Clinical efficacy and pathological outcomes of transanal endoscopic intersphincteric resection for low rectal cancer

BACKGROUND Transanal endoscopic intersphincteric resection(ISR)surgery currently lacks sufficient clinical research and reporting.AIM To investigate the clinical effectiveness of transanal endoscopic ISR,in order to promote the clinical application and development of this technique.METHODS This study utilized a retrospective case series design.Clinical and pathological data of patients with lower rectal cancer who underwent transanal endoscopic ISR at the First Affiliated Hospital of Xiamen University between May 2018 and May 2023 were included.All patients underwent transanal endoscopic ISR as the surgical approach.We conducted this study to determine the perioperative recovery status,postoperative complications,and pathological specimen charac-teristics of this group of patients.RESULTS This study included 45 eligible patients,with no perioperative mortalities.The overall incidence of early complications was 22.22%,with a rate of 4.44%for Clavien-Dindo grade≥III events.Two patients(4.4%)developed anastomotic leakage after surgery,including one case of grade A and one case of grade B.Postoperative pathological examination confirmed negative circumferential resection margins and distal resection margins in all patients.The mean distance between the tumor lower margin and distal resection margin was found to be 2.30±0.62 cm.The transanal endoscopic ISR procedure consistently yielded high quality pathological specimens.CONCLUSION Transanal endoscopic ISR is safe,feasible,and provides a clear anatomical view.It is associated with a low incidence of postoperative complications and favorable pathological outcomes,making it worth further research and application.

Long-term outcomes and failure patterns after laparoscopic intersphincteric resection in ultralow rectal cancers

BACKGROUND Intersphincteric resection(ISR),the ultimate anus-preserving technique for ultralow rectal cancers,is an alternative to abdominoperineal resection(APR).The failure patterns and risk factors for local recurrence and distant metastasis remain controversial and require further investigation.AIM To investigate the long-term outcomes and failure patterns after laparoscopic ISR in ultralow rectal cancers.METHODS Patients who underwent laparoscopic ISR(LsISR)at Peking University First Hospital between January 2012 and December 2020 were retrospectively reviewed.Correlation analysis was performed using the Chi-square or Pearson's correlation test.Prognostic factors for overall survival(OS),local recurrence-free survival(LRFS),and distant metastasis-free survival(DMFS)were analyzed using Cox regression.RESULTS We enrolled 368 patients with a median follow-up of 42 mo.Local recurrence and distant metastasis occurred in 13(3.5%)and 42(11.4%)cases,respectively.The 3-year OS,LRFS,and DMFS rates were 91.3%,97.1%,and 90.1%,respectively Multivariate analyses revealed that LRFS was associated with positive lymph node status[hazard ratio(HR)=5.411,95%confidence interval(CI)=1.413-20.722,P=0.014]and poor differentiation(HR=3.739,95%CI:1.171-11.937,P=0.026),whereas the independent prognostic factors for DMFS were positive lymph node status(HR=2.445,95%CI:1.272-4.698,P=0.007)and(y)pT3 stage(HR=2.741,95%CI:1.225-6.137,P=0.014).CONCLUSION This study confirmed the oncological safety of LsISR for ultralow rectal cancer.Poor differentiation,(y)pT3 stage,and lymph node metastasis are independent risk factors for treatment failure after LsISR,and thus patients with these factors should be carefully managed with optimal neoadjuvant therapy,and for patients with a high risk of local recurrence(N+or poor differentiation),extended radical resection(such as APR instead of ISR)may be more effective.

Clinical outcome of intersphincteric resection for ultra-low rectal cancer

AIM： To analyze oncological outcome of intersphincteric resection （ISR） in ultra-low rectal cancer with intent to spare colostoma. METHODS： From 1995 to 1998, patients with a nonfixed rectal adenocarcinoma （tumor stage T2） preserving the lower margin at 1-3 cm above the dentate line without distant metastasis was enrolled （period I）. ISR was practiced in eight patients, and their postoperative followup was at least 5 years. In addition, from 1999 to 2003, another 10 patients having the same tumor location as period Ⅰ underwent ISR （period Ⅱ）. Among those, 6 patients with T3-4-staged tumor received preoperative chemoradiotherapy. RESULTS： All patients received ISR with curative intention and no postoperative mortality. In these case series at period Ⅰ, local recurrence rate was 12.5% and metastasis rate 25.0%; the S-year survival rate was 87.5% and disease-free survival rate 75.0%. There was no local recurrence or distant metastases in 10 patients with a median follow-up of 30 （range, 18-47） mo at period Ⅱ. CONCLUSION： As to ultra-low rectal cancer, intersphincteric resection could provide acceptable local control and cancerrelated survival with no permanent stoma in early-staged tumor （tumor stage T2）; more- over, preoperative concurrent chemoradiotheraw would make ISR feasible with surgical curative intent in more advanced tumors （tumor stages T3-4）.

