Annals of Coloproctology

Volume 40(4); August 2024

Editorial

From the Editor: Uniting expertise, a new era of global collaboration in coloproctology: In Ja Park; Ann Coloproctol. 2024;40(4):285-286. Published online August 30, 2024; DOI: https://doi.org/10.3393/ac.2024.00514.0073

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Guideline

Anorectal benign disease

The Italian Unitary Society of Colon-Proctology (Società Italiana Unitaria di Colonproctologia) guidelines for the management of acute and chronic hemorrhoidal disease: Antonio Brillantino, Adolfo Renzi, Pasquale Talento, Luigi Brusciano, Luigi Marano, Maurizio Grillo, Mauro Natale Maglio, Fabrizio Foroni, Alessio Palumbo, Maria Laura Sandoval Sotelo, Luciano Vicenzo, Michele Lanza, Giovanna Frezza, Massimo Antropoli, Claudio Gambardella, Luigi Monaco, Ilaria Ferrante, Domenico Izzo, Alfredo Giordano, Michele Pinto, Corrado Fantini, Marcello Gasparrini, Michele Schiano Di Visconte, Francesca Milazzo, Giovanni Ferreri, Andrea Braini, Umberto Cocozza, Massimo Pezzatini, Valeria Gianfreda, Alberto Di Leo, Vincenzo Landolfi, Umberto Favetta, Sergio Agradi, Giovanni Marino, Massimiliano Varriale, Massimo Mongardini, Claudio Eduardo Fernando Antonio Pagano, Riccardo Brachet Contul, Nando Gallese, Giampiero Ucchino, Michele D’Ambra, Roberto Rizzato, Giacomo Sarzo, Bruno Masci, Francesca Da Pozzo, Simona Ascanelli, Patrizia Liguori, Angela Pezzolla, Francesca Iacobellis, Erika Boriani, Eugenio Cudazzo, Francesca Babic, Carmelo Geremia, Alessandro Bussotti, Mario Cicconi, Antonia Di Sarno, Federico Maria Mongardini, Antonio Brescia, Leonardo Lenisa, Massimiliano Mistrangelo, Matteo Zuin, Marta Mozzon, Alessandro Paolo Chiriatti, Vincenzo Bottino, Antonio Ferronetti, Corrado Rispoli, Ludovico Carbone, Giuseppe Calabrò, Antonino Tirrò, Domenico de Vito, Giovanna Ioia, Giovanni Luca Lamanna, Lorenzo Asciore, Ettore Greco, Pierluigi Bianchi, Giuseppe D’Oriano, Alessandro Stazi, Nicola Antonacci, Raffaella Marina Di Renzo, Gianmario Edoardo Poto, Giuseppe Paolo Ferulano, Antonio Longo, Ludovico Docimo; Ann Coloproctol. 2024;40(4):287-320. Published online August 30, 2024; DOI: https://doi.org/10.3393/ac.2023.00871.0124

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Abstract PDF: The aim of these evidence-based guidelines is to present a consensus position from members of the Italian Unitary Society of Colon-Proctology (Società Italiana Unitaria di Colon-Proctologia, SIUCP) on the diagnosis and management of hemorrhoidal disease, with the goal of guiding physicians in the choice of the best treatment option. A panel of experts was charged by the Board of the SIUCP to develop key questions on the main topics related to the management of hemorrhoidal disease and to perform an accurate and comprehensive literature search on each topic, in order to provide evidence-based answers to the questions and to summarize them in statements. All the clinical questions were discussed by the expert panel in multiple rounds through the Delphi approach and, for each statement, a consensus among the experts was reached. The questions were created according to PICO (patients, intervention, comparison, and outcomes) criteria, and the statements were developed adopting the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) methodology. In cases of grade 1 hemorrhoidal prolapse, outpatient procedures including hemorrhoidal laser procedure and sclerotherapy may be considered the preferred surgical options. For grade 2 prolapse, nonexcisional procedures including outpatient treatments, hemorrhoidal artery ligation and mucopexy, laser hemorrhoidoplasty, the Rafaelo procedure, and stapled hemorrhoidopexy may represent the first-line treatment options, whereas excisional surgery may be considered in selected cases. In cases of grades 3 and 4, stapled hemorrhoidopexy and hemorrhoidectomy may represent the most effective procedures, even if, in the expert panel opinion, stapled hemorrhoidopexy represents the gold-standard treatment for grade 3 hemorrhoidal prolapse.

Reviews

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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Abstract PDF: 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.

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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Abstract PDF: 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.

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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Abstract PDF: 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.

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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Abstract PDF: 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.

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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Abstract PDF: 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.

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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Abstract PDF: 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.

Brief Communication

Minimally invasive surgery

First clinical experience using augmented intelligence in robotic colorectal surgery with the Senhance robotic platform: Narimantas Evaldas Samalavicius, Audrius Dulskas; Ann Coloproctol. 2024;40(4):412-414. Published online August 30, 2024; DOI: https://doi.org/10.3393/ac.2023.00815.0116

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