Colorectal Disease最新文献

Aim: Consensus is lacking regarding the management of extramesorectal lymph nodes (EMLN) in rectal cancer. Using simultaneous integrated boost intensity-modulated radiation therapy (SIB-IMRT), we targeted involved EMLN and reserved lateral pelvic lymph nodal dissection (LPLND) for nonresponders. The primary aim of this work was to determine the proportion of patients who avoided LPLND and to establish the pathological EMLN positivity rate.

Method: Consecutive patients with rectal cancer with suspicious EMLN [short axis dimension (SAD) ≥ 7 mm], receiving SIB-IMRT as part of neoadjuvant chemoradiotherapy and subsequently undergoing total mesorectal excision (TME) or watch-and-wait, were included. Our primary objective was to determine the proportion of patients with a good nodal response (EMLN SAD < 5 mm) who were spared LPLND. The 3-year locoregional relapse rate, distant metastasis-free survival (DMFS) and overall survival (OS) were also assessed.

Results: Of the 61 patients studied, 38 (62.3%) responded well to SIB-IMRT. In this group, 32 patients underwent TME alone and six were observed as per watch-and-wait. The remaining 23 (37.7%) patients with persistent EMLN received TME with LPLND. On pathological evaluation, 7 (30.4%) patients had positive nodes while 16 (69.6%) were negative. At a median follow-up of 32 months (95% CI 23.3-40.7 months), 10 (16.4%) patients developed distant metastases while none had local or pelvic relapse. The resultant 3-year DMFS and OS for the whole cohort were 84.4% and 95.1%, respectively. Overall, 5/61 (8.2%) patients encountered radiation-induced toxicity of grade 3 or above and 8/55 (14.5%) patients had severe postoperative complications.

Conclusion: SIB-IMRT targeting EMLN followed by selective LPLND exhibits excellent oncological outcomes. While patients responding to SIB-IMRT safely avoid LPLND, the potential for increased morbidity in nonresponders must be considered.

Aim: Ventral mesh rectopexy (VMR) is an established surgical treatment for rectal prolapse and outlet obstruction. In contrast to continental Europe, in the UK and US the use of synthetic mesh has been abandoned in favour of biologic mesh, due to concerns regarding mesh related morbidity. The current study investigated if either material is superior, in terms of clinical recurrence and mesh related complications.

Methods: VMRs performed between March 2012 and July 2022 in three international pelvic floor centres were prospectively collected and retrospectively analysed, to look at the rate of complications and need for further therapy, including reoperation.

Results: A total of 360 patients were included in the study (140 biologic mesh (bm) / 220 synthetic mesh (sm)). Postoperative complication occurred in 5.7% in bmVMR (5% minor [Clavien-Dindo I and II] and 0.7% major [Clavien-Dindo > = III]) and in 10.9% in smVMR (9.1% minor and 1.8% major) (p = 0.28). Oral laxatives were necessary in 31% after bmVMR and in 35% after smVMR (p = 0.49). Rectal laxatives were used in 11% after bmVMR and in 7% after smVMR (p = 0.34). Clinical recurrence appeared in 9% bmVMR and in 5% smVMR (p = 0.20). Mean time to clinical recurrence in bmVMR was 20.9 (5 to 58) months and in smVMR 20.2 (0-55) months (p = 0.75). Mean overall follow-up time was 18.4 (0-96) months. Reoperation rate due to clinical recurrence was 6.11% in the bmVMR group versus 2.75% in the smVMR group (p = 0.16). No mesh associated complications such as symptomatic erosion or fistulation occurred in either group.

Conclusion: VMR using biologic mesh was equally safe to that using synthetic mesh, with no difference in clinical recurrence rate. No mesh-associated morbidity was observed in either group.

Aim: Laparoscopic complete mesocolic excision (CME) with D3 lymphadenectomy for right colon cancer is gaining acceptance. However, this procedure has not yet been standardized like total mesorectal excision. Ergonomics is very important in this surgery (e.g. patient positioning, port placement) and identification of vascular anatomy is a critical step. The aim of this work is to present ten procedural steps that are simple and reproducible.

