Annals of Coloproctology

Volume 41(2); April 2025

Editorial

Minimally invasive surgery

Minimally invasive transanal excision over conventional transanal excision: pursuing the perfect removal of early rectal cancer: HyungJoo Baik; Ann Coloproctol. 2025;41(2):105-106. Published online April 30, 2025; DOI: https://doi.org/10.3393/ac.2025.00479.0068

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Review

Inflammatory/benign bowel disease

Clinical outcomes and optimal indications for nonoperative management of acute appendicitis in adult patients: a comprehensive literature review: Hyun Gu Lee, In Ja Park; Ann Coloproctol. 2025;41(2):107-118. Published online April 16, 2025; DOI: https://doi.org/10.3393/ac.2023.00192.0027

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Graphical Abstract Abstract PDF: Appendectomy as the standard treatment for acute appendicitis has been challenged by accumulating evidence supporting nonoperative management with antibiotics as a potential primary treatment. This review aimed to summarize the clinical outcomes and the optimal indications for nonoperative management of acute appendicitis in adults. Current evidence suggests that uncomplicated and complicated appendicitis have different pathophysiologies and should be treated differently. Nonoperative management for uncomplicated appendicitis was not inferior to appendectomy in terms of complications and length of stay, with less than a 30% failure rate at 1 year. The risk of perforation and postoperative complications did not increase even if nonoperative management failed. Complicated appendicitis with localized abscess or phlegmon could also be treated conservatively, with a success rate of more than 80%. An interval appendectomy following successful nonoperative management is recommended only for patients over the age of 40 years to exclude appendiceal malignancy. The presence of appendicoliths increased the risk of treatment failure and complications; thus, it may be an indication for appendectomy. Nonoperative management is a safe and feasible option for both uncomplicated and complicated appendicitis. Patients should be informed that nonoperative management may be a safe alternative to surgery, with the possibility of treatment failure.

Original Articles

CRC

Impact of iron-deficiency anemia on short-term outcomes after resection of colorectal cancer liver metastasis: a US National (Nationwide) Inpatient Sample (NIS) analysis: Ko-Chao Lee, Yu-Li Su, Kuen-Lin Wu, Kung-Chuan Cheng, Ling-Chiao Song, Chien-En Tang, Hong-Hwa Chen, Kuan-Chih Chung; Ann Coloproctol. 2025;41(2):119-126. Published online April 24, 2025; DOI: https://doi.org/10.3393/ac.2024.00591.0084

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Abstract PDF Supplementary Material: Purpose
Colorectal cancer (CRC) often spreads to the liver, necessitating surgical treatment for CRC liver metastasis (CRLM). Iron-deficiency anemia is common in CRC patients and is associated with fatigue and weakness. This study investigated the effects of iron-deficiency anemia on the outcomes of surgical resection of CRLM.
Methods
This population-based, retrospective study evaluated data from adults ≥20 years old with CRLM who underwent hepatic resection. All patient data were extracted from the 2005–2018 US National (Nationwide) Inpatient Sample (NIS) database. The outcome measures were in-hospital outcomes including 30-day mortality, unfavorable discharge, and prolonged length of hospital stay (LOS), and short-term complications such as bleeding and infection. Associations between iron-deficiency anemia and outcomes were determined using logistic regression analysis.
Results
Data from 7,749 patients (representing 37,923 persons in the United States after weighting) were analyzed. Multivariable analysis revealed that iron-deficiency anemia was significantly associated with an increased risk of prolonged LOS (adjusted odds ratio [aOR], 2.76; 95% confidence interval [CI], 2.30–3.30), unfavorable discharge (aOR, 2.42; 95% CI, 1.83–3.19), bleeding (aOR, 5.05; 95% CI, 2.92–8.74), sepsis (aOR, 1.60; 95% CI, 1.04–2.46), pneumonia (aOR, 2.54; 95% CI, 1.72–3.74), and acute kidney injury (aOR, 1.71; 95% CI, 1.24–2.35). Subgroup analyses revealed consistent associations between iron-deficiency anemia and prolonged LOS across age, sex, and obesity status categories.
Conclusion
In patients undergoing hepatic resection for CRLM, iron-deficiency anemia is an independent risk factor for prolonged LOS, unfavorable discharge, and several critical postoperative complications. These findings underscore the need for proactive anemia management to optimize surgical outcomes.

