Aim: Anastomotic leakage (AL) remains one of the most serious complications following rectal cancer surgery, particularly in low rectal anastomoses. Endoluminal vacuum therapy (EVT) has emerged as a minimally invasive treatment option aimed at controlling pelvic sepsis and preserving the anastomosis. This study aimed to evaluate the clinical outcomes, safety, and feasibility of EVT in the management of AL following rectal cancer resection. Method: A retrospective two-center case series was conducted between January 2020 and December 2025, including patients who developed AL following rectal cancer surgery and were treated with EVT. Clinically stable patients without generalized peritonitis were included, whereas patients requiring emergency surgical intervention were excluded. Demographic characteristics, leakage features, EVT-related variables, treatment outcomes, and complications were analyzed. Results: A total of 13 patients were included in the study. The mean age was 57.7±12.3 years, and all patients had a protective diverting stoma at the time of EVT initiation. AL was diagnosed at a median of 10 postoperative days (range, 6-115), with most leaks located in low rectal anastomoses (mean leak level: 4.7±1.8 cm from the anal verge); EVT was initiated at a median of 12 postoperative days (range, 8-120). The median number of EVT sessions was three (range, 2-6), and the median time to clinical healing was 16 days (range, 12-34). Clinical resolution of AL was achieved in 12 patients, resulting in an overall success rate of 92.3%; EVT-related complications occurred in 2 patients (15.4%), including one anastomotic stricture, successfully managed with endoscopic balloon dilatation, and one rectovaginal fistula, which required a Hartmann procedure and was considered a treatment failure. No pelvic abscess was observed. Diverting ileostomies were closed 1 month after confirmed healing in all eligible patients. Conclusion: EVT appears to be a promising and feasible minimally invasive treatment option for AL following rectal cancer surgery, particularly in carefully selected clinically stable patients with low rectal anastomoses. The high success rate, acceptable morbidity, and low need for reoperation suggest that EVT may represent a valuable anastomosis-preserving strategy. Larger prospective studies are needed to better define optimal patient selection and treatment timing.
Aim: Retrorectal tumors represent a rare and heterogeneous group of presacral lesions with diverse embryologic origins and pathologic features. Their deep pelvic location and often non-specific presentation pose challenges for both diagnosis and operative planning, and surgical decision-making is frequently guided by anatomy and imaging rather than robust comparative evidence. Method: We retrospectively reviewed adult patients who underwent surgical resection for primary retrorectal tumors between 2016 and 2025 at a tertiary referral center. Preoperative assessment relied mainly on magnetic resonance imaging, with the choice of surgical approach determined by tumor extent in relation to the S3 vertebral level. Demographic data, operative details, histopathologic findings, and postoperative outcomes were evaluated. Results: The study included 16 patients, with a mean age of 48.3±14.2 years and a predominance of female patients. Most tumors were located below the S3 level and were treated via a posterior approach, whereas anterior or combined approaches were selected for lesions with cranial extension. Congenital lesions were most common, whereas malignant tumors accounted for 31.2% of cases and consisted exclusively of chordomas. Macroscopically complete resection was achieved in all patients; one chordoma demonstrated microscopic margin involvement. Postoperative complications were generally low grade, no perioperative mortality occurred, and tumor recurrence was observed in a single patient during follow-up. Conclusion: This single-center experience suggests that preoperative imaging and anatomical considerations may assist surgical planning and enable safe tumor resection in patients with retrorectal tumors.
