Short- and Long-Term Outcomes of Minimally Invasive Total Mesorectal Excision in Obese versus Non-Obese Patients With Rectal Cancer: A Propensity Score–Matched Study

Short- and Long-Term Outcomes of Minimally Invasive Total Mesorectal Excision in Obese versus Non-Obese Patients With Rectal Cancer: A Propensity Score–Matched 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 Short- and Long-Term Outcomes of Minimally Invasive Total Mesorectal Excision in Obese versus Non-Obese Patients With Rectal Cancer: A Propensity Score–Matched Study Guan-Yu Chen, Kun-Yu Tsai, Chun-Kai Liao, Jeng-Fu You, Cheng-Chou Lai, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7773483/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background: Obesity adds technical complexity to colorectal surgery and has been linked to higher rates of perioperative complications and poorer long-term outcomes. Its prevalence is increasing among patients undergoing minimally invasive total mesorectal excision for rectal cancer; however, its impact on perioperative and oncologic outcomes remains controversial. Therefore, the aim of this study was to compare short- and long-term outcomes between obese (BMI ≥27 kg/m²) and non-obese patients undergoing minimally invasive total mesorectal excision. Methods: Retrospective review of rectal cancer patients undergoing laparoscopic, robotic, or transanal TME between January 2015 and December 2022. Propensity score matching (1:1) was performed on baseline characteristics. Primary outcomes included perioperative parameters, postoperative complications, and long-term oncologic outcomes. Results: After matching, 142 patients were included in each group. Obesity was associated with higher conversion rates to open surgery (2.8% vs. 0%, p=0.044) and increased overall complications (40.1% vs. 28.9%, p=0.046), driven mainly by surgical wound infections (9.2% vs. 1.4%, p=0.004). No differences were observed in major complications, anastomotic leakage, hospital stay, margin status, or five-year overall (88% vs. 89.4%, p = 0.409) and disease-free survival (62.7% vs. 72.5%, p = 0.653). Conclusion: Obesity increased conversion and minor complication rates but did not adversely affect short-term outcomes or long-term oncologic outcomes after minimally invasive TME procedures. Tailored perioperative strategies may mitigate obesity-associated risks. Trial registration: Not applicable. Obesity Rectal cancer Total mesorectal excision Minimally invasive surgery Retrospective study Figures Figure 1 Figure 2 1. Introduction Colorectal cancer(CRC) remains a leading cause of cancer-related morbidity and mortality worldwide, with rectal cancer accounting for approximately one-third of all cases.[ 1 ] Surgical resection remains key to curative outcomes regarding the management of locally advanced rectal cancer (LARC). Total mesorectal excision (TME) has revolutionized the surgical management of LARC, significantly reducing local recurrence rates and improving long-term survival by ensuring complete removal of the mesorectal envelope and achieving negative circumferential resection margins. In recent years, the three minimally invasive TME techniques, laparoscopic TME(LapTME), Robotic TME, transanal TME(TaTME), have demonstrated non-inferior oncologic outcomes, improved short-term outcomes such as shorter hospital stays, fewer post-op complications, and faster functional recovery compared to conventional open TME.[ 2 , 3 ] With continuing advancements in surgical instrumentation and techniques, minimally invasive surgery (MIS) has emerged as the standard treatment for CRC. In many Asian countries, obesity is often defined by a body mass index (BMI) exceeding 27 kg/m², whereas Western populations typically use a threshold of 30 kg/m², owing to differences in body fat distribution.[ 4 ] The global prevalence of obesity has demonstrated a steadily increasing trajectory. Data from many Asian countries have indicated a steady increase in the prevalence of overweight and obesity, paralleling economic growth and concurrent changes in dietary habits.[ 5 ] The adoption of Westernized lifestyles may contribute to the rising prevalence of obesity observed in Asian countries. There is a general consensus that CRC serves as a marker of socioeconomic development, with incidence rates closely reflecting the human development index.[ 6 ] Consequently, obesity is increasingly prevalent among patients presenting for rectal cancer surgery. Obesity is associated with numerous adverse outcomes, including metabolic, cardiovascular, musculoskeletal, neurological, respiratory, and gastrointestinal complications, all of which are generally considered to have a greater risk of perioperative complications and technical difficulties compared to normal-weight patients.[ 7 ] The technical complexity of TME is significantly heightened in obese patients due to increased visceral adiposity, bulky mesentery, narrow pelvic anatomy and distorted tissue planes, all of which are associated with increased intraoperative difficulty in MIS, may collectively contribute to prolonged operative times, increased blood loss, and elevated conversion to open rates, reported by meta-analyses and large retrospective studies.[ 8 – 10 ] Moreover, thickened abdominal wall can make ostomy creation more challenging. While many surgeons acknowledge the technical challenges of performing TME in obese patients, considerable disagreement exists in the literature regarding the impact of obesity on surgical outcomes. Several large-scale retrospective and prospective studies have demonstrated that while obese patients experience longer operative times and extended hospital stays, their postoperative complication rates, positive circumferential resection margin rates, lymph node harvest yields, long-term oncologic outcomes are comparable to those of non-obesity patients when treated at specialized centers.[ 10 , 11 ] On the other hand, other studies demonstrated increased rates of wound and cardiopulmonary complications, and even anastomotic leakage rates in obese patients.[ 9 , 12 ] Given the high prevalence of obesity and the technical challenges inherent in rectal cancer surgery, elucidating the impact of obesity on this patient population is essential for optimizing individualized surgical planning. To address the crucial issue, we conducted a retrospective, single-center study to compare the clinical and short- and long-term outcomes of obesity patients and non-obesity patients underwent minimally invasive TME techniques, using propensity score matching to ensure balanced basic characteristics at a high-volume referral center. 2. Materials and Methods 2.1 Patient Selection This retrospective study reviewed patients who underwent restorative proctectomy for rectal cancer at Chang Gung Memorial Hospital between January 2015 and December 2022. The study was approved by the Institutional Review Board (approval number: 202200885B0), and the requirement for informed consent was waived due to the use of de-identified data. This research received no external funding. Due to the retrospective design of the study, the local ethics committee confirmed that informed consent from participants was not necessary. Eligible participants were identified from rectal cancer patients who had undergone comprehensive diagnostic evaluation, including colonoscopy with tissue biopsy, chest - pelvic computed tomography (CT), rectal magnetic resonance imaging (MRI), and endorectal ultrasonography when clinically indicated. Specific inclusion and exclusion criteria were established to define the study population. Inclusion criteria comprised patients with histologically confirmed rectal adenocarcinoma located within 15 cm from the anal verge who were considered candidates for TME with primary anastomosis. Tumor location was determined using rigid proctoscopy to measure the distance from the anal verge. Exclusion criteria included patients requiring conventional open surgery, those with unresectable tumors, patients presenting with stage IV disease at initial diagnosis, and those undergoing alternative surgical approaches such as robotic TaTME, abdominoperineal resection (APR), or Hartmann's procedure. The detailed selection process is illustrated in Fig. 1 . 2.2 Assessment and Treatment Protocol Prior to surgical intervention, all patients underwent standardized preoperative workup consisting of thorough physical assessment, digital rectal examination, complete colonoscopic evaluation with tissue biopsy, and chest - pelvis CT. MRI of the pelvis was performed to characterize local tumor extent and regional involvement patterns. Carcinoembryonic antigen (CEA) were obtained as part of standard laboratory evaluation. Pathological staging was determined using the 8th edition of the Union for International Cancer Control (UICC) TNM classification system.[ 13 ] Treatment planning decisions were formulated through multidisciplinary team consultation, incorporating input from surgical, medical, and radiation oncology specialists. The implementation of neoadjuvant therapy protocols was individualized based on staging results and multidisciplinary consensus recommendations. The selection between surgical techniques was determined through consideration of surgeon expertise, tumor features, and patient-specific clinical factors. The construction of protective stoma was performed based on intraoperative surgical assessment and surgeon clinical judgment. 2.3 Data Collection Clinical information was systematically retrieved from our institution’s electronic medical records. Baseline patient characteristics included demographic data, clinical parameters, laboratory results (serum albumin and CEA levels), and tumor characteristics (location and TNM stage). The analysis covered clinical and procedural factors such as neoadjuvant and adjuvant therapies, surgical details (blood loss, stoma creation, conversion to open surgery), and anastomotic techniques. Pathological evaluation included tumor histology, differentiation, lymphovascular and perineural invasion, circumferential and distal resection margins (CRM and DRM), and lymph node yield. Margins were considered positive if tumor cells were present within 1 mm of the specimen edge. Perioperative morbidity was stratified according to the Clavien-Dindo classification system, with major complications categorized as grade III or above.[ 14 ] Mortality rates were documented throughout the study period. Long-term oncological endpoints included overall survival (OS), disease-free survival (DFS), local recurrence (LR), and distant metastasis (DM). 2.4 Follow-Up Postoperative monitoring adhered to our department’s standardized protocol. Clinical assessments occurred at 3–6 month intervals during the initial three-year period, followed by annual evaluations. Each consultation included comprehensive physical examination, CEA determination, and appropriate imaging studies for recurrence detection. The five-year follow-up strategy incorporated annual whole-body CT and endoscopic evaluation of the colorectum. Accelerated diagnostic workup was initiated when clinical presentation warranted earlier assessment for suspected disease recurrence. The OS was calculated from the operative date to patient death or most recent clinical contact. The DFS was measured from surgery to documented recurrence, death, or final follow-up assessment. Data collection continued through August 7, 2025, to support adequate duration for survival endpoint analysis. 2.5 Statistical Analysis Quantitative variables were presented as medians with interquartile ranges (IQR) and analyzed using the Mann-Whitney U non-parametric test for between-group comparisons. Categorical variables were summarized through frequencies and percentages, analyzed via Chi-square or Fisher’s exact test as appropriate. Survival outcomes were evaluated through Kaplan-Meier survival curves, with between-group differences assessed using log-rank testing. Univariate logistic regression was used to identify risk factors for postoperative complications. Propensity scores were calculated using logistic regression based on key preoperative variables, including tumor location, serum Albumin level, ASA score, and the use of neoadjuvant chemotherapy, and Oxaliplatin frequency. Variables with significant baseline differences among groups informed the matching criteria. An 1:1 propensity score matching (PSM) was performed between the obesity and non-obesity group to establish comparable baseline characteristics and minimize selection bias. Statistical significance was set at p < 0.05. All analyses were performed using SPSS version 26 (IBM Corp., New York, NY, USA). 3. Results 3.1 Patient Characteristics before and after PSM adjustment Baseline and preoperative clinicopathological parameters are presented in Table 1 , demonstrating comparisons before and after PSM. A total of 1186 patients were included prior to matching: 257 in the BMI ≥ 27 kg/m² group and 929 in the BMI < 27 kg/m² group. Prior to matching, the cohorts exhibited statistically significant differences across several key variables, including tumor location (p = 0.045), serum Albumin level (p = 0.028), ASA score (p < 0.001), and the use of neoadjuvant chemotherapy (p = 0.021) and oxaliplatin-containing regimens (p = 0.011). Table 1 Basic characteristics of obese and non-obese groups with rectal cancer who underwent restorative proctectomy before and after propensity score matching. Before Propensity Score Matching After Propensity Score Matching BMI ≥ 27 (n = 257) BMI < 27 (n = 929) P value BMI ≥ 27 (n = 142) BMI < 27 (n = 142) P value Age 61 (14) 63 (16) 0.097 60 (13) 64 (16) 0.065 Gender Male 169(65.8) 572(61.6) 0.220 100 (70.4) 86 (60.6) 0.081 Female 88(34.2) 357(38.4) 42 (29.6) 56 (39.4) Surgical type taTME 42(16.3) 113(12.2) 0.095 40 (28.2) 47 (33.1) 0.271 Robotic LAR 12(4.7) 67(7.2) 15 (10.6) 21 (14.8) LapTME 203(79) 749(80.6) 87 (61.3) 74 (52.1) Tumor location Upper rectum 74(28.8) 250(26.9) 0.045* 15 (10.6) 24 (16.9) 0.121 Middle rectum 124 (48.2) 520 (56) 68 (47.9) 53 (37.3) Lower rectum 59 (23) 159(17.1) 59 (41.5) 65 (45.8) Albumin < 3.5 6 (2.3) 53 (5.7) 0.028* 4 (2.8) 2 (1.4) 0.409 ≥ 3.5 251 (97.7) 876 (94.3) 138 (97.2) 140 (98.6) CEA < 5 199 (77.4) 705 (75.9) 0.607 114 (80.3) 113 (79.6) 0.882 ≥ 5 58 (22.6) 224 (24.1) 28 (19.7) 29 (20.4) ASA score 2 83 (32.3) 450 (48.4) < 0.001* 67 (47.2) 68 (47.9) 0.905 3 174 (67.7) 479 (51.6) 75 (52.8) 74 (52.1) pT-stage T0 15 (5.8) 35 (3.8) 0.098* 13 (9.2) 7 (4.9) 0.305 T1 51 (19.8) 134 (14.4) 21 (14.8) 16 (11.3) T2 45 (17.5) 199 (21.4) 30 (21.1) 36 (25.4) T3 126 (49) 479 (51.6) 71 (50) 70 (49.3) T4 20 (7.8) 82 (8.8) 7 (4.9) 13 (9.2) pN-stage N0 151 (58.8) 555 (59.7) 0.465 91 (64.1) 86 (60.6) 0.623 N1 66 (25.7) 256 (27.6) 38 (26.8) 38 (26.8) N2 40 (15.6) 118 (12.7) 13 (9.2) 18 (12.7) Tumor size 4.4 (6) 4.6 (7.2) 0.657 4.8 (6.3) 5.1 (6.5) 0.061 Neoadjuvant treatment Yes 150 (58.4) 534 (57.5) 0.799 94 (66.2) 99 (69.7) 0.525 No 107 (41.6) 395 (42.5) 48 (33.8) 43 (30.3) Neoadjuvant RT 74(28.8) 272(29.3) 0.880 59 (41.5) 68 (47.9) 0.283 Neoadjuvant chemotherapy 88(34.2) 250(26.9) 0.021* 75 (52.8) 82 (57.7) 0.403 Adjuvant chemotherapy 126(49) 450(48.4) 0.867 80 (56.3) 80 (56.3) 1 Chemotherapy with Oxaliplatin 52(20.2) 261(28.1) 0.011* 37 (26.1) 40 (28.2) 0.689 BMI: Body mass index; LapTME: laparoscopic total mesorectal excision; TaTME: transanal total mesorectal excision; AV: anal verge; ASA score: American Society of Anesthesiology score Following PSM, 142 patients were included in each comparative group. Matching achieved good balance across most baseline variables, eliminating statistically significant differences across tumor location, serum Albumin level, ASA score, and the use of neoadjuvant chemotherapy, and Oxaliplatin frequency between study cohorts. 