Techniques in Coloproctology最新文献

Background and study aim: Endoscopic intermuscular dissection (EID) is an emerging technique for resecting early rectal cancer with deep submucosal infiltration. This study reports the short-term outcomes of EID for early rectal cancer from a single-center experience in China.

Patients and methods: Between January 2024 and March 2025, 12 patients diagnosed with rectal malignant tumors, with CT staging ≤ T2 and no lymph node metastasis underwent EID. For lesions staged as cT2, endoscopic ultrasound confirmation of no muscularis propria invasion was required prior to EID for therapeutic resection at our center. All patients were evaluated by a multidisciplinary team and provided informed consent. The primary outcomes included technical success (defined as macroscopic complete en bloc resection without major intraprocedural complications), postoperative complications, and tumor-free resection margins. Secondary outcomes included hospital stay duration, follow-up completion rates, and short-term oncological outcomes.

Results: Technical success was achieved in 11 of 12 patients (91.7%), with one patient experiencing an intraprocedural perforation. En bloc resection margins were confirmed histopathologically in all cases. One patient (8.3%) experienced delayed perforation requiring additional surgery. All lesions were confirmed as pT1b adenocarcinoma on final pathology. Among patients who reached follow-up timepoints, 6-month follow-up completion was 100% (9/9 eligible patients) and 12-month follow-up completion was 50.0% (2/4 eligible patients). No tumor recurrence was observed in patients with available follow-up data during a median follow-up of 9 months (range 3-16 months).

Conclusion: This preliminary single-center experience suggests that EID may be a feasible technique for carefully selected cases of resecting early rectal cancer with deep submucosal infiltration, demonstrating acceptable rates of complete resection and reasonable short-term safety profiles. However, the small sample size, staging limitations, and short follow-up period mean that these findings require cautious interpretation. Larger multicenter studies with extended follow-up periods are necessary to establish the role of EID in the treatment algorithm for early rectal cancer.

Background: In the Netherlands, approximately 15% of patients with rectal cancer undergo a low Hartmann's procedure (low-HP). This is often preoperatively planned to avoid poor functional outcome or complications, but might be unplanned as a result of intraoperative difficulties. Low-HPs seem to be associated with worse oncological outcomes.

Methods: All patients who underwent either restorative low anterior resection (rLAR), planned low-HP, or unplanned low-HP for primary rectal cancer in 2016 were included from a nationwide cohort. Main outcomes were 4-year local recurrence (LR) rate and disease-free survival (DFS).

Results: Of 2043 patients, 1704 underwent rLAR (83.4%), 253 planned low-HP (12.4%), and 86 unplanned low-HP (4.2%). Among intended rLAR patients (n = 1790), independent risk factors for unplanned low-HP were older age, higher body mass index (BMI), higher American Society of Anesthesiologists (ASA) score, and more distal tumor location. Oncological outcomes after low-HPs were worse than after rLARs (LR 13.7% vs 5.6%, DFS 54.7% vs 71.8%, both p < 0.001), but similar for unplanned and planned low-HP. In multivariable analysis, unplanned and planned low-HP were not associated with LR or DFS, but R1 resection was (HR 6.6 (4.1-10.6), HR 3.0 (2.2-4.0), respectively). In R1 resections, the distal margin was more often involved after low-HP (70.0% vs 28.6%, p = 0.013) compared to rLAR.

Conclusion: Poor outcomes in univariable analysis after low-HP appear to be associated with more challenging procedures and increased risk of involved resection margin rather than the low-HP itself. In case of expected difficulties, an extralevator abdominoperineal excision or referral to an expert center might be an alternative to improve resection margins.

Trial registration: ClinicalTrials.gov, identifier NCT05539417, retrospectively registered on September 16, 2022.

Background: Chronic anal fissures in patients with Crohn's disease (CD) remain a significant therapeutic challenge, particularly when linked to active perianal disease. Conventional treatments often fail, highlighting the need for alternative approaches. This study explores the efficacy and safety of freshly collected autologous adipose tissue injection (AATI) for treating chronic fissures in patients with CD.

Methods: Nine patients with CD with anal fissures were included. The primary outcome was complete healing (CH) at 3 months after last AATI, defined as full fissure re-epithelialization and complete pain relief. Secondary outcomes included changes in defecation pain (visual analog scale [VAS]), anal discomfort (VAS), Perianal Disease Activity Index (PDAI), and St. Mark's Incontinence Score (SMIS).

Results: Five patients (56%) achieved CH after one (n = 4) or two (n = 1) AATI. Partial healing was observed in four patients (44%). Defecation pain improved from a VAS score of 7.5 (IQR 5.0-8.5) to 2.75 (0.0-4.5; p = 0.009), anal discomfort from VAS score of median 5.0 (2.5-6.5) to 1.0 (0.0-2.5; p = 0.014), PDAI from 5.0 (3.0-6.0) to 1.0 (1.0-2.0; p = 0.022), and SMIS from 7.0 (4.0-9.0) to 4.0 (0.0-4.0; p = 0.041). No treatment-related complications occurred.

