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Original Article
Anorectal benign disease
 Proctitis distal to colorectal anastomosis: a retrospective cohort study of an underreported complication after sigmoidectomy
Ajmal Khanorcid, Maziar Nikbergorcid, Kenneth Smedhorcid, Abbas Chabokorcid
Annals of Coloproctology 2024;40(5):498-505.
DOI: https://doi.org/10.3393/ac.2023.00675.0096
Published online: October 22, 2024

Colorectal Unit, Department of Surgery, Centre for Clinical Research Västmanland, Västmanland Hospital Västerås, Uppsala University, Västerås, Sweden

Correspondence to: Ajmal Khan, MD Colorectal Unit, Department of Surgery, Centre for Clinical Research Västmanland, Västmanland Hospital Västerås, Uppsala University, Ingång 29, Västerås 721 89, Sweden Email: ajmal.khan@regionstokcholm.se
• Received: September 29, 2023   • Revised: December 20, 2023   • Accepted: December 28, 2023

© 2024 The Korean Society of Coloproctology

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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  • Purpose
    Proctitis distal to colorectal anastomosis is rare and infrequently reported. We evaluated the incidence, symptoms, treatment, and potential risk factors associated with this condition.
  • Methods
    We conducted a retrospective population-based cohort study in Västmanland County, Sweden. This investigation included all patients who underwent sigmoidectomy with colorectal anastomosis between 2008 and 2020. We excluded patients without an anastomosis and those with inflammatory bowel disease.
  • Results
    Of the 546 patients identified, 233 fulfilled the inclusion criteria, of whom 26 (11.2%) developed proctitis distal to colorectal anastomosis. The most frequent symptoms included urgency (n=16, 61.5%), increased stool frequency (n=12, 46.2%), and anorectal pain (n=12, 46.2%). Endoscopic balloon dilation was performed in 20 cases (76.9%), with 10 requiring only a single therapeutic procedure. The median number of dilations was 3 (range, 1–8). Multivariable analysis revealed that surgery due to malignancy and emergency surgery were associated with elevated risk of proctitis. A subgroup analysis of patients who underwent surgery due to malignancy indicated that smoking (odds ratio, 3.9; 95% confidence interval, 1.1–14.0) and emergency surgery (odds ratio, 6.5; 95% confidence interval, 1.1–37.1) were also associated with increased proctitis risk.
  • Conclusion
    Proctitis distal to colorectal anastomosis is not uncommon following sigmoidectomy. Patients undergoing emergency surgery or surgery due to malignancy and who had a history of smoking displayed an increased risk of developing proctitis. Due to the paucity of symptoms observed, particularly in patients with a diverting stoma, routine endoscopic rectal examination should be performed during follow-up after sigmoidectomy.
  • Keywords: Proctitis; Sigmoidectomy; Colorectal anastomosis; Endoscopic balloon dilation
Sigmoidectomy is a common colorectal surgical procedure that involves the resection of the left side of the colon and/or the sigmoid colon, followed by the creation of an anastomosis between the remaining colon and the upper part of the rectum. In 2019, a total of 1,840 left-sided hemicolectomy and sigmoid colon resection procedures were performed in Sweden [1]. Surgery is commonly indicated for malignancies as well as benign conditions such as diverticular disease, inflammatory bowel disease (IBD), and trauma. Potential postoperative complications include infection, abscess formation, anastomotic leakage (AL), and anastomotic stricture [2, 3]. Of these, AL is particularly feared, with incidence rates ranging from 1% to 20% and consequences including prolonged hospitalization, increased morbidity, and elevated mortality [4]. The site of the colorectal anastomosis is important, as patients undergoing low anterior resection face a higher risk of anastomotic complications and experience worse bowel function than those with anastomoses located in the upper part of the rectum [5–10].
In the early 21st century, at the surgical unit of Västmanland Hospital Västerås (Västerås, Sweden), we observed that a subset of patients developed an inflammatory condition in the rectum following sigmoidectomy. This condition typically presented with varying degrees of rectal narrowing or stricture, hereinafter referred to as proctitis, situated distal to an unaffected colorectal anastomosis after sigmoidectomy. Consequently, we endorsed routine endoscopic examination during the 30-day postoperative follow-up visit. To our knowledge, the literature includes only 1 case of proctitis distal to colorectal anastomosis following sigmoidectomy [11]. Given this context, the present study was conducted to evaluate the incidence, symptoms, treatment, and risk factors associated with proctitis distal to colorectal anastomosis after sigmoidectomy.
