Lower Rectum Research Articles

International real-world study of TOTAL neoadjuvant therapy (TNT) for locally advanced rectal cancer (LARC).

40 Background: TNT has recently emerged as a standard treatment for LARC. However, use and outcome of the different TNT regimens in real-world practice are largely unknown. Methods: This is an international, multicentre, retrospective study sponsored by the Institut Jules Bordet, Brussels. Eligibility was limited to newly diagnosed LARC patients treated with TNT between March 2013 and May 2023 and outside the context of a clinical trial. The primary objective was to describe real-word practice across international centres. Secondary objectives included treatment safety and efficacy. Data were collected into a central electronic database, and remotely monitored. Descriptive statistics were used, and survival outcomes were estimated with Kaplan-Meier curves. Results: 1,272 eligible patients were included from 47 centres across four continents (Europe, Asia, North America and South America). Baseline characteristics were as follows: 63% males, median age 60 years (range 21-88), 47% low rectum, 26% cT4, 47% cN2, 49% EMVI+, 59% CRM+. In the overall population, 21% of the resected patients had a pathological complete response (pCR), while 11.3% were managed according to a watch-&-wait (w&w) strategy. Median follow-up was 24.1 months (IQR 23.7). Local and distant recurrences after curative-intent surgery occurred in 5.5% and 16.2% of patients, respectively. 3-year event-free survival (EFS) was 68.3%, while 3-year overall survival (OS) was 89%. Serious adverse events were reported in 4.3% of patients during radiotherapy, and in 14.7% during chemotherapy. Patient distribution according to the TNT sequence/regimen, and respective efficacy outcomes are reported in the table. Conclusions: This is the largest real-world study of TNT for LARC. Our findings show substantial variation in the choice of TNT sequence and regimen. Efficacy and safety results are overall in line with those reported in clinical trials, and confirm feasibility of TNT in a real-world setting. Patient recruitment is ongoing, and updated results with propensity score matching analyses will be reported at the meeting. [Table: see text]

Can 3D radiological calculations predict operational difficulties for rectal cancer?: A single center retrospective analysis.

Low anterior resection, performing total mesorectal excision with appropriate pelvic dissection to prevent local recurrence, is probably the most challenging type of surgery in colorectal surgery, especially in a narrow pelvis. In this study, we aimed to predict the operation difficulty of rectal cancer by comparing the operation time with 2D and 3D pelvimetry. Sixty-six patients who underwent total mesorectal excision after neoadjuvant chemoradiotherapy due to primary rectal cancer located in the middle and lower rectum (10 cm from the anus) were included in the study. Surgery notes were reviewed and data on demographic factors, tumor stage, duration of surgery, and types of surgery were collected, as well as pelvimetric parameters. All protocols had 2D T2-weighted sequences in 3 planes (axial, sagittal, and coronal). Pelvimetric measurements were made by measuring 8 pelvic lengths and 2 angles. Pelvis and tumor volume were measured by manual margin monitoring. In each slice, both pelvis and tumor boundaries were manually drawn individually in the sagittal plane. Pelvis and tumor volumes were calculated from the set of adjacent images by summing slice thickness and products of area measurements within the pelvis and tumor boundaries. In our results, no correlation was observed with operation time, including pelvic volume. Exception for this were interacetabular distance and tumor volume. In the regression test, the only parameter that correlated with the operation time was tumor volume. In conclusion, we believe that tumor volumetric calculations may be useful in predicting difficult distal rectal carcinoma surgeries.

Short-term outcomes of endoscopic resection for colorectal neuroendocrine tumors: Japanese multicenter prospective C-NET STUDY.

