Machine learning model for prediction of low anterior resection syndrome following laparoscopic anterior resection of rectal cancer:A multicenter study

BACKGROUND Low anterior resection syndrome(LARS)severely impairs patient postoperative quality of life,especially major LARS.However,there are few tools that can accurately predict major LARS in clinical practice.AIM To develop a machine learning model using preoperative and intraoperative factors for predicting major LARS following laparoscopic surgery of rectal cancer in Chinese populations.METHODS Clinical data and follow-up information of patients who received laparoscopic anterior resection for rectal cancer from two medical centers(one discovery cohort and one external validation cohort)were included in this retrospective study.For the discovery cohort,the machine learning prediction algorithms were developed and internally validated.In the external validation cohort,we evaluated the trained model using various performance metrics.Further,the clinical utility of the model was tested by decision curve analysis.RESULTS Overall,1651 patients were included in the present study.Anastomotic height,neoadjuvant therapy,diverting stoma,body mass index,clinical stage,specimen length,tumor size,and age were the risk factors associated with major LARS.They were used to construct the machine learning model to predict major LARS.The trained random forest(RF)model performed with an area under the curve of 0.852 and a sensitivity of 0.795(95%CI:0.681-0.877),a specificity of 0.758(95%CI:0.671-0.828),and Brier score of 0.166 in the external validation set.Compared to the previous preoperative LARS score model,the current model exhibited superior predictive performance in predicting major LARS in our cohort(accuracy of 0.772 for the RF model vs 0.355 for the preoperative LARS score model).CONCLUSION We developed and validated a robust tool for predicting major LARS.This model could potentially be used in the clinic to identify patients with a high risk of developing major LARS and then improve the quality of life.

Application of electroacupuncture in the prevention of low anterior resection syndrome after rectal cancer surgery

BACKGROUND Low anterior resection syndrome(LARS)is one of the common postoperative complications in patients with rectal cancer,which seriously affects their postoperative recovery and quality of life(QoL).Electroacupuncture therapy is one of the characteristic therapies of traditional Chinese medicine.There are few reports on the prevention and treatment of LARS by electroacupuncture therapy.AIM To explore the clinical effectiveness of electroacupuncture in managing rectal cancer patients with postoperative LARS.METHODS A total of 50 patients with LARS after rectal cancer surgery were retrospectively selected as the research subjects.According to the treatment methods,they were divided into an observation group(n=25)and a control group(n=25).During the four-week treatment period,the control group received standard defecation function training,while the observation group received electroacupuncture care and traditional defecation function training.The anal pressure index(which includes anal resting pressure,anal systolic pressure,and maximum tolerable volume),European Organization of Research and Treatment of Cancer(EORTC)QoL C30(QLQ-C30)score,LARS Scale(LARSS)score,Wexner anal incontinence scale score,Xu Zhongfa five-item 10-point scale score,and the occurrence of adverse reactions were compared between the two groups before and after treatment.RESULTS The experimental group showed considerably enhanced LARSS scores compared to those in the control group after four weeks of treatment.In the first week,second week,and fourth week,the LARSS score and Wexner anal incontinence scale score decreased,and the Xu Zhong method five-item 10-point scale score increased,with significant differences(P<0.05).The experimental group showed substantial improvements in anal resting pressure,anal systolic pressure,and maximum tolerance volume after undergoing 4 wk of therapy in the untreated group(P<0.05).The experimental group's QLQ-C30 score on the EORTC QoL questionnaire was higher than that of the control group during the 1st,2nd,and 4th wk(P<0.05).No significant variation between the groups in the frequency of adverse reactions(P>0.05)was observed.CONCLUSION Electroacupuncture positively impacted LARS following rectal cancer surgery,effectively improving clinical symptoms and anal pressure indicators and patients’standard of life.