3.2 Operative Parameters and Short-Term Outcomes Operative parameters are summarized in Table 2 . After PSM, operative time showed no significant difference between the groups (312 ± 139 min vs. 280 ± 118 min, p = 0.287). Estimated blood loss was similar between the two groups (50 ± 55 ml vs. 50 ± 30 ml, p = 0.070). The rate of diverting stoma creation did not differ significantly (50.7% vs. 45.1%, p = 0.342). Conversion to open surgery occurred only in the obesity group (2.8% vs. 0%, p = 0.044), three conversion was due to adhesions and one to advanced disease. Anastomosis methods was comparable between the 2 groups (p = 0.08). Natural orifice specimen extraction was more frequent in the non-obesity group compared to the obesity group (28.2% vs. 35.9%, p = 0.153), although this difference was not statistically significant. Table 2 Post-matching of operative parameters among the obese and non-obese groups BMI ≥ 27 (n = 142) BMI < 27 (n = 142) P value Operative time 312(139) 280 (118) 0.287 Blood loss 50(55) 50(30) 0.07 < 100ml 108(76.1) 113(79.6) 0.475 ≥ 100ml 34(23.9) 29(20.4) Diverting stoma yes 72(50.7) 64(45.1) 0.342 no 70(49.3) 78(54.9) Conversion yes 4(2.8) 0 0.044* no 138(97.2) 142(100) Anastomosis methods No 1(0.7) 7(4.9) 0.08 Hand sewn 22(15.5) 25(17.6) Staples 119(83.8) 110(77.5) Specimen extraction methods NOSE 40(28.2) 51(35.9) 0.153 Pfannenstiel incision 2(1.4) 0 Other abdominal incision 100(70.4) 91(64.1) BMI: Body mass index; LapTME: laparoscopic total mesorectal excision; TaTME: transanal total mesorectal excision; NOSE: natural orifice specimen retraction Table 3 presents the postoperative results. Hospital length of stay and recovery milestones showed no significant variation between cohorts. Overall complication rates were notably elevated in the obesity group compared to the non-obesity group (40.1% vs. 28.9%, p = 0.046). This increase was predominantly due to minor complications (Clavien-Dindo grade < 3), which occurred more frequently in the obesity group (35.9% vs. 23.2%, p = 0.019), while major complication incidence (Clavien-Dindo grade ≥ 3) remained equivalent (4.2% vs. 5.6%, p = 0.584). Common specific complications included ileus (8.5% vs. 10.6%, p = 0.544), intra-abdominal infection (IAI) (9.2% vs. 7.0%, p = 0.514), and anastomosis leakage (4.2% vs. 3.5%, p = 0.758), showing no significant differences. Surgical wound infection occurred more frequently in the obesity group (9.2% vs. 1.4%, p = 0.004). Reoperation (p = 0.22) and permanent stoma rates (p = 0.157) were similar between the groups. Table 3 Post-matching of short-term outcomes among the obese and non-obese groups BMI ≥ 27 (n = 142) BMI < 27 (n = 142) P value Hospital stays 8(5) 7(5) 0.077 First flatus passage 2(1) 2(2) 0.361 First stool passage 2.5(3) 3(2) 0.2 Tolerated liquid diet 3(3) 3(3) 0.128 Tolerated soft diet 5(4) 4(4) 0.354 Remove Foley day 5(4) 5(3) 0.916 Overall complication yes 57(40.1) 41(28.9) 0.046* no 85(59.9) 101(71.1) Clavien-Dindo Classification I 25(17.6) 7(4.9) 0.019* II 26(18.3) 26(18.3) III 5(3.5) 7(4.9) IV 1(0.7) 1(0.7) V 0 0 Major complication(C-D grade ≥ 3) 6(4.2) 8(5.6) 0.584 Minor complication(C-D grade < 3) 51(35.9) 33(23.2) 0.019* Complication type Ileus 12(8.5) 15(10.6) 0.544 Anastomosis leak 6(4.2) 5(3.5) 0.758 IAI 13(9.2) 10(7) 0.514 Surgical wound infection 13(9.2) 2(1.4) 0.004* Others 14(9.9) 9(6.3) 0.277 Re-operation Leakage 6(4.2) 4(2.8) 0.22 Bowel obstruction 0 2(1.4) Others 0 2(1.4) Permanent stoma 17(12) 10(7) 0.157 BMI: Body mass index; LapTME: laparoscopic total mesorectal excision; TaTME: transanal total mesorectal excision; IAI: intra-abdominal infection 3.3 Risk factors for postoperative complications Risk factor analysis for postoperative complications is detailed in Table 4 . Regarding major complications, no statistically significant predictive factors were identified. For overall complications, obesity demonstrated a trend toward increased risk that bordered on statistical significance (OR = 1.721, p = 0.05). Among the various operative techniques employed, none exhibited significant associations with overall complication rates. Additional variables including patient gender, tumor location, ASA score, pathological T-stage, N-stage, utilization of protective stomas, and preoperative adjuvant therapies demonstrated no meaningful correlations with either severe or total postoperative complications. Table 4 Summary of the risk factors for postoperative complications Major complications(C-D grade ≥ 3) Overall complications OR p-value OR p-value BMI > 27 0.668 0.507 BMI > 27 1.721 0.05* LapTME 1 LapTME 1 Robotic LAR 1.063 0.953 Robotic LAR 0.683 0.382 TaTME 0.967 0.139 TaTME 0.957 0.926 Age > 75 years 0.933 0.939 Age > 75 years 1.198 0.652 Male sex 1.613 0.474 Male sex 1.217 0.515 Upper rectum 1 Upper rectum 1 Middle rectum 1.429 0.921 Middle rectum 1.226 0.687 Lower rectum 1.998 0.596 Lower rectum 0.845 0.724 ASA score ASA score 2 1 2 1 3 4.423 0.069 3 1.328 0.341 pT-stage pT-stage 0 + 1 + 2 1 0 + 1 + 2 1 3 1.252 0.746 3 1.199 0.551 4 4.115 0.209 4 1.602 0.430 pN-stage pN-stage N0 1 0 1 N1 0.761 0.717 1 0.536 0.072 N2 1.007 0.994 2 1.672 0.419 Diverting stoma 1.303 0.706 Diverting stoma 0.757 0.698 Neoadjuvant chemotherapy 0.226 0.121 Neoadjuvant chemotherapy 0.768 0.463 Neoadjuvant radiotherapy 1.095 0.913 Neoadjuvant radiotherapy 1.26 0.419 BMI: Body mass index; LapTME: laparoscopic total mesorectal excision; TaTME: transanal total mesorectal excision; OR: odds ratio 3.4 Histopathological Parameters Histopathological findings are presented in Table 5 . Complete pathological response occurred in 5.6% of the obesity group compared to 4.2% in the non-obesity group (p = 0.584). Tumor type (p = 1) and differentiation (p = 0.671) showed no significant variation. Neither lymphovascular (21.8% vs. 16.9%, p = 0.293) nor perineural invasion rates (16.9% vs. 25%, p = 0.747) differed significantly between groups. Circumferential resection margin (CRM) positivity rates were equivalent across groups (4.2% vs. 4.9%, p = 0.776), while positive distal resection margin (DRM) rates also showed no difference (4.9% vs. 7.0%, p = 0.453). Harvested lymph node counts were similar (23 ± 19 vs. 24 ± 14, p = 0.6), and R1 resection showed no significant difference (9.9% vs. 7.7%, p = 0.530). Table 5 Post-matching pathological finding among the obese and non-obese groups BMI ≥ 27 (n = 142) BMI < 27 (n = 142) P value pCR 8(5.6) 6(4.2) 0.584 Histology type Adenocarcinoma 132(93) 132(93) 1 Signet ring cell/Mucinous 10(7) 10(7) Histology Grade Grade I/II 121(85.2) 125(88) 0.671 Grade III 13(9.2) 12(8.5) Unclassified 8(5.6) 5(3.5) Lymphovascular invasion positive 31(21.8) 24(16.9) 0.293 negative 111(78.2) 118(83.1) Perineural invasion positive 24(16.9) 22(25) 0.747 negative 118(83.1) 120(72.5) CRM Positive 6(4.2) 7(4.9) 0.776 Negative 136(95.8) 135(95.1) Distal resection margin, length 1.5(1.75) 1.4(1.5) 0.158 Distal resection margin positive 7(4.9) 10(7) 0.453 negative 135(95.1) 132(93) Lymph node yield 23(19) 24(14) 0.6 R1 resection 14(9.9) 11(7.7) 0.530 BMI: Body mass index; LapTME: laparoscopic total mesorectal excision; TaTME: transanal total mesorectal excision; pCR: pathological complete response; CRM: Circumferential resection margin 3.5 Long-Term Outcomes The median follow-up durations were 51.2 and 36.6 months for the obesity and non-obesity groups, respectively (p = 0.331). Figure 2 depicts the Kaplan‒Meier survival curve. LR rates were 15.5% and 23% (p = 0.753), DM rates were 35.1% and 26.1% (p = 0.912), respectively. Five-year OS rates (88% vs. 89.4%, p = 0.409) and five-year DFS rates (62.7% vs. 72.5%, p = 0.653) did not reach statistical significance as well. 4. Discussion The present study evaluated clinical and oncological results between elevated BMI group with above 27 kg/m² and normal BMI groups following PSM in patients who underwent minimally invasive TME procedures at a high-volume tertiary center. After PSM adjustment, this analysis revealed comparable oncological outcomes between both patient groups. While obesity patients experienced increased conversion rate and overall postoperative complication rates, both short- and long-term outcomes remained equivalent across the groups. With the global rise in obesity, the potential impact on postoperative outcomes following abdominal procedures has garnered considerable interest. In patients with obesity, surgical resection of rectal tumor presents distinctly greater technical complexity. Concerning operative parameters, conversion to open surgery remains to represent a major challenge in laparoscopic surgery. Previous meta-analyses showed significantly higher risk of conversion rate in obesity patients [Odds Ratio (OR) 2.11–3.3], consistent with our findings.[ 9 , 15 , 16 ] Elevated conversion rates demonstrate the cumulative impact of anatomical and surgical challenges. Increased visceral adiposity and mesorectal fat accumulation compromise visualization within the confined pelvic space, particularly in male patients, obscuring tissue planes and increasing the potential for unintended damage to surrounding organs.[ 17 ] These factors may extend operative time and elevate intraoperative blood loss, both contribute to conversion necessity.[ 18 ] Interestingly, shown in previous studies, robotic surgery can overcome certain visualization and maneuverability constraints in particularly high-risk populations such as obese patients, thereby reducing conversion rates in subgroup analysis compared to LapTME [OR 0.22, 95% Confidence Interval (CI) 0.07–0.71, p = 0.011] (OR 0.46, 95% CI 0.21–0.99, p = 0.04).[ 19 , 20 ] Similarly, TaTME decreases conversion rates in obesity patients as the transanal approach offers direct, magnified visualization of the lower rectum and mesorectal tissues, maintaining appropriate dissection planes even within a constricted, adipose-laden pelvis that compromises instrument maneuverability and field of view during LapTME procedures. TaTME decreases conversion rates in obesity patients as the transanal approach offers direct, magnified visualization of the lower rectum and mesorectal tissues, maintaining appropriate dissection planes even within a constricted, adipose-laden pelvis.[ 21 ] The restricted pelvic anatomy and proximity to surrounding structures during rectal surgery amplify procedure-specific complications, surgeon must recognize these complexities during preoperative planning and consider patient selection carefully when considering minimally invasive approaches. A prior investigation demonstrated that in patients with BMI above 27 kg/m², over 85% of Taiwanese, 66% of whites and 55% of blacks exhibited at least one of the comorbidities such as hypertension, diabetes, hypertriglyceridemia and hyperuricemia.[ 4 ] The chronic inflammatory processes and endothelial dysfunction linked to these obesity comorbidities may compromise wound healing capacity, elevate bleeding risk and hematoma formation.[ 22 ] Moreover, increased subcutaneous fat layers diminish vascular supply and oxygenation at surgical sites, limit antimicrobial drug distribution and impair immune cell activity, thus creating an environment conducive to microbial growth and surgical site contamination, particularly in intestinal operations where native bacterial flora are abundant.[ 23 ] In our study, the obesity group had increased overall postoperative complication rates compared to the non-obesity group. The difference mainly resulted from surgical wound infection rate, aligned with previous studies, indicating that obesity represents an established risk factor for surgical wound infection, so as our result(OR 1.721, p = 0.05 ).[ 9 , 24 , 25 ] Additionally, an Surgeons National Surgical Quality Improvement Program(NSQIP) study focused on proctectomy demonstrated progressive increases in superficial wound infections corresponding to elevated BMI classes.[ 24 ] Perioperative strategies require enhancement to mitigate the elevated risk. Body weight-adjusted prophylactic antimicrobial dosing or broad-spectrum antibiotics to ensure sufficient tissue penetration, combined with standardized perioperative protocols, may effectively reduce infection rates. Anastomotic leakage remains a critical complication following TME procedures. Anastomotic leakage is associated with increased morbidity and mortality, often leading to both surgical and radiological re-interventions. Moreover, it has been linked to higher rates of LR and lower long-term survival outcome.[ 26 ] We found no difference between the two groups in risk of anastomotic leakage in our study. An analysis from ACS-NSQIP found no significant association between BMI stratification and the 30-day risk of anastomotic leakage.[ 27 ] Notably, this result remained consistent after multivariate adjustment, supporting that under conditions of standardized perioperative care and high-quality TME that in high-volume centers with stringent technical standards, obesity does not always translate to a higher rate of anastomotic leakage.[ 27 ] Current evidence indicates that long-term oncologic outcomes following TME are comparable between obesity and non-obesity patients. Several single-center studies have shown that the number of lymph nodes harvested, negative margin rates, and DFS rates are not diminished by elevated BMI, particularly when a high-quality mesorectal excision is achieved.[ 10 , 11 ] For mid-to-low rectal cancer patients, matched risk-adjusted analysis has demonstrated comparable five-year OS and DFS rates among different BMI groups, suggesting that the technical difficulty and short-term complications associated with obesity do not translate into negative impact on long-term survival where oncologic principles and TME quality are maintained.[ 28 ] Evidence regarding pathological and specimen quality indicates that complete or nearly-complete TME and negative CRM rate are closely related to lower LR and DM rate.[ 29 ] The association is not affected by BMI, suggesting that the quality of surgical technique, rather than obesity itself, dictates the risk of recurrence. Our study has several limitations. First, the single-center, retrospective design introduces a risk of selection bias and incomplete data capture. The retrospective analysis may not establish causality and is inherently limited by potential confounding variables. Additionally, although BMI is a simple and cost-effective index of patient size, its accuracy may be compromised by extremes of height and gender variations in body fat distribution. Recently, Visceral fat area (VFA), measured by CT imaging at specific abdominal cross-sections to assess intra-abdominal adipose volume, serves as a valuable tool for investigating clinical concerns associated with central or visceral adiposity.[ 30 ] VFA serves as an increasingly important biomarker from a surgical perspective. It may be utilized to differentiate patients with colorectal cancer into more detailed stratification, enabling more precise perioperative assessments. 5. Conclusion In conclusion, the retrospective study demonstrated that although obesity (BMI ≥ 27 kg/m²) was significantly associated with higher rates of conversion and minor postoperative complications, the short-term or long-term outcomes in patients underwent minimally invasive TME approaches were comparable. The findings emphasize the need for tailored surgical and perioperative strategies for obesity patients. While intraoperative difficulties are more pronounced, structured postoperative care can help mitigate differences in complications. Declarations Informed Consent Statement: Due to the retrospective design of the study, the local ethics committee confirmed that informed consent from participants was not necessary. Consent for publication: All authors consent to publish this work. Conflicts of interest: The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article. Funding: This study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors Author Contribution Guan-Yu Chen and Shu-Huan Huang contributed equally. Conception and design of the study: Shu-Huan Huang; Collection and assembly of the data: Guan-Yu Chen; Data analysis and interpretation: Guan-Yu Chen; Drafting the manuscript: Guan-Yu Chen; Writing – review & editing: Guan-Yu Chen, Shu-Huan Huang; Contributed to the operations: Kun-Yu Tsai, Chun-Kai Liao, Jeng-Fu You, Cheng-Chou Lai and Shu-Huan Huang. Acknowledgements: We thank the research team members for their hard work. Institutional Review Board Statement: This study was approved by the Institutional Review Board of Chang Gung Memorial Hospital (approval number 202200885B0). Data Availability All data sets used or analyzed in this study are available from the corresponding author upon request. References Bray, F., et al., Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA: a cancer journal for clinicians, 2024. 