Complications

Bedside endoscopic inspection of colorectal anastomoses in the early postoperative period: a 2-center prospective feasibility study: David J. Nijssen, Roel Hompes, Jurriaan Tuynman, Jimme K. Wiggers, Willem A. Bemelman, Saidah Sahid, James Kinross, Wytze Laméris; Ann Coloproctol. 2025;41(2):127-135. Published online April 14, 2025; DOI: https://doi.org/10.3393/ac.2024.00584.0083

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Abstract PDF: Purpose
Early diagnosis of anastomotic leakage (AL) after colorectal surgery can reduce severe postoperative morbidity and ensure successful treatment. This study evaluated the feasibility of bedside endoscopic inspection of the anastomosis early postoperatively using a point-of-care digital rectoscope.
Methods
This prospective study was conducted at 2 tertiary centers. Patients who underwent minimally invasive or open sphincter-preserving surgery with creation of a colorectal or coloanal anastomosis were included. Data were collected from December 2022 to October 2023. Bedside anastomotic inspections were performed postoperative day (POD) 3 to 5 using a point-of-care digital rectoscope. The primary outcome was feasibility, defined as adequate clinical assessment of the anastomosis during bedside inspection. Secondary outcomes included patient tolerability, efficacy compared to other diagnostic methods, and clinical outcomes during 90 days of follow-up.
Results
In total, 35 patients were included. All bedside anastomotic inspections were carried out successfully. The examination showed complete visibility of the entire anastomosis in 30 patients (85.7%), with minimal discomfort reported by 3 (8.6%). No adverse events were recorded. AL occurred in 6 patients (17.1%), with 3 cases detected during bedside inspections between POD 3 and 5. Two leaks were detected without clinical or biochemical suspicion. Three patients with negative rectoscopy between POD 3 and 5 were later diagnosed with AL: 2 by a computed tomography scan and 1 by a bedside rectoscopy.
Conclusion
Bedside inspection of rectal anastomoses early postoperatively is feasible and tolerable for patients. Routine anastomotic inspections can detect early AL even without clear clinical or biochemical signs.

CRC

Relationships between MMP-2, MMP-9, and ADAMDEC1 serum and tissue levels in patients with colorectal cancer: Zahra Mozooni, Kiana Khajeh Amiri, Nafiseh Golestani, Alireza Shahmohammadi, Sara Minaeian, Leyla Bahadorizadeh; Ann Coloproctol. 2025;41(2):136-144. Published online April 29, 2025; DOI: https://doi.org/10.3393/ac.2024.00227.0032

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Abstract PDF Supplementary Material: Purpose
Colorectal cancer (CRC) is the most common malignancy of the gastrointestinal system globally. Identifying specific gene expression patterns indicative of early-stage CRC could enable early diagnosis and rapid treatment initiation. Matrix metalloproteinases (MMPs) play crucial roles in extracellular matrix degradation and tissue remodeling. Among them, MMP-2 and MMP-9 have been found to be upregulated in various cancers, including CRC, and are associated with tumor invasion, metastasis, and angiogenesis. In contrast, a disintegrin and metalloproteinase like decysin 1 (ADAMDEC1) is a relatively newly discovered gene with demonstrated involvement in immune response and inflammation. This study investigated serum levels of MMP-2 and MMP-9, along with tissue expression of MMP-2, MMP-9, and ADAMDEC1, and explored potential associations with pathological and clinical factors in patients with CRC.
Methods
This study included 100 patients with CRC and 100 control participants. Tissue and blood samples were collected. Serum MMP-2 and MMP-9 levels were analyzed using the enzyme-linked immunosorbent assay. Quantitative real-time polymerase chain reaction was employed to assess the expression levels of MMP-2, MMP-9, and ADAMDEC1 in CRC tissue samples compared to adjacent control tissue.
Results
The expression levels of MMP-2, MMP-9, and ADAMDEC1 were significantly upregulated in CRC relative to adjacent control tissues. Analysis of clinicopathological features revealed statistically significant differences in the expression levels of MMP-2, MMP-9, and ADAMDEC1 between patients with CRC with and without lymphovascular invasion (P<0.001). Based on receiver operating characteristic curve analysis, these genes represent promising candidate diagnostic biomarkers for CRC.
Conclusion
MMP-2, MMP-9, and ADAMDEC1 levels may serve as potential diagnostic biomarkers for CRC.

Anorectal benign disease

A comparative study on efficacy and safety of modified partial stapled hemorrhoidopexy versus conventional hemorrhoidectomy: a prospective randomized controlled trial: Tae Gyu Kim, Chul Seung Lee, Dong Geun Lee, Choon Sik Chung, Seung Han Kim, Sang Hwa Yu, Jeong Eun Lee, Gwan Cheol Lee, Dong Woo Kang, Jeong Sub Kim, Gyu Young Jeong; Ann Coloproctol. 2025;41(2):145-153. Published online April 28, 2025; DOI: https://doi.org/10.3393/ac.2024.00535.0076

