Low Anterior Resection Of Rectum Research Articles

LAPAROSCOPY WITHIN MULTIMODAL OPTIMIZATION PROGRAMM IN PATIENTS WITH COLORECTAL CANCER

AIM to assess the efficacy of combination of laparoscopy and protocol of enhanced recovery in patients with colorectal cancer. MATERIALS AND METHODS. Between 2008-2016 466 patients were randomly allocated into 3 groups. Of them 266 of received perioperative treatment according to enhanced recovery protocol, 191 had routibne open procedure (group 2) and, 75 had laparoscopic operation (group 1). Patients underwent the following procedures: right hemicolectomy (n=53), left hemicolectomy (n=32), sigmoidectomy (n=55), abdomeno-perineal excision (n=67) and low anterior resection of rectum(n=201), other operation - 58. The following variables were analized: operating time, intraoperative blood loss, time of first flatus and defecation, morbidity (wound infections, anastomotic leakage, peritonitis, postoperative ileus, urinary disorders, thrombosis, cardiopulmonary complications). RESULTS. Groups were comparable in gender, comorbidities, body mass index, types of operations. Operating time did not differ significantly between 3 groups. Intraoperative blood loss was higher in conventional group. The time offirstflatus and defecation were better in group 1 and 2. Mortality rate was similar. Morbidity was lower in group 1 and 2 compared with conventional group: wound infections 1,3%, 3,1% vs 9%, anastomotic leakage 4%, 5,5% vs 9%, ileus 1,2 vs 5,4%, peritonitis 2,6%, 1,5% and 3,5%, bowel obstruction caused by the adhesions 0%, 6,8% vs 5,5%. Reoperation rate was 4%, 4,7% vs 5,5%, consequemntly. CONCLUSION. Combination of laparoscopic surgery withenhanced recovery program provides better results of treatment.

Robotic Rectal Resection With a Single-docking Technique Thanks to the Rotation of the R3 Arm.

Robotic surgery for rectal resection presents some advantages compared with the traditional technique; however, it also presents some limitations, especially due to the multiple changes of surgical fields. We describe a new technique to perform low-anterior resection using single docking with the rotation of the third arm and our perioperative results. A total of 31 patients who underwent low-anterior rectal robotic resection with single-docking technique using robotic daVinci SI (Surgical Intuitive System) were included in the study. The mean operative time was 338 minutes. The conversion rate was 3%. The mean time of refeeding was 1.4 days and the mean time of hospital stay was 6 days. Our technique allowed to use the robot for all surgical steps with a single docking, thereby reducing the cost of the hybrid technique and facilitating the operative team in the management of the robotic cart.

MOBILIZATION OF SPLENIC FLEXURE DURING RECTAL RESECTION

Background. Splenic flexure mobilization (SFM) is a difficult step within both conventional and laparoscopic procedures, often associated with intra- and postoperative morbidity. Additional difficulties occur because of the lack of generally accepted methods for performing SFM. Despite many reports, the routine SFM during low rectal resections remains controversial. Aim. This paper presents the strategy for SFM used in our clinic, as well as the surgical treatment outcomes in patients who underwent low rectal resections with or without SFM. Methods. Two retrospective analyzes of the surgical procedures were made. In the first case, the results of all LS operations with SFM (n=120) were analyzed. In the second case, a retrospective analysis of the LS rectal resections was carried out (low anterior resection (LAR) with the SFM (n=32), pull-through rectal resection with the SFM (n=20) and LAR without SFM (n=94)). Results. In the first analysis, patients were divided into 4 groups: LS-left colectomy, LS-low anterior rectal resection, LS-colproctectomy, and LSpull-through rectal resection. There was no significant difference between the groups in terms of intra- and postoperative complications. In the second analysis, the differences in the operation time, blood loss and hospital stay between low rectal resections were not statistically significant. Anastomotic leakage was detected in 2 patients in the LAR with SFM group, in 8 patients (8.5 %, 8/94) in LAR without SFM group, and in 1 patient in pull-through rectal resection group (5 %, 1/20), p=0.17. Conclusions. Using the laparoscopic approach to SFM, optimal surgical outcomes can be achieved. Routine SFM during low anterior rectal resection is not necessary, because it does not lead to decreased incidence of anastomotic leakage and complications. Routine SFM during pull-through rectal resection is necessary.