The incidence of colorectal neuroendocrine tumors (NETs) has increased with colorectal cancer screening programs and increased colonoscopies. The management of colorectal NETs has recently shifted from radical surgery to endoscopic resection. We aimed to evaluate the short-term outcomes of various methods of endoscopic resection for colorectal NETs. Among those registered in the C-NET STUDY, patients with colorectal NETs who underwent endoscopic treatment as the initial therapy were included. Short-term outcomes, such as the en bloc resection rate and R0 resection (en bloc resection with tumor-free margin) rate, were analyzed based on treatment modalities. A total of 472 patients with 477 colorectal NETs received endoscopic treatment. Of these, 418 patients with 421 lesions who met the eligibility criteria were included in the analysis. The median age of the patients was 55 years, and 56.9% of them were men. The lower rectum was the most commonly affected site (88.6%), and lesions <10 mm accounted for 87% of the cases. Endoscopic submucosal resection with a ligation device (ESMR-L, 56.5%) was the most common method, followed by endoscopic submucosal dissection (ESD, 31.4%) and endoscopic mucosal resection using a cap (EMR-C, 8.5%). R0 resection rates <10 mm were 95.5%, 94.8%, and 94.3% for ESMR-L, ESD, and EMR-C, respectively. All 16 (3.8%) patients who developed treatment-related complications could be treated conservatively. Overall, 23 (5.5%) patients had incomplete resection without independent clinicopathological risk factors. ESMR-L, ESD, and EMR-C were equally effective and safe for colorectal NETs with a diameter <10 mm.

Inter-Sphincteric Resection of Rectum for Ulcerated S-100 Negative Large Granular Cell Tumour

Non-neural granular cell tumor was first described in 1991 as an unusual primitive, polypoid variant of the conventional GCT (granular cell tumor). To date, this neoplasm remains as a rare entity and the cell of origin is uncertain. While the histological features are similar to the conventional (traditional) GCTs, it represents a distinct entity, as it is negative for S-100 and lacks true nerve sheath differentiation. We report here a case of a 49-year-old male patient with S-100 negative, vimentin positive large benign, ulcerated, bleeding non-neural GCT in the lower rectum. We confirmed the diagnosis histopathologically and immunohistochemically. We treated it by ISRR (Inter-Sphincteric Resection of Rectum) and primary colo-anal anastomosis. We find no other report of non-neural GCT located in the rectum in surgical literature. This is probably the first case of non-neural GCT identified in the rectum. This case report is presented here to document a non-neural GCT located in the rectum for the first time ever reported, and also to highlight the optimum best surgical approach, as we deemed here for this large ulcerated bleeding tumor in the rectum. This rectal non-neural GCT posed here as an unusual differential diagnosis from such more common neoplastic bleeding lesions in the rectum as carcinoma rectum, hemorrhoid, rectal polyp, etc. Here we like to discuss our experience, reviewing in brief the available literature implicating the biological behavior, histopathological and immunohistochemical features, differential diagnosis and therapeutic considerations of neural and non-neural GCTs. KYAMC Journal Volume: 14, No: 03, October 2023: 181-187.

Intersphincteric resection of low rectal cancer: a retrospective study

Background The use of sphincter-saving resection without a permanent stoma in place of abdominoperineal resection (APR) has been one of the greatest advancements in the area of surgical therapy for low rectal cancer. Aim To assess the oncological and functional outcomes of inter-sphincteric resection of low rectal cancer in order to achieve radicality and a standard of living. Patients and methods At the hospitals affiliated with Menoufia University, a retrospective analysis was done. Forty patients with rectum cancer who were undergoing general surgery at Menoufia University Hospitals were the subject of this investigation. We comprised: older than 18 years old, sexes of both genders, low rectum and anal canal, with internal sphincter or rectal wall restriction on magnetic resonance imaging, differentiated tumour, tumour diameter of 1–5, and good continence. Results Mean operative time was 261.8 (±96.6 SD), the mean blood loss was 185.8 (±156.5 SD). Mean postoperative hospital stay was 11.2 (±4.1S D), the mean pain severity 1 h postoperatively was 5.5 (±1.0 SD), the mean 1 day postoperatively was 5.9 (±1.5 SD), the mean 5 day postoperatively was 3.3 (±1.2 SD), there were three with Anastomotic leakage, two with wound infection, two with hemorrhage, one with urinary tract infection, one with ileus. Regarding complications, mean score of micturition problems was 28.2 (±4.1 SD), the mean GIT symptoms was 32.2 (±3.1 SD), the mean weight loss was 5.5 (±1.0 SD), the mean CTX side effects was 13.9 (±1.5 SD), the mean body image was 70.3±6.2. Conclusion The intersphincteric resection approach improves the rate of sphincter preservation while maintaining oncological and functional results. Symptom-specific quality of life may be adversely affected by preoperative radiation.

