Laparoscopic Anterior Resection Research Articles

Short‐Term Outcomes of Tri‐Staple Versus Universal Staple in Laparoscopic Anterior Resection of Rectal and Distal Sigmoid Colonic Cancer: A Matched‐Pair Analysis

Anastomotic leakage is a serious complication in laparoscopic colorectal surgeries. To resolve this problem, a new stapling technology (Tri-staple) is developed. In this study, we aim to compare the short-term outcomes of Tri-staple versus Universal staple in laparoscopic anterior resection of rectal and distal sigmoid colonic cancer. A total of 446 patients were admitted to our hospital and received laparoscopic anterior resection for rectal and distal sigmoid colonic cancer between January 2016 and December 2020. Among them, Tri-staples were used in 202 patients, and the Universal staples were used in 244 patients. Propensity score matching was performed, followed by a comparison between the two groups (Tri-staple vs. Universal staple) in the incidences of anastomotic leakage, bleeding, and reoperation. In total, 270 patients were included in this retrospective cohort study by the propensity score matching, with each group having 135 patients. Tri-staple group had a significant lower incidence of anastomotic leakage compared with the Universal staple group (4.44% vs. 11.11%, P < 0.05). The reoperation rate was also lower in Tri-staple group than the Universal staple group (3.70% vs. 8.15%, P < 0.05). The anastomotic bleeding rates, average postoperative hospital stay, average drain indwelling period, and average fasting period had no statistical differences between the two groups. The usage of Tri-staple in laparoscopic anterior resection of rectal and distal sigmoid colonic cancer is associated with lower postoperative complications compared with Universal staple. Future high-quality randomized controlled trials are needed to confirm our findings.

The feasibility, safety and short-term clinical efficacy of laparoscopic anterior resection of rectal cancer with left colonic artery (LCA) preservation and natural orifice specimen extraction (NOSE)

BackgroundNatural orifice specimen extraction surgery (NOSES) has the advantages of less postoperative pain, fast bowel function recovery, reduced hospital stay and better cosmetic effects. In our centre, anterior resection of rectal cancer with preservation of the left colonic artery (LCA) was performed using NOSES. The feasibility, safety and short-term clinical efficacy of the technique were discussed.MethodsA retrospective analysis was performed on 19 patients who underwent laparoscopic anterior resection of rectal cancer with left colonic artery preservation and natural orifice specimen extraction in the Gastrointestinal Surgery Center of Sichuan Cancer Hospital from September 2018 to December 2019. General information about the patients, perioperative data and short-term postoperative results were analysed.ResultsAll operations were completed smoothly, with an average operation duration of 304.36 ± 45.04 min, intraoperative bleeding of 76.31 ± 61.12 ml, first time off bed of 14.42 ± 3.56 h, first time to anus exhaust of 15.26 ± 8.92 h, first time to liquid diet of 2.94 ± 1.12 days, and average postoperative stay of 10.21 ± 3.13 days. Two patients developed temporary intestinal obstruction, and one patient developed pulmonary infection. All of them recovered well after active supportive treatment and were successfully discharged.ConclusionLaparoscopic NOSES for rectal cancer with left colon artery preservation is safe and feasible, with satisfactory short-term results, and is worthy of further clinical investigation.

