Techniques in Coloproctology最新文献

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.

Background: This study aims to evaluate the current rates and outcomes of minimally invasive versus open surgery for colonic diverticular disease in Germany, using a nationwide dataset.

Methods: We analyzed data from 36 hospitals, encompassing approximately 1.25 million hospitalizations from 1 January 2019 to 31 December 2023. Patients aged 18 years and older with colonic diverticular disease (International Classification of Diseases, Tenth Revision (ICD-10): K57.2 and K57.3) who underwent surgical treatment were included. Surgeries were classified as open or minimally invasive (laparoscopic or robotic). Outcomes such as in-hospital mortality, complications, and length of stay were assessed using multivariable logistic and linear regression models.

Results: Out of 1670 patients who underwent surgery for colonic diverticular disease, 63.2% had perforation and abscess. The rate of minimally invasive surgery increased from 34.6% in 2019 to 52.9% in 2023 for complicated cases and from 67.8% to 86.2% for uncomplicated cases. Open surgery was associated with higher in-hospital mortality (odds ratio (OR): 7.41; 95% CI: 2.86-19.21) and complications compared with minimally invasive surgery. The length of hospital stay was significantly longer for open surgery patients, with an increase of 4.6 days for those with perforation and abscess and 5.0 days for those without.

Conclusions: Minimally invasive surgery for colonic diverticular disease is increasingly preferred in Germany, especially for uncomplicated cases. However, open surgery remains common for complicated cases, but is associated with higher mortality, more complications, and longer hospital stays.

Background: Neoadjuvant combination immunotherapy is a potential treatment option for patients with proficient mismatch repair/microsatellite stable colorectal cancer. Preoperative screening via endoscopy and imaging examinations could help identify patients who may potentially achieve a complete response after neoadjuvant combination immunotherapy. This study aims to evaluate the diagnostic accuracy of endoscopic and imaging examinations in predicting pathological complete response after neoadjuvant combination immunotherapy.

Methods: This single-center, retrospective, observational study included patients diagnosed with colorectal cancer by biopsy between 2015 and 2023 at a tertiary referral center. The main outcome measures included endoscopic examination, imaging findings, and pathological results after neoadjuvant combination immunotherapy.

Results: This study included 36 patients with locally advanced proficient mismatch repair colorectal cancer. Postoperative pathology revealed that 17 patients (47.2%) achieved a complete response (ypT0N0). The sensitivity, specificity, and accuracy of the endoscopic ypT0N0 diagnosis were 62.5%, 80.0%, and 80.6%, respectively; those of imaging-based ypT0N0 diagnosis were 43.8%, 100%, and 75.0%, respectively; and those of the combined diagnosis were 37.5%, 100%, and 72.2%, respectively. The areas under the receiver-operating characteristic curve for the endoscopic and imaging ypT0N0 diagnoses were 0.768 and 0.706, respectively.

Conclusions: The specificities of endoscopy and imaging for diagnosing complete response after neoadjuvant combination immunotherapy for colorectal cancer were high; however, sensitivities were low. Therefore, radical surgery should still be recommended for patients with an incomplete response based on either examination. Larger scale studies are required to determine if a watch-and-wait strategy is suitable for patients with a complete response based on these two examinations.

Background: Inadequate bowel perfusion is among risk factors for colorectal anastomotic leaks. Perfusion can be assessed with indocyanine green fluorescence angiography (ICG) during colon resections. Possible benefits from its systematic use in high-risk patients with rectal cancer remain inconsistent. This study aimed to evaluate the surgical modifications induced by ICG assessment during rectal cancer surgery and associated anastomotic leaks.

Methods: This prospective before and after cohort study was conducted in a single Canadian high-volume colorectal surgery center. Eligible patients were undergoing a low anterior resection for rectal cancer below 15 cm from the anal margin. Stapled and handsewn coloanal anastomoses were included. The experimental group was recruited prospectively, undergoing surgery using fluorescence angiography with ICG. The control group was built retrospectively from consecutive patients who had been operated on without ICG, prior to its implementation.

