Comparison of Anorectal Function and Quality of Life Measures in Patients Following Intersphincteric Resection and Lower Anterior Resection.

This study explored postoperative outcomes for patients with lower rectal cancer who underwent low anterior resection (LAR) or intersphincteric resection (ISR). A total of 49 patients (33 LAR, 16 ISR) were followed using anorectal manometry and quality of life (QOL) questionnaires over a year, pre- and post surgery. The primary aim of this study is to clarify differences in anal manometry, sphincter function, fecal incontinence, and QOL between the two surgical arms. The secondary aim was to identify indicators suitable for assessing relationships between anorectal manometry measurements, fecal incontinence, and QOL. Anorectal manometry elements (AMEs), such as atmospheric maximum mean squeeze pressure (aMSP), maximum tolerable volume (MTV), and incremental maximum mean squeeze pressure (iMSP), showed no significant differences during the observation period. However, maximum resting pressure (MRP), high-pressure zone length (HPZ), and threshold volume (TV) were significantly worse in the ISR group. Fecal incontinence, measured by Wexner and Kirwan scores, was significantly better in the LAR group. We observed no differences in SF36 between the two groups. Multi-correlation analysis revealed positive and negative correlations among these factors, with inverse correlations between anorectal manometry measurements and incontinence assessments decreasing post-surgery. We found no correlation between SF36 and anorectal manometry at any time. The findings indicate that surgical technique affects postoperative anal function, fecal incontinence, and SF36. However, combined assessment methods should be used with caution when deriving relationships between anal function and SF36.

Comparing the long-term follow-up anal function between robot-assisted and laparoscopic surgery for low rectal cancer: A meta-analysis and systematic review.

BACKGROUND: Robotic-assisted surgery (RAS) is increasingly used for treating low rectal cancer. Its comparative effectiveness against laparoscopic surgery (LAS) in enhancing long-term anal function remains uncertain. METHODS: A meta-analysis was conducted to compare long-term anal function outcomes between patients undergoing RAS and LAS. Meta-regression and sensitivity analyses were performed to assess available evidence. Studies published up to September 2023 in English or Chinese were included. RESULTS: Seven studies were identified. RAS patients exhibited lower low anterior resection syndrome (LARS) scores (standardised mean difference [SMD] = -1.39; 95% confidence interval [CI]: -2.64 to -0.15) and Wexner scores (SMD = -0.74; 95% CI: -1.20 to -0.27) compared with LAS patients. However, RAS did not significantly reduce major LARS risk (odds ratio = 0.85; 95% CI: 0.68-1.04). CONCLUSIONS: RAS slightly improved postoperative anal function compared with LAS. Further studies with large samples are warranted to confirm or update our findings.

A comparative study of acupuncture combined with rehabilitation gymnastics on postoperative anal function of lower rectal cancer.

BACKGROUND: From the anal function, inflammatory response and other indicators, acupuncture combined with rehabilitation gymnastics was applied to patients with cancer undergoing low resection, aiming to improve the prognosis of patients. AIM: To explore the effects of acupuncture combined with rehabilitation gymnastics on anal function after lower rectal cancer surgery. METHODS: From January 2020 to December 2022, 128 patients who underwent rectal cancer surgery in the Department of Oncology of Hebei Provincial Hospital of Traditional Chinese Medicine Hospital were selected and divided into two groups using the random number table method, with 64 patients in each group. Patients in the control group were not treated with acupuncture or rehabilitation gymnastics and served as blank controls. Patients in the study group were treated with acupuncture and rehabilitation gymnastics from the 7th postoperative day. The anal incontinence scores, changes in serum interleukin-4, interleukin-6, and interleukin-10 Levels, and serum motilin, 5-hydroxytryptamine, and vasoactive intestinal peptide levels were compared. RESULTS: There were no significant differences in serum interleukin-4, interleukin-6, and interleukin-10 Levels between the groups before treatment (P > 0.05). After treatment, these levels were better than those of the control group (P < 0.05). There was no significant difference in the anal incontinence scores between the groups before and 7 d after surgery (P > 0.05). Anal incontinence scores in the study group were lower than those in the control group at 14 d, 21 d, and 28 d postoperatively (P < 0.05). There were no significant differences in serum motilin, 5-hydroxytryptamine, or vasoactive intestinal peptide levels between the groups before treatment (P > 0.05). After treatment, these levels were higher in the study group than in the control group, and vasoactive intestinal peptide level was lower in the study group than in the control group (P < 0.05). CONCLUSION: Acupuncture combined with rehabilitation gymnastics can promote the recovery of anal function and reduce the inflammatory response in patients with lower rectal cancer after surgery.

Evaluating the clinical application and effect of acupuncture therapy in anal function rehabilitation after low-tension rectal cancer surgery.

