International Journal of Colorectal Disease最新文献

Objective: To investigate the application of transperineal ultrasound for assessing pelvic floor muscle (PFM) function in male patients with constipation and to evaluate its clinical value.

Methods: The study included 32 male patients with constipation and 32 healthy controls, all of whom underwent transperineal ultrasound examinations. Measured parameters included the anorectal angle (ARA), levator plate angle (LPA), excursions of the ARA and LPA, and displacements of the bulb of the penis (BP), mid-urethra (MU), urethra-vesical junction (UVJ), and anorectal junction (ARJ) at rest, during maximal voluntary contraction (MVC), and during maximal Valsalva maneuver. Reliability was evaluated in 20 healthy controls using intraclass correlation coefficients (ICCs) and Bland-Altman analysis.

Results: (1) The ICCs for each parameter measured by both the same and different observers were above 0.84, indicating high repeatability. At least 90% of the measurements by the same and different observers fell within the 95% confidence interval (CI). (2) At rest, the ARA in patients with constipation was significantly larger than in healthy men (P < 0.05). During MVC, LPA, the ARA excursion, LPA excursion, BP displacement, UVJ displacement, and ARJ displacement in constipation patients were also significantly larger than in healthy men (P < 0.05). Furthermore, BP displacement, UVJ displacement, and ARA excursion during maximal Valsalva maneuver in constipation patients were significantly larger than in healthy men (P < 0.05). (3) Receiver operating characteristic curve analysis revealed that the following indicators demonstrated area under the curve (AUC) values exceeding 0.75: ARA excursion of MVC, ARA excursion of maximal Valsalva maneuver, resting ARA, and ARJ displacement of MVC, with AUC values of 0.782, 0.778, 0.770, and 0.765, respectively. No significant differences in diagnostic performance were found among these indicators (P > 0.05).

Conclusion:  Transperineal ultrasound is a reliable and practical technique for assessing the morphology and function of male PFMs. Parameters such as ARA excursion during MVC, ARA excursion during maximal Valsalva maneuver, resting ARA, and ARJ displacement during MVC are valuable for diagnosing PFM dysfunction in constipated patients.

Purpose: Endoscopic procedures and surgery are common treatments for early colorectal cancer (CRC). However, only approximately 10% of patients who undergo surgery have lymph node metastases (LNM) detected on postoperative pathology, which often leads to overtreatment. This study aims to comprehensively analyze the risk factors for LNM in early CRC patients, establishing a predictive model to aid in treatment decisions.

Methods: This study reviewed the clinicopathologic data of patients with early CRC who underwent surgery from January 2015 to June 2023. Univariate and multivariate logistic regression analyses were employed to identify LNM risk factors. The receiver operating characteristic (ROC) analysis and calibration curves were also constructed to verify the model's discrimination and calibration. A simplified scale was calculated to promote the risk stratification for LNM.

Results: The study analyzed medical records of 375 patients. Of these, 37 (9.9%) cases had LNM. Univariate analysis identified age, nerve invasion, depth of submucosal invasion, histologic grade, LVI, and tumor budding as risk factors. The multivariate analysis confirmed histologic grade (OR, 13.403; 95% CI, 1.415-126.979; P = 0.024), LVI (OR, 6.703; 95% CI, 2.600-17.284; P < 0.001), and tumor budding (OR, 3.090; 95% CI, 1.082-8.820; P = 0.035) as independent predictors. The optimal nomogram, incorporating six risk factors, demonstrated strong predictability with an area under the ROC curve (AUC) of 0.837 (95% CI, 0.762-0.912). A simplified risk assessment scale with a total score of 19 points was developed.

Conclusion: The study developed a nomogram and a simplified risk assessment scale to predict LNM risk, potentially optimizing the management of early CRC patients.

Background: Colostomy formation as part of the Hartmann's procedure is often performed during emergency surgery as a damage limitation measure where attempts at bowel anastomosis and continuity are contraindicated. Hartmann's reversal (HR) remains challenging and can be attempted through open surgery and various minimally invasive techniques (laparoscopic and robotic platforms). We aimed to analyse outcomes of conventional multi-port laparoscopy (CL) versus single-incision approach (SILS) in patients undergoing HR.

