Low Anterior Resection Of Rectum Research Articles

‘Folfirinox’ chemotherapy combined with contact x-ray brachytherapy 50 kVp and ‘CAP50’ chemoradiotherapy aiming at organ preservation for selected intermediate distal-middle cT2-T3 rectal cancers: A feasibility study

PurposeThe standard treatment of T2–T3 rectal adenocarcinoma is radical proctectomy by total mesorectal excision often combined with some neoadjuvant treatment. To reduce morbidity of this surgery, organ preservation strategy using various combination of radiotherapy, chemotherapy and local excision is gaining interest. Some randomized trials have proven the feasibility of such approaches. The OPERA trial demonstrated, for T2 T3<5cm diameter low-middle rectum, that a contact X-ray brachytherapy boost of 90Gy in three fractions over 4 weeks was able to achieve a planned organ preservation in 81% of patients at 3years with 97% success for tumour smaller than 3cm treated with contact X-ray brachytherapy boost first. To try to expand organ preservation to larger tumours we set up a feasibility trial in T2–T3 tumours using total neoadjuvant treatment and a contact X-ray brachytherapy boost. Material and methodThe trial was approved by the institutional review board of Nice. Inclusion criteria were operable patients, 75years or less, adenocarcinoma of the low-middle rectum staged T2c-T3N0 larger than 3.5cm and less than 6cm in diameter or T2-T3N1 less than 6cm in diameter. Treatment started in all cases with neoadjuvant chemotherapy associating 5-fluoro-uracile, irinotecan and oxaliplatin (‘folfirinox’ regimen, four to six cycles). In case of good tumour response after four cycles, a contact X-ray brachytherapy boost (delivering 90Gy in three fractions) was given followed by chemoradiotherapy (external beam radiotherapy delivering 50Gy, with concurrent capecitabine). After six cycles if only a partial response (tumour still larger than 3cm) was seen, chemoradiotherapy was given and contact X-ray brachytherapy boost was delivered after that. At the end of this total neoadjuvant treatment a watch and wait strategy was decided in case of clinical complete response or radical proctectomy by total mesorectal excision for partial response. ResultsBetween July 2019 and October 2022, 14 patients were included; median age was 66years (range: 51–77years), there were nine male and five female, two T2 N1 tumours, seven T3N0, and five T3N1, all were M0. Median tumour diameter was 40mm (range: 11–50mm); three tumours had a circumferential extension greater than 50%. Seven patients received four folfirinox cycles and seven had six cycles. Contact X-ray brachytherapy boost was given during folfirinox chemotherapy before chemoradiotherapy in 11 patients (and after in three). The tolerance was good, with no grade 4–5 toxicity. The main grade 3 early toxicity was in relation with the folfirinox regimen. A clinical complete response was seen in 12 patients at the end of the total neoadjuvant treatment (85%). All these patients are alive and have preserved their rectum with a mean follow-up time of 17.8months (range: 6–48months) and a good bowel function (low anterior rectal resection syndrome score below 30). The main contact X-ray brachytherapy boost toxicity was radiation ulceration in three patients that usually healed within 6 months, sometimes necessitating hyperbaric oxygen. ConclusionThe preliminary results of this feasibility study show that early tolerance of these intensive total neoadjuvant treatment is compatible with an acceptable toxicity. The high rate of organ preservation in this intermediate group of T2–T3 tumours is encouraging and is a good argument to start the next randomized TRESOR trial that will aim at achieving a 65% of 3-year survival with organ preservation in this intermediate tumour group.

