Laparoscopic Abdominoperineal Resection Research Articles

Modified Approach for Extraperitoneal Colostomy Creation in Laparoscopic Abdominoperineal Resection.

Parastomal hernia is a major long-term complication after abdominoperineal resection. Extraperitoneal colostomy has been proposed as an effective step for parastomal hernia prevention, but it has not been widely used as it is technically demanding and time-consuming. We proposed a modified approach for extraperitoneal colostomy creation by entering the extraperitoneal space through the arcuate line of the posterior rectus sheath. To evaluate the safety, difficulty, and efficacy of long-term parastomal hernia prevention of the modified approach for extraperitoneal colostomy creation compared with the conventional transperitoneal colostomy approach. This was a retrospective evaluation of a surgical and video database. This was a single-institution retrospective study. Clinical data of 74 patients who underwent laparoscopic abdominoperineal resection surgery from January 2019 to January 2020 in the Department of General Surgery, Qilu Hospital of Shandong University, were retrospectively reviewed. Baseline characteristics, time required for colostomy creation (from skin incision to colostomy maturation), perioperative complications, and long-term colostomy-related complications were compared. Baseline characteristics did not differ between the 2 approaches. The BMI level ranged from 19.5 to 29.4 for patients undergoing extraperitoneal approach. Time required for colostomy creation median [interquartile range], (22 [21-25] minutes for extraperitoneal vs 23 [21-25] minutes for transperitoneal, p = 0.861) were comparable between the 2 approaches. The cumulative incidence of parastomal hernia was significantly greater with transperitoneal colostomy than extraperitoneal colostomy at 2 and 3 years postoperatively (16.2% vs 0%, p = 0.025, and 21.6% vs 0%, p = 0.005). The remaining perioperative complications and long-term colostomy-related complications did not differ between the 2 approaches. This study is limited by its retrospective design and small sample size. The modified approach for extraperitoneal colostomy creation is safe, technically simple, and effective for long-term parastomal hernia prevention in patients with a BMI of 19.5 to 29.4.

Effectiveness of placing prophylactic mesh with the Sugarbaker technique via laparoscopic abdominoperineal resection for rectal cancer: 1-year results

Abstract Background The aim of this study was to assess the efficacy of parastomal hernia prevention with the Sugarbaker technique via laparoscopic abdominoperineal resection for rectal cancer after a 1-year follow-up at University Medical Center in Ho Chi Minh City, Vietnam. Materials and Methods Prospective study. Between November 2018 and July 2022, 43 patients with low rectal cancer underwent laparoscopic abdominoperineal resection and were divided into 2 groups: study (n = 15) with prophylactic mesh placement with the Sugarbaker technique and control (n = 28). All patients were tracked for at least a year and had an abdominal computed tomography scan. The Kaplan-Meier method was used to calculate the rate of parastomal hernia after 1 year. To compare the rates of parastomal hernia in 2 groups, the log-rank test was used. Results This study included 43 patients, the male-to-female ratio was approximately equal to 1:1, the median age was 62 years, the youngest age was 40 years, and the oldest age was 92 years. Rectal cancer stage III was found in 41.8% of people. Neoadjuvant chemoradiotherapy was used in 27.9% of cases. The average duration of operation was 184 minutes. The average time for mesh placement was 15 minutes. The overall complication rate was 16.4%. There were no issues with mesh placement. At 1 year, the control group had a higher cumulative rate of parastomal hernia than the study group (35.7% vs 0%; log-rank test, 6.4; P = 0.01). Conclusions Prophylactic mesh placement with the Sugarbaker technique via laparoscopic abdominoperineal resection for rectal cancer is safe, does not increase complications, and reduces the cumulative rate of a parastomal hernia at 1 year in patients who have undergone prophylactic mesh placement.

