle and low rectal cancer and undergoing taTME between February 2018 and November 2023 at The First Affiliated Hospital of Xiamen University were included. Independent risk factors for postoperative complications were analyzed using the Least Absolute Shrinkage and Selection Operator (LASSO) regression and multifactorial logistic regression models. A predictive nomogram was constructed using R Studio.ResultsAmong the 207 patients, 57 (27.5%) experienced postoperative complications. The LASSO and multifactorial logistic regression analyses identified operation time (OR = 1.010, P = 0.007), smoking history (OR = 9.693, P < 0.001), anastomotic technique (OR = 0.260, P = 0.004), and ASA score (OR = 9.077, P = 0.051) as significant predictors. These factors were integrated into the nomogram. The model's accuracy was validated through receiver operating characteristic curves, calibration curves, consistency indices, and decision curve analysis.ConclusionThe developed nomogram, incorporating operation time, smoking history, anastomotic technique, and ASA score, effectively forecasts postoperative complication risks in taTME procedures. It is a valuable tool for clinicians to identify patients at heightened risk and initiate timely interventions, ultimately improving patient outcomes.

Essential knowledge and technical tips for total mesorectal excision and related procedures for rectal cancer.

Total mesorectal excision (TME) has greatly improved rectal cancer surgery outcomes by reducing local recurrence and enhancing patient survival. This review outlines essential knowledge and techniques for performing TME. TME emphasizes the complete resection of the mesorectum along embryologic planes to minimize recurrence. Key anatomical insights include understanding the rectal proper fascia, Denonvilliers fascia, rectosacral fascia, and the pelvic autonomic nerves. Technical tips cover a step-by-step approach to pelvic dissection, the Gate approach, and tailored excision of Denonvilliers fascia, focusing on preserving pelvic autonomic nerves and ensuring negative circumferential resection margins. In Korea, TME has led to significant improvements in local recurrence rates and survival with well-adopted multidisciplinary approaches. Surgical techniques of TME have been optimized and standardized over several decades in Korea, and minimally invasive surgery for TME has been rapidly and successfully adopted. The review emphasizes the need for continuous research on tumor biology and precise surgical techniques to further improve rectal cancer management. The ultimate goal of TME is to achieve curative resection and function preservation, thereby enhancing the patient's quality of life. Accurate TME, multidisciplinary-based neoadjuvant therapy, refined sphincter-preserving techniques, and ongoing tumor research are essential for optimal treatment outcomes.

Unraveling the role of computed tomography derived body composition metrics on anastomotic leakages rates in rectal cancer surgery: A protocol for a systematic review and meta-analysis.

Anastomotic leakage is a major concern following total mesorectal excision for rectal cancer, affecting oncological outcomes, morbidity an treatment costs. Body composition has been suggested to influence anastomotic leakage rates. However, literature on how body composition impact anastomotic leakage rates is conflicting. This systematic review aims to evaluate the role of computed tomography derived body composition metrics on anastomotic leakage rates in rectal cancer patients. Databases PubMed/MEDLINE, Cochrane Library, web of science, and EMBASE, will be systematically searched for papers from January 2010 onwards. Study selection, data collection and quality assessment will be independently performed by three research fellows. Outcomes described in three or more studies will be included in the meta-analysis. The Q-test and I2 statistic will be used to assess statistical heterogeneity between studies. Publication bias will be examined by visual inspection of funnel plots and quantified by Egger's test. Sensitivity analyses will be conducted to examine the robustness of the meta-analysis. Reporting of the findings will be in line with the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. This systematic review will synthesize the current evidence and will identify knowledge gaps. Results of the systematic review will aid health care professional in pre-operative decision making and will be distributed through a peer-reviewed publication and presentation of results at international meetings. PROSPERO protocol number: CRD42023471537.

Comparing total mesorectal excision with partial mesorectal excision for proximal rectal cancer: evaluating postoperative and long-term oncological outcomes.

The treatment role of Total Mesorectal Excision (TME) in proximal rectal cancers (PRC) is still debated. Partial Mesorectal Excision (PME) can reduce morbidity in PRC patients. The purpose of this study was to compare short-term clinical and long-term oncological outcomes between the two groups. A total of 157 PRC patients were enrolled in this study (114 performed with PME and 43 with TME). The two groups were compared in terms of perioperative and long-term oncological outcomes. The overall postoperative complications rate was higher in TME group (18.4% vs. 32.5%, p < 0.05). The incidence of diverting ileostomy was also significantly higher in TME group (86.0% vs. 2.6%, p < 0.001). Overall survival rates for 3, 5, and 7years in PME and TME group accordingly were: 94.6%, 89.3%, 81.5% and 93.2%, 87.6%, 78.4% (p = 0.324). Disease-free survival rates for 3, 5, and 7years in PME and TME group were: 90.2%, 84.5%, 78.6% and 88.7%, 81.2%, 75.3% (p = 0.297), respectively. Local recurrence rates for 3, 5, and 7years in PME and TME group were: 2.6%, 6.1%, 8.8% and 4.6%, 9.3%, 11.2% (p = 0.061), respectively. PME is feasible and can be safely performed in PRC patients with favorable oncological outcomes. TME is associated with increasing risk of surgical complications and requires a two-step surgery for stoma takedown.

