Successful surgical treatment of intractable post-radiation rectal bleeding

Patients will typically present symptoms of chronic post-radiation colitis and proctitis 8-12 months after finishing their treatment. Endoscopic methods play the main role the treatment of bleeding caused by post-radiation colitis and proctitis. Surgical treatment is required for remained approximately 10% of patients. Here we present a 64 year old female with metastatic breast cancer, who was referred to us for intractable rectal bleeding. Total colonoscopy and rigid rectosigmoidoscopy revealed proctitis, rectal and sigmoidal telangiectasis, multiple necrotic ulcers between 15 to 30 cm from the anal verge, and also huge ishemic ulcer with patchy necrotic areas about 10 cm from the anal verge. This abnormal irradiated part was resected and then mucosectomy of the remnant rectum, both transabdominally and transanally was done. We performed pull-through technique of normal proximal colon to anal region through the remnant rectal wall and finally did coloanal anastomosis. Diverting stoma was not made because of anastomosis in anal region. With this technique we can achieve benefits such as avoidance of harsh dissection in a frozen pelvis and its consequences, we can avoid intra-abdominal anastomosis, there is no need to a diverting stoma and, most important of all, definite bleeding control.

Serum apolipoprotein B to apolipoprotein A-I ratio is an independent predictor of liver metastasis from locally advanced rectal cancer in patients receiving neoadjuvant chemoradiotherapy plus surgery

Background The ratio of serum apolipoprotein B (apoB) to apolipoprotein A-I (apoAI) had been reported as a prognostic factor in colorectal cancer. This retrospective study aimed to assess the implication of apoB-to-apoAI ratio in predicting liver metastasis from rectal cancer (RC). Methods The clinical data of 599 locally advanced RC patients treated with chemoradiotherapy followed by surgery were reviewed. Serum apoAI, apoB and apoB-to-apoAI ratio were analyzed for their correlation with the liver-metastasis-free, other-metastasis-free and overall survivals, together with the pretreatment and postsurgical pathoclinical features of the patients. Univariate and multivariate survival analyses were realized through the Kaplan-Meier approach and Cox model, respectively. Hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated for independent predictors. Results Carbohydrate antigen 19 − 9 ≥ 26.3 U/ml, apoB-to-apoAI ratio ≥ 0.63, tumor regression grade 5 − 3, pT4 and pN + stage emerged as independent predictors of poorer liver-metastasis-free survival. The hazard ratios were 1.656 (95% CI, 1.094–2.506), 1.919 (95% CI, 1.174–3.145), 1.686 (95% CI, 1.053–2.703), 1.890 (95% CI, 1.110–3.226) and 2.012 (95% CI, 1.314–2.077), respectively. Except apoB-to-apoAI ratio, the other 4 factors were also independent predictors of poorer other-metastasis-free and overall survivals. And the independent predictors of poorer overall survival also included age ≥ 67 years old, distance to anal verge < 5 cm. Conclusions Serum apoB-to-apoAI ratio could be used as a biomarker for prediction of liver metastasis risk in locally advanced RC.

Evaluating the result of sphincteric-preserving surgery (Parks procedure) for low rectal cancer

Sphincter-preserving surgery for low rectal cancer improved the quality of life while maintaining the oncologic outcomes. A retrospective, descriptive study was conducted with 45 patients who underwent sphincter-preserving surgery for low rectal cancer at the National Cancer Hospital and Hanoi Medical University Hospital between January 2016 and April 2020. The mean age was 55.6 years old. Male: female ratio = 0.7:1. Nearly all patients presented with hematochezia (95.6%). 75.6% of the tumors are located within 4-6 cm from the anal verge. The anastomotic leak rate was 4.4%. All patients had a normal postoperative urinary function. The sexual dysfunction rate was low (15.8%) and reversible. None had erectile or ejaculation dysfunction. 97.8% satisfied with sphincter function after one year. Tumors located > 4 cm and the anastomosis sites located > 2 cm from the anal verge were good prognostic factors for the recovery of sphincter function (p < 0.05). The Parks procedure had optimistic postoperative outcomes with a low complication rate, minimal sexual dysfunction, and good sphincter function in long-term follow-up.

