Low Anterior Resection Group Research Articles

Comparison of Anorectal Function and Quality of Life Measures in Patients Following Intersphincteric Resection and Lower Anterior Resection

This study explored postoperative outcomes for patients with lower rectal cancer who underwent low anterior resection (LAR) or intersphincteric resection (ISR). A total of 49 patients (33 LAR, 16 ISR) were followed using anorectal manometry and quality of life (QOL) questionnaires over a year, pre- and post surgery. The primary aim of this study is to clarify differences in anal manometry, sphincter function, fecal incontinence, and QOL between the two surgical arms. The secondary aim was to identify indicators suitable for assessing relationships between anorectal manometry measurements, fecal incontinence, and QOL. Anorectal manometry elements (AMEs), such as atmospheric maximum mean squeeze pressure (aMSP), maximum tolerable volume (MTV), and incremental maximum mean squeeze pressure (iMSP), showed no significant differences during the observation period. However, maximum resting pressure (MRP), high-pressure zone length (HPZ), and threshold volume (TV) were significantly worse in the ISR group. Fecal incontinence, measured by Wexner and Kirwan scores, was significantly better in the LAR group. We observed no differences in SF36 between the two groups. Multi-correlation analysis revealed positive and negative correlations among these factors, with inverse correlations between anorectal manometry measurements and incontinence assessments decreasing post-surgery. We found no correlation between SF36 and anorectal manometry at any time. The findings indicate that surgical technique affects postoperative anal function, fecal incontinence, and SF36. However, combined assessment methods should be used with caution when deriving relationships between anal function and SF36.

Comparison of functional and oncological outcome of conformal sphincter preservation operation, low anterior resection, and abdominoperineal resection in very low rectal cancer: a retrospective comparative cohort study with propensity score matching.

Conformal sphincter preservation operation (CSPO) procedure is a sphincter preservation procedure for preserving the anal canal function for very low rectal cancers. This study investigated the functional and oncological outcome of conformal sphincter preservation operation by comparing with low anterior resection (LAR) and abdominoperineal resection (APR). This is a retrospective comparative study. Patients who received conformal sphincter preservation operation (n=52), low anterior resection (n=54), or abdominoperineal resection (n=69) were included between 2011 and 2016 in a tertiary referral hospital. Propensity score matching was applied to adjust the baseline characteristics which may influence the choice of the surgical procedure. Twenty-one pairs of conformal sphincter preservation operation vs. low anterior resection and 29 pairs of conformal sphincter preservation operation vs. abdominoperineal resection were selected. The first group had a higher tumor location than the second group. Compared with the low anterior resection group, the conformal sphincter preservation operation group had shorter distal resection margins; however, no significant differences were identified in daily stool frequency, Wexner incontinence score, local recurrence, distant metastasis, overall survival, and disease-free survival between both groups. Compared with the abdominoperineal resection group, the conformal sphincter preservation operation group had shorter operative time and shorter postoperative hospital stay. No significant differences were identified in local recurrence, distant metastasis, overall survival, and disease-free survival. Conformal sphincter preservation operation is oncologically safe compared to APR and LAR, and has similar functional findings to LAR. Studies comparing CSPO with intersphincteric resection should be performed.

Complete intersphincteric longitudinal muscle excision May Be key to reducing local recurrence during intersphincteric resection

