Diseases of the Colon & Rectum最新文献

Background: Lymph node metastasis is important for the management and surgical procedures of patients with colorectal cancer. Preoperative identification of D3-metastasis could help evaluate the necessity of D3 lymphadenectomy. No adequate noninvasive method has been developed to detect the status of lymph nodes.

Objective: To establish a ctDNA methylation-based method to preoperatively identify lymph node metastasis and D3-metastasis in colorectal cancer.

Design: This is a prospective and paired diagnostic study. After an analysis of the genome-wide DNA methylation landscape, differential biomarkers were selected. A ctDNA methylation-based model for identifying lymph node metastasis (cMCL) was constructed with a machine learning algorithm. Its performance was compared with that of traditional methods. A nomogram was constructed by incorporating the ctDNA methylation-based model for identifying lymph node metastasis and clinicopathological predictors to identify D3-metastasis. In addition, a traditional clinicopathological method was constructed with the same method but without ctDNA methylation-based model for identifying lymph node metastasis. Comparison between the performance of the two models was performed.

Settings: A single cancer center in China.

Patients: A total of 206 patients with stage I-III colorectal cancer were recruited between June 2022 and September 2023. All patients underwent radical surgical resection and D3 lymphadenectomy without neoadjuvant treatment.

Main outcome measures: The performance of identifying lymph node metastasis and D3-metastasis.

Results: After selecting 27 differential biomarkers, the ctDNA methylation-based model for identifying lymph node metastasis was constructed and yielded a sensitivity of 82.6% and a specificity of 73.3%. The accuracy was superior to that of CT (77.2% vs. 66.5%, p = 0.019). Afterward ctDNA methylation-based model for identifying lymph node metastasis-nomogram was constructed to predict D3-metastasis. The accuracy was also superior to that of traditional method (82.6% vs. 67.4%, p < 0.001).

Limitation: This study included a small number of patients.

Conclusions: The proposed novel approach based on ctDNA methylation could accurately identify lymph node metastasis and D3-metastasis in colorectal cancer preoperatively and inform tailored treatment. See Video Abstract.

Clinical trial registration number: NCT05558436.

Background: Transanal total mesorectal excision (taTME) has been increasingly adopted in the curative resection of low rectal cancer. Obesity is a known risk factor for conversion and morbidity during laparoscopic and robotic TME.

Objective: We sought to compare short-term postoperative and pathologic outcomes and long-term oncologic outcomes of transanal total mesorectal excision between non-obese vs. obese patients across high-volume rectal cancer centers in the United States.

Design: Retrospective cohort study.

Settings: Eight tertiary centers in the United States of America.

Patients: Eligible patients underwent transanal total mesorectal excision for curative resection of primary rectal adenocarcinoma between November 2011 and June 2020.

Main outcome measures: Intraoperative complications, 30-day postoperative complications, local recurrence, distant recurrence, overall survival, disease-free survival.

Results: A total of 390 transanal total mesorectal excision procedures were performed in 271 (69.5%) non-obese (BMI < 30 kg/m2) and 120 (30.5%) obese (BMI ≥ 30 kg/m2) patients with a median BMI of 27.4 kg/m2 (IQR 24.1-31.0). The median follow-up was 29 months (IQR 14-44 months). There were no significant differences in tumor stage or neoadjuvant treatment across groups. Tumors were located ≤ 6cm from the anal verge in 60.6% of patients. Operative time was longer in the obese group, with no significant differences in conversion rates or intraoperative complications. No significant differences in postoperative complications, including Clavien-Dindo grade ≥3 complications, anastomotic complications or reoperation rates were noted between non-obese and obese cohorts. At a median follow-up of 29 months, local recurrence, overall survival, and disease-free survival were comparable between the groups, while obese patients had a significantly lower rate of distant recurrence than non-obese patients.

Limitations: Retrospective design, short median follow up time.

Conclusions: In this multicenter retrospective study, transanal total mesorectal excision resulted in similar conversion and morbidity rates among obese and non-obese patients. Obesity was associated with a significantly lower 3-year distant recurrence with no differences in other mid-term oncologic outcomes.