Anal Sphincter Function after Intersphincteric Resection for Low Rectal Cancer

Objective： To assess the anal sphincter function after intersphincteric resection for low rectal cancer by questionnaire and vectorial manometry. Methods： twenty five patients underwent intersphincteric resection, the controls contained 25 patients of rectal cancer who underwent low anterior resection and 25 healthy people. The therapeutic responses were evaluated using the Vaizey and Wexner scoring systems and vectorial manometry. Results： The Vaizey and Wexner scores after intersphincteric resection were significantly higher than those of low anterior resection controls at one month, but had no significant difference one year after. On the other hand, the indexes of vectorial manometry still had significant difference one year later. The indexes after intersphincteric resection could not reach the normal level. Conclusion： The anal sphincter function after intersphincteric resection is lower than that after low anterior resection in short term, although the long-term results can be accepted, it still can not reach the normal level.

Observation of the Efficacy of Laparoscopic Resection of Anterior Rectal Cancer in Treating Rectal Cancer

Objective:To analyze the efficacy of laparoscopic resection of anterior rectal cancer in treating rectal cancer.Methods:Fifty patients with rectal cancer who were treated in Gucheng County Hospital of Hebei Province from September 2017 to September 2019 were selected and recruited in the present study.These patients were divided into two groups,namely the control group and observation groups,by random number table method.Each group consisted of 25 patients.The control group underwent laparoscopic assisted transanorectal mesorectal excision,whereas the observation group underwent laparoscopic resection of anterior rectal cancer.The two groups were compared for related indicators,indicators pertaining to postoperative recovery,and complications.Results:There was no significant difference in the number of lymph node dissections between the two groups(P>0.05).The amount of intraoperative blood loss,surgical operation time,and incision length in the observation group were lower than those in the control group,and the differences were statistically significant(P<0.05).The time of getting out of bed,anal exhaust,and duration of hospital stay were shorter in the observation group than those of the control group,and the differences were statistically significant(P<0.05).In addition,the incidence of postoperative complications in the observation group was lower than that in the control group,and the differences were statistically significant(P<0.05).Conclusions:Laparoscopic resection of anterior rectal cancer is effective for rectal cancer patients.This treatment method can effectively reduce the amount of intraoperative bleeding,shorten the operation time,the time of anal exhaust,get out of bed,and the length of hospital stay,as well as improve condition of the patients.

Effect of laparoscopic radical resection of rectal cancer on gastrointestinal hormones, visceral protein and pain stress in patients