Biofeedback combined with percutaneous electrical pudendal nerve stimulation for the treatment of low anterior rectal resection syndrome: a study protocol for a randomized controlled trial

BackgroundLow anterior resection syndrome (LARS) is a distressing condition that affects approximately 25–80% of patients following surgery for rectal cancer. LARS is characterized by debilitating bowel dysfunction symptoms, including fecal incontinence, urgent bowel movements, and increased frequency of bowel movements. Although biofeedback therapy has demonstrated effectiveness in improving postoperative rectal control, the research results have not fulfilled expectations. Recent research has highlighted that stimulating the pudendal perineal nerves has a superior impact on enhancing pelvic floor muscle function than biofeedback alone. Hence, this study aims to evaluate the efficacy of a combined approach integrating biofeedback with percutaneous electrical pudendal nerve stimulation (B-PEPNS) in patients with LARS through a randomized controlled trial (RCT).Methods and analysisIn this two-armed multicenter RCT, 242 participants with LARS after rectal surgery will be randomly assigned to undergo B-PEPNS (intervention group) or biofeedback (control group). Over 4 weeks, each participant will undergo 20 treatment sessions. The primary outcome will be the LARS score. The secondary outcomes will be anorectal manometry and pelvic floor muscle electromyography findings and the European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire-Colorectal 29 (EORTC QLQ-CR29) scores. Data will be collected at baseline, post-intervention (1 month), and follow-up (6 months).DiscussionWe anticipate that this study will contribute further evidence regarding the efficacy of B-PEPNS in alleviating LARS symptoms and enhancing the quality of life for patients following rectal cancer surgery.Trial registrationChinese Clincal Trials Register ChiCTR2300078101. Registered 28 November 2023.

The impact of anastomotic leakage on the quality of life of patients after surgery for rectal cancer

AIM: to assess the impact of colorectal anastomotic leakage on the severity of low anterior rectal resection syndrome and the quality of life.PATIENTS AND METHODS: the results of 375 patients with rectal tumors were analyzed. In 26 patients, surgery was complicated by anastomosis failure. For a assessment of the quality of life of patients with anastomotic leakage, each patient was matched with a pair from the group of respondents with an uncomplicated postoperative period. The quality of life was assessed in all patients using the EORTC QLQ-C30 questionnaire with the Cr-29 module.RESULTS: patients with anastomosis leakage have more severe low anterior rectal resection syndrome — 29 (17;34), versus 20 (9;28) points (p = 0.03) and a lower global score (p = 0.01), physical (p = 0.01) and social (p = 0.04) functioning. The symptom scales of the EORTC QLQ-C30 questionnaire, supplemented by the Cr-29 module, had significant differences between groups on the scales of body image (p = 0.01), fecal incontinence (p = 0.04) and embarrassment (p = 0.01).CONCLUSION: colorectal anastomosis leakage negatively affects the quality of life of patients.

Cytomegalovirus infection as a rare cause of colitis.

A 62 year-old-man with low anterior rectal resection and protective ileostomy, for low rectal neo and neoadjuvant QT +RT. Then ileostomy closure without incidences. On the 3rd postoperative day, he started with fever peaks and diarrhea. An abdominal CT scan showed diffuse thickening of the wall of the descending colon compatible with colitis and colonoscopy showed deep rectal ulcers with punch-like morphology with hyperemic mucosa with erythematous stippling of erosive appearance, showing this ulcerative pattern with numerous lesions and intensely edematous and congestive mucosa covered with abundant fibrinopurulent exudate in the descending colon. Biopsies and stool cultures were negative, but serologies were positive for CMV. Suspected CMV infection in a immunosuppressed by chemotherapy patient, he was treated with ganciclovir. The patient presented clinical improvement, without fever or diarrhea and improvement of the punch ulcers in the endoscopic controls, so he could be discharged from the hospital with follow-up in the outpatient consulting offices.

Evaluation of the advantage of surgeons certified by the endoscopic surgical skill qualification system participating in laparoscopic low anterior rectal resection.

A technical qualification system was developed in 2004 by the Japan Society for Endoscopic Surgery. An analysis of the EnSSURE study on 3188 stage II-III rectal cancer patients, which was performed by including the participation of qualified surgeons as assistants and advisers without restricting their participation as operators, revealed that the participation of technically qualified surgeons in surgery improved the technical and oncological safety of laparoscopic rectal resection. This secondary retrospective analysis of the EnSSURE study examined the advantage of qualified surgeons participating in laparoscopic low anterior resection (LAR). The outcomes of low anterior resection were compared between groups with and without the participation of surgeons qualified by the Endoscopic Surgical Skill Qualification System (Q and non-Q groups, respectively). We used propensity score matching to generate paired cohorts at a one-to-one ratio. The postoperative complication rate, short-term results (hemorrhage volume, operative time, number of dissected lymph nodes, open conversion rate, intraoperative complication rate, and R0 resection rate), and long-term results (disease-free survival rate, local recurrence rate, and overall survival rate) were evaluated. The frequencies of postoperative complications, anastomotic bleeding, and intraperitoneal abscess were significantly lower, the operative time was significantly shorter, the postoperative hospital stay was significantly shorter, and the number of dissected lymph nodes was higher in the Q group. No significant differences were observed in disease-free survival, local recurrence, or overall survival rate rates between the groups. The participation of qualified surgeons in LAR is technically advantageous.

