Scarless two-stage delayed coloanal anastomosis: a technique description

Introduction: In current clinical practice, immediate coloanal anastomosis (ICA) remains the standard technique for restoring the gastrointestinal tract following coloproctectomy for low rectal cancer. This anastomosis still requires a temporary diverting stoma to decrease the postoperative morbidity, which remains significantly high. As an alternative, some authors have proposed a two-stage delayed coloanal anastomosis (TS-DCA). This article reports on the surgical technique of TS-DCA. Methods: The case described is of a 53-year-old woman, without any particular history, in whom colonoscopy motivated by rectal bleeding revealed an adenocarcinoma of the low rectum. Magnetic resonance imaging showed a tumor ~ 1 cm above the puborectalis muscle, graded cT3N +. The extension workup was negative. Seven weeks after chemoradiotherapy, a coloproctectomy with total mesorectal excision (TME) was performed. A TS-DCA was chosen to restore the digestive tract. Conclusion: Two-stage delayed coloanal anastomosis is a safe and effective alternative for restoring the digestive tract after proctectomy for low rectal cancer. Recent data seem to show a clear advantage of this technique in terms of morbidity. (AU)

VAAFT PROCEDURE (Video-assisted Anal Fistula Treatment) versus open method in the treatment of high fistula in ano

Background: A common acquired anorectal condition is anal fistula. The treatment approaches that have been employed have been linked to erratic outcomes and sometimes life-threatening consequences. Video-assisted anal fistula treatment (VAAFT), a minimally invasive method, was introduced for adult patients in 2011. Objective: To know the efficacy of the VAAFT procedure in treating high anal fistulas and to compare it to open methods in the Basrah province. Methods: The present study was performed on 200 patients with high fistulas in ano in Basrah province. We divided the patients into 2 groups: Group A: treated by the VAAFT technique and Group B: treated by open fistulotomy Results: The patients treated with VAFFT revealed no occurrence of the following postoperative complication: Infection, incontinence, recurrence, anal stenosis, and bleeding. There was lower incidence of pain, short time for wound healing, rapid return to work, and more patient satisfaction compared with open fistulotomy Conclusion: An innovative method for managing ano fistula is VAAFT. Compared with traditional methods, it has a lot of benefits. It is day case surgeryno open wound.no damage to anal sphincter and no risk of incontinence, it is more affordable.it allow for clear identification of internal office, whole tract and its associated branches and cavity. The instrument can be used for multiple patients after good sterilization and disinfection. (AU)

Management of complex fistula-in-ano by interception of fistula track with application of ksharasutra (IFTAK): a novel technique

Objective: Despite all the technological advances, successful management of complex fistula-in-ano is still a challenge due to recurrence and incontinence. The present study evaluates the outcomes of a novel technique, Interception of Fistula Track with Application of Ksharasutra (IFTAK) in terms of success rate and degree of incontinence. Methods: In the present prospective study, 300 patients with complex fistula-inano were treated by the IFTAK technique, whose surgical steps include: incision at the anterior or posterior midline perianal area, identification and interception of the fistulous track at the level of the external sphincter, rerouting the track (and extensions) at the site of interception, and application of a ksharasutra (medicated seton) in the proximal track (from the site of interception to the internal opening) that is laid open gradually, with the resulting wound healing with minimum scarring. The distal track is allowed to heal spontaneously. Results: There were 227 transsphincteric and 73 intersphincteric varieties of fistula with supralevator extension in 23 cases, of which 130 were recurrent fistulas, 29 had horseshoe track, while 25 had blind fistula with no cutaneous opening. The mean duration of the ksharasutra application was 8.11 ± 3.86 weeks with an overall success rate of 93.33% at the 1-year follow-up. A total of 3.67% of the cases reported with a mild impairment of continence on the Wexner incontinence scoring system. Pre- and postoperative anal manometry evaluation showed minimal reduction in median basal and squeeze pressures. Conclusion: The IFTAK technique is a minimally invasive, daycare surgical procedure for the management of complex fistula-in-ano with low recurrence and minimal sphincter damage. (AU)

