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Background Anastomotic leakage is a devastating complication of colorectal surgery. However, there is no technology indicative of in situ perfusion of a laparoscopic colorectal anastomosis. Methods We detail the use of near-infrared (NIR) laparoscopy (PinPoint System, NOVADAQ, Canada) in association with fluorophore [indocyanine green (ICG), 2.5 mg/ml] injection in 30 consecutive patients who underwent elective minimally invasive colorectal resection using the simultaneous appearance of the cecum or distal ileum as positive control. Results The median (range) age of the patients was 64 (40–81) years with a median (range) BMI of 26.7 (20–35.5) kg/m 2 . Twenty-four patients had left-sided resections (including six low anterior resections) and six had right-sided resections. Of the total, 25 operations were cancer resections and five were for benign disease [either diverticular strictures ( n  = 3) or Crohn’s disease ( n  = 2)]. A high-quality intraoperative ICG angiogram was achieved in 29/30 patients. After ICG injection, median (range) time to perfusion fluorescence was 35 (15–45) s. Median (range) added time for the technique was 5 (3–9) min. Anastomotic perfusion was documented as satisfactory in every successful case and encouraged avoidance of defunctioning stomas in three patients with low anastomoses. There were no postoperative anastomotic leaks. Conclusion Perfusion angiography of colorectal anastomosis at the time of their laparoscopic construction is feasible and readily achievable with minimal added intraoperative time. Further work is required to determine optimum sensitivity and threshold levels for assessment of perfusion sufficiency, in particular with regard to anastomotic viability.

BackgroundEndoscopic intermuscular dissection (EID) is a promising new technique for managing rectal deep submucosal invasive cancer (D-SMIC), but long-term outcome data are currently lacking.ObjectiveThis multicentre study evaluated the three-year oncological outcomes of EID, focusing specifically on patients with rectal D-SMIC who underwent active surveillance following the procedure.DesignData from consecutive, prospectively recorded EID procedures for suspected rectal D-SMIC—based on optical diagnosis—performed at two academic centres between 2019 and 2023 were analysed. D-SMIC was defined as submucosal invasion of sm2–sm3 depth. Histological risk factors included poorly differentiated tumours (G3), lymphovascular invasion, high-grade tumour budding and positive or indeterminate resection margins (R1/Rx). Study outcomes included three-year rates of locoregional recurrence (intramural and nodal), distant recurrence (metastatic disease), non-salvageable recurrence, cancer-specific mortality and secondary rectal surgery. Cumulative incidence was estimated using the Aalen-Johansen method.ResultsAmong the 188 included cases, EID achieved an en bloc resection rate of 94.1% and R0 resection rate of 82.5%, respectively. Of the 177 procedures that were completed, 16% showed non-invasive histology (low-grade dysplasia/high-grade dysplasia; 20/177=11%) or superficial submucosal invasive cancer (sm1, 9/177=5%), and 31% (54/177) showed deeper (≥pT2) invasion. The remaining 94 D-SMIC cases (53%) represented the main target group. Of these, 37% (n=35) were classified as low risk (no histological risk factors), 34% (n=32) as intermediate risk (one risk factor) and 29% (n=27) as high risk (≥2 risk factors). Active surveillance was initiated in all low-risk patients, in 72% of the intermediate-risk cases and in 22% of the high-risk group. The remaining patients underwent completion surgery or adjuvant chemoradiotherapy. At three years, locoregional recurrence occurred in 7% (1/35, 95% CI 1% to 28%) of low-risk and 13% (2/15, 95% CI 2% to 35%) of intermediate-risk patients managed with active surveillance. All were successfully salvaged. Among the six high-risk patients under surveillance, locoregional recurrence was seen in two. No distant recurrences or cancer-specific deaths occurred in any D-SMIC group. Secondary rectal surgery was finally performed in 5.3%, 25.0% and 59.6% of the low, intermediate and high-risk groups, respectively.ConclusionDespite the challenges associated with accurate preoperative staging, EID followed by active surveillance may offer a viable alternative to radical surgery for patients with low- and intermediate-risk rectal D-SMIC, avoiding rectal surgery in most cases while maintaining oncological safety.

