Transanal Transection and Single Stapled Anastomosis as A Reliable Technique for Distal Rectum Transection in Patients Undergoing Low Anterior Resection for Rectal Cancer 

Transanal Transection and Single Stapled Anastomosis as A Reliable Technique for Distal Rectum Transection in Patients Undergoing Low Anterior Resection for Rectal Cancer | 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 Transanal Transection and Single Stapled Anastomosis as A Reliable Technique for Distal Rectum Transection in Patients Undergoing Low Anterior Resection for Rectal Cancer Ayman Hanafy, Haitham Fekry, Muhammad Adel Ali, Ahmed Mostafa Mahmoud This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6792092/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 6 You are reading this latest preprint version Abstract Purpose To evaluate the safety, feasibility, and oncological and functional outcomes of the TTSS technique in rectal cancer surgery. Methods This retrospective study included 23 patients who underwent TTSS for rectal cancer. Data on demographics, tumor characteristics, perioperative variables, and postoperative outcomes were collected. Oncological parameters, anastomotic integrity, and functional outcomes were assessed. Short-term complications and early functional results were evaluated. Results The mean patient age was 48.87 ± 15.91 years, with a mean BMI of 25.22 ± 4.86 kg/m². Laparoscopic surgery was performed in 91.3% of cases, with no conversions to open surgery. The anastomotic leakage rate was 4.3%, managed conservatively. Anastomotic strictures developed in 13% of cases, requiring endoscopic dilation. The average operative time was 287.83 ± 38.70 minutes, and estimated blood loss was 195.65 ± 82.45 ml. The 30-day complication rate was 17.4%, with no major surgical re-interventions. Pathological complete response was achieved in 26.1% of cases, and 87% had negative lymph node involvement. Among patients who underwent ileostomy closure, 85% had complete continence, while 15% experienced minor incontinence symptoms. Conclusion TTSS is a feasible and safe technique for rectal cancer surgery, demonstrating favorable oncological outcomes, a low anastomotic leakage rate, and promising functional results. Transanal total single-stapled anastomosis rectal cancer surgery anastomotic leakage Figures Figure 1 1. Introduction Rectal cancer is a major global health concern, ranking as the third most prevalent cancer and the second leading cause of cancer-related deaths worldwide. Advances in surgical and multimodal treatment strategies have improved outcomes for patients, yet low anterior resection (LAR) with total mesorectal excision (TME) remains the cornerstone of treatment for mid and low rectal cancers. The technical challenges of distal rectum transection and anastomosis, particularly in cases involving a narrow pelvis, continue to complicate surgical outcomes. Emerging techniques like transanal transection with single-stapled anastomosis offer solutions to these challenges by enhancing surgical precision and reducing postoperative complications (1, 2). The concept of TME introduced by Heald et al. emphasized complete mesorectal excision to minimize local recurrence and optimize survival rates. However, achieving a clear distal resection margin and a sound anastomosis remains challenging, especially in low rectal tumors. Traditional transabdominal stapling techniques are often limited by poor visibility and difficult stapler placement in a confined pelvic space, increasing the risk of incomplete margins and technical complications. The transanal approach, by contrast, facilitates direct access and improved visualization, making it a promising alternative for addressing distal rectal tumors (3, 4). Transanal transection combined with single-stapled anastomosis offers a more reliable method for managing distal rectal cancer. This technique enables precise rectal transection and reduces the need for multiple stapler firings, minimizing the risk of technical errors that could compromise anastomotic integrity. Studies have shown that transanal techniques enhance oncological outcomes by ensuring clear circumferential resection margins (CRM) and adequate distal resection margins, essential for reducing local recurrence rates (5, 6). In male patients, those with obesity, or individuals with narrow pelvises, the technical challenges of rectal surgery are magnified. Traditional approaches often result in "dog-ear" formation, jeopardizing anastomotic healing. By improving stapler application and visualization, the transanal approach reduces these risks. Furthermore, the single-stapled technique eliminates the additional stapler line, which is often associated with higher rates of leakage and poor healing (7, 8). Oncological safety is critical in rectal cancer surgery, particularly for low rectal tumors near the anal sphincter. Achieving clear distal and circumferential margins while preserving sphincter function is paramount. The transanal approach has demonstrated superior precision in achieving these outcomes. Recent studies indicate that this method ensures better distal margin clearance and CRM integrity, translating into improved survival rates and lower recurrence (9, 10). Anastomotic leakage is a significant complication of rectal cancer surgery, impacting morbidity, mortality, and quality of life. Transanal techniques have shown promise in reducing leakage rates by ensuring more uniform stapler application and precise alignment of the anastomosis. By addressing technical errors commonly associated with traditional methods, this approach enhances anastomotic safety, which is a critical determinant of postoperative recovery (11, 12). Functional outcomes remain an essential consideration, particularly in sphincter-preserving procedures. The transanal approach may offer advantages in preserving anorectal function by reducing pelvic trauma and enabling more precise anastomotic placement. Emerging evidence suggests that this technique contributes to better continence and defecatory outcomes, along with reduced need for temporary diverting stomas, which significantly influence patient recovery and satisfaction (13, 14). However, the transanal transection and single-stapled anastomosis technique is not without limitations. It requires specialized surgical expertise and a steep learning curve, which can limit its widespread adoption. Moreover, its suitability is restricted in patients with extensive locally advanced tumors requiring radical resection. Proper patient selection and adherence to standardized protocols are crucial to ensuring its success and minimizing associated risks (15, 16). In this study, we aimed to investigate the rate of anastomotic leakage after using Transanl transection and single stapled anastomosis for distal rectal transection and anastomosis. 2. Methods 2.1. Study design and Population This prospective cohort study including patients with mid-low rectal cancer who are candidates for sphincter preserving surgery (Low Anterior Resection using TTSS). Our study was conducted in accordance with declarations of Helsinki. Ethical approval was obtained from the National Cancer Institute (NCI) committee. Written informed consent was obtained from every patient at the time of recruitment. 2.2. Inclusion and Exclusion criteria Eligible participants must be candidates for elective Low Anterior Resection performed via open, laparoscopic, or robotic approaches, provided they have signed an informed consent form. Individuals aged between 16 and 89 years were included, ensuring a broad age range while maintaining patient safety. All participants must have histologically confirmed mid or low rectal carcinoma, with the distal edge of the tumor located 4–10 cm from the anal verge. Additionally, patients with early-stage rectal cancer deemed suitable for upfront LAR, as well as those with stage II or III disease who have completed neoadjuvant multimodality treatment, were considered eligible. The study also accommodates patients with potentially resectable metastatic rectal carcinoma limited to the liver. To ensure optimal surgical outcomes, participants must have an ASA (American Society of Anesthesiologists) performance status of 1 or 2, reflecting a satisfactory preoperative physical condition. Conversely, several exclusion criteria were applied to ensure patient safety and study integrity. Patients with locally advanced rectal cancer that invades adjacent organs (T4) were excluded, as are those requiring emergency interventions for perforated or obstructed rectal cancer. Individuals with an ASA performance status of 3 or 4, indicating significant systemic disease, were not eligible. Furthermore, patients undergoing total mesorectal excision with handsewn anastomosis were excluded from the study to maintain consistency in procedural techniques. Concurrent or prior pelvic malignancies and absolute contraindications to general anesthesia also constitute exclusion criteria, as these factors may compromise the safety and reliability of study outcomes. 2.3. Data collection 2.3.1. Preoperative assessment Complete medical history, clinical examination, and routine laboratory investigations were done for every patient at the time of recruitment. Distance of the tumor from anal verge was measured by per pelvic MRI and DRE. Preoperative tumor staging was done according to AJCC staging (17). 2.3.2. Intraoperative assessment Intraoperatively, the following data were collected, surgical approach (Open, laparoscopic, or robotic), operative time, ligation of inferior mesenteric artery (High or low), method of specimen extraction, diameter of circular stapler used, instruments used for field exposure, operative complications, and estimated blood loss. 2.3.3. Surgical technique Patients were positioned in a lithotomy position under general anesthesia. Standard prophylactic measures, including antibiotic administration and venous thromboembolism prevention, were implemented. The abdomen and perineum were prepped and draped to facilitate simultaneous abdominal and perineal access. The abdominal phase was performed laparoscopically, robotically, or through an open approach, depending on patient-specific factors and surgeon expertise. Following mobilization of the sigmoid colon and rectum, high vascular ligation of the inferior mesenteric artery and vein was performed to ensure adequate oncological margins and optimal lymphadenectomy. The rectum was mobilized down to the level of the pelvic floor with careful preservation of the autonomic nerves to maintain urogenital function. The transanal phase was started once the rectum was mobilized to the planned level of transection. A Lone Star retractor was utilized to expose the anal canal and distal rectum. The distal margin of the tumor was marked under direct visualization, ensuring a minimum distance of 1–2 cm from the tumor edge. An endoscopic linear stapler was introduced transanally and positioned at the marked site (Fig. 1 ). The rectum was transected in a single stapling maneuver, ensuring a clean distal margin and avoiding multiple staple lines that may compromise anastomotic integrity. Following transanal transection, the proximal bowel was prepared for anastomosis. The anvil of a circular stapler was secured to the proximal bowel, ensuring alignment and tension-free positioning. The stapler was introduced transanally, and the anastomosis was performed with precision to create a single, circular staple line. This technique minimizes the risks associated with overlapping staple lines, reducing the likelihood of anastomotic leakage and improving postoperative outcomes. The anastomosis was checked for integrity using a leak test with air insufflation and saline irrigation. The procedure was completed with the placement of a diverting loop ileostomy if indicated, based on patient risk factors and intraoperative findings. Hemostasis was ensured, and the operative field was irrigated thoroughly. A drain was placed near the anastomosis for monitoring purposes. The abdomen was closed in layers, and the patient was transferred to the recovery unit. 2.3.4. Postoperative assessment After surgery, nasogastric tubes have not been used, and the urinary catheters were removed on postoperative day 1. Early mobilization was encouraged with early start of oral intake. De-functioning temporary loop ileostomy was done for all cases. The following data were collected postoperatively as a secondary outcome, histopathological assessment, length of hospital stay, postoperative ileus, closure ileostomy and interval between resection surgery and ileostomy closure, thirty-day complications, anastomotic leak diagnosis, presence of incontinence and its degree, and presence of stenosis and its management. 