Risk Factors for Rectal Cancer Recurrence after Local Excision of T1 Lesions from a Decade-Long Multicenter Retrospective Study.

Background: Local surgical excision of T1 rectal adenocarcinoma is a well-established approach. Yet, there are still open questions regarding the recurrence rates and its risk factors. Methods: A retrospective multicenter study including all patients who underwent local excision of early rectal cancer with an open or MIS approach and had a T1 lesion from 2010 to 2020 in six academic centers. Data included demographics, preoperative studies, surgical findings, postoperative outcomes, and local and systemic recurrence. A univariable and multivariable logistic regression analysis was performed to identify risk factors for recurrence. Results: Overall, 274 patients underwent local excision of rectal lesions. Of them, 97 (35.4%) patients with a T1 lesion were included in the cohort. The mean age was 69 ± 10.5 years, and 42 (43.3%) were female. The mean distance of the lesions from the anal verge was 7.8 ± 3.2 cm, and the average tumor size was 2.7 ± 1.6 cm. Eighty-two patients (85%) had a full-thickness resection. Eight patients (8%) had postoperative complications. Kikuchi classification of submucosal (SM) involvement was reported in 29 (30%) patients. Twelve patients had SM1, two SM2, and fifteen SM3. Following pathology, 24 patients (24.7%) returned for additional surgery or treatment. The overall recurrence rate was 14.4% (14 patients), with 11 patients having a local recurrence and 6 having a systemic metastatic recurrence, 3 of which had both. The mean time for recurrence was 2.78 ± 2.8 years and the overall mortality rate was 11%. On univariable and multivariable logistic regression analysis of recurrence vs. non-recurrence groups, the strongest and most significant association and possible risk factors for recurrence were larger lesions (4.3 vs. 2.5 cm, p < 0.001) with an OR of 6.67 (CI-1.82-24.36), especially for tumors larger than 3.5 cm, mucinous histology (14.3% vs. 1.2%, p = 0.004, OR of 14.02, CI-1.13-173.85), and involved margins (41.7% vs. 16.2%, p = 0.003, OR of 9.59, CI-2.14-43.07). The open transanal excision (TAE) approach was also identified as a possible significant risk factor in univariant analysis, while SM3 level penetration showed only a trend. Conclusion: Surgical local excision of T1 rectal malignancy is a safe and viable option. Still, one in four patients received additional treatment. There is an almost 15% chance for recurrence, especially in large tumors, mucinous histology, or involved margin cases. These high-risk patients might warrant additional intervention and stricter surveillance protocols.

Postoperative urinary retention following transanal versus laparoscopic total mesorectal excision for rectal cancer: A randomized trial report from an experienced center

BackgroundTransanal total mesorectal excision has emerged as a potential solution to certain limitations associated with laparoscopic total mesorectal excision in rectal cancer patients. Differences in surgical approaches have raised questions regarding their impact on the risk of postoperative urinary retention, with limited data available from large scale randomized clinical study. ObjectiveTo report incidence of postoperative urinary retention and evaluate the associated risk factors for transanal total mesorectal excision. DesignIn this randomized controlled trial (ClinicalTrials. gov NCT06147492), we retrieved 524 patients who received total mesorectal excision (TME) for stage I–III rectal cancer between June 2019 and April 2022, and the patients were randomly assigned in a 1:1 ratio to undergo either taTME or laTME. PatientsWe enrolled 524 patients who underwent total mesorectal excision for stage I–III rectal cancer between June 2019 and April 2022. Main outcome measuresThe incidence of postoperative urinary retention. ResultsAmong the 524 enrolled patients, 261 were randomized to the laTME group, while 263 were were randomized the taTME group. The median age was 58 years, and 340 participants (64.8 %) were male. Notably, 37 individuals (7.0 %) experienced postoperative urinary retention during the follow-up period, with no significant disparity was observed between the taTME and laTME groups (6.8 % and 7.2 %, respectively, P = 0.98). Risk factors associated with PUR in patients following taTME encompassed early removal of the urinary catheter (P = 0.006), net infusion rate >4.09 ml kg−1.h−1 (P = 0.006), and an age surpassing 65 years (P = 0.0321). LimitationsThe generalizability of the findings outside specialist rectal cancer centers may be limited. ConclusionsTransanal total mesorectal excision was not found to heighten the risk of postoperative urinary retention. Nonetheless, it is advisable removing postoperative catheter beyond the initial day and exercising caution in the administration of intravenous fluids in clinical practice for taTME procedures.

