Dr. Hassan R. Hashmi

An important randomized trial published in JAMA Surgery addressing a longstanding technical question in re**al cancer surgery: Does the level of inferior mesenteric artery (IMA) ligation influence anastomotic leak?

In this multicenter randomized clinical trial of 293 patients undergoing minimally invasive anterior resection for re**al cancer, symptomatic anastomotic leak occurred in 4.9% of patients with low IMA ligation versus 6.0% with high ligation, a difference that was not statistically significant.

An important nuance: These findings should not be interpreted as establishing equivalence between the two approaches. The number of leak events was small, and the confidence interval was relatively wide.

The practical takeaway is that IMA ligation level should remain individualized rather than viewed as a single determinant of anastomotic safety. Oncologic adequacy, vascular anatomy, conduit reach and tension, and assessment of perfusion all remain important considerations when constructing a colore**al anastomosis.

A valuable contribution to an ongoing surgical debate.

How do you decide ligation level in your own practice?

**alSurgery **alCancer

JAMA The American Society of Colon and Re**al Surgeons - ASCRS American College of Surgeons Colore**al Cancer Alliance American Cancer Society OncoDaily

I’m honored to join Roseman University College of Medicine as a Clinical Assistant Professor.

I look forward to contributing to the education and mentorship of future physicians and sharing my experience in colore**al and general surgery, cancer prevention, and improving access to surgical care.

Proud to support the next generation of physicians here in Southern Nevada.

Roseman University of Health Sciences Roseman University College of Medicine Las Vegas Surgical Associates

**alSurgery

Good morning from Las Vegas!

Happy Independence Day! 🇺🇸
Grateful for the privilege of serving our community. Wishing everyone a safe, healthy, and joyful Fourth of July.

An intriguing concept from .

Could metabolic optimization become part of re**al cancer treatment?

Total neoadjuvant therapy (TNT) has become the standard of care for locally advanced re**al cancer following landmark trials such as RAPIDO, PRODIGE 23, and OPRA, improving pathological complete response rates, treatment compliance, and disease-free survival.

At the same time, GLP-1 receptor agonists have expanded far beyond diabetes and obesity, with emerging evidence suggesting potential anticancer effects. Against this backdrop, a recent BJS review explores the rationale for combining GLP-1 therapy (such as semaglutide) with TNT and highlights a planned phase II randomized trial (NCT07314528).

Potential advantages include:

• Reduced visceral adiposity
• Improved insulin sensitivity
• Lower systemic inflammation
• Enhanced treatment tolerance

Yet an important paradox remains: GLP-1-induced weight loss includes loss of lean muscle mass, and sarcopenia is independently associated with increased treatment toxicity and worse oncologic outcomes in re**al cancer patients undergoing neoadjuvant therapy.

The critical question is not whether patients lose weight, but what kind of weight they lose. Can the metabolic benefits of GLP-1 therapy outweigh the risks of skeletal muscle depletion during TNT?

This study represents the emergence of “metabolic oncology,” the concept that modulating host metabolism may enhance cancer treatment beyond direct antineoplastic effects. The biological rationale is compelling, but prospective evidence is essential.

Critical to the trial’s success will be careful body composition analysis, distinguishing potentially beneficial visceral fat loss from potentially harmful skeletal muscle loss.

If positive, this trial could open an entirely new dimension in re**al cancer management.

I’d be interested in hearing colleagues’ perspectives on the balance between metabolic optimization and sarcopenia risk during TNT.

**alCancer **alSurgery ASCRS American College of Surgeons ASCO The American Cancer Society AmCollegeGastro