Techniques in Coloproctology最新文献

Introduction: Chatbots have been increasingly used as a source of patient education. This study aimed to compare the answers of ChatGPT-4 and Google Gemini to common questions on benign anal conditions in terms of appropriateness, comprehensiveness, and language level.

Methods: Each chatbot was asked a set of 30 questions on hemorrhoidal disease, anal fissures, and anal fistulas. The responses were assessed for appropriateness, comprehensiveness, and reference provision. The assessments were made by three subject experts who were unaware of the name of the chatbots. The language level of the chatbot answers was assessed using the Flesch-Kincaid Reading Ease score and grade level.

Results: Overall, the answers provided by both models were appropriate and comprehensive. The answers of Google Gemini were more appropriate, comprehensive, and supported by references compared with the answers of ChatGPT. In addition, the agreement among the assessors on the appropriateness of Google Gemini answers was higher, attesting to a higher consistency. ChatGPT had a significantly higher Flesh-Kincaid grade level than Google Gemini (12.3 versus 10.6, p = 0.015), but a similar median Flesh-Kincaid Ease score.

Conclusions: The answers of Google Gemini to questions on common benign anal conditions were more appropriate and comprehensive, and more often supported with references, than the answers of ChatGPT. The answers of both chatbots were at grade levels higher than the 6th grade level, which may be difficult for nonmedical individuals to comprehend.

Since the adoption of neoadjuvant chemoradiation and total mesorectal excision as the standard in rectal cancer care, there has been marked improvement in the local recurrence rates. In this context, restaging magnetic resonance imaging (MRI) plays a key role in the assessment of tumor response, occasionally enabling organ-sparing approaches. However, the role of restaging MRI in evaluating lateral lymph nodes remains limited. Most studies suggest a high risk of lateral local recurrence regardless of a decrease in lymph node size on restaging MRI. Therefore, it is recommended that clinical decisions should rely on the primary MRI scan. Watchful waiting may be appropriate only in cases of a clinical complete response with substantial downsizing of lateral lymph nodes (≤ 4.0 mm). Notably, some lateral lymph nodes may enlarge during follow-up despite complete tumor response, in which case, lateral lymph node dissection can be considered while preserving the rectum. Thus, continuous surveillance of lateral lymph nodes is essential during watchful waiting. Restaging MRI may hold greater importance for smaller lymph nodes (5.0-6.9 mm), as those with persistent malignant features on imaging carry a 13% risk of lateral recurrence at 4 years. Understanding these risks is critical when engaging in shared decision-making with the patient.

Metastatic lateral pelvic lymph node (LPN) in rectal cancer has a significant clinical impact on the prognosis and treatment strategies. But there are still debates regarding prediction of lateral pelvic lymph node metastasis and its oncological impact. This review explores the evidence for predicting lateral pelvic lymph node metastasis and survival in locally advanced rectal cancer. Until now many studies have reported that magnetic resonance imaging (MRI) and positron emission tomography/computed tomography (PET/CT) are considered as essential tools for predicting metastatic LPN, with MRI-based size criteria, particularly the short-axis diameter of LPN. But several studies have reported that the addition of tumor location or artificial intelligence (AI) can further enhance diagnostic accuracy. Western practices focus more on neoadjuvant chemoradiation (nCRT), while Eastern countries focus more on lateral pelvic lymph node dissection (LPND). LPND has been shown to reduce lateral local recurrence (LLR) rates compared to total mesorectal excision (TME) alone, particularly in patients with enlarged LPNs, but its impact on overall survival is uncertain. The decision to perform LPND should be individualized according to LPN size and response to nCRT; and through selective LPND based on those criteria, patients could achieve a balance between the benefit of local control and the risk of surgical complications from LPND, such as sexual and urinary dysfunction.