A Case of Transanal Endoscopic Excision for Rectal Tumor Using Surgical Instruments With Multi-jointed Structures.

Transanal endoscopic local excision requires fine operation in a very narrow space in the rectum. We report a case in which the use of surgical instruments with a multi-jointed structure allowed safe resection of a lesion with a stable field of view, resulting in preservation of postoperative function. The patient was a 49-year-old man who had a rectal neuroendocrine tumor (NET) (G1) with erosive changes in the lower rectum. Preoperative imaging showed no evidence of surrounding lymph node or distant metastasis; thus, we performed a transanal endoscopic local excision of the tumor. After positioning the patient under general anesthesia and securing the field of view in the intra-rectal cavity, the flexion of the surgical instruments with a multi-jointed structure was used to secure the operating space to not interfere with the camera and the surgeon's right hand. The operating field was developed, and the tumor was incised by stable traction. After the excision, the needle was advanced in the direction of the intestinal axis using the multi-jointed holder, and continuous suturing was performed. The patient has no recurrence without any defecation disorder. The use of multi-jointed surgical instruments in transanal endoscopic excision of rectal tumors can provide a stable operative field and preserve postoperative function. The advanced flexibility of these instruments allows precise manipulation in the narrow rectal space, resulting in successful tumor resection with minimal invasiveness and no postoperative complications. These findings suggest that multi-jointed instruments are valuable for enhancing the safety and efficacy of minimally invasive rectal surgery.

A case study on Manjalkaram (medicated alkaline lotion) in the management of Powthiram (fistula-in-ano)

Abstract Background: Abscesses around the lower rectum and anal canal are known as anorectal abscesses. These are crucial as they often culminate in fistula-in-ano. Anorectal abscess and fistulas are one of the most frequent results in the manifestation of simple or complex and extensive fistulous tracts. Karam (herbo-mineral preparation) therapy is a Siddha parasurgical technique commonly used to cure anal disease. Materials and Methods: Manjalkaram is a medicated alkaline lotion preparation that acts as herbal chemical cauterization agent to cure anal disease. A 60-year-old male patient, already treated with allopathy, experienced a recurrence of fistula-in-ano. The patient decided to get Siddha treatment and presented with the complaints of pain in the anal area, swelling, and discharge of pus with stool and mild irritation. The patient was diagnosed with fistula-in-ano. Purgatives were given the previous night to clean the bowel, and the following day, local cleaning was carried out by providing Triphala decoction as a herbal antiseptic lotion. A probe was inserted into the fistula, and a Manjalkaram-soaked medicated thread was inserted through the fistula and tied through an external opening to the internal opening with help of the probe. A Manjalkaram-soaked gauze (Manjalkaraseelai) was inserted and changed once in a week. Result: Even though fistula-in-ano is very difficult to treat, the patient got completely healed within 2 months with the effect of Manjalkaram application. Conclusion: Manjalkaram application is found to be an effective, time-saving, affordable, and acceptable treatment for fistula-in-ano.

Survival outcomes according to the tumor location and prognostic factor in metastatic rectal cancer: a multicenter retrospective cohort study.

Prognostic factors of metastatic rectal cancer are not well known. We aim to determine prognostic factors affecting survival for metastatic rectal cancer patients and also to investigate the effect of tumor localization on overall survival. Metastatic rectal cancer patients who received treatment in 5 different centers between 2012 and 2022 were included. Prognostic factors for survival were evaluated using univariate and multivariate analysis. The statistical methods included Pearson's chi-square test, Fisher exact test, Log-rank test, and Cox regression model. A total of 283 patients with metastatic rectal cancer were included in the study. The median OS was not significantly different among the three groups (upper rectum 30.1 months, middle rectum 28.3 months, and low rectum cancer 24.8 months; log-rank p = 0.25). In univariate analysis, Grade 3, ECOG performance status 2, the presence of multiple metastatic sites, the presence of KRAS mutation, the presence of liver metastases, the presence of nonregional lymph node metastases, and the presence of bone metastases were significant predictors of poor survival. In multivariate analysis, Grade 3, ECOG performance status 2, and the presence of multiple metastatic sites were determined as indicators of worse prognosis. Our findings, primary tumor location did not affect survival in metastatic rectal cancer. The most important factors affecting survival were multiple metastatic sites, tumor grade, and ECOG performance status.