74 (3): p. 229–263. Simillis, C., et al., Open versus laparoscopic versus robotic versus transanal mesorectal excision for rectal cancer: a systematic review and network meta-analysis. Annals of surgery, 2019. 270 (1): p. 59–68. Ryan, O.K., et al., Surgical approach for rectal cancer: a network meta-analysis comparing open, laparoscopic, robotic and transanal TME approaches. European Journal of Surgical Oncology, 2021. 47 (2): p. 285–295. Pan, W.-H., et al., Body mass index and obesity-related metabolic disorders in Taiwanese and US whites and blacks: implications for definitions of overweight and obesity for Asians. The American journal of clinical nutrition, 2004. 79 (1): p. 31–39. Collaborators, G.O., Health effects of overweight and obesity in 195 countries over 25 years. New England journal of medicine, 2017. 377 (1): p. 13–27. Fidler, M.M., I. Soerjomataram, and F. Bray, A global view on cancer incidence and national levels of the human development index. International journal of cancer, 2016. 139 (11): p. 2436–2446. Blee, T.H., G.E. Belzer, and P.J. Lambert, Obesity: is there an increase in perioperative complications in those undergoing elective colon and rectal resection for carcinoma? The American surgeon, 2002. 68 (2): p. 163–166. Knol, J. and D.S. Keller, Total mesorectal excision technique—past, present, and future. Clinics in colon and rectal surgery, 2020. 33 (03): p. 134–143. Qiu, Y., et al., Outcome of rectal cancer surgery in obese and nonobese patients: a meta-analysis. World Journal of Surgical Oncology, 2015. 14 (1): p. 23. Chern, H., et al., Effects of obesity in rectal cancer surgery. Journal of the American College of Surgeons, 2010. 211 (1): p. 55–60. Ballian, N., et al., Body mass index does not affect postoperative morbidity and oncologic outcomes of total mesorectal excision for rectal adenocarcinoma. Annals of surgical oncology, 2010. 17 (6): p. 1606–1613. Nugent, T.S., et al., Obesity and anastomotic leak rates in colorectal cancer: a meta-analysis. International Journal of Colorectal Disease, 2021. 36 (9): p. 1819–1829. Jessup, J., et al., Colon and Rectum . 2017. p. 251–274. Dindo, D., N. Demartines, and P.-A. Clavien, Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Annals of surgery, 2004. 240 (2): p. 205–213. Rogers, A.C., et al., Meta-analysis of the clinicopathological characteristics and peri-operative outcomes of colorectal cancer in obese patients. Cancer Epidemiology, 2017. 51 : p. 23–29. Fung, A., et al., Laparoscopic colorectal cancer resections in the obese: a systematic review. Surgical endoscopy, 2017. 31 (5): p. 2072–2088. Bell, S., et al., The effect of increasing body mass index on laparoscopic surgery for colon and rectal cancer. Colorectal Disease, 2018. 20 (9): p. 778–788. Ishiyama, Y., et al., Risk factors of bleeding during rectal cancer surgery in obese patients in Japan. Asian journal of endoscopic surgery, 2024. 17 (3): p. e13316. Crippa, J., et al., Risk factors for conversion in laparoscopic and robotic rectal cancer surgery. Journal of British Surgery, 2020. 107 (5): p. 560–566. Jayne, D., et al., Effect of robotic-assisted vs conventional laparoscopic surgery on risk of conversion to open laparotomy among patients undergoing resection for rectal cancer: the ROLARR randomized clinical trial. Jama, 2017. 318 (16): p. 1569–1580. Yi, X., et al., Comparing perioperative and oncological outcomes of transanal and laparoscopic total mesorectal excision for rectal cancer: a meta-analysis of randomized controlled trials and prospective studies. Surgical Endoscopy, 2023. 37 (12): p. 9228–9243. Engin, A., Endothelial dysfunction in obesity and therapeutic targets. Obesity and Lipotoxicity, 2024: p. 489–538. Balentine, C.J., et al., Obesity increases wound complications in rectal cancer surgery. Journal of Surgical Research, 2010. 163 (1): p. 35–39. Smith, R.K., et al., Impact of BMI on postoperative outcomes in patients undergoing proctectomy for rectal cancer: a national surgical quality improvement program analysis. Diseases of the colon & rectum, 2014. 57 (6): p. 687–693. Almasaudi, A.S., et al., The relationship between body mass index and short term postoperative outcomes in patients undergoing potentially curative surgery for colorectal cancer: a systematic review and meta-analysis. Critical reviews in oncology/hematology, 2018. 121 : p. 68–73. Mirnezami, A., et al., Increased local recurrence and reduced survival from colorectal cancer following anastomotic leak: systematic review and meta-analysis. Annals of surgery, 2011. 253 (5): p. 890–899. Sweigert, P.J., et al., Association of obesity with postoperative outcomes after proctectomy. The American Journal of Surgery, 2020. 220 (4): p. 1004–1009. Aytac, E., et al., Impact of obesity on operation performed, complications, and long-term outcomes in terms of restoration of intestinal continuity for patients with mid and low rectal cancer. Diseases of the colon & rectum, 2013. 56 (6): p. 689–697. Rogers, P., et al., Association Between Mesorectal Grade and Oncologic Outcomes in Rectal Cancer: A Systematic Review and Meta ‐Analysis. Journal of Surgical Oncology, 2025. Yang, T., et al., Impact of visceral obesity on outcomes of laparoscopic colorectal surgery: a meta ‐analysis. ANZ journal of surgery, 2015. 85 (7-8): p. 507–513. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 27 Nov, 2025 Reviews received at journal 15 Nov, 2025 Reviews received at journal 13 Nov, 2025 Reviewers agreed at journal 11 Nov, 2025 Reviewers agreed at journal 10 Nov, 2025 Reviewers invited by journal 09 Nov, 2025 Editor assigned by journal 09 Oct, 2025 Submission checks completed at journal 04 Oct, 2025 First submitted to journal 03 Oct, 2025 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-7773483","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":545566229,"identity":"23cc8093-6f72-49f1-8e47-acc4e34e5c6c","order_by":0,"name":"Guan-Yu Chen","email":"","orcid":"","institution":"Chang Gung Memorial Hospital","correspondingAuthor":false,"prefix":"","firstName":"Guan-Yu","middleName":"","lastName":"Chen","suffix":""},{"id":545566230,"identity":"22c10718-ff92-425c-bcc1-a6f9040d5327","order_by":1,"name":"Kun-Yu Tsai","email":"","orcid":"","institution":"New Taipei Municipal TuCheng Hospital","correspondingAuthor":false,"prefix":"","firstName":"Kun-Yu","middleName":"","lastName":"Tsai","suffix":""},{"id":545566231,"identity":"6bbbfea6-8740-4871-920e-b10dd376e4f2","order_by":2,"name":"Chun-Kai Liao","email":"","orcid":"","institution":"Chang Gung Memorial Hospital","correspondingAuthor":false,"prefix":"","firstName":"Chun-Kai","middleName":"","lastName":"Liao","suffix":""},{"id":545566232,"identity":"4cfb86dc-f770-450f-97f0-c1c02e56794d","order_by":3,"name":"Jeng-Fu You","email":"","orcid":"","institution":"Chang Gung Memorial Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jeng-Fu","middleName":"","lastName":"You","suffix":""},{"id":545566233,"identity":"509132f2-6c5a-4a58-b38f-b805fb7b3966","order_by":4,"name":"Cheng-Chou Lai","email":"","orcid":"","institution":"Chang Gung Memorial Hospital","correspondingAuthor":false,"prefix":"","firstName":"Cheng-Chou","middleName":"","lastName":"Lai","suffix":""},{"id":545566234,"identity":"70e2bdd3-1443-4c37-8918-0f21927c1677","order_by":5,"name":"Shu-Huan Huang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3klEQVRIiWNgGAWjYDACCR4wVW/f3gCkDCyI15JgwHMApEWCFC0SCWAuYR3ys3uPSfzcUZtnLvn86oYfBRIM/O3dCXi1GNw5lybZe+Z4seXsnLKbPUCHSZw5uwG/FokcMwnetmOMDbdz0m7wALUYSOTi1yI/I8dM8i9Iy80zaTf/EKOF4UaOmTRvW03ihhvsx24TZYvBjRxja9m2A8aSPTlst2UMJHgI+gXoMMObb9vq5PjZjz+7+eaPjRx/ey8Bh0HAYSDmMQCxeIhRDgJ1QMz+gFjVo2AUjIJRMMIAAAzaSPUihE4MAAAAAElFTkSuQmCC","orcid":"","institution":"Chang Gung Memorial Hospital","correspondingAuthor":true,"prefix":"","firstName":"Shu-Huan","middleName":"","lastName":"Huang","suffix":""}],"badges":[],"createdAt":"2025-10-03 12:24:31","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7773483/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7773483/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":96307087,"identity":"86d7ac00-cae8-4776-b9be-6201da732de8","added_by":"auto","created_at":"2025-11-19 15:35:59","extension":"jpg","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":72238,"visible":true,"origin":"","legend":"","description":"","filename":"Figure1.Theselectionprocessofpatientdata.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7773483/v1/7e15fde9c07125b82a8bce3a.jpg"},{"id":96365889,"identity":"3485020a-96c5-4850-88f2-67865a6daf2c","added_by":"auto","created_at":"2025-11-20 10:10:55","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":240370,"visible":true,"origin":"","legend":"","description":"","filename":"Manuscript.docx","url":"https://assets-eu.researchsquare.com/files/rs-7773483/v1/5ada4193b16a0df16600f823.docx"},{"id":96307090,"identity":"ff56f7b5-05c1-4190-a42e-e3f84ee76736","added_by":"auto","created_at":"2025-11-19 15:35:59","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":44357,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-7773483/v1/6b8d7bb848566d157897a8c9.docx"},{"id":96365872,"identity":"1d335ae4-c92a-426e-bc75-53dcf34c0dcd","added_by":"auto","created_at":"2025-11-20 10:10:53","extension":"jpg","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":51349,"visible":true,"origin":"","legend":"","description":"","filename":"Figure2a.TheKaplanMeiersurvivalcurveforLR.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7773483/v1/693d266a489c891407e71f9d.jpg"},{"id":96307089,"identity":"268e8da1-8f13-41eb-a594-216c51dc1d1c","added_by":"auto","created_at":"2025-11-19 15:35:59","extension":"jpg","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":52791,"visible":true,"origin":"","legend":"","description":"","filename":"Figure2b.TheKaplanMeiersurvivalcurveforDM.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7773483/v1/757cbf81d14ad43a800a521b.jpg"},{"id":96307091,"identity":"ea167015-8ad9-490f-8e10-ca601c23e978","added_by":"auto","created_at":"2025-11-19 15:35:59","extension":"jpg","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":52954,"visible":true,"origin":"","legend":"","description":"","filename":"Figure2c.TheKaplanMeiersurvivalcurveforOS.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7773483/v1/599c9abba293cc7db8c0bfdc.jpg"},{"id":96307096,"identity":"a8b7aac2-d1a1-4c8b-8a75-813f9fd292c9","added_by":"auto","created_at":"2025-11-19 15:35:59","extension":"jpg","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":51185,"visible":true,"origin":"","legend":"","description":"","filename":"Figure2d.TheKaplanMeiersurvivalcurveforDFS.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7773483/v1/2c543d39dce0dd9d3193fdb3.jpg"},{"id":96365396,"identity":"21195496-1119-4e56-b537-83dc4d355802","added_by":"auto","created_at":"2025-11-20 10:10:19","extension":"json","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":7753,"visible":true,"origin":"","legend":"","description":"","filename":"d60f34da33ad4ce5ab9ab7092926bcfc.json","url":"https://assets-eu.researchsquare.com/files/rs-7773483/v1/0b0637bdaa4ef8262134378b.json"},{"id":96307108,"identity":"90cd45f2-d5e2-42ce-a8b3-b094c83dae58","added_by":"auto","created_at":"2025-11-19 15:35:59","extension":"xml","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":184540,"visible":true,"origin":"","legend":"","description":"","filename":"d60f34da33ad4ce5ab9ab7092926bcfc1enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-7773483/v1/4feb481f16692df9fa11129b.xml"},{"id":96366407,"identity":"e44f27ef-02c3-4718-94fa-8e222d6b1fb5","added_by":"auto","created_at":"2025-11-20 10:11:25","extension":"jpg","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":72238,"visible":true,"origin":"","legend":"","description":"","filename":"Figure1.Theselectionprocessofpatientdata.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7773483/v1/32a512ddc15bdc6afef7dd68.jpg"},{"id":96366381,"identity":"ec010c98-80cd-49e6-8b9f-55529e0bbecc","added_by":"auto","created_at":"2025-11-20 10:11:24","extension":"jpg","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":51349,"visible":true,"origin":"","legend":"","description":"","filename":"Figure2a.TheKaplanMeiersurvivalcurveforLR.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7773483/v1/88a56537adebd2809ac1395b.jpg"},{"id":96307101,"identity":"2d05afa1-d487-462b-9f98-b49b41cc8526","added_by":"auto","created_at":"2025-11-19 15:35:59","extension":"jpg","order_by":11,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":52791,"visible":true,"origin":"","legend":"","description":"","filename":"Figure2b.TheKaplanMeiersurvivalcurveforDM.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7773483/v1/e0fc003a3491be631f070135.jpg"},{"id":96364792,"identity":"fdaef0cc-ede1-4c25-b9a9-c15b50b75600","added_by":"auto","created_at":"2025-11-20 10:09:39","extension":"jpg","order_by":12,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":52954,"visible":true,"origin":"","legend":"","description":"","filename":"Figure2c.TheKaplanMeiersurvivalcurveforOS.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7773483/v1/a5eee3b763d5df97fe1c8d1e.jpg"},{"id":96365192,"identity":"ac8f17e0-e057-4bb6-b092-2b0f1b78715b","added_by":"auto","created_at":"2025-11-20 10:10:04","extension":"jpg","order_by":13,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":51185,"visible":true,"origin":"","legend":"","description":"","filename":"Figure2d.TheKaplanMeiersurvivalcurveforDFS.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7773483/v1/4b74c18a7b1fd3c4445f2d27.jpg"},{"id":96307094,"identity":"10838697-6ea1-4a05-a6e8-f6f4aacd0875","added_by":"auto","created_at":"2025-11-19 15:35:59","extension":"jpeg","order_by":14,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":72238,"visible":true,"origin":"","legend":"","description":"","filename":"Figure1.Theselectionprocessofpatientdata.