LOW ANTERIOR RESECTION TREATMENT FOR MIDDLE AND LOWER RECTAL CANCER

Objective:To evaluate the results of low anteriorresection treatment for middle and lower rectal cancer. Methods:Clinical and follow-up data of 196 patients with middle and lower rectal cancer who received low anteriorresection treatment from June 1991 to June 2001 wereretrospectively analyzed. Results: anterior resectiontechnique including double stapling technique、pull-through and Park抯 operations could get a standard radicalresection and had no significant differences in 1, 3, 5 and 10 years survival rates comparing with the abdominoperineal resection(Miles?. Conclusion:The experience suggests that the low anterior resection technique was safe and simplehad less bleeding and fewer complications and couldincrease the life-quality of the patients with rectal cancer.

Role of protective stoma in low anterior resection for rectal cancer:A meta-analysis

AIM:To provide a comprehensive evaluation of the role of a protective stoma in low anterior resection(LAR)for rectal cancer.METHODS:The Pub Med,EMBASE,and MEDLINE databases were searched for studies and relevant literature published between 2007 and 2014 regarding the construction of a protective stoma during LAR.A pooled risk ratio(RR)with 95%confidence intervals(CIs)was used to assess the outcomes of the studies,including the rate of postoperative anastomotic leakage and reoperations related to leakage.Funnel plots and Egger’s tests were used to evaluate the publication biases of the studies.P values<0.05 were considered statistically significant.RESULTS:A total of 11 studies were included in the meta-analysis.In total,5612 patients were examined,2868 of whom had a protective stoma and 2744 of whom did not.The sample size of the studies varied from 34 to 1912 patients.All studies reported the number of patients who developed an anastomotic leakage and required a reoperation related to leakage.A random effects model was used to calculate the pooled RR with the corresponding 95%CI because obvious heterogeneity was observed among the 11 studies(I2=77%).The results indicated that the creation of a protective stoma during LAR significantly reduces the rate of anastomotic leakage and the number of reoperations related to leakage,with pooled RRs of 0.38(95%CI:0.30-0.48,P<0.00001)and 0.37(95%CI:0.29-0.48,P<0.00001),respectively.The shape of the funnel plot did not reveal any evidence of obvious asymmetry.CONCLUSION:The presence of a protective stoma effectively decreased the incidences of anastomotic leakage and reoperation and is recommended in patients undergoing low rectal anterior resections for rectal cancer.

Colonic J-pouch anal anastomosis after ultralow anterior resection with upper sphincter excision for low-lying rectal cancer

AIM: There is some evidence of functional superiority of colonic J-pouch over straight coloanal anastomosis (CAA)in ultralow anterior resection (ULAR) or intersphincteric resection. On the assumption that colonic J-pouch anal anastomosis is superior to straight CAA in ULAR with upper sphincter excision (USE: excision of the upper part of the internal sphincter) for low-lying rectal cancer, we compare functional outcome of colonic J-pouch vs the straight CAA.METHODS: Fifty patients of one hundred and thirty-three rectal cancer patients in whom lower margin of the tumors were located between 3 and 5 cm from the anal verge received ULAR including USE from September 1998 to January 2002. Patients were randomized for reconstruction using either a straight (n = 26) or a colonic J-pouch anastomosis (n = 24) with a temporary diverting-loop ileostomy. All patients were followed-up prospectively by a standardized questionnaire [Fecal Inco-ntinence Severity Index (FISI) scores and Fecal Incontinence Quality of Life (FIQL) scales].RESULTS: We found that, compared to straight anastomosis patients, the frequency of defecation was significantly lower in J-pouch anastomosis patients for 10 mo afterileostomy takedown. The FISI scores and FIQL scales were significantly better in J-pouch patients than in straight patients at both 3 and 12 mo after ileostomy takedown.Furthermore, we found that FISI scores highly correlated with FIQL scales.CONCLUSION: This study indicates that colonic J-pouch anal anastomosis decreases the severity of fecal incontinence and improves the quality of life for 10 mo after ileostomy takedown in patients undergoing ULAR with USE forlow-lying rectal cancer.

