Pedicled Greater Omentum Flap Reinforcement Reduces Anastomotic Leakage and Improves Functional Recovery After Laparoscopic Sphincter-Preserving Surgery for Middle and Low rectal cancer Rectal Cancer: a Retrospective Comparative Study

Pedicled Greater Omentum Flap Reinforcement Reduces Anastomotic Leakage and Improves Functional Recovery After Laparoscopic Sphincter-Preserving Surgery for Middle and Low rectal cancer Rectal Cancer: a Retrospective Comparative Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Pedicled Greater Omentum Flap Reinforcement Reduces Anastomotic Leakage and Improves Functional Recovery After Laparoscopic Sphincter-Preserving Surgery for Middle and Low rectal cancer Rectal Cancer: a Retrospective Comparative Study Hao Lai, Jiangfeng Yu, Xiaojun Zou, Mingyang Hu, Ju Rong, Xianwei Mo This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8802487/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background The aim of this study is to determine whether reinforcement with a pedicled greater omentum flap is an effective measure for decreasing the incidence of Anastomotic leakage (AL) and low anterior resection syndrome (LARS). Methods The current retrospective comparative study collected patients with mid- and low-rectal cancer undergoing laparoscopic sphincter-preserving surgery between January 2023 and December 2024. The patients were divided into two groups: Group A was subjected to laparoscopic radical resection combined with reinforcement of the pelvic floor using a pedicled greater omentum flap, while Group B was subjected to the standard laparoscopic surgical procedure. The functional outcomes of the patients were recorded at 1, 3, 6, and 12 months using the LARS scoring system and the Wexner incontinence scoring system. Results Fifty-five patients were analyzed (Group A, n = 29; Group B, n = 26), with comparable baseline and perioperative characteristics. AL occurred in 1 patient (3.45%) in Group A (P < 0.05). LARS scores progressively improved in both groups; however, Group A showed significantly lower LARS scores at 1 and 3 months (P < 0.05). Similarly, Group A achieved better continence recovery, with lower Wexner scores at 6 months (P < 0.05). Conclusions The reinforcement of the pelvic floor using a pedicled greater omentum flap has been found to be a safe and feasible option during surgery for mid- and low-RC. The method significantly reduces the rate of AL and hastens recovery. The method has the potential to provide better outcomes for RC patients. rectal cancer anastomosis leakage Low anterior resection syndrome omentum falp Figures Figure 1 Figure 2 Figure 3 Introduction Rectal cancer (RC) is one of the most prevalent colorectal cancers and is a major public health burden in China[ 1 ]. Due to changes in lifestyle, dietary habits, and the aging population, the incidence of RC has been increasing steadily over the years[ 2 ]. What is of particular interest is that 70% of RC cases are low RC, where the cancer is situated in close proximity to the anal verge. This characteristic of RC has resulted in considerable challenges in the achievement of radical resection of cancer while maintaining continence via the anal sphincter mechanism[ 3 ]. Sphincter preservation has become a significant concern in the management of low RC, which has considerable implications for quality of life[ 4 ]. Recently, surgeons have developed a significant level of technical skills in laparoscopic radical surgery. However, the incidence of complications is between 10% and 40% after anal-sparing surgery for low RC [ 5 , 6 ]. The most common complication following surgery is anastomotic leakage (AL), which prolongs hospitalization[ 7 ], increases healthcare costs, and may cause death. Therefore, the prevention of AL is a necessity in surgery. In patients with compromised anastomotic blood supply and rectal spasm, conventional anastomotic repair following radical surgery for RC is associated with a high incidence of AL[ 8 ]. Ileostomy is a measure that is used to prevent AL, but it considerably impacts the quality of life, and patients require a second surgery to reverse it three months after[ 9 ]. LARS symbolizes a common and important adverse outcome following SP procedures. A considerable number of patients are afflicted by postoperative anorectal dysfunction, as indicated by increased defecation frequency, urgency, soiling, and incontinence to varying degrees[ 10 , 11 ]. With a high prevalence rate of 60%-90%, LARS considerably compromises quality of life, and its association with psychological complications such as anxiety and depression makes it a concern[ 12 ]. Thus, the prevention or mitigation of AL as well as LARS becomes an important concern in RC surgery. The greater omentum is a biologically active tissue that is highly adaptable. Once it is exposed to an area of injury or ischemia, it releases a variety of bioactive molecules, including a range of angiogenic growth factors such as vascular endothelial growth factor, progenitor cells, and chemokines such as stromal cell–derived factor‑1α. These molecules play a crucial role in tissue regeneration, wound healing, hemostasis, and immune modulation[ 13 ]. The pedicled flap of the greater omentum is harvested by mobilizing it from the greater curvature of the stomach, maintaining the gastroepiploic vascular arcade[ 14 ]. Owing to these distinctive biological and structural properties, the greater omentum has been increasingly utilized in general surgery as a protective adjunct to reduce the risk of AL. Examples include esophagogastric anastomosis and bile duct AL after liver transplantation[ 15 – 17 ]. However, there have been no previous reports on its use to prevent AL in sphincter-preserving surgery for low RC. In our previous study, we applied a pedicled greater omentum flap to reconstruct the anterior sacral space in low RC surgery. This approach effectively prevented LARS[ 18 ]. In the current study, we will use the greater omentum flap to prevent both AL and LARS in sphincter-preserving surgery for middle and low RC and evaluate its efficacy. Materials and methods Patients This study was conducted in compliance with the ethical guidelines specified in the Declaration of Helsinki (1964)[19] and all subsequent revisions. Ethical approval was granted by the Ethics Committee of Guangxi Medical University Cancer Hospital (No. CS2026(14)), China, and written informed consent was obtained from all participating patients. Clinical information of patients diagnosed with low RC, who underwent surgical procedures utilizing the novel anastomosis approach between January 2023 and December 2024 at our institution, was retrospectively reviewed. Inclusion criteria Inclusion criteria: (1) Patients aged from 18 to 70 years; (2) Tumor location and its distance from the dentate line confirmed preoperatively by electronic colonoscopy and magnetic resonance imaging (MRI), with the lower margin of the tumor ≤10 cm from the anal verge; (3) Histologically proven rectal adenocarcinoma, irrespective of receiving neoadjuvant therapy; (4) Absence of distant organ metastasis confirmed via preoperative CT and no intraperitoneal metastases detected during laparoscopic exploration [22]; (5) Underwent total mesorectal excision (TME); presence of normal preoperative anal sphincter function without a history of frequent fecal incontinence involving solid or liquid stool; and (6) Capable of completing postoperative follow-up assessments of anorectal function. Exclusion criteria (1) Body mass index (BMI) ≥30 kg/m²; (2) Preoperative lax anal sphincter or inflammatory bowel disease; (3) Severe underlying diseases involving major organ systems, such as heart, lungs, or cerebrovascular systems; (4) Recurrent RC requiring reoperation; (5) Postoperative radiotherapy required; (6) Patients who underwent preventive temporary colostomy without subsequent reversal surgery. surgical procedure Laparoscopic low RC surgery The procedure was carried out in adherence to the principles of TME[20], including meticulous vascular management and enbloc lymphadenectomy. The inferior mesenteric vessels were anatomically dissected, and the regional lymph nodes along with the adipose tissue were excised. The rectal mesenteric fat was excised, and the intestine was cut at a portion that is at least 1 cm distal to the tumor. After the laparoscopic procedure, the affected bowel portion was brought out through a small auxiliary abdominal incision, ensuring a proximal margin of at least 10 cm from the tumor. An appropriate anastomosis device was used. The procedure of digestive tract reconstruction was carried out under pneumoperitoneum, and a drainage catheter was placed. None of the patients underwent ileostomy reversal surgery. Pedicled greater omentum transplantation surgery The laparoscopic method was carried out following the standard protocol for mesenteric separation and lymph node dissection, as in conventional laparoscopic practice. In the reconstructive process of the digestive tract, a pedicled flap of the greater omentum was used for the replacement of the rectal mesentery. This process was carried out in three main steps: (1) the preparation and dissection of the vessels of the greater omentum (Figure 1); (2) the beginning of the dissection from the area near the left gastric artery and then extending laterally along the gastric arterial arch from left to right. During this process, emphasis was laid on maintaining an adequate blood supply to the transplanted tissue by preserving the right marginal vessels and their vertical branches. Subsequently, the posterior leaf of the greater omentum was dissected and transplanted to the pelvic cavity. Then, the dissected omentum was laid out to cover the posterior and lateral rectal regions by enveloping the rectal anastomosis (Figure 2). After this, the omentum tissue was attached to the bilateral pelvic peritoneum by using Hemo-lock clips (Figure 3). Care was taken to prevent twisting of the vascular pedicle, avoiding ischemic necrosis of transplanted tissue. After the procedure, a pelvic drainage tube was routinely placed for postoperative monitoring. Postoperative assessment of anal function Evaluation of postoperative anal functions was mainly based on questionnaires