Transversus abdominis release (TAR) is a key technique in complex abdominal wall hernia repair. As extraperitoneal mesh placement with sufficient overlap is feasible in almost every anatomical location, not only large midline defects but also off-midline hernias and those adjacent to osseous abdominal borders can be effectively repaired. Through the introduction of new techniques and instruments (e.g., robotic platforms), TAR can be performed using a minimally invasive approach in many cases. Within this short communication, technical modifications of the original TAR technique, such as posterior rectus sheath release, will be discussed as well.

Immune checkpoint inhibitors (ICIs) show efficacy in treatment of several solid tumors, but microsatellite-stable rectal cancer is largely resistant. Radiotherapy may enhance tumor immunogenicity and thus may make the combination of radiotherapy and ICIs a promising strategy to treat rectal cancer. While anti–programmed cell death protein 1 antibodies in neoadjuvant regimens have been linked to higher complete response rates, the added benefit of including a cytotoxic T-lymphocyte–associated protein 4 (CTLA-4) inhibitor remains unclear. To evaluate the safety and feasibility of combining ipilimumab and nivolumab with neoadjuvant chemoradiotherapy (CRT) for rectal cancer. The CHINOREC trial was a prospective, randomized, open-label, multicenter phase 2 clinical trial conducted from June 2, 2020, to March 15, 2024, across multiple academic and tertiary medical centers in Austria. Analysis was based on intention to treat. Neoadjuvant CRT consisted of 50 Gy in 2-Gy fractions with concurrent capecitabine (1650 mg/m2/d). The experimental arm received additional intravenous ipilimumab (1 mg/kg on day 7) and nivolumab (3 mg/kg every 2 weeks starting on day 14) (CRT plus ipilimumab and nivolumab group). Surgical resection was performed 10 to 12 weeks after CRT. The primary outcome was the safety and feasibility of combining CRT with sequential ipilimumab and nivolumab, assessed by surgical complications and reoperation rates. Secondary outcomes included clinical and pathological response rates. Of the 145 patients assessed, 80 were randomized to receive either CRT alone (CRT group) (n = 30) or to the CRT plus ipilimumab and nivolumab group (n = 50) (49 male [61%]; median age, 60 [range, 36-83] years). Differences in surgical complication rates were not statistically significant between the CRT and CRT plus ipilimumab and nivolumab groups (any grade, 20 of 26 patients [77%] vs 33 of 43 [77%]; P > .99), as were reoperation rates (2 of 26 [8%] vs 3 of 43 [7%]; P > .99). Major pathological response (10 of 26 [38%] vs 16 of 43 [37%]; P > .99) and complete response (9 of 30 [30%] vs 11 of 50 [22%]; P = .44) rates were overall high in both groups. In this randomized clinical trial of patients with rectal cancer, integrating ipilimumab and nivolumab into neoadjuvant CRT was safe and feasible, with no increase in surgical complications. Although complete response rates did not significantly improve, the dual ICI regimen demonstrated promising clinical activity. These findings support further translational research to optimize timing, dosing, and fractionation of radiotherapy and ICI therapy and to guide patient selection. ClinicalTrials.gov Identifier: NCT04124601

