Mesorectal Excision For Rectal Cancer Research Articles

Comparison of local excision and total mesorectal excision for rectal cancer: Systematic review and meta-analysis of randomised controlled trial

ObjectivesTo report the first and largest systematic review and meta-analysis of radomised controlled trials (RCTs) to compare the efficacy and safety of transanal endoscopic microsurgery (TEM) and total mesorectal excision (TME) for rectal cancer for perioperative and oncological outcomes. Methods: We conducted a systematic literature retrieval via PubMed, Embase, Web of Science, and Cochrane until December 2022 for RCTs which evaluated the efficacy and/or safety between TEM and TME for rectal cancer. Outcomes included operative time, blood loss, transfusion rates, hospital stay, complication rates, recurrence rates, and mortality. Results: A total of 5 RCTs involving 545 patients (272 TEM versus 273 TME) were included for the meta-analysis. There were no significant differences between the two groups for age, gender, and distance from lower border of tumor to anal verge. Meta-analysis found that the TEM group was significantly favorable than the TME group for blood loss (WMD: 172.01; 95 % CI: 212.78, −131.24; P < 0.00001), hospital stay (WMD: 2.58; 95 % CI: 3.01, −2.16; P < 0.00001), operative time (WMD: 81.86; 95 % CI: 87.51, −76.21; P < 0.00001) and transfusion rates (RR: 0.05; 95 % CI: 0.01, 0.38; P = 0.004). The complication rates (RR: 0.60; 95 % CI: 0.32, 1.11; P = 0.10), recurrence rates (RR: 1.10; 95 % CI: 0.66, 1.83; P = 0.72), and mortality (RR: 1.23; 95 % CI: 0.67, 2.26; P = 0.51) were similar in the two groups. Conclusions: TEM was an effective and safe approach with advantages in perioperative outcomes compared with TME approach. Caution should be exercised in interpreting the differences in surgical complications between TEM and TME group due to significant heterogeneity and instability.

Cytological Analysis of the Surgical Field During Transanal Total Mesorectal Excision for Rectal Cancer: A Prospective Study.

An unexpectedly large number of patients experienced local recurrence with transanal total mesorectal excision in Norway. This appears to be associated with cancer cell spillage during surgery. To investigate the surgical field cytology during transanal total mesorectal excision. This was a prospective cohort study. This study was conducted at a single center between June and December 2020. Forty patients with rectal cancer underwent transanal total mesorectal excision. Following the irrigation of the surgical field, the water specimens were cytologically evaluated at six representative steps. The first sample was used as an initial control. The second, third, fourth, fifth, and sixth samples were collected after the 1st purse-string suture, rectotomy, the 2nd purse-string suture, specimen resection, and anastomosis, respectively. The clinicopathological features and intraoperative complications of the patients were reviewed. The primary outcome was to evaluate the presence of cancer cells in washing cytological samples. Of the 40 consecutive patients enrolled in this study, 18 patients underwent neoadjuvant chemoradiotherapy. Incomplete first pursestring suture and rectal perforation were observed in 4 (10.0%) and 3 (7.5%) cases, respectively. In the first sample, 31 (77.5%) patients had malignant cells. Malignant findings were detected in two patients (5.0%) from the second to fifth samples. None of the sixth sample exhibited any malignant findings. This single center study had a small sample size. Cancer cells were initially detected by cytology, but only a few were observed throughout the procedure; however, cancer cells were not detected in the final surgical field. Further follow-up and novel studies are required to obtain clinically significant findings using cytology during transanal total mesorectal excision. See Video Abstract.

A systematic review and meta-analysis of oncological outcomes with transanal total mesorectal excision for rectal cancer.

