Annals of Coloproctology

Reviews

Colorectal cancer

Beyond survival: a comprehensive review of quality of life in rectal cancer patients: Won Beom Jung; Ann Coloproctol. 2024;40(6):527-537. Published online December 20, 2024; DOI: https://doi.org/10.3393/ac.2024.00745.0106

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Abstract PDF: Rectal cancer is one of the most common carcinomas and a leading cause of cancer-related mortality. Although significant advancements have been made in the treatment of rectal cancer, the deterioration of quality of life (QoL) remains a challenging issue. Various tools have been developed to assess QoL, including the Functional Assessment of Cancer Therapy-Colorectal (FACT-C) scale, the QLQ-C30 and QLQ-CR29 by the European Organization for Research and Treatment of Cancer (EORTC), and the 36-Item Short Form Health Survey (SF-36). Factors such as the lower location of the tumor, radiation therapy, chemoradiotherapy, and chemotherapy are associated with a decline in QoL. Furthermore, anastomotic leakage following rectal cancer resection is an important risk factor affecting QoL. With the development of novel treatment approaches, including neoadjuvant therapies such as chemoradiotherapy and total neoadjuvant therapy, the rate of clinical complete remission has increased, leading to the emergence of organ-preserving strategies. Both local excision and the “watch-and-wait” approach following neoadjuvant therapy improved functional outcomes and QoL. Efforts to improve QoL after rectal cancer surgery are ongoing in surgical techniques for rectal cancer. Since QoL is determined by a complex interplay of factors, including the patient's physical condition, surgical techniques, and psychological and social elements, a comprehensive approach is necessary to understand and enhance it. This review aims to describe the methods for measuring QoL in rectal cancer patients after surgery, the key risk factors involved, and various strategies and efforts to improve QoL outcomes.

Diagnostic performance of various radiological modalities in the detection of sarcopenia within Asian populations: a systematic review: Shi Wei Ang, Jacqueline Liew, Vanessa Malishree Dharmaratnam, Vanessa Yi Jean Yik, Shawn Kok, Syed Aftab, Cherie Tong, Hui Bing Lee, Shimin Mah, Clement Yan, Bin-Tean Teh, Frederick H. Koh; Received January 28, 2024 Accepted May 20, 2024 Published online December 20, 2024; DOI: https://doi.org/10.3393/ac.2024.00080.0011 [Epub ahead of print]

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Abstract PDF Supplementary Material: Purpose
Diagnosing sarcopenia necessitates the measurement of skeletal muscle mass. However, guidelines lack a standardized imaging modality with thresholds validated among Asians. This systematic review compared ultrasonography, computed tomography (CT), magnetic resonance imaging (MRI), and bioelectrical impedance analysis (BIA)/body composition monitoring in the detection of sarcopenia within Asian populations.
Methods
PubMed and Embase were systematically searched for studies analyzing ultrasonography, CT, MRI, and BIA in diagnosing sarcopenia among Asians. Study quality was assessed using the Newcastle-Ottawa scale.
Results
Pooled findings from 21,598 patients across 25 studies were examined. In receiver operating characteristic analysis, ultrasound displayed a pooled mean area under the curve (AUC) of 0.767 (95% confidence interval [CI], 0.709–0.806), with mean sensitivity of 81.1% (95% CI, 0.744–0.846) and specificity of 73.1% (95% CI, 0.648–0.774), for detecting sarcopenia in Asian populations. CT exhibited an AUC of 0.720 (sensitivity, 54.0%; specificity, 92.0%). MRI demonstrated an AUC of 0.839 (sensitivity, 67.0%; specificity, 66.0%). BIA displayed an AUC of 0.905 (95% CI, 0.842–0.968), 80.7% sensitivity (95% CI, 0.129–0.679), and 82.4% specificity (95% CI, 0.191–0.633).
Conclusion
Various modalities aid in diagnosing sarcopenia, and selection should be individualized. Although only BIA and dual-energy x-ray absorptiometry are recommended by the Asian Working Group for Sarcopenia and the European Working Group on Sarcopenia in Older People, ultrasound imaging may hold diagnostic value for sarcopenia in the Asian population. In certain groups, diagnostic use of CT and MRI is warranted. Future research can standardize and validate modality-specific thresholds and protocols within Asian populations.

