Rectal Cancer Surgery Research Articles

Quadruple Assessment of Colorectal Anastomosis after Laparoscopic Rectal Resection: A Retrospective Analysis of a Propensity-Matched Cohort.

Background: Anastomotic leakage (AL) is one of the most feared complications in colorectal surgery, with an incidence of 12-39% and associated risk of mortality of 2-24%. The causes of AL and the ways to prevent it are currently under investigation. This study aims to verify if a quadruple assessment of colorectal anastomosis could reduce AL incidence. Methods: A retrospective analysis of prospectively collected data on rectal cancer surgery performed from January 2015 to December 2017 and from January 2021 to December 2023 at a tertiary referral cancer centre was performed. Demographics, clinicopathological features, short-term outcomes, recurrences, and survival were investigated. Results: A total of 293 patients were enrolled. AL incidence was lower in the quadruple assessment group than in the control group, reaching a statistically significant result (7.7% vs. 16%; p = 0.001). This result was also confirmed after a propensity score match analysis (PSM), in which the AL rate was lower in the quadruple assessment group (5.4% vs. 12.3%; p = 0.01). Conclusions: This study shows how the systematic implementation of a quadruple assessment when performing a colorectal anastomosis could increase awareness on anastomotic success and reduce the incidence of AL.

Predictors and outcomes of delays between diagnosis and definitive surgery for rectal cancer

BackgroundThe National Accreditation Program for Rectal Cancer (NAPRC) recommends definitive treatment of rectal cancer commence within 60 days from diagnosis. This study aimed to assess predictors of >60 days delay between diagnosis and definitive surgery of rectal cancer and the impact on survival and short-term outcomes. MethodsRetrospective cohort analysis of patients with stage I-III rectal adenocarcinoma who underwent proctectomy without preoperative neoadjuvant treatment from the National Cancer Database (2015–2019). Based on the time interval between diagnosis and definitive surgery, patients were divided into timely non-adherent (>60 days) and timely-adherent (≤60 days) groups. Multivariate analysis determined predictors of delayed definitive surgery. Results9479 patients (57.5 % males; mean age: 63.7 years) had a 41-day median time between diagnosis and definitive surgery. Non-adherence was noted in 27.9 % of patients. Independent predictors of non-adherence were male sex (Odds ratio [OR]: 1.25; p < 0.001), Black (OR: 1.65; p < 0.001) or Asian (OR: 1.33; p = 0.014) race, Charlson score 2 (OR: 1.33; p = 0.005) or 3 (OR: 1.55; p < 0.001), urban residence (OR: 1.21; p = 0.003), abdominoperineal resection (OR: 1.69; p < 0.001), pelvic exenteration (OR: 1.7; p = 0.002), and robotic-assisted surgery (OR: 1.22; p = 0.001). Medicare (OR: 0.725; p = 0.003) and private insurance (OR: 0.711; p < 0.001) were associated with better adherence. 30-day and 90-day mortality, unplanned readmission, and overall survival were similar. ConclusionsMale Black or Asian patients with high Charlson scores, and undergoing abdominoperineal resection, pelvic exenteration, and robotic-assisted surgery were more likely non-adherent with NAPRC standards with >60 days delay before definitive surgery for rectal cancer. Hopefully, recognition for these reasons for delay of definitive surgery will lead to an improvement in adherence to the standards.

Low ligation of the inferior mesenteric artery in robotic mid-low rectal cancer surgery: a comparative study from a single-center.

Laparoscopic total mesorectal excision is the main surgical approach for treating rectal cancer, but there is still no clear consensus on the issue of low ligation of the inferior mesenteric artery during the procedure. Robotic surgery has been shown to have certain advantages over laparoscopic surgery in multiple studies, but further research is needed to better understand the outcomes of robotic surgery in the context of low ligation procedures. In this study, we included 1590 patients with mid-low rectal cancer. Among them, 942 patients underwent low ligation surgery (LL), divided into 138 in the robotic group and 804 in the laparoscopic group. The high ligation surgery (HL) group consisted of 648 patients. The results of LL vs HL showed that the LL group had faster bowel movement recovery (P = 0.003), lower anastomotic leak rate (P = 0.032), and lower International Prostate Symptom Score (IPSS) at 6months postoperatively (P < 0.001). The results of Rob-LL vs Lap-LL showed that the Rob-LL group had longer operative time (P < 0.001), less blood loss (P = 0.001), more lymph nodes retrieved (P = 0.045), and lower Wexner score at 2weeks postoperatively (P = 0.029). The concept of low ligation of the inferior mesenteric artery is a promising surgical approach that can accelerate the patient's functional recovery. When combined with robotic technology, it may offer more benefits than laparoscopic techniques.

