Diseases of the Colon & Rectum最新文献

Background: Standardized Letter of Recommendation was introduced to capture more meaningful fellowship applicant evaluations. There are concerns that this letter may introduce subjectivity to assessments traditionally measured by objective metrics, such as board scores and publications.

Objective: To evaluate the influence of individual application elements on ranking by referee.

Design: Collected data included applicant demographics and objective assessments of academic performance, including in-service exam percentiles, Step 1 and Step 2 scores, and publication count. Summary statistics and odds ratios from repeated measures logistic regression models using the method of generalized estimating equations are reported.

Settings: Standardized letters submitted to a single institution during the 2019 application cycle were analyzed.

Main outcome measures: To determine if objective applicant parameters are associated with being subjectively ranked #1 by the referee.

Results: Among 302 standardized LOR forms, 51.3% of the applicants were ranked #1 by the referee. Applicants ranked #1 had higher junior and senior in-training exam percentiles (60.3 vs 50.9, p = 0.0002 and 59.5 vs 48.0, p < 0.0001, respectively), Step 1 scores (235 vs 231, p = 0.0287) and average number of publications (5.9 vs 3.5, p = 0.0011). For each unit rise of in-training percentile and publication number, the odd ratio for being ranked #1 improved by 1.03 (p = 0.002) and 1.08 (p = 0.013), respectively. Ranks lower than #1 did not demonstrate the expected decline in objective performance metrics with decreasing rank except Step 1 percentile (p ≤ 0.001). Technical ability was the strongest predictor of a #1 ranking.

Limitations: Analyses limited to elements included in standardized letters.

Conclusions: Standardized letters retain the relationship between objective performance metrics and subjective ratings for applicants ranked #1 by referee. However, this relationship is lost when applicants are ranked lower than first place. Our findings provide valuable insights and inform best practices for employing standardized letters of recommendation in the context of fellowship selection. See Video Abstract.

Background: The Milligan-Morgan Hemorrhoidectomy remains the gold standard for IV-degree hemorrhoidal disease. However, postoperative pain, bleeding, and prolonged recovery persist as challenges. Sclerotherapy shows promise but lacks evidence in IV-degree hemorrhoidal disease management.

Objective: This study evaluated the efficacy and safety of open excisional hemorrhoidectomy (Milligan-Morgan hemorrhoidectomy) combined with 3% polidocanol foam sclerotherapy in patients with IV-degree hemorrhoidal disease.

Design: Randomized, open-label, single-center clinical trial.

Settings: Department of Anorectal Surgery, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai, China.

Patients: Thirty-six patients aged 18-75 years with IV-degree hemorrhoidal disease were enrolled and randomized equally to two groups.

Interventions: The experimental group received Milligan-Morgan hemorrhoidectomy combined with 3% polidocanol foam sclerotherapy; the control group received Milligan-Morgan hemorrhoidectomy.

Main outcome measures: The primary outcome is the time to return to daily activities. Secondary outcomes: Hemorrhoidal Disease Symptom Score, Vaizey Incontinence scores, Visual Analogue Scale, Short Health Scale for Hemorrhoidal Disease scores, postoperative bleeding grade, usage of analgesics, and satisfaction.

Results: The experimental group demonstrated a mean 5.78-day earlier return to normal activities and work than the control group (mean ± SD: 19.28 ± 8.35 vs. 25.06 ± 7.85 days, 95% CI: -11.27 to -0.29 days, p = 0.04), reduced postoperative bleeding (0-3 scale, Estimate: -0.45, 95% CI: -0.72 to -0.16, p = 0.002), lower analgesic use (0-3 scale, Estimate: -0.38, 95% CI: -0.66 to -0.09, p = 0.009), and improved symptom scores at 1-2 months (Z -2.52 and -2.11, p < 0.05). Median satisfaction scores were 10 vs. 9.5 (p = 0.12). No adverse events occurred.

Limitations: Small sample size, non-blinded, single-center design, and short follow-up period.

Conclusions: Milligan-Morgan hemorrhoidectomy combined with 3% polidocanol foam sclerotherapy significantly enhances postoperative recovery, reduces complications, and demonstrates comparable patient satisfaction. Long-term follow-up is warranted to validate sustained efficacy. Clinical trial registration number: Chinese Clinical Trial Registry: ChiCTR2400087552. See Video Abstract.

Background: Benefits of transanal total mesorectal excision in patients with obesity remain unclear.

Objective: To evaluate the clinical utility of transanal total mesorectal excision in patients with obesity with mid-to-low rectal cancer.

Design: Retrospective cohort study.

Settings: Single center, between April 2015 and March 2025.

Patients: Six hundred eighty-three patients with mid-to-low rectal cancer.

Intervention: Transanal total mesorectal excision for rectal cancer.