Aim: Minimally invasive surgical techniques for hemorrhoidal disease aim to reduce symptom burden while preserving anorectal function and improving patient-centered outcomes. However, real-world data on both clinical severity and quality-of-life (QoL) outcomes following these procedures remain limited. Method: This single-center retrospective observational study included patients who underwent Doppler-guided hemorrhoidal artery ligation (DG-HAL) for symptomatic hemorrhoidal disease. Demographic data, operative time, and postoperative complications were recorded. Symptoms such as bleeding, soiling, prolapse, and pain were assessed both preoperatively and postoperatively using validated assessment tools; QoL was measured using the Short Form Survey-36 (SF-36) and the World Health Organization QoL-BREF (WHOQOL-BREF) questionnaire. The Hemorrhoidal Disease Symptom Score (HDSS), Wexner Score, and visual analogue scale (VAS) scores were also used to assess the symptomatic improvement. The primary outcome measures were patient satisfaction, QoL, hemorrhoidal symptom scores, and postoperative pain levels. The secondary outcomes were complete healing and recurrence rates. Results: Treatment with DG-HAL was associated with a clinically meaningful reduction in HDSS scores following the procedure. Exploratory analyses demonstrated improvements across multiple domains of WHOQOL-BREF and SF-36; VAS scores also showed improvement on postoperative day 7. Only one patient experienced a complication, namely, persistent anal pain lasting for 1 month; however, by the 2nd postoperative month, the pain had completely resolved. Two patients experienced recurrence postoperatively and subsequently underwent hemorrhoidectomy. Conclusion: In this real-world cohort, DG-HAL was associated with improvement in symptom severity and exploratory QoL measures. These findings require further prospective studies focusing on patient-centered outcomes following minimally invasive surgical treatment.
Aim: Despite the global rise in young‑onset colorectal cancer (CRC), data on the diagnostic yield of colonoscopy in symptomatic adults aged <50 years remain scarce. This study evaluates colonoscopic findings and identifies predictors of clinically significant pathology in this cohort. Method: This retrospective study included symptomatic adults aged 18-49 years who underwent colonoscopy between January 2017 and June 2023 at a Malaysian tertiary referral center. Clinical, endoscopic, histopathological, and complication data were analyzed. Univariate analysis identified predictors of clinically significant pathology, defined as CRC, adenomas (including advanced adenomas), histologically confirmed inflammatory bowel disease (IBD), or diverticulosis, whereas hyperplastic polyps, hemorrhoids, and non-specific colitis were considered non-significant. Results: Among the 397 patients included (mean age 37±8 years; 51% women), the most common indications were altered bowel habits (n=178), abdominal pain (n=126), and rectal bleeding (n=149). Clinically significant pathology was identified in 15.9% of patients, comprising CRC (3.3%), adenomas (5.8%), IBD (2.8%), and diverticulosis (4.0%). Hyperplastic polyps (8.8%) were excluded from clinically significant pathology and reported separately. Rectal bleeding odds ratio (OR) 2.29, 95% confidence interval (CI) 1.22-4.30; p=0.009, weight loss (OR 4.87, 95% CI 1.49-15.87; p=0.009), and altered bowel habits (OR 1.95, 95% CI 1.07-3.56; p=0.03) were independent predictors. No major procedural complications were observed. The adenoma detection rate was 5.8%, and the colonoscopy completion rate was 81.4%, with incomplete procedures mainly due to looping, obstructing lesions, or poor bowel preparation. Conclusion: A substantial proportion of symptomatic adults aged <50 years demonstrate clinically significant pathology. These findings support prioritized, symptom-based referral for early colonoscopy rather than universal screening in this age group but require validation in prospective multicenter studies.
Triangular excision with an advancement flap is an effective yet underreported technique for pilonidal sinus disease with unilateral superolateral secondary pits, where minimally invasive methods often fail. The inverted triangular design allows complete excision of the sinus cavity and pits, and the defect is closed with a tension-free advancement flap, ensuring rapid recovery. Applicable to disease of varying vertical extent within or beyond the navicular area, this approach preserves healthy tissue and provides a practical alternative to conventional flap procedures.
