Background The double-stapled anastomosis (DSA) technique is widely considered the standard approach for colorectal anastomosis after anterior rectal resection (AR). Recently, the single-stapled anastomosis (SSA) technique has gained attention because it may reduce potential weak points that could contribute to anastomotic leakage by avoiding stapler line intersections. This systematic review and meta-analysis aim to compare surgical and functional outcomes between SSA and DSA. Methods A systematic literature search of PubMed, Embase-Medline, and the Cochrane Library was performed in November 2025 to identify studies comparing SSA and DSA after AR. The endpoints were postoperative complications and major low anterior resection syndrome (LARS). A random-effect meta-analysis was performed to synthesise the results. Results Thirteen studies met the inclusion criteria and were included in the meta-analysis (nine cohort studies, one matched case-control study, and three randomised controlled trials). Indications for AR included colorectal cancer, diverticular disease, inflammatory bowel disease, and endometriosis. Overall, 2,537 patients were analysed. SSA was associated with a non-significant reduction in the risk of anastomotic leak (RR 0.77, 95% CI 0.46–1.31; I2 = 49.3%), major postoperative complications (RR 0.67, 95% CI 0.37–1.20; I2 = 4.1%), and anastomotic stricture (RR 0.19, 95% CI 0.02–1.92) compared with DSA. The major LARS risk was similar across techniques (RR 0.94, 95% CI 0.39–2.30). Conclusions SSA appears to be a safe alternative to the DSA technique after restorative AR. Although no statistically significant differences were observed in anastomotic leak, postoperative complications, anastomotic stricture and major LARS risk, SSA may represent a technically appealing option. Further large multicentre randomised trials are required.

BACKGROUND:We aimed to evaluate the impact of advanced medical therapies (biologicals and small molecules) on time to colectomy and oncological outcomes in ulcerative colitis (UC). METHODS:This cohort study included UC patients who underwent colectomy between 2003 and 2022 at 2 referral centers in Belgium and the Netherlands. Exposure was the use of advanced medical therapies. Primary outcomes were time to colectomy and colorectal cancer (CRC) rate, compared between 4 periods: P1 (2003-2007), P2 (2008-2012), P3 (2013-2017), and P4 (2018-2022). Secondary outcomes were oncological outcomes, including incidental cancers found unexpectedly in resection specimens or during endoscopic follow-up for medication switch. RESULTS:Among 716 patients, the usage of advanced therapies increased from 36.8% in P1 to 89.7% in P4 (P < .0001). Median time to colectomy remained comparable (P1: 7.1 years [interquartile ranges (IQR), 2.8-12.9] vs P4: 7.2 years [IQR, 2.7-14.6]; P = not significant). Colectomy and colorectal cancer was diagnosed in 72 (10.1%) patients, with no significant change over time (P = .44). Proportion of CRC was lower in patients treated with advanced therapies (4.7% vs 23.6%, P < .0001) and related to a shorter follow-up (median 6.1 vs 10.3 years, P < .0001). Advanced therapy patients had higher incidental cancer rates (37.5% vs 8.3%, P = .002), which was associated with reduced CRC-related survival (HR for CRC-related death: 3.3, 95% CI 1.17-9.4; P = .02). CONCLUSION:Despite increased usage of advanced medical therapies, time to resection and CRC rates have remained unchanged in UC patients undergoing colectomy over the past 2 decades. Advanced therapy patients had higher incidental cancers rates, associated with decreased CRC survival. Awareness of timely colectomy is crucial for this group.

