Postoperative complications following surgery for rectal cancer. Ann Surg. 2010;251:807-818. [PMID: 20395841 DOI: 10.1097/sla.0b013e3181dae4ed]

Early versus late closure of protective loop ileostomy: functional significant results in a preliminary analysis

BACKGROUND

Protective loop ileostomy (PLI), commonly performed in rectal cancer surgery, is one of the most reliable methods to reduce the risk of sepsis associated with anastomotic complications. The correct timing of PLI closure is not well defined. Recently, most surgeons proposed to close early the PLI. The aim of this study was to evaluate the impact of the timing of stoma closure on postoperative outcomes.

METHODS

We analyzed prospectively data of patients who received PLI anterior resection for rectal cancer between January 2020 to June 2022. Patients were divided into 2 groups according to the timing of stoma closure, until four weeks (EC group) and more than four weeks (LC group). Outpatient clinic follow-up, perioperative data, postoperative complications and evidence of anterior resection syndrome with the Low-Anterior Resection Score (LARS) score were recorded.

RESULTS

In the EC group 24 patients were included while 27 patients were considered for LC group. There were no differences between the groups with respect to all parameters, except for recourse to adjuvant therapy, higher for LC group. Perioperative analyzed characteristics were similar among groups. There was no statistically significant difference between the EC group and the LC group for complication rate. LARS score was higher in the LC group for score >20 and >30.

CONCLUSIONS

Timing of PLI closure was not a significant independent predictor of post-closure complications rate. LARS incidence was significantly related to longer time of closure, with probably late recovery of motility function, but this should be confirmed by randomized studies.

Predictors of early colorectal cancer metastasis to lymph nodes: providing rationale for therapy decisions

With the improvement of national health awareness and the popularization of a series of screening methods, the number of patients with early colorectal cancer is gradually increasing, and accurate prediction of lymph node metastasis of T1 colorectal cancer is the key to determining the optimal therapeutic solutions. Whether patients with T1 colorectal cancer undergoing endoscopic resection require additional surgery and regional lymph node dissection is inconclusive in current guidelines. However, we can be sure that in early colorectal cancer without lymph node metastasis, endoscopic resection alone does not affect the prognosis, and it greatly improves the quality of life and reduces the incidence of surgical complications while preserving organ integrity. Therefore, it is vital to discriminate patients without lymph node metastasis in T1 colorectal cancer, and this requires accurate predictors. This paper briefly explains the significance and shortcomings of traditional pathological factors, then extends and states the new pathological factors, clinical test factors, molecular biomarkers, and the risk assessment models of lymph node metastasis based on artificial intelligence.

Oncological outcomes of local excision versus radical surgery for early rectal cancer in the context of staging and surveillance: A systematic review and meta-analysis

BACKGROUND

Local resection (LR) methods for rectal cancer are generally considered in the palliative setting or for patients deemed a high anaesthetic risk. This systematic review and meta-analysis aimed to compare oncological outcomes of LR and radical resection (RR) for early rectal cancer in the context of staging and surveillance assessment.

METHODS

A literature search of MEDLINE, Embase and Emcare databases was performed for studies that reported data on clinical outcomes for both LR and RR for early rectal cancer from January 1995 to April 2023. Meta-analysis was performed using random-effect models and between-study heterogeneity was assessed. The quality of assessment was assessed using the Newcastle-Ottawa Scale for observational studies and the Cochrane Risk of Bias 2.0 tool for randomised controlled trials.

RESULTS

Twenty studies with 12,022 patients were included: 6,476 patients had LR and 5,546 patients underwent RR. RR led to an improvement in 5-year overall survival (OR 1.84; 95 % CI 1.54-2.20; p < 0.0001; I2 20 %) and local recurrence (OR 3.06; 95 % CI 2.02-4.64; p < 0.0001; I2 39 %) when compared to LR. However, when staging and surveillance methods were clearly adopted in LR cases, there was an improvement in R0 rates (96.7 % vs 85.6 %), 5-year disease-free survival (93.0 % vs 77.9 %) and overall survival (81.6 % vs 79.0 %) compared to when staging and surveillance was not reported/performed.

CONCLUSIONS

LR may be appropriate for selected patients without poor prognostic factors in early rectal cancer. This study also highlights that there is currently no single standardised staging or surveillance approach being adopted in the management of early rectal cancer. A more specified and standardised preoperative staging for patient selection as well as clinical and image-based surveillance protocols is needed.

Point/Counterpoint #2: Current Clinical Considerations With Nonoperative Management of Rectal Cancer

ABSTRACT

Locally advanced rectal cancer has historically been treated with multimodal therapy consisting of radiation therapy, chemotherapy, and total mesorectal excision. However, recent prospective trials and registry studies have demonstrated similar disease outcomes with nonoperative management for patients who experience an excellent clinical response to radiation and chemotherapy. This article reviews data regarding nonoperative management for rectal cancer, and highlights current challenges and limitations in a point-counterpoint format, in the context of two clinical cases.

High Rates of Organ Preservation in Rectal Cancer with Papillon Contact X-ray Radiotherapy: Results from a Swiss Cohort

Rectal cancer typically necessitates a combination of radiotherapy (RT), chemotherapy, and surgery. The associated functional disorders and reduction in quality of life have led to an increasing interest in organ preservation strategies. Response strongly correlates with RT dose, but dose escalation with external beam remains limited even with modern external beam RT techniques because of toxicity of the surrounding tissues. This study reports on the use of Papillon, an endocavitary Radiotherapy device, in the treatment of rectal cancer. The device delivers low energy X-rays, allowing for safe dose escalation and better complete response rate. Between January 2015 and February 2024, 24 rectal cancer patients were treated with the addition of a boost delivered by Papillon to standard RT, with or without chemotherapy, in an upfront organ preservation strategy. After a median follow-up (FU) of 43 months, the organ preservation rate was 96% (23/24), and the local relapse rate was 8% (2/24). None of our patients developed grade 3 or more toxicities. Our results demonstrate that the addition of Papillon contact RT provides a high rate of local remission with sustained long-term organ preservation, offering a promising alternative to traditional surgical approaches in patients with rectal cancer.

Cohort profile of BIGPROMISE: a perioperative biobank of a high-risk surgical population

PURPOSE

Postoperative complications increase mortality, disability and costs. Advanced understanding of the risk factors for postoperative complications is needed to improve surgical outcomes. This paper discusses the rationale and profile of the BIGPROMISE (biomarkers to guide perioperative management and improve outcome in high-risk surgery) cohort, that aims to investigate risk factors, pathophysiology and outcomes related to postoperative complications.

PARTICIPANTS

Adult patients undergoing major surgery in two tertiary teaching hospitals. Clinical data and blood samples are collected before surgery, at the end of surgery and on the first, second and third postoperative day. At each time point a panel of cardiovascular, inflammatory, renal, haematological and metabolic biomarkers is assessed. Aliquots of plasma, serum and whole blood of each time point are frozen and stored. Data on severe complications are prospectively collected during 30 days after surgery. Functional status is assessed before surgery and after 120 days using the WHO Disability Assessment Schedule (WHODAS) 2.0. Mortality is followed up until 2 years after surgery.

FINDINGS TO DATE

The first patient was enrolled on 8 October 2021. Currently (1 January 2024) 3086 patients were screened for eligibility, of whom 1750 (57%) provided informed consent for study participation. Median age was 66 years (60; 73), 28% were female, and 68% of all patients were American Society of Anaesthesiologists (ASA) physical status class 3. Most common types of major surgery were cardiac (49%) and gastro-intestinal procedures (26%). The overall incidence of 30-day severe postoperative complications was 16%.

FUTURE PLANS

By the end of the recruitment phase, expected in 2026, approximately 3000 patients with major surgery will have been enrolled. This cohort allows us to investigate the role of pathophysiological perioperative processes in the cause of postoperative complications, and to discover and develop new biomarkers to improve risk stratification for adverse postoperative outcomes.

TRIAL REGISTRATION NUMBER

NCT05199025.

Effectiveness of anastomotic reinforcement sutures in reducing anastomotic leakage risk after laparoscopic rectal cancer surgery: a pooled and integration analysis

Background and objectives

Anastomotic leakage (AL) is one of the most serious complications after laparoscopic anus-preserving surgery for rectal cancer, which significantly prolongs the patient's hospital stay, leads to dysfunction, and even increases the patient's perioperative morbidity and mortality, and little is known about the effectiveness of anastomotic reinforcement sutures to prevent AL. Thus, this study was conducted to evaluate the efficacy of anastomotic reinforcement sutures as a means to prevent AL during laparoscopic surgery for rectal cancer.

Methods

A comprehensive and systematic search was performed in the literature database by combining subject and free terms up to 10 October 2023. The overall literature included was integrated and analyzed using Stata 12.0 software and Review Manager version 5.4 software to assess the effect of anastomotic reinforcement sutures on the incidence of AL.

Results

A total of 2,452 patients from 14 studies were included, and an integrated analysis showed that the use of anastomotic reinforcement sutures significantly reduced the incidence of AL [odds ratio (OR) = 0.26; 95% confidence interval (CI), 0.18-0.37; P < 0.00001; I2 = 0%]. However, the findings confirmed whether or not the anastomosis reinforced with sutures did not affect the incidence of anastomotic stenosis (OR = 0.69; 95% CI, 0.37-1.32; P = 0.27; I2 = 0%). We performed subgroup analyses of the results of the study, the randomized controlled studies (OR = 0.31; 95% CI, 0.15-0.65; P < 0.001) as well as retrospective studies (OR = 0.28; 95% CI, 0.19-0.41; P < 0.001), 3-0 sutures (OR = 0.28; 95% CI, 0.17-0.45; P < 0.001) versus 4-0 sutures (OR = 0.26; 95% CI, 0.13-0.53; P < 0.001), barbed wire sutures (OR = 0.26; 95% CI, 0.14-0.48; P < 0.001) versus non-barbed wire sutures (OR = 0.30; 95% CI, 0.20-0.46; P < 0.001), interrupted (OR = 0.30, 95% CI, 0.20-0.46; P < 0.001) versus continuous sutures (OR = 0.29, 95% CI, 0.16-0.51; P < 0.001) to the anastomosis, full-thickness suture (OR = 0.29; 95% CI, 0.16-0.51; P < 0.001) versus sutured with the seromuscular layer (OR = 0.27; 95% CI, 0.14-0.53; P < 0.001), anastomotic sutured in one (OR = 0.27; 95% CI, 0.14-0.53; P < 0.001) versus non-one circle (OR = 0.30; 95% CI, 0.20-0.44; P < 0.001), and reinforcing sutures to the dog-ear area (OR = 0.26; 95% CI, 0.14-0.50; P < 0.001) versus the non-dog-ear area (OR = 0.30; 95% CI, 0.20-0.45; P < 0.001), which have suggested that there is no significant difference between each other and that all of them reduce the incidence of AL.