Colorectal cancer

The role of lateral pelvic lymph node dissection in advanced rectal cancer: a review of current evidence and outcomes: Gyu-Seog Choi, Hye Jin Kim; Ann Coloproctol. 2024;40(4):363-374. Published online August 30, 2024; DOI: https://doi.org/10.3393/ac.2024.00521.0074

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Metastatic lateral pelvic lymph nodes (LPNs) in rectal cancer significantly impact the prognosis and treatment strategies. Western practices emphasize neoadjuvant chemoradiotherapy (CRT), whereas Eastern approaches often rely on LPN dissection (LPND). This review examines the evolving role of LPND in the context of modern treatments, including total neoadjuvant therapy (TNT), and the impact of CRT on the management of clinically suspicious LPNs. We comprehensively reviewed the key literature comparing the outcomes of LPND versus preoperative CRT for rectal cancer, focusing on recent advancements and ongoing debates. Key studies, including the JCOG0212 trial and recent multicenter trials, were analyzed to assess the efficacy of LPND, particularly in conjunction with preoperative CRT or TNT. Current evidence indicates that LPND can reduce local recurrence rates compared to total mesorectal excision alone in patients not receiving radiation therapy. However, the benefit of LPND in the context of neoadjuvant CRT is influenced by the size and pretreatment characteristics of LPNs. While CRT can effectively control smaller metastatic LPNs, larger or clinically suspicious LPNs may require LPND for optimal outcomes. Advances in surgical techniques, such as robotic-assisted LPND, offer potential benefits but also present challenges and complications. The role of TNT in controlling metastatic LPNs and improving patient outcomes is emerging but remains underexplored. The decision to perform LPND should be individualized based on patient-specific factors, including LPN size, response to neoadjuvant treatment, and surgeon expertise. Future research should focus on optimizing treatment protocols and further evaluating the role of TNT in managing metastatic LPNs.

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From the Editor: Uniting expertise, a new era of global collaboration in coloproctology
In Ja Park
Annals of Coloproctology.2024; 40(4): 285. CrossRef

Minimally invasive surgery

Robotic colorectal surgery training: Portsmouth perspective: Guglielmo Niccolò Piozzi, Sentilnathan Subramaniam, Diana Ronconi Di Giuseppe, Rauand Duhoky, Jim S. Khan; Ann Coloproctol. 2024;40(4):350-362. Published online August 30, 2024; DOI: https://doi.org/10.3393/ac.2024.00444.0063

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This study aims to discuss the principles and pillars of robotic colorectal surgery training and share the training pathway at Portsmouth Hospitals University NHS Trust. A narrative review is presented to discuss all the relevant and critical steps in robotic surgical training. Robotic training requires a stepwise approach, including theoretical knowledge, case observation, simulation, dry lab, wet lab, tutored programs, proctoring (in person or telementoring), procedure-specific training, and follow-up. Portsmouth Colorectal has an established robotic training model with a safe stepwise approach that has been demonstrated through perioperative and oncological results. Robotic surgery training should enable a trainee to use the robotic platform safely and effectively, minimize errors, and enhance performance with improved outcomes. Portsmouth Colorectal has provided such a stepwise training program since 2015 and continues to promote and augment safe robotic training in its field. Safe and efficient training programs are essential to upholding the optimal standard of care.

