The Application of Intraoperative Strategies to Reduce Prophylactic Stoma in Mid and Low Rectal Cancer: A Retrospective Study Utilizing Indocyanine Green and Precise Anatomical Techniques

The Application of Intraoperative Strategies to Reduce Prophylactic Stoma in Mid and Low Rectal Cancer: A Retrospective Study Utilizing Indocyanine Green and Precise Anatomical Techniques | 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 The Application of Intraoperative Strategies to Reduce Prophylactic Stoma in Mid and Low Rectal Cancer: A Retrospective Study Utilizing Indocyanine Green and Precise Anatomical Techniques Hao Ji, Sufen Han, Jingshu He, Lu Zhao, Chen Wei, Yichao Ma, Jiahao Zhao, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7557920/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 02 Jan, 2026 Read the published version in World Journal of Surgical Oncology → Version 1 posted 9 You are reading this latest preprint version Abstract Background Mid and low rectal cancer is among the most prevalent malignancies worldwide. Total mesorectal excision (TME) remains the standard surgical approach for these cancers; However, anastomotic leakage has consistently emerged as one of the most severe complications associated with surgeries in this patient population. In response to anastomotic complications, on the basis of conventional laparoscopic total mesorectal excision (LaTME), multiple techniques and related studies have been conducted successively. These techniques include: protection of the left colonic artery to enhance blood supply to the proximal intestinal tract; high-ligation of the inferior mesenteric vein; integrated application of indocyanine green (ICG) technology during surgery; splenic flexure mobilization, which can elongate the length of the intestinal tract and mesentery, thereby reducing the tension of the anastomosis; and reinforcement sutures for anastomoses. Our center has innovatively combined these techniques into a novel approach, termed the "PHISTA Technique", using the initials of the involved strategies. Additionally, various methods have been implemented to reduce the incidence of anastomotic leakage, such as the creation of a prophylactic stoma during surgery and placement of an anal decompression tube. The objective of this study is to evaluate the safety and efficacy of the PHISTA Technique in treating mid and low rectal cancer, in comparison with the conventional LaTME approach. Methods Patients diagnosed with mid and low rectal cancer between December 2022 and December 2024 were retrospectively included and categorized into the conventional LaTME group and the PHISTA Technique group. The basic characteristics and short-term outcomes of the two groups were compared. Results A total of 95 patients were enrolled in this study and categorized into two groups. The baseline characteristics of the two groups were similar. The preventive stoma rate in the PHISTA Technique group was 0%, significantly lower than the 31.7% observed in the conventional LaTME group (P < 0.001). The anastomotic leakage rate in the PHISTA Technique group was 5.7%, while that in the conventional LaTME group was 6.7%. The anastomotic leakage rate in the PHISTA Technique group was marginally lower than that in the conventional LaTME group, but no statistically significant difference was found between the two groups (P > 0.05). Regarding intraoperative indicators (e.g., operation time, intraoperative blood loss, and total number of lymph nodes dissected), no statistically significant differences were observed between the PHISTA Technique group and the conventional LaTME group (P values were 0.116, 0.268, and 0.066, respectively). In terms of postoperative recovery indicators (such as the time of first postoperative flatus, the time of first postoperative defecation, and hospital stay), there was no statistically significant difference between the PHISTA Technique group and the conventional LaTME group (P values were 0.409 and 0.342, respectively). Furthermore, the operation time in the PHISTA Technique group was marginally longer than that in the conventional LaTME group, but no statistically significant difference was found between the two groups (median time 145 minutes vs. 132 minutes, P = 0.440). Conclusion The PHISTA Technique can significantly reduce the rate of preventive stoma without increasing the incidence of anastomotic leakage, and may even result in a slightly lower incidence compared to the conventional LaTME group. This approach eliminates the need for a subsequent stoma reversal surgery, thereby reducing patient suffering and economic burden, ultimately providing the greatest benefit to patients. Rectal cancer LaTME Total mesorectal excision Surgical approach Laparoscopy Figures Figure 1 Figure 2 Introduction Mid and low rectal cancer is one of the most prevalent cancers globally, with both incidence and mortality rates ranking prominently. According to the latest global cancer statistics, mid and low rectal cancer ranks among the top five most common cancers worldwide and is a leading cause of cancer-related mortality [1] [2]. With shifts in lifestyle patterns and an aging population, the incidence of rectal cancer has increased in many countries, presenting a significant challenge to public health [3]. The current standard surgical approach for mid and low rectal cancer is LaTME. LaTME effectively removes rectal cancer while preserving surrounding tissues; however, it has certain limitations in treating mid and low rectal cancers, particularly due to a relatively high risk of postoperative anastomotic leakage [4]. To mitigate this risk, conventional LaTME is frequently performed in conjunction with a preventive stoma. However, the use of a preventive stoma can lead to increased postoperative pain and inconvenience for patients, as well as impose economic burdens due to subsequent stoma reversal surgery. Therefore, minimizing the need for preventive stomas without increasing the rate of anastomotic leakage has become a critical focus in improving surgical techniques for rectal cancer [5]. Recent advancements in medical technology have facilitated the gradual adoption of various surgical techniques in rectal cancer surgery. This has resulted in the development of combined strategies designed to address the limitations of conventional LaTME and reduce the incidence of anastomotic leakage [6]. The comprehensive application of these multiple technologies includes:1.ICG tracing navigation: employing indocyanine green (ICG) fluorescence to enhance lymph node dissection through improved tracing [7]; 2. Adequate mobilization of the splenic flexure: ensuring sufficient intestinal length to relieve anastomotic tension [8]; 3. Preservation of the left colic artery with high ligation of the inferior mesenteric vein and dissection of No. 253 lymph nodes—further reducing the risk of local recurrence [9]; 4. Conventional TME technique [10]; 5. ICG-guided assessment of blood supply before and after anastomosis: evaluating blood supply at the anastomotic site to reduce instances of anastomotic leakage resulting from inadequate perfusion [11]. 6. Enhanced anastomotic suturing using barbed sutures: This technique reinforces the anastomotic suture and mitigates the risk of anastomotic leakage [12]. We have innovatively designated this surgical strategy, which integrates the aforementioned techniques, as the "PHISTA Technique" derived from the initial letters of each respective method. Although the theoretical application of PHISTA Technique shows promise in reducing anastomotic leakage, there is a significant lack of systematic evidence regarding its effectiveness and safety in clinical practice. This includes uncertainty regarding whether it can further reduce the incidence of anastomotic leakage in the absence of a preventive stoma. Therefore, this study aims to assess the impact of PHISTA Technique on postoperative anastomotic leakage rates in patients with mid and low rectal cancer through retrospective data analysis, thus providing a reliable reference for clinical practice. Materials and methods Patients A total of 95 patients diagnosed with mid and low rectal cancer were consecutively enrolled at Northern Jiangsu People's Hospital in Jiangsu Province from December 2022 to December 2024. The inclusion criteria for this study were as follows: 1. Age between 18 and 80 years; 2. Diagnosis of rectal adenocarcinoma confirmed by electronic colonoscopy and pathology; 3. First-time surgical intervention; 4. Laparoscopic surgery; 5. Availability of complete clinical and pathological data, along with follow-up information; 6. Absence of severe cardiovascular or metabolic diseases; 7. No evidence of distant metastasis prior to surgery and no administration of neoadjuvant chemoradiotherapy; 8. Informed consent obtained from the patient or their authorized representative. The exclusion criteria were: 1. Preoperative neoadjuvant therapy or perioperative radiotherapy; 2. History of other malignant tumors; 3. Emergency surgery required due to obstruction, perforation, or bleeding; 4. Severe mental illness; 5. Pregnant or lactating women. All surgical procedures were conducted by the same surgical team to ensure consistency in technique and approach. After being fully informed of the advantages and disadvantages associated with both the PHISTA Technique and conventional LaTME surgery, patients were given the autonomy to freely choose their preferred surgical method. Informed consent was obtained from all participants involved in this study, which was approved by the Ethics Committee of Northern Jiangsu People's Hospital in Jiangsu Province (No. 2024ky343). Data collection The fundamental characteristics, perioperative data, and follow-up information of the patients were systematically collected the basic characteristics included gender, age, body mass index (BMI), preoperative hemoglobin levels, maximum tumor diameter, distance from the lower edge of the tumor to the anal verge, degree of tumor differentiation, and the American Joint Committee on Cancer (AJCC) stage. The AJCC stage serves as an indicator of the pathological progression of cancer. Perioperative data included operation time, length of hospital stay, time to first postoperative flatus, time to first postoperative defecation, intraoperative blood loss, total number of lymph nodes dissected, use of intraoperative prophylactic stoma, incidence of postoperative anastomotic leakage, and relevant pathological data, which were obtained from surgical records and pathological reports. The primary outcome was the incidence of postoperative anastomotic leakage. The secondary outcome was the occurrence of postoperative complications. Surgical approaches Statistical analysis 1. Laparoscopic total mesorectal excision(LaTME) : The patient was positioned in the lithotomy position and general anesthesia was administered. Appropriate pneumoperitoneum pressure was established, and trocar insertion was performed at the following locations: 0.5 cm above the umbilicus, at the right midclavicular line 1 fingerbreadth below the umbilicus, at the corresponding position on the left side, and at McBurney's point. Intra-abdominal conditions were meticulously observed. The sigmoid mesocolon was dissected, followed by the freeing and transection of the inferior mesenteric artery and vein. Rectal dissection was performed along the anterior rectal space and presacral space to expose the levator ani muscle. After incising the anterior peritoneum at the fold, dissection of the seminal vesicles was performed in male patients, while in female patients, dissection of the vaginal-rectal septum facilitated exposure of the rectal mesorectum. Rectal dissection was carried out in accordance with the principles of Total Mesorectal Excision (TME). The distal rectal mesorectum was resected at least 5 cm from its lower margin, and the intestinal tract was transected and closed with a stapler placed more than 2 cm below the tumor's lower margin. A 5 cm extension of the midline incision in the lower abdomen was made to facilitate specimen removal following intestinal resection. The blood supply to the intestinal tract was carefully assessed, and if deemed adequate, the intestinal segments were reintroduced into the abdominal cavity and pneumoperitoneum was re-established. A circular stapler was then introduced through the anal canal to perform laparoscopic-assisted intestinal anastomosis, after which the stapler was removed. Anal preservation was not performed when the tumor was located low enough such that a negative margin could not be ensured within 2 cm from the lower edge of the tumor. 