International Journal of Colorectal Disease最新文献

Background: Transanal total mesorectal excision (TaTME), a novel approach for treating low rectal cancer, holds promise. However, concerns exist in certain countries about their oncologic safety due to less-than-optimal outcomes on global studies. This research seeks to evaluate the long-term oncologic outcomes focusing on local recurrence rate and overall survival after TaTME surgery in Germany.

Patients and methods: This study analyzed data from patients who underwent elective TaTME surgery between 2014 and 2021 in four certified colorectal cancer centers in Germany. Primary endpoints were 3-year local recurrence rate and local recurrence-free survival (LRFS). Secondary outcomes encompassed overall survival (OS), operative time, completeness of local tumor resection, lymph node resection, and postoperative complications.

Results: A total of 378 patients were analyzed (mean age 61.6 years; 272 males, 72%). After a median follow-up period of 2.5 years, 326 patients with UICC-stages I-III and tumor operability included in survival analyses. Local recurrence was observed in 8 individuals, leading to a 3-year cumulative local recurrence rate of 2.2% and a 3-year LRFS rate of 88.1%. The 3-year OS rate stood at 88.9%. Within 30 days after surgery, anastomotic leakage occurred in 19 cases (5%), whereas a presacral abscess was present in 12 patients (3.2%).

Conclusion: TaTME proves effective in addressing the anatomical and technical challenges of low rectal surgery and is associated with pleasing short- and long-term results. However, its safe integration into surgical routine necessitates sufficient knowledge and a previously completed training program.

Purpose: Persistent gastrointestinal (GI) symptoms are frequently experienced by colon cancer survivors and may help identify patients with higher utilization of healthcare services. To assess the relationship between GI symptoms and specialty care utilization among colon cancer survivors.

Methods: A prospective longitudinal cohort study at an academic medical center of 126 adults surgically treated for stage I-IV colon cancer between February 2017 and June 2022. Participants reported GI symptoms through the EORTC QLQ-C30 and QLQ-CR29 at enrollment and as frequently as every 6 months for 5 years. Main outcome measures were visits, telephone encounters, and secure messages with a medical provider within specialty oncology clinics within 6 months after each survey completion. Generalized linear mixed regression model for repeated measurements with random trajectory for each participant was performed to estimate the associations between symptoms and healthcare use. Models were adjusted for demographics, clinical and surgical factors, and timing in relation to onset of the COVID-19 pandemic.

Results: In the 6 months after each survey time point, patients averaged 1.2 visits, 0.5 telephone encounters, and 3.2 patient-initiated messages. In adjusted models, those with any abdominal pain (RR 1.45; p = 0.002), buttock pain (RR 1.30; p = 0.050), or increased stool frequency (RR 1.26; p = 0.046) had more clinic visits in the following 6 months than those without these symptoms. Including these three symptoms in one model revealed that only abdominal pain was statistically significantly associated with increased clinic visits (RR 1.36; p = 0.016). Patients with any blood or mucus in stool (RR 2.46; p = 0.009) had significantly more telephone encounters, and those with any abdominal pain (RR 1.65; p = 0.002) had significantly more patient-initiated messages than those without these symptoms.

Conclusions: Our findings identify GI symptoms associated with increased use of oncologic specialty care among colon cancer survivors, with abdominal pain as an important predictor of utilization.

Implications for cancer survivors: Early identification and anticipatory management of colon cancer survivors experiencing abdominal pain may decrease healthcare utilization.

Background: Appendicitis is one of the most common acute surgical conditions globally. However, the association between nighttime appendectomy and patients' morbidity and mortality is unclear. This study aims to compare outcomes following nighttime versus daytime appendectomy.

Methods: The PubMed, Embase, Cochrane Library, and Web of Science databases up to March 26, 2024 (updated on July 1, 2024) were searched. The primary outcomes were postoperative complications and mortality. Secondary outcomes included intraoperative complications, reoperation, readmission, conversion to laparotomy, hospital stay and operation time. Mean difference (MD) or odds ratios (OR) and 95% confidence intervals were calculated.