Ethics statement
This study was approved by the Ethics Committee of the Faculty of Medicine at Uppsala University (No. D.nr 2021-01760/). Informed consent was waived due to the retrospective nature of the study. The study was carried out in accordance with the principles of the Declaration of Helsinki.
Study setting and design
This population-based cohort study included all patients who underwent sigmoidectomy for malignancy or diverticulitis at the surgical department of Västmanland Hospital Västerås between January 1, 2008, and December 31, 2020. Västmanland Hospital Västerås provides medical services to a catchment area with a population of approximately 270,000.
All patients were identified using the Orbit Surgical Database ver. 5.11.3 (Tietoevry Corp) by applying the following specific intervention codes: JGB03/JGB04, indicating high anterior resection; JFB54/JFB54, denoting sigmoid colon resection/sigmoidectomy; and JFB43/JFB54, representing extended left hemicolectomy. The inclusion criteria specified that patients must have undergone high anterior resection/sigmoidectomy or extended left hemicolectomy—collectively referred to as sigmoidectomy in the present article—with anastomosis between the colon and the rectosigmoid junction or the upper rectum, defined as more than 10 cm above the anal verge. Individuals with IBD were excluded. Data from the preoperative, perioperative, and postoperative periods were gathered through a manual review of the hospital records for all study participants. Surgical complications were classified according to the Clavien-Dindo system, with the exclusion of complications typically associated with the panorama of proctitis.
Proctitis was defined as endoscopic evidence of rectal inflammation or rectal stricture occurring distal to colorectal anastomosis following sigmoidectomy, in the absence of any other plausible cause. The initial endoscopic evaluation was routinely conducted at 1 month postoperatively. However, in certain instances, an earlier endoscopic assessment was warranted due to early symptom presentation.
Statistical analysis
Continuous data were presented as means with standard deviations or as medians with ranges. Categorical data were compared using the chi-square test or the Fisher exact test. To identify potential risk factors for proctitis within the study cohort, univariable and multivariable logistic regression analyses were conducted, with adjustments made for confounders. To account for the small number of patients with proctitis and to mitigate the risk of overfitting in the multivariable analysis, an additional analysis was performed that included the following variables: age, smoking status, presence of malignancy, and type of surgery (emergency or elective). Given the heterogeneity of the full cohort, which included both patients with diverticulitis and those with malignancy, a subgroup analysis was also performed. This was focused on identifying potential risk factors in patients who underwent surgery for malignancy, and it was adjusted for age, emergency or elective surgery, sex, smoking status, and the American Society of Anesthesiologists (ASA) physical status. All statistical tests were 2-sided, and a P-value of less than 0.05 was considered to indicate statistical significance. Statistical analyses were performed using IBM SPSS ver. 27 (IBM Corp).
Study population
For this study, 546 patients were initially identified. Following assessment, 313 patients, representing 57.3% of the sample, were excluded for several reasons: low anterior resection (112 patients), IBD (6 patients), absence of anastomosis (165 patients), and incomplete patient records or loss to follow-up (30 patients). The remaining 233 patients constituted the study cohort (Fig. 1).
Of the 233 included patients, 51.9% were male, and the median age was 66 years (range, 34–87 years). Most patients (n=149, 63.9%) had an ASA grade II. The most common comorbidities were hypertension (n=111, 47.6%), diabetes mellitus (n=18, 7.7%), and atrial flutter (n=13, 5.6%). Active smoking was reported in 34 patients (14.6%), as shown in Table 1. Patients with and without proctitis demonstrated comparable baseline characteristics (Table 1). Central ligation of the inferior mesenteric artery was performed in 169 patients (72.5%). The most frequent indication for surgery was malignancy, presented in 164 patients (70.4%). All patients undergoing surgery for malignancy received perioperative rectal irrigation with saline and chlorhexidine. This practice was also applied in 6 patients (8.7%) with diverticulitis. Most of the procedures within the full cohort (n=213, 91.4%) were performed on an elective basis.