BackgroundAlthough total mesorectal excision (TME) is regarded as a standard procedure for rectal cancer, technical definition and evaluation method have not yet been investigated for intersphincteric resection (ISR). This study was performed to introduce a complete ISR procedure, and to assess whether total intersphincteric longitudinal muscle excision (TILME) facilitated the completeness of ISR and reduced recurrence. MethodsA total of 1080 patients with rectal adenocarcinoma who underwent robot-assisted low anterior resection (LAR) over 10 years were consecutively enrolled. Propensity-score matching of the two LAR groups (ISR vs LAR group, 1:1) and three ISR subgroups (partial vs subtotal vs total ISR subgroup, 2:2:1) was performed by strict adjustment of baseline characteristics. Archived specimens and video-/photo-records were reevaluated to examine completeness of TILME. ResultsComplete-TILME was performed in 84.5% of patients who underwent ISR. Multivariate analysis showed that incomplete-TILME was the only parameter independently associated with increased 5-year cumulative local recurrence (odds ratio = 23.385; 95% confidence interval = 1.492–366.421; p = 0.03), and that incomplete-TILME was independently associated with adipose tissue surrounding the intersphincteric longitudinal muscle, coloanal anastomosis, and total ISR (p < 0.001–0.05). Although mean incontinence scores and anorectal manometry deteriorated to some degree 12–24 months after surgery in all patients, they remained acceptable. The 5-year cumulative DFS (74.1% vs 60%, p = 0.18) and OS (85.9% vs 70%, p = 0.10) rates tended to be higher in patients with complete than incomplete-TILME. ConclusionsThe completeness of TILME appears to be an independent indicator of complete ISR, reducing local recurrence following lower rectal cancer surgery.

Flexible endoscopy is enough diagnostic prior to loop ileostomy reversal

PurposeThis study investigates whether contrast enema (CE) and flexible endoscopy (FE) should be performed routinely after low anterior resection (LAR) before ileostomy reversal. Additionally, the impact of previous anastomotic leakage (AL) on diagnostic test accuracy (DTA) was assessed.MethodsThis is a retrospective analysis of prospectively collected tertiary care data of two centers. Consecutive rectal cancer patients undergoing LAR with loop ileostomy formation were included. Before ileostomy reversal, all patients were assessed by CE and FE. DTA of FE and CE for asymptomatic AL in patients who had previously suffered from clinically relevant AL (group 1) compared with those without apparent AL after LAR (group 0) were assessed separately.ResultsTwo hundred ninety-three patients were included in the analysis, 86 in group 1 and 207 in group 0. Overall sensitivity for detection of asymptomatic AL was 76% (FE) and 60% (CE). Specificity was 100% for both tests. DTA of FE was equal or superior to CE in all subgroups. Prevalence of asymptomatic AL at the time of testing was 1.4% in group 0 and 25.6% in group 1.ConclusionFlexible endoscopy is the more accurate diagnostic test for the detection of asymptomatic anastomotic leaks prior to ileostomy reversal. Contrast enema showed no gain of information. In the group without complications after the initial rectal resection, 104 must be tested to find one leak prior to reversal. In those patients, routine diagnostic testing additional to digital rectal examination may be questioned.

Minimally Invasive Proctectomy for Rectal Cancer: A National Perspective on Short-term Outcomes and Morbidity.

Prior randomized trials showed comparable short-term outcomes between open and minimally invasive proctectomy (MIP) for rectal cancer. We hypothesize that short-term outcomes for MIP have improved as surgeons have become more experienced with this technique. Rectal cancer patients who underwent elective abdominoperineal resection (APR) or low anterior resection (LAR) were included from the American College of Surgeons National Surgical Quality Improvement Program database (2016-2018). Patients were stratified based on intent-to-treat protocol: open (O-APR/LAR), laparoscopic (L-APR/LAR), robotic (R-APR/LAR), and hybrid (H-APR/LAR). Multivariable logistic regression analysis was used to assess the impact of operative approach on 30-day morbidity. A total of 4471 procedures were performed (43.41% APR and 36.59% LAR); O-APR 42.72%, L-APR 20.99%, R-APR 16.79%, and H-APR 19.51%; O-LAR 31.48%, L-LAR 26.34%, R-LAR 17.48%, and H-LAR 24.69%. Robotic APR and LAR were associated with shortest length of stay and significantly lower conversion rate. After adjusting for other factors, lap, robotic and hybrid APR and LAR were associated with decreased risk of overall morbidity when compared to open approach. R-APR and H-APR were associated with decreased risk of serious morbidity. No difference in the risk of serious morbidity was observed between the four LAR groups. Appropriate selection of patients for MIP can result in better short-term outcomes, and consideration for MIP surgery should be made.

Recurrence of rectal anastomotic leakage following stoma closure: assessment of risk factors.