Metástasis cutánea metacrónica de carcinoma escamoso de canal anal / Methachronical cutaneous metastasis of squamous carcinoma of the anal canal / Metástase cutânea metacronica de carcinoma escamoso do canal anal

El tratamiento correcto de carcinoma escamoso avanzado requiere de un manejo multidisciplinar entre cirujanos, anatomopatólogos, radioterapeutas y radiólogos. Los protocolos están claros cuando nos hallamos ante una enfermedad localizada, sin embargo, cuando la enfermedad es metastática no existe evidencia científica de los pasos a seguir. Presentamos una paciente con un carcinoma escamoso del ano con una única metástasis cutánea metacrónica que fue tratada con cirugía y radioterapia posterior con buena respuesta.

The right therapy of anal cancer needs a multidisciplinary management of surgeons, pathologists, radiotherapists and radiologist. The treatment of squamous cell carcinoma of the anal canal is well-known when the patient presents a locally disease, nevertheless, there is a lack of information with the advanced anal cancer. We report a case of a 74-year-old woman with a solitary methachronical cutaneous metastasis of anal cancer which responded perfectly to surgery and radiotherapy.

A correta terapêutica do câncer anal necessita de uma gestão multidisciplinar de cirurgiões, patologistas, radio terapeutas e radiologistas.O tratamento do carcinoma espinocelular do canal anal é bem conhecido quando o paciente apresenta uma doença local, porém, há uma falta de informação sobre o câncer anal avançado. Relatamos o caso de uma mulher de 74 anos com metástase cutânea metacrônica solitária de câncer anal que respondeu perfeitamente à cirurgia e à radioterapia.

Reassessment of intersphincteric resection in the sphincter-preserving operation for ultra-low rectal cancer / 中华胃肠外科杂志

Intersphincteric resection (ISR), as an ultra-low sphincter-preserving operation, is widely used in clinical practice at present. ISR can allow some patients with very low rectal cancer to avoid the pain of anal resection while ensuring oncological efficacy. However, the procedure of ISR requires wider intersphincteric dissection which may cause nerve damage, and the removal of partial or total internal anal sphincter as an "inherent defect" of ISR can result in poor anal function postoperatively. Based on the in-depth understanding of regional anatomy and physiological function, the author proposed a new functional sphincter preservation operation for very low rectal cancer-conformal sphincter preservation operation (CSPO) which has achieved good outcome in clinical practice. This article will revisit the brief history of rectal cancer surgery and discuss the main mechanisms underlining the poor anal function after ISR. Based on the anatomical study of the pelvic floor and anal canal, CSPO can improve the postoperative anal function of very low rectal cancer patients by reducing the damage of the autonomic nerves, receptor corpuscles and muscle fibers in the intersphincteric space, retaining more dentate line and internal sphincter with the design of resection line of tumor lower border under direct vision, and elevating the anastomosis height. At the same time, the future treatment prospect of low rectal cancer is envisioned.

Short-term complications after transanal total mesorectal excision for mid-low rectal cancer / 中华胃肠外科杂志

