BACKGROUND: The conversion from a temporary to a permanent stoma (PS) following rectal cancer surgery significantly impacts the quality of life of patients. However, there is currently a lack of practical preoperative tools to predict PS formation. The purpose of this study is to establish a preoperative predictive model for PS using machine learning algorithms to guide clinical practice.
METHODS: In this retrospective study, we analyzed clinical data from a total of 655 patients who underwent anterior resection for rectal cancer, with 552 patients from one medical center and 103 from another. Through machine learning algorithms, five predictive models were developed, and each was thoroughly evaluated for predictive performance. The model with superior predictive accuracy underwent additional validation using both an independent testing cohort and the external validation cohort. The Shapley Additive exPlanations (SHAP) approach was employed to elucidate the predictive factors influencing the model, providing an in-depth visual analysis of its decision-making process.
RESULTS: Eight variables were selected for the construction of the model. The support vector machine (SVM) model exhibited superior predictive performance in the training set, evidenced by an AUC of 0.854 (95 % CI:0.803-0.904). This performance was corroborated in both the testing set and external validation set, where the model demonstrated an AUC of 0.851 (95%CI:0.748-0.954) and 0.815 (95%CI:0.710-0.919), respectively, indicating its efficacy in identifying the PS.
CONCLUSIONS: The model(https://yangsu2023.shinyapps.io/psrisk/) indicated robust predictive performance in identifying PS after anterior resection for rectal cancer, potentially guiding surgeons in the preoperative stratification of patients, thus informing individualized treatment plans and improving patient outcomes.

Robot-assisted laparoscopic anterior resection is a novel technique. However, evidence in the literature regarding the advantages of robot-assisted laparoscopic surgery (RLS) is insufficient. The aim of this study was to compare the outcomes of RLS versus conventional laparoscopic surgery (CLS) for the treatment of sigmoid colon cancer. We performed a retrospective study at the Northern Jiangsu People\'s Hospital. Patients diagnosed with sigmoid colon cancer and underwent anterior resection between January 2019 to September 2023 were included in the study. We compared the basic characteristics of the patients and the short-term and long-term outcomes of patients in the two groups. A total of 452 patients were included. Based on propensity score matching, 212 patients (RLS, n = 106; CLS, n = 106) were included. The baseline data in RLS group was comparable to that in CLS group. Compared with CLS group, RLS group exhibited less estimated blood loss (P = 0.015), more harvested lymph nodes (P = 0.005), longer operation time (P < 0.001) and higher total hospitalization costs (P < 0.001). Meanwhile, there were no significant differences in other perioperative or pathologic outcomes between the two groups. For 3-year prognosis, overall survival rates were 92.5% in the RLS group and 90.6% in the CLS group (HR 0.700, 95% CI 0.276-1.774, P = 0.452); disease-free survival rates were 91.5% in the RLS group and 87.7% in the CLS group (HR 0.613, 95% CI 0.262-1.435, P = 0.259). Compared with CLS, RLS for sigmoid colon cancer was found to be associated with a higher number of lymph nodes harvested, similar perioperative outcomes and long-term survival outcomes. High total hospitalization costs of RLS did not translate into better long-term oncology outcomes.

Complete splenic flexure mobilization is a critical step in left-sided colorectal resections. Surgeons use three approaches-anterior, medial, and lateral-to divide peritoneal ligaments connecting the left colon. The decision to perform mobilization varies, with minimal impact on post-operative outcomes but longer surgery times and rare complications. Pancreatic injury risk is low, though other structures, like arteries and the duodenum, may be at risk. Our video outlines the medial trans-mesocolic approach, with the patient positioned in lithotomy. We expose the duodenal-jejunal flexure, ligate the inferior mesenteric vein, and perform medial to lateral dissection, completing splenic flexure mobilization. This video vignette outlines how to perform this technique for left sided colorectal resections.

Anastomotic leak is the most dreaded complication after anterior resection (AR). To do prophylactic diversion stoma or not is a matter of constant dilemma that most surgeons face. In such a situation, ghost stoma (GS) technique offers a middle path, wherein unnecessary prophylactic stomas can be avoided and at the same time ensuring that a diversion stoma can be created if need arises without the need of any major surgery or anaesthesia. Retrospective data of patients who underwent anterior resection with ghost stoma at our institute from January 2015 to December 2019 was analysed for clinical characteristics, operative outcomes and postoperative complications. Ghost stoma is fashioned by pulling up a loop of intestine up to parietal peritoneum layer of anterior abdominal wall with the help of silicone or plastic tube after anterior resection. During the study period, this technique was used in 68 patients of which 7 patients required creation of stoma under local anaesthesia for suspected or confirmed post-operative leak. One of these patients developed congestion of stoma for which the stoma was refashioned under regional anaesthesia. There were no major complications like bowel obstruction, strangulation or tube migration. However, two patients had prolonged ileus and were managed conservatively. Thus, unnecessary stoma was avoided in 89% patients of anterior resection. This is a simple, easy to learn, less time-consuming and oncologically safe procedure which can prevent patients from morbidity as well as psychological and financial burden associated with unnecessary stoma.