Objective: To investigate the effects of laparoscopic radical resection of rectal cancer on gastrointestinal hormones, visceral protein and pain stress. Methods: A total of 96 patients with rectal cancer radical resection from January 2017 to December 2017 in our hospital, were selected as the research objects, the patients were randomly divided into the observation group (48 cases) and the control group (48 cases). The observation group received laparoscopic radical resection of rectal cancer, while the control group underwent open radical resection of rectal cancer. The levels of gastrin (GAS), motilin (MTL), vasoactive intestinal peptide (VIP), transferrin (TRF), retinol binding protein (RbP), albumin (ALB), prealbumin (PRE), P substance (SP), bradykinin (BK), and prostaglandin-E2 (PGE2) were measured and compared in the two groups. Results: Before operation, there was no significant difference in GAS, MTL and VIP between the two groups. 1, 3, and 5 d after operation, the GAS, MTL and VIP of the two groups were significantly lower than those before operation, and the differences were statistically significant. 1, 3, and 5 d after operation, GAS of the observation group were (66.60±5.79) μmol/L, (71.95±6.16) μmol/L and (77.68±6.38) μmol/L respectively, MTL were (225.68±19.83) pg/mL, (253.76±21.42) pg/mL and (289.98±24.74) pg/mL, VIP were (1.99±0.42) μmol/L, (2.43±0.46) μmol/L, (2.80±0.51) μmol/L, respectively, which were higher than that of the control group at the same time, and the difference was statistically significant. Before operation, there was no significant difference in TRF, RbP, ALB and PRE levels in the two groups. 1, 3 and 5 d after operation, the TRF, RbP, ALB and PRE levels in the two groups were significantly lower than those before operation, and the differences were statistically significant. 1, 3 and 5 d after operation, TRF of the observation group were (1.64±0.33) ng/L, (1.44±0.30) ng/L, (1.46 ±0.32) ng/L, RbP were (19.05±3.85) mg/L, (21.83±4.26) mg/L and (24.54±4.45) mg/L respectively, and ALB were (31.49±2.54) ng/L, (28.21±2.05) ng/L and (28.43±1.99) ng/L, PRE were (0.20±0.06) ng/L, (0.16±0.05) ng/L, (0.15±0.05) ng/L, which were all higher than those in the control group at the same time, and the differences were statistically significant. Before operation, there was no significant difference in SP, BK and PGE2 between the two groups. 1, 3 and 5 d after operation, the SP, BK and PGE2 of the two groups were significantly higher than those before operation and the differences were statistically significant. 1, 3 and 5 d after operation, SP of the observation group was (7.31±0.87) μg/mL, (5.43±0.51) μg/mL and (3.10±0.24) μg/mL, BK was (9.53±0.80) μg/L, (7.81±0.79) μg/L and 6.30±0.53) pg/mL, and PGE2 were (152.42±14.80) pg/mL, (131.22±13.35) pg/mL, (117.86±11.95) pg/mL, which were all lower than those in the control group at the same time, and the differences were statistically significant. Conclusion: Laparoscopic radical resection of rectal cancer can help patients recover gastrointestinal function faster and cause less pain stress.

Narrow pelvic inlet plane area and obesity as risk factors for anastomotic leakage after intersphincteric resection

BACKGROUND Intersphincteric resection(ISR)has been increasingly used as the ultimate sphincter-preserving procedure in extremely low rectal cancer.The most critical complication of this technique is anastomotic leakage.The incidence rate of anastomotic leakage after ISR has been reported to range from 5.1%to 20%.AIM To investigate risk factors for anastomotic leakage after ISR based on clinicopathological variables and pelvimetry.METHODS This study was conducted at Department of Colorectal Surgery,Japanese Red Cross Medical Center,Tokyo,Japan,with a total of 117 patients.We enrolled 117 patients with extremely low rectal cancer who underwent laparotomic and laparoscopic ISRs at our hospital.We conducted retrospective univariate and multivariate regression analyses on 33 items to elucidate the risk factors for anastomotic leakage after ISR.Pelvic dimensions were measured using threedimensional reconstruction of computed tomography images.The optimal cutoff value of the pelvic inlet plane area that predicts anastomotic leakage was determined using a receiver operating characteristic(ROC)curve.RESULTS We observed anastomotic leakage in 10(8.5%)of the 117 patients.In the multivariate analysis,we identified high body mass index(odds ratio 1.674;95%confidence interval:1.087-2.58;P=0.019)and smaller pelvic inlet plane area(odds ratio 0.998;95%confidence interval:0.997-0.999;P=0.012)as statistically significant risk factors for anastomotic leakage.According to the receiver operating characteristic curves,the optimal cutoff value of the pelvic inlet plane area was 10074 mm2.Narrow pelvic inlet plane area(≤10074 mm2)predicted anastomotic leakage with a sensitivity of 90%,a specificity of 85.9%,and an accuracy of 86.3%.CONCLUSION Narrow pelvic inlet and obesity were independent risk factors for anastomotic leakage after ISR.Anastomotic leakage after ISR may be predicted from a narrow pelvic inlet plane area(≤10074 mm2).

