Is the laparoscopic approach for rectal cancer superior to open surgery? A systematic review and meta-analysis on short-term surgical outcomes

Association Between Advanced T Stage and Thick Rectus Abdominis Muscle and Outlet Obstruction and High-Output Stoma After Ileostomy in Patients With Rectal Cancer

Objective

This study aimed to identify factors associated with outlet obstruction and high-output stoma (HOS) after ileostomy creation.

Summary of background data

Ileostomy creation is effective in preventing leakage among patients undergoing low anterior resection for rectal cancer. However, major complications such as outlet obstruction and HOS can occur after surgery. Moreover, these complications cannot be prevented.

Methods

This retrospective study included 34 patients with rectal cancer who underwent low anterior resection and ileostomy creation at Okayama University Hospital from January 2015 to December 2018. Then, the risk factors associated with outlet obstruction and HOS were analyzed.

Results

Of 34 patients, 7 (21%) experienced outlet obstruction. In a multivariate logistic regression analysis, advanced T stage (P = 0.10), ileostomy with a short horizontal diameter (P = 0.01), and thick rectus abdominis (RA) muscle (P = 0.0005) were considered independent risk factors for outlet obstruction. There was a significant correlation between outlet obstruction and HOS (P = 0.03). Meanwhile, the independent risk factors of HOS were advanced T stage (P = 0.03) and thick RA muscle (P = 0.04).

Conclusions

Thick RA muscle and advanced T stage were the common risk factors of outlet obstruction and HOS. Therefore, in high-risk patients, these complications can be prevented by choosing an appropriate ileostomy location according to RA muscle thickness and by preventing tubing into the ileostomy.

Laparoscopic intraarterial catheterization with selective ICG fluorescence imaging in colorectal surgery

The quality of mesorectal resection is crucial for resection in rectal cancer, which should be performed by laparoscopy for better outcome. The use of indocyanine green (ICG) fluorescence is now routinely used in some centers to evaluate bowel perfusion. Previous studies have demonstrated in animal models that selective intra-arterial ICG staining can be used to define and visualize resection margins in rectal cancer. In this animal study, we investigate if laparoscopic intra-arterial catheterization is feasible and the staining of resection margins when performing total mesorectal excision with a laparoscopic medial to lateral approach is possible. In 4 pigs, laparoscopic catheterization of the inferior mesenteric artery (IMA) is performed using a seldinger technique. After a bolus injection of 10 ml ICG with a concentration of 0.25 mg/ml, a continuous intra-arterial perfusion was established at a rate of 2 ml/min. The quality of the staining was evaluated qualitatively. Laparoscopic catheterization was possible in all cases, and the average time for this was 30.25 ± 3.54 min. We observed a significant fluorescent signal in all areas of the IMA supplied, but not in other parts of the abdominal cavity or organs. In addition, the mesorectum showed a sharp border between stained and unstained tissue. Intraoperative isolated fluorescence augmentation of the rectum, including the mesorectum by laparoscopic catheterization, is feasible. Inferior mesenteric artery catheterization and ICG perfusion can provide a fluorescence-guided roadmap to identify the correct plane in total mesorectal excision, which should be investigated in further studies.

Return to work following laparoscopic-assisted resection or open resection for rectal cancer: Findings from AlaCaRT-Australasian Laparoscopic Cancer of the Rectum Trial

BACKGROUND

Maintaining employment for adults with cancer is important, however, little is known about the impact of surgery for rectal cancer on an individual's capacity to return to work (RTW). This study aimed to determine the impact of laparoscopic vs. open resection on RTW at 12 months.

METHODS

Analyses were undertaken among participants randomized in the Australian Laparoscopic Cancer of the Rectum Trial (ALaCaRT), with work status available at baseline (presurgery), and 12 months. Multivariable logistic regression, adjusted for sociodemographic and clinical characteristics estimated the effect of surgery on RTW in any capacity, or return to preoperative work status at 12 months.

RESULTS

About 228 of 449 (51%) surviving trial participants at 12 months completed work status questionnaires; mean age was 62 years, 66% males, 117 of these received laparoscopic resection (51%). Of 228, 120 were employed at baseline (90 full-time, 30 part-time). Overall RTW in 120 participants in paid work at baseline was 78% (84% laparoscopic, 70% open surgery). Those employed full-time were more likely to RTW at 12 months (OR, 3.55; 95% CI, 1.02-12.31). Those with distant metastases at baseline were less likely to RTW (OR, 0.07; 95% CI, <0.01-0.83). Laparoscopic surgery was associated with a higher rate of RTW but did not reach statistical significance (OR 2.88; 95% CI, 0.95-8.76).