An Unusual Cause of Rectal Pain

Question: A 79-year-old man presented with a 1-week history of rectal pain. He had passed a painful, jagged stool with fresh red rectal bleeding. The patient reported that it felt like passing “broken glass.” He had previously undergone a laparoscopic anterior resection with a nonfunctioning ileostomy for adenocarcinoma of rectum (T3 M0 N1) 7 years prior. His ileostomy had been closed and there had been no evidence of disease recurrence on follow-up. In addition, he has atrial fibrillation, hypertension, type 2 diabetes mellitus, and had acute cholecystitis with calcification that was managed conservatively 4 years ago. On examination, he was hemodynamically stable. His abdomen was soft and nontender. An internal rectal examination was tender with intraluminal glass-like material palpable within the rectum. Admission blood tests including liver function tests were normal apart from a C-reactive protein of 37 mg/L and lactate of 3.1 mmol/L. Previous imaging (plain radiograph [Figure A]) from 4 years ago is compared with contemporary imaging (plain radiograph (Figure B) and a computed tomography scan of the abdomen and pelvis with contrast was performed (Figure C, D). What is the most likely diagnosis? Look on page 1181 for the answer and see the Gastroenterology website (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and images in GI. A previous plain radiograph (Figure A) from 4 years before presentation demonstrated an intact porcelain gallbladder. Imaging at the current presentation, a plain radiograph (Figure B) and a computed tomography scan of the abdomen and pelvis (Figure C) demonstrated a porcelain gallbladder and cholecystocolonic fistula. A large portion of the porcelain gallbladder wall had fragmented, passed via the fistula into the transverse colon and had transited to the rectum (Figure D). The patient underwent examination under anesthesia and removal of this part of the porcelain gallbladder wall per rectum (Figure E). Histopathological analysis demonstrated fragments of fibrous tissue with the epithelial lining entirely replaced by extensive calcification and metaplastic bone formation with no evidence of malignancy (Figure F; microscopic section; original magnification ×12.5; Figure G, original magnification ×100, demonstrating metaplastic bone formation). The histopathologist favored a final diagnosis of porcelain gallbladder wall passing via the cholecystocolonic fistula into the colon to the rectum. Postoperatively, the patient recovered well with no further intervention required for the gallbladder or cholecystocolonic fistula. Porcelain gallbladder is also known as calcified gallbladder or calcifying cholecystitis, where the gallbladder becomes encrusted with calcium, brittle, hard, and takes on a bluish discoloration.1Geller S.A. de Campos F.P. Porcelain gallbladder.Autops Case Rep. 2015; 5: 5-7Crossref Google Scholar Patients are often asymptomatic, but occasionally present with right upper quadrant pain, a palpable mass, or symptoms of biliary obstruction.1Geller S.A. de Campos F.P. Porcelain gallbladder.Autops Case Rep. 2015; 5: 5-7Crossref Google Scholar The diagnosis is frequently incidental on an abdominal radiograph or computed tomography scan.1Geller S.A. de Campos F.P. Porcelain gallbladder.Autops Case Rep. 2015; 5: 5-7Crossref Google Scholar The decision to manage porcelain gallbladder conservatively or with cholecystectomy considers the presence of symptoms, biliary complications, and comorbid medical conditions. Although porcelain gallbladder has previously been regarded as a risk factor for gallbladder adenocarcinoma, a recent review of 7 published case series that included 60,665 cholecystectomies suggests that cancer risk is low (<3%).2Khan Z.S. Livingston E.H. Huerta S. Reassessing the need for prophylactic surgery in patients with porcelain gallbladder: case series and systematic review of the literature.Arch Surg. 2011; 146: 1143-1147Crossref PubMed Scopus (57) Google Scholar Among patients who are asymptomatic with good functional status, prophylactic cholecystectomy is recommended despite the limited data regarding true risks of gallbladder cancer because the prognosis of gallbladder cancer is poor.2Khan Z.S. Livingston E.H. Huerta S. Reassessing the need for prophylactic surgery in patients with porcelain gallbladder: case series and systematic review of the literature.Arch Surg. 2011; 146: 1143-1147Crossref PubMed Scopus (57) Google Scholar Gallstone ileus caused by large stones passing through duodenal fistulae causing small bowel obstruction is common. We previously reported a case of large bowel obstruction caused by a large gallstone passing via cholecystocolic fistula into the sigmoid colon.3Ventham N.T. Eves T. Raje D. et al.Sigmoid gallstone ileus: a rare cause of large bowel obstruction.BMJ Case Rep. 2010; 2010Crossref Scopus (4) Google Scholar Previous cases of sigmoid gallstone ileus have been managed conservatively, endoscopically (including use of ultrasonic lithotripsy) and surgically.3Ventham N.T. Eves T. Raje D. et al.Sigmoid gallstone ileus: a rare cause of large bowel obstruction.BMJ Case Rep. 2010; 2010Crossref Scopus (4) Google Scholar This case is the first reported of actual fragments of gallbladder itself, rather than stones, passing via the fistula into the colon. The presentation was with rectal pain alone, rather than any right hypochondral or other colonic or biliary symptoms. Currently, the present authors are not suggesting this as a novel way to perform a cholecystectomy.