Conclusion: AATI may be a promising new treatment of chronic anal fissures in patients with CD. Effects of AATI should be explored further in controlled trials.

Background: The purpose of this study was to compare the perioperative efficacy and safety of neoadjuvant chemoradiotherapy (NCRT) alone versus short-course radiotherapy combined with immunochemotherapy (SCRT + ICT) in patients with proficient mismatch repair (pMMR) rectal cancer.

Methods: This study was designed as a single-center, retrospective, case-matched analysis conducted at a tertiary referral center. The patient cohort consisted of individuals diagnosed with pMMR rectal cancer between 2022 and 2024. The main outcome measures evaluated were pathological complete response (pCR) rate, anus preservation rate, neoadjuvant therapy-related adverse events, and surgery-related complications.

Results: In the final analysis, 46 pairs of patients were included. The SCRT + ICT group had a significantly higher pathological complete response (pCR) rate (47.8% versus 10.9%, P < 0.001) and anus preservation rate (84.8% versus 37.0%, P < 0.001), but also a higher temporary stoma rate (76.1% versus 21.7%, P < 0.001). Both groups achieved a 100% R0 resection rate. Regarding safety, the combined therapy group had lower intraoperative blood loss (20 ml versus 50 ml, P < 0.001) and shorter postoperative hospital stay (6 days versus 8 days, P < 0.001). Adverse events and postoperative complications were similar in both groups. Additionally, logistic regression analysis showed that SCRT + ICT is a protective factor for achieving postoperative pCR, while intraoperative blood loss ≥ 50 ml and elevated pretreatment carcinoembryonic antigen (CEA) levels are risk factors for postoperative pCR.

Conclusions: Short-course radiotherapy combined with immunochemotherapy is safe and effective for patients with pMMR rectal cancer.

Background: The incidence of acute appendicitis in older patients significantly varies from that in younger adults. The coronavirus disease 2019 (COVID-19) pandemic has increased the risk of early post-appendectomy complications (EPAC). This study aimed to investigate the incidence and risk factors associated with EPAC in older patients after appendectomy and to define active COVID-19 infection during surgery as an associated risk factor for EPAC.

Methods: We conducted a retrospective multicenter analysis of older patients aged ≥ 60 years who underwent appendectomy between April 2020 and December 2024. Logistic regression identified the risk factors associated with EPAC.

Results: A total of 585 patients aged ≥ 60 years were divided into the EPAC (n = 32) and no EPAC (n = 553) groups. The incidences of EPAC was 5.5% (32/585), including superficial incisional surgical site infections (SSI) (9/32, 28.1%), deep incisional SSI (2/32, 6.3%), organ/space infection (2/32, 6.3%), intra-abdominal abscess (9/32, 28.1%), ileus (2/32, 6.3%), pneumonia (3/32, 9.4%), acute myocardial infraction (MI) (2/32, 6.3%), fecal fistula (2/32, 6.3%), and acute adhesive intestinal obstruction (1/32, 3.1%). Multivariable analysis identified that active COVID-19 infection during surgery (odds ratio (OR) = 25.9; 95% confidence interval (CI) 4.8-139.1; p < 0.001), American Society of Anesthesiologists (ASA) score ≥ II (OR = 4.5; 95% CI 1.2-17.07; p = 0.02), open approach (OR = 30.6; 95% CI 8.1-115.3; p < 0.001), and high-grade appendicitis ≥ IV (OR = 63.06; 95% CI 7.5-526.4; p < 0.001) were significant associated risk factors for EPAC.

Conclusions: The incidence of EPAC in older patients after appendectomy is 5.5%. Active COVID-19 infection during surgery is strongly associated with an increased risk of EPAC. COVID-19 should be considered in perioperative risk assessment of EPAC.

Trial registration: This study was registered as a clinical trial (NCT06787573). Retrospectively registered.

Background: Mucinous adenocarcinoma (MAC) is typically admixed with other pathological components, including conventional adenocarcinoma, signet ring cell carcinoma, and/or neuroendocrine neoplasms. Specifically, signet ring cell differentiation (MASD) is defined as a signet ring cell component comprising less than 50% of the tumor, and neuroendocrine differentiation (MAND) is defined as a neuroendocrine component constituting less than 30%. Furthermore, MAC admixed with conventional adenocarcinoma was defined as classic mucinous adenocarcinoma (CMAC) in this study. Therefore, the study aimed to investigate the clinicopathologic and prognostic differences between patients with CMAC and those with either MASD or MAND [collectively termed mucous adenocarcinoma mixed with other pathological components (MAM)].

Methods: We collected data from a multi-institutional registry of patients who underwent surgical curative resection for histologically proven MAC between January 2016 and September 2021 at 22 medical institutions in China. Patients with MAC with percentage of signet ring cell ≥ 50% or percentage of neuroendocrine component ≥ 30% were excluded.