Updates of Risk Factors for Anastomotic Leakage after Colorectal Surgery

Anastomotic leakage is a potentially severe complication occurring after colorectal surgery and can lead to increased morbidity and mortality, permanent stoma formation, and cancer recurrence. Multiple risk factors for anastomotic leak have been identified, and these can allow for better prevention and an earlier diagnosis of this significant complication. There are nonmodifiable factors such as male gender, comorbidities and distance of tumor from anal verge, and modifiable risk factors, including smoking and alcohol consumption, obesity, preoperative radiotherapy and preoperative use of steroids or non-steroidal anti-inflammatory drugs. Perioperative blood transfusion was shown to be an important risk factor for anastomotic failure. Recent studies on the laparoscopic approach in colorectal surgery found no statistical difference in anastomotic leakage rate compared with open surgery. A diverting stoma at the time of primary surgery does not appear to reduce the leak rate but may reduce its clinical consequences and the need for additional surgery if anastomotic leakage does occur. It is still debatable if preoperative bowel preparation should be used, especially for left colon and rectal resections, but studies have shown similar incidence of postoperative leak rate.

Evaluation of the Learning Curve for Conformal Sphincter Preservation Operation in The Treatment of Ultra-Low Rectal Cancer

Background: To investigate the learning curve of conformal sphincter preservation operation (CSPO) in the treatment of ultra-low rectal cancer and to further expore the influencing factors of operation time.Methods: From August 2011 to April 2020, 108 consecutive patients with ultra-low rectal cancer underwent CSPO by the same surgeon in the department of colorectal surgery of Changhai Hospital. The moving average and cumulative sum control chart (CUSUM) curve were used to analyze the learning curve. The preoperative clinical baseline data, postoperative pathological data, postoperative complications and survival data were compared before and after the completion of learning curve. The influencing factors of CSPO operation time were analyzed by univariate and multivariate analysis.Results: According to the results of moving average and CUSUM method, CSPO learning curve was divided into learning period (1-45 cases) and learning completion period (46-108 cases). There was no significant difference in preoperative clinical baseline data, postoperative pathological data, postoperative complications and survival data between the two stages. Compared with the learning period, the operation time (P < 0.05), blood loss (P < 0.05), postoperative flatus and defecation time (P < 0.05), liquid diet time (P < 0.05) and postoperative hospital stay (P < 0.05) in the learning completion period were significantly reduced, and the difference was statistically significant. Univariate and multivariate analysis showed that distance of tumor from anal verge (≥ 4cm vs. <4cm, P=0.039) and T stage (T3 vs. T1-2, P=0.022) were independent risk factors for prolonging the operation time of CSPO.Conclusions: For surgeons with laparoscopic surgery experience, about 45 cases of CSPO are needed to cross the learning curve. At the initial stage of CSPO, beginners are recommended to select patients with ultra-low rectal cancer whose distance of tumor from anal verge is less than 4cm and tumor stage is less than T3 for practice, which can enable beginners to reduce the operation time, accumulate experience, build self-confidence and shorten the learning curve on the premise of safety.

The Safety and Feasibility of Laparoscopic Surgery for Very Low Rectal Cancer: A Retrospective Analysis Based on a Single Center’s Experience

