Diverting stoma (DS) is routinely proposed in intersphincteric resection for ultralow rectal cancer, but it is associated with increased stoma-related complications and economic burden. Appropriate patient selection and operative strategies to avoid stoma formation need further elucidation.

To select patients who may not require DS.

This study enrolled 505 consecutive patients, including 84 who underwent stoma-free (SF) intersphincteric resection. After matching, patients were divided into SF (n = 78) and DS (n = 78) groups. The primary endpoint was the anastomotic leakage (AL) rate within 6 months and its protective factors for both the total and SF cohorts. The secondary endpoints included overall survival and disease-free survival.

The AL rate was greater in the SF group than in the DS group (12.8% vs 2.6%, P = 0.035). Male sex [(odds ratio (OR) = 2.644, P = 0.021], neoadjuvant chemoradiotherapy (nCRT) (OR = 6.024, P < 0.001), and tumor height from the anal verge ≤ 4 cm (OR = 4.160, P = 0.007) were identified as independent risk factors. Preservation of the left colic artery (LCA) was protective in both the total cohort (OR = 0.417, P = 0.013) and the SF cohort (OR = 0.312, P = 0.027). The female patients who did not undergo nCRT and had preservation of the LCA experienced a significantly lower incidence of AL (2/97, 2.1%). The 3-year overall survival or disease-free survival did not significantly differ between the groups.

Female patients who do not receive nCRT may avoid the need for DS by preserving the LCA without increasing the risk of AL or compromising oncological outcomes.

(1) Background: In recent years, there has been a change in practice for diverting stomas in rectal cancer surgery, shifting from routine diverting stomas to a more selective approach. Studies suggest that the benefits of temporary ileostomies do not live up to their risks, such as high-output stomas, stoma dysfunction, and reoperation. (2) Methods: All rectal cancer patients treated with a robotic resection in a single tertiary colorectal centre in the UK from 2013 to 2021 were analysed. In 2015, our unit made a shift to a more selective approach to temporary diverting ileostomies. The cohort was divided into a routine diversion group treated before 2015 and a selective diversion group treated after 2015. Both groups were analysed and compared for short-term outcomes and morbidities. (3) Results: In group A, 63/70 patients (90%) had a diverting stoma compared to 98/135 patients (72.6%) in group B (p = 0.004). There were no significant differences between the groups in anastomotic leakages (11.8% vs. 17.8%, p = 0.312) or other complications (p = 0.117). There were also no significant differences in readmission (3.8% vs. 2.6%, p = 0.312) or reoperation (3.8% vs. 2.6%, p = 1.000) after stoma closure. After 1 year, 71.6% and 71.9% (p = 1.000) of patients were stoma-free. One major reason for the delay in stoma reversal was the COVID-19 pandemic, which only occurred in group B (0% vs. 22%, p = 0.054). (4) Conclusions: A more selective approach to diverting stomas for robotic rectal cancer patients does not lead to more complications or leaks and can be considered in the treatment of rectal cancer tumours.

Transanal minimally invasive surgery (TAMIS) is a surgical alternative to proctectomy in the management of complex rectal polyps and early rectal cancers. In 2016, our institution introduced a TAMIS programme. The purpose of this study was to evaluate changes in practice and outcomes in our institution in the 3 years before and after the implementation of TAMIS. We conducted a retrospective analysis of a prospective database of patients who underwent proctectomy or TAMIS for the management of complex rectal polyps or early rectal cancers at our institution between 2013 and 2018. 96 patients were included in this study (41 proctectomy vs 55 TAMIS). A significant reduction was noted in the number of proctectomies performed in the 3 years after the implementation of TAMIS as compared to the 3 years before (13 vs 28) ( P  < 0.001); 43% of patients ( n  = 12) who underwent proctectomy in the period prior to implementation of TAMIS were American Society of Anaesthesiologists grade III, as compared to only 15% ( n  = 2) of patients during the period following TAMIS implementation ( P  = 0.02). TAMIS was associated with a significant reduction in length of inpatient stay ( P  < 0.001). Oncological outcomes were comparable between groups (log rank P  = 0.83). Our findings support TAMIS as a safe and effective alternative to radical resection. The availability of TAMIS has resulted in a significant reduction in the number of comorbid patients undergoing proctectomy at our institution. Consequently, we have observed a significant reduction in postoperative complications over this time period.

<b><br>Introduction:</b> Ileostomy reversal is a common surgical procedure and currently standardized perioperative and surgical protocols are lacking.</br> <b><br>Aim:</b> LILEO study was designed to perform a multicenter analysis on numerous perioperative parameters and estimation of the incidence of postoperative complications.</br> <b><br>Materials and methods:</b> The study is an open multicenter prospective cohort study. Preliminary results of the LILEO study after 3 months were available from 18 Polish surgical centers comprising full data of 59 patients who underwent ileostomy reversal.</br> <b><br>Results:</b> Parameters such as preoperative care, surgical technique, postoperative course and complications were analyzed. Preoperative fasting was used in 49.1% of patients. Fifty nine percent of anastomosis were handsewn and in 72.9% of patients had primary single suture wound closure. Mean length of hospital stay was 7.9 days (min 2 days, max 26 days). Complications occurred overall in 20 patients (33.9%). In 11.9% of patient's complications had grade III A/B in Clavien-Dindo classification.</br> <b><br>Discussion:</b> The perioperative care in the group of patients undergoing ileostomy reversal still lacks standardized and optimized treatment.</br> <b><br>Conclusions:</b> Ileostomy removal is a procedure with high risk of postoperative complications. Standardization of perioperative care based on further multicenter national study could result in a decrease of complications rate.</br>.