Assessments of Pudendal Motor and Sensory Nerves in Patients with or without Fecal Incontinence after Low Anterior Resection for Lower Rectal Cancer

Background:?To clarify the pudendal motor (PMN) and sensory (PSN) nerves?play in preventing fecal incontinence (FI) after low anterior resection (LAR) for lower rectal cancer, the PMN and PSN functions were studied. Methods:?Sixty patients were divided into groups A (n = 20, FI) and B (n = 40, continence). These were compared with group C (n = 30, control subjects). PMN latency (PMNL) (right, left, and posterior sides of the anal canal) was studied by sacral magnetic stimulation. Anal mucosal electric sensitivity (AMES) was measured at the lower, dentate line (DL), and upper zones. Results:?The distance of anastomosis from anal verge (DAAV) in group A was significantly shorter than in group B (p?value p?value p?value p?value Conclusion:?FI after LAR with a short DAAV?may?lead to?external anal sphincter dysfunction due to damage of both PMN and PSN.

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.

Simultaneous laparoscopy-assisted low anterior resection and distal gastrectomy for synchronous carcinoma of rectum and stomach

Laparoscopic resection of rectal cancer or gastric cancer has been advocated for the benefits of a reduced morbidity,a shorter treatment time,and similar outcomes.However,simultaneous laparoscopy-assisted low anterior resection and distal gastrectomy for synchronous carcinoma of rectum and stomach are rarely documented in literature.Endoscopic examination revealed a synchronous carcinoma of rectum and stomach in a 55-year-old male patient with rectal bleeding and epigastric discomfort.He underwent a simultaneous laparoscopy-assisted low anterior resection and distal gastrectomy with regional lymph nodes dissected.The operation time was 270 min and the estimated blood loss was 120 mL.The patient required parenteral analgesia for less than 24 h.Flatus was passed on postoperative day 3,and a solid diet was resumed on postoperative day 7.He was discharged on postoperative day 13.With the advances in laparoscopic technology and experience,simultaneous resection is an attractive alternative to a synchronous gastrointestinal cancer.

Effects of Laparoscopic Pelvic Autonomic Nerve-Preserving Radical Resection of Rectal Cancer on Urinary and Sexual Function

Objective:To investigate and analyze the effect of laparoscopic pelvic autonomic nerve-preserving radical resection of rectal cancer on urinary and sexual function.Methods:Cases of laparoscopic radical resection of rectal cancer in our hospital from April 2018 to April 2023 were selected,and 60 patients who met the requirements were included as research subjects.The patients were divided into an experimental group and a reference group by a double-blind mechanism,with 30 cases in each group.The experimental group underwent laparoscopic pelvic autonomic radical resection,while the reference group underwent ordinary radical resection.The voiding function,urodynamics,sexual function,and blood indexes of the patients of both groups were compared.Results:The total incidence of voiding dysfunction in the experimental group was significantly lower than in the reference group(P<0.05).Urodynamics such as abdominal leak point pressure(ALPP),maximum urethral pressure(MUP),maximum urethral closure pressure(MUCP),and functional urethral length(FUL)in the experimental group were significantly better than those in the reference group(P<0.05).The incidences of erectile dysfunction and ejaculatory dysfunction in the experimental group were significantly lower than those in the reference group(P<0.05).Before the surgery,there were no significant differences in the blood indexes such as C-reactive protein(CRP),cortisol(Cor),and pre-albumin(PA)between the two groups(P>0.05);after the operation,the blood indexes of the patients in the experimental group were significantly better than those in the reference group(P<0.05).Conclusion:Laparoscopic pelvic autonomic nerve-preserving radical resection of rectal cancer has lesser effects on urinary and sexual functions.

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.