Objective: To summarize short-term postoperative complications of transanal total mesorectal excision (taTME) in the treatment of middle-low rectal cancer. Methods: A descriptive case series of cases was constructed. Clinical data of consecutive 83 patients with mid-low rectal cancer who received taTME treatment from November 2016 to April 2021 at Department of General Surgery of Beijing Friendship Hospital, Capital Medical University were collected. Among 83 patients, 58 (69.9%) were males, with a mean age of (61.4±11.8) years; 42 (50.6%) were low rectal cancer, 41 (49.4%) were middle rectal cancer. Short-term postoperative complication was defined as complication occurring within 30 days after operation. The complication was graded according to the Clavien-Dindo classification. At the same time, the morbidity of short-term postoperative complication in the first 40 patients and that in the last 43 patients were compared to understand the differences before and after passing the taTME learning curve. Results: Two patients (2.5%) were converted to laparotomy ; 78 (94.0%) completed anastomosis.While 5 (6.0%) underwent permanent stoma. The total operation time of transabdominal+ transanal procedure was (246.9±85.0) minutes, and the median intraoperative blood loss was 100 (IQR: 100) ml. Seventy-five cases (75 /78, 96.2%) underwent defunctioning stoma, including 74 cases of diverting ileostomy, 1 case of diverting transverse colostomy and 3 cases without stoma. The morbidity of complication within 30 days after operation was 38.6% (32/83), and the morbidity of complication after discharge was 8.4% (7/83). Minor complications accounted for 31.3% (26/83) and major complications accounted for 7.2% (6/83). No patient died within 30 days after operation. The incidence of anastomotic leakage was 15.4% (12/78). Eight patients (9.6%) were hospitalized again due to complications after discharge. The median postoperative hospital stay was 7 (IQR: 3) days. All the patients with minor (I-II) complications received conservative treatment. One patient with grade C anastomotic leakage was transferred to intensive care unit and received a second operation due to sepsis and multiple organ dysfunction. Two patients with paralytic ileus (Clavien-Dindo IIIa) underwent endoscopic ileus catheter placement. There were 3 patients with Clavien-Dindo III or above respiratory complications, including 1 patient with pleural effusion and ultrasound-guided puncture, 2 patients with respiratory failure who were improved and discharged after anti-infection and symptomatic treatment. One patient underwent emergency ureteral stent implantation due to urinary infection (Clavien-Dindo IIIb). The morbidity of postoperative complication in the first 40 cases was 50.0% (20/40), and that in the latter 43 cases decreased significantly (27.9%, 12/43), whose difference was statistically significant (χ(2)=4.270, P=0.039). Conclusions: The procedure of taTME has an acceptable morbidity of short-term postoperative complication in the treatment of mid-low rectal cancer. The accumulation of surgical experience plays an important role in reducing the morbidity of postoperative complication.

Influence of different sphincter-preserving surgeries on postoperative defecation function / 中华胃肠外科杂志

Advances in surgical techniques and treatment concept have allowed more patients with low rectal cancer to preserve sphincter without sacrificing survival benefit. However, postoperative dysfunctions such as fecal incontinence, frequency, urgency, and clustering often occur in patients with low rectal cancer. The main surgical procedures for low rectal cancer include low anterior rectum resection (LAR), intersphincteric resection (ISR), coloanal anastomosis (Parks) and so on. The incidence of major LARS after LAR is up to 84.6%. The postoperative function of ISR is even worse than LAR. Moreover, the greater the extent of resection ISR surgery, the worse the postoperative function. There are few studies on the function of Parks procedure. Current evidence suggests that the short-term function of Parks procedure is inferior to LAR, but function can gradually recovered over time. Colorectal surgeons have attempted to improve postoperative defecation by modifying bowel reconstructions. Current evidence suggests that J pouch or end-to-side anastomosis during LAR does not reduce the incidence of defecation disorders. Pouch reconstruction during ISR cannot reduce the incidence of severe LARS either. In general, the protection of postoperative defecation function in patients with low rectal cancer still has a long way to go.

Surgical technique and considerations about transanal transection and single-stapled (TTSS) anastomosis: the search for a perfect anastomosis

The evaluation of preventivemeasures and risk factors for anastomotic leakage has been a constant concern among colorectal surgeons. In this context, the description of a new way to perform a colorectal, coloanal or ileoanal anastomosis, known as transanal transection and single-stapled (TTSS) anastomosis, deserves an appreciation of its qualities, and a discussion about its properties and technical details. In the present paper, the authors review themost recent efforts aiming to reduce anastomotic dehiscence, and describe the TTSS technique in a patient submitted to laparoscopic total proctocolectomy with ileal pouch-anal anastomosis for familial adenomatous polyposis. Surgical perception raises important advantages such as distal rectal transection under visualization, elimination of double-stapling lines (with cost-effectiveness and potential protection against suture dehiscence), elimination of dog ears, and the opportunity to be accomplished via a transanal approach after open, laparoscopic, or robotic colorectal resections. Future studies to confirm these supposed advantages are needed. (AU)