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From the Editor: Uniting expertise, a new era of global collaboration in coloproctology
In Ja Park
Annals of Coloproctology.2024; 40(4): 285. CrossRef

Translational/basic research

Tissue engineering and regenerative medicine approaches in colorectal surgery: Bigyan B. Mainali, James J. Yoo, Mitchell R. Ladd; Ann Coloproctol. 2024;40(4):336-349. Published online August 30, 2024; DOI: https://doi.org/10.3393/ac.2024.00437.0062

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Tissue engineering and regenerative medicine (TERM) is an emerging field that has provided new therapeutic opportunities by delivering innovative solutions. The development of nontraditional therapies for previously unsolvable diseases and conditions has brought hope and excitement to countless individuals globally. Many regenerative medicine therapies have been developed and delivered to patients clinically. The technology platforms developed in regenerative medicine have been expanded to various medical areas; however, their applications in colorectal surgery remain limited. Applying TERM technologies to engineer biological tissue and organ substitutes may address the current therapeutic challenges and overcome some complications in colorectal surgery, such as inflammatory bowel diseases, short bowel syndrome, and diseases of motility and neuromuscular function. This review provides a comprehensive overview of TERM applications in colorectal surgery, highlighting the current state of the art, including preclinical and clinical studies, current challenges, and future perspectives. This article synthesizes the latest findings, providing a valuable resource for clinicians and researchers aiming to integrate TERM into colorectal surgical practice.

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From the Editor: Uniting expertise, a new era of global collaboration in coloproctology
In Ja Park
Annals of Coloproctology.2024; 40(4): 285. CrossRef

Colorectal cancer

Essential knowledge and technical tips for total mesorectal excision and related procedures for rectal cancer: Min Soo Cho, Hyeon Woo Bae, Nam Kyu Kim; Ann Coloproctol. 2024;40(4):384-411. Published online August 30, 2024; DOI: https://doi.org/10.3393/ac.2024.00388.0055

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Total mesorectal excision (TME) has greatly improved rectal cancer surgery outcomes by reducing local recurrence and enhancing patient survival. This review outlines essential knowledge and techniques for performing TME. TME emphasizes the complete resection of the mesorectum along embryologic planes to minimize recurrence. Key anatomical insights include understanding the rectal proper fascia, Denonvilliers fascia, rectosacral fascia, and the pelvic autonomic nerves. Technical tips cover a step-by-step approach to pelvic dissection, the Gate approach, and tailored excision of Denonvilliers fascia, focusing on preserving pelvic autonomic nerves and ensuring negative circumferential resection margins. In Korea, TME has led to significant improvements in local recurrence rates and survival with well-adopted multidisciplinary approaches. Surgical techniques of TME have been optimized and standardized over several decades in Korea, and minimally invasive surgery for TME has been rapidly and successfully adopted. The review emphasizes the need for continuous research on tumor biology and precise surgical techniques to further improve rectal cancer management. The ultimate goal of TME is to achieve curative resection and function preservation, thereby enhancing the patient’s quality of life. Accurate TME, multidisciplinary-based neoadjuvant therapy, refined sphincter-preserving techniques, and ongoing tumor research are essential for optimal treatment outcomes.

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From the Editor: Uniting expertise, a new era of global collaboration in coloproctology
In Ja Park
Annals of Coloproctology.2024; 40(4): 285. CrossRef
Efficacy of Neoadjuvant Hypofractionated Chemoradiotherapy in Elderly Patients with Locally Advanced Rectal Cancer: A Single-Center Retrospective Analysis
Jae Seung Kim, Jaram Lee, Hyeung-min Park, Soo Young Lee, Chang Hyun Kim, Hyeong Rok Kim
Cancers.2024; 16(24): 4280. CrossRef

Anorectal benign disease

Recent advances in the diagnosis and treatment of complex anal fistula: Pankaj Garg, Kaushik Bhattacharya, Vipul D. Yagnik, G. Mahak; Ann Coloproctol. 2024;40(4):321-335. Published online August 30, 2024; DOI: https://doi.org/10.3393/ac.2024.00325.0046

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Anal fistula can be a challenging condition to manage, with complex fistulas presenting even greater difficulties. The primary concerns in treating this condition are a risk of damage to the anal sphincters, which can compromise fecal continence, and refractoriness to treatment, as evidenced by a high recurrence rate. Furthermore, the treatment of complex anal fistula involves several additional challenges. Satisfactory solutions to many of these obstacles remain elusive, and no consensus has been established regarding the available treatment options. In summary, complex anal fistula has no established gold-standard treatment, and the quest for effective therapies continues. This review discusses and highlights groundbreaking advances in the management of complex anal fistula over the past decade.