Polypoid arteriovenous malformation of the rectum: A case report

BackgroundIntestinal arteriovenous malformation is an abnormal connection between arteries and veins that bypasses the capillary system and may be a cause of significant lower gastrointestinal bleeding. On endoscopy, arteriovenous malformations are usually flat or elevated, bright red lesions. Overall, rectal localization of arteriovenous malformations is rare. The same may be said about polypoid shape arteriovenous malformations. Herein, we present a case of a large rectal polypoid arteriovenous malformations.MethodsClinical, diagnostic, and treatment modalities of the patient were reviewed. Pre- and post-operative parameters were collected and analyzed. The clinical English literature is also reviewed and discussedResultsA 60-year-old female patient was admitted to our emergency department for rectorrhagia and anemia. Rectoscopy revealed a polypoid lesion in the rectum and the biopsy showed fibrosis, necrosis areas, and hyperplastic glands. A total body contrast-enhanced computed tomography (CT) was performed revealing a parietal pseudonodular thickening with concentric growth and contrast enhancement, extending for about 53 mm. The mass wasn't removed endoscopically due to concentric growth, sessile implant, and submucosal nature. The patient underwent an uneventful laparoscopic anterior rectal resection. The postoperative hospitalization was free of complications. Histology showed the presence of a polypoid AVM composed of dilated arteries, veins, capillaries, and lymphatics, engaging the submucosa, muscularis, and subserosa layer.ConclusionAfter a review of the current English literature, we found only one case of rectal polypoid AVM. The scarcity of documented cases encumbers optimal diagnostic and treatment approaches.

Хірургічне лікування раку прямої кишки: обсяг лімфодисекції і проявів неспроможності швів колоректального анастомозу (ретроспективне дослідження)

The purpose of the study was a retrospective analysis and evaluation of the effectiveness of surgical treatment of colorectal cancer, taking into account the technique of surgery, the volume of lymph dissection and postoperative incidence of colorectal anastomotic sutures failure. Materials and methods. The current retrospective analysis includes the results of a comprehensive examination and treatment of 102 patients divided into 2 groups depending on the technique of surgery: 53 people (52%) – laparoscopic anterior resection of the rectum with the formation of hardware "end-to-end" type and 49 (48%) – a similar operation using fluorescent angiography (ICG-technology). Results and discussion. According to the generalized results of retrospective analysis of examination and comprehensive treatment of 102 patients with colorectal cancer, the study groups were formed homogeneously and by statistically significant differences in age, sex, body mass index, nature and spread of tumor growth, location and stage of neoplastic process. The presence of a statistically significant correlation between rectosigmal localization of the nonplastic process, as well as the severity of the tumor response to preoperative chemotherapy / radiation therapy and the number of metastatic affected regional lymph nodes. It was demonstrated that in the study population of 102 patients with regional metastatic spread, the median number of affected lymph nodes was 2.0, and the lower and upper quartiles corresponded to 1 and 3 metastatic lymph nodes. At the same time, N0 samples were intentionally excluded from the analysis in order to ensure the adequacy of the results in the presence of metastatic lesions, because in this case it is important to assess the adequacy of the volume of lymphadenectomy. According to the results of fluorescent angiography, in 3 of 49 patients (6.1%) of group 2, the resection border was moved in the proximal direction to the area of adequate blood supply with subsequent formation of colorectal hardware anastomosis. At the same time, in 53 patients of group 1, the change of the place of application of the conjunctiva, taking into account the results of traditional visual inspection, was not performed at all. Preventive stoma, the need for which was determined by the surgeon, was formed in all 102 (100%) patients. Also in all 102 operated lymphadenectomy was performed. The median duration of surgery in both groups was 200.5 (125–310) minutes. Conclusion. Significant advantages of laparoscopic rectal resection using fluorescent angiography with green indocyanine have been demonstrated, as evidenced by a statistically significant reduction in lymphadenectomy volume – the number of intraoperatively removed lymph nodes, reduction in surgery duration and postoperative period compared with a group of patients who underwent radical surgery without the use of ICG-technology

Analysis of Risk Factors for Anastomotic Leakage After Laparoscopic Anterior Resection of Rectal Cancer and Construction of a Nomogram Prediction Model.

ObjectiveTo explore the risk factors of anastomotic leakage (AL) after laparoscopic anterior resection (AR) of rectal cancer and establish a nomogram prediction model.MethodsClinical and surgical data of patients who underwent AR of rectal cancer at Sichuan Cancer Hospital from January 2017 to December 2020 were retrospectively collected. Univariate and multivariate logistic regression analyses were used to screen the independent risk factors of AL after AR. A nomogram risk prediction model was established based on the selected independent risk factors and the predictive performance of nomogram was evaluated.ResultsA 1013 patients undergoing laparoscopic AR were included, of which 67 had AL, with an incidence of 6.6%. Univariate and multivariate logistic regression analyses showed that male gender, tumors distance from the anus verge of ≤ 5cm, tumors distance from the anus verge of 5–10cm, circumferential tumor growth, operation time ≥ 240min, and no diverting stoma were independent risk factors for AL after AR. A nomogram prediction model was established based on these results. The calibration curve showed that the predicted occurrence probability of the nomogram model was in good agreement with the actual occurrence probability. The area under the receiver operating characteristic (ROC) curve was 0.749.ConclusionThe nomogram prediction model based on the independent risk factors of patients undergoing AL after AR can effectively predict the probability of AL.