BACKGROUND: According to the indexes of serum and anal function, acupuncture therapy was applied to patients with low rectal cancer in order to avoid the occurrence of anal incontinence and reduce complications. AIM: To explore the clinical application and evaluate the effect of acupuncture therapy for anal function rehabilitation after low-tension rectal cancer surgery. METHODS: From the anorectal surgery cases, we selected 120 patients who underwent colorectal cancer surgery between January 2020 and December 2022 and randomly divided them into a control group (n = 60), observation group (n = 60), and control group after surgery for lifestyle intervention (including smoking cessation and exercise), dietary factor adjustment, anal movement, and oral loperamide treatment. The serum levels of motilin, 5-hydroxytryptamine, and vasoactive intestinal peptide (VIP), Wexner score for anal incontinence, and incidence of complications were compared between groups. RESULTS: After treatment, the VIP and 5-hydroxytryptamine levels in the observation group were lower than those in the control group (P < 0.05). The motilin level was higher than that in the control group (P < 0.05). Postoperative anal incontinence was better in the observation group than in the control group (P < 0.05). The incidence of complications in the observation group was 6.67%, which was significantly lower than that in the control group (21.67%; P < 0.05). CONCLUSION: Acupuncture therapy has a positive effect on the rehabilitation of anal function after low-tension rectal cancer surgery; it can effectively help to improve the serum indices of patients, avoid the occurrence of anal incontinence, and reduce the incidence of complications. Popularizing and applying it will be valuable.

Effect of neoadjuvant chemoradiation on anorectal function assessed with anorectal manometry: A systematic review and meta-analysis.

AIM: Improvement in oncological survival for rectal cancer increases attention to anorectal dysfunction. Diagnostic questionnaires can evaluate quality of life but are subjective and dependent on patients' compliance. Anorectal manometry can objectively assess the continence mechanism and identify functional sphincter weakness and rectal compliance. Neoadjuvant chemoradiotherapy is presumed to affect anorectal function. We aim to assess anorectal function in rectal cancer patients who undergo total mesorectal excision, with or without neoadjuvant chemoradiation, using anorectal manometry measurements. METHOD: MEDLINE, Embase, and Cochrane databases were searched for studies comparing perioperative anorectal manometry between neoadjuvant chemoradiation and upfront surgery for rectal cancers. Primary outcomes were resting pressure, squeeze pressure, sensory threshold volume and maximal tolerable volume. RESULTS: Eight studies were included in the systematic review, of which seven were included for metanalysis. 155 patients (45.3%) had neoadjuvant chemoradiation before definitive surgery, and 187 (54.6%) underwent upfront surgery. Most patients were male (238 vs. 118). The standardized mean difference of mean resting pressure, mean and maximum squeeze pressure, maximum resting pressure, sensory threshold volume, and maximal tolerable volume favored the upfront surgery group but without statistical significance. CONCLUSION: Currently available evidence on anorectal manometry protocols failed to show any statistically significant differences in functional outcomes between neoadjuvant chemoradiation and upfront surgery. Further large-scale prospective studies with standardized neoadjuvant chemoradiation and anorectal manometry protocols are needed to validate these findings.

Propensity matched analysis of minimally invasive and open radical resection for rectal cancer: comparison of short-term outcomes in elderly/frail patients.

Although minimally invasive surgery (MIS), such as robotic and laparoscopic procedures, is sometimes a better option than open surgery for patients with rectal cancer, it can present challenges for some elderly or frail patients who have a higher risk of chronic illnesses and poor surgical tolerance. On the basis of several pathophysiological characteristics, the patients were grouped according to their age. The time nodes, which are 65 and 80 years old, can clarify the goal of the study and offer some therapeutic benefit. These subgroups stand to gain a great deal from MIS because of its superior arm of machinery and imagery. The short-term oncological outcomes and postoperative conditions of robotic surgery, laparoscopic surgery, and conventional open surgery were compared in this study using a propensity-matched analysis. In this retrospective study, a total of 2049 consecutive patients who underwent proctectomy between September 2017 and June 2023 were chosen. We then carried out a propensity matching analysis based on inclusion criteria. Patients were split into two age groups: 65-80 and > 80. While the secondary objective was to further investigate the similar characteristics between RS and LS, the major objective was to compare oncological outcomes and postoperative conditions between MIS and OS. K-M survival curves were used to represent oncological outcomes and survival conditions. Complication rate and mFI score were used to assess postoperative conditions. Regarding the functional outcomes, the LARS scale was applied to create questionnaires that calculated the anal function of the patients. 110 cases from the group of patients aged 65-80 were successfully merged after matching 1: 1 by propensity score, whereas 73 instances from patients aged > 80 were incorporated while examining the primary objective between OS and MIS. Regarding the secondary goal, each group contained 45 cases for patients above 80 and 65 cases for patients aged 65-80, respectively. Faster recovery from MIS included quicker first flatus passage, earlier switch to liquid nutrition, and shorter hospital stay. In the meantime, MIS also showed benefits in terms of the proportion of low mFI scores and the rates of wound complications in the two age groups. Less blood loss and shorter operational time are further MIS features. On the other hand, MIS experienced more pulmonary complications than OS. Robotic surgery was statistically no different from laparoscopic surgery in patients aged 65-80, although it was superior in terms of operative time and recovery. Comparable and satisfactory oncological and survival results were obtained with all three treatments. For elderly/frail patients with rectal cancer, MIS could be recognized as an effective procedure with favorable outcomes of recovery that are accompanied by better postoperative conditions. While, robotic surgery is slightly better than laparoscopic surgery in some aspects. However, to further demonstrate the effectiveness of three surgical modalities in treating certain groups, multi-center prospective studies are required.

