Annals of Coloproctology

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Review

Anorectal benign disease

Pharmacotherapy for fecal incontinence: potential treatment with a traditional Japanese medicine Kampo: Kotaro Maeda, Toshinobu Sasaki, Tomohisa Hattori; Ann Coloproctol. 2025;41(5):369-378. Published online October 23, 2025; DOI: https://doi.org/10.3393/ac.2025.00283.0040

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Abstract PDF: Fecal incontinence (FI) significantly impairs patient quality of life and creates substantial distress not only for affected individuals but also for nurses and caregivers. The prevalence of FI among older adults is estimated at up to 20%, although the sensitive nature of the condition often prevents active reporting by patients. This article reviews risk factors and pharmacotherapies for FI, emphasizing the therapeutic potential of Daikenchuto (DKT). The etiology of FI is multifactorial and lacks a singular definition. Currently, no prescription drugs specifically approved for FI are available, leaving treatment options limited. Nonetheless, major clinical guidelines have identified several viable pharmacological approaches. Strongly recommended treatments include the antidiarrheal agent loperamide and stool bulking or solidifying agents, such as dietary fiber and polycarbophil. Other therapeutic options include ramosetron, a 5-HT3 receptor antagonist; amitriptyline, a tricyclic antidepressant; and sodium valproate and diazepam, which are GABAergic neuromodulators. Recently, research has explored the efficacy and mechanism of action of DKT, a traditional Japanese medicine Kampo. Historically used for abdominal symptoms like bloating and known for promoting intestinal motility, emerging evidence suggests DKT may also effectively manage FI.

Original Articles

Minimally invasive surgery

Propensity score–matched comparison of robot-assisted rectal cancer surgery using hinotori and da Vinci: Hidetoshi Katsuno, Koji Morohara, Tomoyoshi Endo, Kenji Kikuchi, Kenichi Nakamura, Kazuhiro Matsuo, Takahiko Higashiguchi, Tetsuya Koide, Hiromi Kanai, Satoshi Arakawa, Tsunekazu Hanai, Zenichi Morise; Ann Coloproctol. 2025;41(4):310-318. Published online August 25, 2025; DOI: https://doi.org/10.3393/ac.2025.00136.0019

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Graphical Abstract Abstract PDF

Purpose
The hinotori Surgical Robot System (hereafter “hinotori”) is a novel platform for robot-assisted surgery, while the da Vinci Surgical System (“da Vinci”) remains the field standard. This study compared short-term surgical outcomes of rectal cancer surgery between these systems using propensity score–matched analysis.
Methods
A retrospective analysis was conducted of 209 consecutive patients who underwent robot-assisted surgery with the da Vinci and 58 patients with the hinotori system. After 2:1 propensity score matching, 108 da Vinci and 54 hinotori cases were included. Surgical outcomes, including operative time, blood loss, postoperative complications, length of hospital stay, and pathological findings, were compared.
Results
After matching, the baseline demographics were well balanced between groups. The hinotori system was associated with significantly longer operative time (266 minutes vs. 227 minutes, P=0.014) and console time (156 minutes vs. 110 minutes, P=0.001). However, estimated blood loss and postoperative complication rate did not differ significantly. Pathological findings, including the number of lymph nodes retrieved and the incidence of positive surgical margins, were comparable between systems.
Conclusion
In rectal surgery, the hinotori system demonstrates comparable short-term safety outcomes to da Vinci. Despite longer operative times and limited integrated instrumentation, hinotori‐assisted procedures may be feasible in selected patients. Further research should address long-term oncological outcomes and strategies to improve procedural efficiency.

Citations

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Racing toward the future of robot-assisted rectal cancer surgery: a comparative study of hinotori and da Vinci
Sung Uk Bae
Annals of Coloproctology.2025; 41(4): 259. CrossRef

Anorectal benign disease

Validation of a novel imaging-guided and anatomy-based classification system for anorectal fistulas: a retrospective clinical evaluation study: Antonio Brillantino, Francesca Iacobellis, Luigi Marano, Adolfo Renzi, Pasquale Talento, Luigi Brusciano, Claudio Gambardella, Umberto Favetta, Michele Schiano Di Visconte, Luigi Monaco, Maurizio Grillo, Mauro Natale Maglio, Fabrizio Foroni, Alessio Palumbo, Maria Laura Sandoval Sotelo, Luciano Vicenzo, Elisa Palladino, Giovanna Frezza, Maria Paola Menna, Paolino Mauro, Stefano Picardi, Mario Massimo Mensorio, Vinicio Mosca, Vincenzo Bottino, Giovanna Ioia, Corrado Rispoli, Marco Di Serafino, Martina Caruso, Roberto Ronza, Barbara Frittoli, Daria Schettini, Luca Stoppino, Franco Iafrate, Giulio Lombardi, Carmine Antropoli, Salvatore Cappabianca, Ludovico Docimo, Roberto Grassi, Alfonso Reginelli; Ann Coloproctol. 2025;41(3):207-220. Published online June 16, 2025; DOI: https://doi.org/10.3393/ac.2024.00675.0096

