Resection For Rectal Cancer Research Articles

An assessment of Cancer Centre Level Designation and guideline adherent care in those with rectal cancer: A population based retrospective cohort study

BackgroundInstitutions providing care to individuals with cancer are organized based on available resources and treatments offered. It is presumed that increasing levels of care will result in improved quality of care and outcomes. The objective is to determine whether Cancer Level Designation is associated with guideline adherent care and/or survival. MethodsThis is a retrospective study of individuals within the Ontario Rectal Cancer Cohort, a population-level database including all adults undergoing surgical resection for rectal cancer between 2010 – 2019 were included in Ontario, Canada. The primary exposure was Cancer Centre Level Designation as defined by Cancer Care Ontario (i.e., Level 1/2 = regional cancer center; Level 3 = affiliate cancer center; Level 4 = satellite cancer center). The primary outcomes were guideline adherent care and survival. Associations were determined using one-way analysis of variances and a multivariable Cox proportional hazards model. Results12,399 patients were included with 54% from a Level 1/2 centre, 33% from a Level 3 centre and 13% from a Level 4+ centre. All assessed aspects of guideline adherent care were associated with cancer centre level designation. Unadjusted 5-year overall survival was associated with cancer centre level designation (Level 1/2 79.5% vs. Level 3 79.1% vs. Level 4/non-designated 75.4%, P = 0.003). Adjusted Cox Proportional Hazard Analysis for overall survival found the following: Level 4/5 HR 1.11 (95%CI 0.99 – 1.25); Level 3 HR 1.01 (95% CI 0.93 – 1.11); Level 1/2 1 [Referent group]. ConclusionsIncreasing Cancer Centre Level Designation was associated with higher likelihood of receiving the appropriate investigations and treatments in those with rectal cancer and may also be associated with survival.Policy Summary: Future work should consider the centralization of complex rectal cancer care as well as quality improvement initiatives aimed at enhancing guideline adherent care across all centres managing rectal cancer.

Deep pelvis and low visceral fat mass as risk factors for neurogenic bladder after rectal cancer surgery

BackgroundPostoperative neurogenic bladder (PONB) frequently occurs as a complication after rectal cancer surgery. This study aimed to analyze risk factors for developing PONB after rectal cancer surgery, particularly the association between pelvic anatomy and visceral fat mass.MethodsWe included 138 patients who underwent rectal resection for lower rectal cancer in our department between 2017 and 2021. PONB was defined as the need for urethral catheter reinsertion or oral medication administration for urinary retention after catheter removal with severe NB that required treatment for ≥ 60 days. We obtained visceral fat area (VFA) at the umbilical level based on a CT scan and measured five pelvic dimensions.ResultsOf the 138 patients, 19 developed PONB, with 16 being severe cases. PONB more frequently occurs in patients with a height of < 158 cm, age ≥ 70 years, surgery lasting ≥ 8 h, intraoperative bleeding volume ≥ 150 mL, lateral lymph node dissection, and narrower pelvis. It was more prevalent in cases with low VFA. Conversely, gender, body mass index (BMI), and medical history showed no significant correlations. Multivariate analysis revealed older age, prolonged surgery, and low VFA as independent risk factors for PONB. Independent risk factors for severe PONB included low VFA, older age, prolonged surgery, and deep pelvis.ConclusionLower VFA, older age, and prolonged surgery are independent risk factors for developing PONB. Additionally, a deep pelvis is an independent risk factor for severe PONB. Delicate surgical techniques should consider the risk of nerve injury in cases with low VFA and deep pelvis.

Identifying timing and risk factors for early recurrence of resectable rectal cancer: A single center retrospective study.

Colorectal cancer is a common malignancy and various methods have been introduced to decrease the possibility of recurrence. Early recurrence (ER) is related to worse prognosis. To date, few observational studies have reported on the analysis of rectal cancer. Hence, we reported on the timing and risk factors for the ER of resectable rectal cancer at our institute. To analyze a cohort of patients with local and/or distant recurrence following the radical resection of the primary tumor. Data were retrospectively collected from the institutional database from March 2011 to January 2021. Clinicopathological data at diagnosis, perioperative and postoperative data, and first recurrence were collected and analyzed. ER was defined via receiver operating characteristic curve. Prognostic factors were evaluated using the Kaplan-Meier method and Cox proportional hazards modeling. We included 131 patients. The optimal cut off value of recurrence-free survival (RFS) to differentiate between ER (n = 55, 41.9%) and late recurrence (LR) (n = 76, 58.1%) was 8 mo. The median post-recurrence survival (PRS) of ER and LR was 1.4 mo and 2.9 mo, respectively (P = 0.008) but PRS was not strongly associated with RFS (R² = 0.04). Risk factors included age ≥ 70 years [hazard ratio (HR) = 1.752, P = 0.047], preoperative concurrent chemoradiotherapy (HR = 3.683, P < 0.001), colostomy creation (HR = 2.221, P = 0.036), and length of stay > 9 d (HR = 0.441, P = 0.006). RFS of 8 mo was the optimal cut-off value. Although ER was not associated with PRS, it was still related to prognosis; thus, intense surveillance is recommended.

