Techniques in Coloproctology最新文献

Background: Low anterior resection syndrome (LARS) is a common postoperative sequala affecting up to 70% of patients following rectal cancer surgery. Characterized by urgency, frequency, incontinence, and incomplete evacuation, LARS can significantly impair quality of life. Sacral neuromodulation (SNM) has emerged as a potential therapy for patients with refractory symptoms.

Methods: This retrospective single-center study included 43 patients with LARS unresponsive to conservative therapy who underwent SNM between 2017 and 2025. All patients received the InterStim™ device following a positive test phase. Demographic, clinical, and surgical data were collected and analyzed. The primary outcomes were changes in LARS and Wexner incontinence scores. Secondary outcomes included changes in quality of life measured by the Fecal Incontinence Quality of Life (FIQL) questionnaire and Patient-Reported Outcomes Measurement Information System Global-10 (PROMIS-10) survey.

Results: LARS scores improved from a mean of 37.9-29.9 (p < 0.001) and Wexner scores from 14.2 to 10.4 (p < 0.001). FIQL scores improved significantly across all subdomains: lifestyle (1.49-2.28, p < 0.001), coping (1.39-2.26, p < 0.001), depression (1.66-2.38 p < 0.001), and embarrassment (1.58-2.40, p < 0.001). PROMIS-10 scores also improved, with physical health increasing from 35.7 to 41.4 (p = 0.01) and mental health from 40.3 to 45.1 (p = 0.02). Six patients required device revision, and three experienced minor complications.

Conclusions: SNM significantly improves bowel function and quality of life in patients with LARS refractory to conservative management and represents a promising therapeutic option.

Background: Colon cancer located at the splenic flexure exhibits dual lymphatic drainage via the left middle colic artery (lt-MCA) to the superior mesenteric artery (SMA) system and the left colic artery (LCA) to the inferior mesenteric artery (IMA) system. However, an additional pathway-the Arc of Riolan (AoR) artery, central anastomotic vessels connecting the SMA and IMA-may also serve as a route for metastasis. This case highlights the importance of central vascular ligation of the AoR in splenic flexure cancer.

Case: We present a rare case of isolated AoR lymph node metastasis in a 72-year-old male with advanced splenic flexure cancer. The patient presented with multiple synchronous tumors (splenic flexure, sigmoid, and rectum) and underwent extended left hemicolectomy with central vascular ligation (CVL) of the AoR, revealing metastatic involvement exclusively in AoR nodes. This represents the first documented case of isolated AoR nodal metastasis, emphasizing the need for AoR lymphadenectomy when present.

Discussion: Recent studies suggest that accessory middle colic arteries (aMCA) and AoR may represent the same anatomical structure, with metastasis rates of 3.7-6.3% in corresponding nodes. Our findings support that AoR should be considered a critical target for CVL in splenic flexure cancer, particularly when identified pre- or intraoperatively.

Conclusions: Surgeons should recognize AoR as a possible isolated metastatic pathway and perform thorough nodal dissection along this vessel when present to ensure optimal oncologic outcomes.

Background: Acute anal fissure is a common cause of severe pain in the anorectal region. The standard treatment is the topical application of a calcium channel blocker or glyceryl trinitrate. Despite acute anal fissure being a common proctologic condition, data on the healing rates and long-term outcomes remain scarce. This study aimed to evaluate data from our centre, with a special focus on long-term follow-up and recurrent disease.

Methods: All consecutive patients who presented with acute anal fissure between January 2016 and December 2016 were retrospectively identified. Patients were included if their clinical symptoms lasted for less than 6 weeks, secondary changes to fissure morphology were absent, and data from follow-up examinations were available. Clinical features, symptoms, therapy and long-term outcomes were evaluated.

Results: A total of 623 patients with a median age of 45 years were included; 342/623 patients were female (54.9%). The median follow-up period was 41 months (range 6 weeks-89 months), and 39.5% of the patients had a follow-up duration exceeding 5 years. Most fissures occurred in the 6 o'clock lithotomy position (63.7%), in the 12 o'clock position (21.0%), or in both (4.5%). In 67/623 patients, the fissure was in an atypical region (10.8%). In 439/623 patients, the fissure healed completely (70.5%). A total of 8.7% of the patients underwent fissurectomy, and 180/623 patients experienced recurrence (28.9%).

Conclusions: The management of acute anal fissure can be challenging because recurrence is common. Conservative management is successful in the majority of cases. Surgery is necessary only for a minority of patients.

Background: Magnetic anchor-guided endoscopic submucosal dissection (MAG-ESD) has significant advantages in the treatment of difficult lesions (Mortagy et al. in World J Gastroenterol 23:2883-2890, 2017). However, the main problem of MAG-ESD is that the placement of the magnetic anchor in vivo often requires the withdrawal and reinsertion of the endoscope, which prolongs the operation time (Zhang et al. in Tech Coloproctol 27:679-683, 2023). We introduced a novel technique, magnetic hydrogel-assisted ESD, and compared it with conventional ESD to explore its advantages and disadvantages.