2.3.5. Assessment of Anastomotic Leakage The evaluation of anastomotic leakage was conducted using a multi-modal approach. Serial measurements of serum C-reactive protein (CRP) levels were obtained on the first, third, and fifth postoperative days to identify potential inflammatory responses indicative of leakage. Clinical signs such as fever, abdominal pain, localized peritonitis, and systemic manifestations of sepsis were meticulously monitored to detect any indication of AL. When clinically warranted, radiological evidence of leakage was sought using contrast-enhanced computed tomography (CT), which remains a definitive tool for confirming the presence and extent of anastomotic complications. 2.3.6. Assessment of Continence Postoperative continence was systematically evaluated following ileostomy closure, employing the Kirwan grading system (18). This validated classification method provides a standardized framework for assessing bowel control by categorizing continence into distinct grades. This approach ensures objective evaluation, enabling consistent comparisons and assessments across patient populations. 2.4. Statistical analysis Data were coded and entered using the statistical package for the Social Sciences (SPSS) version 28 (IBM Corp., Armonk, NY, USA). Data was summarized using mean, standard deviation, median, minimum, and maximum in quantitative data and using frequency (count) and relative frequency (percentage) for categorical data. 3. Results A total number of 23 cases were included in our study. The mean age of our patients at the time of surgery was 48.87 ± 15.91. The mean body mass index (BMI) was 25.22 ± 4.86 Kg/m 2 ranging from 18 to 35 (Table 1 ). Regarding the gender distribution, 13 patients were males (56.5%) while 10 patients were females (43.5%). Of our 23 cases, 13 patients have no medical comorbidities (56.5%), 4 patients are diabetic, 2 patients are hypertensive, and 4 patients are diabetic hypertensive. Regarding American Society of Anesthesiologists (ASA) class, 13 patients are ASA class I (56.5%), 9 patients are ASA class II (39.1%) and 1 patient is ASA III (4.3%). According to the past surgical history, four patients had previous abdominal surgery (17.4%) while 6 patients were smokers (26.1%) (Table 2 ). Table 1 Age and BMI of the studied patients. Variables Mean SD Median Minimum Maximum Age (Years) 48.87 15.91 47.00 19.00 89.00 BMI (Kg/m 2 ) 25.22 4.86 25.00 18.00 35.00 Table 2 Clinical Characteristics of the studied patients. Count % Sex Male 13 56.5% Female 10 43.5% Medical Comorbidities DM 4 17.4% Hypertension 2 8.7% DM, Hypertension 4 17.4% Medically free 13 56.5% ASA score ASA I 13 56.5% ASA II 9 39.1% ASA III 1 4.3% Previous Abdominal Surgeries Yes 4 17.4% No 19 82.6% Smoker Yes 6 26.1% No 17 73.9% In terms of the tumor characteristics, the initial staging was T3 in 21 patients (91.3%), and T2 in 2 patients (8.7%). Fourteen patients were initially N1 (60.9%), while 3 patients were N2 (13%). Six patients were staged as N0 (26.1%) prior to start of treatment. Seventeen patients were initially in stage III (73.9%), while 6 patients were in stage II (26.1%). All patients received a long course of chemoradiation with 6 patients having complete clinical response (26.1%) and 15 patients with partial tumor response (65.2%). Only 2 cases (8.7%) showed no response to treatment on preoperative imaging and clinical evaluation (Table 3 ). Table 3 Tumor Characteristics and Preoperative data of the studied patients. Count % Initial T stage T2 2 8.7% T3 21 91.3% Initial N stage N0 6 26.1% N1 14 60.9% N2 3 13.0% Initial AJCC stage Stage II 6 26.1% Stage III 17 73.9% Neodjuvant chemoradiation protocol Long course 23 100.0% Response to neoadjuvant chemoradiation (Pre) Complete response 6 26.1% Partial response 15 65.2% No response 2 8.7% Distance of tumor from the anal verge (As defined by MRI & digital rectal examination) ranged from 4 to 8 centimeters with an average of 5.87 ± 1.14. The average duration between the end of radiation therapy and surgical procedure is 8.3 ± 1.14 weeks ranging from 6.4 to 10.7 weeks. The average postoperative follow up period for our patients is 16.45 ± 7.64 months (Table 4 ). Table 4 Tumor Characteristics and Preoperative data of the studied patients. Mean SD Median Minimum Maximum Distance of the tumor from anal verge (cm) 5.87 1.14 6.00 4.00 8.00 Interval between End of neoadjuvant therapy surgery (weeks) 8.30 1.14 8.30 6.40 10.70 Follow up period (months) 16.45 7.64 17.70 1.10 25.80 As regards the operative data, of our 23 cases, 21 patients had the procedure laparoscopically (91.3%) with no cases converted to open surgery. 2 cases (8.7%) had an initial open approach. High IMA ligation was performed in 13 cases (56.5%) while 10 cases had a low tie (43.5%). The average operative time for the whole procedure is 287.83 ± 38.70 minutes. The shortest and the longest cases took 240 and 390 minutes respectively. Performing the trans-anal part of the procedure (Transection and anastomosis) took 40 to 90 minutes to perform. The average time is 57.17 ± 16.91 minutes. Circular staplers were used for performing a single stapled anastomosis with size range from 29 to 33 mm in diameter according to surgeon’s preference and size availability. Size 31 mm was the most frequently used (in 12 cases representing 52.17%). Estimated blood loss during the whole procedure is 195.65 ± 82.45 ml in average ranging from 50 to 300 ml. For operative field exposure during trans-anal part of the procedure, we used the ideal setup (in the form of Lone-Star retractor and cylindrical trunk anoscope) in 15 patients (65.2%). A Lone-star® retractor with retraction sutures were used in 2 cases representing 8.7%, Lange beck retractors and retraction sutures were used in 2 cases (8.7%). Cylindrical anoscope with retraction sutures were used in 4 patients (17.4%). The specimen was extracted trans-anally in all cases. No adverse intraoperative major events occurred during the 23 procedures. No conversion to open surgery in laparoscopic cases. Defunctioning temporary ileostomy was performed in all cases (Table 5 a, b). Table 5 a : Operative data of the studied patients. Mean SD Median Minimum Maximum Overall Operative time (minutes) 287.83 38.70 280.00 240.00 390.00 Time of trans-anal part (minutes) 57.17 16.91 50.00 40.00 90.00 Diameter of circular stapler used 30.48 1.24 31.00 29.00 33.00 Estimated blood loss (ml) 195.65 82.45 200.00 50.00 300.00 Table 5 b : Operative data of the studied patients. Count % Surgical approach Laparoscopic 21 91.3% Open 2 8.7% Conversion to open (in minimally invasive cases) N/A 2 8.7% No 21 91.3% Ligation of IMA Low 10 43.5% High 13 56.5% Method of specimen extraction (for minimally invasive cases) Transanal 23 100.0% Instruments used for operative field exposure Retraction sutures, Langenbeck retractors 2 8.7% Lone-Star retractor, Retraction sutures 2 8.7% Lone-Star retractor, Cylindrical anoscope 15 65.2% Cylindrical anoscope, Retraction sutures 4 17.4% Intra-Operative complications No 23 100.0% Temporary ileostomy Yes 23 100.0% As regards the postoperative sequelae and complications, We calculated 30-day complication rate after TTSS cases. 19 patients had uneventful smooth postoperative course, while 4 patients developed postoperative events (17.4%). Those four patients had grade I Clavien-Dindo complications and they didn’t require radiological, endoscopic, or surgical intervention. Among those four patients, two cases developed postoperative wound infection, one case developed minor anastomotic leakage and one case developed atrial fibrillation which necessitated ICU admission for one week to control AF. Anastomotic leakage (AL) was detected in one case (4.3%). The case was a 60-year-old diabetic lady with locally advanced rectal cancer T3 N2 with partial response to preoperative chemoradiation. The tumor was 6 cm from the anal verge. The procedure was performed smoothly without intraoperative events. Anastomotic leak was diagnosed in postoperative day 4 when the patient had turbid drain output with ileus and low-grade fever. The patient was managed conservatively via nutritional support and electrolyte replacement. Patient was discharged on postoperative day 7 and have done well. She had her ileostomy closed 5 months after resection surgery after checking healing of rectal anastomosis using double contrast study. Six patients developed postoperative fever higher than 37.5 degrees representing 26.1% of our study population, while four patients developed postoperative paralytic ileus lasting more than 3 days (17.4%). The average duration of hospital stay for our patients is 6.17 ± 2.15 days ranging from 4 to 14 days. Of our 23 cases, 3 patients developed postoperative anastomotic stricture (13%). Two of those patients had their ileostomy closed successfully after stricture correction through repeated endoscopic and manual dilatation. The third patient is still having sessions of endoscopic dilatation. Temporary loop ileostomy was performed for all cases for defunctioning the anastomosis. Twenty cases had their ileostomy closed (87%). The average period between primary surgery and stoma closure is 5.32 ± 3.22 months ranging from 1 month to 17 months after primary surgery. Three cases didn’t have their stoma closed yet (13%), two of them had their primary surgery within last two months (at the date of data analysis) while the third case is undergoing repeated dilatation for anastomotic stricture. Assessment of continence was done after ileostomy closure using simple Kirwan scoring. Of our 20 patients who had their ileostomy closed, 17 patients had complete continence (85%), while two patients were incontinent to gases (10%). One patient had minor occasional minor soiling (5%). Patients with incontinence showed gradual improvement of their continence score over time (Table 6 a, b). Table 6 a : Postoperative data of the studied patients. Count % 30-day complications Yes 4 17.4% No 19 82.6% Postoperative fever Yes 6 26.1% No 17 73.9% Postoperative ileus Yes 4 17.4% No 19 82.6% Closure of ileostomy Yes 20 87.0% No 3 13.0% Anastomotic leakage Yes 1 4.3% No 22 95.7% Postoperative complications Wound infection 2 8.7% Minor leak 1 4.3% AF 1 4.3% No 19 82.6% Clavien-Dindo grade for post operative complications Grade I 4 17.4% No complication 19 82.6% Anastomotic stricture Yes 3 13.0% No 20 87.0% Postoperative incontinence (Kirwan Grading) (n = 20) Grade 1 (Perfect continence) 17 85.0% Grade 2 (Incontinence to flatus) 2 10% Grade 3 (occasional minor soiling) 1 5% Table 6 b : Postoperative data of the studied patients. Mean SD Median Minimum Maximum Hospital stays (days) 6.17 2.15 6.00 4.00 14.00 Time to ileostomy closure (Months) 5.32 3.22 4.50 1.00 17.00 According to the pathological data of the patients, of our 23 involved cases, 6 patients had pathological complete response to neoadjuvant treatment (26.1%), 10 patients had stage I disease (43.5%), 4 patients had stage II disease (17.4%) and 3 patients had stage III disease (13%). Regarding T stage, 6 of our patients had no residual tumor as they had pathological complete response (26.1%), 4 patients had T1 tumor (17.4%), 8 patients had T2 tumor (34.8%), while 5 patients had T3 tumor (21.7%). Regarding N stage, most cases had no pathologically involved lymph nodes (20 cases representing 87%), while 2 patients had involved one to three LNs (N1) representing 8.7%. One patient had more than three positive LNs (N2) representing 4.3%. The average number of identified LNs (whether involved or not) in surgical specimen is 9.13 ± 3.68 ranging from 3 to 14 LNs. Six patients had complete response to treatment (26.1%), 2 patients had near complete response (8.7%), 13 patients had partial therapy response (56.5%), while two patients had no response to treatment (8.7%). All cases had clear distal margin. The distal tissue donut (a ring-shaped piece of large bowel from a circular end-to-end stapling device) was separately examined and was negative for tumor involvement in all cases. Distal margin was 1.76 ± 0.95 cm in average. The least distal margin was 0.2 cm, while the widest was 3 cm. All cases had a clear circumferential radial margin. The least CRM was documented for every specimen. The average least CRM for our cases is 1.4 ± 0.61 cm ranging from 0.3 cm to 2.5 cm (Table 7 a, b). Table 7 a : Pathological data of the studied patients Count % T (pathological) T0y 6 26.1% T1 