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Rectal cancer treatment has evolved during the past 40 years with the use of a standardized surgical technique for tumour resection: total mesorectal excision. A dramatic reduction in local recurrence rates and improved survival outcomes have been achieved as consequences of a better understanding of the surgical oncology of rectal cancer, and the advent of adjuvant and neoadjuvant treatments to compliment surgery have paved the way for a multidisciplinary approach to disease management. Further improvements in imaging techniques and the ability to identify prognostic factors such as tumour regression, extramural venous invasion and threatened margins have introduced the concept of decision-making based on preoperative staging information. Modern treatment strategies are underpinned by accurate high-resolution imaging guiding both neoadjuvant therapy and precision surgery, followed by meticulous pathological scrutiny identifying the important prognostic factors for adjuvant chemotherapy. Included in these strategies are organ-sparing approaches and watch-and-wait strategies in selected patients. These pathways rely on the close working of interlinked disciplines within a multidisciplinary team. Such multidisciplinary forums are becoming standard in the treatment of rectal cancer across the UK, Europe and, more recently, the USA. This Review examines the essential components of modern-day management of rectal cancer through a multidisciplinary team approach, providing information that is essential for any practising colorectal surgeon to guide the best patient care.Rectal cancer treatment has evolved towards a multidisciplinary approach to disease management. This Review examines the essential components of rectal cancer management through a multidisciplinary team, with a focus on the effect of this approach and the elements used for staging and developing the treatment plan.

Introduction Colorectal cancer is the second most common cause of death from neoplastic disease in men and third in women of all ages. Globally, life expectancy is increasing, and consequently, an increasing number of operations are being performed on more elderly patients with the trend set to continue. Elderly patients are more likely to have cardiovascular and pulmonary comorbidities that are associated with increased peri-operative risk. They further tend to present with more locally advanced disease, more likely to obstruct or have disseminated disease. The aim of this review was to investigate the feasibility of laparoscopic colorectal resection in very elderly patients, and whether there are benefits over open surgery for colorectal cancer. Methods A systematic literature search was performed on Medline, Pubmed, Embase and Google Scholar. All comparative studies evaluating patients undergoing laparoscopic versus open surgery for colorectal cancer in the patients population over 85 were included. The primary outcomes were 30-day mortality and 30-day overall morbidity. Secondary outcomes were operating time, time to oral diet, number of retrieved lymph nodes, blood loss and 5-year survival. Results The search provided 1507 citations. Sixty-nine articles were retrieved for full text analysis, and only six retrospective studies met the inclusion criteria. Overall mortality for elective laparoscopic resection was 2.92% and morbidity 23%. No single study showed a significant difference between laparoscopic and open surgery for morbidity or mortality, but pooled data analysis demonstrated reduced morbidity in the laparoscopic group ( p  = 0.032). Patients undergoing laparoscopic surgery are more likely to have a shorter hospital stay and a shorter time to oral diet. Conclusion Elective laparoscopic resection for colorectal cancer in the over 85 age group is feasible and safe and offers similar advantages over open surgery to those demonstrated in patients of younger ages.

Peritoneal surface malignancies comprise a heterogeneous group of primary tumours, including peritoneal mesothelioma, and peritoneal metastases of other tumours, including ovarian, gastric, colorectal, appendicular or pancreatic cancers. The pathophysiology of peritoneal malignancy is complex and not fully understood. The two main hypotheses are the transformation of mesothelial cells (peritoneal primary tumour) and shedding of cells from a primary tumour with implantation of cells in the peritoneal cavity (peritoneal metastasis). Diagnosis is challenging and often requires modern imaging and interventional techniques, including surgical exploration. In the past decade, new treatments and multimodal strategies helped to improve patient survival and quality of life and the premise that peritoneal malignancies are fatal diseases has been dismissed as management strategies, including complete cytoreductive surgery embedded in perioperative systemic chemotherapy, can provide cure in selected patients. Furthermore, intraperitoneal chemotherapy has become an important part of combination treatments. Improving locoregional treatment delivery to enhance penetration to tumour nodules and reduce systemic uptake is one of the most active research areas. The current main challenges involve not only offering the best treatment option and developing intraperitoneal therapies that are equivalent to current systemic therapies but also defining the optimal treatment sequence according to primary tumour, disease extent and patient preferences. New imaging modalities, less invasive surgery, nanomedicines and targeted therapies are the basis for a new era of intraperitoneal therapy and are beginning to show encouraging outcomes.Peritoneal surface malignancies have heterogeneous origins, including primary peritoneal tumours and metastases of other cancers, for example, digestive tract, reproductive tract, lung, breast and kidney tumours. This Primer reviews the epidemiology, mechanisms and diagnosis of these diseases, and discusses treatment options, patient quality of life and upcoming innovations.