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Abstract PDF Supplementary Material: Purpose
The long-term outcomes and efficacy of partial stapled hemorrhoidopexy (PSH) compared with those of conventional hemorrhoidectomy (CH) are not fully understood. This study aimed to introduce a modified PSH (mPSH) and compare its clinical efficacy and safety with those of CH.
Methods
A prospective randomized controlled trial was conducted. This study was performed at a single hospital and involved 6 colorectal surgeons. In total, 110 patients were enrolled between July 2019 and September 2020. Patients were randomly assigned to undergo either mPSH group (n=55) or CH group (n=55). The primary outcome was to compare postoperative average pain and postoperative peak pain using visual analog scale score between the 2 groups.
Results
The required duration of analgesia was shorter in the mPSH group than in the CH group, although the difference was not statistically significant (P=0.096). However, the laxative requirement duration (P<0.010), return to work (P<0.010), satisfaction score (P<0.010), and Vaizey score (P=0.014) were significantly better in the mPSH group. The average and peak postoperative pain scores were significantly lower in the mPSH group during the 15 days after surgery (P<0.001). The overall complication rate in both groups was 9.1%, with no significant difference between the groups (P=0.867).
Conclusion
The mPSH group demonstrated better improvement in symptoms, lower pain scores, and greater patient early satisfaction after surgery than the CH group. Therefore, this surgical technique appears to be a safe and effective alternative for CH.

Minimally invasive surgery

Impact of single-port laparoscopic approach on scar assessment by patients and observers: a multicenter retrospective study: Sung Uk Bae, Kyeong Eui Kim, Chang-Woo Kim, Ji-Hoon Kim, Woon Kyung Jeong, Yoon-Suk Lee, Seong Kyu Baek, Suk-Hwan Lee, Jun-Gi Kim; Ann Coloproctol. 2025;41(2):154-161. Published online April 29, 2025; DOI: https://doi.org/10.3393/ac.2024.00563.0080

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Abstract PDF: Purpose
This study aimed to compare the wound cosmesis of a single-incision approach on scar assessment after laparoscopic surgery for colon cancer.
Methods
This study included 32 patients undergoing single-port laparoscopic surgery (SPLS) and 61 patients undergoing multiport laparoscopic surgery (MPLS) for colon cancer at 3 tertiary referral hospitals between September 2011 and December 2019. We modified and applied the Korean version of the Patient and Observer Scar Assessment Scale (POSAS) to assess cosmetic outcomes. To assess the interobserver reliability using intraclass correlation coefficient values for the Observer Scar Assessment Scale (OSAS), the surgeons evaluated 5 images of postoperative scars.
Results
No significant differences were observed in the time before the return of normal bowel function, time to sips of water and soft diet initiation, length of in-hospital stay, and postoperative complication rate. The SPLS group had a shorter total incision length than the MPLS group. The POSAS favored the SPLS approach, revealing significant differences in the Patient Scar Assessment Scale (PSAS), OSAS, and overall scores. The SPLS approach was an independent factor influencing the POSAS, PSAS, and OSAS scores. Eleven colorectal surgeons had a significantly substantial intraclass coefficient.
Conclusion
The cosmetic outcomes of SPLS as assessed by the patients and surgeons were superior to those of MPLS in colon cancer. Reducing the number of ports is an independent factor affecting scar assessment by patients and observers.

Minimally invasive surgery

Minimally invasive transanal excision for rectal tumors: technical feasibility compared to conventional approach: Ji Yeon Mun, Gyu Sung Geong, Nina Yoo, Hyung Jin Kim, Hyeon-Min Cho, Bong-Hyeon Kye; Ann Coloproctol. 2025;41(2):162-168. Published online April 29, 2025; DOI: https://doi.org/10.3393/ac.2024.00864.0123

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Graphical Abstract Abstract PDF Supplementary Material: Purpose
The technique for transanal resection of rectal tumors has evolved from conventional methods to minimally invasive approaches. However, the research comparing long-term results between these approaches is limited.
Methods
Between 2016 and 2022, a total of 133 patients who underwent transanal excision were analyzed. Patients were classified into 2 groups according to surgical approach: conventional transanal approach (CTA) and minimally invasive transanal approach (MTA). Medical records were analyzed to compare surgical and oncological outcomes between the 2 groups.
Results
There were no significant differences observed in patient’s demographics and tumor characteristics, except the MTA group exhibited a statistically longer distance from the anal verge. Although statistical significance was not reached, the MTA group demonstrated a 100% margin-negative rate in contrast to the CTA group, which had worse outcomes for both margin status and fragmentation. Recurrence was observed only in the CTA group containing pT1 rectal cancer and grade 1 neuroendocrine tumor, with negative margins and no fragmentation.
Conclusion
The minimally invasive approach did not demonstrate statistical superiority but showed technical feasibility through the absence of margin-positive cases and the use of the clip handle method. Further studies are needed to validate these findings and assess broader applicability.

Video

CRC

Yellow enhancement imaging facilitates identification of surgical planes and key structures during challenging high anterior resection in a patient with obesity: Harpreet Singh, Reuben Suherman, Frederick H. Koh; Ann Coloproctol. 2025;41(2):169-172. Published online April 14, 2025; DOI: https://doi.org/10.3393/ac.2024.00465.0066

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