from patients. The LARS score and Wexner Anorectal Incontinence score were used for this purpose[21, 22]. Data collection was carried out using telephone interviews and follow-up at 1, 3, 6, and 12 months after surgery. The patients were given a LARS score and Wexner scale questionnaire, and their scores were analyzed statistically to evaluate the incidence rate of LARS, factors that influence LARS, and recovery after RC. Statistical analysis Statistical evaluation was performed using SPSS (version 25.0) and MSTATA (www.mstata.com). Measurement data were expressed as mean ± standard deviation (x̄ ± s) or as median and range, as appropriate. Data conforming to normal distribution and homogeneity of variance were presented as "x̄ ± s". Comparisons across multiple groups were made utilizing one-way analysis of variance (ANOVA). Count data were reported as percentages and analyzed by χ² tests or Fisher’s exact tests. For ranked data, multiple comparisons were conducted via the Kruskal-Wallis test, and paired comparisons were analyzed using the Wilcoxon signed-rank test. Statistical significance was set at P < 0.05. Results A total of 55 eligible patients were included for analysis and randomly allocated to two groups according to different surgical methods. Patients who received laparoscopic radical resection with pedicled greater omrntum transplantation were allocated to Group A, and patients who received conventional laparoscopic radical resection were allocated to Group B. There were 29 patients in Group A and 26 patients in Group B. Group B comprised patients whose average age was 58 ± 13 years, with 14 men and 12 women, and an average BMI of 21.51 ± 2.83 kg/m². The demographic data, such as age, gender distribution, and BMI, at the baseline were not significantly different between the groups (P > 0.05). Similarly, there were no significant differences in the use of adjuvant therapy, co-morbid conditions, and TNM staging of the tumor between the two groups (P > 0.05). Surgical outcomes All cases were successfully operated using laparoscopic surgery, without conversion to open surgery. Pathological examination confirmed that all cases in both groups achieved R0 resection. Perioperative indicators, including operative duration, intraoperative blood loss, postoperative first flatus time, hospital stay duration, and overall treatment expenditure, were not significantly different between the two groups (P > 0.05). However, a significantly delayed postoperative defecation time was observed in Group A (P < 0.05). No significant intergroup differences were identified concerning tumor dimensions, lymph node yield, tumor differentiation degree, or the frequency of postoperative complications (Table 2 ). Table 1 Clinical characteristics according to study group. Characteristic Group A ( N = 29) Group B ( N = 26) P value Age 57 ± 13 58 ± 13 P > 0.05 Gender P > 0.05 Male 16 10 Female 13 16 BMI 22.50 ± 2.78 21.51 ± 2.83 P > 0.05 The distance from the lower edge of the tumor to the anal verge (cm) 5.16 ± 2.06 4.96 ± 2.07 P > 0.05 TNM stage I II 8 9 8 7 P > 0.05 III 11 10 a ccompanying disease None 24 20 P > 0.05 Hypertension 4 0 Diabetes 0 2 c oronary heart disease 0 1 Favism 1 0 f atty liver 0 1 c hronic hepatitis B 0 1 Table 2 p ostoperative outcomes. Surgical outcome Group A (N = 29) Group B (N = 26) P value Operative (min) 274 ± 82 264 ± 196 P > 0.05 Blood loss (ml) 51 ± 60 60 ± 36 P > 0.05 Postoerative exhaust time (day) 2.86 ± 1.01 2.42 ± 0.58 P > 0.05 Postoerative hospital stay (day) 7.68 ± 3.98 7.25 ± 2.05 P > 0.05 Histological type P > 0.05 Protrude type 11 (39.3%) 9 (37.5%) Borrmann 17 (60.7%) 15 (62.5%) Tumor differentiation P > 0.05 Well differentiated 2 1 Moderately differentiated 26 23 poorly differentiated 1 0 Lymph node harvest 19 ± 10 19 ± 10 P > 0.05 Clavien-Dindo P > 0.05 Ⅰ Ⅱ 2 2 4 2 Ⅲ 0 0 Ⅳ Ⅴ 0 0 0 0 Postoperative complications of AL Postoperative complications rate of anastomotic leak. were observed in both groups (Table 3 ). In Group A (laparoscopic radical resection with pedicled greater omentum transplantation), complications of AL included one case of AL (3.45%). In the group of conventional laparoscopic resection, which was classified as group B, the complications that were encountered included four cases of AL, which accounted for 15.38%. All the patients who had AL underwent ileostomy, and the reversal of the stoma was done at three months postoperatively. Table 3 Complications rate of anastomotic leak. Group A (N = 29) Group B (N = 26) P value Anastomotic leak 1 4 P < 0.05 None anastomotic leak 28 22 Anal function assessment Quantitative assessment of the functional outcomes following surgery indicated that there was a significant difference between the two groups regarding the progression of LARS (Table 4 ). The two groups experienced severe LARS at the 1-month postoperative period. There was statistically significant difference between the two groups (P < 0.05). Group A also experienced better functional recovery at the 3 months (P 0.05). Table 4 LARS score between group A and group B Evaluate time Group A (N = 29) Group B (N = 26) P value Postoperative 1 month 36.96 ± 1.53 38.62 ± 1.47 < 0.05 Postoperative 3 month 30.3 ± 2.6 32.5 ± 3.6 0.05 Postoperative 12 month 19.3 ± 4.4 20.2 ± 3.4 > 0.05 Assessment using the Wexner Incontinence Score showed a similar recovery pattern (Table 5 ). Group A achieved better continence at 6 months (4.50 ± 1.45 vs. 5.46 ± 0.99; P 0.05). Table 5 Wexner Incontinence Score between two groups of patients. Time Group A (N = 29) Group B (N = 26) P value Postoperative 1 months 14.54 ± 2.56 15.92 ± 2.50 P > 0.05 Postoperative 3 months 9.00 ± 1.56 9.50 ± 2.40 P > 0.05 Postoperative 6 months 4.50 ± 1.45 5.46 ± 0.99 P 0.05 Discussion The greater omentum is mostly made of loose connective tissue with rich vascular and lymphatic networks[ 23 ]. In addition, loose connective tissue is composed of fibroblasts and capillary blood vessels, which are essential for collateral circulation, along with macrophages that play a major role in counteracting inflammatory mediators and foreign particles[ 24 ]. Due to the biological properties of the greater omentum, the pedicled greater omentum flap easily adheres to the surrounding tissues, thereby improving blood circulation. In the current clinical application, the rectal anastomoses were reinforced with a pedicled greater omentum flap in 29 patients, with the aim of preventing AL and LARS. The rate of AL in the omentum flap group was 3.45% (n = 1), which was much lower than the rate of adverse leak in the conventional laparoscopic resection group at 15.38% (n = 4). Furthermore, the postoperative LARS results for the omentum flap group were higher than those of the conventional group. AL after low RC surgery is a multifactorial complication. The major factors are: insufficient blood supply to the anastomosis, excessive tension of the anastomosis, technical problems during surgery, and pelvic infection or contamination[ 25 ]. Other factors include the use of preoperative radiotherapy, the long operative time, intraoperative hypotension, and increased postoperative intraluminal pressure[ 26 ]. Additionally, the low position of the anastomosis by itself is considered an independent factor because of the low vascular supply and high tension. Clinical research has shown that enhancing esophageal and bile duct connections using an omental flap can reduce the occurrence as well as the severity of AL[ 15 – 17 ]. The greater omental flap provides protection against AL through a series of complex mechanisms. First, the rich vascular network of the flap provides an increase in blood flow to the surgical site, increasing oxygen delivery and facilitating healing. Secondly, the omentum provides support to the anastomosis, relieving tension and thereby supporting the anastomotic line. Thirdly, the omentum provides immune and anti-inflammatory power, rich in immune cells and able to produce cytokines and growth factors that regulate healing. Finally, the flap provides a barrier that confines small leaks and prevents them from leading to further complications. All these aspects of the omentum enhance the anastomosis and reduce the risk of AL. LARS is a significant functional complication that is associated with sphincter-preserving surgery for the treatment of RC[ 27 ]. The development of LARS is a complex process that involves a series of changes that intertwine the structural, neural, and functional changes that occur post-surgery. In the current study, both groups showed a continuous decrease in the Wexner continence score. No significant differences between groups were found at 1 month (14.54 ± 2.56 vs. 15.92 ± 2.50), 3 months (9.00 ± 1.56 vs. 9.50 ± 2.40), or 12 months (3.36 ± 1.54 vs. 4.04 ± 1.37) (all P > 0.05). Notably, at 6 months, Group A had lower Wexner scores (4.50 ± 1.45 vs. 5.46 ± 0.99, P < 0.05). The major etiology of LARS is the loss of rectal reservoir function due to rectal resection. This results in decreased colonic compliance and fecal storage. In addition, damage to the autonomic nerves in the pelvis during TME interferes with rectoanal coordination and internal anal sphincter function[ 28 ]. The effects of a low anastomosis include compromised integrity of the anal sphincter and anorectal sensation, causing urgency and incontinence[ 29 ]. Pelvic fibrosis, inflammation, and altered neorectal motility, especially after neoadjuvant chemoradiation, contribute to bowel dysfunction and prolongation of LARS symptoms. The use of a pedicled greater omentum flap is believed to reduce the incidence and severity of LARS by a combination of biological and mechanical effects[ 18 , 30 , 31 ]. Being a vascular and pliable tissue, the omentum fills the pelvic dead space and acts as a biological cushion, reducing adhesions and external pressures on the neorectum, thus maintaining the compliance of the neorectum. The vascular and lymphatic supply of the omentum also provide anti-inflammatory and anti-fibrotic effects, thus promoting the healing of the anastomosis and reducing pelvic fibrosis. The omentum also harbors immunoregulatory cells that could potentially contribute to the repair of the pelvic autonomic nerves, thus promoting functional recovery. The pedicled omental