Background The interest and adoption of transanal total mesorectal excision (TaTME) is growing amongst the colorectal surgical community, but there is no clear guidance on the optimal training framework to ensure safe practice for this novel operation. The aim of this study was to establish a consensus on a detailed structured training curriculum for TaTME. Methods A consensus process to agree on the framework of the TaTME training curriculum was conducted, seeking views of 207 surgeons across 18 different countries, including 52 international experts in the field of TaTME. The process consisted of surveying potential learners of this technique, an international experts workshop and a final expert’s consensus to draw an agreement on essential elements of the curriculum. Results Appropriate case selection was strongly recommended, and TaTME should be offered to patients with mid and low rectal cancers, but not proximal rectal cancers. Pre-requisites to learn TaTME should include completion of training and accreditation in laparoscopic colorectal surgery, with prior experience in transanal surgery. Ideally, two surgeons should undergo training together in centres with high volume for rectal cancer surgery. Mentorship and multidisciplinary training were the two most important aspects of the curriculum, which should also include online modules and simulated training for purse-string suturing. Mentors should have performed at least 20 TaTME cases and be experienced in laparoscopic training. Reviewing the specimens’ quality, clinical outcome data and entering data into a registry were recommended. Assessment should be an integral part of the curriculum using Global Assessment Scales, as formative assessment to promote learning and competency assessment tool as summative assessment. Conclusions A detailed framework for a structured TaTME training curriculum has been proposed. It encompasses various training modalities and assessment, as well as having the potential to provide quality control and future research initiatives for this novel technique.

Disordered vascularity is a hallmark of carcinogenesis. Fluorescence microperfusion heterogeneity may discriminate malignant transformation within significant (> 20 mm) rectal polyps enabling in-situ endoscopic classification via machine learning (ML) methods to inform clinical care. Patients referred for transanal management of rectal neoplasia were recruited. Indocyanine green was administered intravenously and near-infrared (NIR) endoscopic video recorded. Videos were processed with bespoke fluorescence quantification software producing intensity-timeseries plots for neoplastic and normal regions of interest in the same patients. Plot features were extracted to train/test ML classification algorithms, including coefficient of variation (CV), reporting cancer characterisation sensitivity, specificity and accuracy. 190 video recordings from 182 patients (57.9% with cancer) from six cancer centres provided usable dataset (91% of 201 consenting patients). Overall, the software accurately tracked and detailed NIR perfusion features from, on average (SD), 74.7% (25.3) of annotated regions of interest over the five-minute recording phase. The sensitivity/specificity/accuracy rates of traditional endoscopic biopsy ( n  = 172), MRI ( n  = 139) and expert surgeon opinion ( n  = 190) at surgery were 70.8%/100%/81.7%, 85.4%/ 44.1%/72.7% and 79.1%/80%/79.5% respectively. In comparison, trained ML sensitivity/specificity/ accuracy was 77.6%/39.8%/61.1% and 73.5%/48.2%/62.6% with base and CV featured algorithms respectively. Combining point of care clinical data (specifically MRI and clinicians’ preoperative predictions) with the ML algorithms improved sensitivity/specificity/accuracy to 86.0%/71.1%/79.5% and 82.2%/74.7%/79.0% respectively. Malignant transformation precipitates discriminant perfusion patterns, in a manner exploitable digitally, that indicate cancer presence in significant rectal polyps. Combining clinical indicators appears to improve classification accuracy further, especially specificity. Trial registration: Future of Colorectal Cancer Surgery (FOOCCuS1). Clinicatrials.gov. NCT04220242. Clinicaltrials.gov/study/NCT04220242. CLASSICA: Validating AI in Classifying Cancer in Real-Time Surgery. Clinicaltrials.gov. NCT05793554. Clinicaltrials.gov/study/NCT05793554.