Transanal total mesorectal (taTME) excision is a method used to assist in the radical removal of the rectum. By adopting the concept of natural orifice surgery, it offers potential benefits over conventional techniques. Early enthusiasm for this strategy led to its rapid and widespread adoption. The imposing of a local moratorium was precipitated by the discovery in Norway of an uncommon multifocal pattern of locoregional recurrence. The aim of this systematic review and meta-analysis was to determine the incidence of local recurrence after taTME for rectal cancer. Conforming to the Cochrane Handbook for Systematic Reviews of Interventions and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines checklist, a systematic review and meta-analysis was conducted. This included case series and comparative studies between taTME and preferentially laparoscopic procedures published between 2010 and 2021. There were a total of 1175 studies retrieved. After removal and screening for quality and relevance, the final analysis contained 40 studies. The local recurrence rate following taTME was 3.4% (95% CI 2.9%-3.9%, I2 = 0%) in 4987 patients with follow-up durations ranging from 0.7 to 5.5 years. Compared with laparoscopic TME, local recurrence was not statistically different for the taTME group (p = 0.076); however, it was less probable (OR = 0.51, 95% CI 0.24-1.09, I2 = 0%). Systemic recurrence and circumferential resection margin status were secondary outcomes; however, the differences were not statistically significant. Our data suggest that the local recurrence for regular laparoscopic and transanal TME surgeries may be comparable, suggesting that taTME can be performed without influencing locoregional oncological outcomes in patients treated at specialized institutions and who have been cautiously selected.

Laparoscopic right hemicolectomy with complete mesocolic excision and D3 lymphadenectomy using the open book approach: a video vignette.

According to the concept of total mesorectal excision for rectal cancer, Hohenberger translated this concept to colonic cancer by introducing complete mesocolic excision (CME). The concept of this surgical technique was further elucidated by Benz et al. in the form of an open book approach. This article presents and demonstrates in a video a case of laparoscopic right hemicolectomy with CME and D3 lymphadenectomy using open book approach in the treatment of a T3N1M0 distal ascending colonic adenocarcinoma. The final pathology report confirmed moderately differentiated adenocarcinoma with a maximum tumor size of 55 mm and 0/60 lymph nodes. The mesocolic fascia was intact and R0 was achieved. The final staging was pT3pN0pM0. However, D3 lymphadenectomy is not universally adopted due to concerns of higher morbidity we believe that with adequate training and supervision CME with D3 LDN is feasible and safe to be offered to all right-sided colorectal cancers with curative intent treatment.

Management of acute and chronic pelvic sepsis after total mesorectal excision for rectal cancer-a 10-year experience of a national referral centre.

Uncontrolled pelvic sepsis following rectal cancer surgery may lead to dramatic consequences with significant impact on patients' quality of life. The aim of this retrospective observational study is to evaluate management of pelvic sepsis after total mesorectal excision for rectal cancer at a national referral centre. Referred patients with acute or chronic pelvic sepsis after sphincter preserving rectal cancer resection, with the year of referral between 2010 and 2014 (A) or between 2015 and 2020 (B), were included. The main outcome was control of pelvic sepsis at the end of follow-up, with healed anastomosis with restored faecal stream (RFS) as co-primary outcome. In total 136 patients were included: 49 in group A and 87 in group B. After a median follow-up of 82 months (interquartile range 35-100) in group A and 42 months (interquartile range 22-60) in group B, control of pelvic sepsis was achieved in all patients who received endoscopic vacuum assisted surgical closure (7/7 and 2/2), in 91% (19/21) and 89% (31/35) of patients who received redo anastomosis (P = 1.000) and in 100% (18/18) and 95% (41/43) of patients who received intersphincteric resection (P = 1.000), respectively. Restorative procedures resulted in a healed anastomosis with RFS in 61% (17/28) of patients in group A and 68% (25/37) of patients in group B (P = 0.567). High rates of success can be achieved with surgical salvage of pelvic sepsis in a dedicated tertiary referral centre, without significant differences over time. In well selected and motivated patients a healed anastomosis with RFS can be achieved in the majority.

Initial experience of abdominal total mesorectal excision for rectal cancer using the da Vinci single port system.

