Gianpiero Gravante

Colorectal cancer surgery has moved beyond an era in which progress was measured almost exclusively by the ability to perform a safe resection. Contemporary surgical quality is now defined by a broader and more demanding framework: oncological radicality, preservation of function, prevention of complications, perioperative recovery, pathological accuracy, survivorship, cost-effectiveness, and -above all -the capacity to individualize treatment. This Research Topic captures that transition. The included contributions do not simply describe isolated technical refinements; collectively, they show how colorectal cancer surgery is becoming an integrated pathway in which operative technique, perioperative optimization, risk prediction, pathology, nursing care, reconstruction, and long-term functional recovery are increasingly interconnected. A purely descriptive summary of the articles would underestimate the value of the collection.Across the 21 contributions, five major areas emerge: oncological quality and staging, technology-enabled surgical precision, prediction and mitigation of perioperative risk, optimization of recovery through ERAS and prehabilitation, and patient-centered survivorship. These areas are not separate, but represent different expressions of the same evolution: from procedure-centered colorectal surgery to personalized colorectal cancer care.The first thematic area concerns oncological adequacy. Lymph node retrieval, D3 dissection, fluorescence guidance, and pathological processing are presented in the collection not as isolated technical endpoints, but as determinants of staging quality and treatment planning [1,2,3,4].The studies addressing lymph node yield emphasize that the traditional threshold of 12 nodes remains clinically important, but also imperfect. It is affected by patient factors, tumor stage, neoadjuvant therapy, anatomical complexity, surgical dissection, and the methodology of pathological examination [1,2]. Therefore, lymph node count should be interpreted as a multidisciplinary quality indicator rather than as a simple surrogate of surgical performance. This concept is strengthened by the work on fluorescence-guided surgery and right-sided D3 lymphadenectomy [3,4]. Indocyanine green may support intraoperative lymphatic mapping and perfusion assessment, while a more extended medial boundary for D3 dissection may increase nodal yield. However, the collection also reminds us that greater visualization or wider dissection must ultimately be judged against clinically meaningful outcomes: margin status, recurrence, survival, morbidity, and value. The challenge for future research is not merely to demonstrate that more nodes can be retrieved, but to clarify when additional staging information changes adjuvant treatment, follow-up intensity, or survival.A second major theme is the evaluation of surgical innovation. The studies on intracorporeal anastomotic configuration, robotic proctectomy, robotic platform evolution, robotic intersphincteric resection, and robotic versus laparoscopic colorectal surgery converge on a cautious but important conclusion: innovation should be assessed according to indication, anatomy, complexity, learning curve, and patient-centered benefit rather than by technological enthusiasm alone [5,6,7,8,9].The comparison between overlap and pi-shaped ileotransverse anastomosis in laparoscopic right hemicolectomy illustrates this principle well [5]. A reconstruction technique may improve operative efficiency, inflammatory response, bowel recovery, and tolerance of oral intake without necessarily proving superiority for anastomotic leakage, particularly when event rates are low and statistical power is limited. The robotic studies add further nuance [6,7,8,9]. Robotic surgery may offer advantages in selected rectal cancer scenarios, especially in the low pelvis, where access, visualization, instrument articulation, and precision may affect circumferential margin status, mesorectal integrity, sphincter preservation, and functional outcomes. At the same time, the collection shows that robotics is not automatically superior to laparoscopy in all patients. Longer operative time, increased costs, platform-specific performance, and institutional experience remain critical variables. The evolution from Si to Xi platforms demonstrates that 'robotic surgery' is not a fixed exposure; it changes with technology, docking efficiency, team familiarity, and case selection [7]. Future comparative studies should therefore avoid simplistic robotic-versus-laparoscopic framing and instead identify the patient, tumor, and system-level contexts in which robotic surgery definitely provides real incremental value.The third thematic area is perioperative risk. Several contributions focus on anastomotic fistula, moderate-to-severe complications after primary tumor resection in metastatic colorectal cancer, experimental effects of 5-fluorouracil on anastomotic integrity, parastomal hernia, and complex pelvic reconstruction [10,11,12,16,17]. Their common message is that postoperative complications should not be regarded as unpredictable events occurring after the operation; instead, they should be anticipated, modeled, and, where possible, modified before and during surgery.Prediction models for anastomotic fistula and postoperative complications are particularly relevant in this respect [10,12]. Variables such as tumor location and stage, operative duration, albumin level, and patient-related characteristics represent modifiable or actionable domains that may influence nutritional optimization, diversion strategy, operative planning, postoperative surveillance, and informed consent. Similarly, the experimental meta-analysis on 5-fluorouracil and anastomotic healing highlights the biological dimension of anastomotic safety [11]. Although animal data cannot directly dictate clinical practice, they help frame anastomotic leakage as a biological and mechanical event...