In patients with a previous history of rectal anastomotic leakage (AL), the surgical indications and timing for closure of a diverting stoma have to be carefully judged. Even if AL has apparently healed before stoma closure, re-leakage may occur after closure. The aim of this study was to determine the incidence and risk factors for recurrent AL following stoma closure. We also examined the treatment strategies aiming to minimize the risk of recurrent AL. From January 2009 to December 2016, 1008 patients underwent sphincter-saving surgery [low anterior resection, all-sphincter-preserving rectal resection with hand-sewn coloanal anastomosis (CAA) and intersphincteric resection (ISR)] for primary rectal cancer with curative intent at our hospital. A total of 69 patients with AL with a Clavien-Dindo Grade III or more who subsequently underwent closure of a diverting stoma were retrospectively reviewed for this study. The incidence of recurrent leakage after stoma closure in this series was 13% overall with an incidence of 25% in the CAA/ISR group and 5% in the low anterior resection group. Significant risk factors included hand-sewn anastomosis (P=0.0257) compared to stapled anastomosis, ischaemia at the anastomotic site as the cause of initial AL (P<0.001) and a shorter interval between confirmation of healing and stoma closure (P=0.00952). Ischaemia at the anastomotic site was the main risk factor for recurrent leakage, particularly after CAA/ISR. Additional treatment options before stoma closure should be considered to avoid re-leakage in such cases.

The long term microbiota and metabolic status in patients with colorectal cancer after curative colon surgery.

Whether there are subsequent changes of metabolic profiles and microbiota status after partial colectomy remains unknown. We evaluated and compared long-term effects of microbiota status and metabolic profiles in early colorectal cancer (CRC) patients after curative colectomy to the controls. In this cross-sectional study, we analyzed metabolic syndrome occurrence in 165 patients after curative partial colectomy with right hemicolectomy (RH) or low anterior resection (LAR) and 333 age-sex matched controls. Fecal samples from some of those with RH, LAR, and controls were analyzed by next-generation sequencing method. The occurrences of metabolic syndrome were significantly higher in patients after RH, but not LAR, when compared with the controls over the long term (> 5 years) follow-up (P = 0.020). Compared with control group, RH group showed lower bacterial diversity (P = 0.007), whereas LAR group showed significantly higher bacterial diversity at the genera level (P = 0.016). Compared with the control group, the principal component analysis revealed significant differences in bacterial genera abundance after RH and LAR (P < 0.001). Furthermore, the Firmicutes to Bacteroidetes ratio was significantly lower in the RH group than the control group (22.0% versus 49.4%, P < 0.05). In conclusion, early CRC patients after RH but not LAR were associated with a higher occurrence of metabolic syndrome than the controls during long-term follow-up. In parallel with metabolic change, patients with RH showed dysbiosis with a tendency to decreased richness and a significant decrease in the diversity of gut microbiota.

Anthropometric Assessment After Proctocolectomy Due to Ulcerative Colitis.

Postoperative changes in patient anthropometric and nutritional statuses after proctocolectomy due to ulcerative colitis (UC) are unclear. Between January 2015 and December 2017, nine patients who underwent proctocolectomy with temporary ileostomy (PTI) for UC at our hospital were enrolled in this study. For the comparison group, eight patients who underwent low anterior resection (LAR) with temporary ileostomy for rectal cancer in the same period were recruited. Data, including body weight; body mass index (BMI); levels of total protein, albumin, cholinesterase, and hemoglobin; and lymphocyte counts, were analyzed. The changes in these parameters before surgery until 6 months after surgery were compared. Before surgery, the levels of total protein, albumin, cholinesterase, hemoglobin and lymphocyte counts in the PTI group were significantly worse than those in the LAR group. However, significant differences were not identified in these factors at 1 month after surgery. The BMI was significantly lower in the PTI group than in the LAR group until 3 months after surgery. An increase in body weight to greater than that prior to surgery was found from 4 months after surgery in the PTI group. The LAR group did not have any effect of surgery in terms of any factor. BMI appears to be the most useful predictor of clinical and nutritional changes postoperatively.