From November 2021 to February 2022, 15 patients underwent total abdominal mesorectal excision for rectal cancer using the da Vinci single port system. The clinical and pathological results were analyzed retrospectively. All surgeries were performed without conversion. The mean distance from the tumor to the anal verge was 10 cm (range, 2-15 cm). The mean operative time was 191 minutes, the median docking time was 4 minutes (range, 2-10 minutes), and the estimated blood loss was 20 mL (range, 20-50 mL). The mean number of lymph nodes harvested was 16.5, the mean distal resection margin was 3.52 cm, and all patients had circumferential and distal tumor-free resection margins. One patient had minor anastomotic leakage. The mean length of hospital stay was 5.8 ± 2.5 days. Abdominal total mesorectal excision using the da Vinci single port system for rectal cancer is technically feasible and safe, with acceptable pathological and short-term clinical outcomes.

Comparison of the efficacy and safety of single-port versus multi-port robotic total mesorectal excision for rectal cancer: A propensity score-matched analysis

BackgroundIt is unknown whether the da Vinci single-port system performs similarly to the previous multi-port system during complicated procedures, such as rectal cancer surgery. Therefore, we compared the short-term clinical outcomes of single-port and multi-port robotic total mesorectal excision for the treatment of rectal cancer. MethodsThis retrospective study reviewed 128 patients who underwent robotic total mesorectal excision between July 2020 and June 2022, of whom 84 (42 each: single-port versus multi-port) were included in the propensity score-matched cohort. Perioperative and pathologic outcomes were compared between groups. ResultsMedian tumor height was similar between groups (single-port versus multi-port, 5.9 ± 2.1 vs 5.6 ± 1.8 cm, P = .719). Preoperative chemoradiotherapy was performed equally. The total operative time was less (160.0 ± 42.2 minutes vs 199.6 ± 78.6 minutes, P = .005), the total length of incision was shorter (4.0 ±0.3 vs 5.4 ± 0.7 cm, P = .003), postoperative hospital stay was shorter (6.2 ±1.7 vs 7.2 ±2.8 days, P = .050), and C-reactive protein levels on postoperative day 3 trended to be lower (7.3 ± 4.7 vs 8.9 ± 5.6 mg/L, P = .096) in the single-port group, compared with the multi-port group. Postoperative complications did not differ between groups (single-port versus multi-port, 11.9% vs 16.6%, P = .864). Anastomotic leakage occurred in 1 and 2 patients in the single-port and multi-port groups, respectively. The circumferential resection margins were positive in 1 patient in the multi-port group. ConclusionThe perioperative outcomes of single-port robotic total mesorectal excision were comparable to those of multi-port robotic TME. The single-port robot can be considered a surgical option for treating rectal cancer.

Transanal Total Mesorectal Excision for Rectal Cancer: Toward Standardization of the Surgical Technique.

Laparoscopic surgery is widely used for rectal cancer; however, this technique is challenging due to tapering of the mesorectum in the pelvis, and the forward angle of the distal rectum, which renders this part of the rectum less accessible from the abdominal cavity. Hence, concerns regarding its safety and curability have been raised, particularly for inadequate distal and circumferential resection margins. Recently, transanal total mesorectal excision (TaTME), which involves endoscopic total mesorectal excision (TME) retrogradely from the anal side, has attracted attention worldwide as a solution to these problems. TaTME is superior to the conventional laparoscopic approach for rectal cancer in terms of both oncological and functional preservations. However, a shallow learning curve caused by the unfamiliar anatomical view from the anal side can pose challenges. Therefore, an efficient educational system needs to be established. Randomized controlled trials comparing conventional laparoscopic TME with TaTME are ongoing to demonstrate the usefulness of TaTME. This article reviews changes in the surgical treatment of rectal cancer, with a focus on TaTME, and describes the indications, surgical techniques, and training curricula for TaTME.

Comparing perioperative and oncological outcomes of transanal and laparoscopic total mesorectal excision for rectal cancer: a meta-analysis of randomized controlled trials and prospective studies.

