Diseases of the Colon & Rectum最新文献

Background: The optimal management strategy for grade III hemorrhoids remains a subject of ongoing debate. Hemorrhoidectomy is the gold standard, but rubber band ligation offers a less invasive outpatient alternative. Treatment variability persists due to a lack of consensus on the preferred strategy.

Objective: To directly compare the effectiveness of rubber band ligation and hemorrhoidectomy in the treatment of grade III hemorrhoids.

Design: Open-label, parallel-group, randomized controlled non-inferiority trial.

Settings: Multicenter study across 10 Dutch hospitals from October 2019 to September 2022.

Patients: Patients (≥18 years) with symptomatic grade III (Goligher) hemorrhoids. Exclusions: prior rectal/anal surgery, >1 rubber band ligation/injection within the preceding three years, rectal radiation, preexisting sphincter injury, inflammatory bowel disease, medical unfitness for surgery (ASA >3), pregnancy, or hypercoagulability disorders.

Interventions: Randomized 1:1 to rubber band ligation or hemorrhoidectomy, with up to two banding sessions allowed.

Main outcome measures: Primary: 12-month health-related quality of life and recurrence rate. Secondary: complications, pain, work resumption, and patient-reported outcome measures.

Results: Eighty-seven patients were randomized (47 rubber band ligation vs 40 hemorrhoidectomy). Rubber band ligation was not non-inferior to hemorrhoidectomy in quality adjusted life years (-0.045, 95% confidence interval -0.087 to -0.004). Recurrence rate was worse in the rubber band ligation group (47.5% vs 6.1%), with an absolute risk difference of 41% (95% confidence interval 24%-59%). Complication rates were comparable. Post-hemorrhoidectomy pain scores were higher during the first week (visual analogue scale 4 vs 1; p = 0.002). Rubber band ligation group returned to work sooner (1 vs 9 days; p = 0.021). Patient-reported hemorrhoidal symptom scores favored hemorrhoidectomy.

Limitations: The study's primary limitation was its early termination due to funding constraints, resulting in a relatively small sample size and limited statistical power. Patient recruitment was hindered by significant treatment preferences and the COVID-19 pandemic.

Conclusions: Hemorrhoidectomy may benefit patients with grade III hemorrhoids in terms of quality of life, recurrence risk, and symptom burden, while Rubber Band Ligation allows faster recovery with less pain. These findings can guide clinical decision-making. See Video Abstract.

Clinical trial registration number: NCT04621695.

Background: Hemorrhoidal disease is highly prevalent in the United States and frequently queried online. Unfortunately, health education webpages often lack reliable information.

Objective: To evaluate whether online hemorrhoid education materials in English and Spanish meet national recommendations for readability, actionability, and accessibility, and provide critical clinical guidance on when to seek medical care.

Design: Using three search engines (Bing, Google, Yahoo), we selected the top 30 results for formal medical and colloquial English and Spanish search terms regarding hemorrhoids. We assessed readability using validated scoring systems for readability in English and Spanish to report median reading levels and assessed Health Literacy Performance on a six-point checklist in three categories: accessibility, actionability, and critical clinical guidance.

Settings: University of California Los Angeles.

Main outcome measures: Readability and health literacy performance.

Results: After removing duplicates, 90-95 webpages generated from formal English, Spanish, and colloquial English terms remained. There was minimal overlap of results from the formal and colloquial English searches. Median reading levels were first-year university for formal and colloquial English webpages, and eleventh grade for Spanish webpages. 43.2%, 48.4%, and 18.2% of formal English, Spanish, and colloquial English websites, respectively, had minimal Health Literacy Performance. Health Literacy Performance criteria that were met least often were printability and providing specific, actionable goals for patients to implement.

Limitations: Our study represents searches completed at one point in time utilizing specific terms. Colloquial search terms were generated via survey with convenience sampling and may not be representative of all possible searches used by patients seeking information on hemorrhoidal disease.