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7773483/v1/1bb0ef576757a7c336bbb33c.jpeg"},{"id":96307100,"identity":"1852a577-39d2-456d-9105-77aa95578b03","added_by":"auto","created_at":"2025-11-19 15:35:59","extension":"jpeg","order_by":15,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":77786,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7773483/v1/8266f5aeaf90bae0cdb6b0e8.jpeg"},{"id":96365174,"identity":"d831cfae-10fe-47db-959f-4cc6ae39e398","added_by":"auto","created_at":"2025-11-20 10:10:04","extension":"png","order_by":16,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":17288,"visible":true,"origin":"","legend":"","description":"","filename":"OnlineFigure1.Theselectionprocessofpatientdata.png","url":"https://assets-eu.researchsquare.com/files/rs-7773483/v1/c818765db2d09e816cf30d12.png"},{"id":96365962,"identity":"4c8c11c9-193f-4f95-a6a8-4634b6cbccc5","added_by":"auto","created_at":"2025-11-20 10:11:00","extension":"png","order_by":17,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":14670,"visible":true,"origin":"","legend":"","description":"","filename":"OnlineFigure2a.TheKaplanMeiersurvivalcurveforLR.png","url":"https://assets-eu.researchsquare.com/files/rs-7773483/v1/ea2a1f152576c6d37cbea601.png"},{"id":96307103,"identity":"b58788a7-2799-49ef-af6a-0fe599ebdb85","added_by":"auto","created_at":"2025-11-19 15:35:59","extension":"png","order_by":18,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":12597,"visible":true,"origin":"","legend":"","description":"","filename":"OnlineFigure2b.TheKaplanMeiersurvivalcurveforDM.png","url":"https://assets-eu.researchsquare.com/files/rs-7773483/v1/a04e556c7a93c8f6ad850394.png"},{"id":96307109,"identity":"824b2612-bee1-4c32-8af6-4289839d2102","added_by":"auto","created_at":"2025-11-19 15:35:59","extension":"png","order_by":19,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":11357,"visible":true,"origin":"","legend":"","description":"","filename":"OnlineFigure2c.TheKaplanMeiersurvivalcurveforOS.png","url":"https://assets-eu.researchsquare.com/files/rs-7773483/v1/468d0856fc444a3f9a0544e2.png"},{"id":96364731,"identity":"0c0439d3-d438-4843-a724-c0fdf070f75c","added_by":"auto","created_at":"2025-11-20 10:09:35","extension":"png","order_by":20,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":15335,"visible":true,"origin":"","legend":"","description":"","filename":"OnlineFigure2d.TheKaplanMeiersurvivalcurveforDFS.png","url":"https://assets-eu.researchsquare.com/files/rs-7773483/v1/b894769de65936ab4fe7328c.png"},{"id":96364567,"identity":"fb5c9a25-7eaf-4a54-81a9-559690a7b17b","added_by":"auto","created_at":"2025-11-20 10:09:25","extension":"png","order_by":21,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":17288,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7773483/v1/6dd39259e28add704ee3ebd3.png"},{"id":96307105,"identity":"bac5ffce-c0e5-485b-8415-a094e7c0cef1","added_by":"auto","created_at":"2025-11-19 15:35:59","extension":"png","order_by":22,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":28125,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7773483/v1/aaaba6f2339213f3a49e8312.png"},{"id":96307110,"identity":"e8f7030b-7c48-40d3-9db0-70f1c423e8ff","added_by":"auto","created_at":"2025-11-19 15:35:59","extension":"xml","order_by":23,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":184110,"visible":true,"origin":"","legend":"","description":"","filename":"d60f34da33ad4ce5ab9ab7092926bcfc1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7773483/v1/dc388ecdf7a3049cfb33ec98.xml"},{"id":96364997,"identity":"50cc1c76-c6c6-4a49-92ef-fb1d5eec0fb0","added_by":"auto","created_at":"2025-11-20 10:09:53","extension":"html","order_by":24,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":192158,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7773483/v1/56c755c9102051768421094e.html"},{"id":96307085,"identity":"2bd98f5c-1ef7-4ebb-b1bc-a574bf8eec01","added_by":"auto","created_at":"2025-11-19 15:35:59","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":77595,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eThe selection process of patient data\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Figure1.Theselectionprocessofpatientdata.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7773483/v1/49089d10809b82918775c600.jpg"},{"id":96307086,"identity":"28180180-923d-41c2-807b-bbefd3c027f7","added_by":"auto","created_at":"2025-11-19 15:35:59","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":175875,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eThe Kaplan-Meier survival curve\u003c/em\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7773483/v1/7aeded91299a4c7140537dd0.png"},{"id":96453550,"identity":"f65fdf68-cf02-41ed-8144-3502d17d0d45","added_by":"auto","created_at":"2025-11-21 10:00:27","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1458261,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7773483/v1/8f99f3d4-9fac-4707-a1b7-9c60f60f81b1.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Short- and Long-Term Outcomes of Minimally Invasive Total Mesorectal Excision in Obese versus Non-Obese Patients With Rectal Cancer: A Propensity Score–Matched Study","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eColorectal cancer(CRC) remains a leading cause of cancer-related morbidity and mortality worldwide, with rectal cancer accounting for approximately one-third of all cases.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] Surgical resection remains key to curative outcomes regarding the management of locally advanced rectal cancer (LARC). Total mesorectal excision (TME) has revolutionized the surgical management of LARC, significantly reducing local recurrence rates and improving long-term survival by ensuring complete removal of the mesorectal envelope and achieving negative circumferential resection margins. In recent years, the three minimally invasive TME techniques, laparoscopic TME(LapTME), Robotic TME, transanal TME(TaTME), have demonstrated non-inferior oncologic outcomes, improved short-term outcomes such as shorter hospital stays, fewer post-op complications, and faster functional recovery compared to conventional open TME.[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] With continuing advancements in surgical instrumentation and techniques, minimally invasive surgery (MIS) has emerged as the standard treatment for CRC.\u003c/p\u003e\u003cp\u003eIn many Asian countries, obesity is often defined by a body mass index (BMI) exceeding 27 kg/m\u0026sup2;, whereas Western populations typically use a threshold of 30 kg/m\u0026sup2;, owing to differences in body fat distribution.[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] The global prevalence of obesity has demonstrated a steadily increasing trajectory. Data from many Asian countries have indicated a steady increase in the prevalence of overweight and obesity, paralleling economic growth and concurrent changes in dietary habits.[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] The adoption of Westernized lifestyles may contribute to the rising prevalence of obesity observed in Asian countries. There is a general consensus that CRC serves as a marker of socioeconomic development, with incidence rates closely reflecting the human development index.[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] Consequently, obesity is increasingly prevalent among patients presenting for rectal cancer surgery. Obesity is associated with numerous adverse outcomes, including metabolic, cardiovascular, musculoskeletal, neurological, respiratory, and gastrointestinal complications, all of which are generally considered to have a greater risk of perioperative complications and technical difficulties compared to normal-weight patients.[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] The technical complexity of TME is significantly heightened in obese patients due to increased visceral adiposity, bulky mesentery, narrow pelvic anatomy and distorted tissue planes, all of which are associated with increased intraoperative difficulty in MIS, may collectively contribute to prolonged operative times, increased blood loss, and elevated conversion to open rates, reported by meta-analyses and large retrospective studies.[\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] Moreover, thickened abdominal wall can make ostomy creation more challenging.\u003c/p\u003e\u003cp\u003eWhile many surgeons acknowledge the technical challenges of performing TME in obese patients, considerable disagreement exists in the literature regarding the impact of obesity on surgical outcomes. Several large-scale retrospective and prospective studies have demonstrated that while obese patients experience longer operative times and extended hospital stays, their postoperative complication rates, positive circumferential resection margin rates, lymph node harvest yields, long-term oncologic outcomes are comparable to those of non-obesity patients when treated at specialized centers.[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] On the other hand, other studies demonstrated increased rates of wound and cardiopulmonary complications, and even anastomotic leakage rates in obese patients.[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] Given the high prevalence of obesity and the technical challenges inherent in rectal cancer surgery, elucidating the impact of obesity on this patient population is essential for optimizing individualized surgical planning. To address the crucial issue, we conducted a retrospective, single-center study to compare the clinical and short- and long-term outcomes of obesity patients and non-obesity patients underwent minimally invasive TME techniques, using propensity score matching to ensure balanced basic characteristics at a high-volume referral center.\u003c/p\u003e"},{"header":"2. Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e2.1 Patient Selection\u003c/h2\u003e\u003cp\u003eThis retrospective study reviewed patients who underwent restorative proctectomy for rectal cancer at Chang Gung Memorial Hospital between January 2015 and December 2022. The study was approved by the Institutional Review Board (approval number: 202200885B0), and the requirement for informed consent was waived due to the use of de-identified data. This research received no external funding. Due to the retrospective design of the study, the local ethics committee confirmed that informed consent from participants was not necessary.\u003c/p\u003e\u003cp\u003eEligible participants were identified from rectal cancer patients who had undergone comprehensive diagnostic evaluation, including colonoscopy with tissue biopsy, chest - pelvic computed tomography (CT), rectal magnetic resonance imaging (MRI), and endorectal ultrasonography when clinically indicated. Specific inclusion and exclusion criteria were established to define the study population. Inclusion criteria comprised patients with histologically confirmed rectal adenocarcinoma located within 15 cm from the anal verge who were considered candidates for TME with primary anastomosis. Tumor location was determined using rigid proctoscopy to measure the distance from the anal verge. Exclusion criteria included patients requiring conventional open surgery, those with unresectable tumors, patients presenting with stage IV disease at initial diagnosis, and those undergoing alternative surgical approaches such as robotic TaTME, abdominoperineal resection (APR), or Hartmann's procedure. The detailed selection process is illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e2.2 Assessment and Treatment Protocol\u003c/h2\u003e\u003cp\u003ePrior to surgical intervention, all patients underwent standardized preoperative workup consisting of thorough physical assessment, digital rectal examination, complete colonoscopic evaluation with tissue biopsy, and chest - pelvis CT. MRI of the pelvis was performed to characterize local tumor extent and regional involvement patterns. Carcinoembryonic antigen (CEA) were obtained as part of standard laboratory evaluation.\u003c/p\u003e\u003cp\u003ePathological staging was determined using the 8th edition of the Union for International Cancer Control (UICC) TNM classification system.[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] Treatment planning decisions were formulated through multidisciplinary team consultation, incorporating input from surgical, medical, and radiation oncology specialists. The implementation of neoadjuvant therapy protocols was individualized based on staging results and multidisciplinary consensus recommendations.\u003c/p\u003e\u003cp\u003eThe selection between surgical techniques was determined through consideration of surgeon expertise, tumor features, and patient-specific clinical factors. The construction of protective stoma was performed based on intraoperative surgical assessment and surgeon clinical judgment.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e2.3 Data Collection\u003c/h2\u003e\u003cp\u003eClinical information was systematically retrieved from our institution\u0026rsquo;s electronic medical records. Baseline patient characteristics included demographic data, clinical parameters, laboratory results (serum albumin and CEA levels), and tumor characteristics (location and TNM stage).\u003c/p\u003e\u003cp\u003eThe analysis covered clinical and procedural factors such as neoadjuvant and adjuvant therapies, surgical details (blood loss, stoma creation, conversion to open surgery), and anastomotic techniques. Pathological evaluation included tumor histology, differentiation, lymphovascular and perineural invasion, circumferential and distal resection margins (CRM and DRM), and lymph node yield. Margins were considered positive if tumor cells were present within 1 mm of the specimen edge.\u003c/p\u003e\u003cp\u003ePerioperative morbidity was stratified according to the Clavien-Dindo classification system, with major complications categorized as grade III or above.[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] Mortality rates were documented throughout the study period. Long-term oncological endpoints included overall survival (OS), disease-free survival (DFS), local recurrence (LR), and distant metastasis (DM).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003e2.4 Follow-Up\u003c/h2\u003e\u003cp\u003ePostoperative monitoring adhered to our department\u0026rsquo;s standardized protocol. Clinical assessments occurred at 3\u0026ndash;6 month intervals during the initial three-year period, followed by annual evaluations. Each consultation included comprehensive physical examination, CEA determination, and appropriate imaging studies for recurrence detection.\u003c/p\u003e\u003cp\u003eThe five-year follow-up strategy incorporated annual whole-body CT and endoscopic evaluation of the colorectum. Accelerated diagnostic workup was initiated when clinical presentation warranted earlier assessment for suspected disease recurrence.\u003c/p\u003e\u003cp\u003eThe OS was calculated from the operative date to patient death or most recent clinical contact. The DFS was measured from surgery to documented recurrence, death, or final follow-up assessment. Data collection continued through August 7, 2025, to support adequate duration for survival endpoint analysis.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003e2.5 Statistical Analysis\u003c/h2\u003e\u003cp\u003eQuantitative variables were presented as medians with interquartile ranges (IQR) and analyzed using the Mann-Whitney U non-parametric test for between-group comparisons. Categorical variables were summarized through frequencies and percentages, analyzed via Chi-square or Fisher\u0026rsquo;s exact test as appropriate. Survival outcomes were evaluated through Kaplan-Meier survival curves, with between-group differences assessed using log-rank testing. Univariate logistic regression was used to identify risk factors for postoperative complications.\u003c/p\u003e\u003cp\u003ePropensity scores were calculated using logistic regression based on key preoperative variables, including tumor location, serum Albumin level, ASA score, and the use of neoadjuvant chemotherapy, and Oxaliplatin frequency. Variables with significant baseline differences among groups informed the matching criteria. An 1:1 propensity score matching (PSM) was performed between the obesity and non-obesity group to establish comparable baseline characteristics and minimize selection bias. Statistical significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. All analyses were performed using SPSS version 26 (IBM Corp., New York, NY, USA).\u003c/p\u003e\u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003e3.1 Patient Characteristics before and after PSM adjustment\u003c/h2\u003e\u003cp\u003eBaseline and preoperative clinicopathological parameters are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, demonstrating comparisons before and after PSM. A total of 1186 patients were included prior to matching: 257 in the BMI\u0026thinsp;\u0026ge;\u0026thinsp;27 kg/m\u0026sup2; group and 929 in the BMI\u0026thinsp;\u0026lt;\u0026thinsp;27 kg/m\u0026sup2; group. Prior to matching, the cohorts exhibited statistically significant differences across several key variables, including tumor location (p\u0026thinsp;=\u0026thinsp;0.045), serum Albumin level (p\u0026thinsp;=\u0026thinsp;0.028), ASA score (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and the use of neoadjuvant chemotherapy (p\u0026thinsp;=\u0026thinsp;0.021) and oxaliplatin-containing regimens (p\u0026thinsp;=\u0026thinsp;0.011).