Prediction of Anastomotic Leakage After Laparoscopic Low Anterior Resection in Male Rectal Cancer by Pelvic Measurement in Magnetic Resonance Imaging

Spine kinematics during gait in paediatric Hereditary Spastic Paraparesis

BACKGROUND

Many studies already addressed specific gait abnormalities in children affected by Hereditary Spastic Paraparesis (HSP). Some authors investigated the contribution of the upper body to walking pattern, but simplifying trunk and pelvis as two hinged rigid bodies. Recently, we developed a method to detail spinal kinematics in terms of anatomic curvatures and length; we were thus interested in applying such protocol to HSP.

RESEARCH QUESTION

how HSP influences spinal kinematics during gait?

METHODS

we enrolled ten HSP patients (5-17 years, 8 males) and twelve Healthy Children (HC, 8-16 years, 4 males). Kinematic data were recorded with an optoelectronic system using the LAMB full body marker set, which included three physical markers placed on the spine, supplemented with a virtual one reconstructed on the coccix. Calculations included the spinal length (linear distance from C7 to coccix), the kyphosis and lordosis angles, the trunk tilt and obliquity, the pelvis and the shoulder-pelvis angles, as well as the joint angles of the lower limbs. For each variable, the average value and the range of motion (ROM) were extracted and compared between groups.

RESULTS

the ROM of spinal length, the average value and ROM of kyphosis angle and the average value of trunk tilt significantly increased in HSP vs HC. A pathologic "double bump" pattern characterized the pelvic tilt traces, the lordosis angles and, with opposite sign, the kyphosis. Both the average value and ROM of pelvic tilt significantly increased in HSP, while ROM of lower limb angles was reduced.

CONCLUSION

spine kinematics were altered in HSP, who also showed an anterior trunk tilt. Therefore, the trunk should be considered an articulated system and not simplified to a rigid body, a perspective that could be also used in treating gait abnormalities.

Role of pelvimetry in predicting surgical outcomes and morbidity in rectal cancer surgery: A retrospective analysis

BACKGROUND

Rectal cancer has increased in incidence, and surgery remains the cornerstone of multimodal treatment. Pelvic anatomy, particularly a narrow pelvis, poses challenges in rectal cancer surgery, potentially affecting oncological outcomes and postoperative complications.

AIM

To investigate the relationship between radiologically assessed pelvic anatomy and surgical outcomes as well as the impact on local recurrence following rectal cancer surgery.

METHODS

We retrospectively analyzed 107 patients with rectal adenocarcinoma treated with elective rectal surgery between January 1, 2017, and September 1, 2022. Pelvimetric measurements were performed using computed tomography (CT)-based two-dimensional methods (n = 77) by assessing the pelvic inlet area in mm², and magnetic resonance imaging (MRI)-based three-dimensional techniques (n = 52) using the pelvic cavity index (PCI). Patient demographic, clinical, radiological, surgical, and pathological characteristics were collected and analyzed in relation to their pelvimetric data.

RESULTS

When patients were categorized based on CT measurements into narrow and normal/wide pelvis groups, a significant association was observed with male sex, and a lower BMI was more common in the narrow pelvis group (P = 0.002 for both). A significant association was found between a narrow pelvic structure, indicated by low PCI, and increased surgical morbidity (P = 0.049). Advanced age (P = 0.003) and male sex (P = 0.020) were significantly correlated with higher surgical morbidity. Logistic regression analysis identified four parameters that were significantly correlated with local recurrence: older age, early perioperative readmission, longer operation time, and a lower number of dissected lymph nodes (P < 0.05). However, there were no significant differences between the narrow and normal/wide pelvis groups in terms of the operation time, estimated blood loss, or overall local recurrence rate (P > 0.05).

CONCLUSION

MRI-based pelvimetry may be valuable in predicting surgical difficulty and morbidity in rectal cancer surgery, as indicated by the PCI. The observed correlation between low PCI and increased surgical morbidity suggests the potential importance of a preoperative MRI-based pelvimetric evaluation. In contrast, CT-based pelvimetry did not show significant differences in predicting surgical outcomes or cancer recurrence, indicating that the utility of pelvimetry alone may be limited in these respects.