Diverting Ileostomy vs Colostomy in Colorectal Surgery: A Single Institution Outcomes Comparison

Introduction: Diverting stomas often accompany total mesorectal excision (TME) for rectal cancer and for patients having anterior resection for complicated diverticulitis when the risk for anastomotic leak is increased. Diverting stomas are also an option to urgently relieve colonic obstruction from neoplasia or diverticular disease. The diverting stoma choice is often a loop ileostomy that increases the risk for acute kidney injury (AKI) or a diverting loop transverse that may be greater risk for stoma prolapse. The objective of this study is to determine if ileostomy or colostomy is a better diversion option when considering complications and outcomes on a dedicated enhanced recovery colorectal surgery service. Methods: This is a single institution analysis of a prospectively maintained institutional colorectal surgery database between 01/01/2018 and 09/30/2023. The primary outcome was the postoperative 30-day complication rate after diverting ileostomy or colostomy. Secondary outcomes were AKI, stoma prolapse, other individual complications, and readmissions. Strength of association was estimated with multivariable logistic regression models adjusted for patient characteristics. Results: 347 patients met inclusion criteria – 81 with a diverting colostomy and 266 with a diverting ileostomy. Patients undergoing diverting colostomy were older than those undergoing diverting ileostomy (64.2 +/- 14.5 years versus 59.1 +/- 13.9 years, p =0.006), had lower BMI (26.32 +/- 5.95 kg versus 27.66 +/- 6.39 kg, p = 0.028), and had a higher incidence of diabetes (18.5% versus 10.2%, p = 0.043). The overall complication rate was significantly higher for ileostomies (29.6% vs 59.8%, p&lt;0.001 ) as was acute kidney injury (1.2% vs 16.2%, p&lt;0.001), ileus (13.6% vs 35.7%, p&lt;0.001), SSI III (2.5% vs 9.8%, p=0.035), ED visits (9.9% vs 24.4%, p=0.005), and readmissions (6.2% vs 18%, p=0.009). Stoma prolapse within 6 months (4.9% vs 0.4%, p=0.003), reoperation (7.4% vs 0.8%, p&lt;0.001), and postoperative death (4.9% vs 0%, p&lt;0.001) were significantly higher for the colostomy group. Conclusions: Colostomies are associated with fewer complications and may be a better option for fecal diversion when there are no other factors that preclude this choice.

IRIS U kit usefulness in transanal total mesorectal excision for lower rectal cancer to avoid urethral injury

Transanal total mesorectal excision (taTME) has improved the laparoscopic dissection for rectal cancer in the narrow pelvis. Although taTME has more clinical benefits than laparoscopic surgery, such as a better view of the distal rectum and direct determination of distal resection margin, an intraoperative urethral injury could occur in excision ta-TME. This study aimed to determine the feasibility and efficacy of the ta-TME with IRIS U kit surgery. This retrospective study enrolled 10 rectal cancer patients who underwent a taTME with an IRIS U kit. The study endpoints were the safety of access (intra- or postoperative morbidity). The detectability of the IRIS U kit catheter was investigated by using a laparoscope-ICG fluorescence camera system. Their mean age was 71.4±6.4 (58–78) years; 80 were men, and 2 were women. The mean operative time was 534.6 ± 94.5 min. The coloanal anastomosis was performed in 80%, and 20% underwent abdominal peritoneal resection. Two patients encountered postoperative complications graded as Clavien–Dindo grade 2. The transanal approach with IRIS U kit assistance is feasible, safe for patients with lower rectal cancer, and may prevent intraoperative urethral injury.