Real-time vascular anatomical image navigation for laparoscopic surgery: experimental study.

Recognition of the inferior mesenteric artery (IMA) during colorectal cancer surgery is crucial to avoid intraoperative hemorrhage and define the appropriate lymph node dissection line. This retrospective feasibility study aimed to develop an IMA anatomical recognition model for laparoscopic colorectal resection using deep learning, and to evaluate its recognition accuracy and real-time performance. A complete multi-institutional surgical video database, LapSig300 was used for this study. Intraoperative videos of 60 patients who underwent laparoscopic sigmoid colon resection or high anterior resection were randomly extracted from the database and included. Deep learning-based semantic segmentation accuracy and real-time performance of the developed IMA recognition model were evaluated using Dice similarity coefficient (DSC) and frames per second (FPS), respectively. In a fivefold cross-validation conducted using 1200 annotated images for the IMA semantic segmentation task, the mean DSC value was 0.798 (± 0.0161 SD) and the maximum DSC was 0.816. The proposed deep learning model operated at a speed of over 12 FPS. To the best of our knowledge, this is the first study to evaluate the feasibility of real-time vascular anatomical navigation during laparoscopic colorectal surgery using a deep learning-based semantic segmentation approach. This experimental study was conducted to confirm the feasibility of our model; therefore, its safety and usefulness were not verified in clinical practice. However, the proposed deep learning model demonstrated a relatively high accuracy in recognizing IMA in intraoperative images. The proposed approach has potential application in image navigation systems for unfixed soft tissues and organs during various laparoscopic surgeries.

An innovative and convenient technique to reduce anastomotic leakage after double stapling anastomosis: laparoscopic demucositized suture the overlapping point of the "dog ear" area.

Anastomotic leakage (AL) is a major cause of postoperative morbidity and mortality in the treatment of colorectal cancer. The aim of this study was to investigate an innovative and convenient technique of laparoscopic demucositized suture the overlapping point of the "dog ear" area after the double stapling anastomosis (lds-DSA), as an improved alternative for conventional DSA, and whether it could reduce the AL rate in laparoscopic anterior resection (Lapa-AR). Between January 2018 and December 2020, a total of 245 patients who underwent Lapa-AR for the treatment of adenocarcinoma of the sigmoid colon or rectal cancer were divided into the lsd-DSA group (n = 99) and the DSA group (n = 146). Data were analyzed retrospectively. Morbidity, AL rate and other perioperative outcomes were compared between the two groups. Patient demographics, preoperative comorbidity, preoperative chemoradiotherapy, tumor size, stage, and other operative details were comparable between the two groups. There was no difference in surgical time between the two groups (196.41 ± 76.71 vs. 182.39 ± 49.10min, p = 0.088). The overall complication rate was also without a difference (11/99, 11.11% vs. 21/146, 14.38%, p = 0.456), but AL rate significantly lower in the lsd-DSA group than in the DSA group (2/99, 2.02% vs. 12/146, 8.22%, p = 0.040). For other perioperative outcomes, the lsd-DSA group shortened the total and postoperative hospital stay, and the time to pull out drainage tube than in the DSA group. Our comparative study demonstrates lds-DSA to have a better short-term outcome in reducing AL compared with DSA. This technique could be an alternative approach to maximize the patients' benefit in Lapa-AR.

Preservation versus nonpreservation of the left colic artery in anterior resection for rectal cancer: a propensity score-matched analysis

BackgroundPreserving the left colic artery (LCA) during anterior resection for rectal cancer is controversial, and robust evidence of the outcomes of LCA preservation plus apical lymph node dissection is lacking. The purpose of this study was to investigate the impact of LCA preservation plus apical lymph node dissection surgery on anastomotic leakage and number of harvested lymph nodes.MethodsPatients who underwent laparoscopic or robotic anterior resection for rectal cancer between September 2017 and May 2020 were retrospectively assessed. The patients were categorized into two groups: preservation of LCA and nonpreservation of LCA. A one-to-one propensity score-matched analysis was performed to decrease confounding. The primary outcome was anastomotic leakage within 30 days after surgery. The secondary outcomes were number of harvested lymph nodes, 3-year overall survival, and 3-year disease-free survival.ResultsA total of 216 patients were eligible for this study, and propensity score matching yielded 60 patients in each group. Anastomotic leakage in the LCA preservation group was significantly lower than that in the LCA nonpreservation group (3.3% vs. 13.3%, P = 0.048). No significant differences were observed in blood loss, operation time, intraoperative complications, splenic flexure mobilization, total number of harvested lymph nodes, number of positive lymph nodes, time to first flatus, or postoperative hospital stay. Kaplan–Meier survival analysis showed a 3-year disease-free survival of 85.7% vs. 80.5% (P = 0.738) and overall survival of 92.4% vs. 93.7% (P = 0.323) for the preservation and nonpreservation groups, respectively.ConclusionLCA preservation plus apical lymph node dissection surgery for rectal cancer may help reduce the incidence of anastomotic leakage without impairing the number of harvested lymph nodes. Preliminary results suggest that 3-year disease-free survival and overall survival rates may not differ between the two types of surgery, but studies with larger sample sizes are needed to confirm these conclusions.Trial registration ClinicalTrials.gov, NCT03776370. Registered 14 December 2018—Retrospectively registered, https://clinicaltrials.gov.