Background The transanal transection and single-stapled anastomosis (TTSS) is gaining interest as a reconstructive technique whenever a restorative procedure after a total mesorectal excision (TME) is planned. TTSS, allowing lower anastomoses than the conventional DS technique, may raise discussion about its functional outcomes. The aim of this study was to compare long-term functional outcomes of TTSS and DS techniques performed after TME for rectal cancer (RC). Methods This was a prospective, observational, two-parallel cohort study. Consecutive patients undergoing stoma closure after TME for RC with either TTSS or DS approach were included. The Low Anterior Resection Syndrome (LARS) questionnaire was delivered at 6, 12, and 24 months after stoma closure through a web link embedded in a Short Message System (SMS) or email using an electronic system (Esosphera Srl). Results According to sample size calculation, 116 patients (58 per cohort) were included. No difference in the LARS score was found at 6 and 12 months, while a significantly lower median LARS was reported in TTSS cohort at 24 months (p = 0.034). The rate of patients with LARS and LARS sub-domains were comparable except for a lower fractioning in TTSS at 24 months (p = 0.005). Anastomoses in the TTSS cohort were significantly lower (p = 0.027), anastomotic leak rate was higher in the DS (p = 0.016). Conclusions Although lower anastomoses in TTSS cohort, functional outcomes were not inferior of those after DS technique.

Abstract Background The expanding medical armamentarium in ulcerative colitis (UC) has contributed to increased control of inflammation. However, simultaneously, postponed colonic resection with an accumulative inflammatory burden might lead to an increased risk of CRC. Recent studies have reported conflicting results regarding the incidence of colorectal cancer (CRC) in UC patients. Aim To analyse the impact of advanced medical therapies (defined as biologicals and small molecules) on time to colonic resection and risk of CRC in UC patients. Methods Consecutive patients ≥18 years with established UC who underwent colonic resection between January 2003 and October 2022 at the Academic Medical Centre Amsterdam or the University Hospital Leuven were included. Primary outcomes were time to colonic resection and CRC rate in colonic specimens, compared between four time periods: P1 (2003-2007), P2 (2008-2012), P3 (2013-2017) and P4 (2018-2022). Secondary outcomes were the effect of advanced medical therapy on time to resection, cancer stage and risk of CRC. CRC was staged according to the AJCC TNM classification (advanced cancer defined as T3/T4, N1/2 or M1). Results A total of 716 patients were included. The usage of advanced medical therapies prior to surgery increased from 38.2% in P1 to 90.2% in P4 (p<0.001). However, this did not result in an increased time to colonic resection (P1: 7 years (2-12) vs P2: 6 years (2-14) vs P3: 7 years (3-14) vs P4: 7 years (2-14), p=0.94). CRC was diagnosed in 72 (10.1%) patients, and this incidence did also not change over time. Time to resection was significantly longer (median 18 years, IQR 10-24) in CRC patients compared to the overall cohort. The majority of CRC patients (64.8%) were diagnosed with advanced cancer, which did not decrease over time. Patients using advanced medical therapies had significantly shorter follow-up compared to therapy-naïve patients (6 years vs. 10 years, p<0.001), which resulted in a decreased risk of CRC (OR 0.17, p=<0.001). However, the finding of an incidental carcinoma rate (i.e. not preoperatively diagnosed) in this group was 18% whereas this was only 4% in patients without advanced medical therapy (p=0.08). Moreover, the incidence of advanced CRC was numerically higher in UC patients who received ≥2 therapies (83.3% vs 61.0%, p=0.14). Conclusion This study demonstrated that in the last two decades, the increased usage of advanced medical therapies did not result in an increased time to resection, nor in a decreased CRC rate in UC patients undergoing colonic resection. A higher incidence of incidental and advanced cancers was seen in patients with ≥2 therapies. Therefore, care should be taken with improved tailored surveillance in this group.