Aim: The aim of this retrospective cohort study was to evaluate the perioperative and long-term oncological outcomes of patients with malignant colonic obstruction who underwent self-expandable metallic stent (SEMS) implantation as a bridge to surgery (BTS), followed by elective laparoscopic colectomy. Method: One-hundred two consecutive patients initially managed with a SEMS implantation as a BTS constituted a modified intention-to-treat cohort and were retrospectively analyzed. Ninety-five of these patients (the per-protocol cohort) went on to undergo a resection with curative intent between 2013 and 2023 at a tertiary referral center. Clinical demographics, operative findings, pathological results, postoperative complications, and survival outcomes for all participants were systematically recorded. The primary endpoints were overall survival, laparoscopic completion rate, and R0 resection rate. Secondary endpoints included postoperative morbidity, anastomotic leakage, recurrence, distant metastasis, disease-free survival, metastasis-free survival, and stent-to-surgery interval. Median follow-up values were calculated using the reverse Kaplan-Meier method. Results: Stent placement was technically successful in all (95/95) patients in the operative (per-protocol) cohort. The mean interval between SEMS placement and surgery was 10±3 days. Laparoscopic resection was completed in 84.2% of these patients, whereas 15.8% required a conversion to open surgery. The mean operative time was 148±32 minutes, and intraoperative complications occurred in 4.2% of cases. An adequate lymphadenectomy count (≥12 nodes) was achieved in over 90% of patients, with a median lymph node yield of 21. The R0 resection rate was 93.7%. Postoperative complications, including anastomotic leakage, occurred in approximately 40% of patients, including both laparoscopic and open surgery cases. No 30-day mortality was observed. During the reverse Kaplan-Meier median follow-up period of 31.8 months, recurrence occurred in 28.4% of cases, and distant metastasis in 21.0%. The 3-year OS rate was 76%, with no significant difference between laparoscopic and open surgery procedures (p>0.05). Kaplan-Meier curves with number-at-risk tables support these findings. Conclusion: Endoscopic stenting, followed by elective laparoscopic colectomy, represents a feasible and clinically sound BTS strategy for malignant colonic obstruction. This approach provides acceptable perioperative outcomes, enables high rates of minimally invasive resection, and does not appear to negatively influence medium-term oncological outcomes in appropriately selected patients. Further prospective studies are needed to refine the patient selection process and validate the long-term oncologic safety of this approach.
Aim: Acute appendicitis during pregnancy presents a diagnostic challenge due to physiological and anatomical changes that can obscure classical symptoms. This study aimed to evaluate the predictive value of inflammatory markers—particularly C-reactive protein (CRP) and the CRP/albumin ratio (CAR)—for detecting complicated acute appendicitis in pregnant women. Method: This retrospective study included 67 pregnant patients who underwent appendectomy for acute appendicitis between October 2019 and December 2024. Patients were categorized into complicated and non-complicated appendicitis groups based on histopathological findings. Laboratory parameters comprising the platelet-to-lymphocyte ratio, lymphocyte-to-monocyte ratio, neutrophil-to-lymphocyte ratio, systemic immune inflammation index, systemic inflammatory response index, receiver operating characteristic (ROC) curve, and decision curve analysis (DCA) were used to assess diagnostic and clinical performance. Results: Complicated appendicitis was identified in 25.4% (n=17) of patients. Multivariate regression demonstrated that CRP [odds ratio (OR)=1.095; 95% confidence interval (CI)=1.042-1.151; p<0.001] and CAR (OR=23.863; 95% CI=4.223-134.830; p<0.001) were independent predictors. The ROC analysis demonstrated high diagnostic accuracy for CRP [area under the curve (AUC)=0.954] and CAR (AUC=0.946). The DeLong test revealed no significant difference between CRP and CAR (p=0.878), and DCA confirmed that both markers provided higher net clinical benefit than “treat-all” or “treat-none” strategies. Conclusion: The results show that CRP and CAR may be promising, cost-effective biomarkers for early identification of complicated appendicitis in pregnancy, particularly where imaging is limited, but these single-center data require cautious interpretation and external validation before routine clinical use.
