Rectal Cancer Surgery Research Articles

Urinary and sexual dysfunction after rectal cancer surgery: A surgical challenge

This manuscript focused on the surgical challenge of urinary and sexual dysfunction after rectal cancer surgery based on the interesting results demonstrated by the observational study of Chen et al , which was published in the World Journal of Gastrointestinal Surgery . Urinary dysfunction occurs in one-third of patients treated for rectal cancer. Surgical nerve damage is the main cause of urinary dysfunction. Radiotherapy seems to exacerbate sexual dysfunction. The role of Denonvilliers' fascia preservation vs resection when performing total mesorectal excision (TME), the impact of robotic and transanal TME, alternatives to open and laparoscopic TME, as well as intraoperative pelvic neuromonitoring are discussed in this report. In conclusion, exact knowledge of the highly complex pelvic neuroanatomy and the use of novel surgical techniques can lead to a reduction in urinary and sexual dysfunction after rectal cancer surgery.

Does a surgical access for rectal cancer in older patients affect postoperative morbidity and oncological safety?

AIM: to evaluate the effect of a surgical access on postoperative morbidity and oncological safety in older patients.PATIENTS AND METHODS: a multicenter retrospective study included 179 patients aged 60–74 years who underwent surgery for middle and low rectal cancer (T1-3N0-N2bM0) in 2021-2023. The patients were divided into 3 groups: the first ones underwent robotic (ROB) surgery (n = 62), the second — laparoscopic (LAP) surgery (n = 55), and the third — open (OPEN) surgery (n = 62). Parameters of pre-, intra-, and postoperative periods and histopathological findings were evaluated. Neural network modeling was used to predict anastomotic leakage (AL).RESULTS: the blood loss was 150 (100; 200) ml with OPEN versus 100 (50; 100) with ROB and LAP, the operation time was 255 (210; 300) min with ROB versus 180 (150; 240) min with LAP and 140 (120; 150) min with OPEN. In ROB and LAP groups, anastomoses were formed in 61 (98.4%) and 54 (98.2%) cases compared with 45 (72.6%) cases in the OPEN group (p = 0.00001). The splenic flexure was mobilized in 54 (98.2%) cases in the LAP group, 55 (88.7%) cases in the OPEN group, and 50 (80.7%) cases in the ROB group (p = 0.01). Conversion rates were 10.9% (6/55) and 1.6% (1/62) in LAP and ROB groups, respectively (p = 0.00001). Postoperative complications in the OPEN group occurred in 48 (77.4%) cases compared with 31 (50%) and 12 (21.8%) in ROB and LAP groups (p = 0.02). Inflammatory complications predominated in the OPEN group. Distal and lateral margins, the quality of mesorectal excision, and the number of examined and affected lymph nodes did not differ. However, the good quality of mesorectal excision prevailed in ROB and OPEN groups, where as the satisfactory quality was more common in the LAP group. The most important predictors of AL were American Society of Anesthesiologists (ASA) physical status II, neoadjuvant chemoradiotherapy, stage I and IIa cancer, end-to-end anastomosis, Charlson Comorbidity Index scores of 3–4, and surgeon’s experience (20–40 operations for rectal cancer per year). The least important predictors were the level of mesenteric vessel ligation and the access.CONCLUSIONS: the surgical access does not affect the AL rate. The histology revealed that all the 3 approaches ensure compliance with principles of oncological safety. Compared with open surgery, robotic and laparoscopic surgery result in less blood loss and faster recovery of intestinal function; however, the operation time increases.

Reconstruction of the pelvic floor and perineal wound after extralevator abdominoperineal resection of the rectum.