139 Background: Immune checkpoint inhibitors (ICIs) seem only effective in a primed tumor immune microenvironment (TIME). Neoadjuvant radiotherapy (RT) has been shown to induce an immunogenic cell death (ICD) and thereby restores the susceptibility to ICI. This study evaluates the safety of neoadjuvant chemoradiotherapy (CRT) with concomitant ipilimumab (IPI) and nivolumab (NIVO) in curative rectal cancer (RC) patients. Methods: The CHINOREC study (ClinicalTrials.gov identifier NCT04124601) is a prospective, randomized (ratio 50:30), open-label, multicenter, phase II investigator-initiated trial (IIT). Patients with RC received neoadjuvant CRT (50 Gy in 2 Gy fractions with concurrent capecitabine 1650 mg/m 2 /d) alone or in combination with IPI (1 mg/kg IV at day 7), following 3 cycles of NIVO (3 mg/kg IV Q2W, starting on day 14). Surgical resection was performed 10-12 weeks post CRT. The primary endpoint was surgical safety and feasibility (Clavien-Dindo Classification) of neoadjuvant CRT with sequential IPI and NIVO following surgical resection. Secondary outcome was complete response rate (clinical and pathological). Results: Between June 2020 and November 2023, 145 patients were screened and 80 randomly assigned to CRT (n=30) or CRT+IPI/NIVO (n=50). The primary endpoint (any surgical complication) did not differ between the 2 groups (78% vs. 77%). The reoperation rate (≥Grade IIIb) was comparable low in both groups (8% vs. 7%). No new safety signals were identified. The rate of major pathological response (MPR) and complete response (CR) was also comparable high in both arms (38% vs. 37% and 30% vs. 22%, respectively). Conclusions: Neoadjuvant IPI/NIVO can be safely applied concomitant with CRT in patients with RC, as it does not increase the rate of reoperation or surgical complications. The validity of the encouraging CR rate needs to be elucidated over time. Further translational analyses will elucidate mechanistic insight regarding improved fraction, dosing and timing of CRT and ICI. Clinical trial information: NCT04124601 .

Anastomotic leakage still represents the most feared complication in colorectal surgery. However, there is limited data focusing on management and how this affects outcome in case of leakage following open versus laparoscopic right colectomy. We, therefore, performed an observational multicenter study addressing this issue. Data of patients undergoing elective right colectomy for benign and malignant disease using an open or laparoscopic approach were collected in seven colorectal units among Austria between January 2010 and December 2019. Patients undergoing emergency surgery or suffering from Crohn’s disease with chronic anastomotic fistula were excluded. Demographic, peri- and postoperative data were analyzed retrospectively. During the study, a total of 3446 patients were operated on using an open (n = 2282, 66.2

Importance:Immune checkpoint inhibitors (ICIs) show efficacy in treatment of several solid tumors, but microsatellite-stable rectal cancer is largely resistant. Radiotherapy may enhance tumor immunogenicity and thus may make the combination of radiotherapy and ICIs a promising strategy to treat rectal cancer. While anti-programmed cell death protein 1 antibodies in neoadjuvant regimens have been linked to higher complete response rates, the added benefit of including a cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) inhibitor remains unclear. Objective:To evaluate the safety and feasibility of combining ipilimumab and nivolumab with neoadjuvant chemoradiotherapy (CRT) for rectal cancer. Design, Setting, and Participants:The CHINOREC trial was a prospective, randomized, open-label, multicenter phase 2 clinical trial conducted from June 2, 2020, to March 15, 2024, across multiple academic and tertiary medical centers in Austria. Analysis was based on intention to treat. Intervention:Neoadjuvant CRT consisted of 50 Gy in 2-Gy fractions with concurrent capecitabine (1650 mg/m2/d). The experimental arm received additional intravenous ipilimumab (1 mg/kg on day 7) and nivolumab (3 mg/kg every 2 weeks starting on day 14) (CRT plus ipilimumab and nivolumab group). Surgical resection was performed 10 to 12 weeks after CRT. Main Outcome and Measures:The primary outcome was the safety and feasibility of combining CRT with sequential ipilimumab and nivolumab, assessed by surgical complications and reoperation rates. Secondary outcomes included clinical and pathological response rates. Results:Of the 145 patients assessed, 80 were randomized to receive either CRT alone (CRT group) (n = 30) or to the CRT plus ipilimumab and nivolumab group (n = 50) (49 male [61%]; median age, 60 [range, 36-83] years). Differences in surgical complication rates were not statistically significant between the CRT and CRT plus ipilimumab and nivolumab groups (any grade, 20 of 26 patients [77%] vs 33 of 43 [77%]; P > .99), as were reoperation rates (2 of 26 [8%] vs 3 of 43 [7%]; P > .99). Major pathological response (10 of 26 [38%] vs 16 of 43 [37%]; P > .99) and complete response (9 of 30 [30%] vs 11 of 50 [22%]; P = .44) rates were overall high in both groups. Conclusions and Relevance:In this randomized clinical trial of patients with rectal cancer, integrating ipilimumab and nivolumab into neoadjuvant CRT was safe and feasible, with no increase in surgical complications. Although complete response rates did not significantly improve, the dual ICI regimen demonstrated promising clinical activity. These findings support further translational research to optimize timing, dosing, and fractionation of radiotherapy and ICI therapy and to guide patient selection. Trial Registration:ClinicalTrials.gov Identifier: NCT04124601.