flap, by providing support to the neorectum and to a certain degree reconstructing the pelvic anatomy, could potentially contribute to the development of a functional neorectal reservoir, thus improving the storage capacity of the stool and reducing the incidence of urgency, frequency, and fecal incontinence. However, there are some limitations of this study that should be highlighted. Firstly, the study might be limited in terms of the generalizability of the results to the wider population, given the relatively small sample size that is characteristic of single-center trials. Secondly, although the inclusion and exclusion criteria were rigorously applied, the fact that the study is observational means that there is a risk of selection bias. Thirdly, the study might be limited in terms of the long-term functional results, the long-term risk of anastomotic complications, and the oncological safety of the procedure, given that the study had a 12-month follow-up. Fourthly, the study might be limited in terms of the assessment of postoperative anorectal function, given that it relied solely on questionnaire data, which might not be a true reflection of postoperative function, given that it is based on subjective perceptions. However, the study may have the limitation of the lack of anorectal manometry, which could have offered additional information on postoperative anorectal physiology. Further studies, including multicenter randomized controlled trials with a larger sample size and longer follow-up period, are warranted to validate the findings of the current study and to further define the efficacy of pedicled greater omrntum flap reinforcement during RC. In summary, the reinforcement of rectal anastomoses using a pedicled greater omrntum flap during laparoscopic SPRC has been proven to be a safe and effective method. The method has been proven to reduce the risk of AL during mid-term follow-up. In addition, the method has been proven to have a positive impact on bowel function, as evidenced by improved LARS and Wexner scores. The method may also have a positive impact on the healing of rectal anastomoses. The method may also have a positive impact on the tumor microenvironment. The method has the potential to mitigate the risk of functional impairments during the early and late stages following RC. Conclusions Pedicled greater omentum flap reinforcement is safe and feasible during laparoscopic sphincter-preserving surgery for middle and low RC. This technique significantly reduces AL and accelerates functional recovery, representing a promising adjunct for optimizing surgical and bowel outcomes. Abbreviation AL Anastomosis leakage LARS Low anterior resection syndrome RC rectal cancer MRI magnetic resonance imaging BMI Body mass index Declarations Author contributions All authors contributed to the study conception and design. First, JF Y, HL and YX L conceived the study. Second, MY H and HL contributed to data acquisition and analysis. MY H, and JR interpreted data and drafted the manuscript. Finally, HL and XW M revised the manuscript and proved the final version. In addition, all of the authors revised and approved the manuscript. Data availability The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request. Declaration of Conflicting Interests The authors have declared that no competing interest exists. Ethics approval and consent to participate The ethics review committee of Guangxi Medical University Cancer Hospital approved the present study (No. CS2026(14)). Consent for publication Written informed consent for this research was obtained from the patient prior to surgery. The patient has provided written permission for the publication. Funding This work was supported by Project of Guangxi Science and Technology Department (GuikeAB18221086). References Wang X, Zou J, Sun Y, Zheng Z, Tang Y, Huang S, et al. Inverse effects of lymph node count on oncological outcomes in rectal cancer based on lymph node positivity status post-neoadjuvant CRT: a large-volume Chinese center experience. International journal of colorectal disease 2025; 40: 163. Ge W, Shao LH, Chen G, Qiu YD. Suspension and suturing technique can reduce the incidence of anastomotic leakage after rectal cancer excision: a single, prospective, cohort study. Scientific reports 2024; 14: 29197. Noiret B, Vendrely V, Delattre A, Vavasseur A, Maillou-Martinaud H, Nougaret S, et al. A randomized phase III trial of structured tumour response surveillance and shared decision-making for organ preservation in rectal cancer - PRODIGE 101-GRECCAR 20-EVAREC trial protocol. Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland 2026; 28: e70371. Meng W, Zhu Y, Wang J, Gan J, Liu J, Wang D, et al. Intra-arterial Delivery of Tislelizumab plus Transarterial Chemoembolization for Rectal Cancer: A Novel Regimen to Achieve Sphincter Preservation and Prevent Anastomotic Leakage. MedComm 2025; 6: e70456. Yuan X, Cui X, Wang Y, Wang Y, Duan X, Shen H. Application of self-management program for lower and middle rectal cancer patients after sphincter preservation surgery based on internet plus: A retrospective cohort study. Medicine 2025; 104: e45193. Sarangi Y, Kumar A. Predictive model for sphincter preservation in lower rectal cancer. World journal of clinical oncology 2025; 16: 107596. Luo G, Lu J, Yang Y, Ma H. Incidence and Outcomes of Low Anterior Resection Syndrome in Patients Undergoing Preventive Ostomy for Laparoscopic Rectal Cancer Surgery. Annali italiani di chirurgia 2025; 96: 152-9. Ju HE, Lee CS, Bae JH, Lee HJ, Yoon MR, Al-Sawat A, et al. High incidence of late anastomosis leakage in patients for rectal cancer after neoadjuvant chemoradiotherapy: A comparative study. Asian journal of surgery 2022; 45: 1832-42. Petersen DR, Faaborg PM, Al-Najami I, Thygesen MM, Mølstrøm APB, Möller S, et al. Impact of timing of ileostomy reversal and anastomotic leakage on bowel function and health-related quality of life following rectal cancer surgery: a cross-sectional study. Surgical endoscopy 2026 Holte SS, Avaliani N, Hoff G, Kazaryan AM, Jaioun K, Lauzikas G, et al. Effect of psyllium husk on low anterior resection syndrome after rectal cancer surgery-a pilot prospective cohort study. Frontiers in surgery 2025; 12: 1686486. Al-Kubati WR. Advanced Reconstructive Techniques: Mitigating Low Anterior Resection Syndrome Post-TME in Low Rectal Cancer - A Single-Center Randomised Controlled Study. Cancer management and research 2025; 17: 2469-85. Huu Phu L, Tat Bang H, Viet Binh N, Danh Tan H, Van Viet U, Tin NT. Major Low Anterior Resection Syndrome (LARS) and Quality of Life in Patients With Low Rectal Cancer: A Preoperative Survey Using LARS Score and European Organisation for Research and Treatment of Cancer's 30-Item Core Quality of Life Questionnaire. Cureus 2023; 15: e50074. Cullinane DM, Niblett A, Knerr RM, Coulombe J, Kwasnik E, McDermott C, et al. The Greater Omentum: A Proposed Mechanism of Movement in the Abdomen. Clinical anatomy (New York, NY) 2025 Joseph TS, Hogan E, Cesmebasi A, Carrasco M, Ang C, Davis N, et al. A systematic review and surgical anatomy of the greater omentum. Morphologie : bulletin de l'Association des anatomistes 2025; 110: 101072. Matsui Y, Hirooka S, Kotsuka M, Yamaki S, Yamamoto T, Kosaka H, et al. Use of a piece of free omentum to prevent bile leakage after subtotal cholecystectomy. Surgery 2018; 164: 419-23. Liu QX, Deng XF, Hou B, Min JX, Dai JG. Preventing and localizing esophagogastric anastomosis leakage by sleeve-wrapping of the pedicled omentum. World journal of gastroenterology 2014; 20: 16282-6. Bhat MA, Dar MA, Lone GN, Dar AM. Use of pedicled omentum in esophagogastric anastomosis for prevention of anastomotic leak. The Annals of thoracic surgery 2006; 82: 1857-62. Liao J, Qin H, Wang Z, Meng L, Wang W, Liu J, et al. Mesorectal reconstruction with pedicled greater omental transplantation to relieve low anterior resection syndrome following total intersphincteric resection in patients with ultra-low rectal cancer. BMC surgery 2023; 23: 236. Wen B, Zhang G, Zhan C, Chen C, Yi H. The 2024 revision of the Declaration of Helsinki: a modern ethical framework for medical research. Postgraduate medical journal 2025; 101: 371-82. Kagiyama H, Matsuda T, Hasegawa H, Otowa Y, Ando M, Koterazawa Y, et al. Is Transanal total mesorectal excision (TME) as safe and effective as laparoscopic TME for low rectal cancer? A propensity score-matched analysis. Surgery today 2025 Carrillo A, Enríquez-Navascués JM, Rodríguez A, Placer C, Múgica JA, Saralegui Y, et al. Incidence and characterization of the anterior resection syndrome through the use of the LARS scale (low anterior resection score). Cir Esp 2016; 94: 137-43. Essangri H, Majbar MA, Benkabbou A, Amrani L, Mohsine R, Souadka A. Transcultural adaptation and validation of the Moroccan Arabic dialect version of the Wexner incontinence score in patients with low anterior resection syndrome after rectal surgery. Surgery 2021; 170: 47-52. Pitts L, Pasic M, Wert L, Nersesian G, Kaemmel J, Buz S, et al. Mediastinal transposition of the greater omentum for treatment of infected prostheses of the ascending aorta and aortic arch. European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery 2024; 65 Wang AW, Prieto JM, Cauvi DM, Bickler SW, De Maio A. The Greater Omentum-A Vibrant and Enigmatic Immunologic Organ Involved in Injury and Infection Resolution. Shock (Augusta, Ga) 2020; 53: 384-90. Kim HK, Park IJ, Kang JC, Lee JL, Kim CW, Yoon YS, et al. Late Anastomotic Leakage After Rectal Cancer Surgery: Incidence and Differential Risk Factors. Diseases of the colon and rectum 2026 Dias VE, Castro P, Padilha HT, Pillar LV, Godinho LBR, Tinoco ACA, et al. Preoperative risk factors associated with anastomotic leakage after colectomy for colorectal cancer: a systematic review and meta-analysis. Revista do Colegio Brasileiro de Cirurgioes 2022; 49: e20223363. Gurluk M, Karagulle OO, Cakar E, Avci B, Cakir E, Rakici IT, et al. Pelvic index/mesorectal length ratio: a new predictive factor for rectal cancer prognosis and low anterior resection syndrome. Cirugia y cirujanos 2025; 93: 590-8. Lunca S, Morarasu S, Osman C, Shatarat FA, Gramada T, Razniceanu M, et al. Predictive Risk Factors for Low Anterior Resection Syndrome (LARS) in Rectal Cancer-An Observational Cohort Study. Journal of clinical medicine 2025; 14 Sguinzi R, Fiechter J, Bafumi L, Gremaud B, Geng B, Janiak P, et al. Score assessment and treatment in patients presenting with low anterior resection syndrome after sphincter-sparing rectal cancer surgery. International journal of colorectal disease 2025; 40: 115. Meng L, Qin H, Huang Z, Liao J, Cai J, Feng Y, et al. Analysis of presacral tissue structure in LARS and the prevention of LARS by reconstruction of presacral mesorectum with pedicled greater omentum flap graft. Techniques in coloproctology 2021; 25: 1291-300. Qin H, Meng L, Huang Z, Liao J, Feng Y, Luo S, et al. A study on the clinical application of greater omental pedicle flap transplantation to correct anterior resection syndrome in patients with low rectal cancer. Regenerative therapy 2021; 18: 146-51. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8802487","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":600875471,"identity":"ff112f5f-eb24-40b2-bb2f-50cb912750f1","order_by":0,"name":"Hao Lai","email":"","orcid":"","institution":"Guangxi Medical University Cancer Hospital","correspondingAuthor":false,"prefix":"","firstName":"Hao","middleName":"","lastName":"Lai","suffix":""},{"id":600875472,"identity":"47ba2bec-0bb8-41af-8354-9a49fb84d1c9","order_by":1,"name":"Jiangfeng Yu","email":"","orcid":"","institution":"Guangxi Medical University Cancer Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jiangfeng","middleName":"","lastName":"Yu","suffix":""},{"id":600875473,"identity":"b0f24bf5-0da9-4dae-9c76-5ef16c240b11","order_by":2,"name":"Xiaojun Zou","email":"","orcid":"","institution":"Guangxi Medical University Cancer Hospital","correspondingAuthor":false,"prefix":"","firstName":"Xiaojun","middleName":"","lastName":"Zou","suffix":""},{"id":600875474,"identity":"5204b0eb-5284-4fe6-97ac-95ca2d6d1921","order_by":3,"name":"Mingyang Hu","email":"","orcid":"","institution":"Guangxi Medical University Cancer Hospital","correspondingAuthor":false,"prefix":"","firstName":"Mingyang","middleName":"","lastName":"Hu","suffix":""},{"id":600875475,"identity":"b600e4b5-5c00-4a5f-aa51-7cc89caedd31","order_by":4,"name":"Ju Rong","email":"","orcid":"","institution":"Guangxi Medical University Cancer Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ju","middleName":"","lastName":"Rong","suffix":""},{"id":600875476,"identity":"7f546f32-5e7a-410a-ae53-89bc84085c4d","order_by":5,"name":"Xianwei Mo","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA00lEQVRIiWNgGAWjYJCCAyCCjb354IMPBjZ2JGjhOZZsOKMgLZkEuyRyzKR5PhxibCCkULe9x/DAzx2H5fiAthjbGBxgZmA/fHQDPi1mZ44lHOw9c9gY5JfHOQZ3+Bh40tJu4NVyI/nAAd6224ltIFtyDJ4xM0jwmBHQkthw8G/b7fo2kF8sDA4zNhDWknzgMNCWBDaQFgaitAD9cli27b8hyGGGPQZpyWwE/XK8x/jj27Y0efl2YFT++GNjx89++BheLZiAjTTlo2AUjIJRMAqwAQC1RVGTNU+IuAAAAABJRU5ErkJggg==","orcid":"","institution":"Guangxi Medical University Cancer Hospital","correspondingAuthor":true,"prefix":"","firstName":"Xianwei","middleName":"","lastName":"Mo","suffix":""}],"badges":[],"createdAt":"2026-02-06 04:23:36","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8802487/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8802487/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104294422,"identity":"eeb02e03-d704-4f3e-9f6b-cff6aeec40ca","added_by":"auto","created_at":"2026-03-10 07:35:12","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":13804032,"visible":true,"origin":"","legend":"\u003cp\u003eProcessing and dissection of the greater omentum vessels.\u003c/p\u003e","description":"","filename":"figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-8802487/v1/9a0887944e187198998c48fb.png"},{"id":104294423,"identity":"67704c46-2886-480d-ad03-ed3d5ef704c0","added_by":"auto","created_at":"2026-03-10 07:35:13","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":13804776,"visible":true,"origin":"","legend":"\u003cp\u003eThe dissected greater omentum is fully spread to cover the posterior and lateral aspects of the rectum, enveloping the rectal anastomosis.\u003c/p\u003e","description":"","filename":"figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-8802487/v1/e0fa06223f19f4aee38edc9b.png"},{"id":104294421,"identity":"d6d2f5e8-c7f9-4f4e-99b8-37d4138f5d35","added_by":"auto","created_at":"2026-03-10 07:35:12","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":14865167,"visible":true,"origin":"","legend":"\u003cp\u003eThe greater omentum is secured to the bilateral pelvic peritoneum using Hem-o-lok clips.\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-8802487/v1/7820249096b66408b6708ecd.png"},{"id":106403298,"identity":"8be375b2-89bc-4a62-b11f-7853bed2986c","added_by":"auto","created_at":"2026-04-08 09:14:01","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":41122359,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8802487/v1/c7dec2c6-6b8c-4cee-bd1c-761e63778bb8.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Pedicled Greater Omentum Flap Reinforcement Reduces Anastomotic Leakage and Improves Functional Recovery After Laparoscopic Sphincter-Preserving Surgery for Middle and Low rectal cancer Rectal Cancer: a Retrospective Comparative Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eRectal cancer (RC) is one of the most prevalent colorectal cancers and is a major public health burden in China[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Due to changes in lifestyle, dietary habits, and the aging population, the incidence of RC has been increasing steadily over the years[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. What is of particular interest is that 70% of RC cases are low RC, where the cancer is situated in close proximity to the anal verge. This characteristic of RC has resulted in considerable challenges in the achievement of radical resection of cancer while maintaining continence via the anal sphincter mechanism[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Sphincter preservation has become a significant concern in the management of low RC, which has considerable implications for quality of life[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRecently, surgeons have developed a significant level of technical skills in laparoscopic radical surgery. However, the incidence of complications is between 10% and 40% after anal-sparing surgery for low RC [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The most common complication following surgery is anastomotic leakage (AL), which prolongs hospitalization[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], increases healthcare costs, and may cause death. Therefore, the prevention of AL is a necessity in surgery. In patients with compromised anastomotic blood supply and rectal spasm, conventional anastomotic repair following radical surgery for RC is associated with a high incidence of AL[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Ileostomy is a measure that is used to prevent AL, but it considerably impacts the quality of life, and patients require a second surgery to reverse it three months after[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eLARS symbolizes a common and important adverse outcome following SP procedures. A considerable number of patients are afflicted by postoperative anorectal dysfunction, as indicated by increased defecation frequency, urgency, soiling, and incontinence to varying degrees[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. With a high prevalence rate of 60%-90%, LARS considerably compromises quality of life, and its association with psychological complications such as anxiety and depression makes it a concern[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Thus, the prevention or mitigation of AL as well as LARS becomes an important concern in RC surgery.\u003c/p\u003e \u003cp\u003eThe greater omentum is a biologically active tissue that is highly adaptable. Once it is exposed to an area of injury or ischemia, it releases a variety of bioactive molecules, including a range of angiogenic growth factors such as vascular endothelial growth factor, progenitor cells, and chemokines such as stromal cell\u0026ndash;derived factor‑1α. These molecules play a crucial role in tissue regeneration, wound healing, hemostasis, and immune modulation[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The pedicled flap of the greater omentum is harvested by mobilizing it from the greater curvature of the stomach, maintaining the gastroepiploic vascular arcade[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Owing to these distinctive biological and structural properties, the greater omentum has been increasingly utilized in general surgery as a protective adjunct to reduce the risk of AL. Examples include esophagogastric anastomosis and bile duct AL after liver transplantation[\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. However, there have been no previous reports on its use to prevent AL in sphincter-preserving surgery for low RC.\u003c/p\u003e \u003cp\u003eIn our previous study, we applied a pedicled greater omentum flap to reconstruct the anterior sacral space in low RC surgery. This approach effectively prevented LARS[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. In the current study, we will use the greater omentum flap to prevent both AL and LARS in sphincter-preserving surgery for middle and low RC and evaluate its efficacy.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003ePatients\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study was conducted in compliance with the ethical guidelines specified in the Declaration of Helsinki (1964)[19] and all subsequent revisions. Ethical approval was granted by the Ethics Committee of Guangxi Medical University Cancer Hospital (No. CS2026(14)), China, and written informed consent was obtained from all participating patients. Clinical information of patients diagnosed with low RC, who underwent surgical procedures utilizing the novel anastomosis approach between January 2023 and December 2024 at our institution, was retrospectively reviewed.