The Spine Lengthens During Walking in Healthy Participants, with Age-Related Changes in Kinematic Parameters

Background: While the importance of the upper and lower limbs in locomotion is well understood, the kinematics of the trunk during walking remains largely unexplored. Two decades ago, a casual observation was reported indicating spine lengthening in a small sample of mostly children during walking, but this observation was never replicated. Objectives: This study aims to verify the preliminary observation that spine lengthening occurs during walking and to explore changes in spine kinematics across three different age groups. Methods: A convenience sample of 45 healthy participants was divided into three groups of 15 individuals each: children (ages 5 to 13), young adults (ages 18 to 30), and older adults (ages 50 to 70). The spinal length, defined as the distance between C7 and the coccyx, and other kinematic parameters were analyzed using a motion analysis system while participants stood and walked standing and walking at their natural cadence. Results: In all groups, the length of the spine increased while walking compared to standing. This change was primarily due to a reduction in the inferior spinal angle, which is associated with lumbar lordosis, rather than a change in the superior spinal angle, which is related to thoracic kyphosis. The average change in spinal length during the walking cycle was approximately 7% in children, while it was only about 1% in adults. We also found a reduction in the range of motion for almost all the variables in adults. Conclusions: The increase in the spinal length during walking is related to a reduction in the physiological spine curve. This occurs due to muscle contractions which are needed to stabilize the locomotor system. As people age, the reduction in spinal length changes is associated with decreased spinal mobility and to a natural tendency toward anterior trunk flexion.

Simple pelvimetry predicts the pelvic manipulation time in robot-assisted low and ultra-low anterior resection for rectal cancer

PURPOSE

This study explored the difficulty factors in robot-assisted low and ultra-low anterior resection, focusing on simple measurements of the pelvic anatomy.

METHODS

This was a retrospective analysis of the clinical data of 61 patients who underwent robot-assisted low and ultra-low anterior resection for rectal cancer between October 2018 and April 2023. The relationship between the operative time in the pelvic phase and clinicopathological data, especially pelvic anatomical parameters measured on X-ray and computed tomography (CT), was evaluated. The operative time in the pelvic phase was defined as the time between mobilization from the sacral promontory and rectal resection.

RESULTS

Robot-assisted low and ultra-low anterior resections were performed in 32 and 29 patients, respectively. The median operative time in the pelvic phase was 126 (range, 31-332) min. A multiple linear regression analysis showed that a short distance from the anal verge to the lower edge of the cancer, a narrow area comprising the iliopectineal line, short anteroposterior and transverse pelvic diameters, and a small angle of the pelvic mesorectum were associated with a prolonged operative time in the pelvic phase.

CONCLUSION

Simple pelvic anatomical measurements using abdominal radiography and CT may predict the pelvic manipulation time in robot-assisted surgery for rectal cancer.

Dynamic evaluation of spine kinematics in individuals with Parkinson's disease and freezing of gait

BACKGROUND

Freezing of gait (FoG) is an episodic failure of gait exposing people with Parkinson's disease (PD) to a high risk of falling. Despite growing evidence of the interconnection between impaired trunk control and FoG, a detailed description of spinal kinematics during walking is still lacking in this population.

RESEARCH QUESTION

Do spinal alterations impact gait performance in individuals with PD and FoG?

METHODS

We analyzed kinematic data of 47 PD participants suffering (PD-FOG, N = 24) or not suffering from FoG (PD-NFOG, N = 23) and 15 healthy controls (HCO) during quiet standing and unperturbed walking. We estimated the main spinal variables (i.e., spinal length, lordosis and kyphosis angles, trunk inclination), the pelvis angles, and the shoulder-pelvis angles during gait and standing. We studied differences across conditions and groups and the relationships between postural and gait parameters using linear regression methods.

RESULTS

During standing and walking, both PD groups showed increased trunk inclination and decreased lordosis angle with respect to HCO, as well as a decreased range in variation of kyphosis angle, pelvic obliquity, and shoulder-pelvis angles. Only PD-FOG participants showed reduced range of lordosis angle and spinal length compared to HCO. PD-FOG individuals were also not able to straighten their spine during walking compared to standing. Stride length and velocity were decreased in both patient groups compared to HCO, while swing duration was reduced only in the PD-FOG group. In individuals with FoG, trunk inclination and lordosis angle showed moderate but significant positive correlations with all gait alterations.

SIGNIFICANCE

Spine alterations impacted gait performance in individuals with PD suffering from FoG. Excessive trunk inclination and poor mastering of the lordosis spinal region may create an unfavourable postural precondition for forward walking. Physical therapy should target combined spinal and stepping alterations in these individuals.