2. PHISTA Technique : The patient was placed in the lithotomy position, general anesthesia was administered, and an appropriate pneumoperitoneum pressure was established. Under endoscopic guidance, incisions were made at the umbilical level and in the left and right lower abdomen, with Trocar insertion at these locations. Intra-abdominal conditions were closely monitored via laparoscopy. Indocyanine green (ICG) solution was injected into the serosal layer 1 cm from the tumor margin ( Fig. 1 A- 1 C ) , and the splenic region was dissected upward along the lateral aspect of the sigmoid colon. The splenic region was fully mobilized, followed by complete mobilization of the left colon ( Fig. 1 D- 1 F ) . The mesocolon was approached via the intermediate route, and the sigmoid mesocolon was carefully dissected. The left colic artery was preserved under fluorescence-guided laparoscopic imaging, and No. 253 lymph nodes, including those along the mesenteric artery and retroperitoneal lymph nodes, were excised ( Fig. 1 G- 1 I ) . The inferior mesenteric vein was ligated at a high level ( Fig. 2 A- 2 C ) . The dissection was extended laterally through Toldt’s space, and the dorsal aspect of the left colon was fully mobilized. The dissection continued downward along the presacral space in accordance with Total Mesorectal Excision (TME) principles, reaching the level of the levator ani muscle. The bowel was exposed, and the anterior rectal wall was separated from the bladder within the space between Denonvillier’s fascia. The bowel was fully mobilized, and an EC60 stapler was employed to transect the colon. In cases of high rectal cancer, the rectum was mobilized approximately 5 cm below the tumor. Similarly, in cases of low rectal cancer, the rectum was also mobilized 5 cm below the tumor. A 4 cm midline abdominal incision was made, and following entry into the abdominal cavity, a plastic bag was used to protect the incision. The proximal rectum containing the tumor was extracted from the abdominal cavity, and the rectum was transected approximately 10 cm above the tumor. The specimen was removed, a purse-string clamp was applied, sutures were placed at the base, tightened, and returned to the abdominal cavity for safekeeping. Pneumoperitoneum was re-established, and the anal canal was irrigated with saline prior to the insertion of an anastomosis stapler transanally. Prior to anastomosis, ICG was injected intravenously to assess bowel perfusion ( Fig. 2 D- 2 F ) . If the blood supply was deemed adequate, the anastomosis was reinforced with barbed sutures under laparoscopic guidance ( Fig. 2 G- 2 I ) . Anal preservation was not performed when the tumor was located sufficiently low such that a negative margin could not be assured within 2 cm from the lower edge of the tumor. Statistical analysis Data analysis was conducted using SPSS 26.0 (SPSS, Chicago, Illinois, USA). Categorical data are presented as percentages (%). Fisher's exact test or χ2 test was employed to assess the accuracy of comparative analysis. Normally distributed continuous variables were analyzed using the t-test and are presented as mean ± standard deviation (mean ± SD). Non-normally distributed continuous variables were analyzed using non-parametric tests and are presented as median (interquartile range). A P-value of < 0.05 was considered statistically significant. Results A total of 95 patients were ultimately included in the study, among which 35 were in the PHISTA Technique group and 60 in the LaTME group. The follow-up results of the patients were recorded until discharge. Basic characteristics of the patients A total of 95 patients were enrolled in this study, with 35 in the PHISTA Technique group and 60 in the LaTME group. No significant differences were observed in baseline characteristics between the two groups ( Table 1 ). Table 1 Basic characteristics of the patients Characteristics PHISTA (n = 35) LaTME (n = 60) X²/t/Z P Sex, n (%) X²=0.794 0.373 Male 22(62.9) 43(71.7) Female 13(37.1) 17(28.3) Age (years), mean (SD) 65.06 ± 11.84 66.03 ± 10.78 t=-0.410 0.682 BMI (kg/m2), median (IQR) 22.49(21.19,24.44) 23.32(21.34,25.44) Z=-1.300 0.194 Preoperative hemoglobin, n (%) X²=0.145 0.703 <120g/L 10(28.6) 15(25.0) ≥ 120g/L 25(71.4) 45(75.0) The maximal diameter of the tumor (cm), mean (SD) 4.11 ± 1.44 3.80 ± 1.11 t = 1.187 0.238 The distance from the inferior margin of the tumor to the anal verge, median (IQR) 10.00(8.00,12.00) 8.00(5.00,10.00) Z=-0.702 0.482 AJCC stage, n (%) X²=0.008 0.928 I-II 19(54.3) 32(53.3) III-IV 16(45.7) 28(46.7) Tumor differentiation, n (%) X²=1.733 0.368 Well and moderate 1(2.9) 0(0) Poor 34(97.1) 60(100.0) Perioperative outcomes The preventive stoma rate in the PHISTA Technique group was 0%, significantly lower than that in the LaTME group (31.7%, P < 0.001). The anastomotic leakage rate in the PHISTA Technique group was 5.7%, compared to 6.7% in the LaTME group. The anastomotic leakage rate in the PHISTA Technique group was slightly lower than that in the conventional TME group; however, no significant difference was found between the two groups (P > 0.05). No statistically significant differences were observed between the PHISTA Technique group and the LaTME group regarding intraoperative indicators (e.g., operation time, intraoperative blood loss, and number of lymph nodes dissected) (P values: 0.116, 0.268, and 0.066, respectively). No statistically significant differences were observed between the PHISTA Technique group and the LaTME group in terms of postoperative recovery indicators (e.g., time to first postoperative flatus, time to first postoperative defecation, and length of hospital stay) (P values: 0.409 and 0.342, respectively). The operation time in the PHISTA Technique group was slightly longer than in the LaTME group; however, no statistically significant difference was found between the two groups (median time: 145 minutes vs. 132 minutes, P = 0.440) ( Table 2 ) . Table 2 Perioperative outcomes Characteristics PHISTA (n = 35) LaTME (n = 60) X²/t/Z P Operation time (min), median (IQR) 145.00(110.00,175.00) 132.(110.00,155.00) Z=-0.773 0.440 Postoperative hospitalization (d), median (IQR) 13.04(11.03,15.71) 11.96(10.03,14.57) Z=-1.836 0.066 Time to first gas passing (d), median (IQR) 4.00(3.00,5.00) 3.00(3.00,4.00) Z=-1.573 0.116 Time to first stool passing (d), median (IQR) 5.00(4.00,6.00) 5.00(3.25,6.00) Z=-1.107 0.268 Estimated blood loss (ml), median (IQR) 50.00(20.00,50.00) 50.00(20.00,50.00) Z=-0.825 0.409 Number of lymph nodes dissected, mean (SD) 14.60 ± 6.98 13.37 ± 5.08 t = 0.992 0.324 Number of preventive stomas, n (%) 0(0) 19(31.7) X²=13.854 <0.001 Number of anastomotic leaks, n (%) 2(5.7) 4(6.7) X²=0.034 1.000 Discussion This study assessed the treatment outcomes of the PHISTA Technique—a composite of various surgical approaches for rectal cancer resection—in the context of mid and low rectal cancer, a subject that has been scarcely explored in the literature. This study assessed the treatment outcomes of the PHISTA Technique—a composite of various surgical approaches for rectal cancer resection—in the context of mid and low rectal cancer, a subject that has been scarcely explored in the literature. A total of 95 patients were included in a retrospective, comprehensive analysis to evaluate the feasibility, safety, and efficacy of the PHISTA Technique. The results demonstrate that, compared to conventional laparoscopic total mesorectal excision (LaTME), the PHISTA Technique significantly reduces the preventive stoma rate while maintaining an anastomotic leakage rate that is comparable to or slightly lower than that of the LaTME group. Colorectal cancer, particularly rectal cancer, represents one of the most prevalent malignancies worldwide, with both its incidence and mortality rates ranking among the highest across all cancer types. The incidence of rectal cancer has been steadily increasing, driven by changes in lifestyle and dietary habits. Specifically, mid and low rectal cancers present significant challenges in surgical treatment due to their distinctive anatomical location. Surgical procedures must not only ensure complete tumor resection but also strike a balance between resection extent and anal function preservation, necessitating advanced surgical expertise. Additionally, postoperative complications, particularly anastomotic leakage, remain critical factors influencing patient recovery. Treatment goals for mid and low rectal cancer typically include: (1) complete tumor resection to ensure no residual cancer cells; (2) maximizing anal function preservation to minimize postoperative incontinence and maintain quality of life; (3) reducing postoperative complications, particularly anastomotic leakage, a major contributor to poor recovery outcomes; and (4) enhancing overall patient quality of life and facilitating prompt recovery. However, despite advancements in conventional surgical techniques, the incidence of anastomotic leakage remains notably high, particularly in mid and low rectal cancer cases. Anastomotic leakage not only prolongs hospital stays but also significantly increases the risk of reoperation, imposing substantial physical and psychological burdens on patients [13]. These challenges have prompted clinical researchers and surgeons to continuously pursue more refined and effective surgical techniques. Recently, several modified surgical approaches have emerged, aimed at enhancing safety, improving surgical outcomes, and facilitating postoperative recovery while minimizing complication rates. The ongoing refinement and innovation of these techniques seek to provide better treatment options for patients with mid and low rectal cancer, ultimately enhancing prognosis and quality of life. Total mesorectal excision (TME) remains the gold standard surgical approach for rectal cancer treatment. The core principle involves complete removal of the rectum and its mesorectum to achieve radical tumor resection and reduce the rate of local recurrence [14]. With advancements in laparoscopic technology, laparoscopic total mesorectal excision (LaTME) has progressively become one of the standard treatment modalities for mid and low rectal cancer [15]. However, LaTME presents certain limitations: (1) In patients with mid and low rectal cancer, the incidence of anastomotic leakage following LaTME remains relatively high. Anastomotic leakage following surgery can severely impede postoperative recovery, significantly prolong hospital stays, and exacerbate both the physical and psychological suffering of patients [16]. (2) To mitigate the risk of anastomotic leakage, LaTME frequently necessitates the creation of a preventive stoma. However, preventive stomas negatively affect both the quality of life and mental health of patients, and require a subsequent stoma reversal surgery, which increases both the economic burden and patient suffering [13]. Therefore, minimizing the need for preventive stomas without elevating the anastomotic leakage rate is a critical focus in ongoing advancements in rectal cancer surgical techniques. Consequently, based on LaTME, numerous techniques and related research have been conducted to mitigate anastomotic complications, including preservation of the left colic artery, high-ligation of the inferior mesenteric vein, integrated application of ICG technology during surgery, splenic flexure mobilization, and anastomotic reinforcement suturing. The innovative integration of these techniques forms the "PHISTA Technique", which optimizes intraoperative strategies to enhance the blood supply and tension at the anastomosis, reduce the incidence of anastomotic leakage, and diminish the need for preventive stomas. Low-level ligation of the inferior mesenteric artery (i.e., preservation of the LCA), represents a core advancement in the PHISTA Technique. Conventional LaTME emphasizes complete resection of the rectal mesorectum, typically involving high-ligation of the IMA at its root to excise mesenteric root lymph nodes. However, high-level ligation may compromise blood supply to the proximal left colon, thereby increasing the risk of anastomotic leakage [17]. In contrast, the PHISTA Technique focuses on low-level ligation of the IMA and preservation of the LCA and its ascending branch, which significantly enhances blood supply to the proximal intestinal segment of the anastomosis [18]. A study by Sung et al. visually demonstrated, using ICG injection and infrared fluorescence imaging, that preserving the LCA ensures a more robust blood supply to the anastomosis [19]. Further research by Li et al. demonstrated that clamping the LCA markedly reduced the