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Abstract Objective To evaluate diagnostic of serrated colorectal lesions using standardized histopathological criteria and immunohistochemical markers (BRAF V600E and Annexin A10) integrated into a proposed morphologic-immunohistochemical scoring system. Materials and Methods We performed a retrospective, blinded review of colorectal serrated lesions from institutional archives. Cases were re-evaluated by three gastrointestinal pathologists according to 2019 World Health Organization (WHO) criteria. Morphologic variables (crypt architecture, basal dilation, serration extent, mucinous differentiation, lesion size, and presence of dysplasia) were recorded. Immunohistochemistry for BRAF V600E (VE1 clone) and Annexin A10 was performed when material was available. Associations between markers, morphology and lesion size were tested using chi-square or Fisher's exact test as appropriate. A composite diagnostic score was developed combining morphology, lesion size (> 5 mm) and immunopositivity patterns of the aforementioned markers. Results Reclassification according to 2019 WHO criteria and application of the composite score showed to be a diagnostic tool in cases of suspicion, considering the actual panorama of morphological assessment alone. BRAF V600E immunopositivity and Annexin A10 expression were significantly associated with lesions of the serrated pathway. Conclusion Integration of selected morphological features with BRAF and Annexin A10 immunohistochemistry into a structured scoring system enhances may improve diagnostic accuracy for serrated colorectal lesions.

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Abstract Objective Chronic anal fissure (CAF) causes significant quality of life impairment. Botulinum A toxin (Botox; brand name Dysport, Ipsen Biopharmaceuticals Inc.) injection into the anal sphincter is an established treatment. In New Zealand and Australia, anal Botox injection is often performed under general anesthesia (GA). The primary aim of the current study was to investigate the efficacy of treating CAF with outpatient anal Botox injection without sedation. The secondary aims were to assess its safety and cost-saving potential. Materials and Methods A retrospective audit was conducted at a tertiary public hospital between 2011 and 2013. Patients diagnosed with CAF underwent an anorectal examination and received Botox injection in the outpatient clinic. Demographic and comorbidity data were recorded. Patients were followed by telephone or clinic visit after 2 weeks, and then, as required. Success was defined as symptom resolution or patient-reported improvement such that no further treatment was required. Results A total of 163 patients were treated (median age: 40.5 years; range: 15–88 years). After 1 Botox injection, 106 patients (65.0%) reported satisfactory symptom resolution at follow-up. After 1 to 2 injections, 134 patients (82.2%) achieved symptom resolution. A total of 29 patients (17.8%) reported refractory symptoms despite 2 injections, and they were offered a third injection in the outpatient clinic or an examination under GA. No major complications were reported. Conclusion Botox injections can effectively treat CAF in an outpatient setting, with similar success rates to injection under GA. Widespread adoption of this technique could lead to significant cost savings in healthcare resources.

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Abstract Background A colorectal polyp is a small mass that forms on the lining mucosa of the colon and rectum. Most of these polyps are harmless, but some of them may eventually turn into malignant tumors with a high mortality rate in later stages. Objective To analyze the histopathological spectrum of different colorectal polyps diagnosed at a tertiary care hospital via colonoscopy and to determine their association with the patients' age and gender to better understand their potential premalignant significance. Materials and Methods The current is a retrospective, cross-sectional study conducted at the Al-Kindy Teaching Hospital), in Baghdad, Iraq. Data were collected from 113 patients with colorectal polyps diagnosed via colonoscopy from 2014 to 2024. The patients underwent colonoscopy, and a biopsy was performed and sent for a histopathological study. Results The study sample presented a higher percentage of male (71.68%) compared to female patients (28.31%). Their ages ranged from 17 to 95 years, with a mean of 65 ± 2.92 years. The most common type of polyp was hyperplastic (27.43%), followed by adenomatous (tubulovillous; 23.89%), and the least common types were serrated polyps and those with malignant transformation (0.88% each). Conclusion Colorectal polyps are more prevalent among older adults, with a marked predominance in male subjects. In the present study most of them were asymptomatic, and the dominant histopathological subtype was adenomatous.

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Abstract Transanal minimally invasive surgery (TAMIS) represents a significant advancement in the local excision of rectal neoplasms, yet its adoption is hindered by a demanding learning curve characterized by instrument crowding and restricted triangulation. Traditional training models, such as cadaveric or animal workshops, are often limited by high costs and ethical constraints. The present study describes the development and technical validation of a synthetic simulator for TAMIS training using an elastomeric pelvic mannequin. Unlike models requiring active CO2 insufflation, this simulator ensures self-sustaining lumen patency due to the material's resilience, effectively mimicking the middle and upper rectum in a benchtop setting. The experimental setup utilized a standard single-access port (GelPoint Path, Applied Medical) lubricated with lidocaine gel and a 10-mm 30-degree laparoscope to replicate clinical conditions. Technical assessment focused on intraluminal rectal wall suturing, demonstrating realistic tissue resistance and accurate reproduction of spatial constraints. This reproducible and portable model offers a viable alternative for democratizing advanced proctology education, allowing for exhaustive deliberate practice in a risk-free environment prior to clinical application.