Efficacy of the Intraoperative Use of Indocyanine-Green Fluorescence Angiography in Laparoscopic Rectal Resections

Background: In traditional laparoscopic colorectal cancer surgery, the surgeon’s method assess intestinal stumps blood supply is subject to certain subjectivity and blindness. Indocyanine green (ICG) real-time blood perfusion fluorescence angiography in laparoscopic radical resection of rectal cancer has great potential clinical value and can visually judge intestinal tract blood supply to improve the surgery safety, reduce postoperative complications, and ensure the recovery of patients after surgery. Objective: To explore the efficacy of the intraoperative use of indocyanine-green fluorescence angiography in laparoscopic rectal resections in patients with rectal cancer. Methods: In the present study, 109 rectal cancer patients were included and assigned to different surgical groups [ICG and control groups] for analysis. Statistical analysis was carried out for various common postoperative complications in the two groups. Finally, the patients in the ICG fluorescence imaging group had a timely adjustment of the proximal resection of the intestinal tube before the proximal bowel of the lesion was cut off when the intestinal blood supply was insufficiently assessed by fluorescence imaging. Two subgroups, the adjustment and the non-adjustment groups, were analyzed. Results: Compared with the control group, the postoperative anal ventilation time in the ICG group was shorter than that in the control group (P 0.05). In addition, the postoperative complications were lower than those in the control group, and the differences were statistically significant (P 0.05). However, the distance between the tumor from the anal verge in the adjustment group was smaller than that in the non-adjustment group, and the difference was statistically significant (P 0.01). Conclusion: Compared with conventional laparoscopic radical resection of rectal cancer, ICG real-time indocyanine green fluore- scence angiography was safe and feasible. This technique is a promising intraoperative tool for the assessment of bowel perfusion especially suitable for patients with lower rectal cancer.

Short-term clinical outcomes of laparoscopic vs open rectal excision for rectal cancer: A systematic review and metaanalysis

AIM To review evidence on the short-term clinical outcomes of laparoscopic(LRR) vs open rectal resection(ORR) for rectal cancer.METHODS A systematic literature search was performed using Cochrane Central Register, MEDLINE, EMBASE, Scopus, Open Grey and Clinical Trials.gov register for randomized clinical trials(RCTs) comparing LRR vs ORR for rectal cancer and reporting short-term clinical outcomes. Articles published in English from January 1, 1995 to June, 30 2016 that met the selection criteria were retrieved and reviewed. The Preferred Reporting Items for Systematic reviews and Meta-Analysis(PRISMA) statements checklist for reporting a systematic review was followed. Random-effect models were used to estimate mean differences and risk ratios. The robustness and heterogeneity of the results were explored by performing sensitivity analyses. The pooledeffect was considered significant when P < 0.05.RESULTS Overall, 14 RCTs were included. No differences were found in postoperative mortality(P = 0.19) and morbidity(P = 0.75) rates. The mean operative time was 36.67 min longer(95%CI: 27.22-46.11, P < 0.00001), the mean estimated blood loss was 88.80 ml lower(95%CI:-117.25 to-60.34, P < 0.00001), and the mean incision length was 11.17 cm smaller(95%CI:-13.88 to-8.47, P < 0.00001) for LRR than ORR. These results were confirmed by sensitivity analyses that focused on the four major RCTs. The mean length of hospital stay was 1.71 d shorter(95%CI:-2.84 to-0.58, P < 0.003) for LRR than ORR. Similarly, bowel recovery(i.e., day of the first bowel movement) was 0.68 d shorter(95%CI:-1.00 to-0.36, P < 0.00001) for LRR. The sensitivity analysis did not confirm a significant difference between LRR and ORR for these latter two parameters. The overall quality of the evidence was rated as high. CONCLUSION LRR is associated with lesser blood loss, smaller incision length, and longer operative times compared to ORR. No differences are observed for postoperative morbidity and mortality.

Role of laparoscopy in rectal cancer:A review

Despite established evidence on the advantages of laparoscopy in colon cancer resection,the use of laparoscopy for rectal cancer resection is still controversial.The initial concern was mainly regarding the feasibility of laparoscopy to achieve an adequate total mesorectal excision specimen.These concerns have been raised following early studies demonstrating higher rates of circumferential margins positivity following laparoscopic resection,as compared to open surgery.Similar to colon resection,patients undergoing laparoscopic rectal cancer resection are expected to benefit from a shorter length of hospital stay,less analgesic requirements,and a faster recovery of bowel function.In the past decade there have been an increasing number of large scale clinical trials investigating the oncological and perioperative outcomes of laparoscopic rectal cancer resection.In this review we summarize the current literature available on laparoscopic rectal cancer surgery.