Transanal minimally-invasive surgery (TAMIS): experience with no closure of the rectal defect

Background: In transanalminimally-invasive surgery (TAMIS), the closure of the rectal defect is controversial, and endoluminal suture is one of the most challenging aspects. The goal of the present study is to evaluate the short- andmedium-term complications of a consecutive series of patients with extraperitoneal rectal injuries who underwent TAMIS without closure of the rectal defect. Materials and Methods: A prospective, longitudinal, descriptive study conducted between August 2013 and July 2019 in which all patients with extraperitoneal rectal lesions, who were operated on using the TAMIS technique, were consecutively included. The lesions were: benign lesions ≥ 3 cm; neuroendocrine tumors ≤ 2 cm; adenocarcinomas in stage T1N0; and adenocarcinomas in stage T2N0, with high surgical risk, or with the patients reluctant to undergo radical surgery, and others with doubts about complete remission after the neoadjuvant therapy. Bleeding, infectious complications, rectal stenosis, perforations, and death were evaluated. Results: A total of 35 patients were treated using TAMIS without closure of the defect. The average size of the lesionswas of 3.68±2.1 cm(95% confidence interval [95%CI]: 0.7cmto 9 cm), their average distance from the anal margin was of 5.7±1.48cm, and the average operative time was of 39.2±20.5 minutes, with a minimum postoperative follow-up of 1 year. As for the pathologies, they were: 15 adenomas; 3 carcinoid tumors; and 17 adenocarcinomas. In all cases, the rectal defect was left open. The overall morbidity was of 14.2%. Two patients (grade II in the Clavien-Dindo classification) were readmitted for pain treatment, and three patients (grade III in the Clavien-Dindo classification) were assisted due to postoperative bleeding, one of whom required reoperation. Conclusion: The TAMIS technique without closure of the rectal defect yields good results, and present a high feasibility and low complication rate. (AU)

C-reactive protein as a marker of postoperative complication of emergency colorectal surgery

Introduction: The literature converges regarding the use of C-reactive protein (CRP) tests between postoperative days (PODs) 3 and 5 of elective procedures. In this period, they have great sensitivity and negative predictive value (NPV) for severe and anastomotic complications about two days before the first clinical sign. The few studies on colorectal urgency suggest that, despite the different initial values according to the surgical indication, following POD 3, the level of CRP is similar to that of elective procedures. However, given the heterogeneity of the studies, there is no consensus on the cutoff values for this use. Objective: To validate the use and propose a PO CRP cut-off value in urgent colorectal procedures as an exclusion criterion for complications of anastomosis or the abdominal cavity. Method: Retrospective analysis of the medical records of 308 patients who underwent urgent colorectal surgical procedures between January 2017 and December 2019. The following data were considered: age, gender, surgical indication, type of procedure performed, complications, CRP levels preoperatively and from POD 1 to 4, and the severity of the complications. We compared the CRP levels and the percentage variations between the preoperative period and PODs 1 to 4 as markers of severe complications using the receiver operating characteristic (ROC) curve. Results: The levels of CRP on POD4, and their percentage drops between PODs 2 to 4 and PODs 3 to 4, were better to predict severe complications. A cutoff of 7.45mg/dL on POD 4 had 91.7% of sensitivity and NPV. A 50% drop between PODs 3 and 4 had 100% of sensitivity and NPV. Conclusion: Determining the level of CRP is useful to exclude severe complications, and it could be a criterion for hospital discharge in POD 4 of emergency colorectal surgery. (AU)

The ligation of the intersphincteric fistula tract (LIFT) technique for simple and complex fistula-in-ano