Long-term Outcomes After Surgery Involving the Pelvic Floor in Rectal Cancer: Physical Activity, Quality of Life, and Health Status

PurposeThis study has aimed to evaluate the effects of surgery on physical activity (PA), quality of life (QoL), and disease-specific health status, by analyzing the differences between sphincter-preserving surgery (low anterior resection (LAR)) and abdominoperineal resection (APR) among rectal cancer survivors. MethodsIndividuals who were diagnosed with rectal cancer and who underwent an APR or a LAR between 2000 and 2009 were included. The different questionnaires on QoL, disease-specific health status, and physical activity began their surveys in 2010. Differences in QoL, health status, and physical activity were analyzed between the APR group and the LAR group. ResultsThe study included 905 rectal cancer survivors (LAR, 632; APR, 273). Besides a higher rate of radiotherapy treatment in the APR group (94% vs. 75%, p < 0.001), there were no differences in clinical characteristics or in comorbid conditions between the LAR group and APR group. No significant differences were found in PA level between the patients who had undergone an APR vs. a LAR. Regarding QoL, APR patients did report a worse physical (p = 0.009) and role functioning (p = 0.03), as well as a worse body image (p = 0.001), compared to patients who had undergone a LAR. However, they reported fewer constipation (p = 0.02) and gastrointestinal problems (p = 0.009). Finally, compared to patients who had undergone a LAR with a permanent ostomy, APR patients reported a better body image (p = 0.048) and less stoma-related problems (p = 0.001). ConclusionsThis study showed no differences in PA level among the patients who had undergone an APR versus a LAR. With respect to their QoL, their physical and role functioning seemed to be worse in the APR patients. However, these differences in outcomes resolved when comparing the APR group with patients after a LAR with a permanent ostomy.

The Number of Lymph Nodes Harvested in Open and Laparoscopic Colo-Rectal Surgery: A Comparative Study

Background: The prognostic significance of identifying lymph node metastasis in cancer colon and rectum is of great importance. There is an association between the number of lymph nodes in the resection specimen and survival particularly in node negative cancer. Aim: This study aims at comparing the number of lymph nodes harvested in open and laparoscopic colorectal surgery for colorectal cancer. Patients and methods: This is a prospective study involving 40 patients with left sided colonic cancer and rectal cancer. The patients were divided into equal 4 groups: Group (1A): patients who underwent open left hemicolectomy or sigmoidectomy Group (1B): Patients who underwent laparoscopic left hemicolectomy or sigmoidectomy Group (2A): Patients who underwent open anterior or low anterior resection Group (2B): Patients who underwent laparoscopic anterior or low anterior resection Histopathological examination of the retrieved specimens and assessment of the number of lymph nodes was done. Data was compared among different groups. Results: In laparoscopic procedures, more lymph nodes were retrieved than in open surgery with statistically significant difference (p-value 0.019). The mean SD of number of lymph nodes retrieved was 14 in the laparoscopic group versus 10.5 in the open group. Conclusion: Laparoscopic resection of left sided colorectal cancer yields adequate samples of lymph nodes number that are comparable to those obtained by open surgery.

Quality of Life After "Total Mesorectal Excision (TME)" for Rectal Carcinoma: a Study from a Tertiary Care Hospital in Northern India.

Quality of life (QoL) is a key element in rectal cancer (RC) patients. There is not much data regarding this from North India. This study assesses QoL following low anterior resection (LAR) and abdominoperineal resection (APR), operated for low rectal tumors at a high-volume center in northern India. One-hundred-thirty patients of rectal carcinoma were prospectively assessed for quality of life using the European Organization for Cancer QLQ-30 and CR29 questionnaires and compared with reference data population. There was no significant difference in the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 functional or symptom score between the study group and reference data population. Specific functional and symptom QoL scores of the study group were comparable to that of reference data population. There was no significant difference in the EORTC QLQ-C30 functional or symptom score between APR and LAR groups, except for the symptom of nausea and vomiting which was reported significantly more by the LAR group patients than APR group (p=0.001). LAR patients had significantly higher scores with regard to nausea and vomiting than patients with an APR (p<0.05). APR patients had significantly higher scores with regards to urinary frequency (p=0.0001), abdominal pain (p=0.0001), and embarrassment (p=0.0001) than LAR patients. Quality of life after APR and LAR for rectal carcinoma was found to be comparable to the reference data population, and the QoL after APR was similar to that after LAR barring a few symptoms.