Analysis of decision-making factors for defunctioning ileostomy after rectal cancer surgery and their impact on perioperative recovery: a retrospective study of 1082 patients.

To explore the decision-making factors for defunctioning ileostomy (DI) after rectal cancer surgery and to analyze the impact of the DI on perioperative outcomes. A retrospective case-control study was conducted that included rectal cancer patients who underwent low anterior resection from January 2013 to December 2023. Among them, 33 patients did not undergo DI but with anastomotic leakage (AL) after surgery, and 1030 patients were without AL. Preoperative, operative and tumor factors between these two groups were compared to explore the decision-making factors for DI. Meanwhile, the differences of perioperative outcomes between the DI group of 381 cases and non-DI group of 701 cases were compared. For preoperative factors, the proportions of male patients and preoperative chemoradiotherapy (CRT) in the AL with non-DI group were greater than those in the non-AL group (p < 0.05); for operative factors, the proportion of patients in the AL with non-DI group with a surgical time > 180min were greater (p < 0.05); for tumor factors, the proportion of T3-4 stage was higher in the AL with non-DI group (p < 0.05). Multiple regression analysis revealed that male sex and preoperative CRT were the independent risk factors affecting DI. For perioperative outcomes, the DI did not reduce the incidence of all and symptomatic AL and non-AL postoperative complications (p > 0.05) but with 12.07% stoma-related complications, and increase hospitalization costs (p < 0.05); however, it can shorten the postoperative hospital stay, pelvic drainage tube removal time, and reduce the anal tube placement rate and readmission rate (all p < 0.05). Male patients and preoperative CRT were the independent risk factors affect the decision of DI in our study, and DI can shorten the postoperative hospitalization, pelvic drainage tube removal time, and decrease the anal tube placement rate and readmission rate during the perioperative period but with a higher economic cost.

Essential updates 2022-2023: Surgical and adjuvant therapies for locally advanced colorectal cancer.

Pivotal articles that had been published between 2022 and 2023 on surgical and perioperative adjuvant treatments for locally advanced colorectal cancer (CRC) were reviewed. This review focuses on new evidence in the following areas: optimization of surgical procedures for colon cancer, including the optimal length of bowel resection and use of the no-touch isolation technique; minimally invasive surgery for rectal cancer, such as laparoscopic transanal total mesorectal excision and robotic surgery; neoadjuvant treatments for rectal cancer, including total neoadjuvant therapy; neoadjuvant chemotherapy for colon cancer; and postoperative adjuvant chemotherapy for Stage II and III colon cancer. Although the current understanding may not enable perfect decision-making for patients and medical professionals, ongoing advancements are expected to result in more effective personalized treatment plans, ultimately improving the prognosis and quality of life of patients.

The Rise of Patients Declining Rectal Cancer Surgery in the Era of Total Neoadjuvant Therapy.