Results: Fifteen studies totaling 33,596 patients were included. There were no differences between nighttime and daytime appendectomy for rates of overall postoperative complications (OR 0.93, 95% CI 0.87, 1.00, 14 studies), mortality (OR 1.70, 95% CI 0.37, 7.88, 7 studies), intraoperative complications (OR 0.88, 95% CI 0.08, 9.86; 2 studies), reoperation (OR 0.39, 95% CI 0.06, 2.55; 3 studies) and readmission (OR 0.86, 95% CI 0.65, 1.13; I² = 0%, 5 studies). However, the conversion to laparotomy risks (OR 1.92, 95% CI 1.12, 3.29; 6 studies) among patients who underwent appendectomy during nighttime was significantly elevated compared to daytime.

Conclusions: There was no increased risk or difference in postoperative mortality and complication rates associated with nighttime compared with daytime appendectomy. However, future studies should assess the reasons for higher conversion rates during the night.

Purpose: Concerns exist regarding the potential for transanal total mesorectal excision (TaTME) to yield poorer functional outcomes compared to laparoscopic TME (LaTME). The aim of this study is to assess the functional outcomes following taTME and LaTME, focusing on bowel, anorectal, and urogenital disorders and their impact on the patient's QoL.

Methods: A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and A Measurement Tool to Assess systematic Reviews (AMSTAR) guidelines. A comprehensive search was conducted in Medline, Embase, Scopus, and Cochrane Library databases. The variables considered are: Low Anterior Resection Syndrome (LARS), International Prostate Symptom Score (IPSS) and Jorge-Wexner scales; European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C29 and QLQ-C30 scales.

Results: Eleven studies involving 1020 patients (497-taTME group/ 523-LaTME group) were included. There was no significant difference between the treatments in terms of anorectal function: LARS (MD: 2.81, 95% CI: - 2.45-8.08, p = 0.3; I2 = 97%); Jorge-Wexner scale (MD: -1.3, 95% CI: -3.22-0.62, p = 0.19). EORTC QLQ C30/29 scores were similar between the groups. No significant differences were reported in terms of urogenital function: IPSS (MD: 0.0, 95% CI: - 1.49-1.49, p = 0.99; I² = 72%).

Conclusions: This review supports previous findings indicating that functional outcomes and QoL are similar for rectal cancer patients who underwent taTME or LaTME. Further research is needed to confirm these findings and understand the long-term impact of the functional sequelae of these surgical approaches.

Purpose: To explore whether previous participation in clinical studies increases adherence to management guidelines in acute uncomplicated diverticulitis (AUD).

Methods: This retrospective cohort study was designed to give a SNAPSHOT of the management of AUD at six hospitals, three of which had participated in the AVOD trial comparing antibiotic versus non-antibiotic treatment of AUD. Patients with AUD were included from March 2019 through June 2020 and followed for 90 days. The primary outcome was treatment of AUD categorised by antibiotic treatment and inpatient or outpatient management compared between AVOD and non-AVOD hospitals. Descriptive statistics were compiled, and differences between hospitals were assessed with Pearson's chi-squared test.

Results: The cohort included 449 patients with AUD of which 63% were women and the median age was 63 (IQR: 52-73) years. Patient characteristics were comparable across the hospitals. Antibiotics were administered to 84 (19%) patients and 113 (25%) patients were managed as inpatients. Management varied significantly between AVOD and non-AVOD hospitals. The mean proportion of patients treated with antibiotics was 7% at AVOD hospitals compared to 38% at non-AVOD hospitals (p < 0.001). The mean proportion of in-hospital management was 18% at AVOD hospitals versus 38% at non-AVOD hospitals (p < 0.001).

Conclusion: Most patients with AUD were managed according to current guidelines. However, the management varies between hospitals and previous participation in clinical studies may increase knowledge of and adherence to guidelines.

Background: The utilization of three-dimensional printing has grown rapidly within the field of surgery over recent years. Within the subspecialty of colorectal surgery, the technology has been used to create personalized anatomical models for preoperative planning, models for surgical training, and occasionally customized implantable devices and surgical instruments. We aim to provide a systematic review of the current literature discussing clinical applications of three-dimensional printing in colorectal surgery.

Methods: Full-text studies published in English which described the application of 3D printing in pre-surgical planning, advanced surgical planning, and patient education within the field of colorectal surgery were included. Exclusion criteria were duplicate articles, review papers, studies exclusively dealing with surgical training and/or education, studies which used only virtual models, and studies which described colorectal cancer only as it pertained to other organs.