Economic burden of pelvic sepsis after anastomotic leakage following rectal cancer surgery: A retrospective cost-of-illness analysis.

Anastomotic leakage following rectal cancer surgery remains a challenging complication, with a nonhealing rate of approximately 50% at 1 year. Pelvic sepsis may require tertiary treatment that encompasses additional admissions, extensive surgery and other types of interventions. The aim of this study is to analyse the financial burden of pelvic sepsis in a tertiary hospital. From 2010 until 2020, all patients referred to a tertiary centre for pelvic sepsis after low anterior resection for rectal cancer were prospectively registered and retrospectively reviewed. The cost analysis adhered to Dutch National Healthcare Institute guidelines and covered hospital-imposed medical costs from salvage surgery to the last registered intervention, adjusted for inflation and priced in euros. This analysis included 126 patients, with an average total cost per patient of €31 131. Salvage surgery accounted for €21 326, with an additional €9805 for reinterventions and readmissions. Salvage surgery comprised nonrestorative surgery in 48% and restorative salvage surgery in the remaining cases. Length of hospital stay averaged 9.6 days on the general ward and 0.8 days in the intensive care unit. Common reinterventions included endoscopic vacuum sponge changes (n = 153), stoma closures (n = 59) and radiological abscess drainages (n = 51). Total costs did not differ significantly between nonrestorative surgery and restorative surgery (mean = €31 950 vs. €30 362, respectively; p = 0.893). Treating pelvic sepsis after rectal cancer resection in a tertiary hospital carries a substantial economic burden, averaging €31 131 per patient, and this work helps to quantify the potential economic impact of innovative care to reduce anastomotic leakage.

Systematic review and meta-analysis comparing robotic total mesorectal excision versus transanal total mesorectal excision for rectal cancer

Introduction: The best approach for total mesorectal excision (TME) remains controversial. Two recently described approaches are robotic TME (RTME) and transanal TME (TaTME). This systematic review and meta-analysis aimed to compare the outcomes between robotic surgery and TaTME in patients undergoing rectal cancer resection. Methods: We structured this systematic review and meta-analysis according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines 2020 and Assessing the Methodological Quality of Systematic Reviews (AMSTAR) guidelines. An electronic search of relevant literature was conducted on 20 May 2023. The protocol was registered in PROSPERO (CRD42023435259). Results: Eleven eligible nonrandomised studies were included in this study. The study included 2796 patients (RTME = 1800; TaTME = 996). The RTME group had a higher rate of complete TME. However, no significant differences were observed in mortality, morbidity, severe complications, operative time, conversion rate, anastomotic leak, hospital stay, CRM-positive resection margin, distal resection margin, number of harvested lymph nodes, abdominoperineal resection (APR) rate, or local recurrence between the RTME and TaTME groups. Conclusion: The RTME technique may ensure a higher rate of complete TME than TaTME. However, no significant differences were observed in most postoperative outcomes and oncological safety between the RTME and TaTME groups. Evidence does not conclusively favor one technique over the other, highlighting the need for additional randomized controlled trials to better define their roles in rectal cancer surgery.

Application of modified extralevator abdominoperineal excision for low rectal cancer resection.

Laparoscopic ELAPE surgery has been carried out in our center for a long time, and some modifications have been made in clinical practice. In this study, we compared conventional ELAPE operation with modified ELAPE operation to investigate the efficacy and safety of modified ELAPE operation. We retrospectively analyzed the data from 339 patients with low rectal cancer undergoing abdominoperineal resection from 2017 to 2021 in the Department of General Surgery, Qilu Hospital of Shandong University. Patients were classified into modified ELAPE groups (199 patients) and conventional ELAPE groups (140 patients). Total operation time, reconstruction time, postoperative hospital stay, total cost, intraoperative data, postoperative short-term and long-term complications and tumor recurrence were compared. The baseline characteristics were comparable between the two groups. Total operation time was less with modified ELAPE group compared to conventional ELAPE group (190.6 ± 33.1min vs 230.1 ± 51.6min, P = 0.022). Pelvic floor reconstruction time was also less with modified ELAPE group compared to conventional ELAPE group (4.3 ± 1.2min vs 11.9 ± 1.7min, P = 0.004). Positive CRM was observed in 11 and 9 patients in modified ELAPE groups and conventional ELAPE groups (P = 0.744). IOP occurred in 12 and 7 patients in modified ELAPE group and conventional ELAPE group (P = 0.701). Total cost was also less with modified ELAPE group compared to conventional ELAPE group (9004 ± 1146 USD vs 10,336 ± 2047 USD, P = 0.031). The incidence of parastomal hernia was less with modified ELAPE group compared to conventional ELAPE group (7/199 vs 22/140, P < 0.001). Three-year follow-up data did not show any difference in overall survival rate or local occurrence between the two groups. Modified ELAPE surgery is technically safe and feasible, and oncologically comparable to that of conventional ELAPE surgery, which can be considered for popularization and application.