With the increasing use of decompressing stoma as a bridge to surgery for left-sided obstructive colon cancer (LSOCC), the timing of restoration of bowel continuity (ROBC) is a subject of debate. There is a lack of data on immediate ROBC during elective resection as an alternative for a 3-stage procedure. This study analysed if immediate ROBC during tumour resection is safe and of any benefit for patients who underwent decompressing stoma for LSOCC.

In a Dutch nationwide collaborative research project, 3153 patients who underwent resection for LSOCC in 75 hospitals (2009-2016) were identified. Extensive data on disease and procedural characteristics, and outcomes was collected by local collaborators. For this analysis, 332 patients who underwent decompressing stoma followed by curative resection were selected. Immediate ROBC during tumour resection was compared to two no immediate ROBC groups, (1) tumour resection with primary anastomosis (PA) with leaving the decompressing stoma in situ, and (2) tumour resection without PA.

Immediate ROBC was performed in 113 patients (34.0%) and no immediate ROBC in 219 patients [168 with PA (50.6%) and 51 patients without PA (15.4%)]. No differences at baseline between the groups were found for age, ASA score, cT, and cM. Major surgical complications (8.8% immediate ROBC vs. 4.8% PA with decompressing stoma and 7.8% no PA; P =0.37) and mortality (2.7% vs. 2.4% and 0%, respectively; P =0.52) were similar. Immediate ROBC resulted in a shorter time with a stoma (mean 41 vs. 240 and 314 days, respectively; P <0.001), and fewer permanent stomas (7% vs. 21% and 80%, respectively; P <0.001) as compared to PA with a decompressing stoma or no PA.

After a decompressing stoma for LSOCC, immediate ROBC during elective resection appears safe, reduces the total time with a stoma and the risk of a permanent stoma.

Transanal TME (taTME) combines abdominal and transanal dissection to facilitate sphincter preservation in patients with low rectal tumors. Few phase II/III trials report long-term oncologic and functional results. We report early results from a North American prospective multicenter phase II trial of taTME (NCT03144765).

100 patients with stage I-III rectal adenocarcinoma located ≤ 10 cm from the anal verge (AV) were enrolled across 11 centers. Primary and secondary endpoints were TME quality, pathologic outcomes, 30-day and 90-day outcomes, and stoma closure rate. Univariable regression analysis was performed to assess risk factors for incomplete TME and anastomotic complications.

Between September 2017 and April 2022, 70 males and 30 females with median age of 58 (IQR 49-62) years and BMI 27.8 (IQR 23.9-31.8) kg/m2 underwent 2-team taTME for tumors located a median 5.8 (IQR 4.5-7.0) cm from the AV. Neoadjuvant radiotherapy was completed in 69%. Intersphincteric resection was performed in 36% and all patients were diverted. Intraoperative complications occurred in 8% including 3 organ injuries, 2 abdominal and 1 transanal conversion. The 30-day and 90-day morbidity rates were 49% (Clavien-Dindo (CD) ≥ 3 in 28.6%) and 56% (CD ≥ 3 in 30.4% including 1 mortality), respectively. Anastomotic complications were reported in 18% including 10% diagnosed within 30 days. Higher anastomotic risk was noted among males (p = 0.05). At a median follow-up of 5 (IQR 3.1-7.4) months, 98% of stomas were closed. TME grade was complete or near complete in 90%, with positive margins in 2 cases (3%). Risk factors for incomplete TME were ASA ≥ 3 (p = 0.01), increased time between NRT and surgery (p = 0.03), and higher operative blood loss (p = 0.003).

When performed at expert centers, 2-team taTME in patients with low rectal tumors is safe with low conversion rates and high stoma closure rate. Mid-term results will further evaluate oncologic and functional outcomes.

We performed pull-through hand-sewn coloanal anastomosis immediately after sphincter-preserving ultralow anterior resection (ULAR) [pull-through ultra (PTU)] to avoid permanent stoma and reduce postoperative complications of lower rectal tumors. This study aimed to compare the clinical outcomes of PTU versus non-PTU (stapled or hand-sewn coloanal anastomosis with diverting stoma) after sphincter-preserving ULAR for lower rectal tumors.

This retrospective cohort study analyzed prospectively maintained data from 100 consecutive patients who underwent PTU (n = 29) or non-PTU (n = 71) after sphincter-preserving ULAR for rectal tumors between January 2011 and March 2023. In PTU, hand-sewn coloanal anastomosis was immediately performed using 16 stitches of 4-0 monofilament suture during primary surgery. The clinical outcomes were assessed. The primary outcomes were rates of permanent stomas and overall postoperative complications.

The PTU group was significantly less likely to require a permanent stoma than the non-PTU group (P < 0.01). None of the patients in the PTU group required permanent stoma and the rate of overall complications was significantly lower in the PTU group (P = 0.01). The median operative time was comparable between the two groups (P = 0.33) but the median operative time during the second stage was significantly shorter in the PTU group (P < 0.01). The rates of anastomotic leakage and complications of Clavien-Dindo grade III were comparable between the two groups. Diverting ileostomy was performed in two patients with an anastomotic leak in the PTU group. The PTU group was significantly less likely to require a diverting ileostomy than those in the non-PTU group (P < 0.01). The composite length of hospital stay was significantly shorter in the PTU group (P < 0.01).

PTU via immediate coloanal anastomosis for lower rectal tumors is a safe alternative to the current sphincter-preserving ULAR with diverting ileostomy for patients who wish to avoid a stoma.