Main outcome measures: Patients were categorized as nonobese (body mass index < 25.0 kg/m2), obese I (25.0-29.9 kg/m2), and obese II (≥ 30 kg/m2). Surgical and pathological outcomes-conversion to open surgery, sphincter preservation, and resection margin status-were compared. Results with corrected p value < 0.05 were considered significant.

Results: Overall, 485 (71%) patients were categorized as nonobese, 159 (23%) as obese I, and 39 (6%) as obese II. Clinicopathological characteristics were similar among the groups. Operative times were longer in the obese I and II groups (218 and 265 vs. 194 min, p < 0.05), with greater blood loss (44 and 90 vs. 39 mL, p < 0.05). Sphincter-preserving surgery was performed as planned in all patients; conversion to open surgery (1.0%, 1.3%, and 0%, p = 0.783) were comparable, whereas anastomotic leakage was more frequent in the obese II group (4.5%, 6.3%, and 15.4%, p = 0.016). The overall circumferential resection margin-positivity rate was 3.4%, with no significant differences among the groups (3.3%, 3.1%, and 5.1%).

Limitations: Single high-volume cancer center with surgeons experienced in transanal total mesorectal excision limits generalizability; lack of comparative cohort limits direct assessment of the efficacy of the approach; the obese II group had few patients; and BMI's accuracy as a surrogate for visceral fat is limited.

Conclusions: Transanal total mesorectal excision appears to represent a promising strategy for patients with obesity with mid-to-low rectal cancer, offering low conversion and high sphincter preservation rates while maintaining oncologic safety. See Video Abstract.

Background: Anastomotic leakage is a major complication of rectal cancer surgery, contributing to increased morbidity, poorer oncologic outcomes, and permanent stoma formation. However, consensus on its diagnostic timeframe and risk factors is lacking. Anastomotic leakage in the late postoperative period is usually under-recognized owing to inconsistent definitions and variable surveillance protocols.

Objective: To investigate the serial incidence and risk factors for overall and late anastomotic leakage following curative-intent rectal cancer surgery.

Design: Retrospective cohort study.

Settings: Asan Medical Center, a tertiary referral center in Seoul, Korea.

Patients: This study included 4,472 patients who underwent rectal cancer resection with anastomosis between 2012 and 2020. Patients undergoing palliative or combined surgeries were excluded.

Main outcome measures: We analyzed the incidence and timing of anastomotic leakage and identified independent risk factors for overall and late anastomotic leakage using logistic regression.

Results: The overall anastomotic leakage incidence was 3.2% (n = 145), with late anastomotic leakage comprising 48.3% (n=70) of cases. Notably, 24.1% (n=35) were diagnosed over 1 year postoperatively. Of those with late anastomotic leakage, 78.6% (n = 56) had undergone diverting stoma formation. Independent risk factors for overall anastomotic leakage included younger age, male sex, low tumor location, and high inferior mesenteric artery ligation. Late anastomotic leakage was independently associated with neoadjuvant chemoradiotherapy (odds ratio 3.573), robotic surgery (odds ratio 4.734), and adjuvant chemotherapy (odds ratio 3.420).

Limitations: Retrospective design and single-institution surveillance protocol may limit generalizability.

Conclusions: Late anastomotic leakage occurs at a rate comparable to early anastomotic leakage and presents with distinct risk factors. Extended surveillance and tailored management are warranted in high-risk patients. See Video Abstract.

Introduction: Achieving margin-negative complete resection in locally recurrent rectal cancer often requires en bloc resection involving adjacent structures such as the sacrum. However, sacrectomy is technically demanding and poses a high risk of significant intraoperative bleeding and postoperative pelvic sepsis due to the dead space created after resection. We developed a minimally invasive surgical technique to address these challenges.

Technique: We employed a laparoscopic approach to sacrectomy as part of en bloc resection for posterior locally recurrent rectal cancer. In this technique, the anterior and lateral dissection of the sacrum was performed laparoscopically, whereas the final sacral transection was carried out under direct vision in the prone position. Preoperative imaging was used to identify the planned sacral transection line, which was reproduced intraoperatively using a premeasured vascular tape. Anterior and lateral dissection of the sacrum was performed laparoscopically to allow secure vascular control. Final sacral transection was performed under direct vision in the prone position. A pedicled omental flap and a dead-space filling non-functional anastomosis were used to fill the pelvic cavity and prevent postoperative sepsis. A double-barreled stoma was created to facilitate fecal diversion.

Results: Laparoscopic sacrectomy was successfully performed in 43 patients with locally recurrent rectal cancer. The margin-negative complete resection rate was 86%, which is notably high for this challenging population. The 5-year overall survival rate was approximately 59%. No cases of major intraoperative bleeding or early complications related to the dead-space filling non-functional anastomosis were observed.

Conclusions: This laparoscopic technique offers a safe and feasible option for selected patients with posterior locally recurrent rectal cancer. Combined dead-space management may further help reduce postoperative complications while preserving oncological validity.