Background: Anastomotic leak rates after colorectal surgery remain high. In most left-sided colon and rectal resection surgeries, a circular stapler is utilized to create the primary bowel anastomosis. However, it remains unclear whether a relationship between circular stapler technology and anastomotic leak in left-sided colorectal surgery exists. Methods: A post-hoc analysis was conducted using a prospectively collected data set of patients from the 2017 European Society of Coloproctology snapshot audit who underwent elective left-sided resection (left hemicolectomy, sigmoid colectomy, or rectal resection) with a manual circular stapled anastomosis. Rates of anastomotic leak and unplanned intensive care unit stay in association with manual circular stapling were assessed. Patient-, disease-, geographical-, and surgeon-related factors as well as stapler brand were explored using multivariable regression models to identify predictors of adverse outcomes. Results: Across 3305 procedures, 8.0% of patients had an anastomotic leak and 2.1% had an unplanned intensive care unit stay. Independent predictors of anastomotic leak were male sex, minimal-access surgery converted to open surgery, and anastomosis height C11 (lower third rectum) (all P < 0.050). Independent predictors of unplanned intensive care unit stay were minimal-access surgery converted to open surgery and American Society of Anesthesiologists grade IV (all P < 0.050). Stapler device brand was not a predictor of anastomotic leak or unplanned intensive care unit stay in multivariable regression analysis. There were no differences in rates of anastomotic leak and unplanned intensive care unit stay according to stapler head diameter, geographical region, or surgeon experience. Conclusion: In patients undergoing left-sided bowel anastomosis, choice of manual circular stapler, in terms of manufacturer or head diameter, is not associated with rates of anastomotic leak and unplanned intensive care unit stay.

Background: In some patients with chronic wounds, the surrounding skin is so injured due to various underlying conditions that negative pressure dressing cannot be applied or cannot function properly. Having faced this problem in our everyday practice, we developed a new skin-sparing technique for vacuum-assisted wound closure, which ensures that the peri-wound skin does not come into contact with the transparent adhesive films. Methods: For 9 months (April–December 2022), we performed 32 vacuum wound dressings with the newly developed technique using the 3M ActiV.A.C. Therapy Unit and accessories, and Convatec’s VARIHESIVE, avoiding skin contact with the adhesive films. Results: Seven patients with 11 wounds who had sensitive skin or allergy to the conventionally used adhesive films were successfully treated with the new technique. The negative pressure wound dressings remained intact and functioned properly for up to 168 hours without compromising patients’ daily activities and therapy. Conclusion: The novel “no foil-to-skin contact” technique for vacuum-assisted wound closure can successfully be incorporated in the treatment of patients in whom conventional negative pressure dressings are otherwise not applicable.

There is an ongoing debate on surgical techniques for colorectal deep endometriosis (DE) and their effects on gastrointestinal (GI) function. The aim of this study was to prospectively investigate the differences in pre‐ and postsurgical GI function, health profiles and pain symptoms in women undergoing colorectal surgery for symptomatic DE either with a modified segmental resection technique, so‐called nerve‐vessel sparing segmental resection (NVSSR), or full thickness discoid resection (FTDR). Complication rates and fertility outcomes were also evaluated.