Methods: We uniformly configured 0.5% sodium alginate (Sanchez-Ballester et al. in Carbohydr Polym 270:118399, 2021) (SA) solution, 1% CaCl₂ solution and nano-Fe₃O₄ (Chen et al. in Electromagn Biol Med 34:309-316, 2015) to produce a magnet hydrogel with ideal ratios. Fresh isolated porcine colons were used as a model; these were divided into a magnetic hydrogel-assisted ESD group and conventional ESD group to assess whether magnetic hydrogel-assisted ESD was feasible and advantageous.

Results: The median submucosal dissection time for magnetic hydrogel-assisted ESD (MHA-ESD) and conventional ESD was 15.13 min (IQR 11.21-19.05) and 17.89 min (IQR 13.74-22.04), respectively. The submucosal dissection time for MHA-ESD was significantly shorter compared to conventional ESD (P = 0.0368). Similarly, the submucosal dissection speed for MHA-ESD and conventional ESD was 74.81 mm²/min (IQR 72.18-80.39) and 60.86 mm²/min (IQR 58.96-67.77), respectively. The MHA-ESD group demonstrated a significantly faster submucosal dissection speed compared to the conventional ESD group (P < 0.001).

Conclusions: Compared with conventional ESD, MHA-ESD significantly accelerates the speed of submucosal dissection, effectively improves surgical efficiency, and enhances procedural convenience, thereby reducing the overall difficulty of ESD.

Purpose: To report the quality of life (QoL) and functional outcomes in patients with colorectal disease after receiving treatment in a multidisciplinary, nurse-led low anterior resection syndrome (LARS) outpatient clinic post surgery.

Methods: A retrospective observational study was conducted that included all patients with colorectal disease referred to the LARS outpatient clinic at VieCuri Medical Centre between January 2021 and December 2024. A standardized treatment protocol was implemented, complemented by a nurse-led component that enabled early symptom detection and provided accessible, intensive patient contact and follow-up. The structured five-phase protocol ranges from preoperative counseling and conservative management to multidisciplinary care and, if necessary, invasive interventions. Bowel function and quality of life were assessed pre- and post-treatment using validated instruments, including the LARS score, Wexner score, and the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 and QLQ-C29 questionnaires.

Results: A total of 96 patients were included. Median LARS scores decreased from 38.0 to 13.0 (p < 0.001), with 76% of patients transitioning from major to no LARS. Wexner scores improved from 11.0 to 2.0 (p < 0.001), and global QoL increased from 66.7 to 83.3 (p < 0.001). Pharmacological treatment was administered to 93% of patients, most commonly psyllium and loperamide. In addition, 85% were referred to a dietitian, 50% to pelvic floor physiotherapy, and 26% to a psychologist or sexologist. Transanal irrigation was introduced in 14% of cases. Only one patient required sacral neuromodulation, and one opted for a permanent stoma. The median follow-up consisted of three in-person and three telephone consultations per patient.

Conclusions: A multidisciplinary, nurse-led LARS clinic significantly improved bowel function and QoL in patients with colorectal cancer (CRC). These findings support the implementation of structured, individualized care pathways for LARS management.

Background: For many surgeons performing laparoscopic colectomies, splenic flexure mobilization (SFM) remains one of the most technically challenging phases. To resolve challenges in laparoscopic SFM, we utilized Artisential^®, a line of articulated laparoscopic instruments (ALI), to gain more freedom in traction and enlarge the visualized working space. We developed a study to demonstrate how Artisential^® allowed for a more efficient usage of surgical space during splenic flexure mobilization without surgical quality.

Methods: This study consisted of two parts. First was a comparative analysis of dead space shown on screen during surgery with and without Artisential^® usage. Video recordings of nine consecutive laparoscopic low anterior resections (LAR) performed by a single surgeon using an Artisential^® grasper in the left (nondominant) hand were chosen as the experimental group. Among 43 LAR cases performed by the same surgeon in the previous year without the Artisential^®, 9 cases most similar to the control were chosen by propensity score matching (PSM) of sex, age, distance from the anal verge, and preoperative chemoradiotherapy status. We compared the two groups in terms of average operation duration, postoperative complication severity, and the number of lymph nodes harvested.

Results: Using an Artisential^® grasper for traction for splenic flexure mobilization during laparoscopic low anterior resections increased screen visualization by 11.8% compared with using conventional laparoscopic graspers. Length of operation, severity of postoperative complications, and number of harvested lymph nodes were comparable in both modalities.

Conclusions: Angulated traction was utilized for splenic flexure mobilization in laparoscopic low anterior resections using a grasper from Artisential^®, a line of articulated laparoscopic instruments. The surgeon was able to create a significantly larger working field and better exposure of target structures. This implementation did not affect operation time, recovery, or specimen integrity.