Aim: This retrospective cohort study used the Turkish Society of Colon and Rectal Surgery Colorectal Cancer Database to compare the preoperative clinical characteristics and 30-day postoperative outcomes of patients undergoing curative surgery for adenocarcinomas of the sigmoid colon, rectosigmoid junction, and upper rectum. Method: Patients who underwent curative resection for non-metastatic adenocarcinoma of the sigmoid colon, rectosigmoid junction, or upper rectum between January 2017 and January 2025 were identified. Tumors ≥10 cm from the anal verge were classified as upper rectal cancers. The three anatomical groups were compared regarding clinical parameters, 30-day outcomes, and histopathology. Statistical comparisons were performed using the chi-squared or Fisher’s exact tests for categorical variables and the t-test or Mann-Whitney U test for continuous variables. Results: A total of 634 patients were analyzed [sigmoid: 274 (43.3%), rectosigmoid: 174 (27.4%), upper rectum: 186 (29.3%)]. Patients with sigmoid cancer were older (mean 64±12 years) with a higher proportion of women (42%) than those with rectosigmoid and upper rectum cancer (p-value <0.001). Magnetic resonance imaging use was significantly higher in upper rectal tumors (73%) than in rectosigmoid (11%) and sigmoid (0%) tumors. Neoadjuvant therapy was administered to 62% of upper rectal and 11% of rectosigmoid tumors but only 4% of sigmoid tumors (p-value <0.001). Stage III disease occurred more frequently in rectosigmoid (40%) and upper rectum (55%) cancer than in sigmoid (32%) cancer (p-value <0.001). Lymph node positivity was highest in the upper rectum (57%). Conclusion: Significant differences in diagnostic workup and treatment strategies exist across these segments. Rectosigmoid tumors share oncologic characteristics with rectal tumors but are often managed as colonic cancers, highlighting the need for clearer anatomical definitions and treatment guidelines.
Ogilvie’s syndrome, or acute colonic pseudo-obstruction, is a rare but potentially life-threatening condition characterized by massive colonic dilatation in the absence of mechanical obstruction. It predominantly affects elderly and postoperative patients. Cases in younger individuals who are neurologically impaired remain exceedingly rare. We report a 39-year-old man with severe intellectual disability and lifelong immobility who presented with progressive abdominal distension and no defecation for 72 hours. Computed tomography imaging revealed diffuse colonic dilatation with a cecal diameter of 9.2 cm. Mechanical obstruction was excluded. Due to the unavailability of neostigmine, the patient was managed conservatively using nasogastric decompression, rectal tube placement, and intravenous metoclopramide. Substantial clinical improvement occurred within 24 hours, with the complete resolution of symptoms by day 4. The patient was discharged with a structured bowel regimen and showed no recurrence at early follow-up. Informed consent for publication was obtained from the patient’s legal guardians prior to the writing of this case report. This case highlights a rare presentation of Ogilvie’s syndrome in a young adult with neurodevelopmental impairment and demonstrates that non-pharmacological conservative treatment may be sufficient in the absence of neostigmine.
Robotic platforms are being adopted in surgery at an increasingly rapid pace, with implications for the field of general surgery and residency training. This evolution has prompted discussion on the ideal methods used to train current surgical residents in the use of robotic platforms. The colorectal surgery department at our institution has implemented a standardized robotic surgery curriculum designed to establish clear expectations for residents’ progression, autonomy, and the skills that should be acquired by the conclusion of their training. The curriculum outlines key surgical objectives, representing essential steps that require distinct skills and anatomical knowledge, organized by postgraduate year level as a general guide to the resident’s ability. The goals of this standardized curriculum include increasing resident engagement in acquiring robotic skills, dividing complete procedures into manageable steps and objectives, and promoting faculty participation to allow residents to operate independently, within defined competency levels. Upon completion of the curriculum, residents report confidence in performing common robotic colorectal surgeries. We aim to expand the implementation of this curriculum model to other departments within our institution and encourage the adoption of similar standardized robotic training by other academic centers in this new era of robotic surgery. To underscore the benefits and importance of a standardized robotic surgery curriculum for residents with our experience in the division of colorectal surgery.