Application of a combined clinical prediction model based on enhanced T1-weighted image(T1WI) full volume histogram in peripheral nerve invasion (PNI) and lymphatic vessel invasion (LVI) in rectal cancer.

This study aims to use a combined clinical prediction model based on enhanced T1-weighted image(T1WI) full volume histogram to predict preoperative peripheral nerve invasion (PNI) and lymphatic vessel invasion (LVI) in rectal cancer. We included a total of 68 PNI patients and 80 LVI patients who underwent surgical resection and pathological confirmation of rectal cancer. According to the PNI/LVI status, patients were divided into PNI positive group (n = 39), the PNI negative group (n = 29), LVI positive group (n = 48), and the LVI negative group (n = 32). External validation included a total of 42 patients with nerve and vascular invasion in patients with surgically resected and pathologically confirmed rectal cancer at another healthcare facility, with a PNI positive group (n = 32) and a PNI-negative group (n = 10) as well as an LVI positive group (n = 35) and LVI-negative group (n = 7). All patients underwent 3.0T magnetic resonance T1WI enhanced scanning. We use Firevoxel software to delineate the region of interest (ROI), extract histogram parameters, and perform univariate analysis, LASSO regression, and multivariate logistic regression analysis in sequence to screen for the best predictive factors. Then, we constructed a clinical prediction model and plotted it into a column chart for personalized prediction. Finally, we evaluate the performance and clinical practicality of the model based on the area under curve (AUC), calibration curve, and decision curve. Multivariate logistic regression analysis found that variance and the 75th percentile were independent risk factors for PNI, while maximum and variance were independent risk factors for LVI. The clinical prediction model constructed based on the above factors has an AUC of 0.734 (95% CI: 0.591-0.878) for PNI in the training set and 0.731 (95% CI: 0.509-0.952) in the validation set; The training set AUC of LVI is 0.701 (95% CI: 0.561-0.841), and the validation set AUC is 0.685 (95% CI: 0.439-0.932). External validation showed an AUC of 0.722 (95% CI: 0.565-0.878) for PNI; and an AUC of 0.706 (95% CI: 0.481-0.931) for LVI. This study indicates that the combination of enhanced T1WI full volume histogram and clinical prediction model can be used to predict the perineural and lymphovascular invasion status of rectal cancer before surgery, providing valuable reference information for clinical diagnosis.

SP3.1 - Could shorter length of stay and oncological non inferiority justify a radical paradigm shift towards RAS to be the gold standard for all rectal cancer resections

Abstract Aim Robotic-assisted surgery (RAS) has proven to be an effective alternative to open (OP) and laparoscopic-assisted (LAP) rectal cancer resections. We aim to evaluate pathological and peri-operative outcomes of patients in a single centre undergoing rectal cancer resections using all three surgical techniques to evaluate whether RAS should be the gold-standard. Methods We retrospectively identified all elective rectal cancer resection cases since 2019 at our centre offering OP, LAP, and RAS services. We audited length-of-stay (LoS), complications, readmission rates, margin clearance status, and lymph node yield. Results Since 2019, there were 28 OP, 77 LAP, and 35 RAS resections performed. The median LoS for OP resections was 11 days, for LAP was 8 days (p=0.02) and was lowest for RAS resections (3 days, p=0.005). Readmission rates were highest for OP resections (21.4%) and were identical for LAP and RAS resections (14.2% each). Complications (OP 25%, LAP 34%, RAS 37%; p&amp;gt;0.05) were categorized using Clavien-Dindo (CD) classification with LAP having highest proportions of CD-IV (7.7%) and CD-V (7.7%), whereas RAS and OP resections had no severe complications (CD-IVa/IVb/V). Conclusion Our analysis shows significantly superior outcomes for shorter LoS and clear non-inferiority of RAS in all other aspects as compared to conventional approaches. Efforts must be bolstered to introduce RAS for rectal cancer resections in the long run considering the need for increasing training opportunities and improved resources to allow for a stable transition to RAS led services, rather than a radical conversion. Further studies are warranted to substantiate our observation.

