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Background: Anastomotic stricture (AS) is a common complication following rectal cancer surgery with anastomosis, but its diagnosis and management pose significant challenges due to the lack of standardized diagnostic criteria. We present a case highlighting the complexities encountered in diagnosing and managing occult AS post-rectal cancer surgery. Case presentation: A 51-year-old male patient presented with symptoms suggestive of AS following robot-assisted laparoscopic low anterior resection for rectal adenocarcinoma. Despite conventional evaluations, including colonoscopy, digital rectal examination, and radiography, AS was not identified. Following prolonged and ineffective treatment for suspected conditions such as low anterior resection syndrome (LARS), the patient underwent anal dilatation, resulting in significant symptom improvement. Conclusions: This case underscores the challenges associated with diagnosing and managing occult AS following rectal cancer surgery. The absence of standardized diagnostic criteria and reliance on conventional modalities may lead to underdiagnosis and inadequate treatment. A comprehensive diagnostic approach considering intestinal diameter, elasticity, and symptoms related to difficult defecation may enhance diagnostic accuracy. Further research is needed to refine the diagnostic and therapeutic strategies for occult AS.

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BACKGROUND: In this study, we aimed to identify the risk factors in patients with rectal anastomotic re-leakage and develop a prediction model to predict the probability of rectal anastomotic re-leakage after stoma closure. METHODS: This study was a single-center retrospective analysis of patients with rectal cancer who underwent surgery between January 2010 and December 2020. Among 3225 patients who underwent Total or Partial Mesorectal Excision (TME/PME) surgery for rectal cancer, 129 who experienced anastomotic leakage following stoma closure were enrolled. Risk factors for rectal anastomotic re-leakage were analyzed, and a prediction model was established for rectal anastomotic re-leakage. RESULTS: Anastomotic re-leakage after stoma closure developed in 13.2% (17/129) of patients. Multivariable analysis revealed that neoadjuvant chemoradiotherapy (odds ratio, 4.07; 95% confidence interval, 1.17-14.21; p = 0.03), blood loss > 50 ml (odds ratio, 4.52; 95% confidence interval, 1.31-15.63; p = 0.02), and intersphincteric resection (intersphincteric resection vs. low anterior resection: odds ratio, 6.85; 95% confidence interval, 2.01-23.36; p = 0.002) were independent risk factors for anastomotic re-leakage. A nomogram was constructed to predict the probability of anastomotic re-leakage, with an area under the receiver operating characteristic curve of 0.828 in the cohort. Predictive results correlated with the actual results according to the calibration curve. CONCLUSIONS: Neoadjuvant chemoradiotherapy, blood loss > 50 ml, and intersphincteric resection are independent risk factors for anastomotic re-leakage following stoma closure. The nomogram can help surgeons identify patients at a higher risk of rectal anastomotic re-leakage.

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BACKGROUND: Artificial intelligence (AI) has the potential to enhance surgical practice by predicting anatomical structures within the surgical field, thereby supporting surgeons' experiences and cognitive skills. Preserving and utilising nerves as critical guiding structures is paramount in rectal cancer surgery. Hence, we developed a deep learning model based on U-Net to automatically segment nerves. METHODS: The model performance was evaluated using 60 randomly selected frames, and the Dice and Intersection over Union (IoU) scores were quantitatively assessed by comparing them with ground truth data. Additionally, a questionnaire was administered to five colorectal surgeons to gauge the extent of underdetection, overdetection, and the practical utility of the model in rectal cancer surgery. Furthermore, we conducted an educational assessment of non-colorectal surgeons, trainees, physicians, and medical students. We evaluated their ability to recognise nerves in mesorectal dissection scenes, scored them on a 12-point scale, and examined the score changes before and after exposure to the AI analysis videos. RESULTS: The mean Dice and IoU scores for the 60 test frames were 0.442 (range 0.0465-0.639) and 0.292 (range 0.0238-0.469), respectively. The colorectal surgeons revealed an under-detection score of 0.80 (± 0.47), an over-detection score of 0.58 (± 0.41), and a usefulness evaluation score of 3.38 (± 0.43). The nerve recognition scores of non-colorectal surgeons, rotating residents, and medical students significantly improved by simply watching the AI nerve recognition videos for 1 min. Notably, medical students showed a more substantial increase in nerve recognition scores when exposed to AI nerve analysis videos than when exposed to traditional lectures on nerves. CONCLUSIONS: In laparoscopic and robot-assisted rectal cancer surgeries, the AI-based nerve recognition model achieved satisfactory recognition levels for expert surgeons and demonstrated effectiveness in educating junior surgeons and medical students on nerve recognition.