Conclusions

This study provides evidence that performing reinforcement suturing of the anastomosis during laparoscopic rectal surgery significantly lowers the incidence of postoperative AL but has no significant effect on anastomotic stenosis. It is important to note that further randomized controlled studies are required to confirm this conclusion.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42022368631.

Robotic transanal minimally invasive surgery (r-TAMIS): perioperative and short-term outcomes for local excision of rectal cancers

BACKGROUND

Transanal minimally invasive surgery (TAMIS) is an advanced technique for excision of early rectal cancers. Robotic TAMIS (r-TAMIS) has been introduced as technical improvement and potential alternative to total mesorectal excision (TME) in early rectal cancers and in frail patients. This study reports the perioperative and short-term oncological outcomes of r-TAMIS for local excision of early-stage rectal cancers.

METHODS

Retrospective analysis of a prospectively collected r-TAMIS database (July 2021-July 2023). Demographics, clinicopathological features, short-term outcomes, recurrences, and survival were investigated.

RESULTS

Twenty patients were included. Median age and body mass index were 69.5 (62.0-77.7) years and 31.0 (21.0-36.5) kg/m2. Male sex was prevalent (n = 12, 60.0%). ASA III accounted for 66.7%. Median distance from anal verge was 7.5 (5.0-11.7) cm. Median operation time was 90.0 (60.0-112.5) minutes. Blood loss was minimal. There were no conversions. Median postoperative stay was 2.0 (1.0-3.0) days. Minor and major complication rates were 25.0% and 0%, respectively. Seventeen (85.0%) patients had an adenocarcinoma whilst three patients had an adenoma. R0 rate was 90.0%. Most tumours were pT1 (55.0%), followed by pT2 (25.0%). One patient (5.0%) had a pT3 tumour. Specimen and tumour maximal median diameter were 51.0 (41.0-62.0) mm and 21.5 (17.2-42.0) mm, respectively. Median specimen area was 193.1 (134.3-323.3) cm2. Median follow-up was 15.5 (10.0-24.0) months. One patient developed local recurrence (5.0%).

CONCLUSIONS

r-TAMIS, with strict postoperative surveillance, is a safe and feasible approach for local excision of early rectal cancer and may have a role in surgically unfit and elderly patients who refuse or cannot undergo TME surgery. Future prospective multicentre large-scale studies are needed to report the long-term oncological outcomes.

Evaluating Postoperative Prognosis: A Single Surgeon's Experience With Total Mesorectal Excision in Middle and Lower Rectal Cancer Cases in Iraq

INTRODUCTION

Surgical intervention for rectal cancer is widely recognized for its potential to significantly impact quality of life, chiefly due to the high probability of permanent colostomy and the associated postoperative complications.

OBJECTIVE

This study aimed to evaluate the short-term outcomes and morbidity associated with total mesorectal excision for middle and lower rectal cancer within an Iraqi cohort, in a prospective setting.

METHODS

This study prospectively collected and analyzed data from 89 patients who underwent a standardized radical rectal resection, with a follow-up period extending to one month post-surgery.

RESULTS

The mean age of patients was 54.4 ± 12.9 years, with a gender distribution of 46 males and 43 females. A total of 33 patients presented with preoperative comorbidities, which heightened the risk of adverse short-term outcomes by a factor of 7.51. The most prevalent comorbidities were hypertension and diabetes mellitus, affecting 22 and 20 patients, respectively. Patients aged 60 years and above were at a 3.97 times greater risk of developing complications. The overall complication rate was 21.35%, with wound infections (9.0%) and cardiovascular events (3.4%) being the most common. Mortality during the follow-up was 1.1%.

CONCLUSION

The findings indicate that increased age and the presence of comorbidities are significant risk factors for morbidity and mortality post-surgery. Neoadjuvant chemoradiotherapy or radiotherapy was shown to reduce morbidity and mortality rates while improving survival. The morbidity and mortality rates observed in this study concur with existing literature.

Outcome variation and the role of caseload in certified colorectal cancer centers - a retrospective cohort analysis of 90 000 cases

BACKGROUND

Studies have shown that surgical treatment of colorectal carcinomas in certified centers leads to improved outcomes. However, there were considerable fluctuations in outcome parameters. It has not yet been examined whether this variability is due to continuous differences between hospitals or variability within a hospital over time.

MATERIALS AND METHODS

In this retrospective observational cohort study, administrative quality assurance data of 153 German-certified colorectal cancer centers between 2010 and 2019 were analyzed. Six outcome quality indicators (QIs) were studied: 30-day postoperative mortality (POM) rate, surgical site infection (SSI) rate, anastomotic insufficiency (AI) rate, and revision surgery (RS) rate. AI and RS were also analyzed for colon (C) and rectal cancer operations (R). Variability was analyzed by funnel plots with 95% and 99% control limits and modified Cleveland dot plots.

RESULTS

In the 153 centers, 90 082 patients with colon cancer and 47 623 patients with rectal cancer were treated. Average QI scores were 2.7% POM, 6.2% SSI, 4.8% AI-C, 8.5% AI-R, 9.1% RS-C, and 9.8% RS-R. The funnel plots revealed that for every QI, about 10.1% of hospitals lay above the upper 99% and about 8.7% below the lower 99% control limit. In POM, SSI, and AI-R, a significant negative correlation with the average annual caseload was observed.

CONCLUSION

The analysis showed high variability in outcome quality between and within the certified colorectal cancer centers. Only a small number of hospitals had a high performance on all six QIs, suggesting that significant quality variation exists even within the group of certified centers.

Applications of endoscopic vacuum therapy in the lower gastrointestinal tract: Tips and tricks and a review of the literature

Endoscopic vacuum therapy (EVT) is an established technique for the treatment of rectal wall defects and especially anastomotic leaks. A wide range of EVT devices, both handmade and commercially available, allow for their successful placement even in small defects and difficult localizations. Reported success rates range between 85 and 97 %, while periintervenional morbidity is low and major adverse events are very rare. EVT has proven its effectiveness in the lower gastrointestinal tract and is now considered first line treatment for pelvic anastomotic leaks. This narrative review summarizes the current literature on EVT in the lower gastrointestinal tract, focusing on its indications, technical aspects and results, and offers tips and tricks for its clinical applications.

"WATCH AND WAIT" STRATEGY IN RECTAL CANCER PATIENTS WITH A COMPLETE CLINICAL RESPONSE AFTER NEOADJUVANT CHEMORADIATION THERAPY: A SINGLE-CENTER EXPERIENCE

BACKGROUND

The non-operative management of rectal adenocarcinoma (RA) after neoadjuvant chemoradiation therapy (nCRT) has gained increasing attention. The "Watch and Wait" ("W&W") strategy allows one to avoid surgery-related reduction in the quality of life due to permanent pelvic organ dysfunction or irreversible stoma. Still, the oncological safety of this strategy is under evaluation.

AIM

To share a single-center experience of the "W&W" strategy.

MATERIALS AND METHODS

The retrospective analysis of 125 patients who received nCRT in 2016-2021 was performed. Patients who met the European Society for Medical Oncology (ESMO, 2017) criteria of clinical complete response (cCR) and received non-operative management were analyzed.

RESULTS

Ten patients (8%) were re-staged after nCRT as cCR and followed the "W&W" strategy. Patients' characteristics: 7 female, 3 male; mean age 67.3 years. Tumor characteristics: pre-treatment N+ was present in 7 cases; G1 adenocarcinoma in a majority of cases; mean tumor distance from the anal verge - 5.85 cm; mean tumor circumference - 71%; mean tumor length - 3.87 cm. The mean follow-up time was 30 months. Local regrowth or/and distant metastases developed in 3 cases. The 2-year disease-free survival was 70%.

CONCLUSIONS

Most of the patients following the "W&W" strategy have benefited. However, to reduce the number of relapses, it is necessary to perform a more careful selection of patients.

Updates on the Management of Colorectal Cancer in Older Adults

Colorectal cancer (CRC) poses a significant global health challenge. Notably, the risk of CRC escalates with age, with the majority of cases occurring in those over the age of 65. Despite recent progress in tailoring treatments for early and advanced CRC, there is a lack of prospective data to guide the management of older patients, who are frequently underrepresented in clinical trials. This article reviews the contemporary landscape of managing older individuals with CRC, highlighting recent advancements and persisting challenges. The role of comprehensive geriatric assessment is explored. Opportunities for treatment escalation/de-escalation, with consideration of the older adult's fitness level. are reviewed in the neoadjuvant, surgical, adjuvant, and metastatic settings of colon and rectal cancers. Immunotherapy is shown to be an effective treatment option in older adults who have CRC with microsatellite instability. Promising new technologies such as circulating tumor DNA and recent phase III trials adding later-line systemic therapy options are discussed. Clinical recommendations based on the data available are summarized. We conclude that deliberate efforts to include older individuals in future colorectal cancer trials are essential to better guide the management of these patients in this rapidly evolving field.

Development and validation of machine learning models and nomograms for predicting the surgical difficulty of laparoscopic resection in rectal cancer

BACKGROUND

The objective of this study is to develop and validate a machine learning (ML) prediction model for the assessment of laparoscopic total mesorectal excision (LaTME) surgery difficulty, as well as to identify independent risk factors that influence surgical difficulty. Establishing a nomogram aims to assist clinical practitioners in formulating more effective surgical plans before the procedure.