FP3.9 - Loop ileostomy reversal in anterior resection: A single centre cohort Study

Abstract Aims Defunctioning loop ileostomy is commonly undertaken in &amp;lt;40% of anterior resections especially mid and low rectal cancer resections. Loop ileostomy allows early enteral nutrition and rehabilitation and reduces the impact of post operative ileus, anastomotic leaks and pelvic sepsis complications Closure of loop ileostomy is usually advocated after 3 months of the index malignant colorectal resection. The aim of this study was to assess the reversal intervals and delays in ileostomy reversal. Methods This is a cohort study carried out since January 2008 to December 2023 at a single centre. Descriptive demography &amp; surgical outcomes were evaluated for all Anterior Resections with loop ileostomy. All anterior resections without covering loop ileostomy carried out since 2008 were recruited as controls. Results AR loop ileostomy (n = 152) AR no stoma (n = 297) Mann Whitney U (p test) Age(yrs) 67.0 ± 0.8 68.4 ± 0.7 NS Sex(M:F) 96 : 56 180 : 117 NS ASA(median) 2 2 NS BMI 26.5 ± 0.4 27.2 ± 0.3 NS Lap : Open(n) 94 : 58 220 : 77 &amp;lt; 0.05 Op time(mins) (index op) 256.3 ± 6.8 219.2 ± 4.7 &amp;lt; 0.0001 LOS(days)(index op) 10 ± 4.5 6 ± 3 Reversal (n) 111 Days to reversal 262 ± 102 Reverse op time(mins) 84.3 ± 4.9 LOS reversal(days) 6 ± 3.5 Conclusion Delays in loop ileostomy reversal in our intuition were due to: progressive CRC disease diagnosis, adjuvant treatments, patient frailty/death, patient choice, delays in anastomotic integrity checks, &amp; theatre availability. To avoid delay, reversal should be planned at time of defunctioning loop ileostomy.

Randomized clinical trial on accelerated preoperative hyperfractionated radiotherapy versus preoperative hyperfractionated radio-chemotherapy in locally advanced rectal cancer.

The aim of this study was to compare pathological response rates after preoperative hyperfractionated radiotherapy with co-administration of chemotherapy based on 5FU (HART-CT) versus preoperative hyperfractionated radiotherapy (HART) in patients with resectable rectal cancer. Patients with T2/N+ or T3/any N rectal cancer were randomized either to HART twice a day (28 fractions of 1.5 Gy) to total dose 42 Gy or to HART-CT. Tumour regression grade was postoperatively assessed according to the 4-point scale as recommended by the American Joint Committee on Cancer (AJCC). The secondary endpoints included overall survival (OS), disease-free survival (DFS), toxicity of preoperative treatment, locoregional, and distant failure rates. There were 187 patients eligible for analysis: 95 in HART and 92 in the HART-CT. Median follow-up was 5.6 years. The analysis demonstrated a significantly higher chance of achieving pathologic complete response in HART-CT arm: complete response was achieved in 4/95, 4% (HART) and 11/92, 12% (HART-CT) (P = .045). The differences in OS and DFS, while tending to favour HART-CT, were not significant: OS (P = .13, hazard ratio [HR] = 0.82, 95% CI, 0.63-1.06) and DFS (P = .32; HR = 0.88, 95% CI, 0.69-1.13). The locoregional failure and distant metastases rates did not statistically differ between the trial arms. The rate of late complications was similar (P = .51), grade 3+ being 8% versus 11% in the HART/HART-CT group, respectively. The hyperfractionated preoperative radiotherapy with concurrent 5-Fu-based chemotherapy (HART-CT) improved pathological response rate compared to HART. This translated into favourable OS and DFS in HART-CT, but the differences did not reach the threshold for significance. A new hyperfractionated chemo-RT scheme is proposed. Histopathological major response (TRG 0-1) is associated with better clinical outcome.

An actinomycosis infection resembling peritoneal dissemination of rectal cancer: a case report