Background: Proctocolectomy with ileal pouch-anal anastomosis is the treatment of choice for patients with ulcerative colitis with medical refractory disease or dysplasia. The aim of this research was to describe the evolution of ileal pouch-anal anastomosis surgery and surgical outcomes over a three-decade interval in a high-volume referral centre. Methods: All consecutive patients undergoing ileal pouch-anal anastomosis for ulcerative colitis between 1990 and 2022 at the University Hospitals of Leuven were retrospectively included. Patients were divided into three interval arms (interval A 1990-2000, interval B 2001-2010 and interval C 2011-2022). The primary outcomes of interest were anastomotic leakage at 30 days and pouch failure. Results: Overall, 492 patients were included. The use of preoperative advanced therapies increased over time (P < 0.001). An increase in laparoscopic procedures (23.2% in interval A, 66.4% in interval B, 86.0% in interval C; P < 0.001) and a shift towards delayed ileal pouch-anal anastomosis (colectomy-first approach with delayed ileal pouch-anal anastomosis construction: 23.0% in interval A, 40.9% in interval B, 85.8% in interval C; P < 0.001) were observed. Anastomotic leakage rate decreased from 16.7% (interval A) to 8.4% (interval C) (P = 0.04). Delayed ileal pouch-anal anastomosis was the most relevant factor in limiting leakage (OR 0.49 (95% c.i. 0.27 to 0.87); P = 0.016). Median follow-up was 7.5 years (interquartile range 2.5-16). Cumulative pouch failure incidence was 8.2%, not significantly different between the three intervals (P = 0.580). Anastomotic leakage was the only significant risk factor for pouch failure (HR 2.82 (95% c.i. 1.29 to 6.20); P = 0.010). Conclusion: Significant changes in the management of ulcerative colitis patients occurred. Despite the widespread use of advanced therapies and the expanded surgical indications, anastomotic leakage rate decreased over time. In the context of a delayed ileal pouch-anal anastomosis, diverting ileostomy could be avoided in selected cases. Anastomotic leakage remains the most relevant risk factor for pouch failure. Pouch failure incidence remained stable over the years.

Anal squamous cell carcinoma (ASCC) is the most common histological subtype of malignant tumor affecting the anal canal. Chemoradiotherapy (CRT) is the first-line treatment in nearly all cases, ensuring complete clinical response in up to 80% of patients. Abdominoperineal resection (APR) is typically reserved as salvage therapy in those patients with persistent or recurrent tumor after CRT. In locally advanced tumors, an extralevator abdominoperineal excision (ELAPE), which entails excision of the anal canal and levator muscles, might be indicated to obtain negative resection margins. In this setting, the combination of highly irradiated tissue and large surgical defect increases the risk of developing postoperative perineal wound complications. One of the most dreadful complications is perineal evisceration (PE), which requires immediate surgical treatment to avoid irreversibile organ damage. Different techniques have been described to prevent perineal complications after ELAPE, although none of them have reached consensus. In this technical note, we present a case of PE after ELAPE performed for a recurrent ASCC. Perineal evisceration was approached by combining a uterine retroversion with a gluteal transposition flap to obtain wound healing and reinforcement of the pelvic floor at once, when a mesh placement is not recommended.

The incidence of rectal cancer (RC) is increasing in the population aged ≤ 49 (early-onset RC-EORC). EORC patients are more likely to present with locally advanced disease at diagnosis than late-onset RC (LORC; aged ≥ 50) patients. As a consequence, more EORC patients undergo neoadjuvant therapies. The response to treatment in EORC patients is still unknown. This study aims to explore the effect of age of onset on the pathological response to neoadjuvant therapies in sporadic locally advanced RC (LARC) patients. Based on an institutional prospectively maintained database, LARC patients undergoing neoadjuvant therapies and radical surgery between January 2010 and December 2022 were allocated to the EORC and LORC groups. The primary endpoint was the rate of incomplete response (Dworak 0-2). A total of 326 LORC and 79 EORC patients were included. Pre-neoadjuvant tumor features were comparable. A significantly higher rate of incomplete response was observed in EORC patients (49% vs. 35%; p = 0.028). From multivariable analysis, early age of onset, smoking and extramural invasion presented as independent risk factors for a worse response. This study demonstrates that an early age of onset is related to a worse response and calls for different multimodal strategies in this group of patients.