Propensity matched analysis of robotic and laparoscopic operations for mid-low rectal cancer: short-term comparison of anal function and oncological outcomes.

Laparoscopic surgery for rectal cancer, while in some respects equivalent or even preferable to open surgery, is challenged in specific conditions where the tumor is located in the middle and lower third of the rectum. Robotic surgery equipped with a superior arm of machinery and gained better visualization can compensate for the deficiency of the laparoscopic approach. This study adopted a propensity matched analysis to compare the functional and oncological short-term outcomes of laparoscopic and robotic surgery. All patients who underwent proctectomy have been collected prospectively between December 2019 and November 2022. After censoring for inclusion criteria, we performed a propensity matching analysis. A detailed collection of post-operative examination indicators was performed, while the K-M survival curves were plotted to analyze post-operative oncology outcomes. The LARS scale was designed to evaluate the anal function of patients in the form of questionnaires. Totally, 215 patients underwent robotic operations while 1011 patients selected laparoscopic operations. Patients matched 1∶1 by propensity score were divided into the robotic and laparoscopic groups, 210 cases were included in each group. All patients underwent a follow-up for a median period of 18.3 months. Robotic surgery was connected with an enhanced recovery including the earlier time to first flatus passage without ileostomy (P = 0.050), the earlier time to liquid diet without ileostomy (P = 0.040), lower incidence of urinary retention (P = 0.043), better anal function 1 month after LAR without ileostomy (P < 0.001), longer operative time (\P = 0.042), compared with laparoscopic operations. The oncological outcomes and occurrence of other complications were comparable between the two approaches. For mid-low rectal cancer, robotic surgery could be recognized as an effective technique with identical short-term outcomes of oncology and better anal function in comparison to laparoscopic surgery. However, multi-center studies with larger samples are expected to validate the long-term outcomes of robotic surgery.

Comparison of robotic-assisted and laparoscopic-assisted natural orifice specimen extraction surgery in short-terms outcomes of middle rectal cancer.

BACKGROUND: Surgery is becoming less invasive as technology advances. Natural orifice specimen extraction surgery (NOSES) ushered in a new era of minimally invasive techniques. At the same time, NOSES is gaining popularity in the world. With their distinct advantages, surgical robots have advanced the development of NOSES. The aim of current study was to compare the short-term outcomes between robotic-assisted NOSES and laparoscopic-assisted NOSES for the treatment of middle rectal cancer. METHODS: Patients with middle rectal cancer who underwent robotic-assisted or laparoscopic-assisted NOSES at the First Affiliated Hospital of Nanchang University between January 2020 and June 2022 had their clinicopathological data collected retrospectively. 46 patients were enrolled in the study: 23 in the robotic group and 23 in the laparoscopic group. Short-term outcomes and postoperative anal function in the two groups were compared. RESULTS: There was no significant difference in the clinicopathological data between the two groups. The robotic group had less intraoperative blood loss (p = 0.04), less postoperative abdominal drainage (p = 0.02), lower postoperative white blood cell counts (p = 0.024) and C-reactive protein levels (p = 0.017), and shorter catheter removal time when compared to the laparoscopic group (p = 0.003). Furthermore, there were no significant difference in mean operative time (159 ± 31 min vs 172 ± 41 min) between the robotic and laparoscopic groups (p = 0.235), but time to naked the rectum (86.4 ± 20.9 min vs. 103.8 ± 31.5 min p = 0.033) and time of digestive tract reconstruction (15.6 ± 3.88 min vs. 22.1 ± 2.81 min p < 0.01) in the robotic group were significantly shorter than laparoscopic group. The robotic group had lower postoperative Wexner scores than the laparoscopic group. CONCLUSIONS: This research reveals that combining a robotic surgical system and NOSES results in superior outcomes, with short-term outcomes preferable to laparoscopic-assisted NOSES.

Comparison of anal function and quality of life after conformal sphincter preservation operation and intersphincteric resection of very low rectal cancer: a multicenter, retrospective, case-control analysis.