Results: Eighteen studies were included in this review. There were two randomized controlled trials, one retrospective outcomes study, five case reports/series, one animal model, and nine technical notes/feasibility studies. There were three studies on advanced surgical planning/device manufacturing, six on pre-surgical planning, two on pelvic anatomy modeling, eight on various types of anatomy modeling, and one on patient education.

Conclusions: While more studies with a higher level of evidence are needed, the findings of this review suggest many promising applications of three-dimensional printing within the field of colorectal surgery with the potential to improve patient outcomes and experiences.

Introduction: Anastomotic stenosis (AS) is a common complication after colorectal resection. However, the predisposing factors for stricture formation are not fully understood. Previous studies have shown anastomotic leakage (AL) to be a risk factor for the occurrence of AS. Therefore, we aim to investigate the impact of anastomotic leakage characteristics on the occurrence of anastomotic stenosis after colorectal resection.

Methods: Consecutive patients with AL following elective, sphincter preserving, colorectal resection, with or without diversion ostomy, between January 2009 and March 2023 were identified from a prospectively collected database. The characteristics of the anastomotic leakage, patient baseline and operative characteristics as well as the postoperative outcomes were analyzed using univariate and multivariate logistic regression to identify factors associated with the occurrence of post-leakage AS.

Results: A total of 129 patients developed AL and met the inclusion criteria. Among these, 28 (21.7%) patients were diagnosed with post-leakage AS. There was a significantly higher frequency of patients with neoadjuvant radiotherapy (18% vs 3%; p = .026) and hand-sewn anastomoses (39% vs 17%; p = .011) within the AS group. Furthermore, the extent of the anastomotic defect was significantly higher in the AS group compared with the non-AS group (50%, IQR 27-71 vs. 20%, IQR 9-40, p = 0.011). Similar findings were observed between the study groups regarding age, sex, BMI, ASA score, medical comorbidities, diagnosis, surgical procedure, surgical approach (open vs. minimally invasive), and anastomotic fashioning (side-to-end vs. end-to-end). On multivariate analysis, the extent of the anastomotic defect (OR 1.01; 95% CI 1.00-1.03; p = 0.034) and hand-sewn anastomoses (OR 2.68; 95% CI 1.01-6.98; p = 0.043) were confirmed as independent risk factors for post-leakage AS. No correlation could be observed between the occurrence of post-leakage AS and the ISREC grading of AL, the anastomotic height or the management of AL. Time to ostomy reversal was significantly longer in the AS group (202d, IQR 169-275 vs. 318d IQR 192-416, p = 0.014).

Conclusion: The extent of the anastomotic defect and hand-sewn anastomoses were confirmed as independent risk factors for the occurrence of post-leakage AS. No correlation could be observed between the ISREC grading of AL, the anastomotic height or AL management, and the occurrence of post-leakage AS.

Background: Pemphigus vulgaris (PV) is a potentially life-threatening mucocutaneous autoimmune disease that affects desmoglein-1 and desmoglein-3, leading to intraepithelial vesiculobullous lesions. In the oral mucosa, PV lesions can mimic other diseases such as mucous membrane pemphigoid, other forms of pemphigus, recurrent aphthous stomatitis, erythema multiforme, Stevens-Johnson syndrome, and virus-induced ulcers like herpes simplex virus (HSV), making diagnosis challenging. The co-occurrence of PV with Crohn's disease is rare and predominantly seen in younger patients. The therapeutic mainstay for both PV and Crohn's disease usually involves systemic corticosteroids combined with immunosuppressants and immunobiological drugs. Literature indicates that the use of these drugs, particularly TNF-alpha inhibitors, for managing autoimmune diseases like Crohn's can potentially induce other autoimmune diseases known as autoimmune-like syndromes, which include episodes of lupus-like syndrome and inflammatory neuropathies. There are few cases in the literature reporting the development of PV in individuals with CD undergoing infliximab therapy.

