Diseases of the Colon & Rectum最新文献

Background: Colectomy for benign or malignant disease may be elective, urgent, or emergent. Data suggest successively worse outcomes for non-elective colectomy. Few data exist on the contribution of high area deprivation index and care fragmentation to non-elective colectomy.

Objective: Determine the association between area deprivation and non-elective colectomy in the Veterans Health Administration and assess whether accounting for differences in care fragmentation alters the association across indications and for benign and malignant conditions separately.

Design: Retrospective cohort with multivariable multinomial logit models to evaluate associations between high deprivation care fragmentation, and the adjusted odds of non-elective colectomy. We calculated total, direct, and indirect effects to assess whether the association varied by levels of care fragmentation.

Setting: Veterans receiving care in the private sector and Veterans Health Administration.

Patients: Veterans ≥ 65 years undergoing colectomy between 2013 and 2019.

Main outcome/measures: Colectomy case acuity.

Results: We identified 6538 colectomy patients, of which 3006 (46.0%) were for malignancy. The odds of emergent colectomy were higher for patients in high deprivation areas when the indication was for benign pathology (aOR 1.51 95% CI: 1.15, 2.00). For malignant indications, there was no association between high deprivation and non-elective colectomy. More fragmented care was associated with a higher odds of urgent and emergent colectomy for both benign and malignant indications but the association between deprivation and non-elective colectomy did not vary by care fragmentation.

Limitations: Inherent to large administrative retrospective databases.

Conclusions: Veterans living in high deprivation areas are at higher risk for emergent colectomy for benign conditions. Care fragmentation is also associated with a higher risk of emergent colectomy across indications. Efforts to reduce care fragmentation and promote early detection of inflammatory bowel disease and diverticular disease in high deprivation neighborhoods may lower the risk for non-elective colectomy in Veterans. See Video Abstract.

Background: High adherence to the enhanced recovery after surgery pathway reduces morbidity and mortality rates after elective colorectal surgery.

Objective: To evaluate the effect of adherence to the enhanced recovery after surgery pathway on the failure to rescue rates after elective colorectal surgery.

Design: Retrospective analysis of a prospective database.

Patients: Adults (≥ 18 years old) who underwent elective colorectal resection with anastomosis for benign and malignant disease.

Settings: Prospective enrolment in 78 centers in Italy from 2019 to 2021.

Interventions: All the outcomes were measured at 60 days after surgery. Several patient-, disease-, treatment-, hospital-, and complication-related variables were analyzed for the outcomes. After univariate analyses, independent predictors of the endpoints were identified through logistic regression analyses, presenting odds ratios and 95% confidence intervals.

Main outcome measures: Failure to rescue after any adverse event, defined as the ratio between the number of deaths and the number of patients showing any adverse event; failure to rescue after any major adverse event, with the denominator represented by the number of patients showing any major adverse event.

Results: An adverse event was recorded in 2,321 out of 8,359 patients (27.8%), a major adverse event in 523 patients (6.3%), and death in 88 patients (1.0%). The failure to rescue rates were 3.8% after any adverse event and 16.8% after any major adverse event. Independent predictors of primary endpoints were identified among patient- (age, American Society of Anesthesiologists class, nutritional status), treatment- (type of resection), and complication-related (anastomotic leakage, reoperation) variables. Enhanced recovery pathway adherence > 70% independently reduced failure to rescue rates.

Limitations: Clustering from multicenter data, and unmeasured confounding from observational data.

Conclusions: Following elective colorectal resection, adherence > 70% to the enhanced recovery pathway independently decreased failure to rescue rates, along with other patient- or treatment-related factors. See Video Abstract.

Background: Risk-reducing colectomy in familial adenomatous polyposis syndrome is the standard of care. This has increased the importance of surveillance for extra-colonic malignancies in post-colectomy individuals.

Objective: We sought to define the present-day incidence of all cancers and mortality in familial adenomatous polyposis.

Design: Retrospective longitudinal cohort study.

Settings: Two large academic hospitals.

Patients: Eligible patients carried an APC pathogenic variant or met clinical criteria for familial adenomatous polyposis.

Main outcomes measures: Cancer diagnosis, mortality, associated risk factors.

Results: A total of 358 patients were identified. The percentage who exhibited a classic familial adenomatous polyposis phenotype was 63.7%; 21.2% were de novo, and 82.7% had a colectomy. Colorectal cancer was the most common cancer (N = 59, 16.5%). Colorectal cancer diagnoses were associated with de novo familial adenomatous polyposis (odds ratio 7.8 [95% CI 3.51-17.35; p < 0.001]). Thyroid, duodenal/small bowel, gastric, and neuroendocrine tumors were reported in 7.5%, 3.1%, 2.8%, and 2.5% of patients, respectively. Rates of cancer were similar in classic and attenuated familial adenomatous polyposis. Thirty-nine patients (10.9%) died at a mean age of 49.6±17.1 years. Twenty-six deaths were malignancy-related, and colorectal cancer was the leading cause (N = 10). All colorectal cancer-related deaths occurred in individuals with classic familial adenomatous polyposis, and 9/10 were not previously diagnosed with the syndrome. Gastric and duodenal/small bowel cancer were the second leading causes (4 deaths each), and all occurred after colectomy. Fifty-nine percent of all deaths were attributable to a familial adenomatous polyposis-related malignancy or morbidity.

Limitations: Retrospective clinical data.

Conclusions: Colorectal cancer remains the most common malignancy and cause of death in familial adenomatous polyposis. However, nearly all colorectal cancer-related deaths occurred in individuals unaware of their familial adenomatous polyposis diagnosis, and none occurred in the attenuated syndrome. In patients who had a colectomy, gastric and duodenal/small bowel cancers are now the leading causes of death. See Video Abstract.

Background: Whether the level of the inferior mesenteric artery ligation affects the incidence of anastomotic leakage remains unclear.

Objective: To assess the impact of the level of inferior mesenteric artery ligation on the blood flow to the anastomotic site and the incidence of anastomotic leakage using indocyanine green fluorescence imaging.

Design: A post hoc analysis of EssentiAL trial.

Settings: This study was conducted at 41 tertiary referral centers in Japan.

Patients: 839 rectal cancer patients (<12 cm from the anal verge).

Main outcome measures: The incidence of anastomotic leakage and perfusion status were compared between the high and low ligation groups.

Results: The median fluorescence time was similar at 25 seconds in both groups (p= 0.74). Although no statistical difference was noted, the high ligation group was more likely to have greater outliers in fluorescence time compared to the low ligation group. The high ligation group demonstrated higher poor perfusion rates than the low ligation group (2.8% vs 1.5%). In the high ligation group, anastomotic leakage occurred in one case of poor perfusion where additional resection was not performed by the surgeon's intraoperative judgment. Additionally, the additional resection rate nearly doubled with the use of indocyanine green fluorescence imaging. After propensity score matching (129 patients per group), the overall anastomotic leakage rate was 13.2% in the high ligation group and 10.9% in the low ligation group (p = 0.57).

Limitations: This study was a post hoc analysis, the sample size was small, and the anastomosis methods varied.

Conclusions: The level of inferior mesenteric artery ligation did not affect blood flow at the anastomotic site or the incidence of anastomotic leakage statistically, but assessing bowel perfusion using indocyanine green fluorescence imaging can offer clinical benefits, optimizing patient outcomes. See Video Abstract.

Trial registration: The Japan Registry of Clinical Trials (jRCTs-CRB3180007), the Japanese Clinical Trials Registry (UMIN-CTR000030240). See Video.