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BACKGROUND: Bladder drainage is systematically used in rectal cancer surgery; however, the optimal type of drainage, transurethral catheterization (TUC) or suprapubic catheterization (SPC), is still controversial. The aim was to compare the rates of urinary tract infection on the fourth postoperative day (POD4) between TUC and SPC, after rectal cancer surgery regardless of the day of removal of the urinary drain. METHODS: This randomized clinical trial in 19 expert colorectal surgery centers in France and Belgium was performed between October 2016 and October 2019 and included 240 men (with normal or subnormal voiding function) undergoing mesorectal excision with low anastomosis for rectal cancer. Patients were followed at postoperative days 4, 30, and 180. RESULTS: In 208 patients (median age 66 years [IQR 58-71]) randomized to TUC (n = 99) or SPC (n = 109), the rate of urinary infection at POD4 was not significantly different whatever the type of drainage (11/99 (11.1%) vs. 8/109 (7.3%), 95% CI, - 4.2% to 11.7%; p = 0.35). There was significantly more pyuria in the TUC group (79/99 (79.0%) vs. (60/109 (60.9%), 95% CI, 5.7-30.0%; p = 0.004). No difference in bacteriuria was observed between the groups. Patients in the TUC group had a shorter duration of catheterization (median 4 [2-5] vs. 4 [3-5] days; p = 0.002). Drainage complications were more frequent in the SPC group at all followup visits. CONCLUSIONS: TUC should be preferred over SPC in male patients undergoing surgery for mid and/or lower rectal cancers, owing to the lower rate of complications and shorter duration of catheterization. TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT02922647.

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INTRODUCTION: Stenosis is a serious complication associated with stomas. The initial treatment for stoma stenosis is mainly the finger-bougie technique or balloon dilatation, and recurrence requires stomal reconstruction. However, the use of local triamcinolone injections for treating stoma stenosis has not been reported. Herein, we reported a case of repeated stoma stenosis in a high-risk patient in whom balloon dilatation combined with local triamcinolone injection effectively avoided stomal reconstruction. PRESENTATION OF CASE: A woman in her 70s was admitted to our hospital with the chief complaint of a positive fecal occult blood test and was diagnosed with Ra advanced rectal cancer. Owing to the presence of multiple comorbidities, a laparoscopic Hartmann procedure with D3 dissection was performed. The operative time was 165 min and the intraoperative blood loss was 5 mL. On postoperative day 2, the colostomy stump became discolored, and stoma necrosis was diagnosed, which was successfully treated conservatively, with no findings of stoma falling or peritonitis. Six months after surgery, late stoma stenosis causing colonic obstruction was diagnosed, and the finger-bougie technique and balloon dilatation were ineffective. To avoid reoperation under general anesthesia, balloon dilatation using a CRE™ PRO GI Wireguided (Boston Scientific) at 19 mm for 3 min combined with a 40 mg injection of local triamcinolone into the stoma orifice scar was successfully performed. DISCUSSION: No restenosis was observed after treatment. CONCLUSION: Balloon dilatation combined with local triamcinolone injections may be effective for recurrent stoma stenosis in patients with high-risk comorbidities after rectal cancer surgery.