Lateral pelvic lymph node dissection (LPLND) for rectal adenocarcinoma is an established treatment modality for selected patients with abnormal lateral pelvic lymph nodes on magnetic resonance imaging (MRI) imaging. The goal of this treatment is to achieve a true R0 resection, including lymphadenectomy, with the aim of improving patient oncological outcome, potentially at the expense of surgical and functional complications. However, there remain several areas of controversy resulting from a distinct lack of clarity regarding effective patient selection, lymph node size criteria, the role and extent of routine neoadjuvant treatment versus surgery alone in selected cases, the impact on patient survival metrics and whether the existing data are even valid in the era of total neoadjuvant therapy (TNT). Furthermore, the lack of widely disseminated surgical standardisation and expertise in performing this procedure potentially contributes to the lack of utilisation in certain countries and regions. In this narrative review, we summarize the current state of the literature and attempt to answer the question of what oncological benefits there are, if any, from LPLND after neoadjuvant therapy in rectal cancer, and whether these justify the risks and potential need for inter-hospital transfer.

Background: The introduction of total mesorectal excision improved locoregional control for rectal adenocarcinoma significantly. Standardisation of the technique of LPLND is lacking in literature.

Methods: We describe the current practices of case selection and technical details of lateral lymph node dissection in rectal cancer. We also describe the approach when post neo-adjuvant fibrosis renders standard resection unsafe.

Results: Careful case selection and standardisation of the lateral lymph node dissection technique is important to ensure an oncologically sound and surgically procedure . Step-by-step procedures of LPLND are described in this article, and a video is demonstrated.

Conclusions: Standardisation of the techniques of lateral lymph node dissection is essential. The procedure has a definite learning curve, requiring considerable expertise to avoid complications and achieve optimal outcomes.

Lateral lymph node dissection (LLND) is getting global attention as an a surgical option to reduce local recurrence in locally advanced rectal cancer. As the transanal total mesorectal excision (TaTME) is gaining popularity worldwide, a novel LLND approach was established adopting a two-team approach that combines the transabdominal and transanal approaches using the TaTME technique. This narrative review describes the advantages, anatomical landmarks, surgical techniques, and pitfalls of transanal LLND (TaLLND). The advantages of TaLLND include a magnified view and enhanced maneuverability of the laparoscopic instruments in the deep pelvis. TaLLND is also beneficial for LLND in patients with a history of pelvic surgery because surgeons can have access to the areas unaffected by previous surgery. To master the TaLLND technique, the procedure should be understood according to the following steps: S4 nerve identification, lateral space entry, lateral dissection, obturator vein, artery, and nerve identification, dissection along the external iliac vein, medial dissection, median and bottom dissection, dissection along the internal iliac artery, and dissection along the obturator nerve. TaLLND can be applied to highly advanced disease that requires combined resection of the major internal iliac vessels, pelvic nerves, or adjacent organs. In such cases, simultaneous transanal and transabdomiinal LLND utilizing a two team approach has advantages as these approaches can provide mutual complementary roles. TaLLND is expected to overcome the difficulty of transabdominal LLND and improve the quality of LLND.

Background: Incomplete mesorectal excision during rectal cancer surgery often leads to positive circumferential margins, with uncertain prognostic impacts. This study examines whether negative margins can mitigate the poorer prognosis typically associated with incomplete total mesorectal excision (TME) in rectal cancer surgery, thus potentially challenging the prevailing emphasis on complete mesorectal excision.

Patients and methods: A retrospective analysis was conducted on patients who underwent proctectomy for rectal adenocarcinoma with incomplete TME at a single center from 2010 to 2022. Patients were stratified by margin status as determined by pathologic analysis into three groups: involved, not involved with closest margin distance ≤ 2 mm, and not involved with closest margin distance > 2 mm. Outcomes included recurrence and survival. Effects of neoadjuvant therapy protocols on margin status were also assessed.

Results: From 2010 to 2022, 7941 patients underwent proctectomy for rectal cancer, with 236 (3%) having incomplete TME. The median age of these patients was 64 years, and 63% were male. Overall, margin involvement was observed in 54 (23%) patients. The median tumor size was 3.05 cm (interquartile range (IQR): 2-6) for the whole group. Involved margins (23.2%) had reduced overall survival (60.5 months versus 87.3 months, p < 0.001), increased local recurrence (20.4% versus 9.4%, p = 0.024), and lower disease-free survival (45.2 versus 58.9 months, p = 0.006) versus uninvolved margins. Margin involvement was prognostic for decreased survival even after adjusting for confounders (p < 0.05). Among uninvolved margins, distance (> 2 mm versus ≤ 2 mm) did not affect outcomes. Total neoadjuvant therapy (versus standard chemoradiation) was associated with lower involved margins (p = 0.007).

