International Journal of Colorectal Disease最新文献

Introduction: In June 2023, our institution adopted the Medtronic Hugo RAS system for colorectal procedures. This system's independent robotic arms enable personalized docking configurations. This study presents our refined multi-docking strategy for robotic low anterior resection (LAR) and deep pelvic procedures, designed to maximize the Hugo RAS system's potential in rectal surgery, and evaluates the associated learning curve.

Methods: This retrospective analysis included 31 robotic LAR procedures performed with the Hugo RAS system using our novel multi-docking strategy. Docking times were the primary outcome. The Mann-Kendall test, Spearman's correlation, and cumulative sum (CUSUM) analysis were used to assess the learning curve and efficiency gains associated with the strategy.

Results: Docking times showed a significant negative trend (p < 0.01), indicating improved efficiency with experience. CUSUM analysis confirmed a distinct learning curve, with proficiency achieved around the 15th procedure. The median docking time was 6 min, comparable to other robotic platforms after proficiency.

Conclusion: This study demonstrates the feasibility and effectiveness of a multi-docking strategy in robotic LAR using the Hugo RAS system. Our personalized approach, capitalizing on the system's unique features, resulted in efficient docking times and streamlined surgical workflow. This approach may be particularly beneficial for surgeons transitioning from laparoscopic to robotic surgery, facilitating a smoother adoption of the new technology. Further research is needed to validate the generalizability of these findings across different surgical settings and experience levels.

Introduction: The role of neoadjuvant therapy (NAT) in the treatment of locally advanced rectal cancer (LARC) has been well proven, but its impact on patients who relapse remains unknown. This study aims to elucidate the influence of initial treatment and MRI-defined risk factors on postrecurrent survival in patients with LARC recurrence.

Patients and methods: LARC patients who underwent radical surgery and subsequently developed recurrence were retrospectively identified. Patients were stratified on the basis of MRI-defined local risk assessment and the initial treatment modality for the primary tumor (NAT or primary surgery). The patients were classified into four groups: high-risk LARC with NAT (HiN), high-risk LARC with primary surgery (HiS), low-risk LARC with NAT (LoN), and low-risk LARC with primary surgery (LoS). The primary endpoint was survival after recurrence.

Results: A total of 381 patients who experienced relapse were identified from among 2329 LARC patients. Salvage surgery was performed on 33.1% of these patients. Patients who experienced single-site recurrence or who underwent salvage surgery exhibited significantly prolonged survival times after recurrence (P < 0.001). Patients in the HiS group had poorer survival after recurrence than those in the other three groups (P = 0.034). This subset of patients, characterized by receiving less adjuvant treatment after primary surgery, had a shorter recurrence interval than those in the other groups (P = 0.001).

Conclusions: Our findings reaffirm the prognostic significance of salvage surgery in patients from a LARC cohort who experienced relapse. Moreover, MRI-defined high-risk LARC patients who received upfront surgery without NAT had shorter intervals of recurrence and poorer survival outcomes after recurrence. Our results highlight the critical role of NAT in improving patient survival after recurrence.

Trial registration: Supplementary registration was carried out at clinicaltrials.gov (Registration number: NCT06314737) on March 14, 2024. The study was retrospectively registered.

Purpose: Anastomotic leak (AL) remains the most important complication after left-sided colic anastomoses and technical complications during anastomotic construction are responsible of higher leakage incidence. Powered circular stapler (PCS) in colorectal surgery has been introduced in order to reduce technical errors and post-operative complications due to the manual circular stapler (MCS).

Methods: A systematic review and meta-analysis were performed. An electronic systematic search was performed using Web of Science, PubMed, and Embase of studies comparing PCS and MCS. The incidence of AL, anastomotic bleeding (AB), conversion, and reoperation were assessed. PROSPERO Registration Number: CRD42024512644.