A prospective cohort study on the clinical value of pelvic peritoneal reconstruction in laparoscopic anterior resection for middle and low rectal cancer

Objective: To investigate the safety and efficacy of pelvic peritoneal reconstruction and its effect on anal function in laparoscopy-assisted anterior resection of low and middle rectal cancer. Methods: A prospective cohort study was conducted. Consecutive patients with low and middle rectal cancer who underwent laparoscopy-assisted transabdominal anterior resection at Naval Military Medical University Changhai Hospital from February 2020 to February 2021 were enrolled. Inclusion criteria: (1) the distance from tumor to the anal verge ≤10 cm; (2) laparoscopy-assisted transabdominal anterior resection of rectal cancer; (3) complete clinical data; (4) rectal adenocarcinoma diagnosed by postoperative pathology. Exclusion criteria: (1) emergency surgery; (2) patients with a history of anal dysfunction or anal surgery; (3) preoperative diagnosis of distant (liver, lung) metastasis; (4) intestinal obstruction; (5) conversion to open surgery for various reasons. The pelvic floor was reconstructed using SXMD1B405 (Stratafix helical PGA-PCL, Ethicon). The first needle was sutured from the left anterior wall of the neorectum to the right. Insertion of the needle was continued to suture the root of the sigmoid mesentery while the Hemo-lok was used to fix the suture. The second needle was started from the beginning of the first needle, after 3-4 needles, a drainage tube was inserted through the left lower abdominal trocar to the presacral space. Then, the left peritoneal incision of the descending colon was sutured, after which Hemo-lok fixation was performed. The operative time, perioperative complications, postoperative Wexner anal function score and low anterior resection syndrome (LARS) score were compared between the study group and the control group. Three to six months after the operation, pelvic MRI was performed to observe and compare the pelvic floor anatomical structure of the two groups. Results: A total of 230 patients were enrolled, including 58 who underwent pelvic floor peritoneum reconstruction as the study group and 172 who did not undergo pelvic floor peritoneum reconstruction as the control group. There were no significant differences in general data between the two groups (all P>0.05). The operation time of the study group was longer than that of control group [(177.5±33.0) minutes vs. (148.7±45.5) minutes, P<0.001]. There was no significant difference in the incidence of perioperative complications (including anastomotic leakage, anastomotic bleeding, postoperative pneumonia, urinary tract infection, deep vein thrombosis, and intestinal obstruction) between the two groups (all P>0.05). Eight cases had anastomotic leakage, of whom 2 cases (3.4%) in the study group were discharged after conservative treatment, 5 cases (2.9%) of other 6 cases (3.5%) in the control group were discharged after the secondary surgical treatment. The Wexner score and LARS score were 3.1±2.8 and 23.0 (16.0-28.0) in the study group, which were lower than those in the control group [4.7±3.4 and 27.0 (18.0-32.0)], and the differences were statistically significant (t=-3.018, P=0.003 and Z=-2.257, P=0.024). Severe LARS was 16.5% (7/45) in study group and 35.5% (50/141) in control group, and the difference was no significant differences (Z=4.373, P=0.373). Pelvic MRI examination 3 to 6 months after surgery showed that the incidence of intestinal accumulation in the pelvic floor was 9.1% (3/33) in study group and 46.4% (64/138) in control group (χ(2)=15.537, P<0.001). Conclusion: Pelvic peritoneal reconstruction using stratafix in laparoscopic anterior resection of middle and low rectal cancer is safe and feasible, which may reduce the probability of the secondary operation in patients with anastomotic leakage and significantly improve postoperative anal function.

