Techniques in Coloproctology最新文献

Background: Right-sided colon cancer surgery is a highly difficult operation, and ensuring perioperative safety is an important issue. While various approaches have been proposed for right-sided colon cancer, there are few reports comparing them. The present study compared the inferior approach (IA) and medial approach (MA) for right-sided colon cancer surgery and evaluated their safety.

Methods: We compared 528 cases of right-sided colon cancer surgery performed at our five affiliated institutions from 2017 to 2023, divided into IA and MA groups of 122 cases each using propensity score matching. Short-term outcomes of both groups were retrospectively evaluated, focusing on perioperative complications and perioperative mortality as the primary outcomes.

Results: After propensity score matching, all baseline variables were well balanced. All patients underwent complete mesocolic excision. No statistically significant difference (p < 0.05) was observed between the two groups in the incidence of postoperative complications, and no cases of severe complications were observed in either group. The incidence rates of Clavien-Dindo grade ≥ 3 complications (IA/ MA): anastomotic leakage (0%/ 0.8%); intraabdominal abscess (0.8%/ 1.6%); surgical site infection (0.8%/ 3.2%); ileus (0%/ 0.8%); and anastomotic bleeding: (0%/ 0%). Postoperative hospital stay was significantly shorter in the IA group. Although there was a significant difference in the number of dissected lymph nodes, both groups had good R0 resection rates.

Conclusions: Both IA and MA represent safe and feasible approaches for right-sided colon cancer and can be selected on the basis of the surgeon's preference.

Background: We investigated factors associated with pathologic complete response (pCR) and tumor regression grade (TRG) on the basis of clinical and pathological variables and their impact on cancer-free survival (CFS) after surgery for locally advanced rectal cancer (LARC).

Methods: All patients with LARC undergoing neoadjuvant treatment before curative total mesorectal excision surgery were included in a prospective institutional database connected to the National Mortality Registry. One-way analysis of variance and Pearson's chi-squared test were utilized to compare TRG groups. The Kaplan-Meier method and regression models were used to evaluate CFS, radiation modality, and staging factors.

Results: Of 700 patients operated on for rectal cancer between 2014 and 2024, 159 (22.7%) had LARC without known systemic cancer. Twenty-seven patients had pCR (TRG 0, 17.0%), 46 TRG 1 (29.0%), 70 TRG 2 (44.0%), and 16 TRG 3 (10%). Poor tumor regression was associated with increasing age (p = 0.009), vascular (p < 0.001) and neural invasion (p = 0.005), less differentiated tumors (p < 0.001), short-course 5 Gy × 5 (p < 0.001) rather than long-course 2 Gy × 25 radiotherapy, and omission of neoadjuvant chemotherapy (p < 0.001). Older age was a predictor of short-course radiotherapy and omission of chemotherapy (p < 0.001). Follow-up time was 46.6 months (IQR 20-80.3 months). No differences were found in CFS between TRG groups 0-3 (p = 0.18), however pCR was associated with improved CFS (p = 0.047).

Conclusions: Decreased tumor regression was associated with reduced radiotherapy and chemotherapy, neural and vascular invasion, poor differentiation, and increasing age. The latter may reflect reduced application of neoadjuvant treatment in older patients. Complete responders experienced increased cancer-free survival.

Background: The response of lateral pelvic lymph nodes (LPLNs) to various neoadjuvant treatments has not been thoroughly investigated. This study aims to compare the effects of long-course chemoradiotherapy (LCCRT) and total neoadjuvant therapy (TNT), i.e., short-course radiotherapy (SCRT) with consolidation chemotherapy, on LPLNs size reduction. The secondary objective is to compare the pathological positivity rates of LPLNs dissection (LPLND) postneoadjuvant treatment.

Methods: This is a retrospective analysis based on a prospectively maintained database. Patients with rectal cancer registered between January 2020 and December 2021 with radiologically positive LPLNs who underwent neoadjuvant radiation therapy were included. Patients were divided into two groups: LCCRT and TNT.