Granular cell tumor of the perineum (clinical case)

Aim: to present a clinical case of a rare granular cell tumor (Abrikosov’s tumor) with perianal site.Patients and Methods: a patient had a slowly progressive growth of a perianal tumor. The tumor with dimensions of 40 × 30 mm intimately adheres to the lower ampullary rectum and anterior portion of m. levator ani, no signs of malignant transformation occurred. Trepanobiopsy was performed followed by immunohistochemical study. The biopsies contain mainly fibrous tissue and clusters of cells with rounded nuclei and granular cytoplasm. Immunohistochemistry showed diffuse positive cytoplasmic reaction with antibodies to S100. The tumor was positive for CD8, vimentin and negative for GFAP. The expression of the Ki67 protein was 2%. Diagnosis: granulocellular tumor (Abrikosov’s tumor), the tumor was removed by perineal access.Resultss: the removal of the tumor, originating from the low rectum, was performed with perineal access and with the restoration of the muscular layer of the bowel wall. No complications occurred, patient discharged 5 days after surgery.Conclusion: Abrikosov’s tumor is a rare benign neoplasm. Surgery is possible in coloproctological units with sufficient level of surgeons.

Predicting the Response to Neoadjuvant Chemoradiotherapy in Locally Advanced Rectal Cancer Using Soluble Immune Checkpoints.

Introduction: Personalizing neoadjuvant therapy for locally advanced rectal cancer (LARC) requires identifying biomarkers that predict treatment response. This study aims to evaluate soluble immune checkpoints (sICPs) as predictive markers for neoadjuvant treatment response in LARC patients located in the middle and lower rectum. Materials and Methods: This prospective study included patients diagnosed with clinical stage T3 or T4 rectal cancer (RC) based on pelvic magnetic resonance imaging, with or without pelvic lymph node involvement. The modified Ryan scoring system was used to assess the response to neoadjuvant chemoradiotherapy (nCRT). Blood samples were collected from all RC patients before initiating nCRT. Various sICPs (sCD25, 4-1BB, B7.2, free active TGF-β1, CTLA-4, PD-L1, PD-1, Tim-3, LAG-3, galectin-9), along with age, gender, stage, blood cell counts, and biochemical variables, were recorded and compared based on tumor regression grade (TRG). Results: Among 38 participants, lymphocyte count was higher, and platelet-to-lymphocyte ratio (PLR), neutrophil-to-lymphocyte ratio (NLR), and platelet count were lower in patients with complete/near-complete response (TRG 0/1). In addition, TRG 0/1 patients had significantly lower levels of soluble galectin-9 than TRG 2/3 patients. Furthermore, platelet count was the only parameter that showed a significant difference among the three groups (TRG 0/1, TRG 2, and TRG 3). PLR demonstrated the highest sensitivity and specificity, with >80% for both measures. Conclusions: Lymphocyte count, PLR, NLR, platelet count, and galectin-9 may help predict favorable neoadjuvant treatment response in LARC patients, although without providing a definitive outcome. Personalized therapy based on these markers could enhance treatment decision making in LARC management.

Low Rectal Cancers at Initial Staging MRI.