Laparoscopic low anterior resection for rectal carcinoma:Complications and management in 132 consecutive patients

AIM:To analyze the clinical manifestations and risk fac-tors of complications in laparoscopic low anterior resection(LAR)for rectal cancer patients.METHODS:A series of 132 consecutive patients who received laparoscopic LAR for rectal cancer in our center were included.The etiology,diagnosis,treatment and prevention of rectal cancer were studied among the patients with surgery-related complications using both univariate and multivariate regression analysis.RESULTS:No conversion to open surgery was observed and 5 cases converted to hand-assisted laparoscopic operation.The overall morbidity rate was 20.5%.Complications occurred during the operation in 7 patients(5.3%),within 30 postoperative days in 24 patients(18.2%),and within 3 mo in 2 patients(1.5%).The most significant complications were anastomotic leak-age(9.1%)and anastomotic hemorrhage(5.3%).Sizeand location of tumor,pathological staging and preoperative nutrition were significant factors associated with LAR complications,while gender,age and pathological type showed no relevance.Binary logistics regression showed that the size and location of tumor,and pathological staging were independent factors of laparoscopic LAR.All the complications were treated during their onset of clinical manifestations by interventional or conservative therapy.CONCLUSION:Anastomotic leakage is a major com-plication in laparoscopic LAR.The complications may be associated with tumor size and site,and pathological stage.Interventional therapies are of value in the management of laparoscopic LAR complications.

Assessment and management of low anterior resection syndrome after sphincter preserving surgery for rectal cancer

Many patients develop a variety of bowel dysfunction after sphincter preserving surgeries(SPS)for rectal cancer.The bowel dysfunction usually manifests in the form of low anterior resection syndrome(LARS),which has a negative impact on the patients'quality of life.This study reviewed the LARS after SPS,its mechanism,risk factors,diagnosis,prevention,and treatment based on previously published studies.Adequate history taking,physical examination of the patients,using validated questionnaires and other diagnostic tools are important for assessment of LARS severity.Treatment of LARS should be tailored to each patient.Multimodal therapy is usually needed for patients with major LARS with acceptable results.The treatment includes conservative management in the form of medical,pelvic floor rehabilitation and transanal irrigation and invasive procedures including neuromodulation.If this treatment failed,fecal diversion may be needed.In conclusion,Initial meticulous dissection with preservation of nerves and creation of a neorectal reservoir during anastomosis and proper Kegel exercise of the anal sphincter can minimize the occurrence of LARS.Pre-treatment counseling is an essential step for patients who have risk factors for developing LARS.

Sphincter-preserving R0 total mesorectal excision with resection of internal genitalia combined with pre-or postoperative chemoradiation for T4 rectal cancer in females

AIM: To evaluate the impact of chemoradiation admi- nistered pre- or postoperatively on prognosis in females following R0 extended resection with sphincter- preserving total mesorectal excision (TME) for locally advanced rectal cancer and to assess the association between chemoradiation and intra- and postoperative variables. METHODS: Twenty-one females were treated for locally advanced but preoperatively assessed as primarily resectable rectal cancer involving reproductive organs. Anterior resection with TME and excision of internal genitalia was combined with neo- or adjuvant chemoradiation. Two-year disease-free survival analysis was performed with the Kaplan-Meier method and log- rank test. The association between chemoradiation and other variables was evaluated with the Fisher’s exact test and Mann-Whitney test. RESULTS: Survival rate decreased in anaemic females (51.5% vs 57.4%), in patients older than 60 years (41.8% vs 66.7%) with poorly differentiated cancers (50.0% vs 55.6%) and tumors located ≤ 7 cm from the anal verge (42.9% vs 68.1%) but with the lack of importance. Patients with negative lymph nodes and women chemoradiated preoperatively had significantly favourable prognosis (85.7% vs 35.7%; P= 0.03 and 80.0% vs 27.3%; P = 0.01, respectively). Preoperative chemoradiation compared to adjuvant radiochemotherapy was not significantly associated with the duration of surgery, incidence of intraoperative bowel perforation and blood loss ≥ 1 L, rate of postoperative bladder and anorectal dysfunction, and minimal distal resection margin. It significantly influenced minimal radial margin (mean 4.2 mm vs 1.1 mm; P < 0.01). CONCLUSION: Despite involving internal genitalia, long-term disease-free survival and sphincter preservation may be achieved with combined-modality therapy for females with T4 locally advanced rectal carcinoma. Neoadjuvant chemoradiation does not compromise functional results and may significantly improve oncological outcomes probably due to enhanced radial clearance.