METHODS

This study included 186 patients with rectal cancer who underwent LaTME from January 2018 to December 2020. They were divided into a training cohort (n = 131) versus a validation cohort (n = 55). The difficulty of LaTME was defined based on Escal's et al. scoring criteria with modifications. We utilized Lasso regression to screen the preoperative clinical characteristic variables and intraoperative information most relevant to surgical difficulty for the development and validation of four ML models: logistic regression (LR), support vector machine (SVM), random forest (RF), and decision tree (DT). The performance of the model was assessed based on the area under the receiver operating characteristic curve(AUC), sensitivity, specificity, and accuracy. Logistic regression-based column-line plots were created to visualize the predictive model. Consistency statistics (C-statistic) and calibration curves were used to discriminate and calibrate the nomogram, respectively.

RESULTS

In the validation cohort, all four ML models demonstrate good performance: SVM AUC = 0.987, RF AUC = 0.953, LR AUC = 0.950, and DT AUC = 0.904. To enhance visual evaluation, a logistic regression-based nomogram has been established. Predictive factors included in the nomogram are body mass index (BMI), distance between the tumor to the dentate line ≤ 10 cm, radiodensity of visceral adipose tissue (VAT), area of subcutaneous adipose tissue (SAT), tumor diameter >3 cm, and comorbid hypertension.

CONCLUSION

In this study, four ML models based on intraoperative and preoperative risk factors and a nomogram based on logistic regression may be of help to surgeons in evaluating the surgical difficulty before operation and adopting appropriate responses and surgical protocols.

Preoperative risk factors and cumulative incidence of temporary ileostomy non-closure after sphincter-preserving surgery for rectal cancer: a meta-analysis

BACKGROUND

Temporary ileostomy (TI) has proven effective in reducing the severity of anastomotic leakage after rectal cancer surgery; however, some ileostomies fail to reverse over time, leading to conversion into a permanent stoma (PS). In this study, we aimed to investigate the preoperative risk factors and cumulative incidence of TI non-closure after sphincter-preserving surgery for rectal cancer.

MATERIALS AND METHODS

We conducted a meta-analysis after searching the Embase, Web of Science, PubMed, and MEDLINE databases from their inception until November 2023. We collected all published studies on the risk factors related to TI non-closure after sphincter-preserving surgery for rectal cancer.

RESULTS

A total of 1610 studies were retrieved, and 13 studies were included for meta-analysis, comprising 3026 patients. The results of the meta-analysis showed that the identified risk factors included older age (p = 0.03), especially > 65 years of age (p = 0.03), male sex (p = 0.009), American Society of Anesthesiologists score ≥ 3 (p = 0.004), comorbidity (p = 0.001), and distant metastasis (p < 0.001). Body mass index, preoperative hemoglobin, preoperative albumin, preoperative carcinoma embryonic antigen, tumor location, neoadjuvant chemoradiotherapy, smoking, history of abdominal surgery, and open surgery did not significantly change the risk of TI non-closure.

CONCLUSION

We identified five preoperative risk factors for TI non-closure after sphincter-preserving surgery for rectal cancer. This information enables surgeons to identify high-risk groups before surgery, inform patients about the possibility of PS in advance, and consider performing protective colostomy or Hartmann surgery.

Component separation repair of incisional hernia: evolution of practice and review of long-term outcomes in a single center

PURPOSE

To review the long-term outcomes of complex abdominal wall reconstruction using anterior and posterior component separation (CS) techniques in our center.

METHODS

This was a descriptive analytical study. Analysis of data from a prospectively collected database of patients who had undergone Component Separation (CS) repair of incisional hernias was performed. Two techniques were used. Anterior component separation (ACS) and posterior component separation with transversus abdominis release (PCS/TAR). Follow-up was clinical review at 6 weeks, 6 months, and 12 months with direct access telephone review thereafter. Long-term outcome data was obtained from electronic records and based on either clinical or CT assessment. Minimum physical follow-up was 6 months for all patients.

RESULTS

89 patients with large incisional hernias underwent CS repair. 29 patients had ACS while 60 underwent PCS/TAR. Mean follow-up was 60 months (range 6-140 months) in the ACS group and 20 months (range 6-72 months) in the PCS group. Twenty-five patients (28%) had simultaneous major procedures including 21 intestinal anastomoses. Twenty-six (29%) of patients had associated stomas. Twenty-seven (30.3%) of the patients had undergone previous hernia repairs. Seromas occurred in 24 (26.97%) patients. Wound infections were more common after ACS. There have been 10 (11.2%) recurrences to date.

CONCLUSION

Component separation repair techniques result in good long-term outcomes with acceptable complication rates. They can be performed simultaneously with gastrointestinal procedures with low morbidity. Appropriate patient selection and use of appropriate mesh are important.

Interdisciplinary Spanish consensus on a watch-and-wait approach for rectal cancer

Watch-and-wait has emerged as a new strategy for the management of rectal cancer when a complete clinical response is achieved after neoadjuvant therapy. In an attempt to standardize this new clinical approach, initiated by the Spanish Cooperative Group for the Treatment of Digestive Tumors (TTD), and with the participation of the Spanish Association of Coloproctology (AECP), the Spanish Society of Pathology (SEAP), the Spanish Society of Gastrointestinal Endoscopy (SEED), the Spanish Society of Radiation Oncology (SEOR), and the Spanish Society of Medical Radiology (SERAM), we present herein a consensus on a watch-and-wait approach for the management of rectal cancer. We have focused on patient selection, the treatment schemes evaluated, the optimal timing for evaluating the clinical complete response, the oncologic outcomes after the implementation of this strategy, and a protocol for surveillance of these patients.

Development and validation of a nomogram to predict the risk factors of major complications after radical rectal cancer surgery

Purpose

The aim of this study was to establish a validated nomogram to predict risk factors for major post-operative complications in patients with rectal cancer (RC) by analyzing the factors contributing to major post-operative complications in RC patients.

Methods

We retrospectively collected baseline and surgical information on patients who underwent RC surgery between December 2012 and December 2022 at a single-center teaching hospital. The entire cohort was randomly divided into two subsets (60% of the data for development, 40% for validation). Independent risk factors for major post-operative complications were identified using multivariate logistic regression analyses, and predictive models were developed. Area under the curve (AUC) was calculated using receiver operating characteristic curve (ROC) to assess predictive probability, calibration curves were plotted to compare the predicted probability of the nomogram with the actual probability, and the clinical efficacy of the nomogram was assessed using decision curve analysis (DCA).

Results

Our study included 3151 patients who underwent radical surgery for RC, including 1892 in the development set and 1259 in the validation set. Forty (2.1%) patients in the development set and 26 (2.1%) patients in the validation set experienced major post-operative complications. Through multivariate logistic regression analysis, age (p<0.01, OR=1.044, 95% CI=1.016-1.074), pre-operative albumin (p<0.01, OR=0.913, 95% CI=0.866-0.964), and open surgery (p<0.01, OR=2.461, 95% CI=1.284-4.761) were identified as independent risk factors for major post-operative complications in RC, and a nomogram prediction model was established. The AUC of the ROC plot for the development set was 0.7161 (95% Cl=0.6397-0.7924), and the AUC of the ROC plot for the validation set was 0.7191 (95% CI=0.6182-0.8199). The predicted probabilities in the calibration curves were highly consistent with the actual probabilities, which indicated that the prediction model had good predictive ability. The DCA also confirmed the good clinical performance of the nomogram.

Conclusion

In this study, a validated nomogram containing three predictors was created to identify risk factors for major complications after radical RC surgery. Due to its accuracy and convenience, it could contribute to personalized management of patients in the perioperative period.

Poly-ϵ-caprolactone scaffold as staple-line reinforcement of rectal anastomosis: an experimental piglet study

PURPOSE

Rectal anastomoses have a persisting high incidence of anastomotic leakage. This study aimed to assess whether the use of a poly-ϵ-caprolactone (PCL) scaffold as reinforcement of a circular stapled rectal anastomosis could increase tensile strength and improve healing compared to a control in a piglet model.

METHOD

Twenty weaned female piglets received a stapled rectal anastomosis and were randomised to either reinforcement with PCL scaffold (intervention) or no reinforcement (control). On postoperative day five the anastomosis was subjected to a tensile strength test followed by a histological examination to evaluate the wound healing according to the Verhofstad scoring.

RESULTS

The tensile strength test showed no significant difference between the two groups, but histological evaluation revealed significant impaired wound healing in the intervention group.

CONCLUSION

The incorporation of a PCL scaffold into a circular stapled rectal anastomosis did not increase anastomotic tensile strength in piglets and indicated an impaired histologically assessed wound healing.

Endoscopic Predictors of Residual Tumor After Total Neoadjuvant Therapy: A Post Hoc Analysis From the Organ Preservation in Rectal Adenocarcinoma Trial

BACKGROUND

Restaging endoscopy plays a critical role in selecting patients with locally advanced rectal cancer who respond to neoadjuvant therapy for nonoperative management.

OBJECTIVE

This study evaluated the restaging endoscopic features that best predict the presence of residual tumor in the bowel wall.

DESIGN

This was a post hoc analysis of a prospective randomized trial.

SETTINGS

The Organ Preservation in Rectal Adenocarcinoma Trial randomly assigned patients across 18 institutions with stage II/III rectal adenocarcinoma to receive either induction or consolidation total neoadjuvant therapy. Surgeons completed a restaging tumor assessment form, which stratified patients across 3 tiers of clinical response.

PATIENTS

Patients enrolled in the Organ Preservation in Rectal Adenocarcinoma Trial with a completed tumor assessment form were included.

MAIN OUTCOME MEASURES

The main outcome was residual tumor, which was defined as either an incomplete clinical response or local tumor regrowth within 2 years of restaging. Independent predictors of residual tumor were identified using backward-selected multivariable logistic regression analysis. Subgroup analyses for complete and near complete clinical responders were performed.

RESULTS

Surgeons completed restaging forms for 263 patients at a median of 7.7 weeks after neoadjuvant therapy; 128 patients (48.7%) had a residual tumor. On multivariable regression analysis, several characteristics of a near complete response, including ulcer (OR 6.66; 95% CI, 2.54-19.9), irregular mucosa (OR 3.66; 95% CI, 1.61-8.68), and nodularity (OR 2.96; 95% CI, 1.36-6.58), remained independent predictors of residual tumor. A flat scar was associated with lower odds of harboring residual disease (OR 0.32; 95% CI, 0.11-0.93) for patients categorized as clinical complete responders.

LIMITATIONS

Limitations include analysis of endoscopic features at a single time point and ambiguities in tumor assessment form response criteria.