Background: Fistula-in-ano is one of the most common clinical condition encountered in a surgical outpatient department. Many treatment modalities have been described with variable outcomes but gold standard surgical treatment is yet to be agreed upon. The aim of the present study is to evaluate the treatment outcomes of ligature of intersphincteric fistula tract (LIFT) technique in the treatment of simple and complex fistula-in-ano with the primary objective of recurrence rate and broad objective of other postoperative complications during the period of study and after long-term follow-up. Methods: It is a retrospective study of prospectively collected data from the patients who havebeen operated for fistula-in-ano using the LIFT technique at our institute from February 2018 to March 2020 and followed-up until September 2020. Results: A total of 56 patients with fistula-in-ano were treated with the LIFT procedure during the study period, of which 20 patients had simple fistula and 36 had complex fistula. A success rate of 83% was obtained with completely healed fistulas in 46 patients. No patient developed postoperative incontinence. Conclusion: Ligature of intersphincteric fistula tract is an effective treatmentmodality for fistula-in-ano with less procedure-related morbidity, but it is associated with a higher recurrence rate in simple fistula than in complex fistula. (AU)

Evaluation of fistulotomy with immediate sphincteric reconstruction in the treatment of high transsphincteric perianal fistula

Background: High perianal fistula treatment remains challenging, mainly due to the variability in success and recurrence rates as well as continence impairment risks. So far, no procedure can be considered the gold standard for surgical treatment. Yet, strong efforts to identify effective and complication-free surgical options are ongoing. Fistulotomy can be considered the best perianal fistula treatment option, providing a perfect surgical field view, allowing direct access to the source of chronic inflammation. Controversy exists concerning the risk of continence impairment associated with fistulotomy. The present study aimed to assess the outcomes of fistulotomy with immediate sphincteric reconstruction regaring fistula recurrence, incontinence, and patient satisfaction. Methods: This interventional study was performed at the General Surgery Department of Zagazig University Hospital during the period from July 2018 to December 2019 on 24 patients with a clinical diagnosis of high transsphincteric fistula-in-ano. The fistulous tract was laid open over the probe placed in the tract. After the fistula tract had been laid open, the tract was curetted and examined for secondary extensions. Then, suturing muscles to muscles, including the internal and external sphincters, by transverse mattress sutures. Results: Our study showed that 2 patients develop incontinence to flatus ~ 8.3%.and only one patient develop incontinence to loose stool, 4.2%. Complete healing was achieved in 83% and recurrence was 16.6%. Conclusion: Fistulotomy with immediate sphincteric reconstruction is considered to be an effective option in the management of high perianal fistula, with low morbidity and high healing rate with acceptable continence state. (AU)

End-to-end anal sphincter repair in treatment of post-traumatic fecal incontinence

The present report describes the end-to-end technique of anal sphincter repair in a 36-year-old female patient with post-vaginal delivery fecal incontinence (FI). The patient had a history of two vaginal deliveries and the symptoms of FI were observed after the second delivery. On assessment of the severity of FI using the Wexner incontinence score, the patient had a score of 12. Endoanal ultrasonography revealed an anterior defect of the external anal sphincter extending from 11 to 3 o'clock. The patient had no previous anal surgery and did not have any medical comorbidities. The operation time was 45minutes. No intraoperative complications were recorded. At 12 months of follow-up, the patient showed significant improvement in the continence state, with her Wexner score dropping to 4. No postoperative complications were recorded. We can conclude that end-to-end anal sphincter repair is a technically feasible operation that confers satisfactory improvement in the continence state without imposing much tension on the site of sphincter repair. (AU)

Short- and Long-Term Outcomes of Overlap Anal Sphincter Repair for Fecal Incontinence Following Sphincter Injury / Resultados em curto e longo prazos do reparo por sobreposição do esfíncter anal para incontinência fecal após lesão esfincteriana

