International Journal of Colorectal Disease最新文献

Objective: This long-term follow-up study evaluates clinical and functional outcomes after ileocecal resection with either Kono-S or conventional anastomosis techniques in patients with Crohn's disease. The goal was to determine whether the Kono-S approach confers a long-term advantage in preventing disease recurrence and improving quality of life. While the Kono-S anastomosis has shown promise in reducing recurrence rates in Crohn's disease following surgery, most existing evidence stems from short- to medium-term follow-up. High-quality long-term data remain scarce, particularly in real-world clinical settings. This study aims to fill that gap.

Methods: A retrospective-prospective cohort analysis was performed including patients who underwent ileocecal resection for Crohn's disease between 2015 and 2017 at a single academic center. Patients were grouped according to anastomosis technique (Kono-S vs. conventional). Long-term follow-up data were obtained via chart review, imaging studies, and patient-reported questionnaires, including the Gastrointestinal Quality of Life Index (GIQLI). Primary outcomes included recurrence rates, postoperative complications, and quality of life.

Results: Seventy patients were included in the final analysis (Kono-S: n = 31; conventional: n = 39). The median follow-up duration was 8.1 years (interquartile range = 6.9-8.8 years). No significant differences were observed between groups regarding endoscopic inflammation (Kono-S = 19.4%, conventional = 25.6%, p = 0.39), restenosis (Kono-S = 9.7%, conventional = 2.6%, p = 0.34), or GIQLI scores (Kono-S: median 116 vs. 110, p = 0.08). Rehospitalization rates were numerically higher in the Kono-S group (16.1% vs. 2.6%, p = 1.0), but not statistically significant. Importantly, approximately 40% of all patients retrospectively stated they would have preferred earlier surgical intervention, independent of the anastomotic technique.

Conclusion: After more than 7 years of follow-up, the Kono-S anastomosis demonstrates comparable long-term outcomes to conventional techniques in terms of recurrence, complications, and quality of life. Patient reflections suggest a potential benefit of earlier surgical intervention, highlighting the need for more proactive surgical referral in gastroenterological practice.

Background: Preoperative mechanical bowel preparation (MBP) and oral antibiotics (OA) are widely used to decrease the risk of postoperative septic complications after colorectal resections. Unfortunately, it is not clear whether bowel preparation can lead to symptoms of small bowel obstruction, which might even increase the risk of postoperative morbidity.

Methods: Consecutive Crohn's disease patients undergoing bowel resections with formation of ileocolic or colocolic anastomosis were included in the present prospective observational study. Urgent surgery, surgery without preoperative MBP, colorectal cancer, and fecal diversion were exclusion criteria. A polyethylene glycol solution (2 L) was used for MBP. OA consisted of paramomycin and metronidazole taken at 7 p.m. and 11 p.m. at the evening before surgery. Occurrence of complications at the anastomotic site (leakage, peritonitis, abscess, or fistula in direct proximity to the anastomosis) was a primary outcome measure. Complications of MBP were recorded. Mechanical bowel preparation was defined as "incomplete" when patients took a lesser amount of MBP solution than scheduled.

Results: Between 2016 and 2024, ileocolic or colorectal resections with formation of an anastomosis were performed in 284 patients with Crohn's disease. Nausea, vomiting, or abdominal pain occurred during the MBP in 29% of patients (n = 78), leading to termination of intake in 53 patients (19%). Women (p < 0.001), patients hospitalized urgently because of acute abdominal pain (p = 0.008), patients presenting with severe anemia before surgery (p = 0.007), and patients scheduled for resections completed by ileocolic anastomosis as opposed to colocolic or colorectal anastomosis (p = 0.01) demonstrated a significantly increased risk of incomplete MBP. Thirty-two percent of patients demonstrated apparent dilatation of small bowel at the time of surgery. The incidence of anastomotic complications was 4% in patients who were able to complete MBP and 7.5% after an incomplete MBP (p = 0.27). There were no deaths. The conversion rate from laparoscopy to open surgery was increased in patients with small bowel dilatation (17% vs. 6%); however, the difference was not statistically significant (p = 0.13).

Conclusion: There is a considerable incidence of obstructive symptoms after preoperative mechanical bowel preparation in Crohn's disease patients. Nevertheless, an incomplete MBP is not associated with increased risk of intra- or postoperative complications and can be used safely in that particular population.