This article presents an innovative technique for perineal wound reconstruction following extralevator abdominoperineal excision (ELAPE) in rectal cancer surgery. The authors trace the evolution of surgical methods for rectal cancer treatment, from W.E. Miles' abdominoperineal resection (APR) to T. Holm's ELAPE technique introduced in 2007. The proposed metod's primary advantage lies in its ability to completely fill the extensive deep and superficial perineal wound defect by moving two flaps from both sides of the wound and overlapping them. This approach potentially reduces postoperative complications and improves patients' quality of life following ELAPE. The authors describe the procedure in detail, including specific measurements and angles for flap creation. They also present a case study of a 52-year-old female patient with lower rectal ampulla cancer, demonstrating the practical application of this technique. This innovative reconstruction method addresses the current lack of consensus on perineal wound plastic surgery techniques following ELAPE and offers a promising solution to reduce postoperative morbidity in rectal cancer patients undergoing this procedure.

Systematic review of the feasibility of sparing the rectoprostatic fascia in male patients undergoing total mesorectal excision for rectal cancer.

The main purpose of this study was to determine the feasibility of sparing the rectoprostatic fascia (RPF) in adult male cadavers and in adult male patients who underwent total mesorectal excision (TME) for rectal cancer. A secondary objective was to evaluate urogenital function following rectal cancer surgery, pathologic, and oncologic outcomes. In accordance with PRISMA guidelines, we performed a systematic review with an a priori design to identify relevant studies via MESH terms and keywords. Research was conducted from March 1stto July31st 2023andwas updated betweenSeptember 30thtoOctober 10th 2024 in MEDLINE, SCOPUS, the Web of Science, Google Scholar, and reference lists. Disagreements between individual judgments were resolved by referral to a third researcher. In total, 3693 studies were identified, 22 of which were relevant to the main research question. Overall, 785 living individuals and 25 cadavers were included in whom RPF was identified and spared (498/785 patients or 63.44%). The quality of the surgical specimen was considered good in all cases. Urogenital integrity at 6months after RPF-TME and the classic TME were compromised in 27.9% and 41% of patients, respectively. One study revealed that at 3years, local/systemic recurrence was similar between the two groups. Despite the fact that the current practice of rectal cancer surgery requires the TME to extend anteriorly to the RPF, RPF-sparing TME is not only a feasible and safe option but also important for preserving fair male urogenital function, especially for young patients whose erectile function is a priority. CRD42020171188.

A prospective study on the enhancement of surgical safety in robotic surgery: The BirdView camera system.

To investigate the surgical safety and benefits of using the BirdView camera system with a wide field of view in robotic surgery for rectal cancer in a prospective clinical study. This study included 20 consecutive patients who underwent robotic surgery at our institution between the years 2022 and 2023. The primary endpoint was perioperative safety, which was defined as the occurrence of adverse events, including other organ injuries and malfunctions, caused by the BirdView camera system. There were no injuries to any other organs caused by the console surgeon or assistant forceps during surgery. Surgical adverse events occurred in five cases (atelectasis, paralytic ileus, and anastomotic leakage) during the postoperative course. There were no cases of device failure or damage to the surrounding organs, including peritoneal heat damage. We believe that the BirdView system could be valuable in improving the safety of robotic surgery by enabling the observation of blind spots, thus preventing harm to other organs.

Enhancing support for patients with low anterior resection syndrome: insights and educational resources from the LARSCAT project

PurposeTo address the educational gaps and support needs of patients with low anterior resection syndrome (LARS) following rectal cancer surgery. The LARSCAT project aimed to develop comprehensive resources to better inform patients and enhance their quality of life.MethodsA qualitative study was conducted between November 2022 and March 2023. Seven focus groups were formed, including six patients, two surgeons, and three nurses. Patients had undergone rectal cancer surgery with stoma reversal 2 to 12 years earlier, and all experienced major LARS. The focus groups, held in-person and online, explored the impact on daily life, social and sexual health, mood, rest, and relationships. Thematic analysis was performed to identify key issues and support strategies following the COREQ guidelines.ResultsParticipants reported insufficient information regarding potential dysfunctions after rectal cancer surgery, and difficulties finding reliable information online. The timing of receiving information varied according to individual coping mechanisms. LARS symptoms significantly impacted daily life, social activities, sexual health, and mood. Patients emphasised the need for more tailored information and supplementary written materials to read at their own pace. Consequently, three comprehensive documents were created and made available online.ConclusionThis study highlights a significant gap in patient education on the long-term effects of rectal cancer surgery. The resources developed by the LARSCAT project aim to provide essential support to patients and healthcare professionals. Future research should focus on integrating these resources into routine care and evaluating their impact on patient outcomes and quality of life.