\u003c/p\u003e\n\u003cp\u003eInclusion criteria\u003c/p\u003e\n\u003cp\u003eInclusion criteria: (1) Patients aged from 18 to 70 years; (2) Tumor location and its distance from the dentate line confirmed preoperatively by electronic colonoscopy and magnetic resonance imaging (MRI), with the lower margin of the tumor \u0026le;10 cm from the anal verge; (3) Histologically proven rectal adenocarcinoma, irrespective of receiving neoadjuvant therapy; (4) Absence of distant organ metastasis confirmed via preoperative CT and no intraperitoneal metastases detected during laparoscopic exploration [22]; (5) Underwent total mesorectal excision (TME); presence of normal preoperative anal sphincter function without a history of frequent fecal incontinence involving solid or liquid stool; and (6) Capable of completing postoperative follow-up assessments of anorectal function.\u003c/p\u003e\n\u003cp\u003eExclusion criteria\u003c/p\u003e\n\u003cp\u003e(1) Body mass index (BMI) \u0026ge;30 kg/m\u0026sup2;; (2) Preoperative lax anal sphincter or inflammatory bowel disease; (3) Severe underlying diseases involving major organ systems, such as heart, lungs, or cerebrovascular systems; (4) Recurrent RC requiring reoperation; (5) Postoperative radiotherapy required; (6) Patients who underwent preventive temporary colostomy without subsequent reversal surgery.\u003c/p\u003e\n\u003cp\u003esurgical procedure\u003c/p\u003e\n\u003cp\u003eLaparoscopic low RC surgery\u003c/p\u003e\n\u003cp\u003eThe procedure was carried out in adherence to the principles of TME[20], including meticulous vascular management and enbloc lymphadenectomy. The inferior mesenteric vessels were anatomically dissected, and the regional lymph nodes along with the adipose tissue were excised. The rectal mesenteric fat was excised, and the intestine was cut at a portion that is at least 1 cm distal to the tumor. After the laparoscopic procedure, the affected bowel portion was brought out through a small auxiliary abdominal incision, ensuring a proximal margin of at least 10 cm from the tumor. An appropriate anastomosis device was used. The procedure of digestive tract reconstruction was carried out under pneumoperitoneum, and a drainage catheter was placed. None of the patients underwent ileostomy reversal surgery.\u003c/p\u003e\n\u003cp\u003ePedicled greater omentum transplantation surgery\u003c/p\u003e\n\u003cp\u003eThe laparoscopic method was carried out following the standard protocol for mesenteric separation and lymph node dissection, as in conventional laparoscopic practice. In the reconstructive process of the digestive tract, a pedicled flap of the greater omentum was used for the replacement of the rectal mesentery. This process was carried out in three main steps: (1) the preparation and dissection of the vessels of the greater omentum (Figure 1); (2) the beginning of the dissection from the area near the left gastric artery and then extending laterally along the gastric arterial arch from left to right. During this process, emphasis was laid on maintaining an adequate blood supply to the transplanted tissue by preserving the right marginal vessels and their vertical branches. Subsequently, the posterior leaf of the greater omentum was dissected and transplanted to the pelvic cavity. Then, the dissected omentum was laid out to cover the posterior and lateral rectal regions by enveloping the rectal anastomosis (Figure 2). After this, the omentum tissue was attached to the bilateral pelvic peritoneum by using Hemo-lock clips (Figure 3). Care was taken to prevent twisting of the vascular pedicle, avoiding ischemic necrosis of transplanted tissue. After the procedure, a pelvic drainage tube was routinely placed for postoperative monitoring.\u003c/p\u003e\n\u003cp\u003ePostoperative assessment of anal function\u003c/p\u003e\n\u003cp\u003eEvaluation of postoperative anal functions was mainly based on questionnaires from patients. The LARS score and Wexner Anorectal Incontinence score were used for this purpose[21, 22].\u003c/p\u003e\n\u003cp\u003eData collection was carried out using telephone interviews and follow-up at 1, 3, 6, and 12 months after surgery. The patients were given a LARS score and Wexner scale questionnaire, and their scores were analyzed statistically to evaluate the incidence rate of LARS, factors that influence LARS, and recovery after RC.\u003c/p\u003e\n\u003cp\u003eStatistical analysis\u003c/p\u003e\n\u003cp\u003eStatistical evaluation was performed using SPSS (version 25.0) and MSTATA (www.mstata.com).\u0026nbsp;Measurement data were expressed as mean \u0026plusmn; standard deviation (x̄ \u0026plusmn; s) or as median and range, as appropriate. Data conforming to normal distribution and homogeneity of variance were presented as \u0026quot;x̄ \u0026plusmn; s\u0026quot;. Comparisons across multiple groups were made utilizing one-way analysis of variance (ANOVA). Count data were reported as percentages and analyzed by\u0026nbsp;\u0026chi;\u0026sup2; tests or Fisher\u0026rsquo;s exact tests. For ranked data, multiple comparisons were conducted via the Kruskal-Wallis test, and paired comparisons were analyzed using the Wilcoxon signed-rank test. Statistical significance was set at P \u0026lt; 0.05.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 55 eligible patients were included for analysis and randomly allocated to two groups according to different surgical methods. Patients who received laparoscopic radical resection with pedicled greater omrntum transplantation were allocated to Group A, and patients who received conventional laparoscopic radical resection were allocated to Group B. There were 29 patients in Group A and 26 patients in Group B. Group B comprised patients whose average age was 58\u0026thinsp;\u0026plusmn;\u0026thinsp;13 years, with 14 men and 12 women, and an average BMI of 21.51\u0026thinsp;\u0026plusmn;\u0026thinsp;2.83 kg/m\u0026sup2;. The demographic data, such as age, gender distribution, and BMI, at the baseline were not significantly different between the groups (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Similarly, there were no significant differences in the use of adjuvant therapy, co-morbid conditions, and TNM staging of the tumor between the two groups (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003eSurgical outcomes\u003c/p\u003e \u003cp\u003eAll cases were successfully operated using laparoscopic surgery, without conversion to open surgery. Pathological examination confirmed that all cases in both groups achieved R0 resection. Perioperative indicators, including operative duration, intraoperative blood loss, postoperative first flatus time, hospital stay duration, and overall treatment expenditure, were not significantly different between the two groups (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). However, a significantly delayed postoperative defecation time was observed in Group A (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). No significant intergroup differences were identified concerning tumor dimensions, lymph node yield, tumor differentiation degree, or the frequency of postoperative complications (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eClinical characteristics according to study group.\u003c/span\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup A\u003c/p\u003e \u003cp\u003e( N\u0026thinsp;=\u0026thinsp;29)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGroup B\u003c/p\u003e \u003cp\u003e( N\u0026thinsp;=\u0026thinsp;26)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57\u0026thinsp;\u0026plusmn;\u0026thinsp;13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58\u0026thinsp;\u0026plusmn;\u0026thinsp;13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP\u0026thinsp;\u0026gt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP\u0026thinsp;\u0026gt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22.50\u0026thinsp;\u0026plusmn;\u0026thinsp;2.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21.51\u0026thinsp;\u0026plusmn;\u0026thinsp;2.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP\u0026thinsp;\u0026gt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe distance from the lower edge of the tumor to the anal verge (cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.16\u0026thinsp;\u0026plusmn;\u0026thinsp;2.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.96\u0026thinsp;\u0026plusmn;\u0026thinsp;2.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP\u0026thinsp;\u0026gt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTNM stage\u003c/p\u003e \u003cp\u003eI\u003c/p\u003e \u003cp\u003eII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP\u0026thinsp;\u0026gt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ea\u003c/span\u003eccompanying disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP\u0026thinsp;\u0026gt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ec\u003c/span\u003eoronary heart disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFavism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ef\u003c/span\u003eatty liver\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ec\u003c/span\u003ehronic hepatitis B\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ep\u003c/span\u003eostoperative outcomes.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical outcome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup A (N\u0026thinsp;=\u0026thinsp;29)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGroup B\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;26)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperative (min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e274\u0026thinsp;\u0026plusmn;\u0026thinsp;82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e264\u0026thinsp;\u0026plusmn;\u0026thinsp;196\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP\u0026thinsp;\u0026gt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood loss (ml)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51\u0026thinsp;\u0026plusmn;\u0026thinsp;60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60\u0026thinsp;\u0026plusmn;\u0026thinsp;36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP\u0026thinsp;\u0026gt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoerative exhaust time (day)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.86\u0026thinsp;\u0026plusmn;\u0026thinsp;1.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.42\u0026thinsp;\u0026plusmn;\u0026thinsp;0.