Purpose: Perianal fistula is a common disease that significantly affects the quality of life of patients. Several treatment options are available; loose seton is one of the most popular options. Aim of this study was to evaluate the relationships between quality of life and different types of knots used during the application of anal fistula.

Methods: Patients who presented with anal fistulas between 2021 and 2024 were included in this study. Patients were divided into 3 groups on the basis of the type of knot used for treatment. In group A, the seton ends were tied in the alpha configuration. In group B, a ring-like seton with overlapping ends was used. In group C, a knotless seton was applied. All patients completed the quality of life assessment with the Anal Fistula Questionnaire at 15, 30, and 90 days after surgery.

Results: Sixty-three patients were randomized. A total of 52 men were included. Median age was 43 years. Three patients in group C and five patients in group B experienced complications, including abscess, anal pain, loss of seton, and second fistula. Physical and mental component scores revealed that postoperative quality of life was similar among the three groups.

Conclusion: No differences in postoperative quality of life among groups were observed at 15, 30, or 90 days after surgery. Physical and mental component scores of quality of life in patients in Anal Fistula Questionnaire revealed that quality of life improved over time in all three groups.

Clinical trial registration: The study was registered at ClinicalTrials.gov (Study ID: NCT05348473, date: 04/29/2022).

Purpose: Assessment of local response to neo-adjuvant therapy for rectal cancer incorporates digital rectal exam (DRE), endoscopy and pelvic MRI. Despite this process patients are mistakenly identified with tumour persistence or recurrence resulting in overtreatment. This retrospective cohort study aimed to investigate the assessment of patients who had a complete pathological response (ypT0N0) after neo-adjuvant treatment for rectal cancer and evaluate clinical decision making.

Method: ypT0N0 cases were identified from a cohort of patients discussed at the Royal North Shore Hospital Colorectal Cancer Multidisciplinary Meeting (MDT) treated for rectal cancer from January 2016 to December 2024. The medical record was accessed to retrieve clinical information. Decision making was assessed from MDT discussion records.

Results: 110 patients were treated with neo-adjuvant therapy during the study period, with 71 proceeding to surgery. Twelve patients (17%) had ypT0N0 pathology. The decision to resect was prompted by concerning tumour signal on MRI (10/11), endoscopic evidence of tumour (3/6), palpable disease on DRE (3/9) and biopsy (2/3). Discordant investigations were common. The sensitivity and specificity of MDT decisions for complete clinical response were 61% and 95% respectively. Patients underwent either abdominal perineal resection or ultralow anterior resection; (6/12) experienced Clavien-Dindo 3 or 4 complications.

Conclusions: The clinical assessment of response to neo-adjuvant therapy in patients with rectal cancer is an area that requires improvement due to overtreatment. ypT0N0 patients often have discordant investigations. Management decisions based on the concordance of investigations may reduce the number of ypT0N0 resections.

Purpose: Currently, too many Patient-Reported Outcome Measures (PROMs) with redundant and repetitive domains are adopted to assess defecation disorders, resulting in more extended clinical visits and increased patient burden. The aim of this study was to develop a new comprehensive Defecation Disorders Scoring System (DDSS) by incorporating all items of the most commonly used and validated PROMs.

Methods: This is a prospective observational study on patients waiting for rectal prolapse and defecation disorders surgery. Preoperatively, each patient completed seven different authoritative PROMs, two questionnaires assessing constipation, two questionnaires for obstructed defecation, two questionnaires to evaluate fecal incontinence, and one questionnaire aiming to assess both. Spearman's correlation and Principal Component Analysis with varimax rotation were applied. Internal consistency was evaluated using Cronbach's α.

Results: A total of 127 female patients completed all 57 items across the seven validated PROMs and were included. Several items highly correlated with others expressing the same concept were reconsidered and excluded. A final set of 19 items was identified and arranged into DDSS, encompassing five core components regarding specific aspects of incontinence, bowel movements/defecation frequency, evacuation effort and duration, type of assistance, and abdominal discomfort. Regarding internal consistency, the derived DDSS and its five components demonstrated satisfactory results.

Conclusions: This study highlights the potential for reducing item redundancy across existing PROMs for defecation disorders. Despite some limitations, the proposed DDSS could potentially provide a concise, comprehensive tool for assessing multiple aspects of defecation disorders, potentially available in electronic format. Future studies will be required to further evaluate and validate DDSS across different patient populations.