Meta-analysis of the results of transanal total mesorectal excision (taTME) and laparoscopic TME (laTME) regarding perioperative and oncological outcomes have been conducted. Due to the lack of high-quality randomized controlled trials (RCTs) and prospective studies in the included literature, the conclusions are unreliable. This study included RCTs and prospective studies for analysis to obtain more reliable conclusions. Systematic searches of the PubMed, Embase, and Cochrane Library databases were conducted up to June 2023. To assess the quality, the Cochrane quality assessment tool and the Newcastle-Ottawa Scale were employed. The perioperative and oncological outcomes were then analyzed. The I2 statistic was used to evaluate statistical heterogeneity and sensitivity analyses was conducted. A total of 22 studies, comprising 5056 patients, were included in the analysis, of which 6 were RCTs and 16 were prospective studies. The conversion rate in the taTME group was significantly lower than that in the laTME group (OR 0.14, 95% CI 0.09 to 0.22, P < 0.01), and the circumferential resection margin (CRM) was longer (MD 0.99mm, 95% CI 0.66 to 1.32mm, P < 0.01), with a lower rate of positive CRM involvement (OR 0.68, 95% CI 0.47 to 0.97, P = 0.03). No statistically significant differences were found in terms of the operation time, intraoperative blood loss, complications, anastomotic leakage, uroschesis, obstruction, secondary operation, hospital stay, urethral injury, readmission, mortality rate within 30days, mesorectal resection quality, number of harvested lymph nodes, distal resection margin (DRM), positive DRM, local recurrence, and distance recurrence (P > 0.05). According to the findings of this meta-analysis, which is based on RCTs and prospective studies, taTME appears to have an advantage over laTME in terms of conversion rate and CRM involvement.

Multicenter phase II trial of transanal total mesorectal excision for rectal cancer: preliminary results

BackgroundTransanal TME (taTME) combines abdominal and transanal dissection to facilitate sphincter preservation in patients with low rectal tumors. Few phase II/III trials report long-term oncologic and functional results. We report early results from a North American prospective multicenter phase II trial of taTME (NCT03144765).Methods100 patients with stage I–III rectal adenocarcinoma located ≤ 10 cm from the anal verge (AV) were enrolled across 11 centers. Primary and secondary endpoints were TME quality, pathologic outcomes, 30-day and 90-day outcomes, and stoma closure rate. Univariable regression analysis was performed to assess risk factors for incomplete TME and anastomotic complications.ResultsBetween September 2017 and April 2022, 70 males and 30 females with median age of 58 (IQR 49–62) years and BMI 27.8 (IQR 23.9–31.8) kg/m2 underwent 2-team taTME for tumors located a median 5.8 (IQR 4.5–7.0) cm from the AV. Neoadjuvant radiotherapy was completed in 69%. Intersphincteric resection was performed in 36% and all patients were diverted. Intraoperative complications occurred in 8% including 3 organ injuries, 2 abdominal and 1 transanal conversion. The 30-day and 90-day morbidity rates were 49% (Clavien–Dindo (CD) ≥ 3 in 28.6%) and 56% (CD ≥ 3 in 30.4% including 1 mortality), respectively. Anastomotic complications were reported in 18% including 10% diagnosed within 30 days. Higher anastomotic risk was noted among males (p = 0.05). At a median follow-up of 5 (IQR 3.1–7.4) months, 98% of stomas were closed. TME grade was complete or near complete in 90%, with positive margins in 2 cases (3%). Risk factors for incomplete TME were ASA ≥ 3 (p = 0.01), increased time between NRT and surgery (p = 0.03), and higher operative blood loss (p = 0.003).ConclusionWhen performed at expert centers, 2-team taTME in patients with low rectal tumors is safe with low conversion rates and high stoma closure rate. Mid-term results will further evaluate oncologic and functional outcomes.Graphical abstract

Intervention Beyond Total Mesorectal Excision in Rectal Cancer: Is Laparoscopic Approach Justified?