BackgroundActinomycosis is a suppurative and granulomatous inflammation commonly caused by Actinomyces israelii. Due to its rarity and the paucity of characteristic clinical features, diagnosis of intra-abdominal actinomycosis is challenging, especially when the patient has a treatment history of abdominal cancer.Case presentationThe patient is a 72-year-old man who has a history of multiple abdominal surgeries for rectal cancer, including low anterior resection for primary rectal cancer, partial hepatic resection for metachronous liver metastasis, and Hartmann surgery for local recurrence. The patient has also undergone parastomal hernia repair using the Sugarbaker method. One year after hernia repair, computed tomography (CT) identified a mass lesion between the abdominal wall and the mesh, suggesting the possibility of peritoneal recurrence of rectal cancer. The accumulation of fluorodeoxyglucose (FDG) was evident via positron emission tomography-CT (PET-CT), while tumor marker levels were within the normal range. On laparotomy, the small intestine, abdominal wall, mesh, colon, and stoma were observed to be associated with the mass lesion, and en bloc resection was carried out. However, postoperative histopathological examination revealed an actinomyces infection without any cancerous cells.ConclusionsThis case highlights the challenges faced by surgeons regarding preoperative diagnosis of actinomycosis, especially when it occurs after the resection of abdominal cancer. Also, this case reminds us of the importance of a histopathological examination for abdominal masses or nodules before starting chemotherapy.

Robotic purse-string suture technique for intracorporeal anastomosis using double-stapling technique in robotic resection of rectal and sigmoid colon cancer: a propensity score-matched analysis

BackgroundRobotic three-dimensional magnified visual effects and field of view stabilization have enabled precise surgical operations. Intracorporeal anastomosis in right-sided colorectal cancer surgery is expected to shorten operation times, avoid paralytic ileus, and shorten wound lengths; however, there are few reports of intracorporeal anvil fixation for intestinal anastomosis in left-sided colorectal cancer surgery. Herein, we introduce a simple, novel procedure for using robotic purse-string suture (RPSS) in intracorporeal anastomosis with the double-stapling technique in rectal and sigmoid cancer surgery and report short-term outcomes.MethodsFrom September 2022 to April 2024, 105 consecutive patients underwent robotic surgery with double-stapling technique anastomosis for rectal or sigmoid colon cancer at our institution. Their data were retrospectively analyzed. Intracorporeal anastomosis with the double-stapling technique using RPSS was performed in 26 patients (the RPSS group), while the double-stapling technique anastomosis with extracorporeal anvil fixation was performed in 79 patients (the EC group). A 1:1 propensity score-matched analysis was performed (matching criteria: sex, age, body mass index (BMI), tumor location and tumor size) using a caliper 0.3.In the RPSS group, after tumor-specific or total mesorectal excision, specimens were extracted from the umbilical wound with simultaneous anvil placement in the body cavity. The oral colonic stump was robotically excised and robotically circumferentially stitched with 3–0 Prolene in all layers. After anvil insertion into the stump, the bowel wall of the colon was completely sewn onto the central rod of the anvil. Reconstructions were anastomosed using the double-stapling technique.ResultsThe matched cohort contained 23 patients in each group. The RPSS group had significantly less bleeding than the EC group (p = 0.038). Super-low anterior resection (SLAR) in the RPSS group had shorter total operative times than those in the EC group (p = 0.045). The RPSS group experienced no perioperative complications greater than Clavien–Dindo grade III or any anastomosis-related complications.ConclusionsThe RPSS technique can be performed safely without any anastomosis-related complications and reduces the total operative times in SLAR and blood loss through total robotic surgery. This may be a useful modality for robotic colorectal surgery.

The risk for rectal cancer recurrence and overall mortality is not increased in men previously diagnosed with prostate cancer: a report from the Swedish colorectal cancer registry

IntroductionLimited data exists on oncological outcomes following rectal cancer surgery in men who have previously been diagnosed with prostate cancer (PC). This study aimed to assess overall mortality and rectal cancer recurrence in men previously diagnosed with PC who underwent bowel resection.MethodsData from the Swedish Colorectal Cancer Registry identified men who had rectal cancer surgery between 2000 and 2016, and the National Prostate Cancer Registry was used to identify those with a prior PC diagnosis. Cox regression analysis with propensity score matching was employed for data analysis. The primary outcome was overall mortality. Secondary outcome was recurrence for rectal cancer.ResultsOut of 13,299 men undergoing bowel resection for rectal cancer between 2000 and 2016, 1130 had a history of PC. Overall mortality did not significantly differ between men with and without a prior PC diagnosis. Cox regression analyses with propensity score matching revealed that men with previously diagnosed low- or intermediate-risk (HR, 0.79; 95% CI, 0.70–0.90) and high-risk PC (HR, 0.85; 95% CI, 0.74–0.98) had lower overall mortality after rectal cancer surgery compared with men without a PC. There was no significant difference in rectal cancer recurrence between men with a previous low or intermediate-risk PC (HR, 0.92; 95% CI, 0.74–1.14) or high-risk PC (HR, 0.73; 95% CI, 0.52–1.01) compared with those without PC history.ConclusionMen undergoing rectal cancer surgery with a previous diagnosis of prostate cancer do not experience an increased risk of rectal cancer recurrence or overall mortality compared with men without a previous history of prostate cancer.