Case report: A young female with severe Crohn's disease, treated with the TNF-alpha inhibitor infliximab, developed friable pseudomembranous oral ulcerations. Histopathological and immunofluorescence analyses confirmed these as PV. The treatment included clobetasol propionate and low-level photobiomodulation, which resulted in partial improvement. The patient later experienced severe intestinal bleeding, requiring intravenous hydrocortisone therapy, which improved both her systemic condition and oral lesions. Weeks later, new ulcerations caused by herpes virus and candidiasis were identified, leading to treatment with oral acyclovir, a 21-day regimen of oral nystatin rinse, and photodynamic therapy, ultimately healing the oral infections. To manage her condition, the gastroenterologists included methotrexate (25 mg) in her regimen to reduce the immunogenicity of infliximab and minimize corticosteroid use, as the patient was in remission for Crohn's disease, and the oral PV lesions were under control.

Conclusion: Young patients with Crohn's disease should be referred to an oral medicine specialist for comorbidity investigation, as oral PV and opportunistic infections can arise during immunosuppressive therapy. The use of TNF-alpha inhibitors in patients treated for inflammatory bowel disease, such as Crohn's, should be carefully evaluated for potential side effects, including oral PV.

Purpose

Colorectal cancer is the second leading cause of cancer death worldwide. Standard treatments for locally advanced rectal cancer include neoadjuvant chemoradiotherapy and total mesorectal excision (TME), which are associated with significant morbidity. After neoadjuvant therapy, one-third of patients achieve a pathological complete response (pCR) and are eligible for a watch-and-wait approach without TME. The purpose of this study was to determine the potential predictors of pCR before surgery.

Methods

The demographic, clinical, and endoscopic data of 119 patients with primary locally advanced rectal cancer without distant metastasis who underwent restaging endoscopy and TME 6–8 weeks after the end of neoadjuvant therapy were collected. The absence of tumor cells in the histological examination of the TME specimen after neoadjuvant therapy was considered pCR. Binary logistic regression and receiver operating characteristic curves were utilized for analysis.

Results

According to the multivariate logistic regression analysis, flattening of marginal tumor swelling (p value < 0.001, odds ratio = 100.605) emerged as an independent predictor of pCR in rectal cancer patients. Additionally, receiver operating characteristic curve analysis revealed that lower preoperative carcinoembryonic antigen and erythrocyte sedimentation rate levels predict pCR, with cutoffs of 2.15 ng/ml and 19.0 mm/h, respectively.

Conclusion

Carcinoembryonic antigen and erythrocyte sedimentation rate, along with the presence of flattening of marginal tumor swelling, can predict pCR after neoadjuvant chemoradiotherapy in patients with primary rectal cancer. These factors offer a potential method for selecting candidates for conservative treatment based on endoscopic and laboratory findings.

Objective: To explore the value of treatment choice and clinical prognosis for Riolan's arch in chronic superior mesenteric artery (SMA) ischaemic disease in vascular surgery.

Methods: The clinical data of 215 patients with SMA ischaemic disease (41 cases with Riolan's arch and 174 cases without) admitted to the Department of Vascular Surgery, Affiliated Drum Tower Hospital, Medical School of Nanjing University (China) from January 2019 to April 2023 were reviewed. Clinical characteristics, imaging findings, treatment, perioperative complications, and patient follow-up data were analysed to observe the impact of Riolan's arch on the prognosis of patients with SMA ischaemic disease.

Results: There were significant differences in body mass index (Riolan's arch group: 22.82 ± 3.28 vs 24.03 ± 4.26 in non-Riolan's arch group, P = 0.049), Takayasu's arteritis (4.9% vs 0, respectively, P = 0.036), and secondary intervention (3.3% vs 1.9%, respectively, P < 0.001) between the two groups. Propensity score matching was used to exclude the effect of baseline data on patient outcomes. There were significant differences related to therapy method (conservative treatment, Riolan's arch group: 24.1% vs 39.7% in the non-Riolan's arch group; operative treatment, Riolan's arch group: 51.7% vs 20.7% in the non-Riolan's arch group, P = 0.014), as well as in-hospital time (9.79 ± 4.20 vs 6.86 ± 4.32, respectively, P = 0.011). There was no statistically significant difference in Kaplan-Meier curves between the two groups (log-rank test P = 0.476).

Conclusions: Riolan's arch plays an important compensatory role in SMA ischaemic disease, especially in chronic disease. We found significant differences in the treatment methods and length of hospital stay of Riolan's arch, which may suggest that Riolan's arch has some reference value in the choice of treatment mode.