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Waheeb Radman Al-Kubati1– 3 1Department of Surgery, 21st September University, Sana’a, Yemen; 2Department of Surgery, Althowra Modern General Hospital, Sana’a, Yemen; 3Department of Physiology, Sana’a University, Sana’a, YemenCorrespondence: Waheeb Radman Al-Kubati, Email waheebradman@yahoo.comBackground: Low Anterior Resection Syndrome (LARS) is a debilitating complication of sphincter-preserving surgeries, particularly after Total Mesorectal Excision (TME) for very low rectal cancer. LARS adversely impacts bowel function and quality of life, highlighting the need for effective preventive strategies.Objective: This study evaluates advanced reconstructive techniques, including taeniectomy pouch (TP), transverse coloplasty (TCP), colonic J-pouch (CJP), smooth muscle plasty (SMP), and greater omentum transplantation (GOT), in reducing LARS incidence and severity.Methods: This was a single-center randomized controlled trial (RCT) conducted between April 2018 and March 2024, involving 88 patients undergoing total mesorectal excision (TME) for very low rectal cancer. The trial was registered locally at our tertiary referral center. Patients were randomized in a 1:1 ratio to either the control group (straight coloanal anastomosis) or the test group (advanced reconstructive techniques: transverse coloplasty, colonic J-pouch, taeniectomy pouch, or smooth muscle plasty, with or without greater omentum transplantation). Eligible patients had histologically confirmed, well- or moderately-differentiated adenocarcinoma located 1– 6 cm from the anal verge. Propensity score adjustment was applied during analysis to minimize residual confounding. The primary endpoint was the incidence of major Low Anterior Resection Syndrome (LARS; score > 30), assessed by validated questionnaires at 6 weeks, 3, 6, 12, and 24 months postoperatively. Secondary outcomes included stool frequency, continence recovery, and quality-of-life scores. Trial registration: [AMG-HOSP-RCT-2018-003].Results: At six weeks, major LARS occurred in 10% of the test group (95% CI: 4– 23%) versus 80% of controls (95% CI: 68– 88%) (P < 0.001). Mild LARS (score < 20) was observed in 80% of test patients compared to 5% of controls. Stool frequency improved from 4.5/day to 2.7/day within 12 months in the test group, consistently outperforming controls. Major incontinence was recorded in 10% (95% CI: 4– 23%) of test patients versus 80% (95% CI: 68– 88%) of controls. GOT combined with TP or SMP achieved the most favorable outcomes, with faster recovery of anal function and greater LARS score improvement at six weeks post-surgery. Pairwise comparisons confirmed significantly lower stool frequency in both test subgroups at all follow-up points (mean differences − 1.8 to − 0.4 without GOT; − 2.2 to − 0.6 with GOT; all P< 0.0056). Logistic regression identified test group allocation and GOT as strong independent predictors of reduced major LARS, while prior CRT was the most significant risk factor.Conclusion: GOT and other advanced techniques effectively mitigate LARS severity, resulting in enhanced postoperative quality of life. This study demonstrates the potential benefits of neorectal reservoir techniques and GOT in enhancing functional outcomes after TME for very low rectal cancer. The findings provide promising evidence supporting their role in LARS management; however, broader adoption requires validation in larger, multicenter trials with longer follow-up.Plain Language Summary: Patients with very low rectal cancer often undergo total mesorectal excision (TME), a surgery that can lead to a common complication known as Low Anterior Resection Syndrome (LARS). LARS includes problems like frequent bowel movements, urgency, and difficulty controlling stools, which can significantly affect quality of life.This study explored whether using advanced reconstructive techniques during surgery could help reduce these symptoms. These techniques included creating different types of internal pouches—such as a taeniectomy pouch, J-pouch, or transverse coloplasty—as well as using smooth muscle plasty and transplanting the body’s own omentum (a fatty tissue layer from the abdomen) to support healing and function.The results suggest that combining these approaches may improve bowel control and recovery after TME, offering better long-term outcomes for patients.Keywords: low anterior resection syndrome, TME, advanced reconstructive techniques, taeniectomy pouch, J-pouch, transverse coloplasty, smooth muscle plasty, omentum transplantation