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP\u0026thinsp;\u0026gt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoerative hospital stay (day)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.68\u0026thinsp;\u0026plusmn;\u0026thinsp;3.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.25\u0026thinsp;\u0026plusmn;\u0026thinsp;2.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP\u0026thinsp;\u0026gt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHistological type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP\u0026thinsp;\u0026gt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProtrude type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (39.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (37.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBorrmann\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (60.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (62.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTumor differentiation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP\u0026thinsp;\u0026gt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWell differentiated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerately differentiated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epoorly differentiated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLymph node harvest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19\u0026thinsp;\u0026plusmn;\u0026thinsp;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19\u0026thinsp;\u0026plusmn;\u0026thinsp;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP\u0026thinsp;\u0026gt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClavien-Dindo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP\u0026thinsp;\u0026gt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eⅠ\u003c/p\u003e \u003cp\u003eⅡ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eⅢ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eⅣ\u003c/p\u003e \u003cp\u003eⅤ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ePostoperative complications of AL\u003c/p\u003e \u003cp\u003ePostoperative complications rate of anastomotic leak. were observed in both groups (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). In Group A (laparoscopic radical resection with pedicled greater omentum transplantation), complications of AL included one case of AL (3.45%). In the group of conventional laparoscopic resection, which was classified as group B, the complications that were encountered included four cases of AL, which accounted for 15.38%. All the patients who had AL underwent ileostomy, and the reversal of the stoma was done at three months postoperatively.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComplications rate of anastomotic leak.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup A\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;29)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGroup B\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;26)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnastomotic leak\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone anastomotic leak\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAnal function assessment\u003c/p\u003e \u003cp\u003eQuantitative assessment of the functional outcomes following surgery indicated that there was a significant difference between the two groups regarding the progression of LARS (Table \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). The two groups experienced severe LARS at the 1-month postoperative period. There was statistically significant difference between the two groups (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Group A also experienced better functional recovery at the 3 months (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05), reflected by the low mean scores of LARS compared to Group B. This was not pronounced at the 6 months and 12 months between two group of patients (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eLARS score between group A and group B\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEvaluate time\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup A (N\u0026thinsp;=\u0026thinsp;29)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGroup B (N\u0026thinsp;=\u0026thinsp;26)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP value\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative 1 month\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e36.96\u0026thinsp;\u0026plusmn;\u0026thinsp;1.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e38.62\u0026thinsp;\u0026plusmn;\u0026thinsp;1.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative 3 month\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e30.3\u0026thinsp;\u0026plusmn;\u0026thinsp;2.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e32.5\u0026thinsp;\u0026plusmn;\u0026thinsp;3.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative 6 month\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e24.3\u0026thinsp;\u0026plusmn;\u0026thinsp;4.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e26.9\u0026thinsp;\u0026plusmn;\u0026thinsp;3.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative 12 month\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e19.3\u0026thinsp;\u0026plusmn;\u0026thinsp;4.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e20.2\u0026thinsp;\u0026plusmn;\u0026thinsp;3.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAssessment using the Wexner Incontinence Score showed a similar recovery pattern (Table \u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). Group A achieved better continence at 6 months (4.50\u0026thinsp;\u0026plusmn;\u0026thinsp;1.45 vs. 5.46\u0026thinsp;\u0026plusmn;\u0026thinsp;0.99; P\u0026thinsp;\u0026lt;\u0026thinsp;0.05), despite no differences at 1, 3 and 12 months. (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eWexner Incontinence Score between two groups of patients.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup A\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;29)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGroup B\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;26)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative 1 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e14.54\u0026thinsp;\u0026plusmn;\u0026thinsp;2.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e15.92\u0026thinsp;\u0026plusmn;\u0026thinsp;2.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP\u0026thinsp;\u0026gt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative 3 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e9.00\u0026thinsp;\u0026plusmn;\u0026thinsp;1.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e9.50\u0026thinsp;\u0026plusmn;\u0026thinsp;2.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP\u0026thinsp;\u0026gt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative 6 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e4.50\u0026thinsp;\u0026plusmn;\u0026thinsp;1.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e5.46\u0026thinsp;\u0026plusmn;\u0026thinsp;0.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative 12 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e3.36\u0026thinsp;\u0026plusmn;\u0026thinsp;1.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e4.40\u0026thinsp;\u0026plusmn;\u0026thinsp;1.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP\u0026thinsp;\u0026gt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe greater omentum is mostly made of loose connective tissue with rich vascular and lymphatic networks[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. In addition, loose connective tissue is composed of fibroblasts and capillary blood vessels, which are essential for collateral circulation, along with macrophages that play a major role in counteracting inflammatory mediators and foreign particles[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Due to the biological properties of the greater omentum, the pedicled greater omentum flap easily adheres to the surrounding tissues, thereby improving blood circulation. In the current clinical application, the rectal anastomoses were reinforced with a pedicled greater omentum flap in 29 patients, with the aim of preventing AL and LARS. The rate of AL in the omentum flap group was 3.45% (n\u0026thinsp;=\u0026thinsp;1), which was much lower than the rate of adverse leak in the conventional laparoscopic resection group at 15.38% (n\u0026thinsp;=\u0026thinsp;4). Furthermore, the postoperative LARS results for the omentum flap group were higher than those of the conventional group.\u003c/p\u003e \u003cp\u003eAL after low RC surgery is a multifactorial complication. The major factors are: insufficient blood supply to the anastomosis, excessive tension of the anastomosis, technical problems during surgery, and pelvic infection or contamination[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Other factors include the use of preoperative radiotherapy, the long operative time, intraoperative hypotension, and increased postoperative intraluminal pressure[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Additionally, the low position of the anastomosis by itself is considered an independent factor because of the low vascular supply and high tension.\u003c/p\u003e \u003cp\u003eClinical research has shown that enhancing esophageal and bile duct connections using an omental flap can reduce the occurrence as well as the severity of AL[\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The greater omental flap provides protection against AL through a series of complex mechanisms. First, the rich vascular network of the flap provides an increase in blood flow to the surgical site, increasing oxygen delivery and facilitating healing. Secondly, the omentum provides support to the anastomosis, relieving tension and thereby supporting the anastomotic line. Thirdly, the omentum provides immune and anti-inflammatory power, rich in immune cells and able to produce cytokines and growth factors that regulate healing. Finally, the flap provides a barrier that confines small leaks and prevents them from leading to further complications. All these aspects of the omentum enhance the anastomosis and reduce the risk of AL.