UNASSIGNED: Placement of an indwelling transanal drainage tube (TDT) to prevent anastomotic leakage (AL) after anterior rectal cancer surgery has become a routine choice for surgeons in the recent years. However, the specific indwelling time of the TDT has not been explored. We performed this meta-analysis and considered the indwelling time a critical factor in re-analyzing the effectiveness of TDT placement in prevention of AL after anterior rectal cancer surgery.
UNASSIGNED: Randomized controlled trials (RCTs) and cohort studies which evaluated the effectiveness of TDT in prevention of AL after rectal cancer surgery and considered the indwelling time of TDT were identified using a predesigned search strategy in databases up to November 2022. This meta-analysis was performed to estimate the pooled AL rates (Overall and different AL grades) and reoperation rates at different TDT indwelling times and stoma statuses.
UNASSIGNED: Three RCTs and 15 cohort studies including 2381 cases with TDT and 2494 cases without TDT were considered eligible for inclusion. Our meta-analysis showed that the indwelling time of TDT for ≥5-days was associated with a significant reduction (TDT vs. Non-TDT) in overall AL (OR=0.46,95% CI 0.34-0.60, p<0.01), grade A+B AL (OR=0.64, 95% CI 0.42-0.97, p=0.03), grade C AL (OR=0.35, 95% CI 0.24-0.53, p<0.01), overall reoperation rate (OR=0.36, 95%CI 0.24-0.53, p<0.01) and that in patients without a prophylactic diverting stoma (DS) (OR=0.24, 95%CI 0.14-0.41, p<0.01). There were no statistically significant differences in any of the abovementioned indicators (p>0.05) when the indwelling time of TDT was less than 5 days.
UNASSIGNED: Extending the postoperative indwelling time of TDT to 5 days may reduce the overall AL and the need for reoperation in patients without a prophylactic DS.
UNASSIGNED: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023407451, identifier CRD42023407451.

The creation of a protective stoma is considered a valid life-saving tool, significantly reducing the effects of anastomotic leakage in terms of related morbidity, mortality, and reoperation rate. The aim of this study was to evaluate the impact of a protective loop ileostomy in terms of short- and long-term postoperative morbidity, quantifying the stoma-related complications arising after stoma creation and stoma closure and the risk of permanent stoma. From January 2009 to January 2020, 149 patients with rectal cancer treated by anterior resection and protective ileostomy were enrolled in the study. A total of 113 (75.84%) patients were preoperatively treated with neoadjuvant radiochemotherapy. A clinically relevant anastomotic leak occurred in two patients (1.34%). The postoperative stoma complication rate was 6%. According to the Clavien classification, the stoma-related complication grade was I in seven patients (4.7%) and II in two patients (1.3%). A late stoma-related parastomal hernia occurred in one patient (0.67%). In 129 patients (86.57%), it was possible to close the stoma. Postoperative complications of stoma closure occurred in 12 patients (9.3%). The stoma closure complication grade was I in seven cases (5.43%), II in two cases (1.55%), and ≥3 in three cases (2.33%). Incisional hernia was the only late complication recorded in seven cases (5.42%). The permanent stoma rate was 13.43%. A protective ileostomy has a nonnegligible complication rate, but the rate of severe complications is low. Every effort should be made to clearly identify patients in whom the risk of anastomotic leakage justifies the stoma.

BACKGROUND: Postoperative ileus (POI) is a major cause of morbidity in patients undergoing colorectal surgery. The aim of our study was to evaluate potential risk factors for POI in cases with anterior resection for rectal cancer.
METHODS: A retrospective cohort study was performed on 136 patients who underwent open anterior resection for rectal cancer between 2004 and 2018 at a single tertiary referral center. POI was defined as reinsertion of nasogastric tube or nil per os by postoperative day 4 and/or administration of neostigmine postoperatively. Uni- and multivariate analysis was performed to identify potential risk factors for POI.
RESULTS: POI was observed in 18 patients (13.2%). Epidural anesthesia, type of ostomy, and history of abdominal surgery were not found to be related with POI. Advanced age was a statistically significant risk factor both in the uni- and in the multivariate analyses. An increase in age by 1 year was found to increase the odds of POI by 5% [95%CI: 0.4%-9.7%; p = 0.032].
CONCLUSIONS: Increased age was identified as a non-modifiable, patient-related risk factor for POI after anterior resection for rectal cancer. This finding is of particular importance as it turns the focus on the elderly patient and underlines the need for close clinical observation of this subgroup and liberal use of preventive and/or therapeutic measures postoperatively.