CONCLUSIONS

Full-time work presurgery and the presence of metastatic disease predicts RTW status at 12 months. A laparoscopic-assisted surgical approach to rectal cancer may facilitate more patients to RTW, however, larger sample sizes are likely needed to confirm this result.

Endoscopic fenestration in the diagnosis and treatment of delayed anastomotic submucosal abscess: A case report and review of literature

BACKGROUND

Abscess formation is one of the complications after radical resection of rectal cancer; cases with delayed postoperative anastomotic abscess are rare. Here, we report a rare case of postoperative anastomotic abscess with a submucosal neoplasm appearing after rectal surgery. Ultimately, the patient was diagnosed and treated by endoscopic fenestration. In addition, we review the literature on the appearance of an abscess as a complication after rectal cancer surgery.

CASE SUMMARY

A 57-year-old man with a history of rectal malignancy resection complained of a smooth protuberance near the anastomotic stoma. Endoscopic ultrasonography revealed a hypoechoic structure originating from the muscularis propria, and a submucosal tumor was suspected. The patient was subsequently referred to our hospital and underwent pelvic contrast-enhanced computed tomography, which revealed no thickening or strengthening of the anastomotic wall. In order to clarify the origin of the lesion and obtain the pathology, endoscopic fenestration was performed. After endoscopic procedure, a definitive diagnosis of delayed anastomotic submucosal abscess was established. The patient achieved good recovery and prognosis after the complete clearance of abscess.

CONCLUSION

Endoscopic fenestration may be safe and effective for the diagnosis/treatment of delayed intestinal smooth protuberance after rectal cancer surgery.

Laparoscopic versus open liver resections of posterolateral liver segments - a systematic review and meta-analysis

INTRODUCTION

Laparoscopic resection has become an accepted approach to liver tumour surgery. However, it is considered difficult, especially in unfavourably located lesions.

AIM

To compare the outcomes of laparoscopic (LLR) and open liver resection (OLR) of posterolateral segments.

MATERIAL AND METHODS

We searched the PubMed, EMBASE, and Scopus databases from inception to 30 September 2019. Full text articles and conference abstracts were included for further analysis. This review follows the PRISMA guidelines.

RESULTS

From 643 articles, 15 studies (N = 1196 patients) were included in the meta-analysis. All of them were non-randomised. Our findings showed that LLR had significantly lowered overall morbidity compared to OLR (MD = 0.66; 95% CI: 0.51-0.86; p = 0.002). Length of hospital stay (MD = 2.48; 95% CI: -3.87, -1.08; p < 0.001) was also shorter in the LLR group. Operative time (MD = 55.65; 95% CI: 24.14-87.16; p < 0.001) was significantly shorter in the OLR group. In terms of blood loss, major complications, R0 resection rates, and resection margin, there were no significant differences.

CONCLUSIONS

Our meta-analysis showed that the laparoscopic approach to resections of posterolateral liver segments is beneficial. However, the results are based on non-randomised trials, and further research is needed to fully establish their clinical application.

Intra-arterial versus negative-staining of embryonal resection borders with indocyanine green (ICG) fluorescence for total mesorectal excision in colorectal cancer - an experimental feasibility study in a porcine model

Background: Colorectal cancer (CRC) is one of the most common malignancies worldwide. Laparoscopic lower rectal resections in accordance with the oncological principles are recommended as the gold standard for CRC surgical management. However, the learning curve for adopting these techniques is quite steep and the incomplete resections are predictive of local recurrence. This study was conducted in an attempt to find a way to help surgeons to overcome some of these difficulties and define the right resection margins.Material and methods: As such, we carried out two laparoscopic lower rectal resections in porcine models. The first resection was performed following the ligation and selective infusion of Indocyanine Green (ICG) into the inferior mesenteric artery (IMA), and the second after the ligation of both inferior mesenteric artery and vein (IMV) and systemic intravenous infusion of ICG. Fluorescence was detected in real time by means of an infrared imaging system.Results: Sharp resection margins were defined after intra-arterial infusion, and all the tissues in the IMA basin were colored in the first case. In the second model every organ and tissue was colored except the rectum, urinary bladder and ductus deferens.Conclusions: Although systemic intra-venous application of ICG and negative-staining of the rectum including the mesorectum is much easier compared to laparoscopic inter-arterial perfusion through IMA, image results of selevtive IMA-perfusion appear in sharper discrimination of the several layers. Further investigation should focus on simplifying this technique.