Overall, 26 patients (11.2%) developed proctitis distal to the site of colorectal anastomosis. Among these patients, 24 (92.3%) had undergone surgery for malignancy and the remainder for diverticulitis. Among all patients who underwent surgery for diverticulitis, 6 had received perioperative rectal irrigation, none of whom experienced proctitis. In the malignancy subgroup, emergency surgery was performed in 10 cases (38.5%), and 5 (50%) of the patients developed proctitis. The corresponding proportions in the diverticulitis group were 14.5% (n=10) and 20.0% (n=2), respectively.
In the study cohort, the overall incidence of AL was 3.9%, with no observed difference between patients with proctitis and those without the condition. However, anastomotic stenosis was significantly more common among those with proctitis (P=0.003) (Table 2). Additionally, patients with proctitis exhibited significantly higher levels of postoperative inflammatory markers, namely C-reactive peptide levels on postoperative days 2, 3, 4, and 5 along with significantly elevated white blood cell counts on days 2 and 3 (Fig. 2).
Symptoms and endoscopic findings
The most frequently observed specific symptoms in patients who developed proctitis distal to colorectal anastomosis included stool urgency, reported by 16 patients (61.5%), followed by increased stool frequency and anorectal pain, each reported by 12 patients (46.2%). The median time from surgery to the presentation of symptoms was 26 days (range, 8–49 days). Among 8 patients with diverting stoma, only 1 reported symptoms, specifically lower abdominal pain. Consequently, proctitis in this patient subgroup was identified during routine endoscopic examination at the outpatient clinic (Table 3).
Table 3 summarizes the endoscopic findings in patients with proctitis. The most frequent observations were noncircumferential mucosal inflammation, present in 10 cases (38.5%), and circumferential inflammation, found in 12 patients (46.2%) (Fig. 3). In contrast, the most severe finding—mucosal ulceration—was observed in 4 patients (15.4%). Narrowing of the rectal lumen was noted in 24 patients (92.3%); of these patients, 13 (54.2%) had strictures so pronounced that a flexible endoscope with a 12-mm diameter could not be passed. Biopsies were taken from the rectal stricture in 3 patients, predominantly revealing granulation tissue.
Treatment
Various treatment strategies were employed, including endoscopic balloon dilation of proctitis strictures distal to the colorectal anastomosis, as well as pharmacological interventions such as mesalamine or prednisolone suppositories and various laxatives. At the initial follow-up appointment, which occurred 4 weeks after surgery, 3 patients exhibited strictures already necessitating treatment with endoscopic balloon dilation. Overall, 20 patients (77% of those with proctitis) underwent endoscopic balloon dilation, and in 10 (50%) of the patients, this procedure represented both the first-line treatment and the sole treatment approach needed. The median number of dilations required was 3 (range, 1–8). While medical treatments were commonly combined with endoscopic balloon dilation, mesalamine and laxatives were administered as standalone therapies in 1 and 3 cases, respectively. One patient underwent rectal resection with permanent colostomy due to treatment failure.
Risk factors for developing proctitis
In univariable analyses, both malignancy (odds ratio [OR], 5.7; 95% confidence interval [CI], 1.3–25.0; P=0.020) and emergency surgery (OR, 5.5; 95% CI, 2.0–15.4; P=0.001) were significantly associated with the development of proctitis distal to colorectal anastomosis. Multivariable logistic regression analyses revealed that the occurrence of proctitis remained significantly associated with malignancy (OR, 10.0; 95% CI, 2.0–53.0; P=0.009) and emergency surgery (OR, 9.5; 95% CI, 2.6–34.0; P<0.001) (Table 4). After adjusting for potential overfitting—considering factors such as age, type of surgery (emergency or elective), underlying condition (malignancy or diverticulitis), and smoking status—both emergency surgery and malignancy continued to demonstrate significant associations with the development of proctitis.
Subgroup analysis
Since most of the cohort underwent surgery due to malignancy, a subgroup analysis was conducted to evaluate risk factors within this patient population. In both univariate and multivariate analyses, a history of smoking (OR, 3.9; 95% CI, 1.1–14.0; P=0.037) and the need for emergency surgery (OR, 6.5; 95% CI, 1.1–37.1; P=0.036) were independently associated with an increased risk of proctitis distal to colorectal anastomosis after sigmoidectomy.