Low rectal cancers, which are associated with increased risk of local recurrent disease and poorer prognosis, have unique anatomic considerations and issues for staging and treatment that do not apply to mid and high rectal cancers. Although tumor histology help drive the staging and treatment of all rectal cancers, it is of particular importance in low rectal cancers, which may involve the anal canal, to help establish whether a low rectal mass should be staged and treated as a rectal cancer (ie, adenocarcinoma) or an anal cancer (ie, squamous cell carcinoma). Optimal staging and treatment of rectal cancer are contingent on tumor location and local extent, which help guide management decisions including neoadjuvant therapy and curative surgical treatment strategies. Tumor location in the low rectum and local involvement of the anal canal, sphincter, and pelvic floor help determine whether a patient can undergo sphincter-preserving resection such as a low anterior resection versus abdominoperineal resection to achieve negative surgical margins. Issues exist related to the anatomy and patterns of disease spread that are unique to the low rectum and include how to determine and stage anal sphincter involvement, mesorectal fascia status at the pelvic floor, and nodal status of extramesorectal nodes such as the external iliac and inguinal lymph nodes. For these reasons, it is imperative that radiologists who interpret rectal cancer staging MRI examinations feel comfortable with the unique anatomy of the low rectum and anal canal, nuances of low rectal cancer local disease spread, and treatment paradigms for low rectal cancer. ©RSNA, 2023 Online supplemental material is available for this article. Quiz questions for this article are available through the Online Learning Center. See the invited commentary by Gollub in this issue.

Transanal total mesorectal excision (TaTME) in rectal cancer treatment within an expert center

The objective of this study was to evaluate treatment outcomes in patients who underwent the TaTME procedure for cancer of the middle and low rectum in an expert center. Prospective analysis of the outcomes of all consecutive patients treated using the TaTME technique for cancer of the middle and distal rectum at the our medical center between March 1, 2015, and March 31, 2022. A total of 128 patients (34 women, 94 men; mean age 66.01 [38–85] years) with cancer of the middle and distal rectum qualified for TaTME. TaTME procedures were performed in 127/128 (99.22%) patients. Complications of surgery were observed in 22/127 (17.32%) patients. Negative proximal and distal margins were confirmed in all 127 patients. Complete (R0) resection of the mesorectum was confirmed in 125/127 (98.43%) and nearly complete (R1) resection was confirmed in 2/127 (1.57%) patients. The average follow-up period was 795 days (296–1522) days. Local recurrence was detected during the follow-up period in 2/127 (1.57%) patients. This study showed that the TaTME procedure is an effective and safe method for the minimally invasive treatment of middle and low rectal cancers, particularly within an expert center setting.

Outcomes of Watch and Wait Following Total Neoadjuvant Therapy for Rectal Cancer

To evaluate the outcomes of patients with locally advanced rectal cancer who achieved a clinical complete response (cCR) after total neoadjuvant therapy and enrolled in a prospective watch and wait (WW) database. Consecutive patients with locally advanced rectal cancer who achieved cCR following total neoadjuvant therapy (long-course chemoradiotherapy plus systemic chemotherapy) and were enrolled in our institutional WW surveillance protocol from 2014 through 2022 with the intention of organ preservation. Patients with lack of follow up according to our institutional protocol were excluded. Primary outcomes included local tumor regrowth and distant metastatic disease recurrence. Thirty-three consecutive patients (48% male; median age 61 [33-77] years) with the diagnosis of locally advanced rectal adenocarcinoma were managed by a multidisciplinary team. All patients had Eastern Cooperative Oncology Group Performance Status score of 0 or 1 at time of rectal cancer diagnosis. Location of tumor included upper rectum (18%), middle rectum (40%), and lower rectum (42%). On initial staging magnetic resonance imaging, 4 (12%) patients had evidence of extramural venous invasion, 6 (18%) had a threatened mesorectal margin, and 4 (12%) had anal sphincter or levator ani tumor involvement. A majority (61%) received chemotherapy followed by long-course chemoradiotherapy. Only one patient had an unplanned break during radiotherapy. Local tumor regrowth was diagnosed in 4 (12%) patients and all underwent successful salvage surgery without additional local failures at a median follow-up of 19 [12-48] months. Two of these four patients remain disease-free at a median follow-up time of 12.5 months. Mean time to local tumor regrowth as first site of cancer recurrence was 33.5 [18-46] months. Distant metastatic disease as the first site of recurrence occurred two patients (6%). Mean time to distant metastatic disease as first site of recurrence was 27 months. Only one mortality occurred in the entire group at a median follow-up of 49 [8-102] months. Organ preservation after total neoadjuvant therapy for locally advanced rectal cancer yields excellent outcomes with low local and distant relapse rates. Structured surveillance protocols and multidisciplinary care are essential for success.