Results: Five observational studies were eligible for inclusion reporting on 2379 patients. The estimated pooled Risk Ratios for AL and AB rates following PCS were significantly lower than those observed with MCS (0.44 and 0.23, respectively; both with p < 0.01). Conversion and reoperation rate did not show any significant difference: 0.41 (95% CI 0.09-1.88; p = 0.25) and 0.78 (95% CI 0.33-1.84; p = 0.57); respectively.

Conclusion: The use of PCS demonstrates a lower incidence of AL and AB compared to MCS but does not exhibit a discernible influence on reintervention or conversion rates. The call for future randomized clinical trials aims to definitively clarify these issues and contribute to further advancements in refining surgical strategies for left-sided colonic resection.

Purpose: Immunogenicity is a major reason for secondary loss of response to infliximab (IFX). Recent work suggested potentially lower immunogenicity of subcutaneous (SC) compared to intravenous (IV) IFX. However, it is unknown whether re-exposure to IFX SC after secondary loss of response and immunogenicity to its intravenous formulation is safe and effective.

Methods: In a retrospective cohort study conducted at two medical centers, patients with clinically (Harvey-Bradshaw Index ≥ 5) and/or biochemically (fecal calprotectin > 250 µg/g) active Crohn's disease (CD) and previous immunogenic failure of IFX IV underwent exposure to IFX SC. Harvey-Bradshaw Index, fecal calprotectin, IFX serum concentration, and anti-drug antibodies were assessed until month 12.

Results: Twenty CD patients were included. The majority of patients (90%) had previous treatment with three or more biologics. Fifteen (75%) and ten (50%) of 20 patients continued IFX SC treatment until months 6 and 12, respectively. No immediate hypersensitivity reactions were observed. Two patients discontinued IFX SC treatment because of delayed hypersensitivity at week 2 and week 4. IFX serum concentrations increased from baseline to month 12, while anti-drug antibody levels decreased. Combined clinical and biochemical remission at month 12 was observed in seven of 20 patients (35%).

Conclusion: Subcutaneous infliximab treatment of Crohn's disease patients with previous immunogenic failure of intravenous infliximab was well tolerated and effective in a cohort of patients with refractory Crohn's disease.

Objective: This study aims to explore the causal relationship between cholecystectomy and inflammatory bowel disease (IBD)/irritable bowel syndrome (IBS) and the role of serum bile acids and gut microbiota in this context.

Methods: Utilizing genetic variant data from previous Genome-Wide Association Studies (GWAS), this study employed a two-sample MR approach to assess the causal effect of cholecystectomy on IBD/IBS.

Results: The MR analysis suggested a potential negative causal relationship between cholecystectomy and UC (p = 0.0233, OR 0.9773, 95%CI 0.9581-0.9969) and a positive causal relationship between cholecystectomy and IBS (p = 0.0395, OR 4.077, 95%CI 1.0699-15.5362). Various sensitivity analyses reinforced the reliability of the causal relationship. However, the analysis did not find definitive results between serum bile acids or gut microbiota and cholecystectomy or IBD/IBS, possibly due to insufficient statistical power. MVMR find a causal relationship between bile acids and IBS (p = 0.0015, b = 0.4085) and UC (p = 0.0198, b = 0.0029).

Conclusion: This study provides evidence of a causal relationship between cholecystectomy and IBD/IBS, highlighting the potential risk reduction for UC and increased risk for IBS following cholecystectomy. The role of bile acids and gut microbiota in this relationship remains unclear, necessitating further research to validate the causality and explore underlying mechanisms.

Background: Before the era of biological agents, most Crohn's disease patients required at least one intestinal resection surgery after diagnosis. However, clinical data regarding the abdominal surgery rates for Crohn's disease patients in the era of biological agents is not yet fully clear and needs to be updated.

Materials and methods: We retrospectively collected clinical data from 1115 Crohn's disease patients diagnosed and treated medically at The Second Xiangya Hospital of Central South University from January 2016 to January 2024. Using abdominal intestinal resection surgery as a clinical outcome, propensity score matching was employed to eliminate confounding factors. We explored the timing and proportion of abdominal surgery in patients with different Montreal classifications of Crohn's disease during the natural course of the disease, as well as the impact of the duration of the natural course and the use of biological agents on surgical outcomes.