The positive surgical margin (PSM) and biochemical recurrence (BCR) are two main factors associated with poor oncotherapeutic outcomes after prostatectomy. This is an Asian population study based on a single-surgeon experience to deeply investigate the predictors for PSM and BCR. We retrospectively included 419 robot-assisted radical prostatectomy cases. The number of PSM cases was 126 (30.1%), stratified as 22 (12.2%) in stage T2 and 103 (43.6%) in stage T3. Preoperative prostate-specific antigen (PSA) > 10 ng/mL ( p  = 0.047; odds ratio [OR] 1.712), intraoperative blood loss > 200 mL ( p  = 0.006; OR 4.01), and postoperative pT3 stage ( p  < 0.001; OR 6.901) were three independent predictors for PSM while PSA > 10 ng/mL ( p  < 0.015; hazard ratio [HR] 1.8), pT3 stage ( p  = 0.012; HR 2.264), International Society of Urological Pathology (ISUP) grade > 3 ( p  = 0 . 02; HR 1.964), and PSM ( p  = 0.027; HR 1.725) were four significant predictors for BCR in multivariable analysis. PSMs occurred mostly in the posterolateral regions (73.8%) which were associated with nerve-sparing procedures ( p  = 0.012) while apical PSMs were correlated intraoperative bleeding ( p  < 0.001). A high ratio of pT3 stage after RARP in our Asian population-based might surpass the influence of PSM on BCR. PSM was less significant than PSA and ISUP grade for predicting PSA recurrence in pT3 disease. Among PSM cases, unifocal and multifocal positive margins had a similar ratio of the BCR rate ( p  = 0.172) but ISUP grade > 3 ( p  = 0.002; HR 2.689) was a significant BCR predictor. These results indicate that PSA and pathological status are key factors influencing PSM and BCR.

In the present paper, the meshfree collocation technique is implemented for analyzing the bending behavior of bidirectional porous functionally graded material (BPFGM) plates resting on an elastic foundation in the framework of higher-order shear deformation plate theory (HSDT). The variation of material properties in both the thickness and length directions of skewed BPFGM plates will adhere to a modified power-law distribution, encompassing two different porosity distributions. The Meshless Collocation Technique (MCT) is based on Wendland radial basis functions (WRBF) and is used to discretize the governing differential equations (GDEs) obtained via energy principles. The accuracy and effectiveness of the MCT are verified by comparing the computed results with other numerical solutions reported by many researchers in the literature. Additionally, detailed parametric studies are carried out to investigate the effects of various factors on the flexural responses of BPFGM plates, including the grading index, plate length-to-thickness ratio, elastic foundation, aspect ratio, porosity index, porosity distribution, and the effect of transverse loading. Results demonstrate that the WRBF method can effectively predict the flexural behavior of BPFGM plates under different conditions. Overall, this paragraph provides a brief overview of the study's objectives, methodology, and findings, highlighting the development of a meshfree method based on radial basis functions for analyzing the flexural behavior of BPFGM plates and its effectiveness in predicting the plate's response under various conditions.

BackgroundThe transanal approach to pelvic dissection has gained considerable traction and utilization continues to expand, fueled by the transanal total mesorectal excision (TaTME) for rectal cancer. The same principles and benefits of transanal pelvic dissection may apply to the transanal restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA)-the TaPouch procedure. Our goal was to review the literature to date on the development and current state of the TaPouch.Materials and methodsWe performed a PubMed database search for original articles on transanal pelvic dissections, IPAA, and the TaPouch procedure, with a manual search from relevant citations in the reference list. The main outcomes were the technical aspects of the TaPouch, clinical and functional outcomes, and potential advantages, drawbacks, and future direction for the procedure.ResultsThe conduct of the procedure has been defined, with the safety and feasibility demonstrated in small series. The reported rates of conversion and anastomotic leakage are low. There are no randomized trials or large-scale comparative studies available for comparative effectiveness compared to the traditional IPAA.ConclusionsThe transanal approach to ileal pouch-anal anastomosis is an exciting adaption of the transanal total mesorectal excision for refining the technical steps of a complex operation. Additional experience is needed for comparative outcomes and defining the ideal training and implementation pathways.