blood supply to the proximal intestinal segment of the anastomosis from 9.2 IU/s to 5.4 IU/s, thereby heightening the risk of anastomotic leakage [20]. Furthermore, a study by Huang et al. indicated that there was no statistically significant difference in the clearance of No. 253 lymph nodes between patients with and without LCA preservation [21]. In summary, these findings suggest that preserving the LCA not only enhances the blood supply to the anastomosis but also does not interfere with the clearance of No. 253 lymph nodes or adversely affect patients' oncological prognosis, while reducing the risk of postoperative anastomotic leakage. Overall, preservation of the left colic artery during radical resection of rectal cancer ensures improved blood supply to the proximal colon, fosters favorable In addition to left colic artery preservation, high-ligation of the inferior mesenteric vein (IMV) constitutes another key aspect of the PHISTA Technique. The site of IMV ligation during rectal cancer surgery remains a subject of debate. Researchers in Europe and the United States advocate for high-ligation of the IMV at the lower edge of the pancreas, in accordance with the principle of central vascular ligation. This approach is believed to prevent tumor spread, facilitate lymph node dissection at the vessel root, and increase bowel mobility, thus reducing anastomotic tension and facilitating bowel anastomosis [22]. In contrast, Japanese researchers suggest ligating and transecting the IMV as distally as possible to avoid intestinal congestion [23]. In our center, the inferior mesenteric vein is ligated at a high position, specifically at the lower edge of the pancreas. Subsequently, the transverse mesocolon and splenic flexure mesocolon are dissected along the avascular plane towards the vascular arch, further alleviating anastomotic tension. Furthermore, due to the abundant venous collateral circulation within the mesocolon, no complications related to high IMV ligation have been observed in our patients thus far, providing preliminary evidence for its safety. However, it is important to note that the current sample size is limited. While initial results suggest that high ligation of the IMV is both safe and effective, its long-term clinical impact requires validation through larger-scale and multi-center studies. Future research, with the accumulation of more surgical cases and in-depth clinical data analysis, will allow for a more comprehensive evaluation of the clinical significance of high IMV ligation in rectal cancer surgery. Further optimization of this technique will offer more ideal treatment options for patients with mid and low rectal cancer, thereby reducing surgical difficulty, minimizing the risk of postoperative anastomotic leakage, and improving postoperative recovery and quality of life. The complete or partial mobilization of the splenic flexure of the colon further enhances the efficacy of the PHISTA Technique. Mobilization of this anatomical region is of considerable clinical significance in the radical resection of rectal cancer. It facilitates comprehensive tumor excision, improves blood supply to the proximal intestinal segment, and alleviates tension at the anastomotic site, thereby reducing the risk of anastomotic leakage [24]. However, the question of whether to perform complete or partial mobilization of the splenic flexure remains a topic of ongoing debate. Some scholars advocate for transecting only the phrenocolic ligament, asserting that this method is relatively simple and does not significantly prolong the operative time [25]. In contrast, others recommend a more standardized approach, which involves not only cutting through the gastrocolic ligament, but also the splenocolic ligament, phrenocolic ligament, and the left portion of the transverse mesocolon, thereby achieving full mobilization of both the left half of the transverse colon and the splenic flexure [26]. At our center, the decision to sever ligaments is made based on the individual characteristics of each patient, in order to achieve effective mobilization of the intestinal segments. This targeted approach to splenic flexure mobilization allows for thorough detachment of both the intestinal segments and mesentery, while minimizing the risk of anastomotic leakage, though it may slightly increase the operation time. Furthermore, careful dissection around the ligaments and omentum adjacent to the colon helps reduce traction on the spleen, thereby minimizing the risk of iatrogenic splenic injury. Additionally, the use of ICG fluorescence navigation technology has further improved the clinical efficacy of the PHISTA technique. In 2006, Nagata et al. published the first research on the application of ICG in colorectal surgery [27]. As fluorescence imaging technology has matured, ICG has been increasingly used in colorectal surgery for intraoperative assessment of anastomotic blood perfusion and lymph node visualization, yielding significant results. (1) ICG-guided dissection of the No. 253 lymph nodes: The No. 253 lymph nodes is identified as the lymph node located along the inferior mesenteric artery (IMA), extending from the origin of the left colic artery to the point of origin of the IMA. This lymph node serves as the third station for lymphatic drainage in cases of rectal cancer and represents a significant pathway for the dissemination and metastasis of cancer cells, particularly in advanced stages of rectal cancer. The degree of dissection of the No. 253 lymph nodes has a direct influence on prognosis [28]. In recent years, ICG fluorescence navigation has played a significant role in the dissection of the No. 253 lymph nodes. Studies have demonstrated that ICG fluorescence imaging can visualize lymphatic drainage, thus improving the accuracy and completeness of lymph node resection in colorectal cancer surgery [29]. Another study investigated the use of ICG in radical lymph node dissection for sigmoid colon and rectal cancer, revealing that ICG imaging aids in complete dissection of D3 lymph nodes and identification of overlooked D3 lymph nodes, thereby improving the dissection rate, providing better surgical staging, and enhancing patient survival [30]. In summary, the use of ICG fluorescence imaging for lymph node dissection enhances detection range and improves surgical quality. (2) Beyond its role in lymph node visualization, ICG fluorescence also plays a crucial role in assessing anastomotic blood perfusion during surgery [19]. Anastomotic leakage (AL) is a severe complication following rectal cancer surgery, often leading to prolonged hospital stays, increased costs, and decreased survival. Poor anastomotic perfusion is a major risk factor [31] [32]. Therefore, intraoperative assessment of blood supply is crucial. NIR-ICG provides accurate information on anastomotic perfusion during rectal cancer surgery and is a highly valuable detection method. Jafari et al. observed 16 patients who underwent robotic low anterior resection (LAR) of the rectum. With ICG fluorescence angiography, 19% of cases achieved a more precise resection, indicating that ICG-NIR imaging can effectively reduce AL incidence [33]. In a multicenter phase II trial involving 90 LAR patients, ICG fluorescence guidance was used for all, with only 3% developing AL, significantly lower than those who did not use ICG guidance during the same period [34]. However, limitations exist in current ICG fluorescence systems. According to clinical practice [35], various factors such as the dose of ICG, duration of use, laparoscopic lens position, distance to the intestine, ambient light, NIR intensity, patient characteristics, and the surgeon’s subjective perception may influence the accuracy and consistency of ICG imaging, thereby impacting lymph node dissection and anastomotic perfusion assessment. Future development of more precise and stable ICG technologies is crucial for enhancing the thoroughness and accuracy of lymph node dissection, while providing an objective, quantitative tool for assessing anastomotic perfusion, thereby improving surgical precision and patient outcomes. Finally, the reinforced suture of the anastomosis using barbed suture provides a more stable assurance for the PHISTA technique. The reinforcement of the anastomotic suture following digestive tract surgery can address potential defects at the anastomosis site [27]. The comprehensive application of the aforementioned techniques has ensured moderate tension and optimal blood perfusion at the anastomosis. Building on this foundation, the use of reinforced sutures with barbed sutures can further diminish the incidence of anastomotic leakage, particularly in high-risk patients such as those with diabetes and severe anemia [36]. Research indicates that reinforced suturing significantly reduces rates of anastomotic leakage, a finding corroborated by multiple meta-analyses [37] [38]. Short-term efficacy was a primary outcome measure in this study. The results indicated that the preventive stoma rate in the PHISTA Technique group was 0%, which is significantly lower than the 31.7% observed in the conventional LaTME group (P < 0.001). Furthermore, the anastomotic leakage rate in the PHISTA Technique group was recorded at 5.7%, compared to 6.7% in the conventional LaTME group. Although the anastomotic leakage rate in the PHISTA Technique group was marginally lower than that of the conventional LaTME group, no statistically significant difference was found between these two groups (P > 0.05).Regarding intraoperative indicators—such as operation time, intraoperative blood loss, and total number of lymph nodes dissected—there were no statistically significant differences between the PHISTA Technique and LaTME groups (P values were 0.116, 0.268, and 0.066, respectively). Similarly, for postoperative recovery indicators—including time to first postoperative exhaust, time to first postoperative defecation, and length of hospital stay—no statistically significant differences were noted between these two techniques (P values were 0.409 and 0.342 respectively). Additionally, while it is worth noting that operation time for patients undergoing PHISTA Technique was slightly longer than that for those receiving LaTME (median times being 145 minutes vs.132 minutes), this difference did not reach statistical significance (P = 0.440). These findings suggest that while employing the PHISTA Technique can substantially reduce preventive stoma rates without increasing anastomotic leakage rates beyond those seen with traditional LaTME methods—and may even result in a slight decrease—it also demonstrates comparable short-term recovery outcomes relative to LaTME. This aligns with existing literature and further substantiates both safety and feasibility associated with utilizing the PHISTA Technique despite its marginally extended operation duration when compared to standard practices within this domain. In conclusion, the findings of this study indicate that the PHISTA Technique offers significant advantages in the treatment of mid and low rectal cancer. This innovative approach integrates multiple advanced surgical techniques and optimizes both the surgical process and postoperative recovery conditions for patients with mid and low rectal cancer from various perspectives. As a result, it provides a safe, effective, and novel treatment option. The PHISTA Technique notably reduces the rate of preventive stoma without increasing the incidence of anastomotic leakage. Furthermore, it enhances patients' quality of life while alleviating the economic burden and psychological stress associated with subsequent stoma reversal surgery. This model of multi-technique integration presents a more efficient and secure treatment alternative for rectal cancer patients, thereby diminishing their economic and psychological burdens. Overall, these findings underscore the important clinical value of promoting this innovative technique within medical practice. Although PHISTA Technique has shown substantial theoretical and practical advantages, it also entails several potential limitations: (1) Technical learning curve: The application of PHISTA Technique requires advanced technical proficiency from the surgeon, necessitating specialized training and experience accumulation. Novices may face challenges in mastering this technique. (2) Extended operation time: Due to its inherent complexity, the operation time for PHISTA Technique is somewhat longer than conventional LaTME procedures. However, the authors argue that as surgeons gain experience through practice, the additional time required for certain surgical steps may