This study highlights an underreported complication following sigmoidectomy with colorectal anastomosis. Our findings revealed that 11.2% of patients who underwent this procedure developed proctitis to varying degrees. The most frequently observed symptoms of proctitis after sigmoidectomy were anorectal pain, increased stool frequency, and urgency. The results indicate that in patients with a diverting stoma, a follow-up endoscopic examination is beneficial, as these patients may not exhibit defecatory symptoms despite having underlying proctitis that could exacerbate a rectal stricture. Endoscopic balloon dilation is a safe and effective treatment approach for most patients with proctitis with a concomitant rectal stricture. Additionally, emergency surgery and surgery for malignancy, particularly in patients with a history of smoking, displayed a significantly increased risk of developing proctitis distal to the colorectal anastomosis following sigmoidectomy.
Ischemic proctitis following sigmoidectomy is an uncommon complication, and to our knowledge, only 1 case has been reported [10]. In that instance, sigmoidectomy was performed with a colorectal anastomosis created 30 cm from the anal verge. No immediate complications were observed. However, 6 months postoperatively, the patient presented with anal pain and bloody stool, leading to a diagnosis of ischemic proctitis. The primary distinction between that case and our cohort is the level of the anastomosis. In our opinion, the anastomosis in the previous case report was colocolic, rather than colorectal. Furthermore, the onset of proctitis symptoms in our cohort occurred substantially earlier, with a median of 26 days compared to 6 months. Disruption of the rectal microcirculation may play a pivotal role in triggering this inflammatory condition, as this can be impacted by emergency surgery, smoking, and extensive surgery for malignancy (involving high ligation of the inferior mesenteric artery). Prior research has underscored increased cardiovascular burden as a recognized risk factor for ischemic bowel complications, including ischemic colitis [11, 12]. The use of rectal irrigation with chlorhexidine as a potential trigger of rectal proctitis is unlikely to account for the high incidence of proctitis in our cohort, given that patients with diverticulitis who did not undergo rectal washout also developed the condition [13].
In the literature, incidence rates of 3% to 30% have been reported for strictures in cases of colorectal anastomosis [14]; the corresponding rate in our cohort was 3.4%. However, among patients with proctitis distal to colorectal anastomosis, the rate of anastomotic stricture was 15.4%. This finding is likely attributable to the secondary effects of rectal inflammation or the same pathological process responsible for proctitis.
In line with prior research on the treatment of benign colorectal anastomotic strictures [15], endoscopic balloon dilation was found to be a safe and effective treatment for rectal stricture due to proctitis distal to colorectal anastomosis following sigmoidectomy.
To our knowledge, this is the first study with a large cohort to present this specific and underreported type of proctitis after sigmoidectomy. Nevertheless, several limitations must be acknowledged, including the retrospective nature of the study, its confinement to a single center, the impact of the COVID-19 pandemic on in-person follow-up appointments, variations in awareness of the condition among clinicians, and the small size of the diverticulitis cohort. Additionally, certain risk factors may have been unmeasured and therefore could not be adjusted for. Nonetheless, and although the small number of patients who developed proctitis might raise concerns about the strength of the statistical analysis, the adjusted analysis to prevent overfitting revealed consistent associations with those presented in Table 4.
Several factors contributed to the accuracy of this study, including the use of consistent surgical techniques, rigorous follow-up protocols involving endoscopy, and a thorough medical review of complications with few missing variables. At many institutions, surgeons do not routinely conduct follow-up postoperative endoscopic examinations of the rectum, which likely accounts for the underreporting of this condition. Additionally, the tendency of the stricture to heal spontaneously may offer another credible explanation for its underreporting.
The incidence of proctitis distal to colorectal anastomosis following sigmoidectomy was higher than anticipated prior to this study. Our findings reveal a significantly elevated risk of developing proctitis in patients who undergo emergency surgery or surgery for malignancy and have a history of smoking. These results support the recommendation for routine outpatient endoscopic examination after sigmoidectomy, to facilitate the early detection of proctitis. Such detection is crucial to prevent progression to stricture, especially in patients with a diverting stoma who may not exhibit symptoms.