Dose Escalation Using Magnetic Resonance Guided High-Dose-Rate Endorectal Brachytherapy to Enhance Clinical Response after Neoadjuvant Radiotherapy in Rectal Adenocarcinoma

To assess the proportion of patients with rectal adenocarcinoma achieving clinical complete response after neoadjuvant chemoradiation (NACTRT) and MR guided endorectal brachytherapy boost (MR-ERBT) MATERIALS/METHODS: Patients with rectal cancers (T2-T4/N0-N+) treated with concurrent chemoradiotherapy (50Gy/25# with Capecitabine) between June-2017 to April-2022. Post RT, patients having residual non-circumferential lesions <8cm in length were administered escalated-dose MR-ERBT with Ir192 HDR source. A median dose of 12Gy (8-15Gy) in 3 (2-3) fractions at 3-5 day intervals was delivered using MR-ERBT after external radiation. Data on near complete/complete clinical response (nCR/cCR) rates, local regrowth rates and clinical outcome were collected for analysis. Of the 145 patients who received MR-ERBT, majority were staged as T3(78.7%) and N1-2 (77.5%) rectal cancers. Median tumor length was 4cm and 123 (85%) of the tumors were located in the lower rectum (0-5cm from anal verge). Seventy-six (52%) patients achieved cCR or nCR (37 cCR, 39 nCR) and were advised observation or watch and wait (WW) management. The 69 patients having partial response were advised surgery. The patients having nCR 16 (29%) underwent resection, of these 10 (62%) had pathological complete response (pCR). The patients with partial or poor response, 57 underwent resection and of these 11 (19%) had pCR, 12 patients refused surgery due to fear of permanent stoma and continued to be on follow up. Of the 79 patients undergoing resection, 36 (45.5%) had sphincter preserving surgeries. At the median follow up of 30 months, local regrowth was seen in 8 (10.5%) of patients on WW and 6 were surgically salvaged while other 2 had synchronous metastatic relapse. Thus, 56 (41%) achieved organ preservation and continued to be on WW management. Twelve (8,2%) patients developed distant metastasis in the entire cohort, 3 in the WW group and 9 in the resected group. There were no pelvic recurrences seen in the resected patients. The disease-free survival at 3 years were (96.1% vs 89% Observation vs. resected (p_0.05) respectively. The overall survival at 3 years were (93% vs 98% Observation vs. resected (p_0.44) respectively. Late rectal toxicity was observed in 16(11%) patients on observation CONCLUSION: Dose Escalated MR-EBRT is an effective and safe method to enhance complete clinical response, thus improving the rate of organ preservation for distal rectal cancers.

Primary Extra Renal Papillary Renal Cell Carcinoma Masquerading as A Metastatic Carcinoma: A Unique Case with Dual Malignancies

A 50-year-old male presented with abdominal pain, pain during defaecation, constipation, bleeding per rectum for 2 months. Colonoscopy showed an ulcero-proliferative growth, that is 2.5 cm from anal verge. Further PET-CT confirmed the growth in the lower rectum with mesorectal fat stranding and an irregular, lobulated, encapsulated solid-cystic mass in right perinephric fat, separated from the kidney (suggestive of metastasis), with intact bilateral kidneys. Biopsy of the rectum revealed an adenocarcinoma and biopsy of right perinephric mass revealed a papillary neoplasm. Following which abdominoperineal resection with perinephric mass excision was performed, due to encapsulation of mass. Histopathological evaluation and further immunohistochemistry performed was positive for vimentin, AMACR, CD10 and negative for other markers to rule out metastasis of either. This led to the diagnosis of synchronous primaries i.e., Extra-renal papillary renal cell carcinoma and adenocarcinoma of rectum.

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.