decrease. (3) Study limitations: This study is a single-center retrospective analysis with a relatively small sample size, which may limit the generalizability of our findings. Future multi-center, large-scale clinical studies are crucial for validating these results. (4) Long-term oncological prognosis validation: While PHISTA Technique has demonstrated promising short-term efficacy, its long-term oncological outcomes remain unexamined. Therefore, future multi-center, prospective studies with larger sample sizes and extended follow-up periods are necessary to further evaluate the oncological effects and safety profile of PHISTA Technique. Conclusion Our research provides compelling evidence supporting the feasibility, effectiveness, and safety of the PHISTA Technique in skilled surgical centers. It was observed that the PHISTA Technique significantly reduces the rate of preventive stoma without increasing the incidence of anastomotic leakage when compared to the conventional LaTME group; in fact, it may even slightly lower this incidence. This approach eliminates the necessity for subsequent stoma reversal surgery for patients, thereby alleviating their suffering and economic burden while ultimately delivering substantial benefits to them. Although the operation time for the PHISTA Technique was marginally longer than that of the LaTME group, its advantages—such as reducing preventive stoma rates, optimizing anastomosis, and minimizing risks associated with anastomotic leakage—outweigh this slight increase in duration. This surgical method exhibits unique advantages and good repeatability and is particularly suitable for treating patients with mid and low rectal cancer when performed by practitioners who are proficient in this technique. However, continuous long-term monitoring remains essential to confirm both the enduring effectiveness and safety of this novel surgical approach. Declarations Ethics approval and consent to participate All surgical procedures were conducted by the same surgical team to ensure consistency in technique and approach. After being fully informed of the advantages and disadvantages associated with both the PHISTA Technique and conventional LaTME surgery, patients were given the autonomy to freely choose their preferred surgical method. Informed consent was obtained from all participants involved in this study, which was approved by the Ethics Committee of Northern Jiangsu People's Hospital in Jiangsu Province (No. 2024ky343). Disclosures Hao Ji, Sufen Han, Lu Zhao, Chen Wei, Yichao Ma, Jiahao Zhao, Jiayi Zhang, Daorong Wang and Dong Tang have no conflicts of interest or financial ties to disclose. Funding This work was supported by the Graduate Research- Innovation Project in Jiangsu province [No. SJCX21_1644], the Academic Science and Technology Innovation Fund for College Students [No. 202011117056Y], Social development project of key R & D plan of Jiangsu Provincial Department of science and technology [No. BE2022773]. The funding bodies had no role in the design of the study; in the collection, analysis, and interpretation of the data; and in the writing the manuscript. Author Contribution Hao Ji, Sufen Han and Jingshu He wrote the main manuscript text. Lu Zhao prepared Figure 1. Chen Wei prepared Figure 2. Yichao Ma prepared Table 1. Jiahao Zhao and Jiayi Zhang prepared Table 2. Dong Tang is the corresponding author. All the authors reviewed the manuscript. Data Availability The datasets used and/or analysed during the current study available from thecorresponding author on reasonable request References Bray F, Laversanne M, Sung H, Ferlay J, Siegel RL, Soerjomataram I, Jemal A: Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries . CA Cancer J Clin 2024, 74 (3):229-263. 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Cite Share Download PDF Status: Published Journal Publication published 02 Jan, 2026 Read the published version in World Journal of Surgical Oncology → Version 1 posted Editorial decision: Revision requested 04 Oct, 2025 Reviews received at journal 04 Oct, 2025 Reviews received at journal 24 Sep, 2025 Reviewers agreed at journal 15 Sep, 2025 Reviewers agreed at journal 14 Sep, 2025 Reviewers invited by journal 14 Sep, 2025 Editor assigned by journal 12 Sep, 2025 Submission checks completed at journal 07 Sep, 2025 First submitted to journal 07 Sep, 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. 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1","display":"","copyAsset":false,"role":"figure","size":256505,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eA.\u003c/strong\u003e Indocyanine green (ICG) solution was injected into the serosal layer 1 cm from the tumor margin; \u003cstrong\u003eB. \u003c/strong\u003eFluorescence mode; \u003cstrong\u003eC. \u003c/strong\u003eVisualization of lymph nodes; \u003cstrong\u003eD、E、F.\u003c/strong\u003e Mobilization of the splenic flexure; \u003cstrong\u003eG、H、I.\u003c/strong\u003e The left colic artery was preserved under fluorescence-guided laparoscopic imaging, and No. 253 lymph nodes, including those along the mesenteric artery and retroperitoneal lymph nodes, were excised\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7557920/v1/2de40680c42be353dd897aa2.jpg"},{"id":91956148,"identity":"819c53a8-c590-4333-bcb9-c77d138a5940","added_by":"auto","created_at":"2025-09-23 07:11:00","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":290549,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eA、B、C.\u003c/strong\u003e The inferior mesenteric vein was ligated at a high level; \u003cstrong\u003eD、E、F.\u003c/strong\u003e Prior to anastomosis, ICG was injected intravenously to assess bowel perfusion; \u003cstrong\u003eG、H、I.\u003c/strong\u003e Reinforcement of the anastomosis with barbed suture under laparoscopic guidance\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7557920/v1/a02285dc2c2c04769f6474f6.jpg"},{"id":99545539,"identity":"da497803-8165-45e8-87b8-840a92de39bb","added_by":"auto","created_at":"2026-01-05 16:08:24","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3651725,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7557920/v1/98442603-07ad-4488-a6a1-133c171dca29.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Application of Intraoperative Strategies to Reduce Prophylactic Stoma in Mid and Low Rectal Cancer: A Retrospective Study Utilizing Indocyanine Green and Precise Anatomical Techniques","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMid and low rectal cancer is one of the most prevalent cancers globally, with both incidence and mortality rates ranking prominently. According to the latest global cancer statistics, mid and low rectal cancer ranks among the top five most common cancers worldwide and is a leading cause of cancer-related mortality [1] [2]. With shifts in lifestyle patterns and an aging population, the incidence of rectal cancer has increased in many countries, presenting a significant challenge to public health [3].\u003c/p\u003e\u003cp\u003eThe current standard surgical approach for mid and low rectal cancer is LaTME. LaTME effectively removes rectal cancer while preserving surrounding tissues; however, it has certain limitations in treating mid and low rectal cancers, particularly due to a relatively high risk of postoperative anastomotic leakage [4]. To mitigate this risk, conventional LaTME is frequently performed in conjunction with a preventive stoma. However, the use of a preventive stoma can lead to increased postoperative pain and inconvenience for patients, as well as impose economic burdens due to subsequent stoma reversal surgery. Therefore, minimizing the need for preventive stomas without increasing the rate of anastomotic leakage has become a critical focus in improving surgical techniques for rectal cancer [5]. Recent advancements in medical technology have facilitated the gradual adoption of various surgical techniques in rectal cancer surgery. This has resulted in the development of combined strategies designed to address the limitations of conventional LaTME and reduce the incidence of anastomotic leakage [6]. The comprehensive application of these multiple technologies includes:1.ICG tracing navigation: employing indocyanine green (ICG) fluorescence to enhance lymph node dissection through improved tracing [7]; 2. Adequate mobilization of the splenic flexure: ensuring sufficient intestinal length to relieve anastomotic tension [8]; 3. Preservation of the left colic artery with high ligation of the inferior mesenteric vein and dissection of No. 253 lymph nodes\u0026mdash;further reducing the risk of local recurrence [9]; 4. Conventional TME technique [10]; 5. ICG-guided assessment of blood supply before and after anastomosis: evaluating blood supply at the anastomotic site to reduce instances of anastomotic leakage resulting from inadequate perfusion [11]. 6. Enhanced anastomotic suturing using barbed sutures: This technique reinforces the anastomotic suture and mitigates the risk of anastomotic leakage [12]. We have innovatively designated this surgical strategy, which integrates the aforementioned techniques, as the \"PHISTA Technique\" derived from the initial letters of each respective method.\u003c/p\u003e\u003cp\u003eAlthough the theoretical application of PHISTA Technique shows promise in reducing anastomotic leakage, there is a significant lack of systematic evidence regarding its effectiveness and safety in clinical practice. This includes uncertainty regarding whether it can further reduce the incidence of anastomotic leakage in the absence of a preventive stoma. Therefore, this study aims to assess the impact of PHISTA Technique on postoperative anastomotic leakage rates in patients with mid and low rectal cancer through retrospective data analysis, thus providing a reliable reference for clinical practice.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n\u003ch2\u003ePatients\u003c/h2\u003e\n\u003cp\u003eA total of 95 patients diagnosed with mid and low rectal cancer were consecutively enrolled at Northern Jiangsu People's Hospital in Jiangsu Province from December 2022 to December 2024. The inclusion criteria for this study were as follows: 1. Age between 18 and 80 years; 2. Diagnosis of rectal adenocarcinoma confirmed by electronic colonoscopy and pathology; 3. First-time surgical intervention; 4. Laparoscopic surgery; 5. Availability of complete clinical and pathological data, along with follow-up information; 6. Absence of severe cardiovascular or metabolic diseases; 7. No evidence of distant metastasis prior to surgery and no administration of neoadjuvant chemoradiotherapy; 8. Informed consent obtained from the patient or their authorized representative. The exclusion criteria were: 1. Preoperative neoadjuvant therapy or perioperative radiotherapy; 2. History of other malignant tumors; 3. Emergency surgery required due to obstruction, perforation, or bleeding; 4. Severe mental illness; 5. Pregnant or lactating women.\u003c/p\u003e\n\u003cp\u003eAll surgical procedures were conducted by the same surgical team to ensure consistency in technique and approach. After being fully informed of the advantages and disadvantages associated with both the PHISTA Technique and conventional LaTME surgery, patients were given the autonomy to freely choose their preferred surgical method. Informed consent was obtained from all participants involved in this study, which was approved by the Ethics Committee of Northern Jiangsu People's Hospital in Jiangsu Province (No. 2024ky343).\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eThe fundamental characteristics, perioperative data, and follow-up information of the patients were systematically collected the basic characteristics included gender, age, body mass index (BMI), preoperative hemoglobin levels, maximum tumor diameter, distance from the lower edge of the tumor to the anal verge, degree of tumor differentiation, and the American Joint Committee on Cancer (AJCC) stage. The AJCC stage serves as an indicator of the pathological progression of cancer. Perioperative data included operation time, length of hospital stay, time to first postoperative flatus, time to first postoperative defecation, intraoperative blood loss, total number of lymph nodes dissected, use of intraoperative prophylactic stoma, incidence of postoperative anastomotic leakage, and relevant pathological data, which were obtained from surgical records and pathological reports. The primary outcome was the incidence of postoperative anastomotic leakage. The secondary outcome was the occurrence of postoperative complications.