Preoperative lymphocyte-to-monocyte ratio predicts postoperative infectious complications after laparoscopic colorectal cancer surgery

BACKGROUND AND AIM

Postoperative infectious complications (POI), which can increase length of hospital stay, medical cost, and worsen overall survival, are a concern in minimally invasive colorectal cancer (CRC) surgeries. Recent reports showed that relatively new inflammation-based score, lymphocyte-to-monocyte ratio (LMR) is an independent predictor of long-term outcomes after CRC surgeries. In this study, LMR was evaluated as a predictor of short-term postoperative outcomes.

PATIENTS AND METHODS

This was a single-institutional retrospective study of 211 consecutive patients who had undergone laparoscopic CRC surgery with primary tumor resection from January 2014 to August 2015 at Nippon Medical School Chiba Hokusoh Hospital. The patients were divided into two groups (no POI; n = 176 and POI; n = 35). The associations between inflammation-based scores, namely neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, and LMR, and the occurrence of POI were investigated. Receiving operator characteristic curve analysis was used to determine the cutoff point of preoperative LMR.

RESULTS

Low LMR (cut-off 3.46), long operative time, and smoking were found to be independent predictors of POI in a multivariate analysis (LMR: Odds ratio 5.61, 95% confidence interval 1.98-15.9, P = 0.001). Patients with low LMR also appeared to have more advanced and aggressive tumours.

CONCLUSION

This is the first study to report that the lower LMR is a predictive factor of POI after laparoscopic CRC surgery, and it may provide additional information for treatment decisions to prevent POI.

Investigating Risk Factors for Complications after Ileostomy Reversal in Low Anterior Rectal Resection Patients: An Observational Study

Introduction: Defunctioning ileostomy has been widely used in patients undergoing low anterior rectal resection to reduce the rate of postoperative leakage. It is still not clear whether interval between primary procedure and ileostomy reversal has an impact on treatment outcomes. Methods: In our prospective observational study we reviewed 164 consecutive cases of patients who underwent total mesorectal excision with primary anastomosis. Univariate and multivariate regression models were used to search for risk factors for prolonged length of stay and complications after defunctioning ileostomy reversal. Receiver operating characteristic curves were utilized to set cut-off points for prolonged length of stay and perioperative morbidity. Results: In total, 132 patients were included in the statistical analysis. The median interval between primary procedure and defunctioning ileostomy reversal was 134 (range: 17-754) days, while median length of stay was 5 days (4-6 interquartile range (IQR)). Prolonged length of stay cut-off was established at 6 days. Regression models revealed that interval between primary surgery and stoma closure as well as complications after primary procedure are risk factors for complications after defunctioning ileostomy reversal. Prolonged length of stay has been found to be related primarily to interval between primary surgery and stoma closure. Conclusions: In our study interval between primary surgery and stoma closure along with complication occurrence after primary procedure are risk factors for perioperative morbidity and prolonged length of stay (LOS) after ileostomy reversal. The effort should be made to minimize the interval to ileostomy reversal. However, randomized studies are necessary to avoid the bias which appears in this observational study and confirm our findings.

Functional outcomes after resections for low rectal tumors: comparison of Transanal with laparoscopic Total Mesorectal excision

Background

Aim of this study was to evaluate functional outcomes of transanal total mesorectal excision (TaTME) in comparison to conventional laparoscopic approach (LaTME) in terms of low anterior resection syndrome (LARS).

Methods

Forty-six patients who underwent total mesorectal excision for low rectal cancer between 2013 and 2017 were enrolled. Primary outcome was the severity of faecal incontinence, assessed both before the treatment and 6 months after ileostomy reversal. LARS score and Jorge-Wexner scale were utilized to analyze its severity.