PURPOSE: Conformal sphincter preservation operation (CSPO) is a sphincter preservation operation for very low rectal cancers. Compared to intersphincteric resection (ISR), CSPO retains more dentate line and distal rectal wall, and also avoids damaging the nerves in the intersphincteric space. This study aimed to compare the postoperative anal function and quality of life between the CSPO and ISR. METHOD: Patients with low rectal cancer undergoing CSPO (n = 117) and ISR (n = 66) were included from Changhai and Huashan Hospital, respectively, between 2011 and 2020. A visual analog scale (range 0-10) was utilized to evaluate satisfaction with anal function and quality of life. The anal function was evaluated with Wexner scores and low anterior resection syndrome (LARS) score. Quality of life was evaluated with the EORTC QLQ-C30 and QLQ-CR38. RESULTS: The CSPO group had more male patients (65.8% vs. 50%, p = 0.042), more preoperative chemoradiotherapy (33.3% vs. 10.6%, p < 0.001), lower tumor position (3.45 ± 1.13 vs. 4.24 ± 0.86 cm, p < 0.001), and more postoperative chemotherapy (65% vs. 13.6%, p < 0.001) compared to the ISR group. In addition, CSPO patients had shorter postoperative stay (6.63 ± 2.53 vs. 7.85 ± 4.73 days, p = 0.003) and comparable stoma reversal rates within 1 year after surgery (92.16% vs. 96.97%, p = 0.318). Multivariable analysis showed that CSPO significantly contributed to higher satisfaction with anal function (beta = 1.752, 95% CI 0.776-2.728) and with quality of life (beta = 1.219, 95% CI 0.374-2.064), but not to Wexner, LARS score, or EORTC QLQ-C30 and QLQ-CR38. CONCLUSION: CSPO improved the satisfaction with anal function and quality of life but utilized more preoperative chemoradiotherapy. CSPO may be an alternative choice for patients with very low rectal cancers in better physical health and with higher requirements for anal function and quality of life.

Perianal Bowen's disease treated with radiotherapy preserving anal function with a unique skin reaction considered as 'tumoritis'.

Bowen's disease (BD) is a form of intraepidermal squamous cell carcinoma (SCC), and it occasionally occurs on the perianal site. BD is often treated with surgical excision; however, sometimes surgical excision for perianal BD cannot preserve anal function. We report the case of a 72-year-old man presenting with perianal pain and BD. He was treated with Radiotherapy (RT) and preserved his normal anal sphincter function without any recurrence or late adverse event. Moreover, we observed the unique skin reaction called 'tumoritis', which is characterized by mucosal inflammation. Tumoritis indicates the true extent of the tumor and evaluating the tumor or lesion size based on the extent of tumoritis when performing RT is important.

Tissue-selecting-technique mega-window stapler combined with anal canal epithelial preservation operation in prolapsed hemorrhoids.

OBJECTIVE: This study aimed to compare the efficiency of these two combined surgeries [prolapse and hemorrhoids (PPH) combined with the external hemorrhoidectomy and inferior internal hemorrhoid ligation; tissue selecting technique with mega-window stapler (TST-MS) combined with anal canal epithelial preservation operation]. METHODS: This is a single-center, evaluator-blinded randomized controlled trial (RCT). A total of 204 participants were randomly divided into the two groups. The anal function, reoccurrence, intraoperative variables, and operative complications were assessed. The measurement data were compared by paired t test and rank sum test. Chi-squared or Fisher's exact test was used for count data and rank sum test for ranked data. To assess differences within each group in different time points, the repeated-measures analysis of variance was conducted. RESULTS: TST-MS combined with anal canal epithelial preservation operation had lower Wexner score of anal incontinence (Z = 3.062, P = 0.002), higher patients' satisfaction degree (t = 7.32, P < 0.001), less residual skin tags (χ2 = 18.141, P < 0.001), longer operative time (Z = -2.281, P = 0.023), and bigger volume of excised rectal mucosa (t = 2.35, P = 0.020). There was no significant difference between the two groups in the anal canal circumference, recurrence, intraoperative blood loss, weight of excised rectal mucosa, anal pain, bleeding, urinary retention, anal edge edema, and anatomical anal stenosis (all P > 0.05). CONCLUSIONS: TST-MS combined with anal canal epithelial preservation operation showed better clinical efficiency in the treatment of prolapsed hemorrhoids. TRIAL REGISTRATION: This study has been registered in Chinese Clinical Trial Registry (ChiCTR2000038533).