Elderly Rectal Cancer: An Updated Review

PURPOSE OF REVIEW

Treatment of rectal cancer patients of advanced age should be modulated by life expectancy and tolerance. Due to the rapid advance of this field, we aim to conduct an updated review of this topic.

RECENT FINDINGS

The field of elderly rectal cancer has advanced a lot. This review covers all the treatment aspects of elderly rectal cancer, including the prognostic factor, surgery, radiotherapy, chemotherapy, and palliative treatment. We also provide the future aspect of the management of elderly rectal cancer. The advancement of prognostic factor research, surgery, radiotherapy, chemotherapy, and palliative treatment has made the care of elderly rectal cancer patients better. The future of these fields should focus on the definition of the elderly and the application of particle therapy.

What affects the selection of diverting ileostomy in rectal cancer surgery: a single-center retrospective study

BACKGROUND

The selection of diverting ileostomy (DI) is controversial. This study aimed to explore the factors affecting the selection of diverting ileostomy (DI) following laparoscopic low anterior resection for rectal cancer.

METHODS

This retrospective, case-control study included patients who underwent laparoscopic-assisted sphincter-saving surgery for mid-low rectal cancer from January 2019 to June 2021. Univariate and multivariate analyses were performed on the patient's clinicopathological characteristics and pelvic dimensions measured by abdominopelvic electron beam computed tomography.

RESULTS

A total of 382 patients were included in the analysis, of which 182 patients (47.6%) did not undergo DI, and 200 patients (52.4%) underwent DI. The univariate analysis suggested that male sex (p = 0.003), preoperative radiotherapy (p < 0.001), patients with an anastomosis below the levator ani plane (p < 0.001), the intertuberous distance (p < 0.001), the sacrococcygeal distance (p = 0.025), the mid pelvis anteroposterior diameter (p = 0.009), and the interspinous distance (p < 0.001) were associated with performing DI. Multivariate analysis confirmed that preoperative radiotherapy (p = 0.037, odds ratio [OR] = 2.98, 95% confidence interval [CI] = 1.07-8.30), anastomosis below the levator ani plane (p < 0.001, OR = 7.09, 95% CI = 4.13-12.18), and the interspinous distance (p = 0.047, OR = 0.97, 95% CI = 0.93-1.00) were independently associated with performing DI.

CONCLUSION

Pelvic parameters also influence the choice of DI. According to this single-center experience, patients with a shorter interspinous distance, particularly narrow pelvic with an interspinous distance of < 94.8 mm, preoperative radiotherapy, and anastomosis below the levator ani plane, prefer to have a DI and should be adequately prepared by the physician.

Validation of an endoscopic anastomotic grading score as an intraoperative method for assessing stapled rectal anastomoses

PURPOSE

Anastomotic leak is a dreaded complication of colorectal surgery. An endoscopic grading score of the perianastomotic mucosa has been previously developed at our institution (UCI) to assess colorectal anastomotic integrity. The objective of this study is to validate the UCI anastomotic score and determine its impact in anastomotic failure.

METHODS

As a follow-up study of the UCI grading score implementation during 2011 to 2014, patients undergoing stapled colorectal anastomoses after sigmoidectomy or proctectomy at a single institution from 2015 to 2018 were retrospectively reviewed. Patients were grouped into three tiers based on endoscopic appearance (grade 1, circumferentially normal mucosa; grade 2, ischemia/congestion < 30% of circumference; grade 3, ischemia/congestion > 30% of circumference).

RESULTS

On the basis of endoscopic mucosal evaluation, grade 1 anastomosis was observed in 299 patients (94%), grade 2 anastomosis in 14 patients (4.4%), and grade 3 anastomosis in 5 patients (1.6%). All grade 3 classifications were immediately and successfully revised intraoperatively with reclassification as a grade 1 anastomosis. The anastomotic leak rate of the follow-up study period from 2015 to 2018 was 6.4% which was lower compared to the anastomotic leak rate of 12.2% in the original study period from 2011 to 2014 (p = 0.07). Anastomotic leak rate for the entire patient series was 8.5%. A grade 2 anastomosis was associated with higher anastomotic leak rate compared to a grade 1 anastomosis (35.7% vs. 7.4%, p < 0.05). None of the five grade 3 anastomoses resulted in an anastomotic leak upon revision.