The treatment landscape for rectal cancer is rapidly evolving, particularly with the increasing use of neoadjuvant therapies. Still, up to 50% of patients with stage II-III disease require surgical resection post-neoadjuvant therapy to achieve the best oncologic outcomes. Many patients, however, hope to avoid surgery. This study aimed to assess trends and factors associated with declining recommended oncologic resection after systemic therapy nationally and in our institution. This is a retrospective analysis using the National Cancer Database from 2009 to 2021 and an institutional cohort at an academic center between 2009 and 2022 including adults with stage I-III rectal adenocarcinoma who underwent neoadjuvant therapy and were suitable for surgery. Of 96,997 patients nationally, the rate of declining surgery increased from 2.3% in 2009 to 6.3% in 2021, a trend mirrored in our institutional cohort of 365 patients (0% in 2009/2010 to approximately 6-12% in 2021/2022). Locally, patients who declined surgery had higher rates of tobacco use, temporary loss to follow-up during therapy, and a more robust, albeit incomplete, tumor response to neoadjuvant therapy compared with controls who underwent surgery. Despite a stoma being the most cited reason for declining surgery, 30.4% of patients who declined oncologic resection died with a stoma. Our findings underscore a notable trend of patients declining oncologic resections following neoadjuvant therapy for rectal cancer. By shedding light on the outcomes of patients who opt against surgery, we address a critical gap in the literature essential for informing patients about potential risks.

The impact of plasma-rich platelet injection to perianal sphincters on incontinence and quality of life in patients with rectal cancer after low anterior or intersphincteric resection: a prospective cohort study

BackgroundIncontinence is not rare after rectal cancer surgery. Platelet-rich plasma may promote tissue repair and generation but has never been tested for the treatment of anal incontinence. This study evaluated the impact of platelet-rich plasma injection on the severity of incontinence and quality of life after low rectal cancer surgery.MethodsThis is a prospective cohort proof of concept study in a colorectal cancer institution. Patients had undergone low anterior or intersphincteric resection for low rectal cancer and had a Wexner score > 4. Ten milliliters of platelet-rich plasma were injected into the internal and external sphincters under endoanal ultrasound (EAUS) guidance. Primary outcome measure was > 2 point improvement in Wexner score (improved group). The patients were assessed with endo-anal ultrasound examination, manometry, the Wexner Questionnaire and SF-36 Health Surveys, and patients were asked whether they used pads and antidiarrheal medications before and 6 months after PRP injection.ResultsOf 20 patients included in the study, 14 (70%) were men, and the average age was 56.8 (SD = 9.5) years. No statistically significant difference was found in Wexner scores before and after PRP injection (p = 0.66). Seven (35%) patients experienced a > 2 point improvement in Wexner score. Rectal manometry demonstrated improved squeezing pressure (p = 0.0096). Furthermore, physical functioning scoring (p = 0.023), role limitation (p = 0.016), emotional well-being (p = 0.0057) and social functioning (p = 0.043) domains on the SF-36 questionnaire improved. One (5%) and three (15%) patients stopped using pads and antidiarrheal medications.ConclusionPlatelet-rich plasma injection does not restore Wexner scores, but more than one-third of patients may benefit from this application with an improvement of > 2 points in their scores. Platelet-rich plasma injection may improve squeezing pressure and certain life quality measures for incontinent patients after rectal cancer surgery.

Systemic assessment of manual circular stapler versus powered circular stapler for anastomosis in rectal cancer: A large-scale Chinese multicenter prospective cohort study.

Mechanical anastomosis in rectal cancer surgery offers several advantages but is plagued by complications like leaks and strictures. Variations in surgeons' experiences affect outcomes, but powered circular anastomosis has emerged as a promising solution, ensuring uniform staple formation and reducing manual manipulation. This multicenter, randomized, parallel-controlled study in China compared IntoCare™'s powered circular staplers (ICS) with manual circular staplers (MCS) in 382 patients (195 ICS, 187 MCS). Both groups had comparable anastomotic leakage rates. ICS significantly reduced anastomosis time while maintaining similar safety profiles. Postoperative recovery and complication rates were closely matched. The use of ICS in rectal cancer surgeries effectively reduces anastomosis time without compromising safety, offering a promising innovation to enhance the efficacy of rectal cancer surgeries while maintaining patient safety.

Clinical application of eight-zone laparoscopic dissection strategy for rectal cancer: Experience and discussion.