Conflict of interest

No potential conflict of interest relevant to this article was reported.

Funding

This research was supported by grants from the County of Västmanland and the Uppsala-Örebro Regional Research Council, Sweden.

Author contributions

Conceptualization: all authors; Data curation: KA; Formal analysis: KA; Funding acquisition: KA, NM; Investigation: KA; Methodology: all authors; Supervision: AC; Project administration: KA; Visualization: KA; Writing–original draft: KA, NM, KS; Writing–review & editing: all authors. All authors read and approved the final manuscript.

Fig. 1.
Flowchart illustrating the recruitment process.
ac-2023-00675-0096f1.jpg
Fig. 2.
Comparison between patients with and without proctitis. (A) White blood cell (WBC) level. (B) C-reactive peptide (CRP) level. *P<0.05.
ac-2023-00675-0096f2.jpg
Fig. 3.
(A, B) Circumferent proctitis distal to the colorectal anastomosis in 2 patients.
ac-2023-00675-0096f3.jpg
Table 1.
Baseline characteristics of patients who underwent sigmoidectomy
Characteristic Total cohort (n=233) Proctitis P-value*
No (n=207, 88.8%) Yes (n=26, 11.2%)
Male sex 121 (51.9) 107 (51.7) 14 (53.8) 0.850
Age (yr) 66 (34–87) 66 (34–87) 66 (49–86) >0.999
ASA physical statusa 0.550
 I 39 (16.7) 35 (16.9) 4 (15.4)
 II 149 (63.9) 134 (64.7) 15 (57.7)
 III 37 (15.9) 31 (15.0) 6 (23.1)
Body mass index (kg/m2) 26 (18–56) 26 (18–56) 25 (18–41) 0.380
Hemoglobin (g/L) 134 (102–174) 134 (103–174) 134 (102–158) 0.350
Plasma albumin (g/L) 39.5 (27–48) 40 (27–48) 39 (32–47) 0.320
C-reactive peptide (mg/L) 4 (1–366) 4 (1–366) 3 (1–183) 0.380
White blood cells (×109/L) 7 (4–18) 7 (4–18) 8 (4–14) 0.130
Previous pelvic intervention >0.999
 Surgery 26 (11.2) 24 (11.6) 2 (7.7)
 Neoadjuvant therapy 10 (4.7) 10 (4.8) 0 (0)
 Radiation 8 (3.4) 8 (3.9) 0 (0)
Hypertension 111 (47.6) 96 (46.4) 15 (57.7) 0.270
Diabetes 18 (7.7) 14 (6.8) 4 (15.4) 0.120
Atrial flutter 13 (5.6) 12 (5.8) 1 (3.8) >0.999
Preoperative stoma 11 (4.7) 10 (4.8) 1 (3.8) >0.999
History of smokingb 0.280
 Yes 34 (14.6) 29 (14.0) 5 (19.2)
 No 189 (81.1) 169 (81.6) 20 (76.9)
 Ex-smoker 9 (3.9) 9 (4.4) 0 (0)

Values are presented as number (%) or median (range).

ASA, American Society of Anesthesiologists.

aThe sum of the values does not equal the total due to missing data. bThe sum for the with proctitis group does not equal the total due to missing data.