\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\u003eBasic characteristics of obese and non-obese groups with rectal cancer who underwent restorative proctectomy before and after propensity score matching.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\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\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003eBefore Propensity Score Matching\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003eAfter Propensity Score Matching\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBMI\u0026thinsp;\u0026ge;\u0026thinsp;27\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;257)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eBMI\u0026thinsp;\u0026lt;\u0026thinsp;27\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;929)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eBMI\u0026thinsp;\u0026ge;\u0026thinsp;27\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;142)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eBMI\u0026thinsp;\u0026lt;\u0026thinsp;27\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;142)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e61 (14)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e63 (16)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.097\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e60 (13)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e64 (16)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.065\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\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\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\u003e169(65.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e572(61.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.220\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e100 (70.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e86 (60.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.081\u003c/p\u003e\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\u003e88(34.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e357(38.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e42 (29.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e56 (39.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSurgical 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\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003etaTME\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e42(16.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e113(12.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.095\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e40 (28.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e47 (33.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.271\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRobotic LAR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12(4.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e67(7.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e15 (10.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e21 (14.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLapTME\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e203(79)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e749(80.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e87 (61.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e74 (52.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTumor location\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\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUpper rectum\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e74(28.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e250(26.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.045*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e15 (10.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e24 (16.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.121\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMiddle rectum\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e124 (48.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e520 (56)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e68 (47.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e53 (37.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLower rectum\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e59 (23)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e159(17.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e59 (41.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e65 (45.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAlbumin\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\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt; 3.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (2.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e53 (5.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.028*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4 (2.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2 (1.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.409\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026ge; 3.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e251 (97.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e876 (94.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e138 (97.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e140 (98.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCEA\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\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt; 5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e199 (77.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e705 (75.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.607\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e114 (80.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e113 (79.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.882\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026ge; 5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e58 (22.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e224 (24.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e28 (19.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e29 (20.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eASA score\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\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e83 (32.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e450 (48.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e67 (47.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e68 (47.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.905\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e174 (67.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e479 (51.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e75 (52.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e74 (52.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003epT-stage\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\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eT0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15 (5.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e35 (3.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.098*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e13 (9.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e7 (4.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.305\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eT1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e51 (19.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e134 (14.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e21 (14.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e16 (11.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eT2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e45 (17.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e199 (21.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e30 (21.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e36 (25.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eT3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e126 (49)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e479 (51.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e71 (50)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e70 (49.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eT4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20 (7.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e82 (8.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e7 (4.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e13 (9.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003epN-stage\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\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eN0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e151 (58.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e555 (59.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.465\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e91 (64.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e86 (60.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.623\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eN1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e66 (25.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e256 (27.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e38 (26.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e38 (26.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eN2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e40 (15.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e118 (12.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e13 (9.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e18 (12.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTumor size\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.4 (6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.6 (7.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.657\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4.8 (6.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e5.1 (6.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.061\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNeoadjuvant treatment\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\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e150 (58.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e534 (57.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.799\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e94 (66.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e99 (69.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.525\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e107 (41.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e395 (42.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e48 (33.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e43 (30.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNeoadjuvant RT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e74(28.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e272(29.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.880\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e59 (41.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e68 (47.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.283\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNeoadjuvant chemotherapy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e88(34.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e250(26.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.021*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e75 (52.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e82 (57.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.403\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAdjuvant chemotherapy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e126(49)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e450(48.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.867\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e80 (56.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e80 (56.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChemotherapy with Oxaliplatin\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e52(20.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e261(28.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.011*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e37 (26.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e40 (28.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.689\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"7\"\u003eBMI: Body mass index; LapTME: laparoscopic total mesorectal excision; TaTME: transanal total mesorectal excision; AV: anal verge; ASA score: American Society of Anesthesiology score\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eFollowing PSM, 142 patients were included in each comparative group. Matching achieved good balance across most baseline variables, eliminating statistically significant differences across tumor location, serum Albumin level, ASA score, and the use of neoadjuvant chemotherapy, and Oxaliplatin frequency between study cohorts.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003e3.2 Operative Parameters and Short-Term Outcomes\u003c/h2\u003e\u003cp\u003eOperative parameters are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. After PSM, operative time showed no significant difference between the groups (312\u0026thinsp;\u0026plusmn;\u0026thinsp;139 min vs. 280\u0026thinsp;\u0026plusmn;\u0026thinsp;118 min, p\u0026thinsp;=\u0026thinsp;0.287). Estimated blood loss was similar between the two groups (50\u0026thinsp;\u0026plusmn;\u0026thinsp;55 ml vs. 50\u0026thinsp;\u0026plusmn;\u0026thinsp;30 ml, p\u0026thinsp;=\u0026thinsp;0.070). The rate of diverting stoma creation did not differ significantly (50.7% vs. 45.1%, p\u0026thinsp;=\u0026thinsp;0.342). Conversion to open surgery occurred only in the obesity group (2.8% vs. 0%, p\u0026thinsp;=\u0026thinsp;0.044), three conversion was due to adhesions and one to advanced disease. Anastomosis methods was comparable between the 2 groups (p\u0026thinsp;=\u0026thinsp;0.08). Natural orifice specimen extraction was more frequent in the non-obesity group compared to the obesity group (28.2% vs. 35.9%, p\u0026thinsp;=\u0026thinsp;0.153), although this difference was not statistically significant.\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\u003ePost-matching of operative parameters among the obese and non-obese groups\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=\"char\" char=\".\" 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\u003eBMI\u0026thinsp;\u0026ge;\u0026thinsp;27\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;142)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eBMI\u0026thinsp;\u0026lt;\u0026thinsp;27\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;142)\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 time\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e312(139)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e280 (118)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.287\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBlood loss\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e50(55)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e50(30)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.07\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt; 100ml\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e108(76.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e113(79.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.475\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026ge; 100ml\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e34(23.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e29(20.4)\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\u003eDiverting stoma\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\u003eyes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e72(50.