Double inferior vena cava, an uncommon but relevant anatomical anomaly in surgery for lower rectal cancer: a report of two cases

BackgroundDouble inferior vena cava (DIVC) is rare and usually detected incidentally. DIVC may be associated with several anatomical variants of the retroperitoneal and pelvic veins. These variants can pose a clinical problem during colorectal surgery. We present two patients with lower rectal cancer who also had a DIVC.Case presentationCase 1 was a 72-year-old man with advanced lower rectal cancer (T3N0M0) who underwent robot-assisted low anterior resection after neoadjuvant therapy. A DIVC was detected on preoperative computed tomography (CT). During the operation, a presacral vein was injured while mobilizing the rectum and hemostasis could not be achieved. We converted to open surgery and packed the pelvic cavity for hemostasis. Retrospective analysis suggested the injured vein arose from an interiliac vein of the presacral pelvic venous plexus. Case 2 was a 50-year-old woman with lower rectal cancer (T3N0M0), immune thrombocytopenic purpura, and a DIVC. Although preoperative three-dimensional CT angiography showed no obvious pelvic vein abnormalities, a short course of preoperative radiotherapy was delivered to avoid lateral pelvic lymph node dissection. Chemotherapy was deferred owing to her thrombocytopenic disease. Laparoscopic abdominoperineal resection was performed meticulously to minimize bleeding and achieve rapid hemostasis. No intraoperative complications occurred.ConclusionDIVC is often accompanied by venous malformations that may pose a problem when mobilizing the mesorectum from the retroperitoneum. Preoperative assessment of pelvic vessel anatomy using three-dimensional CT is essential in patients with a DIVC who undergo rectal surgery.

A case report of anal fistula-associated mucinous adenocarcinoma developing 3 years after treatment of perianal abscess

BackgroundA long-standing (over 10 years) anal fistula is considered a fundamental cause of fistula-associated mucinous adenocarcinoma (FAMC). Perianal abscesses and anal fistulas are two sequential phases of the same anorectal infectious process. We experienced a case of FAMC which developed 3 years after the treatment of a perianal abscess.Case presentationA 68-year-old woman was admitted to our hospital because of progressive anal pain and a palpable tumor. She had a history of undergoing a drainage operation for a perianal abscess 3 years previously. A 15 × 15-mm tumor at the former drainage site was identified; transanal ultrasonography showed an intersphincteric fistula connecting to the tumor. A biopsy taken from the tumor demonstrated mucinous adenocarcinoma; the tumor was diagnosed as FAMC. Laparoscopic abdominoperineal resection was performed. Histopathology showed highly dysplastic cells lining the lumen of the anal fistula and poorly differentiated mucinous adenocarcinoma proliferating in the dermis and epidermis in the distal aspect of the fistula.ConclusionsFAMC can develop within fewer than 3 years after the development of a perianal abscess and anal fistula.

A short-term study of laparoscopic-dominant individualised levator ani resection in abdominoperineal resection: A retrospective investigation.

The objective is to investigate if laparoscopic-dominant abdominoperineal resection (LDAPR) with individualised levator ani resection inhibits local recurrence (LR) and prolongs survival as compared to laparoscopic abdominoperineal resection (APR). Rectal cancer surgery cases were retrospectively identified from September 2014 to December 2019. LDAPR-treated group (55 patients) and the APR-treated group (71 patients) were included in the study. The operation time, circumferential resection margin (CRM), intraoperative tumor surgery (ITP), post-operative complications, the 2-year overall survival (OS) and LR were compared in the two groups. The CRM and ITP were significantly reduced in the LDAPR as compared to the APR group (3.6% vs. 16.9%, t = 5.522, P = 0.019; 3.6% vs. 14.1%, t = 3.926, P = 0.048). In terms of post-operative complications, the incidence of urinary retention in LDAPR was significantly reduced than the APR group (10.9% vs. 25.4%, χ2 = 4.139, P = 0.041). Similarly, perineal pain at 6 months or 1 year after surgery was significantly down-regulated in LDAPR than in the APR group (72.7% vs. 88.7%, χ2 = 5.320, P = 0.021; 18.2% vs. 43.2%, χ2 = 8.288, P = 0.004). However, there was no statistically significant difference in the post-operative complications between the LDAPR and APR groups. Finally, LDAPR led to a significantly improved 2-year OS and a reduced LR compared to APR. LDAPR reduces CMR, ITP and LR and simplified the perineum operation, subsequently protecting the pelvic autonomic nerves. Compared to the conventional APR, LDAPR is a promising procedure worth adopting for rectal cancer treatment.