*P<0.05

Table 2.
Surgical details of patients who underwent sigmoidectomy
Variable Total cohort (n=233) Proctitis
 P-value
No (n=207, 88.8%) Yes (n=26, 11.2%)
Type of surgery 0.003*
 Emergency 20 (8.6) 13 (6.3) 7 (26.9)
 Elective 213 (91.4) 194 (93.7) 19 (73.1)
Cause of operation 0.023*
 Adenocarcinoma 164 (70.4) 140 (67.6) 24 (92.3)
 Diverticulitis 69 (29.6) 67 (32.4) 2 (7.7)
Surgical approach 0.080
 Open surgery 168 (72.1) 153 (73.9) 15 (57.7)
 Laparoscopy 65 (27.9) 54 (26.1) 11 (42.3)
Central ligation of inferior mesenteric artery 168 (74.0)a 147 (73.1)a 21 (80.8) 0.400
Duration of surgery (min) 241.5 (112–550) 230.5 (112–550) 269.5 (148–431) 0.150
Postoperative stoma 0.150
 New stoma 39 (16.7) 31 (15.0) 8 (30.8)
 Preserved preoperative stoma 8 (3.4) 8 (3.9) 0 (0)
Postoperative complicationb (Clavien-Dindo grade) 0.015
 I 26 (11.2) 24 (11.6) 2 (7.7) 0.560
 II 41 (17.6) 32 (15.5) 9 (34.6) 0.020*
 III 7 (3.0) 5 (2.4) 2 (7.7) 0.160
 IV 2 (0.9) 1 (0.5) 1 (3.8) 0.140
Surgical complication
 Anastomotic stenosis 8 (3.4) 4 (1.9) 4 (15.4) 0.003*
 Anastomotic leakage 9 (3.9) 8 (3.9) 1 (3.8) 0.990
Anastomosisc 0.370
 End-to-end 16 (6.9) 16 (7.7) 0 (0)
 Side-to-end 172 (73.8) 149 (72.0) 23 (88.5)
Blood transfusion received during hospital stay 9 (3.9) 7 (3.4) 2 (7.7) 0.330

Values are presented as number (%) or median (range).

aSix cases were missing.

bSymptoms related to proctitis were excluded from both analyses regarding postoperative complications.

cThe sum of the values does not equal the total due to missing data (the type of anastomosis was not recorded in certain cases).

*P<0.05.

Table 3.
Symptoms and endoscopic findings of patients with proctitis following sigmoidectomy
Variable Value (n=26)
Symptom
 Fecal incontinence 2 (7.7)
 Increased stool frequency 12 (46.2)
 Urgency 16 (61.5)
 Anorectal pain 12 (46.2)
Endoscopic finding
 Noncircumferent mucosal inflammation 10 (38.5)
 Circumferent mucosal inflammation 12 (46.2)
 Mucosal ulceration 4 (15.4)
 Distance of proctitis from the anal verge (cm) 9 (5–15)
 Distance of proctitis from anastomosis (cm) 2 (1–5)
 Impassable rectal stricturea 13 (50.0)

Values are presented as number (%) or median (range).

aPatients with severe rectal stricture through which a sigmoidoscope could not be passed.

Table 4.
Univariable and multivariable analysis on risk factors for the development of proctitis in patients who underwent sigmoidectomy due to malignancy or diverticulitis
Variable Univariable analysis Multivariable analysis
Crude OR (95% CI) P-value Adjusted OR (95% CI) P-value
Sex 0.840 0.930
 Female 1 1
 Male 1.1 (0.5–2.5) 1.0 (0.4–2.6)
Age (yr) 1.0 (0.9–1.1) 0.320 1.0 (0.9–1.1) 0.590
Cause of surgery 0.020* 0.009*
 Benign condition 1 1
 Malignancy 5.7 (1.3–25.0) 10.0 (2.0–53.0)
Type of surgery 0.001* <0.001*
 Elective 1 1
 Emergency 5.5 (2.0–15.4) 9.5 (2.6–34.0)
ASA physical status 0.280 0.776
 I, II 1 1
 ≥III 1.7 (0.6–4.7) 1.2 (0.4–3.9)
Smoking status 0.430 0.105
 No 1 1
 Yes 1.5 (0.5–4.4) 2.8 (0.8–9.6)

OR, odds ratio; CI, confidence interval; ASA, American Society of Anesthesiologists.

