Colorectal Disease最新文献

Aim: This study aimed to evaluate the global perspectives of healthcare professionals on LARS, including awareness, use of diagnostic tools, management strategies, resource access and multidisciplinary involvement, and to provide a contemporary international snapshot that identifies gaps in care and informs future consensus-building and education.

Method: A cross-sectional, international online survey was distributed to healthcare professionals involved in the care of patients following rectal cancer surgery. The survey assessed awareness of LARS, use of validated diagnostic tools, treatment approaches, access to multidisciplinary services and availability of advanced therapeutic options. Responses were analysed descriptively.

Results: A total of 238 healthcare professionals from 46 countries participated; most were surgeons (79.0%). While 86.6% reported informing patients about LARS risk, only 17.6% reported using POLARS score. Access to specialized services such as pelvic floor physiotherapy or multidisciplinary support varied widely. Initial management commonly included dietary modifications (81.1%) and antidiarrhoeal medications (73.5%), while advanced therapies, such as pelvic floor physical therapy (41.6%), transanal irrigation (32.8%) and sacral neuromodulation (28.6%), were unavailable or underutilized.

Conclusion: Global inconsistencies in LARS care highlight the need for provider education, standardized pathways, wider use of validated tools and improved access to multidisciplinary interventions. Involving patient representatives will be essential to ensure consensus reflects patient priorities and optimizes quality of life.

Originality statement: This study provides the most comprehensive contemporary global overview of Low Anterior Resection Syndrome care, capturing real-world variation in awareness, assessment, management and resource access across 46 countries and identifying critical gaps to inform international consensus, education and equitable survivorship care.

Background: The 1 mm rule for circumferential resection margin (CRM) involvement in rectal cancer is deeply embedded in international practice, defining R1 resection as tumour at or within 1 mm of the resection margin. While this threshold has strong evidence in major resections for primary rectal cancer, its universal application is increasingly questioned. Advances in imaging, surgical technique and pathological understanding suggest that R1 status may require context-specific interpretation across three distinct clinical settings: encapsulated nodal involvement in locally advanced rectal cancer (LARC), locally recurrent rectal cancer (LRRC) and locally excised early rectal cancer (LERC).

Methods: This opinion article reviews current literature, international datasets and emerging evidence to challenge the uniformity of the 1 mm definition. It draws upon The International Collaboration on Cancer Reporting (ICCR) dataset, Royal College of Pathologists (RCPath) guidance and recent large cohort and registry analyses to explore the biological and clinical relevance of close margins in these scenarios.

Results: Evidence indicates that the prognostic value of the 1 mm rule varies by anatomical and pathological context. In LARC, a lymph node metastasis abutting the CRM without extracapsular extension behaves biologically as R0 and should not be upstaged. For LRRC, narrow but clear margins (>0 mm) confer equivalent outcomes to wider margins, supporting the use of a 0 mm R1 definition. In LERC, a ≤1 mm margin may be oncologically acceptable in the absence of high-risk histological features.

Conclusion: The current evidence supports a tailored approach to R1 definition, preserving rigour while aligning classification with modern oncological, anatomical and pathological realities.

Background: Small bowel obstruction (SBO) is a common surgical emergency associated with impaired gastrointestinal (GI) function and prolonged recovery. The PRO-diGI patient-reported outcome measure (PROM) assesses patients' reports on key domains of appetite, nausea, bowel function, well-being and overall GI function. This study evaluated the influence of demographic and treatment factors on GI recovery following SBO and examined whether these associations persisted after balancing for baseline differences using propensity score matching (PSM).

Methods: An international prospective multicentre cohort study enrolled adult patients undergoing treatment for SBO of any aetiology. GI recovery was assessed using the PRO-diGI tool. Multivariable regression models were used to identify associations between clinical factors and PROM scores. Regression coefficients (β) with 95% confidence intervals were calculated. PSM was performed within the adhesional SBO subgroup to minimize confounding from differences in follow-up time and baseline characteristics.

Results: Of 1734 participants, 644 completed all PROM domains. Among patients contributing PROM data, surgical intervention was associated with improved nausea (β 5.9, 95% confidence interval 1.1-11.0) and overall GI function (β 6.8, 95% confidence interval 0.54-13.0) scores. Complications were linked to worse nausea (β -9.3, 95% confidence interval -17.0 to -1.7), well-being (β -17.0, 95% confidence interval -29.0 to -4.3), and overall function (β -12.0, 95% confidence interval -22.0 to -1.4). Previous nonoperative SBO episodes were associated with reduced appetite scores (β -7.3, 95% confidence interval -13.0 to -1.7). In the adhesion PSM cohort, overall GI function remained higher after surgery, and laparoscopic adhesiolysis was associated with superior appetite and overall function scores.