Association of Surgical Approaches and Outcomes in Total Mesorectal Excision and Margin Status for Rectal Cancer

IntroductionDespite being a key metric with a significant correlation with the outcomes of patients with rectal cancer, the optimal surgical approach for total mesorectal excision (TME) has not yet been identified. The aim of this study was to assess the association of the surgical approach on the quality of TME and surgical margins and to characterize the surgical and long-term oncologic outcomes in patients undergoing robotic, laparoscopic, and open TME for rectal cancer. MethodsPatients with primary, nonmetastatic rectal adenocarcinoma who underwent either lower anterior resection or abdominoperineal resection via robotic (Rob), laparoscopic (Lap), or open approaches were selected from the US Rectal Cancer Consortium database (2007-2017). Quasi-Poisson regression analysis with backward selection was used to investigate the relationship between the surgical approach and outcomes of interest. ResultsAmong the 664 patients included in the study, the distribution of surgical approaches was as follows: 351 (52.9%) underwent TME via the open approach, 159 (23.9%) via the robotic approach, and 154 (23.2%) via the laparoscopic approach. There were no significant differences in baseline demographics among the three cohorts. The laparoscopic cohort had fewer patients with low rectal cancer (<6 cm from the anal verge) than the robotic and open cohorts (Lap 28.6% versus Rob 59.1% versus Open 45.6%, P = 0.015). Patients who underwent Rob and Lap TME had lower intraoperative blood loss compared with the Open approach (Rob 200 mL [Q1, Q3: 100.0, 300.0] versus Lap 150 mL [Q1, Q3: 75.0, 250.0] versus Open 300 mL [Q1, Q3: 150.0, 600.0], P < 0.001). There was no difference in the operative time (Rob 243 min [Q1, Q3: 203.8, 300.2] versus Lap 241 min [Q1, Q3: 186, 336] versus Open 226 min [Q1, Q3: 178, 315.8], P = 0.309) between the three approaches. Postoperative length of stay was shorter with robotic and laparoscopic approach compared to open approach (Rob 5.0 d [Q1, Q3: 4, 8.2] versus Lap 5 d [Q1, Q3: 4, 8] versus Open 7.0 d [Q1, Q3: 5, 9], P < 0.001). There was no statistically significant difference in the quality of TME between the robotic, laparoscopic, and open approaches (79.2%, 64.9%, and 64.7%, respectively; P = 0.46). The margin positivity rate, a composite of circumferential margin and distal margin, was higher with the robotic and open approaches than with the laparoscopic approach (Rob 8.2% versus Open 6.6% versus Lap 1.9%, P = 0.17), Rob versus Lap (odds ratio 0.21; 95% confidence interval 0.05, 0.83) and Rob versus Open (odds ratio 0.5; 95% confidence interval 0.22, 1.12). There was no difference in long-term survival, including overall survival and recurrence-free survival, between patients who underwent robotic, laparoscopic, or open TME (Figure 1). ConclusionsIn patients undergoing surgery with curative intent for rectal cancer, we did not observe a difference in the quality of TME between the robotic, laparoscopic, or open approaches. Robotic and open TME compared to laparoscopic TME were associated with higher margin positivity rates in our study. This was likely due to the higher percentage of low rectal cancers in the robotic and open cohorts. We also reported no significant differences in overall survival and recurrence-free survival between the aforementioned surgical techniques.

Functional Outcomes After Transanal Total Mesorectal Excision (taTME) for Rectal Cancer: Results From the Phase II North American Multicenter Prospective Observational Trial.

To investigate fecal incontinence and defecatory, urinary, and sexual functional outcomes after transanal total mesorectal excision (taTME). Proctectomy for rectal cancer may result in alterations in defecatory, urinary, and sexual function that persist beyond 12 months. The recent multicenter phase II taTME trial demonstrated the safety of taTME in patients with stage I to III tumors. Prospectively registered self-reported questionnaires were collected from 100 taTME patients. Fecal continence [Fecal Incontinence Quality of Life (FIQL), Wexner], defecatory function [Colorectal Functional Outcome (COREFO)], urinary function (International Prostate Symptom Score), and sexual function (Female Sexual Function Index-female, International Index of Erectile Function-male) were assessed preoperatively (PQ), 3 to 4 months postileostomy closure (FQ1), and 12 to 18 months post-taTME [postoperative questionnaire 2 (FQ2)]. Among 83 patients who responded at all 3 time points, FIQL, Wexner, and COREFO significantly worsened postileostomy closure. Between FQ1 and FQ2, FIQL lifestyle and coping, Wexner, and COREFO incontinence, social impact, frequency, and need for medication significantly improved, while FIQL depression and embarrassment did not change. International Prostate Symptom Score did not change relative to preoperative scores. For females, Female Sexual Function Index declined for desire, orgasm, and satisfaction between PQ and FQ1, and did not improve between FQ1 and FQ2. In males, International Index of Erectile Function declined with no change between FQ1 and FQ2. Although taTME resulted in initial decline in defecatory function and fecal continence, most functional domains improved by 12 months after ileostomy closure, without returning to preoperative status. Urinary function was preserved while sexual function declined without improvement by 18 months post-taTME. Our results address patient expectations and inform shared decision-making regarding taTME.