Hartmann Procedure Research Articles

COLORECTAL CANCER IN YOUNG ADULTS: A CASE SERIES

Introduction & Background: Colorectal cancer (CRC) is a frequent tumor in adults, it rarely occurs before the age of 25 years, with an annual incidence of only 1-2 cases per 10,00,000 people, accounting for only about 80 cases per year worldwide. Overall incidence of CRC involving hepatic exure is 2%, ascending colon is 5%, sigmoid colon is 21% which is very rare in young age group. Herein we report a 3 rare cases of CRC in young adults less than 25 years of age involving hepatic exure, ascending colon and sigmoid colon respectively. Case Description: Case 1: A 20 year-old male presented with complaints of abdominal distension and constipation for 1 week and loss of weight for 1 month. Patient had no comorbities and no family history of malignancy. CECT done showed an asymmetric wall thickening involving proximal transverse colon with signicant luminal narrowing. He underwent emergency laparotomy and intra operatively patient had a growth at hepatic exure of colon with dilated ascending colon, caecum and distal ileum and multiple enlarged mesenteric lymph nodes. He was proceeded with right hemicolectomy with ileo transverse anastomosis. Post operative histopathology revealed mucinous adenocarcinoma involving hepatic exure. Case 2: A 25 year-old female was hospitalized due to com plaint s of abdominal pain for 3 months, lower abdomen mass for 1 month and melena for the past 15 days and loss of weight and appetite. Patient had no comorbities and no family history of malignancy. CECT done showed a suspicious wall thickening involving ascending colon. The patient was taken up for laparotomy and per operative ndings showed a ulceroproliferative growth involving ascending colon. Patient was proceeded with right hemicolectomy with ileo transverse anastomosis. Post operative histopathology revealed mucinous adenocarcinoma involving ascending colon.Case 3: A 22 year-old male was admitted for comp laint s of lower abdominal pain for 4 months, bleeding per rectum on and off for 1 month and abdomen distension and constipation for 5 days and loss of weight and appetite. Patient had no comorbities and no family history of malignancy. CECT done showed a circumferential wall thickening involving sigmoid colon. Hence the patient was proceeded for emergency laparotomy and per operative ndings showed a stenosing growth involving sigmoid colon. Patient was proceeded with Hartmann's procedure. Post operative histopathology revealed adenocarcinoma involving sigmoid colon. Conclusion: Within a young group, CRC is usually diagnosed later andpotentially associated with worst prognosis. Detecting CRC at an early, more treatable stage is important for cure and survival. This report suggest a greater suspicion rate and early screening that necessary when evaluating young patients with common symptoms.

Emergency Surgery for Diverticulitis: Relationship of Outcomes to Patient Age and Surgical Procedure.

To compare outcomes in emergent surgical treatment of acute diverticulitis in the older population. Retrospective multi-institute database cohort analysis. American College of Surgeons National Surgical Quality Improvement Project (ACS NSQIP) and NSQIP Colectomy Targeted Database. The American College of Surgeons National Surgical Quality Improvement Project Colectomy Targeted Database was merged with the main participate use file to identify adult patients undergoing emergent Hartmann procedure or primary anastomosis with diverting loop ileostomy for acute diverticulitis. Patients were subdivided into age cohorts (<65years, 65-79years, ≥80years) and primary postoperative outcomes including mortality, morbidity, and readmission were compared using multivariate regression. A total of 6091 patients were identified. On multivariate analysis, 30-day mortality was higher in patients undergoing a Hartmann procedure aged 65-79years [odds ratio (OR) 2.39, P < .001] and ≥80years (OR 6.28, P < .001) compared to patients aged <65years. In patients undergoing a primary anastomosis with diverting loop ileostomy, 30-day morbidity was lower only in the cohort aged ≥80years (OR 2.63, P= .04). Readmission rates were similar across age groups within each procedure cohort. Comparing the 2 procedures, readmission rates in patients aged 65-79years who underwent a Hartmann procedure were lower than those that underwent a primary anastomosis with diverting loop ileostomy (OR 2.43, P= .001). In patients aged ≥80years, readmission rates were lower in patients who underwent a primary anastomosis with diverting loop ileostomy (OR 0.12, P= .04). Thirty-day mortality was also lower in patients aged ≥80years if they underwent a primary anastomosis with diverting loop ileostomy (OR 0.15, P= .03) but similar for patients aged 65-79years (OR 0.81, P= .70). In patients undergoing a Hartmann procedure emergently for diverticulitis, mortality is higher in older patients. Patients aged ≥ 80years had increased mortality if they underwent a Hartmann procedure compared to a primary anastomosis with diverting ileostomy; however, readmission rates vary with procedure performed. Careful consideration of age should be taken into account when operating emergently for diverticulitis.