METHOD OF «HIDDEN COLOSTOMY» IN LOW ANTERIOR RESECTIONS OF RECTUM

The authors present their experience, methodology and advantages of the method of «hidden colostomy» in treatment of anastomotic leakage after low anterior resection of rectum. The operations using the method of «hidden colostomy» were performed on 67 patients. All the patients underwent the low anterior resection of rectum operation concerning cancer with anastomosis formation at the distance of 3-8 cm from anus. The leakage of rectal anastomosis was revealed in 6 (8,9%) patients. A delayed double-barrel transverse stoma using preventive turnpike was formed in surgical dressing room without typical relaparotomy according to described method. Continuity of large intestine was restored in all patients during 2 months after operation. The method of «hidden colostomy» allowed doctors to avoid formation of vain protective intestinal stoma. This method helped to treat patients in a very simple and effective way in case of leakage of colorectal anastomosis.

The Use of Robotic and Laparoscopic Surgical Stapling Devices During Minimally Invasive Colon and Rectal Surgery: A Comparison

To date there exists no published study examining the safety and efficacy of the EndoWrist 45 (Intuitive Surgical, Inc.) robotic stapler. We compared outcomes between the robotic and comparable laparoscopic stapler in robotic-assisted colorectal procedures. We conducted a retrospective review of 93 patients who underwent robotic-assisted colorectal surgery at our institution from 2012 to 2014. Surgeries included left, sigmoid, subtotal and total colectomies, and low anterior rectal resections. Indications were malignancy and diverticular and inflammatory bowel disease. Preoperative demographics, intraoperative data, and postoperative outcomes were examined. Student's t-test and Fischer's exact used were appropriate. Forty-five millimeters laparoscopic staplers were used in 58 cases, while the 45 mm robotic stapler was used in 35 cases. There was no difference in age (P = .651), gender (P = .832), or body mass index (P = .204) between groups. There was no difference in estimated blood loss (P = .524), operative time (P = .769), length of stay (P = .895), or complication rate (P = .778). The robotic stapler group had one anastomotic leak, while the laparoscopic stapler group had six (P = .705). There were more laparoscopic stapler fires (2.69) per patient than robotic stapler fires (1.86) (P = .001). The cost per patient for the laparoscopic group was $631.45 versus $473.28 for the robotic group (P = .001). This is the first study to evaluate the robotic stapler. Advantages of the robotic stapler include large range of motion and 90° of articulation, which may provide a benefit when using the stapler in difficult areas like the pelvis. The robotic stapler has a comparable level of safety as a 45 mm laparoscopic stapler and is more cost effective.

Benefit of extraperitonization to prevent septic intraabdominal complications after distal rectal cancer surgery

Colorectal cancer is one of the most common oncological diseases. Surgery is the main treatment modality and laparoscopic colorectal resection has been gaining popularity over the past two decades. Neoadjuvant therapy is considered standard treatment for 2nd and 3rd stage distal rectal cancer. We present our retrospective study of 127 patients with anterior rectum resection (ARR) and total mesorectal excision (TME) for low rectal cancer operated on between 2012 and 2015 in two surgical wards. In all 59 laparoscopic ARR neoadjuvant therapy, intraabdominal drainage and ileostomy was performed, while extra-peritonization was done in 21 and no pre-sacral drainage was used. In the conventional group of 68 ARR, 21 had neo-adjuvant therapy, everyone has had extra-peritonization, pre-sacral drainage and no protective ileostomy performed. Early postoperative complications were registered in 25 patients, 24 related to the operation and 1 due to a recurrent brain stroke, all classified from I to III by Clavien Dindo scale. There were 9 anastomosis insufficiences: 6 in conventional and 3 in laparoscopic operations. In 3 patients (2 conventional and 1 laparoscopic) with low ARR and signs of peritoneal contamination re-laparotomy was performed with successive outcome. All patients survived. Our routine practice of extra-peritonization and pre-sacral-perianal drainage in open ARR eliminate the possibility of postoperative peritonitis after anastomosis insufficiency, limiting the infection to low pelvic phlegmona and local intra-abdominal pelvic infection in overlooked cases.

