Techniques in Coloproctology最新文献

Background: In laparoscopic preresection, the use of double anastomosis techniques creates a potential anastomotic angle (called a "dog-ear"), which represents an area with a high incidence of anastomotic leakage.

Methods: This prospective study, conducted from July 2022 to July 2023, ultimately included 471 patients undergoing laparoscopic colorectal cancer surgery using dual anastomosis techniques. Among them, 179 patients had one or two stapled corners removed during the surgery using a modified double stapling technique (MDST), while 292 patients did not have stapled corners removed during surgery using the traditional double stapler technique (DST). The incidence of anastomotic fistula and the probability of anastomotic bleeding within 30 days after operation were analyzed.

Results: In the surgery, 179 patients had one or two dog-ears removed, constituting the MDST group (n = 179). The remaining 292 patients did not have a dog-ear removed, constituting the no dog-ear removal group (DST group, n = 292). Statistical analysis revealed a significant difference between the two groups in terms of anastomotic leakage (6 [3.4%] vs 23 [7.9%]; relative risk 0.426; 95% CI 0.177-1.025; p = 0.047). Additionally, a significant difference was observed in preventing anastomotic bleeding by removing one or both dog-ears (7 [3.9%] vs 30 [10.3%], relative risk 0.381; 95% CI 0.171-0.848; p = 0.013).

Conclusions: This prospective study indicates that removing one or both dog-ears during surgery is beneficial in preventing anastomotic leakage and anastomotic bleeding.

Background: The ANSUR surgical unit^® is a newly formulated robot that plays the roles of both the first assistant and scopist. This surgical unit was approved as a medical device in Japan in 2023. We report the first case of robot-assisted laparoscopic sigmoid resection for sigmoid colon cancer using the ANSUR surgical unit.

Methods: Robot-assisted laparoscopic sigmoid resection using the ANSUR surgical unit was planned for a 69-year-old woman with advanced sigmoid colon cancer.

Results: Tumor resection was successfully completed without conversion to open surgery. The operative time was 147 min, and the estimated blood loss was 36 mL. The roll-in, roll-out, docking, and undocking times were 182, 36, 387, and 41 s, respectively. No mechanical failure or malfunction of the surgical unit was observed. Moreover, no adverse events related to the surgical unit were observed. The patient was discharged 5 days postoperatively without complications. The histopathological diagnosis was T3N1aM0, stage IIIB, with clear proximal and distal resection margins. During follow-up 30 days later, an uneventful patient recovery was noted.

Conclusions: This is the first case of robot-assisted laparoscopic sigmoid resection for sigmoid colon cancer using the ANSUR surgical unit. The procedure was performed with technical and oncological safety.

Background: Robotic-assisted total mesorectal excision (RaTME) and transanal TME (TaTME) are well-established approaches for rectal cancer with promising oncological outcomes. Concerns about postoperative defecatory, urinary, and sexual dysfunction have been raised and the impact on patients' quality of life remained uncertain. This study compared anorectal and urogenital functional outcomes after RaTME and TaTME.

Methods: Patients with mid to low rectal cancer who underwent sphincter-saving surgery between January 2016 and December 2021 were reviewed. Questionnaires regarding low anterior resection syndrome (LARS), Wexner incontinence score, International Prostate Symptom Score (IPSS), and International Index of Erectile Function (IIEF-5) were administered at 1, 3, 6, and 12 months after index operation without stoma or after stoma closure.

Results: Two hundred patients were included with 108 and 92 patients in the RaTME and TaTME group, respectively. After matching, 74 patients were analyzed in each group. LARS scores were significantly lower in the RaTME group than the TaTME group at 6 months (27 [interquartile range (IQR) 13-36] vs 30 [IQR 24-39], p = 0.038) but similar at 12 months (27 [IQR 13-33] vs 29 [IQR 13-36], p = 0.369) after stoma closure. Urinary function deteriorated after both operations but recovered at 6 months after RaTME and 12 months after TaTME. For sexual function, IIEF scores remained similar in the two groups.

Conclusion: RaTME provided better anorectal function with lower LARS score at initial postoperative 6 months but similar after 1 year. Urinary function recovered earlier at 6 months after RaTME while sexual function was comparable between two groups.

Objective: This study aims to compare the clinical efficacy of natural orifice specimen extraction surgery (NOSES) and conventional laparoscopic surgery (CLS) in the treatment of rectal cancer, assessing the advantages and disadvantages of both surgical approaches.