Background: The Crohn's Anal Fistula Quality of Life scale was recently developed as the first disease-specific patient-reported outcome measure for patients with perianal fistulizing Crohn's disease. After cross-cultural validation, the Crohn's Anal Fistula Quality of Life scale may be implemented internationally to measure quality of life among patients with perianal fistulizing Crohn's disease.

Objective: To translate and validate the Crohn's Anal Fistula Quality of Life scale in Dutch patients with active perianal fistulizing Crohn's disease.

Study design: Prospective observational cohort study.

Setting: Forty-one Dutch academic and non-academic hospitals.

Patients: Patients with active perianal fistulizing Crohn's disease who completed all quality of life questionnaires at time of inclusion.

Main outcome measures: Construct validity, internal consistency, test-retest reliability and responsiveness of the Crohn's Anal Fistula Quality of Life scale. Item response theory was used to investigate individual properties of the Crohn's Anal Fistula Quality of Life scale and differential item functioning for age, sex and educational level was tested.

Results: Questionnaires were completed by 263/403 patients (response rate 65.3%). Evaluation of the construct validity showed a moderate correlation with sIBDQ (r = -0.61) and EQ-5D-5L (r = -0.58 [utility], r = -0.42 [VAS]). Overall internal consistency (Cronbach's alpha) was 0.93. Test-retest reliability was high (intraclass correlation coefficient 0.89). Responsiveness was reported in both improved and worsened perianal fistulizing Crohn's disease (p < 0.01). Item response theory analyses identified the majority of the questions (72.7%) have a moderate to high discrimination predicting quality of life. No differential item functioning with clinical impact was identified.

Limitations: potential selection bias of respondents to questionnaires, the absence of a clinical gold standard for assessing fistula status, and a relatively small sample size for the test-retest reliability analysis.

Conclusion: In this prospective multicenter study, the Crohn's Anal Fistula Quality of Life scale was validated as a robust tool to measure quality of life among patients with active perianal fistulizing Crohn's disease. Additionally, this cross-cultural validation facilitates broader international implementation and future adaptations into other languages and cultural contexts. Further studies are required to define a minimal (clinically) important difference and/or minimal detectable change on the Crohn's Anal Fistula Quality of Life scale to measure treatment effects. See Video Abstract.

Background: Patients treated for stage I-III colorectal cancer are at high risk for developing new and recurrent colon cancers. Therefore, professional organizations recommend a surveillance colonoscopy approximately 1-year post-surgical resection to ensure early detection. Despite these guidelines, surveillance colonoscopy completion rates remain suboptimal.

Objective: This multi-methods study aimed to explore patient-identified barriers and facilitators affecting the completion of 1-year surveillance colonoscopies among stage I-III colorectal cancer survivors.

Design: Multi-methods study.

Settings: The study was conducted within the Hutchinson Institute for Cancer Outcomes Research Value in Cancer Care Network, comprising 46 clinics across 13 counties in Washington State.

Patients: We enrolled stage I-III colorectal cancer survivors who had not completed surveillance colonoscopy within 18 months of surgery. Participants completed questionnaires and semi-structured interviews between December 2023 and June 2024.

Main outcome measures: Questionnaire data and interview transcripts were independently coded and analyzed by two coders to identify key themes and subthemes related to barriers and facilitators of surveillance colonoscopy completion.

Results: The study included nineteen patients. The median (interquartile range) participant age was 73 (17.8) years, 9 (47.4%) were male and 8 (42.1%) had stage I cancer. All participants reported cognitive and environmental factors as barriers or facilitators to surveillance colonoscopy completion. The most reported barriers were fear of the colonoscopy results and cancer recurrence (cognitive) and challenges with the bowel preparation (environmental). The most frequently reported facilitators were patient's motivation to receive reassurance (cognitive) and clinic assistance in scheduling appointments (environmental).

Limitations: Results may not be generalizable due to population and selection bias of participants.