Conservative Management using the Triple Approach and the Rouen Technique in Large Deep Rectovaginal Endometriosis

Background Colorectal resection is performed in numerous patients presenting with large endometriosis of mid and lower rectum; however, it may lead to low anterior rectal resection syndrome. To avoid such outcomes, we propose an original technique combining vaginal excision of infiltrated vaginal cul de sac, laparoscopic deep rectal shaving and transanal disc excision using a semi-circular stapler: the Rouen technique. Methods The video presents the procedure performed in a 31-year-old nullipara referred with a large endometriotic nodule infiltrating the vaginal posterior cul de sac and the anterior wall of the mid rectum on more than 30 mm length responsible for symptomatic stenosis. The first step of the procedure is represented by the excision of vaginal infiltration using a vaginal approach. The second step includes a laparoscopic deep rectal shaving performed using exclusively the plasma energy. Then, transanal excision is performed from rectal approach, by placing traction parachute sutures on the shaved area. Their traction induces the prolapse of shaved rectal wall that is resected using a semi-circular stapler. Results Operative time was 140 min. Immediate postoperative outcomes were uneventful. One year after the surgery, the patient reported one stool/day, without dyskesia, normal anal continence and no deep dsypareunia. To date, the Rouen technique was successfully carried out in 42 women with large deep endometriosis of the mid and lower rectum. Conclusions The Rouen technique is feasible and reproducible in large mid and lower rectal endometriosis and might avoid the risk of unfavourable outcomes related to low colorectal resection.

Surface Electromyography Reliably Records Electrophysiologically Evoked Internal Anal Sphincter Activity: A More Minimally Invasive Approach for Monitoring Extrinsic Innervation

Background: Even in the case of minimally invasive pelvic surgery, sparing of the autonomic nerve supply is a prerequisite for maintaining anal sphincter function. Internal anal sphincter (IAS) innervation could be electrophysiologically identified based on processed electromyographic (EMG) recordings with conventional bipolar needle electrodes (NE). This experimental study aimed for the development of a minimally invasive approach via intra-anal surface EMG for recordings of evoked IAS activity. Methods: Six male pigs underwent nerve-sparing low anterior rectal resection. Electric autonomic nerve stimulations were performed under online-processed EMG of the IAS. EMG recordings were simultaneously carried out with conventional bipolar NE as the reference method and newly developed intra-anal surface electrodes (SE) in different designs. Results: In all experiments, the IAS activity could be continuously visualized via EMG recordings based on NE and SE. The median number of bipolar electric stimulations per animal was 27 (range 5-52). The neurostimulations resulted in significant EMG amplitude increases for both recording types [NE: median 3.0 µV (interquartile range, IQR 2.8-3.5) before stimulation vs. 7.1 µV (IQR 3.9-13.8) during stimulation, p < 0.001; SE: median 3.6 µV (IQR 3.1-4.3) before stimulation vs. 6.8 µV (IQR 4.8-10.3) during stimulation, p < 0.001]. Conclusions: Intra-anal SE enabled reliable EMG of electrophysiologically evoked IAS activity similar to the conventional recording via NE. The transfer of the method to access platforms for transanal total mesorectal excision or robotics may offer a practical more minimally invasive approach for monitoring extrinsic innervation.