4 17.4% T2 8 34.8% T3 5 21.7% N (pathological) N0 20 87.0% N1 2 8.7% N2 1 4.3% AJCC stage (pathological) Stage 0 6 26.1% Stage I 10 43.5% Stage II 4 17.4% Stage III 3 13.0% Response to neoadjuvant treatment According to modified Ryan Scheme 0 (Complete response) 6 26.1% 1 (Near complete response) 2 8.7% 2 (Partial response) 13 56.5% 3 (No response) 2 8.7% Distal Margin status Negative 23 100.0% Infiltrated distal Doughnuts of circular stapler No 23 100.0% Circumferential margin status Negative 23 100.0% Table 7 b : Pathological data of the studied patients Mean SD Median Minimum Maximum Distal margin from tumor edge (cm) 1.76 0.95 2.00 0.20 3.00 Total number of extracted LNs 9.13 3.68 9.00 3.00 14.00 Least CRM (cm) 1.40 0.61 1.20 0.30 2.50 4. Discussion Rectal cancer remains a significant global health challenge, necessitating continuous advancements in surgical techniques to optimize oncological and functional outcomes. Low anterior resection is the preferred sphincter-preserving procedure for mid and low rectal tumors, yet achieving a safe and reliable anastomosis remains a critical concern, especially given the risk of anastomotic leakage. Conventional double-stapled techniques have been widely employed; however, they are associated with technical difficulties and potential complications, particularly in patients with a narrow pelvis or ultra-low tumors. Transanal transection and single-stapled anastomosis is an emerging technique designed to enhance distal rectum transection precision and improve anastomotic security. By utilizing direct transanal visualization and reducing the reliance on transabdominal access, TTSS facilitates optimal distal margin acquisition, particularly for low rectal tumors (19). This study investigates the rate of anastomotic leakage following TTSS and evaluates its feasibility, safety, and short-term outcomes in patients undergoing LAR for rectal cancer. Additionally, we aimed to evaluate the oncological adequacy and feasibility of this technique, particularly in addressing the challenges associated with distal rectal transection. AL is one of the most critical complications following rectal cancer surgery. The TTSS technique minimizes ischemic stress by avoiding multiple staple firings, thereby reducing the risk of AL. The precise transanal transection also allows for better vascularization at the anastomotic site. Our study showed that, the anastomotic leakage rate was 4.3% (1 out of 23 patients), which was managed conservatively. A systematic review reported AL rates of 6.8% in transanal total mesorectal excision (taTME) procedures, suggesting our findings are within the expected range (20). Another meta-analysis found no significant difference in AL rates between taTME and laparoscopic TME (LaTME), indicating comparable outcomes between techniques (21). The oncological effectiveness of TTSS is evident in its high rate of negative margins and complete responses to neoadjuvant treatment. The direct transanal visualization ensures precise distal margin determination, which is crucial for local tumor control. In our study, pathological complete response was observed in 26.1% of cases, while 87% had no lymph node involvement postoperatively. Studies have reported positive circumferential resection margin (CRM) rates of 3.9% in taTME procedures, indicating favorable oncological outcomes (22). In Hajibandeh’s meta-analysis, they found that taTME was associated with a lower rate of positive CRM (OR 0.67, P = 0.04), supporting the oncological efficacy of the transanal approach (21). TTSS allows for controlled distal rectal transection, which may contribute to slightly prolonged operative times but offers precision in anastomotic construction. The moderate blood loss is likely attributed to meticulous dissection and controlled hemostasis during the transanal phase. In our study, the average operative time was 287.83 ± 38.70 minutes, and the estimated blood loss was 195.65 ± 82.45 ml. Our operative time was comparable to studies on taTME, which report times ranging from 250 to 320 minutes (19). Traditional double-stapled techniques often report shorter operative times but may compromise distal margin control (23). The TTSS technique minimizes intraoperative trauma, reducing severe complications. The observed complications were mostly minor, including wound infections and transient postoperative ileus. In our study, the 30-day complication rate was 17.4%, with no major complications requiring surgical re-intervention. Our overall complication rate is lower than some studies on conventional LAR, which report rates between 20% and 30% (24). Studies on transanal techniques show similar or slightly lower complication rates, supporting TTSS as a feasible approach (5). The absence of major complications in our cohort highlights the safety profile of TTSS, though larger studies are needed to confirm these findings. Stricture formation is a known risk in rectal surgery, potentially influenced by ischemia at the anastomotic site. The single-stapled approach may contribute to localized scarring due to altered tissue tension. Anastomotic strictures occurred in 13% of cases, requiring endoscopic dilation in three patients. Our stricture rate is slightly higher than the 7–10% reported for double-stapled techniques (23). taTME studies report stricture rates between 5% and 15%, placing our findings within the expected range (6). Further studies are needed to identify factors contributing to stricture formation in TTSS patients. TTSS preserves sphincter function by avoiding excessive manipulation of the distal rectum. The relatively high continence rates suggest a favorable functional outcome. Of the 20 patients who underwent ileostomy closure, 85% had complete continence, while 10% were incontinent to gases, and 5% had minor soiling. Our continence rates are comparable to studies on sphincter-preserving techniques, which report complete continence in 80–90% of cases (11). Some studies suggest that transanal approaches may increase the risk of low anterior resection syndrome (LARS), though our study did not specifically assess this (24). The favorable pathological outcomes observed in our study, including high rates of pathological complete response, early-stage disease, and clear resection margins, have favorable implications for long-term prognosis and disease control in patients undergoing TTSS for rectal cancer. These findings support the role of TTSS as a safe and effective surgical approach in achieving oncological outcomes. Furthermore, the meticulous surgical technique employed in TTSS, coupled with clear resection margins and favorable tumor characteristics, underscores the oncological adequacy and safety of this approach in achieving disease control and reducing the risk of local recurrence. The low incidence of postoperative complications, including anastomotic leakage and anastomotic stricture, further supports the role of TTSS as a safe and effective surgical modality, offering potential advantages in terms of reduced morbidity, shorter hospital stays, and improved quality of life for patients undergoing rectal cancer surgery. This study has multiple limitations, including its single-center, non-comparative methodology and a rather modest sample size. Comprehensive, multicenter studies with prolonged follow-up are essential to more accurately evaluate the long-term oncological and functional outcomes of TTSS in rectal cancer. Randomized trials comparing TTSS to traditional procedures are necessary to validate its safety, effectiveness, and oncologic equivalency. Notwithstanding these constraints, our pathology findings provide significant insights into tumor behavior and surgical outcomes, affirming TTSS as a potential strategy in the multidisciplinary management of rectal cancer. Additional studies is required to enhance patient selection and improve long-term outcomes. 5. Conclusion Our findings support TTSS as a safe and effective surgical approach in rectal cancer management, offering favorable oncological outcomes and low complication rates. The technique's versatility, compatibility with various surgical approaches, and potential cost savings underscore its utility in contemporary surgical practice Declarations Ethical approval and consent to participate The Local Ethics Committee of Scientific Research, National Cancer Institute committee, approved the study. Informed consent was obtained from each patient before data collection, aim and methodology of this study were explained to the selected subjects, all data, which were obtained from the present study, were in private consideration and for scientific purposes only. Consent for Publication Consent to publish patients’ data was obtained Funding Not applicable Author Contribution A.H. and H.F. conceptualized and designed the study. M.A.A. performed the surgical procedures and collected the data. A.M.M. conducted the data analysis and interpretation. A.H. and H.F. wrote the main manuscript text, while M.A.A. and A.M.M. prepared the tables and figures. All authors reviewed and approved the final version of the manuscript. Data Availability Sequence data that support the findings of this study are available upon request from the Editors. References Heald RJ, Moran BJ, Ryall RD, et al. Total mesorectal excision: an historical perspective. Arch Surg. 1998;133(8):894–899. doi:10.1001/archsurg.133.8.894 Gagliardi G, Thompson MR. The challenges of achieving complete rectal cancer resection. Dis Colon Rectum. 2003;46(8):1151–1156. doi:10.1097/01.DCR.0000081546.83963.6A Sylla P, Rattner DW, Delgado S, Lacy AM. Transanal, minimally invasive surgery for rectal cancer. Ann Surg. 2010;251(6):954–960. doi:10.1097/SLA.0b013e3181d96981 Atallah S, Albert M, Larach S. Transanal minimally invasive surgery: a technique for excision of rectal tumors. Surg Endosc. 2010;24(9):2200–2205. doi:10.1007/s00464-010-0917-6 van Oostendorp SE, Belgers E, Gosselink MP, et al. Transanal total mesorectal excision (TaTME): short-term outcomes of 100 consecutive cases in a teaching hospital. Ann Surg. 2020;271(3):585–592. doi:10.1097/SLA.0000000000003147 Denost Q, Loughlin P, Chevalier R, et al. Transanal versus abdominal stapling of low rectal anastomoses: a multicenter randomized trial. Ann Surg. 2011;254(5):749–757. doi:10.1097/SLA.0b013e3182365145 Lelong B, Meillat H, Zemmour C, et al. Short- and long-term outcomes after transanal versus laparoscopic total mesorectal excision for rectal cancer: a case-matched study. JAMA Surg. 2017;152(3):234–242. doi:10.1001/jamasurg.2016.4672 Ota DM, Jacobs DO. The use of stapling instruments in colorectal surgery. Dis Colon Rectum. 1981;24(4):251–255. doi:10.1007/BF02588147 Stevenson ARL, Solomon MJ, Brown CS, et al. Transanal total mesorectal excision: an international registry. JAMA. 2019;321(20):2047–2058. doi:10.1001/jama.2019.3864 van der Valk MJM, Schuit E, Berbée M, et al. Tailored treatment for rectal cancer: a review of the evidence. J Gastrointest Oncol. 2020;11(5):635–646. doi:10.21037/jgo-20-208 Rullier E, Laurent C, Garrelon JL, et al. Impact of distal margin on local recurrence after sphincter-preserving resection for rectal cancer. Ann Surg. 2005;241(3):465–469. doi:10.1097/01.sla.0000157132.72418.4a Bordeianou L, Maguire LH, Alavi K. Sphincter-preserving techniques for rectal cancer. J Am Coll Surg. 2013;216(1):44–51. doi:10.1016/j.jamcollsurg.2012.09.016 Akagi T, Inomata M, Minagawa N, et al. Functional outcomes of transanal total mesorectal excision for rectal cancer. Dis Colon Rectum. 2018;61(6):633–639. doi:10.1097/DCR.0000000000001087 Marks JH, Nassif GJ, Schoonyoung HP, et al. Transanal minimally invasive surgery for early rectal cancer: functional and oncologic outcomes. Surg Endosc. 2020;34(1):404–410. doi:10.1007/s00464-019-06714-6 Sylla P, Knol JJ, D’Andrea AP, et al. Current status of transanal total mesorectal excision for rectal cancer. Ann Surg. 2015;261(2):221–229. doi:10.1097/SLA.0000000000000867 Quirke P, Steele R, Monson J, et al. Effect of quality of surgery on outcomes in rectal cancer. Lancet Oncol. 2009;10(11):1076–1085. doi:10.1016/S1470-2045(09)70288-3 Amin MB, Greene FL, Edge SB, Compton CC, Gershenwald JE, Brookland RK, Meyer L, Gress DM, Byrd DR, Winchester DP. The Eighth Edition AJCC Cancer Staging Manual: Continuing to build a bridge from a population-based to a more "personalized" approach to cancer staging. CA Cancer J Clin. 2017 Mar;67(2):93–99. doi: 10.3322/caac.21388. Epub 2017 Jan 17. Eldamshety O, Kotb S, Khater A, Roshdy S, Elashry M, Zahi MS, Elkalla HMHR, Elnahas W, Farouk O, Fathi A, Senbel A, Hamed EE, et al. Early and Late Functional Outcomes of Anal Sphincter-Sparing Procedures With Total Mesorectal Excision for Anorectal Adenocarcinoma. Ann Coloproctol. 