Feasibility and safety of specimen extraction via an enlarged (U-Plus) skin bridge loop ileostomy: a single-center retrospective comparative study.

To investigate the feasibility and safety of specimen extraction via an enlarged (U-Plus) skin bridge loop ileostomy. A retrospective analysis of 95 patients with rectal cancer who underwent laparoscopic low anterior rectal resection and skin bridge loop ileostomy between August 2018 and August 2022, including 44 patients with specimen extraction via an enlarged (U-Plus) skin bridge loop ileostomy (experimental group) and 51 patients with specimen extraction via an abdominal incision (control group). Following the application of propensity score matching (PSM), 34 pairs of data were successfully matched. Subsequently, a comparative analysis was conducted on the clinical data of the two groups. The experimental group exhibited significantly better outcomes than the control group in various aspects. Specifically, the experimental group had lower values for average operative time (P < 0.001), estimated blood loss (P < 0.001), median length of visible incision after surgery (P < 0.001), median VAS pain score on the first day after surgery (P = 0.015), and average postoperative hospitalization (P = 0.001). There was no statistical significance observed in the incidence of stoma-related complications in both groups (P > 0.05). Within each group, the stoma-QOL scores before stoma closure surgery were significantly higher than those at one month and two months after the surgery, with statistical significance (P < 0.05). Specimen extraction via a U-Plus skin bridge loop ileostomy is a safe and feasible method that shortens operation time and postoperative visual incision length, decreases estimated blood loss, and reduces patient postoperative pain compared with specimen extraction via an abdominal incision.

Clinical application of a novel stent-assisted in situ intestinal bypass in preventing postoperative anastomotic leakage for low-mid rectal cancer: A retrospective study.

This study aimed to investigate the safety and feasibility of a novel stent-assisted in situ intestinal bypass for low-mid rectal cancer patients. Patients who were diagnosed with rectal cancer and received laparoscopic low anterior rectal resection plus a novel stent-assisted in situ intestinal bypass were respectively included from March 2022 to June 2022. Biofragmentable intestinal stent with a protective sleeve was placed in the proximal colon before anastomosis, and feces could be discharged through the protective sleeve without touching the anastomosis, which achieved an in situ bypass of feces. Perioperative characteristics and short-term outcomes were collected. Rectal imaging was performed each week after surgery for the first 3 weeks to surveil the stent and feces delivery. Follow-ups were conducted for more than 3 months. Thirty patients who successfully received surgery were included in this study. There were 18 (60.0%) males and 12 (40.0%) females. As for perioperative characteristics, operation time was 213.8 ± 43.0 minutes, blood loss was 53.3 ± 24.6 mL, time to first flatus via protective sleeve after surgery was 3.2 ± 1.1 days, postoperative hospital stay was 11.8 ± 1.6 days, and time to discharge stent was 22.4 ± 3.2 days. As for short-term outcomes, 6 patients suffered from pneumonia, urinary tract infection or incision infection. During the follow-up, there was no anastomotic leakage or mortality. This novel stent-assisted in situ intestinal bypass is safe and feasible, it might be an applicable way to prevent postoperative anastomotic leakage for patients with low-mid rectal cancer.