Features to Prevent Failed Hardware Colorectal Anastomoses in Laparoscopic Rectal Resections

The aim of research was to study proper results of laparoscopic anterior rectal resection using intraoperative measures to prevent failure of hardware colorectal anastomoses in patients with rectal tumor.Material and methods. Out of 68 patients included in the study, colorectal anastomotic leakage occurred clinically only in 2 cases (2.9%, class A and B) and required no further surgical interventions. When evaluating the risk of colorectal anastomosis failure in each specific case, it is necessary to consider pre- and intraoperative risk factors. Formation of colorectal anastomosis with one angular end of the rectal stump followed by immersion; additional strengthening of the anastomosis zone with interrupted serous-muscular sutures; adequate drainage of the pelvic cavity (the most effective - transperineal presacral) are intraoperative methods that reduce the risk of failed hardware colorectal anastomoses.Results. Out of 68 operated patients, colorectal anastomosis failure occurred clinically only in 2 cases (2.9%, class A and B) and did not require repeated surgical intervention. When assessing the risk of colorectal anastomosis failure in each specific case, it is necessary to take into account pre-and intraoperative risk factors. Formation of a colorectal anastomosis with one angular end of the rectal stump, followed by its immersion; additional strengthening of the anastomosis zone with nodular serous-muscular sutures; adequate drainage of the pelvic cavity (most effectively - trans-interventional presacral) - intraoperative methods that reduce the risk of failure of hardware colorectal anastomoses.Conclusion. Reasonable doubts in the intraoperative evaluation of the blood supply to the end section of the descending colon, viability of the colorectal anastomosis, presence of 3 or more risk factors, low position of anastomosis (less than 10 cm from the outer end of the anal canal) indicate the necessity to form preventive transversostomy.

Risk factors for Low Anterior Resection Syndrome (LARS) in patients undergoing laparoscopic surgery for rectal cancer

BackgroundTotal mesorectal excision (TME) represents the “gold standard” of rectal cancer surgery. In locally advanced lesions neoadjuvant treatments (e.g. radiotherapy-nRT, radio chemotherapy-cnRT) have been shown to improve TME oncological results, reducing local recurrences rate. Nevertheless, these treatments have significant functional consequences impacting patients’ quality of life (QoL). The resulting syndrome is known as Low Anterior Resection Syndrome (LARS). The purpose of this work was to evaluate the association between risk factors and the development of LARS in a prospective series of laparoscopic sphincter-saving TME.MethodsThe study was conducted as a retrospective observational epidemiological study of a prospective database, including all patients undergoing laparoscopic anterior resection surgery for rectal cancer at our Unit from 1st January 2013 to 31st May 2018. The diagnosis of LARS was performed using the LARS Score. We classified risk factors in patient-related, pre-, intra- and post-operative factors.ResultsThe sample included 153 consecutive patients. Forty-one were affected by “low” rectal cancer, 74 by “middle” rectal cancer, 38 by “high” rectal cancer. The prevalence of overall LARS (major LARS + minor LARS) in our series was 35.9% (55/153 cases). Association between nRT and overall/major LARS was significant (respectively p = 0.03 and 0.02). Distal localization of tumor was also significantly associated with LARS [overall LARS (p = 0.03), major LARS (p = 0.014)].ConclusionsIn our study, neoadjuvant radiotherapy and tumor localization resulted independent risk factors for LARS after laparoscopic sphincter-saving TME. Tumor localization in the “middle” and “high” rectum resulted a protective factor compared to the localization in “low” rectum.

Pelvic floor peritoneum reconstruction is a protective factor for defecation dysfunction after laparoscopic anterior resection in patients with middle and low rectal cancer.