Anorectal dysfunction in patients with mid-low rectal cancer after surgery: A pilot study with three-dimensional high-resolution manometry

BACKGROUND The quality of life in patients who develop low anterior resection syndrome(LARS)after surgery for mid-low rectal cancer is seriously impaired.The underlying pathophysiological mechanism of LARS has not been fully investigated.AIM To assess anorectal function of mid-low rectal cancer patients developing LARS perioperatively.METHODS Patients diagnosed with mid-low rectal cancer were included.The LARS score was used to evaluate defecation symptoms 3 and 6 mo after anterior resection or a stoma reversal procedure.Anorectal functions were assessed by threedimensional high resolution anorectal manometry preoperatively and 3-6 mo after surgery.RESULTS The study population consisted of 24 patients.The total LARS score was decreased at 6 mo compared with 3 mo after surgery(P<0.05),but 58.3%(14/24)lasted as major LARS at 6 mo after surgery.The length of the high-pressure zone of the anal sphincter was significantly shorter,the mean resting pressure and maximal squeeze pressure of the anus were significantly lower than those before surgery in allpatients (P < 0.05), especially in the neoadjuvant therapy group after surgery (n = 18). The focalpressure defects of the anal canal were detected in 70.8% of patients, and those patients had higherLARS scores at 3 mo postoperatively than those without focal pressure defects (P < 0.05). Spasticperistaltic contractions from the new rectum to anus were detected in 45.8% of patients, whichwere associated with a higher LARS score at 3 mo postoperatively (P < 0.05).CONCLUSIONThe LARS score decreases over time after surgery in the majority of patients with mid-low rectalcancer. Anorectal dysfunctions, especially focal pressure defects of the anal canal and spasticperistaltic contractions from the new rectum to anus postoperatively, might be the majorpathophysiological mechanisms of LARS.

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.

Is laparoscopic colorectal cancer surgery equal to open surgery? An evidence based perspective

Laparoscopic colorectal surgery(LCS) is an evolving subject.Recent studies show that LCS can not only offer safe surgery but evidence is growing that this new technique can be superior to classical open procedures.Fewer perioperative complications and faster postoperative recovery are regularly mentioned when studies of LCS are presented.Even though the learning curve of LCS is frequently debated when limitations of laparoscopic surgeries are reviewed,studies show that in experienced hands LCS can be a safe procedure for colorectal cancer treatment.The learning curve however,is associated with high conversion rates and economical aspects such as higher costs and prolonged hospital stay.Nevertheless,laparoscopic colorectal cancer surgery(LCCR) offers several advantages such as less co-morbidity and less postoperative pain in comparison with open procedures.Furthermore,the good exposure of the pelvic cavity by laparoscopy and the magnification of anatomical structures seem to facilitate pelvic dissection laparoscopically.Moreover,recent studies describe no difference in safety and oncological radicalness in LCCR compared to the open total mesorectal excision(TME).The oncological adequacy of LCCR still remains unproven today,because long-term results do not yet exist.To date,only a few studies have described the results of laparoscopic TME combined with preoperative adjuvant treatment for colorectal cancer.The aim of this review is to examine the various areas of development and controversy of LCCR in comparison to the conventional open approach.

