Abdominoperineal resection (APR) for low rectal cancer results in permanent stoma, psychosocial distress, and systemic inflammation, impairing quality of life and survival. This study evaluated whether app-based cognitive behavioral therapy (CBT) plus biomarker-guided nutrition could improve recovery and survival. In this prospective, single-center, non-randomized controlled cohort, 186 patients with stage I-III low rectal adenocarcinoma undergoing curative abdominoperineal resection (APR) all received standard Enhanced Recovery After Surgery (ERAS) care. Patients were managed with ERAS alone or ERAS plus an integrative program combining digital cognitive behavioral therapy (CBT) and inflammation-guided precision nutrition, tailored according to prognostic nutritional index (PNI), C-reactive protein (CRP), and interleukin-6 (IL-6). Interventions began two weeks preoperatively and continued for six months. Primary outcomes were longitudinal changes in depression, sleep quality, sexual function, and health-related quality of life. Secondary outcomes included inflammatory markers, skeletal muscle index (SMI), and two-year disease-free and overall survival. By month 3, the intervention group showed greater improvements in all primary outcomes, sustained through 24 months (all p < 0.001). CRP and IL-6 were reduced by day 7 (both p < 0.001), with faster recovery and shorter hospitalization. SMI was better preserved at 24 months (p = 0.046). Two-year DFS (hazard ratio [HR] = 0.48, 95% confidence interval [CI] 0.26-0.89, p = 0.021) and OS (HR = 0.44, 95% CI 0.20-0.95, p = 0.036) were significantly improved. Findings remained robust in multivariable and sensitivity analyses. Among patients undergoing APR managed within an ERAS pathway, the addition of digital CBT and inflammation-guided nutrition was associated with improved multidimensional recovery and favorable survival signals. Given the non-randomized design, these results should be regarded as hypothesis-generating and support further evaluation of ERAS-based integrative strategies in randomized multicenter trials.

Background: The use of neoadjuvant chemoradiation (NCRT) for upper rectal cancer remains controversial. Our aim was to determine whether NCRT was associated with improved outcomes. Methods: The US Rectal Cancer Consortium was queried for patients who underwent resection of nonmetastatic upper rectal cancer (≥12cm from anal verge) from 2007-2017. Primary outcomes were recurrence-free (RFS) and overall survival (OS). Secondary outcomes were postoperative complications. Results: 193 pts met inclusion criteria; 100 (52%) did not receive NCRT and 93 (48%) did. Patients in each group had similar age, gender, and pathological stage (non-NCRT: 22% stage I, 32% stage II, 36% stage III; NCRT: 21% stage I, 23% stage II, 33% stage III; P = 0.143). Median follow-up was 31 months (non-NCRT) and 34 months (NCRT). On Kaplan-Meier analysis, NCRT was not associated with improved RFS compared to non-NCRT (3-year RFS 85% vs 80%; P = 0.34) or OS (3-year OS 88% vs 90%; P = 0.49). This finding persisted on multivariable cox regression. R0 resection rate was similar between groups at 99% (non-NCRT) and 97% (NCRT; P = 0.27). Anastomotic leak occurred in 11% of both cohorts. Creation of a diverting loop ileostomy (DLI) was nearly 3 times higher in NCRT (82%) vs non-NCRT patients (29%; P < 0.001). Conclusions: Among patients with nonmetastatic upper rectal cancer, NCRT did not improve survival or recurrence rates, but was associated with a nearly 3-fold higher DLI rate. Although NCRT is a mainstay of treatment for lower rectal cancer, our results do not support its use in upper rectal cancer.