Anastomotic leakage after resection for rectal cancer and recurrence-free survival in relation to postoperative C-reactive protein levels

BackgroundAnastomotic leakage after rectal cancer surgery is linked to reduced survival and higher recurrence rates. While an aggravated inflammatory response may worsen outcomes, few studies have explored the combined effects of leakage and inflammation.MethodsThis is a retrospective multicenter cohort study including patients operated with anterior resection for rectal cancer in Sweden during 2014–2018. Anastomotic leakage within 12 months was exposure and primary outcome was recurrence-free survival. Mediation analysis was performed to evaluate the potential effect of systemic inflammatory response, as measured by the highest postoperative C-reactive protein (CRP) level within 14 days of surgery. Confounders were chosen using a causal diagram.ResultsSome 1036 patients were eligible for analysis, of whom 218 (21%) experienced an anastomotic leakage. At the end of follow-up at a median of 61 months after surgery, recurrence-free survival amounted to 82.6% and 77.8% in the group with and without leakage, respectively. The median highest postoperative CRP value after surgery was higher in the leakage group (219 mg/l), compared with the group without leakage (108 mg/l). Leakage did not lead to worse recurrence-free survival (HR 0.66; 95% CI 0.43–0.94), and there was no apparent effect through postoperative highest CRP (HR 1.12; 95% CI 0.93–1.29).ConclusionsIn conclusion, anastomotic leakage, with its accompanying CRP increase, was not found to be associated with recurrence-free survival after anterior resection for rectal cancer in this patient cohort. Larger, even more detailed studies are needed to further investigate this topic.

Combined therapy of intraoperative radiotherapy and surgery for rectal cancer with inguinal lymph node metastasis: a case description.

Combined therapy of intraoperative radiotherapy and surgery for rectal cancer with inguinal lymph node metastasis: a case description.

Relationship between pathological outcomes and centre volume in rectal cancer surgery

Relationship between pathological outcomes and centre volume in rectal cancer surgery

Long-term follow-up after rectal cancer surgery

Long-term follow-up after rectal cancer surgery

Safety and feasibility of conversion of Double stapling technique to Single stapling technique for reducing the Anastomotic leakage after rectal cancer surgery

Safety and feasibility of conversion of Double stapling technique to Single stapling technique for reducing the Anastomotic leakage after rectal cancer surgery

Transanal minimally invasive surgery for early rectal cancer: experience of a department

Transanal minimally invasive surgery for early rectal cancer: experience of a department

Prior antibiotics exposure is associated with an elevated risk of surgical site infections, including anastomotic leakage, after colon cancer but not rectal cancer surgery: A register-based study of 38,839 patients.

Gut microbiota composition has been implicated in surgical site complications after colorectal cancer surgery. Antibiotics affect gut microbiota, but evidence for a role in surgical site complications is inconclusive. We aimed to investigate use of prescription antibiotics during the years before surgery in relation to the risk of surgical site infections, including anastomotic leakage, within 30 days after surgery. Cardiovascular/neurological complications and the urinary antiseptic methenamine hippurate, for which there is no clear link with the microbiota, were used as negative controls. We conducted a patient cohort study using complete population data from Swedish national registers between 2005 and 2020. The final study population comprised 26,527 colon cancer and 12,312 rectal cancer cases with a 4.5 year exposure window. In colon cancer patients, antibiotics use was associated with a higher risk of surgical site infections (adjusted odds ratio (aOR) for any versus no use = 1.20, 95% confidence interval (CI) 1.10-1.33) and anastomotic leakage in particular (aOR =1.19, 95% CI 1.03-1.36), both with dose-response relationships for increasing cumulative antibiotics use (Ptrend = <0.001 and Ptrend = 0.047, respectively). Conversely, associations in rectal cancer patients, as well as for the negative controls cardiovascular/neurological complications and methenamine hippurate, were null. In conclusion, prescription antibiotics use up to 4.5 years before colorectal cancer surgery is associated with a higher risk of surgical site infections, including anastomotic leakage, after colon cancer but not rectal cancer surgery. These findings support a role for antibiotics-induced intestinal dysbiosis in surgical site infections.