Robotic Rectal Cancer Surgery

The oncological outcome of patients with rectal cancer has improved considerably over the past few decades. This is mainly due to the introduction of the surgical concept of total mesorectal excision (TME) and the implementation of multimodal treatment strategies. Additionally, it has recently been demonstrated that the oncological results of open and laparoscopic TME are comparable. For some time there has been an ongoing debate on the potential relevance of robotic assistance systems in visceral surgery. The aim of this study was to evaluate the operative and perioperative outcomes of patients with rectal or rectosigmoid cancer, who were operated on using the Da Vinci Surgical System. We retrospectively analysed the outcomes of 202 consecutive patients, who were operated between September 2010 and November 2015 in three Surgical Centers. The cohort consisted of 136 men and 66 women with a mean BMI of 28. We performed the following procedures: 49 anterior rectal resections, 119 low anterior rectal resections, and 34 abdominoperineal excisions. Conversion to an open procedure was required in 13 patients. Non-surgical complications (n = 27) occurred in 24 patients (12%) and surgical complications (n = 67) in 62 patients (31%). Most complications were due to abdominal or sacral wound infections (n = 25) and anastomotic leaks (n = 18). The mortality rate within 30 days was 2%. The rate of R0 resections was 95%, with circumferential resection margins being negative in 98% of the patients. The quality of the mesorectal resection was scored as good in 91% of the patients. The Da Vinci Surgical System can be used safely and with a low complication rate for surgical treatment of rectal cancer. While primary evidence suggests that the outcome of robotic-assisted surgery is comparable with open and laparoscopic surgery, its definitive value has to be determined upon publication of the prospective randomized ROLARR trial. The main advantages of the Da Vinci system are its endowristed instruments with multiple degrees of freedom and its optimised visualisation (3D, stable camera platform controlled by the surgeon). Another positive feature is the significant ergonomic advantage for the surgeon.

THE FEASIBILITY OF FAST TRACK PROTOCOL FOR ELDERELY PATIENTS WITH COLORECTAL CANCER

Fast track protocol is widely used in major colorectal surgery. It decreases operative stress, shortens hospital stay and reduces complications rate. However feasibility and safety of this approach is still controversial in patients older than 70 years. The AIM of the study was to estimate the safety and effectiveness of fast track protocol in elderly patients with colorectal cancer. MATERIALS AND METHODS. Prospective randomized study included 138 elective colorectal resectionfor cancer during period from 1.01.10 till 1.06.15. The main criteria for the patients selection were age over 70 years and diagnosis of colorectal cancer. 82 of these patients received perioperative treatment according to fast track protocol, other 56 had conventional perioperative care. Patients underwent following procedures: right hemicolectomy (n=7), left hemicolectomy (n=12), transverse colectomy (n=1), sigmoidectomy (n=23), abdomeno-perineal excision (n=19) and low anterior resection of rectum (n=76). Following data were analized: duration of operation, intraoperative blood loss, time offirst flatus and defecation, complications rates. RESULTS. Mean age was 77,4 ± 8 years. There were no differences in gender, co morbidities, body mass index, types of operations between groups. Duration of operations didn't differ significantly between 2 groups. Intraoperative blood loss was higher in conventional group. The time of first flatus and defecation were better in FT-group. There was no mortality in FT-group vs 1,8 %o mortality in conventional group. Complications rate was lower in FT-group: wound infections 3,6% vs 9 %, anastomotic leakage 4,8 %o vs 9 %o, ileus 1,2 vs 5,4 %o, peritonitis 2,4 %o vs 3,6%o, bowel obstruction caused by the adhesions 6 % vs 5,3 %. Reoperation rate was similar 4,8 % vs 3,6 %. CONCLUSION. Fast track protocol in major elective colorectal surgery can be safely applied in elderly patients. The application of fast track protocol in elderly patients improves the restoration of bowel function and reduces the risk of postoperative complication.

