Annals of Coloproctology

Reviews

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.

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.

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.

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.

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.

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.

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.

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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PDF

Original Article

Anorectal benign disease

Immediate sphincter repair following fistulotomy for anal fistula: does it impact the healing rate and septic complications?: Maher A. Abbas, Anna T. Tsay, Mohammad Abbass; Ann Coloproctol. 2024;40(3):217-224. Published online June 28, 2024; DOI: https://doi.org/10.3393/ac.2022.01144.0163

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Abstract PDF: Purpose
Fistulotomy is considered the most effective treatment for anal fistula; however, it carries a risk of incontinence. Sphincteroplasty in the setting of fistulotomy is not standard practice due to concerns regarding healing and potential infectious complications. We aimed to compare the outcomes of patients who underwent fistulotomy with primary sphincteroplasty to those who did not undergo repair.
Methods
This was a retrospective review of consecutive patients who underwent fistulotomy for cryptoglandular anal fistula. All operations were performed by one colorectal surgeon. Sphincteroplasty was performed for patients perceived to be at higher risk for continence disturbance. The main outcome measures were the healing rate and postoperative septic complications.
Results
In total, 152 patients were analyzed. Group A (fistulotomy with sphincteroplasty) consisted of 45 patients and group B (fistulotomy alone) included 107 patients. Both groups were similar in age (P=0.16) and sex (P=0.20). Group A had higher proportions of multiple fistulas (26.7% vs. 6.5%, P<0.01) and complex fistulas (mid to high transsphincteric, 37.8% vs. 10.3%; P<0.01) than group B. The median follow-up time was 8 weeks. The overall healing rate was similar in both groups (93.3% vs. 90.6%, P=0.76). No significant difference between the 2 groups was noted in septic complications (6.7% vs. 3.7%, P=0.42).
Conclusion
Fistulotomy with primary sphincter repair demonstrated a comparable healing rate to fistulotomy alone, without an increased risk of postoperative septic complications. Further prospective randomized studies are needed to confirm these findings and to explore the functional outcomes of patients who undergo sphincteroplasty.

Technical Note

Technical tips

Transvaginal removal of rectal stromal tumor with Martius flap interposition: a feasible option for a large tumor at the anterior wall of the rectum: Weerapat Suwanthanma, Ploybutsara Kittiwetsakun, Samart Phuwapraisirisan, Pitichote Hiranyatheb; Ann Coloproctol. 2024;40(3):276-281. Published online June 26, 2024; DOI: https://doi.org/10.3393/ac.2023.00556.0079

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Abstract PDF: Neoadjuvant imatinib treatment, followed by complete transvaginal removal, presents a feasible option for large rectal gastrointestinal tumors located on the anterior wall of the rectum and protruding into the vagina. The use of Martius flap interposition is convenient and can be employed to prevent rectovaginal fistula.

Original Articles

Colorectal cancer

Obstructing colorectal cancer: a population-based review of colonic stenting in Queensland, Australia: Cian Keogh, Julie Moore, Danica Cossio, Nick Smith, David A. Clark; Ann Coloproctol. 2024;40(3):268-275. Published online June 25, 2024; DOI: https://doi.org/10.3393/ac.2023.00640.0091

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Abstract PDF: Purpose
Stenting is a useful treatment option for malignant colonic obstruction, but its role remains unclear. This study was designed to establish how stents have been used in Queensland, Australia, and to review outcomes.
Methods
Patients diagnosed with colorectal cancer in Queensland from January 1, 2008, to December 31, 2014, who underwent colonic stent insertion were reviewed. Primary outcomes of 5-year survival, 30-day mortality, and overall length of survival were calculated. The secondary outcomes included patient and tumor factors, and stoma rates.
Results
In total, 319 patients were included, and distant metastases were identified in 183 patients (57.4%). The 30-day mortality rate was 6.6% (n=21), and the 5-year survival was 11.9% (n=38). Median survival was 11 months (interquartile range, 4–27 months). A further operation (hazard ratio [HR], 0.19; P<0.001) and chemotherapy and/or radiotherapy (HR, 0.718; P=0.046) reduced the risk of 5-year mortality. The presence of distant metastases (HR, 2.052; P<0.001) and a comorbidity score of 3 or more (HR, 1.572; P=0.20) increased mortality. Surgery was associated with a reduced risk of mortality even in patients with metastatic disease (HR, 0.14; P<0.001). Twenty-two patients (6.9%) ended the study period with a stoma.
Conclusion
Colorectal stenting was used in Queensland in several diverse scenarios, in both localized and metastatic disease. Surgery had a survival advantage, even in patients with metastatic disease. There was no survival difference according to whether patients were socioeconomically disadvantaged, diagnosed in a major city or not, or treated at private or public hospitals. Stenting proved a valid treatment option with low stoma rates.

Anorectal benign disease

Long-term outcomes of sacral neuromodulation for low anterior resection syndrome after rectal cancer surgery: Mario J. de Miguel Valencia, Gabriel Marin, Ana Acevedo, Ana Hernando, Alfonso Álvarez, Fabiola Oteiza, Mario J. de Miguel Velasco; Ann Coloproctol. 2024;40(3):234-244. Published online June 25, 2024; DOI: https://doi.org/10.3393/ac.2023.00542.0077