Conclusions: Most English and Spanish hemorrhoid-focused webpages failed to provide appropriate patient education, as they exceeded the recommended sixth-grade reading level, lacked actionable recommendations, were not accessible, and failed to provide critical clinical guidance. Online resources are essential for patients of all health literacy levels; improvement is critical to reduce healthcare disparities. See Video Abstract.

Background: The jejunum has a wide lymphatic drainage field, making radical surgery difficult.

Objective: Extrapolate results from 2 methodologies to define jejunal artery lymphatic clearances and lymphovascular bundle shapes for radical bowel-sparing surgery.

Design: Two cohort studies.

Settings: The first dataset comprised dissections of cadavers at the University of Geneva. The second dataset incorporated preoperative 3D-computed tomography vascular reconstructions of patients included in the "Surgery with Extended (D3) Mesenterectomy for Small Bowel Tumors" clinical trial.

Patients: Eight cadavers were dissected. The 3D-computed tomography dataset included 101 patients.

Main outcome measures: Lymph vessels ran parallel and interlaced with jejunal arteries. Lymphatic clearance was minimal at the jejunal artery's origin, radially spreading thereafter. Jejunal arteries were categorized into 3 groups based on position to the middle colic artery origin on 3D-computed tomography. Group A: jejunal artery origins lie cranially and caudally to the middle colic artery. Group B: jejunal artery origins lie caudal to the middle colic artery. Group C: jejunal artery origins lie cranial to the middle colic artery. Jejunal veins were classified into 3 groups based on their trajectories to the superior mesenteric artery (dorsally/ventrally/combined).

Results: Lymph vessel clearances were 1.5 ± 1.0 mm at jejunal artery origins. Group A was present in 81 (80.2%), group B in 13 (12.9%), group C in 7 (6.9%) cases. Jejunal artery median was 4. A 57 (56.4%) of jejunal veins ran dorsally to the superior mesenteric artery, 16 (15.8%) ran ventrally, and 28 (27.8%) had combined course.

Limitations: Lymph nodes weren't counted during dissection because the main observation was the position of lymph vessels.

Conclusion: Minimal jejunal artery lymphatic clearance implies ligating tumor-feeding vessels at origin. The intermingled jejunal artery lymphatics imply lymph node dissection along the proximal and distal vessels to the level of the first arcade. Classifying jejunal arteries and veins could simplify the anatomy for surgeons. See Video Abstract.

Clinical trial registration number: NCT05670574.

Background: Colectomy for benign or malignant disease may be elective, urgent, or emergent. Data suggest successively worse outcomes for non-elective colectomy. Few data exist on the contribution of high area deprivation index and care fragmentation to non-elective colectomy.

Objective: Determine the association between area deprivation and non-elective colectomy in the Veterans Health Administration and assess whether accounting for differences in care fragmentation alters the association across indications and for benign and malignant conditions separately.

Design: Retrospective cohort with multivariable multinomial logit models to evaluate associations between high deprivation care fragmentation, and the adjusted odds of non-elective colectomy. We calculated total, direct, and indirect effects to assess whether the association varied by levels of care fragmentation.

Setting: Veterans receiving care in the private sector and Veterans Health Administration.

Patients: Veterans ≥ 65 years undergoing colectomy between 2013 and 2019.

Main outcome/measures: Colectomy case acuity.

Results: We identified 6538 colectomy patients, of which 3006 (46.0%) were for malignancy. The odds of emergent colectomy were higher for patients in high deprivation areas when the indication was for benign pathology (aOR 1.51 95% CI: 1.15, 2.00). For malignant indications, there was no association between high deprivation and non-elective colectomy. More fragmented care was associated with a higher odds of urgent and emergent colectomy for both benign and malignant indications but the association between deprivation and non-elective colectomy did not vary by care fragmentation.

Limitations: Inherent to large administrative retrospective databases.

Conclusions: Veterans living in high deprivation areas are at higher risk for emergent colectomy for benign conditions. Care fragmentation is also associated with a higher risk of emergent colectomy across indications. Efforts to reduce care fragmentation and promote early detection of inflammatory bowel disease and diverticular disease in high deprivation neighborhoods may lower the risk for non-elective colectomy in Veterans. See Video Abstract.