Abstract Objective Several techniques are used to repair the anal sphincter following injury. The aim of the present study is to comprehensively analyze the short- and long-term outcomes of overlap repair following anal sphincter injury. Methods A search was conducted in the PubMed, Medline, Embase, Scopus and Google Scholar databases between January 2000 and January 2020. Studies that described the outcomes that are specific to overlap sphincter repair for fecal incontinence with a minimum follow-up period of one year were selected. Results A total of 22 studies described the outcomes of overlap sphincter repair. However, 14 studies included other surgical techniques in addition to overlap repair, and were excluded from the analysis. Finally, data from 8 studies including 429 repairs were analyzed. All studies used at least one objective instrument; however, there was significant heterogeneity among them. Most patients were female (n=407; 94.87%) and the mean age of the included individuals was 44.6 years. The majority of the procedures were performed due to obstetric injuries (n=384; 89.51%). The eight included studies described long-term outcomes, and seven of them demonstrated statistically significant improvements regarding the continence; one study described poor outcomes in terms of overall continence. The long-term scores were significantly better compared with the preoperative scores. However, compared with the shortterm scores, a statistically significant deterioration was noted in the long-term. Conclusion The majority of the studies described good long-term outcomes in terms of anal continence after overlap sphincter repair. However, further studies are needed

Resumo Objetivo Diversas técnicas são usadas no reparo do esfíncter anal após lesões. O objetivo deste estudo é fazer uma análise completa dos desfechos nos curto e longo prazos do reparo por sobreposição após lesão do esfíncter anal. Métodos Realizou-se uma busca nas bases de dados PubMed, Medline, Embase, Scopus e Google Scholar entre janeiro de 2000 e janeiro de 2020. Estudos que descreviam desfechos específicos do reparo de esfíncter por sobreposição para incontinência fecal, com um mínimo de 1 ano de seguimento, foram selecionados. Resultados No total, 22 estudos descreviam os desfechos do reparo de esfíncter por sobreposição. No entanto, 14 estudos incluíam outras técnicas cirúrgicas além do reparo por sobreposição, e foram excluídos da análise. Por fim, dados de 8 estudos que incluíam 429 reparos foram analisados. Todos os estudos usaram pelo menos um instrumento objetivo, mas havia uma heterogeneidade significativa entre eles. A maioria dos pacientes era do sexo feminino (n=407; 94,87%), e a idade média dos indivíduos incluídos foi de 44,6 anos. A maioria das cirurgias foi realizada devido a lesões obstétricas (n=384; 89,51%). Os oito estudos incluídos descreveram os desfechos no longo prazo, e sete deles demonstraram melhoras estatisticamente significativas com relação à continência; um estudo descreveu resultados ruins em termos gerais com relação à continência. As pontuações no longo prazo foram significativamente melhores em comparação com as pontuações no pré-operatório. No entanto, em comparação com as pontuações no curto prazo, percebeu-se uma piora estatisticamente significativa no longo prazo. Conclusão A maioria dos estudos descrevia bons resultados no longo prazo em termos de continência anal depois do reparo do esfíncter por sobreposição. Entretanto mais estudos são necessários para que se identifiquem os fatores associados aos desfechos ruins para auxiliar na seleção de pacientes para o reparo por sobreposição.

Long-term results from modified sphincteroplasty in patients with traumatic sphincter injury: a retrospective study

ABSTRACT BACKGROUND: The results from sphincteroplasty may worsen over time. Reseparation of the rectum and vagina/scrotum in conjunction with sphincteroplasty achieves good results. Improving the surgical effect of sphincteroplasty through perineal body reconstruction is crucial. OBJECTIVE: To evaluate the long-term results from anterior sphincteroplasty and perineal body reconstruction (modified sphincteroplasty) among patients with traumatic sphincter injury. DESIGN AND SETTING: Retrospective study among patients who underwent modified sphincteroplasty in a university hospital between January 2006 and December 2018. Fifty patients were evaluated in detail. METHODS: The following variables were evaluated: gender, age, additional disease status, time interval between trauma and surgery, surgical technique, duration of hospitalization, follow-up period after surgery, manometric values, electromyography results, magnetic resonance imaging scans, Wexner scores, satisfaction levels with surgery and surgical outcomes. RESULTS: The patients' mean age was 44.6 ± 15.1 years. The median follow-up period was 62 months (range, 12-118). The mean Wexner scores preoperatively, postoperatively in first month (M1S) and at the time of this report (AAS) were 15.5 ± 3.2, 1.9 ± 3.15 and 3.9 ± 5.3, respectively. Although improvements in the patients' mean Wexner scores became impaired over time, the postoperative Wexner scores were still significantly better than the preoperative Wexner scores (P = 0.001). CONCLUSION: Good or excellent results were obtained surgically among patients with traumatic sphincter injury. Performing perineal body reconstruction in addition to sphincteroplasty can provide better long-term continence. Surgical outcomes were found to be better, especially among patients younger than 50 years of age and among patients who underwent surgery within the first five years after trauma.