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BACKGROUND: Rectal cancer (RC) is a surgical challenge due to its technical complexity. The double-stapled (DS) technique, a standard for colorectal anastomosis, has been associated with notable drawbacks, including a high incidence of anastomotic leak (AL). Low anterior resection with transanal transection and single-stapled (TTSS) anastomosis has emerged to mitigate those drawbacks. METHODS: Observational study in which it described the technical aspects and results of the initial group of patients with medium-low RC undergoing elective laparoscopic total mesorectal excision (TME) and TTSS. RESULTS: Twenty-two patients were included in the series. Favourable postoperative outcomes with a median length of stay of 5 days and an AL incidence of 9.1%. Importantly, all patients achieved complete mesorectal excision with tumour-free margins, and no mortalities were reported. CONCLUSION: TTSS emerges as a promising alternative for patients with middle and lower rectal tumours, offering potential benefits in terms of morbidity reduction and oncological integrity compared with other techniques.

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Aim: The Coronavirus Disease 2019 (COVID-19) pandemic affected the allocation of various medical resources to several areas, including intensive care units (ICUs). However, currently, its impact on the short-term postoperative outcomes of gastrointestinal cancer surgeries remains unclear. We aimed to evaluate the impact of the pandemic on the incidence of complications occurring after low anterior resection in patients with rectal cancer in Japan. Methods: Data from the Japanese National Clinical Database between 2018 and 2021 were retrospectively examined. The primary outcome of the study was the postoperative morbidity and mortality rates before and after COVID-19 pandemic. Moreover, the postoperative ICU admission rate was assessed. Morbidity and mortality rates were also assessed using a standardized morbidity/mortality ratio (SMR, the ratio of the actual number of incidences to the expected number of incidences calculated by the risk calculator). Results: This study included 74 181 patients, including 43 663 (58.9%) from COVID-19 epidemic areas. The mean actual incidences of anastomotic leakage (AL) and pneumonia during the study period were 9.2% and 0.9%, respectively. The SMRs of these complications did not increase during the pandemic but those of AL declined gradually. The mean 30-day mortality and operative mortality rates were 0.3% and 0.5%, respectively. Moreover, SMRs did not change significantly in the pandemic or regional epidemic status. The ICU admission rate temporarily decreased, especially in the epidemic areas. Conclusion: Although the pandemic temporarily decreased the ICU admission rate, its impact on short-term outcomes following low anterior resection in patients with rectal cancer was insignificant in Japan.

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To compare the urinary and sexual outcomes between robot-assisted rectal cancer (RC) surgery (RRCS) and laparoscopic RC surgery (LRCS) using a meta-analysis, searches were conducted of the Embase, PubMed, Cochrane Library, CNKI, and Wanfang databases. The International Prostate Symptom Score (IPSS) was the primary outcome. Eleven studies (790 patients with RRCS and 888 with LRCS) were included. The IPSS scores were significantly lower for RRCS than LRCS from baseline to 3 months (weighted mean difference [WMD] = - 1.21, 95% confidence interval [CI]: - 1.8,-0.62, I2 = 89.9%), to 6 months (WMD = - 1.13, 95% CI: - 1.74, - 0.52, I2 = 93.3%), and to 12 months (WMD = - 0.93, 95% CI: - 1.59, - 0.26, I2 = 93.8%). The International Index of Erectile Function (IIEF) scores were significantly higher for RRCS than LRCS from baseline to 3 months (WMD = 3.36, 95% CI: 1.28, 5.44, I2 = 92.7%). The female sexual function index (FSFI) scores were significantly higher for RRCS than LRCS from baseline to 3 months (WMD = 1.31, 95% CI: 0.87, 1.76, I2 = 0), to 6 months (WMD = 2.36, 95% CI: 1.93, 2.79, I2 = 24.3%), and to 12 months (WMD = 1.67, 95% CI: 0.41, 2.93, I2 = 90.9%). RRCS also achieved a better recovery of the urological and sexual function than LRCS for patients with RC. Larger-scale prospective randomized control trials are needed to verify these results.