Clinical efficacy of redo rectal resection and coloanal anastomosis / 中华消化外科杂志

Objective:To investigate the clinical efficacy of redo rectal resection and coloanal anastomosis.Methods:The retrospective and descriptive study was conducted. The clinicopatholo-gical data of 49 patients who underwent redo rectal resection and coloanal anastomosis for the treatment of local recurrence of tumors and failure of colorectal or coloanal anastomosis after rectal resection in the Sixth Affiliated Hospital of Sun Yat-sen University from November 2012 to December 2021 were collected. There were 32 males and 17 females, aged 57(range,31-87)years. Redo rectal resection and coloanal anastomosis was performed according to the patient′s situations. Observa-tion indicators: (1) surgical situations; (2) postoperative situations; (3) follow-up. Measurement data with normal distribution were represented as Mean± SD, and measurement data with skewed distri-bution were represented as M( Q1, Q3) or M(range). Count data were described as absolute numbers or percentages. Results:(1) Surgical situations. All 49 patients underwent redo rectal resection and coloanal anastomosis successfully, with the interval between the initial surgery and the reopera-tion as 14.2(7.1,24.3)months. The operation time and volume of intraoperative bold loss of 49 patients in the redo rectal resection and coloanal anastomosis was 313(251,398)minutes and 125(50,400)mL, respectively. Of the 49 patients, there were 38 cases receiving laparoscopic surgery including 12 cases with transanoscopic laparoscopic assisted surgery, 11 cases receiving open surgery including 2 cases as conversion to open surgery, there were 20 cases undergoing Bacon surgery, 14 cases undergoing Dixon surgery, 12 cases undergoing Parks surgery, 2 cases undergoing intersphincter resection and 1 case undergoing Kraske surgery, there were 20 cases undergoing rectum dragging out excision and secondary colonic anastomosis, 13 cases undergoing dragging out excision single anastomosis, 12 cases undergoing rectum dragging out excision double anastomosis, 4 cases undergoing first-stage manual anastomosis, there were 21 cases with enterostomy before surgery, 16 cases with prophylactic enterostomy after surgery, 12 cases without prophylactic enterostomy after surgery. The duration of postoperative hospital stay of 49 patients was (14±7)days. (2) Postoperative situations. Fifteen of 49 patients underwent postoperative complications, including 8 cases with grade Ⅱ Clevien-Dindo complications and 7 cases with ≥grade Ⅲ Clevien-Dindo complications. None of 49 patient underwent postoperative transferring to intensive care unit and no patient died during hospitalization. Results of postoperative histopathological examination in 23 patients with tumor local recurrence showed negative incision margin of the surgical specimen. (3) Follow-up. All 49 patients underwent post-operative follow-up of 90 days. There were 42 cases undergoing redo rectal resection and coloanal anastomosis successfully and 7 cases failed. Of the 37 patients with enterostomy, 20 cases failed in closing fistula, and 17 cases succeed. There were 46 patients receiving follow-up with the median time as 16.1(7.5,34.6)months. The questionnaire response rate for low anterior resection syndrome (LARS) score was 48.3%(14/29). Of the patients who underwent redo coloanal anastomosis and closure of stoma successfully, there were 9 cases with mild-to-moderate LARS.Conclusion:Redo rectal resection and coloanal anastomosis is safe and feasible for patients undergoing local recurr-ence of tumors and failure of colorectal or coloanal anastomosis after rectal resection, which can successfully restore intestinal continuity in patients and avoid permanent enterostomy.

Effect of incision and thread-drawing selective suture in the treatment of high complex anal fistula and its influence on anal function and complications / 国际外科学杂志

Objective:To investigate the therapeutic effect of open suture and selective suture in patients with high complexity anal fistula and its effect on anal function and complications.Methods:Prospectively selected 174 patients with high complex anal fistula who were hospitalized in the Anorectal Surgery Department of the Second People′s Hospital of Yibin City from December 2018 to December 2021 as the study subjects, including 138 males and 36 females, aged from 26 to 45 years, with an average of (35.20 ± 8.86) years. According to the admission order of patients, grouped them into single and double numbers, with single numbers being the control group ( n=87) and double numbers being the observation group ( n=87). The control group was treated with traditional incision and thread hanging therapy, while the observation group was treated with selective suture through incision and thread hanging therapy. Compared the surgical time, blood loss, surgical cost, wound healing time, and anal function at 6 months after surgery between the two groups of patients. Compared the treatment effects of two groups of patients at 6 months after surgery. Compared the postoperative complications within 6 months and recurrence within 1 year between the two groups. The measurement data subject to normal distribution were expressed by mean ± standard deviation( ± s). The two groups were compared by independent sample t test, and the count data were compared by Chi-square test. Rank sum test was used for comparison of hierarchical data. Results:The surgical time in the observation group was higher than that in the control group [(44.30 ± 8.11) min vs (42.18 ± 7.25) min, ( t=-2.44, P<0.05], and the surgical cost was higher than that in the control group [(1184.81 ± 372.68) yuan vs (835.28 ± 320.03) yuan, t=-8.75, P<0.001]. There was no statistically significant difference in blood loss data between the two groups [(19.57 ± 6.07) mL vs (18.35 ± 5.25) mL, t=-1.88, P>0.05]. The length of wound healing time in the observation group was lower than that in the control group [(24.18 ± 4.35) d vs (29.35 ± 5.08) d, t=11.09, P<0.001]. The anal function score of the observation group at 6 months after surgery was lower than that of the control group [(4.80 ± 1.21) score vs (6.71 ± 1.35) score, t=14.72, P<0.001]. All patients did not experience any loss of follow-up. In the comparison of treatment effects 6 months after surgery, the observation group had a better efficacy rating than control group ( Z=3.86, P<0.001). At 6 months after surgery, the incidence of complications in the observation group was lower than that in the control group [2.30% (2/87) vs 10.34% (9/87), χ2=4.76, P<0.05]. One year after surgery, the recurrence rate in the observation group was lower than that in the control group [2.30% (2/87) vs 10.34% (9/87), χ2=4.76, P<0.05]. Conclusion:The application of incision and thread-drawing selective suture in the treatment of patients with high complex anal fistula is beneficial to the treatment effect of patients, reduces postoperative complications, and protects the anal function of patients, with good use value.