Clinical efficacy of laparoscopic modified Parks operation on the ultra-low rectal cancer / 中南大学学报(医学版)

OBJECTIVES@#To investigate the clinical efficacy of laparoscopic modified Parks operation on the patients with ultra-low rectal cancer.@*METHODS@#According to the preoperative stage and intraoperative anastomotic position, 98 patients with ultra-low rectal cancer above T2 stage underwent laparoscopic Dixon operation, modified Parks operation and Miles operation, respectively. All patients were divided into 3 groups: a Dixon operation group (@*RESULTS@#The patients were more obese, the distance between tumor and anal margin was closer, and the operation time was longer in the modified Parks operation group than those in the Dixon operation group (all @*CONCLUSIONS@#Laparoscopic modified Parks operation is a safe, economical and effective anus preservation operation, which can not only save the anus for some patients who had to perform Miles operation, but also recover better and faster after operation. Although the early anal function of patients performed with the modified operation is poor, it can gradually recover to the same level as the patients performed with the Dixon operation.

Recognition of surgical anatomy for intersphincteric resection / 中华胃肠外科杂志

Intersphincteric resection (ISR) involves the anatomy of hiatal ligament, internal and external sphincter and conjoined longitudinal muscle. The hiatal ligament is actually a branch of the longitudinal muscle of rectum, shown as an uneven ring attached to the levator ani muscle. The internal sphincter is the end of the circular muscle of rectum which begins at the level of hiatal ligament formation. The distance from the upper boundary of internal sphincter to dentate line is significantly different among individuals. Although there is adipose tissue in the space between the internal and external sphincters, no evidence of mesentery structure in the anal canal is found as in the rectum. The conjoined longitudinal muscle is the remaining branch of the longitudinal muscle, whose return passes through the external sphincter and ends at the anococcygeal ligament/coccyx after reaching the anal margin. The synergistic action of conjoined longitudinal muscle and the hiatal ligament participates in the defecation process. The individualized difference of ISR-related anatomy affects the operation, especially the anastomosis.

Efficacy of transanal hand-sewn reinforcement in low rectal stapled anastomosis in preventing anastomotic leak after transanal total mesorectal excision / 中华胃肠外科杂志