CONCLUSIONS

Patients with ulcer, nodularity, or irregular mucosa, on restaging endoscopy have higher odds of residual tumor. Recognizing negative prognostic implications of these features will help surgeons better select candidates for nonoperative management and suggests that patients with high-risk characteristics would benefit from close interval surveillance. See Video Abstract .

PREDICTORES ENDOSCPICOS DE TUMOR RESIDUAL DESPUS DE TERAPIA NEOADYUVANTE TOTAL UN ANLISIS POST HOC DEL ENSAYO DE PRESERVACIN DE RGANOS EN ADENOCARCINOMA RECTAL

ANTECEDENTES:La reestadificación por endoscopia juega un papel crítico en la selección de pacientes con cáncer de recto localmente avanzado que responden a la terapia neoadyuvante para el manejo no quirúrgico.OBJETIVO:Este estudio evaluó las características endoscópicas de reestadificación que mejor predicen la presencia de tumor residual en la pared intestinal.DISEÑO:Este fue un análisis post hoc de un ensayo prospectivo aleatorizado.ESCENARIO:El ensayo Organ Preservation in Rectal Adenocarcinoma aleatorizó a pacientes de 18 instituciones con adenocarcinoma de recto en estadio II/III para recibir terapia neoadyuvante total de inducción o consolidación. Los cirujanos completaron un formulario de reestadificación de evaluación del tumor, que estratificó a los pacientes en tres niveles de respuesta clínica.PACIENTES:Se incluyeron pacientes inscritos en el ensayo de preservación de órganos en adenocarcinoma rectal con un formulario de evaluación del tumor completado.PRINCIPALES MEDIDAS DE RESULTADO:El resultado principal fue presencia de tumor residual, que se definió como una respuesta clínica incompleta o un nuevo crecimiento local del tumor dentro de los dos años posteriores a la reestadificación. Los predictores independientes de tumor residual se identificaron mediante un análisis de regresión logística multivariable seleccionado hacia atrás. Se realizaron análisis de subgrupos para pacientes con respuesta clínica completa y casi completa.RESULTADOS:Los cirujanos completaron formularios de reestadificación para 263 pacientes en una mediana de 7.7 semanas después de la terapia neoadyuvante; 128 (48.7%) tenían tumor residual. En el análisis de regresión multivariable, varias características de una respuesta casi completa, incluyendo úlcera (OR 6.66; IC 95% 2.54-19.9), mucosa irregular (OR 3.66; IC 95% 1.61-8.68) y nodularidad (OR 2.96; IC 95% 1.36 -6.58) siguieron siendo predictores independientes de tumor residual. Una cicatriz plana se asoció con menores probabilidades de albergar enfermedad residual (OR 0.32; IC del 95 %: 0.11-0.93) para los pacientes clasificados como respondedores clínicos completos.LIMITACIONES:Las limitaciones de este estudio incluyen el análisis de las características endoscópicas en un solo momento y las ambigüedades en los criterios de respuesta.en la forma de evaluación del tumorCONCLUSIONES:Los pacientes con úlcera, nodularidad o mucosa irregular en la endoscopia de reestadificación tienen mayores probabilidades de tumor residual. El reconocer las implicaciones pronósticas negativas de estas características ayudará a los cirujanos a seleccionar mejor a los candidatos para el tratamiento no quirúrgico y sugiere que los pacientes con características de alto riesgo se beneficiarían de una vigilancia a intervalos estrechos. (Traducción-Dr. Jorge Silva Velazco ).

Management after non-curative endoscopic resection of T1 rectal cancer

Since the introduction of population-based screening, increasing numbers of T1 rectal cancers are detected and removed by local endoscopic resection. Patients can be cured with endoscopic resection alone, but there is a possibility of residual tumor cells remaining after the initial resection. These can be located intraluminally at the resection site or extraluminally in the form of (lymph node) metastases. To decrease the risk of residual cells progressing towards more advanced disease, additional treatment is usually needed. However, with the currently available risk stratification models, it remains challenging to determine who should and should not be further treated after non-curative endoscopic resection. In this review, the different management strategies for patients with non-curatively treated T1 rectal cancers are discussed, along with the available evidence for each strategy and relevant considerations for clinical decision making. Furthermore, we provide practical guidance on the management and surveillance following non-curative endoscopic resection of T1 rectal cancer.

Adoption of Total Neoadjuvant Therapy in the Treatment of Locally Advanced Rectal Cancer

Local and metastatic recurrence are primary concerns following the treatment of locally advanced rectal cancer (LARC). Chemoradiation (CRT) can reduce the local recurrence rates and has subsequently moved to the neoadjuvant setting from the adjuvant setting. Pathological complete response (pCR) rates have also been noted to be greater in patients treated with neoadjuvant CRT prior to surgery. The standard approach to treating LARC would often involve CRT followed by surgery and optional adjuvant chemotherapy and remained the treatment paradigm for almost two decades. However, patients were often unable to complete adjuvant chemotherapy due to a decreased tolerance of chemotherapy following surgery, which led to upfront treatment with both CRT and chemotherapy, and total neoadjuvant therapy, or TNT, was created. The efficacy outcomes of local recurrence, disease-free survival, and pCR have improved in patients receiving TNT compared to the standard approach. Additionally, more recent data suggest a possible improvement in overall survival as well. Patients with a complete clinical response following TNT have the opportunity for watch-and-wait surveillance, allowing some patients to undergo organ preservation. Here, we discuss the clinical trials and studies that led to the adoption of TNT as the standard of care for LARC, with the possibility of watch-and-wait surveillance for patients achieving complete responses. We also review the possibility of overtreating some patients with LARC.

A Novel Fluorescence-Based Leak Test Method for Rectal Anastomoses Using Aerosolized Indocyanine Green

BACKGROUND

The intraoperative air leak test is commonly performed during rectal surgery to evaluate anastomotic integrity. However, its drawbacks include occasional difficulties in visualizing the exact point of the leak while maintaining the pelvis under saline, the need for repeat testing to identify the leak point, and a lack of continuous visualization of the leak point.

OBJECTIVE

To evaluate the feasibility and clinical applicability of using aerosolized indocyanine green, a fluorescent tracer, for detecting rectal anastomotic leakage.

DESIGN

Animal preclinical study.

SETTING

Animal laboratory at Kagawa University.

PATIENTS

Six healthy adult female beagles were included.

INTERVENTIONS

An anastomotic leakage model with a single air leak point was created in each dog. Indocyanine green was aerosolized using a nebulizer kit with a stream of carbon dioxide flowing at 1.5 to 2.0 L/min. The aerosol was administered into the rectum transanally, and laparoscopic observations were performed.

MAIN OUTCOME MEASURES

Air leak points were observed using a near-infrared fluorescence laparoscope, after which the presence of corresponding indocyanine green fluorescence was verified.

RESULTS

Aerosolized indocyanine green was visualized laparoscopically at all anastomosis sites but not elsewhere. The median time from the administration of the aerosol to its visualization was 4.5 seconds. Pathological examinations were performed 4 weeks postsurgery in all dogs, and no histological abnormalities related to aerosolized indocyanine green administration were observed at the anastomosis sites.

LIMITATIONS

The leak points were surgically created and did not occur naturally.

CONCLUSIONS

Visualization of air leaks at the sites of rectal anastomosis was laparoscopically achievable by administering aerosolized indocyanine green transanally into the rectum in our canine model. This novel fluorescent leak test could be a valid alternative to established methods.

Risk Factors for Rectal Stump Leakage After Discontinuity Resection: Stump Length Matters Most

BACKGROUND

Discontinuity resection is commonly conducted to avoid anastomotic leakage in high-risk patients but potentially results in rectal stump leakage. Although risk factors for anastomotic leakage have been widely studied, data on rectal stump leakage rates and underlying risk factors are scarce.

OBJECTIVE

To determine rectal stump leakage rates following Hartmann's procedure and to identify patient-and surgery-associated risk factors.

DESIGN

A retrospective study with univariate and multivariate analyses was performed to identify risk factors of rectal stump leakage. A subgroup analysis of scheduled operations was performed.

SETTINGS

The study was conducted at Heidelberg University Hospital, Germany.

PATIENTS

Patients were included who underwent discontinuity resection with rectal stump formation between 2010 and 2020.

MAIN OUTCOME MEASURES

The main outcome measures included rectal stump leakage rates, 30-day mortality, length of hospitalization, and necessity for further invasive treatment.

RESULTS

Rectal stump leakage occurred in 11.78% of patients. Rectal stump leakage rates varied considerably depending on the surgical procedure performed and were highest following subtotal pelvic exenteration (34%). Diagnosis of rectal stump leakage peaked on postoperative day 7. A short rectal stump ( p = 0.001), previous pelvic radiotherapy ( p = 0.04), chemotherapy ( p = 0.004), and previous laparotomy ( p = 0.03) were independent risk factors for rectal stump leakage in the entire patient collective. In patients undergoing scheduled surgery, a short rectal stump was the only independent risk factor ( p = 0.003). Rectal stump leakage was not associated with increased 30-day mortality but prolonged length of hospitalization and frequently necessitated further invasive treatment.

LIMITATIONS

Study results are limited by the retrospective design, a high number of emergency operations, and the mere inclusion of symptomatic leakages.

CONCLUSIONS

Rectal stump leakage is a relevant complication after discontinuity resection. Risk factors should be considered during surgical decision-making when both discontinuity resection and abdominoperineal resection are feasible. See Video Abstract.