Lymphovascular invasion is a dominant risk factor for lymph node metastasis in T2 rectal cancer.

Background and study aims Surgical resection is standard treatment of T2 rectal cancer due to risk of concomitant lymph node metastases (LNM). Local resection could potentially be an alternative to surgical treatment in a subgroup of patients with low risk of LNM. The aim of this study was to identify clinical and histopathological risk factors of LNM in T2 rectal cancer. Patients and methods This was a retrospective registry-based population study on prospectively collected data on all patients with T2 rectal cancer undergoing surgical resection in Sweden between 2009 and 2021. Potential risk factors of LNM, including age, gender, resection margin, lymphovascular invasion (LVI), histologic grade, mucinous cancer, and perineural invasion (PNI) were analyzed using univariate and multivariate logistic regression. Results Of 1607 patients, 343 (21%) with T2 rectal cancer had LNM. LVI (odds ratio [OR] = 4.21, P < 0.001) and age < 60 years (OR = 1.80, P < 0.001) were significant and independent risk factors. However, PNI (OR = 1.50, P = 0.15), mucinous cancer (OR = 1.14, P = 0.60), histologic grade (OR = 1.47, P = 0.07) and non-radical resection margin (OR = 1.64, P = 0.38) were not significant risk factors for LNM in multivariate analyses. The incidence of LNM was 15% in the absence of any risk factor. Conclusions This was a large study on LNM in T2 rectal cancer which showed that LVI is the dominant risk factor. Moreover, low age constituted an independent risk factor, whereas gender, resection margin, PNI, histologic grade, and mucinous cancer were not independent risk factors of LNM. Thus, these findings may provide a useful basis for management of patients after local resection of early rectal cancer.

Blood perfusion assessment by near-infrared fluorescence angiography of epiploic appendages in prevention of anastomotic leakage after laparoscopic intersphincteric resection for ultra-low rectal cancer: a case-matched study.

The role of intraoperative near-infrared fluorescence angiography with indocyanine green in reducing anastomotic leakage (AL) has been demonstrated in colorectal surgery, however, its perfusion assessment mode, and efficacy in reducing anastomotic leakage after laparoscopic intersphincteric resection (LsISR) need to be further elucidated. Aim was to study near-infrared fluorescent angiography to help identify bowel ischemia to reduce AL after LsISR. A retrospective case-matched study was conducted in one referral center. A total of 556 consecutive patients with ultra-low rectal cancer including 140 patients with fluorescence angiography of epiploic appendages (FAEA)were enrolled. Perfusion assessment by FAEA in the monochrome fluorescence mode. Patients were divided into two groups based on perfusion assessment by FAEA. The primary endpoint was the AL rate within 6 months, and the secondary endpoint was the structural sequelae of anastomotic leakage (SSAL). After matching, the study group (n = 109) and control group (n = 190) were well-balanced. The AL rate in the FAEA group was lower before (3.6% vs. 10.1%, P = 0.026) and after matching (3.7% vs. 10.5%, P = 0.036). Propensity scores matching analysis (OR 0.275, 95% CI 0.035-0.937, P 0.039), inverse probability of treatment weighting (OR 0.814, 95% CI 0.765-0.921, P 0.002), and regression analysis (OR 0.298, 95% CI 0.112-0.790, P = 0.015), showed that FAEA was an independent protector factor for AL. This technique can significantly shorten postoperative hospital stay [9 (6-13) vs. 10 (8-13), P = 0.024] and reduce the risk of SSAL (1.4% vs. 6.0%, P = 0.029). Perfusion assessment by FAEA can achieve better visualization in LsISR and reduce the incidence of AL, subsequently avoiding SSAL after LsISR.

Development and validation of an MRI and clinicopathological factors prediction model for low anterior resection syndrome in anterior resection of middle and low rectal cancer

ObjectiveTo validate the predictive power of newly developed magnetic resonance (MR) morphological and clinicopathological risk models in predicting low anterior resection syndrome (LARS) 6 months after anterior resection of middle and low rectal cancer (MLRC). MethodsFrom May 2018 to January 2021, 236 patients with MLRC admitted to two hospitals (internal and external validation) were included. MR images, clinicopathological data, and LARS scores (LARSS) were collected. Tumor morphology data included longitudinal involvement length, maximum tumor diameter, proportion of tumor to circumference of the intestinal wall, tumor mesorectal infiltration depth, circumferential margin status, and distance between the tumor and anal margins. Pelvic measurements included anorectal angle, mesenterial volume (MRV), and pelvic volume. Univariate and multivariate logistic regression was used to obtain independent risk factors of LARS after anterior resection Then, the prediction model was constructed, expressed as a nomogram, and its internal and external validity was assessed using receiver operating characteristic curves. ResultsThe uni- and multivariate analysis revealed distance between the tumor and anal margins, MRV, pelvic volume, and body weight as significant independent risk factors for predicting LARS. From the nomogram, the area under the curve (AUC), sensitivity, and specificity were 0.835, 75.0 %, and 80.4 %, respectively. The AUC, sensitivity, and specificity in the external validation group were 0.874, 83.3 %, and 91.7 %, respectively. ConclusionThis study shows that MR imaging and clinicopathology presented by a nomogram can strongly predict LARSS, which can then individually predict LARS 6 months after anterior resection in patients with MLRC and facilitate clinical decision-making. Clinical relevance statementWe believe that our study makes a significant contribution to the literature. This method of predicting postoperative anorectal function by preoperative measurement of MRV provides a new tool for clinicians to study LARS.