Surgical repair of intractable chylous ascites following laparoscopic anterior resection

Chylous ascites is the accumulation of a milk-like peritoneal fluid rich in triglycerides and it is an unusual complication following surgical treatment of colorectal cancer. Conservative management is usually sufficientin patients with chylous ascites after surgery. However,we describe a patient with intractable chylous ascites after laparoscopic anterior resection for sigmoid colon cancer who failed initial conservative treatment. This patient was successfully managed by surgery.

Colonic pouch confers better bowel function and similar postoperative outcomes compared to straight anastomosis for low rectal cancer

BACKGROUND With advancements in laparoscopic technology and the wide application of linear staplers,sphincter-saving procedures are increasingly performed for low rectal cancer.However,sphincter-saving procedures have led to the emergence of a unique clinical disorder termed anterior rectal resection syndrome.Colonic pouch anastomosis improves the quality of life of patients with rectal cancer>7 cm from the anal margin.But whether colonic pouch anastomosis can reduce the incidence of rectal resection syndrome in patients with low rectal cancer is unknown.AIM To compare postoperative and oncological outcomes and bowel function of straight and colonic pouch anal anastomoses after resection of low rectal cancer.METHODS We conducted a retrospective study of 72 patients with low rectal cancer who underwent sphincter-saving procedures with either straight or colonic pouch anastomoses.Functional evaluations were completed preoperatively and at 1,6,and 12 mo postoperatively.We also compared perioperative and oncological outcomes between two groups that had undergone low or ultralow anterior rectal resection.RESULTS There were no significant differences in mean operating time,blood loss,time to first passage of flatus and excrement,and duration of hospital stay between the colonic pouch and straight anastomosis groups.The incidence of anastomotic leakage following colonic pouch construction was lower(11.4%vs 16.2%)but not significantly different than that of straight anastomosis.Patients with colonic pouch construction had lower postoperative low anterior resection syndrome scores than the straight anastomosis group,suggesting better bowel function(preoperative:4.71 vs 3.89,P=0.43;1 mo after surgery:34.2 vs 34.7,P=0.59;6 mo after surgery:22.70 vs 29.0,P<0.05;12 mo after surgery:15.5 vs 19.5,P=0.01).The overall recurrence and metastasis rates were similar(4.3%and 11.4%,respectively).CONCLUSION Colonic pouch anastomosis is a safe and effective procedure for colorectal reconstruction after low and ultralow rectal resections.Moreover,colonic pouch construction may provide better functional outcomes compared to straight anastomosis.

Neoadjuvant radiotherapy for rectal cancer management

Thirty per cent of all colorectal tumours develop in the rectum.The location of the rectum within the bony pelvis and its proximity to vital structures presents significant therapeutic challenges when considering neoadjuvant options and surgical interventions.Most patients with early rectal cancer can be adequately managed by surgery alone.However,a significant proportion of patients with rectal cancer present with locally advanced disease and will potentially benefit from down staging prior to surgery.Neoadjuvant therapy involves a variety of options including radiotherapy,chemotherapy used alone or in combination.Neoadjuvant radiotherapy in rectal cancer has been shown to be effective in reducing tumour burden in advance of curative surgery.The gold standard surgical rectal cancer management aims to achieve surgical removal of the tumour and all draining lymph nodes,within an intact mesorectal package,in order to minimise local recurrence.It is critically important that all rectal cancer cases are discussed at a multidisciplinary meeting represented by all relevant specialties.Pre-operative staging including CT thorax,abdomen,pelvis to assess for distal disease and magnetic resonance imaging to assess local involvement is essential.Staging radiology and MDT discussion are integral in identifying patients who require neoadjuvant radiotherapy.While Neoadjuvant radiotherapy is potentially beneficial it may also result in morbidity and thus should be reserved for those patients who are at a high risk of local failure,which includes patients with nodal involvement,extramural venous invasion and threatened circumferential margin.The aim of this review is to discuss the role of neoadjuvant radiotherapy in the management of rectal cancer.

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.