Aim: Serum lactate dehydrogenase (LDH) may be a prognostic marker in metastatic colorectal cancer (mCRC). However, mCRC is a heterogeneous disease, and data on LDH-related subgroups are limited. This study aimed to investigate clinical and molecular features associated with LDH in mCRC. Method: Demographic, clinical, treatment response, and survival data from a retrospective cohort of patients diagnosed with synchronous mCRC between 2019 and 2023 were analyzed according to serum LDH levels. Lactate dehydrogenase A (LDHA) gene expression and molecular features were assessed in an independent cohort. Results: The clinical cohort included 135 patients. The median LDH level was 231 U/L (range: 106-5,655), and 55.1% (n=75) of patients had high LDH. The presence of liver metastases (p=0.037), the number of liver metastases (≥5 vs. <5, p=0.035), carcinoembryonic antigen (p=0.000), carbohydrate antigen 19-9 (p=0.042), and C-reactive protein (p=0.002) levels were significantly associated with high LDH. Among patients with liver-only metastases, high LDH was significantly associated with worse overall survival (OS) (19.7 months [95% confidence interval (CI): 13.8-28.1] vs. 39.0 months (95% CI: 19.8-59.2), p=0.017). Non-responders to 5-fluorouracil, leucovorin, and oxaliplatin had higher LDH levels (p=0.016) and worse OS [11.4 months (95% CI: 6.2-12.7) vs. not reached, p=0.002]. Among 84 patients in the independent mCRC cohort, 16.7% (n=14) had high LDHA expression in tumor tissue. High LDHA expression was associated with lower microsatellite instability scores (p=0.048) and higher hypoxia scores (p for Buffa=0.001, Winter=0.003), but not with tumor mutational burden or aneuploidy score. Expression of metabolic–epithelial–mesenchymal transition pathway genes was correlated with LDHA expression. Conclusion: LDH may be a potential marker in microsatellite-stable (MSS), nonimmunogenic, liver-dominant mCRC. Whether LDH could serve as a biomarker for immunotherapy studies in MSS colorectal cancer warrants investigation in future studies.
Blastocystis hominis (B. hominis) is an intestinal parasite that is usually asymptomatic and transmitted by the feco-oral route. It is commonly found in human and animal fecal samples. The role of Blastocystis in human health and disease is controversial. Studies have shown a relationship between subtypes and symptom presentation. Patients frequently present with abdominal pain, nausea, bloating, and diarrhea. In our case, intestinal obstruction was observed, which is the exact opposite of the usual B. hominis symptoms. The patient was evaluated for malignancy. On radiologic examination, the appearance of an almost complete obstruction of the distal sigmoid colon passage was highly suspicious of malignancy. An endoscopic evaluation revealed a mass almost completely obstructing the lumen. Malignancy was not pathologically confirmed. We performed surgical treatment in accordance with oncologic principles. This study aimed to share our experience in the diagnosis and treatment of an obstructive mass caused by a single-celled organism.
A 26-year-old man underwent appendectomy for acute phlegmonous appendicitis, and postoperative histopathology revealed a well-differentiated appendiceal neuroendocrine tumor (NET) (G1, 1.3 cm, Ki-67 <1%), confined to the subserosa without mesoappendiceal invasion or lymphovascular/perineural involvement. Surgical margins were clear, and the patient recovered uneventfully. According to guidelines, right hemicolectomy is selectively considered for 1-2 cm tumors with high-risk features. As none were present, appendectomy was deemed sufficient following a multidisciplinary team review. This case highlights the importance of thorough histopathological assessment and individualized management of incidentally detected appendiceal NETs within the 1-2 cm gray-zone category.
Aim: Pilonidal sinus is a common condition in general surgery practice, with various treatment options available. Treatment effectiveness varies based on individual patient characteristics, and recurrence rates of up to 30% have been reported. Crystallized phenol has gained attention as a minimally invasive method due to its low morbidity and enhanced patient comfort. This study aimed to examine the clinical effectiveness of crystallized phenol and factors influencing recurrence. Method: This retrospective cohort study included 82 patients aged 18 years and older treated between September 2022 and September 2024. Data on age, body mass index (BMI), gender, sinus number, hospital stay, return to normal activities, follow-up duration, and complications were collected. Patients were followed up at 1 and 30 days post-procedure and for an average of 2 years. Recurrence rates were recorded through clinic examination. Results: Eighty-two patients (54 men) were included in the study. The mean age was 25.9±8.1 years, and the mean BMI was 28.7±3.9, with 17.6% of patients classified as obese. Crystallized phenol was applied under spinal anesthesia in 63 cases (76.8%). At the end of the follow-up period, a 10% recurrence rate was observed. Conclusion: Crystallized phenol is a minimally invasive, low-complication treatment that enables a quick return to daily life. High BMI and sinus pit number were identified as significant factors for recurrence. Similar recurrence rates were observed across centers, highlighting the consistency of the method. Further prospective randomized controlled trials are needed to confirm these findings.