В настоящее время лапароскопические технологии активно применяются в хирургическом лечении рака прямой кишки. Однако отношение к выполнению видеоассистированных комбинированных вмешательств в полости таза остаётся настороженным, безопасность и онкологическая адекватность таких операций ставиться под сомнение. Настоящая статья демонстрирует обзор результатов исследований, представленных в современной литературе и посвящённых оценке приемлемости лапароскопической экстрафасциальной тотальной мезоректумэктомии. Несмотря на презентацию отдельных примеров успешного выполнения лапароскопических комбинированных вмешательств, малое количество наблюдений пока не позволяет рекомендовать рутинное использование указанного метода у больных раком прямой кишки T4b.

Author response to: Comment on: Oncological outcomes after transanal total mesorectal excision for rectal cancer.

Author response to: Comment on: Oncological outcomes after transanal total mesorectal excision for rectal cancer.

Comment on: Oncological outcomes after transanal total mesorectal excision for rectal cancer.

Comment on: Oncological outcomes after transanal total mesorectal excision for rectal cancer.

Ileostomy versus colostomy: impact on functional outcomes after total mesorectal excision for rectal cancer.

Even if a defunctioning stoma mitigates the serious consequences of anastomotic leakage after total mesorectal excision (TME) for rectal cancer, the presence of a temporary stoma or having a stoma for a prolonged period of time may also be a determining factor for further morbidities and poor bowel function. The aim of this study was to evaluate the impact of diverting stomas on clinical and functional outcomes after TME, comparing ileostomy or colostomy effects. All consecutive patients who underwent TME for rectal cancer between March 2017 and December 2020 in three Italian referral centres were enrolled in the present study. For every patient sex, age, stage of the tumour, neoadjuvant therapy, surgical technique, anastomotic technique, the presence of a diverting stoma, perioperative complications and functional postoperative status were recorded. Considering the diverting stoma, the kind of stoma, length of time before closure and stoma related complications were evaluated. During the study period 416 consecutive patients (63% men) were included. Preoperative neoadjuvant therapy was performed in 79%. A minimally invasive approach was performed in >95% of patients. Temporary stoma was performed during the operation in 387 patients (93%) (ileostomy 71%, colostomy 21%). The stoma was closed in 84% of patients. The median time from surgery to stoma closure was 145 days. No difference was found between ileostomy and colostomy in overall morbidity after stoma creation and closure. Moreover, increased postoperative functional disturbance seemed to be significantly proportional to the attending time for closure for ileostomy. The presence of a defunctioning stoma seems to have a negative impact on functional bowel activity, especially for delayed closure for ileostomy. This should be considered when the kind of stoma (ileostomy vs. colostomy) is selected for each patient.

Long-term outcomes after transanal total mesorectal excision for rectal cancer in Denmark: A prospective multicenter study from the late implementation phase

PurposeThe aim of this study was to evaluate the long-term surgical and oncological outcomes after transanal total mesorectal excision (TaTME) for rectal cancer during an implementation phase on a national level. MethodThis is a retrospective review of prospectively recorded data. Registration was initiated by the Danish Colorectal Cancer Group in order to assess the quality of care during the implementation of TaTME in Denmark. Data from four centers were pooled for simultaneous analysis. Short-term data was available from a prior study, and long-term data regarding recurrences, chemotherapy, and mortality was collected. ResultsFrom August 2016 to April 2019, 115 TaTME procedures were registered. Patients were predominantly male (n = 85, 74%) with mid-rectal (n = 88, 77%) tumors. The overall local recurrence rate was 7.8% (n = 9) of which six patients also had systemic recurrence. Mean long-term follow-up was 59.4 months, and median time to local recurrence was 24.9 months. Local recurrences occurred predominantly among initial implementation cases. The overall mortality rate was 13% (n = 15). Of the 17 patients with recurrence, 35% (n = 6) died and developed either solely distant recurrence (n = 2, 12%) or in combination with local recurrence (n = 4, 24%). ConclusionWe found acceptable long-term oncological results after TaTME during the implementation phase in Denmark. There was an accumulation of local recurrences in the early phase of the study which emphasizes the importance of thorough training and proctoring when starting the approach.