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From the Editor: Uniting expertise, a new era of global collaboration in coloproctology
In Ja Park
Annals of Coloproctology.2024; 40(4): 285. CrossRef
Surgeon oriented reporting template for magnetic resonance imaging and endoanal ultrasound of anal fistulas enhances surgical decision-making
Si-Ze Wu
World Journal of Radiology.2024; 16(12): 712. CrossRef

Colorectal cancer

Dissection layer selection based on an understanding of pelvic fascial anatomy in transanal total mesorectal excision: Daichi Kitaguchi, Masaaki Ito; Ann Coloproctol. 2024;40(4):375-383. Published online August 30, 2024; DOI: https://doi.org/10.3393/ac.2024.00178.0025

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This study aimed to review the historical transition of rectal cancer surgery and recent evidence regarding transanal total mesorectal excision (TaTME). Additionally, it outlined the anatomical landmarks and technical considerations essential for successful TaTME. Anatomical studies and surgical techniques were analyzed to identify key landmarks and procedural steps crucial for TaTME. TaTME offers improved visibility and maneuverability even in the deep and narrow pelvis and is expected to contribute to tumor radical cure rates. By securing the circumferential resection margin and distal margin while preserving pelvic autonomic nerve function, TaTME holds promise for maintaining postoperative urinary and sexual functions. Key anatomical landmarks include the endopelvic fascia posteriorly, the S4-pelvic splanchnic nerve laterally, and the prostate or posterior vaginal wall anteriorly. Selecting the appropriate dissection layer based on tumor depth and ensuring precise incision of the tendinous arch of the pelvic fascia contributes to successful TaTME outcomes. TaTME represents a significant advancement in rectal cancer surgery, offering improved outcomes through meticulous attention to anatomical detail and precise dissection techniques. Understanding the historical context of rectal cancer surgery alongside recent evidence on TaTME is essential for optimizing patient outcomes and expanding the safe implementation of this innovative approach.

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From the Editor: Uniting expertise, a new era of global collaboration in coloproctology
In Ja Park
Annals of Coloproctology.2024; 40(4): 285. CrossRef
Efficacy of Neoadjuvant Hypofractionated Chemoradiotherapy in Elderly Patients with Locally Advanced Rectal Cancer: A Single-Center Retrospective Analysis
Jae Seung Kim, Jaram Lee, Hyeung-min Park, Soo Young Lee, Chang Hyun Kim, Hyeong Rok Kim
Cancers.2024; 16(24): 4280. CrossRef

Benign bowel disease

Colorectal screening following appendectomy in adult patients: a systematic review: Francesco Esposito, Marco Del Prete, Matilde Magri, Fanny Dufour, Alexandre Cortes; Ann Coloproctol. 2024;40(5):417-423. Published online August 1, 2024; DOI: https://doi.org/10.3393/ac.2023.00528.0075

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Abstract PDF: Purpose
Although the association between appendicitis and colorectal cancer in older patients has received attention, postoperative colorectal screening through endoscopy is not currently recommended. This study conducted a systematic review of the literature on colorectal screening following appendectomy in adult patients.
Methods
A literature search was performed using online databases. Studies reporting colorectal surveillance after appendectomy in adult patients were retrieved for assessment.
Results
Eight articles including a total of 3,995 patients were published between 2013 and 2023. An age of 40 years was the lower threshold in 6 of the 8 articles. Postoperative colorectal screening occurred in 771 patients (19.3%). Endoscopy was performed in 95.2% of cases and computed tomography–colonography in 4.8%. During endoscopic examinations, a lesion was discovered in 184 of 771 patients (24.0%), and an adenomatous polyp was found in 154 of 686 patients (22.5%). The overall cancer rate was 3.9% (30 of 771 patients). The tumor was located in the right-sided colon in 46.7% of the patients, in the cecum in 20.0%, in the rectum in 16.7%, in the left-sided colon in 10.0%, and in the sigmoid colon in 6.7%.
Conclusion
Performing post-appendectomy colorectal screening in patients >40 years of age could allow early detection of an underlying lesion.