CONCLUSION

This study further validates the anastomotic grading score and suggests that its systematic implementation can result in a reduction in anastomotic leaks.

Tumour, narrow pelvis and surgery specific factors for total mesorectal excision quality and morbidity following rectal cancer resection

BACKGROUND

Pelvic anatomy is critical in challenging rectal resections. This study investigated how pelvic anatomy relates to total mesorectal excision (TME) quality, anastomotic leakage rate, and long-term oncological outcomes.

METHODS

Patients undergoing elective rectal cancer resection from 2008 to 2017 in an Austrian institution were retrospectively reviewed regardless of the surgical approach. CT scans were analysed for pelvic measurements and volumes. The primary outcomes of interest were the correlation between pelvic dimensions and the TME quality and anastomotic leakage. Subanalysis was done by surgical approach (open, laparoscopic, transanal TME). Secondary outcomes were overall and disease-free survivals.

RESULTS

Among 154 eligible patients, 112 were included. The angle between pubic symphysis and promontory significantly correlated with worse TME grades (TME grade 1: mean(s.d.) 102.7(5.7)°; TME grade 2: 92.0(4.4)°; TME grade 3: 91.4(3.6)°; P < 0.001). A significantly lower distance between tumour and circumferential resection margin (CRM) was observed in grade 3 resections, whereas no difference appeared in grade 1 and grade 2 resection (TME grade 1: mean(s.d.) 11.92(9.4) mm; TME grade 2: 10.8(8.1) mm; TME grade 3: 3.1(4.1) mm; P = 0.003). The anastomotic leakage rate was significantly higher in case of a lower CRM (patients with anastomotic leakage: mean(s.d.) 6.8(5.8) mm versus others: 12.6(9.8) mm, P = 0.027), but not associated with pelvimetry measurements. The transanal TME (TaTME) subgroup displayed a wider angle between the pubic symphysis and promontory, younger age and improved TME quality compared to others (respectively, mean TME grades in TaTME versus open versus laparoscopic: 1.0 ± 0.0, 1.5 ± 0.7 and 1.3 ± 0.5, P = 0.013). Finally, oncological survival was not impacted by pelvic measurements or worse TME quality.

CONCLUSION

The angle between the pubic symphysis and promontory and the distance between tumour and CRM were associated with worse TME grades. The anastomotic leakage was associated with a lower CRM but not with pelvimetric measures.

Operative blood loss adversely affects short and long-term outcomes after colorectal cancer surgery: results of a systematic review and meta-analysis

BACKGROUND

The aim of this meta-analysis was to assess the impact of operative blood loss on short and long-term outcomes following colorectal cancer surgery.

METHODS

A systematic literature review and meta-analysis were performed, from inception to the 10th of August 2020. A comprehensive literature search was performed on the 10th of August 2020 of PubMed MEDLINE, Embase, Science Citation Index Expanded, and Cochrane Central Register of Controlled Trials. Only studies reporting on operative blood loss and postoperative short term or long-term outcomes in colorectal cancer surgery were considered for inclusion.

RESULTS

Forty-three studies were included, reporting on 59,813 patients. Increased operative blood loss was associated with higher morbidity, for blood loss greater than 150-350 ml (odds ratio [OR] 2.09, p < 0.001) and > 500 ml (OR 2.29, p = 0.007). Anastomotic leak occurred more frequently for blood loss above a range of 50-100 ml (OR 1.14, p = 0.007), 250-300 ml (OR 2.06, p < 0.001), and 400-500 ml (OR 3.15, p < 0.001). Postoperative ileus rate was higher for blood loss > 100-200 ml (OR 1.90, p = 0.02). Surgical site infections were more frequent above 200-500 ml (OR 1.96, p = 0.04). Hospital stay was increased for blood loss > 150-200 ml (OR 1.63, p = 0.04). Operative blood loss was significantly higher in patients that suffered morbidity (mean difference [MD] 133.16 ml, p < 0.001) or anastomotic leak (MD 69.56 ml, p = 0.02). In the long term, increased operative blood loss was associated with worse overall survival above a range of 200-500 ml (hazard ratio [HR] 1.15, p < 0.001), and worse recurrence-free survival above 200-400 ml (HR 1.33, p = 0.01). Increased blood loss was associated with small bowel obstruction caused by colorectal cancer recurrence for blood loss higher than 400 ml (HR 1.97, p = 0.03) and 800 ml (HR 3.78, p = 0.02).

