Diseases of the Colon & Rectum最新文献

Background: Anastomotic leakage remains a severe complication following low anterior resection for rectal cancer, often leading to routine use of protective stomas, which can cause additional complications. Inspired by the watch-and-wait approach in rectal cancer treatment, we hypothesized that deferring stoma creation could be feasible through the Safe Anastomosis Project that includes minimizing technical risk factors, enabling early detection of preclinical leakage, and intervening only when necessary.

Objective: To evaluate whether technical modifications, comprehensive surveillance, and selective stoma creation can reduce the rate of protective stoma use while maintaining acceptable anastomotic leakage rates.

Design: Prospective cohort study.

Setting: Single-center, tertiary referral hospital.

Patients: Between January and December 2024, 184 patients underwent curative resection for rectal cancer.

Interventions: A standardized protocol was applied, including perfusion assessment with indocyanine green, single-stapled anastomosis creation using purse-string sutures, reinforcement with continuous or intermittent manner, extraperitoneal pelvic drain placement, and assessment of anastomotic integrity. Patients were grouped by anastomotic technique: single-stapled with reinforcement, single-stapled alone, or double-stapled with reinforcement.

Main outcome measures: Rates of protective stoma creation and anastomotic leakage.

Results: A total of 99 patients completed the study protocol. 27 (27.3%) received a protective stoma and 11 (11.1%) developed anastomotic leakage. Patients with single-stapled technique with reinforcement had the lowest rates of both protective stoma use (18.8%) and leakage (6.3%). Robotic surgery was more frequently used in this group (78.1%). Most leakages occurred within 8 days postoperatively and were managed with transanal repair, with or without stoma.

Limitations: Single-center design and modest sample size.

Conclusions: Deferral of protective stoma creation after low anterior resection appears feasible. Technical refinement, particularly single-stapled anastomosis with reinforcement and robotic assistance, may optimize outcomes. Further study based on larger cohort is warranted. See Video Abstract.

Background: The association between preoperative exposure to biologics and postoperative outcomes after surgery for inflammatory bowel disease remains controversial.

Objective: We hypothesized biologic exposure within 60 days of surgery is safe and not associated with an increase in postoperative adverse events.

Design: Multicenter national cohort.

Settings: Twenty-four inflammatory bowel disease centers, 2020-2024.

Patients: Adult patients from the American College of Surgeons National Quality Improvement Program Inflammatory Bowel Disease Collaborative.

Main outcome measures: The primary outcome was adverse event rates within 30 days postoperatively; secondary outcomes included rates of infectious and overall complications. The primary predictor was exposure to biologics within 60 days of surgery. Propensity score-based causal inference modeling was performed. Point estimates were expressed as relative risks (RR) with 95% confidence intervals.

Results: A total of 2,926 patients were included: 1,427 (48.8%) exposed to biologic exposed and 1,499 (51.2%) not exposed. Preoperatively, the biologic cohort was more likely to have Crohn's disease, be younger, be from high-volume centers (all p < 0.0001), be anemic and malnourished (both p = 0.02), and exposed to corticosteroids and/or immunomodulators (both p < 0.0001). Intraoperatively, the biologic cohort had shorter operative times, more minimally invasive procedures and partial colectomies, and fewer ileoanal pouches and ileostomies (all p < 0.0001). Inverse probability treatment weighting revealed biologics were not associated with postoperative infections (0.97, 0.72-1.05), complications (0.92, 0.81-1.04), or adverse events (0.92, 95% CI: 0.83-1.02). Similar results were observed in unadjusted, propensity score-adjusted, and propensity score-matched models.

Limitations: Generalizability, selection bias, unmeasured confounders, and 60-day window for biologics.

Conclusions: Preoperative biologic exposure within 60 days of surgery for inflammatory bowel disease was not associated with any causal increase in postoperative adverse outcomes. These findings indicate that biologic before inflammatory bowel disease surgery are safe and do not increase short-term adverse outcomes. See Video Abstract.