ERAS

Tolerance to and postoperative outcomes with early oral feeding following elective bowel surgery: a systematic review with meta-analysis: Lord Mvoula, Evelyn Irizarry; Ann Coloproctol. 2024;40(6):538-547. Published online July 31, 2024; DOI: https://doi.org/10.3393/ac.2023.00472.0067

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Abstract PDF: Purpose
Advancements in gastrointestinal surgery have directed attention toward optimizing recovery, including through the use of feeding methods that reduce prolonged postoperative hospital stays, complications, and mortality, among other undesirable outcomes. This study’s primary goals were to identify current peer-reviewed literature reporting the postoperative outcomes of elective bowel surgery and to evaluate the clinical evidence of patients’ tolerance to oral feeding following elective bowel surgery.
Methods
An exhaustive literature search was conducted via PubMed and Scopus. The search results were screened for potential articles, and articles were assessed for eligibility based on prespecified eligibility criteria. The data were synthesized, and the results were reported and discussed thematically.
Results
The database search yielded 1,667 articles, from which 18 randomized controlled trials were chosen for inclusion in this study. This study included 874 early oral feeding (EOF) patients, 865 traditional oral feeding patients, and 91 patients whose postoperative care was unspecified. Data synthesis was done, and meta-analyses were conducted. The results showed that EOF patients required a significantly shorter time to tolerate a solid diet and had shorter hospital stays. In addition, bowel function was restored earlier in EOF groups.
Conclusion
The results show good tolerance to EOF, shorter hospitalizations, and faster restoration of bowel function, suggesting that EOF after elective bowel surgery is relatively safe. However, further studies with similar baseline conditions should be conducted to verify these results.

Colorectal cancer

Postoperative outcomes after prehabilitation for colorectal cancer patients undergoing surgery: a systematic review and meta-analysis of randomized and nonrandomized studies: Ian Jun Yan Wee, Isaac Seow-En, Aik Yong Chok, Eileen Sim, Chee Hoe Koo, Wenjie Lin, Chang Meihuan, Emile Kwong-Wei Tan; Ann Coloproctol. 2024;40(3):191-199. Published online May 16, 2024; DOI: https://doi.org/10.3393/ac.2022.01095.0156

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Abstract PDF

Purpose
Prehabilitation (PH) is purported to improve patients’ preoperative functional status. This systematic review and meta-analysis sought to compare short-term postoperative outcomes between patients who underwent a protocolized PH program and the existing standard of care among colorectal cancer patients awaiting surgery.
Methods
A search in MEDLINE/PubMed, the Cochrane Library, Embase, Scopus, and CINAHL was conducted to identify relevant articles. Repetitive and exhaustive combinations of MeSH search terms (“prehabilitation,” “colorectal cancer,” “colon cancer,” and “rectal cancer”) were used to identify randomized and nonrandomized studies comparing PH versus standard of care for colorectal cancer patients awaiting surgery. The primary outcomes included postoperative morbidity, length of hospital stay, and readmission rates.
Results
Seven studies including 1,042 colorectal cancer patients (PH, 382) were included. No significant differences were found in intraoperative outcomes. The postoperative complication rates were comparable between groups (Clavien-Dindo grades I and II: risk ratio, 0.82; 95% confidence interval, 0.62–1.07; P=0.15; Clavien-Dindo grades ≥III: risk ratio, 1.02; 95% confidence interval, 0.72–1.44; P=0.92). There were also no significant differences in length of hospital stay (P=0.21) or the risk of 30-day readmission (P=0.68).
Conclusion
Although PH does not appear to improve short-term postoperative outcomes following colorectal cancer surgery, the quality of evidence is impaired by the limited trials and heterogeneity. Thus, further large-scale trials are warranted to draw definitive conclusions and establish the long-term effects of PH.