CURRENT MODE OF TREATMENT IN ACUTE DIVERTICULITIS

Purpose: The purpose of our study is to determine whether patients with acute uncomplicated diverticulitis with micro-perforation should really be treated as patients without perforation and to identify differences in recurrence rates, complications and mode of treatment Material and Methods: A total of 47 patients with a diagnosis of acute diverticulitis were admitted to the hospital for a three-year period from 01.01.2018 to 01.01.2020 in the Department of General, Visceral and Emergency Surgery at UMHATEM "Pirogov". Of those hospitalized, women were 21 (44.68%), men 26 (55.32%). The age in this retrospective analysis varied from 27 to 81 years (average 51.3 years). Results: All patients had leukocytosis, abdominal pain, and tenderness. From the group of 47 patients hospitalized with acute diverticulitis, twenty-five (53.19%) were diagnosed with micro-perforation by pneumoperitoneum data from X-ray and CT or free intraperitoneal fluid from ultrasound. The other three (6.38%) were identified intraoperatively (by laparoscopy or laparotomy) based on an indication of peritoneal irritation. The remaining 19 (40.43%) with mild symptoms for conservative management (38.89%) - through physical examination, laboratory data and imaging diagnostic methods (X-ray, ultrasound and CT). Of the 28 operated, 13 patients had laparoscopy performed lavage and drainage, with the remaining 15 (with laparotomy) - had Hartmann's procedure. Conclusion: Acute diverticulitis with micro-perforation showed no significant differences in the complications and course of antibiotic therapy compared to the group of acute diverticulitis without micro-perforation. Neither group required surgery after one-month discharge. Accordingly, to these outcomes, the mode of treatment should be identical.

Labor Market Attachment 2 Years After Colorectal Cancer Surgery: A Population-based Study.

To investigate the association between clinical/sociodemographic factors and labor market attachment, and to estimate employment probability 2 years after colorectal cancer (CRC) surgery. A rising prevalence of younger CRC survivors commands a stronger focus on labor market attachment. The association between clinical factors like type of surgery and CRC survivors' labor market attachment remains poorly investigated. National registries provided information on employment status and clinical/sociodemographic variables for all 20- to 60-year-old CRC patients without previous cancer diagnosed in Denmark from 2001 to 2014, undergoing surgery and being attached to the labor market. Associations between clinical/sociodemographic factors and labor market attachment were investigated in multiple logistic regression analyses. A total of 5755 CRC patients were included. Two years after surgery, 59.7% were working. Factors significantly associated with a higher probability of working were being in the 46 to 50 years age group, male gender, higher educational level, no comorbidity, working at the time of diagnosis, lower Union for International Cancer Control stage, and undergoing surgery in the most recent of four time-periods. Two years after undergoing surgery, the probability of working was significantly higher for left-sided than for right-sided colon resections, higher for low anterior resection (LAR)/high tumor than for LAR/low tumor, and higher for abdominoperineal resection than for Hartmann's procedure. Of the 4798 (86.8%) patients alive 2 years after surgery, 68.8% were working, 7.8% had retired, whereas 23.4% were on temporary benefits, sick leave, or disability pension. Clinical/sociodemographic factors were associated with the probability of working 2 years after surgery. This knowledge can be used to inform patients and target interventions towards patients with low post-CRC probability of working.