Oncological outcomes after transanal total mesorectal excision for rectal cancer.

Oncological outcomes after transanal total mesorectal excision for rectal cancer.

Robotic Anterior Rectal Resection for Rectal Cancer with Partial Pelvic Peritonectomy for Carcinosis from Pancreatic Cancer

Introduction: Advanced robotic technology enhances a total mesorectal excision for rectal cancer and may overcome challenges associated with difficult pelvic anatomy.1,2 Moreover, minimally invasive approach may be used to address several common complications of solid organ malignancies.3,4 This video shows a patient with rectal cancer who underwent neoadjuvant therapy with a new finding of a primary pancreatic cancer at postneoadjuvant re-evaluation. The patient underwent a palliative robotic anterior rectal resection for a bleeding adenocarcinoma of the rectum. Materials and Methods: A 70-year-old patient presented to the outpatient clinic with diarrhea and rectal bleeding. Diagnostic work-up included a colonoscopy that showed an adenocarcinoma of the rectum at 8–9 cm from the anal verge. A CT scan revealed no pulmonary disease and no carcinosis, and a pelvic MRI confirmed a substenotic, full thickness infiltrating tumor of the rectum. Multidisciplinary tumor board recommended neoadjuvant treatment based on capecitabine and RT (total dose 55 Gy/25 fractions). Postneoadjuvant re-evaluation included a pelvic MRI that showed a partial response of the rectal tumor. A CT scan identified a new finding of a neoplasm at the level of the pancreatic body. Endoscopic ultrasonography showed a mesopancreatic tumor with splenic vessel involvement. Histologic examination documented an adenocarcinoma and magnetic resonance cholangiopancreatography confirmed the tumor. Multidisciplinary tumor board recommended gemcitabine but it was halted for rectal bleeding after 1 week. A rectoscopy confirmed the bleeding from the rectal lesion. Palliative rectal surgery was recommended, and the patient underwent an anterior rectal resection with S3 metastasectomy and partial pelvic peritonectomy for carcinosis with an end-to-end colorectal anastomosis according to the Knight & Griffen technique and a diverting ileostomy (S3 metastasis and carcinosis were intraoperative findings). Results: The patient was discharged on postoperative day 6. The postoperative course was uneventful and afterward systemic treatment with gemcitabine and paclitaxel was resumed. At re-evaluation by CT and MRI, no pelvic recurrence was diagnosed, whereas the volume of the pancreatic lesion was reduced. A stereotactic ablation was performed on the pancreatic lesion. The patient underwent ileostomy closure, but after 1 year from the primary surgery, the patient referred was admitted with an intestinal obstruction. An explorative laparoscopy revealed diffuse carcinosis from the pancreatic lesion. The patient died a few months later. Conclusion: Robotic technique is a safe and an efficacious tool for palliative surgery. In complex cases, a robotic technique provides a fast recovery and a quick reprise for further oncologic treatments. Palliative surgery, however, must be delivered as part of an interdisciplinary team and should be attempted through a minimally invasive approach to reduce pain and adverse effects of surgical intervention.5 No competing financial interests exist. Runtime of video: 10 mins

Impact of the approach on conversion to open surgery during minimally invasive restorative total mesorectal excision for rectal cancer.

The aim of this study is to explore the impact of the approach on conversion in patients undergoing minimally invasive restorative total mesorectal excision within a single unit. A retrospective cohort study was conducted. Patients with rectal cancer undergoing minimally invasive restorative total mesorectal excision between January 2006 and June 2020 were included. Subjects were classified according to the presence or absence of conversion. Baseline variables and short-term outcomes were compared. Regression analyses were conducted to assess the relationship between the approach and conversion. During the study period, 318 patients underwent a restorative proctectomy. Of these, 240 met the inclusion criteria. Robotic and laparoscopic approaches were undertaken in 147 (61.3%) and 93 (38.8%) cases, respectively. A transanal approach was utilised in 62 (25.8%) cases (58.1% in combination with a robotic transabdominal approach). Conversion to open surgery occurred in 30 cases (12.5%). Conversion was associated with an increased overall complication rate (P = 0.003), surgical complications (P = 0.009), superficial surgical site infections (P = 0.02) and an increased length of hospital stay (P = 0.006). Robotic and transanal approaches were both associated with decreased conversion rates. The multiple logistic regression analysis, however, showed that only a transanal approach was independently associated with a lower risk of conversion (OR 0.147, 0.023-0.532; P = 0.01), whilst obesity was an independent risk factor for conversion (OR 4.388, 1.852-10.56; P < 0.00). A transanal component is associated with a reduced conversion rate in minimally invasive restorative total mesorectal excision, regardless of the transabdominal approach utilised. Larger studies will be required to confirm these findings and define which subgroup of patients could benefit from transanal component when a robotic approach is undertaken.