Conclusions: This study identified barriers and facilitators to completing a 1-year surveillance colonoscopy to guide future interventions. Addressing both psychological concerns and improving communication between patients and clinics could be key strategies to enhance adherence rates and improve long-term outcomes for colorectal cancer survivors. See Video Abstract.

Background: Patients older than 70 account for 44% of all rectal cancer cases. Although surgery is the gold standard treatment, elderly patients can also be offered other treatments, such as total neoadjuvant therapy with watch and wait.

Objective: This study aimed to investigate whether postoperative 90-day mortality is increased in the elderly compared to younger patients.

Design: This nationwide retrospective study included all consecutive resections of rectal cancer between 2005-2016 using data from the RALAR study. Patients were divided into 2 groups based on their age: non-elderly <70 years and elderly ≥70.

Setting: Data were obtained from 19 Italian referral centers for colorectal surgery.

Patients: A total of 3,573 patients underwent rectal surgery: non-elderly (2,071 [57.9%]) and elderly (1,502 [42%]).

Main outcome measures: The primary endpoint was 90-day postoperative mortality. Secondary endpoints included intensive care unit stay, hospitalization, surgical and general postoperative complications, overall survival, disease-specific survival, and recurrence rate.

Results: Ninety-day postoperative mortality was comparable between groups (0.41% non-elderly vs 1.05% elderly, p = 0.087). Elderly patients were monitored more frequently in intensive care unit and developed more postoperative general complications, while no differences were found between the groups in terms of postoperative surgical complications. Hospitalization was longer in elderly (median [IQR]: 12.3 [9.7] vs 11.1 [14.6] days). Five-year overall survival was higher in non-elderly (77.3%) compared to elderly (45.8%, adjusted OR 1.70, 95% CI: 0.57, 5.65), while the disease-specific survival was similar between groups.

Limitations: There are limitations inherent in this retrospective study, i.e., the long accrual period and the unknown proportion of patients who didn't undergo surgery.

Conclusions: Although elderly patients experience a higher rate of postoperative general complications without an increase in postoperative mortality, rectal surgery yields similar surgical and oncological outcomes compared to younger patients. This study suggests that age alone shouldn't exclude someone from surgery. See Video Abstract.

Background: End colostomy reversal with colorectal anastomosis (Hartmann's reversal) is a technically challenging procedure associated with significant morbidity due to adhesions and distorted anatomy following the index surgery.

Objective: To compare perioperative outcomes of open, laparoscopic, and robotic approaches for Hartmann's reversal.

Design: Retrospective analysis of prospectively maintained data.

Settings: High-volume tertiary referral center with specialized colorectal surgery expertise.

Patients: A total of 218 underwent Hartmann's reversal between May 2018 and April 2023.

Main outcome measures: Primary outcomes included hospital length of stay and rate of conversion. Secondary outcomes included overall complication rates and time to return of bowel function.

Results: Of 218 patients, 139 (63.8%) underwent open surgery, 48 (22.0%) underwent laparoscopic surgery, and 31 (14.2%) underwent robotic surgery. Robotic surgery had the lowest estimated blood loss (median, 77.5 ml vs. 100 ml laparoscopic and 150 ml open, p < 0.0001). Conversion to open occurred in 16.1% of robotic cases versus 35.4% of laparoscopic cases (p = 0.0618). Minimally invasive approaches were associated with shorter hospital length of stay (median 3.0 days vs. 4.0 days, p < 0.0001) and faster return of bowel function (median 2.0 days vs 3.0 days, p = 0.0095) compared to open surgery. Overall 30-day morbidity was 23.4%, with no significant difference among approaches (p = 0.30). The temporal trend showed increasing adoption of robotic techniques, from 0% in 2018 to 53.8% in 2023, and a decrease in the proportion of cases approached by open surgery from 76.9% in 2018 to 23.1% in 2023.

Limitations: Retrospective design and single-institution experience with limited follow-up duration.

Conclusions: Minimally invasive approaches to Hartmann's reversal are associated with improved short-term outcomes compared to open surgery. The robotic approach shows promise in reducing conversion rates, potentially extending the benefits of minimally invasive surgery to more patients undergoing this challenging procedure. See Video Abstract.