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eSurgical approaches Statistical analysis\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003e\u003cstrong\u003e1. Laparoscopic total mesorectal excision(LaTME)\u003c/strong\u003e: The patient was positioned in the lithotomy position and general anesthesia was administered. Appropriate pneumoperitoneum pressure was established, and trocar insertion was performed at the following locations: 0.5 cm above the umbilicus, at the right midclavicular line 1 fingerbreadth below the umbilicus, at the corresponding position on the left side, and at McBurney's point. Intra-abdominal conditions were meticulously observed. The sigmoid mesocolon was dissected, followed by the freeing and transection of the inferior mesenteric artery and vein. Rectal dissection was performed along the anterior rectal space and presacral space to expose the levator ani muscle. After incising the anterior peritoneum at the fold, dissection of the seminal vesicles was performed in male patients, while in female patients, dissection of the vaginal-rectal septum facilitated exposure of the rectal mesorectum. Rectal dissection was carried out in accordance with the principles of Total Mesorectal Excision (TME). The distal rectal mesorectum was resected at least 5 cm from its lower margin, and the intestinal tract was transected and closed with a stapler placed more than 2 cm below the tumor's lower margin. A 5 cm extension of the midline incision in the lower abdomen was made to facilitate specimen removal following intestinal resection. The blood supply to the intestinal tract was carefully assessed, and if deemed adequate, the intestinal segments were reintroduced into the abdominal cavity and pneumoperitoneum was re-established. A circular stapler was then introduced through the anal canal to perform laparoscopic-assisted intestinal anastomosis, after which the stapler was removed. Anal preservation was not performed when the tumor was located low enough such that a negative margin could not be ensured within 2 cm from the lower edge of the tumor.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2. PHISTA Technique\u003c/strong\u003e: The patient was placed in the lithotomy position, general anesthesia was administered, and an appropriate pneumoperitoneum pressure was established. Under endoscopic guidance, incisions were made at the umbilical level and in the left and right lower abdomen, with Trocar insertion at these locations. Intra-abdominal conditions were closely monitored via laparoscopy. Indocyanine green (ICG) solution was injected into the serosal layer 1 cm from the tumor margin \u003cstrong\u003e(\u003c/strong\u003eFig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003eA-\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003eC\u003cstrong\u003e)\u003c/strong\u003e, and the splenic region was dissected upward along the lateral aspect of the sigmoid colon. The splenic region was fully mobilized, followed by complete mobilization of the left colon \u003cstrong\u003e(\u003c/strong\u003eFig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003eD-\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003eF\u003cstrong\u003e)\u003c/strong\u003e. The mesocolon was approached via the intermediate route, and the sigmoid mesocolon was carefully dissected. The left colic artery was preserved under fluorescence-guided laparoscopic imaging, and No. 253 lymph nodes, including those along the mesenteric artery and retroperitoneal lymph nodes, were excised \u003cstrong\u003e(\u003c/strong\u003eFig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003eG-\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003eI\u003cstrong\u003e)\u003c/strong\u003e. The inferior mesenteric vein was ligated at a high level \u003cstrong\u003e(\u003c/strong\u003eFig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003eA-\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003eC\u003cstrong\u003e)\u003c/strong\u003e. The dissection was extended laterally through Toldt\u0026rsquo;s space, and the dorsal aspect of the left colon was fully mobilized. The dissection continued downward along the presacral space in accordance with Total Mesorectal Excision (TME) principles, reaching the level of the levator ani muscle. The bowel was exposed, and the anterior rectal wall was separated from the bladder within the space between Denonvillier\u0026rsquo;s fascia. The bowel was fully mobilized, and an EC60 stapler was employed to transect the colon. In cases of high rectal cancer, the rectum was mobilized approximately 5 cm below the tumor. Similarly, in cases of low rectal cancer, the rectum was also mobilized 5 cm below the tumor. A 4 cm midline abdominal incision was made, and following entry into the abdominal cavity, a plastic bag was used to protect the incision. The proximal rectum containing the tumor was extracted from the abdominal cavity, and the rectum was transected approximately 10 cm above the tumor. The specimen was removed, a purse-string clamp was applied, sutures were placed at the base, tightened, and returned to the abdominal cavity for safekeeping. Pneumoperitoneum was re-established, and the anal canal was irrigated with saline prior to the insertion of an anastomosis stapler transanally. Prior to anastomosis, ICG was injected intravenously to assess bowel perfusion \u003cstrong\u003e(\u003c/strong\u003eFig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003eD-\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003eF\u003cstrong\u003e)\u003c/strong\u003e. If the blood supply was deemed adequate, the anastomosis was reinforced with barbed sutures under laparoscopic guidance \u003cstrong\u003e(\u003c/strong\u003eFig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003eG-\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003eI\u003cstrong\u003e)\u003c/strong\u003e. Anal preservation was not performed when the tumor was located sufficiently low such that a negative margin could not be assured within 2 cm from the lower edge of the tumor.\u003c/p\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\n\u003ch2\u003eStatistical analysis\u003c/h2\u003e\n\u003cp\u003eData analysis was conducted using SPSS 26.0 (SPSS, Chicago, Illinois, USA). Categorical data are presented as percentages (%). Fisher's exact test or \u0026chi;2 test was employed to assess the accuracy of comparative analysis. Normally distributed continuous variables were analyzed using the t-test and are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD). Non-normally distributed continuous variables were analyzed using non-parametric tests and are presented as median (interquartile range). A P-value of \u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 95 patients were ultimately included in the study, among which 35 were in the PHISTA Technique group and 60 in the LaTME group. The follow-up results of the patients were recorded until discharge.\u003c/p\u003e\n\u003ch3\u003eBasic characteristics of the patients\u003c/h3\u003e\n\u003cp\u003eA total of 95 patients were enrolled in this study, with 35 in the PHISTA Technique group and 60 in the LaTME group. No significant differences were observed in baseline characteristics between the two groups \u003cstrong\u003e(\u003c/strong\u003eTable \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cstrong\u003e).\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eBasic characteristics of the patients\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCharacteristics\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePHISTA\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;35)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eLaTME\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;60)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eX\u0026sup2;/t/Z\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eP\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSex, n (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eX\u0026sup2;=0.794\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e0.373\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e22(62.9)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e43(71.7)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e13(37.1)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e17(28.3)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (years), mean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e65.06\u0026thinsp;\u0026plusmn;\u0026thinsp;11.84\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e66.03\u0026thinsp;\u0026plusmn;\u0026thinsp;10.78\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003et=-0.410\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.682\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eBMI (kg/m2), median (IQR)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e22.49(21.19,24.44)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e23.32(21.34,25.44)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eZ=-1.300\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.194\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePreoperative hemoglobin, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eX\u0026sup2;=0.145\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.703\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;120g/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e10(28.6)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e15(25.0)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ge;\u0026thinsp;120g/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e25(71.4)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e45(75.0)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eThe maximal diameter of the tumor (cm), mean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e4.11\u0026thinsp;\u0026plusmn;\u0026thinsp;1.44\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e3.80\u0026thinsp;\u0026plusmn;\u0026thinsp;1.11\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003et\u0026thinsp;=\u0026thinsp;1.187\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.238\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eThe distance from the inferior margin of the tumor to the anal verge, median (IQR)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e10.00(8.00,12.00)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e8.00(5.00,10.00)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eZ=-0.702\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.482\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAJCC stage, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eX\u0026sup2;=0.008\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.928\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eI-II\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e19(54.3)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e32(53.3)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIII-IV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e16(45.7)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e28(46.7)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTumor differentiation, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eX\u0026sup2;=1.733\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.368\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWell and moderate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e1(2.9)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e0(0)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePoor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e34(97.1)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e60(100.0)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\n \u003ch2\u003ePerioperative outcomes\u003c/h2\u003e\n \u003cp\u003eThe preventive stoma rate in the PHISTA Technique group was 0%, significantly lower than that in the LaTME group (31.7%, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The anastomotic leakage rate in the PHISTA Technique group was 5.7%, compared to 6.7% in the LaTME group. The anastomotic leakage rate in the PHISTA Technique group was slightly lower than that in the conventional TME group; however, no significant difference was found between the two groups (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). No statistically significant differences were observed between the PHISTA Technique group and the LaTME group regarding intraoperative indicators (e.g., operation time, intraoperative blood loss, and number of lymph nodes dissected) (P values: 0.116, 0.268, and 0.066, respectively). No statistically significant differences were observed between the PHISTA Technique group and the LaTME group in terms of postoperative recovery indicators (e.g., time to first postoperative flatus, time to first postoperative defecation, and length of hospital stay) (P values: 0.409 and 0.342, respectively). The operation time in the PHISTA Technique group was slightly longer than in the LaTME group; however, no statistically significant difference was found between the two groups (median time: 145 minutes vs. 132 minutes, P\u0026thinsp;=\u0026thinsp;0.440) \u003cstrong\u003e(\u003c/strong\u003eTable\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cstrong\u003e)\u003c/strong\u003e.