Laparoscopic Reduction of Sigmoidorectal Intussusception by a Modified Hutchinson’s Maneuver

Traditionally, adult intestinal intussusception is treated using Hutchinson’s maneuver, i.e., manual proximal bowel compression and reduction of intussusception. However, the lack of manual contact in laparoscopic surgery limits the application of Hutchinson’s maneuver. Moreover, when the lead point is located distal to the peritoneal refection, and the intussusception cannot be reduced prior to bowel resection, stoma construction (e.g., Hartmann surgery or abdominoperineal resection) becomes necessary. Here, we report a case of sigmoidorectal intussusception treated laparoscopically using a modified Hutchinson’s maneuver. A 74-year-old man was diagnosed with sigmoidorectal intussusception caused by sigmoid colon cancer. Colonoscopy revealed a malignant-appearing obstructing mass telescoping into the rectum, with the lead point at 3 cm from the anal verge. During the endoscopic examination, the lead point did not move. A biopsy of the mass showed adenocarcinoma, leading to a diagnosis of sigmoid cancer with sigmoidorectal intussusception. Since the patient had no symptoms of intestinal ischemia, and defecations were observed, elective laparoscopic surgery was planned. Intraoperatively, an attempt was made to pull out the intussuscepted segment proximally, but the presence of fibrous adhesions made the intussusception irreducible. Therefore, the rectum and mesorectum were mobilized completely up to the level of the levator ani so that the lower rectum could be wrapped with gauze on the anal side of the lead point of the intussusception. The gauze was then pulled up to the oral side and simultaneously, a surgeon pushed the distal end of the intussuscepted segment up using a laparoscopic bowel grasper, with another surgeon pushing the lead point through the anus with fingers. Thereby, the intussusception was reduced to some extent, allowing for low anterior resection. The resected specimen contained an ulcerated moderately differentiated adenocarcinoma of the sigmoid colon measuring 3.5 cm × 3.0 cm, combined with circumferential ischemia with mucosal loss and necrosis over an 8 cm length on the distal side of the tumor. The tumor was stage III (T3 N1). We provide a laparoscopic approach for treating intussusception using a modified Hutchinson’s maneuver. This method will be useful in reducing the intussuscepted segment while avoiding stoma construction.

Single-team transanal total mesorectal excision for mid and lower rectal cancer: Snow Leopard approach

Background Transanal total mesorectal excision (TaTME) is a recently developed technique to overcome difficulties of rectal cancer resection spatially in male patients, large tumors, high body mass index, and low rectal cancer. Methods From April 2018 to March 2021, 30 patients were included. Single-team TaTME was done, using traditional Laparoscopic instruments and a two-dimensional HD camera, starting with the abdominal phase. The analysis focused on operative data and short-term surgical outcomes. Results 30 taTME procedures were performed, 16 (53.3%) males and 14 (47.7%) females, with a mean age of 50.43 years. There were 21 (70%) patients with tumors in the middle part of the rectum and 9 (30%) patients with tumors in the low rectum. All patients received Long Course Neoadjuvant CRT. The duration of hospital stay was 5.27±1.08 days. The median operative time was 135.27 min the estimated blood loss was 133.67 66.59 ml. Complete mesorectal excision was achieved in all patients. Circumferential radial margin (CRM) was negative in all cases. 1 (3.3%) case needed conversion to an open approach. The overall postoperative complications rate was 6.6% (2 cases). Postoperative ileus occurred once, and anastomotic leakage occurred in one patient. Conclusions In experienced hands, TaTME is a safe technique but still a challenging procedure. The author suggest that single team approach is not time-consuming (operative time was less than what had been reported by other authors using the two-team approach), and dissection should be done through the proper plane (TME planes) lateral to the urosacral ligament in females and its analog in males named prostatosacral ligament as described in the Paper to minimize the incidence of local recurrence.