Results: Each cohort included 113 patients. The use of ICG led to modifications from initial surgical plan in 10.6% of patients, with no occurrence of anastomotic leaks in this specific group. When comparing leak rates, using ICG seemed to be protective, but this could not be statistically proven, overall (13.3% vs. 6.2%, p = 0.07), nor for handsewn coloanal anastomoses (11.8% vs. 5.9%, p = 0.67). A lack of power could explain such non-significant results, especially with low overall anastomotic leak rates recorded.

Conclusion: ICG influenced ultimate proximal resection margin in a clinically relevant proportion of cases. It might be associated with reduced leak rates although not formally proven with this data. This technology is safe and easy to apply in high-volume colorectal centers.

Background: Anal fissure is one of the most painful anal conditions. Various management options are available, including topical nitrites, calcium channel blockers, botulinum toxin injection, and lateral internal sphincterotomy. This study aimed to assess the efficacy and safety of botulinum toxin A (BT) injection for the management of symptomatic chronic anal fissures by conducting a systematic review of the literature and meta-analysis of published randomized controlled trials (RCTs).

Methods: A systematic search was conducted using the Embase and Medline search platforms. The search identified 264 papers published from January 1974 to December 2023, 35 of which were RCTs. Meta-analysis was performed on the collected data with a random effects model using Freeman-Tukey arcsine-transformed proportions. A p value less than 0.05 was considered to indicate statistical significance. The I² test was used to assess heterogeneity.

Results: A total of 1532 patients were included. After data were pooled, 1117 patients out of 1532 (72.7%) demonstrated healing of the fissure after the first injection of BT (P < 0.001, I² = 86.6%). Subgroup analysis was performed on the basis of the follow-up period in months. Nine studies reported that a second BT injection was needed for patients who did not respond after the initial injection. Twenty-nine out of 38 patients (78.5%) responded to the second injection (p < 0.001, I² = 50.6%). Complications were observed in 88 out of 1532 patients (4.02%) (p < 0.001, I² = 60.2%).

Conclusion: BT injection is a safe treatment approach for chronic symptomatic anal fissures, typically associated with only minor, temporary complications. Evidence also supports the use of repeat injections for managing recurrent or persistent symptoms.

Background: Trends of stoma creation at index surgery for Crohn's disease (CD) in the biologics era has not been thoroughly investigated. This study aimed to assess the impact of increasing biologics use on stoma rates at index surgery of CD, as well as identifying risk factors for the creation and nonreversal of CD-related stoma.

Methods: In this single-center retrospective analysis, consecutive CD patients who underwent index bowel surgery from 2007 to 2021 were reviewed. The rates of diverting stoma formation and reversal were compared across different time periods, delineated by January 2019, as biologics [anti-tumor necrosis factor (anti-TNF)] were included in national health insurance coverage in China. Logistic regression models and Cox proportional hazards models were utilized to assess factors influencing stoma creation and its reversal, respectively.

Results: Among 1022 CD patients, 27.9% received a diverting stoma during index surgery. Despite increasing preoperative use of biologics, the incidence of stoma creation remained statistically unchanged pre- and post-2019 (29.5% versus 25.2%; P = 0.14). Factors contributing to stoma creation included colonic and perianal involvement, penetrating CD, poorer preoperative conditions, and preoperative steroid usage, but not preoperative biologics. Among diverted patients, 68.8% underwent successful bowel restoration, with the reversal rate significantly increasing from 63.0% before 2019 to 80.2% after 2019 (P < 0.01). Patients with postoperative use of immunomodulators and biologics were more likely to have the stoma closed, with a reversal rate of 90.0% for those receiving biologics compared with 64.0% for those not.

Conclusions: Increasing prevalence of biologics did not alter the stoma rates in CD patients. Additionally, postoperative biologics were independently associated with a higher probability of stoma reversal.