The benefit of radiotherapy for rectal cancer is based largely on a balance between a decrease in local recurrence and an increase in bowel dysfunction. Predicting postoperative disability is helpful for recovery plans and early intervention. We aimed to develop and validate a risk model to improve the prediction of major bowel dysfunction after restorative rectal cancer resection with neoadjuvant radiotherapy using perioperative features.
Eligible patients more than 1 year after restorative resection following radiotherapy were invited to complete the low anterior resection syndrome (LARS) score at 3 national hospitals in China. Clinical characteristics and imaging parameters were assessed with machine learning algorithms. The post-radiotherapy LARS prediction model (PORTLARS) was constructed by means of logistic regression on the basis of key factors with proportional weighs. The accuracy of the model for major LARS prediction was internally and externally validated.
A total of 868 patients reported a mean LARS score of 28.4 after an average time of 4.7 years since surgery. Key predictors for major LARS included the length of distal rectum, anastomotic leakage, proximal colon of neorectum, and pathologic nodal stage. PORTLARS had a favorable area under the curve for predicting major LARS in the internal dataset (0.835; 95% CI, 0.800-0.870, n = 521) and external dataset (0.884; 95% CI, 0.848-0.921, n = 347). The model achieved both sensitivity and specificity >0.83 in the external validation. In addition, PORTLARS outperformed the preoperative LARS score for prediction of major events.
PORTLARS could predict major bowel dysfunction after rectal cancer resection following radiotherapy with high accuracy and robustness. It may serve as a useful tool to identify patients who need additional support for long-term dysfunction in the early stage.
gov, number NCT05129215.

UNASSIGNED: Colorectal intussusception can be quite challenging to identify, especially its malignant nature. This is a fairly rare presentation and hence, there is not much associated research or cases reported in the literature.
METHODS: We present a 69 year old male with lower abdominal pain and a significant rectal prolapse. He has a background history of heavy smoking and significant alcohol intake. The prolapse was irreducible and had papillomatous changes present on the prolapsed mucosa. A computerized tomography (CT) scan demonstrated a large rectal prolapse followed by a Magnetic Resonance Imaging (MRI) Pelvis which showed an intussusception at the S2-3 level, consistent with a carcinoma, The patient then proceeded to have a flexible sigmoidoscopy with a planned proceed to an anterior resection. Histopathology revealed sigmoid and descending colon adenocarcinoma with mucinous differentiation pT3N0. He had an unremarkable hospital stay and remained well on follow up. His case was discussed at the multidisciplinary meeting and was not for any adjuvant chemotherapy.
UNASSIGNED: Imaging can help aid early diagnosis of a colorectal intussusception. Colonoscopies can be useful too; however these can be tricky to diagnose pre-operatively. If there is a high suspicion of malignancy, routine resection is the preferred method of treatment in cases of colorectal intussusception.
CONCLUSIONS: Although not a very common presentation, diagnosis of colorectal cancer presenting as an intussusception can be dealt with imminently by considering operative measures.

BACKGROUND: The aim of this systematic review and meta-analysis is to evaluate clinical, functional, and anorectal physiology outcomes of the side-to-end vs colonic J-pouch (CJP) anastomosis following anterior resection for rectal cancer.
METHODS: A PRISMA-compliant systematic review and meta-analysis was conducted using multiple electronic databases and clinical trial registers and all studies comparing side-to-end vs CJP anastomosis were included. Peri-operative complications, mortality rate, functional bowel, and anorectal outcomes were evaluated.
RESULTS: Eight randomized controlled trials (RCTs) and two observational studies with 1125 patients (side-to-end: n = 557; CJP: n = 568) were included. Of the entire functional bowel outcome parameters analyzed, only the sensation of incomplete bowel evacuation was significant in the CJP group at 6 months [OR: 2.07; 95% CI 1.06 - 4.02, P = .03]. Peri- and post-operative clinical parameters were comparable in both groups (total operative time, intra-operative blood loss, anastomotic leak rate, return to theater, anastomotic stricture formation and mortality). Equally, most of the analyzed anorectal physiology parameters (anorectal volume, anal squeeze pressure, maximum anal volume) were not significantly different between the two groups. However, anal resting pressure (mmHg) 2 years post-operatively was noted to be significantly higher in the side-to-end group than that of the CJP configuration [MD: -8.76; 95% CI - 15.91 - 1.61, P = .02].
CONCLUSIONS: Clinical and functional outcomes following CJP surgery and side-to-end coloanal anastomosis are comparable. Neither technique appears to proffer solution to low anterior resection syndrome in the short term but future well-designed; high-quality RCTs with long term follow-up are required.