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Identifying and optimizing psychosocial frailty in surgical practice
Kurt S. Schultz, Caroline E. Richburg, Emily Y. Park, Ira L. Leeds
Seminars in Colon and Rectal Surgery.2024; 35(4): 101061. CrossRef

ERAS

Venous thromboembolism among Asian populations with localized colorectal cancer undergoing curative resection: is pharmacological thromboprophylaxis required? A systematic review and meta-analysis: Shih Jia Janice Tan, Emile Kwong-Wei Tan, Yvonne Ying Ru Ng, Rehena Sultana, John Carson Allen, Isaac Seow-En, Ronnie Mathew, Aik Yong Chok; Ann Coloproctol. 2024;40(3):200-209. Published online May 16, 2024; DOI: https://doi.org/10.3393/ac.2022.01046.0149

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Abstract PDF: Purpose
We compared the incidence of venous thromboembolism (VTE) among Asian populations with localized colorectal cancer undergoing curative resection with and without the use of pharmacological thromboprophylaxis (PTP).
Methods
A comprehensive literature search was undertaken to identify relevant studies published from January 1, 1980 to February 28, 2022. The inclusion criteria were patients who underwent primary tumor resection for localized nonmetastatic colorectal cancer; an Asian population or studies conducted in an Asian country; randomized controlled trials, case-control studies, or cohort studies; and the incidence of symptomatic VTE, deep vein thrombosis, and/or pulmonary embolism as the primary study outcomes. Data were pooled using a random-effects model. This study was registered in PROSPERO on October 11, 2020 (No. CRD42020206793).
Results
Seven studies (2 randomized controlled trials and 5 observational cohort studies) were included, encompassing 5,302 patients. The overall incidence of VTE was 1.4%. The use of PTP did not significantly reduce overall VTE incidence: 1.1% (95% confidence interval [CI], 0%–3.1%) versus 1.9% (95% CI, 0.3%–4.4%; P = 0.55). Similarly, PTP was not associated with significantly lower rates of symptomatic VTE, proximal deep vein thrombosis, or pulmonary embolism.
Conclusion
The benefit of PTP in reducing VTE incidence among Asian patients undergoing curative resection for localized colorectal cancer has not been clearly established. The decision to administer PTP should be evaluated on a case-bycase basis and with consideration of associated bleeding risks.

Colorectal cancer

Performance reporting design in artificial intelligence studies using image-based TNM staging and prognostic parameters in rectal cancer: a systematic review: Minsung Kim, Taeyong Park, Bo Young Oh, Min Jeong Kim, Bum-Joo Cho, Il Tae Son; Ann Coloproctol. 2024;40(1):13-26. Published online February 28, 2024; DOI: https://doi.org/10.3393/ac.2023.00892.0127

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Abstract PDF

Purpose
The integration of artificial intelligence (AI) and magnetic resonance imaging in rectal cancer has the potential to enhance diagnostic accuracy by identifying subtle patterns and aiding tumor delineation and lymph node assessment. According to our systematic review focusing on convolutional neural networks, AI-driven tumor staging and the prediction of treatment response facilitate tailored treatment strategies for patients with rectal cancer.
Methods
This paper summarizes the current landscape of AI in the imaging field of rectal cancer, emphasizing the performance reporting design based on the quality of the dataset, model performance, and external validation.
Results
AI-driven tumor segmentation has demonstrated promising results using various convolutional neural network models. AI-based predictions of staging and treatment response have exhibited potential as auxiliary tools for personalized treatment strategies. Some studies have indicated superior performance than conventional models in predicting microsatellite instability and KRAS status, offering noninvasive and cost-effective alternatives for identifying genetic mutations.
Conclusion
Image-based AI studies for rectal cancer have shown acceptable diagnostic performance but face several challenges, including limited dataset sizes with standardized data, the need for multicenter studies, and the absence of oncologic relevance and external validation for clinical implantation. Overcoming these pitfalls and hurdles is essential for the feasible integration of AI models in clinical settings for rectal cancer, warranting further research.

