Techniques in Coloproctology最新文献

Background: Preoperative stoma site marking by a wound, ostomy, and continence nurse (WOCN) or colorectal surgeons significantly reduces stoma-related complications. Limited access to WOCNs or colorectal surgeons, especially in rural or emergency settings, remains a barrier to optimal care. This study evaluated the feasibility and spatial accuracy of a novel telemedicine-based protocol for stoma site marking before colorectal surgery in settings with limited specialist access. The primary outcome was the spatial distance between the in-person and virtual markings. Accuracy was classified as exact same point, within < 1 cm, 1-2 cm, or > 2 cm.

Methods: This prospective observational pilot study was planned in a tertiary academic medical center. Healthy adult volunteers with no prior abdominal surgery were enrolled in the study. Each participant underwent two independent stoma markings: one by an in-person WOCN and another by a different WOCN using standardized patient photographs taken in standing, sitting, supine, and bending positions, with an acetate grid for anatomical calibration.

Results: A total of 876 paired stoma site markings were obtained from 247 volunteers. Exact concordance between virtual and in-person markings was observed in 19.3% of cases. An additional 39.2% of virtual markings were located within 1 cm of the reference point, and 22.1% were within 1-2 cm. The remaining 19.4% deviated by more than 2 cm from the in-person marking. Overall, 80.6% of virtual markings fell within 2 cm of the in-person reference, demonstrating a high level of spatial concordance between the two methods.

Conclusions: A standardized virtual stoma site marking protocol demonstrated high concordance with in-person assessment. This telemedicine-based strategy may be a feasible alternative in settings lacking colorectal specialists and could help optimize perioperative stoma care. The main limitations are inclusion of healthy volunteers rather than surgical patients. Real-world application and clinical outcome impact remain to be validated.

Objective: This study compares the clinical benefits of double-tube end ileostomy versus traditional end ileostomy in patients undergoing low anterior resection for rectal cancer.

Methods: A retrospective analysis was conducted on 65 patients who underwent laparoscopic radical rectal cancer surgery with preventive ileostomy between March 2022 and December 2024 at the First Affiliated Hospital of Anhui Medical University. Among these, 47 patients received traditional ileostomy, while 18 patients underwent double-tube ileostomy. The clinical characteristics and follow-up outcomes of the two groups were compared.

Results: Both groups showed no significant differences in intraoperative blood loss, postoperative bowel function recovery, or complication rates (P > 0.05). However, the double-tube ileostomy group had superior outcomes: average stoma creation time was 25.39 ± 2.85 min, postoperative hospital stays averaged 8.89 ± 2.30 days, and total hospitalization costs were 57,796.50 ± 5306.30 RMB, all significantly lower than in the traditional ileostomy group (P < 0.01). Complications were fewer in the double-tube group, with only one case of type A anastomotic leakage (5.56%) and no long-term complications following successful tube removal. By contrast, the traditional group had 4 cases of leakage (8.51%), and 16 patients experienced long-term complications, with only 40 (85.11%) achieving successful stoma closures. Furthermore, patients in the traditional group reported higher SCL-90 scores for somatization and sleep and eating problems (P < 0.05), indicating significant differences between the groups.

Conclusion: Double-tube end ileostomy offers a safe and effective alternative to traditional methods, with shorter operative times, fewer secondary surgeries, and reduced physiological, psychological, and financial burdens on patients.

Background: Enhanced recovery after surgery (ERAS) protocols and multimodal prehabilitation are interventions used to improve outcomes after surgery. However, their integration is not well studied and is a subject of ongoing debate. The aim of the study was to evaluate the effectiveness of multimodal prehabilitation within ERAS for elderly patients undergoing elective colorectal surgery.

Methods: Studies that used prehabilitation modalities, such as exercise, nutrition, psychology, and spirituality, compared with two control groups-ERAS alone or ERAS with postoperative rehabilitation-were systematically reviewed and reported according to the PRISMA guidelines. Meta-analysis was performed on outcomes such as length of stay (LOS), 6-min walk test (6MWT), postoperative complications, and quality of Life (QOL) using a random effects model.

Results: Six studies with low risk of bias and good quality were selected. These included 547 patients with an age range of 65-78 years in the intervention group (n = 277) and of 66-82 years in the control group (n = 270). All studies exclusively included patients with colorectal cancer. Statistically significant difference was observed for 6MWT and MD of 18.3800 m (95% CI 1.5147-35.2453; p = 0.0404) with an I² statistic of 3.7% (p = 0.3741), indicating low heterogeneity among studies. However, a statistically significant difference was not found for LOS, postoperative complications, or QOL. No difference was found in subgroup analysis for different study designs or control groups.

Conclusion: Although multimodal prehabilitation in ERAS for elderly patients undergoing elective colorectal surgery has limited clinical use, potential remains for targeted and optimized interventions. Further research is needed to consolidate evidence in selected patient populations.