2020 Jul;36(3):148–154. doi: 10.3393/ac.2018.07.19 Detering, R. A., et al. (2021). "Operative Time and Outcomes in Transanal Total Mesorectal Excision: A Multicenter Analysis." Surgical Endoscopy, 35(8), 4125–4134. An Y, Roodbeen SX, Talboom K, Tanis PJ, Bemelman WA, Hompes R. A systematic review and meta-analysis on complications of transanal total mesorectal excision. Colorectal Dis. 2021 Oct;23(10):2527–2538. doi: 10.1111/codi.15792. Hajibandeh S, Hajibandeh S, Eltair M, George AT, Thumbe V, Torrance AW, Budhoo M, Joy H, Peravali R. Meta-analysis of transanal total mesorectal excision versus laparoscopic total mesorectal excision in management of rectal cancer. Int J Colorectal Dis. 2020 Apr;35(4):575–593. doi: 10.1007/s00384-020-03545-7. Gachabayov M, Tulina I, Bergamaschi R, Tsarkov P. Does transanal total mesorectal excision of rectal cancer improve histopathology metrics and/or complication rates? A meta-analysis. Surg Oncol. 2019 Sep;30:47–51. doi: 10.1016/j.suronc.2019.05.012. Larsen, S. G., et al. (2020). "Surgical Outcomes in Single vs. Double-Stapled Techniques." European Journal of Surgical Oncology, 46(11), 2068–2075. Schiffmann, L. M., et al. (2021). "Postoperative Complications in Laparoscopic vs. Transanal Techniques." JAMA Surgery, 156(2), 139–146. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 03 Jul, 2025 Reviewers agreed at journal 24 Jun, 2025 Reviewers invited by journal 13 Jun, 2025 Editor assigned by journal 09 Jun, 2025 Submission checks completed at journal 09 Jun, 2025 First submitted to journal 31 May, 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-6792092","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":470976269,"identity":"91d7041f-ac57-48a1-82f8-8592f9fcaf87","order_by":0,"name":"Ayman Hanafy","email":"data:image/png;base64,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","orcid":"","institution":"National Cancer Institute, Cairo University","correspondingAuthor":true,"prefix":"","firstName":"Ayman","middleName":"","lastName":"Hanafy","suffix":""},{"id":470976272,"identity":"da1bfc78-8e23-43e3-93a3-4313017d0b0b","order_by":1,"name":"Haitham Fekry","email":"","orcid":"","institution":"National Cancer Institute, Cairo University","correspondingAuthor":false,"prefix":"","firstName":"Haitham","middleName":"","lastName":"Fekry","suffix":""},{"id":470976273,"identity":"03f2caba-c617-4d5c-89df-9518788a896a","order_by":2,"name":"Muhammad Adel Ali","email":"","orcid":"","institution":"National Cancer Institute, Cairo University","correspondingAuthor":false,"prefix":"","firstName":"Muhammad","middleName":"Adel","lastName":"Ali","suffix":""},{"id":470976277,"identity":"4eeaab84-c72f-4b38-8419-08da3900bd3f","order_by":3,"name":"Ahmed Mostafa Mahmoud","email":"","orcid":"","institution":"National Cancer Institute, Cairo University","correspondingAuthor":false,"prefix":"","firstName":"Ahmed","middleName":"Mostafa","lastName":"Mahmoud","suffix":""}],"badges":[],"createdAt":"2025-05-31 16:38:06","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6792092/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6792092/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":84859872,"identity":"db879625-99cd-4b32-b1db-7bae9bc1865e","added_by":"auto","created_at":"2025-06-18 06:42:30","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":461632,"visible":true,"origin":"","legend":"\u003cp\u003eOperative photos of field setup.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6792092/v1/26351974e12bb5f9ddc197ab.png"},{"id":84861115,"identity":"1ce45bab-c188-4846-a5ea-676495412747","added_by":"auto","created_at":"2025-06-18 06:58:31","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2458424,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6792092/v1/d0d3316e-8a00-4da7-8411-b00f532998e5.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Transanal Transection and Single Stapled Anastomosis as A Reliable Technique for Distal Rectum Transection in Patients Undergoing Low Anterior Resection for Rectal Cancer ","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eRectal cancer is a major global health concern, ranking as the third most prevalent cancer and the second leading cause of cancer-related deaths worldwide. Advances in surgical and multimodal treatment strategies have improved outcomes for patients, yet low anterior resection (LAR) with total mesorectal excision (TME) remains the cornerstone of treatment for mid and low rectal cancers. The technical challenges of distal rectum transection and anastomosis, particularly in cases involving a narrow pelvis, continue to complicate surgical outcomes. Emerging techniques like transanal transection with single-stapled anastomosis offer solutions to these challenges by enhancing surgical precision and reducing postoperative complications (1, 2).\u003c/p\u003e \u003cp\u003eThe concept of TME introduced by Heald et al. emphasized complete mesorectal excision to minimize local recurrence and optimize survival rates. However, achieving a clear distal resection margin and a sound anastomosis remains challenging, especially in low rectal tumors. Traditional transabdominal stapling techniques are often limited by poor visibility and difficult stapler placement in a confined pelvic space, increasing the risk of incomplete margins and technical complications. The transanal approach, by contrast, facilitates direct access and improved visualization, making it a promising alternative for addressing distal rectal tumors (3, 4).\u003c/p\u003e \u003cp\u003eTransanal transection combined with single-stapled anastomosis offers a more reliable method for managing distal rectal cancer. This technique enables precise rectal transection and reduces the need for multiple stapler firings, minimizing the risk of technical errors that could compromise anastomotic integrity. Studies have shown that transanal techniques enhance oncological outcomes by ensuring clear circumferential resection margins (CRM) and adequate distal resection margins, essential for reducing local recurrence rates (5, 6).\u003c/p\u003e \u003cp\u003eIn male patients, those with obesity, or individuals with narrow pelvises, the technical challenges of rectal surgery are magnified. Traditional approaches often result in \"dog-ear\" formation, jeopardizing anastomotic healing. By improving stapler application and visualization, the transanal approach reduces these risks. Furthermore, the single-stapled technique eliminates the additional stapler line, which is often associated with higher rates of leakage and poor healing (7, 8).\u003c/p\u003e \u003cp\u003eOncological safety is critical in rectal cancer surgery, particularly for low rectal tumors near the anal sphincter. Achieving clear distal and circumferential margins while preserving sphincter function is paramount. The transanal approach has demonstrated superior precision in achieving these outcomes. Recent studies indicate that this method ensures better distal margin clearance and CRM integrity, translating into improved survival rates and lower recurrence (9, 10).\u003c/p\u003e \u003cp\u003eAnastomotic leakage is a significant complication of rectal cancer surgery, impacting morbidity, mortality, and quality of life. Transanal techniques have shown promise in reducing leakage rates by ensuring more uniform stapler application and precise alignment of the anastomosis. By addressing technical errors commonly associated with traditional methods, this approach enhances anastomotic safety, which is a critical determinant of postoperative recovery (11, 12).\u003c/p\u003e \u003cp\u003eFunctional outcomes remain an essential consideration, particularly in sphincter-preserving procedures. The transanal approach may offer advantages in preserving anorectal function by reducing pelvic trauma and enabling more precise anastomotic placement. Emerging evidence suggests that this technique contributes to better continence and defecatory outcomes, along with reduced need for temporary diverting stomas, which significantly influence patient recovery and satisfaction (13, 14).\u003c/p\u003e \u003cp\u003eHowever, the transanal transection and single-stapled anastomosis technique is not without limitations. It requires specialized surgical expertise and a steep learning curve, which can limit its widespread adoption. Moreover, its suitability is restricted in patients with extensive locally advanced tumors requiring radical resection. Proper patient selection and adherence to standardized protocols are crucial to ensuring its success and minimizing associated risks (15, 16).\u003c/p\u003e \u003cp\u003eIn this study, we aimed to investigate the rate of anastomotic leakage after using Transanl transection and single stapled anastomosis for distal rectal transection and anastomosis.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1. Study design and Population\u003c/h2\u003e \u003cp\u003eThis prospective cohort study including patients with mid-low rectal cancer who are candidates for sphincter preserving surgery (Low Anterior Resection using TTSS). Our study was conducted in accordance with declarations of Helsinki. Ethical approval was obtained from the National Cancer Institute (NCI) committee. Written informed consent was obtained from every patient at the time of recruitment.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2. Inclusion and Exclusion criteria\u003c/h2\u003e \u003cp\u003e Eligible participants must be candidates for elective Low Anterior Resection performed via open, laparoscopic, or robotic approaches, provided they have signed an informed consent form. Individuals aged between 16 and 89 years were included, ensuring a broad age range while maintaining patient safety. All participants must have histologically confirmed mid or low rectal carcinoma, with the distal edge of the tumor located 4\u0026ndash;10 cm from the anal verge. Additionally, patients with early-stage rectal cancer deemed suitable for upfront LAR, as well as those with stage II or III disease who have completed neoadjuvant multimodality treatment, were considered eligible. The study also accommodates patients with potentially resectable metastatic rectal carcinoma limited to the liver. To ensure optimal surgical outcomes, participants must have an ASA (American Society of Anesthesiologists) performance status of 1 or 2, reflecting a satisfactory preoperative physical condition.\u003c/p\u003e \u003cp\u003eConversely, several exclusion criteria were applied to ensure patient safety and study integrity. Patients with locally advanced rectal cancer that invades adjacent organs (T4) were excluded, as are those requiring emergency interventions for perforated or obstructed rectal cancer. Individuals with an ASA performance status of 3 or 4, indicating significant systemic disease, were not eligible. Furthermore, patients undergoing total mesorectal excision with handsewn anastomosis were excluded from the study to maintain consistency in procedural techniques. Concurrent or prior pelvic malignancies and absolute contraindications to general anesthesia also constitute exclusion criteria, as these factors may compromise the safety and reliability of study outcomes.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3. Data collection\u003c/h2\u003e \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003ch2\u003e2.3.1. Preoperative assessment\u003c/h2\u003e \u003cp\u003eComplete medical history, clinical examination, and routine laboratory investigations were done for every patient at the time of recruitment. Distance of the tumor from anal verge was measured by per pelvic MRI and DRE. Preoperative tumor staging was done according to AJCC staging (17).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e \u003ch2\u003e2.3.2. Intraoperative assessment\u003c/h2\u003e \u003cp\u003eIntraoperatively, the following data were collected, surgical approach (Open, laparoscopic, or robotic), operative time, ligation of inferior mesenteric artery (High or low), method of specimen extraction, diameter of circular stapler used, instruments used for field exposure, operative complications, and estimated blood loss.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003e2.3.3. Surgical technique\u003c/h2\u003e \u003cp\u003ePatients were positioned in a lithotomy position under general anesthesia. Standard prophylactic measures, including antibiotic administration and venous thromboembolism prevention, were implemented. The abdomen and perineum were prepped and draped to facilitate simultaneous abdominal and perineal access.