Value of multi-disciplinary input into laparoscopic management of rectal cancer-An observational study

AIMTo assess the impact of multi-disciplinary teams (MDTs) management in optimising the outcome for rectal cancers. METHODSWe undertook a retrospective review of a prospectively maintained database of patients with rectal cancers (defined as tumours ≤ 15 cm from anal verge) discussed at our MDT between Jan 2008 and Jan 2011. The data was validated against the national database to ensure completeness of dataset. The clinical course and follow-up data was validated using the institution’s electronic patient records. The data was analysed in terms of frequencies and percentages. Significance of any differences were analysed using χ2 test. A Kaplan-Meier analysis was performed for overall survival and disease free survival. RESULTSFollowing appropriate staging, one hundred and thirty-three patients were suitable for potentially curative resections. Seventy two (54%) were upper rectal cancer (URC) - tumour was > 6 cm from the anal verge and 61 (46%) were lower rectal cancers (LRC) - lower extent of the tumour was palpable ≤ 6 cm. Circumferential resection margin (CRM) appeared threatened on pre-operative MRI in 19/61 (31%) patients with LRC requiring neo-adjuvant therapy (NAT). Of the 133 resections, 118 (89%) were attempted laparoscopically (5% conversion rate). CRM was positive in 9 (6.7%) patients; Median lymph node harvest was 12 (2-37). Major complications occurred in 8 (6%) patients. Median follow-up was 53 mo (0-82). The 90-d mortality was 2 (1.5%). Over the follow-up period, disease related mortality was 11 (8.2%) and overall mortality was 39 (29.3%). Four (3%) patients had local recurrence and 22 (16.5%) patients had distant metastases. CONCLUSIONManagement of rectal cancers can be optimized with multi-disciplinary input to attain acceptable long-term oncological outcomes even when incorporating a laparoscopic approach to rectal cancer resection.

Analysis of the Clinical Effect of Laparoscopic Total Mesorectal Excision for the Treatment of Middle and Low Rectal Cancer

The purpose of this study was to analyze the clinical efficacy of laparoscopic total mesorectal excision for the treatment of middle and low rectal cancer.First,30 patients who received treatment in the hospital from March 2013 to May 2018 were randomly selected as the laparotomy group to receive laparotomy.30 patients who received treatment in the hospital from March 2013 to May 2018 were randomly selected as the laparoscopic group to receive laparoscopic surgery.The postoperative and complications of total rectal mesorectal excision were compared between the two groups.The results showed that the amount of blood loss during laparoscopy was(169.36±106.96)mL,and that during laparoscopy was(180.65±153.22)mL,which was significantly lower than that of the open group(209.65±186.65)mL and(356.54±170.32)mL.Intraoperative blood loss in laparoscopic patients was significantly lower than that in the open group,and the difference was statistically significant(t=2.95,2.87,P<0.05).The duration of anal sparing surgery in the laparoscope group was(232.65±56.35)min,which was longer than that in the laparoscope group(227.65±68.65)min.The duration of non-sparing anal surgery in the laparoscopic group was(246.95±52.65)min,which was significantly shorter than that in the open group(299.65±64.32)min.There was no statistically significant difference in the duration of operation between the laparoscopic group and the open group.The recovery time of intestinal function in the laparoscopic group was(2.11±1.82)days,which was significantly shorter than that in the open group(4.63±1.52)days.The postoperative hospital stay in the laparoscopic group was(11.32±10.01)d,which was significantly shorter than that in the open group(26.62±12.43 d).The recovery time of intestinal function and postoperative hospital stay of patients in the laparoscopic group were shorter than those in the open group,with statistically significant differences(T=2.31,2.43,P<0.05).The tumor diameter was(4.03±1.20)cm in the laparoscopic group and(3.95±1.43)cm in the open group.The number of lymph nodes in the laparoscopic group was(12.75±6.51)cm,while that in the open group was(13.62±7.05).There was no significant difference in the number of lymph nodes dissected or tumor diameter between the two groups(t=0.11,0.22,P>0.05).The complication rate of the abdominal group was 20.00%,significantly lower than that of the open group(66.67%).Complications after total mesorectal resection were significantly higher in the open group than in the laparoscopic group,and the difference between the two groups was statistically significant(χ2=13.30,P<0.05).Therefore,laparoscopic total rectal mesorectal resection for patients with middle and low rectal cancer is safer and can be used as a reliable treatment plan.

