Diseases of the Colon & Rectum最新文献

Background: The choice of operation for chronic pilonidal sinus disease remains controversial.

Objective: To compare the outcomes of common operations for chronic pilonidal disease.

Data sources: We searched PubMed, Embase, and Cochrane Library.

Study selection: We included randomized trials in English or Danish language, published 2002-2024 comparing operations treating chronic pilonidal disease in adults and teenagers.

Interventions: We compared the outcomes of secondary healing, primary midline closure, Bascom's-, Limberg's- and Karydakis' flap operations.

Main outcome measures: The primary outcome was recurrence; secondary outcomes were infection, healing time, and length-of-stay. We compared recurrence and infection rates in meta-analyses for all techniques. We assessed the risk-of-bias and the quality of all trials.

Results: Fifty trials included a total of 5762 participants. In a meta-analysis, the flap-operations had fewer recurrences than primary midline closure (OR 0.31 (95% CI, 0.19 to 0.51, p < 0.01). The trials comparing Flap-operations with secondary healing were heterogeneous and did not reach significance (OR 0.38 (95% CI, 0.13 to 1.13, p = 0.08). Recurrence was similar between Limberg's- and Karydakis' operations. Infection rates were lower for the flap-operations compared with primary closure (OR 0.33 (95% CI, 0.23 to 0.48, p < 0.01) and with secondary healing (OR 0.48 (95% CI, 0.30 to 0.77, p < 0.01). Two trials tested Bascom's procedure against Limberg's operation without significant differences. All trials found secondary healing to have significantly longer healing times than any other operation.

Limitations: Most studies had a high or medium risk-of-bias, resulting in very-low to low certainty of evidence. The trials generally had small numbers, short follow-ups, and no reported primary outcomes or power calculations.

Conclusions: Primary closure and secondary healing performed poorly compared with the flap techniques. Most trials tested Limberg's operation; only 2 tested Bascom's operation. The literature suggests the surgeon's expertise determines the choice of flap technique.

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.