Diseases of the Colon & Rectum最新文献

Introduction: Achieving margin-negative complete resection in locally recurrent rectal cancer often requires en bloc resection involving adjacent structures such as the sacrum. However, sacrectomy is technically demanding and poses a high risk of significant intraoperative bleeding and postoperative pelvic sepsis due to the dead space created after resection. We developed a minimally invasive surgical technique to address these challenges.

Technique: We employed a laparoscopic approach to sacrectomy as part of en bloc resection for posterior locally recurrent rectal cancer. In this technique, the anterior and lateral dissection of the sacrum was performed laparoscopically, whereas the final sacral transection was carried out under direct vision in the prone position. Preoperative imaging was used to identify the planned sacral transection line, which was reproduced intraoperatively using a premeasured vascular tape. Anterior and lateral dissection of the sacrum was performed laparoscopically to allow secure vascular control. Final sacral transection was performed under direct vision in the prone position. A pedicled omental flap and a dead-space filling non-functional anastomosis were used to fill the pelvic cavity and prevent postoperative sepsis. A double-barreled stoma was created to facilitate fecal diversion.

Results: Laparoscopic sacrectomy was successfully performed in 43 patients with locally recurrent rectal cancer. The margin-negative complete resection rate was 86%, which is notably high for this challenging population. The 5-year overall survival rate was approximately 59%. No cases of major intraoperative bleeding or early complications related to the dead-space filling non-functional anastomosis were observed.

Conclusions: This laparoscopic technique offers a safe and feasible option for selected patients with posterior locally recurrent rectal cancer. Combined dead-space management may further help reduce postoperative complications while preserving oncological validity.

Background: Anastomotic leakage remains a severe complication following low anterior resection for rectal cancer, often leading to routine use of protective stomas, which can cause additional complications. Inspired by the watch-and-wait approach in rectal cancer treatment, we hypothesized that deferring stoma creation could be feasible through the Safe Anastomosis Project that includes minimizing technical risk factors, enabling early detection of preclinical leakage, and intervening only when necessary.

Objective: To evaluate whether technical modifications, comprehensive surveillance, and selective stoma creation can reduce the rate of protective stoma use while maintaining acceptable anastomotic leakage rates.

Design: Prospective cohort study.

Setting: Single-center, tertiary referral hospital.

Patients: Between January and December 2024, 184 patients underwent curative resection for rectal cancer.

Interventions: A standardized protocol was applied, including perfusion assessment with indocyanine green, single-stapled anastomosis creation using purse-string sutures, reinforcement with continuous or intermittent manner, extraperitoneal pelvic drain placement, and assessment of anastomotic integrity. Patients were grouped by anastomotic technique: single-stapled with reinforcement, single-stapled alone, or double-stapled with reinforcement.

Main outcome measures: Rates of protective stoma creation and anastomotic leakage.

Results: A total of 99 patients completed the study protocol. 27 (27.3%) received a protective stoma and 11 (11.1%) developed anastomotic leakage. Patients with single-stapled technique with reinforcement had the lowest rates of both protective stoma use (18.8%) and leakage (6.3%). Robotic surgery was more frequently used in this group (78.1%). Most leakages occurred within 8 days postoperatively and were managed with transanal repair, with or without stoma.

Limitations: Single-center design and modest sample size.

Conclusions: Deferral of protective stoma creation after low anterior resection appears feasible. Technical refinement, particularly single-stapled anastomosis with reinforcement and robotic assistance, may optimize outcomes. Further study based on larger cohort is warranted. See Video Abstract.