Delayed pull-through coloanal anastomosis without temporary stoma: an alternative to the standard manual side-to-end coloanal anastomosis with temporary stoma? A comparative study in 223 patients with low rectal cancer.

After total mesorectal excision (TME) for low rectal cancer, current guideline recommendations for sphincter-saving surgery are to perform a side-to-end manual coloanal anastomosis (CAA) (or with J-pouch) with a temporary stoma. Our study aimed to evaluate if delayed pull-through coloanal anastomosis (DCAA) without a temporary stoma could represent a safe alternative in low rectal cancer. From 2003 to 2020, 223 consecutive patients with low rectal cancer undergoing TME were compared: CAA and diverting stoma (n=190) versus DCAA without stoma (n=33). Overall 3-month and severe (Dindo ≥ IIIb) morbidity rates were similar in CAA versus DCAA groups: 34% (65/190) vs. 36% (12/33) and 2.6% (5/190) vs. 3% (1/33), respectively. In the DCAA group, only one patient (3%) underwent reoperation (Hartmann's procedure) at day 3 due to colon necrosis. The anastomotic leakage rate (both clinical and radiological) was significantly higher after CAA than DCAA: 28% (53/190) vs. 3% (1/33; p=0.00138). Failure of the procedure (with return to stoma) was observed in 8% (15/190) vs. 6% (2/33) of patients after CAA and DCAA respectively (not significant). Our comparative study suggested that in patients with low rectal cancer, DCAA without a temporary stoma could represent an interesting alternative to the actual recommended CAA with a temporary ileostomy. DCAA could offer two major advantages over CAA: a significantly lower rate of anastomotic leakage and absence of a temporary stoma and its potential complications (rehospitalization, dehydration, wound hernia after stoma closure).

Small Bowel Evisceration Through a Perforated Stercoral Ulcer.

Stercoral ulcers are localized areas of loss of colonic mucosal integrity. They result from pressure necrosis of the colonic mucosa, secondary to chronic constipation and fecal inspissation. These ulcers are rare and, are associated with serious complications, including bleeding and perforation. We present the case of a 50-year-old woman who presented with small bowel evisceration through the anal canal secondary to extraperitoneal perforation of the rectum. The patient underwent emergent exploratory laparotomy with reduction of the bowel, followed by second look laparotomy in 24 hours. A full thickness defect in the rectum was identified and Hartmann's procedure was performed. The patient's postoperative course was uneventful. Extraperitoneal perforation and evisceration of bowel is a rare clinical entity. These cases are diagnosed early due to the obvious clinical presentation and however may be misdiagnosed as prolapse. They necessitate urgent and careful surgical planning, to ensure preservation of bowel and complete recovery.

Clinical Treatment for Periostomy Bullous Pemphigoid with Generalized Progression

Background: We presented an 84y/o male patient with S-colon carcinoma obstruction, he received emergent Hartmann procedure. Pathology revealed T4aN1bM0. Postoperative outpatient follows up is smooth until peri-ostomy skin lesion happened 17 months later after operation. The patient had multiple bullous erythematous painful sensation around end colostomy, and he visited other physician taken NSAID medication or anti-histamine without relief. The bullous skin lesion progressed to whole abdomen, face and upper arm.

Is length of the rectal stump predictive for postoperative outcome in Hartmann's reversal surgery? A multicenter experience of 105 consecutive cases.