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Abstract Objective To evaluate whether computed tomography (CT) was overused in the early postoperative period in oncologic colorectal surgery. Materials and Methods We conducted a single-center retrospective study including all patients who underwent colorectal resection with an anastomosis for colorectal adenocarcinoma between 2018 and 2022. The indications and findings of postoperative abdominopelvic CT scans performed during the initial hospital stay were collected, excluding the CT scans performed after discharge. Results A total of 1,091 patients were included. The overall morbidity rate was of 32%. Abdominopelvic CT scans were performed in 284 patients (26%), including 25% for isolated C-reactive protein (CRP) elevation without clinical signs. In total, 30% of the scans performed (n = 84) were normal, with 93% of those patients subsequently experiencing no severe postoperative complications. In cases of isolated CRP elevation, the rate of normal abdominopelvic CT scans was of 38%. In the multivariate analysis, we identified 3 factors associated with a normal abdominopelvic CT: scans performed within the first 4 postoperative days (p = 0.004), isolated CRP elevation (p = 0.010), and absence of a diverting ileostomy (p = 0.044). A predictive score based on these factors showed probabilities of a normal CT of 7%, 22%, 35%, and 54% when 0, 1, 2, or 3 factors were present respectively. Among patients with a normal scan, 39% were discharged within 24 hours, rising to 68% when the CT was performed for isolated CRP elevation. Conclusion Postoperative abdominopelvic CT scans are frequently performed after colorectal surgery, with normal findings in about 1/3 of the cases in our experience. When normal—especially in the context of isolated CRP elevation—abdominopelvic CT scans exclude major complications and help accelerate an earlier and safe patient discharge.

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Abstract Introduction The incidence of low rectal adenocarcinoma has increased. Surgery plays an important role in achieving optimal outcomes. Measuring surgical and oncological quality parameters helps to identify variables that need correction and reduces costs. Objective To evaluate the results of applying quality parameters known as textbook outcomes (TO) in abdominoperineal resection (APR) due to lower rectal adenocarcinoma. Materials and Methods The variables comprising the surgical textbook outcomes (STO) and oncological textbook outcomes (OTO) were evaluated in 192 patients undergoing APR for rectal adenocarcinoma. Variables that affected compliance with quality measures were also analyzed. Results Of the 192 patients, 37% met the STO and 37.5% met the OTO. Complications and R0 resections were the factors that most affected STO compliance. Minimally invasive surgery was associated with higher adherence compared to open surgery. Age over 65 years, transfusions, and incomplete mesorectal resection were variables associated with noncompliance. Conclusion Noncompliance with TO is associated with a higher rate of recurrence. Implementing quality assessment through STO and OTO helps identify weak points in outcomes, target improvement interventions, and reduce costs.

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Abstract Introduction Colorectal cancer (CRC) is responsible for at least 880 thousand deaths worldwide each year. Colonoscopy is considered the gold standard for CRC screening, and adequate bowel preparation is essential for exam quality. Objective To evaluate the quality of bowel preparation at the endoscopy service of Hospital Universitário Evangélico Mackenzie (HUEM) using the adenoma detection rate (ADR) and the Boston Bowel Preparation Scale (BBPS), according to the type of preparation administered to participants. Materials and Methods The first group, consisting of 32 participants, received a split-dose sulfate solution, with 1 dose taken on the day before the exam. The second group, with 19 participants, received the same solution in a single dose taken only on the day prior to the colonoscopy. Results The ADR was higher in the group that received the split-dose preparation. Participants in this group also reported a higher incidence of sleep disturbances. Both the cecal intubation rate and the rates of adequate and excellent preparations (BBPS = 9) were higher in the split-dose group. There was no significant difference between the groups in terms of tolerability of the preparation. Conclusion Split-dose bowel preparation proved effective in the present study, improving the ADR and the cecal intubation rate, which is consistent with findings previously reported in the literature.

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Abstract Objective To evaluate whether preoperative anorectal manometric parameters are associated with postoperative fecal incontinence in continent patients undergoing anal surgery. Materials and Methods The current prospective observational study included adult continent patients scheduled for elective anal surgery. All participants underwent preoperative high-resolution anorectal manometry following the London Protocol. Postoperative fecal continence was assessed using the Wexner score. Patients were classified according to postoperative continence status, and preoperative manometric parameters were compared between groups. Results The study included 29 patients. Postoperative fecal incontinence was identified in 12 patients (41.4%), all classified as mild. Patients who developed fecal incontinence had significantly lower preoperative resting anal pressures compared with continent patients. However, all values remained within normal reference ranges. No significant differences were observed regarding age, sex, parity, prior anorectal surgery, or squeeze pressures. Conclusions Although lower preoperative resting anal pressures were statistically associated with postoperative fecal incontinence, all values remained within normal reference ranges, limiting their clinical relevance. Routine preoperative anorectal manometry does not appear to provide meaningful predictive value for postoperative fecal incontinence in continent patients undergoing anal surgery.