\u003c/p\u003e \u003cp\u003eThe abdominal phase was performed laparoscopically, robotically, or through an open approach, depending on patient-specific factors and surgeon expertise. Following mobilization of the sigmoid colon and rectum, high vascular ligation of the inferior mesenteric artery and vein was performed to ensure adequate oncological margins and optimal lymphadenectomy. The rectum was mobilized down to the level of the pelvic floor with careful preservation of the autonomic nerves to maintain urogenital function.\u003c/p\u003e \u003cp\u003eThe transanal phase was started once the rectum was mobilized to the planned level of transection. A Lone Star retractor was utilized to expose the anal canal and distal rectum. The distal margin of the tumor was marked under direct visualization, ensuring a minimum distance of 1\u0026ndash;2 cm from the tumor edge. An endoscopic linear stapler was introduced transanally and positioned at the marked site (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The rectum was transected in a single stapling maneuver, ensuring a clean distal margin and avoiding multiple staple lines that may compromise anastomotic integrity.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFollowing transanal transection, the proximal bowel was prepared for anastomosis. The anvil of a circular stapler was secured to the proximal bowel, ensuring alignment and tension-free positioning. The stapler was introduced transanally, and the anastomosis was performed with precision to create a single, circular staple line. This technique minimizes the risks associated with overlapping staple lines, reducing the likelihood of anastomotic leakage and improving postoperative outcomes. The anastomosis was checked for integrity using a leak test with air insufflation and saline irrigation.\u003c/p\u003e \u003cp\u003eThe procedure was completed with the placement of a diverting loop ileostomy if indicated, based on patient risk factors and intraoperative findings. Hemostasis was ensured, and the operative field was irrigated thoroughly. A drain was placed near the anastomosis for monitoring purposes. The abdomen was closed in layers, and the patient was transferred to the recovery unit.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003e2.3.4. Postoperative assessment\u003c/h2\u003e \u003cp\u003eAfter surgery, nasogastric tubes have not been used, and the urinary catheters were removed on postoperative day 1. Early mobilization was encouraged with early start of oral intake. De-functioning temporary loop ileostomy was done for all cases. The following data were collected postoperatively as a secondary outcome, histopathological assessment, length of hospital stay, postoperative ileus, closure ileostomy and interval between resection surgery and ileostomy closure, thirty-day complications, anastomotic leak diagnosis, presence of incontinence and its degree, and presence of stenosis and its management.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003e2.3.5. Assessment of Anastomotic Leakage\u003c/h2\u003e \u003cp\u003eThe evaluation of anastomotic leakage was conducted using a multi-modal approach. Serial measurements of serum C-reactive protein (CRP) levels were obtained on the first, third, and fifth postoperative days to identify potential inflammatory responses indicative of leakage. Clinical signs such as fever, abdominal pain, localized peritonitis, and systemic manifestations of sepsis were meticulously monitored to detect any indication of AL. When clinically warranted, radiological evidence of leakage was sought using contrast-enhanced computed tomography (CT), which remains a definitive tool for confirming the presence and extent of anastomotic complications.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section3\"\u003e \u003ch2\u003e2.3.6. Assessment of Continence\u003c/h2\u003e \u003cp\u003ePostoperative continence was systematically evaluated following ileostomy closure, employing the Kirwan grading system (18). This validated classification method provides a standardized framework for assessing bowel control by categorizing continence into distinct grades. This approach ensures objective evaluation, enabling consistent comparisons and assessments across patient populations.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e2.4. Statistical analysis\u003c/h2\u003e \u003cp\u003eData were coded and entered using the statistical package for the Social Sciences (SPSS) version 28 (IBM Corp., Armonk, NY, USA). Data was summarized using mean, standard deviation, median, minimum, and maximum in quantitative data and using frequency (count) and relative frequency (percentage) for categorical data.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003eA total number of 23 cases were included in our study. The mean age of our patients at the time of surgery was 48.87\u0026thinsp;\u0026plusmn;\u0026thinsp;15.91. The mean body mass index (BMI) was 25.22\u0026thinsp;\u0026plusmn;\u0026thinsp;4.86 Kg/m \u003csup\u003e2\u003c/sup\u003e ranging from 18 to 35 (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Regarding the gender distribution, 13 patients were males (56.5%) while 10 patients were females (43.5%). Of our 23 cases, 13 patients have no medical comorbidities (56.5%), 4 patients are diabetic, 2 patients are hypertensive, and 4 patients are diabetic hypertensive. Regarding American Society of Anesthesiologists (ASA) class, 13 patients are ASA class I (56.5%), 9 patients are ASA class II (39.1%) and 1 patient is ASA III (4.3%). According to the past surgical history, four patients had previous abdominal surgery (17.4%) while 6 patients were smokers (26.1%) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAge and BMI of the studied patients.\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=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMedian\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMinimum\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMaximum\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge (Years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e48.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e47.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e19.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e89.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBMI (Kg/m\u003c/b\u003e\u003csup\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e25.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e18.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e35.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\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\u003eClinical Characteristics of the studied patients.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCount\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eMale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e56.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eFemale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e43.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eMedical Comorbidities\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eDM\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e17.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eHypertension\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eDM, Hypertension\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e17.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eMedically free\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e56.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eASA score\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eASA I\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e56.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eASA II\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e39.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eASA III\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003ePrevious Abdominal Surgeries\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eYes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e17.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eNo\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e82.6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eSmoker\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eYes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e26.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eNo\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e73.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn terms of the tumor characteristics, the initial staging was T3 in 21 patients (91.3%), and T2 in 2 patients (8.7%). Fourteen patients were initially N1 (60.9%), while 3 patients were N2 (13%). Six patients were staged as N0 (26.1%) prior to start of treatment. Seventeen patients were initially in stage III (73.9%), while 6 patients were in stage II (26.1%). All patients received a long course of chemoradiation with 6 patients having complete clinical response (26.1%) and 15 patients with partial tumor response (65.2%). Only 2 cases (8.7%) showed no response to treatment on preoperative imaging and clinical evaluation (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\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\u003eTumor Characteristics and Preoperative data of the studied patients.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCount\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eInitial T stage\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eT2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eT3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e91.3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eInitial N stage\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eN0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e26.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eN1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e60.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eN2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eInitial AJCC stage\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eStage II\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e26.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eStage III\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e73.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNeodjuvant chemoradiation protocol\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eLong course\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eResponse to neoadjuvant chemoradiation (Pre)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eComplete response\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e26.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003ePartial response\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e65.2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eNo response\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eDistance of tumor from the anal verge (As defined by MRI \u0026amp; digital rectal examination) ranged from 4 to 8 centimeters with an average of 5.87\u0026thinsp;\u0026plusmn;\u0026thinsp;1.14. The average duration between the end of radiation therapy and surgical procedure is 8.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.14 weeks ranging from 6.4 to 10.7 weeks. The average postoperative follow up period for our patients is 16.45\u0026thinsp;\u0026plusmn;\u0026thinsp;7.64 months (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\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\u003eTumor Characteristics and Preoperative data of the studied patients.\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\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMedian\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMinimum\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMaximum\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDistance of the tumor from anal\u003c/p\u003e \u003cp\u003everge (cm)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.87\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.14\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.00\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.00\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8.00\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInterval between End of neoadjuvant therapy surgery\u003c/p\u003e \u003cp\u003e(weeks)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.30\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.14\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.30\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.40\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10.70\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFollow up period (months)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e17.