The aim of this study was to analyze the available literature by conducting a systematic review to assess the possible effects of nerve-sparing segmental resection and conventional bowel resection on postoperative complications for the treatment of colorectal endometriosis. Pubmed, Clinical Trials.gov , Cochrane Library, and Web of Science were comprehensively searched from 1997 to 2021 in order to perform a systematic review. Studies including patients undergoing segmental resection for colorectal endometriosis including adequate follow-up, data on postoperative complications and postoperative sequelae were enrolled in this review. Selected articles were evaluated and divided in two groups: Nerve-sparing resection (NSR), and conventional segmental resection not otherwise specified (SRNOS). Within the NSRs, studies mentioning preservation of the rectal artery supply (artery and nerve-sparing SR – ANSR) and not reporting preservation of the artery supply (NSR not otherwise specified – NSRNOS) were further analyzed. PROSPERO ID: CRD42021250974. A total of 7549 patients from 63 studies were included in the data analysis. Forty-three of these publications did not mention the preservation or the removal of the hypogastric nerve plexus, or main rectal artery supply and were summarized as SRNOS. The remaining 22 studies were listed under the NSR group. The mean size of the resected deep endometriosis lesions and patients’ body mass index were comparable between SRNOS and NSR. A mean of 3.6% (0–16.6) and 2.3% (0–10.5%) of rectovaginal fistula development was reported in patients who underwent SRNOS and NSR, respectively. Anastomotic leakage rates varied from 0% to 8.6% (mean 1.7 ± 2%) in SRNOS compared with 0% to 8% (mean 1.7 ± 2%) in patients undergoing NSR. Urinary retention (4.5% and 4.9%) and long-term bladder catheterization (4.9% and 5.6%) were frequently reported in SRNOS and NSR. There was insufficient information about pain or the recurrence rates for women undergoing SRNOS and NSR. Current data describe the outcomes of different segmental resection techniques. However, the data are inhomogeneous and not sufficient to reach a conclusion regarding a possible advantage of one technique over the other.

The aim of this study was to investigate long-term outcomes in terms of pain, quality of life (QoL), and gastrointestinal symptoms in women following colorectal surgery for deep endometriosis. In this historical cohort, women who underwent surgical treatment for deep endometriosis by either nerve-sparing full-thickness discoid resection (DR) or colorectal segmental resection (SR) between March 2011 and August 2016 were re-evaluated through telephone interviews about their long-term pain symptoms, subjective overall QoL as rated using a score from 0 (worst) to 10 (optimal), and gastrointestinal outcomes reflected by lower anterior resection syndrome (LARS) following a first postsurgical evaluation (visit 1) published previously and a long-term follow-up evaluation (visit 2). The median long-term follow-up time was 35.4 months at visit 1 and 86 months at visit 2. Of 134 patients, 77 were eligible for final analysis and 57 were lost to follow-up. Compared with presurgical values, QoL scores were significantly increased at both postsurgical evaluation visits in both the SR cohort (scores of 3, 8.5, and 10 at the presurgical visit, visit 1, and visit 2, respectively; p  < 0.001) and the DR cohort (scores of 3, 9, and 10, respectively; p  < 0.001). Pain scores for dysmenorrhea (SR group scores of 8, 2, and 2, respectively; p  < 0.001; DR group scores of 9, 2, and 1, respectively; p  < 0.001), dyspareunia (SR group scores of 4, 0, and 0, respectively; p  < 0.001; DR group scores of 5, 0, and 1, respectively; p  = 0.003), and dyschezia (SR group scores of 8, 2, and 2, respectively; p  < 0.001; DR group scores of 9, 2, and 1, respectively; p  < 0.001) significantly decreased after surgery and remained stable in both cohorts over the follow-up period. Minor and major LARS, reflecting gastrointestinal function, was observed in 6.5% and 8.1% of the SR group and in 13.3% and 6.7% of the DR group, respectively, at visit 1 and in 3.2% and 3.2% of the SR group and 0% and 0% of the DR group, respectively, at visit 2, without significant differences between the SR and DR groups. Colorectal surgery for deep endometriosis, either by DR or SR, provides stable and long-term pain relief with low rates of permanent gastrointestinal function impairment.