Purpose: Pelvic cancer resections increase the risk of pelvic dead space, which increases the risk of postoperative complications. Robot-assisted pelvic reconstruction surgeries are a novel approach that may be beneficial, but it is unclear what impact it has on surgical outcomes in pelvic reconstruction with rectus abdominis muscle flaps. The aim of the study was to systematically review the surgical outcomes of robot-assisted pelvic reconstruction using rectus abdominis muscle flaps in patients with any pelvic cancers.

Method: A systematic search of the literature was conducted in PubMed, Web of Science, Cochrane Library, and Embase following the PRISMA guidelines, and the final search on all databases was performed on the 13th of May 2024. Studies reporting surgical outcomes of robot-assisted pelvic reconstruction with rectus abdominis muscle flaps were eligible based on predefined criteria. Two reviewers independently screened the literature, extracted data, and assessed risk of bias of included studies.

Results: Five studies, including 143 patients in total, met the inclusion criteria, comprising two retrospective cohort studies and three case series. Of these, 36 patients underwent robot-assisted pelvic reconstruction using rectus abdominis flaps. All studies reported wound complications, which were lower in the robot-assisted groups compared to open surgery groups. One study reported shorter length of stay. Two studies reported better visualization and avoidance of excessive blood loss when performing robot-assisted surgery.

Conclusions: Early reports indicate that robot-assisted surgery with flaps in pelvic reconstruction could improve postoperative outcomes. Further research should investigate the potential benefits through larger and controlled patient groups.

Purpose: Postoperative ileus(POI) occurs in 10-19% of colorectal surgeries. The identification of patients at-risk for POI is a key for nasogastric tube(NGT) placement. Point-of-care ultrasound(POCUS) has shown potential in predicting POI by assessing gastric volume, but its role has never been explored. The aim was to evaluate the association between the ratio of gastric volume on postoperative day (POD)2/POD0, measured by Point-of-care ultrasound(POCUS), and the risk of vomiting, postoperative ileus(POI) and the need for nasogastric tube(NGT) insertion after colorectal surgery.

Methods: This prospective monocentric study included 112 patients who underwent colorectal resection with or without anastomosis between August 2020 and April 2023. Gastric volume was measured using POCUS at POD0 and POD2. The primary outcome was the ratio of POD2/POD0. Area under the ROC curve based on multivariate model was estimated for the prediction of the need for NGT insertion was calculated.

Results: Among the 112 patients included in the study, 22 had postoperative nausea (19.6%), 16 experimented POI (14.3%) and 13 needed postoperative NGT insertion(11.6%). A larger POD2/POD0 ratio was significantly associated with nausea, POI and postoperative NGT insertion. In multivariate analysis, the POD2/POD0 ratio was an independent factor associated with the risk of postoperative nausea and postoperative NGT insertion. Finally, the POD2/POD0 ratio predicted the risk for postoperative NGT insertion with an area under ROC curve at 0.79(95%CI:0.67-0.91).

Conclusion: POCUS of the gastric volume is a promising tool to select patient requiring NGT insertion after colorectal surgery.

Clinical trial registry: NCT04461067.

Background: This study aimed to evaluate the learning curve of robotic intracorporeal single-stapling anastomosis (RiSSA) using risk-adjusted cumulative sum (RA-CUSUM) analysis based on standardized procedural intervals.

Methods: We retrospectively analyzed 36 consecutive patients who underwent robotic left-sided colorectal resection with RiSSA by a single surgeon. Eight intraoperative timepoints were annotated from surgical videos to define two composite metrics: pure RiSSA interval and total purse-string suture time. RA-CUSUM analysis was applied to assess technical proficiency over time.

Results: The RA-CUSUM curve showed an inflection point at case 17 for the pure RiSSA interval and at case 11 for purse-string suture time, indicating earlier acquisition of suture skills compared to overall procedural fluency. Two Clavien-Dindo grade ≥ III complications occurred in the late phase, including one anastomotic leak (5.3%, 1/19), whereas no major complications were observed during the early phase, although the limited sample size precludes any definitive safety interpretation. Technical metrics, including console time, pure RiSSA interval, and total purse-string suture duration, significantly improved after the inflection point.