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e25.80\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAs regards the operative data, of our 23 cases, 21 patients had the procedure laparoscopically (91.3%) with no cases converted to open surgery. 2 cases (8.7%) had an initial open approach. High IMA ligation was performed in 13 cases (56.5%) while 10 cases had a low tie (43.5%). The average operative time for the whole procedure is 287.83\u0026thinsp;\u0026plusmn;\u0026thinsp;38.70 minutes. The shortest and the longest cases took 240 and 390 minutes respectively. Performing the trans-anal part of the procedure (Transection and anastomosis) took 40 to 90 minutes to perform. The average time is 57.17\u0026thinsp;\u0026plusmn;\u0026thinsp;16.91 minutes. Circular staplers were used for performing a single stapled anastomosis with size range from 29 to 33 mm in diameter according to surgeon\u0026rsquo;s preference and size availability. Size 31 mm was the most frequently used (in 12 cases representing 52.17%). Estimated blood loss during the whole procedure is 195.65\u0026thinsp;\u0026plusmn;\u0026thinsp;82.45 ml in average ranging from 50 to 300 ml. For operative field exposure during trans-anal part of the procedure, we used the ideal setup (in the form of Lone-Star retractor and cylindrical trunk anoscope) in 15 patients (65.2%). A Lone-star\u0026reg; retractor with retraction sutures were used in 2 cases representing 8.7%, Lange beck retractors and retraction sutures were used in 2 cases (8.7%). Cylindrical anoscope with retraction sutures were used in 4 patients (17.4%). The specimen was extracted trans-anally in all cases. No adverse intraoperative major events occurred during the 23 procedures. No conversion to open surgery in laparoscopic cases. Defunctioning temporary ileostomy was performed in all cases (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e5\u003c/span\u003ea, b).\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\u003e\u003cb\u003ea\u003c/b\u003e: Operative data of the studied patients.\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\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMedian\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMinimum\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMaximum\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverall Operative time (minutes)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e287.83\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38.70\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e280.00\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e240.00\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e390.00\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime of trans-anal part (minutes)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57.17\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.91\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50.00\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e40.00\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e90.00\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDiameter of circular stapler used\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e29.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e33.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEstimated blood loss (ml)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e195.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e82.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e200.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e50.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e300.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003eb\u003c/b\u003e: Operative data of the studied patients.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCount\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eSurgical approach\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eLaparoscopic\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e91.3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eOpen\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eConversion to open (in minimally invasive cases)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eN/A\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eNo\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e91.3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eLigation of IMA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eLow\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e43.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eHigh\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e56.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMethod of specimen extraction (for minimally invasive\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003ecases)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eTransanal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eInstruments used for operative field exposure\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eRetraction sutures, Langenbeck retractors\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eLone-Star retractor, Retraction sutures\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eLone-Star retractor, Cylindrical anoscope\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e65.2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eCylindrical anoscope, Retraction sutures\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e17.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIntra-Operative complications\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eNo\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTemporary ileostomy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eYes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAs regards the postoperative sequelae and complications, We calculated 30-day complication rate after TTSS cases. 19 patients had uneventful smooth postoperative course, while 4 patients developed postoperative events (17.4%). Those four patients had grade I Clavien-Dindo complications and they didn\u0026rsquo;t require radiological, endoscopic, or surgical intervention. Among those four patients, two cases developed postoperative wound infection, one case developed minor anastomotic leakage and one case developed atrial fibrillation which necessitated ICU admission for one week to control AF. Anastomotic leakage (AL) was detected in one case (4.3%). The case was a 60-year-old diabetic lady with locally advanced rectal cancer T3 N2 with partial response to preoperative chemoradiation. The tumor was 6 cm from the anal verge. The procedure was performed smoothly without intraoperative events. Anastomotic leak was diagnosed in postoperative day 4 when the patient had turbid drain output with ileus and low-grade fever. The patient was managed conservatively via nutritional support and electrolyte replacement. Patient was discharged on postoperative day 7 and have done well. She had her ileostomy closed 5 months after resection surgery after checking healing of rectal anastomosis using double contrast study. Six patients developed postoperative fever higher than 37.5 degrees representing 26.1% of our study population, while four patients developed postoperative paralytic ileus lasting more than 3 days (17.4%). The average duration of hospital stay for our patients is 6.17\u0026thinsp;\u0026plusmn;\u0026thinsp;2.15 days ranging from 4 to 14 days. Of our 23 cases, 3 patients developed postoperative anastomotic stricture (13%). Two of those patients had their ileostomy closed successfully after stricture correction through repeated endoscopic and manual dilatation. The third patient is still having sessions of endoscopic dilatation. Temporary loop ileostomy was performed for all cases for defunctioning the anastomosis. Twenty cases had their ileostomy closed (87%). The average period between primary surgery and stoma closure is 5.32\u0026thinsp;\u0026plusmn;\u0026thinsp;3.22 months ranging from 1 month to 17 months after primary surgery. Three cases didn\u0026rsquo;t have their stoma closed yet (13%), two of them had their primary surgery within last two months (at the date of data analysis) while the third case is undergoing repeated dilatation for anastomotic stricture. Assessment of continence was done after ileostomy closure using simple Kirwan scoring. Of our 20 patients who had their ileostomy closed, 17 patients had complete continence (85%), while two patients were incontinent to gases (10%). One patient had minor occasional minor soiling (5%). Patients with incontinence showed gradual improvement of their continence score over time (Table\u0026nbsp;\u003cspan refid=\"Tab8\" class=\"InternalRef\"\u003e6\u003c/span\u003ea, b).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab7\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003ea\u003c/b\u003e: Postoperative data of the studied patients.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCount\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e30-day complications\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eYes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eNo\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e82.6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003ePostoperative fever\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eYes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eNo\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e73.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003ePostoperative ileus\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eYes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eNo\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e82.6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eClosure of ileostomy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eYes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e87.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eNo\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eAnastomotic leakage\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eYes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eNo\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003ePostoperative complications\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eWound infection\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eMinor leak\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eAF\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eNo\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e82.6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eClavien-Dindo grade for post operative complications\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eGrade I\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eNo complication\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e82.6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eAnastomotic stricture\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eYes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eNo\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e87.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003ePostoperative incontinence (Kirwan Grading)\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(n\u0026thinsp;=\u0026thinsp;20)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eGrade 1 (Perfect continence)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e85.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eGrade 2 (Incontinence to flatus)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eGrade 3 (occasional minor soiling)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab8\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003eb\u003c/b\u003e: Postoperative data of the studied patients.\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=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\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\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMedian\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMinimum\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMaximum\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHospital stays (days)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e14.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTime to ileostomy closure (Months)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e17.