Effects of fluid therapy combined with a preoperative glucose load regimen on postoperative recovery in patients with rectal cancer.

Patients with rectal cancer undergoing radical resection often have poor postoperative recovery due to preoperative fasting and water deprivation and the removal of diseased tissue, and have a high risk of complications. Therefore, it is of great significance to apply appropriate rehydration regimens to patients undergoing radical resection of rectal cancer during the perioperative period to improve the postoperative outcomes of patients. To analyze the effects of goal-directed fluid therapy (GDFT) with a preoperative glucose load regimen on postoperative recovery and complications in patients undergoing radical resection for rectal cancer. Patients with rectal cancer who underwent radical resection (n = 184) between January 2021 and December 2023 at our hospital were randomly divided into either a control group or an observation group (n = 92 in each group). Both groups received a preoperative glucose load regimen, and routine fluid replacement and GDFT were additionally implements in the control and observation groups, respectively. The operative conditions, blood levels of lactic acid and inflammatory markers, postoperative recovery, cognitive status, hemodynamic indicators, brain oxygen metabolism, and complication rates were compared between the groups. The colloidal fluid dosage, total infusion, and urine volume, as well as time to first exhaust, time to food intake, and postoperative length of hospital stay, were lower in the observation group (P < 0.05). No significant differences were observed between the two groups in terms of operation time, bleeding volume, crystalloid liquid consumption, time to tracheal extubation, complication rate, heart rate, or mean arterial pressure (P > 0.05). Compared with the control group, in the observation group the lactic acid level was lower immediately after the surgery (P < 0.05); the Mini-Mental State Examination score was higher on postoperative day 3 (P < 0.05); the pulse pressure variability (PPV) was lower at 30 min after pneumoperitoneum (P < 0.05), though the differences in the PPV of the two groups was not significant at the remaining time points (P > 0.05); tumor necrosis factor-α and interleukin-6 levels were lower on postoperative day 3 (P < 0.05); and the left and right regional cerebral oxygen saturation was higher immediately after the surgery and 30 min after pneumoperitoneum (P < 0.05). GDFT combined with the preoperative glucose load regimen is a safe and effective treatment strategy for improving postoperative recovery and risk of complications in patients with rectal cancer undergoing radical resection.

Lone-Star retractor perineal exposure method for laparoscopic abdominal perineal resection of rectal cancer.

The abdominal perineal resection (APR), historically referred to as Mile's procedure, stands as a time-honored surgical intervention for rectal cancer management. Advancements in surgical techniques and the advent of neoadjuvant therapies have significantly improved the rate of sphincter preservation among patients afflicted with rectal cancer, including those with ultralow rectal cancer. Despite these improvements, APR maintains its irreplaceable role in the clinical landscape, particularly for cases involving low rectal cancer with encroachment on the external anal sphincter or levator ani muscles. Optimal perineal exposure stands as a pivotal phase in APR, given that the precision of this maneuver is directly correlated with both the safety of the surgery and the patient's subsequent long-term prognosis. To evaluate the value of Lone-Star retractor (LSR) perineal exposure method in the treatment for laparoscopic APR of rectal cancer. We reviewed the records of 38 patients with rectal cancer at Anqing Municipal Hospital from January 2020 to December 2023, including 20 patients who underwent the APR procedure with a LSR perineal exposure method (LSR group) and 18 patients who underwent the APR procedure with a conventional perineal exposure method (control group). In the LSR group, following incision of the skin and subcutaneous tissue, the LSR was placed and dynamically adjusted according to the surgical plane to fully expose the perineal operative field. A total of 38 patients underwent laparoscopic APR, none of whom were found to have distant metastasis upon intraoperative exploration. Perineal blood loss, the postoperative hospital stays and the wound pain scores in the LSR group were significantly lower than those in the control group. A single surgeon completed the perineal operation significantly more often in the LSR group than in the control group (P < 0.05). The incidence of infection via the perineal incision in the LSR group was significantly lower than that in the control group (P < 0.05). No cases of distant metastasis or local recurrence were found among the patients at the postoperative follow-up. The application of the LSR technique might be helpful for performing perineal exposure during APR for rectal cancer and could reduce the incidence of perineal complications, shorten the postoperative hospital stay, improve postoperative pain, and allow one surgeon to perform the perineal operation.