A case of one‐stage laparoscopic drainage and ureterocystoneostomy for iatrogenic ureteral injury associated with infected urinoma

IntroductionIatrogenic ureteral injury is a rare but often encountered complication of abdominal and gynecological surgery. This is a case of iatrogenic ureteral injury with infected urinoma treated with one‐stage laparoscopic drainage and ureterocystoneostomy.Case presentationAn 80‐year‐old man with rectal cancer had robot‐assisted low anterior rectum resection and left lateral lymph node dissection after colostomy and preoperative chemoradiotherapy. On the 14th postoperative day, he had a fever, and a noncontrast‐enhanced computed tomography scan revealed a low‐density polycystic area in the left pelvic cavity. Retrograde pyelography revealed contrast medium leaking from the left lower ureter, preventing ureteral stent placement. We identified it as a delayed ureteral injury with infected urinoma and performed laparoscopic one‐stage drainage and ureterocystoneostomy.ConclusionThis study reported a case of one‐stage laparoscopic drainage and ureterocystoneostomy for iatrogenic ureteral injury with infected urinoma.

Does robotic TME bring difference in lymph node yield and quality of TME?

Oncological outcomes of the robotic low anterior rectal resection with total mesorectal excision (TME) are still under discussion. Few studies have proven that robotic TME (rTME) is a safe and equivalent method for treatment of rectal carcinoma. But there is almost no comparison between the rTME and conventional TME in terms of the number of lymph nodes obtained and the quality of the TME. A single institution retrospective study was designed in a cohort of 261 patients. Cohort was divided into two groups depending on the type of surgery (rTME versus TME) and within these two groups, patients were divided according to whether they underwent neoadjuvant chemoradiation (nCHRT) or did not. The primary objective of the study was to compare obtained number of the lymph nodes in specimen. Secondary objectives were comparison of the quality of the TME and the number of positive circumferential resection margins. Results of the study have shown no significant difference in number of the lymph nodes obtained by the rTME and TME. There was no difference in the quality of the TME, neither in the group with the previous nCHRT nor in the group without a nCHRT. With results from the study we consider the rTME to be non-inferior to the conventional TME. Therefore, at least identical oncological results can be expected in patients treated by the rTME.

Possible Advantages of Minimal-Invasive Approaches in Rectal Cancer Surgery: A Nationwide Analysis.

(1) Background: Laparoscopic resection for colon and rectal cancer was introduced in the early 1990s; the aim of this analysis was to show possible advantages of minimal-invasive approaches in rectal cancer surgery. (2) Methods: From 2016 to 2020, all patients undergoing open, laparoscopic or robotic-assisted rectal cancer surgery in Germany were retrospectively analyzed regarding sex distribution, conversion rates and in-hospital mortality rates according to nationwide hospital billing data based on diagnosis-related groups (DRGs). (3) Results: In total, 68,112 patients were analyzed, and most commonly, low anterior rectal resections with primary anastomosis (n = 25,824) were performed with an increase of minimal-invasive procedures over the years (open: 51% to 27%; laparoscopic: 47% to 63% and robotic: 2% to 10%). In-hospital mortality rate was 2.95% (n = 2012). In total, 4.61%, 1.77%, 1.14% and 3.95% of patients with open, laparoscopic, robotic and converted-to-open surgery died during hospital stay, respectively (open vs. laparoscopic p < 0.0001; open vs. robotic p < 0.00001; laparoscopic vs. robotic p = 0.001). Conversion rates were significantly more favorable in the robotic compared to the laparoscopic group. (11.94% vs. 2.53%; p < 0.0001). (4) Conclusion: Minimal-invasive rectal cancer surgery might have some advantages in terms of a reduced in-hospital mortality, and an improved conversion rate for the robotic approach.

Assessment of the efficacy of Handmade Vacuum-Assisted Sponge Drain for Treatment of Anastomotic leakage after Low Anterior Rectal Resection.