Objective: To explore the efficacy and feasibility of transanal hand-sewn reinforcement of low stapled anastomosis in preventing anastomotic leak after transanal total mesorectal excision (taTME). Methods: A descriptive cohort study was conducted. Clinical data of 51 patients with rectal cancer who underwent taTME with transanal hand-sewn reinforcement of low stapled anastomosis at Department of Colorectal Surgery, the Sixth Affiliated Hospital of Sun Yat-sen University from January 2019 to December 2020 were retrospectively collected. Inclusion criteria: (1) age >18 years old; (2) rectal cancer confirmed by preoperative pathology; (3) distance from tumor to anal verge ≤ 8 cm according to pelvic MR; (4) the lesion was evaluated to be resectable before operation; (5) with or without neoadjuvant chemotherapy and radiotherapy; (6) taTME, end-to-end stapled anastomosis, and reinforcement in the anastomosis with absorbable thread intermittently were performed, and the distance between anastomosis and anal verge was ≤ 5 cm. Exclusion criteria: (1) previous history of colorectal cancer surgery; (2) emergency surgery due to intestinal obstruction, bleeding or perforation; (3) patients with local recurrence or distant metastasis; (4) the period of postoperative follow-up less than 3 months. The procedure of transanal hand-sewn reinforcement was as follows: firstly, no sign of bleeding was confirmed after checking the anastomosis. Then, the anastomosis was reinforced by suturing the muscle layer of rectum intermittently in a figure-of-eight manner using 3-0 single Vicryl. The entry site of the next suture was close next to the exit site of the last one. Any weak point of the anastomosis could also be reinforced according to the specimen from the circular stapler. The primary outcome were the incidence of anastomotic leak, methods of the secondary operation, anastomotic infection, anastomotic stricture, and conditions of Intraoperative and postoperative. Results: All the 51 enrolled patients completed surgery successfully without any conversion to open surgery. The median operative time was 169 (109-337) minutes, and the median intraoperative blood loss was 50 (10-600) ml. The median postoperative hospital stay was 8 (5-16) days. The mssorectum was complete and distal resection margin was negative in all patients. Postive circumferential resection margin was observed in 1 patients (2.0%). Twelve (23.5%) patients underwent prophylactic ileostomy. One patient developed anastomosis stricture which was cured by digital dilatation of the anastomosis. ISREC grade C anastomotic leak was observed in 3 (5.9%) male patients, of whom 2 cases did not received prophylactic ileostomy during the operation, and were cured by a second operation with the ileostomy and anastomotic repair. The other one healed by transanal repair of the anastomosis and anti-infection therapy. One (2.0%) patient suffered from perianal infection and healed by sitz bath and anti-infection therapy. No death was reported within 30 days after operation. Conclusion: Transanal hand-sewn reinforcement in low rectal stapled anastomosis in preventing anastomotic leak after taTME is safe and feasible.

Investigation on the status quo of diagnosis and treatment related to the protection of defecation function in sphincter-preserving resections for rectal cancer: a cross-sectional study of Chinese colorectal surgeons / 中华胃肠外科杂志

Objective: To understand the current status of diagnosis and treatment regarding the protection of defecation function in Chinese surgeons performing sphincter-preserving resections (SPR) for rectal cancer in order to discover the problems existing in the function protection during SPR and provide support and reference for the standardized clinical management of rectal cancer. Methods: A cross-sectional survey was performed. Colorectal surgeons who obtained the medical qualifications and volunteered to participate in this study were included, and respondents with incomplete information were excluded. From October 18 to 22, 2020, randomized sampling was conducted among Chinese colorectal surgeons from Chinese Association of Colorectal Surgeons, Chinese Colorectal Cancer Committee, Chinese Sexology Association Anal functional Surgery Committee and National Health Commission Capacity Building and Continuing Education Committee. The questionnaire included basic information of the respondents, assessment of defecation function before SPR, intraoperative details, postoperative follow-up, evaluation and intervention of patients with low anterior resection syndrome (LARS). Observation indicator: results of the questionnaire survey. Result: A total of 231 questionnaires were collected, and 230 were effective, with an effective rate of 99.6%. Among these participants, 217 (94.3%) were males; 107 (46.5%) had medical doctor degrees; 129 (56.1%) were national commission members in colorectal surgery; 137 (59.6%) performed more than 50 SPR operations per year; 211 (91.7%) assessed defection function by auxiliary examinations before SPR. Rigid sigmoidoscopy (n=116, 55.0%) and anorectal manometer (n=81, 38.4%) were the most commonly used method. Among the 230 respondents, 64.8% (n=149) of surgeons used 2D laparoscopy for SPR surgery most commonly, and 51.3% (n=118) of surgeons performed direct colorectal anastomosis for reconstruction, and 98.3% (n=226) used staplers during anastomosis. All the surgeons indicated that they would follow up patients after SPR, and outpatient clinic was the most common method (84.4%, 184/230). When LARS occurred, 50.0% (115/230) of surgeons chose defecation function scale and 78.7% (181/230) actively provided guidance and intervention for patients. Conclusions: Chinese colorectal surgeons still have shortcomings in the protection of defecation function during SPR for rectal cancer. They do not make enough preoperative functional evaluation and postoperative functional recovery estimate for patients. The knowledge and use of defecation function scales and interventions on LARS are expected to be standardized.