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PURPOSE: To understand referral practices for rectal cancer surgical care and to secondarily determine differences in referral practices by two main hypothesized drivers of referral: the rurality of the community endoscopists' practice and their affiliation with a colorectal surgeon. METHODS: Community gastroenterologists and general surgeons in Iowa completed a mailed questionnaire on practice demographics, volume, and referral practices for rectal cancer patients. Rurality was operationalized with RUCA codes. RESULTS: Twenty-two of 53 gastroenterologists (42%) and 120 of 188 general surgeons (64%) (total 144/241, 60%) in Iowa responded. Most performed colonoscopies, including 22 gastroenterologists (100%) and 96 general surgeons (80%). Regular referral of rectal cancer patients to colorectal surgeons was reported for 57% of urban physicians affiliated with a colorectal surgeon, 33% of urban physicians not affiliated with a colorectal surgeon, and 57% and 72% of physicians in large and small rural areas, respectively, who were not affiliated with a colorectal surgeon. High surgeon volume, high hospital volume, and colorectal surgeon specialty were important factors in the referral decisions for over half the physicians. 69% of diagnosing urban general surgeons reported performing rectal cancer surgery about half the time or more, while 85% of small rural and 60% of large rural diagnosing general surgeons reported never or rarely performing rectal cancer surgery. CONCLUSIONS: Diagnosing physicians have variable rectal cancer referral practices, including consistency in referred to surgeon and prioritization of volume and specialization. Prioritizing specialized or high-volume rectal cancer surgical care would require changing existing referring patterns.

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La exenteración pélvica masculina es un procedimiento complejo con elevada morbilidad. En casos muy seleccionados, el abordaje robótico puede facilitar la disección y reducir la morbilidad gracias a la mejor visión y versatilidad de movimientos. Describimos la técnica de exenteración pélvica robótica sistematizada con DaVinci Xi y sus variantes en varones, tras haber intervenido tres casos en nuestro Centro. Describimos la colocación de trocares, material necesario, localización de minilaparotomía y secuencia de los procedimientos a realizar paso a paso. Distinguimos tres supuestos: exenteración pélvica total con amputación de recto, colostomía y urostomía; exenteración pélvica con preservación de esfínter, anastomosis colo-rectal/anal y urostomía; exenteración pélvica con amputación de recto, colostomía y reconstrucción de tracto urinario. (AU)

Male pelvic exenteration is a challenging procedure with high morbidity. In very selected cases robotic approach could make dissection easier and decrease morbidity due to a better view and higher range of movements. In this paper we describe port placement, instruments, minilaparotomy location and sequence of procedures step by step. We differentiate three situations: total pelvic exenteration with abdominoperineal resection, colostomy and urostomy; pelvic exenteration with colo-rectal/anal anastomosis and urostomy; pelvic exenteration with abdominoperineal resection, colostomy and urinary tract reconstruction. (AU)

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BACKGROUND: Total mesorectal excision along the "holy plane" is the only radical surgery for rectal cancer, regardless of tumor size, localization or even tumor stage. However, according to the concept of membrane anatomy, multiple fascial spaces around the rectum could be used as the surgical plane to achieve radical resection. AIM: To propose a new membrane anatomical and staging-oriented classification system for tailoring the radicality during rectal cancer surgery. METHODS: A three-dimensional template of the member anatomy of the pelvis was established, and the existing anatomical nomenclatures were clarified by cadaveric dissection study and laparoscopic surgical observation. Then, we suggested a new and simple classification system for rectal cancer surgery. For simplification, the classification was based only on the lateral extent of resection. RESULTS: The fascia propria of the rectum, urogenital fascia, vesicohypogastric fascia and parietal fascia lie side by side around the rectum and form three spaces (medial, middle and lateral), and blood vessels and nerves are precisely positioned in the fascia or space. Three types of radical surgery for rectal cancer are described, as are a few subtypes that consider nerve preservation. The surgical planes of the proposed radical surgeries (types A, B and C) correspond exactly to the medial, middle, and lateral spaces, respectively. CONCLUSION: Three types of radical surgery can be precisely defined based on membrane anatomy, including nerve-sparing procedures. Our classification system may offer an optimal tool for tailoring rectal cancer surgery.