Robotic total mesorectal excision for rectal cancer based on the theory of fundamental use of surgical energy

Improving oncological curability and preserving urinary function must be established in robotic total mesorectal excision (TME) for rectal cancer. To achieve this, it is important to avoid nerve injury by sharp dissection of the avascular plane by the monopolar device and thermal spread. The aim of this study was to improve the robotic TME quality by focusing on the theory of fundamental use of surgical energy (FUSE) of the monopolar device and investigating the surgical procedure. In this single-center retrospective study, 26 consecutive patients who underwent robotic TME for rectal cancer at Tokyo Medical University Hospital between June 2022 and August 2022 were included. All surgeries were performed by FUSE-certified surgeons in accordance with FUSE theory, which was, thermal effect = current density (current/area) squared × tissue resistance × contact time. The median age of the patients was 64years (range 40-79years), and 17 patients were male. The median operative time was 287min (range 229-430min); median bleeding volume, 22ml (range 5-223ml); and the median number of harvested lymph nodes, 17 (range 4-40). The conversion rate to open surgery was 0%. A breakdown of Clavien-Dindo classification Grade ≥ II post-operative complications was as follows: surgical site infection, one patient (3.8%); ileus, one patient (3.8%); and urinary dysfunction, one patient (3.8%). No surgery-related or in-hospital deaths occurred. The pathological positive resection margin was not observed. Robotic TME for rectal cancer based on the theory of FUSE can be safely performed, making it a promising surgical procedure. It is suggested that robotic surgeons acquire surgical operation skills with monopolar devices based on the principles of FUSE, which may lead to an increased quality of robotic TME.

The impact of the anastomotic configuration on low anterior resection syndrome 3 years after total mesorectal excision for rectal cancer: a national cohort study.

After low anterior resection, the bowel can be anastomosed in different ways. It is not clear which configuration is optimal from a functional and complication point of view. The primary aim was to investigate the impact of the anastomotic configuration on bowel function evaluated by the low anterior resection syndrome (LARS) score. Secondarily, the impact on postoperative complications was evaluated. All patients who had undergone low anterior resection from 2015 to 2017 were identified in the Swedish Colorectal Cancer Registry. Three years after surgery, patients were sent an extensive questionnaire and were analysed based on anastomotic configuration ('J-pouch/side-to-end anastomosis' or 'straight anastomosis'). Inverse probability weighting by propensity score was used to adjust for confounding factors. Among 892 patients, 574 (64%) responded, of whom 494 patients were analysed. After weighting, the anastomotic configuration had no significant impact on the LARS score (J-pouch/side-to-end OR 1.05, 95% confidence interval [CI] 0.82-1.34). The J-pouch/side-to-end anastomosis was significantly associated with overall postoperative complications (OR 1.43, 95% CI 1.06-1.95). No significant difference was seen regarding surgical complications (OR 1.14, 95% CI 0.78-1.66). This is the first study investigating the impact of the anastomotic configuration on long-term bowel function, evaluated by the LARS score, in an unselected national cohort. Our results suggested no benefit for J-pouch/side-to-end anastomosis on long-term bowel function and postoperative complication rates. The anastomotic strategy may be based upon the anatomical conditions of the patient and surgical preference.