Background: High adherence to the enhanced recovery after surgery pathway reduces morbidity and mortality rates after elective colorectal surgery.

Objective: To evaluate the effect of adherence to the enhanced recovery after surgery pathway on the failure to rescue rates after elective colorectal surgery.

Design: Retrospective analysis of a prospective database.

Patients: Adults (≥ 18 years old) who underwent elective colorectal resection with anastomosis for benign and malignant disease.

Settings: Prospective enrolment in 78 centers in Italy from 2019 to 2021.

Interventions: All the outcomes were measured at 60 days after surgery. Several patient-, disease-, treatment-, hospital-, and complication-related variables were analyzed for the outcomes. After univariate analyses, independent predictors of the endpoints were identified through logistic regression analyses, presenting odds ratios and 95% confidence intervals.

Main outcome measures: Failure to rescue after any adverse event, defined as the ratio between the number of deaths and the number of patients showing any adverse event; failure to rescue after any major adverse event, with the denominator represented by the number of patients showing any major adverse event.

Results: An adverse event was recorded in 2,321 out of 8,359 patients (27.8%), a major adverse event in 523 patients (6.3%), and death in 88 patients (1.0%). The failure to rescue rates were 3.8% after any adverse event and 16.8% after any major adverse event. Independent predictors of primary endpoints were identified among patient- (age, American Society of Anesthesiologists class, nutritional status), treatment- (type of resection), and complication-related (anastomotic leakage, reoperation) variables. Enhanced recovery pathway adherence > 70% independently reduced failure to rescue rates.

Limitations: Clustering from multicenter data, and unmeasured confounding from observational data.

Conclusions: Following elective colorectal resection, adherence > 70% to the enhanced recovery pathway independently decreased failure to rescue rates, along with other patient- or treatment-related factors. See Video Abstract.

Background: Risk-reducing colectomy in familial adenomatous polyposis syndrome is the standard of care. This has increased the importance of surveillance for extra-colonic malignancies in post-colectomy individuals.

Objective: We sought to define the present-day incidence of all cancers and mortality in familial adenomatous polyposis.

Design: Retrospective longitudinal cohort study.

Settings: Two large academic hospitals.

Patients: Eligible patients carried an APC pathogenic variant or met clinical criteria for familial adenomatous polyposis.

Main outcomes measures: Cancer diagnosis, mortality, associated risk factors.

Results: A total of 358 patients were identified. The percentage who exhibited a classic familial adenomatous polyposis phenotype was 63.7%; 21.2% were de novo, and 82.7% had a colectomy. Colorectal cancer was the most common cancer (N = 59, 16.5%). Colorectal cancer diagnoses were associated with de novo familial adenomatous polyposis (odds ratio 7.8 [95% CI 3.51-17.35; p < 0.001]). Thyroid, duodenal/small bowel, gastric, and neuroendocrine tumors were reported in 7.5%, 3.1%, 2.8%, and 2.5% of patients, respectively. Rates of cancer were similar in classic and attenuated familial adenomatous polyposis. Thirty-nine patients (10.9%) died at a mean age of 49.6±17.1 years. Twenty-six deaths were malignancy-related, and colorectal cancer was the leading cause (N = 10). All colorectal cancer-related deaths occurred in individuals with classic familial adenomatous polyposis, and 9/10 were not previously diagnosed with the syndrome. Gastric and duodenal/small bowel cancer were the second leading causes (4 deaths each), and all occurred after colectomy. Fifty-nine percent of all deaths were attributable to a familial adenomatous polyposis-related malignancy or morbidity.

Limitations: Retrospective clinical data.

Conclusions: Colorectal cancer remains the most common malignancy and cause of death in familial adenomatous polyposis. However, nearly all colorectal cancer-related deaths occurred in individuals unaware of their familial adenomatous polyposis diagnosis, and none occurred in the attenuated syndrome. In patients who had a colectomy, gastric and duodenal/small bowel cancers are now the leading causes of death. See Video Abstract.