Extended reality (XR) is an umbrella term for technologies that incorporate digital and physical elements to alter a user’s experience, namely: augmented reality (AR), virtual reality (VR) and mixed reality (MR). With National Health Service waiting lists at record levels, a shortage of trained endoscopists within the UK, and a greater likelihood of non-standard training outcomes following the COVID-19 pandemic, there is a requirement for significant developments in colorectal surgical training. AR has useful applications within both simulation training and intraoperative guidance, such as image overlays and conceptualisation. Both AR and VR offer three-dimensional reconstruction of radiological images, thereby allowing for enhanced appreciation and visualisation of anatomical structures. There is, however, a much greater evidence base for the validity of VR within the sphere of colorectal surgical training; primarily for simulation with respect to endoscopy, laparoscopy and robotics. MR is a developing field with technological advancements allowing for a combination of AR and VR. Potential advantages of XR teaching over conventional approaches include integration with artificial intelligence; objective assessments; immediate feedback; a wider exposure to pathologies and procedures and potential downstream safety benefits to patients. Environmental and socioeconomic factors require further evaluation, with the potential for meta-conferences or meta-hospitals. Disadvantages may include a lack of focus on patient communication skills and the lack of standardised XR training protocols. These technologies have an exciting future in serving as adjuncts to colorectal surgical training.

BackgroundDuring laparoscopy, the abdominal cavity is insufflated with carbon dioxide (CO2) that could become contaminated with viruses and surgical smoke. Medical staff is potentially exposed when this gas leaks into the operating room through the instruments and past trocar valves. No detailed studies currently exist that have quantified these leakage pathways. Therefore, the goal of this study was to quantify the gas leakages through trocars and instruments, during minimally invasive procedures.MethodsA model of the surgical environment was created, consisting of a rigid container with an interface for airtight clamping of laparoscopic equipment such as trocars and surgical instruments. The model was insufflated to 15 mm Hg using a pressure generator and a pneumotachograph measured the equipment gas leak. A protocol of several use cases was designed to simulate the motions and forces the surgeon exerts on the trocar during surgery.ResultsTwenty-three individual trocars and twenty-six laparoscopic instruments were measured for leakage under the different conditions of the protocol. Trocar leakages varied between 0 L/min and more than 30 L/min, the instruments revealed a range of leakages between 0 L/min and 5.5 L/min. The results showed that leakage performance varied widely between trocars and instruments and that the performance and location of the valves influenced trocar leakage.ConclusionsWe propose trocar redesigns to overcome specific causes of gas leaks. Moreover, an international testing standard for CO2 leakage for all new trocars and instruments is needed so surgical teams can avoid this potential health hazard when selecting new equipment.

Background Management of rectal cancer has a number of potentially appropriate alternatives for each patient. Despite acceptance of standards, practices may vary among regions. There is significant paucity of data in this area. The objective was to create a snapshot of the regional differences. Design This online survey included 10 questions. Enquiries focused on controversial topics, on surgeon and hospital volume, surgical margins, appropriateness of surgical approaches and techniques, watch-and-wait strategies, and total neoadjuvant therapy. Major colorectal surgery societies around the world were asked to invite their members to complete the survey. Outcome Measures Frequency of responses across regions within each question was compared by Fisher’s exact test. Results Seven hundred and fifty-three participants from 60 countries responded. Eight regions were identified, and four had sufficient representation for comparisons. Similarities and differences in the therapies among these regions were identified. Robotic surgery penetrance is higher in North America, and watch and wait is more accepted in South America. Patients in Oceania are more likely to be diverted; Europe has more usage of taTME. Discussion This online survey was practical as a mean to provide a rapid assessment of the international picture on consistency and variability of rectal cancer patients’ care, and to potentially identify opportunities to standardized care to patients. Medical surveys have inherent limitations; pertinence to our study is selection bias. Conclusions The management of rectal cancer varies among different regions. Identification of differences is important when considering global efforts to improve management and interpret data.

India is a major producer of fly ash due to its coal-based thermal power plants. The elemental characterization of the fly ash facilitates its better utilization and safe disposal, which was accomplished using k0-based internal mono standard neutron activation analysis and X-ray fluorescence techniques in the present study. The fly ash was mainly composed of useful elements such as Si, Al, Fe, K and Ca. The same was also found to contain the rare earth elements from minor to trace levels in the order of Ce > La > Nd > Sm > Yb > Eu > Tb > Lu and the heavy and toxic elements such as U, Th, As, Pb etc. in minor and trace level.