Anastomotic leakage is one of the major complications of colorectal surgery, which might lead to reoperation, increased hospital stays, further intervention and mortality. Vacuum-assisted closure by devices such as Endo-SPONGE® produced by (B-Braun Medical B.V.) is currently being used to treat leakage and fistula. In this study, we aimed to assess the handmade vacuum-assisted sponge drain for anastomotic leakage following low anterior resection. This prospective study included 22 patients who had undergone sponge drain placement to treat anastomotic leakage. All patients had anastomotic leaks or defects after left anterior rectal resection (LAR) without ileostomy. They were treated with neo-adjuvant chemotherapy before the surgery and then subjected to rigid recto-sigmoidoscopy for 30days following the operation. Any sign of leakage, such as perianal and pelvic pain, was immediately identified and followed up with a CT scan and another recto-sigmoidoscopy. Twenty-two patients were enrolled in this study, 12 men (54.5%) and 10 women (47.4%). All patients had received neo-adjuvant chemotherapy with an average follow-up of 22.30 ± 3.81. 75% of patients (15 cases) were successfully treated, and 17 patients (85%) underwent successful ostomy closure. Treatment failed in 5 patients (25%), including three men and two women. This study shows that handmade vacuum-assisted sponge drain is a cost-effective method of anastomotic leakage management with efficacy similar to that of Endo-SPONGE®.

Comparison of specimen extraction site and another site for protective loop ileostomy in laparoscopic low anterior rectal resection: a retrospective comparative study

BackgroundProtective loop ileostomy is commonly performed in laparoscopic low anterior rectal resection to prevent the serious complications of anastomotic fistula. It is usually created at the right lower quadrant of the abdomen and another wound is required for stoma. The study aimed to evaluate the outcomes of ileostomy at the specimen extraction site (SES) and another site (AS) beside the auxiliary incision.MethodsA retrospective analysis was conducted on 101 eligible patients with pathologically diagnosed adenocarcinoma of the rectum from January 2020 to December 2021 in the study center. According to whether the ileostomy was at the specimen extraction site, patients were divided into SES group (40 patients) and AS group (61 patients). Clinicopathological characteristics, the intraoperative details, and postoperative outcomes of the two groups were measured.ResultsUnivariate analysis showed that the operative time was significantly shorter and the blood loss was significantly less in the SES group than in the AS group during laparoscopic low anterior rectal resection, the time to first flatus was significantly shorter, and the pain was significantly less in the SES group than in the AS group during ileostomy closure. The postoperative complications were similar in both groups. Multivariable analysis showed that ileostomy at the specimen extraction site was a significant factor influencing the operative time and blood loss of rectal resection, and influencing the pain and the time to first flatus during ileostomy closure.ConclusionCompared to ileostomy at AS, protective loop ileostomy at SES was time-saving and less bleeding during laparoscopic low anterior rectal resection, and more quick to first flatus and less pain during stoma closure, and did not lead to more postoperative complications. The median incision of the lower abdomen and the left lower abdominal incision were both good sites for ileostomy.

The role and place of transanal endoscopic resections in rectal cancer

The aim of the work is to improve the algorithm of intraoperative diagnosis of rectal cancer metastasis in order to optimize surgical intervention and reduce the number of intraoperative and postoperative complications. Materials and methods. 184 operated patients with rectal cancer (RC) were divided into 2 groups: group 1 – patients with stage I RC (T1–2N0M0), and group 2 – stage II RC (T3N0M0), who underwent intraoperative detection and examination of sentinel lymph nodes. The volume and surgical approach depended on the stage and the presence of metastases (MTS). The average period of postoperative observation was 12–60 months, taking into account early (purulent-septic complications, bleeding, intestinal perforation) and late (recurrent rectal cancer) complications. Results. The patients of group 1 had no MTS lesions of the sentinel lymph nodes, the surgical intervention was limited to transanal microsurgery due to this fact. Among the complications were the following: bleeding – 2.2 %; intraoperative perforation of the intestinal wall – 5.6 %. No purulent-septic cases, no recurrences of rectal cancer were detected. In group 2, 36 (38.3 %) out of 94 patients had MTS detected intraoperatively in the sentinel lymph nodes which required a low anterior rectal resection with total mesorectumectomy. Among the complications was bleeding – 6.3 %. No intraoperative perforations of the intestinal wall and no purulent-septic complications were detected. Recurrence of rectal cancer was detected in 12 (12.8 %) patients. Conclusions. Performing transanal endoscopic resections in patients with stage I RC and especially stage II RC is possible only under the conditions of mandatory intraoperative staining and urgent histological examination of the sentinel lymph nodes. The extent of the surgical intervention is determined on the operating table based on urgent histological examination results. When MTS lesions of the mesorectal sentinel lymph nodes are detected, the operation should be continued with mandatory mesorectumectomy.