A preliminary report of laparoscopic extraperitoneal colostomy anterior to posterior sheath of rectus abdominis-transversus abdominis to prevent parastomal hernia

Objective: To examine the preliminary effect of laparoscopic extraperitoneal colostomy anterior to posterior sheath of rectus abdominis-transversus abdominis for the prevention of parastomal hernia after abdominoperineal resection for rectal cancer. Methods: This study is a prospective case series study. From June 2021 to June 2022, patients with low rectal cancer underwent laparoscopic abdominoperineal resection combined with extraperitoneal colostomy anterior to posterior sheath of rectus abdominis-transversus abdominis at the First Department of General Surgery, Shaanxi Provincial People's Hospital were enrolled. The clinical data and postoperative CT images of patients were collected to analyze the incidence of surgical complication and parastomal hernia. Results: Totally 6 cases of patient were enrolled, including 3 males and 3 females, aging 72.5 (19.5) years (M(IQR)) (range: 55 to 79 years). The operation time was 250 (48) minutes (range: 190 to 275 minutes), the stoma operation time was 27.5 (10.7) minutes (range: 21 to 37 minutes), the bleeding volume was 30 (35) ml (range: 15 to 80 ml). All patients were cured and discharged without surgery-related complications. The follow-up time was 136 (105) days (range: 98 to 279 days). After physical examination and abdominal CT follow-up, no parastomal hernia occurred in the 6 patients up to this article. Conclusions: A method of laparoscopic extraperitoneal colostomy anterior to posterior sheath of rectus abdominis-transversus abdominis is established. Permanent stoma can be completed with this method safely. It may have a preventive effect on the occurrence of parastomal hernia, which is worthy of further study.

Laparoscopic Abdominoperineal Resection with En Bloc Vaginal Resection and Immediate Neovaginal Reconstruction with Colonic Flap and Pelvic Floor Reconstruction with Mucosa-Removed Colonic Flap.

Bunyajetpong, Sumet M.D.1,2; Sahakitrungruang, Chucheep M.D., M.Sc.1 Author Information

Locally Advanced Rectal Cancer Invading the Gluteus Maximus Muscle Completely Responded to Total Neoadjuvant Therapy.

A 70-year-old male with anal pain and fever was diagnosed with rectal cancer perforation and abscess in the right gluteus maximus (GM) muscle. He underwent a transverse colon colostomy followed by preoperative capecitabine+oxaliplatin. Some local control was achieved but a residual abscess was observed in the right GM muscle. To secure circumferential resection margin by tumor reduction, he received chemoradiotherapy as total neoadjuvant therapy (TNT) and underwent laparoscopic abdominoperineal resection, D3 lymph node dissection, combined coccyx resection, and partial resection of the right GM muscle. The skin defect and pelvic dead space were filled with a right lateral vastus lateral great muscle flap. Histopathologically, the resected specimen showed no tumor cells in the primary tumor or lymph nodes, indicating a pathological complete response (pCR). This case suggests that TNT might improve the R0 resection and pCR rates and overall survival.

Malignant Melanoma of the Anorectal Region: A Case Study and Review of the Contemporary Treatment Options

Aims: Anorectal melanoma, an uncommon malignancy of mucosal origin accounts for 0.05 per cent of all colorectal malignancies and 1 per cent of tumours of the anal canal. The typical clinical presentation includes local pain, palpable mass, bleeding, change in bowel habits, and weight loss. The symptoms are somewhat nondescript and unremarkable and can be easily confused with other conditions native to the region. Hence, a careful and timely assessment is imperative in treating this condition.
 Presentation of Case: A case involving a 54-year-old male who presented with a 3-month history of rectal bleeding and pain. Further assessment revealed a malignant melanoma of the anal canal. After undergoing laparoscopic abdominoperineal resection, the patient was on 6 cycles of dacarbazine. He was subsequently found to have liver metastasis. He subsequently started oral Temozolomide for 2 cycles. He has been on close follow-up for the last 6 months and the disease has not progressed since.
 Discussion: The course of evaluation in suspected cases of anorectal melanoma is a rectal examination, biopsy and histopathologic examination. Immunohistochemistry aids in the confirmation of the diagnosis. Laparoscopic abdominoperineal resection demonstrates good response rates. Adjuvant chemotherapy in anorectal melanoma can be given in patients following surgical resection of the primary anorectal tumour and with a high risk of recurrence. Targeted therapies like c-kit inhibitors, BRAF inhibitors, anti- CTLA-4 antibodies and anti-PD-1 antibodies can also be used.
 Conclusion: Melanomas of the anorectal region present a diagnostic dilemma and carry poor prognoses. Despite an aggressive management approach, the disease maintains an average five-year survival rate of 20%.