The incidence of rectal cancer is increasing worldwide, and surgery remains the primary treatment modality. With the advent of total mesorectal excision (TME) technique, the probability of tumor recurrence post-surgery has significantly decreased. Surgeons' focus has gradually shifted towards minimizing the impact of surgery on urinary and sexual functions. Among these concerns, the optimal dissection of the rectal lateral ligaments and preservation of the pelvic floor neurovascular bundle have become critical. To explore the optimal surgical technique for TME and establish a standardized surgical protocol to minimize the impact on urinary and sexual functions, we propose the eight-zone dissection strategy for pelvic floor anatomy. To compare the differences in surgical specimen integrity and postoperative quality of life satisfaction between the traditional pelvic floor dissection strategy and the innovative eight-zone dissection strategy. We analyzed the perioperative data of patients who underwent laparoscopic radical resection of rectal cancer at Qilu Hospital of Shandong University between January 1, 2021 and December 1, 2023. This study included a total of 218 patients undergoing laparoscopic radical surgery for rectal cancer, among whom 109 patients underwent traditional pelvic floor dissection strategy, and 109 patients received the eight-zone dissection strategy. There were no significant differences in general characteristics between the two groups. Patients in the eight-zone dissection group had higher postoperative specimen integrity (88.1% vs 78.0%, P = 0.047). At the 3-month follow-up, patients in the eight-zone surgery group had better scores in urinary issues (6.8 ± 3.3 vs 5.3 ± 2.5, P = 0.045) and male sexual desire (2.2 ± 0.6 vs 2.5 ± 0.5, P = 0.047) compared to the traditional surgery strategy group. This study demonstrates that the eight-zone dissection strategy for laparoscopic lateral ligament dissection of rectal cancer is safe and effective. Compared with the traditional pelvic floor dissection strategy, this approach can reduce the risk of nerve injury and minimize the impact on urinary and sexual functions. Therefore, we recommend the clinical application of this strategy to better serve patients with rectal cancer.

Feasibility and outcomes of robotic sphincter-preserving surgery for rectal cancer after neoadjuvant treatment in patients with preexisting colostomy

BackgroundDiverting colostomy followed by neoadjuvant treatment is a treatment of choice for obstructive rectal cancer. Such patients may be treated via a robotic approach with several advantages over conventional laparoscopic surgery. Conversely, the existing stoma may interfere with the optimal trocar position and thus affect the quality of robotic surgery. Moreover, the console surgeon does not face the patient, which may endanger the stoma.MethodsPatients with rectal cancer who underwent sphincter-preserving surgery were retrospectively investigated using a robotic platform after neoadjuvant treatment at our hospital. Based on pretreatment stoma creation, patients were divided into the NS (those without a stoma) and S groups (patients with a stoma). Baseline characteristics, types of neoadjuvant treatment, short-term surgical outcomes, postoperative anorectal manometric data, and survival were compared between the groups.ResultsThe NS and S groups comprised 65 and 9 patients, respectively. Conversion to laparotomy was required in three patients in the NS group. The S group required a longer console time than the NS group (median: 367 vs. 253 min, respectively, p = 0.038); however, no difference was observed in the total operative time (p = 0.15) and blood loss (p = 0.70). Postoperative complication rates, anorectal function, and oncological outcomes were similar between the groups.ConclusionsAlthough console time was longer in patients with a stoma, robotic surgery could be performed safely like in those without a stoma after neoadjuvant treatment.

The modified Surgical Apgar Score predictive value for postoperative complications after robotic surgery for rectal cancer.

The Surgical Apgar Score quantifies three intraoperative parameters: lowest heart rate, lowest mean arterial pressure, and estimated blood loss (EBL). This scoring system predicts postoperative complications based on these measured factors. The aim of this study was to investigate the value of modified Surgical Apgar Score (mSAS) in predicting postoperative complications in patients with rectal cancer treated with robotic surgery in order to improve the survival and quality of life of rectal cancer patients. The study included patients with rectal cancer who underwent robotic surgery in the Department of Gastrointestinal Surgery at the First Affiliated Hospital of Nanchang University from January 2015 to December 2023. In minimally invasive surgery, we developed a modified Surgical Apgar Score (mSAS) tailored for robotic rectal cancer surgery, incorporating an adjusted threshold for EBL. This threshold was derived from quartile analysis of a cohort of 524 patients, with a median EBL of 100mL (IQR 80-130mL). We analyzed the association of postoperative complications with low mSAS. This study included 524 patients, of which 91 (17.4%) experienced complications and 22 (4.2%) suffered severe complications. mSAS of 6 provided maximal Youden index and were determined as the cut-off values. The area under the ROC curve for predicting complications using the mSAS was 0.740. Univariate and multivariate analyses indicated that an older age, lower tumor localization, longer operation time, radiotherapy alone, combined chemoradiotherapy, and lower mSAS as independent risk factors for complications. The AUC of the prediction nomogram was 0.834 (95% CI 0.774-0.867). The calibration curve demonstrated excellent concordance with the nomogram, indicating the prediction curve ft the diagonal well. This study suggests that mSAS might be a valuable predictive indicator for postoperative complications following robotic rectal cancer surgery, with potentially higher clinical utility.