Background: Non-restorative low anterior resection (NRLAR) may result in inferior oncological outcomes compared to restorative low anterior resection (RLAR) and abdominoperineal resection (APR). While NRLAR is often performed when poor functional or technical challenges are anticipated, comprehensive data on its oncological outcomes remain scarce. This study aimed to retrospectively evaluate the intermediate-term oncological outcomes of patients—who underwent RLAR, NRLAR, or APR for primary rectal cancer. Methods: This analysis included all elective NRLAR, RLAR, and APR procedures for primary rectal carcinoma performed across 11 Dutch centers from 2013 to 2020. The primary outcome was 3-year disease-free survival (DFS). Secondary outcomes included 3-year overall survival (OS) and 3-year local recurrence (LR). KaplanMeier survival analysis with log-rank testing and multivariate Cox regression analysis were employed. Results: A total of 253 (12.5%) patients underwent NRLAR, 1109 (55.0%) RLAR, and 656 (32.5%) APR. NRLAR was associated with a lower 3-year DFS (71.4%) versus RLAR (82.0%) and APR (77.4%) (p = 0.003). The 3-year OS was lower for NRLAR (82.9%) versus RLAR (93.5%) and APR (90.2%) (p < 0.001), with a higher 3-year LR rate for NRLAR (8.1%) versus RLAR (3.3%) and APR (4.5%) (p = 0.003). Multivariate Cox regression analyses confirmed NRLAR as an independent predictor for poorer DFS (HR 1.34; 95% CI: 1.01–1.80; p = 0.046), OS (HR 1.57; 95% CI: 1.04–2.36, p = 0.032), and higher LR risk (HR 2.66; 95% CI: 1.53–4.65; p <= 0.001). Conclusions: NRLAR is associated with poorer intermediate-term oncological outcomes. When technically feasible, restorative options should be considered, and prospective studies are required to further investigate causal relationships.

Rectal cancer is common with a 60% 5-year survival rate. Treatment usually involves surgery with or without neoadjuvant chemoradiotherapy or adjuvant chemotherapy. Sphincter saving curative treatment can result in debilitating changes to bowel function known as low anterior resection syndrome (LARS). There are currently no clear guidelines on the management of LARS with only limited evidence for different treatment modalities. Patients who have undergone an anterior resection for rectal cancer in the last 10 years will be approached for the study. The feasibility trial will take place in four centres with a 9-month recruitment window and 12 months follow-up period. The primary objective is to assess the feasibility of recruitment to the POLARiS trial which will be achieved through assessment of recruitment, retainment and follow-up rates as well as the prevalence of major LARS.Feasibility outcomes will be analysed descriptively through the estimation of proportions with confidence intervals. Longitudinal patient reported outcome measures will be analysed according to scoring manuals and presented descriptively with reporting graphically over time. Ethical approval has been granted by Wales REC1; Reference 22/WA/0025. The feasibility study is in the process of set up. The results of the feasibility trial will feed into the design of an expanded, international trial. CT05319054.

Background: Robot-assisted total mesorectal excision has been proposed as an alternative to laparoscopic TME for rectal cancer. However, its short-term outcomes and long-term oncological efficacy remain debated, especially in Western populations. This study evaluates the short-term clinical and long-term oncological outcomes of robot-assisted total mesorectal excision performed by experienced surgeons in high-volume European centres. Methods: This multicentre, international, retrospective cohort study included 1390 patients from the EUREKA collaborative dataset who underwent robot-assisted total mesorectal excision for rectal cancer between January 2013 and January 2022. All surgeries were performed by expert surgeons beyond the learning curve. Data were analysed for patient demographics, perioperative outcomes, pathological findings, and three-year survival metrics. Kaplan–Meier analysis was used to evaluate overall and disease-free survival. Results: Of 1390 patients, 60.6% underwent restorative low anterior resection. Conversion to open surgery occurred in 3.7%, and postoperative complications were reported in 28.7%. Anastomotic leakage occurred in 14.7% of patients who underwent restorative low anterior resection. The median operative time was 223 min. R0 resection was achieved in 94.7%, and circumferential resection margin positivity was 5.5%. Three-year overall survival was 90.1%, disease-free survival was 88.6%, and local recurrence was 2.9%. Conclusions: Robot-assisted total mesorectal excision performed by experienced surgeons in high-volume European centres is safe, with low conversion rates, acceptable complication rates, and favourable oncological outcomes. These findings underscore the potential of robot-assisted total mesorectal excision as a standard approach for rectal cancer in specialised settings.

