Colorectal Disease最新文献

Aim: Local excision (LE) for T1 rectal cancer may be recommended in those with low-risk disease, while resection is typically recommended in those with a high risk of luminal recurrence or lymph node metastasis. The aim of this work was to compare survival between resection and LE.

Method: This was a population-based retrospective cohort study set in the Canadian province of Ontario. Patients were individuals with T1Nx rectal cancer between 2010 and 2014 and demographics, disease characteristics, treatments and outcomes were determined using linked administrative databases. This study does not include clinical information regarding individual patient treatment decisions. The main outcome measure was overall survival (OS).

Results: A total of 719 patients were identified, including 359 with upfront resection, 113 with LE and immediate resection (<90 days) and 247 with LE with definitive intent. The majority of LEs were performed via colonoscopy. Piecemeal excision (42% vs. 49%, p = 0.28) and positive margin (50% vs. 77%, p < 0.01) rates were high in both LE groups, with the highest rate in those with immediate resection. The prevalence of poor differentiation (<5%, p = 0.70) and lymphovascular invasion (LVI) (14%, p = 0.80) was similar across groups. In those with LE with definitive intent, 21% ultimately underwent resection (median 150 days, interquartile range 114-181 days) and 4% received radiation. There was no difference in 5-year OS between groups (resection 83.2% vs. LE and immediate resection 82.3% vs. definitive LE 83.3%; p = 0.33). Adjusted analyses demonstrated no association between approach and survival [definitive intent LE hazard ratio (HR) 0.97 (95% CI 0.70-1.35), LE and immediate resection HR 0.97 (95% CI 0.60-1.45), upfront resection HR 1 (Ref); p = 0.98]. Differentiation, piecemeal excisions and LVI were not associated with OS in the LE groups.

Conclusion: There were no observed differences in survival between those who underwent resection, LE and immediate resection and definitive intent LE. Although, these are observational data, they call into question the reflexive decision to offer radical resection for those with suspected T1 rectal cancer.

Aim: Total proctocolectomy (TPC) is the standard of care for patients with ulcerative colitis (UC) and dysplasia not amenable to endoscopic management. However, the risks of an extensive resection may outweigh the benefits in high-risk surgical patients. Therefore, we performed a systematic review and meta-analysis to assess postoperative outcomes between segmental colectomy (SEG) versus TPC in patients with UC.

Study design: Global databases were searched from inception until August 2022 for comparative studies reporting the postoperative outcomes of patients with UC undergoing SEG versus TPC. The primary outcomes were subsequent neoplasia development and overall survival. Odds ratios (ORs), hazard ratios (HRs) and their corresponding 95% confidence intervals (CIs) were calculated. The Newcastle-Ottawa Scale and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) were used for quality-of-evidence assessment.

Results: Eight retrospective studies comprising 4856 patients were included. Overall, 1620 (33%) patients underwent SEG. SEG patients were older, had more comorbidities and mostly underwent right colectomy (40%) and sigmoidectomy (16%). Most studies included UC patients and concomitant colorectal cancer. Reoperation and Clavien-Dindo III-IV odds were equivalent (OR 3.17; 95% CI 0.12, 81.25; I² 66%; OR 0.79; 95% CI 0.48, 1.31; I² 74%). There was no difference in neoplasia development (OR 5.05, 95% CI 0.37, 68.66; I² 61%) nor in overall survival (HR 1.20, 95% CI 0.73, 1.97; I² 61%). The risk of bias was high in all included studies and the quality of evidence was low.

Conclusion: Low-quality evidence failed to demonstrate any discernible differences in the postoperative outcomes between SEG and TPC. However, given the limited granularity of the analysed data and the high likelihood of imprecise results, we cannot assert that SEG and TPC are equivalent. Furthermore, there was a suggestion of an elevated risk of neoplasia development and inferior overall survival in the SEG group.

Aim: Lymphovascular invasion (LVI) is a well-known risk factor in colorectal cancer that is associated with a worse prognosis. The present study aimed to assess the characteristics of patients with LVI-positive colon cancer according to the status of nodal metastases and to study the association between LVI-nodal status and survival.

Method: This retrospective study assessed the association between LVI and lymph node metastases in colon cancer, using data from the National Cancer Database. Patients were classified according to the pathological N stage into pN0 and pN1-2. The risk factors for LVI were determined in each group using multivariable regression analyses. The primary outcome was LVI and the secondary outcome was 5-year overall survival (OS). A modification of the tumour, node, metastasis (TNM) staging system that incorporates LVI in each stage was proposed.