Results: A total of 2023 patients from 22 medical institutions who met the study criteria were included. MAM, compared to CMAC, showed more aggressive histologic features, including higher rates of lymphovascular invasion (47.0% vs. 18.0%, p < 0.01), perineural invasion (68.0% vs. 35.1%, p < 0.01), T4 stage (33.5% vs. 26.5%, p < 0.01), N2 stage (56.2% vs. 17.8%, p < 0.01), and TNM stage III disease (73.5% vs. 49.2%, p < 0.01). MAMs had lower 3-year overall survival compared to those with CMAC (66.7% vs. 81.6%, p < 0.01). Multivariable analysis indicated that MAMs, including MASD and MAND, was an independent prognostic factor for poor disease-free survival and overall survival.

Conclusion: Our analysis of a large patient cohort confirmed the aggressive clinicopathological features and poor prognostic outcomes of MAM, including MAND and MASD, compared with CMAC. These findings underscore the need for surveillance protocols for MAM in clinical practice.

Background: Lateral lymph node dissection (LLND) remains controversial owing to differences in oncological principles between East and West, complex pelvic anatomy and the risk of complications. The aim of this systematic review is to determine the number of cases required to achieve surgical competence in LLND and to evaluate postoperative outcomes across different phases of the learning curve.

Methods: A systematic literature search was conducted in PubMed and Google Scholar for studies analyzing the LLND learning curve in rectal cancer resection. The three-phase pattern, consisting of learning, competence, and proficiency, was followed for data analysis and presentation. A separate learning curve analysis for open, laparoscopic and robotic LLND was performed. Blood loss, operative time, lymph node yield, urinary complications and postoperative morbidity were assessed across the phases of the learning curve for robotic LLND.

Results: Of the 616 articles screened, eight studies met the inclusion criteria. Seven studies reported the learning curve analysis for robotic LLND, and one study for laparoscopic and open approach. Five studies had operative time as a learning outcome, two studies the lymph node yield and one study both lymph node yield and urinary retention. All studies used the cumulative sum (CUSUM) method for learning curve analysis. Regardless of learning outcome, surgical competence for robotic LLND was achieved after 12-53 cases, for laparoscopic LLND after 19 cases, and for the open approach no inflection point was identified. In robotic LLND, blood loss, urinary complications, and morbidity decreased during the proficiency phase.

Conclusions: The LLND learning curve is not yet standardized owing to variability in study design, type of LLND, and learning outcomes. Further well-designed and methodologically consistent studies are required to establish learning benchmarks and improve patient outcomes.

Registration in prospero database: CRD420251050015.

Background: The National Health System is responsible for 8-10% of total greenhouse gas emissions. Operating rooms are responsible for 60-70% of all hospital waste. Over the last 30 years abdominal surgery transcended from a laparoscopic approach toward a robot-assisted approach. The role of robot-assisted laparoscopic surgery is still debated in some procedures, such as colorectal surgery. The studies available in scientific literature comparing laparoscopic and robot-assisted left hemicolectomy are focused on clinical outcomes. The environmental sustainability of these procedures remains largely unexplored, representing a key area that our study seeks to investigate.

Methods: In this pilot study consecutive patients scheduled for a minimally invasive left hemicolectomy for diverticular disease or cancer were recruited and randomly assigned 1:1 to the laparoscopic or robotic groups. The "Green Team" supported the operating room staff in separate waste collection during the surgical procedures. Primary end point was CO₂ consumption and secondary endpoints the specific mass of the most important waste stream.

Results: Ten patients were enrolled. Robot-assisted left hemicolectomy required more CO₂ consumption in liters to maintain pneumoperitoneum (p = 0.03) compared with laparoscopic left hemicolectomy and required a longer operation time (p = 0.04). In total, the robot and laparoscopic approaches produced a total of 74.5 and 54 kg of plastic, non-woven fabric (TNT), unsorted waste bins, and biohazardous waste combined, which cost €92 and €71 to dispose of.

Conclusion: Robot-assisted left hemicolectomy seems to have a greater environmental impact compared with laparoscopic left hemicolectomy in terms of both CO₂ emissions and waste production. Given the growing focus on operating room sustainability, further studies are needed to compare laparoscopic and robotic techniques to inform surgical decisions.

Pilonidal sinus disease is a common condition affecting the skin and subcutaneous tissue in the upper natal cleft. Bascom's cleft lift procedure, an established surgical technique, treats the disease by excising the sinus tract, flattening the gluteal cleft, and displacing the incision off the midline (Immerman in Cureus, 2021. 10.7759/cureus.13053; Leventoglu et al. in Colorectal Dis 25:1938-1939, 2023. 10.1111/codi.16701). The seagull excision technique, developed as an alternative to the proven cleft lift procedure, aims to achieve similar surgical goals while offering a different flap design and closure strategy. This video demonstrates the application of the seagull excision technique in a 37-year-old male patient with pilonidal sinus disease.