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003ePerioperative outcomes\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCharacteristics\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePHISTA\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;35)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eLaTME\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;60)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eX\u0026sup2;/t/Z\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eP\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eOperation time (min), median (IQR)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e145.00(110.00,175.00)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e132.(110.00,155.00)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eZ=-0.773\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e0.440\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePostoperative hospitalization (d), median (IQR)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e13.04(11.03,15.71)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e11.96(10.03,14.57)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eZ=-1.836\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e0.066\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime to first gas passing (d), median (IQR)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e4.00(3.00,5.00)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e3.00(3.00,4.00)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eZ=-1.573\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.116\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime to first stool passing (d), median (IQR)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e5.00(4.00,6.00)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e5.00(3.25,6.00)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eZ=-1.107\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.268\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eEstimated blood loss (ml), median (IQR)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e50.00(20.00,50.00)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e50.00(20.00,50.00)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eZ=-0.825\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.409\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of lymph nodes dissected, mean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e14.60\u0026thinsp;\u0026plusmn;\u0026thinsp;6.98\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e13.37\u0026thinsp;\u0026plusmn;\u0026thinsp;5.08\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003et\u0026thinsp;=\u0026thinsp;0.992\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.324\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of preventive stomas, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e0(0)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e19(31.7)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eX\u0026sup2;=13.854\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of anastomotic leaks, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e2(5.7)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e4(6.7)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eX\u0026sup2;=0.034\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.000\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study assessed the treatment outcomes of the PHISTA Technique\u0026mdash;a composite of various surgical approaches for rectal cancer resection\u0026mdash;in the context of mid and low rectal cancer, a subject that has been scarcely explored in the literature. This study assessed the treatment outcomes of the PHISTA Technique\u0026mdash;a composite of various surgical approaches for rectal cancer resection\u0026mdash;in the context of mid and low rectal cancer, a subject that has been scarcely explored in the literature. A total of 95 patients were included in a retrospective, comprehensive analysis to evaluate the feasibility, safety, and efficacy of the PHISTA Technique. The results demonstrate that, compared to conventional laparoscopic total mesorectal excision (LaTME), the PHISTA Technique significantly reduces the preventive stoma rate while maintaining an anastomotic leakage rate that is comparable to or slightly lower than that of the LaTME group.\u003c/p\u003e\u003cp\u003eColorectal cancer, particularly rectal cancer, represents one of the most prevalent malignancies worldwide, with both its incidence and mortality rates ranking among the highest across all cancer types. The incidence of rectal cancer has been steadily increasing, driven by changes in lifestyle and dietary habits. Specifically, mid and low rectal cancers present significant challenges in surgical treatment due to their distinctive anatomical location. Surgical procedures must not only ensure complete tumor resection but also strike a balance between resection extent and anal function preservation, necessitating advanced surgical expertise. Additionally, postoperative complications, particularly anastomotic leakage, remain critical factors influencing patient recovery.\u003c/p\u003e\u003cp\u003eTreatment goals for mid and low rectal cancer typically include: (1) complete tumor resection to ensure no residual cancer cells; (2) maximizing anal function preservation to minimize postoperative incontinence and maintain quality of life; (3) reducing postoperative complications, particularly anastomotic leakage, a major contributor to poor recovery outcomes; and (4) enhancing overall patient quality of life and facilitating prompt recovery. However, despite advancements in conventional surgical techniques, the incidence of anastomotic leakage remains notably high, particularly in mid and low rectal cancer cases. Anastomotic leakage not only prolongs hospital stays but also significantly increases the risk of reoperation, imposing substantial physical and psychological burdens on patients [13]. These challenges have prompted clinical researchers and surgeons to continuously pursue more refined and effective surgical techniques. Recently, several modified surgical approaches have emerged, aimed at enhancing safety, improving surgical outcomes, and facilitating postoperative recovery while minimizing complication rates. The ongoing refinement and innovation of these techniques seek to provide better treatment options for patients with mid and low rectal cancer, ultimately enhancing prognosis and quality of life.\u003c/p\u003e\u003cp\u003eTotal mesorectal excision (TME) remains the gold standard surgical approach for rectal cancer treatment. The core principle involves complete removal of the rectum and its mesorectum to achieve radical tumor resection and reduce the rate of local recurrence [14]. With advancements in laparoscopic technology, laparoscopic total mesorectal excision (LaTME) has progressively become one of the standard treatment modalities for mid and low rectal cancer [15]. However, LaTME presents certain limitations: (1) In patients with mid and low rectal cancer, the incidence of anastomotic leakage following LaTME remains relatively high. Anastomotic leakage following surgery can severely impede postoperative recovery, significantly prolong hospital stays, and exacerbate both the physical and psychological suffering of patients [16]. (2) To mitigate the risk of anastomotic leakage, LaTME frequently necessitates the creation of a preventive stoma. However, preventive stomas negatively affect both the quality of life and mental health of patients, and require a subsequent stoma reversal surgery, which increases both the economic burden and patient suffering [13]. Therefore, minimizing the need for preventive stomas without elevating the anastomotic leakage rate is a critical focus in ongoing advancements in rectal cancer surgical techniques. Consequently, based on LaTME, numerous techniques and related research have been conducted to mitigate anastomotic complications, including preservation of the left colic artery, high-ligation of the inferior mesenteric vein, integrated application of ICG technology during surgery, splenic flexure mobilization, and anastomotic reinforcement suturing. The innovative integration of these techniques forms the \"PHISTA Technique\", which optimizes intraoperative strategies to enhance the blood supply and tension at the anastomosis, reduce the incidence of anastomotic leakage, and diminish the need for preventive stomas.\u003c/p\u003e\u003cp\u003eLow-level ligation of the inferior mesenteric artery (i.e., preservation of the LCA), represents a core advancement in the PHISTA Technique. Conventional LaTME emphasizes complete resection of the rectal mesorectum, typically involving high-ligation of the IMA at its root to excise mesenteric root lymph nodes. However, high-level ligation may compromise blood supply to the proximal left colon, thereby increasing the risk of anastomotic leakage [17]. In contrast, the PHISTA Technique focuses on low-level ligation of the IMA and preservation of the LCA and its ascending branch, which significantly enhances blood supply to the proximal intestinal segment of the anastomosis [18]. A study by Sung et al. visually demonstrated, using ICG injection and infrared fluorescence imaging, that preserving the LCA ensures a more robust blood supply to the anastomosis [19]. Further research by Li et al. demonstrated that clamping the LCA markedly reduced the blood supply to the proximal intestinal segment of the anastomosis from 9.2 IU/s to 5.4 IU/s, thereby heightening the risk of anastomotic leakage [20]. Furthermore, a study by Huang et al. indicated that there was no statistically significant difference in the clearance of No. 253 lymph nodes between patients with and without LCA preservation [21]. In summary, these findings suggest that preserving the LCA not only enhances the blood supply to the anastomosis but also does not interfere with the clearance of No. 253 lymph nodes or adversely affect patients' oncological prognosis, while reducing the risk of postoperative anastomotic leakage. Overall, preservation of the left colic artery during radical resection of rectal cancer ensures improved blood supply to the proximal colon, fosters favorable\u003c/p\u003e\u003cp\u003eIn addition to left colic artery preservation, high-ligation of the inferior mesenteric vein (IMV) constitutes another key aspect of the PHISTA Technique. The site of IMV ligation during rectal cancer surgery remains a subject of debate. Researchers in Europe and the United States advocate for high-ligation of the IMV at the lower edge of the pancreas, in accordance with the principle of central vascular ligation. This approach is believed to prevent tumor spread, facilitate lymph node dissection at the vessel root, and increase bowel mobility, thus reducing anastomotic tension and facilitating bowel anastomosis [22]. In contrast, Japanese researchers suggest ligating and transecting the IMV as distally as possible to avoid intestinal congestion [23]. In our center, the inferior mesenteric vein is ligated at a high position, specifically at the lower edge of the pancreas. Subsequently, the transverse mesocolon and splenic flexure mesocolon are dissected along the avascular plane towards the vascular arch, further alleviating anastomotic tension. Furthermore, due to the abundant venous collateral circulation within the mesocolon, no complications related to high IMV ligation have been observed in our patients thus far, providing preliminary evidence for its safety. However, it is important to note that the current sample size is limited. While initial results suggest that high ligation of the IMV is both safe and effective, its long-term clinical impact requires validation through larger-scale and multi-center studies. Future research, with the accumulation of more surgical cases and in-depth clinical data analysis, will allow for a more comprehensive evaluation of the clinical significance of high IMV ligation in rectal cancer surgery. Further optimization of this technique will offer more ideal treatment options for patients with mid and low rectal cancer, thereby reducing surgical difficulty, minimizing the risk of postoperative anastomotic leakage, and improving postoperative recovery and quality of life.