Rectal neuroendocrine tumors: surgical therapy

The incidence of rectal neuroendocrine tumors (NET) has increased in recent years. Most of these neoplasms are asymptomatic and are diagnosed by colonoscopy screening, which could be one of the reasons for the increasing occurrence. As less than 1 % of rectal NET produce serotonin they are practically never discovered due to a carcinoid syndrome. The current guidelines of the European (ENETS) and North American (NANETS) Neuroendocrine Tumor Societies support clinicians with useful diagnostic and treatment algorithms. The most important criteria for therapy are tumor size and histopathological risk factors for metastases. For well-differentiated rectal neuroendocrine neoplasms < 1cm, local endoscopic or surgical excision is recommended. Due to the lack of evidence tumors sized 1-2cm represent a grey area for prognosis and treatment. All NET > 1.5cm must be excised by radical surgery as low anterior rectal resection or abdominoperineal extirpation with total mesorectal excision (TME). Resectable liver and lung metastases of well-differentiated NETs should be surgically treated with curative intent.

Gastrointestinal Stromal Tumor of the Rectum Diagnosed by Prostate Needle Biopsy: Report of a Case

A 52-year-old man was referred to our institution with the presentation of rectal bleeding, and change in caliber of his stools. On rectal examination a solid mass was palpated in the prostate area. Transrectal needle biopsy and cytology showed a gastrointestinal stromal tumor. Subsequent rectal ultrasound demonstrated a hypoechogenic lesion that appeared to be growing out of the muscularis propria of the anterior rectal wall. Magnetic resonance imaging showed a well demarcated mass measuring 9 cm in diameter, which occupied the cavity of the lesser pelvis. A low anterior rectal resection with protective ileostomy was performed. The macroscopic findings showed the tumor measuring 9 cm, growing from the anterior wall of the rectum. Histological examination of the excised specimen revealed up to 5 mitoses per 50 high-power fields. The postoperative course was uneventful and ileostomy was closed after six weeks. Magnetic resonance imaging on follow-up five years postoperatively showed no signs of recurrence.

The new approach to the rectal cancer: 'down-to-up' double endolaparoscopic pelvic access. Preliminary evaluation of outcomes.

Laparoscopic access in low anterior rectal resection is widely adopted, performing an 'up-to-down' dissection. The aim of this study is to present and analyze the outcomes of a novel surgical 'down-to-up' total mesorectal excision technique that could obviate to the well-known issues of the standard treatment. 18 suitable patients underwent double endolaparoscopic pelvic access (DEPA) 'down-to-up' technique. DEPA TME was completed in all patients, with intact mesorectum. Mean operative time was 365 min (range 280-510 min). The morbidity rate was 22%, including three radiologically detected leakage (grade A) and one pelvic abscess, requiring only a conservative management. Mortality rate at 30 and 90 days was 0%. Resection margins were negative in all patients. A median of 11 nodes (range 5-19) was retrieved per specimen. Mean length of hospital stay was 9 days (range 7-19 days). Patients were followed for an average of 14 months (range 0-42 months), with no recurrence. Despite exiguous patient's sample in this pilot study, transanal endoscopic TME with laparoscopic assistance seems to be feasible and safe, and is a promising alternative to open and laparoscopic TME. However, a conspicuous functional and oncologic long-term evaluation is required, before the widespread adoption could be recommended.

SIDE-TO-END ANASTOMOSIS IN LOW ANTERIOR RECTAL RESECTION

The authors have launched a prospective randomized study aimed to make a comparison of functional results of formation of straight coloanal (control group) and side-to end (main group) anastomosis in case of low anterior rectal resection since 2012. Each group consisted of 40 patients undergoing operation concerning uncomplicated rectal cancer of medium-ampullar section of rectum. It was noted that patients of the main group had lower stool frequency in postoperative period. A function of the interior sphincter was less damaged and the rate of compliance of rectum was high.

Meta-analysis of defunctioning stoma in low anterior resection with total mesorectal excision for rectal cancer: evidence based on thirteen studies.