Patients suffering from colorectal deep endometriosis (DE) experience gastrointestinal symptoms with almost the same frequency as gynecological pain symptoms. Preoperatively existing gastrointestinal symptoms may translate into pathological gastrointestinal quality of life index (GIQLI) and low anterior resection syndrome scores (LARS). This prospective questionnaire-based case control study aims to assess the prevalence of gastrointestinal complaints reflected by changes in LARS and GIQLI scores in patients with colorectal deep endometriosis prior to surgical treatment and compare those to a healthy control group. The study was conducted at the Hospital St. John of God in Vienna and included a total of 97 patients with histologically confirmed colorectal DE with radical surgical treatment and 96 women in whom DE was excluded via transvaginal sonography (TVS) or visually. Gastrointestinal symptoms reflected by LARS and GIQLI scores were evaluated presurgically and in controls. A total of 193 premenopausal patients were included in this study. A mean GIQLI of 90.7 ± 22.0 and 129.4 ± 11.1 was observed among patients and controls, respectively, showing a significantly higher morbidity concerning gastrointestinal symptoms and decreased quality of life (QoL) compared to healthy controls (p < 0.001). The LARS score results demonstrated that 18.6

INTRODUCTION:The aim of this study was to analyze the available literature by conducting a systematic review to assess the possible effects of nerve-sparing segmental resection and conventional bowel resection on postoperative complications for the treatment of colorectal endometriosis. MATERIAL AND METHODS:Pubmed, Clinical Trials.gov, Cochrane Library, and Web of Science were comprehensively searched from 1997 to 2021 in order to perform a systematic review. Studies including patients undergoing segmental resection for colorectal endometriosis including adequate follow-up, data on postoperative complications and postoperative sequelae were enrolled in this review. Selected articles were evaluated and divided in two groups: Nerve-sparing resection (NSR), and conventional segmental resection not otherwise specified (SRNOS). Within the NSRs, studies mentioning preservation of the rectal artery supply (artery and nerve-sparing SR - ANSR) and not reporting preservation of the artery supply (NSR not otherwise specified - NSRNOS) were further analyzed. PROSPERO ID:CRD42021250974. RESULTS:A total of 7549 patients from 63 studies were included in the data analysis. Forty-three of these publications did not mention the preservation or the removal of the hypogastric nerve plexus, or main rectal artery supply and were summarized as SRNOS. The remaining 22 studies were listed under the NSR group. The mean size of the resected deep endometriosis lesions and patients' body mass index were comparable between SRNOS and NSR. A mean of 3.6% (0-16.6) and 2.3% (0-10.5%) of rectovaginal fistula development was reported in patients who underwent SRNOS and NSR, respectively. Anastomotic leakage rates varied from 0% to 8.6% (mean 1.7 ± 2%) in SRNOS compared with 0% to 8% (mean 1.7 ± 2%) in patients undergoing NSR. Urinary retention (4.5% and 4.9%) and long-term bladder catheterization (4.9% and 5.6%) were frequently reported in SRNOS and NSR. There was insufficient information about pain or the recurrence rates for women undergoing SRNOS and NSR. CONCLUSIONS:Current data describe the outcomes of different segmental resection techniques. However, the data are inhomogeneous and not sufficient to reach a conclusion regarding a possible advantage of one technique over the other.