\u003c/p\u003e \u003cp\u003eLARS is a significant functional complication that is associated with sphincter-preserving surgery for the treatment of RC[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. The development of LARS is a complex process that involves a series of changes that intertwine the structural, neural, and functional changes that occur post-surgery. In the current study, both groups showed a continuous decrease in the Wexner continence score. No significant differences between groups were found at 1 month (14.54\u0026thinsp;\u0026plusmn;\u0026thinsp;2.56 vs. 15.92\u0026thinsp;\u0026plusmn;\u0026thinsp;2.50), 3 months (9.00\u0026thinsp;\u0026plusmn;\u0026thinsp;1.56 vs. 9.50\u0026thinsp;\u0026plusmn;\u0026thinsp;2.40), or 12 months (3.36\u0026thinsp;\u0026plusmn;\u0026thinsp;1.54 vs. 4.04\u0026thinsp;\u0026plusmn;\u0026thinsp;1.37) (all P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Notably, at 6 months, Group A had lower Wexner scores (4.50\u0026thinsp;\u0026plusmn;\u0026thinsp;1.45 vs. 5.46\u0026thinsp;\u0026plusmn;\u0026thinsp;0.99, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003eThe major etiology of LARS is the loss of rectal reservoir function due to rectal resection. This results in decreased colonic compliance and fecal storage. In addition, damage to the autonomic nerves in the pelvis during TME interferes with rectoanal coordination and internal anal sphincter function[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. The effects of a low anastomosis include compromised integrity of the anal sphincter and anorectal sensation, causing urgency and incontinence[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Pelvic fibrosis, inflammation, and altered neorectal motility, especially after neoadjuvant chemoradiation, contribute to bowel dysfunction and prolongation of LARS symptoms. The use of a pedicled greater omentum flap is believed to reduce the incidence and severity of LARS by a combination of biological and mechanical effects[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Being a vascular and pliable tissue, the omentum fills the pelvic dead space and acts as a biological cushion, reducing adhesions and external pressures on the neorectum, thus maintaining the compliance of the neorectum. The vascular and lymphatic supply of the omentum also provide anti-inflammatory and anti-fibrotic effects, thus promoting the healing of the anastomosis and reducing pelvic fibrosis. The omentum also harbors immunoregulatory cells that could potentially contribute to the repair of the pelvic autonomic nerves, thus promoting functional recovery. The pedicled omental flap, by providing support to the neorectum and to a certain degree reconstructing the pelvic anatomy, could potentially contribute to the development of a functional neorectal reservoir, thus improving the storage capacity of the stool and reducing the incidence of urgency, frequency, and fecal incontinence.\u003c/p\u003e \u003cp\u003eHowever, there are some limitations of this study that should be highlighted. Firstly, the study might be limited in terms of the generalizability of the results to the wider population, given the relatively small sample size that is characteristic of single-center trials. Secondly, although the inclusion and exclusion criteria were rigorously applied, the fact that the study is observational means that there is a risk of selection bias. Thirdly, the study might be limited in terms of the long-term functional results, the long-term risk of anastomotic complications, and the oncological safety of the procedure, given that the study had a 12-month follow-up. Fourthly, the study might be limited in terms of the assessment of postoperative anorectal function, given that it relied solely on questionnaire data, which might not be a true reflection of postoperative function, given that it is based on subjective perceptions. However, the study may have the limitation of the lack of anorectal manometry, which could have offered additional information on postoperative anorectal physiology. Further studies, including multicenter randomized controlled trials with a larger sample size and longer follow-up period, are warranted to validate the findings of the current study and to further define the efficacy of pedicled greater omrntum flap reinforcement during RC.\u003c/p\u003e \u003cp\u003eIn summary, the reinforcement of rectal anastomoses using a pedicled greater omrntum flap during laparoscopic SPRC has been proven to be a safe and effective method. The method has been proven to reduce the risk of AL during mid-term follow-up. In addition, the method has been proven to have a positive impact on bowel function, as evidenced by improved LARS and Wexner scores. The method may also have a positive impact on the healing of rectal anastomoses. The method may also have a positive impact on the tumor microenvironment. The method has the potential to mitigate the risk of functional impairments during the early and late stages following RC.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003ePedicled greater omentum flap reinforcement is safe and feasible during laparoscopic sphincter-preserving surgery for middle and low RC. This technique significantly reduces AL and accelerates functional recovery, representing a promising adjunct for optimizing surgical and bowel outcomes.\u003c/p\u003e"},{"header":"Abbreviation ","content":"\u003cp\u003eAL Anastomosis leakage\u003c/p\u003e\n\u003cp\u003eLARS Low anterior resection syndrome\u003c/p\u003e\n\u003cp\u003eRC rectal cancer\u003c/p\u003e\n\u003cp\u003eMRI magnetic resonance imaging\u003c/p\u003e\n\u003cp\u003eBMI Body mass index\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eAuthor contributions\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception and design. First, JF Y, HL and YX L conceived the study. Second, MY H and HL contributed to data acquisition and analysis. MY H, and JR interpreted data and drafted the manuscript. Finally, HL and XW M revised the manuscript and proved the final version. In addition, all of the authors revised and approved the manuscript.\u003c/p\u003e\n\u003cp\u003eData availability\u003c/p\u003e\n\u003cp\u003eThe datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003eDeclaration of Conflicting Interests\u003c/p\u003e\n\u003cp\u003eThe authors have declared that no competing interest exists.\u003c/p\u003e\n\u003cp\u003eEthics approval and consent to participate\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe ethics review committee of Guangxi Medical University Cancer Hospital approved the present study (No. CS2026(14)).\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eWritten informed consent for this research was obtained from the patient prior to surgery. The patient has provided written permission for the publication.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThis work was supported by Project of Guangxi Science and Technology Department (GuikeAB18221086).\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eWang X, Zou J, Sun Y, Zheng Z, Tang Y, Huang S, et al. Inverse effects of lymph node count on oncological outcomes in rectal cancer based on lymph node positivity status post-neoadjuvant CRT: a large-volume Chinese center experience. \u003cem\u003eInternational journal of colorectal disease\u0026nbsp;\u003c/em\u003e2025; \u003cstrong\u003e40:\u003c/strong\u003e 163.\u003c/li\u003e\n \u003cli\u003eGe W, Shao LH, Chen G, Qiu YD. Suspension and suturing technique can reduce the incidence of anastomotic leakage after rectal cancer excision: a single, prospective, cohort study. \u003cem\u003eScientific reports\u0026nbsp;\u003c/em\u003e2024; \u003cstrong\u003e14:\u003c/strong\u003e 29197.\u003c/li\u003e\n \u003cli\u003eNoiret B, Vendrely V, Delattre A, Vavasseur A, Maillou-Martinaud H, Nougaret S, et al. A randomized phase III trial of structured tumour response surveillance and shared decision-making for organ preservation in rectal cancer - PRODIGE 101-GRECCAR 20-EVAREC trial protocol. \u003cem\u003eColorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland\u0026nbsp;\u003c/em\u003e2026; \u003cstrong\u003e28:\u003c/strong\u003e e70371.\u003c/li\u003e\n \u003cli\u003eMeng W, Zhu Y, Wang J, Gan J, Liu J, Wang D, et al. Intra-arterial Delivery of Tislelizumab plus Transarterial Chemoembolization for Rectal Cancer: A Novel Regimen to Achieve Sphincter Preservation and Prevent Anastomotic Leakage. \u003cem\u003eMedComm\u0026nbsp;\u003c/em\u003e2025; \u003cstrong\u003e6:\u003c/strong\u003e e70456.\u003c/li\u003e\n \u003cli\u003eYuan X, Cui X, Wang Y, Wang Y, Duan X, Shen H. Application of self-management program for lower and middle rectal cancer patients after sphincter preservation surgery based on internet plus: A retrospective cohort study. \u003cem\u003eMedicine\u0026nbsp;\u003c/em\u003e2025; \u003cstrong\u003e104:\u003c/strong\u003e e45193.\u003c/li\u003e\n \u003cli\u003eSarangi Y, Kumar A. Predictive model for sphincter preservation in lower rectal cancer. \u003cem\u003eWorld journal of clinical oncology\u0026nbsp;\u003c/em\u003e2025; \u003cstrong\u003e16:\u003c/strong\u003e 107596.\u003c/li\u003e\n \u003cli\u003eLuo G, Lu J, Yang Y, Ma H. Incidence and Outcomes of Low Anterior Resection Syndrome in Patients Undergoing Preventive Ostomy for Laparoscopic Rectal Cancer Surgery. \u003cem\u003eAnnali italiani di chirurgia\u0026nbsp;\u003c/em\u003e2025; \u003cstrong\u003e96:\u003c/strong\u003e 152-9.\u003c/li\u003e\n \u003cli\u003eJu HE, Lee CS, Bae JH, Lee HJ, Yoon MR, Al-Sawat A, et al. High incidence of late anastomosis leakage in patients for rectal cancer after neoadjuvant chemoradiotherapy: A comparative study. \u003cem\u003eAsian journal of surgery\u0026nbsp;\u003c/em\u003e2022; \u003cstrong\u003e45:\u003c/strong\u003e 1832-42.\u003c/li\u003e\n \u003cli\u003ePetersen DR, Faaborg PM, Al-Najami I, Thygesen MM, M\u0026oslash;lstr\u0026oslash;m APB, M\u0026ouml;ller S, et al. Impact of timing of ileostomy reversal and anastomotic leakage on bowel function and health-related quality of life following rectal cancer surgery: a cross-sectional study. \u003cem\u003eSurgical endoscopy\u0026nbsp;\u003c/em\u003e2026\u003c/li\u003e\n \u003cli\u003eHolte SS, Avaliani N, Hoff G, Kazaryan AM, Jaioun K, Lauzikas G, et al. Effect of psyllium husk on low anterior resection syndrome after rectal cancer surgery-a pilot prospective cohort study. \u003cem\u003eFrontiers in surgery\u0026nbsp;\u003c/em\u003e2025; \u003cstrong\u003e12:\u003c/strong\u003e 1686486.