Results: Among 1200 registered rectal cancer cases, 160 had positive LPLNs, with 142 included in the analysis. A total of 61 patients received LCCRT, and 81 patients received TNT. No significant differences were found in tumor (T) and node (N) staging between the groups. However, the TNT cohort had a significantly higher proportion of patients with metastases (p < 0.001), poorly differentiated tumors (p = 0.021), and extramural venous invasion (p = 0.002). Baseline mean nodal sizes were similar between groups. Postneoadjuvant nodal sizes were 5.3 mm for LCCRT and 6.2 mm for TNT, with mean reductions of 5.7 mm and 4.6 mm, respectively (p = 0.136 and 0.54). Surgery was conducted in 77% of the LCCRT group and 59% of the TNT group, with 22 (46.8%) and 26 (54.1%) undergoing LPLND in their respective groups. The pathological positivity rates for LPLNs were similar (27.3% versus 23.1%, p = 0.731).

Conclusions: SCRT with consolidation chemotherapy does not provide a significant advantage over LCCRT in reducing LPLNs size or reducing the need for LPLND.

Background: High anal fistulae require more complicated treatment than low anal fistulae. Because of their complexity, this study aimed to assess the rerouting role in high anal fistulae treatment, as well as to assess recurrence and incontinence, and determine whether rerouting of the tract is a good option for treating high anal fistulae.

Methods: This is a prospective interventional study that was conducted on 83 patients with high perianal fistula, ranging in age from 18 to 72 years old, of both genders. All cases were assigned to history taking, laboratory investigations, clinical examination (general examination and local examination), and magnetic resonance imaging (MRI) for objective delineation of the fistulous tract and its association to the anal sphincters.

Results: After a minimum follow-up period of 9 months, five cases (6.02%) experienced recurrence. Mild incontinence was reported in four patients (4.8%), while four patients (4.8%) developed infection. In addition, tract gangrene was observed in two patients (2.41%). In multivariate regression analysis, suprasphincteric fistulae and infection were independent predictors for recurrence.

Conclusions: The rerouting procedure is a feasible and safe surgical option for managing high transsphincteric perianal fistulae. It is associated with low postoperative complication rates, including short-term recurrence. It combines the advantages of fistulotomy and sphincter-preserving fistula surgery. However, further studies involving a large number of suprasphincteric fistula cases are needed to evaluate the efficacy of the rerouting technique in treating such fistulae.

Background: A precise evaluation of the positional distribution of hemorrhoidal piles has not been distinctly conducted. We hypothesized that the distribution of hemorrhoidal piles follows a predictable anatomical pattern influenced by disease duration and recurrence.

Methods: Our retrospective study analyzed the demographic data, surgical records, operative photographs, previous treatments, and associated colorectal symptoms of patients who underwent invasive procedures for advanced hemorrhoidal disease (2020-2024).

Results: Of the 171 patients (123 male; 71.9%; median age 41 ± 12.04 years, range 18-88), 35 had prior interventions (recurrent cases). The largest pile was most commonly in the left lateral quadrant (40.14%), followed by right posterior (31.97%), right anterior (23.47%), and atypical locations (4.42%). Left lateral predominance was significantly higher in primary cases than in recurrent cases (p = 0.031). Most patients had more than one pile (87.7%). Symptom duration positively correlated with pile number (Spearman's rho = 0.229, p = 0.013), but not with hemoroid grade (p = 0.977). No significant differences in pile distribution were observed in patients with defecation disorders, labor history, or concomitant anal fissure (p > 0.05). Of the 48 patients with anal fissure had significantly shorter symptom duration compared to those without fissure (p = 0.011).

Conclusion: The classical three-quadrant distribution is confirmed, with the left lateral pile being predominant in primary cases. The association between prolonged symptom duration and increased pile number offers novel insights, highlighting left lateral predominance in primary cases and its reduction in recurrence, enhancing clinical understanding and management.