CONCLUSIONS

Increased operative blood loss may adversely impact short term and long-term postoperative outcomes. Measures should be taken to minimize operative blood loss during colorectal cancer surgery. Due to the uncertainty of evidence identified, further research, with standardised methodology, is required on this important subject.

Advances in pelvic imaging parameters predicting surgical difficulty in rectal cancer

Due to the fixed bony structure of the pelvis, the pelvic operation space is limited, complicating the surgical operation of rectal cancer, especially middle and low rectal cancer. The closer the tumor is to the anal verge, the smaller the operative field and operating space, the longer the operative time, and the greater the incidence of intraoperative side injuries and postoperative complications. To date, there is still no clear definition of a difficult pelvis that affects the surgical operation of rectal cancer. Few related research reports exist in the literature, and views on this aspect are not the same between countries. Therefore, it is particularly important to predict the difficulty of rectal cancer surgery in a certain way before surgery and to select the surgical method most suitable for each case during the treatment of rectal cancer.

Comprehensive abdominal composition evaluation of rectal cancer patients with anastomotic leakage compared with body mass index-matched controls

BACKGROUND

Anastomotic leakage (AL) is a fatal complication in patients with rectal cancer after undergoing anterior resection. However, the role of abdominal composition in the development of AL has not been studied.

AIM

To investigate the relationship between abdominal composition and AL in rectal cancer patients after undergoing anterior resection.

METHODS

A retrospective case-matched cohort study was conducted. Complete data for 78 patients with AL were acquired and this cohort was defined as the AL group. The controls were matched for the same sex and body mass index (± 1 kg/m2). Parameters related to abdominal composition including visceral fat area (VFA), subcutaneous fat area (SFA), subcutaneous fat thickness (SFT), skeletal muscle area (SMA), skeletal muscle index (SMI), abdominal circumference (AC), anterior to posterior diameter of abdominal cavity (APD), and transverse diameter of abdominal cavity (TD) were evaluated based on computed tomography (CT) images using the following Hounsfield Unit (HU) thresholds: SFA: -190 to -30, SMA: -29 to 150, and VFA: -150 to -20. The significance of abdominal composition-related parameters was quantified using feature importance analysis; an artificial intelligence method was used to evaluate the contribution of each included variable.

RESULTS

Two thousand two hundred and thirty-eight rectal cancer patients who underwent anterior resection from 2010 to 2020 in a large academic hospital were investigated. Finally, 156 cases were enrolled in the study. Patients in the AL group showed longer operative time (225.03 ± 55.29 vs 207.17 ± 40.80, P = 0.023), lower levels of preoperative hemoglobin (123.32 ± 21.17 vs 132.60 ±1 6.31, P = 0.003) and albumin (38.34 ± 4.01 vs 40.52 ± 3.97, P = 0.001), larger tumor size (4.07 ± 1.36 vs 2.76 ± 1.28, P < 0.001), and later cancer stage (P < 0.001) compared to the controls. Patients who developed AL exhibited a larger VFA (125.68 ± 73.59 vs 97.03 ± 57.66, P = 0.008) and a smaller APD (77.30 ± 23.23 vs 92.09 ± 26.40, P < 0.001) and TD (22.90 ± 2.23 vs 24.21 ± 2.90, P = 0.002) compared to their matched controls. Feature importance analysis revealed that TD, APD, and VFA were the three most important abdominal composition-related features.

CONCLUSION

AL patients have a higher visceral fat content and a narrower abdominal structure compared to matched controls.

Interischial Spine Distance Is a Simple Index of the Narrow Pelvis That Can Predict Difficulty During Laparoscopic Low Anterior Resection

BACKGROUND

A narrow pelvis makes laparoscopic rectal resection difficult. This study aimed to evaluate whether a simple measurement on computed tomography can predict procedural difficulty.

METHODS

A total of 62 patients with low rectal cancer underwent conventional laparoscopic low anterior resection. The interischial spine (IS) distance (ie, the distance between the ischial spines) was measured on an axial computed tomography slice. The operative time, blood loss, and time from the insertion of linear staplers to completion of clamping on the distal end of the rectum (clamp time) were compared between patients with narrow or wide pelvises.