Background: Metachronous cancer risk varies by mismatch repair mutation in patients with hereditary nonpolyposis colorectal cancer. Total colectomy offers decreased risk of metachronous colorectal cancers but decreased quality of life compared with segmental colectomy.

Objective: Compare segmental versus total colectomy for colon cancer via a mutation-specific Markov decision model.

Design: Simulated survival and colorectal metachronous occurrence among patients with MLH1, MSH2, or MSH6 mutations undergoing either segmental or total colectomy.

Settings: National databases, literature review.

Patients: Simulated patients with hereditary nonpolyposis colorectal cancer.

Main outcome measures: Overall survival, quality-adjusted life years based on procedure-specific utility states (segmental colectomy 0.99, total colectomy 0.95).

Results: Among patients aged 25, total colectomy offered less than one year of increased mean survival compared with segmental resection across all mutations (MLH1: 0.8 years, MSH2: 0.9, MSH6: 0.3). This difference in survival decreased with increasing age. Segmental resection offered a small increase in quality-adjusted life years compared with total colectomy across all ages. This difference was highest for MSH6 (0.9 years vs. MLH1: 0.6 and MSH2: 0.4 at age 25), particularly at younger ages of diagnosis. In a sensitivity analysis, lower total colectomy utility states resulted in greater increases in quality-adjusted life years with segmental colectomy across all mutations.

Limitations: Metachronous cancer risk data does not distinguish between colon and rectal cancers and is extrapolated beyond age 70.

Conclusions: Segmental and total colectomy offer similar survival and quality-adjusted life year outcomes. With decreased risk of metachronous cancers, patients with MSH6 mutations across all ages may prefer segmental resection due to higher quality-adjusted life years and lower survival benefits from total colectomy compared with MLH1 and MSH2 patients. Operative strategy in patients with hereditary nonpolyposis colorectal cancer should be individualized, and this study shows that mutation-specific differences in survival and quality-adjusted life years are small. See Video Abstract.

Background: Colorectal surgery for familial adenomatous polyposis requires a balance between minimizing cancer risk, surgical risk, and quality-of-life preservation. Options include total colectomy/ileorectal anastomosis or proctocolectomy/ileal pouch-anal anastomosis. Prior studies comparing short-term postoperative outcomes are dated and mainly include laparotomies. Minimally invasive surgery is common in current practice, but there are no contemporary studies comparing postoperative outcomes between the 2 surgeries.

Objective: This study investigated postoperative outcomes including leak, obstruction, and surgical site infection after ileorectal anastomosis versus ileal pouch-anal anastomosis in familial adenomatous polyposis.

Design: This was a retrospective, observational cohort study.

Settings: This study was conducted at a single academic institution using a prospectively maintained hereditary colorectal cancer syndrome database from 2008-2023.

Patients: Patients with familial adenomatous polyposis who underwent index ileorectal anastomosis or ileal pouch-anal anastomosis during the study period and met inclusion criteria were selected.

Main outcome measures: Main outcome measures include development of a postoperative complication, readmission, and reoperation within 30 and 90 days.

Results: A total of 217 patients were included - 146 (67.3%) with ileorectal anastomosis and 71 (31.7%) with ileal pouch-anal anastomosis. 85.3% had minimally invasive surgery and 14.7% had open surgery. 87.3% of ileal pouch-anal anastomosis patients had an ileostomy. No significant difference in the number of patients who developed a 30 or 90-day complication was observed. The most common 90-day complication was ileus (34.2% vs 21.2%) and most common 90-day severe complication was anastomotic leak (4.8% vs 7.0%). Patients had a higher frequency of readmission and reoperation after ileal pouch-anal anastomosis (13.0% vs 33.8% and 6.8% vs 18.3%, respectively).

Limitations: This study is limited by its retrospective nature and short follow-up time.

Conclusions: In the modern era, with most surgeries being done minimally invasively, and the majority of ileal pouch-anal anastomosis patients being diverted, surgeries are safe. Severe complications are uncommon and similar between groups. See Video Abstract.