Results: The study included 357 724 patients (51.1% female, median age 70 years). LVI was detected in 11.6% and 52.5% of patients with node-negative and node-positive disease, respectively. The independent predictors of LVI in pN0 stage were poorly differentiated carcinomas (OR: 3.6, p < 0.001), undifferentiated carcinomas (OR: 3.3, p < 0.001), mucinous carcinomas (OR: 0.61, p < 0.001), and perineural invasion (OR: 4.2, p < 0.001). The independent predictors of LVI in pN1-2 disease were poorly differentiated carcinomas (OR: 2.36, p < 0.001), undifferentiated carcinomas (OR: 3.23, p < 0.001), and perineural invasion (OR: 3.33, p < 0.001). LVI was significantly associated with worse 5-year OS and the adverse survival impact of LVI was higher in pN1-2 disease (HR: 1.47, p < 0.001) than in pN0 disease (HR: 1.28, p < 0.001). When LVI was present, the 5-year OS was reduced by 1.5% in stage I, 5.6% in stage II, and 11.5% in stage III.

Conclusion: LVI was more prevalent in patients with colon cancer with lymph node metastases than in patients with node-negative disease. However, LVI was not detected in approximately half of patients with nodal disease. The adverse survival effect of LVI was proportional to the stage of colon cancer.

Aim: Total pelvic exenteration (TPE) can be complicated by empty pelvis syndrome (EPS), and none of the currently available procedures completely mitigate this problem. The aim of this study was to evaluate the feasibility and effectiveness of a pedicled anterolateral thigh (p-ALT) flap for preventing EPS.

Method: All cases of TPE at the National Cancer Center Hospital in Tokyo between 2008 and 2022 were retrospectively reviewed. The main indication for TPE was colorectal cancer, with some other malignancies. Background factors, surgical outcomes and postoperative complications were compared between patients who underwent primary suture closure (the PC group) and those who underwent p-ALT flap reconstruction (the flap group).

Results: A total of 114 patients underwent TPE during the study period. Twenty patients in whom a different procedure was performed or a different flap was used for reconstruction were excluded, leaving 94 for analysis (PC group, n = 54; flap group, n = 40). There was no significant between-group difference in patient characteristics. Severe pelvic abscess developed in 12 patients (22.2%) in the PC group and 2 (5%) in the flap group. Multivariable analysis identified a significantly lower risk of severe pelvic abscess in the p-ALT flap reconstruction (OR 0.07, 95% CI 0.01-0.58, p = 0.01). EPS-related readmissions were more common in the PC group [37.0% (20/54) vs. 25% (10/40)].

Conclusions: The risk of severe pelvic abscesses and readmission for EPS was significantly lower after perineal reconstruction with a p-ALT flap. Perineal reconstruction with this flap is a feasible and effective method in TPE.

Aim: Artificial intelligence (AI) chatbots such as Chat Generative Pretrained Transformer-4 (ChatGPT-4) have made significant strides in generating human-like responses. Trained on an extensive corpus of medical literature, ChatGPT-4 has the potential to augment patient education materials. These chatbots may be beneficial to populations considering a diagnosis of colorectal cancer (CRC). However, the accuracy and quality of patient education materials are crucial for informed decision-making. Given workforce demands impacting holistic care, AI chatbots can bridge gaps in CRC information, reaching wider demographics and crossing language barriers. However, rigorous evaluation is essential to ensure accuracy, quality and readability. Therefore, this study aims to evaluate the efficacy, quality and readability of answers generated by ChatGPT-4 on CRC, utilizing patient-style question prompts.

Method: To evaluate ChatGPT-4, eight CRC-related questions were derived using peer-reviewed literature and Google Trends. Eight colorectal surgeons evaluated AI responses for accuracy, safety, appropriateness, actionability and effectiveness. Quality was assessed using validated tools: the Patient Education Materials Assessment Tool (PEMAT-AI), modified DISCERN (DISCERN-AI) and Global Quality Score (GQS). A number of readability assessments were measured including Flesch Reading Ease (FRE) and the Gunning Fog Index (GFI).

Results: The responses were generally accurate (median 4.00), safe (4.25), appropriate (4.00), actionable (4.00) and effective (4.00). Quality assessments rated PEMAT-AI as 'very good' (71.43), DISCERN-AI as 'fair' (12.00) and GQS as 'high' (4.00). Readability scores indicated difficulty (FRE 47.00, GFI 12.40), suggesting a higher educational level was required.

Conclusion: This study concludes that ChatGPT-4 is capable of providing safe but nonspecific medical information, suggesting its potential as a patient education aid. However, enhancements in readability through contextual prompting and fine-tuning techniques are required before considering implementation into clinical practice.