FACTORES DE RIESGO PARA LA FUGA DEL MUN RECTAL DESPUS DE UNA RESECCIN POR DISCONTINUIDAD LA LONGITUD DEL MUN ES LO MS IMPORTANTE

ANTECEDENTES:La resección de discontinuidad se realiza comúnmente para evitar la fuga anastomótica en pacientes de alto riesgo, pero potencialmente da como resultado una fuga del muñón rectal. Si bien los factores de riesgo de fuga anastomótica se han estudiado ampliamente, los datos sobre las tasas de fuga del muñón rectal y los factores de riesgo subyacentes son escasos.OBJETIVO:Determinar las tasas de fuga del muñón rectal después del procedimiento de Hartmann e identificar los factores de riesgo asociados con el paciente y la cirugía.DISEÑO:Se realizó un estudio retrospectivo con análisis univariado y multivariado para identificar los factores de riesgo de fuga del muñón rectal. Se llevó a cabo un análisis de subgrupos de las operaciones programadas.AJUSTES:El estudio se realizó en el Hospital Universitario de Heidelberg, Alemania.PACIENTES:Se incluyeron pacientes que se sometieron a resección de discontinuidad con formación de muñón rectal entre 2010 y 2020.MEDIDAS DE RESULTADO PRINCIPALES:Las principales medidas de resultado incluyeron las tasas de fuga del muñón rectal, la mortalidad a los 30 días, la duración de la hospitalización y la necesidad de un tratamiento invasivo adicional.RESULTADOS:La fuga del muñón rectal ocurrió en el 11,78% de los pacientes. Las tasas de fuga del muñón rectal variaron considerablemente según el procedimiento quirúrgico realizado y fueron más altas después de la exenteración pélvica subtotal (34%). El diagnóstico de fuga del muñón rectal alcanzó su punto máximo en el día 7 del postoperatorio. Un muñón rectal corto (p = 0,001), radioterapia pélvica previa (p = 0,04), quimioterapia (p = 0,004) y laparotomía previa (p = 0,03) fueron factores de riesgo independientes de fuga rectal. Fuga del muñón en todo el colectivo de pacientes. En los pacientes sometidos a cirugía programada, el muñón rectal corto fue el único factor de riesgo independiente (p = 0,003). La fuga del muñón rectal no se asoció con un aumento de la mortalidad a los 30 días, pero con una duración prolongada de la hospitalización y con frecuencia requirió un tratamiento invasivo adicional.LIMITACIONES:Los resultados del estudio están limitados por el diseño retrospectivo, un alto número de operaciones de emergencia y la mera inclusión de fugas sintomáticas.CONCLUSIONES:La fuga del muñón rectal es una complicación relevante tras la resección por discontinuidad. Se deben considerar los factores de riesgo durante la toma de decisiones quirúrgicas cuando son factibles tanto la resección por discontinuidad como la resección abdominoperineal. (Traducción-Yesenia Rojas-Khalil ).

Computed Diffusion-Weighted Images of Rectal Cancer: Image Quality, Restaging, and Treatment Response after Neoadjuvant Therapy

BACKGROUND

Computed diffusion-weighted images (cDWI) of random b value could be derived from acquired DWI (aDWI) with at least two different b values. However, its comparison between aDWI and cDWI images in locally advanced rectal cancer (LARC) patients after neoadjuvant therapy (NT) is needed.

PURPOSE

To compare the cDWI and aDWI in image quality, restaging, and treatment response of LARC after NT.

STUDY TYPE

Retrospective.

POPULATION

Eighty-seven consecutive patients.

FIELD STRENGTH/SEQUENCE

3.0 T/DWI.

ASSESSMENT

All patients underwent two DWI sequences, including conventional acquisition with b = 0 and 1000 s/mm2 (aDWIb1000 ) and another with b = 0 and 700 s/mm2 on a 3.0-T MR scanner. The images of the latter were used to compute the diffusion images with b = 1000 s/mm2 (cDWIb1000 ). Four radiologists with 3, 4, 14, and 25 years of experience evaluated the images to compare the image quality, TN restaging performance, and treatment response between aDWIb1000 and cDWIb1000 .

STATISTICAL TESTS

Interclass correlation coefficients, weighted κ coefficient, paired Wilcoxon, and McNemar or Fisher test were used. A significance level of 0.05 was used.

RESULTS

The cDWIb1000 images were superior to the aDWIb1000 ones in both subjective and objective image quality. In T restaging, the overall diagnostic accuracy of cDWIb1000 images was higher than that of aDWIb1000 images (57.47% vs. 49.43%, P = 0.289 for the inexperienced radiologist; 77.01% vs. 63.22%, significant for the experienced radiologist), with better sensitivity in determining ypT0-Tis tumors. Additionally, it increased the sensitivity in detecting ypT2 tumors for the inexperienced radiologist and ypT3 tumors for the experienced radiologist. N restaging and treatment response were found to be similar between two sequences for both radiologists.

DATA CONCLUSION

Compared to aDWIb1000 images, the computed ones might serve as a wise approach, providing comparable or better image quality, restaging performance, and treatment response assessment for LARC after NT.

LEVEL OF EVIDENCE

3 TECHNICAL EFFICACY STAGE: 2.

Evolution of therapy for locally advanced rectal cancer

Rectal cancer is a prevalent disease worldwide. The standard treatment of locally advanced rectal cancer (LARC) is preoperative chemoradiotherapy followed by surgery and adjuvant systemic chemotherapy. Studies have been done to determine the best sequence of treatments to improve survival, cure rate and long term toxicity profile. In this paper, we will review the literature regarding the evolution of LARC treatment.

Survival outcomes of salvage surgery in the watch-and-wait approach for rectal cancer with clinical complete response after neoadjuvant chemoradiotherapy: a systematic review and meta-analysis

PURPOSE

This systematic review and meta-analysis compared the outcomes of the watch-and-wait (WW) approach versus radical surgery (RS) in rectal cancers with clinical complete response (cCR) after neoadjuvant chemoradiotherapy.

METHODS

This study followed the PRISMA guidelines. Major databases were searched to identify relevant articles. WW and RS were compared through meta-analyses of pooled proportions. Primary outcomes included overall survival (OS), disease-free survival (DFS), local recurrence, and distant metastasis rates. Pooled salvage surgery rates and outcomes were also collected. The Newcastle-Ottawa scale was employed to assess the risk of bias.

RESULTS

Eleven studies including 1,112 rectal cancer patients showing cCR after neoadjuvant chemoradiation were included. Of these patients, 378 were treated nonoperatively with WW, 663 underwent RS, and 71 underwent local excision. The 2-year OS (risk ratio [RR], 0.95; P = 0.94), 5-year OS (RR, 2.59; P = 0.25), and distant metastasis rates (RR, 1.05; P = 0.80) showed no significant differences between WW and RS. Local recurrence was more frequent in the WW group (RR, 6.93; P < 0.001), and 78.4% of patients later underwent salvage surgery (R0 resection rate, 97.5%). The 2-year DFS (RR, 1.58; P = 0.05) and 5-year DFS (RR, 2.07; P = 0.02) were higher among RS cases. However, after adjustment for R0 salvage surgery, DFS showed no significant between-group difference (RR, 0.82; P = 0.41).

CONCLUSION

Local recurrence rates are higher for WW than RS, but complete salvage surgery is often possible with similar long-term outcomes. WW is a viable strategy for rectal cancer with cCR after neoadjuvant chemoradiation, but further research is required to improve patient selection.

Transition from laparoscopic to robotic approach in rectal cancer: a single-center short-term analysis based on the learning curve

As a novel procedure becomes more and more used, knowledge about its learning curve and its impact on outcomes is useful for future implementations. Our aim is (i) to identify the phases of the robotic rectal surgery learning process and assess the safety and oncological outcomes during that period, (ii) to compare the robotic rectal surgery learning phases outcomes with laparoscopic rectal resections performed before the implementation of the robotic surgery program. We performed a retrospective study, based on a prospectively maintained database, with methodological quality assessment by STROBE checklist. All the procedures were performed by the same two surgeons. A total of 157 robotic rectal resections from June 2018 to January 2022 and 97 laparoscopic rectal resections from January 2018 to July 2019 were included. The learning phase was completed at case 26 for surgeon A, 36 for surgeon B, and 60 for the center (both A & B). There were no differences in histopathological results or postoperative complications between phases, achieving the same ratio of mesorectal quality, circumferential and distal resection margins as the laparoscopic approach. A transitory increase of major complications and anastomotic leakage could occur once overcoming the learning phase, secondary to the progressive complexity of cases. Robotic rectal cancer surgery learning curve phases in experienced laparoscopic surgeons was completed after 25-35 cases. Implementation of a robotic rectal surgery program is safe in oncologic terms, morbidity, mortality and length of stay.

Meta-analysis of efficacy of perioperative oral antibiotics in intestinal surgery with surgical site infection

OBJECTIVES

Surgical site infection (SSI) is a serious complication of intestinal surgery. In this meta-analysis, we aimed to explore the efficacy and safety of different preoperative oral antibiotic preparation (OABP) compared with intravenous antibiotic preparation (IVAP) and/or mechanical bowel preparation (MBP).

METHODS

A meta-analysis consisting of adult patients adopting oral antibiotics versus other regimens during the preoperative preparation of elective intestinal surgery was performed. The outcome included overall SSI, organ space SSI, superficial SSI, deep SSI, and mortality rate.

RESULTS

A total of 35 randomized controlled trials (RCTs) consisting of 8445 adult patients were included in our present analysis. OABP regimens were combined with IVAP in 29 RCTs. In general, the incidence of overall SSI in the OABP group was less compared with the IVAP alone or IVAP+MBP group (RR 0.56, 95% CI 0.46-0.69, P < .00001, I2 = 47%). Metronidazoles plus quinolones or aminoglycosides showed the best effect on reducing the overall SSI. OABP in combination with preoperative and postoperative IVAP was both significantly associated with reduced SSI. IVAP before and within 24 h after surgery showed the best advantage. No difference was found between the OABP without IVAP group and the control group in reducing SSI. OABP regimens also demonstrated a lower incidence rate of organ space SSI, superficial SSI, deep SSI, and mortality.

CONCLUSION

OABP in combination with preoperative IVAP and within 24 h post-operation significantly reduced the incidence of SSI in intestinal surgery. Metronidazoles accompanied with quinolones or aminoglycosides might be the appropriate combinations for OABP regimens.

Bio-Inspired Self-Healing, Shear-Thinning, and Adhesive Gallic Acid-Conjugated Chitosan/Carbon Black Composite Hydrogels as Suture Support Materials

The occurrence of leakage from anastomotic sites is a significant issue given its potential undesirable complications. The management of anastomotic leakage after gastrointestinal surgery is particularly crucial because it is directly associated with mortality and morbidity in patients. If adhesive materials could be used to support suturing in surgical procedures, many complications caused by leakage from the anastomosis sites could be prevented. In this study, we have developed self-healing, shear-thinning, tissue-adhesive, carbon-black-containing, gallic acid-conjugated chitosan (CB/Chi-gallol) hydrogels as sealing materials to be used with suturing. The addition of CB into Chi-gallol solution resulted in the formation of a crosslinked hydrogel with instantaneous solidification. In addition, these CB/Chi-gallol hydrogels showed enhancement of the elastic modulus (G') values with increased CB concentration. Furthermore, these hydrogels exhibited excellent self-healing, shear-thinning, and tissue-adhesive properties. Notably, the hydrogels successfully sealed the incision site with suturing, resulting in a significant increase in the bursting pressure. The proposed self-healing and adhesive hydrogels are potentially useful in versatile biomedical applications, particularly as suture support materials for surgical procedures.