The Impact of a Modular Robotic Total Mesorectal Excision Training Program on Perioperative and Oncological Outcomes in Robotic Rectal Cancer Surgery.

Structured training programs for robotic colorectal surgery are limited, and there are concerns about surgical outcomes and operating times. To compare perioperative and oncological outcomes of robotic total mesorectal excision for rectal cancer performed by expert consultants and surgical trainees in a modular surgical training program. Retrospective cohort study. Conducted at a colorectal training referral center for robotic surgery. Consecutive robotic total mesorectal excision cases between May 2013 and December 2017 were evaluated retrospectively from a prospectively maintained institutional database and divided into 2 groups: group I comprised expert surgeons and group II comprised supervised trainees. Robotic total mesorectal excision training modules (5 modules) were performed stepwise with increasing complexity. Patients' demographic, perioperative, and oncological data were collected. Modular robotic training. Comparable R0 resection rate, lymph node harvest, and oncological outcomes between experts and trainees, suggesting good quality in oncological resection. A total of 177 robotic total mesorectal excision resections were performed (group I: n = 80, group II: n = 97). Four trainees completed 37.5 modules each. Patients' age, sex, and BMI were similar between groups. Group II had a higher ASA III score (6.3% vs 25.8%, p = 0.002). Clinical TNM and neoadjuvant chemoradiotherapy rates were similar. Group II had a longer operative time (225 [197.5-297.5] vs 250 [230-300] minutes, p = 0.004). No conversion occurred. There were no differences in intra- or postoperative outcomes between groups. The rate of R0 resection and the number of harvested lymph nodes were also similar between groups. The median follow-up was 75 (64.0-81.7) and 47 (38.0-55.0) months, respectively. Local and distant recurrence rates, 5-year overall survival (81.1% group I vs 81.3% group II, p = 0.832), and 5-year disease-free survival (79.7% group I vs 80.7% group II, p = 0.725) were similar between groups. The groups operated in 2 consecutive periods. The robotic total mesorectal excision modular surgical training program maximizes training experience without significantly affecting the perioperative and oncological outcomes of patients with rectal cancer. See Video Abstract. ANTECEDENTES:Los programas de entrenamiento estructurados para la cirugía colorrectal robótica están limitados debido a preocupaciones sobre los resultados quirúrgicos y los tiempos de operación.OBJETIVO:Comparar los resultados perioperatorios y oncológicos de la escisión mesorrectal total robótica para el cáncer de recto realizada por consultores expertos y aprendices de cirugía en un programa modular de entrenamiento quirúrgica.DISEÑO:Estudio de cohorte retrospectivo.AJUSTES:Realizado en un centro de referencia de entrenamiento colorrectal para cirugía robótica.PACIENTES:Se evaluaron retrospectivamente casos consecutivos de escisión mesorrectal total robótica entre mayo de 2013 y diciembre de 2017 a partir de una base de datos institucional mantenida prospectivamente y se dividieron en dos grupos: Grupo I: cirujanos expertos; Grupo II: aprendices supervisados. Los módulos de entrenamiento robótico de escisión mesorrectal total (cinco módulos) se realizaron paso a paso con complejidad creciente. Se recogieron datos demográficos, perioperatorios y oncológicos.INTERVENCIONES:Entrenamiento modular en robótica.PRINCIPALES MEDIDAS DE RESULTADO:Tasa de resección R0 comparable, extracción de ganglios linfáticos y resultados oncológicos entre expertos y aprendices que sugieren buena calidad en la resección oncológica.RESULTADOS:Se realizaron un total de 177 resecciones por escisión mesorrectal total robótica (Grupo I: n = 80, Grupo II: n = 97). Cuatro alumnos completaron 37,5 módulos cada uno. La edad, el sexo y el IMC fueron similares entre los grupos. El grupo II tuvo una puntuación más alta de la Sociedad Americana de Anestesiólogos III (6,3% frente a 25,8%, p = 0,002). Las tasas clínicas de TNM y quimiorradioterapia neoadyuvante fueron similares. El grupo II tuvo mayor tiempo operatorio (225 (197,5-297,5) vs 250 (230-300) minutos, p = 0,004). No se produjo ninguna conversión. No hubo diferencias en los resultados intra o posoperatorios entre los grupos. La tasa de resección R0 y el número de ganglios linfáticos extraídos también fueron similares entre los grupos. La mediana de seguimiento fue de 75 (64,0-81,7) y 47 (38,0-55,0) meses, respectivamente. Tasas de recurrencia local y a distancia, supervivencia general a 5 años (81,1% Grupo I vs. 81,3% Grupo II, p = 0,832) y supervivencia libre de enfermedad a 5 años (79,7% Grupo I vs. 80,7% Grupo II, p = 0,725) fueron similares entre los grupos.LIMITACIONES:Los grupos operaron en dos períodos consecutivos.CONCLUSIONES:El programa de entrenamiento quirúrgico modular para la escisión mesorrectal total robótica maximiza la experiencia de capacitación sin afectar significativamente los resultados perioperatorios y oncológicos de los pacientes con cáncer de recto. (Traducción-Dr. Aurian Garcia Gonzalez).