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Graphical Abstract Abstract PDF: Purpose
This study was conducted to evaluate the validity of a new imaging-guided, anatomy-based classification of anorectal fistulas in defining disease severity and predicting surgical outcomes.
Methods
This multicenter, retrospective cohort study analyzed data from patients with perianal fistulas who underwent surgery between 2017 and 2023. All patients underwent preoperative 3-dimensional endoanal ultrasound, with adjunctive magnetic resonance imaging performed if ultrasound indicated a complex fistula. Imaging examinations were retrospectively evaluated to categorize fistulas according to the Garg classification and the newly proposed classification system. The new classification included 6 severity grades based on the characteristics of the primary tract: submucosal, intersphincteric, low transsphincteric, high transsphincteric, multiple, and suprasphincteric/extrasphincteric. Each grade was further subdivided into 3 subtypes (A, B, C) based on the extension of secondary tracts.
Results
When compared with the new classification, the Garg classification demonstrated a slightly lower ability to predict the feasibility of fistulotomy in simple fistulas (94.2% vs 99.1%; Fisher exact test, P=0.006). A strong positive correlation was found between the surgery failure rate and the severity grade of the new classification (Spearman rho, 0.90; P<0.001), whereas the Garg classification showed a nonsignificant positive correlation with surgical failure rate (Spearman rho, 0.90; P=0.08).
Conclusion
The new imaging-guided, anatomy-based classification of anorectal fistulas demonstrates high accuracy in defining disease severity. It represents a valuable tool for preoperative grading of anal fistulas, standardizing the reporting of diagnostic imaging, and improving the communication of findings among healthcare professionals.

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.

Citations

Citations to this article as recorded by

Minimally invasive transanal excision over conventional transanal excision: pursuing the perfect removal of early rectal cancer
HyungJoo Baik
Annals of Coloproctology.2025; 41(2): 105. CrossRef

Anorectal benign disease

Antibiotic use during the first episode of acute perianal sepsis: a still-open question: Stanislas Blondin, David Lobo, Axel Egal, Saliha Ysmail-Dahlouk, Milad Taouk, Josée Bourguignon, David Blondeel, Isabelle Etienney; Ann Coloproctol. 2025;41(1):40-46. Published online February 3, 2025; DOI: https://doi.org/10.3393/ac.2024.00472.0067

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Abstract PDF: Purpose
The role of antibiotics in preventing fistula formation following an initial abscess remains a subject of debate. This study compared the incidence of fistula in ano in patients experiencing their first episode of acute perianal sepsis, with and without antibiotic therapy, and evaluated the prevalence of fistula in ano necessitating surgical intervention at 1 year.
Methods
This retrospective cohort study was conducted at a tertiary care hospital with a dedicated proctology department. All patients who presented to the emergency proctology unit with a first episode of acute perianal sepsis were eligible for inclusion.
Results
This study included 276 patients. At 1 year, fistula formation was identified in 65.6% of all patients, 54.0% of those who had received antibiotics, and 75.0% of those who had not (P<0.001). This finding remained significant after weighted propensity analysis (odds ratio, 0.53; 95% confidence interval, 0.31–0.92; P=0.025).
Conclusion
The rate of fistula formation was relatively high in this study. However, it was lower among patients with perianal sepsis who were treated with antibiotics, although a causal relationship could not be established. Prolonged follow-up is needed to clarify the role of antibiotic therapy in preventing or delaying fistula development in patients with acute perianal sepsis.

Anorectal benign disease

Ligation of the intersphincteric fistula tract (LIFT) for high transsphincteric fistulas: a double-center retrospective study with long-term follow-up: Leichang Zhang, Chuanyu Zhan, Lu Li, Wanjin Shao, Guidong Sun, Yugen Chen, Guanghua Chen, Yulei Lang, Zenghua Xiao, Xiao Xiao; Ann Coloproctol. 2025;41(1):77-83. Published online January 17, 2025; DOI: https://doi.org/10.3393/ac.2024.00024.0003

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Abstract PDF: Purpose
This study aimed to evaluate the long-term efficacy of the ligation of the intersphincteric fistula tract (LIFT) procedure in treating high transsphincteric fistulas.
Methods
We conducted a retrospective study to evaluate the success rate of LIFT treatment in 82 patients with high transsphincteric fistulas involving at least one-third of the external sphincter. This study was carried out across 2 centers from November 2009 to February 2023.
Results
All patients underwent successful surgery with a median operative time of 48.9 minutes (range, 20–80 minutes), and no intraoperative or postoperative complications were reported. The median follow-up duration was 85.5 months (range, 4–120 months), with 5 patients (6.1%) lost to follow-up. Treatment was successful in 62 patients, whose symptoms disappeared and both the external opening and the intersphincteric incision completely healed, yielding an overall efficiency rate of 80.5%. There were 15 cases (19.5%) of treatment failure, including 6 (7.8%) that converted to intersphincteric anal fistula and 9 (11.7%) that experienced persistent or recurrent fistulas. Only 1 patient reported minor overflow during the postoperative follow-up, but no other patients reported any significant discomfort. There were no statistically significant differences between patients with surgical success and those with treatment failure in terms of fistula length, history of previous abscess or anal fistula surgery, number of external orifices or fistulas, and location of fistulas (all P>0.05).
Conclusion
LIFT is a safe and effective sphincter-preserving procedure that yields satisfactory healing outcomes and has minimal impact on anal function.

Technical Note

Anorectal benign disease

Botulinum injection technique to reduce spasms in refractory anal fissures and after anal fistula or hemorrhoid surgery: Pankaj Garg, Vipul D. Yagnik, Kaushik Bhattacharya; Ann Coloproctol. 2024;40(6):610-612. Published online December 2, 2024; DOI: https://doi.org/10.3393/ac.2023.00696.0099

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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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11 Citations

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