\u003c/p\u003e\u003cp\u003eThe complete or partial mobilization of the splenic flexure of the colon further enhances the efficacy of the PHISTA Technique. Mobilization of this anatomical region is of considerable clinical significance in the radical resection of rectal cancer. It facilitates comprehensive tumor excision, improves blood supply to the proximal intestinal segment, and alleviates tension at the anastomotic site, thereby reducing the risk of anastomotic leakage [24]. However, the question of whether to perform complete or partial mobilization of the splenic flexure remains a topic of ongoing debate. Some scholars advocate for transecting only the phrenocolic ligament, asserting that this method is relatively simple and does not significantly prolong the operative time [25]. In contrast, others recommend a more standardized approach, which involves not only cutting through the gastrocolic ligament, but also the splenocolic ligament, phrenocolic ligament, and the left portion of the transverse mesocolon, thereby achieving full mobilization of both the left half of the transverse colon and the splenic flexure [26]. At our center, the decision to sever ligaments is made based on the individual characteristics of each patient, in order to achieve effective mobilization of the intestinal segments. This targeted approach to splenic flexure mobilization allows for thorough detachment of both the intestinal segments and mesentery, while minimizing the risk of anastomotic leakage, though it may slightly increase the operation time. Furthermore, careful dissection around the ligaments and omentum adjacent to the colon helps reduce traction on the spleen, thereby minimizing the risk of iatrogenic splenic injury.\u003c/p\u003e\u003cp\u003eAdditionally, the use of ICG fluorescence navigation technology has further improved the clinical efficacy of the PHISTA technique. In 2006, Nagata et al. published the first research on the application of ICG in colorectal surgery [27]. As fluorescence imaging technology has matured, ICG has been increasingly used in colorectal surgery for intraoperative assessment of anastomotic blood perfusion and lymph node visualization, yielding significant results. (1) ICG-guided dissection of the No. 253 lymph nodes: The No. 253 lymph nodes is identified as the lymph node located along the inferior mesenteric artery (IMA), extending from the origin of the left colic artery to the point of origin of the IMA. This lymph node serves as the third station for lymphatic drainage in cases of rectal cancer and represents a significant pathway for the dissemination and metastasis of cancer cells, particularly in advanced stages of rectal cancer. The degree of dissection of the No. 253 lymph nodes has a direct influence on prognosis [28]. In recent years, ICG fluorescence navigation has played a significant role in the dissection of the No. 253 lymph nodes. Studies have demonstrated that ICG fluorescence imaging can visualize lymphatic drainage, thus improving the accuracy and completeness of lymph node resection in colorectal cancer surgery [29]. Another study investigated the use of ICG in radical lymph node dissection for sigmoid colon and rectal cancer, revealing that ICG imaging aids in complete dissection of D3 lymph nodes and identification of overlooked D3 lymph nodes, thereby improving the dissection rate, providing better surgical staging, and enhancing patient survival [30]. In summary, the use of ICG fluorescence imaging for lymph node dissection enhances detection range and improves surgical quality. (2) Beyond its role in lymph node visualization, ICG fluorescence also plays a crucial role in assessing anastomotic blood perfusion during surgery [19]. Anastomotic leakage (AL) is a severe complication following rectal cancer surgery, often leading to prolonged hospital stays, increased costs, and decreased survival. Poor anastomotic perfusion is a major risk factor [31] [32]. Therefore, intraoperative assessment of blood supply is crucial. NIR-ICG provides accurate information on anastomotic perfusion during rectal cancer surgery and is a highly valuable detection method. Jafari et al. observed 16 patients who underwent robotic low anterior resection (LAR) of the rectum. With ICG fluorescence angiography, 19% of cases achieved a more precise resection, indicating that ICG-NIR imaging can effectively reduce AL incidence [33]. In a multicenter phase II trial involving 90 LAR patients, ICG fluorescence guidance was used for all, with only 3% developing AL, significantly lower than those who did not use ICG guidance during the same period [34]. However, limitations exist in current ICG fluorescence systems. According to clinical practice [35], various factors such as the dose of ICG, duration of use, laparoscopic lens position, distance to the intestine, ambient light, NIR intensity, patient characteristics, and the surgeon\u0026rsquo;s subjective perception may influence the accuracy and consistency of ICG imaging, thereby impacting lymph node dissection and anastomotic perfusion assessment. Future development of more precise and stable ICG technologies is crucial for enhancing the thoroughness and accuracy of lymph node dissection, while providing an objective, quantitative tool for assessing anastomotic perfusion, thereby improving surgical precision and patient outcomes.\u003c/p\u003e\u003cp\u003eFinally, the reinforced suture of the anastomosis using barbed suture provides a more stable assurance for the PHISTA technique. The reinforcement of the anastomotic suture following digestive tract surgery can address potential defects at the anastomosis site [27]. The comprehensive application of the aforementioned techniques has ensured moderate tension and optimal blood perfusion at the anastomosis. Building on this foundation, the use of reinforced sutures with barbed sutures can further diminish the incidence of anastomotic leakage, particularly in high-risk patients such as those with diabetes and severe anemia [36]. Research indicates that reinforced suturing significantly reduces rates of anastomotic leakage, a finding corroborated by multiple meta-analyses [37] [38].\u003c/p\u003e\u003cp\u003eShort-term efficacy was a primary outcome measure in this study. The results indicated that the preventive stoma rate in the PHISTA Technique group was 0%, which is significantly lower than the 31.7% observed in the conventional LaTME group (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Furthermore, the anastomotic leakage rate in the PHISTA Technique group was recorded at 5.7%, compared to 6.7% in the conventional LaTME group. Although the anastomotic leakage rate in the PHISTA Technique group was marginally lower than that of the conventional LaTME group, no statistically significant difference was found between these two groups (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05).Regarding intraoperative indicators\u0026mdash;such as operation time, intraoperative blood loss, and total number of lymph nodes dissected\u0026mdash;there were no statistically significant differences between the PHISTA Technique and LaTME groups (P values were 0.116, 0.268, and 0.066, respectively). Similarly, for postoperative recovery indicators\u0026mdash;including time to first postoperative exhaust, time to first postoperative defecation, and length of hospital stay\u0026mdash;no statistically significant differences were noted between these two techniques (P values were 0.409 and 0.342 respectively). Additionally, while it is worth noting that operation time for patients undergoing PHISTA Technique was slightly longer than that for those receiving LaTME (median times being 145 minutes vs.132 minutes), this difference did not reach statistical significance (P\u0026thinsp;=\u0026thinsp;0.440). These findings suggest that while employing the PHISTA Technique can substantially reduce preventive stoma rates without increasing anastomotic leakage rates beyond those seen with traditional LaTME methods\u0026mdash;and may even result in a slight decrease\u0026mdash;it also demonstrates comparable short-term recovery outcomes relative to LaTME. This aligns with existing literature and further substantiates both safety and feasibility associated with utilizing the PHISTA Technique despite its marginally extended operation duration when compared to standard practices within this domain.\u003c/p\u003e\u003cp\u003eIn conclusion, the findings of this study indicate that the PHISTA Technique offers significant advantages in the treatment of mid and low rectal cancer. This innovative approach integrates multiple advanced surgical techniques and optimizes both the surgical process and postoperative recovery conditions for patients with mid and low rectal cancer from various perspectives. As a result, it provides a safe, effective, and novel treatment option. The PHISTA Technique notably reduces the rate of preventive stoma without increasing the incidence of anastomotic leakage. Furthermore, it enhances patients' quality of life while alleviating the economic burden and psychological stress associated with subsequent stoma reversal surgery. This model of multi-technique integration presents a more efficient and secure treatment alternative for rectal cancer patients, thereby diminishing their economic and psychological burdens. Overall, these findings underscore the important clinical value of promoting this innovative technique within medical practice.\u003c/p\u003e\u003cp\u003eAlthough PHISTA Technique has shown substantial theoretical and practical advantages, it also entails several potential limitations: (1) Technical learning curve: The application of PHISTA Technique requires advanced technical proficiency from the surgeon, necessitating specialized training and experience accumulation. Novices may face challenges in mastering this technique. (2) Extended operation time: Due to its inherent complexity, the operation time for PHISTA Technique is somewhat longer than conventional LaTME procedures. However, the authors argue that as surgeons gain experience through practice, the additional time required for certain surgical steps may decrease. (3) Study limitations: This study is a single-center retrospective analysis with a relatively small sample size, which may limit the generalizability of our findings. Future multi-center, large-scale clinical studies are crucial for validating these results. (4) Long-term oncological prognosis validation: While PHISTA Technique has demonstrated promising short-term efficacy, its long-term oncological outcomes remain unexamined. Therefore, future multi-center, prospective studies with larger sample sizes and extended follow-up periods are necessary to further evaluate the oncological effects and safety profile of PHISTA Technique.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOur research provides compelling evidence supporting the feasibility, effectiveness, and safety of the PHISTA Technique in skilled surgical centers. It was observed that the PHISTA Technique significantly reduces the rate of preventive stoma without increasing the incidence of anastomotic leakage when compared to the conventional LaTME group; in fact, it may even slightly lower this incidence. This approach eliminates the necessity for subsequent stoma reversal surgery for patients, thereby alleviating their suffering and economic burden while ultimately delivering substantial benefits to them. Although the operation time for the PHISTA Technique was marginally longer than that of the LaTME group, its advantages\u0026mdash;such as reducing preventive stoma rates, optimizing anastomosis, and minimizing risks associated with anastomotic leakage\u0026mdash;outweigh this slight increase in duration. This surgical method exhibits unique advantages and good repeatability and is particularly suitable for treating patients with mid and low rectal cancer when performed by practitioners who are proficient in this technique.\u003c/p\u003e\u003cp\u003eHowever, continuous long-term monitoring remains essential to confirm both the enduring effectiveness and safety of this novel surgical approach.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e\u003cp\u003eAll surgical procedures were conducted by the same surgical team to ensure consistency in technique and approach. After being fully informed of the advantages and disadvantages associated with both the PHISTA Technique and conventional LaTME surgery, patients were given the autonomy to freely choose their preferred surgical method. Informed consent was obtained from all participants involved in this study, which was approved by the Ethics Committee of Northern Jiangsu People's Hospital in Jiangsu Province (No. 2024ky343).