Introduction The aim of this study was to investigate long-term outcomes in terms of pain, quality of life (QoL), and gastrointestinal symptoms in women following colorectal surgery for deep endometriosis. Material and methods In this historical cohort, women who underwent surgical treatment for deep endometriosis by either nerve-sparing full-thickness discoid resection (DR) or colorectal segmental resection (SR) between March 2011 and August 2016 were re-evaluated through telephone interviews about their long-term pain symptoms, subjective overall QoL as rated using a score from 0 (worst) to 10 (optimal), and gastrointestinal outcomes reflected by lower anterior resection syndrome (LARS) following a first postsurgical evaluation (visit 1) published previously and a long-term follow-up evaluation (visit 2). Results The median long-term follow-up time was 35.4 months at visit 1 and 86 months at visit 2. Of 134 patients, 77 were eligible for final analysis and 57 were lost to follow-up. Compared with presurgical values, QoL scores were significantly increased at both postsurgical evaluation visits in both the SR cohort (scores of 3, 8.5, and 10 at the presurgical visit, visit 1, and visit 2, respectively; p < 0.001) and the DR cohort (scores of 3, 9, and 10, respectively; p < 0.001). Pain scores for dysmenorrhea (SR group scores of 8, 2, and 2, respectively; p < 0.001; DR group scores of 9, 2, and 1, respectively; p < 0.001), dyspareunia (SR group scores of 4, 0, and 0, respectively; p < 0.001; DR group scores of 5, 0, and 1, respectively; p = 0.003), and dyschezia (SR group scores of 8, 2, and 2, respectively; p < 0.001; DR group scores of 9, 2, and 1, respectively; p < 0.001) significantly decreased after surgery and remained stable in both cohorts over the follow-up period. Minor and major LARS, reflecting gastrointestinal function, was observed in 6.5% and 8.1% of the SR group and in 13.3% and 6.7% of the DR group, respectively, at visit 1 and in 3.2% and 3.2% of the SR group and 0% and 0% of the DR group, respectively, at visit 2, without significant differences between the SR and DR groups. Conclusions Colorectal surgery for deep endometriosis, either by DR or SR, provides stable and long-term pain relief with low rates of permanent gastrointestinal function impairment.