The pelvic cavity is a monolithic structure whose integrity plays an important role in the pelvic organ function. Currently, pelvic floor peritoneum reconstruction (PFPR) is rarely performed during laparoscopic surgery for middle and low rectal cancer patients. This study evaluated the effect of PFPR using barbed wire during laparoscopic surgery on the postoperative defecation function in middle and low rectal cancer patients. This was a retrospective study involving a total of 252 middle and low rectal cancer patients who had been subjected to laparoscopic-assisted anterior resection of rectal cancer at Shanghai Changhai Hospital from March 2018 to April 2020. The Wexner and low anterior resection syndrome (LARS) scores were used to evaluate the postoperative defecation function among patients. A Wexner score ≥ 8 and LARS score ≥ 30 were considered to indicate major defecation dysfunction. A total of 229 patients (52 patients subjected to PFPR) were followed up, and the Wexner and LARS scores were recorded. The follow-up rate was 90.87%, the mean follow-up time was 22.88 ± 6.93months, the stoma rate was 64.29%, the ileostomy reduction surgical rate was 90.74%, and the stoma duration was 7.64 ± 2.94months. Regarding the assessment of postoperative defecation dysfunction using the Wexner score, a multivariate analysis revealed that a long operation time (odds ratio [OR], 0.991; 95% confidence interval [CI], 0.984-0.999, p = 0.026) and radiotherapy (OR, 0.352; 95% CI, 0.156-0.797, p = 0.012) were independent risk factors for major defecation dysfunction, while a high tumor location (OR, 1.318; 95% CI, 1.151-1.657, p = 0.001) and PFPR (OR, 4.770; 95% CI, 1.435-15.857, p = 0.011) were independent protective factors for major defecation dysfunction. Regarding the assessment of the postoperative defecation function using the LARS score, a multivariate analysis revealed that a high tumor location (OR, 1.293; 95% CI, 1.125-1.486, p < 0.001) and PFPR (OR, 3.010; 95% CI, 1.345-6.738, p = 0.007) were independent protective factors for major defecation dysfunction. A subgroup analysis showed that the postoperative Wexner score (3.13 ± 2.79 vs. 4.71 ± 3.45 p = 0.003) and LARS score (21.77 ± 8.62 vs. 25.14 ± 8.78 p = 0.015) were lower for patients with PFPR than for patients without PFPR. Regarding patients with low rectal cancer, those with PFPR had a lower LARS score than those without it (23.62 ± 8.94 vs. 28.40 ± 7.90, p = 0.022), but there was no significant difference in the Wexner score between the groups. A total of 9.76% of patients with PFPR and 48.89% of those without PFPR showed an intestinal accumulation in the sacral front (p < 0.001). PFPR and a high tumor location are protective factors for postoperative defecation dysfunction in middle and low rectal cancer patients. PFPR can be routinely performed during laparoscopic surgery.

Multifocal diffuse large cell neuroendocrine carcinoma of the colon

Large cell neuroendocrine carcinomas (LCNEC) of the colon are an extremely rare and aggressive type of colorectal cancer. While multifocality is more frequently seen in small intestine NECs, no cases of multifocal NEC of the colon have been reported before. A 69-year-old male patient presented with abdominal pain. Colonoscopy revealed a necrotic-polypoid mass in the sigmoid colon and the biopsy result was reported as malignant epithelial tumor. Laparoscopic anterior resection was performed with the preliminary diagnosis of colon adenocarcinoma. Histopathological examination revealed three polypoid tumors, the largest of which was 4 cm, in the sigmoid colon. Immunohistochemical examination showed positivity for synaptophysin, chromogranin, and CDX2. High Ki67 proliferation index, high mitosis, and widespread p53 expression were observed in all tumors. With these findings, a diagnosis of multifocal large cell NEC was made. To the best of our knowledge, this is the first report describing a case of multifocal large cell NEC of the colon. LCNECs of the colon are very aggressive. Here, we report for the first time a case of multifocal LCNEC. In a short period of 1 month after the surgery, new widespread metastases were detected in the liver. Therefore, these tumors should be followed more closely than usual for early treatment.

Application of the Bioabsorbable Polyglycolic Acid Sheet in Colorectal Anastomosis in Animal Models.

Anastomotic complications after colorectal surgery are one of the most serious outcomes. To address this issue, this study used the newly developed bioabsorbable polyglycolic acid (PGA) sheet to assess its usefulness and safety using two approaches of double stapling technique (DST) after laparoscopic anterior resection (AR) in pig models. Rectal intratissue pressure was assessed after DST anastomosis in two groups, i.e., with (PGA group) or without PGA sheet (nonPGA group), which was sandwiched between the anastomosis in the first approach. In the second approach, after laparoscopic DST anastomosis with PGA sheet attached at anvil side, the clinical short-term outcomes within 1 week and histological findings at 1 week after the surgery were evaluated. Assessment of rectal intratissue pressure showed a mean pressure of 9.28 kPa in the PGA group versus 5.78 kPa in the nonPGA group (p = 0.39). The results of clinical short-term outcomes revealed that there were no anastomotic complications. The results of histological findings in anastomotic bowel tissues with PGA sheet were not significantly different from those of the control case. The bioabsorbable PGA sheet can be used for colorectal DST anastomosis in animal models and may be a valuable tool for this procedure.