Method: The French position is adopted. The surgeon stands between the patient's legs. Four ports are placed: a camera port 2.5 cm to the left of the umbilicus; two working ports-a 12 mm right-hand port 5-7 cm below the umbilicus in the midline and a 5 mm left-hand port 2.5 cm medial and at the level of anterior superior iliac spine-and an assistant port at the level of the umbilicus at the pararectal line. This is most comfortable position in the 'caudal to cranial approach' for CME dissection. The right-hand instrument always dissects parallel to the superior mesenteric artery (SMA) axis so there is less chance of injury to major vascular structures. When clipping the ileocolic, right colic and gastrocolic trunk (GCT) branches, the instrument is always perpendicular to these structures, giving ease of clipping and division. An intentional attempt is made to dissect all tributaries of the GCT. This avoids inadvertent injury and bleeding. Identifying the SMA/superior mesenteric vein (SMV) axis and ileocolic pedicle is the most crucial step. We use surface landmarks for this-the ligamentum teres and SMA/SMV are both midline structures. Giving traction on the transverse mesocolon just below the ligamentum makes the pulsatile SMA visible irrespective of the patient's body mass index. Giving traction at the ileocaecal junction mesentery makes the ileocolic pedicle prominent. These two landmarks for identification of the vascular anatomy make this technique unique and reproducible. CME dissection is done caudal to cranial and lateral to medial. Supracolic and lateral mobilization of the colon is simple. While starting dissection in the right paracolic gutter the already dissected CME plane make this step easier. Anastomosis can be made intracorporeal or extracorporeal.

Conclusion: Ergonomics and landmarks for identification of the vascular anatomy make this technique simple and reproducible.

Aim: In contrast to significant advances in organ preservation in locally advanced rectal cancer, the contemporary management of early-stage rectal cancer, including the frequency of abdominoperineal resections, remains largely unexplored in the United States. Therefore, we assessed the utilization of neoadjuvant therapy and oncological resections in early-stage rectal cancer patients.

Study design: This is a retrospective cohort study of patients with cT1-T3N0 rectal cancer who underwent proctectomies between 2016 and 2022 in the National Surgical Quality Improvement Project proctectomy files. Multivariable logistic regression was used to identify factors associated with abdominoperineal resections and Kendall's tau statistics to evaluate clinical-pathological staging agreement.

Results: In all, 3078 patients (29.6% cT1-2N0, 70.4% cT3N0) were included with 55.3% of tumours <5 cm from the anal verge. Overall, 58.2% received neoadjuvant therapy within 3 months of surgery (30.6% for cT1-T2N0 vs. 69.8% for cT3N0, P < 0.001), and 58.6% underwent abdominoperineal resection (55.5% for cT1-T2N0 vs. 59.9% for cT3N0, P = 0.058). The adjusted odds of undergoing abdominoperineal resection were associated with increasing age (OR 1.4 per every 10-year increase; 95% CI 1.2-1.5), cT3N0 tumours (OR 1.7; 95% CI 1.1-2.7) and tumour location <5 cm from the anal verge (OR 10.6; 95% CI 7.7-14.7). There was a weak clinical-pathological T staging correlation (Kendal tau coefficient 0.25; 95% CI 0.20-0.29).

Conclusion: In this large cohort of patients with early-stage rectal cancer with high rates of neoadjuvant therapy, over half of patients underwent abdominoperineal resection and one in five had a pathological complete response. These findings underscore opportunities for organ preservation in early-stage rectal cancer, suggesting that treatments typically reserved for locally advanced disease may extend to early stages with the completion of ongoing clinical trials.

Aim: Pilonidal sinus disease (PSD) poses significant treatment challenges due to a lack of consensus on the diverse range of surgical approaches routinely employed, prompting a renewed focus on the patient experience. The aim of this study was to explore the lived experience of patients with PSD to better inform future person-centred treatment.

Method: A systematic review was performed to identify papers reporting qualitative studies on the lived experience of PSD. The MEDLINE, EMBASE and CINAHL databases were searched, using a predefined search strategy. Studies were dual screened at each stage, with conflicts resolved by a third reviewer. Analytical frameworks were extracted, along with supporting quotes. A meta-ethnographic approach was used to systemically compare and synthesize frameworks in line with the eMERGe meta-ethnography protocol. The study was registered on PROSPERO (CRD42024495608).

Results: Four full texts covering three studies were included. Three key themes emerged: (1) disruption to activities of daily living; (2) impact on psychological well-being; (3) navigating healthcare. Reduction of physical activity was patient-led, owing to fears of exacerbating symptoms and wound complications. PSD had a complex influence on self-perception and emotional state, leading to changed relationships with others. This was largely driven by the forced reliance on others for wound care. The final theme highlighted concerns regarding unexpected disease course and outcomes stemming from a lack of patient awareness of PSD.