BackgroundRecent studies have shown that a protective stoma can reduce morbidity in low anterior resection for rectal cancer; however, the necessity of it is still controversially discussed.MethodsWe performed this meta-analysis to provide a comprehensive evaluation of the role of defunctioning stoma in low anterior resection for rectal cancer on the rates of anastomotic leakage and reoperation related to leakage with or without defunctioning stoma by calculating the pooled risk ratio.ResultsStudies and relevant literature published between 2004 and 2014 regarding the construction of a protective stoma after low anterior resection were searched though PubMed and EMBASE databases. Finally, a total of 13 studies including 8,002 patients were included in this meta-analysis. The results indicated that protective stomas significantly reduced the rate of postoperative anastomotic leakage and reoperation after low anterior rectal resection. The pooled risk ratios were 0.47 (95% CI: 0.33–0.68, P <0.0001) and 0.36 (95% CI: 028–0.46, P <0.00001), respectively.ConclusionsThe findings from this present meta-analysis suggest that a defunctioning stoma could effectively reduce the clinical consequences of anastomotic leakage and reoperation, it is recommended in patients undergoing low rectal anterior resection for rectal cancer.

The Functional Outcomes of Coloanal and Low Colorectal Anastomoses with Reservoirs after Low Rectal Cancer Resections

Nearly half of patients undergoing low anterior rectal cancer resection have a functional sequelae after straight coloanal or low colorectal anastomoses (SA), including low anterior rectal resection syndrome, which combines stool fragmentation, urge incontinence, and incontinence. SA are responsible for anastomotic leakage rates of 0 to 29.2 per cent. Adding a colonic reservoir improves the functional results while reducing anastomotic complications. These colonic reservoir techniques include the colonic J pouch (CJP), transverse coloplasty (TC), and side-to-end anastomosis (STEA) procedures. The aim of this literature review was to compare the functional outcomes of these three techniques from a high level of evidence. CJP with a 4- to 6-cm reservoir is a good surgical option because it reduces functional impairments during the first year, and probably up to 5 years, but is not always feasible. TC appears to perform as well as CJP, is achievable in over 95 per cent of patients, but still with some doubts about a higher anastomotic leakage rate and worse functional outcomes. STEA appears equivalent to CJP in terms of morbidity and even better functional outcomes. STEA, with a terminal side segment size of 3 cm, is feasible in the majority of nonobese patients, combines good functional results, has low anastomotic leakage rates, and is easy to complete.

SINGLE PORT LAPAROSCOPIC SURGERY FOR RIGHT COLON CANCER CAUSE ANALYSIS FOR CONVERSION TO LAPAROTOMY

Purpose: Analysis about disease, technical characteristics of 17 right colon cancer patients underwent conversion to laparotomy from single port laparoscopic surgery and propose related factors for indications. Methold: Consist of 17 colon cancer patients, who were conversion to laparotomy from single port laparoscopic colectomy at Hue Central Hospital from october 2010 to august 2014. Results: Mean age 61.3±14.2 years, rate male/female 11/6. Tumor invasion: T2 11.8%, T3 58.8%, T4 29.4%. Mean tumor size on CT 6.5±2.2cm. The causes of conversion: very big tumors 29.4%, invasive-adhesive tumors 47.1%, extended surgery 23.5%. Open procedures: right hemicolectomy 70.6%, right hemicolectomy plus cholecystectomy 5.9%, right hemicolectomy plus wedge-shape duodenectomy 11.8%, right hemicolectomy plus intestinal segmentectomy 5.9% and right hemicolectomy plus low-anterior rectal resection, hysterectomy 5.9%. Conclusion: Conversion to laparotomy from single port laparoscopic colectomy is necessary for very big tumors, excessive tumor adhesions and exceed the technical limitations of laparoscopic dissection. Key words: Single incision laparoscopic colectomy (SILC), single port laparoscopic colectomy (SILC), conversion to laparotomy.