Low Anterior Resection Syndrome (LARS) is a debilitating complication of sphincter-preserving surgeries, particularly after Total Mesorectal Excision (TME) for very low rectal cancer. LARS adversely impacts bowel function and quality of life, highlighting the need for effective preventive strategies. This study evaluates advanced reconstructive techniques, including taeniectomy pouch (TP), transverse coloplasty (TCP), colonic J-pouch (CJP), smooth muscle plasty (SMP), and greater omentum transplantation (GOT), in reducing LARS incidence and severity. This was a single-center randomized controlled trial (RCT) conducted between April 2018 and March 2024, involving 88 patients undergoing total mesorectal excision (TME) for very low rectal cancer. The trial was registered locally at our tertiary referral center. Patients were randomized in a 1:1 ratio to either the control group (straight coloanal anastomosis) or the test group (advanced reconstructive techniques: transverse coloplasty, colonic J-pouch, taeniectomy pouch, or smooth muscle plasty, with or without greater omentum transplantation). Eligible patients had histologically confirmed, well- or moderately-differentiated adenocarcinoma located 1-6 cm from the anal verge. Propensity score adjustment was applied during analysis to minimize residual confounding. The primary endpoint was the incidence of major Low Anterior Resection Syndrome (LARS; score >30), assessed by validated questionnaires at 6 weeks, 3, 6, 12, and 24 months postoperatively. Secondary outcomes included stool frequency, continence recovery, and quality-of-life scores. Trial registration: [AMG-HOSP-RCT-2018-003]. At six weeks, major LARS occurred in 10% of the test group (95% CI: 4-23%) versus 80% of controls (95% CI: 68-88%) (P < 0.001). Mild LARS (score <20) was observed in 80% of test patients compared to 5% of controls. Stool frequency improved from 4.5/day to 2.7/day within 12 months in the test group, consistently outperforming controls. Major incontinence was recorded in 10% (95% CI: 4-23%) of test patients versus 80% (95% CI: 68-88%) of controls. GOT combined with TP or SMP achieved the most favorable outcomes, with faster recovery of anal function and greater LARS score improvement at six weeks post-surgery. Pairwise comparisons confirmed significantly lower stool frequency in both test subgroups at all follow-up points (mean differences -1.8 to -0.4 without GOT; -2.2 to -0.6 with GOT; all P<0.0056). Logistic regression identified test group allocation and GOT as strong independent predictors of reduced major LARS, while prior CRT was the most significant risk factor. GOT and other advanced techniques effectively mitigate LARS severity, resulting in enhanced postoperative quality of life. This study demonstrates the potential benefits of neorectal reservoir techniques and GOT in enhancing functional outcomes after TME for very low rectal cancer. The findings provide promising evidence supporting their role in LARS management; however, broader adoption requires validation in larger, multicenter trials with longer follow-up.

Injury and repair of the tendon-bone interface (TBI) pose a significant challenge in the fields of orthopedics and sports medicine. Due to the gradients in structure, composition, mechanical properties, and biological signals across the TBI, transitioning from flexible tendon to rigid bone, traditional surgical approaches often struggle to reconstruct its functional structure, leading to poor mechanical properties of the interface after repair and high re-tear rates. In contrast, gradient biomimetic scaffolds, by mimicking the continuous gradients of native TBI, offer an effective solution for achieving functional TBI regeneration. This review systematically summarizes the research progress of gradient biomimetic scaffolds for TBI regeneration in recent years. Firstly, we discuss the fine structure, physiological functions of native TBI, and the repair challenges faced after its injury, emphasizing the necessity of reconstructing gradient structures. Subsequently, it focuses on the design principles and core biomimetic strategies of gradient biomimetic scaffolds, discussing in depth the principles of construction and implementation strategies for physical structure gradients (e.g., porosity, fiber orientation, mechanical modulus), chemical composition gradients (e.g., degree of mineralization, polymer/ECM components), and biological signal gradients (e.g., growth factors, genes). Building upon this, this review comprehensively reviews various biomaterials for gradient scaffold construction, including natural polymers (collagen, silk fibroin, chitosan, etc.), synthetic polymers (PCL, PLGA, PU, etc.), and inorganic bioactive materials (calcium phosphate ceramics, bioactive glass), analyzing their characteristics, functionalization methods, and applications in gradient construction. Furthermore, this review also systematically summarizes and compares major fabrication techniques for gradient biomimetic scaffolds, particularly the advantages and limitations of electrospinning and additive manufacturing (3D printing) in constructing specific gradient features, and highlights emerging techniques such as microfluidics. Finally, building upon the summarized existing research findings, this review critically analyzes the key challenges and technical bottlenecks currently facing gradient biomimetic scaffolds regarding structural biomimetic accuracy, spatio-temporal control of biological functions, vascularization, and immunocompatibility, and offers perspectives on future research directions, such as smart scaffolds, integration of multiple gradients, personalized manufacturing, and clinical translation strategies.