Anastomotic Leakage after Colorectal Surgery: Risk Factors, Diagnosis and Therapeutic Options.

we conducted a retrospective study on 28 AL recorded after 315 elective colorectal cancer surgeries performed in 1st Surgery Clinic of Craiova over an 8-year period (2014-2022). The overall incidence of AL was 8.88%. The identified risk factors were rectal cancer (22.38%), low anterior rectal resection (50%), open approach, advanced age (82.15% over 60 years old), male sex (3:1), and the presence of two or more co-morbidities. Medical conservative treatment was the primary line of treatment in all cases. Leakage closure was achieved in 22 cases (78.56%), with exclusive conservative treatment in 15 cases (46.42%) and combined conservative and surgical treatment in 7 cases (25.0%). Overall morbidity was recorded at 64.28%, with 8 cases of general evolving complications and 10 cases of local complications. General mortality was reported at 6 (21.42%), with 3 (16.66%) occurring after conservative treatment and 3 after re-interventions (30%). our study identified advanced age, the presence of two or more co-morbidities, male sex, rectal surgery, and neoadjuvant chemoradiation as the most important risk factors for AL. Medical conservative treatment was the primary treatment modality, while reoperation was necessary in cases of uncontrollable sepsis and MODS. Mortality after re-intervention was nearly double compared to conservative treatment.

Early ileostomy closure is safe and feasible in patients with low and ultra-low anterior rectal resection for colorectal cancer. Multicentric randomized clinical trial in South-America.

Early ileostomy closure is safe and feasible in patients with low and ultra-low anterior rectal resection for colorectal cancer. Multicentric randomized clinical trial in South-America.

A propensity score matching investigation of short-term results of single-incision laparoscopic low anterior rectal resection via ileostomy site.

The study was performed to verify the results of single-incision laparoscopic surgery (SILS) through the ileostomy site for low rectal cancer compared with conventional laparoscopic surgery (CLS). From January 2019 to November 2021, 133 patients with low rectal cancer underwent single-incision (n = 27) or conventional (n = 106) methods of low anterior rectal resection surgery with ileostomy. All patients were balanced by propensity score matching for basic information in a ratio of 1:2, resulting in 27 and 54 in SILS and CLS groups, respectively. Relative to the CLS group, the SILS group exhibited fewer leucocyte changes, shorter time to first exhaust and first bowel sounds, shorter length of hospital stay and lower Visual Analogue Score on post-operative days (POD2) and POD3. Intraoperative or post-operative complications or readmissions were comparable between the two groups. The oncologic results remained consistent between the two groups other than the number of lymph nodes dissected in group no. 253. Single-incision laparoscopic low rectal resection surgery through the ileostomy site has advantages in terms of reduced post-operative pain, shorter post-operative exhaust time and length of hospital stay while also achieving oncologic outcomes similar to those of conventional laparoscopy. It can be an alternative procedure for patients with low rectal cancer who require ileostomy.

Research on improved intestinal image classification for LARS based on ResNet.

Low anterior rectal resection is an effective way to treat rectal cancer at present, but it is easy to cause low anterior resection syndrome after surgery; so, a comprehensive diagnosis of defecation and pelvic floor function must be carried out. There are few studies on the classification of diagnoses in the field of intestinal diseases. In response to these outstanding problems, this research will focus on the design of the intestinal function diagnosis system and the image processing and classification algorithm of the intestinal wall to verify an efficient fusion method, which can be used to diagnose the intestinal diseases in clinical medicine. The diagnostic system designed in this paper makes up for the singleness of clinical monitoring methods. At the same time, the Res-SVDNet neural network model is used to solve the problems of small intestinal image samples and network overfitting, and achieve efficient fusion diagnosis of intestinal diseases in patients. Different models were used to compare experiments on the constructed datasets to verify the applicability of the Res-SVDNet model in intestinal image classification. The accuracy of the model was 99.54%, which is several percentage points higher than other algorithm models.

