Diseases of the Colon & Rectum最新文献

Background: Deloyers technique addresses challenges in restoring bowel continuity following extended left hemicolectomies. Despite being first described in 1958, the technique remains underutilized, with limited data on long-term outcomes.

Objective: To evaluate the indications, surgical and functional outcomes of Deloyers technique and review existing literature.

Design: Using a prospectively maintained database, patient demographics and perioperative data were collected. A telephone interview was conducted to assess bowel function and statistical analysis identified factors affecting bowel function.

Settings: Single tertiary care center.

Patients: Patients that underwent Deloyers technique from January 1995 to February 2023.

Results: A total of 97 patients were included. Most common indications were colorectal cancer (50.5%) and diverticular disease (21.6%). In 53.6% of cases DT was performed at re-operations and in 70.1% a diverting loop ileostomy was created. Early surgical complications occurred in 7.2% of patients, including five anastomotic leaks, one colonic conduit ischemia and one small bowel obstruction. Late complications occurred in 8.2%, including 6 anastomotic strictures and 2 chronic leaks. There was no perioperative mortality. A total of 40 patients were interviewed and reported an average of 3.5 bowel movements per day and 0.5 at night, 17.5% used bowel stoppers and 52.5% of patients reported that their bowel function did not impact their quality of life. Previous radiotherapy and anastomosis less than eight cm from the anal verge were associated with having four or more bowel movements per day (p < 0.01).

Main outcomes measures: Postoperative morbidity and bowel function.

Limitations: Retrospective analysis of a heterogeneous group of patients with different pathologies and indications for surgery.

Conclusion: Deloyers technique is a safe and effective alternative for restoring bowel continuity after extended left hemicolectomy. Postoperative functional results are generally satisfactory, with more favorable outcomes noted in patients with higher anastomoses and those who have not undergone prior pelvic radiotherapy.

Background: The treatment of locally recurrent rectal cancer has evolved dramatically in recent decades. As the boundaries of exenterative surgery continue to be pushed, one of the unanswered and controversial questions is the role of radical salvage surgery for locally recurrent rectal cancer in the setting of oligometastatic disease.

Objective: To investigate the impact of synchronous or previously treated distant metastases on survival following pelvic exenteration for locally recurrent rectal cancer.

Design: Retrospective analysis of a prospectively maintained database.

Settings: A high-volume specialist exenteration center.

Patients: Consecutive adult patients undergoing pelvic exenteration with curative intent for locally recurrent rectal cancer between 1994 and 2023.

Main outcome measures: Overall survival from time of pelvic exenteration.

Results: Of the 300 patients included, 193 (64%) were male and the median age was 62 years (range, 29-86). Median time from primary rectal cancer surgery to pelvic exenteration was 35 months (range, 4-191). In total, 56 patients (19%) had a history of metastatic disease; of which 42 (14%) had previously treated metastases and 18 patients (6%) had synchronous metastatic disease (including 4 patients with both synchronous and previously treated metastases). Five-year and median overall survival was 41% and 45 months, respectively. There was a trend toward poorer 5-year overall survival in patients with a history of metastatic disease compared to those without (25% vs 45%); however, this did not reach statistical significance (p = 0.110), possibly due to lack of statistical power. Five-year overall survival was 27%, 25% and 45% for patients with synchronous metastases, previously treated metastases, and no history of metastases, respectively (p = 0.260).

Limitations: Findings may not be applicable beyond highly selected patients treated at specialized exenteration centers.

Conclusions: Long-term survival is achievable in highly selected patients with locally recurrent rectal cancer and synchronous or previously treated distant metastases. Therefore, oligometastatic disease should not be considered an absolute contraindication to exenterative surgery. See Video Abstract.

Background: Non-antibiotic outpatient treatment of acute uncomplicated diverticulitis is safe; however, uptake remains low.

Objective: To assess the success of non-antibiotic management of uncomplicated diverticulitis through a nurse clinician-led outpatient program.

Design: Retrospective audit from June 2022-March 2024.

Settings: Nurse clinician-led outpatient program for non-antibiotic management of acute uncomplicated diverticulitis at a university-affiliated hospital.

Patients: Immunocompetent adults with CT-proven acute uncomplicated diverticulitis and C-reactive protein <150 mg/L. Eligible patients not referred to the program but treated in the Emergency Department during the same time period were also reviewed.

Interventions: This program included education, diet modification, analgesia, clinic visit, and telephone follow-ups by a nurse-clinician.