Background: Mucopexy has emerged as a nonexcisional alternative to Milligan–Morgan (MM) hemorrhoidectomy. Objective: This study compares MM, mucopexy, and hybrid MM/mucopexy procedures in patients with grade III hemorrhoidal disease (HD). Design: Retrospective cohort study. Setting: Tertiary referral setting. Patients: Symptomatic grade III HD treated between 2016 and 2018. Interventions: Four groups were defined: group 1 included patients treated with MM alone; group 2 received mucopexy on one pile combined with MM on the remaining two; group 3 underwent mucopexy on two piles with MM on the remaining one; and group 4 was treated with mucopexy alone. Main outcomes measures: Recurrence rates and patient-reported outcome measures (PROMs) using a visual-analogic scale (VAS) at 2 years, postoperative pain at 7 days, early complication rates at 30 days, and PROMs at 30 days. Results: A total of 686 consecutive patients with III-degree HD were included in the analysis. The most frequent approach was MM alone (group 1, n = 309, 45%), followed by mucopexy alone (group 4, n = 138, 20.2%), then the combined approaches (group 2, n = 120, 17.5%; group 3, n = 119, 17.3%). Group 4 had the lowest pain scores and the highest 30-day PROM ( p < 0.001), whereas group 1 showed the best long-term results, with the lowest recurrence rate (4.2% versus 14.5% in group 4) and highest long-term PROM. Limitations: Retrospective analysis. Conclusions: Mucopexy and the hybrid procedures reduce morbidity and enhances early postoperative PROM in grade III HD. However, its higher recurrence rate suggests that a patient- and pile-specific approach may help balance efficacy with surgical invasiveness.

Purpose: The Malone antegrade continence enema (MACE) offers a minimally invasive and potentially reversible option for managing chronic constipation and fecal incontinence (FI). This systematic review evaluates its efficacy, safety, and long-term outcomes in adults. Methods: A comprehensive search was conducted across PubMed, EMBASE, and CENTRAL databases up to April 2025 to identify studies on MACE in adults. Study quality was assessed using the Newcastle–Ottawa scale. The primary outcome was the proportion of patients continuing MACE at follow-up (treatment success); failure was defined as conversion to definitive colostomy. Results: Seventeen studies with 404 patients were included. Study quality was rated moderate to good. The most common indications were neurological disorders (25.8%), prior surgeries (16.8%), idiopathic constipation (14.2%), and traumatic spinal injuries (11.6%). Techniques included terminal ileal loop (37.9%), percutaneous endoscopic cecostomy (26.0%), and appendicostomy (24.8%). Minor stoma-related complications were most frequent (39.1%), followed by fecal leakage (16.2%) and stoma stenosis (11.3%). Median follow-up was 28.5 months. At final follow-up, 75.1% of patients continued using MACE, while 9.8% required colostomy. Satisfactory outcomes were reported by 60%–83% of patients, with improvements in symptoms and quality of life. Conclusions: MACE is a safe and effective option for adults with refractory constipation or FI, especially in those aiming to avoid a permanent colostomy.

Background Chronic anal fissures (CAF) are a common proctological condition that significantly impacts patients’ quality of life. Lateral internal sphincterotomy (LIS) is widely considered the gold-standard treatment for CAF; however, postoperative fecal incontinence remains a potential risk. The aim of this study is to evaluate long-term incontinence rates following traditional LIS for CAF. Methods A retrospective analysis was conducted on patients with CAF who underwent traditional LIS. Patients with any degree of continence impairment prior to surgery, as well as those who experienced events potentially affecting continence function after surgery, were excluded from the analysis. Incontinence was assessed using the Vaizey score both preoperatively and at follow-up. Results Between January 2014 and May 2019, 98 patients met the inclusion criteria. The mean follow-up duration was 7 years (range 5–10 years). At follow-up, the Vaizey score ranged from 1 to 4 in 19 patients (19.4%) and from 5 to 9 in 5 patients (5.1%). Incontinence primarily involved gas or liquid stool; no patients reported solid stool incontinence. A total of four patients (4.1%) experienced defecatory urgency. No patients required constipating medications or reported lifestyle changes; only one patient (1.0%) required the use of pads. No correlation was found with age, sex, BMI, or smoking status. Conclusions When present, incontinence following traditional LIS is generally mild, does not require constipating medications, and does not interfere with patients’ lifestyle.