Endoskopická submukózna disekcia v rekte – naša skúsenosť

Summary: Introduction: Endoscopic submucosal dissection (ESD) is an endoscopic treatment method for the removal of neoplastic lesions of the digestive tract. Thanks to this technique, we can achieve complete (en bloc) R0 endoscopic resection of even large lesions in one piece. We thereby obtain a valuable resection for further histopathological evaluation and, with a suitably chosen lesion, achieve a curative resection. Methods: Retrospective analysis of our file in the period 1/2020–01/2023. The primary objective was to determine how endoscopic evaluation and selection of included rectal lesions treated with the ESD technique correlates with histopathological results. The secondary objective was to determine the curability of the treatment we performed in our group of patients. We included lesions over 20 mm with the assumption of maximum invasion into the surface parts of the submucosa, i.e., JNET 2B. In addition, we included recurrent lesions in the scar after previous endoscopic or surgical treatment, submucosal lesions up to 20 mm and lesions smaller than 20 mm, especially in the lower rectum, which cannot be radically removed en bloc by loop-based techniques. Results: We included a total of 76 rectal lesions. JNET 2B lesions were 59 of them (77.6%). The most common histopathological diagnosis was high-grade dysplasia (HGD) in 35 (46%) cases. We achieved curative endoscopic resection in the majority (93.4%) of patients. Five patients (5.26%) required subsequent surgical or oncological therapy after ESD and further staging. Conclusion: The results of our work confirm the effectiveness of ESD as a therapeutic method suitable for achieving en bloc R0 resection of rectal lesions and thus their correct histopathological evaluation. However, the correct selection of patients remains crucial. Key words: endoscopic submucosa dissection – rectal lesions – curative resection

Gastrointestinal: Unusual pathology of an anorectal lesion mimicking a benign laterally spreading tumor.

A 70-year-old woman was referred to our institution for the diagnosis and treatment of an anorectal lesion detected on colonoscopy performed at a previous hospital for hematochezia. Colonoscopy revealed a 32-mm flat elevated lesion in the lower rectum with an anal component extending to the dentate line (Fig. 1a). Chromoendoscopy with indigo carmine spraying demonstrated a papillary surface (Fig. 1b). Magnifying endoscopy with narrowband imaging (NBI) displayed an irregular vessel resembling the intrapapillary capillary loop (IPCL) of the Japan Esophageal Society Classification Type B1 (Fig. 1c). Magnifying endoscopy with 0.05% crystal violet staining revealed the absence of discernible glandular ducts, hindering the evaluation of the pit pattern (Fig. 1d). The endoscopic appearance resembled a large adenoma or condyloma acuminatum; however, the absence of a pit pattern indicated that the lesion was covered with squamous epithelium and not columnar. Moreover, the irregular vessel pattern suggested a neoplastic lesion. Based on these observations, the lesion was diagnosed as a neoplasm originating from the squamous epithelium of the anal canal. Thus, we performed endoscopic submucosal dissection for complete elimination. Histological examination revealed a papillary growing squamous cell carcinoma (SCC) exhibiting low-grade and high-grade atypia and abundant dilated vessels (Fig. 2a). The tumor extended from the anal transitional zone (ATZ) to the rectum and entrapped the rectal crypts (Fig. 2b). Some tumor cells had a clear cytoplasm, indicative of koilocytosis (Fig. 2c), and positive p16 immunohistochemical staining suggested human papillomavirus (HPV) infection (Fig. 2d). The final diagnosis was HPV-associated SCC in situ originating from the ATZ with rectal extension. Anal canal cancer (ACC) is a rare disease that accounts for only 0.3% of all malignancies and is strongly associated with high-risk HPV (HPV-16 and HPV-18). This case was unusual because of the extensive infiltration of the columnar epithelium. Therefore, it might be misidentified as a rectal adenoma. Early ACC shows irregular vessel patterns reminiscent of esophageal SCC on magnified endoscopic NBI, which has been reported to be useful in diagnosing ACC. However, laterally spreading tumor (LST) can exhibit similar irregular capillary vessels. The difference in endoscopic appearance between ACC and LST can be explained by their different epithelial anatomies. ACC develops in the squamous cell epithelium and has no orifice or crypt. In contrast, LST originates from the columnar epithelium and has crypt openings. Condyloma acuminatum has a similar endoscopic appearance but with milder vascular dilatation and caliber changes. In conclusion, HPV-associated anal canal cancer can be suspected in papillary tumors with an irregular esophageal SCC-like vascular pattern and absence of glandular structures. Piecemeal endoscopic mucosal resection can be selected for large adenomas; conversely, en bloc resection is the preferred method for ACC to mitigate the risk of recurrence. To ensure the implementation of appropriate treatment, more attention should be paid to lesions extending along the anal canal to the rectum.