*P<0.05.

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        Proctitis distal to colorectal anastomosis: a retrospective cohort study of an underreported complication after sigmoidectomy
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        DOI: https://doi.org/10.3393/ac.2023.00675.0096
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      Proctitis distal to colorectal anastomosis: a retrospective cohort study of an underreported complication after sigmoidectomy
      Image Image Image
      Fig. 1. Flowchart illustrating the recruitment process.
      Fig. 2. Comparison between patients with and without proctitis. (A) White blood cell (WBC) level. (B) C-reactive peptide (CRP) level. *P<0.05.
      Fig. 3. (A, B) Circumferent proctitis distal to the colorectal anastomosis in 2 patients.

      Fig. 1.

      Fig. 2.

      Fig. 3.

      Proctitis distal to colorectal anastomosis: a retrospective cohort study of an underreported complication after sigmoidectomy
      Characteristic Total cohort (n=233) Proctitis P-value*
      No (n=207, 88.8%) Yes (n=26, 11.2%)
      Male sex 121 (51.9) 107 (51.7) 14 (53.8) 0.850
      Age (yr) 66 (34–87) 66 (34–87) 66 (49–86) >0.999
      ASA physical statusa 0.550
       I 39 (16.7) 35 (16.9) 4 (15.4)
       II 149 (63.9) 134 (64.7) 15 (57.7)
       III 37 (15.9) 31 (15.0) 6 (23.1)
      Body mass index (kg/m2) 26 (18–56) 26 (18–56) 25 (18–41) 0.380
      Hemoglobin (g/L) 134 (102–174) 134 (103–174) 134 (102–158) 0.350
      Plasma albumin (g/L) 39.5 (27–48) 40 (27–48) 39 (32–47) 0.320
      C-reactive peptide (mg/L) 4 (1–366) 4 (1–366) 3 (1–183) 0.380
      White blood cells (×109/L) 7 (4–18) 7 (4–18) 8 (4–14) 0.130
      Previous pelvic intervention >0.999
       Surgery 26 (11.2) 24 (11.6) 2 (7.7)
       Neoadjuvant therapy 10 (4.7) 10 (4.8) 0 (0)
       Radiation 8 (3.4) 8 (3.9) 0 (0)
      Hypertension 111 (47.6) 96 (46.4) 15 (57.7) 0.270
      Diabetes 18 (7.7) 14 (6.8) 4 (15.4) 0.120
      Atrial flutter 13 (5.6) 12 (5.8) 1 (3.8) >0.999
      Preoperative stoma 11 (4.7) 10 (4.8) 1 (3.8) >0.999
      History of smokingb 0.280
       Yes 34 (14.6) 29 (14.0) 5 (19.2)
       No 189 (81.1) 169 (81.6) 20 (76.9)
       Ex-smoker 9 (3.9) 9 (4.4) 0 (0)
      Variable Total cohort (n=233) Proctitis
      		 P-value
      No (n=207, 88.8%) Yes (n=26, 11.2%)
      Type of surgery 0.003*
       Emergency 20 (8.6) 13 (6.3) 7 (26.9)
       Elective 213 (91.4) 194 (93.7) 19 (73.1)
      Cause of operation 0.023*
       Adenocarcinoma 164 (70.4) 140 (67.6) 24 (92.3)
       Diverticulitis 69 (29.6) 67 (32.4) 2 (7.7)
      Surgical approach 0.080
       Open surgery 168 (72.1) 153 (73.9) 15 (57.7)
       Laparoscopy 65 (27.9) 54 (26.1) 11 (42.3)
      Central ligation of inferior mesenteric artery 168 (74.0)a 147 (73.1)a 21 (80.8) 0.400
      Duration of surgery (min) 241.5 (112–550) 230.5 (112–550) 269.5 (148–431) 0.150
      Postoperative stoma 0.150
       New stoma 39 (16.7) 31 (15.0) 8 (30.8)
       Preserved preoperative stoma 8 (3.4) 8 (3.9) 0 (0)
      Postoperative complicationb (Clavien-Dindo grade) 0.015