Transanal total mesorectal excision combined with intersphincteric resection has similar long-term oncological outcomes to laparoscopic abdominoperineal resection in low rectal cancer:a propensity score-matched cohort study

Background Transanal total mesorectal excision(taTME)or intersphincteric resection(ISR)has recently proven to be a valid and safe surgical procedure for low rectal cancer.However,studies focusing on the combination of these two technologies are limited.This study aimed to evaluate perioperative results,long-termoncologic outcomes,and anorectal functions of patients with low rectal cancer undergoing taTME combined with ISR,by comparing with those of patients undergoing laparoscopic abdominoperineal resection(laAPR).Methods After 1:1 propensity score matching,200 patients with low rectal cancer who underwent laAPR(n=100)or taTME combined with ISR(n=100)between September 2013 and November 2019 were included.Patient demographics,clinicopathological characteristics,oncological outcomes,and anal functional results were analysed.Results Patients in the taTME-combined-with-ISR group had less intraoperative blood loss(79.6672.6 vs 107.3665.1 mL,P=0.005)and a lower rate of post-operative complications(22.0%vs 44.0%,P<0.001)than those in the laAPR group.The overall local recurrence rates were 7.0%in both groups within 3 years after surgery.The 3-year disease-free survival rates were 86.3%in the taTME-combined-with-ISR group and 75.1%in the laAPR group(P=0.056),while the 3-year overall survival rates were 96.7%and 94.2%,respectively(P=0.319).There were 39 patients(45.3%)in the taTME-combined-with-ISR group who developed major low anterior resection syndrome,whereas 61 patients(70.9%)had good post-operative anal function(Wexner incontinence score≤10).Conclusion We found similar long-term oncological outcomes for patients with low rectal cancer undergoing laAPR and those undergoing taTME combined with ISR.Patients receiving taTME combined with ISR had acceptable post-operative anorectal function.

Preservation of the continence function after intersphincteric resection using a prolapsing technique in the patients with low rectal cancer and its clinical prognosis

Background The technique of intersphincteric resection of tumors combined with coloanal anastomosis has been used to avoid permanent colostomy for patients with a rectal cancer located 〈5 cm from the anal verge. This study aimed at assessing the preservation of continence function of the residual rectum and the clinical prognosis of patients with lower rectal cancer after intersphincteric resection using a prolapsing technique. Methods This study included patients with the following inclusion criteria： （1） pathological evidence of rectal cancer and the tumors within distal margins located 5 cm or less from the anus by preoperative endoscopic examination; （2） no evidence by MRI of infiltration of either the external sphincter, puborectalis or the levator muscle; （3） the patients are eligible for intersphincteric resection and lower coloanal anastomosis with a preoperative biopsy showing the tumors with well-to-moderate differentiation. From January 2000 to June 2004, 23 patients with low rectal cancer were included in this study. We used the standard abdominoperineal approach to perform radical resection of tumors with excision of the mesorectum and total or part of the internal sphincters. The patients were followed for assessment of the function of the residual rectum and of cancer recurrence after the operations. Results The median tumor distance from the anal margin was 4.5 （range 3.5-5.0） cm and the mean distal surgical margin 1.6 （range 1.0-2.0） cm. Cancer was classified into Stage Ⅰ （30.4%）, Stage Ⅱ （47.8%）, and Stage Ⅲ （21.7%） according to the TNM classification. Two patients developed anastomotic fistula after the surgical resection and 2 patients （8.7%） developed later stages of anastomotic stricture at the site of coloanal anastomosis. The median follow-up period was 31.5 months （range 12-54） and 2 patients （8.7%） developed local recurrence. Three deaths were associated with distal organ metastasis. Twenty patients （87.0%） have maintained competence to control solid or liquid stool and the capacity of flatus continence after the surgery. Among these patients, 2 patients were able to control solid stool and occasionally lose continence of liquid stool. And only 1 patient （4.4%） has retained partial rectum function with good continence of solid stool but not liquid after the operations. Average times of defecation per day of 3, 6, 12, 24 and 36 months after the surgery were 13.1, 4.7, 3.1, 2.9, and 3.2 times/day. Anal manometer measurements showed a decrease of pressure during the resting time after intersphincteric resection and this change remained during the period of follow-up. The maximum squeeze pressure was improved after an initial decrease after the surgery. Conclusions More residual rectum function after the surgery may be preserved by intersphincteric resection of low rectum cancer. At the same time this technique is safe with few postoperative complication and low tumor recurrence after the surgery.