Although Hartmann's procedure is commonly performed, subsequent reversal is less frequent. The most common reasons for reversal surgery are advanced age, comorbidities, and perceived surgical difficulties. The main objective of this study was to investigate if the length of the rectal stump influences the outcome of Hartmann's reversal surgery. We conducted a retrospective case study analyzing data from 105 patients who underwent Hartmann's reversal procedure between 2007 and 2019 in two centers. We evaluated patient demographics, length of rectal stump, intraoperative surgical details, short-term and long-term outcomes. From 2007 to 2019, 105 patients underwent Hartmann's reversal surgery. Short-term morbidity rate was 58% (61 patients), including 16% (17 patients) with severe postoperative complication (Clavien-Dindo ≥ 3). Anastomotic leakage rate was 2.9% (3 patients). Long-term complications were present in 41% (43 patients) of which abdominal wall defect was the most frequent complication. The mean length of the rectal stump was 15cm. In almost 1 out of 5 patients (17%) the rectal stump was shorter than 10cm. The three anastomotic leakages appeared in the long rectal stump group (3.6% vs. 0%, p = 0.273). The complication rate for patients with a short rectal stump was similar to those with a longer rectal stump (50% vs. 63%, p = 0.275). Smoking, high ASA score, obesity, and advanced age did not influence the outcomes of the reversal procedure either. Length of the rectal stump is not a predictive factor for postoperative complications after Hartmann's reversal surgery.

Essential updates 2020/2021: Colorectal diseases (benign)-Current topics in the surgical and medical treatment of benign colorectal diseases.

The development of new drugs for inflammatory bowel disease (IBD) is remarkable, and treatment strategies using multiple agents and various techniques are required; however, the treatment strategy is likely to be complex. Therefore, appropriate evaluation of traditional surgical treatment strategies and accurate knowledge of the efficacy and limitations of novel treatments are required. Total infectious complications were found to be associated with the use of corticosteroids and anti‐tumor necrosis factor‐α agents, but not with immunomodulators, anti‐integrin agents, and 5‐aminosalicylic acid. Regarding surgical procedures for IBD, conceived anastomosis methods, including Kono‐S for Crohn's disease stenosis, are associated with better outcomes than conventional techniques. Autologous cell transplantation for Crohn's fistulae has been shown to have a favorable outcome. Diverticulitis is increasing and will be treated more frequently in the future. Risk factors for the incidence of diverticulitis and differences in pathogenesis according to right or left side diverticulitis have been reported. Antibiotic therapy may be omitted for uncomplicated diverticulitis. Moreover, regarding surgical procedures, both bowel resection and anastomosis are associated with favorable short‐term outcomes, higher stoma closure rate, and superior medical economy compared to Hartmann's procedure. Risk factors for recurrence after diverticulitis surgery may provide better postoperative follow‐up. In this review, we explore the current topics of colorectal benign diseases, focusing on IBD and diverticulitis, based on clinical trials and meta‐analyses from 2020‐2021. This review consolidates the available knowledge and improves the quality of surgical procedures and perioperative management for IBD and diverticulitis.

Comparison of surgical outcomes for colostomy closure performed by acute care surgeons versus a dedicated colorectal surgery service

Despite colostomy closure being a common procedure, it remains highly morbid. Previous literature suggests that complication rates, including surgical site infections, intra-abdominal abscess, and anastomotic failures, reach as high as 50%. With the creation of a dedicated colorectal service, colostomy reversals have been largely migrated from the acute care surgery services. This study analyzes the differences in outcomes in colostomy closures performed between colorectal surgeons and acute care surgeons. We retrospectively analyzed our experience with 127 colostomy closures performed in our hospital system by acute care surgeons and colorectal surgeons from 2016 through 2020. Demographic data, operative data, and outcomes such as abscess formation, anastomotic leak, and readmission were analyzed. Multivariate regression analysis was performed for intraabdominal abscesses and anastomotic leaks. In total, 71 colostomy closures were performed by colorectal surgeons (56%) and 56 by acute care surgeons (43%). The majority of colostomy reversals were after Hartmann's procedure for perforated diverticulitis. No differences in demographics were identified, except for a shorter interval to closure in the acute care surgeons group (10.0 vs 7.2 months; P= .049). Two (3.6%) acute care surgeon patients required colorectal surgeon consultation during the definitive repair. Regression analysis identified body mass index (odds ratio 2.43; P= .001), male gender (odds ratio -2.39; P= .18), and colorectal surgeons (odds ratio -2.28; P= .025) as significant risk factors for anastomotic leak. Analysis of the current series identified female gender and increased body mass index as higher risk, while procedures performed by colorectal surgeons were at decreased risk for anastomotic leak. Our study identified colostomy reversals performed by a dedicated colorectal service decreased the rate of anastomotic leak.