Results

Twenty (87%) from TaTME and 21 (91%) from LaTME group developed LARS postoperatively. There were no significant differences between groups in terms of LARS occurrence (p = 0.63) and severity. The median Wexner score was comparable in both groups (8 [IQR: 4–12] vs 7 [3–11], p = 0.83). Univariate analysis revealed that postoperative complications were a risk factor for LARS development (p = 0.02). Perioperative outcomes, including operative time, blood loss and intraoperative adverse events did not differ significantly between groups either. Five TaTME patients developed postoperative complications, while there were morbidity 6 cases in LaTME group. Quality of mesorectal excision was comparable with 20 and 19 complete cases in TaTME and LaTME groups, respectively.

Conclusions

TaTME provided comparable outcomes in terms of functional outcomes in comparison to LaTME for total mesorectal excision in low rectal cancers. Having said that, LARS prevalence is still high and requires further evaluation of the technique.

Comparison of Oncologic Outcomes in Laparoscopic versus Open Surgery for Non-Metastatic Colorectal Cancer: Personal Experience in a Single Institution

The oncologic merits of the laparoscopic technique for colorectal cancer surgery remain debatable. Eligible patients with non-metastatic colorectal cancer who were scheduled for an elective resection by one surgeon in a medical institution were randomized to either laparoscopic or open surgery. During this period, a total of 188 patients received laparoscopic surgery and the other 163 patients received the open approach. The primary endpoint was cancer-free five-year survival after operative treatment, and the secondary endpoint was the tumor recurrence incidence. Besides, surgical complications were also compared. There was no statistically significant difference between open and laparoscopic groups regarding the average number of lymph nodes dissected, ileus, anastomosis leakage, overall mortality rate, cancer recurrence rate, or cancer-free five-year survival. Even though performing a laparoscopic approach used a significantly longer operation time, this technique was more effective for colorectal cancer treatment in terms of shorter hospital stay and less blood loss. Meanwhile, fewer patients receiving the laparoscopic approach developed postoperative urinary tract infection, wound infection, or pneumonia, which reached statistical significance. For non-metastatic colorectal cancer patients, laparoscopic surgery resulted in better short-term outcomes, whether in several surgical complications and intra-operative blood loss. Though there was no significant statistical difference in terms of cancer-free five-year survival and tumor recurrence, it is strongly recommended that patients undergo laparoscopic surgery if not contraindicated.

Laparoscopic Major Gastrointestinal Surgery Is Safe for Properly Selected Patient with COPD: A Meta-Analysis

Background

Laparoscopy has been widely applied in gastrointestinal surgery, with benefits such as less intraoperative blood loss, faster recovery, and shorter length of hospital stay. However, it remains controversial if laparoscopic major gastrointestinal surgery could be conducted for patients with chronic obstructive pulmonary disease (COPD) which was traditionally considered as an important risk factor for postoperative pulmonary complications. The present study was conducted to review and assess the safety and feasibility of laparoscopic major abdominal surgery for patient with COPD.

Materials and Methods

Databases including PubMed, EmBase, Cochrane Library, and Wan-fang were searched for all years up to Jul 1, 2018. Studies comparing perioperative results for COPD patients undergoing major gastrointestinal surgery between laparoscopic and open approaches were enrolled.

Results

Laparoscopic approach was associated with less intraoperative blood loss (MD = −174.03; 95% CI: −232.16 to −115.91, P < 0.00001; P < 0.00001, I²=93% for heterogeneity) and shorter length of hospital stay (MD = −3.30; 95% CI: −3.75 to −2.86, P < 0.00001; P = 0.99, I²=0% for heterogeneity). As for pulmonary complications, laparoscopic approach was associated with lower overall pulmonary complications rate (OR = 0.58; 95% CI: 0.48 to 0.71, P < 0.00001; P = 0.42, I²=0% for heterogeneity) and lower postoperative pneumonia rate (OR = 0.53; 95% CI: 0.41 to 0.67, P < 0.00001; P = 0.57, I²=0% for heterogeneity). Moreover, laparoscopic approach was associated with lower wound infection (OR = 0.51; 95% CI: 0.42 to 0.63, P < 0.00001; P = 0.99, I²=0% for heterogeneity) and abdominal abscess rates (OR = 0.59; 95% CI: 0.44 to 0.79, P < 0.0004; P = 0.24, I²=30% for heterogeneity).

Conclusions

Laparoscopic major gastrointestinal surgery for properly selected COPD patient was safe and feasible, with shorter term benefits.

Transanal versus laparoscopic total mesorectal excision for mid and low rectal cancer: a meta-analysis of short-term outcomes

Introduction

The benefit of transanal total mesorectal excision (TaTME) for mid and low rectal cancer is conflicting.