Trans-Anastomotic Drainage Tube Placement After Hand-Sewn Anastomosis in Patients Undergoing Intersphincteric Resection for Low Rectal Cancer: An Alternative Drainage Method.

Anastomotic leakage (AL) is a common complication after intersphincteric resection (ISR). It significantly reduces quality of life and causes great distress to patients. Although traditional drainage (e.g., anal and pelvic catheters) may reduce the impact of AL to some extent, their role in reducing the incidence of AL remains controversial. In this study, we developed a novel drainage technique involving the placement of drainage tubes through the gap between sutures during handsewn anastomosis, to reduce the occurrence of anastomotic leakage. We retrospectively analyzed 34 consecutive patients who underwent intersphincteric resection requiring handsewn anastomosis between February 1, 2017, and January 1, 2021. Patients were classified into the trans-anastomotic drainage tube group (TADT, n = 14) and the non-TADT group (n = 20) based on whether trans-anastomotic tube placement was performed. The incidence of postoperative complications, such as AL, was compared between the two groups, and anal function of patients at 1-year post-ISR was evaluated. Six cases of AL occurred in the non-TADT group, while none occurred in the TADT group; this difference was statistically significant (p=0.031). The TADT group also had a shorter hospital stay (p=0.007). There were no other significant intergroup differences in operation time, blood loss, pain score, anastomotic stenosis, intestinal obstruction, or incidence of wound infection. In the 30 patients (88.2%) evaluated for anal function, there were no significant intergroup differences in stool frequency, urgency, daytime/nocturnal soiling, Wexner incontinence score, or Kirwan grading. Taken together, trans-anastomotic tube placement is a novel drainage method that may reduce AL after ISR requiring handsewn anastomosis and without adversely affecting anal function.

Modified Perineal Reconstruction Combined with Anal Sphincter Repair for Obstetric Anal Sphincter Injuries.

Objective: The aim of this study was to investigate the clinical effectiveness of modified perineal reconstruction combined with anal sphincter repair in the treatment of obstetric anal sphincter injuries (OASIS). Methods: Twenty consecutive patients with an OASI who underwent modified perineal reconstruction combined with anal sphincter repair in the Department of Colorectal and Anal Surgery of the First Hospital of Jilin University from October 2015 to September 2017 were retrospectively enrolled in this study. Anal function was evaluated using the Williams grade, the Wexner score, anorectal manometry, and transrectal ultrasound. Results: Differences in both the Williams grade and the Wexner score prior to operation and following surgery indicated that anal function had improved, and these differences were statistically significant (P < 0.05). These indices also showed further improvement six months after surgery as compared with values at one month, and again, these differences were statistically significant (P < 0.05). In addition, anorectal manometry at six months following surgery showed statistically significant differences in the maximum anal resting pressure, maximum anal systolic pressure, and anal defecation pressure as compared with values prior to operation (P < 0.05). Postoperative endorectal ultrasound revealed that the anal sphincter presented with close imbricated overlapping. Conclusion: Modified perineal reconstruction combined with anal sphincter repair in the treatment of female perineal defect is associated with a good clinical outcome, strengthening anal function, and reconstructing the perineum, and is a possible method for clinical treatment.

Short- and long-term outcomes as well as anal function of transanal natural orifice specimen extraction surgery versus conventional laparoscopic surgery for sigmoid colon or rectal cancer resection: a retrospective study with over 5-year follow-up.