Low rectal cancer:Sphincter preserving techniques-selection of patients,techniques and outcomes

Low rectal cancer is traditionally treated by abdominoperineal resection. In recent years, several new techniques for the treatment of very low rectal cancer patients aiming to preserve the gastrointestinal continuity and to improve both the oncological as well as the functional outcomes, have been emerged. Literature suggest that when the intersphincteric resection is applied in T1-3 tumors located within 30-35 mm from the anal verge, is technically feasible, safe, with equal oncological outcomes compared to conventional surgery and acceptable quality of life. The Anterior Perineal Plan E for Ultra-low Anterior Resection technique, is not disrupting the sphincters, but carries a high complication rate, while the reports on the oncological and functional outcomes are limited. Transanal Endoscopic Micro Surgery(TEM) and Trans Anal Minimally Invasive Surgery(TAMIS) should represent the treatment of choice for T1 rectal tumors, with specific criteria according to the NCCN guidelines and favorable pathologic features. Alternatively to the standard conventional surgery, neoadjuvant chemo-radiotherapy followed by TEM or TAMIS seems promising for tumors of a local stage T1sm2-3 or T2. Transanal Total Mesorectal Excision should be performed only when a board approved protocol is available by colorectal surgeons with extensive experience in minimally invasive and transanal endoscopic surgery.

Magnetic resonance imaging-based deep learning model to predict multiple firings in double-stapled colorectal anastomosis

BACKGROUND Multiple linear stapler firings during double stapling technique(DST)after laparoscopic low anterior resection(LAR)are associated with an increased risk of anastomotic leakage(AL).However,it is difficult to predict preoperatively the need for multiple linear stapler cartridges during DST anastomosis.AIM To develop a deep learning model to predict multiple firings during DST anastomosis based on pelvic magnetic resonance imaging(MRI).METHODS We collected 9476 MR images from 328 mid-low rectal cancer patients undergoing LAR with DST anastomosis,which were randomly divided into a training set(n=260)and testing set(n=68).Binary logistic regression was adopted to create a clinical model using six factors.The sequence of fast spin-echo T2-weighted MRI of the entire pelvis was segmented and analyzed.Pure-image and clinical-image integrated deep learning models were constructed using the mask region-based convolutional neural network segmentation tool and three-dimensional convolutional networks.Sensitivity,specificity,accuracy,positive predictive value(PPV),and area under the receiver operating characteristic curve(AUC)was calculated for each model.RESULTS The prevalence of≥3 linear stapler cartridges was 17.7%(58/328).The prevalence of AL was statistically significantly higher in patients with≥3 cartridges compared to those with≤2 cartridges(25.0%vs 11.8%,P=0.018).Preoperative carcinoembryonic antigen level>5 ng/mL(OR=2.11,95%CI 1.08-4.12,P=0.028)and tumor size≥5 cm(OR=3.57,95%CI 1.61-7.89,P=0.002)were recognized as independent risk factors for use of≥3 linear stapler cartridges.Diagnostic performance was better with the integrated model(accuracy=94.1%,PPV=87.5%,and AUC=0.88)compared with the clinical model(accuracy=86.7%,PPV=38.9%,and AUC=0.72)and the image model(accuracy=91.2%,PPV=83.3%,and AUC=0.81).CONCLUSION MRI-based deep learning model can predict the use of≥3 linear stapler cartridges during DST anastomosis in laparoscopic LAR surgery.This model might help determine the best anastomosis strategy by avoiding DST when there is a high probability of the need for≥3 linear stapler cartridges.

Progress in the surgery of rectal cancer

The treatment of rectal cancer has been improved a great deal within the last 20 years. Major progress has been made in the preoperative evaluation by introducing MRI- imaging as a basis for the further management. Neoadjuvant radiochemotherapy has been shown to be effective in downstaging of advanced tumours. The surgical technique has been improved in many respects.- Total mesorectal excision has reduced local recurrences, sphincter saving techniques such as low anterior resection and intersphincteric resection reduced the need for a permanent stoma to 10%-20%. Recently the introduction of minimal invasive techniques and the application of robotic systems have reduced the surgical trauma.