Hartmann's procedure versus sigmoidectomy with primary anastomosis for perforated diverticulitis with purulent or fecal peritonitis: Three-year follow-up of a randomised controlled trial

BackgroundThe aim of the present study is to present the three years follow-up a randomised controlled trial that compared Hartmann's Procedure (HP) with sigmoidectomy with primary anastomosis (with or without defunctioning ileostomy) (PA) in a randomised design to determine the optimal treatment strategy for perforated diverticulitis with purulent or fecal peritonitis. MethodsData were prospectively gathered for the first 12 months after randomization and retrospectively collected up to 36 months. The primary long-term endpoint was stoma free rate 36 months after the index procedure. Secondary outcomes were patients with a stoma at 36 months, percentage of stoma reversals, related reinterventions, parastomal/incisional hernia rates, total in hospital days including all readmissions regardless their relation to the intervention, overall morbidity and mortality. ResultsThree years follow-up was completed in 119 of the originally 130 included patients, with 57 (48%) in the PA-group and 62 (52%) patients in the HP-group. 36 months stoma free rate was significantly better for patients undergoing PA compared with HP (PA 92% vs HP 81%, hazard ratio 2.326 [95% CI 1.538–3.517]; log-rank p < 0·0001). Stoma reversal rates did not significantly differ (PA 31/40(78%) versus HP 45/61(74%), p = 0.814). Overall cumulative morbidity (PA 21/57(36%) versus HP 30/62(48%), p = 0.266) and mortality (PA 6/57(11%) versus HP 7/62 (11%), p = 1.000) did not differ between groups. However, more parastomal hernias occurred in the HP-group (HP 10/62(16%) vs PA 1/57(2%), p = 0.009) and the mean total in hospital days after three years follow-up was significantly lower in the PA-group compared to the HP-group (PA 14 days (IQR 9.5–22.5) versus HP 17 days (IQR 12.5–27.5)), p = 0.025). ConclusionLong-term results showed that in haemodynamically stable, immunocompetent patients primary anastomosis is superior to Hartmann's procedure as treatment for perforated diverticulitis with respect to long-term stoma free rate, overall hospitalization and parastomal hernias.

Intraoperative adverse events as a risk factor for local recurrence of rectal cancer after resection surgery.

AimFailure to achieve a radical resection as well as intraoperative rectal perforation are important risk factors for local recurrence after rectal cancer surgery, but the importance of other intraoperative adverse events for the prognosis is unknown. The aim of this study was to assess the occurrence of intraoperative adverse events during rectal cancer surgery, and to determine whether these were associated with an increased risk of local recurrence.MethodsA retrospective population‐based cohort study was undertaken, including all patients in Region Västra Götaland, Sweden, who had undergone primary resection surgery for rectal cancer diagnosed between 2010 and 2014, registered in the Swedish Colorectal Cancer Registry. Data were retrieved from the registry and through review of the medical records.ResultsIn total, 1208 patients were included in the study of whom 78 (6%) developed local recurrence during the follow‐up period of at least 5 years. Intraoperative adverse events were common and occurred in 62/78 (79%) of patients with local recurrence compared to 604/1130 (53%) of patients without local recurrence. In multivariate analysis intraoperative adverse events were found to be an independent risk factor for local recurrence of rectal cancer, as were nonradical resection, a high pathological T stage, the presence of lymph node metastases, type of surgery and refraining from rectal washout during anterior resection and Hartmann's procedure.ConclusionsIntraoperative adverse events were found to be an independent risk factor for local recurrence of rectal cancer and could possibly be used together with other known risk factors to select patients for intensified postoperative surveillance.