Our experience at Bangabandhu Sheikh Mujib Medical University on laparoscopic assisted surgery for rectal cancer

Background: Rectal cancer is a leading cause of mortality worldwide, with laparoscopic surgery emerging as a viable alternative to open surgery due to its benefits in postoperative recovery, pain management and survival rates. Despite its advantages, laparoscopic colorectal resection faces scrutiny over oncologic safety and technical demands, limiting its widespread adoption. Methods: This retrospective descriptive study analyzed 60 patients with colorectal adenocarcinoma treated at the Department of Colorectal Surgery, BSMMU, from January 2018 to December 2018. Inclusion criteria encompassed clinically diagnosed colorectal cancer with histological confirmation. Data on demographics, tumor characteristics, surgical details and postoperative outcomes were collected and analyzed with SPSS software. Results: Among the 60 patients, 32 were male, with a mean age of 52 years. Tumors within 5 cm of the anal verge necessitated abdominoperineal resections (n=44), while anterior resections were performed for the remaining (n=16). All patients achieved adequate proximal margins (&gt;5 cm) and most (90%) had distal margins &gt;2 cm. The average operative time ranged from 190 to 270 minutes, with no intraoperative complications and a postoperative stay of 3-5 days. Patients reported less postoperative pain and faster recovery. Conclusions: Laparoscopic colorectal surgery demonstrated similar oncologic outcomes to open surgery but involved a longer operative time and required advanced surgical skills. The benefits included reduced blood loss, lower postoperative pain and a shorter hospital stay, although costs were higher. A need for expert surgeons in selected patients is emphasized for optimal outcomes. Laparoscopic resection for rectal cancer aligns with oncologic principles and offers a safe, effective approach, yielding improved recovery metrics compared to traditional surgery. Further analysis on cost-effectiveness, especially for lower socioeconomic populations, is warranted to enhance accessibility.

Influence of the ligation sequence of the inferior mesenteric artery and vein on circulating tumor cells in laparoscopic rectal cancer surgery: a prospective pilot study

BackgroundThere is no regulation in the current guidelines on the sequence of ligation of the inferior mesenteric artery and vein during rectal cancer surgery owing to a lack of sufficient evidence. Circulating tumor cells (CTCs) in peripheral blood can be used as potential indicators for predicting prognosis in colorectal cancer patients. This study aims to explore the feasibility of different ligation sequences for the inferior mesenteric vessels and their potential influence on CTCs.MethodsThis pilot study involved 29 stage I-III rectal adenocarcinoma patients undergoing laparoscopic surgery. Patients were allocated into two groups based on the sequence of vascular ligation: vein-first (V-first) and artery-first (A-first). The primary objective was to assess the impact of the ligation sequence on peripheral blood CTC levels pre- and post-operatively. Secondary outcomes included intraoperative complications, surgical duration, blood loss, and number of lymph nodes harvested, and postoperative complications. The study was approved by the ethics committee of our hospital (SCCHEC-02-2024-102), and all patients provided informed consent.ResultsNo significant differences were found between the two groups regarding surgical duration, blood loss, lymph nodes harvested, or postoperative complications. A reduction in CTCs postoperatively was observed in 36% of patients in the V-first group, in comparison to 20% in the A-first group.ConclusionBoth A-first and V-first ligation sequences are viable and safe options in laparoscopic rectal cancer surgery. The V-first approach may be more effective in reducing levels of CTCs in peripheral blood. Further randomized studies are warranted to explore these findings comprehensively.