The effect of cardiovascular disease on the perioperative period of radical surgery in elderly rectal cancer

AimTo investigate the impact of preoperative cardiovascular disease on the perioperative period of rectal cancer patients over 75 years old.MethodsThe clinicopathological data of 625 elderly patients aged ≥ 75 years who underwent radical rectal cancer surgery in the Cancer Hospital of the Chinese Academy of Medical Sciences and affiliated Heji Hospital of Changzhi Medical College from January 2011 to December 2022 were retrospectively collected and analyzed. According to preoperative comorbidities, all patients were divided into cardiovascular disease group (n = 361) and non-cardiovascular disease group (n = 264). One hundred and ninety-two pairs were selected from each group through Propensity score-matched to further analysis. Perioperative indexes and postoperative complications were compared between the two groups.ResultsThere were no significant differences in clinicopathological data between the two groups (P > 0.05). The proportion of elderly patients with cardiovascular disease who went to ICU after radical surgery was significantly higher than those without cardiovascular disease (19.3% vs. 10.4%, P = 0.015). There was no significant difference between the two groups in the time to first flatus (3.0 vs. 3.5 days, P = 0.332) and postoperative hospital stay (11.3 vs. 10.5 days, P = 0.297). One patient in the cardiovascular disease group died due to pulmonary embolism. A total of 100 patients (26.0%) developed postoperative complications, and the incidence of overall complications (30.7% vs. 21.4%, P = 0.036) and grade 3–5 complications (12.5% vs. 6.3%, P = 0.036) in the cardiovascular disease group was significantly higher than that in the non-cardiovascular disease group. In terms of gastrointestinal disorders, the incidence of anastomotic leakage (6.8% vs. 2.1%, P = 0.026) in elderly patients with cardiovascular diseases was significantly higher than that in patients without cardiovascular disease. In addition, the incidence of cardiac disorders (8.3% vs. 2.6%, P = 0.014) in elderly patients with cardiovascular disease was significantly higher.ConclusionElderly rectal cancer patients over 75 years old with cardiovascular disease are more likely to develop severe complications after radical surgery, especially anastomotic leakage and cardiac disorders.

Is centralization for rectal cancer surgery necessary?