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Abstract MUTYH-associated polyposis (MAP) is a rare autosomal recessive syndrome caused by biallelic mutations in the MUTYH gene, responsible for about 1% of colorectal cancers (CRCs). We present the case of a 58-year-old female with abdominal pain, changes in bowel habits, and anemia. Colonoscopy revealed multiple polyps and synchronous sigmoid tumor. Pathology confirmed multiple adenomas and adenocarcinoma. Genetic testing confirmed MAP. The patient underwent laparoscopic total proctocolectomy with terminal ileostomy. The postoperative course was uneventful. This case highlights the importance of genetic testing and early surgical intervention in MAP to reduce CRC risk.

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Abstract Complex fistula-in-ano (FIA) presents significant surgical challenges, with recurrence often driven by inflammatory, anatomical, and microbiological factors. Mycobacterium abscessus, a multidrug-resistant nontuberculous mycobacterium (NTM), is rarely implicated in FIA and is more commonly associated with respiratory and skin infections. A man in his mid 30s with recurrent complex FIA underwent multiple surgeries over four years. Imaging and surgical exploration revealed a left ischiorectal collection and a sinus tract extending to the supralevator space. Tissue cultures grew M. abscessus subspecies massiliense, and histology showed non-necrotising granulomatous inflammation. The patient was a regular bidet user; this was considered the plausible source of inoculation given the organism's presence in water. He was treated with combination antimicrobial therapy comprising concurrent long-term oral azithromycin and clofazimine with an overlapping intravenous regimen including amikacin and imipenem resulting in clinical and radiological resolution. Environmental NTM exposure may underlie refractory FIA. Early recognition and targeted antimicrobial therapy are essential to avoid repeated surgery and prolonged morbidity.

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Abstract Introduction Rectal sensory dysfunction plays a central role in constipation, fecal incontinence, and functional defecatory disorders, yet its physiological basis and clinical interpretation remain not completely established. Advances in neuroanatomy and high-resolution anorectal manometry (HRAM) have reshaped current diagnostic paradigms, prompting reconsideration of the traditional threshold-based definition of rectal hyposensitivity. Objective To provide the current mechanisms of rectal sensitivity measurements with critical analysis, and to show the emerging technological advances that can fill the existing gaps as well as the possibilities in the future. Materials and Methods The present narrative review synthesizes emerging evidence on anorectal neurophysiology, HRAM-derived sensory thresholds, biomechanical contributors to rectal perception, and the role of novel technologies, such as translumbosacral magnetic stimulation and endoluminal functional lumen imaging probe (EndoFLIP) (technologies scheduled to arrive in Brazil this year), and the interaction of artificial intelligence (AI). Multicenter HRAM datasets evaluating the clinical significance of isolated abnormal thresholds were critically examined. Results Rectal sensory thresholds reflect a complex interplay of afferent signaling, rectal wall biomechanics, and cortical processing. Multicenter analyses show that even a single elevated threshold may correlate with symptom severity, especially in women, although using a one-threshold definition. Distinguishing primary afferent dysfunction from biomechanical alterations is crucial, with pressure-volume analysis and emerging technologies offering complementary insights. Sensory biofeedback improves outcomes in true afferent hyposensitivity but is less effective when biomechanical factors predominate. Conclusion Current evidence supports maintaining the London Classification definition of rectal hyposensitivity (≥ 2 abnormal thresholds), while recognizing that isolated abnormalities may indicate early dysfunction in selected patients. Integrating HRAM findings with biomechanical and neurophysiological metrics may refine diagnostic precision. Future developments may allow a single abnormal parameter to reliably define clinically meaningful rectal hyposensitivity.

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Abstract Background Length of hospital stay after colorectal surgery has decreased progressively with the adoption of enhanced recovery after surgery (ERAS) programs and minimally invasive techniques. Early discharge strategies, including discharge within 72 and 24 hours, as well as same-day discharge, have been increasingly implemented; however, concerns regarding safety and readmission persist. Objective To systematically review the evidence on the feasibility and safety of early discharge after elective colorectal surgery. Materials and Methods A systematic review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) 2020 guidelines. The MEDLINE, Embase, and the Cochrane Library databases were searched for studies evaluating early discharge after elective colorectal surgery. Primary outcomes included 30-day readmission, postoperative complications, reoperation, and mortality. Secondary outcomes included length of stay and feasibility of early discharge targets. Results Observational cohorts and randomized studies conducted predominantly in ERAS-based settings were included. Discharge within 72 hours was consistently safe and widely achievable. Discharge within 24 hours, including evidence from a large cohort published in Colorectal Disease, was feasible in selected patients without increased major morbidity or mortality, with readmission rates generally ranging from 5 to 10%. Same-day discharge was achievable only in highly selected patients and required dedicated outpatient support. Conclusion Early discharge after colorectal surgery is safe when embedded within structured perioperative pathways. Discharge within 24 hours represents a pragmatic intermediate strategy between conventional ERAS care and same-day discharge models and may be particularly relevant for centers seeking to optimize hospital bed utilization without compromising patient safety.