Aim

To assess and compare the short-term outcomes of TaTME with conventional laparoscopic total mesorectal excision (LaTME) for middle and low rectal cancer.

Material and methods

We searched PubMed, Embase and Cochrane Library databases for studies addressing TaTME versus conventional LaTME for rectal cancer between 2008 and December 2018. Randomized controlled trials (RCTs) and retrospective studies which compared TaTME with LaTME were included.

Results

Twelve retrospective case-control studies were identified, including a total of 899 patients. We did not find significant differences in overall intraoperative complications, blood loss, conversion rate, operative time, overall postoperative complication, anastomotic leakage, ileus, or urinary morbidity. Also no significant differences in oncological outcomes including circumferential resection margin (CRM), positive CRM, distal margin distance (DRM), positive DRM, quality of mesorectum, number of harvested lymph nodes, temporary stoma or local recurrence were found. Although the TaTME group had better postoperative outcomes (readmission, reoperation, length of hospital stay) on average, the difference did not reach statistical significance.

Conclusions

Transanal total mesorectal excision offers a safe and feasible alternative to LaTME although the clinicopathological features were not superior to LaTME in this study. Currently, with the lack of evidence on benefits of TaTME, further evaluation of TaTME requires large randomized control trials to be conducted.

Evaluation of the learning curve of transanal total mesorectal excision: single-centre experience

Introduction

Transanal total mesorectal excision (TaTME) has been recently proposed to overcome the difficulties of the standard TME approach, allowing better visualization and dissection of the mesorectal fascia. Although TaTME seems very promising, the evidence and body of knowledge on achieving proficiency in performing it are still sparse.

Aim

To evaluate the learning curve of TaTME based on a single centre’s experience.

Material and methods

Consecutive patients undergoing TaTME since 2014 in a tertiary referral department were included in the study. All procedures were performed by one experienced surgeon. CUSUM curve analyses were performed to evaluate learning curves.

Results

Sixty-six patients underwent TaTME. After analysis of postoperative morbidity rate, intraoperative adverse effects and operative time, we estimated that 40 cases are needed to achieve TaTME proficiency. Subsequently, patients were divided into two groups: before (40 patients) and after overcoming the learning curve (26 patients). Group 1 had higher readmission (p = 0.041) and complication rates (p = 0.019). There were no statistically significant differences in terms of intraoperative adverse effects, length of stay or pathological quality of the specimen.

Conclusions

Transanal total mesorectal excision is a promising yet technically demanding procedure and requires at least 40 cases to complete the learning curve. More data are needed to introduce it as a standard procedure for low rectal cancer treatment.

Transanal versus transabdominal specimen extraction in laparoscopic rectal cancer surgery: a retrospective analysis from China

Introduction

Comparison of transanal specimen extraction (TSE) and transabdominal specimen extraction (TASE) in laparoscopic rectal surgery is still sparsely reported. Trauma, pain, scarring, and bad psychological suggestion have long been considered an inevitable outcome of surgery. For laparoscopic rectal cancer surgery, whether TSE or TASE is beneficial in terms of technical platforms, indications, contraindications, technical requirements for aseptic operation, tumor-free operation, prevention and treatment of complications still has not reached a unified consensus and standards. Recently, comparison of TSE and TASE in laparoscopic rectal surgery has still been sparsely reported.

Aim

In this study, we retrospectively analyzed the short-term outcomes of TSE and TASE in laparoscopic rectal surgery in a single institution in southern China.

Material and methods

Patients who underwent laparoscopic radical rectal cancer surgery using either TSE or TASE were recruited. Data, including patient demographics, perioperative and postoperative variables, were analyzed retrospectively.

Results

Sixty-seven patients were included in this study. Thirty patients underwent TSE and 37 patients underwent TASE. The two groups were similar in demographics and tumor characteristics. Postoperative complications were similar in both groups, except that wound infection was lower for the TSE group (p = 0.122). The TSE group had a better cosmetic result with no abdominal incision and no differences in circumferential margins, distal resection margins or completeness of total mesorectal excision.

Conclusions

Laparoscopic TSE is recommended in the treatment of rectal cancer with similar oncologic outcomes compared with conventional TASE. It is mini-invasive surgery and has the advantage of better cosmetic results. There is a need for further randomized studies to refine the applicability of laparoscopic TSE in rectal cancer.