Objective To investigate the agreement of measurements of the three diameters of rectosigmoid deep endometriosis (DE) lesions between presurgical evaluation using transvaginal sonography (TVS) and postsurgical specimen measurement (PSM). Methods This was a prospective observational multicenter study including symptomatic women undergoing surgical treatment for DE involving the rectosigmoid, by either discoid or segmental resection, from April 2017 to December 2019. TVS was performed presurgically to evaluate lesion size (craniocaudal-midsagittal length, anteroposterior thickness and transverse diameter), in accordance with the International Deep Endometriosis Analysis (IDEA) group consensus statement, and was compared with PSM. The agreement of lesion dimensions between the two methods was assessed by Bland-Altman plots and limits of agreement and additionally by the intraclass correlation coefficient (ICC) and Pearson's correlation coefficient. Systematic and proportional bias was assessed using the paired t-test. Results A total of 207 consecutive women were eligible for inclusion. Forty-one women were excluded, leaving 166 women for final analysis. A total of 123 segmental resections and 46 discoid resections were performed (both procedures were performed in three women). The mean difference between TVS and PSM was 0.90 (95% CI, 0.85-0.95) mm for lesion length measurements, 1.03 (95% CI, 0.98-1.09) mm for lesion thickness measurements and 0.84 (95% CI, 0.79-0.89) mm for transverse diameter measurements. Bland-Altman analysis demonstrated good agreement between the two methods for measurements of lesion length. Furthermore, there was good reliability and correlation between TVS and PSM for lesion length measurements, as demonstrated by an ICC of 0.82 (95% CI, 0.75-0.87) and Pearson's correlation coefficient of 0.72 (95% CI, 0.62-0.80), moderate-to-good reliability and correlation for lesion thickness measurements, with an ICC of 0.76 (95% CI, 0.67-0.82) and Pearson's correlation coefficient of 0.61 (95% CI, 0.51-0.70), and poor-to-moderate reliability and correlation for transverse diameter measurements, with an ICC of 0.58 (95% CI, 0.39-0.71) and Pearson's correlation coefficient of 0.46 (95% CI, 0.33-0.58). Conclusion Preoperative TVS determines accurately rectosigmoid DE lesion length. TVS can thereby contribute to optimal planning of surgical treatment options in women with rectosigmoid DE. (C) 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Study Objective: To compare a preoperative evaluation of deep endometriosis (DE) by transvaginal sonography (TVS) according to the Enzian classification with the intraoperatively assessed extent of DE using the Enzian system. Design: Prospective diagnostic accuracy study. Setting: Tertiary referral center for endometriosis. Patients: Women undergoing TVS and surgery for DE between 2017 and 2019 (N = 195). Interventions: Evaluation of DE lesion sizes according to the Enzian classification as evaluated by preoperative TVS compared with surgical findings. Measurements and Main Results: The rate of exact concordances between preoperative TVS-based predictions of DE lesion sizes and intraoperatively assessed lesion sizes according to the Enzian classification varied depending on anatomic localizations, that is, Enzian compartments, and evaluated lesion size. The highest rate of exact concordances was found in Enzian compartment C (rectosigmoid) in which 86% of all TVS C3 lesions were confirmed as such at surgery. Enzian com-partment A (vagina, rectovaginal septum) showed similar results. The rates of exact concordances were slightly lower in Enzian compartment B (uterosacral ligaments, parametria), with confirmation at surgery of 71% of TVS B2 lesions. In most cases of discordant findings, an underestimation of the lesion size by 1 severity grade was observed compared with the intra-operative findings. In Enzian compartment FB (urinary bladder), 91% of the lesions seen at TVS and 98% of cases without any lesion at TVS were confirmed surgically. TVS could detect DE preoperatively in compartments A, B, C, and FB with an overall sensitivity of 84%, 91%, 92%, and 88%, respectively, anda specificity of 85%, 73%, 95%, and 99%, respectively. Conclusion: TVS provides a valuable preoperative estimation of DE localization and lesion size using the Enzian classifica-tion, especially for Enzian compartments A, C, and FB. For Enzian compartment B, the exact assessment of the lesion size using the Enzian system seems to be less precise than for the other compartments. (C) 2021 AAGL. All rights reserved.

Aim The Enhanced Recovery After Surgery (ERAS (R)) Society guidelines aim to standardize perioperative care in colorectal surgery via 25 principles. We aimed to assess the variation in uptake of these principles across an international network of colorectal units. Method An online survey was circulated amongst European Society of Coloproctology members in 2019-2020. For each ERAS principle, respondents were asked to score how frequently the principle was implemented in their hospital, from 1 ('rarely') to 4 ('always'). Respondents were also asked to recall whether practice had changed since 2017. Subgroup analyses based on hospital characteristics were conducted. Results Of hospitals approached, 58% responded to the survey (195/335), with 296 individual responses (multiple responses were received from some hospitals). The majority were European (163/195, 83.6%). Overall, respondents indicated they 'most often' or 'always' adhered to most individual ERAS principles (18/25, 72%). Variability in the uptake of principles was reported, with universal uptake of some principles (e.g., prophylactic antibiotics; early mobilization) and inconsistency from 'rarely' to 'always' in others (e.g., no nasogastric intubation; no preoperative fasting and carbohydrate drinks). In alignment with 2018 ERAS guideline updates, adherence to principles for prehabilitation, managing anaemia and postoperative nutrition appears to have increased since 2017. Conclusions Uptake of ERAS principles varied across hospitals, and not all 25 principles were equally adhered to. Whilst some principles exhibited a high level of acceptance, others had a wide variability in uptake indicative of controversy or barriers to uptake. Further research into specific principles is required to improve ERAS implementation.

