Techniques in Coloproctology最新文献

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.

Background: In accordance with Enhanced Recovery After Surgery (ERAS) principles, it has recently been suggested that preoperative stoma education protocols be routinely introduced in perioperative care. Potential benefits of such programs include shorter postoperative length of stay (LOS) and decreased readmission following discharge. We designed this systematic review and meta-analysis to further investigate the effect of preoperative stoma education on postoperative outcomes.

Methods: A search in MEDLINE, Embase, and CENTRAL from inception to February 2024 was performed. We included randomized controlled trials or observational cohort studies evaluating patients who underwent stoma formation during colorectal surgery and compared those receiving and not receiving preoperative stoma education. Main outcomes included stoma-related morbidity, peristomal complications, overall morbidity, postoperative LOS, readmission, and quality of life (QoL). Meta-analyses were performed using inverse variance random effects models.

Results: Nine studies (four randomized studies and five cohort studies) met inclusion criteria. Overall, 507 patients (mean age: 60.95 ± 12.86 years, 40.1% female) received preoperative stoma education prior to stoma formation, and 356 patients (mean age: 61.75 ± 12.31 years, 39.2% female) did not. Meta-analysis showed that peristomal skin complications were significantly reduced with preoperative stoma education (two studies, 9.5% versus 19.4%, risk ratio (RR) 0.45, 95% confidence interval (CI) 0.29-0.72, p < 0.01, I² = 0%).There were no significant differences in other outcomes, and there was insufficient available data for meta-analysis of stoma-related morbidity or QoL.

Conclusions: This study presents very low-certainty evidence suggesting that preoperative stoma education may reduce peristomal skin complications, but otherwise no significant clinical benefits were identified. Future prospective studies are warranted to further investigate the impact of preoperative stoma education.

Prospero registration: CRD4202451323.

Background: Obstructed defecation syndrome (ODS) is a prevalent pelvic floor disorder, often impairing patients' quality of life. Noninvasive therapies, including posterior tibial nerve stimulation (PTNS), have been explored as alternative treatments. This study evaluates the efficacy of bilateral transcutaneous posterior tibial nerve stimulation (BT-PTNS) compared to medical treatment alone in patients with ODS without anatomical abnormalities.

Methods: A prospective randomized controlled study was conducted on 50 patients diagnosed with ODS. Patients were randomly assigned into two groups: group A received BT-PTNS sessions three times weekly for 6-12 weeks alongside medical treatment, while group B received medical treatment only. Outcomes were assessed using the Modified Obstructed Defecation Syndrome (MODS) score, Patient Assessment of Constipation Quality of Life (PAC-QOL) questionnaire, and quantitative electromyography of pelvic floor muscles. Statistical analysis was performed using SPSS software.

Results: Group A exhibited a significant reduction in MODS scores (mean decrease = 10 points) compared to group B (mean decrease = 4 points) after 6 weeks (p < 0.001). PAC-QOL scores improved significantly in group A (65% reduction) compared to group B (37% reduction). Electromyographic analysis in group A showed significant improvement in amplitude, number of motor unit turns, and duration (p < 0.001). No adverse events were reported in either group.

Conclusion: BT-PTNS is a safe and effective noninvasive treatment for ODS without anatomical abnormalities, significantly improving symptom severity and quality of life. Further multicentric trials are warranted to standardize treatment protocols and assess long-term outcomes.

Trial registration: Clinical Trial Number IORG0008812; E/C.S/N.R2/2017.

Introduction: Ileocecal resection is the most common surgery in Crohn's disease (CD). As recurrences often occur at the anastomosis it has been questioned whether surgical technique may have a role in its prevention. The Kono-S anastomosis, first described in 2011, has shown potential to reduce anastomotic recurrence while maintaining luminal width and preventing distortion. The classic surgery described was a handsewn anastomosis. Lately a stapled approach has emerged which is less technically demanding, and requires shorter operative time. We compared stapled versus handsewn Kono-S ileocolonic anastomosis in patients with Crohn's disease, evaluating operative time and perioperative outcomes.

Methods: Data on all consecutive patients with CD aged ≥ 18 years at a single tertiary center, who underwent ileocolonic resection by inflammatory bowel disease (IBD)-dedicated surgeons with Kono-S anastomosis from July 2023 to April 2025, were collected retrospectively.

