Aim: Surgical decision making in the context of pilonidal disease (PD) can be challenging. Current evidence for the management of PD is inadequate and optimum treatment is not clear. This paper reports on patient experience of shared decision making (SDM) and decision regret following surgical management of PD.
Method: The Pilonidal Trial. Studying the Treatment Options (PITSTOP) study (ISRCTN95551898) is a prospective cohort study of patients with PD treated between May 2019 and March 2022. This subanalysis reports the results of quantitative data capture between baseline and 6 months post-procedure. Baseline data consisted of patient and disease characteristics, surgical procedure and impression of SDM. Post-procedure data consisted of operative outcomes and decision regret. Multiple linear regression analysis was used to analyse the relationship between clinical outcomes and decision regret.
Results: Overall, 677 patients were included, and follow-up data to 6 months were available for 476 (71%). Most (59.5%) patients underwent major excisional surgery; 45.1% of patients experienced a postoperative complication. Participant impression of SDM was positive, with a median CollaboRATE mean-score response of 3 (interquartile range: 3-4). Of the patients who underwent a 'leave open' approach, 20.6% were dissatisfied or very dissatisfied with their treatment. Postoperative complications (β = 3.21, 95% CI: -12.75 to 7.25, p < 0.001) and disease recurrence (β = 11.5, 95% CI: -10.6 to 9.4, p < 0.001) were both associated with higher rates of decision regret.
Conclusion: The clinical outcomes, postoperative complications and recurrence, were associated with higher levels of decision regret. Surgeons treating patients with PD should practice SDM and ensure that patient priorities inform treatment approach.
Aim: Minimal evidence exists regarding faecal immunochemical tests (FITs) for colorectal cancer (CRC) site, stage and grade in symptomatic patients. The primary aim is to determine any association between faecal haemoglobin concentration (f-Hb) (analysed with OC-Sensor™ Pledia) and these prognostic factors. The secondary aim is to determine the association between f-Hb and anaemia, microcytosis and iron deficiency (Hb, mean corpuscular volume [MCV] and ferritin).
Methodology: Symptomatic 2-week wait CRC patients with FIT were included (July 2019-October 2022). Median f-Hb and interquartile range according to sex, stage, grade and site (right-sided, caecum to transverse colon, R-CRC; left-sided, splenic flexure to rectum, L-CRC) were compared using the Mann-Whitney U test. Hb, MCV and ferritin were categorized into two groups and the median f-Hb was compared using the Mann-Whitney U test.
Results: In all, 114 patients (57 women, 57 men) were studied; 46 had R-CRC (f-Hb = 113 μg Hb/g) and 68 had L-CRC (f-Hb = 342 μg Hb/g) (P = 0.07). Sixty-nine were moderately differentiated CRC (f-Hb = 183 μg Hb/g) and 29 were poorly differentiated (f-Hb = 866 μg Hb/g) (P = 0.04). By T-stage, 35 were early (T1/2) (f-Hb = 170 μg Hb/g) and 79 were advanced (T3/4) (f-Hb = 200 μg Hb/g) (P = 0.06). The relationship between f-Hb and Hb, MCV and ferritin was not significant. Poorly differentiated (P = 0.04) and later stage (P = 0.02) R-CRC had significantly lower f-Hb compared to L-CRC.
Conclusions: Right-sided CRC is associated with lower f-Hb than left. Poorly differentiated and later staged L-CRC had higher median f-Hb. These data add to existing evidence suggesting that FIT may be less sensitive for right-sided CRC. Strategies to mitigate the potential for missed or FIT-negative right-sided CRC are required.
The rate of surgical recurrence following ileorectal anastomosis (IRA) in patients with Crohn's disease (CD) remains poorly understood. Most studies were conducted before the advent of biologics. Our aim was to assess the fate of IRA in patients with CD during the biologics era and identify risk factors for endoscopic, clinical, and surgical recurrence.