Results of reconstructive surgery with formation of low colorectal anastomoses after previous Hartmann's procedure

To evaluate the efficacy and safety of original access to short rectal stump compared to traditional direct one. A retrospective-prospective cohort comparative study was conducted between 2012 and 2018. Inclusion criterion was previous Hartmann's procedure with formation of a short rectal stump. Short stump was determined by its length from anal-skin line to the cupola <7 cm. There were 93 patients who were divided into 2 groups: the main group - new approach (n=38), the control group - traditional direct approach (n=55). We analyzed surgery time, blood loss, intraoperative, early and late postoperative morbidity. Surgery time and blood loss were similar in both groups (299.9 vs. 288.3 min, p=0.82; 204.5 vs. 112.4 ml, p=0.94, respectively). Intraoperative complications occurred in 7 patients of the control group (0 vs. 12.7% (7/55), p=0.02). Incidence of early postoperative complications was similar (28.9% (11/38) vs. 25.5% (14/55), p=0.71). Adverse events Clavien-Dindo grade I and IIIa were more common in the main group, grade IIIb and IVa - in the control group. Incidence of delayed postoperative complications were similar (10.5% (4/38) vs. 7.3% (4/55), p=0.58). Colorectal anastomosis stricture prevailed in the control group, ureteral stricture - in the main group. Neurophysiological and complex urodynamic examinations revealed no between-group differences. The new method ensures access to the rectal stump and formation of colorectal anastomosis under direct visual control. Postoperative outcomes demonstrated safety and effectiveness of this technique.

S状結腸憩室穿孔に対する腹腔鏡下ハルトマン，ハルトマンリバーサル手術の経験

S状結腸憩室穿孔に対する腹腔鏡下ハルトマン，ハルトマンリバーサル手術の経験

Is it possible to restore digestive continuity in all patients after a Hartmann procedure? Multicentric retrospective experience in 360 consecutive patients

BackgroundHartmann's procedure (HP) remains controversial because more than half of patients will not recover, thus maintaining a permanent stoma. The aim of this retrospective multicentric study was to evaluate independent predictive factors for Hartmann's reversal (HR) after HP. MethodsAmong all consecutive patients who underwent HP between 2009 and 2016 in three hospitals, we included patients who survived for up to 6 months. The primary outcome was to identify independent predictive factors for HR, and the secondary outcomes were to assess both mortality and morbidity rates within 90 days. ResultsAmong the 283 patients alive at 6 months, 189 (67%) underwent HR. Indications for HP included complicated diverticulitis in 142 patients (54%), malignancy in 52 patients (13%), colonic ischemia in 16 patients (12%), and miscellaneous in 69 patients (21%). Independent risk factors for HR in multivariate analysis included an age under 70 years (OR 3.78 95% CI [1.88–7.60]), ASA score below 3 (OR 2.04 95% CI [1.0.6–3.92]) and absence of neurological comorbidity (OR 4.31 95% CI [0.1–0.47]). HR was associated with a 1.6% mortality rate within 90 days, and 23 (12%) developed severe postoperative complications (Dindo-Clavien ≥ III), requiring reintervention in 19 of them (82%). At the end of follow-up, 2.6% had a definitive stoma. ConclusionThis study suggests that HR is possible in 2/3 of patients, especially if they are young, without neurological comorbidities and with a low anesthetic risk. In selected patients, the morbidity and mortality rates are similar to elective colonic resection.

2021 Canadian Surgery Forum: Virtual, online Sept. 21-24, 2021.

# 01. Design and validation of a unique endoscopy simulator using a commercial video game {#article-title-2} Procedural simulation has been shown to enhance early endoscopy training. In this proof of concept study, we aimed to show that a first-person shooter (FPS) video game with a novel in-house

Adenocarcinoma occurring from a sigmoid colostomy 20years after Hartmann's procedure for rectal cancer: A case report.