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAccording to the pathological data of the patients, of our 23 involved cases, 6 patients had pathological complete response to neoadjuvant treatment (26.1%), 10 patients had stage I disease (43.5%), 4 patients had stage II disease (17.4%) and 3 patients had stage III disease (13%). Regarding T stage, 6 of our patients had no residual tumor as they had pathological complete response (26.1%), 4 patients had T1 tumor (17.4%), 8 patients had T2 tumor (34.8%), while 5 patients had T3 tumor (21.7%). Regarding N stage, most cases had no pathologically involved lymph nodes (20 cases representing 87%), while 2 patients had involved one to three LNs (N1) representing 8.7%. One patient had more than three positive LNs (N2) representing 4.3%. The average number of identified LNs (whether involved or not) in surgical specimen is 9.13\u0026thinsp;\u0026plusmn;\u0026thinsp;3.68 ranging from 3 to 14 LNs. Six patients had complete response to treatment (26.1%), 2 patients had near complete response (8.7%), 13 patients had partial therapy response (56.5%), while two patients had no response to treatment (8.7%). All cases had clear distal margin. The distal tissue donut (a ring-shaped piece of large bowel from a circular end-to-end stapling device) was separately examined and was negative for tumor involvement in all cases. Distal margin was 1.76\u0026thinsp;\u0026plusmn;\u0026thinsp;0.95 cm in average. The least distal margin was 0.2 cm, while the widest was 3 cm. All cases had a clear circumferential radial margin. The least CRM was documented for every specimen. The average least CRM for our cases is 1.4\u0026thinsp;\u0026plusmn;\u0026thinsp;0.61 cm ranging from 0.3 cm to 2.5 cm (Table\u0026nbsp;\u003cspan refid=\"Tab10\" class=\"InternalRef\"\u003e7\u003c/span\u003ea, b).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab9\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003ea\u003c/b\u003e: Pathological data of the studied patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCount\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eT (pathological)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eT0y\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e26.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eT1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e17.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eT2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e34.8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eT3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e21.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eN (pathological)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eN0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e87.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eN1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eN2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eAJCC stage (pathological)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eStage 0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e26.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eStage I\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e43.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eStage II\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e17.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eStage III\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eResponse to neoadjuvant treatment According to modified Ryan Scheme\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e0 (Complete response)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e26.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e1 (Near complete response)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e2 (Partial response)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e56.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e3 (No response)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDistal Margin status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eNegative\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInfiltrated distal\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eDoughnuts of circular stapler\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eNo\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCircumferential margin status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eNegative\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab10\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003eb\u003c/b\u003e: Pathological data of the studied patients\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=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\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\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMedian\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMinimum\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMaximum\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDistal margin from tumor edge (cm)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal number of extracted LNs\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e14.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLeast CRM (cm)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2.50\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eRectal cancer remains a significant global health challenge, necessitating continuous advancements in surgical techniques to optimize oncological and functional outcomes. Low anterior resection is the preferred sphincter-preserving procedure for mid and low rectal tumors, yet achieving a safe and reliable anastomosis remains a critical concern, especially given the risk of anastomotic leakage. Conventional double-stapled techniques have been widely employed; however, they are associated with technical difficulties and potential complications, particularly in patients with a narrow pelvis or ultra-low tumors. Transanal transection and single-stapled anastomosis is an emerging technique designed to enhance distal rectum transection precision and improve anastomotic security. By utilizing direct transanal visualization and reducing the reliance on transabdominal access, TTSS facilitates optimal distal margin acquisition, particularly for low rectal tumors (19). This study investigates the rate of anastomotic leakage following TTSS and evaluates its feasibility, safety, and short-term outcomes in patients undergoing LAR for rectal cancer. Additionally, we aimed to evaluate the oncological adequacy and feasibility of this technique, particularly in addressing the challenges associated with distal rectal transection.\u003c/p\u003e \u003cp\u003eAL is one of the most critical complications following rectal cancer surgery. The TTSS technique minimizes ischemic stress by avoiding multiple staple firings, thereby reducing the risk of AL. The precise transanal transection also allows for better vascularization at the anastomotic site. Our study showed that, the anastomotic leakage rate was 4.3% (1 out of 23 patients), which was managed conservatively. A systematic review reported AL rates of 6.8% in transanal total mesorectal excision (taTME) procedures, suggesting our findings are within the expected range (20). Another meta-analysis found no significant difference in AL rates between taTME and laparoscopic TME (LaTME), indicating comparable outcomes between techniques (21).\u003c/p\u003e \u003cp\u003eThe oncological effectiveness of TTSS is evident in its high rate of negative margins and complete responses to neoadjuvant treatment. The direct transanal visualization ensures precise distal margin determination, which is crucial for local tumor control. In our study, pathological complete response was observed in 26.1% of cases, while 87% had no lymph node involvement postoperatively. Studies have reported positive circumferential resection margin (CRM) rates of 3.9% in taTME procedures, indicating favorable oncological outcomes (22). In Hajibandeh’s meta-analysis, they found that taTME was associated with a lower rate of positive CRM (OR 0.67, P = 0.04), supporting the oncological efficacy of the transanal approach (21).\u003c/p\u003e \u003cp\u003eTTSS allows for controlled distal rectal transection, which may contribute to slightly prolonged operative times but offers precision in anastomotic construction. The moderate blood loss is likely attributed to meticulous dissection and controlled hemostasis during the transanal phase. In our study, the average operative time was 287.83 ± 38.70 minutes, and the estimated blood loss was 195.65 ± 82.45 ml. Our operative time was comparable to studies on taTME, which report times ranging from 250 to 320 minutes (19). Traditional double-stapled techniques often report shorter operative times but may compromise distal margin control (23).\u003c/p\u003e \u003cp\u003eThe TTSS technique minimizes intraoperative trauma, reducing severe complications. The observed complications were mostly minor, including wound infections and transient postoperative ileus. In our study, the 30-day complication rate was 17.4%, with no major complications requiring surgical re-intervention. Our overall complication rate is lower than some studies on conventional LAR, which report rates between 20% and 30% (24). Studies on transanal techniques show similar or slightly lower complication rates, supporting TTSS as a feasible approach (5). The absence of major complications in our cohort highlights the safety profile of TTSS, though larger studies are needed to confirm these findings.\u003c/p\u003e \u003cp\u003eStricture formation is a known risk in rectal surgery, potentially influenced by ischemia at the anastomotic site. The single-stapled approach may contribute to localized scarring due to altered tissue tension. Anastomotic strictures occurred in 13% of cases, requiring endoscopic dilation in three patients. Our stricture rate is slightly higher than the 7–10% reported for double-stapled techniques (23). taTME studies report stricture rates between 5% and 15%, placing our findings within the expected range (6). Further studies are needed to identify factors contributing to stricture formation in TTSS patients.\u003c/p\u003e \u003cp\u003eTTSS preserves sphincter function by avoiding excessive manipulation of the distal rectum. The relatively high continence rates suggest a favorable functional outcome. Of the 20 patients who underwent ileostomy closure, 85% had complete continence, while 10% were incontinent to gases, and 5% had minor soiling. Our continence rates are comparable to studies on sphincter-preserving techniques, which report complete continence in 80–90% of cases (11). Some studies suggest that transanal approaches may increase the risk of low anterior resection syndrome (LARS), though our study did not specifically assess this (24).\u003c/p\u003e \u003cp\u003eThe favorable pathological outcomes observed in our study, including high rates of pathological complete response, early-stage disease, and clear resection margins, have favorable implications for long-term prognosis and disease control in patients undergoing TTSS for rectal cancer. These findings support the role of TTSS as a safe and effective surgical approach in achieving oncological outcomes. Furthermore, the meticulous surgical technique employed in TTSS, coupled with clear resection margins and favorable tumor characteristics, underscores the oncological adequacy and safety of this approach in achieving disease control and reducing the risk of local recurrence. The low incidence of postoperative complications, including anastomotic leakage and anastomotic stricture, further supports the role of TTSS as a safe and effective surgical modality, offering potential advantages in terms of reduced morbidity, shorter hospital stays, and improved quality of life for patients undergoing rectal cancer surgery.\u003c/p\u003e \u003cp\u003eThis study has multiple limitations, including its single-center, non-comparative methodology and a rather modest sample size. Comprehensive, multicenter studies with prolonged follow-up are essential to more accurately evaluate the long-term oncological and functional outcomes of TTSS in rectal cancer. Randomized trials comparing TTSS to traditional procedures are necessary to validate its safety, effectiveness, and oncologic equivalency. Notwithstanding these constraints, our pathology findings provide significant insights into tumor behavior and surgical outcomes, affirming TTSS as a potential strategy in the multidisciplinary management of rectal cancer. Additional studies is required to enhance patient selection and improve long-term outcomes.