Colorectal Disease最新文献

Aim

The aim of this work was to quantify post-colonoscopy colorectal cancer (PCCRC) rates in National Health Service (NHS) Scotland using World Endoscopy Association guidelines, compare incidence between health boards and referral streams and explore comparisons in results with published data from other healthcare systems.

Method

This is a population-based cohort study using NHS Scotland data between 2012 and 2018. All people undergoing colonoscopy between 2012 and 2018 and subsequently diagnosed as having bowel cancer up to 3 years after their investigation were included. The main outcome measures are national trends in the PCCRC rate at 3 years (PCCRC-3yr). with comparison between bowel screening and non-screening referral routes, board of referral and analysis of factors associated with occurrence.

Results

The overall unadjusted PCCRC-3yr was 7.9% (7.4%–8.3%). There was no change in the annual rate over the 7-year study period. The PCCRC rate was lower for the Scottish Bowel Cancer Screening Programme (6.7% vs. 8.3%), but compared unfavourably with rates reported by the NHS England Bowel Cancer Screening Programme from an earlier time period. There was wide variation in rates between health boards of similar population size. Rates were higher in women, with increasing age and in patients with a history of inflammatory bowel disease or diverticular disease.

Conclusion

Despite advances in technology, there has been no improvement in the PCCRC rate in Scotland between 2012 and 2018. Rates in bowel screening colonoscopy are better than in nonscreening colonoscopy but compare unfavourably with NHS England, possibly as a result of less robust endoscopist selection and training. Quality improvement is required in colonoscopy in order to improve patient outcomes nationally, and to allow equitable access to higher-quality colonoscopy in different regions of the country.

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

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

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

Crohn's disease (CD) is regarded as a wasting disease, yet there is a growing population of CD patients with a body mass index (BMI) of 35 and above. The rate of postoperative complications is relatively high in CD patients but might be even higher in CD with morbid obesity (MO).

Methods

This was a retrospective study using a prospectively maintained database of all patients undergoing Ileocolic resection for CD between 2014 and 2021 in two referral centres, comparing postoperative complication rates according to BMI.

Results

Three hundred and forty-six patients were identified. Sixty patients (17%) had a BMI over 30 kg/m², and 28 (8.1%) had a BMI of over 35 kg/m² (>35 group). The BMI >35 group had more women (78.6% vs. 52%, P < 0.1), a higher rate of patients not receiving an anastomosis (7.1% vs. 2.5%, P = 0.02), a higher rate of any postoperative surgical complication (32.1% vs. 25.2%, P = 0.4), with a higher rate of Clavien–Dindo ≥3 (14.3% vs. 7.2%, P = 0.25), a higher rate of stoma creation on reoperation for complications (7.2% vs. 1.7%, P = 0.04), a higher rate of 30-day readmission due to intra-abdominal abscess (10.7% vs. 4.7%, P = 0.2), but a lower rate of postoperative medical complications (3.6% vs. 15.7%, P < 0.01).

Conclusions

The rate of MO among CD patients requiring ileocolonic resection is on the rise. MO in this setting is associated with statistically non-significant increases in all surgical complications, severe complications, readmission, and a higher chance for a bailout stoma creation upon reoperation. However, MO seems to be a protective factor for medical postoperative complications, which might suggest better nutritional status.

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

Complete mesocolic excision (CME) is an oncologically driven technique for treating right colon cancer. While laparoscopic CME is technically demanding and has been associated with more complications, the robotic approach might reduce morbidity. The aim of this study was to assess the safety of stepwise implementation of robotic CME.

Method

A multicentre retrospective analysis of prospectively collected data on robotic right colectomy was performed at five European tertiary centres. Patients were classified for type of surgery: R-RHC (standard right colectomy), R-impCME (learning cases towards robotic CME defined as R-RHC with one but not all the hallmarks of CME) or R-CME (robotic CME). Primary outcomes were overall and severe 30-day complication rates before and after propensity score matching (PSM) analysis.

Results

Five hundred and fifty-one consecutive patients undergoing robotic surgery for (pre)malignant lesions of the right colon between 2010 and 2020 were included: R-RHC (n = 101), R-impCME (n = 135) and R-CME (n = 315). Baseline characteristics differed for American Society of Anesthesiologists score (p = 0.0012) and preoperative diagnosis of adenocarcinoma (p < 0.001). Procedure time increased by surgical complexity (p < 0.001). Vascular event rates did not differ, with no superior mesenteric vein injuries. Conversion, complication and anastomotic leak rates, time to flatus/soft diet and length of stay (LOS) did not differ. While R-RHC was performed for a lower rate of malignancies (p < 0.001), lymph node yield was significantly higher in R-CME (p < 0.001). After PSM, analyses on 186 patients documented no differences in overall and severe 30-day complication rate, conversion rate, LOS or 30-day mortality.

Conclusion

R-CME can be implemented without increasing the overall or 30-day severe complication rate.