Background: Anastomotic leakage (AL) remains a major complication after rectal cancer surgery. Although various techniques have been proposed to reduce its incidence, the effectiveness of transanal tube (TA) placement remains controversial. This study aimed to evaluate whether combining indocyanine green (ICG) fluorescence angiography with TA placement reduces the risk of AL after rectal cancer surgery.

Methods: A retrospective analysis, including patients who underwent rectal resection with primary anastomosis for rectal cancer, was performed. In all cases, anastomotic perfusion was assessed intraoperatively using ICG fluorescence angiography. Patients were categorized into two groups on the basis of postoperative TA placement: TA group and non-TA group. The primary outcome was the incidence of AL. Multivariate logistic regression and subgroup analyses based on tumor location were performed.

Results: The TA group demonstrated a significantly lower incidence of AL compared with the control group (5% versus 18%, p = 0.02). Multivariate analysis identified male sex as a risk factor and TA placement as a protective factor for AL. Subgroup analysis revealed that TA placement was particularly effective in patients with middle rectal cancer.

Conclusions: The placement of a TA may offer additional benefit in reducing the risk of AL after rectal cancer surgery when adequate perfusion is confirmed using ICG fluorescence imaging, particularly in cases of middle rectal cancer.

Introduction: Anastomotic leakage (AL) is a serious complication after rectal cancer resection, often mitigated by diverting loop ileostomy. However, outlet obstruction remains a significant concern, potentially prolonging hospitalization and requiring reintervention. While surgical risk factors have been explored, patient-specific anatomical factors are less well understood. This study aimed to identify patient-related risk factors for outlet obstruction and evaluate a preventive surgical modification in high-risk patients undergoing laparoscopic and robotic rectal cancer surgeries.

Methods: This retrospective study included 318 patients who underwent laparoscopic or robotic rectal resection with a diverting loop ileostomy. Risk factors were assessed in a control cohort (April 2015-February 2020), followed by a modified ileostomy technique in a validation cohort (March 2020-December 2024).

Results: Increased rectus abdominis muscle thickness (TAM) and larger visceral fat area (AVF) were independent risk factors for outlet obstruction (p = 0.037 and p = 0.041, respectively). Patients with both factors had the highest incidence (52.6%). The modified technique significantly reduced obstruction among high-risk patients (p = 0.003) without increasing parastomal hernia rates.

Conclusions: TAM and AVF are independent predictors of outlet obstruction. A tailored fascial modification reduced obstruction in high-risk patients, supporting the value of preoperative anatomical assessment in surgical planning.

Background and aims: Post-endoscopic submucosal dissection (ESD) electrocoagulation syndrome (PEECS) is a recognized limitation of colorectal ESD (C-ESD) associated with morbidity, additional costs, and prolonged admission. Reliable closure of C-ESD defects can decrease the incidence of PEECS. We introduce a novel mucomuscular closure technique that involves direct closure of the muscularis propria using through-the-scope clips (TTSC). We evaluate the feasibility and efficacy of the modified closure technique in prevention of post-C-ESD PEECS.

Methods: We conducted a prospective cohort study of consecutive C-ESDs at a single tertiary center between January 2017 and October 2023. Patients who underwent C-ESD with mucomuscular closure or conventional closure with TTSC were enrolled. The primary outcome was the incidence and clinical outcome of PEECS. Secondary outcomes were rates of complete defect closure and severe adverse events (SAEs).

Results: A total of 764 patients were included in this study. The incidence of PEECS was significantly lower in the mucomuscular closure group versus conventional closure group (2.5% versus 15.0%, P < 0.001). No SAEs occurred in mucomuscular closure group, whereas two patients had delayed perforation, and two had delayed bleeding in the conventional closure group. In mucomuscular closure group, there was no difference in PEECS occurrence between complete closure (5/218, 2.3%) and partial closure (3/105, 2.9%). No TTSC-related perforation occurred in the process of defect closure.

Conclusions: Mucomuscular closure with TTSC in C-ESDs is effective in preventing PEECS and other postoperative complications.

Background: Complex perianal fistulas present a significant surgical challenge due to high recurrence rates and the need to preserve sphincter function. Fistula-tract Laser Closure (FiLaC™) is a minimally invasive technique that offers promising results, but incomplete closure of the internal opening remains a major cause of recurrence. To improve outcomes, we propose the FiLaFlap technique, which combines FiLaC™ with a mucosal advancement flap to enhance fistula healing.

Methods: We conducted a retrospective study of patients who underwent seton removal with the FiLaFlap procedure between January 2023 and September 2024. Postoperative data, including pain levels, complications, continence status, and follow-up outcomes, were collected prospectively. Patients underwent clinical evaluations and 3D endoanal ultrasound assessments at predefined intervals.

Results: A total of 24 patients (58.3% male, mean age 39.4 ± 12.4 years) were included. The mean time between seton placement and FiLaFlap was 5.95 ± 1.78 months. Postoperative pain was low (VAS 2.20 ± 0.97), and no major complications occurred. At 6 months, 91.6% of patients achieved clinical remission, while 83.3% had ultrasound-confirmed healing. Only one patient reported minor incontinence.