RESULTS

Overall, 42 men and 20 women with low rectal cancer were assessed. The mean tumor size was 34.5 mm. Total or tumor-specific mesorectal excisions were performed in all cases; high ligation and resection of the inferior mesenteric arteries were carried out in 92% of patients. The mean operative time and blood loss were 206 minutes and 15 mL, respectively. Four patients (6.5%) experienced postoperative complications, including 2 anastomotic leaks (3.2%). The mean IS distance was 93.3 mm. In simple linear regression analysis, a shorter IS distance correlated with a longer operative time (R2=0.08, P=0.030) and the clamp time (R2=0.07, P=0.046). Using a receiver operating characteristic curve, a narrow pelvis was defined as an IS distance <94.7 mm. Multivariate regression analysis revealed that an IS distance <94.7 mm (odds ratio: 3.51; P=0.04) was independently associated with a longer clamp time.

CONCLUSIONS

The IS distance is a simple and useful measurement for predicting the difficulty of laparoscopic low anterior resection.

Early experience with the ARTISENTIAL® articulated instruments in laparoscopic low anterior resection with TME

Background

The notion of articulation in surgery has been largely synonymous with robotics. The ARTISENTIAL^® instruments aim at bringing advanced articulation to laparoscopy to overcome challenges in narrow anatomical spaces. In this paper, we present first single-center results of a series of low anterior resections, performed with ARTISENTIAL^®.

Methods

Between September 2020 and August 2021, at the Department of Surgery, St. Marienkrankenhaus Siegen, Siegen, Germany, patients with cancer of the mid- and low rectum were prospectively enrolled in a pilot feasibility study to evaluate the ARTISENTIAL^® articulated instruments in performing a laparoscopic low anterior resection. Perioperative and short-term postoperative data were analyzed.

Results

Seventeen patients (10 males/7 females) were enrolled in this study. The patients had a median age of 66 years (range 47–80 years) and a median body mass index of 28 kg/m² (range 23–33 kg/m²). The median time to rectal transection was 155 min (range 118–280 min) and the median total operative time was 276 min (range 192–458 min). The median estimated blood loss was 30 ml (range 5–70 ml) and there were no conversions to laparotomy. The median number of harvested lymph nodes was 15 (range 12–28). Total mesorectal excision (TME) quality was ‘good’ in all patients with no cases of circumferential resection margin involvement (R0 = 100%). The median length of stay was 9 days (range 7–14 days). There were no anastomotic leaks and the overall complication rate was 17.6%. There was one unrelated readmission with no mortality.

Conclusions

Low anterior resection with ARTISENTIAL^® is feasible and safe. All patients had a successful TME procedure with a good oncological outcome. We will now seek to evaluate the benefits of ARTISENTIAL^® in comparison with standard laparoscopic instruments through a larger study.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10151-022-02588-y.

A systematic review of the literature assessing operative blood loss and postoperative outcomes after colorectal surgery

PURPOSE

There is no consensus in the literature regarding the association between operative blood loss and postoperative outcomes in colorectal surgery, despite evidence suggesting a link. Therefore, this systematic review assesses the association between operative blood loss, perioperative and long-term outcomes after colorectal surgery.

METHODS

A literature search of MEDLINE, EMBASE, Science Citation Index Expanded and Cochrane was performed to identify studies reporting on operative blood loss in colorectal surgery.

RESULTS

The review included forty-nine studies reporting on 61,312 participants, with a mean age ranging from 53.4 to 78.1 years. The included studies demonstrated that major operative blood loss was found to be a risk factor for mortality, anastomotic leak, presacral abscess, and postoperative ileus, leading to an increased duration of hospital stay. In the long term, the studies suggest that significant blood loss was an independent risk factor for future small bowel obstruction due to colorectal cancer recurrence and adhesions. Studies found that survival was significantly reduced, whilst the risk of colorectal cancer recurrence was increased. Reoperation and cancer-specific survival were not associated with major blood loss.

CONCLUSION

The results of this systematic review suggest that major operative blood loss increases the risk of perioperative adverse events and has short and long-term repercussions on postoperative outcomes. Laparoscopic and robotic surgery, vessel ligation technology and anaesthetic considerations are essential for reducing blood loss and improving outcomes. This review highlights the need for further high quality, prospective, multicentre trials with a greater number of participants, and accurate and standardised methods of measuring operative blood loss.