Hand sewn versus stapler anastomosis in elective gastro intestinal surgeries

Background: The technique for intestinal anastomosis in elective gastrointestinal surgeries depends on site, bowel calibre and underlying disease. The decision to choose hand sewn or stapler anastomosis depends on surgical experience and preference. The objective of this study was to study the outcome of hand sewn anastomosis compared with stapler anastomosis in elective gastrointestinal surgeries.Methods: Retrospective comparative study was conducted in surgical wards of a tertiary referral hospital from July’2013 to June’2016. Data analysed with independent samples T-test to compare mean values between methods and Chi-square tests used to compare proportion of the two values.Results: Significant difference in duration of procedure, return of bowel sounds, starting of oral feeds, hospitalization days, return to work noted in stapler anastomosis compared with hand sewn anastomosis in subtotal gastrectomy and gastrojejunostomy. No difference in appearance of bowel sounds in right hemicolectomy and other resection and anastomoses group, no difference in return to work in right hemicolectomy group, no difference in starting of oral feeds in low anterior resection group. Other parameters were statistically significant in right hemicolectomy, low anterior resection and other resection and anastomosis groups. No significant difference observed in anastomotic leak between hand sewn and stapler methods. There was no mortality in stapler group.Conclusions: Stapler method significantly reduces duration of surgery, has early recovery with less mortality. Stapling is quick to perform in inaccessible situations like low colorectal anastomosis. Stapler anastomosis can be used safely and effectively in elective gastrointestinal surgeries.

Sexual dysfunction in males following low anterior resection.

The purpose of this study was to explore the prevalence of sexual dysfunction in males one year after undergoing low anterior resection and to determine whether health care professionals discuss sexual issues with patients after surgery. Sexual dysfunction in males may be a complication after low anterior resection for rectal cancer, but few studies have explored this issue in Taiwan. A descriptive comparison study design. A descriptive comparison design was used, and a group of 133 participants underwent a low anterior resection procedure for rectal cancer. The results were compared with those of a group of males who underwent colectomy (n=58) for colon cancer. The following instruments were used: the five-item version of the International Index of Erectile Function, personal demographics and medical variables. The results showed that the prevalence of erectile dysfunction among the low anterior resection patients was 97·0% (129/133), and the erectile dysfunction prevalence was 75·9% (44/58) for the males who underwent colectomy. The generalised linear model showed that after controlling for hypertension and stoma, the low anterior resection group had worse sexual function than those in the colectomy group, and stoma was also a factor that impacted patients' sexual function. The results also revealed that only 32·8-35·3% of health care providers talked about sexual dysfunction with people who have rectal cancer prior to surgery. This study demonstrated that men who have undergone low anterior resection have a high risk of sexual dysfunction and that health care professionals infrequently discuss these issues with patients. When patients are diagnosed with rectal cancer and before they undergo surgery, an assessment and discussion of sexual function issues should be incorporated into standard care. Continued follow-up after hospital discharge and evaluations of sexual function are vital factors for male postoperative rectal cancer patients.

Meta-analysis of oncological outcome after abdominoperineal resection or low anterior resection for lower rectal cancer.