Results: Montreal classification type B had the greatest impact on Crohn's disease surgery, especially with a higher proportion of type B3 patients undergoing surgery. Type A1 Crohn's disease patients underwent surgery earlier than types A2 and A3. The occurrence of behavior changes (B Change) during the natural course of the disease is a poor prognostic signal, indicating a significantly increased likelihood of surgery. The duration of the natural course from the onset of gastrointestinal symptoms to diagnosis and clinical observation outcomes did not directly affect the likelihood of surgery in Crohn's disease patients. Compared with Crohn's disease patients who did not receive biological agents, the surgery rate was significantly lower in patients who used biological agents. Additionally, Crohn's disease patients who received biological agents within 1 month of diagnosis had a significantly lower likelihood of undergoing surgical intervention. Moreover, Crohn's disease patients who received biological agent treatment within 19 months of the onset of gastrointestinal symptoms also had a significantly lower likelihood of undergoing surgery than other Crohn's disease patients.

Conclusions: In the era of biological agents, the risk of surgical intervention varies among Crohn's disease patients with different Montreal classifications, particularly when there is type B3 disease or a B Change. Clinicians should pay closer attention to surgical indications in such cases. For Crohn's disease patients, shortening the natural course before diagnosis and early use of biological agents after diagnosis can significantly reduce the risk of abdominal surgery.

Purpose: Advanced obstructive colorectal cancer (AOCC) presents surgical challenges. Consideration must be given to alleviating symptoms and also quality of life and survival time. This study compared prognostic efficacies of palliative self-expanding metal stents (SEMSs) and surgery to provide insights into AOCC treatment.

Methods: PubMed, Web of Science, MEDLINE, and Cochrane Library were searched for studies that met inclusion criteria. Using a meta-analysis approach, postoperative complications, survival rates, and other prognostic indicators were compared between patients treated with SEMSs and those treated surgically. Network meta-analysis was performed to compare prognoses between SEMS, primary tumor resection (PTR), and stoma/bypass (S/B).

Results: Twenty-one studies were selected (1754 patients). The odds ratio (OR) of SEMS for clinical success compared with surgery was 0.32 (95% confidence interval [CI] 0.15, 0.65). The ORs for early and late complications were 0.34 (95% CI 0.19, 0.59) and 2.30 (95% CI 1.22, 4.36), respectively. The ORs for 30-day mortality and stoma formation were 0.65 (95% CI 0.42, 1.01) and 0.11 (95% CI 0.05, 0.22), respectively. Standardized mean difference in hospital stay was - 2.08 (95% CI - 3.56, 0.59). The hazard ratio for overall survival was 1.24 (95% CI 1.08, 1.42). Network meta-analysis revealed that SEMS had the lowest incidence of early complications and rate of stoma formation and the shortest hospital stay. PTR ranked first in clinical success rate and had the lowest late-complication rate. The S/B group exhibited the lowest 30-day mortality rate.

Conclusion: Among palliative treatments for AOCC, SEMSs had lower early complication, stoma formation, and 30-day mortality rates and shorter hospital stays. Surgery had higher clinical success and overall survival rates and lower incidence of late complications. Patient condition/preferences should be considered when selecting AOCC treatment.

Background: Standardized clinical care processes for patients with Crohn's disease (CD) and a permanent ileostomy (PI) are lacking. The EndOTrial consortium aims to address this gap by developing pathways for care.

Methods: In this umbrella review, we searched major databases for relevant systematic reviews (SRs) or scoping reviews (ScR) published until January 5, 2024. Screening, data extraction, and quality appraisal (AMSTAR 2) were performed by two independent reviewers.