Introduction: To date, long-term safety including functional outcomes of transanal natural orifice specimen extraction surgery (NOSES) for colorectal cancer resection has not been confirmed. Aim: To explore the short- and long-term outcomes as well as anal function of transanal NOSES versus conventional laparoscopic surgery for sigmoid colon or rectal cancer resection. Material and methods: A retrospective review of data from a prospectively maintained database was performed to analyze the data of 69 patients who underwent transanal NOSES for sigmoid colon or rectal cancer resections and another 69 matched patients who underwent conventional laparoscopic (CL) surgery. Anal function of patients was evaluated using the Wexner fecal incontinence scale postoperatively. Results: Transanal NOSES resulted in faster recovery of intestinal function, shorter postoperative length of stay, less incisional pain, fewer postoperative complications and shorter scars than CL surgery (p < 0.05). The two groups had similar overall survival (p = 0.863) and disease-free survival (p = 0.961). Wexner scores of the NOSES group at 1, 3 and 6 months after surgery were higher than in the CL group (p < 0.05), and there was no difference between the two groups at 12, 18 and 24 months after surgery. Conclusions: Transanal NOSES achieves similar survival outcomes to CL surgery. Transanal NOSES has the advantages of faster recovery, shorter postoperative hospital stay, less incisional pain, shorter scars, etc. However, transanal NOSES can indeed impair anal function, needing more attention.

[A prospective cohort study on the clinical value of pelvic peritoneal reconstruction in laparoscopic anterior resection for middle and low rectal cancer].

Objective: To investigate the safety and efficacy of pelvic peritoneal reconstruction and its effect on anal function in laparoscopy-assisted anterior resection of low and middle rectal cancer. Methods: A prospective cohort study was conducted. Consecutive patients with low and middle rectal cancer who underwent laparoscopy-assisted transabdominal anterior resection at Naval Military Medical University Changhai Hospital from February 2020 to February 2021 were enrolled. Inclusion criteria: (1) the distance from tumor to the anal verge ≤10 cm; (2) laparoscopy-assisted transabdominal anterior resection of rectal cancer; (3) complete clinical data; (4) rectal adenocarcinoma diagnosed by postoperative pathology. Exclusion criteria: (1) emergency surgery; (2) patients with a history of anal dysfunction or anal surgery; (3) preoperative diagnosis of distant (liver, lung) metastasis; (4) intestinal obstruction; (5) conversion to open surgery for various reasons. The pelvic floor was reconstructed using SXMD1B405 (Stratafix helical PGA-PCL, Ethicon). The first needle was sutured from the left anterior wall of the neorectum to the right. Insertion of the needle was continued to suture the root of the sigmoid mesentery while the Hemo-lok was used to fix the suture. The second needle was started from the beginning of the first needle, after 3-4 needles, a drainage tube was inserted through the left lower abdominal trocar to the presacral space. Then, the left peritoneal incision of the descending colon was sutured, after which Hemo-lok fixation was performed. The operative time, perioperative complications, postoperative Wexner anal function score and low anterior resection syndrome (LARS) score were compared between the study group and the control group. Three to six months after the operation, pelvic MRI was performed to observe and compare the pelvic floor anatomical structure of the two groups. Results: A total of 230 patients were enrolled, including 58 who underwent pelvic floor peritoneum reconstruction as the study group and 172 who did not undergo pelvic floor peritoneum reconstruction as the control group. There were no significant differences in general data between the two groups (all P>0.05). The operation time of the study group was longer than that of control group [(177.5±33.0) minutes vs. (148.7±45.5) minutes, P<0.001]. There was no significant difference in the incidence of perioperative complications (including anastomotic leakage, anastomotic bleeding, postoperative pneumonia, urinary tract infection, deep vein thrombosis, and intestinal obstruction) between the two groups (all P>0.05). Eight cases had anastomotic leakage, of whom 2 cases (3.4%) in the study group were discharged after conservative treatment, 5 cases (2.9%) of other 6 cases (3.5%) in the control group were discharged after the secondary surgical treatment. The Wexner score and LARS score were 3.1±2.8 and 23.0 (16.0-28.0) in the study group, which were lower than those in the control group [4.7±3.4 and 27.0 (18.0-32.0)], and the differences were statistically significant (t=-3.018, P=0.003 and Z=-2.257, P=0.024). Severe LARS was 16.5% (7/45) in study group and 35.5% (50/141) in control group, and the difference was no significant differences (Z=4.373, P=0.373). Pelvic MRI examination 3 to 6 months after surgery showed that the incidence of intestinal accumulation in the pelvic floor was 9.1% (3/33) in study group and 46.4% (64/138) in control group (χ(2)=15.537, P<0.001). Conclusion: Pelvic peritoneal reconstruction using stratafix in laparoscopic anterior resection of middle and low rectal cancer is safe and feasible, which may reduce the probability of the secondary operation in patients with anastomotic leakage and significantly improve postoperative anal function.