Despite the advances in medical treatment of Crohn's disease (CD), most of the patients require one or more surgical bowel resections during their life for complicated disease.Surgery for CD has gone through progressive technical refinement over time.Minimally invasive surgery and bowel-sparing techniques have been validated with regard to surgical trauma reduction, and their role has been clearly defined in the current guidelines.Nevertheless, continuous technology advancement has further expanded the surgical tools with single-access and robotic-assisted surgery.With the aim of further reducing the impact of surgery, the concept of "strategic surgery" has been explored.On the one hand, patients' optimization before surgery has the potential to reduce post-operative complications.On the other, early intervention for the uncomplicated disease before medical therapy escalation has been demonstrated equally reliable with respect to biologics in terms of quality of life and advantageous in terms of health-care costs.Ultimately, a better comprehension of the pathological mechanisms underlying the disease is the key to radically changing the surgical management of both abdominal and perianal CDs.In fact, novel surgical strategies aiming at reducing disease recurrence which take into account the anastomotic configuration and the role of the mesentery as an active player in the disease process have been pursued in the past decade.The purpose of this review is to describe the recent innovations in the surgical treatment of CD focusing on their potential impact on the short-and long-term outcomes.

This record contains raw data related to article “Multidisciplinary Tumor Board in the Management of Patients with Colorectal Liver Metastases: A Single-Center Review of 847 Patients" Abstract There is still debate over how reviewing oncological histories and addressing appropriate therapies in multidisciplinary team (MDT) discussions may affect patients' overall survival (OS). The aim of this study was to describe MDT outcomes for a single cancer center's patients affected by colorectal liver metastases (CRLMs). From 2010 to 2020, a total of 847 patients with CRLMs were discussed at our weekly MDT meeting. Patients' characteristics and MDT decisions were analyzed in two groups: patients receiving systemic therapy (ST) versus patients receiving locoregional treatment (LRT). Propensity-score matching (PSM) was run to reduce the risk of selection bias. The median time from MDT indication to treatment was 27 (IQR 13-51) days. The median OS was 30 (95%CI = 27-34) months. After PSM, OS for patients undergoing LRT was 51 (95%CI = 36-64) months compared with 15 (95%CI = 13-20) months for ST patients (p < 0.0001). In this large retrospective study, the MDT discussions were useful in providing the patients with all available locoregional options.

The data that support the findings of this study are available from the corresponding author upon reasonable request. Video S1: Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

This record contains data related to article “Invasive IPMN relapse later and more often in lungs in comparison to pancreatic ductal adenocarcinoma” Background: The different oncological outcomes of invasive intraductal papillary mucinous neoplasm (I-IPMN) and pancreatic ductal adenocarcinoma (PDAC) are debated. This study aimed to compare disease recurrence patterns and histopathological characteristics in patients with resected I-IPMN and PDAC. Methods: Consecutive patients undergoing surgical resection for stage I-III I-IPMN or PDAC between 2010 and 2016 were retrospectively analyzed. Patients treated with neoadjuvant therapy or resected for Tis neoplasia were excluded. All surgical specimens were re-staged according to AJCC-8th-edition. Results: A total of 330 patients were included, of whom 43 had I-IPMN and 287 had PDAC. Median follow-up time was 26.7 (1.3-92.3) months and estimated median disease-free survival (DFS) was 60.3 months (47.2-73.4) for I-IPMN and 23.8 (19.3-28.2) months for PDAC (p < 0.001). During follow-up, 32.6% of I-IPMN and 67.9% of PDAC patients experienced recurrence (p < 0.001). The sites of first recurrence were the lungs (38.5% vs 13.1%, p = 0.027), liver (28.6% vs 45.0%, p = 0.180) and local (15.4% vs 36.6%, p = 0.101) for I-IPMN and PDAC, respectively. At multivariate analysis, I-IPMN histology remained an independent predictive factor for longer DFS (OR 0.528, CI 95% 0.278-1.000, p = 0.050), regardless of stage or adjuvant chemotherapy. I-IPMN and PDAC differed in rates of neuroinvasion (51.2% vs 97.2%) and positive lymph node status (N+) (46.5% vs 82.7%), especially in patients with lower T status. Conclusion: I-IPMN showed a different recurrence pattern compared to PDAC, with a higher lung tropism, and longer DFS. This different biological behavior is associated with lower rates of neuroinvasion and nodal involvement, especially in early-stage disease.