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OBJECTIVES: This study aimed to examine the effectiveness of a bowel function improvement program for male patients with rectal cancer who underwent low anterior resection. METHODS: A prospective, unblinded, and randomized controlled trial was conducted. The enrolled 42 patients were assigned to the experimental or control group at a 1:1 ratio. The bowel function improvement program comprised a 4-week intensive program (face-to-face education and telephone coaching) and an 8-week maintenance program (text messages). Self-efficacy, bowel function, health-related quality of life, and healthcare resource utilization were measured. Collected data were analyzed using independent t-tests, chi-square tests, analysis of covariance, and generalized estimation equations to evaluate the effects of the program based on intention-to-treat. RESULTS: The bowel function improvement program was effective in improving bowel function 3 months after discharge. Additionally, the number of unplanned pharmacy visits was lower in the experimental group than in the control group. Health-related quality of life, self-efficacy, and utilization of other healthcare resources were not statistically or clinically significant. CONCLUSION: These findings indicated that the bowel function improvement program for male patients with rectal cancer was effective in improving bowel function and reducing unplanned healthcare resource utilization. The bowel function improvement program can be delivered as a nurse-led program in clinical practice to promote early recovery after low anterior resection. TRIAL REGISTRATION NUMBER: KCT0003505. https://cris.nih.go.kr/cris/search/detailSearch.do/13708.

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Male pelvic exenteration is a challenging procedure with high morbidity. In very selected cases, the robotic approach could make dissection easier and decrease morbidity due to the better vision provided and higher range of movements. In this paper, we describe port placement, instruments, minilaparotomy location, and the stepwise sequence of these procedures. We address 3 different situations: total pelvic exenteration with abdominoperineal resection, colostomy and urostomy; pelvic exenteration with colorectal/anal anastomosis and urostomy; and pelvic exenteration with abdominoperineal resection, colostomy and urinary tract reconstruction.

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The narrow pelvis causes special challenges in surgery, and robotic-assisted surgery has been proven beneficial in these circumstances. While robotic surgery has some specific advantages in rectal cancer surgery, there is still limited evidence of the learning curve of the technique involved. The aim here was to study the transition from laparoscopic to robotic-assisted surgery among experienced laparoscopic surgeons. The data for this study were collected from a prospectively compiled register that includes patients operated on by the Da Vinci Xi robot in Tampere University Hospital. Each consecutive rectal cancer patient was included. The information on the surgical and oncological outcomes was analysed. The learning curve was assessed using cumulative sum (CUSUM) analysis. CUSUM already demonstrated an overall positively sloped curve at the beginning of the study, with neither the conversion rate nor morbidity reaching unacceptable thresholds. Conversions (4%) and postoperative complications (Clavien-Dindo III-IV 15%, no intraoperative complications) were rare. One patient died within one month and the death was not procedure-associated. While surgical and oncological outcomes were similar among all surgeons, the console times showed a decreasing trend and were shorter among those with more experience in laparoscopic rectal cancer surgery. Robotic-assisted rectal cancer surgery can be safely adapted by experienced laparoscopic colorectal surgeons.