This study aimed to clarify the lymphatic network around the anorectum using cadavers and consider a treatment strategy for locally advanced lower rectal cancer (LARC). We performed microscopic observations of three female cadavers using India ink into the submucosa at the dentate line (DL) of the cadaver. We examined the clinical outcomes of 74 patients with LARC who underwent total mesorectal excision after preoperative treatment, classifying them as anterior (A), lateral (L), or posterior (P) based on the deepest part of the tumor. Two of the three anterior walls contained the Denonvilliers' fascia (DVF), and the DVF became indistinct at the height of DL, where India ink extended to the vagina via the perivascular space and was absorbed into the vaginal lymph vessels. One case did not have DVF, and lymph vessels in the rectum distributed in close proximity to vagina. On the lateral posterior wall, the ink spread extensively from DL and the front of the levator ani muscle, whereas on the posterior wall, lymph vessels containing absorbed ink were observed from the hiatal ligament to the front of the sacrum. In the survival analysis, the 3-year disease-free survival rates were 71.9%, 100%, and 69.7% for A, L, and P groups, respectively, with a higher recurrence rate in the anterior and posterior walls. Lymphatic network beyond fascia around anorectum was spread to a specific route by location. The anatomical diversity of this network was thought to be involved in the poor outcome for LARC.

BACKGROUND Traditional laparoscopic total mesorectal excision (LaTME) presents challenges in patients with low rectal cancer, including difficult surgical exposure and positive margin risks. AIM To compare the short-term outcomes of laparoscopic-assisted transanal total mesorectal excision (TaTME) and LaTME for mid-to-low rectal cancer. METHODS A retrospective analysis of 138 patients with rectal cancer was conducted, and they were divided into the TaTME group (n = 66) and the LaTME group (n = 72). Surgical indicators, pathological outcomes, recovery parameters, inflammatory markers, and anal function were compared. RESULTS The two groups showed comparable baseline characteristics (P &gt; 0.05). The TaTME group demonstrated superior intraoperative performance with significantly less blood loss (78.4 ± 28.6 mL vs 118.7 ± 35.2 mL, P &lt; 0.001), reduced hemoglobin decrease (18.3 ± 8.7 g/L vs 26.8 ± 12.4 g/L, P = 0.002), and lower vasoactive drug requirement (6.1% vs 15.3%, P = 0.044). Pathologically, TaTME achieved better oncological outcomes including lower circumferential resection margin-positive rate (4.5% vs 13.9%, P = 0.032), higher lymph node harvest (17.8 ± 4.6 vs 15.2 ± 4.1, P = 0.001), and improved complete total mesorectal excision rate (89.4% vs 77.8%, P = 0.048). The TaTME group exhibited accelerated gastrointestinal recovery with shorter times to first flatus (2.1 ± 0.8 days vs 2.8 ± 1.2 days, P = 0.001) and reduced hospital stay (7.8 ± 2.1 days vs 9.4 ± 2.8 days, P = 0.001). Inflammatory markers were significantly lower, including postoperative day 2 interleukin (IL)-6 (42.6 ± 12.8 pg/mL vs 56.3 ± 15.7 pg/mL, P &lt; 0.001) and C-reactive protein peaks (68.4 ± 18.2 mg/L vs 89.7 ± 24.6 mg/L, P &lt; 0.001). Multivariate analysis revealed TaTME as an independent protective factor for good anal function (odds ratio = 0.234, P = 0.003), while tumor distance ≤ 2 cm, elevated IL-6, and neoadjuvant therapy were risk factors. These findings demonstrate TaTME's advantages in surgical safety, oncological quality, postoperative recovery, and functional preservation. CONCLUSION TaTME demonstrates superior short-term outcomes in surgical safety, oncological quality, and functional recovery to LaTME, warranting clinical promotion.