Conclusions: In this single-surgeon cohort, RiSSA demonstrated a definable learning trajectory, with technical efficiency stabilizing after approximately 17 cases. The occurrence of major complications after the learning phase highlights that technical proficiency does not eliminate procedural risks. The pure RiSSA interval offers a reproducible metric to evaluate anastomotic proficiency and could support skill assessment frameworks in robotic colorectal procedures. Studies involving multiple surgeons and institutions are warranted to determine the generalizability of these findings.

Purpose: The incidence of colorectal cancer (CRC) is increasing in individuals aged < 50 years of age. This study aimed to examine whether high-frequency follow-up after CRC surgery reduces 5-year overall mortality, cancer-specific mortality and recurrence in patients with CRC aged ≤ 50 years.

Methods: The COLOFOL trial performed between 2006 and 2010 was used to analyse patients randomised to high-frequency (computed tomography [CT] of the abdomen and thorax and a carcinoembryonic antigen [CEA] test at 6, 12, 18, 24 and 36 months) versus low-frequency (CT and CEA at 12 and 36 months) follow-up after curative CRC surgery. Intention-to-treat and per-protocol analyses were performed to study the primary outcomes (5-year overall mortality and cancer-specific mortality) and the secondary outcome (CRC recurrence), comparing the age groups ≤ 50, 51-70 and > 70 years.

Results: In total, 2,509 patients were included in the intention-to-treat analysis with 183, 1,714 and 612 patients aged ≤ 50, 51-70 and > 70 years, respectively. The 5-year overall mortality risk for patients aged ≤ 50 was 8.3% in the high-frequency group compared with 8.4% in the low-frequency group (risk difference 0.2% [95% CI, - 8.0; 8.3]). The cancer-specific mortality risk for patients aged ≤ 50 years was 7.1% in the high-frequency group compared with 7.4% in the low-frequency group (risk difference, 0.3% [95% CI, - 7.4; 8.0]). The cancer-specific recurrence risk for patients aged ≤ 50 years was 12.9% in the high-frequency group compared with 21.0% in the low-frequency group (risk difference 8.1% [95% CI, - 2.6; 18.7]).

Conclusion: Among individuals aged ≤ 50 years with stage II-III CRC, there was no reduction in overall mortality, cancer-specific mortality and cancer-specific recurrence with more intensive follow-up using CT and CEA.

Background: Anastomotic leakage (AL) is a severe complication after rectal cancer surgery. This network meta-analysis (NMA) compares reinforced suturing (RS), transanal drainage tube (TDT), and no additional intervention (NRT) for AL prevention.

Methods: An NMA was conducted according to PRISMA-NMA guidelines. PubMed, Web of Science, and Embase were searched for randomized controlled trials and observational studies comparing RS, TDT, or NRT in adults undergoing anterior resection for rectal cancer, with AL as the primary outcome. Secondary outcomes included Grade C AL, stricture, bleeding, ileus, and wound infection.

Results: 16 studies (3 RCTs, 11 RNCTs, and 2 PNCTs; n = 4562) were included. For overall AL incidence, both RS (OR 0.32, 95% CrI 0.16-0.62) and TDT (OR 0.47, 95% CrI 0.33-0.63) significantly reduced AL vs. NRT. RS ranked highest (SUCRA 0.93). Although RS had the highest SUCRA for overall AL, the RS-TDT contrast was not statistically significant(OR 1.44, 95% CrI 0.68-3.09), so ranking should not be over-interpreted as proof of superiority. For Grade C AL, RS significantly reduced risk versus both TDT (OR 5.01, 95% CrI 1.33-28.67) and NRT (OR 0.10, 95% CrI 0.02-0.32; SUCRA 0.99). No significant differences were found among interventions for anastomotic bleeding, ileus, or wound infection. TDT showed a trend toward reduced anastomotic stricture risk (SUCRA 0.73), but the effect was not statistically significant (TDT vs. NRT: OR 0.68, 95% CrI 0.19-2.27). Sensitivity analysis restricted to larger studies (≥ 100 patients/group) confirmed the robustness of primary outcomes.

Conclusions: Both RS and TDT were associated with a reduction in overall AL risk compared to NRT. Network estimates suggested that RS may be more effective than TDT in preventing the more severe Grade C AL; however, this finding is based on indirect comparisons with wide credible intervals and requires confirmation in future head-to-head trials. The choice of intervention may therefore depend on patient risk profile and clinical context.