Rectal cancer surgery is complex and more technically challenging than colonic surgery. Over the last 30 years internationally, there has been a growing impetus for centralizing care to improve outcomes for rectal cancer. Centralizing care may potentially reduce variations of care, increase standardization and compliance with clinical practice guidelines. However, there are barriers to implementation at a professional, political, governance and resource allocation level. Centralization may increase inequalities to accessing healthcare, particularly impacting socioeconomically disadvantaged and rural populations with difficulties to commuting longer distances to "centres of excellence". Furthermore, it is unclear if centralization actually improves outcomes. Recent studies demonstrate that individual surgeon volume rather than hospital volume may be more important in achieving optimal outcomes. In this review, we examine the literature to assess the value of centralization for rectal cancer surgery.

Laparoscopic vs. open surgery for rectal cancer in patients with obesity: short-term outcomes and relapse-free survival across age groups.

To investigate the efficacy of laparoscopic surgery for rectal cancer in obese and older patients, who are often characterized by a higher prevalence of comorbidities and physical decline. This large-scale multicenter retrospective cohort study included 524 patients with a body mass index of 25 or higher who underwent either open or laparoscopic surgery for stage II or III rectal cancer between 2009 and 2013. We assessed the short-term outcomes and relapse-free survival by comparing these surgical modalities. The patients were stratified into 404 non-elderly (< 70years) and 120 elderly (≥ 70 years) patients. In both patient groups, laparoscopic surgery was associated with a significantly reduced blood loss (non-elderly: 41 vs. 545ml; elderly: 50 vs. 445ml) and shorter hospital stays (non-elderly: 10 vs. 19days; elderly: 15 vs. 20days) than open surgery. The overall complications and relapse-free survival showed no significant differences between the two surgical techniques in either age group. Additionally, the impact of the laparoscopic procedure on the relapse-free survival remained consistent between the age groups. Laparoscopic surgery offers short-term benefits for patients with obesity and rectal cancer compared to open surgery, regardless of age, without influencing the long-term prognosis.

Patient perspective on adapting to bowel dysfunction after rectal cancer surgery.

Bowel dysfunction continues to be a clinically significant consequence of rectal cancer surgery, affecting quality of life. Rectal cancer patients value self-empowerment and adaptation to change to improve their quality of life in the context of bowel dysfunction. There are limited qualitative data addressing patients' perspectives on adapting to bowel dysfunction. The aim of this study is to evaluate patients' perspectives on adapting to bowel dysfunction after rectal cancer surgery. Adult patients who underwent rectal cancer surgery with sphincter preservation at a single colorectal referral centre from July 2017 to July 2020 were included. Patients were excluded if they had surgery <1 year since recruitment, received a permanent stoma or developed recurrence or metastasis. Semistructured interviews were held by phone and transcribed verbatim. Bowel dysfunction was assessed via the low anterior resection syndrome (LARS) score. Thematic analysis was used to identify adaptations which patients found helpful for improving bowel dysfunction after rectal cancer surgery. A total of 54 patient interviews were included. The distribution of patients with no, minor and major LARS was 39%, 22% and 39%, respectively. Four main themes were conceived from the analysis: implementing lifestyle changes, fostering supportive relationships and self-compassion, communication and access to resources, and adapting to social and cultural challenges. Associated subthemes were identified, namely forward planning, self-compassion and addressing social stigma. Patients' valuable perspective on adapting to bowel dysfunction involve subtle themes which expand the existing literature. These themes inform a patient-centred approach, which may improve outcomes and quality of care for rectal cancer patients.

Does surgeon or hospital volume influence outcome in dedicated colorectal units?-AViennese perspective.