In this work we intend to validate the long-term oncologic outcomes for very low rectal cancer over the past 20 years and to determine whether laparoscopic procedures are useful options for very low rectal cancer. A total of 327 patients, who electively underwent laparoscopic rectal cancer surgery for a lesion within 5 cm from the anal verge, were enrolled in this study and their long-term outcomes were reviewed retrospectively. Of 327 patients, 70 patients underwent laparoscopic low anterior resection (LAR), 164 underwent laparoscopic abdominal transanal proctosigmoidocolectomy with coloanal anastomosis (LATA), and 93 underwent laparoscopic abdominoperineal resection (APR). The conversion rate was 1.22% (4/327). The overall postoperative morbidity rate was 26.30% (86/327). The 5-year disease free survival (DFS), 5-year overall survival (OS), and 3-year local recurrence (LR) were 64.3%, 79.7%, and 9.2%, respectively. The CRM involvement was a significant independent factor for DFS (p = 0.018) and OS (p = 0.042) in multivariate analysis. Laparoscopic APR showed poorer 5-year DFS (47.8%), 5-year OS (64.0%), and 3-year LR (17.6%) than laparoscopic LAR (74.1%, 86.4%, 1.9%) and laparoscopic LATA (69.2%, 83.6%, 9.2%). Laparoscopic procedures for very low rectal cancer including LAR, LATA, and APR could be good surgical options in selective patients with very low rectal cancer.

Clinical Efficacy of Intersphincteric Resection for Low Rectal Cancer Compared With Abdominoperineal Resection: A Single-Center Retrospective Study

Background In recent years, intersphincteric resection (ISR) has been increasingly used to replace abdominoperineal resection (APR) in the surgical treatment of ultra-low rectal cancer. Aim This study was to compare the clinical efficacy of ISR and APR. Methods Between 2012 and 2018, 74 consecutive patients with ultra-low rectal cancer underwent ISR or APR in our medical center. A retrospective comparison of these 2 procedures was performed. Results A total of 43 patients underwent ISR and 31 underwent APR were included in the study. No significant differences were found between 2 groups in gender, age, BMI, and ASA score. Intersphincteric resection group showed shorter operative time ( P = .02) and less blood loss ( P = .001). Hospital stays, time to soft diet, and postoperative 30-day complications were not significantly different between the 2 groups. R0 resection achieved 100% in both the groups. As for the long-term outcomes, the survival and recurrence rate were similar between 2 groups. Moreover, the LARS and Wexner score showed that the postoperative anal function after ISR were satisfactory. Conclusion This study suggested that ISR was feasible and safe for selected patients with ultra-low rectal cancer, with clinically superior outcomes in select patients (small tumors/further from the anal verge) and similar oncological outcomes to APR, and the anal functional outcomes after ISR were acceptable.

MANAGEMENT OF GUD BHRANSHA WITH KASISADI TAIL - A CASE STUDY

Gud Bhransha is a protrusion of mucous membrane of the Rectum from outside the anal verge with membrane or without membrane. It can be partial or complete. This condition is common in children and elderly patients. There are two types of treatment of rectal prolapse are conservative and surgical. The type of treatment of rectal prolapse depends on the severity of the disease. A clinical study was conducted on the patient of Gudbhransh with an elderly patient disease to evaluate the contraction effect of the Kasisadi tail which is traditionally practised in rural areas of Igatpuri, Maharashtra, India based on a survey. The aim and objective of this study were to evaluate the contraction effect of the Kasisadi tail over prolapsed rectal mucosa. Which was successfully treated by conserva- tive Ayurvedic management Gudbhransh is treated in line with the treatment of Ayurveda as a complication of Atisar by the Kasisadi tail by anal route for correction of prolapse locally. The case result confirms that rectal prolapse can be managed effectively with Ayurvedic treatment in a short duration of time. Keywords: Kasisadi Tail, Gudbhransh, Rectal prolapse, Atisar

COVID-19 Pandemic Lockdown Resulting in an Unusual Rectal Foreign Body in a Young Male

Foreign body rectum may cause serious consequences, especially in psychologically vulnerable patients, In critical conditions like pandemic COPVID-19, when depression, fear boredom, loneliness such incidence may occur. An 18 years old young male presented in emergency with a foreign body rectum. He was a laborer on daily wages. During the COVID-19 pandemic, loneliness, anxiety, and unemployment have exposed him to bizarre behavior, resulting in inserting potato into his rectum. He denied any history of homosexuality. The diagnosis was made by examination. Per rectal examination found FB just above the anal verge. The foreign body was removed rectally under G/A. He was then referred to a psychiatrist for evaluation.