Clinical efficacy of different approaches for laparoscopic intersphincteric resection of low rectal cancer: a comparison study.

BACKGROUND: The operative results of different approaches for the laparoscopic intersphincteric resection (LAISR) of low rectal cancer vary, and the patient characteristics associated with the best outcomes for each procedure have not been reported. We compared the efficacy of different approaches for LAISR of low rectal cancer and discussed the surgical indications for each approach. METHODS: We retrospectively reviewed data from 235 patients with low rectal cancer treated via LAISR from October 2010 to September 2016. Patients underwent either the transabdominal approach for ISR (TAISR, n = 142), the transabdominal perineal approach for ISR (TPAISR, n = 57), or the transanal pull-through approach for ISR (PAISR, n = 36). RESULTS: The PAISR and TAISR groups exhibited shorter operation times and less intraoperative blood loss than the TPAISR group. The anastomotic distance was shorter in the PAISR and TPAISR groups than in the TAISR group. No differences in the ability to perform radical resection, overall complications, postoperative recovery, Wexner score recorded 12 months after ostomy closure, 3-year disease-free survival, local recurrence-free survival, distant metastasis-free survival, or overall survival (OS) were observed among the three groups. CONCLUSIONS: TAISR, TPAISR, and PAISR have unique advantages and do not differ in terms of operation safety, patient outcomes, or anal function. TPAISR requires a longer time to complete and is associated with more bleeding and a slower recovery of anal function. PAISR should be considered when TAISR cannot ensure a negative distal margin and the tumor and BMI are relatively small; otherwise, TPAISR is required.

Electrical contraction of the anal sphincter for intraoperative visualization of anal function.

BACKGROUND: Repairing sphincter defects to restore the anal aperture is a cornerstone of surgical treatment in cases of anal preserving surgery. Such procedures are selected and performed according to the surgeons' experience. In the present study, we aimed to investigate a method for clear and intuitive intraoperative assessment of anal function under general anesthesia. METHODS: This study was conducted in three-month-old female (35 kg) domestic swine (n = 8) under standard general anesthesia. Electrical stimulation of the anal sphincter was performed using prototype electric devices, and then the anal pressure was measured by manometry. We generated an anal dysfunctional model by excising the left puborectalis muscle. Anal function was semi-quantified and visualized using anorectal manometry. RESULTS: Electrical stimulation with 12.5 mA output current and 15% duty ratio produced maximum anal pressure using the smallest amount of electricity. Histological examination confirmed the safety of the electrical muscular stimulation. Three-dimensional reconstruction of the results from the pressure curves of each sensor-enabled visualization of the functional anal canal. Monitoring using manometry under general anesthesia revealed the recovery of anal function upon suturing the excised puborectalis. CONCLUSIONS: Electrical muscular stimulation feasibly enabled visualization of anal function under general anesthesia in a porcine model.

A Retrospective Study on the Feasibility of Completely Laparoscopic Transabdominal Approach Partial Intersphincteric Resection.

Background: With the development of surgical techniques, gastrointestinal surgeons seek ways to improve the quality of life (QOL) for postoperative patients, while ensuring the tumor radical effect, such as reducing trauma, alleviating pain, and preserving the anus. This article discusses the postoperative outcomes of completely laparoscopic transabdominal approach partial intersphincteric resection (CLTPISR). Materials and Methods: The clinical data of 68 patients who underwent CLTPISR at the Affiliated Hospital of Chengde Medical College between May 2017 and June 2020, including procedure-related data, general postoperative conditions, and postoperative anal function data, were retrospectively analyzed to investigate the feasibility and safety of CLTPISR. Results: All 68 rectal cancer patients completed the CLTPISR. The average age was (60.47 ± 7.08) years, the average operative time was (196.22 ± 8.15) minutes, the mean operative bleeding was (49.12 ± 29.61) mL, and the average postoperative hospital stay was (13.46 ± 4.78) days. The postoperative pathology showed that the circumferential margins and distal margins were all negative, the maximum tumor diameter was (3.26 ± 1.11) cm, the distance from the anal verge was (3.92 ± 0.89) cm, and the average number of lymph nodes cleared was (11.06 ± 3.67). There were 28 stage I patients (41.18%), 21 stage II patients (30.88%), and 19 stage III patients (27.94%). The median follow-up time after surgery was 28 months, and the rates of distant metastasis, disease-free survival, and overall survival of the patients were 8.82%, 91.18%, and 95.59%, respectively. The patient's postoperative anal function gradually recovered as time increased. Conclusions: Under the premise of strictly grasping the indications, the CLTPISR is a safe and feasible surgery. It could achieve maximum anal preservation and improve patients' QOL, while maintaining the tumor radical effect, and had the advantages of the short operation time, low intraoperative bleeding, and quick recovery. The Clinical Trial Registration number is LL2020397.