Endoscopic management of anastomotic leakage after colorectal cancer surgery in a Moroccan center: A case series and literature review

Endoscopic management has become an alternate treatment to a revision surgery for colorectal fistulas. Eight patients who were treated by endoscopy for postoperative anastomotic leakage to colorectal cancer were included. A univariate analysis was carried out to determine the predictive factors of success. All our patients were treated using metallic clips. The primary efficiency of this technique was 50%. In a univariate analysis, the size of the fistula and its distance from the anal margin had an influence on the efficiency of the endoscopic treatment, which was not the case for either the surgical technique or the use of neoadjuvant radiotherapy. This endoscopic treatment is effective and represents a more secure alternative than revision surgery. In our study, the use of metallic clips showed a 50% success rate, going up to 100% for the group of patients with a fistula ostium of a size ⩽1 cm, proving the necessity of using this technique.

The Crying Need for a Better Response Assessment in Rectal Cancer

OPINION STATEMENT

Since total neoadjuvant treatment achieves almost 30% pathologic complete response, organ preservation has been increasingly debated for good responders after neoadjuvant treatment for patients diagnosed with rectal cancer. Two organ preservation strategies are available: a watch and wait strategy and a local excision strategy including patients with a near clinical complete response. A major issue is the selection of patients according to the initial tumor staging or the response assessment. Despite modern imaging improvement, identifying complete response remains challenging. A better selection could be possible by radiomics analyses, exploiting numerous image features to feed data characterization algorithms. The subsequent step is to include baseline and/or pre-therapeutic MRI, PET-CT, and CT radiomics added to the patients' clinicopathological data, inside machine learning (ML) prediction models, with predictive or prognostic purposes. These models could be further improved by the addition of new biomarkers such as circulating tumor biomarkers, molecular profiling, or pathological immune biomarkers.

Organ Preservation in MSS Rectal Cancer

Rectal cancer is a heterogeneous disease with complex genetic and molecular subtypes. Emerging progress of neoadjuvant therapy has led to increased pathological and clinical complete response (cCR) rates for microsatellite stable (MSS) rectal cancer, which responds poorly to immune checkpoint inhibitor alone. As a result, organ preservation of MSS rectal cancer as an alternative to radical surgery has gradually become a feasible option. For patients with cCR or near-cCR after neoadjuvant treatment, organ preservation can be implemented safely with less morbidity. Patient selection can be done either before the neoadjuvant treatment for higher probability or after with careful assessment for a favorable outcome. Those patients who achieved a good clinical response are managed with nonoperative management, organ preservation surgery, or radiation therapy alone followed by strict surveillance. The oncological outcomes of patients with careful selection and organ preservation seem to be noninferior compared with those of radical surgery, with lower postoperative morbidity. However, more studies should be done to seek better regression of tumor and maximize the possibility of organ preservation in MSS rectal cancer.

High-dose rate endorectal brachytherapy for rectal cancer: A state-of-the-art review

Rectal cancer is a common malignancy that requires multidisciplinary treatment. By utilizing the dose-response relationship in rectal cancer radiotherapy, increasing the radiotherapy dose can improve clinical complete remission rates. High-dose rate endorectal brachytherapy (HDREBT) is a novel technique that delivers high doses of radiotherapy directly to the tumor via an endorectal applicator, sparing the adjacent normal tissues from excessive radiation exposure. HDREBT includes contact X-ray brachytherapy and high-dose-rate intracavitary brachytherapy. We introduce the latest developments in applicators and imaging techniques for HDREBT in rectal cancer and summarize the current evidence on the efficacy, safety, and feasibility of HDREBT as a neoadjuvant, definitive, or palliative treatment option for all stages of rectal cancer patients. We also discuss the potential advantages and challenges of HDREBT in achieving organ preservation and improving the quality of life of rectal cancer patients. HDREBT has shown promising results in achieving high complete response rates, enabling nonoperative management, improving organ preservation rates, and providing effective palliation in rectal cancer patients. More studies are needed to optimize its dose and fractionation schemes in different clinical scenarios.

Risk factors for ischemia/necrosis of the colonic stump after proctectomy and delayed coloanal anastomosis

INTRODUCTION

Delayed coloanal anastomosis (DCAA) is a two-stage procedure. DCAA has been increasingly reused in recent years in the management of rectal cancer. Such increased use of DCAA has highlighted the complications associated with this procedure. We aimed to evaluate the risk and risk factors of ischemia/necrosis of the colonic stump between the two stages of DCAA.

PATIENTS AND METHODS

All patients who underwent a proctectomy with a DCAA were included in this retrospective single-centre study from November 2012 to June 2022. Two groups of patients were defined: patients with a well vascularized colonic stump (well vascularized group) and those who experienced ischemia or necrosis of the colonic stump (ischemic group). The primary endpoint was the rate of ischemia or necrosis of the colonic stump and an evaluation of the associated risk factors.

RESULTS

During the study period, 43 patients underwent DCAA. Amongst them, 32 (75%) had a well-vascularized colonic stump (well-vascularized group) and 11 (25%) ischemia of the colonic stump (ischemic group). Relative to patients in the well-vascularized group, those in the ischemic group were more often men (81.8% vs 40.6%, p = 0.034), had a higher BMI (29.2 kg/m2 vs 25.7 kg/m2, p = 0.03), were more frequently diabetic (63.6% vs 21.9%, p = 0.01) and more frequently had had preoperative radiotherapy (100% vs 53.1%, p = 0.008). On the preoperative CT scan, the interspinous diameter was shorter in the ischemic group (9.4 ± 1.01 cm vs 10.6 ± 1.01 cm, p = 0.001), the intertuberosity diameter was shorter (9.2 ± 1.18 cm vs 11.9 ± 1.18 cm, p < 0.0001), and the length of the anal canal was longer (31.9 ± 3 mm vs 27.4 ± 3.2 mm, p < 0.0001).

CONCLUSION

This study highlights clear risk factors for ischemia/necrosis of the colonic stump after proctectomy with DCAA.

Urethral Injury in Rectal Cancer Surgery: A Comprehensive Study Using Cadaveric Dissection, Imaging Analyses, and Clinical Series

Male urethral injury during rectal cancer surgery is rare but significant. Scant information is available about the distances between the rectourethral space and neighboring structures. The aim of this study is to describe the anatomical relations of the male urethra. This three-pronged study included cadaveric dissection, retrospective MRI analysis, and clinical cases. Measurements included the R-Mu distance (shortest distance between the rectum and the membranous urethra), R-Am distance (distance from the anterior rectal wall to anal margin nearest to the membranous urethra), and the anal canal-rectum axis angle. The clinical study analyzed the incidence of urethral injury and associated factors among 244 consecutive men from January 2016 to January 2023. The overall incidence of urethral injury in our series was low (0.73%), but in men with tumors < 10 cm from the anal margin, it was 4% in abdominoperineal resection and 3.2% in TaTME. On preoperative MRI, the median R-Mu distance was 1 cm (IQR, range, 0.2-2.3), the median R-Am distance was 4.3 cm (range, 2-7.3), and the median anorectal angle was 128° (range, 87-160). In the cadaveric study (nine adult male pelvises), the mean R-Mu distance was 1.18 cm (range 0.8-2), and the mean R-Am distance was 2.64 cm (range 2.1-3). Avoiding urethral injury is crucial. The critical point for injury lies 2-7.3 cm from the anal margin, with a 0.2-2.3 cm distance between the rectum and the membranous urethra. Collaborating with anatomists and radiologists improves surgeons' anatomy knowledge.

Oncologic outcomes of watch-and-wait strategy or surgery for low to intermediate rectal cancer in clinical complete remission after adjuvant chemotherapy: a systematic review and meta-analysis

BACKGROUND

A watch-and-wait (WW) strategy or surgery for low to intermediate rectal cancer that has reached clinical complete remission (cCR) after neoadjuvant chemotherapy (nCRT) or total neoadjuvant therapy (TNT) has been widely used in the clinic, but both treatment strategies are controversial.

OBJECTIVE

The aim of this study was to compare the oncologic outcomes of a watch-and-wait strategy or a surgical approach to treat rectal cancer in complete remission and to report the evidence-based clinical advantages of the two treatment strategies.

METHODS

Seven national and international databases were searched for clinical trials comparing the watch-and-wait strategy with surgical treatment for oncological outcomes in patients with rectal cancer in clinical complete remission.

RESULTS

In terms of oncological outcomes, there was no significant difference between the watch-and-wait strategy and surgical treatment in terms of overall survival (OS) (HR = 0.92, 95% CI (0.52, 1.64), P = 0.777), and subgroup analysis showed no significant difference in 5-year disease-free survival (5-year DFS) between WW and both local excision (LE) and radical surgery (RS) (HR = 1.76, 95% CI (0.97, 3.19), P = 0.279; HR = 1.98, 95% CI (0.95, 4.13), P = 0.164), in distant metastasis rate (RR = 1.12, 95% CI (0.73, 1.72), P = 0.593), mortality rate (RR = 1.62, 95% CI (0.93, 2.84), P = 0.09), and organ preservation rate (RR = 1.05, 95% CI (0.94, 1.17), P = 0.394) which were not statistically significant and on the outcome indicators of local recurrence rate (RR = 2.09, 95% CI (1.44, 3.03), P < 0.001) and stoma rate (RR = 0.35, 95% CI (0.20, 0.61), P < 0.001). There were significant differences between the WW group and the surgical treatment group.

CONCLUSION

There were no differences in OS, 5-year DFS, distant metastasis, and mortality between the WW strategy group and the surgical treatment group. The WW strategy did not increase the risk of local recurrence compared with local resection but may be at greater risk of local recurrence compared with radical surgery, and the WW group was significantly better than the surgical group in terms of stoma rate; the WW strategy was evidently superior in preserving organ integrity compared to radical excision. Consequently, for patients who exhibit a profound inclination towards organ preservation and the evasion of stoma formation in the scenario of clinically complete remission of rectal cancer, the WW strategy can be contemplated as a pragmatic alternative to surgical interventions. It is, however, paramount to emphasize that the deployment of such a strategy should be meticulously undertaken within the ambit of a multidisciplinary team's management and within specialized centers dedicated to rectal cancer management.