7693 Deep Infiltrating Endometriosis: Laparoscopic Treatment with Discal Resection

<h3>Study Objective</h3> To show how deep intestinal endometriosis can be managed safely and effectively with laparoscopic discoid resection. <h3>Design</h3> Stepwise demonstration of the technique with narrated video footage. <h3>Setting</h3> The surgical management of deep endometriosis infiltrating the rectum employs either colorectal segmental resection or conservative techniques, i.e., shaving and discoid resection. When the nodule measures less than 3 cm in diameter, the discoid resection is applicable as an alternative to segmental colorectal resection. For surgery, the patient was placed in a dorsal modified lithotomy position. The surgeon was on the patient's left side, the first assistant on the right, and the second assistant between the patient's legs. <h3>Patients or Participants</h3> A 32-year-old patient presented to our center with dysmenorrhea, dyspareunia, dyschezia and chronic pelvic pain. On physical examination, in the pouch of Douglas, a painful nodule of approximately 2 cm was palpable, involving the left uterosacral ligament. In the MRI, it can be observed in the sagittal section T2 a hypointense nodule that obliterates the pouch of Douglas and involves the anterior wall of the rectum. The nodule contacts with the anterior wall of the rectum with a 27 mm expansion and a 9 mm maximal invasion. The distance between the nodule and the anal margin is 8 cm. <h3>Interventions</h3> Laparoscopic approach with discal resection to treat deep infiltrating endometriosis. Step-by-step demonstration of the surgery with the key points through a narrated video. <h3>Measurements and Main Results</h3> Patient evolves favorably in post operative care. Hospital discharge is given 48hs after the intervention. At 6-month follow-up, the patient reported resolution of all initial symptoms. <h3>Conclusion</h3> Discoid resection is an effective and safe alternative for trained surgeons with the aim of better preserving rectal function and reducing the risk of low anterior rectal resection syndrome that can be generated with bowel resection.

5 year oncological outcomes of the HIGHLOW randomized clinical trial

IntroductionThe oncological outcomes of low ligation (LL) compared to high ligation (HL) of the inferior mesenteric artery (IMA) during low-anterior rectal resection (LAR) with total mesorectal excision are still debated. The aim of this study is to report the 5 year oncologic outcomes of patients undergoing laparoscopic LAR with either HL vs. LL of the IMA Materials and methodsBetween June 2014 and December 2016, patients who underwent elective laparoscopic LAR + TME in 6 Italian non-academic hospitals were randomized to HL or LL of IMA after meeting the inclusion criteria (HighLow trial; ClinicalTrials.gov Identifier NCT02153801). We analyzed the rate of local recurrence, distant metastasis, overall survival, disease-specific survival, and disease-free survival at 5 years of patients previously enrolled. ResultsFive-year follow up data were available for 196 patients. Recurrence happened in 42 (21.4%) of patients. There was no statistically significant difference in the distant recurrence rate (15.8% HL vs. 18.9% LL; P = 0.970) and pelvic recurrence rate (4,9% HL vs 3,2% LL; P = 0.843). No statistically significant difference was found in 5-year OS (p = 0.545), DSS (p = 0.732) or DFS (p = 0.985) between HL and LL. Low vs medium and upper rectum site of tumor, conversion rate, Clavien-Dindo post-operative grade ≥3 complications and tumor stage were found statistically significantly associated to poor oncological outcomes in univariate analysis; in multivariate analysis, however, only conversion rate and stage 3 cancer were found to be independent risk factors for poor DFS at 5 years. ConclusionWe confirmed the results found in the previous 3-year survival analysis, the level of inferior mesenteric artery ligation does not affect OS, DSS and DFS at 5-year follow-up.

Effectiveness of prehabilitation in Low Anterior Rectal Resection Surgery (LARS) with previous neoadjuvant therapy

Objectives: There is a limited amount of evidence regarding prehabilitation in elective abdominal surgeries, leading to controversial recommendations within the main enhanced-recovery guidelines to date. Thus, our goal was to compare the effectiveness of prehabilitation in reducing post-operative complications and hospital stay in low anterior rectal resection surgery (LARS).