Background Anastomotic leakage (AL) is a common and severe complication after colon cancer resection, but studies investigating various treatment strategies and factors influencing outcomes are scarce. Objectives (1) To identify predictive factors associated with 90-day mortality and 90-day Clavien-Dindo grade 4–5 complications amongst patients who developed AL following colon cancer resection with subsequent development and validation of prediction models, and (2) to explore and compare the effectiveness of various treatment strategies for AL following colon cancer resection, adjusting for type of index surgery, different leak entities and patient factors. Methods The TENTACLE – Colon is an international multicentre retrospective cohort study. Consecutive patients with AL after colon cancer resection operated between 1 January 2018 and 31 December 2022 from participating centres will be included. The planned sample size is 2000 patients. The primary outcome is 90-day mortality and the co-primary composite endpoint is Clavien-Dindo grade 4–5 complications. Secondary outcomes include: hospital and intensive care unit length of stay, number of radiological and surgical reinterventions within one year after resection, mortality (in-hospital, 30-day, and 1-year), the comprehensive complication index, and 1-year stoma-free survival. For objective 1, regression models will be used to identify predictors associated with 90-day mortality and grade 4–5 complications. For objective 2, comparative analyses of various treatment strategies will be performed for the specified outcomes, adjusting for patient, tumour, resection and leakage characteristics. Trial registration This study is registered at clinicaltrials.gov (NCT 06528054) since July 30th, 2024.

IntroductionNowadays, most rectal tumours are treated open or minimally invasive, using laparoscopic, robot-assisted or transanal total mesorectal excision. However, insight into the total costs of these techniques is limited. Since all three techniques are currently being performed, including cost considerations in the choice of treatment technique may significantly impact future healthcare costs. Therefore, this systematic review aims to provide an overview of evidence regarding costs in patients with rectal cancer following open, laparoscopic, robot-assisted and transanal total mesorectal excision.Methods and analysisA systematic search will be conducted for papers between January 2000 and March 2022. Databases PubMed/MEDLINE, EMBASE, Scopus, Web of Science and Cochrane Library databases will be searched. Study selection, data extraction and quality assessment will be performed independently by four reviewers and discrepancies will be resolved through discussion. The Consensus Health Economic Criteria list will be used for assessing risk of bias. Total costs of the different techniques, consisting of but not limited to, theatre, in-hospital and postoperative costs, will be the primary outcome.Ethics and disseminationNo ethical approval is required, as there is no collection of patient data at an individual level. Findings will be disseminated widely, through peer-reviewed publication and presentation at relevant national and international conferences.Trial registration numberCRD42021261125.

Background Pelvic sepsis after surgery for rectal cancer is a severe complication, mostly originating from anastomotic leakage. Complex salvage surgery, during which an omentoplasty is often used for filling of the pelvic cavity, is seldomly required. If this fails, a symptomatic recurrent presacral abscess with a risk of progressive inflammation can develop. Such patients have often undergone multiple surgeries and have disturbed abdominal wall integrity, adhesion formation, and presence of one or two stoma(s). Subsequent salvage surgery via the conventional anterior abdominal approach is therefore less suitable. We describe three cases with a chronic presacral sinus and failure of first salvage surgery. All three patients underwent a prone only approach with tailored sacrectomy. This novel approach provided direct access to the pelvic abscess with optimal exposure for complete and safe debridement. A unilateral or bilateral gluteal V–Y fasciocutaneous advancement flap was created to completely fill the cavity with well vascularized tissue. Case presentations Three male patients of 80, 66 and 51 years of age initially underwent low anterior resection with neo-adjuvant radiotherapy for rectal cancer. The first patients underwent intersphincteric resection of the anastomosis with omentoplasty 128 months after index surgery, and second salvage surgery 2 months later. The second patient underwent abdominoperineal resection with omentoplasty for locally recurrent rectal cancer, cystoprostatectomy with revision of the omentoplasty for pelvic sepsis 100 months after index surgery, and second salvage surgery 16 months later. In the third patient, the anastomosis was dismantled with subsequent intersphincteric proctectomy and omentoplasty 20 months after index surgery, and second salvage surgery was performed 93 months later. Second salvage surgery in all three patients was indicated because of symptomatic recurrent pelvic sepsis. Second salvage surgery consisted of sacrectomy, complete debridement of the presacral area, and filling with a gluteal advancement flap. This resulted in favorable postoperative recovery with ultimate healing of the pelvic cavity. Conclusion The dorsal approach with tailored sacrectomy and gluteal V–Y advancement flap is a valuable option in highly selected patients to treat recurrent pelvic sepsis after multiple prior transabdominal interventions for chronic presacral sinus.