Background: Chronic anal fissures (CAF) are a common proctological condition that significantly impacts patients' quality of life. Lateral internal sphincterotomy (LIS) is widely considered the gold-standard treatment for CAF; however, postoperative fecal incontinence remains a potential risk. The aim of this study is to evaluate long-term incontinence rates following traditional LIS for CAF.

Methods: A retrospective analysis was conducted on patients with CAF who underwent traditional LIS. Patients with any degree of continence impairment prior to surgery, as well as those who experienced events potentially affecting continence function after surgery, were excluded from the analysis. Incontinence was assessed using the Vaizey score both preoperatively and at follow-up.

Results: Between January 2014 and May 2019, 98 patients met the inclusion criteria. The mean follow-up duration was 7 years (range 5-10 years). At follow-up, the Vaizey score ranged from 1 to 4 in 19 patients (19.4%) and from 5 to 9 in 5 patients (5.1%). Incontinence primarily involved gas or liquid stool; no patients reported solid stool incontinence. A total of four patients (4.1%) experienced defecatory urgency. No patients required constipating medications or reported lifestyle changes; only one patient (1.0%) required the use of pads. No correlation was found with age, sex, BMI, or smoking status.

Conclusions: When present, incontinence following traditional LIS is generally mild, does not require constipating medications, and does not interfere with patients' lifestyle.

Background: In laparoscopic colectomy, overlap anastomosis (OA) is the most standard method of intracorporeal anastomosis. To avoid narrowing the anastomotic area, the closure of the enterotomy is often performed with handsewn running sutures of the monofilament. The purpose of this study was to compare two porcine in vitro colon models of stapled versus handsewn closure of enterotomy in intracorporeal OA.

Methods: In total, 40 porcine in vitro colon OA models (20 cases in the stapled closure, SC group, in which the enterotomy was closed with a stapler, and 20 cases in the handsewn closure with monofilament, HC group) were created, and anastomotic area with maximum intensity projection-computed tomography, anastomotic time, and leakage pressure were measured.

Results: In the anastomotic area, there was no significant difference between in the SC group and HC group (474.0 ± 105.0 mm² versus 502.6 ± 155.6 mm², p = 0.552). The anastomotic time was significantly shorter in the SC group than in the HC group (185.9 ± 38.3 s versus 292.4 ± 67.8 s, p < 0.001). The leakage pressure was significantly higher in the SC group than in the HC group (30.1 ± 3.8 mmHg versus 21.6 ± 5.3 mmHg, p < 0.001).

Conclusions: The findings of this study using porcine in vitro colon model showed that, in OA, the anastomotic area was similar, anastomotic time was significantly shorter, and leakage pressure was significantly higher in SC compared with HC. The results suggest that SC may be superior to HC when performing intracorporeal OA in laparoscopic surgery for colon cancer.

Background: Proper intestinal anastomosis healing in colorectal surgery relies on optimal microcirculation, with surgeons choosing between the hand-sewn and stapled techniques. However, the impact of these methods on the microcirculation remains unclear. This study used laser speckle contrast imaging (LSCI) to objectively assess the impact of hand-sewn and stapled techniques on microcirculation in a porcine model during open surgery and examined microcirculatory changes during hypotension and norepinephrine (NE) correction.

Methods: Ten healthy female pigs underwent midline laparotomy, with one hand-sewn and one stapled anastomosis in both the small intestine and colon. LSCI measurements were obtained before creation (baseline), immediately after anastomosis (T₀), after 1 h of rest (T₆₀), during induced hypotension, and after NE infusion. Measurements were performed directly on the anastomosis, adjacent tissue, and an untouched area of the intestine.