Results: In total, 25 patients were included. Overall, 15 (60%) underwent handsewn anastomosis and 10 (40%) underwent stapled anastomosis. There were no clinical or demographic differences. Median operative time was shorter in the stapled group (151 versus 203 min, p = 0.01). Postoperative complications occurred in 2/10 patients (20%) in the stapled group and 4/15 (26.7%) in the handsewn group (p = 0.70). One patient required reoperation in the handsewn group. Postoperative day 3 C-reactive protein (CRP) was lower in the stapled group (median 69 versus 165 mg/L, p = 0.03). There was one case of 30-day rehospitalization in the stapled group.

Conclusions: The stapled Kono-S anastomosis technique is a shorter procedure with similar perioperative outcomes compared with the handsewn technique. Follow-up studies, with larger sample sizes, are required to evaluate long-term efficacy and disease recurrence rates.

Background: This study aimed to compare the perioperative outcomes of robotic versus laparoscopic complete mesocolic excision (CME) and to assess the safety and feasibility of robotic CME (R-CME) for right-sided colon cancer. As part of this analysis, the feasibility and safety of the robotic approach were also evaluated.

Methods: Patients who underwent right hemicolectomy with either robotic CME (R-CME, 48 patients) or laparoscopic CME (L-CME, 123 patients) between April 2016 and December 2023 were retrospectively analyzed using propensity score matching (PSM).

Results: After matching, the R-CME and L-CME groups each of the 40 included patients. The R-CME group had less intraoperative blood loss (P = 0.007), a shorter median time to first flatus (P < 0.001), and a shorter median postoperative hospital stay (P = 0.012) than the L-CME group. The other surgical outcomes were not significantly different between the two groups.

Conclusions: R-CME was associated with less blood loss, faster recovery of bowel function, and shorter hospital stay than L-CME, suggesting that robotic CME using a cranial approach may be a feasible and safe option for right-sided colon cancer. These favorable outcomes may reflect not only the general advantages of the robotic platform but also the procedural benefits of the cranial approach, which enables early vascular control and reduced bowel interference.

Introduction: This study aims to compare the intraoperative and postoperative outcomes of single-port laparoscopic Hartmann's reversal (SPLHR) and open Hartmann's reversal (OHR).

Material and methods: Consecutive patients who underwent OHR and SPLHR between 2019 and 2021 were analyzed retrospectively from a prospectively maintained database.

Results: During the study period, 23 patients underwent SPLHR and 24 patients underwent OHR. The median age, gender, body mass index (BMI), comorbidities, and presence of midline/parastomal hernias were similar across the groups. The median estimated blood loss was significantly lower (100 versus 175 ml, p = 0.011), and also the median operation time (92 versus 120 min, p = 0.016) was shorter in the SPLHR group. Inadvertent bowel injury was more frequently observed in OHR group (37.5% versus 8.7%, p = 0.02). Overall postoperative complications did not differ between groups, but wound infections were significantly more common in the OHR group (33.3% versus 4.3%, p = 0.023). The SPLHR group experienced a shorter time to first flatus (median 2 versus 3 days, p = 0.04), a shorter time to resuming a soft diet (median 2 versus 3 days, p = 0.002), and a shorter length of hospital stay (4 versus 4.5 days, p = 0.007).

Conclusion: This study confirms that SPLHR is a reliable and efficient method. SPLHR has several advantages in terms of perioperative morbidity and postoperative outcomes compared with OHR in selected patients.

Introduction: Rectal-sparing strategies for locally advanced rectal cancer are gaining interest owing to favorable oncological results and reduced impact on functional outcomes. In patients managed with watch-and-wait or local excision after neoadjuvant chemoradiotherapy (nCRT), local regrowth occurs in approximately 15-30% of cases. Total mesorectal excision (TME) is the standard treatment for regrowth; however, local excision (LE) may be considered in selected cases to preserve rectal function. This narrative review evaluates clinical and oncological outcomes of patients undergoing LE for suspected regrowth.

Methods: A narrative review of the literature was conducted using databases and search terms including "rectal cancer," "rectal sparing," and "local regrowth."

Results: Five retrospective studies were identified, encompassing a total of 159 patients. Treatment protocols, neoadjuvant regimens, and follow-up strategies varied across the studies. Histopathological findings revealed ypT ≥ 2 in 45.3% of cases. Reported overall survival (OS) was consistently above 94.5%, while 2-year locoregional recurrence-free survival ranged from 74% to 85%. Systemic recurrence occurred in 9.1% of patients. LE was associated with shorter operative time, reduced blood loss, and lower rates of Clavien-Dindo ≥ 3 complications.

Conclusions: Local excision for regrowth may represent a feasible alternative to radical surgery in selected patients, particularly within specialized centers and under strict surveillance protocols. Further prospective studies are warranted to validate its long-term oncologic safety and functional outcomes.