Methods: A propensity score matching (PSM) method was used to analyze 221 patients with rectal cancer treated at Qilu Hospital of Shandong University Dezhou Hospital (Dezhou People's Hospital) from January 2022 to January 2025. The NOSES group included 24 cases, while the CLS group included 197 cases. After 1:1 matching, 46 cases (23 in each group) were included. This study compared surgical time, blood loss, white blood cell count, C-reactive protein (CRP), visual analog scale (VAS) scores, time to passage of flatus, postoperative hospital stay, hospitalization costs, complications, and additional analgesia requirements between the two groups.

Results: The NOSES group showed significant advantages in time to passage of flatus (1.78 ± 0.60 d versus 3.57 ± 1.08 d, P < 0.001), time to get out of bed (1.13 ± 0.34 d versus 1.70 ± 0.47 d, P < 0.001), and VAS scores on postoperative days 1 (1.70 ± 0.56 versus 3.30 ± 1.26, P < 0.001), 3 (1.48 ± 0.51 versus 2.91 ± 1.24, P < 0.001), and 7 (1.13 ± 0.55 versus 2.30 ± 1.36, P < 0.001) compared with the CLS group. The NOSES group also required no additional analgesia (χ² = 9.684, P = 0.002). No significant differences were observed in surgical time, blood loss, or complication rates (P > 0.05).

Conclusions: NOSES effectively alleviates postoperative pain, demonstrates significant minimally invasive advantages, and facilitates short-term patient recovery, highlighting its clinical value.

Background: Patients with lateral lymph node metastasis (LLNM) present particular challenges for both diagnosis and treatment. This study aimed to assess whether indocyanine green (ICG)-assisted lymph node mapping with near-infrared imaging (NIRI) enhances the effectiveness of lateral lymph node dissection (LLND) by further categorizing the lateral lymph nodes in patients with mid-low rectal cancer.

Methods: Submucosal indocyanine green injection was performed on the distal margin of the rectal cancer. In the ICG-LLND group, the lymphatic drainage pathway and distribution of lateral lymph nodes (LLNs) were explored using a laparoscopic NIRI system. Pathological evaluations were conducted for both the ICG-LLND group and the control group.

Results: The ICG-LLND group demonstrated a significantly shorter postoperative hospital stay compared to the control group, both before (P < 0.001) and after (P = 0.001) matching. While blood loss and operating time were similar between groups, the ICG-LLND group had fewer cases of anastomotic leakage (P = 0.206). Postoperative lymph node harvesting was significantly higher in the ICG-LLND group, with more total lymph nodes (P = 0.001) and lateral lymph nodes (P = 0.002) harvested. The number of harvested lymph nodes in the obturator and internal iliac regions was also higher in the ICG-LLND group (P = 0.001), and the number of positive lymph nodes in these regions was significantly greater before (P = 0.027) and after (P = 0.013) matching. Univariate and multivariate analyses showed that ICG-LLND, nCRT, and positive pN stage were associated with increased lymph node harvest.

Conclusions: ICG-LLND improved lateral lymph node harvest, particularly obturator lymph nodes, and shortened postoperative hospital stay without increasing complications. This technique may enhance surgical outcomes in patients requiring lymph node dissection.

Background: Postoperative benign anastomotic rectal stenosis (BAS) has a significant incidence rate (2-30%). Recently, it has been shown that its incidence decreases with a larger anastomotic diameter (≥ 31 mm). The level of awareness of this data and the interest in creating an intraoperative anastomotic dilation system remain unknown. The aim of the study is to evaluate, using a survey sent to Spanish colorectal surgeons, the knowledge of postoperative strictures in rectal surgery as well as the use of methods to prevent them.

Methods: An observational cross-sectional study was conducted using a survey sent to 101 colorectal surgeons from 49 colorectal surgery units in Spanish hospitals in June 2024.

Results: Eighty-seven responses were obtained (86.1%); 39 (44.8%) were aware of their BAS rate, 41 (47.1%) recognized it as similar to the rate reported by our group (16.3%), and 82 (94.3%) considered this rate too high. Regarding mechanical sutures, none used 25-mm sutures, 43/87 (49.4%) used 28-29-mm sutures, 39/87 (44.8%) used 31-mm sutures, and only 5/87 (5.7%) used 33-mm sutures; 72.4% (63/87) were unaware of the existence of dilation mechanisms, while 15 (17.2%) knew about or used some type of device. In an ideal dilation situation, mechanical dilation (60%) predominated over pneumatic, although the same number of surgeons would choose to use dilators (21/87) as would opt not to use them (22/87). Forty-three of 87 (43.9%) would tend to use larger anastomotic diameters (31 mm).