In lower rectal cancer, postoperative outcome is still subject of controversy between the advocates of abdominoperineal resection (APR) and low anterior resection (LAR). Reports suggest that low anterior resection may be oncologically superior to abdominoperineal excision, although no good evidence exists to support this. Publications were identified which assessed the differences comparing 5-year survival, local recurrence, circumferential resection margin rate, complications and so on. A meta-analysis was performed to clarify the safety and feasibility of the two procedures with several types of outcome measures. A total of 13 studies met the inclusion criteria, and comprised 6,850 cases. Analysis of these data showed that LAR group was highly correlated with 5-year survival (pooled OR = 1.73, 95%CI: 1.30–2.29, P = 0.0002 random-effect). And local recurrence rate of APR group was significantly higher than that in LAR group (pooled OR = 0.63, 95%CI: 0.53–0.75, P < 0.00001 fixed-effect). Also, the circumferential resection margin (CRM) were high involved in APR group than in LAR group. (5 trials reported the data, pooled OR = 0.43, 95%CI: 0.36–0.52, P < 0.00001 fixed-effect). Besides, the incidents of overall complications of APR group was higher compared with LAR group (pooled OR = 0.52, 95%CI: 0.29–0.92, P = 0.03 random-effect). Patients treated by APR have a higher rate of CRM involvement, a higher local recurrence, and poorer prognosis than LAR. And there is evidence that in selected low rectal cancer patients, LAR can be used safely with a better oncological outcome than APR. due to the inherent limitations of the present study, for example, the trails available for this systematic review are limited and the finite retrospective data, future prospective randomized controlled trials will be useful to fully investigate these outcome measures and to confirm this conclusion.

Surgical approach to inflammatory bowel disease in Tayside, east of Scotland

s / International Journal of Surgery 12 (2014) S13eS117 S29 Conclusions: The data shows that higher values of faecal calprotectin correspond to an increased degree of mucosal inflammation. 0602: APER IN A DISTRICT GENERAL HOSPITAL e SHOULD WE BE DOING MORE? Adenike Odeleye, Simran Choudary, Henry Lee, O.A. Lalude, S. Vivekanandan. Princess Alexandra Hospital, London, UK. Introduction: Appropriate surgical management of rectal cancer is crucial to survival. The decision for abdominoperineal excision of rectum (APER) goes against surgical inclinations to engineer an anastomosis with a low anterior resection (LAR). Inappropriately optimistic surgical decisions are known to foster high local recurrence rates and poor overall survival. We aimed to inspect the APER rate and outcomes of patients with rectal cancer in our centre. Methods: A prospectively maintained departmental database was interrogated to determine all patients undergoing AR or APER between 1/1/ 2008-31/12/2010. Recurrence was identified on post-operative CT scans at 2 years. Results: Patients underwent an APER 16% n1⁄414 or AR 84% n1⁄469. The overall average age was 71. Male to Female ratio 1.6:1. One of the LAR patients had local recurrence (1.5%) at 2years whilst there was no evidence of recurrence in the APER group. Distant metastases were identified in 14% of the APER group vs. 5.9% in the LAR group. Nil significant difference in recurrence rates (P-value <0.05). Conclusions: Our centre's APER rate of 16% is favourably comparable to the established literature recommending <30%. The surgical rationale in our unit is supported by the low and comparable risk of recurrence for both LAR and APER at 2 years. 0616: SURGICAL APPROACH TO INFLAMMATORY BOWEL DISEASE IN TAYSIDE, EAST OF SCOTLAND Omar Ashour, Dorin Ziyaie. Ninewells Hospital, Dundee, UK. Introduction: To investigate the surgical approach to IBD in Tayside and to compare it with literature findings. This will hopefully help to elucidate the gold standard operations in the management of IBD and its true extent in practice. Methods: 97 patient notes from Medical-Records were systematically reviewed. A standard template was used to collect certain information, e.g. diagnosis, part of bowel affected, surgical treatment, complications, and functional outcome. Results: The most common type of surgery performed in CD was a right hemicolectomy, RHC (64.9%), followed by a subtotal colectomy, STC (24.6%).Complications such as strictures (18.6%), adhesions (8.1%), perforation (5.4%) and obstruction (5.4%) affected the outcome in RHC, but not STC. With RHC, disease recurrence and re-operation rates were 35.1% and 51.4% respectively compared to 14.2% and 35.7% with STC. UC patients; 92.3% underwent STC-with-end-ileostomy. Following STC, twothirds had either IPAA (64.7%) or TPC (35.3%). Complications with IPAA included pouchitis (36.4%), sepsis (18.2%), pouch failure (16.7%) and haemorrhage (16.7%), whereas an ileostomy only had wound infection (16.7%). Conclusions: Segmental resection in CD has been controversial as it carries a higher recurrence-rate but has all the functional benefits of colonic preservation. STC has higher complication rates compared to RHC from sepsis, wound infection and poor stoma function. Despite complications, IPAA still offered the closest thing to faecal continuity without the use of a stoma bag. 0621: ACTIVATED SYSTEMIC INFLAMMATORY RESPONSE AT DIAGNOSIS REDUCES LYMPH NODE COUNT IN COLONIC CARCINOMA Brenda Murphy, Rory Kennelly, Hamad Yousef, Paul McCormick, Brian Mehigan. Department of Colorectal Surgery, St. James' Hospital,