INTRODUCTION:Anastomotic leakage (AL) following colorectal resection is a devastating complication affecting morbidity, mortality, and quality of life of patients in the long term. Different tissue sealants and biologic glues were tested showing conflicting results regarding their influence on anastomotic healing and leak prevention. Application of autologous platelet-rich fibrin (Vivostat A/S, Alleroed, Denmark), which acts as a source of angiogenic growth factors and cytokines, showed promising results in an in-vivo porcine model. Herein, we present the first human study of stapled colorectal anastomoses supplemented with an autologous-derived platelet-rich fibrin matrix (Obsidian ASG®, Rivolution GmbH, Rosenheim, Germany and Vivostat A/S, Alleroed, Denmark).MATERIALS AND METHODS:A retrospective analysis of prospectively accumulated data was performed in two colorectal centers (Linz, Vienna) on patients undergoing left-sided colorectal or coloanal stapled anastomosis between October 2018 and December 2019. The Obsidian ASG® Matrix was applied to the rectal stump, and after closure with the circular stapling device, at the circumference of anastomosis in every single case. Anastomoses were supplemented with intra- and extra-anastomotic application (IAA-intra-anastomotic application developed by Rivolution GmbH, Rosenheim, Germany) of Obsidian ASG® Matrix. The primary endpoints were incidence of perioperative complications and anastomotic leak rate.RESULTS:Two-hundred-sixty-one (138 female) patients underwent left-sided colonic (n=177) or rectal resection (n=84). In 253 (96.9%) cases, a laparoscopic or robotic-assisted approach was used. There were no complications attributable to the intraoperative application of the Obsidian ASG® Matrix. All intraoperative leak tests were negative. Overall, anastomotic leak rate accounted for 2.3% (6/261). AL following colonic and rectal resection was seen in 2.3% (4/177) and 2.4% (2/84), respectively. Complication and leak rate was similar in the two participating centers. Postoperative fever and elevated CRP levels were significantly correlated to AL. There was no significant risk factor for AL on multivariate analysis.CONCLUSION:Application of an autologous-derived platelet-rich fibrin matrix (Obsidian ASG®) at anastomotic site following colorectal resection is safe and associated with a low rate of anastomotic leakage.

There is increasing evidence that intermediate and long-term bowel dysfunction may occur as a consequence of radical surgery for rectal deep endometriosis (DE). Typical symptoms include constipation, feeling of incomplete evacuation, clustering of stools, and urgency. This is described in the colorectal surgical literature as low anterior resection syndrome (LARS). Within this, several studies suggested that differences regarding functional outcomes could be favorable to more conservative surgical approaches, that is, excision of endometriotic tissue with preservation of the luminal structure of the rectal wall when compared with classical segmental resection techniques for DE, especially when performed for low DE. A total of 211 patients undergoing rectal surgery for low DE (≤7 cm from the anal verge) in three different tertiary referral centers between October 2009 and December 2018 were retrospectively reviewed regarding major complications and LARS. From the 211 eligible patients, six women were excluded because of loss to follow-up. Finally, a total number of 205 patients were enrolled for the statistical analysis; 139 with nerve- and vessel-sparing segmental resection (NVSSR) and 66 operated for laparoscopic-transanal disk excision (LTADE) were included. Gastrointestinal functional outcomes of the two procedures were compared using the validated LARS questionnaire. The median follow-up time was 46 ± 11 months. As a secondary outcome, the surgical sequelae were examined. We found no statistically significant difference between the incidence of LARS (31.7% and 37.9%, respectively) among patients operated by LTADE when compared with NVSSR ( P  = .4). The occurrence of LARS was positively associated with the use of protective ileostomy or colostomy ( P  = .02). A higher rate of severe complications was observed in women undergoing LTADE (19.7%) when compared with patients with NVSSR (9.0%, P  = .029). LARS is not more frequent after NVSSR when compared with a more conservative approach such as LTADE in patients undergoing rectal surgery for low DE. To confirm our findings prospective studies are required.