Aclear relationship between higher surgeon volume and improved outcomes has not been convincingly established in rectal cancer surgery. The aim of this study was to evaluate the impact of individual surgeon's caseload and hospital volume on perioperative outcome. We retrospectively analyzed 336 consecutive patients undergoing oncological resection for rectal cancer at two Viennese hospitals between 1 January 2015 and 31 December 2020. The effect of baseline characteristics as well as surgeons' caseloads (low volume: 0-5cases per year, high volume > 5cases per year) on postoperative complication rates (Clavien-Dindo Classification groups of < 3 and ≥ 3) were evaluated. No differences in baseline characteristics were found between centers in terms of sex, smoking status, or comorbidities of patients. Interestingly, only 14.7% of surgeons met the criteria to be classified as high-volume surgeons, while accounting for 66.3% of all operations. There was asignificant difference in outcomes depending on the treating center in univariate and multivariate binary logistic regression analysis (odds ratio (OR) = 2.403, p = 0.008). Open surgery was associated with lower complication rates than minimally invasive approaches in univariate analysis (OR = 0.417, p = 0.003, 95%CI = 0.232-0.739) but not multivariate analysis. This indicated that the center's policy rather than surgeon volume or mode of surgery impact on postoperative outcomes. Treating center standards impacted on outcome, while individual caseload of surgeons or mode of surgery did not independently affect complication rates in this analysis. The majority of rectal cancer resections are performed by asmall number of surgeons in Viennese hospitals.

Impact of neoadjuvant immunotherapy on postoperative complications after surgery for rectal cancer.

Despite the increasing use of immunotherapy in treating various cancer types, there is still limited understanding of its impact on surgical complications. We used a national database to examine the difference in surgical outcomes for rectal cancer patients who received standard neoadjuvant chemoradiation plus neoadjuvant immunotherapy and patients who received neoadjuvant chemoradiation only. This retrospective cohort study used the National Cancer Database (NCDB). We selected patients aged 18-90 with T1-3, N1-2, and M0 rectal cancer who underwent curative-intent surgery between 2010 and 2020. We performed a 1:1 propensity match to control for patient age, sex, Charlson-Deyo comorbidity index, surgical approach, and tumor site. Our primary outcome was difference in surgical outcomes (hospital length of stay, unplanned 30-day readmission, 30-day mortality) between the two groups. Secondary outcomes included days from diagnosis to surgery and pathologic outcomes. Our study included 26 229 patients, of which 126 received immunotherapy in addition to chemoradiation and 26 103 received only chemoradiation. In our matched population of 125 pairs of patients, patients who received immunotherapy and chemoradiation underwent surgery later compared to patients who only received chemoradiation (median 245 vs. 144 days, p < 0.001). There were no significant differences in median length of stay (5 vs. 5 days, p = 0.202), unplanned 30-day readmission (7 vs. 9, p = 0.617), and 30-day mortality (0 vs. 1, p = 1.000) between the two groups. Neoadjuvant immunotherapy for rectal cancer is not associated with adverse surgical outcomes. This work can help clinicians optimize treatment protocols and move closer toward strategies tailored to specific patient profiles.

71606 - Comparison of short-term outcomes in robotic-assisted versus laparoscopic surgery for rectal cancer - a population-based study

71606 - Comparison of short-term outcomes in robotic-assisted versus laparoscopic surgery for rectal cancer - a population-based study

Dissection layer selection based on an understanding of pelvic fascial anatomy in transanal total mesorectal excision.

This study aimed to review the historical transition of rectal cancer surgery and recent evidence regarding transanal total mesorectal excision (TaTME). Additionally, it outlined the anatomical landmarks and technical considerations essential for successful TaTME. Anatomical studies and surgical techniques were analyzed to identify key landmarks and procedural steps crucial for TaTME. TaTME offers improved visibility and maneuverability even in the deep and narrow pelvis and is expected to contribute to tumor radical cure rates. By securing the circumferential resection margin and distal margin while preserving pelvic autonomic nerve function, TaTME holds promise for maintaining postoperative urinary and sexual functions. Key anatomical landmarks include the endopelvic fascia posteriorly, the S4-pelvic splanchnic nerve laterally, and the prostate or posterior vaginal wall anteriorly. Selecting the appropriate dissection layer based on tumor depth and ensuring precise incision of the tendinous arch of the pelvic fascia contributes to successful TaTME outcomes. TaTME represents a significant advancement in rectal cancer surgery, offering improved outcomes through meticulous attention to anatomical detail and precise dissection techniques. Understanding the historical context of rectal cancer surgery alongside recent evidence on TaTME is essential for optimizing patient outcomes and expanding the safe implementation of this innovative approach.