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L’intelligence artificielle pourrait-elle aider le chirurgien digestif dans la prise en charge du cancer du rectum ?
Arnaud Alves, Karem Slim
Journal de Chirurgie Viscérale.2024; 161(4): 253. CrossRef
Can artificial intelligence help a digestive surgeon in management of rectal cancer?
Arnaud Alves, Karem Slim
Journal of Visceral Surgery.2024; 161(4): 231. CrossRef
Artificial intelligence for the colorectal surgeon in 2024 – A narrative review of Prevalence, Policies, and (needed) Protections
Kurt S. Schultz, Michelle L. Hughes, Warqaa M. Akram, Anne K. Mongiu
Seminars in Colon and Rectal Surgery.2024; 35(3): 101037. CrossRef
Artificial Intelligence in Coloproctology: A Review of Emerging Technologies and Clinical Applications
Joana Mota, Maria João Almeida, Miguel Martins, Francisco Mendes, Pedro Cardoso, João Afonso, Tiago Ribeiro, João Ferreira, Filipa Fonseca, Manuel Limbert, Susana Lopes, Guilherme Macedo, Fernando Castro Poças, Miguel Mascarenhas
Journal of Clinical Medicine.2024; 13(19): 5842. CrossRef

Colorectal cancer

Survival outcomes of salvage surgery in the watch-and-wait approach for rectal cancer with clinical complete response after neoadjuvant chemoradiotherapy: a systematic review and meta-analysis: Wenjie Lin, Ian Jun Yan Wee, Isaac Seow-En, Aik Yong Chok, Emile Kwong-Wei Tan; Ann Coloproctol. 2023;39(6):447-456. Published online December 28, 2023; DOI: https://doi.org/10.3393/ac.2022.01221.0174

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Abstract PDF Supplementary Material

Purpose
This systematic review and meta-analysis compared the outcomes of the watch-and-wait (WW) approach versus radical surgery (RS) in rectal cancers with clinical complete response (cCR) after neoadjuvant chemoradiotherapy.
Methods
This study followed the PRISMA guidelines. Major databases were searched to identify relevant articles. WW and RS were compared through meta-analyses of pooled proportions. Primary outcomes included overall survival (OS), disease-free survival (DFS), local recurrence, and distant metastasis rates. Pooled salvage surgery rates and outcomes were also collected. The Newcastle-Ottawa scale was employed to assess the risk of bias.
Results
Eleven studies including 1,112 rectal cancer patients showing cCR after neoadjuvant chemoradiation were included. Of these patients, 378 were treated nonoperatively with WW, 663 underwent RS, and 71 underwent local excision. The 2-year OS (risk ratio [RR], 0.95; P = 0.94), 5-year OS (RR, 2.59; P = 0.25), and distant metastasis rates (RR, 1.05; P = 0.80) showed no significant differences between WW and RS. Local recurrence was more frequent in the WW group (RR, 6.93; P < 0.001), and 78.4% of patients later underwent salvage surgery (R0 resection rate, 97.5%). The 2-year DFS (RR, 1.58; P = 0.05) and 5-year DFS (RR, 2.07; P = 0.02) were higher among RS cases. However, after adjustment for R0 salvage surgery, DFS showed no significant between-group difference (RR, 0.82; P = 0.41).
Conclusion
Local recurrence rates are higher for WW than RS, but complete salvage surgery is often possible with similar long-term outcomes. WW is a viable strategy for rectal cancer with cCR after neoadjuvant chemoradiation, but further research is required to improve patient selection.