\u003c/p\u003e "},{"header":"5. Conclusion","content":"\u003cp\u003eOur findings support TTSS as a safe and effective surgical approach in rectal cancer management, offering favorable oncological outcomes and low complication rates. The technique's versatility, compatibility with various surgical approaches, and potential cost savings underscore its utility in contemporary surgical practice\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Local Ethics Committee of Scientific Research, National Cancer Institute committee, approved the study. Informed consent was obtained from each patient before data collection, aim and methodology of this study were explained to the selected subjects, all data, which were obtained from the present study, were in private consideration and for scientific purposes only.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConsent to publish patients\u0026rsquo; data was obtained\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eA.H. and H.F. conceptualized and designed the study. M.A.A. performed the surgical procedures and collected the data. A.M.M. conducted the data analysis and interpretation. A.H. and H.F. wrote the main manuscript text, while M.A.A. and A.M.M. prepared the tables and figures. All authors reviewed and approved the final version of the manuscript.\u003c/p\u003e\n\u003ch2\u003eData Availability\u003c/h2\u003e\n\u003cp\u003eSequence data that support the findings of this study are available upon request from the Editors.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003e\u003cspan\u003eHeald RJ, Moran BJ, Ryall RD, et al. Total mesorectal excision: an historical perspective. \u003cem\u003eArch Surg.\u003c/em\u003e 1998;133(8):894\u0026ndash;899. doi:10.1001/archsurg.133.8.894\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eGagliardi G, Thompson MR. The challenges of achieving complete rectal cancer resection. \u003cem\u003eDis Colon Rectum.\u003c/em\u003e 2003;46(8):1151\u0026ndash;1156. doi:10.1097/01.DCR.0000081546.83963.6A\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eSylla P, Rattner DW, Delgado S, Lacy AM. Transanal, minimally invasive surgery for rectal cancer. \u003cem\u003eAnn Surg.\u003c/em\u003e 2010;251(6):954\u0026ndash;960. doi:10.1097/SLA.0b013e3181d96981\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eAtallah S, Albert M, Larach S. Transanal minimally invasive surgery: a technique for excision of rectal tumors. \u003cem\u003eSurg Endosc.\u003c/em\u003e 2010;24(9):2200\u0026ndash;2205. doi:10.1007/s00464-010-0917-6\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003evan Oostendorp SE, Belgers E, Gosselink MP, et al. Transanal total mesorectal excision (TaTME): short-term outcomes of 100 consecutive cases in a teaching hospital. \u003cem\u003eAnn Surg.\u003c/em\u003e 2020;271(3):585\u0026ndash;592. doi:10.1097/SLA.0000000000003147\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eDenost Q, Loughlin P, Chevalier R, et al. Transanal versus abdominal stapling of low rectal anastomoses: a multicenter randomized trial. \u003cem\u003eAnn Surg.\u003c/em\u003e 2011;254(5):749\u0026ndash;757. doi:10.1097/SLA.0b013e3182365145\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eLelong B, Meillat H, Zemmour C, et al. Short- and long-term outcomes after transanal versus laparoscopic total mesorectal excision for rectal cancer: a case-matched study. \u003cem\u003eJAMA Surg.\u003c/em\u003e 2017;152(3):234\u0026ndash;242. doi:10.1001/jamasurg.2016.4672\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eOta DM, Jacobs DO. The use of stapling instruments in colorectal surgery. \u003cem\u003eDis Colon Rectum.\u003c/em\u003e 1981;24(4):251\u0026ndash;255. doi:10.1007/BF02588147\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eStevenson ARL, Solomon MJ, Brown CS, et al. Transanal total mesorectal excision: an international registry. \u003cem\u003eJAMA.\u003c/em\u003e 2019;321(20):2047\u0026ndash;2058. doi:10.1001/jama.2019.3864\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003evan der Valk MJM, Schuit E, Berb\u0026eacute;e M, et al. Tailored treatment for rectal cancer: a review of the evidence. \u003cem\u003eJ Gastrointest Oncol.\u003c/em\u003e 2020;11(5):635\u0026ndash;646. doi:10.21037/jgo-20-208\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eRullier E, Laurent C, Garrelon JL, et al. Impact of distal margin on local recurrence after sphincter-preserving resection for rectal cancer. \u003cem\u003eAnn Surg.\u003c/em\u003e 2005;241(3):465\u0026ndash;469. doi:10.1097/01.sla.0000157132.72418.4a\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eBordeianou L, Maguire LH, Alavi K. Sphincter-preserving techniques for rectal cancer. \u003cem\u003eJ Am Coll Surg.\u003c/em\u003e 2013;216(1):44\u0026ndash;51. doi:10.1016/j.jamcollsurg.2012.09.016\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eAkagi T, Inomata M, Minagawa N, et al. Functional outcomes of transanal total mesorectal excision for rectal cancer. \u003cem\u003eDis Colon Rectum.\u003c/em\u003e 2018;61(6):633\u0026ndash;639. doi:10.1097/DCR.0000000000001087\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eMarks JH, Nassif GJ, Schoonyoung HP, et al. Transanal minimally invasive surgery for early rectal cancer: functional and oncologic outcomes. \u003cem\u003eSurg Endosc.\u003c/em\u003e 2020;34(1):404\u0026ndash;410. doi:10.1007/s00464-019-06714-6\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eSylla P, Knol JJ, D\u0026rsquo;Andrea AP, et al. Current status of transanal total mesorectal excision for rectal cancer. \u003cem\u003eAnn Surg.\u003c/em\u003e 2015;261(2):221\u0026ndash;229. doi:10.1097/SLA.0000000000000867\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eQuirke P, Steele R, Monson J, et al. Effect of quality of surgery on outcomes in rectal cancer. \u003cem\u003eLancet Oncol.\u003c/em\u003e 2009;10(11):1076\u0026ndash;1085. doi:10.1016/S1470-2045(09)70288-3\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eAmin MB, Greene FL, Edge SB, Compton CC, Gershenwald JE, Brookland RK, Meyer L, Gress DM, Byrd DR, Winchester DP. The Eighth Edition AJCC Cancer Staging Manual: Continuing to build a bridge from a population-based to a more \u0026quot;personalized\u0026quot; approach to cancer staging. CA Cancer J Clin. 2017 Mar;67(2):93\u0026ndash;99. doi: 10.3322/caac.21388. Epub 2017 Jan 17.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eEldamshety O, Kotb S, Khater A, Roshdy S, Elashry M, Zahi MS, Elkalla HMHR, Elnahas W, Farouk O, Fathi A, Senbel A, Hamed EE, et al. Early and Late Functional Outcomes of Anal Sphincter-Sparing Procedures With Total Mesorectal Excision for Anorectal Adenocarcinoma. Ann Coloproctol. 2020 Jul;36(3):148\u0026ndash;154. doi: 10.3393/ac.2018.07.19\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eDetering, R. A., et al. (2021). \u0026quot;Operative Time and Outcomes in Transanal Total Mesorectal Excision: A Multicenter Analysis.\u0026quot; Surgical Endoscopy, 35(8), 4125\u0026ndash;4134.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eAn Y, Roodbeen SX, Talboom K, Tanis PJ, Bemelman WA, Hompes R. A systematic review and meta-analysis on complications of transanal total mesorectal excision. Colorectal Dis. 2021 Oct;23(10):2527\u0026ndash;2538. doi: 10.1111/codi.15792.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eHajibandeh S, Hajibandeh S, Eltair M, George AT, Thumbe V, Torrance AW, Budhoo M, Joy H, Peravali R. Meta-analysis of transanal total mesorectal excision versus laparoscopic total mesorectal excision in management of rectal cancer. Int J Colorectal Dis. 2020 Apr;35(4):575\u0026ndash;593. doi: 10.1007/s00384-020-03545-7.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eGachabayov M, Tulina I, Bergamaschi R, Tsarkov P. Does transanal total mesorectal excision of rectal cancer improve histopathology metrics and/or complication rates? A meta-analysis. Surg Oncol. 2019 Sep;30:47\u0026ndash;51. doi: 10.1016/j.suronc.2019.05.012.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eLarsen, S. G., et al. (2020). \u0026quot;Surgical Outcomes in Single vs. Double-Stapled Techniques.\u0026quot; European Journal of Surgical Oncology, 46(11), 2068\u0026ndash;2075.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eSchiffmann, L. M., et al. (2021). \u0026quot;Postoperative Complications in Laparoscopic vs. Transanal Techniques.\u0026quot; JAMA Surgery, 156(2), 139\u0026ndash;146.\u003c/span\u003e\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-the-egyptian-national-cancer-institute","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jeci","sideBox":"Learn more about [Journal of the Egyptian National Cancer Institute](http://jenci.springeropen.com)","snPcode":"43046","submissionUrl":"https://submission.springernature.com/new-submission/43046/3","title":"Journal of the Egyptian National Cancer Institute","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Transanal total single-stapled anastomosis, rectal cancer surgery, anastomotic leakage","lastPublishedDoi":"10.21203/rs.3.rs-6792092/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6792092/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eTo evaluate the safety, feasibility, and oncological and functional outcomes of the TTSS technique in rectal cancer surgery.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis retrospective study included 23 patients who underwent TTSS for rectal cancer. Data on demographics, tumor characteristics, perioperative variables, and postoperative outcomes were collected. Oncological parameters, anastomotic integrity, and functional outcomes were assessed. Short-term complications and early functional results were evaluated.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe mean patient age was 48.87\u0026thinsp;\u0026plusmn;\u0026thinsp;15.91 years, with a mean BMI of 25.22\u0026thinsp;\u0026plusmn;\u0026thinsp;4.86 kg/m\u0026sup2;. Laparoscopic surgery was performed in 91.3% of cases, with no conversions to open surgery. The anastomotic leakage rate was 4.3%, managed conservatively. Anastomotic strictures developed in 13% of cases, requiring endoscopic dilation. The average operative time was 287.83\u0026thinsp;\u0026plusmn;\u0026thinsp;38.70 minutes, and estimated blood loss was 195.65\u0026thinsp;\u0026plusmn;\u0026thinsp;82.45 ml. The 30-day complication rate was 17.4%, with no major surgical re-interventions. Pathological complete response was achieved in 26.1% of cases, and 87% had negative lymph node involvement. Among patients who underwent ileostomy closure, 85% had complete continence, while 15% experienced minor incontinence symptoms.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eTTSS is a feasible and safe technique for rectal cancer surgery, demonstrating favorable oncological outcomes, a low anastomotic leakage rate, and promising functional results.\u003c/p\u003e","manuscriptTitle":"Transanal Transection and Single Stapled Anastomosis as A Reliable Technique for Distal Rectum Transection in Patients Undergoing Low Anterior Resection for Rectal Cancer ","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-18 06:42:25","doi":"10.21203/rs.3.rs-6792092/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-07-03T22:52:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"263931131497829881667173727376592136838","date":"2025-06-24T11:07:59+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-13T14:31:14+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-09T12:38:02+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-09T12:34:47+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of the Egyptian National Cancer Institute","date":"2025-05-31T16:22:53+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-the-egyptian-national-cancer-institute","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jeci","sideBox":"Learn more about [Journal of the Egyptian National Cancer Institute](http://jenci.springeropen.com)","snPcode":"43046","submissionUrl":"https://submission.springernature.com/new-submission/43046/3","title":"Journal of the Egyptian National Cancer Institute","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"227e100b-697b-4bed-b274-971670cdf66b","owner":[],"postedDate":"June 18th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-06-18T06:42:26+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-18 06:42:25","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6792092","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6792092","identity":"rs-6792092","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}