Methods: A comprehensive online search of various databases was conducted in accordance with PRISMA guidelines including Medline, PubMed, Embase, and Cochrane. Comparative studies of patients undergoing CL and SILS for HR were included. Analysed primary outcomes were total operative time and mortality rate. Secondary outcomes included post-operative complications, length of hospital stay, risk of visceral injury intra-operatively, and re-operation rate. Combined overall effect sizes were calculated using the random-effects model, and the Newcastle-Ottawa Scale (NOS) was used to assess bias.

Results: Two observational studies matching our inclusion criteria with a total of 160 patients (SILS 100 vs. CL 60) were included. Statistical difference was observed for one outcome measure: operative duration (MD - 44.79 CI - 65.54- - 24.04, P < 0.0001). No significant difference was seen in mortality rate (OR 1.66 CI 0.17-16.39, P = 0.66), overall post-operative complications (OR 0.60 CI 0.28-1.32, P = 0.20), length of stay (MD - 0.22 CI - 4.25-3.82, P = 0.92), Clavien-Dindo III + complications (OR 0.61 CI 0.15-2.53, P = 0.50), risk of visceral injury (OR 1.59 CI 0.30-8.31, P = 0.58), and re-operation rates (OR 0.73 CI 0.08-6.76, P = 0.78).

Conclusion: Accounting for study limitations, the SILS procedure seems to be quicker with non-inferior outcomes compared with the conventional multi-port approach. This may lead to better patient satisfaction and cosmesis and potentially reduce the risk of future incisional hernia occurrence. However, well-designed, randomised studies are needed to draw more robust conclusions and recommendations.

Purpose: The optimal treatment of ypT1 rectal cancer after neoadjuvant chemoradiotherapy (nCRT) remains controversial. This study aimed to determine whether local excision is non-inferior to radical surgery and whether adjuvant chemotherapy (ACT) would improve survival in patients with ypT1 rectal cancer after nCRT.

Methods: We enrolled 1212 and 91 patients with ypT1 rectal cancer underwent nCRT followed by radical surgery from the SEER database (2004-2018) and the Zhejiang Cancer Hospital (ZJCH) (2010-2022), respectively. Another 62 patients underwent LE were also identified from SEER registries. Propensity score matching was performed to balance baseline characteristics between patients in different treatment groups.

Results: Regional nodal metastasis was histopathologically detected in 257 patients (20.7%) within the SEER cohort, showing a significant association with poor cancer-specific survival (CSS) and overall survival (OS). Consistent findings were also observed in the ZJCH cohort. After 1:1 propensity score matching (60 pairs), no significant differences were observed between the extended resection and local excision groups in CSS (hazard ratio [HR] 0.88, P = 0.785) and OS (HR 0.81, P = 0.450). Patients with regional nodal metastases were more likely to receive ACT, while no apparent survival benefit was observed with additional ACT after PSM adjusting (187 pairs). Notwithstanding, for individuals younger than 50 years, ACT might provide a survival benefit in CSS (HR 0.25, P = 0.033) and OS (HR 0.30, P = 0.022).

Conclusion: Although patients with ypT1 rectal cancer have a non-negligible risk for nodal metastasis, oncologic outcomes of local excision following nCRT seem to be comparable to radical surgery. ACT could not effectively improve prognosis in patients with ypT1 tumors, except for those younger than 50 years of age.

Purpose: The purpose of this study was to evaluate the concordance between patient-reported performance status (prPS) and surgeon-reported performance status (srPS), and to assess the correlation between srPS and prPS and postoperative complications following elective colorectal cancer surgery. Not all patients are deemed suitable for undergoing a surgical procedure. We aimed to assess whether prPS can aid the surgeons' decision-making prior to surgery.

Methods: In this retrospective study, 524 patients undergoing colorectal cancer surgery were included. prPS were collected via questionnaires, while 30-day postoperative complications were obtained from the Danish Colorectal Cancer Group (DCCG) database. To evaluate the agreement between prPS and srPS, linearly weighted kappa statistics were applied. Rank-biserial correlation analysis was used to calculate the correlation between prPS and srPS with postoperative complications.

Results: In total, there was an approximate 71% concordance between the assessments. Around 17% of the patients rated themselves with a higher PS status than the surgeons, while 13% of the patients rated themselves with a lower PS. Overall postoperative complications, minor surgical complications, and medical complications were all significantly correlated to both srPS and prPS, while only srPS was correlated with major surgical complications. Neither srPS nor prPS were correlated with overall surgical complications (major and minor collapsed).