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e64(45.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.342\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eno\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e70(49.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e78(54.9)\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\u003eConversion\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\u003eyes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4(2.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.044*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eno\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e138(97.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e142(100)\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\u003eAnastomosis methods\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\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1(0.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7(4.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.08\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHand sewn\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e22(15.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25(17.6)\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\u003eStaples\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e119(83.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e110(77.5)\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\u003eSpecimen extraction methods\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\u003eNOSE\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e40(28.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e51(35.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.153\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePfannenstiel incision\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2(1.4)\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\u003eOther abdominal incision\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e100(70.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e91(64.1)\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\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eBMI: Body mass index; LapTME: laparoscopic total mesorectal excision; TaTME: transanal total mesorectal excision; NOSE: natural orifice specimen retraction\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e presents the postoperative results. Hospital length of stay and recovery milestones showed no significant variation between cohorts. Overall complication rates were notably elevated in the obesity group compared to the non-obesity group (40.1% vs. 28.9%, p\u0026thinsp;=\u0026thinsp;0.046). This increase was predominantly due to minor complications (Clavien-Dindo grade\u0026thinsp;\u0026lt;\u0026thinsp;3), which occurred more frequently in the obesity group (35.9% vs. 23.2%, p\u0026thinsp;=\u0026thinsp;0.019), while major complication incidence (Clavien-Dindo grade\u0026thinsp;\u0026ge;\u0026thinsp;3) remained equivalent (4.2% vs. 5.6%, p\u0026thinsp;=\u0026thinsp;0.584). Common specific complications included ileus (8.5% vs. 10.6%, p\u0026thinsp;=\u0026thinsp;0.544), intra-abdominal infection (IAI) (9.2% vs. 7.0%, p\u0026thinsp;=\u0026thinsp;0.514), and anastomosis leakage (4.2% vs. 3.5%, p\u0026thinsp;=\u0026thinsp;0.758), showing no significant differences. Surgical wound infection occurred more frequently in the obesity group (9.2% vs. 1.4%, p\u0026thinsp;=\u0026thinsp;0.004). Reoperation (p\u0026thinsp;=\u0026thinsp;0.22) and permanent stoma rates (p\u0026thinsp;=\u0026thinsp;0.157) were similar between the groups.\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\u003ePost-matching of short-term outcomes among the obese and non-obese groups\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=\"char\" char=\".\" 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\u003eBMI\u0026thinsp;\u0026ge;\u0026thinsp;27\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;142)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eBMI\u0026thinsp;\u0026lt;\u0026thinsp;27\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;142)\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\u003eHospital stays\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8(5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7(5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.077\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFirst flatus passage\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2(1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2(2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.361\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFirst stool passage\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.5(3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3(2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTolerated liquid diet\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3(3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3(3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.128\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTolerated soft diet\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5(4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4(4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.354\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRemove Foley day\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5(4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5(3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.916\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOverall complication\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\u003eyes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e57(40.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e41(28.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.046*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eno\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e85(59.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e101(71.1)\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\u003eClavien-Dindo Classification\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\u003eI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e25(17.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7(4.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.019*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eII\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e26(18.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26(18.3)\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\u003e5(3.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7(4.9)\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\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1(0.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1(0.7)\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\u003eV\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\u003eMajor complication(C-D grade\u0026thinsp;\u0026ge;\u0026thinsp;3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6(4.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8(5.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.584\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMinor complication(C-D grade\u0026thinsp;\u0026lt;\u0026thinsp;3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e51(35.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e33(23.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.019*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eComplication 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\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIleus\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12(8.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15(10.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.544\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAnastomosis leak\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6(4.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5(3.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.758\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIAI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13(9.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10(7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.514\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSurgical wound infection\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13(9.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2(1.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.004*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOthers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14(9.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9(6.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.277\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRe-operation\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\u003eLeakage\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6(4.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4(2.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.22\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBowel obstruction\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(1.4)\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\u003eOthers\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(1.4)\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\u003ePermanent stoma\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17(12)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10(7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.157\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eBMI: Body mass index; LapTME: laparoscopic total mesorectal excision; TaTME: transanal total mesorectal excision; IAI: intra-abdominal infection\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003e3.3 Risk factors for postoperative complications\u003c/h2\u003e\u003cp\u003eRisk factor analysis for postoperative complications is detailed in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. Regarding major complications, no statistically significant predictive factors were identified. For overall complications, obesity demonstrated a trend toward increased risk that bordered on statistical significance (OR\u0026thinsp;=\u0026thinsp;1.721, p\u0026thinsp;=\u0026thinsp;0.05). Among the various operative techniques employed, none exhibited significant associations with overall complication rates. Additional variables including patient gender, tumor location, ASA score, pathological T-stage, N-stage, utilization of protective stomas, and preoperative adjuvant therapies demonstrated no meaningful correlations with either severe or total postoperative complications.\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\u003eSummary of the risk factors for postoperative complications\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\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\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eMajor complications(C-D grade\u0026thinsp;\u0026ge;\u0026thinsp;3)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e\u003cp\u003eOverall complications\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eOR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBMI\u0026thinsp;\u0026gt;\u0026thinsp;27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.668\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.507\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eBMI\u0026thinsp;\u0026gt;\u0026thinsp;27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.721\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.05*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLapTME\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\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eLapTME\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRobotic LAR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.063\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.953\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRobotic LAR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.683\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.382\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTaTME\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.967\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.139\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTaTME\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.957\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.926\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge\u0026thinsp;\u0026gt;\u0026thinsp;75 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.933\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.939\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eAge\u0026thinsp;\u0026gt;\u0026thinsp;75 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.198\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.652\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale sex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.613\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.474\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMale sex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.217\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.515\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUpper rectum\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\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eUpper rectum\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMiddle rectum\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.429\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.921\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMiddle rectum\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.226\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.687\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLower rectum\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.998\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.596\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eLower rectum\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.845\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.724\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eASA score\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\u003eASA score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\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\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.423\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.069\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.328\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.341\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003epT-stage\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\u003epT-stage\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e0\u0026thinsp;+\u0026thinsp;1\u0026thinsp;+\u0026thinsp;2\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\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0\u0026thinsp;+\u0026thinsp;1\u0026thinsp;+\u0026thinsp;2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.252\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.746\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.199\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.551\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.115\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.209\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.602\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.430\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003epN-stage\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\u003epN-stage\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eN0\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\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eN1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.761\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.717\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.536\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.072\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eN2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.007\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.994\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.672\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.419\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDiverting stoma\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.303\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.706\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDiverting stoma\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.757\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.698\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNeoadjuvant chemotherapy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.226\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.121\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNeoadjuvant chemotherapy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.768\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.463\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNeoadjuvant radiotherapy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.095\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.913\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNeoadjuvant radiotherapy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.419\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003eBMI: Body mass index; LapTME: laparoscopic total mesorectal excision; TaTME: transanal total mesorectal excision; OR: odds ratio\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003e3.4 Histopathological Parameters\u003c/h2\u003e\u003cp\u003eHistopathological findings are presented in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e. Complete pathological response occurred in 5.6% of the obesity group compared to 4.2% in the non-obesity group (p\u0026thinsp;=\u0026thinsp;0.584). Tumor type (p\u0026thinsp;=\u0026thinsp;1) and differentiation (p\u0026thinsp;=\u0026thinsp;0.671) showed no significant variation. Neither lymphovascular (21.8% vs. 16.9%, p\u0026thinsp;=\u0026thinsp;0.293) nor perineural invasion rates (16.9% vs. 25%, p\u0026thinsp;=\u0026thinsp;0.747) differed significantly between groups. Circumferential resection margin (CRM) positivity rates were equivalent across groups (4.2% vs. 4.9%, p\u0026thinsp;=\u0026thinsp;0.776), while positive distal resection margin (DRM) rates also showed no difference (4.9% vs. 7.0%, p\u0026thinsp;=\u0026thinsp;0.453). Harvested lymph node counts were similar (23\u0026thinsp;\u0026plusmn;\u0026thinsp;19 vs. 24\u0026thinsp;\u0026plusmn;\u0026thinsp;14, p\u0026thinsp;=\u0026thinsp;0.6), and R1 resection showed no significant difference (9.9% vs. 7.7%, p\u0026thinsp;=\u0026thinsp;0.530).\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\u003ePost-matching pathological finding among the obese and non-obese groups\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\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBMI\u0026thinsp;\u0026ge;\u0026thinsp;27\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;142)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eBMI\u0026thinsp;\u0026lt;\u0026thinsp;27\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;142)\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\u003epCR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8(5.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6(4.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.584\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHistology 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\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAdenocarcinoma\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e132(93)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e132(93)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSignet ring cell/Mucinous\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10(7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10(7)\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\u003eHistology Grade\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\u003eGrade I/II\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e121(85.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e125(88)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.671\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGrade III\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13(9.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12(8.5)\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\u003eUnclassified\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8(5.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5(3.5)\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\u003eLymphovascular invasion\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\u003epositive\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e31(21.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24(16.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.293\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003enegative\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e111(78.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e118(83.1)\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\u003ePerineural invasion\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\u003epositive\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e24(16.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22(25)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.747\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003enegative\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e118(83.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e120(72.5)\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\u003eCRM\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\u003ePositive\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6(4.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7(4.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.776\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNegative\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e136(95.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e135(95.1)\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\u003eDistal resection margin, length\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.5(1.75)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.4(1.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.158\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDistal resection margin\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\u003epositive\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7(4.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10(7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.453\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003enegative\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e135(95.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e132(93)\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 yield\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e23(19)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24(14)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eR1 resection\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14(9.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11(7.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.530\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eBMI: Body mass index; LapTME: laparoscopic total mesorectal excision; TaTME: transanal total mesorectal excision; pCR: pathological complete response; CRM: Circumferential resection margin\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003e3.5 Long-Term Outcomes\u003c/h2\u003e\u003cp\u003eThe median follow-up durations were 51.2 and 36.6 months for the obesity and non-obesity groups, respectively (p\u0026thinsp;=\u0026thinsp;0.331). Figure\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e depicts the Kaplan‒Meier survival curve. LR rates were 15.5% and 23% (p\u0026thinsp;=\u0026thinsp;0.753), DM rates were 35.1% and 26.1% (p\u0026thinsp;=\u0026thinsp;0.912), respectively. Five-year OS rates (88% vs. 89.4%, p\u0026thinsp;=\u0026thinsp;0.409) and five-year DFS rates (62.7% vs. 72.5%, p\u0026thinsp;=\u0026thinsp;0.653) did not reach statistical significance as well.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThe present study evaluated clinical and oncological results between elevated BMI group with above 27 kg/m\u0026sup2; and normal BMI groups following PSM in patients who underwent minimally invasive TME procedures at a high-volume tertiary center. After PSM adjustment, this analysis revealed comparable oncological outcomes between both patient groups. While obesity patients experienced increased conversion rate and overall postoperative complication rates, both short- and long-term outcomes remained equivalent across the groups.\u003c/p\u003e\u003cp\u003eWith the global rise in obesity, the potential impact on postoperative outcomes following abdominal procedures has garnered considerable interest. In patients with obesity, surgical resection of rectal tumor presents distinctly greater technical complexity. Concerning operative parameters, conversion to open surgery remains to represent a major challenge in laparoscopic surgery. Previous meta-analyses showed significantly higher risk of conversion rate in obesity patients [Odds Ratio (OR) 2.11\u0026ndash;3.3], consistent with our findings.[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] Elevated conversion rates demonstrate the cumulative impact of anatomical and surgical challenges. Increased visceral adiposity and mesorectal fat accumulation compromise visualization within the confined pelvic space, particularly in male patients, obscuring tissue planes and increasing the potential for unintended damage to surrounding organs.[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] These factors may extend operative time and elevate intraoperative blood loss, both contribute to conversion necessity.[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] Interestingly, shown in previous studies, robotic surgery can overcome certain visualization and maneuverability constraints in particularly high-risk populations such as obese patients, thereby reducing conversion rates in subgroup analysis compared to LapTME [OR 0.22, 95% Confidence Interval (CI) 0.07\u0026ndash;0.71, p\u0026thinsp;=\u0026thinsp;0.011] (OR 0.46, 95% CI 0.21\u0026ndash;0.99, p\u0026thinsp;=\u0026thinsp;0.04).[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] Similarly, TaTME decreases conversion rates in obesity patients as the transanal approach offers direct, magnified visualization of the lower rectum and mesorectal tissues, maintaining appropriate dissection planes even within a constricted, adipose-laden pelvis that compromises instrument maneuverability and field of view during LapTME procedures. TaTME decreases conversion rates in obesity patients as the transanal approach offers direct, magnified visualization of the lower rectum and mesorectal tissues, maintaining appropriate dissection planes even within a constricted, adipose-laden pelvis.[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] The restricted pelvic anatomy and proximity to surrounding structures during rectal surgery amplify procedure-specific complications, surgeon must recognize these complexities during preoperative planning and consider patient selection carefully when considering minimally invasive approaches.\u003c/p\u003e\u003cp\u003eA prior investigation demonstrated that in patients with BMI above 27 kg/m\u0026sup2;, over 85% of Taiwanese, 66% of whites and 55% of blacks exhibited at least one of the comorbidities such as hypertension, diabetes, hypertriglyceridemia and hyperuricemia.[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] The chronic inflammatory processes and endothelial dysfunction linked to these obesity comorbidities may compromise wound healing capacity, elevate bleeding risk and hematoma formation.[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] Moreover, increased subcutaneous fat layers diminish vascular supply and oxygenation at surgical sites, limit antimicrobial drug distribution and impair immune cell activity, thus creating an environment conducive to microbial growth and surgical site contamination, particularly in intestinal operations where native bacterial flora are abundant.[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] In our study, the obesity group had increased overall postoperative complication rates compared to the non-obesity group. The difference mainly resulted from surgical wound infection rate, aligned with previous studies, indicating that obesity represents an established risk factor for surgical wound infection, so as our result(OR 1.721, p\u0026thinsp;=\u0026thinsp;0.05 ).[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] Additionally, an Surgeons National Surgical Quality Improvement Program(NSQIP) study focused on proctectomy demonstrated progressive increases in superficial wound infections corresponding to elevated BMI classes.[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] Perioperative strategies require enhancement to mitigate the elevated risk. Body weight-adjusted prophylactic antimicrobial dosing or broad-spectrum antibiotics to ensure sufficient tissue penetration, combined with standardized perioperative protocols, may effectively reduce infection rates.\u003c/p\u003e\u003cp\u003eAnastomotic leakage remains a critical complication following TME procedures. Anastomotic leakage is associated with increased morbidity and mortality, often leading to both surgical and radiological re-interventions. Moreover, it has been linked to higher rates of LR and lower long-term survival outcome.[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] We found no difference between the two groups in risk of anastomotic leakage in our study. An analysis from ACS-NSQIP found no significant association between BMI stratification and the 30-day risk of anastomotic leakage.[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] Notably, this result remained consistent after multivariate adjustment, supporting that under conditions of standardized perioperative care and high-quality TME that in high-volume centers with stringent technical standards, obesity does not always translate to a higher rate of anastomotic leakage.[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eCurrent evidence indicates that long-term oncologic outcomes following TME are comparable between obesity and non-obesity patients. Several single-center studies have shown that the number of lymph nodes harvested, negative margin rates, and DFS rates are not diminished by elevated BMI, particularly when a high-quality mesorectal excision is achieved.[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] For mid-to-low rectal cancer patients, matched risk-adjusted analysis has demonstrated comparable five-year OS and DFS rates among different BMI groups, suggesting that the technical difficulty and short-term complications associated with obesity do not translate into negative impact on long-term survival where oncologic principles and TME quality are maintained.[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] Evidence regarding pathological and specimen quality indicates that complete or nearly-complete TME and negative CRM rate are closely related to lower LR and DM rate.[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] The association is not affected by BMI, suggesting that the quality of surgical technique, rather than obesity itself, dictates the risk of recurrence.