Background In sphincter-preserving surgery for low rectal cancer (LRC), Immediate coloanal anastomosis (ICA) combined with prophylactic ileostomy remains the standard approach. However, this procedure is associated with the need for a second operation to reverse the stoma and risks of stoma-related complications. Delayed coloanal anastomosis (DCA) has recently regained attention as an alternative strategy, particularly in the context of evolving principles of minimally invasive surgery and enhanced recovery after surgery (ERAS). This meta-analysis aimed to systematically evaluate and compare DCA and ICA in terms of perioperative outcomes, postoperative complications, and oncological efficacy. Methods Following the PRISMA guidelines, we conducted a comprehensive literature search across PubMed, MEDLINE, Embase, Cochrane Library, Web of Science, and the Chinese Biomedical Literature Database (CBM) from database inception to October 2025. We included clinical studies comparing DCA and ICA for the treatment of LRC. The Risk of Bias 2 (ROB2) tool was used to assess bias in randomized controlled trials (RCTs), and the ROBINS-I tool was applied for non-randomized studies. Meta-analyses were performed using R 4.2.0 and RevMan 5.3 software. Results A total of 16 studies (2 RCTs and 14 retrospective cohort studies) involving 1,409 patients (822 in the ICA group and 587 in the DCA group) were included. No statistically significant differences were observed between the two groups in operative time (SMD = 0.10, 95% CI: -0.23 to 0.44, P = 0.55), intraoperative blood loss (SMD = 0.34, 95% CI: -0.19 to 0.86, P = 0.21), or length of hospital stay (SMD = -0.37, 95% CI: -1.14 to 0.40, P = 0.34). However, the ICA group had significantly higher risks of total complications (OR = 2.74, 95% CI: 1.89–3.98, P &amp;lt; 0.00001), anastomosis-related complications (OR = 3.46, 95% CI: 2.32–5.15, P &amp;lt; 0.00001), and postoperative anastomotic leakage (OR = 2.79, 95% CI: 1.71–4.57, P &amp;lt; 0.0001) compared to the DCA group. There were no significant differences in local recurrence rate (OR = 1.02, 95% CI: 0.40–2.63, P = 0.98) or distant metastasis rate (OR = 1.51, 95% CI: 0.89–2.54, P = 0.13). Publication bias assessment revealed no substantial asymmetry in key outcomes, and sensitivity analyses confirmed the stability and robustness of the findings. Conclusion Compared with ICA, DCA is associated with significantly lower risks of overall complications, anastomotic complications, and anastomotic leakage in sphincter-preserving surgery for LRC, without compromising oncological safety. It demonstrates comparable performance in core perioperative indicators and may offer particular advantages for patients seeking minimally invasive approaches, those unable to tolerate stomas, or those at high risk of anastomotic failure. Therefore, DCA represents a viable and potentially preferable surgical option in the management of LRC. This study strictly adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and was registered on the PROSPERO international systematic review registration platform (registration number: CRD420251233006).

Precise preoperative assessment and the development of individualized surgical strategies are critical determinants in minimizing operative risks and enhancing surgical outcomes, serving as a cornerstone for improving long-term patient survival. The application of artificial intelligence technology in the diagnosis and treatment of colorectal cancer offers new insights for achieving individualized surgical treatment of mid-low rectal cancer. By utilizing deep learning algorithms to analyze extensive imaging data, such as CT and MRI, AI provide surgeons with quantitative insights to support surgical planning, selection of approaches, and extend of lymphadenectomy. Moreover, augmented reality (AR) technology enables real-time intraoperative tumor localization, visualization of anatomical dissection planes, and navigation toward metastatic lymph nodes. These capabilities facilitate maximal tumor resection while preserving critical organs and vessels, thereby reducing the incidence of complication. Furthermore, through the integration of multi-modal data, AI facilitates the development of predictive models for early detection and dynamic monitoring of postoperative complications, supports precision interventions. In conclusion, AI promotes the evolution of surgical treatment for mid-low rectal cancer toward fully personalized and precision-based paradigms.