\u003c/li\u003e\n \u003cli\u003eAl-Kubati WR. Advanced Reconstructive Techniques: Mitigating Low Anterior Resection Syndrome Post-TME in Low Rectal Cancer - A Single-Center Randomised Controlled Study. \u003cem\u003eCancer management and research\u0026nbsp;\u003c/em\u003e2025; \u003cstrong\u003e17:\u003c/strong\u003e 2469-85.\u003c/li\u003e\n \u003cli\u003eHuu Phu L, Tat Bang H, Viet Binh N, Danh Tan H, Van Viet U, Tin NT. Major Low Anterior Resection Syndrome (LARS) and Quality of Life in Patients With Low Rectal Cancer: A Preoperative Survey Using LARS Score and European Organisation for Research and Treatment of Cancer\u0026apos;s 30-Item Core Quality of Life Questionnaire. \u003cem\u003eCureus\u0026nbsp;\u003c/em\u003e2023; \u003cstrong\u003e15:\u003c/strong\u003e e50074.\u003c/li\u003e\n \u003cli\u003eCullinane DM, Niblett A, Knerr RM, Coulombe J, Kwasnik E, McDermott C, et al. The Greater Omentum: A Proposed Mechanism of Movement in the Abdomen. \u003cem\u003eClinical anatomy (New York, NY)\u0026nbsp;\u003c/em\u003e2025\u003c/li\u003e\n \u003cli\u003eJoseph TS, Hogan E, Cesmebasi A, Carrasco M, Ang C, Davis N, et al. A systematic review and surgical anatomy of the greater omentum. \u003cem\u003eMorphologie : bulletin de l\u0026apos;Association des anatomistes\u0026nbsp;\u003c/em\u003e2025; \u003cstrong\u003e110:\u003c/strong\u003e 101072.\u003c/li\u003e\n \u003cli\u003eMatsui Y, Hirooka S, Kotsuka M, Yamaki S, Yamamoto T, Kosaka H, et al. Use of a piece of free omentum to prevent bile leakage after subtotal cholecystectomy. \u003cem\u003eSurgery\u0026nbsp;\u003c/em\u003e2018; \u003cstrong\u003e164:\u003c/strong\u003e 419-23.\u003c/li\u003e\n \u003cli\u003eLiu QX, Deng XF, Hou B, Min JX, Dai JG. Preventing and localizing esophagogastric anastomosis leakage by sleeve-wrapping of the pedicled omentum. \u003cem\u003eWorld journal of gastroenterology\u0026nbsp;\u003c/em\u003e2014; \u003cstrong\u003e20:\u003c/strong\u003e 16282-6.\u003c/li\u003e\n \u003cli\u003eBhat MA, Dar MA, Lone GN, Dar AM. Use of pedicled omentum in esophagogastric anastomosis for prevention of anastomotic leak. \u003cem\u003eThe Annals of thoracic surgery\u0026nbsp;\u003c/em\u003e2006; \u003cstrong\u003e82:\u003c/strong\u003e 1857-62.\u003c/li\u003e\n \u003cli\u003eLiao J, Qin H, Wang Z, Meng L, Wang W, Liu J, et al. Mesorectal reconstruction with pedicled greater omental transplantation to relieve low anterior resection syndrome following total intersphincteric resection in patients with ultra-low rectal cancer. \u003cem\u003eBMC surgery\u0026nbsp;\u003c/em\u003e2023; \u003cstrong\u003e23:\u003c/strong\u003e 236.\u003c/li\u003e\n \u003cli\u003eWen B, Zhang G, Zhan C, Chen C, Yi H. The 2024 revision of the Declaration of Helsinki: a modern ethical framework for medical research. \u003cem\u003ePostgraduate medical journal\u0026nbsp;\u003c/em\u003e2025; \u003cstrong\u003e101:\u003c/strong\u003e 371-82.\u003c/li\u003e\n \u003cli\u003eKagiyama H, Matsuda T, Hasegawa H, Otowa Y, Ando M, Koterazawa Y, et al. Is Transanal total mesorectal excision (TME) as safe and effective as laparoscopic TME for low rectal cancer? A propensity score-matched analysis. \u003cem\u003eSurgery today\u0026nbsp;\u003c/em\u003e2025\u003c/li\u003e\n \u003cli\u003eCarrillo A, Enr\u0026iacute;quez-Navascu\u0026eacute;s JM, Rodr\u0026iacute;guez A, Placer C, M\u0026uacute;gica JA, Saralegui Y, et al. Incidence and characterization of the anterior resection syndrome through the use of the LARS scale (low anterior resection score). \u003cem\u003eCir Esp\u0026nbsp;\u003c/em\u003e2016; \u003cstrong\u003e94:\u003c/strong\u003e 137-43.\u003c/li\u003e\n \u003cli\u003eEssangri H, Majbar MA, Benkabbou A, Amrani L, Mohsine R, Souadka A. Transcultural adaptation and validation of the Moroccan Arabic dialect version of the Wexner incontinence score in patients with low anterior resection syndrome after rectal surgery. \u003cem\u003eSurgery\u0026nbsp;\u003c/em\u003e2021; \u003cstrong\u003e170:\u003c/strong\u003e 47-52.\u003c/li\u003e\n \u003cli\u003ePitts L, Pasic M, Wert L, Nersesian G, Kaemmel J, Buz S, et al. Mediastinal transposition of the greater omentum for treatment of infected prostheses of the ascending aorta and aortic arch. \u003cem\u003eEuropean journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery\u0026nbsp;\u003c/em\u003e2024; \u003cstrong\u003e65\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003eWang AW, Prieto JM, Cauvi DM, Bickler SW, De Maio A. The Greater Omentum-A Vibrant and Enigmatic Immunologic Organ Involved in Injury and Infection Resolution. \u003cem\u003eShock (Augusta, Ga)\u0026nbsp;\u003c/em\u003e2020; \u003cstrong\u003e53:\u003c/strong\u003e 384-90.\u003c/li\u003e\n \u003cli\u003eKim HK, Park IJ, Kang JC, Lee JL, Kim CW, Yoon YS, et al. Late Anastomotic Leakage After Rectal Cancer Surgery: Incidence and Differential Risk Factors. \u003cem\u003eDiseases of the colon and rectum\u0026nbsp;\u003c/em\u003e2026\u003c/li\u003e\n \u003cli\u003eDias VE, Castro P, Padilha HT, Pillar LV, Godinho LBR, Tinoco ACA, et al. Preoperative risk factors associated with anastomotic leakage after colectomy for colorectal cancer: a systematic review and meta-analysis. \u003cem\u003eRevista do Colegio Brasileiro de Cirurgioes\u0026nbsp;\u003c/em\u003e2022; \u003cstrong\u003e49:\u003c/strong\u003e e20223363.\u003c/li\u003e\n \u003cli\u003eGurluk M, Karagulle OO, Cakar E, Avci B, Cakir E, Rakici IT, et al. Pelvic index/mesorectal length ratio: a new predictive factor for rectal cancer prognosis and low anterior resection syndrome. \u003cem\u003eCirugia y cirujanos\u0026nbsp;\u003c/em\u003e2025; \u003cstrong\u003e93:\u003c/strong\u003e 590-8.\u003c/li\u003e\n \u003cli\u003eLunca S, Morarasu S, Osman C, Shatarat FA, Gramada T, Razniceanu M, et al. Predictive Risk Factors for Low Anterior Resection Syndrome (LARS) in Rectal Cancer-An Observational Cohort Study. \u003cem\u003eJournal of clinical medicine\u0026nbsp;\u003c/em\u003e2025; \u003cstrong\u003e14\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003eSguinzi R, Fiechter J, Bafumi L, Gremaud B, Geng B, Janiak P, et al. Score assessment and treatment in patients presenting with low anterior resection syndrome after sphincter-sparing rectal cancer surgery. \u003cem\u003eInternational journal of colorectal disease\u0026nbsp;\u003c/em\u003e2025; \u003cstrong\u003e40:\u003c/strong\u003e 115.\u003c/li\u003e\n \u003cli\u003eMeng L, Qin H, Huang Z, Liao J, Cai J, Feng Y, et al. Analysis of presacral tissue structure in LARS and the prevention of LARS by reconstruction of presacral mesorectum with pedicled greater omentum flap graft. \u003cem\u003eTechniques in coloproctology\u0026nbsp;\u003c/em\u003e2021; \u003cstrong\u003e25:\u003c/strong\u003e 1291-300.\u003c/li\u003e\n \u003cli\u003eQin H, Meng L, Huang Z, Liao J, Feng Y, Luo S, et al. A study on the clinical application of greater omental pedicle flap transplantation to correct anterior resection syndrome in patients with low rectal cancer. \u003cem\u003eRegenerative therapy\u0026nbsp;\u003c/em\u003e2021; \u003cstrong\u003e18:\u003c/strong\u003e 146-51.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"rectal cancer, anastomosis leakage, Low anterior resection syndrome, omentum falp","lastPublishedDoi":"10.21203/rs.3.rs-8802487/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8802487/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe aim of this study is to determine whether reinforcement with a pedicled greater omentum flap is an effective measure for decreasing the incidence of Anastomotic leakage (AL) and low anterior resection syndrome (LARS).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThe current retrospective comparative study collected patients with mid- and low-rectal cancer undergoing laparoscopic sphincter-preserving surgery between January 2023 and December 2024. The patients were divided into two groups: Group A was subjected to laparoscopic radical resection combined with reinforcement of the pelvic floor using a pedicled greater omentum flap, while Group B was subjected to the standard laparoscopic surgical procedure. The functional outcomes of the patients were recorded at 1, 3, 6, and 12 months using the LARS scoring system and the Wexner incontinence scoring system.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eFifty-five patients were analyzed (Group A, n\u0026thinsp;=\u0026thinsp;29; Group B, n\u0026thinsp;=\u0026thinsp;26), with comparable baseline and perioperative characteristics. AL occurred in 1 patient (3.45%) in Group A (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). LARS scores progressively improved in both groups; however, Group A showed significantly lower LARS scores at 1 and 3 months (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Similarly, Group A achieved better continence recovery, with lower Wexner scores at 6 months (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe reinforcement of the pelvic floor using a pedicled greater omentum flap has been found to be a safe and feasible option during surgery for mid- and low-RC. The method significantly reduces the rate of AL and hastens recovery. The method has the potential to provide better outcomes for RC patients.\u003c/p\u003e","manuscriptTitle":"Pedicled Greater Omentum Flap Reinforcement Reduces Anastomotic Leakage and Improves Functional Recovery After Laparoscopic Sphincter-Preserving Surgery for Middle and Low rectal cancer Rectal Cancer: a Retrospective Comparative Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-10 07:35:00","doi":"10.21203/rs.3.rs-8802487/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3975507d-4c2d-4b1e-8c69-46c68f7386bf","owner":[],"postedDate":"March 10th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-04T22:38:44+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-10 07:35:00","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8802487","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8802487","identity":"rs-8802487","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}