\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eDisclosures\u003c/h2\u003e\u003cp\u003eHao Ji, Sufen Han, Lu Zhao, Chen Wei, Yichao Ma, Jiahao Zhao, Jiayi Zhang, Daorong Wang and Dong Tang have no conflicts of interest or financial ties to disclose.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eThis work was supported by the Graduate Research- Innovation Project in Jiangsu province [No. SJCX21_1644], the Academic Science and Technology Innovation Fund for College Students [No. 202011117056Y], Social development project of key R \u0026amp; D plan of Jiangsu Provincial Department of science and technology [No. BE2022773]. The funding bodies had no role in the design of the study; in the collection, analysis, and interpretation of the data; and in the writing the manuscript.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eHao Ji, Sufen Han and Jingshu He wrote the main manuscript text. Lu Zhao prepared Figure 1. Chen Wei prepared Figure 2. Yichao Ma prepared Table 1. Jiahao Zhao and Jiayi Zhang prepared Table 2. Dong Tang is the corresponding author. All the authors reviewed the manuscript.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets used and/or analysed during the current study available from thecorresponding author on reasonable request\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBray F, Laversanne M, Sung H, Ferlay J, Siegel RL, Soerjomataram I, Jemal A: \u003cstrong\u003eGlobal cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries\u003c/strong\u003e. \u003cem\u003eCA Cancer J Clin \u003c/em\u003e2024, \u003cstrong\u003e74\u003c/strong\u003e(3):229-263.\u003c/li\u003e\n\u003cli\u003eSung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, Bray F: \u003cstrong\u003eGlobal Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries\u003c/strong\u003e. \u003cem\u003eCA Cancer J Clin \u003c/em\u003e2021, \u003cstrong\u003e71\u003c/strong\u003e(3):209-249.\u003c/li\u003e\n\u003cli\u003eArnold M, Sierra MS, Laversanne M, Soerjomataram I, Jemal A, Bray F: \u003cstrong\u003eGlobal patterns and trends in colorectal cancer incidence and mortality\u003c/strong\u003e. \u003cem\u003eGut \u003c/em\u003e2017, \u003cstrong\u003e66\u003c/strong\u003e(4):683-691.\u003c/li\u003e\n\u003cli\u003eHeald RJ, Husband EM, Ryall RD: \u003cstrong\u003eThe mesorectum in rectal cancer surgery--the clue to pelvic recurrence?\u003c/strong\u003e \u003cem\u003eBr J Surg \u003c/em\u003e1982, \u003cstrong\u003e69\u003c/strong\u003e(10):613-616.\u003c/li\u003e\n\u003cli\u003eMontedori A, Cirocchi R, Farinella E, Sciannameo F, Abraha I: \u003cstrong\u003eCovering ileo- or colostomy in anterior resection for rectal carcinoma\u003c/strong\u003e. \u003cem\u003eCochrane Database Syst Rev \u003c/em\u003e2010(5):CD006878.\u003c/li\u003e\n\u003cli\u003ePedziwiatr M, Pisarska M, Major P, Grochowska A, Matlok M, Przeczek K, Stefura T, Budzynski A, Klek S: \u003cstrong\u003eLaparoscopic colorectal cancer surgery combined with enhanced recovery after surgery protocol (ERAS) reduces the negative impact of sarcopenia on short-term outcomes\u003c/strong\u003e. \u003cem\u003eEur J Surg Oncol \u003c/em\u003e2016, \u003cstrong\u003e42\u003c/strong\u003e(6):779-787.\u003c/li\u003e\n\u003cli\u003eBarabino G, Klein JP, Porcheron J, Grichine A, Coll JL, Cottier M: \u003cstrong\u003eIntraoperative Near-Infrared Fluorescence Imaging using indocyanine green in colorectal carcinomatosis surgery: Proof of concept\u003c/strong\u003e. \u003cem\u003eEur J Surg Oncol \u003c/em\u003e2016, \u003cstrong\u003e42\u003c/strong\u003e(12):1931-1937.\u003c/li\u003e\n\u003cli\u003eHohenberger W, Weber K, Matzel K, Papadopoulos T, Merkel S: \u003cstrong\u003eStandardized surgery for colonic cancer: complete mesocolic excision and central ligation--technical notes and outcome\u003c/strong\u003e. \u003cem\u003eColorectal Dis \u003c/em\u003e2009, \u003cstrong\u003e11\u003c/strong\u003e(4):354-364; discussion 364-355.\u003c/li\u003e\n\u003cli\u003eLange MM, Buunen M, van de Velde CJ, Lange JF: \u003cstrong\u003eLevel of arterial ligation in rectal cancer surgery: low tie preferred over high tie. 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imaging\u003c/strong\u003e. \u003cem\u003eColorectal Dis \u003c/em\u003e2011, \u003cstrong\u003e13 Suppl 7\u003c/strong\u003e:12-17.\u003c/li\u003e\n\u003cli\u003eBaek SJ, Kim J, Kwak J, Kim SH: \u003cstrong\u003eCan trans-anal reinforcing sutures after double stapling in lower anterior resection reduce the need for a temporary diverting ostomy?\u003c/strong\u003e \u003cem\u003eWorld J Gastroenterol \u003c/em\u003e2013, \u003cstrong\u003e19\u003c/strong\u003e(32):5309-5313.\u003c/li\u003e\n\u003cli\u003eZhang T, Wang G, Fang G, Qiu L, Lu F, Yin K, Miao Y: \u003cstrong\u003eClinical efficacy of anastomotic reinforcement suture in preventing anastomotic leakage after rectal cancer surgery: a systematic review and meta-analysis\u003c/strong\u003e. \u003cem\u003eLangenbecks Arch Surg \u003c/em\u003e2023, \u003cstrong\u003e408\u003c/strong\u003e(1):322.\u003c/li\u003e\n\u003cli\u003eWang C, Li X, Lin H, Ju J, Zhang H, Yu Y: \u003cstrong\u003eEffect of intraoperative anastomotic reinforcement suture on the prevention of anastomotic leakage of double-stapling anastomosis for laparoscopic rectal cancer: a systematic review and meta-analysis\u003c/strong\u003e. \u003cem\u003eLangenbecks Arch Surg \u003c/em\u003e2023, \u003cstrong\u003e408\u003c/strong\u003e(1):305.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"world-journal-of-surgical-oncology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"wjso","sideBox":"Learn more about [World Journal of Surgical Oncology](http://wjso.biomedcentral.com)","snPcode":"12957","submissionUrl":"https://submission.nature.com/new-submission/12957/3","title":"World Journal of Surgical Oncology","twitterHandle":"@OncoBioMed","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Rectal cancer, LaTME, Total mesorectal excision, Surgical approach, Laparoscopy","lastPublishedDoi":"10.21203/rs.3.rs-7557920/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7557920/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eMid and low rectal cancer is among the most prevalent malignancies worldwide. Total mesorectal excision (TME) remains the standard surgical approach for these cancers; However, anastomotic leakage has consistently emerged as one of the most severe complications associated with surgeries in this patient population. In response to anastomotic complications, on the basis of conventional laparoscopic total mesorectal excision (LaTME), multiple techniques and related studies have been conducted successively. These techniques include: protection of the left colonic artery to enhance blood supply to the proximal intestinal tract; high-ligation of the inferior mesenteric vein; integrated application of indocyanine green (ICG) technology during surgery; splenic flexure mobilization, which can elongate the length of the intestinal tract and mesentery, thereby reducing the tension of the anastomosis; and reinforcement sutures for anastomoses. Our center has innovatively combined these techniques into a novel approach, termed the \"PHISTA Technique\", using the initials of the involved strategies. Additionally, various methods have been implemented to reduce the incidence of anastomotic leakage, such as the creation of a prophylactic stoma during surgery and placement of an anal decompression tube. The objective of this study is to evaluate the safety and efficacy of the PHISTA Technique in treating mid and low rectal cancer, in comparison with the conventional LaTME approach.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003ePatients diagnosed with mid and low rectal cancer between December 2022 and December 2024 were retrospectively included and categorized into the conventional LaTME group and the PHISTA Technique group. The basic characteristics and short-term outcomes of the two groups were compared.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eA total of 95 patients were enrolled in this study and categorized into two groups. The baseline characteristics of the two groups were similar. The preventive stoma rate in the PHISTA Technique group was 0%, significantly lower than the 31.7% observed in the conventional LaTME group (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The anastomotic leakage rate in the PHISTA Technique group was 5.7%, while that in the conventional LaTME group was 6.7%. The anastomotic leakage rate in the PHISTA Technique group was marginally lower than that in the conventional LaTME group, but no statistically significant difference was found between the two groups (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Regarding intraoperative indicators (e.g., operation time, intraoperative blood loss, and total number of lymph nodes dissected), no statistically significant differences were observed between the PHISTA Technique group and the conventional LaTME group (P values were 0.116, 0.268, and 0.066, respectively). In terms of postoperative recovery indicators (such as the time of first postoperative flatus, the time of first postoperative defecation, and hospital stay), there was no statistically significant difference between the PHISTA Technique group and the conventional LaTME group (P values were 0.409 and 0.342, respectively). Furthermore, the operation time in the PHISTA Technique group was marginally longer than that in the conventional LaTME group, but no statistically significant difference was found between the two groups (median time 145 minutes vs. 132 minutes, P\u0026thinsp;=\u0026thinsp;0.440).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eThe PHISTA Technique can significantly reduce the rate of preventive stoma without increasing the incidence of anastomotic leakage, and may even result in a slightly lower incidence compared to the conventional LaTME group. This approach eliminates the need for a subsequent stoma reversal surgery, thereby reducing patient suffering and economic burden, ultimately providing the greatest benefit to patients.\u003c/p\u003e","manuscriptTitle":"The Application of Intraoperative Strategies to Reduce Prophylactic Stoma in Mid and Low Rectal Cancer: A Retrospective Study Utilizing Indocyanine Green and Precise Anatomical Techniques","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-23 07:10:55","doi":"10.21203/rs.3.rs-7557920/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-04T16:38:32+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-04T16:34:25+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-24T05:30:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"184563271107413189453586348192740571332","date":"2025-09-15T07:54:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"203844437465574287583586442892772541858","date":"2025-09-14T23:25:26+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-14T12:51:23+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-13T03:40:11+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-08T00:53:35+00:00","index":"","fulltext":""},{"type":"submitted","content":"World Journal of Surgical Oncology","date":"2025-09-07T17:38:08+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"world-journal-of-surgical-oncology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"wjso","sideBox":"Learn more about [World Journal of Surgical Oncology](http://wjso.biomedcentral.com)","snPcode":"12957","submissionUrl":"https://submission.nature.com/new-submission/12957/3","title":"World Journal of Surgical Oncology","twitterHandle":"@OncoBioMed","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"38d1d891-9653-4629-b452-59b60f0d0fb9","owner":[],"postedDate":"September 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-01-05T16:05:51+00:00","versionOfRecord":{"articleIdentity":"rs-7557920","link":"https://doi.org/10.1186/s12957-025-04180-8","journal":{"identity":"world-journal-of-surgical-oncology","isVorOnly":false,"title":"World Journal of Surgical Oncology"},"publishedOn":"2026-01-02 15:56:54","publishedOnDateReadable":"January 2nd, 2026"},"versionCreatedAt":"2025-09-23 07:10:55","video":"","vorDoi":"10.1186/s12957-025-04180-8","vorDoiUrl":"https://doi.org/10.1186/s12957-025-04180-8","workflowStages":[]},"version":"v1","identity":"rs-7557920","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7557920","identity":"rs-7557920","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}