Benefits of transanal total mesorectal excision in patients with obesity remain unclear. To evaluate the clinical utility of transanal total mesorectal excision in patients with obesity with mid-to-low rectal cancer. Retrospective cohort study. Single center, between April 2015 and March 2025. Six hundred eighty-three patients with mid-to-low rectal cancer. Transanal total mesorectal excision for rectal cancer. Patients were categorized as nonobese (body mass index < 25.0 kg/m2), obese I (25.0-29.9 kg/m2), and obese II (≥ 30 kg/m2). Surgical and pathological outcomes-conversion to open surgery, sphincter preservation, and resection margin status-were compared. Results with corrected p value < 0.05 were considered significant. Overall, 485 (71%) patients were categorized as nonobese, 159 (23%) as obese I, and 39 (6%) as obese II. Clinicopathological characteristics were similar among the groups. Operative times were longer in the obese I and II groups (218 and 265 vs. 194 min, p < 0.05), with greater blood loss (44 and 90 vs. 39 mL, p < 0.05). Sphincter-preserving surgery was performed as planned in all patients; conversion to open surgery (1.0%, 1.3%, and 0%, p = 0.783) were comparable, whereas anastomotic leakage was more frequent in the obese II group (4.5%, 6.3%, and 15.4%, p = 0.016). The overall circumferential resection margin-positivity rate was 3.4%, with no significant differences among the groups (3.3%, 3.1%, and 5.1%). Single high-volume cancer center with surgeons experienced in transanal total mesorectal excision limits generalizability; lack of comparative cohort limits direct assessment of the efficacy of the approach; the obese II group had few patients; and BMI's accuracy as a surrogate for visceral fat is limited. Transanal total mesorectal excision appears to represent a promising strategy for patients with obesity with mid-to-low rectal cancer, offering low conversion and high sphincter preservation rates while maintaining oncologic safety. See Video Abstract.

Background: Perineal wound healing complications frequently occur following abdominoperineal resection (APR) for low-lying rectal cancers, posing significant reconstructive challenges. Among various reconstructive options, gracilis muscle flaps have gained prominence due to their reliability in addressing sacral dead-space defects. Despite their popularity, decision-making criteria regarding unilateral versus bilateral gracilis flap use, supplementary adipose tissue flaps, and optimal timing for reconstruction remain inadequately defined. Materials and Methods: We conducted a retrospective single-center cohort study including 25 patients who underwent perineal reconstruction using unilateral or bilateral gracilis muscle flaps after APR complications. Variables collected encompassed demographic characteristics, preoperative treatments, operative details, and postoperative outcomes classified according to the Clavien–Dindo criteria. Additionally, we assessed the efficacy of supplementary adipose tissue flaps harvested from the ischiorectal region. Results: Among the 25 patients studied, unilateral gracilis flap reconstruction was performed in 64%, and bilateral flaps in 36%. Eleven cases (44%) received supplementary adipose tissue flaps. The overall complication rate was 44%, with 28% requiring surgical revision. Negative pressure wound therapy (NPWT) cycles pre-reconstruction significantly correlated with higher complication rates ( P = 0.013), likely reflecting underlying wound severity. Although not statistically significant, a trend indicated that a shorter interval between oncological resection and reconstructive surgery resulted in fewer complications (mean: 8.2 vs. 34.8 months; P = 0.14). Ultimately, complete healing was achieved in all patients. Conclusion: Gracilis muscle flaps, complemented by ischiorectal adipose flaps, represent an effective strategy for perineal reconstruction post-APR, though the optimal timing warrants further investigation. Although these findings are limited by the small cohort size and retrospective design, minimizing preoperative NPWT cycles and avoiding excessive delays in reconstruction may improve clinical outcomes.

To compare perioperative and oncologic outcomes between robotic surgical platforms (Si vs. Xi) in rectal carcinoma. A retrospective cohort study of 86 robotic rectal cancer resections (Si: n = 31; Xi: n = 55) were analyzed at Tianjin Medical University Cancer Hospital between November 2019 and June 2024. Among 86 patients with comparable baseline clinicopathological variables (all p > 0.05), the Xi system showed superior perioperative efficiency: shorter operation (226.7 vs. 282.1 min, p = 0.010), console (p = 0.016) and docking times (p = 0.013), less blood loss (83.8 vs. 155.8 mL, p = 0.005), and a shorter postoperative stay (7.8 vs. 9.7 days, p = 0.016). On multivariable analyses, Xi remained independently associated with a shorter operative time (p = 0.002), reduced blood loss (p = 0.027), and decreased length of stay (p = 0.038). Complication rates, lymph node yield, and short-term oncologic quality indicators (distal resection margin [DRM], circumferential resection margin [CRM], mesorectal integrity) were comparable between two systems (all p > 0.05). In low rectal cancers (≤ 5 cm from the anal verge) with balanced baselines, Xi achieved a higher sphincter preservation rate (90.5% vs. 55.6%, p = 0.049). Survival trends numerically favored Xi (3-year DFS 79.8% vs. 73.0%; OS 92.0% vs. 83.0%), but differences were not significant (DFS: p = 0.54; OS: p = 0.26). On Cox regression, TNM stage independently predicted both DFS (p = 0.041) and OS (p = 0.029). However, the robotic platform (Xi vs. Si) showed no survival advantage (DFS: HR = 1.33, 95% CI 0.53-3.37, p = 0.548; OS: HR = 1.43, 95% CI 0.76-2.67, p = 0.267). Compared with Si, the Xi platform confers measurable perioperative advantages-shorter operative time, less blood loss, and reduced hospitalization-without compromising short-term oncologic quality or survival. In low rectal tumors, Xi may facilitate sphincter preservation under comparable baselines. Long-term outcomes appear driven primarily by disease stage rather than platform generation.

