Diseases of the Colon & Rectum最新文献

Background: Anal squamous intraepithelial lesions are identifiable and treatable precancerous lesions that lack defined risk factors determining screening necessity.

Objective: Assess the prevalence and risk factors associated with low- and high-grade anal squamous intraepithelial lesions and anal squamous cell carcinoma.

Design: Retrospective cohort analysis of veterans with HIV between 1999-2023.

Settings: National multicenter study of the Department of Veterans Affairs.

Patients: Veterans with HIV who had >1 year of follow-up and no anal squamous intraepithelial lesions or anal cancer diagnosis prior to the study period.

Main outcomes and measures: Primary outcomes include the prevalence, disease-free survival rates, and hazard ratios associated with risk factors for developing anal squamous intraepithelial lesions and/or anal cancer.

Results: 48,368 patients were analyzed. The average age of patients at study initiation was 47.8 years with a mean follow-up of 12.3 years. 7,572 (16%) patients had at least one anal cytopathology or histopathology result. Prevalence of anal disease was recorded for low-grade disease (n = 1,513, 3.1%), high-grade disease (n = 1,484, 3.1%), and cancer (n = 664, 1.4%). Mean times to first incident low-grade disease, high-grade disease, and cancer were 8.5 (SD = 6.0), 9.1 (SD = 6.0), and 9.7 (SD = 6.2) years, respectively. 5-year, 10-year, and 20-year disease-free survival rates for development of low-grade disease, high-grade disease, or cancer were 97.5%, 94.5%, and 88.4%, respectively. Cox regression modeling demonstrated CD4/CD8 ratios <0.5 were associated with increased risk of anal cancer (HR: 3.93, 95% CI: 3.33-4.63, p < 0.001).

Limitations: Retrospective study that focuses almost exclusively on male U.S. veterans. Results might not apply to non-male, non-U.S. populations.

Conclusions: National analysis of over 48,000 veterans with HIV demonstrates 16% had anal cytopathology or histopathology results with an anal cancer prevalence of 1.4%. CD4/CD8 ratios <0.5 correlate strongly with severity of anal disease and can help identify patients at highest risk for anal cancer to prioritize screening efforts. See Video Abstract.

Background: Transanal endoscopic microsurgery is a treatment option for a wide range of rectal lesions. Postoperative urinary retention is a frequently associated complication. Some studies have suggested that the use of alpha-1-blockers may reduce the risk of postoperative urinary retention after hernia and colorectal surgery, but evidence is lacking.

Objective: This trial aims to evaluate if prophylactic use of an alpha-1-blocker reduces the rate of postoperative urinary retention following transanal endoscopic microsurgery.

Design: Double-blind, placebo-controlled trial.

Settings: Single high-volume Canadian colorectal center.

Patients: Adult male patients awaiting transanal endoscopic microsurgery and not on alpha-1-blocker were included.

Intervention: Patients were allocated to either Tamsulosin or placebo from 5 days prior to surgery to 2 days postoperatively.

Main outcomes measures: The primary outcome was the incidence of post-operative urinary retention. Secondary outcomes were urinary retention-related hospitalization, time to removal of bladder catheter and International Prostate Symptom Score, before and after treatment, and adverse events.

Results: 158 patients were randomized between October 2017 and July 2022. There was no significant difference in postoperative urinary retention between groups (23% vs 14%; p = 0.16) respectively in the tamsolusin and placebo groups. Time to removal of bladder catheter was not statistically different between groups (4.8 vs 8.6 days, p = 0.26). No failure of same-day discharge, nor readmissions related to urinary retention occurred. International Prostate Symptom Scores were not significantly different at the time of surgery (3.8 vs 5.4; p = 0.11) and reported adverse events did not differ between groups.

Limitations: We cannot exclude a potential type II error.

Conclusion: Prophylactic use of an alpha-1-blocker for patients undergoing transanal endoscopic microsurgery was not associated with a reduction in post-operative urinary retention. See Video Abstract.

Trial registration: ClinicalTrials.gov Identifier: NCT03314025.

Background: Colorectal emergencies represent a large proportion of acute general surgical workload and carry significant mortality.

Objective: Identify the influence of surgeon specialization on mortality and other outcomes in emergency colorectal surgery.

Data sources: Systematic searches of Ovid MEDLINE, Ovid Embase, and Cochrane electronic databases were performed for studies published from January 1, 1990, to August 27, 2023.

Study selection: Studies investigating outcomes in emergency colorectal surgery for adults, comparing colorectal against noncolorectal surgeon specialization, were included. Exclusion criteria were: 1) publications studying primarily pediatric populations; 2) studies incorporating patients who had undergone surgery before 1990; and 3) studies only published in abstract form or non-English language.

Main outcome measures: Primary outcomes were 30-day mortality and in-hospital mortality. Secondary outcomes were rates of anastomotic leak, reintervention, primary anastomosis, and laparoscopic approach.

Results: Of 7676 studies identified, 155 were selected for full-text review and 21 were included for quantitative analysis. Eleven studies showed improved 30-day (OR 0.64; 95% CI, 0.60-0.68; p < 0.0001) and in-hospital mortality (OR 0.66; 95% CI, 0.49-0.89; p = 0.007) with colorectal specialization. There was a significantly higher rate of primary anastomosis (OR 2.95; 95% CI, 2.02-4.31; p < 0.0001) and use of laparoscopic surgery (OR 2.38; 95% CI, 1.42-4.00; p = 0.001) among specialized colorectal surgeons. Specialization was also associated with a significant reduction in any stoma formation (OR 0.52; 95% CI, 0.28-0.98; p = 0.04). No significant difference was observed for anastomotic leak (OR 0.70; 95% CI, 0.45-1.07; p = 0.10) or reintervention rates (OR 0.78; 95% CI, 0.55-1.10; p = 0.16).

Limitations: Heterogeneity exists within the included patient populations and definitions of colorectal specialization observed in different countries.

Conclusions: Emergency colorectal surgery undertaken by specialized colorectal surgeons is associated with significantly improved postoperative mortality, lower rates of stoma formation, and increased rates of primary anastomosis and minimally invasive surgery.

Prospero registration: CRD42022300541.