Effects of wound infection on prognosis after laparoscopic abdominoperineal resection of rectal cancer.

In two facilities in Chongqing, this research sought to retrospectively evaluate the effects of perineal wound infection on survival after laparoscopic abdominoperineal resection (LAPR) of rectal cancer. To obtain clinical information on patients who underwent LAPR between January 2013 and December 2021, we performed a multicenter cohort study. A total of 473 patients were enrolled: 314 in the non-infection group and 159 in the group with perineal infection. The general data, perioperative conditions, and tumor outcomes between groups were analyzed. The infection rates, recurrence rates, and survival rates of the two centers were compared. The age, height, weight, body mass index (BMI), preoperative complications, preoperative treatment, and intraoperative conditions of patients in the LAPR infection group were not statistically different from those in the non-infection group. The percentage of men, typical postoperative hospital stay, length of initial postoperative therapy, and recurrence and metastasis rates were all considerably higher in the infection group than those in the non-infection group. Wound infection was an independent factor affecting tumor recurrence and metastasis after LAPR as well as an independent factor shortening patient survival time according to multivariate analysis. The incidence of wound infection, the rate of recurrence, and the rate of mortality did not vary significantly across sites. Wound infection after LAPR increases the mean postoperative hospital stay, prolongs the time to first postoperative treatment, and decreases the disease-free survival (DFS) and overall survival (OS). Therefore, decreasing the rate of LAPR wound infection is expected to shorten the postoperative hospital stay and prolong the patient DFS and OS. Patients with postoperative infection may require intensive adjuvant therapy.

Laparoscopic Abdomino-perineal Resection Followed by Early Postoperative Acute Small Bowel Obstruction- A Case Report with Review of Literature

Abdominoperineal Resection (APR) is the long established therapeutic surgical procedure for cancers of the lower rectum. With the advent of minimal access surgery, APR too has come under its ambit. The large pelvic peritoneal defect and raw area left behind, after dissection are unique to APRs. This report describes the case of a 75-year-old male patient diagnosed with low rectal cancer, who underwent a laparoscopic APR and developed an early post-operative adhesive acute small bowel obstruction. Having failed a trial of conservative management, the same was successfully managed by a re-look laparoscopy. The risk of postoperative adhesions decreases significantly with laparoscopy. APR (whether open or laparoscopic), is a unique operation that causes the formation of a large pelvic raw area, which is very prone to attracting small bowel adhesion/s. The advent of various anti-adhesion barriers (liquid and films) has helped in decreasing the incidence of adhesions. However, in spite of the availability of a wide array of options, there is no consensus among surgeons as to the most optimum agent. Ideally, a tension free closure of the pelvic peritoneal defect formed during APR should be attempted. Failing this, covering of the wide pelvic raw area by a dual mesh or an anti-adhesion barrier agent (fluid or film) or omentopexy have been reported as adhesion preventing manoeuvres. Interceed® promises to be a useful long term adhesion preventing barrier option.

An Intriguing Case of Chronic Peristomal Ulcer.

An Intriguing Case of Chronic Peristomal Ulcer.

Laparoscopic extralevator abdominoperineal excision in distal rectal cancer patients: a retrospective comparative study