Conclusion: The agreement between prPS and srPS is poor and in nearly one-third of the cases, disagreement occurs. Overall, both prPS and srPS were correlated to postoperative complications, with srPS demonstrated a slightly higher correlation.

Purpose: To determine the clinical outcomes of endoscopic submucosal dissection (ESD) for colorectal tumors in older patients and predictors of mortality.

Methods: We retrospectively evaluated 207 lesions in 195 consecutive older patients aged ≥ 75 years who underwent ESD for colorectal tumors between January 2007 and December 2018. Outcomes of ESD were evaluated, and the prognosis was assessed in terms of both curability and the patient's baseline physical condition as determined by several indices. Cox regression analyses were performed to identify factors associated with reduced overall survival (OS).

Results: Treatment outcomes included a median procedure time of 55 min, en bloc resection rate of 97%, histological en bloc resection rate of 92%, postoperative bleeding rate of 2.4%, and intraoperative perforation rate of 3.4%. Postoperative bleeding and intraoperative perforation could be treated conservatively. Delayed perforation occurred in one patient and required emergency surgery. Three-year OS was 99.4% and 5-year OS was 95.8%. Overall, three patients experienced recurrence (one local, two distant metastasis), and one patient died of primary cancer. Multivariate analysis identified the Charlson Comorbidity Index (CCI) score ≥ 3 as the only independent predictor of reduced OS (hazard ratio 4.26; 95% confidence interval 1.60-11.38; P = 0.004).

Conclusion: Our results suggest that colorectal ESD is safe and effective in older patients aged ≥ 75 years. There was a significant independent association of reduced OS with high CCI score, but not with curability by ESD. The CCI score should be considered when determining the indications for ESD in older patients.

Background: The Skeletal Muscle Index (SMI) serves as an objective metric for assessing nutritional status in patients with malignant tumors. Research has found baseline nutritional status can influence both the efficacy and prognosis of targeted anti-tumor therapies, with growth factor tyrosine kinase inhibitors frequently inducing drug-related sarcopenia. Fruquintinib has received approval for the treatment of metastatic colorectal cancer. This study examines the prognostic significance of baseline SMI in patients with metastatic colorectal cancer undergoing treatment with fruquintinib. Additionally, the study investigates the incidence of SMI reduction following fruquintinib therapy to assess its impact on patient prognosis.

Methods: A retrospective multicenter study was conducted to analyze patients with metastatic colorectal cancer who received fruquintinib treatment across eight medical centers in Eastern China. The muscle area at the third lumbar vertebra was assessed, and both baseline and post-treatment SMI values were calculated independently. The relationship between SMI and patient survival was subsequently examined.

Results: The median progression-free survival (PFS) for the cohort of 105 patients was 4.2 months (95% CI, 3.7 to 4.9 months), while the median overall survival (OS) was 10.2 months (95% CI, 9.0 to 12.7 months). Notably, the baseline SMI prior to the initiation of fruquintinib therapy exhibited a significant correlation with OS (P = 0.0077). Multivariate analysis indicated that baseline SMI serves as an independent prognostic factor for OS (P = 0.005). Furthermore, after Propensity Score Matching (PSM) analysis, there was still a significant correlation between baseline SMI and OS. Among the patients, 28.87% developed sarcopenia following oral administration of fruquintinib. However, no statistically significant difference in OS was observed between the group with reduced SMI and the group without SMI reduction after treatment with fruquintinib.

Conclusion: The baseline SMI was identified as an independent prognostic factor for OS and may influence the survival outcomes of patients with metastatic colorectal cancer undergoing treatment with fruquintinib. Despite the potential of fruquintinib to induce sarcopenia, no significant correlation was observed between changes in SMI following treatment and patient survival.

Purpose: Colorectal cancer cells containing mobile lipids are said to be an early indicator of chemotherapy effects. The objective of the study was to examine the frequency and clinical relevance of intratumoral fat deposition in colorectal liver metastases (CRLM) post-chemotherapy using dual-echo chemical shift gradient-echo magnetic resonance imaging (MRI).