Standardized surgical procedure for natural orifice specimen extraction surgery of precision functional sphincter-preserving surgery for ultra-low rectal cancer (NOSES-PPS) (2024 edition)

Natural orifice specimen extraction surgery of precision functional sphincter- preserving surgery for ultra-low rectal cancer (NOSES-PPS) is an innovative surgical technique that builds upon traditional laparoscopic surgery for low rectal cancer. This method utilizes a specially designed transparent screw-thread anal dilator and associated equipment to achieve precise tumor localization and resection through direct visualization via the anus. Digestive tract reconstruction is then accomplished using a combination of a precision circular stapler and manual suturing, thereby preserving sphincter function in patients with ultra-low rectal cancer. NOSES-PPS has been widely adopted across multiple provinces and cities in China, with over 500 cases successfully performed to date. The technique and its outcomes have been published in both national and international peer-reviewed journals, receiving significant recognition from the medical community. However, as a novel approach to rectal cancer surgery, there is currently a lack of authoritative clinical practice guidelines detailing the specific procedural steps of NOSES-PPS. To address this gap, the Colorectal Tumor Committee of the Chinese Medical Association, the Colorectal Cancer Committee of the Chinese Anti-cancer Association, and the China NOSES Collaborative Group have jointly led an effort to establish standardized guidelines for NOSES-PPS. This initiative involved the collaboration of experts in colorectal oncology from numerous large medical centers across China. Through multiple rounds of consultation and discussion, these experts have developed a comprehensive set of guidelines that detail the definition of NOSES-PPS, requirements for instrumentation, indications, key operative techniques, and the management of perioperative and postoperative complications. This guideline aims to promote the standardized implementation of NOSES-PPS in clinical practice.

Application of Zhao Shi Lei-huo-jiu Based on ERAS Concept in Managing Postoperative Gastrointestinal Symptom Cluster in Rectal Cancer

This study explores the application value of Zhao Shi Lei-huo-jiu in managing common postoperative gastrointestinal symptom clusters following rectal cancer surgery, under the framework of the Enhanced Recovery After Surgery (ERAS) concept. By detailing the development, core elements, and application of ERAS in colorectal surgery, combined with the historical origins, unique techniques, and mechanisms of Zhao Shi Lei-huo-jiu, this paper highlights the innovation of integrating traditional Chinese medicine treatments with modern surgical recovery principles. Through a rigorously designed research process, rectal cancer postoperative patients were selected as research subjects, and the data collection and implementation steps were explicitly outlined. The study results provide scientific evidence for the practical efficacy and advantages of Zhao Shi Lei-huo-jiu in postoperative rehabilitation for rectal cancer, offering significant practical implications for guiding clinical practice and promoting early patient recovery.

Feasibility of robot-assisted surgery for defining circumferential resection margins for rectal cancer: a retrospective study

BackgroundLocal recurrence is a major problem after surgery for rectal cancer. Precision of the circumferential resection margin (CRM) has been shown to be an independent predictor of local recurrence. The purpose of this study is to evaluate the usefulness of robotic surgery for defining the CRM.MethodsA retrospective cohort study of patients with rectal cancer who underwent radical surgery at Tokushima University Hospital from January 2012 to April 2023 was included in this study to evaluate risk factors for CRM involvement. Short-term outcomes, including CRM rates, as well as long-term outcomes, were compared between patients who had undergone robot-assisted versus laparoscopic surgery following propensity score analysis.ResultsA total of 223 patients were analyzed in this study. Multivariate analysis demonstrated that lymph node metastasis was the most significant predictive factor for CRM involvement (p = 0.030), and that robot-assisted surgery tended to lead to less CRM involvement (p = 0.085). The CRM involvement rate for robotic and laparoscopic surgery before propensity score matching was 4.7% and 11.7%, respectively. Following propensity score matching, the CRM involvement rate for robotic surgery was 4.5% versus 11.4% for laparoscopic surgery. Disease-free survival (DFS) and overall survival (OS) rates for patients who had undergone robot-assisted and laparoscopic surgery were not significantly different before or after matching (DFS before matching: p = 0.876, DFS after matching: p = 0.805, OS before matching: p = 0.511, OS after matching: p = 0.458).ConclusionRobot-assisted surgery may be useful in defining the CRM for rectal cancer.