Successful total shift from multiport to single-port laparoscopic surgery in low anterior resection of colorectal cancer.

To assess the possibility of using single-port low anterior resection (LAR) in place of conventional laparoscopic LAR. Though single-port LS is gradually evolving, the application of single-port LS techniques in LAR have been viewed with skepticism due to technical difficulties. Data from patients who had undergone either conventional laparoscopic LAR (n = 49) or single-port LAR (n = 67) for colorectal cancers between March 2006 and March 2013 were analyzed retrospectively. In single-port LAR group, oncologic outcomes were satisfactory with respect to attainment of lymph nodes (23.4 ± 15.3) and surgical margins (proximal cut margin: 7.1 ± 4.6 cm, distal cut margin: 7.7 ± 5.7 cm). Single-port LAR showed acceptable clinical outcomes manifested by comparable outcomes of post-operative analgesics requirement and length of hospital stay, and by low incidence of post-operative complications (conventional laparoscopic LAR group: 30.6% vs. single-port LAR group: 14.9%; P < 0.01). Operative time was comparable between groups (conventional laparoscopic LAR group: 309 ± 93 min vs. single-port LAR group: 277 ± 106 min; P = 0.097). Throughout a series of 67 consecutive single-port LARs, no conversion to multiport or open surgery was occurred. This study shows that single-port LAR is both safe and feasible for use in resection of colorectal cancer when performed by surgeons who are trained in conventional laparoscopic technique. If further and more extensive studies support our results, then single-port LAR can be an acceptable alternative to conventional laparoscopic LAR for treatment of colorectal cancer.

Role of epidural and patient-controlled analgesia in site-specific laparoscopic colorectal surgery.

Background and Objectives:Limited data are available comparing epidural and patient-controlled analgesia in site-specific colorectal surgery. The aim of this study was to evaluate 2 modes of analgesia in patients undergoing laparoscopic right colectomy (RC) and low anterior resection (LAR).Methods:Prospectively collected data on 433 patients undergoing laparoscopic or laparoscopic-assisted colon surgery at a single institution were retrospectively reviewed from March 2004 to February 2009. Patients were divided into groups undergoing RC (n = 175) and LAR (n = 258). These groups were evaluated by use of analgesia: epidural analgesia, “patient-controlled analgesia” alone, and a combination of both. Demographic and perioperative outcomes were compared.Results:Epidural analgesia was associated with a faster return of bowel function, by 1 day (P < .001), in patients who underwent LAR but not in the RC group. Delayed return of bowel function was associated with increased operative time in the LAR group (P = .05), patients with diabetes who underwent RC (P = .037), and patients after RC with combined analgesia (P = .011). Mean visual analogue scale pain scores were significantly lower with epidural analgesia compared with patient-controlled analgesia in both LAR and RC groups (P < .001).Conclusion:Epidural analgesia was associated with a faster return of bowel function in the laparoscopic LAR group but not the RC group. Epidural analgesia was superior to patient-controlled analgesia in controlling postoperative pain but was inadequate in 28% of patients and needed the addition of patient-controlled analgesia.