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BACKGROUND/AIM: The safety of carbon-ion radiotherapy (CIRT) for patients with prostate cancer after rectal cancer surgery remains unknown. This is a retrospective analysis of the safety of CIRT in patients with prostate cancer after rectal cancer surgery. PATIENTS AND METHODS: The subjects were 13 consecutive patients with prostate cancer who underwent CIRT after rectal cancer surgery at the Kanagawa Cancer Center from December 2015 to April 2022. A total dose of 51.6 Gy (relative biological effectiveness) was administered in 12 fractions over 3 weeks. The criteria stated in the Common Terminology Criteria for Adverse Events, version 5.0, were used to assess toxicity. Fisher's exact test was performed to assess the associations between patient clinical factors and rectal toxicity. RESULTS: The median patient age was 71 years (range=66-83 years). The median observation period was 27.4 months (range=10.6-82.4 months). The median duration from rectal surgery to CIRT was 6.9 years (1.0-16.8 years). Five (38.5%) and six (46.2%) patients had a planning target volume (PTV)-adjacent rectal anastomosis and diabetes mellitus, respectively, and two (15.4%) patients had both. Grades 1 and 2 late gastrointestinal toxicities were observed in one case each. Development of gastrointestinal toxicity was significantly associated with both a PTV adjacent rectal anastomosis and diabetes mellitus (p=0.013). CONCLUSION: Late gastrointestinal toxicity was tolerable in patients with prostate cancer treated with CIRT after rectal cancer surgery. Patients with both a PTV adjacent rectal anastomosis and diabetes mellitus were more likely to experience late gastrointestinal toxicity.

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Aim: The best bowel preparation method for rectal surgery remains controversial. In this study we compared the efficacy and safety of mechanical bowel preparation (MBP) alone and MOABP (MBP combined with oral antibiotic bowel preparation [OABP]) for rectal cancer surgery. Methods: In this retrospective study we analyzed data from the Japanese Diagnosis Procedure Combination (DPC) database on 37 291 patients who had undergone low anterior resection for rectal cancer from 2014 to 2017. Propensity score matching analysis was used to compare postoperative outcomes between MBP alone and MOABP. Results: A total of 37 291 patients were divided into four groups: MBP alone: 77.7%, no bowel preparation (NBP): 16.9%, MOABP: 4.7%, and OABP alone: 0.7%. In propensity score matching analysis with 1756 pairs, anastomotic leakage (4.84% vs 7.86%, P < 0.001), small bowel obstruction (1.54% vs 3.08%, P = 0.002) and reoperation (3.76% vs 5.98%, P = 0.002) were less in the MOABP group than in the MBP group. The mean duration of postoperative antibiotics medication was shorter in the MOABP group (5.2 d vs 7.5 d, P < 0.001) than in the MBP group. There was no significant difference between the two groups in the incidence of Clostridium difficile (CD) colitis (0.40% vs 0.68%, P = 0.250) and methicillin-resistant Staphylococcus aureus (MRSA) colitis (0.11% vs 0.17%, P = 0.654). There was no significant difference in in-hospital mortality between the two groups (0.00% vs 0.11% respectively, P = 0.157). Conclusion: MOABP for rectal surgery is associated with a decreased incidence of postoperative complications without increasing the incidence of CD colitis and MRSA colitis.

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BACKGROUND: D3 lymph node dissection with left colic artery (LCA) preservation in rectal cancer surgery seems to have little effect on reducing postoperative anastomotic leakage. So we first propose D3 lymph node dissection with LCA and first sigmoid artery (SA) preservation. This novel procedure deserves further study. METHODS: Rectal cancer patients who underwent laparoscopic D3 lymph node dissection with LCA preservation or with LCA and first SA preservation between January 2017 and January 2020 were retrospectively assessed. The patients were categorized into two groups: the preservation of the LCA group and the preservation of the LCA and first SA group. A 1:1 propensity score-matched analysis was performed to decrease confounding. RESULTS: Propensity score matching yielded 56 patients in each group from the eligible patients. The rate of postoperative anastomotic leakage in the preservation of the LCA and first SA group was significantly lower than that in the LCA preservation group (7.1% vs. 0%, P=0.040). No significant differences were observed in operation time, length of hospital stay, estimated blood loss, length of distal margin, lymph node retrieval, apical lymph node retrieval, and complications. A survival analysis showed patients' 3-year disease-free survival (DFS) rates of group 1 and group 2 were 81.8% and 83.5% (P=0.595), respectively. CONCLUSION: D3 lymph node dissection with LCA and first SA preservation for rectal cancer may help reduce the incidence of anastomotic leakage without compromising oncological outcomes compare with D3 lymph node dissection with LCA preservation alone.