Different radiomics annotation methods comparison in rectal cancer characterisation and prognosis prediction: a two-centre study

ObjectivesTo explore the performance differences of multiple annotations in radiomics analysis and provide a reference for tumour annotation in large-scale medical image analysis.MethodsA total of 342 patients from two centres who underwent radical resection for rectal cancer were retrospectively studied and divided into training, internal validation, and external validation cohorts. Three predictive tasks of tumour T-stage (pT), lymph node metastasis (pLNM), and disease-free survival (pDFS) were performed. Twelve radiomics models were constructed using Lasso-Logistic or Lasso-Cox to evaluate and four annotation methods, 2D detailed annotation along tumour boundaries (2D), 3D detailed annotation along tumour boundaries (3D), 2D bounding box (2DBB), and 3D bounding box (3DBB) on T2-weighted images, were compared. Radiomics models were used to establish combined models incorporating clinical risk factors. The DeLong test was performed to compare the performance of models using the receiver operating characteristic curves.ResultsFor radiomics models, the area under the curve values ranged from 0.627 (0.518–0.728) to 0.811 (0.705–0.917) in the internal validation cohort and from 0.619 (0.469–0.754) to 0.824 (0.689–0.918) in the external validation cohort. Most radiomics models based on four annotations did not differ significantly, except between the 3D and 3DBB models for pLNM (p = 0.0188) in the internal validation cohort. For combined models, only the 2D model significantly differed from the 2DBB (p = 0.0372) and 3D models (p = 0.0380) for pDFS.ConclusionRadiomics and combined models constructed with 2D and bounding box annotations showed comparable performances to those with 3D and detailed annotations along tumour boundaries in rectal cancer characterisation and prognosis prediction.Critical relevance statementFor quantitative analysis of radiological images, the selection of 2D maximum tumour area or bounding box annotation is as representative and easy to operate as 3D whole tumour or detailed annotations along tumour boundaries.Key PointsThere is currently a lack of discussion on whether different annotation efforts in radiomics are predictively representative.No significant differences were observed in radiomics and combined models regardless of the annotations (2D, 3D, detailed, or bounding box).Prioritise selecting the more time and effort-saving 2D maximum area bounding box annotation.Graphical

Lymph node ratio prognosticates overall survival in patients with stage IV colorectal cancer

BackgroundLymph node ratio (LNR) is suggested to address the shortcomings of using only lymph node yield (LNY) or status in colorectal cancer (CRC) prognosis. This study explores how LNR affects survival in patients with metastatic colorectal cancer (mCRC), seeking to provide clearer insights into its application.MethodsThis observational cohort study investigated stage IV patients with CRC (1995–2021) who underwent an upfront resection of their primary tumour at Concord Hospital, Sydney. Clinicopathological data were extracted from a prospective database, and LNR was calculated both continuously and dichotomously (LNR of 0 and LNR > 0). The primary endpoint was overall survival (OS). The associations between LNR and various clinicopathological variables were tested using regression analyses. Kaplan–Meier and Cox regression analyses estimated OS in univariate and multivariate survival models.ResultsA total of 464 patients who underwent a primary CRC resection with clear margins (mean age 68.1 years [SD 13.4]; 58.0% M; colon cancer [n = 339,73.1%]) had AJCC stage IV disease. The median LNR was 0.18 (IQR 0.05–0.42) for colon cancer (CC) resections and 0.21 (IQR 0.09–0.47) for rectal cancer (RC) resections. A total of 84 patients had an LNR = 0 (CC = 66 patients; RC = 18 patients). The 5-year OS for the CC cohort was 10.5% (95% CI 8.7–12.3) and 11.5% (95% CI 8.4–14.6) for RC. Increasing LNR demonstrated a decline in OS in both CC (P < 0.001) and RC (P < 0.001). In patients with non-lymphatic dissemination only (LNR = 0 or N0 status), there was better survival compared with those with lymphatic spread (CC aHR1.50 [1.08–2.07;P = 0.02], RC aHR 2.21 [1.16–4.24;P = 0.02]).ConclusionsLNR is worthy of consideration in patients with mCRC. An LNR of 0 indicates patients have a better prognosis, underscoring the need for adequate lymphadenectomy to facilitate precise mCRC staging.