The landscape of cranial base surgery has undergone monumental transformations over the past several decades. This article serves as a comprehensive survey, detailing both the historical and current techniques and technologies that have propelled this field into an era of unprecedented capabilities and sophistication. In the prologue, we traverse the historical evolution from rudimentary interventions to the state-of-the-art neurosurgical methodologies that define today’s practice. Subsequent sections delve into the anatomical complexities of the anterior, middle, and posterior cranial fossa, shedding light on the intricacies that dictate surgical approaches. In a section dedicated to advanced techniques and modalities, we explore cutting-edge evolutions in minimally invasive procedures, pituitary surgery, and cranial base reconstruction. Here, we highlight the seamless integration of endocrinology, biomaterial science, and engineering into neurosurgical craftsmanship. The article emphasizes the paradigm shift towards “Functionally” Guided Surgery facilitated by intraoperative neuromonitoring. We explore its historical origins, current technologies, and its invaluable role in tailoring surgical interventions across diverse pathologies. Additionally, the digital era’s contributions to cranial base surgery are examined. This includes breakthroughs in endoscopic technology, robotics, augmented reality, and the potential of machine learning and AI-assisted diagnostic and surgical planning. The discussion extends to radiosurgery and radiotherapy, focusing on the harmonization of precision and efficacy through advanced modalities such as Gamma Knife and CyberKnife. The article also evaluates newer protocols that optimize tumor control while preserving neural structures. In acknowledging the holistic nature of cranial base surgery, we advocate for an interdisciplinary approach. The ecosystem of this surgical field is presented as an amalgamation of various medical disciplines, including neurology, radiology, oncology, and rehabilitation, and is further enriched by insights from patient narratives and quality-of-life metrics. The epilogue contemplates future challenges and opportunities, pinpointing potential breakthroughs in stem cell research, regenerative medicine, and genomic tailoring. Ultimately, the article reaffirms the ethos of continuous learning, global collaboration, and patient-first principles, projecting an optimistic trajectory for the field of cranial base surgery in the coming decade.

Introduction Complete abdominal wall infiltration with neoplastic gastrocutaneous fistula is an unexpected and out of the ordinary presentation of locally advanced gastric cancer. It is very rare to encounter case reports presenting diffuse abdominal wall invasion, but a complete parietal destruction is an exceptional event. Case presentation Here we describe the case of an 81-year-old Caucasian woman presenting a carcinoma perforating her anterior gastric wall and infiltrating all layers of her abdominal wall. The gastric tumor infiltrated her transverse mesocolon, the rectus abdominis muscles bilaterally and overran them anteriorly, causing a large parietal deficit and a complete external fistula. Treatment consisted of a complex surgical procedure requiring general and reconstructive surgery cooperation in order to perform an en bloc gastric resection including colon and abdominal wall, followed by a parietal reconstruction through positioning of prosthesis and reverse abdominoplasty. Conclusions Clinical presentation, histology and therapeutic options are discussed. The importance of a multidisciplinary approach when encountering extremely rare clinical presentations is emphasized.