Treatments for low degree hemorrhoids (I-III degree) are numerous and so are their counterparts for higher degrees. These treatments present nebulous differences in terms of indications and outcomes among techniques. Methods previously abandoned due to side effects and long-term results have recently rejoined the mainstream due to recent peculiar modifications: Hemorrhoidal sclerotherapy is enjoying a new age of interest due to the use of the foam form of polidocanol, which is more effective than the liquid one. Various articles have already shown promising results and the logical next step is the combination of polidocanol foam with rubber-band ligation (the historical counterpart of sclerotherapy) in a technique called “sclerobanding”. In this article, we comment on the publication by Qu et al further modifying the use of sclerobanding through an endoscopic delivery for patients with grade II-III internal hemorrhoids, and present results compared with endoscopic rubber band ligation. The results achieved are promising.

Background and Objectives: We reviewed our series of anal squamous cell carcinomas (ASCC) treated over the last two decades.Methods: ASCC patients undergoing treatment at the Leicester Royal Infirmary between 1998 and 2016 were selected. Age, gender, pathological tumor characteristics, treatment adopted, the overall survival (OS), cancer‐specific survival (CSS), and disease‐free survival (DFS) at 5‐year follow‐up were recorded and calculated.Results: A total of 190 ASCC were reviewed, of these 64.2% (n = 122) received primary radical chemoradiotherapy. Complete response rate was 92.6% (n = 113) and four patients with residual disease underwent a salvage APER. Twenty‐eight patients experienced recurrent disease (23.0%) either systemic (n = 8), local (n = 14), or both (n = 6); six had a salvage APER. Complete follow‐up data are available for 63.1% patients (77/122). Overall, the locoregional failure rate of primary chemoradiotherapy (residual + recurrent disease) was present in 29 patients (29/122; 23.8%). OS was 41.6% CSS was 69.2% and DFS 60.0% at 5 years follow‐up.Conclusions: In our series of ASCC primary chemoradiotherapy had achieved significant initial complete response rates, however, long term‐follow ups still present systemic and local recurrences. APR is able to treat 30% of the pelvic recurrences (6/20), the others are either associated with systemic disease or locally inoperable masses.

Background and Objectives We have reviewed our series of rectal cancer patients with circumferential resection margin involvement (R1) with particular regard to survival and prognostic factors. Methods R1 rectal cancer patients undergoing surgery at the Leicester Royal Infirmary between 1998 and 2008. Age, gender, radiological, and pathological tumor characteristics, neoadjuvant and adjuvant therapies were examined as prognostic factors on the overall survival (OS) and disease‐free survival (DFS) at 5‐year follow‐up. Results A total of 885 rectal cancers were reviewed. Six hundred ninety‐nine patients underwent a mesorectal excision and 71 of them were R1 resections (12.9%). OS was 43.7% (CI95% 33.5–53.8%; median survival 39 months). DFS was 57.4% (CI95% 43.0–71.8%; median survival 31 months). Pelvic recurrence rate occurred in 16 patients (26.2%, CI95% 16.5–36.0%), systemic recurrence rate in 23 patients (37.7%, CI95% 25.5–49.9%). At Cox‐regression LNR and adjuvant chemotherapy were associated with both OS and DFS. No significant association was found between OS or DFS and adjuvant radiotherapy. Conclusions In our series of R1 patients, the rates of local recurrence and OS at 5 years were 26.2% and 43.7%, respectively. Factors influencing systemic recurrences (LNR, adjuvant chemotherapy) are more associated with OS and DFS than those potentially affecting locoregional recurrences (adjuvant radiotherapy). J. Surg. Oncol. 2016;114:642–648.

Gallstone disease is a major health problem that affects 1% to 4% of the Western world population every year and almost 10% to 15% during their lifetime.¹ This percentage corresponds to 6.3 million men and 14.2 million women aged 20 to 74 years in the United States.² “Difficult gallbladder” (GB) is a procedure with an increased surgical risk compared with standard cholecystectomies.^3,4 With an incidence of 16% (1 in 6) in a large series,³ difficult GB is usually associated with severe inflammation that distorts the local anatomy and renders dissections more difficult (ie, acute cholecystitis, empyema, gangrene, perforation, and Mirizzi syndrome) or with cirrhotic livers that increase the risk of bleeding. A scale was introduced by Nassar et al^5,6 to score GB difficulty based on the GB status, cystic pedicle, and degree of adhesions. This scale graded cholecystectomies into 4 grades, with grades 3 and 4 being the most difficult.