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

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.