Conclusions: There is a significant lack of knowledge about the incidence of BAS and its relationship with the anastomotic diameter. Increased awareness of these issues is needed, aiming to use the widest possible mechanical sutures (> 31 mm) and considering the need for dilation devices to reduce the incidence of BAS.

Background: Indocyanine green fluorescence angiography (ICG-FA) in colorectal surgery allows changing the section line (CSL) based on objective evaluation of the vascular supply. The aim of this prospective study is to report our experience with CSL based on ICG-FA during colorectal surgery and to report risk factors influencing it.

Methods: From 2014 to 2023, all patients who underwent any colorectal surgical procedure with anastomosis and ICG-FA were enrolled. Patients for whom changing the section line based on ICG-FA was not necessary were included in group A, and patients for whom ICG-FA determined a CSL were included in group B.

Results: Four hundred consecutive patients underwent laparoscopic surgery, except for two. In 334 patients (group A, 83.5%), CSL based on ICG-FA did not occur, while CSL occurred in 66 patients (group B, 16.5%). In group B, median time from ICG injection and fluorescence visualization (TIFV) was statistically significantly longer than in group A (28.5 s versus 23 s, p = 0.003). Anastomotic leakage rate was 1.8% and 4.5% in group A and B, respectively, without a statistically significant difference. The multivariate logistic regression analysis identified age > 60 years and TIFV ≥ 20 s as independent risk factors for CSL.

Conclusions: Factors influencing the CSL are identified, which could be useful to determine the cases in which this technology should be mandatory and to consider when ICG is not available. These factors could also influence the decision-making process during surgery, such as using protective ileostomy.

Background: The optimal surgical approach for chronic pilonidal sinus disease (PSD) remains unclear, resulting in variation in surgical practice. This study aimed to provide an overview of PSD subtypes and assess practice variation and short-term outcomes.

Methods: A nationwide prospective observational cohort study was conducted. All patients with PSD and who underwent surgery were included during a 3-month inclusion period between March 1, 2020 and March 1, 2021. Primary endpoints were PSD classification and type and frequency of surgical approach. Secondary endpoints included symptoms, complications, recurrent open wounds, wound healing rate, time to wound healing, time to resume daily activities, reasons for selecting therapy, antibiotic prophylaxis, type of anesthesia, and hospital admission.

Results: A total of 36 hospitals participated in the study, and 405 patients had chronic disease. The median follow-up period was 42 days. Mean age was 28 years and 335 (82.7%) patients were male. Simple (n = 213) and complex PSD (n = 192) was equally common. Twelve different treatment modalities were performed. Minimally invasive techniques were used the most (61.2%) and off-midline closure in only a small proportion of patients (5.7%). Minimally invasive techniques showed a significantly higher wound healing rate (41.1% vs 28.6%) and a shorter median time to closure (41 vs 78 days) compared to excision with secondary healing. They also had the shortest median time to resume daily activities (14 days).

Conclusions: Simple and complex PSD were equally common. Practice variation in surgery is substantial. Minimally invasive techniques were most frequently performed and showed good short-term outcomes.

Background: Postoperative complications in colorectal surgery can significantly impact patient outcomes and healthcare costs. Accurate prediction of these complications enables targeted perioperative management, improving patient safety and optimizing resource allocation. This study evaluates the application of machine learning (ML) models, particularly deep learning neural networks (DLNN), in predicting postoperative complications following laparoscopic right hemicolectomy for colon cancer.

Methods: Data were drawn from the CoDIG (ColonDx Italian Group) multicenter database, which includes information on patients undergoing laparoscopic right hemicolectomy with complete mesocolic excision (CME) and central vascular ligation (CVL). The dataset included demographic, clinical, and surgical factors as predictors. Models such as decision trees (DT), random forest (RF), and DLNN were trained, with DLNN evaluated using cross-validation metrics. To address class imbalance, the synthetic minority over-sampling technique (SMOTE) was employed. The primary outcome was the prediction of postoperative complications within 1 month of surgery.

Results: The DLNN model outperformed other models, achieving an accuracy of 0.86, precision of 0.84, recall of 0.90, and an F1 score of 0.87. Relevant predictors identified included intraoperative minimal bleeding, blood transfusion, and adherence to the fast-track recovery protocol. The absence of intraoperative bleeding, intracorporeal anastomosis, and fast-track protocol adherence were associated with a reduced risk of complications.

Conclusion: The DLNN model demonstrated superior predictive performance for postoperative complications compared to other ML models. The findings highlight the potential of integrating ML models into clinical practice to identify high-risk patients and enable tailored perioperative care. Future research should focus on external validation and implementation of these models in diverse clinical settings to further optimize surgical outcomes.