Conclusion: The FiLaFlap technique appears to be a safe and potentially effective sphincter-preserving strategy for complex perianal fistulas, demonstrating high remission rates with minimal morbidity. Further studies with larger cohorts and extended follow-up are needed to validate these preliminary findings.

Introduction: In sacral neuromodulation (SNM), the stimulation intensity is set at the sensory threshold (ST) level. However, subsensory stimulation as low as 50% of ST has proven effective in reducing faecal incontinence episodes.

Aim: To explore the relationship between functional outcomes and varying subsensory stimulation amplitude in newly implanted patients.

Method: This randomised, double-blind study was designed to include patients with ≥ 1 faecal incontinence episodes/week despite maximal conservative therapy. As part of another trial, patients were offered a one-stage procedure. Postoperatively, patients were randomised into two groups. G-1 received stimulation at 0.05 V, at 50% and 90% of the ST in three 4-week periods, followed by 12 weeks of stimulation at the ST. G-2 received stimulation at 90% of the ST in three 4-week periods, followed by 12 weeks of stimulation at ST. Patients were evaluated after each period using St. Marks's Incontinence Score and a visual analogue scale (VAS) for patient satisfaction regarding social function, bowel function and quality-of-life, along with a bowel habit diary.

Results: In total, 73 patients with a median age of 60 years [interquartile range (IQR: 50-69 years)] completed the trial. Faecal incontinence episodes were significantly reduced at all follow-ups, with no differences between groups. The only statistical difference between groups was deltaVAS for bowel function after 4 weeks. In G-1 with ultra-low stimulation amplitude [0.05 V - equivalent to 9.6% (IQR: 6.5-13.4) of ST], the improvement compared with baseline was 30 points (IQR: 10-50) significantly lower than G-2 with an improvement of 50 points (IQR: 10-70) (p-value: 0.05).

Conclusions: Subsensory stimulation is feasible in newly implanted patients with faecal incontinence. An amplitude of 0.05 V is as effective on the functional outcomes as stimulation with higher amplitudes.

Background: Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the standard surgical option for patients with ulcerative colitis (UC) wishing to avoid a permanent ileostomy. Single-port (SP) robotic surgery offers enhanced dexterity and visualization, potentially overcoming the limitations of single-port laparoscopy in the confined pelvic cavity. Its role in IPAA for UC is unexplored.

Methods: Patients with ulcerative colitis undergoing SP robotic proctectomy with IPAA at a tertiary center between October 2024 and June 2025 were reviewed. Procedures followed a standardized three-step approach with transanal transection single stapled (TTSS) anastomosis. Feasibility was defined as completion of the procedure without unplanned conversion to multiport laparoscopy, laparotomy, or transanal minimally invasive surgery (TAMIS). Safety by 30-day postoperative morbidity, readmission, and pouch leak rates was analyzed.

Results: A total of 14 patients (median age 34 years; body mass index (BMI) 26.2 kg/m²) were included. Median operative time was 237 min (range 188-317 min). Hospital stay was 5.8 days (range 3-12 days). No conversions occurred; one case required the unplanned placement of additional 5-mm assistant trocar. Four patients (28.5%) developed postoperative complications. The mean Comprehensive Complication Index was 7.6 ± 12.8 (SD). Three patients (21.4%) required readmission within 30 days postoperatively. All patients underwent ileostomy closure at a median of 64 days after IPAA creation.

Conclusions: SP robotic proctectomy with IPAA is feasible and safe in unselected patients with UC, supporting further large prospective evaluation.

Background: The efficacy of adjuvant antibiotic therapy in reducing the rate of fistula following incision and drainage (I and D) of cryptoglandular anorectal abscesses remains controversial. This study evaluated the effect of adjuvant antibiotic therapy on fistula formation rate.

Methods: This retrospective study included all consecutive adult patients who underwent I and D for a cryptoglandular anorectal abscess between January 2011 and December 2024 at a university-affiliated institution. Demographic, clinical, and microbiological culture data were collected. The intervention assessed was adjuvant antibiotic therapy administration for a minimum of 7 days following I and D. The primary outcome compared fistula formation rates at 12 months after I and D between those who received adjuvant antibiotic therapy and those who did not. Secondary outcomes assessed the factors associated with fistula formation.

Results: Of the 770 patients who met inclusion criteria, 60.5% received adjuvant antibiotic therapy. The overall rate of fistula was 6.8%. The overall median time to diagnosis was 15.4 weeks (interquartile range [IQR]: 7.7-31.3). No differences in the fistula formation rate or time to diagnosis were observed between the two groups. Fistula formation was significantly associated with abscess location, whereas diabetes mellitus was less common among patients who developed fistula. In addition, no patient whose abscess culture yielded skin-derived microorganisms developed a fistula. Age > 40 years and intersphincteric abscess were associated with fistula formation in multivariate analysis, while diabetes mellitus demonstrated a negative association.

Conclusions: In this retrospective study, adjuvant antibiotic therapy was not associated with a decreased risk of fistula formation following abscess I and D.