Cancer arising from the stoma is relatively rare. There is no established surgical procedure for stomal cancer. Furthermore, when a subcutaneous lymphovascular invasion occurs, there is no consensus on whether lymph node dissection along the lymph flow is required. We diagnosed colorectal cancer 20years after radical resection of rectal cancer. We encountered a 70-year-old man who had undergone Hartmann's procedure for rectal cancer 20years before consultation. Colonoscopy revealed a 30-mm-sized sub-pedunculated polyp with a base at the stoma, and a well-differentiated adenocarcinoma was detected. Approximately 30mm of the intestinal tract, including the stoma and skin in contact with the tumor, was resected. Pathological examination revealed submucosal invasive cancer with infiltration into the resected skin dermis and invasion of lymphatic vessels under the mucosa. Surgical margins were negative. It is thought that several causes overlap for stomal cancer, although a clear cause of occurrence is yet to be identified. However, as no established surgical procedure exists, the necessity for resection of the lymph nodes without exposure appears indisputable. Although it was reported that skin or subcutaneous metastasis in colorectal cancer is generally regarded as a symptom of systemic metastasis, opinions on the subcutaneous dissection margin of stomal cancer are rarely discussed. Stomal cancer can be observed macroscopically without colonoscopy. Patients and staff engaged in stoma care should be fully aware that continuous observation of the stoma is necessary even after rectal cancer surveillance is complete.

Comparison Between Primary Resection Anastomosis and Hartmann Procedure for the Treatment of Hinchey III and IV Acute Diverticulitis in the Emergency Setting

Comparison Between Primary Resection Anastomosis and Hartmann Procedure for the Treatment of Hinchey III and IV Acute Diverticulitis in the Emergency Setting

The development and challenge of colorectal surgery

In the past, people summarized and invented a series of surgical procedures for the treatment of colorectal cancer after continuous thinking and exploration. Some of these surgical procedures, such as Miles, Dixon, and Hartmann procedures, are considered to be classic and still in use today. In general, the surgical development has gone through roughly four stages: palliative surgery, radical surgery, extended radical surgery, and tumor functional surgery. As far as the surgical procedure of colorectal surgery is concerned, it mainly includes five elements: surgical approach, intestinal segment resection, degree of lymph node dissection, digestive tract reconstruction, and specimen removal. Only by fully understanding the five elements of surgical procedures and seeking for variables from them can innovation be achieved and benefit patients. This article will discuss the evolution of colorectal surgery according to development of medicine and surgery. "Taking history as a mirror, we can know the rise and fall." Only by correctly understanding history can we objectively understand the nature of things and the laws of their development. This is true for humans, and it is true for medicine.

Long-term stoma-related reinterventions after anterior resection for rectal cancer with or without anastomosis: population data from the Dutch snapshot study.

The aim of this study was to analyze the stoma-related reinterventions, complications and readmissions after an anterior resection for rectal cancer, based on a cross-sectional nationwide cohort study with 3-year follow-up. Rectal cancer patients who underwent a resection with either a functional anastomosis, a defunctioned anastomosis, or Hartmann's procedure (HP) with an end colostomy in 2011 in 71 Dutch hospitals were included. The primary outcome was number of stoma-related reinterventions. Of the 2095 patients with rectal cancer, 1400 patients received an anterior resection and were included in this study; 257 received an initially functional anastomosis, 741 a defunctioned anastomosis, and 402 patients a HP. Of the 1400 included patients, 62% were males, 38% were females and the mean age was 67years (SD 11.1). Following a primary functional anastomosis, 48 (19%) patients received a secondary stoma. Stoma-related complications occurred in six (2%) patients, requiring reintervention in one (0.4%) case. In the defunctioned anastomosis group, stoma-related complications were present in 92 (12%) patients, and required reintervention in 23 (3%) patients, in 10 (1%) of these more than 1year after initial resection. Stoma-related complications occurred in 92 (23%) patients after a HP, and required reintervention in 39 (10%) patients in 17 (4%) of cases more than 1year after initial resection. The permanent stoma rate was 11% and 20%, in the functional anastomosis and the defuctioned anastomosis group, respectively. The end colostomy in the HP group was reversed in 4% of cases. Construction of a stoma after resection for rectal cancer with preservation of the sphincter is accompanied with long-term stoma-related morbidity. Stoma complications are more frequent after a HP. Even after1year, a significant number of reinterventions are required.