Conclusions: Positive margins retain negative prognostic impact with incomplete TME. Optimization of surgical resection remains vital. Total neoadjuvant therapy was associated with a lower rate of margin involvement.

Background: The goal of cytoreductive surgery for peritoneal malignancy is to remove all macroscopic disease, which occasionally requires the excision of the umbilicus. While the absence of the umbilicus can be aesthetically undesirable for patients, umbilical reconstruction is rarely performed due to the perceived complexity and increased risk of wound infections (Sakata et al. in Colorectal Dis 23:1153-1157, 2021). This study aims to evaluate the outcomes, cosmetic results and patient satisfaction of umbilical reconstruction during cytoreductive surgery.

Methods: Consecutive patients from a prospectively maintained database who underwent cytoreductive surgery with umbilical excision and reconstruction were evaluated. Our technique for umbilical reconstruction involved recreating the subcutaneous fat space and fashioning umbilical skin flaps that anchor to the anterior fascia. Outcomes assessed included post-operative infection rate, wound dehiscence, seroma formation, wound appearance and patient satisfaction.

Results: Umbilical reconstruction was performed on 50 patients, with 12 (24%) experiencing wound-related complications. Of these, eight patients (16%) had superficial wound infections, while one patient (2%) developed a deep wound infection; three patients (6%) required local wound drainage, though none needed surgical revision. There were no reports of wound seromas, skin necrosis, wound widening nor umbilical stenosis. All patients reported satisfaction with the outcome of their reconstruction.

Conclusions: Our novel technique for umbilical reconstruction during cytoreductive surgery did not negatively impact wound healing outcomes. Recreating the umbilicus improved cosmetic results and patient satisfaction, enhancing body image for those undergoing major abdominal surgery. This approach should be considered for patients undergoing major laparotomies that necessitates umbilical excision.

Objective: To investigate the efficacy of laparoscopic sigmoid extraperitoneal colostomy combined with pelvic peritoneal closure in abdominoperineal resection for low rectal cancer.

Methods: We retrospectively analyzed the clinical data of 162 patients with low rectal cancer, who underwent laparoscopic abdominoperineal resection from January 2015 to January 2019 at the Affiliated Peace Hospital of Changzhi Medical College. Extraperitoneal stoma construction was performed in 98 patients (study group), while 64 patients (control group) underwent the procedure without suturing the pelvic peritoneum. All patients were followed up for 24 months postoperatively. The outcome measures were intra- and postoperative conditions and short- and long-term postoperative complications.

Results: The patients in both groups successfully underwent laparoscopic surgery, and no conversion to laparotomy was required. The operation time (165.93 ± 24.91 vs 159.75 ± 21.60), intraoperative blood loss (120.71 ± 49.16 vs 120.63 ± 45.63), flatus elimination time (55.14 ± 10.67 vs 53.1 ± 10.53), and degree of cancer differentiation did not differ statistically between the two groups (P > 0.05). However, the pelvic peritoneal closure time (10.16 ± 1.98 vs 0.00), ostomy time (24.17 ± 2.26 vs 20.61 ± 2.0), and postoperative hospital stay duration (14.43 ± 2.49 vs 16.19 ± 3.50) showed statistically significant differences (P < 0.05). A comparison of the incidence of short-term complications between the two groups showed that intestinal obstruction occurred in three patients in the study group and eight patients in the control group, with a statistically significant difference (P < 0.05); however, the incidence of other complications did not differ statistically between the two groups (P > 0.05). Moreover, comparing the long-term complications revealed no significant differences in the incidence of intestinal obstruction and perineal hernia between the two groups (P > 0.05). Long-term complications were reported in two patients in the study group (extraperitoneal stoma approach) and nine patients in the control group (intraperitoneal stoma approach), with a statistically significant difference (P < 0.05).

Conclusion: Sigmoid extraperitoneal colostomy with pelvic peritoneal closure in abdominoperineal resection for low rectal cancer is safe and feasible. This approach can effectively reduce the postoperative incidence of intestinal obstruction, hospital stay duration, and stomal complications.