Intraoperative Monitoring of Bladder and Internal Anal Sphincter Innervation: A Predictor of Erectile Function following Low Anterior Rectal Resection for Rectal Cancer? Results of a Prospective Clinical Study

Background: The objective was to investigate whether two-dimensional intraoperative neuromonitoring (IONM) of pelvic autonomic nerves has the potential to predict erectile function (EF) following surgery for rectal cancer. Methods: A consecutive series of 17 sexually active male rectal cancer patients undergoing IONM-based nerve-sparing low anterior rectal resection were evaluated prospectively. IONM was performed by electric stimulation of the pelvic splanchnic nerves with concomitant electromyography of the internal anal sphincter and cystomanometry. Sexual function was assessed using a validated questionnaire. Results: The degree of agreement between electromyography-based and cystomanometry-based IONM with postoperative EF was moderate and good (κ = 0.43 and κ = 0.66). Combined assessment yielded the best agreement (κ = 0.76) with sensitivity of 90%, specificity of 86%, positive predictive value of 90%, negative predictive value of 86%, and overall accuracy of 88%, respectively, in terms of prediction of postoperative EF. Conclusion: The method may be suitable to predict male EF following rectal resection.

Extended Low Hartmann Operation with Total Mesorectal Excision - Optimal Surgical Treatment in Stage IV Mid and Upper Rectal Cancer

Background: The main surgeries that can be performed in upper and mid rectal cancer are low anterior rectal resection (LAR), lateral colostomy (LC), and extended Hartmann operation with mesorectal excision (EHO). Compared to lateral colostomy, EHO is a curative surgery; it also takes a shorter time to perform and has a lower mortality compared with LAR. Objective: The aim of this study was to analyze the postoperative surgical complications in patients who underwent LAR, LC, or EHO. Methods: The study is a prospective analysis based on a Surveillance protocol for patients with liver metastases of colorectal origin used in First Surgical Oncology Unit, Regional Institute of Oncology IaAŸi, Romania. The postoperative complications occurring within 60 days postoperatively were analyzed. Results: In the interval June 2012 – May 2014, 87 patients were diagnosed with upper and mid-rectal cancer and liver metastases; LAR was performed in 18 patients, LC in 19 patients and in 50 patients EHO with pelvic drainage abdominally exteriorized or perineally (37 and 13 patients, respectively). The postoperative complications related to surgical wound, stoma, pelvic abscess, postoperative bleeding, prolonged postoperative ileus, anastomotic leakage, reinterventions, readmissions, and mortality were analyzed. A higher rate of pelvic abscesses was found in EHO patients (24%, n=12), of which 9 patients (18%) required reinterventions for drainnage of pelvic fluid collection; all these patients had pelvic drainage exteriorized abdominally. No presacral abscesses were recorded in patients with pelvic drainage exteriorized perineally. Conclusions: Extended Hartmann Operation (EHO) remains a safe technique, that shares some indications with LAR and LC; however, it is associated with a higher percentage of pelvic abscesses and reinterventions that can be avoided by postoperative perineal drainage of the presacral space

Endoscopic Tattooing to Mark Distal Margin for Low Anterior Rectal and Select Sigmoid Resections

Obtaining a reliable distal margin during anterior colorectal resection can be difficult. In this study, endoscopic transmural tattoos were placed to mark the distal transection point in patients with distal colorectal neoplasms who undergo bowel resection. In the operating room, before surgery, sigmoidoscopy is performed with a 2-channel scope using CO₂ insufflation. Through channel 1, a biopsy forceps, marked 5 cm from its end, is inserted to the tumor's distal edge; in channel 2, a sclerotherapy catheter is placed. The scope is then withdrawn and forceps inserted at the same rate until the mark is seen, next, via the needle catheter, 4 tattoos are placed at that level circumferentially. After rectal mobilization, visible external tattoos guide stapler placement. If no tattoo is seen, sigmoidoscopy is done and the tattoos used to guide stapler placement. In all 27 patients, the tattoos guided stapler placement; tattoos were seen via the abdomen in 26 and the stapler placed as per tattoos in 25. In 2 patients, repeat endoscopy was done and tattoos used to guide or confirm stapler placement. The margin was ≤1 cm from target in 74% while in 22% the margin was 2 to 3.5 cm off target (mean deviation from target margin = 0.33 cm). In conclusion, this method facilitates stapler placement and provides more reliable margins.