       I 26 (11.2) 24 (11.6) 2 (7.7) 0.560
       II 41 (17.6) 32 (15.5) 9 (34.6) 0.020*
       III 7 (3.0) 5 (2.4) 2 (7.7) 0.160
       IV 2 (0.9) 1 (0.5) 1 (3.8) 0.140
      Surgical complication
       Anastomotic stenosis 8 (3.4) 4 (1.9) 4 (15.4) 0.003*
       Anastomotic leakage 9 (3.9) 8 (3.9) 1 (3.8) 0.990
      Anastomosisc 0.370
       End-to-end 16 (6.9) 16 (7.7) 0 (0)
       Side-to-end 172 (73.8) 149 (72.0) 23 (88.5)
      Blood transfusion received during hospital stay 9 (3.9) 7 (3.4) 2 (7.7) 0.330
      Variable Value (n=26)
      Symptom
       Fecal incontinence 2 (7.7)
       Increased stool frequency 12 (46.2)
       Urgency 16 (61.5)
       Anorectal pain 12 (46.2)
      Endoscopic finding
       Noncircumferent mucosal inflammation 10 (38.5)
       Circumferent mucosal inflammation 12 (46.2)
       Mucosal ulceration 4 (15.4)
       Distance of proctitis from the anal verge (cm) 9 (5–15)
       Distance of proctitis from anastomosis (cm) 2 (1–5)
       Impassable rectal stricturea 13 (50.0)
      Variable Univariable analysis Multivariable analysis
      Crude OR (95% CI) P-value Adjusted OR (95% CI) P-value
      Sex 0.840 0.930
       Female 1 1
       Male 1.1 (0.5–2.5) 1.0 (0.4–2.6)
      Age (yr) 1.0 (0.9–1.1) 0.320 1.0 (0.9–1.1) 0.590
      Cause of surgery 0.020* 0.009*
       Benign condition 1 1
       Malignancy 5.7 (1.3–25.0) 10.0 (2.0–53.0)
      Type of surgery 0.001* <0.001*
       Elective 1 1
       Emergency 5.5 (2.0–15.4) 9.5 (2.6–34.0)
      ASA physical status 0.280 0.776
       I, II 1 1
       ≥III 1.7 (0.6–4.7) 1.2 (0.4–3.9)
      Smoking status 0.430 0.105
       No 1 1
       Yes 1.5 (0.5–4.4) 2.8 (0.8–9.6)
      Table 1. Baseline characteristics of patients who underwent sigmoidectomy

      Values are presented as number (%) or median (range).

      ASA, American Society of Anesthesiologists.

      aThe sum of the values does not equal the total due to missing data. bThe sum for the with proctitis group does not equal the total due to missing data.

      P<0.05

      Table 2. Surgical details of patients who underwent sigmoidectomy

      Values are presented as number (%) or median (range).

      Six cases were missing.

      Symptoms related to proctitis were excluded from both analyses regarding postoperative complications.

      The sum of the values does not equal the total due to missing data (the type of anastomosis was not recorded in certain cases).

      P<0.05.

      Table 3. Symptoms and endoscopic findings of patients with proctitis following sigmoidectomy

      Values are presented as number (%) or median (range).

      Patients with severe rectal stricture through which a sigmoidoscope could not be passed.

      Table 4. Univariable and multivariable analysis on risk factors for the development of proctitis in patients who underwent sigmoidectomy due to malignancy or diverticulitis

      OR, odds ratio; CI, confidence interval; ASA, American Society of Anesthesiologists.

      P<0.05.

      Table 1.

      Table 2.

      Table 3.

      Table 4.

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