There is still debate over how reviewing oncological histories and addressing appropriate therapies in multidisciplinary team (MDT) discussions may affect patients’ overall survival (OS). The aim of this study was to describe MDT outcomes for a single cancer center’s patients affected by colorectal liver metastases (CRLMs). From 2010 to 2020, a total of 847 patients with CRLMs were discussed at our weekly MDT meeting. Patients’ characteristics and MDT decisions were analyzed in two groups: patients receiving systemic therapy (ST) versus patients receiving locoregional treatment (LRT). Propensity-score matching (PSM) was run to reduce the risk of selection bias. The median time from MDT indication to treatment was 27 (IQR 13–51) days. The median OS was 30 (95%CI = 27–34) months. After PSM, OS for patients undergoing LRT was 51 (95%CI = 36–64) months compared with 15 (95%CI = 13–20) months for ST patients (p < 0.0001). In this large retrospective study, the MDT discussions were useful in providing the patients with all available locoregional options.

Flavio MILANA*, Simone FAMULARO, Antonio LUBERTO, Eloisa FRANCHI, Matteo CIMINO, Guido COSTA, Angela PALMISANO, Fabio PROCOPIO, Matteo DONADON, Guido TORZILLI. Ann Hepatobiliary Pancreat Surg 2022;26:S227. https://doi.org/10.14701/ahbps.2022S1.LV-PP-9-4

The evidence does not support the routine use of abdominal drainage (AD) in colorectal surgery. However, there is no data on the usefulness of AD, specifically, after ileal pouch-anal anastomosis (IPAA). The aim of this study is to assess post-operative outcomes of patients undergoing IPAA with or without AD at a high volume referral center. A retrospective analysis of prospectively collected data of consecutive patients undergoing IPAA with AD (AD group) or without AD (NAD group) was performed. Baseline characteristics, operative, and postoperative data were analyzed and compared between the two groups. A total of 97 patients were included in the analysis, 46 were in AD group and 51 in NAD group. AD group had a higher BMI (23.9 ± 3.9 kg/m2 vs 21.9 ± 3.0 kg/m2; p = 0.007) and more commonly underwent two-stage proctocolectomy with IPAA compared to the NAD group (50.0

The incidence of colorectal cancer (CRC) is increasing in the population aged ≤ 49 (early-onset CRC-EOCRC). Recent studies highlighted the biological and clinical differences between EOCRC and late-onset CRC (LOCRC-age ≥ 50), while comparative results about long-term survival are still debated. This study aimed to investigate whether age of onset may impact on oncologic outcomes in a surgical population of sporadic CRC patients. Patients operated on for sporadic CRC from January 2010 to January 2022 were allocated to the EOCRC and LOCRC groups. The primary endpoint was the recurrence/progression-free survival (R/PFS). A total of 423 EOCRC and 1650 LOCRC was included. EOCRC had a worse R/PFS (p < 0.0001) and cancer specific survival (p < 0.0001) compared with LOCRC. At Cox regression analysis, age of onset, tumoral stage, signet ring cells, extramural/lymphovascular/perineural veins invasion, and neoadjuvant therapy were independent risk factors for R/P. The analysis by tumoral stage showed an increased incidence of recurrence in stage I EOCRC (p = 0.014), and early age of onset was an independent predictor for recurrence (p = 0.035). Early age of onset was an independent predictor for worse prognosis, this effect was stronger in stage I patients suggesting a potentially—and still unknown—more aggressive tumoral phenotype in EOCRC.

INTRODUCTION:Into blood relatives of patients affected by breast cancer, the prevalence of pancreatic ductal adenocarcinoma (PDAC) seems to be elevated. BRCA1/2 mutations as other VUS (variants of uncertain significance) could be responsible.METHODS:We retrospectively revised dataset of Pancreatic Surgery Unit of Humanitas Clinical and Research Center - IRCCS and identified patients who underwent resection for PDAC between 2010 and 2018. We evaluated neoplastic family history and remote pathological history, particularly for breast and prostate tumors. The characteristics of family history were described. Overall survival (OS) and progression free survival (PFS) were calculated for different identified groups.RESULTS:483 PDAC have been analyzed; 57% had a family history positive for neoplasia; 25% at least showed a blood relative affected by one of these type of cancers: PDAC, breast and prostate, of which 88% was a first degree relative (FDR). One hundred and six patients (22%) had a previous neoplasia, of which 8% a breast cancer and 4% a prostate one. Into this group of patients, 54% had a family history positive for neoplasia and 23% consisted of either a pancreatic neoplasm, or breast tumor or prostate cancer; 71% was a FDR. With a median follow-up of 54.9 months (range 0.066-120), the median survival was 22,8 months. Both OS than PFS weren't statistically significant, considering family history and remote pathological history.CONCLUSIONS:There appears to be a high prevalence of breast and prostate cancer in family members and patients with PDAC. PDAC patients have the prognosis of the pancreatic cancer, not influenced by a previous treated neoplasia.