A quest for sphincter-saving surgery in ultralow rectal tumours-a single-centre cohort study

INTRODUCTION

Despite the progress in the treatment of colorectal cancer, there is still no optimal strategy for tumours located adjacent to the anal sphincter. This study aims to evaluate oncological and functional results of surgery for rectal cancer in unfavourable locations in proximity to anal sphincters.

MATERIALS AND METHODS

Patients with rectal cancer, which was either initially infiltrating the anal sphincter or located in the close proximity of the sphincter, were included in the study. Patients were submitted to extralevator abdominoperineal resection (APR), intersphincteric resection, or transanal total mesorectal excision (TaTME). Primary outcomes were perioperative data: operative time, blood loss, complications, length of stay (LOS), and 30-day mortality. Secondary outcomes were pathological quality of the specimens and functional outcome 6 months after defunctioning ileostomy closure.

RESULTS

Among patients with cancer adjacent to the anal sphincter, 13 (25%) underwent APR, 14 (27%) patients were submitted to intersphincteric resection, and 25 (48%) patients were treated with the TaTME approach. Operative time was 240 (210-270 IQR) for APR, 212.5 (170-260 IQR) for intersphincteric resection, and 270 (240-330 IQR) for TaTME (p = 0.018). Perioperative morbidity was 31% for APR, 36% for intersphincteric resections, and 12% for the TaTME group (p = 0.181). Complete mesorectal excision was achieved in 92% of specimens in the TaTME group, 93% in intersphincteric resections, and 78% in the APR group (p = 0.72). Median circumferential resection margin in APR was 6 mm (4-7 IQR), in intersphincteric resections 7.5 mm (2.5-10 IQR), and in the TaTME group 4 mm (2.8-8 IQR). All patients after intersphincteric resections developed major low anterior resection syndrome (LARS). Four patients in the TaTME group developed minor LARS, and 21 had major LARS.

CONCLUSION

Sphincter-saving rectal resections are a feasible alternative to APR with good clinical, pathological, and oncological outcomes. Intersphincteric resections and TaTME seem to be equal in terms of clinicopathological results. The functional outcome is yet to be investigated.

TRIAL REGISTRATION

The study was retrospectively registered in Thai Clinical Trials Registry (23-07-2018, ID TCTR20180724001 ).

Defunctioning ileostomy and mechanical bowel preparation may contribute to development of low anterior resection syndrome

INTRODUCTION

Laparoscopic surgery is an approved technique in colorectal cancer treatment. Functional and quality-of-life studies have revealed significant changes in faecal continence.

AIM

To assess the incidence and risk factors of low anterior resection syndrome (LARS) in patients undergoing rectal resections for cancer.

MATERIAL AND METHODS

We enrolled patients undergoing rectal resections in a general surgery department of a university hospital. The primary outcomes were the Jorge-Wexner scale and the LARS score 6 months after the end of treatment. The secondary outcomes were the risk factors for LARS development.

RESULTS

Fifty-six patients were included; 15 (26%) developed major LARS and 10 (18%) had minor LARS at 6 months. In univariate analysis the risk factors were: preoperative radiotherapy (p < 0.001, OR = 11.9, 95% CI: 2.98-47.48); shorter distance of the tumour from the anal verge (p = 0.001, OR = 0.69, 95% CI: 0.55-0.86); bowel preparation (p = 0.01, OR = 6.27, 95% CI: 1.51-26.07); low anterior rectal resection (p = 0.01, OR = 17.07, 95% CI: 1.86-156.83); and protective ileostomy (p = 0.001, OR = 15.97, 95% CI: 4.07-61.92). The risk factors for a higher Jorge-Wexner score in univariate analysis were greater diameter of tumour (p = 0.035), radiotherapy (p = 0.001), shorter distance from the anal verge (p = 0.002), bowel preparation (p = 0.042), low anterior rectal (LAR) (p = 0.01), ileostomy (p = 0.001), perioperative complications (p = 0.032), and readmission within 30 days (p = 0.034). In the multivariate analysis, readmissions and perioperative complications were significant.

CONCLUSIONS

In addition to typically described risk factors, two new ones have been identified. Mechanical bowel preparation and defunctioning ileostomy may also contribute to LARS development. However, due to the limitations of this study our observations require further confirmation in future trials.