Clinical outcomes of endoscopic submucosal dissection for giant rectal tumors larger than 8 cm: A European referral center experience

BACKGROUND AND AIMS

To date, western data on colorectal ESD are limited. This study aimed to assess the efficacy and safety of rectal ESD for superficial lesions ≥ 8 cm.

METHODS

A total of 138 superficial rectal neoplasms treated by ESD were allocated in two groups: 25 in the "giant" ESD group and 113 in the control group.

RESULTS

En bloc resection was achieved in 96% of cases in both groups. En bloc R0 resection rate was similar between the "giant" ESD group and the control group (84% vs 86%; p: 0.5) and curative resection was higher in the control group (81%) than in "giant" ESD group (68%) without reaching statistical significance (p: 0.2). Dissection time was significantly longer in the "giant" ESD group (251 vs 108 min; p <0.001), however, dissection speed was significantly higher (0.35 vs 0.17 cm2/min; p: 0.02).). Post-ESD stenosis was observed in 2 patients from the "giant" ESD group (8% vs 0% of control group, p: 0.03). No significant differences were found in delayed bleeding, perforation, local recurrences, and need for additional surgery.

CONCLUSIONS

ESD for superficial rectal tumors ≥ 8 cm is a feasible, safe, and effective therapeutic option.

Features and outcomes of rectal cancer patients treated in a hospital in Bogotá, Colombia: a retrospective cohort study

Rectal cancer is an increasing disease worldwide. The outcomes of its treatment are related to the preoperative characteristics of the patient. The objective of this study was to describe sociodemographic, clinical and surgical characteristics and outcomes of patients operated on for rectal cancer at Hospital Universitario Mayor Méderi (HUM) during the period within 2013-2017.A retrospective descriptive cohort-type study was carried out by consulting the clinical records of patients above the age of 18 years with a clinical/histopathological diagnosis of rectal cancer and an institutional follow-up in those who underwent surgery with laparoscopic anterior resection of the rectum carried out by the coloproctology service of the HUM between 2013 and 2017. For statistical analysis, the SPSS V22 program was used.Data from 133 patients were collected during the study period, most of them male, with more frequent involvement of the lower rectum. Complications occurred in 25% of the patients. Conversion rate to open surgery was 8.6%, in-hospital death was associated with cardiovascular comorbidity, corticosteroid uses and with the presence of complications. Sociodemographic characteristics of the patients were similar to the world population. The institution has a low prevalence of anastomotic dehiscence, global complications are comparable with international statistics.

A primer on rectal MRI in patients on watch-and-wait treatment for rectal cancer

Total neoadjuvant treatment (TNT) for rectal cancer is becoming an accepted treatment paradigm and is changing the landscape of this disease, wherein up to 50% of patients who undergo TNT are able to avoid surgery. This places new demands on the radiologist in terms of interpreting degrees of response to treatment. This primer summarizes the Watch-and-Wait approach and the role of imaging, with illustrative "atlas-like" examples as an educational guide for radiologists. We present a brief literature summary of the evolution of rectal cancer treatment, with a focus on magnetic resonance imaging (MRI) assessment of response. We also discuss recommended guidelines and standards. We outline the common TNT approach entering mainstream practice. A heuristic and algorithmic approach to MRI interpretation is also offered. To illustrate management and common scenarios, we arranged the illustrative figures as follows: (I) Clinical complete response (cCR) achieved at the immediate post-TNT "decision point" scan time; (II) cCR achieved at some point during surveillance, later than the first post-TNT MRI; (III) near clinical complete response (nCR); (IV) incomplete clinical response (iCR); (V) discordant findings between MRI and endoscopy where MRI is falsely positive, even at follow-up; (VI) discordant cases where MRI seems to be falsely positive but is proven truly positive on follow-up endoscopy; (VII) cases where MRI is falsely negative; (VIII) regrowth of tumor in the primary tumor bed; (IX) regrowth outside the primary tumor bed; and (X) challenging scenarios, i.e., mucinous cases. This primer is offered to achieve its intended goal of educating radiologists on how to interpret MRI in patients with rectal cancer undergoing treatment using a TNT-type treatment paradigm and a Watch-and-Wait approach.

International Society of University Colon and Rectal Surgeons survey of surgeons' preference on rectal cancer treatment

PURPOSE

Rectal cancer treatment has a wide range of possible approaches from radical extirpative surgery to nonoperative watchful waiting following chemoradiotherapy, with or without, additional chemotherapy. Our goal was to assess the personal opinion of active practicing surgeons on rectal cancer treatment if he/she was the patient.

METHODS

A panel of the International Society of University Colon and Rectal Surgeons (ISUCRS) selected 10 questions that were included in a questionnaire that included other items including demographics. The questionnaire was distributed electronically to ISUCRS fellows and other surgeons included in our database and remained open from April 16 to 28, 2020.

RESULTS

One hundred sixty-three specialists completed the survey. The majority of surgeons (n=65, 39.9%) chose the minimally invasive (laparoscopic) surgery for their personal treatment of rectal cancer. For low-lying rectal cancer T1 and T2, the treatment choice was standard chemoradiation+local excision (n=60, 36.8%) followed by local excision±chemoradiotherapy if needed (n=55, 33.7%). In regards to locally advanced low rectal cancer T3 or greater, the preference of the responders was for laparoscopic surgery (n=65, 39.9%). We found a statistically significant relationship between surgeons' age and their preference for minimally invasive techniques demonstrating an age-based bias on senior surgeons' inclination toward open approach.

CONCLUSION

Our survey reveals an age-based preference by surgeons for minimally invasive surgical techniques as well as organ-preserving techniques for personal treatment of treating rectal cancer. Only 1/4 of specialists do adhere to the international guidelines for treating early rectal cancer.

Transatmospheric ileal stoma manometry can be applied for the early detection of stoma outlet obstruction

Background

Stoma outlet obstruction (SOO) is a common complication of diverting ileostomy and usually detected at the advanced stage when the intestine is obviously obstructed. The objective of this study is to explore the efficacy of transatmospheric ileal stoma manometry (TISM) in early detection of SOO before the manifestation of intestinal obstruction.

Methods

A single-center prospective study was performed in patients scheduled to undergo reversal ileostomy and laparoscopic anterior rectal resection and diverting ileostomy in Second Affiliated Hospital of Zhejiang University School of Medicine from 1st July 2022 to 31st December 2022. The stoma pressure was measured by TISM at different time points.

Results

The mean stoma pressure of the 30 patients before reversal ileostomy was 5.21 cmH2O which was considered as normal standard of stoma pressure, and ranged from 1.2 to 8.56 cmH2O. After excluding two patients with anastomotic leakage, a total of 38 patients who were subjected to laparoscopic anterior rectal resection and diverting ileostomy were further included in this study. The incidence of anastomotic leakage was 5% and that of SOO was 12.5%. The mean postoperative obstruction time was 5.2 (3-7) days and the mean time from elevated stoma pressure to diagnosed as SOO was 2.8 (2-4) days in the five patients who developed SOO. The pressure measured at the third stoma manometry time point (second day after return of gut function) (10.23 vs. 6.04 cmH2O, p<0.001) and the postoperative hospital stay (10 vs. 8.49 days, p=0.028) showed significantly difference between the SOO and non-SOO groups. The pressures measured at the first time point (before return of gut function) (4 vs. 4.49 cmH2O, p=0.585), the second time point (the day of return of gut function) (6.8 vs. 5.62 cmH2O, p=0.123), and the fourth time point (discharge day) (5.88 vs. 5.9 cmH2O, p=0.933) showed no significant difference in both groups.

Conclusion

TISM can be utilized for early detection of SOO and can be incorporated as a novel diagnostic method together with abdominal CT scan to realize the goal of ERAS.

Impact of anastomotic leakage on long-term prognosis after colorectal cancer surgery

Colorectal cancer (CRC) is one of the most common malignancies in the world. Despite significant improvements in surgical technique, postoperative complications still occur in a fair percentage of patients undergoing colorectal surgery. The most feared complication is anastomotic leakage. It negatively affects short-term prognosis, with increased post-operative morbidity and mortality, higher hospitalization time and costs. Moreover, it may require further surgery with the creation of a permanent or temporary stoma. While there is no doubt about the negative impact of anastomotic dehiscence on the short-term prognosis of patients operated on for CRC, still under discussion is its impact on the long-term prognosis. Some authors have described an association between leakage and reduced overall survival, disease-free survival, and increased recurrence, while other Authors have found no real impact of dehiscence on long term prognosis. The purpose of this paper is to review all the literature about the impact of anastomotic dehiscence on long-term prognosis after CRC surgery. The main risk factors of leakage and early detection markers are also summarized.

Efficacy of the polyglycolic acid sheet for preventing anastomotic leakage in double-stapling technique anastomosis for left-sided colon or rectal cancer surgery: a propensity score-matched study

BACKGROUND

To prevent anastomotic leakage in patients with left-sided colorectal cancer who underwent double-stapling technique (DST) anastomosis, we investigated a new method: DST anastomosis with a polyglycolic acid (PGA) sheet. This procedure has been shown to have the potential to decrease the rate of anastomotic leakage. However, due to the small number of cases enrolled in our previous study, it was not possible to compare the outcomes of the new and conventional procedures. The aim of this study was to evaluate the effect of the PGA sheet on preventing anastomotic leakage in patients with left-sided colorectal cancer who underwent DST anastomosis by retrospectively comparing the anastomotic leakage rate between the PGA sheet and conventional groups.

METHODS

A total of 356 patients with left-sided colorectal cancer who underwent DST anastomosis during surgery at Osaka City University Hospital between January 2016 and April 2022 were enrolled in this study. Propensity score matching was performed to reduce the confounding effects secondary to imbalances in the use of PGA sheets.

RESULTS

The PGA sheet was used in 43 cases (PGA sheet group) and it was not used in 313 cases (conventional group). After propensity score matching, the incidence of anastomotic leakage in the PGA sheet group was significantly lower than that in the conventional group.