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Advancing Personalized Medicine in the Treatment of Locally Advanced Rectal Cancer
Francesco Giulio Sullo, Alessandro Passardi, Chiara Gallio, Chiara Molinari, Giorgia Marisi, Eleonora Pozzi, Leonardo Solaini, Alessandro Bittoni
Journal of Clinical Medicine.2024; 13(9): 2562. CrossRef
Tailoring rectal cancer surgery: Surgical approaches and anatomical insights during deep pelvic dissection for optimal outcomes in low‐lying rectal cancer
Youn Young Park, Nam Kyu Kim
Annals of Gastroenterological Surgery.2024; 8(5): 761. CrossRef
Combined Transanal and Laparoscopic Approach for Full-Thickness Local Excision of Locally Advanced Rectal Cancer Following Near-Complete Response after Chemotherapy
Joshua S. H. Lim, Si-Lin Koo, Iain Beehuat Tan, Isaac Seow-En
World Journal of Colorectal Surgery.2024; 13(3): 95. CrossRef
Watch‐and‐Wait Approach Following Neoadjuvant Chemo‐Radiotherapy for Locally Advanced Rectal Cancer: A Retrospective Single‐Center Cohort Study
Georgi Kalev, Sylvia Buettner, Tianzuo Zhan, Ralf‐Dieter Hofheinz, Judit Boda‐Heggemann, Christoph Reissfelder, Steffen Seyfried, Georgi Vassilev, Julia Hardt
Journal of Surgical Oncology.2024;[Epub] CrossRef
Phase 2, Multicenter, Open-label, Nonrandomized Study of Neoadjuvant Chemotherapy Liposomal Irinotecan With 5-Fluorouracil, Leucovorin, and Oxaliplatin, Followed by Chemoradiotherapy in Patients With Rectal Cancer in a Watch-and-Wait Program
César Muñoz, María-C. Riesco Martinez, Lisardo Ugidos, Pilar García-Alfonso, Rafael Alvarez-Gallego, Paloma Peinado, Carmen Toledano, Luka Mihic-Góngora, Justo Gabriel Ortega Anselmi, Enrique Sanz Garcia, Emilio Vicente, Yolanda Quijano, Hipólito J. Durán
American Journal of Clinical Oncology.2024;[Epub] CrossRef

Colorectal cancer

Essential anatomy for lateral lymph node dissection: Yuichiro Yokoyama, Hiroaki Nozawa, Kazuhito Sasaki, Koji Murono, Shigenobu Emoto, Hiroyuki Matsuzaki, Shinya Abe, Yuzo Nagai, Yuichiro Yoshioka, Takahide Shinagawa, Hirofumi Sonoda, Daisuke Hojo, Soichiro Ishihara; Ann Coloproctol. 2023;39(6):457-466. Published online December 8, 2023; DOI: https://doi.org/10.3393/ac.2023.00164.0023

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Abstract PDF

In Western countries, the gold-standard therapeutic strategy for rectal cancer is preoperative chemoradiotherapy (CRT) following total mesorectal excision (TME), without lateral lymph node dissection (LLND). However, preoperative CRT has recently been reported to be insufficient to control lateral lymph node recurrence in cases of enlarged lateral lymph nodes before CRT, and LLND is considered necessary in such cases. We performed a literature review on aspects of pelvic anatomy associated with rectal surgery and LLND, and then combined this information with our experience and knowledge of pelvic anatomy. In this review, drawing upon research using a 3-dimensional anatomical model and actual operative views, we aimed to clarify the essential anatomy for LLND. The LLND procedure was developed in Asian countries and can now be safely performed in terms of functional preservation. Nonetheless, the longer operative time, hemorrhage, and higher complication rates with TME accompanied by LLND than with TME alone indicate that LLND is still a challenging procedure. Laparoscopic or robotic LLND has been shown to be useful and is widely performed; however, without a sufficient understanding of anatomical landmarks, misrecognition of vessels and nerves often occurs. To perform safe and accurate LLND, understanding the landmarks of LLND is essential.

Citations

Citations to this article as recorded by

The role of lateral pelvic lymph node dissection in advanced rectal cancer: a review of current evidence and outcomes
Gyu-Seog Choi, Hye Jin Kim
Annals of Coloproctology.2024; 40(4): 363. CrossRef
Dissection layer selection based on an understanding of pelvic fascial anatomy in transanal total mesorectal excision
Daichi Kitaguchi, Masaaki Ito
Annals of Coloproctology.2024; 40(4): 375. CrossRef

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