Methods: A retrospective analysis of 98 patients with CRLM diagnosed between 2017 and 2022 (69 M, mean age 62.87 ± 10.73 years old) who had an MRI after chemotherapy was performed. On dual-echo chemical shift gradient-echo MRI, intratumoral fat deposition of CRLM was evaluated. A signal intensity drop of ≥ 12% in opposed-phase images vs. in-phase images indicated intratumoral fat. After chemotherapy, the presence of fat deposition was correlated with patients' overall survival.

Results: Before and after chemotherapy, 0 (0%) and 29 (29.59%) patients exhibited intratumoral fat. The number of CRLM ranged from 1 to 25 with a median of 3 and a mean size of 32.58 ± 22.95 mm. The groups had statistically different survival times. Overall survival was shorter for patients with intratumoral fat deposition in CRLM (32 months (24-60, 95% CI)) than for patients without fat deposition in CRLM (48 months (36-NA, 95% CI)).

Conclusion: In our group, nearly 30% of CRLM patients exhibited intratumoral fat after chemotherapy. Patients with intratumoral fat deposition in CRLM have a shorter overall survival time. The presence of fat in CRLM correlates with a poor long-term prognosis.

Introduction: Recent studies have suggested that ambulatory management is feasible for acute uncomplicated diverticulitis (AUD); however, there is still no consensus regarding the most appropriate management settings. This study presents a multi-centre experience of managing patients presenting with AUD, specifically focusing on clinical outcomes and comparing ambulatory treatment with in-patient management.

Methods: A retrospective multi-centre study was conducted across four hospitals in the UK and included all adult patients with computed tomography (CT) confirmed (Hinchey grade 1a) acute diverticulitis over a 12-month period (January - December 2022). Patient medical records were followed up for 1-year post-index episode, and outcomes were compared between those treated through the ambulatory pathway versus inpatient treatment using 1:1 propensity score matching (PSM). All statistical analysis was performed using the R Foundation for Statistical Computing, version 4.4.

Results: A total of 348 patients with Hinchey 1a acute diverticulitis were included (260 in-patients; 88 ambulatory pathway), of which nearly a third (31.3%) had a recurrent disease. Inpatient management was dominant (74.7%), with a median of 3 days of hospital stay. PSM resulted in 172 patients equally divided between the two care settings. Ambulatory management was associated with a lower readmission rate (P = 0.02 before PSM, P = 0.08 after PSM), comparable surgical (P = 0.57 before PSM, 0% in both groups after PSM) and radiological interventions (P = 0.99 before and after PSM) within one year. In both matched and non-matched groups, a strong association between readmissions and inpatient management was noted in univariate analysis (P = 0.03 before PSM, P = 0.04 after PSM) and multivariate analysis (P = 0.02 before PSM, P = 0.03 after PSM).

Conclusion: Our study supports the safety and efficacy of managing patients with AUD through a well-designed ambulatory care pathway. In particular, hospital re-admission rates are lower and other outcomes are non-inferior to in-patient treatment. This has implications for substantial cost-savings and better utilisation of limited healthcare resources.

Background: The ileal pouch-anal anastomosis (IPAA) is a restorative procedure performed after proctocolectomy to improve quality of life in patients with colorectal conditions like ulcerative colitis, familial adenomatous polyposis, and selected cases of Crohn's disease and Lynch syndrome. However, severe pouch dysfunction can occur, often necessitating further surgical intervention.

Objective: This technical note aims to describe the operative approach and perioperative management for diverting ileostomy as a treatment for dysfunctional ileoanal pouches.

Methods: Indications for the procedure include complications such as pelvic sepsis, pouchitis, fistulas, and Crohn's disease of the pouch. Preoperative planning involves a multidisciplinary team, stoma site marking, and imaging to assess bowel integrity. The surgical technique utilizes laparoscopic access with careful adhesiolysis to minimize bowel injury, with intraoperative pouchoscopy to identify anatomical landmarks. An ileostomy is created by selecting a tension-free small bowel segment and approximating it to a pre-marked stoma site. Attention is given to preserving bowel length to allow for potential future restorative procedures. Postoperative care focuses on stoma management and addressing ongoing pouch dysfunction symptoms.

Conclusions: Diverting ileostomy offers symptom relief for patients with pouch dysfunction while avoiding more complex procedures like pouch excision. It is a valuable option in managing pouch failure.