CONCLUSION

DST anastomosis with PGA sheet, which is easy to perform, contributes to the reduction of anastomotic leakage rate by increasing the strength of the anastomotic site.

Delayed TME Surgery in a Watch-and-Wait Strategy After Neoadjuvant Chemoradiotherapy for Rectal Cancer: An Analysis of Hospital Costs and Surgical and Oncological Outcomes

BACKGROUND

A watch-and-wait strategy for patients with rectal cancer with a clinical complete response after neoadjuvant chemoradiotherapy is a valuable alternative for rectal resection. However, there are patients who will have residual tumor or regrowth during watch and wait.

OBJECTIVE

The aim of this study was to investigate safety and costs for patients who underwent delayed surgery after neoadjuvant chemoradiotherapy.

DESIGN

This is a retrospective cohort study with prospectively collected data.

SETTINGS

The study was conducted at a large teaching hospital.

PATIENTS

Between January 2015 and May 2020, 622 new rectal cancer patients were seen, of whom 200 received neoadjuvant chemoradiotherapy. Ninety-four patients were included, 65 of whom underwent immediate surgery and 29 of whom required delayed surgery after an initial watch-and-wait approach.

MAIN OUTCOME MEASURES

Outcome measures included 30-day postoperative morbidity rate, hospital costs. 2-year overall and disease-free survival.

RESULTS

There was no difference in length of stay (9 vs 8; p = 0.83), readmissions (27.6% vs 10.0%; p = 0.10), surgical re-interventions (15.0% vs 3.4%; p = 0.16), or stoma-free rate (52.6% vs 31.0%; p = 0.09) between immediate and delayed surgery groups. Hospital costs were similar in the delayed group (€11,913 vs €13,769; p = 0.89). Two-year overall survival (93% vs 100%; p = 0.23) and disease-free survival (78% vs 81%; p = 0.47) rates were comparable.

LIMITATIONS

Limitations included small sample size, follow-up time and retrospective design.

CONCLUSION

Delayed surgery for regrowth in a watch-and-wait program or for persistent residual disease after a repeated assessment is not associated with an increased risk of postoperative morbidity or a significant rise in costs compared to immediate total mesorectal excision. There also appears to be no evident compromise in oncological outcome. Repeated response assessment in patients with a near complete clinical response after neoadjuvant chemoradiotherapy is a useful approach to identify more patients who can benefit from a watch-and-wait strategy. See Video Abstract at http://links.lww.com/DCR/B836 .

CIRUGA DE TME RETRASADA EN UNA ESTRATEGIA DE WATCH AND WAIT DESPUS DE LA QUIMIORRADIOTERAPIA NEOADYUVANTE PARA CNCER DE RECTO UN ANLISIS DE COSTOS HOSPITALARIOS, Y DE RESULTADOS QUIRRGICOS Y ONCOLGICOS

ANTECEDENTES: Una estrategia de Watch and Wait para pacientes con cáncer de recto con una respuesta clínica completa después de quimiorradioterapia neoadyuvante es una alternativa valiosa en vez de resección rectal. Sin embargo, hay pacientes que tendrán tumor residual o un recrecimiento durante el Watch and Wait .OBJETIVO: El objetivo fue investigar la seguridad y los costos para los pacientes que se sometieron a una cirugía diferida después de la quimiorradioterapia neoadyuvante.DISEÑO: Este es un estudio de cohorte retrospectivo con datos recolectados prospectivamente.AJUSTE: El estudio se llevó a cabo en un gran hospital universitario.PACIENTES: Entre enero de 2015 y mayo de 2020, se atendieron 622 nuevos pacientes con cáncer de recto, de los cuales 200 recibieron quimiorradioterapia neoadyuvante. Se incluyeron 94 pacientes, de los cuales 65 se sometieron a cirugía inmediata y 29 pacientes requirieron cirugía diferida después de un enfoque inicial de observación y espera.PRINCIPALES MEDIDAS DE RESULTADO: se incluyeron la tasa de morbilidad posoperatoria a 30 días, los costos hospitalarios y las sobrevidas general y libre de enfermedad a dos años.RESULTADOS: No hubo diferencia en la duración de la estancia (9 vs 8, p = 0,83), reingresos (27,6% vs 10,0%, p = 0,10), reintervenciones quirúrgicas (15,0% vs 3,4%, p = 0,16) y tasa libre de estoma (52,6% vs 31,0%, p = 0,09) entre los grupos de cirugía inmediata y tardía. Los costos hospitalarios fueron similares en el grupo retrasado (11913 € frente a 13769 €, p = 0,89). Las tasas de sobrevida general a dos años (93% frente a 100%, p = 0,23) y sobrevida libre de enfermedad (78% frente a 81%, p = 0,47) fueron comparables.LIMITACIONES: Tamaño de muestra pequeño, tiempo de seguimiento y diseño retrospectivo.CONCLUSIÓN: La cirugía tardía para el recrecimiento en un programa de Watch and Wait o para la enfermedad residual persistente después de una evaluación repetida no se asocia con un riesgo mayor de morbilidad posoperatoria ni con un aumento significativo en los costos, en comparación con la escisión total de mesorrecto inmediata. Tampoco parece haber un compromiso evidente en el resultado oncológico. La evaluación repetida de la respuesta en pacientes con una respuesta clínica casi completa después de la quimiorradioterapia neoadyuvante es un enfoque útil para identificar más pacientes que pueden beneficiarse de una estrategia de Watch and Wait . Consulte Video Resumen en http://links.lww.com/DCR/B836 . (Traducción-Dr. Juan Carlos Reyes ).

Organ preservation strategy: new therapeutic alternative in rectal cancer

BACKGROUND

The therapeutic modalities for nonmetastatic rectal cancer are presently undergoing major changes. The standard treatment is multidisciplinary, combining radiotherapy, chemotherapy, and surgery. The aim of this minireview is to provide an update on the place of organ preservation in the treatment of nonmetastatic rectal cancer in 2022.

MAIN TEXT

The multimodal strategy based on initial radiochemotherapy followed by radical surgery with excision of the mesorectum has improved oncological results but at the expense of morbidity and sequelae altering life quality. The strategy of rectal preservation has been proposed since the 2000s after the publication of the results of the Brazilian study that proposed a simple surveillance after radiochemotherapy without surgery in good responders. In fact, preoperative radiochemotherapy was able to obtain a complete histological response in 10 to 30% of case. In view of this non-negligible percentage of tumor sterilization, which may well increase with the standardization of total neoadjuvant treatment, a strategy of organ preservation can be proposed in these patients to avoid morbidity and postoperative sequelae.

SHORT CONCLUSION

This nonoperative approach is currently widely studied in certain patients who have a complete response (clinical, endoscopic, and radiological). However, the selection of these patients is not simple and still complex.

Total neoadjuvant treatment and organ preservation strategies in the management of localized rectal cancer: a narrative review and evidence-based algorithm

The multimodal approach with total mesorectal excision preceded by neoadjuvant (chemo)radiotherapy represented the mainstay treatment for locally advanced rectal cancer (LARC) for a long time. However, the benefit of adjuvant chemotherapy in terms of distant relapse reduction is limited. Recently, chemotherapy regimens administered before surgery and incorporated with (chemo)radiotherapy in total neoadjuvant treatment protocols have been established as new options in the management of LARC. Meanwhile, patients with clinical complete response to neoadjuvant treatment can benefit from organ preservation strategies, aimed at sparing surgery and long-term post-operative morbidities, while preserving an adequate disease control. However, the introduction of a non-operative management in clinical practice is a matter of debate with some concerns regarding the risk of local recurrence and long-term outcomes. In this review, we discuss how these recent advances are reshaping the multimodal management of localized rectal cancer and propose an algorithm to place them in the clinical practice.

Microbiota Phenotype Promotes Anastomotic Leakage in a Model of Rats with Ischemic Colon Resection

Anastomotic leakage (AL) is a major cause of morbidity and mortality after colorectal surgery, but the mechanism behind this complication is still not fully understood. Despite the advances in surgical techniques and perioperative care, the complication rates have remained steady. Recently, it has been suggested that colon microbiota may be involved in the development of complications after colorectal surgery. The aim of this study was to evaluate the association of gut microbiota in the development of colorectal AL and their possible virulence strategies to better understand the phenomenon. Using 16S rRNA sequencing of samples collected on the day of surgery and the sixth day following surgery, we analyzed the changes in tissue-associated microbiota at anastomotic sites created in a model of rats with ischemic colon resection. We discovered a trend for lower microbial diversity in the AL group compared to non-leak anastomosis (NLA). There were no differences in relative abundance in the different types of microbial respiration between these groups and the high abundance of the facultative anaerobic Gemella palaticanis is a marker species that stands out as a distinctive feature.

Parachute-like pull-through anastomosis for low rectal cancer: a new method for preservation of anal function

BACKGROUND

With recent improvements in surgical technique, oncological outcomes of low rectal cancer have improved over time. But the QoL impairment as a result of anal functional disorder cannot be ignored. And the incidence of anastomosis-related complications cannot be ignored. To address these problems, a personal technique for pull-through coloanal anastomosis (parachute-like intussuscept pull-through anastomosis) was introduced and evaluated. This technique can relatively reduce surgical complications, minimize the impact of anal function, and obviate a colostomy creation.

METHODS

Between June 2020 and April 2021, 14 consecutive patients with rectal cancer underwent laparoscopic-assisted resection of rectal cancer in our hospital. Parachute-like pull-through anastomosis method was performed in all patients. Anal function, perioperative details, and postoperative outcomes were analyzed.

RESULTS

The mean (SD) operative time of first stage was 282.1 min (range 220-370) with an average estimated blood loss of 90.3 mL (range 33-200). And the mean (SD) operative time of second was 46 min (range 25-76) with an average estimated blood loss of 16.1 mL (range 5-50). Wexner scores declined significantly during the median follow-up of 18 months. Four postoperative anastomosis-related complications occurred in 14 patients, including perianastomotic abscess: 1 case (7%), anastomotic stricture: 1 case (7%), and colonic ischemia of the exteriorized colonic segment: 2 cases (14%).

CONCLUSION

The results suggest that the method can facilitate safe and easy completion of coloanal anastomosis, using parachute-like pull-through anastomosis, with acceptable anal function.