Effect of endoscopic surgical skill qualification system for laparoscopic rectal surgery: Japanese multicenter analysis.

Laparoscopic rectal surgery is often technically difficult. The Endoscopic Surgical Skill Qualification System (ESSQS) was established in Japan as an objective measure of skill for laparoscopic surgeons. However, the advantages of the ESSQS qualification for laparoscopic rectal surgery have been limited. The aim of this multicenter study was to assess the effects of the ESSQS on short- and long-term outcomes for laparoscopic rectal cancer surgery. We retrospectively reviewed 933 rectal cancer patients who underwent laparoscopic surgery between 2016 and 2023. Patients were divided into two groups: those for whom surgery was performed by an ESSQS-qualified surgeon (Expert group, n = 568); and those for whom surgery was performed by an ESSQS-unqualified surgeon (Non-expert group, n = 365). After propensity score matching, 299 patients from each group were matched. Short- and long-term outcomes were compared between groups. Before matching, the Expert group showed greater frequencies of poor performance status (PS) (PS ≥ 3, 10.6% vs 4.1%, p < 0.001), lower rectum cancer (32.0% vs 18.4%, p < 0.001), preoperative treatment (17.3% vs 8.2%, p < 0.001), and pelvic lymph node dissection (30.8% vs 21.4%, p = 0.001). After matching, the Expert group showed lower frequencies of open conversion (0.3% vs 2.3%, p = 0.034) and postoperative complications (18.1% vs 26.1%, p = 0.037). Relapse-free survival (p = 0.811) and overall survival (p = 0.374) were similar between groups. Superior results such as lower conversion rates and postoperative complication rates were obtained for laparoscopic rectal surgery performed by ESSQS-qualified surgeons.

Nomograms Predicting Survival, Recurrence and Beneficiary Identification of Adjuvant Chemotherapy in Treatment-naïve Patients with Rectal Cancer who Underwent Upfront Curative Resection: A multi-institutional study

Objective: To create and validate nomograms predicting overall survival and recurrence in treatment-naïve rectal cancer (RC) patients who underwent upfront surgery. Background: Although multidisciplinary treatment is standard for locally advanced RC, understanding surgical efficacy is important for determining indications for perioperative adjuvant therapy. Methods: RC patients who underwent upfront surgery at the Japanese Society for Cancer of the Colon and Rectum institutions were analyzed. A training cohort (n = 1925) of treatment-naïve patients who underwent surgery between 2007 and 2008 was analyzed to construct prognostic models predicting postoperative survival and recurrence. Discrimination and calibration were performed using an external validation cohort (n = 2957; Japanese colorectal cancer registry, procedures in 2005–2006). Effects of adjuvant chemotherapy on survival were evaluated based on nomogram prediction and Surveillance, Epidemiology, and End Results (SEER) data (n = 10,482; upfront surgery for RC in 2010–2015). Results: In the training cohort, age predicted survival, venous invasion predicted recurrence, and sex, tumor location, histological type, preoperative carcinoembryonic antigen, invasion depth, lymphatic invasion, positive radial margin, and numbers of metastatic nodes and examined nodes predicted both. Internal and external validated Harrell’s C-index values were respectively 0.77 and 0.75 for survival and 0.75 and 0.74 for recurrence. RC patients who underwent upfront surgery in the SEER database were stratified into 3 risk levels by nomogram score. Adjuvant chemotherapy did not improve 5-year survival in low-risk patients, but did so for middle-risk (62.4% vs 76.8%) and high-risk (39.4% vs 63.5%) patients. Conclusion: These nomograms could predict survival and recurrence after upfront curative resection of RC and identify cases expected to benefit more from adjuvant chemotherapy.