Results: Of 1349 screened papers, 22 reviews met our inclusion criteria, including 20 SRs (eight with meta-analysis) and 2 ScRs. None exclusively focused on PI. Furthermore, nine reviews did not mention patients with inflammatory bowel disease (IBD), and only two reviews included patients with high-output ileostomy, highlighting a large evidence gap. The identified reviews covered six categories with nine types of interventions, including ostomy care pathways, peristomal skin care, patient education, clinical management of high-output stoma, management and prevention of postoperative ileus, dietary and nutritional support, nursing and supporting care, telemedicine, and self-management interventions. Most SRs including nursing interventions for stoma care highlighted nurses' role in a variety of standard and specialized treatments. Notably, none of the reviews exclusively examined disease recurrence, stoma pouching systems or adhesives, behavioral interventions, or mental health in patients living with ileostomy.

Conclusions: Evidence for best practice interventions to treat complications and improve quality of life in patients living with an ileostomy for CD is limited and heterogeneous. These results outline the need for standardized clinical care processes and pathways tailored to the unique needs of this patient population.

Purpose: The anatomical location of inflammation in and around the ileal pouch affects the pouch survival rate, and diffuse inflammation has poor pouch survival rates. We aimed to clarify the symptoms and histological findings of diffuse inflammation of the pouch.

Methods: We evaluated the symptoms, treatment, and histological findings according to the endoscopic phenotypes of diffuse inflammation, focal inflammation, and normal as the pouch body phenotype and afferent limb involvement, inlet involvement, cuffitis, and fistula as the peripheral findings.

Results: Of the 318 pouchoscopies, 47 had diffuse inflammation, 201 had focal inflammation, and 70 were normal. Symptomatic patients had diffuse inflammation more frequently (46.8%) than focal inflammation (13.4%) and normal (14.2%), with no difference between focal inflammation and normal. Antibiotics and steroids were higher rate administered in cases of diffuse inflammation, but not in cases of focal inflammation or in normal cases. Histological inflammation, inflammatory bowel disease (IBD)-specific finding, and colonic metaplasia showed severity in the order of diffuse inflammation > focal inflammation > normal. The number of peripheral inflammatory findings overlapped in the following order: diffuse inflammation > focal inflammation > normal. The number of symptomatic patients increased as the number of peripheral inflammatory findings increased.

Conclusion: Pouches with diffuse inflammation are more symptomatic, have a higher use of therapeutic agents, and have more severe histological inflammation, IBD-specific finding, and colonic metaplasia accompanying peripheral inflammatory findings than the other groups. The higher the overlap of inflammatory findings in the surrounding tissues, the more symptomatic the patients will appear.

Purpose

The population in Western countries differs significantly from that in Eastern countries, and the prevalence of lateral pelvic lymph node (LPLN) involvement in Western populations remains largely unknown due to the limited application of LPLN dissection (LPLND). This discrepancy is primarily attributed to the higher body mass index commonly observed in Western populations, which increases the risk of intraoperative complications. Consequently, the aim of this study is to describe a specific Western clinico-radiological selection tool for LPLND, namely, the lateral pelvic lymph node positivity (LPLNP) score.

Methods

This retrospective single center study was designed to elaborate the LPLNP score, which was further tested on a prospective cohort of patients. Clinical and MRI factors associated with LPLN involvement were identified, and logistic regression was used to establish the LPLNP score.

Results

In the retrospective series, 120 patients underwent lateral pelvic lymph node dissection. After stepwise logistic regression, five parameters were ultimately included in the LPLNP score. When tested on 66 prospectively selected patients, 40 with an LPLNP score > 0.23 (corresponding to the highest sensitivity and specificity) underwent LPLND: 22 patients (55%) had pathologically confirmed positive LPLN. The negative predictive value of the LPLNP score was 96%, with a sensitivity of 95.7% and a specificity of 58.1%.

Conclusion

The LPLNP score was developed based on the largest group of Western patients with locally advanced rectal cancer. This scoring system demonstrated high sensitivity and specificity during validation on the prospective series, correctly identifying LPLN involvement in 55% of cases.