Results: At T₀, microcirculation significantly decreased across all anastomosis types, with hand-sewn anastomoses experiencing a greater decline than stapled anastomoses. An improvement was noted at T₆₀ for all anastomoses. Hypotension worsened microcirculation in all anastomosis types, and NE infusion did not improve microcirculation despite increased and stabilized mean arterial pressure (MAP).

Conclusions: Stapled anastomoses initially exhibited superior microcirculation compared with hand-sewn anastomoses, but the disparity disappeared after 1 h. Hypotension significantly impairs simple anastomotic microcirculation. Moreover, while NE is effective in stabilizing the general blood pressure, it contributed to further diminishment in intestinal microcirculation, especially around anastomoses. Thus, the use of NE postoperatively may be considered a risk factor for anastomotic leakage.

Background: Colorectal cancer (CRC) is a significant health burden, with lymph node dissection (LND) playing a critical role in staging and guiding treatment. However, the optimal extent of LND for the oldest-old population (aged ≥ 90 years) remains undefined because of insufficient targeted clinical data. This study aimed to compare the short-term outcomes of D3 versus non-D3 LND in Stage II-III CRC in oldest-old patients.

Methods: This retrospective cohort study utilized data from the Setouchi Colorectal Neoplasm Registration database, including 282 oldest-old patients with CRC treated between 2011 and 2022. Patients were stratified into D3 and non-D3 LND groups, with inverse-probability-weighted regression adjustment implemented to address potential confounding factors. Postoperative complications and hospital stays were analyzed using regression models and descriptive statistics.

Results: D3 LND resulted in significantly higher lymph node harvests in both Stage II and Stage III patients (p < 0.01). There were no significant differences in overall or major postoperative complications between D3 and non-D3 groups. Hospital stays were comparable for Stage II patients but shorter for Stage III patients in the D3 group (p < 0.01). Complication rates ranged from 28% to 47.7%, with surgical site infections and pneumonia being the most common.

Conclusions: D3 LND can be safely performed in oldest-old patients with CRC without increasing postoperative complications or extending hospital stays. These findings support the feasibility of extensive LND in this age group, but further studies are needed to evaluate its oncological benefits.

Background: Radical resection for mid and low rectal cancer is probably the most challenging type of surgery in colorectal surgery, especially in a narrow male pelvis. In this study, we aimed to define a simple and effective evaluation method based on magnetic resonance imaging (MRI) and body mass index (BMI) to predict the operation difficulty of radical resection for mid and low rectal cancer in male patients.

Methods: A total of 264 male patients who underwent total mesorectal excision (TME) due to primary rectal cancer located in the mid and low rectum (distal tumor margin distance from the anal verge ≤ 7 cm) were retrospectively included in the study. An angle SAU° [formed by two lines: line 1 (connecting the anteroinferior border of the fifth sacral vertebra and center point of anus) and line 2 (connecting internal urethral orifice and center point of anus)] was measured using the built-in software of MRI for every patient. The patients were categorized into four groups according to the angle SAU° and BMI. The operative time, estimated blood loss, TME quality, and anastomotic leakage (AL) were compared between group 1 and group 2 as well as between group 3 and group 4.

Results: Group 1 included 111 patients with angle SAU° > 60 and BMI < 25 kg/m²; group 2 included 51 patients with angle SAU° ≤ 60 and BMI < 25 kg/m²; group 3 included 74 patients with angle SAU° > 60 and BMI ≥ 25 kg/m²; group 4 included 28 patients with angle SAU° ≤ 60 and BMI ≥ 25 kg/m². The operative time, estimated blood loss, and the rate of AL in group 1 and group 3 were significantly less than those in group 2 and group 4, respectively (P < 0.05). Similarly, the TME quality in group 1 and group 3 was significantly better than that in group 2 and group 4, respectively (P < 0.05).

Conclusion: Angle SAU° based on MRI combined with BMI is a simple and effective evaluation method to predict the difficulty in TME for male patients with mid and low rectal cancer. It may also have value in predicting AL.