Diagnosis of Anastomotic Leak

Anastomotic leaks after colorectal surgery is associated with increased morbidity and mortality. Understanding the impact of anastomotic leaks and their risk factors can help the surgeon avoid any modifiable pitfalls. The diagnosis of an anastomotic leak can be elusive but can be discerned by the patient's global clinical assessment, adjunctive laboratory data and radiological assessment. The use of inflammatory markers such as C-Reactive Protein and Procalcitonin have recently gained traction as harbingers for a leak. A CT scan and/or a water soluble contrast study can further elucidate the location and severity of a leak. Further intervention is then individualized on the spectrum of simple observation with resolution or surgical intervention.

Determining the protective characteristics and risk factors for the development of anastomotic leakage after low anterior resection for rectal cancer

Purpose

Anastomotic leakage is one of the most serious postoperative complications associated with surgery for rectal cancer. The present study aimed to identify the protective characteristics and risk factors associated with anastomotic leakage after low anterior resection for rectal cancer.

Methods

This was a retrospective, single-center study conducted between January 2009 and December 2017 at our institution. In total, 136 rectal cancer patients who underwent low anterior resection were included in the study. We analyzed preoperative and intraoperative factors. In addition, the pelvic dimensions were measured using computed tomography in all cases.

Results

Among the 136 patients, anastomotic leakage occurred in 21 (15.4%), including 18 males and 3 females. The median body mass index was 21.1 kg/m². The construction of a covering stoma was found to be a protective factor. In addition, the operation time (≥ 373 min), intraoperative blood loss (≥ 105 ml), and size of the pelvic inlet (≥ 113 mm) were identified as risk factors for anastomotic leakage.

Conclusion

The construction of a covering stoma was a possible protective factor. However, a longer operation time, higher intraoperative blood loss, and larger pelvic inlet dimensions were possible risk factors for developing anastomotic leakage after low anterior resection in patients with rectal cancer.

Mechanotechnical faults and particular issues of anastomotic complications following robot-assisted anterior resection in 968 rectal cancer patients

BACKGROUND

As most risk factors for anastomotic complications (AC) in rectal cancer patients appear to be noncorrectable, it is needed to find the correctable causes. Additionally, the outcomes of indocyanine-green fluorescence imaging (IFI) and robot-stapled anastomosis have yet been undetermined.

METHODS

This study retrospectively analyzed 968 consecutive patients with rectal cancer, who underwent curative robot-assisted anterior resections between 2010 and 2018. IFI parameters and stapling features in the surgical records were reviewed, and reconfirmed.

RESULTS

AC occurred in 54 patients (5.6%), 34 (3.5%) with anastomotic leakage (AL) and 24 (2.5%) with anastomotic stenosis (AS). Mechanotechnical faults including defective stapling configurations, including angles lesser than or equal to 150° and outer deviation (more than half from the center of the circle) of linear staples, between the two linear staples were independently associated with AL (P < .001 each). IFI significantly reduced AL rate (2.5% vs 5.3%, P = .029) and AS rate (2% vs 18.8%, P = .006), respectively. Robot linear stapling enabled to maintain the obtuse angle during consecutive staplings and reduced console time. AL and AS were independent risk factors for disease-free survival (P = .02) and local recurrence (P = .03), respectively.

CONCLUSIONS

AC were associated with some correctable causes, namely, mechanotechnical errors and lack of use of IFI.

Anatomical basis for the choice of laparoscopic surgery for low rectal cancer through the pelvic imaging data-a cohort study

Background

Low rectal cancer surgery without anus conservation needs permanent ileostomy or colostomy which seriously affects the quality of life of patients. Therefore, low rectal cancer surgery not only pays attention to the safety of surgical treatment but also to the anus conservation.

Methods

Sixty-seven patients suffering from low rectal cancer had undergone laparoscopic surgery which was analyzed through retrospective study. They were divided into the anus-conserving and non-anus-conserving groups. Thirty-five set of pelvic data was obtained from the preoperative CT and MRI images. After that, the discriminant function was obtained to predict the surgery methods for patients with low rectal carcinoma.

Results

Anal-conserving group discriminant function (F1) = − 33.698 + 6.045 × anal margin distance (cm) + 1.105 × T4; non-anus-conserving group discriminant function (F2) = − 14.125 + 3.138 × anal margin distance (cm) + 0.804 × T4. If F1 is greater than F2, then the case can be treated as the anus reservation while if F2 is greater than F1 the case cannot be treated anus reservation. The accuracy of the discriminant function was evaluated which was found to be 97%.

Conclusion

The discriminant function of pelvic data provides anatomical basis for the choice of surgical methods for low rectal cancer.