Introduzione. In familiari di pazienti affetti da neoplasia mammaria si è riscontrata un’elevata prevalenza di adenocarcinoma duttale del pancreas (PDAC). In questo scenario possono essere implicate mutazioni dei geni BRCA1/2, così come mutazioni non ancora conosciute. Metodi. Sono stati estrapolati dal dataset della Chirurgia Pancreatica di Humanitas Clinical and Research Center – IRCCS i soggetti operati tra il 2010 e il 2018 di PDAC ed è stata valutata l’anamnesi patologica remota e familiare positiva per una neoplasia, in particolare mammaria e prostatica. L’analisi della familiarità è descrittiva. Abbiamo stimato la sopravvivenza globale (OS) e libera da progressione (PFS). Risultati. Sono stati analizzati 483 PDAC; il 57% aveva una familiarità positiva per neoplasia; il 25% aveva almeno un familiare affetto o da PDAC, o da tumore mammario o prostatico, di cui l’88% era un parente di I grado (FDR). Centosei pazienti (22%) avevano avuto una precedente neoplasia, di cui l’8% mammaria e il 4% prostatica. Nel 54% di questi ultimi c’era una familiarità positiva per neoplasia, per il 23% consisteva o di una neoplasia pancreatica, o mammaria o prostatica e nel 71% dei casi era un FDR. Con un follow-up mediano di 54,9 mesi (range 0,066-120), la sopravvivenza mediana della popolazione in studio era di 22,8 mesi. Sia la OS che la PFS non sono risultate statisticamente differenti, considerando l’anamnesi patologica remota personale e familiare. Conclusioni. Sembra esserci una prevalenza elevata di neoplasie mammaria e prostatica nei pazienti affetti da PDAC e nei loro familiari. La prognosi di un soggetto affetto da PDAC è determinata da questo tumore e non è influenzata da una neoplasia precedentemente curata.

Total mesorectal excision (TME) has become the gold standard technique for rectal cancer surgery with curative intent. Advantages in technology and surgical innovation lead to the introduction of minimally invasive techniques including laparoscopic, robotic and, more recently, transanal TME (TaTME). The concept of TaTME has been proposed to overcome the technical challenges encountered with the transabdominal approaches (open, laparoscopic, robotic) in the most difficult cases (obese, male patients with mid-low rectal cancer and a narrow, radiated pelvis and bulky mesorectum). Additionally, it has been recently claimed that TaTME offers at least 3 oncological advantages: (I) a longer distal resection margin (DRM), (II) a decreased rate of positive circumferential resection margin (CRM), (III) improved quality of TME. However, the oncological outcomes of TaTME compared to those of laparoscopic and robotic TMEs, remain controversial. Hence, a review of all the literature examining oncological outcomes after TaTME was performed. Two reviewers independently conducted a search of electronic databases (PubMed, MEDLINE, Cochrane Library). The last search was performed on August, 30th 2019. After the initial screen of 326 articles, 32 papers were selected for review, of these 19 were comparative studies and 1 a randomized controlled trial. TaTME resulted to provide oncologic outcomes at least comparable with the other minimally invasive approaches (laparoscopic, robotic) and seems to be associated with a lower rate of CRM involvement and TME incompleteness when compared to the laparoscopic, robotic, open approaches. Scarcity of data and short follow-up time made it impossible to draw conclusions on long-term oncologic outcomes. Hopefully, the COLOR III multicenter RCTs will shed a light on short- and long-term oncologic outcomes after TaTME.