At present, abdominoperineal excision with neoadjuvant chemoradiotherapy (nCRT) is one of the treatment modalities of distal rectal cancer. Our study analyzed the effects of laparoscopic extralevator abdominoperineal resection (ELAPE) compared with laparoscopic conventional abdominoperineal resection(cAPR) in the treatment of distal rectal cancer. Retrospective analysis was conducted on the clinicopathological data of 177 distal rectal cancer patients treated with a laparoscopic abdominoperineal resection between 2011 and 2018. The patients were divided into four groups as follows: ELAPE without nCRT (group A), cAPR without nCRT (group B), ELAPE with long-course nCRT (group C) and cAPR with long-course nCRT (group D). Positive circumferential resection margin (CRM), local recurrence rate, 3-year disease-free survival (DFS) and 3-year overall survival (OS) did not differ between group A and group B. The rate of positive CRM in group C was lower than group D (4.4% vs. 11.9%, respectively), although the difference was not significant (P = 0.377). The 3-year local recurrence rate in group C was lower compared with group D (6.6% vs. 16.7%, respectively), although the difference was not significant (P = 0.135). Three-year DFS and 3-year OS were not different between groups C and D. This study showed that the effect of laparoscopic ELAPE in patients with low-risk rectal cancer is similar to laparoscopic cAPR, revealing that laparoscopic cAPR can be routinely selected for patients with low-risk rectal cancer. Furthermore, laparoscopic ELAPE has a tendency to reduce the rate of positive CRM and local recurrence in patients with high-risk rectal cancer. Laparoscopic ELAPE can be routinely considered for patients with high-risk rectal cancer.

A case of percutaneous transhepatic stomal varices embolization and partial splenic artery embolization for rectal cancer after CAPOX/BEV chemotherapy: the summary of the stomal varices related to oxaliplatin administration

Capecitabine and oxaliplatin (CAPOX) plus bevacizumab (BEV) therapy (CAPOX/BEV) is a standard treatment recommended as the first-line treatment for colorectal cancer recurrence. Recently, sinusoidal obstruction syndrome (SOS) and resulting portal hypertension have been reported as important side effects of oxaliplatin. We herein report a rectal cancer patient who underwent percutaneous transhepatic stoma variceal embolization (PTO) and partial splenic artery embolization (PSE) for stomal variceal bleeding and splenomegaly due to portal hypertension caused by SOS after CAPOX therapy. A 43-year-old man who underwent robot-assisted laparoscopic abdominoperineal resection for advanced lower rectal cancer was started on CAPOX/BEV therapy for early recurrence 1 month after surgery. In the sixth course, splenomegaly rapidly worsened, stomal varices appeared, and the stoma began bleeding. At 5 months after the appearance of stomal varices, the splenomegaly worsened, the frequency of stomal bleeding increased, and PTO was performed. Five months later, PSE was performed for splenomegaly and thrombocytopenia. At 5 months since the PSE, the stoma bleeding has not recurred, and the thrombocytopenia has been corrected. The patient has been able to continue chemotherapy. We suggest that staged treatment by PTO and PSE be considered an important treatment option for stomal varices and splenomegaly associated with SOS.

Postoperative Complications in Patients Undergoing Nonabdominal Wall Flap Reconstruction after Laparoscopic or Robotic Abdominoperineal Resection

INTRODUCTION: Abdominoperineal resection (APR) is the treatment of choice for patients with rectal cancer. Typically, reconstruction after APR is done with a rectus abdominus myocutaneous (RAM) flap. Given the increased management with laparoscopic APRs, abdominally based flap reconstruction is inappropriate because of its invasiveness and significant abdominal wall morbidity. Therefore, a nonabdominal wall based free flap alternative, such as an anterior lateral thigh flap, gluteal flap, or gracilis flap, may be a superior approach looking forward. The aim of this study is to evaluate postoperative short- and long-term complication rates in patients undergoing nonabdominal wall flap reconstruction after laparoscopic or robotic APR. METHODS: We conducted a review of the literature to include adults with rectal cancer and looked at short-term complications such as increased healing time, seroma, hematoma, surgical site infection, dehiscence rates, reoperation rates, as well as long term complications such as perineal hernia rates. RESULTS: Our study included 64 articles and 306 flaps. The overall wound complication rate was 15.0%. In the short-term, 23 patients experienced hematomas, 16 patients experienced surgical site infection, 3 patients dehisced, and 4 required reoperations. The ALT flap offered the lowest rate of complications at 9.3%. CONCLUSION: In conclusion, the wound complication rate of 15.2% was comparable with literature findings of 14.3% in patients with RAM flap reconstruction. Nonabdominal wall-based flap reconstruction is effective after APR. Owing to its low complication rate, the ALT flap may serve as a superior treatment option for laparoscopic or robotic APR in patients with rectal cancer.

