Low Anterior Resection Syndrome. Anatomical Changes after Anterior Rectal Resection.

In this editorial, the authors bring to the attention of surgeons a personal point of view with the intention of offering a series of anatomical arguments to explain the high rate of functional complications following ultralow rectal resections, resections dominated by faecal incontinence of various intensities. Having as a starting point the anatomy of the pelvic floor and the posterior perineum, the authors are concerned with the functional outcomes of the sphincter-saving anterior rectal resection, regarding the low and ultralow resection. Technically, a conservative surgery for low rectal cancer has been currently performed. If 25 years ago the abdominoperineal resection was the gold standard for rectal cancer located under 7cm from the anal verge, nowadays the preservation of the anal canal as a partner for colon anastomosis has been accomplished. Progressively, from a desire to preserve the normal passage of stool into the anal canal, as anatomically and physiologically as possible, the distal limit of resection was lowered to 2-4 cm from the anal verge and ultra-low anastomoses were created, within the anal sphincter complex. The stated goal: keep the oncological safety standard and, at the same time, avoid definitive colostomy. Starting from the normal anatomy of the pelvic floor and the anorectal segment, the authors take a look at the alterations of the visceral, muscular, and nerve structures as a consequence of the low anterior resection and, particularly, the ultralow anterior resection. A significant degree of functional outcomes regarding defecation, with the onset of marked disabilities of anal continence, the major consequence being anal incontinence (30-70%), have been noticed. The authors go under review for the main anatomical and physiological changes that accompany anterior rectal resection. Conclusions: Thus, the following questions arise: what is the lower limit of resection to avoid total fecal incontinence? Is total incontinence a greater handicap than colostomy or is it not? The answers cannot be supported by solid arguments at this time, but the need to initiate future studies dedicated to this problem emerges.

Specific Septic Complications after Rectal Cancer Surgery: A Critical Multicentre Study.

The postoperative septic complications in gastrointestinal surgery impact immediate as well as long-term outcomes, which lead to reinterventions and additional costs. The authors presented the experience of three surgery clinics in Romania regarding the specific septic complications occurring in patients operated on for rectal cancer. The study group comprised 2674 patients who underwent surgery over a 5-year period (2017-2021). Neoplasms of the middle and lower rectum (76%) were the majority. There were 85% rectal resections and 15% abdominoperineal excisions of the rectum. In total, 68.54% of patients were operated on laparoscopically, and 31.46% received open surgery. Without taking wound infections into account, 97 (3.67%) patients had abdominal-pelvic septic complications. The aim was to evaluate the causes of the complications. The percentage of suppurations after surgery of the rectum treated by radiochemotherapy was considerably higher than after surgery of the non-radiated upper rectum. The fatality rate was 5.15%. The risk of fistulas was significantly associated with the preoperative treatment, tumour position and type of intervention. Sex, age, TNM stage or grade were not significant at 0.05 the threshold. The risk of fistulas is reduced with low anterior resection, but the gravity of these complications is higher in the lower rectum compared with the superior rectum. Preoperative radiochemotherapy is a contributing factor to septic complications.