Sexual Dysfunction in Women After Low Anterior Resection

Low anterior resection procedures are likely to negatively affect pelvic floor function, which are correlated with sexual dysfunction. The purpose of the study was to explore the prevalence of sexual problems in women with rectal cancer after low anterior resection (LAR). The study consisted of an LAR group (n = 32) and a group of healthy women (n = 32). Female sexual function was evaluated using the Female Sexual Function Index (FSFI). A total of 71.8% of those with LAR reported sexual dysfunction, compared to 18.8% in those who are healthy. The FSFI domain scores were significantly lower for the LAR group relative to the healthy group. Logistic regression revealed that group, education, and age were predictors of female sexual functioning. Women who have had an LAR are at higher risk of sexual function problems. The sexual function of women with LAR should be evaluated in patient discharge planning; nurses should provide more information regarding the impact of LAR on sexual function.

Treatment for early ultralow rectal cancer: pull-through intersphincteric stapled transection and anastomosis (PISTA) versus low anterior resection

The aim of this study was to compare the functional and oncologic results of pull-through intersphincteric stapled transection and anastomosis (PISTA) with low anterior resection (LAR) in the treatment for early ultralow rectal cancer. A total of 278 patients with early ultralow rectal cancer were retrospectively included and analyzed, with 136 in the PISTA group and 142 in the LAR group. Gender, age, tumor diameter, distance from the dentate line to the inferior margin of the tumor, tumor stage, length of operation and postoperative complications were comparable in the two groups. Compared with the LAR group, the PISTA group had a more accurate distal transection site, a lower daily fecal frequency (6 (5-7) vs. 8 (7-9), p < 0.001) and a lower Wexner incontinence score (13 (10-14) vs. 14 (13-16), p < 0.001) 3 months after ileostomy reversal, and a higher rate of satisfactory fecal continence (97.1 % vs. 90.8 %, p = 0.043). The follow-up period of the PISTA group was similar to that of the LAR group (56 (30-81) months vs. 54 (30-80) months, p = 0.982). The PISTA group was associated with a lower local recurrence rate (2.2 % vs. 11.3 %, p = 0.003). Kaplan-Meier analysis also showed that the PISTA group was associated with longer overall survival (p = 0.018) and longer local recurrence-free survival (p = 0.004) than the LAR group, while distant metastasis-free survival (p = 0.896) was comparable in the two groups. Multivariate analysis identified lymph node metastasis (p < 0.001) and operation (PISTA vs. LAR, p = 0.031) as independent predictive factors for local recurrence-free survival. PISTA is a technically simple, oncologically safe and functionally favorable procedure for the treatment for early ultralow rectal cancer.

Abdominoperineal resection and low anterior resection: comparison of long-term oncologic outcome in matched patients with lower rectal cancer

The current study aimed to compare the oncologic outcome and pattern of metastasis after abdominoperineal resection (APR) and low anterior resection (LAR) treating lower rectal cancer. A total of 804 patients undergoing curative resection (R0) were enrolled prospectively. The APR and LAR groups (n = 402, respectively) were matched for gender, age, and stage, for a retrospectively comparative analysis. In a multivariate analysis with potential variables, APR itself was not a risk factor for increased local recurrence (LR) or reduced survival (P = 0.243-0.994). Circumferential resection margin (CRM) involvement as an operation-related risk was 1.6-fold more frequent in the APR group and was significantly associated with LR and systemic recurrence (OR, 2.487-4.017; P < 0.01). Circumferential margin positivity (CRM+) was concurrently correlated with advanced stage, larger tumor (long diameter, >4 cm), and longer sagittal midpelvic diameter (>10 cm) in a multivariate analysis (P < 0.001-0.05). The site of metastasis did not differ between the two groups, with the exception of lung metastasis which was more frequent in the APR group (APR vs. LAR: 15.9 vs. 10 %, P = 0.015). In the APR group, CRM+ and the presence of an infiltrating tumor were correlated with disease-free survival (hazard ratio (HR), 1.644 and 1.654, respectively), whereas elevated serum carcinoembryonic antigen and LVI+ were correlated with overall survival (HR, 1.57 and 1.671, respectively), in a multivariate analysis with potential variables (P < 0.05). When performed with appropriate skill to achieve R0 resection, APR can be used safely without impairing oncological outcome, although sphincter-preserving surgery should remain the preferred option.