Effectiveness of placing prophylactic mesh with the Sugarbaker technique via laparoscopic abdominoperineal resection for rectal cancer

Abstract Introduction: The aim of this study was to assess the efficacy of parastomal hernia prevention with the Sugarbaker technique via laparoscopic abdominoperineal resection for rectal cancer after a one-year follow-up at University Medical Center in Ho Chi Minh City. Patients and methods: Intervention study. Between 11/2018 and 7/2022, 43 patients with low rectal cancer underwent laparoscopic abdominoperineal resection and were divided into two groups: intervention (n = 15) with prophylactic mesh placement using the Sugarbaker technique and control (n = 28). All patients were tracked for at least a year and had an abdominal computed tomography scan. The Kaplan Meier method was used to calculate the rate of parastomal hernia after one year. To compare the rates of parastomal hernia in two groups, the logrank test was used. Results: This study included 43 patients; the male to female ratio was approximately equal to 1:1; the median age was 62; the youngest age was 40; and the oldest age was 92. Rectal cancer stage III was found in 41.8% of people. Neoadjuvant chemoradiotherapy was used in 27.9% of cases. The average duration of operation was 184 minutes. The average time for mesh placement was 15 minutes. The overall complication rate was 16.4%. There were no issues with mesh placement. At one year, the control group had a higher cumulative rate of parastomal hernia than the intervention group (35.7% versus 0%, logrank 6.4, p = 0.01). Conclusions: Prophylactic mesh placement using the Sugarbaker technique during laparoscopic abdominoperineal resection for rectal cacner is safe, does not increase complications, and reduces the cumulative rate of a parastomal hernia at 1 year in patients who have undergone prophylactic mesh placement. Keywords: Prophylactic mesh placement, Sugarbaker technique, Laparoscopic abdominoperineal resection.

Laparoscopic extraperitoneal colostomy has a lower risk of parastomal hernia and bowel obstruction than transperitoneal colostomy.

Several studies indicate that an extraperitoneal colostomy can prevent the development of a parastomal hernia (PSH) as compared to a transperitoneal colostomy. However, the clinical value of laparoscopic extraperitoneal colostomy, and its influence on bowel obstruction and PSH remain unclear. The present study aimed to clarify the impact of laparoscopic extraperitoneal colostomy on the development of a PSH and bowel obstruction. This study included 327 consecutive patients who underwent laparoscopic abdominoperineal resection or Hartmann's procedure between January 2013 and December 2019 after fulfilling selection criteria. The incidence of a PSH (Clavien-Dindo classification ≥ grade I) and bowel obstruction (≥ grade IIIa) in the transperitoneal and extraperitoneal route groups were analyzed using univariate and multivariate analysis. The patients were classified into transperitoneal (n = 222) and extraperitoneal (n = 105) route groups. The patient characteristics, except for body mass index and operative time, were comparable between the groups. A PSH and bowel obstruction occurred more frequently in the transperitoneal than in the extraperitoneal route group (17.1% vs. 1.9% and 15.3% vs. 6.7%, respectively; p < 0.01 and p = 0.03, respectively). The multivariate analysis showed that age ≥ 70years, body mass index ≥ 22.4kg/m2, and a transperitoneal route were independent risk factors for the development of a PSH, and a transperitoneal route was an independent risk factor for bowel obstruction. The transperitoneal route was identified as a risk factor for the development of both a PSH and bowel obstruction after laparoscopic abdominoperineal resection or Hartmann's procedure.

Basaloid squamous cell carcinoma of the rectum. Case report

Introduction: SCC is a subtype of epithelial origin tumors that are common in glandular organs such as the lungs and pancreas, but are relatively rare in the large intestine. Pure squamous cell carcinoma (SCC) of the colorectum is extremely rare. Case presentation: A 47-year-old woman was admitted to the hospital for surgical treatment of a rectal tumor initially diagnosed as a neuroendocrine tumor. She underwent neoadjuvant chemotherapy followed by laparoscopic abdomino-perineal resection of the rectum. Collected tissues of the tumor underwent histopathological evaluation in which the infiltration of BSCC (G2) was described. The p16 antigen were positively expressed in immunohistochemistry, which indicates an existing HPV infection with high oncogenic potential. Conclusions: It is certain that only histopathological diagnosis can give a reliable diagnosis of SCC and enable the implementation of appropriate treatment in the case of unresectable lesions. Keywords: squamous cell carcinoma, SCC, basaloid squamous cell carcinoma, BSCC