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Background: There is controversy about the outcomes of prophylactic ileostomy via the specimen extraction site (SES) after laparoscopic rectal cancer surgery (LRCS). We, therefore, performed a meta-analysis to determine the efficacy and safety of stoma through the SES versus new site (NS). Methods: All relevant studies from 1997 to 2022 were searched in the PubMed, EMBASE, Cochrane Library, CNKI, VIP databases. This meta-analysis was performed using RevMan software 5.3 for statistical analysis. Results: 7 studies with 1736 patients were included. The present meta-analysis noted that prophylactic ileostomy via SES was associated with a higher risk of overall stoma-related complications, especially parastomal hernia (OR, 2.39, 95% CI 1.43-4.00; p=0.0008). No statistical difference was found in terms of wound infection, ileus, stoma edema, stoma prolapse, stoma necrosis, stoma infection, stoma bleeding, stoma stenosis, skin inflammation around the stoma, stoma retraction and postoperative pain score on postoperative day 1 and 3 between SES group and NS group. However, prophylactic ileostomy via SES was associated with lesser blood loss (MD = -0.38, 95% CI: -0.62 - -0.13; p=0.003), shorter operation time(MD = -0.43, 95% CI: -0.54 - -0.32 min; p<0.00001), shorter post-operative hospital stay (MD = -0.26, 95% CI: -0.43 - -0.08; p=0.004), shorter time to first flatus(MD = -0.23, 95% CI: -0.39 - -0.08; p=0.003) and lower postoperative pain score on postoperative day 2. Conclusion: Prophylactic ileostomy via SES after LRCS reduces new incision, decreases operative time, promotes postoperative recovery, and improves cosmetic outcomes, but may increase the incidence of parastomal hernias. The vast majority of parastomal hernias can be repaired by closing the ileostomy, therefore SES remain an option for temporary ileostomy after LRCS.

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INTRODUCTION: The oncological outcomes of low ligation (LL) compared to high ligation (HL) of the inferior mesenteric artery (IMA) during low-anterior rectal resection (LAR) with total mesorectal excision are still debated. The aim of this study is to report the 5 year oncologic outcomes of patients undergoing laparoscopic LAR with either HL vs. LL of the IMA MATERIALS AND METHODS: Between June 2014 and December 2016, patients who underwent elective laparoscopic LAR + TME in 6 Italian non-academic hospitals were randomized to HL or LL of IMA after meeting the inclusion criteria (HighLow trial; ClinicalTrials.gov Identifier NCT02153801). We analyzed the rate of local recurrence, distant metastasis, overall survival, disease-specific survival, and disease-free survival at 5 years of patients previously enrolled. RESULTS: Five-year follow up data were available for 196 patients. Recurrence happened in 42 (21.4%) of patients. There was no statistically significant difference in the distant recurrence rate (15.8% HL vs. 18.9% LL; P = 0.970) and pelvic recurrence rate (4,9% HL vs 3,2% LL; P = 0.843). No statistically significant difference was found in 5-year OS (p = 0.545), DSS (p = 0.732) or DFS (p = 0.985) between HL and LL. Low vs medium and upper rectum site of tumor, conversion rate, Clavien-Dindo post-operative grade ≥3 complications and tumor stage were found statistically significantly associated to poor oncological outcomes in univariate analysis; in multivariate analysis, however, only conversion rate and stage 3 cancer were found to be independent risk factors for poor DFS at 5 years. CONCLUSION: We confirmed the results found in the previous 3-year survival analysis, the level of inferior mesenteric artery ligation does not affect OS, DSS and DFS at 5-year follow-up.

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