Conclusion: This study informs a more sophisticated understanding of the experience of individuals living with PSD and has identified recommendations that should guide future clinical practice and research.

Aim: Cytoreductive surgery provides a chance for long-term survival and cure in selected patients with colorectal peritoneal metastases. As clinical and academic interest in this field increases, heterogeneity in outcome reporting hinders the valid and meaningful synthesis of data into high-quality meta-analyses. The aim of this systemic review was to investigate variability in outcome reporting following cytoreductive surgery with or without intraperitoneal chemotherapy for colorectal peritoneal metastases.

Method: Five electronic databases [MEDLINE, Embase, Scopus, Cochrane Central Register of Controlled Trials (CENTRAL) and Cumulative Index to Nursing and Allied Health Literature (CINAHL)] were interrogated from 2000 to October 2023 to identify all reported outcomes in the current literature. Extracted outcomes were catalogued and reviewed by a multidisciplinary working group into standardized terms and domains.

Results: A total of 294 studies, from 5112 screened, were included for analysis. We extracted 2903 outcomes verbatim from included studies and catalogued them into 85 standardized outcomes across seven outcome domains. The most frequently reported domains were survival, in 274 (93%) studies, and pathological outcomes, in 232 (79%) studies. Outcomes pertaining to function and life impact were only reported in seven (2%) studies. Reported outcomes were only defined in 35% of cases, and significant variability existed between definitions.

Conclusion: This systematic review highlights the heterogeneity of outcome measurement and reporting following cytoreductive surgery for colorectal peritoneal metastases. Patient-reported outcomes are relatively underrepresented in the current literature. The results of this review will inform an international collaborative effort to create a core outcome set to address these issues.

Aim: Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are the two main techniques used for endoscopic resection of superficial rectal tumours. The aim of this study was to compare the outcomes of ESD and EMR in treating superficial rectal tumours.

Method: A retrospective observational study was conducted at two French centres including all patients treated with ESD or EMR for superficial rectal tumours. The primary outcome was the rate of local recurrence at the first follow-up endoscopy after endoscopic resection. Secondary outcomes included the curative resection rate, procedure duration, length of hospital stay, complication rates and the need for additional surgery.

Results: A total of 254 patients were included, 159 treated with ESD and 95 treated with EMR. The local recurrence rate at the first follow-up endoscopy was 8.6% and was significantly lower in the ESD group than in the EMR group (4.3% vs. 16.9%; p = 0.005). The rates of en bloc and histologically complete resections were higher in the ESD group (88.1% vs. 42.7% and 85.5% vs. 38.9%, respectively; p < 0.001), while the curative resection rate was 90.6% in the EMR group and 92.5% in the ESD group (p = 0.59). Mostly due to poor histoprognostical criteria, 6.0% of patients underwent additional surgery (6.3% vs. 5.2% in the ESD vs. EMR group, respectively; p = 0.73).

Conclusion: ESD demonstrated higher rates of en bloc, R0 resection than EMR, translating into significantly lower rates of local recurrence at the first follow-up endoscopy.

Aim: Low-grade appendiceal mucinous neoplasm (LAMN) of the appendix is a rare tumour that can progress to pseudomyxoma peritonei (PMP). There is a lack of standardization of surveillance following resection of LAMN as the progression rate to PMP is unclear. The aim of this study was to evaluate the rate of progression following resection of LAMN to PMP in a structured surveillance programme.

Method: Data for all patients referred for LAMN surveillance from 2013 to 2021 were retrospectively collected. The surveillance regime consisted of annual CT and tumour markers for a 5-year period. Patients who progressed to PMP were identified.

Results: Of the patients enrolled in surveillance following appendicectomy and LAMN diagnosis (65.1% female, median age 56 years), 83 had completed at least 1 year of surveillance (median follow-up 24 months). Of these, 6% (n = 5) showed disease progression during follow-up. The median time to progression was 23 months. Survival analysis revealed no statistically significant difference in progression with regards to T staging (p = 0.39), margin positivity (p = 0.11) or appendiceal perforation (p = 0.26). No patients with Tis disease developed PMP. A statistically significant difference in progression was seen in patients with M1b staging (p = 0.021) and in those with mucin beyond the right iliac fossa at diagnosis (p = 0.04).

Conclusion: The observed progression rate justifies the necessity of postappendicectomy surveillance in patients with LAMN, with the risk of progression being highest within the first 3 years of diagnosis. The described surveillance programme allows for early detection of subclinical progression to PMP.