This retrospective multicentre cohort study included patients with CD who underwent IRA between 2006 and 2022. The association of patient characteristics and postoperative measures with each type of postoperative recurrence and need for a definitive stoma was investigated using the chi-square test or Fisher's exact test.
During a median follow-up period of 60 months, the rates of endoscopic, clinical, and surgical postoperative recurrence were 70%, 59%, and 35%, respectively. The rate of perianal lesions was higher in patients who underwent a definitive stoma (70% vs. 35%, p = 0.007) and with endoscopic (50% vs. 25%, p = 0.038), clinical (54% vs. 24%, p = 0.006), and surgical (63% vs. 34%, p = 0.015) recurrence. The incidence of residual microscopic disease at the rectal margin was higher in patients with endoscopic recurrence (p = 0.047). Biologics were identified as protective factors against the need for a definitive stoma (p = 0.044).
IRA is a good treatment option for extensive colitis in patients with CD. However, its consideration should be weighed in the presence of perianal lesions, which have been shown to be a risk factor for delayed proctectomy.
Anastomotic leakage following rectal cancer surgery remains a challenging complication, with a nonhealing rate of approximately 50% at 1 year. Pelvic sepsis may require tertiary treatment that encompasses additional admissions, extensive surgery and other types of interventions. The aim of this study is to analyse the financial burden of pelvic sepsis in a tertiary hospital.
From 2010 until 2020, all patients referred to a tertiary centre for pelvic sepsis after low anterior resection for rectal cancer were prospectively registered and retrospectively reviewed. The cost analysis adhered to Dutch National Healthcare Institute guidelines and covered hospital-imposed medical costs from salvage surgery to the last registered intervention, adjusted for inflation and priced in euros.
This analysis included 126 patients, with an average total cost per patient of €31 131. Salvage surgery accounted for €21 326, with an additional €9805 for reinterventions and readmissions. Salvage surgery comprised nonrestorative surgery in 48% and restorative salvage surgery in the remaining cases. Length of hospital stay averaged 9.6 days on the general ward and 0.8 days in the intensive care unit. Common reinterventions included endoscopic vacuum sponge changes (n = 153), stoma closures (n = 59) and radiological abscess drainages (n = 51). Total costs did not differ significantly between nonrestorative surgery and restorative surgery (mean = €31 950 vs. €30 362, respectively; p = 0.893).
Treating pelvic sepsis after rectal cancer resection in a tertiary hospital carries a substantial economic burden, averaging €31 131 per patient, and this work helps to quantify the potential economic impact of innovative care to reduce anastomotic leakage.
Aim: Pilonidal sinus disease (PSD) is a common condition. Despite a relatively large proportion of patients presenting as post-pubertal adolescents, only small cohorts focusing on this PSD subcategory have been published, and surgical treatment remains challenging.
Method: The study is based on a prospective database established at Randers Regional Hospital in 2016. All patients undergoing Bascom's cleft lift (BCL) surgery from June 2016 until June 2020 were included in this study, focusing on patients ≤18 years of age comparing them to adult patients. Indications for BCL surgery were primary extensive manifestation, non-healing disease after previous elective surgery or disease recurrence.
Results: In total, n = 380 PSD patients were operated, of which n = 79 were post-pubertal adolescents with a median age at time of surgery of 17.2 years (interquartile range 16.3, 18.0). Sixty-six (84%) were boys. Twenty-seven (34%) presented with primary extensive manifestation, 34 (43%) due to non-healing wounds and 18 (23%) due to recurrence. Fifty-four patients (69%) healed uneventfully. There was no difference between the indications of surgery groups in terms of overall healing or time to healing if prolonged (P = 0.6). The median follow-up was 62 months (interquartile range 48, 73), with a 5-year recurrence rate of 19%, compared to 17% (P = 0.6) in the adult population.
Conclusion: Our study is the first to investigate long-term clinical outcomes of BCL surgery for PSD in post-pubertal adolescent patients. Recurrences seem to occur more frequently compared to adults. However, we demonstrate that post-pubertal adolescent patients with advanced PSD can be treated with BCL surgery with acceptable outcomes.
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