\u003c/p\u003e\u003cp\u003eOur study has several limitations. First, the single-center, retrospective design introduces a risk of selection bias and incomplete data capture. The retrospective analysis may not establish causality and is inherently limited by potential confounding variables. Additionally, although BMI is a simple and cost-effective index of patient size, its accuracy may be compromised by extremes of height and gender variations in body fat distribution. Recently, Visceral fat area (VFA), measured by CT imaging at specific abdominal cross-sections to assess intra-abdominal adipose volume, serves as a valuable tool for investigating clinical concerns associated with central or visceral adiposity.[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] VFA serves as an increasingly important biomarker from a surgical perspective. It may be utilized to differentiate patients with colorectal cancer into more detailed stratification, enabling more precise perioperative assessments.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eIn conclusion, the retrospective study demonstrated that although obesity (BMI\u0026thinsp;\u0026ge;\u0026thinsp;27 kg/m\u0026sup2;) was significantly associated with higher rates of conversion and minor postoperative complications, the short-term or long-term outcomes in patients underwent minimally invasive TME approaches were comparable. The findings emphasize the need for tailored surgical and perioperative strategies for obesity patients. While intraoperative difficulties are more pronounced, structured postoperative care can help mitigate differences in complications.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eInformed Consent Statement:\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eDue to the retrospective design of the study, the local ethics committee confirmed that informed consent from participants was not necessary.\u003c/p\u003e\n\u003ch2\u003eConsent for publication:\u003c/h2\u003e\n\u003cp\u003eAll authors consent to publish this work.\u003c/p\u003e\n\u003ch2\u003eConflicts of interest:\u003c/h2\u003e\n\u003cp\u003eThe authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article.\u003c/p\u003e\n\u003ch2\u003eFunding:\u003c/h2\u003e\n\u003cp\u003eThis study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eGuan-Yu Chen and Shu-Huan Huang contributed equally. Conception and design of the study: Shu-Huan Huang; Collection and assembly of the data: Guan-Yu Chen; Data analysis and interpretation: Guan-Yu Chen; Drafting the manuscript: Guan-Yu Chen; Writing \u0026ndash; review \u0026amp; editing: Guan-Yu Chen, Shu-Huan Huang; Contributed to the operations: Kun-Yu Tsai, Chun-Kai Liao, Jeng-Fu You, Cheng-Chou Lai and Shu-Huan Huang.\u003c/p\u003e\n\u003ch2\u003eAcknowledgements:\u003c/h2\u003e\n\u003cp\u003eWe thank the research team members for their hard work.\u003c/p\u003e\n\u003ch2\u003eInstitutional Review Board Statement:\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eThis study was approved by the Institutional Review Board of Chang Gung Memorial Hospital (approval number 202200885B0).\u003c/p\u003e\n\u003ch2\u003eData Availability\u003c/h2\u003e\n\u003cp\u003eAll data sets used or analyzed in this study are available from the corresponding author upon request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBray, F., et al., \u003cem\u003eGlobal cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries.\u003c/em\u003e CA: a cancer journal for clinicians, 2024. \u003cstrong\u003e74\u003c/strong\u003e(3): p. 229\u0026ndash;263.\u003c/li\u003e\n\u003cli\u003eSimillis, C., et al., \u003cem\u003eOpen versus laparoscopic versus robotic versus transanal mesorectal excision for rectal cancer: a systematic review and network meta-analysis.\u003c/em\u003e Annals of surgery, 2019. \u003cstrong\u003e270\u003c/strong\u003e(1): p. 59\u0026ndash;68.\u003c/li\u003e\n\u003cli\u003eRyan, O.K., et al., \u003cem\u003eSurgical approach for rectal cancer: a network meta-analysis comparing open, laparoscopic, robotic and transanal TME approaches.\u003c/em\u003e European Journal of Surgical Oncology, 2021. \u003cstrong\u003e47\u003c/strong\u003e(2): p. 285\u0026ndash;295.\u003c/li\u003e\n\u003cli\u003ePan, W.-H., et al., \u003cem\u003eBody mass index and obesity-related metabolic disorders in Taiwanese and US whites and blacks: implications for definitions of overweight and obesity for Asians.\u003c/em\u003e The American journal of clinical nutrition, 2004. \u003cstrong\u003e79\u003c/strong\u003e(1): p. 31\u0026ndash;39.\u003c/li\u003e\n\u003cli\u003eCollaborators, G.O., \u003cem\u003eHealth effects of overweight and obesity in 195 countries over 25 years.\u003c/em\u003e New England journal of medicine, 2017. \u003cstrong\u003e377\u003c/strong\u003e(1): p. 13\u0026ndash;27.\u003c/li\u003e\n\u003cli\u003eFidler, M.M., I. Soerjomataram, and F. Bray, \u003cem\u003eA global view on cancer incidence and national levels of the human development index.\u003c/em\u003e International journal of cancer, 2016. \u003cstrong\u003e139\u003c/strong\u003e(11): p. 2436\u0026ndash;2446.\u003c/li\u003e\n\u003cli\u003eBlee, T.H., G.E. Belzer, and P.J. Lambert, \u003cem\u003eObesity: is there an increase in perioperative complications in those undergoing elective colon and rectal resection for carcinoma?\u003c/em\u003e The American surgeon, 2002. \u003cstrong\u003e68\u003c/strong\u003e(2): p. 163\u0026ndash;166.\u003c/li\u003e\n\u003cli\u003eKnol, J. and D.S. Keller, \u003cem\u003eTotal mesorectal excision technique\u0026mdash;past, present, and future.\u003c/em\u003e Clinics in colon and rectal surgery, 2020. \u003cstrong\u003e33\u003c/strong\u003e(03): p. 134\u0026ndash;143.\u003c/li\u003e\n\u003cli\u003eQiu, Y., et al., \u003cem\u003eOutcome of rectal cancer surgery in obese and nonobese patients: a meta-analysis.\u003c/em\u003e World Journal of Surgical Oncology, 2015. \u003cstrong\u003e14\u003c/strong\u003e(1): p. 23.\u003c/li\u003e\n\u003cli\u003eChern, H., et al., \u003cem\u003eEffects of obesity in rectal cancer surgery.\u003c/em\u003e Journal of the American College of Surgeons, 2010. \u003cstrong\u003e211\u003c/strong\u003e(1): p. 55\u0026ndash;60.\u003c/li\u003e\n\u003cli\u003eBallian, N., et al., \u003cem\u003eBody mass index does not affect postoperative morbidity and oncologic outcomes of total mesorectal excision for rectal adenocarcinoma.\u003c/em\u003e Annals of surgical oncology, 2010. \u003cstrong\u003e17\u003c/strong\u003e(6): p. 1606\u0026ndash;1613.\u003c/li\u003e\n\u003cli\u003eNugent, T.S., et al., \u003cem\u003eObesity and anastomotic leak rates in colorectal cancer: a meta-analysis.\u003c/em\u003e International Journal of Colorectal Disease, 2021. \u003cstrong\u003e36\u003c/strong\u003e(9): p. 1819\u0026ndash;1829.\u003c/li\u003e\n\u003cli\u003eJessup, J., et al., \u003cem\u003eColon and Rectum\u003c/em\u003e. 2017. p. 251\u0026ndash;274.\u003c/li\u003e\n\u003cli\u003eDindo, D., N. Demartines, and P.-A. Clavien, \u003cem\u003eClassification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey.\u003c/em\u003e Annals of surgery, 2004. \u003cstrong\u003e240\u003c/strong\u003e(2): p. 205\u0026ndash;213.\u003c/li\u003e\n\u003cli\u003eRogers, A.C., et al., \u003cem\u003eMeta-analysis of the clinicopathological characteristics and peri-operative outcomes of colorectal cancer in obese patients.\u003c/em\u003e Cancer Epidemiology, 2017. \u003cstrong\u003e51\u003c/strong\u003e: p. 23\u0026ndash;29.\u003c/li\u003e\n\u003cli\u003eFung, A., et al., \u003cem\u003eLaparoscopic colorectal cancer resections in the obese: a systematic review.\u003c/em\u003e Surgical endoscopy, 2017. \u003cstrong\u003e31\u003c/strong\u003e(5): p. 2072\u0026ndash;2088.\u003c/li\u003e\n\u003cli\u003eBell, S., et al., \u003cem\u003eThe effect of increasing body mass index on laparoscopic surgery for colon and rectal cancer.\u003c/em\u003e Colorectal Disease, 2018. \u003cstrong\u003e20\u003c/strong\u003e(9): p. 778\u0026ndash;788.\u003c/li\u003e\n\u003cli\u003eIshiyama, Y., et al., \u003cem\u003eRisk factors of bleeding during rectal cancer surgery in obese patients in Japan.\u003c/em\u003e Asian journal of endoscopic surgery, 2024. \u003cstrong\u003e17\u003c/strong\u003e(3): p. e13316.\u003c/li\u003e\n\u003cli\u003eCrippa, J., et al., \u003cem\u003eRisk factors for conversion in laparoscopic and robotic rectal cancer surgery.\u003c/em\u003e Journal of British Surgery, 2020. \u003cstrong\u003e107\u003c/strong\u003e(5): p. 560\u0026ndash;566.\u003c/li\u003e\n\u003cli\u003eJayne, D., et al., \u003cem\u003eEffect of robotic-assisted vs conventional laparoscopic surgery on risk of conversion to open laparotomy among patients undergoing resection for rectal cancer: the ROLARR randomized clinical trial.\u003c/em\u003e Jama, 2017. \u003cstrong\u003e318\u003c/strong\u003e(16): p. 1569\u0026ndash;1580.\u003c/li\u003e\n\u003cli\u003eYi, X., et al., \u003cem\u003eComparing perioperative and oncological outcomes of transanal and laparoscopic total mesorectal excision for rectal cancer: a meta-analysis of randomized controlled trials and prospective studies.\u003c/em\u003e Surgical Endoscopy, 2023. \u003cstrong\u003e37\u003c/strong\u003e(12): p. 9228\u0026ndash;9243.\u003c/li\u003e\n\u003cli\u003eEngin, A., \u003cem\u003eEndothelial dysfunction in obesity and therapeutic targets.\u003c/em\u003e Obesity and Lipotoxicity, 2024: p. 489\u0026ndash;538.\u003c/li\u003e\n\u003cli\u003eBalentine, C.J., et al., \u003cem\u003eObesity increases wound complications in rectal cancer surgery.\u003c/em\u003e Journal of Surgical Research, 2010. \u003cstrong\u003e163\u003c/strong\u003e(1): p. 35\u0026ndash;39.\u003c/li\u003e\n\u003cli\u003eSmith, R.K., et al., \u003cem\u003eImpact of BMI on postoperative outcomes in patients undergoing proctectomy for rectal cancer: a national surgical quality improvement program analysis.\u003c/em\u003e Diseases of the colon \u0026amp; rectum, 2014. \u003cstrong\u003e57\u003c/strong\u003e(6): p. 687\u0026ndash;693.\u003c/li\u003e\n\u003cli\u003eAlmasaudi, A.S., et al., \u003cem\u003eThe relationship between body mass index and short term postoperative outcomes in patients undergoing potentially curative surgery for colorectal cancer: a systematic review and meta-analysis.\u003c/em\u003e Critical reviews in oncology/hematology, 2018. \u003cstrong\u003e121\u003c/strong\u003e: p. 68\u0026ndash;73.\u003c/li\u003e\n\u003cli\u003eMirnezami, A., et al., \u003cem\u003eIncreased local recurrence and reduced survival from colorectal cancer following anastomotic leak: systematic review and meta-analysis.\u003c/em\u003e Annals of surgery, 2011. \u003cstrong\u003e253\u003c/strong\u003e(5): p. 890\u0026ndash;899.\u003c/li\u003e\n\u003cli\u003eSweigert, P.J., et al., \u003cem\u003eAssociation of obesity with postoperative outcomes after proctectomy.\u003c/em\u003e The American Journal of Surgery, 2020. \u003cstrong\u003e220\u003c/strong\u003e(4): p. 1004\u0026ndash;1009.\u003c/li\u003e\n\u003cli\u003eAytac, E., et al., \u003cem\u003eImpact of obesity on operation performed, complications, and long-term outcomes in terms of restoration of intestinal continuity for patients with mid and low rectal cancer.\u003c/em\u003e Diseases of the colon \u0026amp; rectum, 2013. \u003cstrong\u003e56\u003c/strong\u003e(6): p. 689\u0026ndash;697.\u003c/li\u003e\n\u003cli\u003eRogers, P., et al., \u003cem\u003eAssociation Between Mesorectal Grade and Oncologic Outcomes in Rectal Cancer: A Systematic Review and Meta\u003c/em\u003e\u003cem\u003e‐Analysis.\u003c/em\u003e Journal of Surgical Oncology, 2025.\u003c/li\u003e\n\u003cli\u003eYang, T., et al., \u003cem\u003eImpact of visceral obesity on outcomes of laparoscopic colorectal surgery: a meta\u003c/em\u003e\u003cem\u003e‐analysis.\u003c/em\u003e ANZ journal of surgery, 2015. \u003cstrong\u003e85\u003c/strong\u003e(7-8): p. 507\u0026ndash;513.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"techniques-in-coloproctology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"tcol","sideBox":"Learn more about [Techniques in Coloproctology](http://link.springer.com/journal/10151)","snPcode":"10151","submissionUrl":"https://submission.nature.com/new-submission/10151/3","title":"Techniques in Coloproctology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Obesity, Rectal cancer, Total mesorectal excision, Minimally invasive surgery, Retrospective study","lastPublishedDoi":"10.21203/rs.3.rs-7773483/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7773483/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Obesity adds technical complexity to colorectal surgery and has been linked to higher rates of perioperative complications and poorer long-term outcomes. Its prevalence is increasing among patients undergoing minimally invasive total mesorectal excision for rectal cancer; however, its impact on perioperative and oncologic outcomes remains controversial. Therefore, the aim of this study was to compare short- and long-term outcomes between obese (BMI ≥27 kg/m²) and non-obese patients undergoing minimally invasive total mesorectal excision.\u003cbr\u003e\n \u003cstrong\u003eMethods:\u003c/strong\u003e Retrospective review of rectal cancer patients undergoing laparoscopic, robotic, or transanal TME between January 2015 and December 2022. Propensity score matching (1:1) was performed on baseline characteristics. Primary outcomes included perioperative parameters, postoperative complications, and long-term oncologic outcomes.\u003cbr\u003e\n \u003cstrong\u003eResults:\u003c/strong\u003e After matching, 142 patients were included in each group. Obesity was associated with higher conversion rates to open surgery (2.8% vs. 0%, p=0.044) and increased overall complications (40.1% vs. 28.9%, p=0.046), driven mainly by surgical wound infections (9.2% vs. 1.4%, p=0.004). No differences were observed in major complications, anastomotic leakage, hospital stay, margin status, or five-year overall (88% vs. 89.4%, p = 0.409) and disease-free survival (62.7% vs. 72.5%, p = 0.653).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e Obesity increased conversion and minor complication rates but did not adversely affect short-term outcomes or long-term oncologic outcomes after minimally invasive TME procedures. Tailored perioperative strategies may mitigate obesity-associated risks.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration: \u003c/strong\u003eNot applicable.\u003c/p\u003e","manuscriptTitle":"Short- and Long-Term Outcomes of Minimally Invasive Total Mesorectal Excision in Obese versus Non-Obese Patients With Rectal Cancer: A Propensity Score–Matched Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-19 15:35:54","doi":"10.21203/rs.3.rs-7773483/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-11-27T08:48:31+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-15T14:44:17+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-13T19:47:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"56986516667264048918010777116788188289","date":"2025-11-11T22:13:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"320177686902145733663263948452608321003","date":"2025-11-10T06:33:11+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-09T17:45:55+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-09T15:32:08+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-04T06:03:39+00:00","index":"","fulltext":""},{"type":"submitted","content":"Techniques in Coloproctology","date":"2025-10-03T12:19:23+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"techniques-in-coloproctology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"tcol","sideBox":"Learn more about [Techniques in Coloproctology](http://link.springer.com/journal/10151)","snPcode":"10151","submissionUrl":"https://submission.nature.com/new-submission/10151/3","title":"Techniques in Coloproctology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"af87733d-3bf8-4ef9-94d7-c021e581bc78","owner":[],"postedDate":"November 19th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-01-28T03:54:52+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-19 15:35:54","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7773483","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7773483","identity":"rs-7773483","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}