Letter to the Editor: insights into "Robotic versus laparoscopic surgery for middle and low rectal cancer: a retrospective cohort study emulating the target trial".

Refining watch-and-wait in low rectal cancer after neoadjuvant chemoradiotherapy: pilot study of endoscopic full-thickness resection.

The application of intraoperative strategies to reduce protective stoma in mid and low rectal cancer: a retrospective study utilizing indocyanine green and precise anatomical techniques

Circadian and gut-brain axis modulation is associated with neuroimmune and symptom recovery after rectal cancer surgery: An exploratory randomized controlled trial.

Clinical implications of radiologic criteria and prognostic factors for lateral lymph node metastasis in low rectal cancer

Metastasis to the lateral lymph nodes (LLNs) occurs in 15%-20% of patients with cT3-4 low rectal cancer and remains a key factor in local recurrence after surgery. While laparoscopic LLN dissection (LLND) is increasingly performed, its technical demands raise concerns regarding safety and efficacy. This study aimed to evaluate the feasibility, safety, and oncological equivalence of the laparoscopic approach compared with the open approach. This retrospective, single-centre study included 60 patients who underwent LLND between 2007 and 2022. Peri-operative and oncological outcomes were compared between the laparoscopic (n = 33) and open (n = 27) approaches. In addition, peri-operative outcomes of laparoscopic LLND were compared between the initial 16 and the subsequent 17 cases. Blood loss was significantly reduced in the laparoscopic group (median, 200 mL vs. 794 mL; p < 0.001), with a significant reduction in the latter laparoscopic cases compared with the initial cases (100 vs. 323.5 mL; p < 0.001). Post-operative hospital stay was significantly shorter in the laparoscopic group (16 vs. 23 days; p = 0.006) and was further reduced in the latter laparoscopic cases compared with the initial cases (14 vs. 19 days; p < 0.001). No significant differences were observed in terms of 5-year cancer-specific survival (96.4 vs. 95.7%; p = 0.46), relapse-free survival (85.6 vs. 82.6%; p = 0.71), or cumulative local recurrence rates (7.1 vs. 4.3%; p = 0.69). Laparoscopic LLND provides clear short-term advantages over open dissection while achieving comparable oncological outcomes. Moreover, the peri-operative outcomes of laparoscopic LLND improve further with increasing surgical experience.

ObjectiveTo compare the impact of retromesenteric versus anterior mesenteric approaches on postoperative outcomes after laparoscopic radical resection for low rectal cancer.MethodsThis single-center retrospective cohort study included 157 patients (59 retromesenteric, 98 anterior mesenteric) treated between 2020 and 2023. Primary outcomes were postoperative inflammatory response, including C-reactive protein (CRP) and procalcitonin (PCT) levels on days 1, 3, and 7. Secondary outcomes included complications and recovery indicators. Logistic regression adjusted for confounders.ResultsBaseline characteristics were comparable. On postoperative day 1, CRP (68.4 ± 12.3 vs. 85.2 ± 14.7 mg/L, P < 0.01) and PCT (0.45 ± 0.08 vs. 0.61 ± 0.10 ng/mL, P < 0.01) were significantly lower in the retromesenteric group, with similar trends on day 3. Anastomotic leakage was less frequent in the retromesenteric group (6.2% vs. 18.4%, P = 0.048), confirmed as an independent protective factor in multivariable logistic regression analysis (OR = 3.16, 95% CI: 1.009–9.894). No significant differences were observed in incisional infection, ileus, or intra-abdominal infection (P > 0.05). Time to first flatus was shorter in the retromesenteric group (48.6 ± 6.3 vs. 52.3 ± 7.1 h, P < 0.01), while hospital stay and 30-day readmission rates were similar.ConclusionThe retromesenteric approach is superior to the anterior mesenteric approach in reducing postoperative inflammatory reactions and the risk of anastomotic leakage, and promotes postoperative intestinal function recovery, which provides an important basis for the selection of surgical approaches for low rectal cancer.Trial registrationNot applicable.