Development and Validation of a Machine Learning Model to Predict Low Anterior Resection Syndrome Following Laparoscopic Anterior Resection of Rectal Cancer: A Multicenter Study

Development and Validation of a Machine Learning Model to Predict Low Anterior Resection Syndrome Following Laparoscopic Anterior Resection of Rectal Cancer: A Multicenter Study

Internal hernia following laparoscopic anterior resection for cancer: higher prevalence than expected of an under-reported complication

Internal hernia (IH) after laparoscopic colorectal surgery is a potentially severe complication. It may go undiagnosed in patients having their abdominal CT scan during oncologic follow-up. We evaluated the occurrence of IH on CT scans after laparoscopic curative resection for rectal cancer (LRRC) and routine closure of the mesenteric defect. Data from 189 consecutive patients undergoing elective curative LRRC in a 14-year period (June 2005-june 2019) were prospectively collected. Only patients with abdominal CT scans, performed as routine oncologic follow-up, between 3months and 7years post-operatively were included in the study and reviewed by a surgeon and a radiologist. A total of 161 patients were eligible for the study with a median age of 69years (IQR: 59-77) at surgery. They had abdominal follow-up CT scans at a median of 39.5months (IQR: 12.8-62.7) after surgery. The prevalence of IH was 11.2% (18/161 patients). Of the 18 patients, 15 (83.3%) were fully asymptomatic, 2 (11.1%) reported chronic abdominal discomfort (including mostly nausea and colicky pain) during their oncologic follow-up (however, IH was not suspected neither prompted additional investigations), and 1 (5.6%) was reoperated elsewhere for IH and acute small bowel obstruction. IH following LRRC is not uncommon, with a prevalence > 10% in our experience. Most of these patients remain fully asymptomatic, but in a few patients, IH might be responsible for some symptoms or require reoperation. Awareness of this complication is important, given the potential risk of acute small bowel obstruction.

Preoperative Elemental Diet before Laparoscopic Anterior Resection in Patients with Advanced Stenotic Rectal Cancer.

Objectives: To evaluate the feasibility of our new preoperative enteral nutrition protocol using ElentalⓇ without mechanical bowel preparation (MBP) before laparoscopic anterior resection (LAR) in patients with advanced stenotic rectal cancer. Methods: Among 74 patients with advanced rectal cancer (clinical stages T3 and T4) scheduled to undergo LAR, 42 patients with stenotic rectal cancer were administered ElentalⓇ (900 kcal/day) without MBP before LAR (group S). Thirty-two patients without stenosis (group NS) did not receive preoperative nutritional support but underwent MBP. Results: Group S patients were maintained in a fasting state and received an elemental diet approximately 10 days preoperatively without severe adverse effects. The incidence of postoperative complications (Clavien-Dindo classification ≥ grade 2) was significantly lower in group S than that in group NS (adjusted odds ratio [OR]: 6.046, P = 0.008). Logistic regression analysis revealed that group NS exhibited higher risks of developing postoperative complications than those exhibited by group S (OR: 4.32, 95% confidence interval [CI]: 1.28-17.28, P = 0.018). Among preoperative characteristics, the clinical tumor stage indicated a significant intergroup difference. Thus, the clinical stage was selected as a covariate and adjusted in the logistic regression model to calculate a covariate-adjusted OR. Group NS exhibited a higher incidence of postoperative complications than group S (adjusted OR: 6.05, 95% CI: 1.58-28.35, P = 0.008). Conclusions: Administration of an elemental diet using ElentalⓇ without MBP before LAR is a feasible strategy in patients with advanced stenotic rectal cancer. Application of this research may encourage use of ElentalⓇ in the clinical setting.

Clinical Observation of Preserving Left Colonic Artery in Laparoscopic Anterior Resection of Rectal Cancer

Clinical Observation of Preserving Left Colonic Artery in Laparoscopic Anterior Resection of Rectal Cancer

Efficacy and Safety of Endoscopic Clipping for Acute Anastomotic Bleeding After Colorectal Surgery.

PurposeAnastomotic bleeding after colorectal surgery is a rare, mostly self-limiting, postoperative complication that could lead to a life-threatening condition. Therefore, prompt management is required. This study aimed to evaluate the efficacy and safety of endoscopic clipping for acute anastomotic bleeding after colorectal surgery.MethodsWe retrospectively reviewed the data of patients pathologically diagnosed with colorectal cancer at National Cancer Center, Korea from January 2018 to November 2020, which presented with anastomotic bleeding within the first postoperative week and were endoscopically managed with clips.ResultsNine patients had anastomotic bleeding, underwent endoscopic management, and, therefore, were included in this study. All patients underwent laparoscopic (low/ultralow) anterior resection with mechanical double-stapled anastomosis. Anastomotic bleeding was successfully managed through a colonoscopy with clips on the first trial in all patients. Hypovolemic shock occurred in one patient, following anastomotic breakdown.ConclusionEndoscopic clipping seems to be an effective and safe treatment for anastomotic bleeding with minimal physiologic stress, easy accessibility, and scarce postoperative complications. However, a surgical backup should always be considered for massive bleeding.