Discussion: Surgical treatment without complications was associated with improved patient-reported GI recovery after SBO. Persistence of these associations following matching indicates that patient-reported GI recovery differs across treatment pathways in selected patients, supporting the feasibility and discriminatory value of PRO-diGI as a patient-centred outcome measure.

Background: High rectovaginal fistulas (RVFs) remain a challenging condition, often requiring transabdominal surgery associated with significant morbidity, particularly in patients with hostile abdomens and multiple prior pelvic operations. Minimally invasive, video-assisted and sphincter-preserving alternatives have been described for mid and low RVF but exceptionally reported for high and large defects.

Technique: We describe a fully transanal endoscopic approach for the repair of large, high post-anastomotic rectovaginal fistulas using the transanal endoscopic operation (TEO®) platform. According to the IDEAL framework, this represents an IDEAL stage 1 procedure aimed at demonstrating technical feasibility and immediate safety. The technique involves six standardized steps, including marking of the defect, precise endoscopic dissection to achieve adequate reciprocal mobilization of the rectal and vaginal walls, followed by tension-free, layered closure of both defects under stable endoscopic vision. A concise instructional video accompanies the manuscript to illustrate the key technical steps.

Results: The technique was applied in a representative patient with a large high post-anastomotic RVF and a hostile surgical history. The procedure was completed successfully without intraoperative complications. Postoperative imaging and endoscopic evaluation confirmed complete closure of the fistula. The postoperative course was uneventful, and no recurrence was observed after 2 years of follow-up.

Conclusion: This technical note demonstrates the feasibility of a fully transanal endoscopic approach for selected large and high rectovaginal fistulas. By avoiding transabdominal access, this organ-preserving technique may represent a valuable option in experienced centres for patients in whom conventional approaches are associated with high morbidity. Further evaluation in larger series is warranted.

Background: Screening colonoscopy prevents colorectal cancer (CRC) by detecting and removing premalignant lesions. Metabolic syndrome (MetS) has been proposed as an additional risk marker to refine risk stratification beyond age-based screening, but its independent association with advanced colorectal neoplasia remains uncertain.

Methods: We conducted a cross-sectional analysis of asymptomatic adults undergoing screening colonoscopy in the Salzburg Colon Cancer Prevention Initiative. Analyses were limited to participants with complete-case data for the Adult Treatment Panel III (ATP III) MetS definition (N = 4891). The primary endpoint was advanced colorectal lesions, defined as advanced adenoma and/or CRC. We estimated incidence rate ratios (IRR) using Poisson regression with robust variance in unadjusted, age/sex-adjusted and fully adjusted models (demographic and lifestyle covariates). Sensitivity analyses applied the International Diabetes Federation (IDF) MetS definition and insulin resistance (HOMA-IR; binary and per doubling). In an exploratory subsample, leptin (per doubling) was evaluated, including joint models with MetS. Bayesian models (non-informative, pessimistic, sceptical priors) quantified posterior effect distributions and equivalence probabilities.

Results: Advanced lesions occurred in 389/4891 participants (7.95%) and were more frequent in ATP III MetS (9.66% vs. 6.97%; p = 0.001). In frequentist analyses, ATP III MetS was associated with advanced lesions in unadjusted models (IRR: 1.39; 95% CI, 1.15-1.68) but not after age/sex adjustment (IRR: 1.09; 95% CI, 0.90-1.32) or full adjustment (IRR: 1.06; 95% CI, 0.83-1.36). Age was the dominant predictor (fully adjusted IRR: 1.73 per decade; 95% CI, 1.53-1.95), while female sex was protective (IRR: 0.57; 95% CI, 0.44-0.73). Findings were concordant using the IDF definition (unadjusted IRR: 1.39; age/sex-adjusted 1.09; fully adjusted 1.07) and for HOMA-IR (binary: no association; per doubling: unadjusted IRR: 1.10, p = 0.052; adjusted null). In the leptin subsample (N = 602), leptin was not independently associated with advanced lesions (per doubling IRR: 0.85 unadjusted; 0.96 age/sex-adjusted; 0.95 fully adjusted) and did not materially alter MetS estimates. Bayesian analyses mirrored attenuation with adjustment; in fully adjusted models, sceptical priors yielded a posterior median IRR of 1.01 (95% CrI: 0.91-1.12) with a 92.9% probability that the MetS effect lay within ±10% of no effect.

Conclusions: The apparent excess risk of advanced colorectal lesions in MetS is explained by age and sex. Across MetS definitions, HOMA-IR, leptin and Bayesian sensitivity analyses, MetS does not provide independent incremental information for CRC screening risk stratification beyond established demographic factors.