Abstract Low rectal cancer is surgically managed with one of two primary procedures: low anterior resection (LAR) or abdominoperineal resection (APR). Each procedure has a unique profile of potential complications, oncologic outcomes, and quality-of-life impacts. The acceptability of these outcomes is highly driven by patient values. Consequently, shared decision-making is essential to selecting the optimal procedure for each patient. Evidence has shown that patient decision aids (PtDAs) improve patient knowledge, reduce decisional conflict, and support value-congruent decisions. This review describes the development of a rectal cancer PtDA for the choice between LAR and APR. This PtDA was designed according to the International Patient Decision Aid Standards and Ottawa Decision Support Framework. Evaluation of this rectal cancer PtDA demonstrated increased patient knowledge, reduced decisional conflict, and enhanced patient preparedness for decision-making. Despite strong evidence for their utility, PtDAs remain underutilized. This review highlights key barriers in implementing PtDAs and proposes strategies to facilitate the effective integration of PtDAs into surgical practice.

Unraveling variations and enhancing prediction of successful sphincter-preserving resection for low rectal cancer: a post hoc analysis of the multicentre LASRE randomized clinical trial: Erratum.

ABSTRACTBackgroundThis study aimed to evaluate the long‐term oncologic outcomes of robotic‐assisted versus laparoscopic surgery in non‐metastatic patients with locally advanced rectal cancer and to identify prognostic factors influencing overall survival (OS) and disease‐free survival (DFS).Material and MethodsIn this retrospective cohort study, 74 patients with mid or low rectal cancer underwent either laparoscopic (Gr. 1) (n = 28) or robotic‐assisted (Gr. 2) (n = 46) surgery over 10 years. Baseline characteristics, surgical details, postoperative complications, and survival outcomes were analyzed. Multivariate Cox regression was used to identify independent predictors of OS and DFS.ResultsBoth groups had no significant difference in hospital stay, conversion rates, or postoperative complications. Multivariate analysis revealed that robotic surgery was independently associated with improved OS (HR: 2.651; p = 0.019). Other significant predictors of poor OS included tumor grade G3, perineural invasion, and postoperative complications. For DFS, perineural invasion, postoperative complications, conversion to open surgery, and tumor recurrence were associated with worse outcomes. Restoration of bowel continuity via end‐to‐end anastomosis was linked to improved survival.ConclusionsRobotic‐assisted surgery offers comparable, and in some aspects superior, long‐term oncologic outcomes to laparoscopic surgery for locally advanced rectal cancer. Independent predictors of poor survival included high‐grade tumors, perineural invasion, conversion to open surgery, and postoperative complications. Surgical technique, selection criteria, and perioperative care remain crucial for optimizing outcomes.

Robotic-assisted surgery represents a significant advancement in minimally invasive colorectal cancer (CRC) surgery, providing enhanced precision, superior visualization, and potentially improved oncological outcomes compared to laparoscopy. These benefits are particularly significant in low rectal cancer, characterized by narrow pelvic anatomy and critical autonomic nerve preservation. Nonetheless, challenges such as increased operative times, high costs, and extensive training requirements hinder broader adoption. This commentary reviews clinical advantages, current limitations, and future perspectives of robotic colorectal surgery, aiming to inform colorectal surgeons and healthcare stakeholders on the evolving role of robotics in CRC treatment.