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Abstract PDF: Purpose
This study assessed the long-term outcomes and quality of life in patients who underwent sacral neuromodulation (SNM) due to low anterior resection syndrome (LARS).
Methods
This single-center retrospective study, conducted from 2005 to 2021, included 30 patients (21 men; median age, 70 years) who had undergone total mesorectal excision with stoma closure and had no recurrence at inclusion. All patients were diagnosed with LARS refractory to conservative treatment. We evaluated clinical and quality-of-life outcomes after SNM through a stool diary, Wexner score, LARS score, the Fecal Incontinence Quality of Life (FIQL) questionnaire, and EuroQol-5D (EQ-5D) questionnaire.
Results
Peripheral nerve stimulation was successful in all but one patient. Of the 29 patients who underwent percutaneous nerve evaluation, 17 (58.62%) responded well to SNM and received permanent implants. The median follow-up period was 48 months (range, 18–153 months). The number of days per week with fecal incontinence episodes decreased from a median of 7 (range, 2–7) to 0.38 (range, 0–1). The median number of bowel movements recorded in patient diaries fell from 5 (range, 4–12) to 2 (range, 1–6). The median Wexner score decreased from 18 (range, 13–20) to 6 (range, 0–16), while the LARS score declined from 38.5 (range, 37–42) to 19 (range, 4–28). The FIQL and EQ-5D questionnaires demonstrated enhanced quality of life.
Conclusion
SNM may benefit patients diagnosed with LARS following rectal cancer surgery when conservative options have failed, and the treatment outcomes may possess long-term sustainability.

Colorectal cancer

Lymphovascular invasion in colorectal cancers: can we predict it preoperatively?: Elbrus Zarbaliyev, Nihan Turhan, Sebahattin Çelik, Mehmet Çağlıkülekçi; Ann Coloproctol. 2024;40(3):245-252. Published online June 25, 2024; DOI: https://doi.org/10.3393/ac.2023.00458.0065

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Abstract PDF: Purpose
This study aimed to investigate preoperative predictors of lymphovascular invasion (LVI), which is a poor prognostic factor usually detected postoperatively in patients with colorectal cancer.
Methods
Results for all patients operated on for colorectal cancer between January 1, 2006, and December 31, 2021, were retrospectively analyzed. Potential preoperative factors and postoperative pathology results were recorded. The patients were categorized as those with LVI and those without LVI. Potential factors that may be associated with LVI were compared between the 2 groups.
Results
The study included 335 patients. The incidence of LVI was 3.11 times higher in patients with ascending colon tumors (odds ratio [OR], 3.11; 95% confidence interval [CI], 1.34–7.23; P=0.008) and 4.28 times higher in those with metastatic tumors (OR, 4.28; 95% CI, 2.18–8.39; P<0.001). Diabetes mellitus was inversely related to LVI in colorectal cancer patients; specifically, LVI was 56% less common in colorectal cancer patients with diabetes mellitus, irrespective of its duration (OR, 0.44; 95% CI, 0.25–0.76; P<0.001).
Conclusion
The presence of preoperative LVI in colorectal cancer patients is difficult to predict. In particular, the effect of the effect of factors such as chronic disease accompanied by microvascular pathologies on LVI is still unclear. Advances in the neoadjuvant treatment of colorectal cancer patients, who are becoming more widespread every day, will encourage the investigation of different methods of preoperatively predicting LVI as a poor prognostic factor in these patients.

Video

Video clip

Cranial-first approach for laparoscopic extended right hemicolectomy: Kyong-Min Kang, Heung-Kwon Oh, Hong-Min Ahn, Tae-Gyun Lee, Hye-Rim Shin, Mi-Jeong Choi, Duck-Woo Kim, Sung-Bum Kang; Ann Coloproctol. 2024;40(3):282-284. Published online June 19, 2024; DOI: https://doi.org/10.3393/ac.2023.00661.0094

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Abstract PDF Supplementary Material: Complete mesocolic excision and central vascular ligation with D3 lymphadenectomy are important surgical principles for improving oncological outcomes in colon cancer. The cranial-first approach is a colonic mobilization–first approach to radical right hemicolectomy, which has several advantages, including early feasibility assessment, safe dissection from surrounding organs, preestablished inferior margin of lymph node dissection, and revelation of the tangible anatomy of the tributaries of the gastrocolic trunk. This video demonstrates the cranial-first approach to radical right hemicolectomy in a 66-year-old man with locally advanced cecal cancer.

Original Article

Minimally invasive surgery

Preoperative localization of potentially invisible colonic lesions on the laparoscopic operation field: using autologous blood tattooing: Ji Yeon Mun, Hyunjoon An, Ri Na Yoo, Hyeon-Min Cho, Bong-Hyeon Kye; Ann Coloproctol. 2024;40(3):225-233. Published online June 19, 2024; DOI: https://doi.org/10.3393/ac.2023.00059.0008

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Graphical Abstract Abstract PDF: Purpose
Preoperative colonoscopic (POC) localization is recommended for patients scheduled for elective laparoscopic colectomy for early colon cancer. Among the various localization method, POC tattooing localization has been widely used. Several dyes have been used for tattooing, but dye has disadvantages, including foreign body reactions. For this reason, we have used autologous blood tattooing for POC localization. This study aimed to evaluate the safety and efficacy of the autologous blood tattooing method.
Methods
This study included patients who required POC localization of the colonic neoplasm among the patients who were scheduled for elective colon resection. The indication for localization was early colon cancer (clinically T1 or T2) or colonic neoplasms that could not be resected endoscopically. POC autologous blood tattooing was performed after saline injection, and 2 hemoclips were applied.
Results
A total of 45 patients who underwent autologous blood tattooing and laparoscopic colectomy were included in this study. All POC localization sites were visible in the laparoscopic view. POC localization sites showed almost perfect agreement with intraoperative surgical findings. There were no complications like bowel perforation, peritonitis, hemoperitoneum, and mesenteric hematoma.
Conclusion
Autologous blood is a safe and effective agent for localizing materials that can replace previous dyes. However, a large prospective case-control study is required for the routine application of this procedure in early colon cancer or colonic neoplasms.

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