Aseptic abscess in the abdominal wall accompanied by monoclonal gammopathy simulating the local recurrence of rectal cancer:A case report

BACKGROUND Infectious abscesses in the abdominal wall can be secondary to retained foreign bodies(e.g.,stones,use of artificial mesh,use of silk yarn in surgical suture),inflammatory diseases(e.g.,acute appendicitis),and perforated malignancies of the digestive tract(particularly the colon).Aseptic abscesses(AAs)are relatively rare.To the best of our knowledge,this is the first report of an AA in the abdominal wall accompanied by monoclonal gammopathy of undetermined significance(MGUS)at 5 years after laparoscopic proctectomy.CASE SUMMARY A 72-year-old female patient presented with an enlarged painless mass in the lower abdomen for 1 year.She had a history of obesity,diabetes,and MGUS.Her surgical history was laparoscopic resection for rectal cancer 6 years prior,followed by chemotherapy.She was afebrile.Abdominal examination revealed a smooth abdomen with a clinically palpable solid mass under a laparotomy scar in the left lower quadrant.No obvious tenderness or skin redness was spotted.Laboratory data were not remarkable.Computed tomography scan revealed a low-density mass of 4.8 cm in diameter in the lower abdominal wall,which showed high uptake on positron emission tomography.The preoperative diagnosis was an abscess or tumor,and surgical resection was recommended.The mass was confirmed to be an AA by microbiological and pathological examinations.The patient recovered well after surgery.There was no evidence of recurrence 2 years later.CONCLUSION It is important to consider underlying conditions(diabetes,chemotherapy,MGUS)which may contribute to AA formation in the surgical wound.

基于症状管理理论的精准护理模式在经括约肌间切除术后患者中的应用

目的基于症状管理理论构建经括约肌间切除术后患者精准护理模式,评价其应用效果。方法采用非随机同期对照研究设计,前瞻性选取2023年6月至2024年3月在武汉大学中南医院结直肠肛门外科行经括约肌间切除术的患者为研究对象,按照入院时间先后分为对照组与试验组。对照组实施常规护理,试验组在常规护理的基础上实施基于症状管理理论的精准护理模式。比较两组患者术后肛门直肠功能、吻合口并发症发生率以及生活质量。结果共纳入111例患者,其中试验组56例,对照组55例。试验组患者术后肛门直肠功能优良率显著优于对照组(69.64%vs.34.55%,P<0.05),试验组在生活质量功能领域的躯体形象、体重、焦虑、性欲以及症状领域的尿频、便频、腹胀等方面得分均优于对照组(P<0.05),但两组在术后吻合口并发症发生率上差异无统计学意义(3.57%vs.10.91%,P>0.05)。结论基于症状管理理论的精准护理模式可以有效恢复经括约肌间切除术后患者的肛门直肠功能,提升患者术后生活质量。

基于MRI的三维重建技术在保留盆腔自主神经的腹腔镜直肠癌D3根治术中的应用价值

目的 评估利用MRI图像三维重建直肠癌患者盆腔自主神经以及周围器官在腹腔镜直肠癌D3根治术中的应用价值。方法 将56例直肠癌患者随机分为重建组和对照组,重建组术前依照MRI三维重建结果制定手术方案,对照组按常规方式制定手术方案,比较2组术中及术后功能恢复相关指标。结果 重建的三维模型能个体化呈现患者盆腔自主神经以及周围器官分布关系。与对照组相比,重建组的手术时间缩短[(143.7±13.3)min vs.(151.5±12.1)min,P=0.040)],失血量减少[(31.3±12.1)mLvs.(39.4±11.6) mL,P=0.024)],国际前列腺症状评分(IPSS)更优[(6.0±1.3)分vs.(7.9±2.6)分,P=0.003)]。此外,重建组的术后拔除尿管时间较对照组短[2.0(2.0,2.0)d vs.3.5(3.0,4.0)d,P <0.001]。结论 基于MRI的盆腔自主神经三维重建能准确呈现盆腔自主神经及器官的解剖关系,提高了D3根治术的效率和安全性,可为术者制定精细化、个性化的手术方案提供重要参考。