Anal fistula metastasis of rectal cancer after neoadjuvant therapy: a case report

BackgroundAnal metastasis of colorectal cancer is very rare and may present synchronously or metachronously, regardless of pre-existing anal diseases. We report a case of anal fistula metastasis after completion of neoadjuvant therapy for rectal cancer, followed by surgical resection of the primary tumor and metastatic lesion.Case presentationA 50-year-old man was diagnosed with rectal cancer located 5 cm from the anal verge, with a clinical stage of cT3N0M0. He denied any medical or surgical history, and physical examination revealed no perianal disease. He underwent preoperative chemoradiation therapy (CRT) consisting of a tegafur/gimeracil/oteracil potassium (S-1)-based regimen with 45 Gy of radiation. After completion of CRT, computed tomography (CT) revealed the primary tumor’s partial response, but a liver mass highly suggestive of metastasis was detected. This mass was later diagnosed as cavernous hemangioma 3 months after CRT initiation. He then underwent and completed six cycles of consolidation chemotherapy with a capecitabine-based regimen. Subsequent colonoscopy revealed the complete response of the primary tumor, but CT showed thickening of the edematous rectal wall. Therefore, we planned to perform low anterior resection as a radical surgery. However, he presented with persistent anal pain after the last chemotherapy, and magnetic resonance imaging revealed a high-intensity mass behind the anus, suggestive of an anal fistula. We considered the differential diagnosis of a benign anal fistula or implantation metastasis into the anal fistula. Fistulectomy was performed, and a pathological diagnosis of tubular adenocarcinoma, suggestive of implantation metastasis, was made. Thereafter, we performed laparoscopic abdominoperineal resection. Histopathological examination revealed well-differentiated adenocarcinoma, ypT2N0, with a grade 2 therapeutic effect. Subsequent immunohistochemistry of the resected anal fistula showed a CDX-2-positive, CK20-positive, CK7-negative, and GCDFP-15 negative tumor, with implantation metastasis. There was no cancer recurrence 21 months after the radical surgery.ConclusionsThis is the first report of anal fistula metastasis after neoadjuvant therapy for rectal cancer in a patient without a previous history of anal disease. If an anal fistula is suspected during or after neoadjuvant therapy, physical and radiological assessment, differential diagnosis, and surgical intervention timing for fistula must be carefully discussed.

Is it worthwhile to perform closure of the pelvic peritoneum in laparoscopic extralevator abdominoperineal resection?

There is no uniformity in the use of closure of the pelvic peritoneum (CPP) after laparoscopic extralevator abdominoperineal excision (ELAPE). This study aimed to evaluate the short-term outcomes of CPP after ELAPE and provide supporting evidence for the performance of CPP in laparoscopic ELAPE. Patients with rectal cancer who underwent ELAPE from January 2014 to April 2019 were retrospectively investigated. CPP was routinely performed unless it was not feasible. The main outcome was the difference in the occurrence of perineal hernia (PH), small bowel obstruction (SBO) and perineal wound complications between laparoscopic and open ELAPE, which were compared using Kaplan-Meier curves. Of the 244 patients included, 104 received laparoscopic ELAPE, and 140 received open ELAPE. Patients in the laparoscopic group suffered a higher incidence of PH (11.5% (12/104) vs. 5.0% (7/140), p = 0.049), SBO (10.6% (11/104) vs. 7.9% (11/140), p = 0.433) and major perineal wound complications (12.5% (13/104) vs. 7.9% (11/140), p = 0.228) than those in the open group. Multivariate analysis showed that no-CPP was an independent risk factor for the occurrence of PH (p = 0.022, OR 3.436, 95% CI 1.199-9.848) and major perineal wound complications (p = 0.012, OR 3.683, 95% CI 1.337-10.146). In this comparative cohort study with a risk of allocation bias, CPP was associated with a lower incidence of radiological PH and major perineal wound complications regardless of the surgical approach. Thus, we believe CPP could serve as an option L-ELAPE for the prevention of perineal complications. To further determine the impact of CPP on postoperative complications after ELAPE, a prospective multicentre study is needed.