Main outcome measures: Primary outcome was success of the program, defined as the proportion not requiring an Emergency Department visit, admissions within 60 days of diagnosis or need for antibiotics.

Results: Of 236 patients referred to the program, 84 met inclusion criteria, of which 43 (51.2%) were started on antibiotics before referral but were treated by the program. Forty-one (48.8%) completed the non-antibiotic protocol (48.8%, n = 41), with 97.6% success. Concurrently, 219 eligible patients were treated in the Emergency Department but not referred to the program. There was no difference in the number of Emergency Department visits between the 2 groups [program: n = 7 (8.3%) vs Emergency Department: n = 27 (12.3%)] within 60 days of diagnosis. Two patients (2.3%) treated in the program required admission, while 7 (3.2%) patients in the Emergency Department group were admitted. Overall, antibiotics were started before referral in 51.2% of patients in the program compared to 92.2% in the Emergency Department (p < 0.005).

Limitations: Modest sample size, single institutional data and retrospective design.

Conclusions: Implementation of non-antibiotic treatment for mild acute uncomplicated diverticulitis can be successful using an outpatient nurse-clinician led program with referrals from the Emergency Department and community. See Video Abstract.

Background: Venous thromboembolism after colorectal cancer resection is common and highly morbid. Extended pharmacologic venous thromboembolism prophylaxis after cancer surgery lowers venous thromboembolism risk and is recommended by major professional societies. Adherence is low in contemporary local and regional studies.

Objective: Assess patient and hospital factors associated with receipt of prophylaxis after colorectal cancer surgery in a national data set.

Design: Retrospective cohort study.

Settings: Surveillance, epidemiology, and end results Medicare dataset.

Patients: Patients over age 64 undergoing resection for colorectal cancer between 2016 and 2017.

Main outcome measures: Primary outcome was receipt of prophylaxis within 7 days of discharge. Patient and hospital factors associated with receiving prophylaxis were identified using multivariable logistic regression. Secondary outcomes included 30- and 90-day venous thromboembolism.

Results: Of 23,527 patients, 4.7% received prophylaxis. Utilization increased from 2016 to 2017 (3.9% vs. 5.5%; p < 0.001). Patients treated at National Cancer Institute designated hospitals received prophylaxis more frequently than teaching, non-National Cancer Institute hospitals and non-teaching, non-National Cancer Institute hospitals (10.2% vs. 5.6% vs. 1.7%; p < 0.001). Patients receiving care at larger hospitals by bed size quartile were more likely to receive prophylaxis compared to those at smaller hospitals (9.0% vs. 4.0% vs. 3.4% vs. 2.2%; p < 0.01). On multivariable regression, National Cancer Institute status, larger bed size, White race (compared to other), rectal tumor location and more recent year of treatment were independently associated with prophylaxis utilization. Venous thromboembolism events at 30- and 90-days were 1.87% and 2.63%, respectively. Prophylaxis was associated with decreased 30-day venous thromboembolism (1.26% vs. 1.9%; p = 0.1211).

Limitations: Retrospective, large database study.

Conclusions: Utilization of prophylaxis after colorectal cancer surgery remains limited even in large, specialized hospitals. Further work is needed to understand this departure from guideline concordant care. See Video Abstract.

Background: The preservation of the pelvic autonomic nervous system in total mesorectal excision remains challenging to date. The application of laparoscopy has enabled visualization of fine anatomical structures; however, the rate of urogenital dysfunction remains high.

Objective: To establish an artificial intelligence neurorecognition system to perform neurorecognition during total mesorectal excision.

Design: This retrospective study.

Setting: The study was conducted at a single hospital.

Patients: Intraoperative images or video screenshots of rectal cancer patients admitted to the Department of Gastrointestinal Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, between January 2016 and December 2023 were retrospectively collected.

Main outcome measure: Mean intersection over union, precision, recall, and F1 of the model.

Results: A total of 1424 high-quality intraoperative images were included in the training group. The proposed model was obtained after 700 iterations. The mean intersection over union was 0.75, and it slowly increased with an increase in training time. The precision and recall of the nerve category were 0.7494 and 0.6587, respectively, and the F1 was 0.7011. From the video prediction, we can observe that the model achieves a high accuracy rate, which could facilitate effective neurorecognition.

Limitation: This was a single-center study.

Conclusion: The artificial intelligence model for real-time visual neurorecognition in total mesorectal excision was successfully established for the first time in China. Better identification of these autonomic nerves should allow for better preservation of urogenital function, but further research is needed to validate this claim. See Video Abstract.