Techniques in Coloproctology最新文献

Background: Evidence of superiority of robotic-assisted surgery for colorectal resections remains limited. This systematic review and meta-analysis aims to compare robotic-assisted and laparoscopic surgical techniques in high-risk patients undergoing resections for colorectal cancer.

Methods: Systematic searches were performed using Pubmed, Embase and Cochrane library databases from inception until December 2024. Randomised and non-randomised studies reporting outcomes of robotic-assisted or laparoscopic resections in the following high-risk categories were included: obesity, male gender, the elderly, low rectal cancer, neoadjuvant chemoradiotherapy and previous abdominal surgery. Comparative meta-analyses for all sufficiently reported outcomes were completed. Risk of bias was assessed using the ROBINS-I and RoB 2 tools for non-randomised and randomised studies, respectively.

Results: 48 studies, including a total of 34,846 patients were eligible for inclusion and 32 studies were utilised in the comparative meta-analyses. Conversion to open rates were significantly lower for robotic-assisted surgery in patients with obesity, male patients and patients with low rectal tumours (obese OR 0.41 [CI 0.32-0.51], p < 0.00001); male gender (OR 0.28 [CI 0.22-0.34], p < 0.00001); low tumours OR 0.10 [CI 0.02-0.58], p = 0.01). Length of stay was significantly reduced for robotic-assisted surgery in patients with obesity (SMD 0.25 [CI - 0.41 to - 0.09], p = 0.002). Operative time was significantly longer in all subgroups (obesity SMD 0.57 [CI 0.31-0.83], p < 0.0001; male gender SMD 0.77 [CI 0.17-1.37], p = 0.01; elderly SMD 0.50 [CI 0.18-0.83], p = 0.002; low rectal tumours SMD 0.48 [CI 0.12-0.84], p = 0.008; neoadjuvant chemoradiotherapy SMD 0.72 [CI 0.34-1.09], p = 0.0002; previous surgery SMD 1.55 [CI 0.05-3.06], p = 0.04). When calculable, blood loss, length of stay, complication rate and lymph node yield were comparable in all subgroups.

Conclusions: This review provides further evidence of non-inferiority of robotic-assisted surgery for colorectal cancer and demonstrates conversion rates are superior in specific, technically challenging operations.

Introduction: Excisional haemorrhoidectomy remains the gold-standard treatment for grade III-IV haemorrhoids owing to the high success rate. However, post-operative pain management is an ongoing challenge. Botulinum toxin injection is thought to improve pain by targeting the internal anal sphincter spasm which occurs following haemorrhoidectomy. This systematic review and meta-analysis examines the effects of concurrent botulinum toxin injection on post-haemorrhoidectomy pain.

Methods: A search of MEDLINE, EMBASE and Cochrane Databases for randomised controlled trials (RCTs) of botulinum toxin injection compared with placebo for management of post-haemorrhoidectomy pain was conducted following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Outcomes assessed included daily post-operative pain scores assessed using an analogue scale (0-10), pain at first defecation, analgesia use, complication rates and time to return to work.

Results: A total of seven RCTs assessing 340 patients who underwent an excisional haemorrhoidectomy were included. In total, seven studies (n = 340) found significant reduction in pain post-procedure with botulinum toxin use on day 1 (mean difference, MD -1.53; 95% confidence intervals, CI -2.12, -0.94; p < 0.00001), with similar findings on day 2 and 4 (MD -1.84, 95% CI -3.28, -0.41; p = 0.01 and MD -1.63, 95% CI -2.15, -1.09; p < 0.00001, respectively). However, the analgesic effects were not seen on subsequent analyses up to day 14. Botulinum toxin was seen to be safe, with no significant difference in faecal incontinence (MD 1.05, 95% CI 0.40, 2.75; p = 0.93) or urinary retention (MD 0.37, 95% CI 0.09, 1.53; p = 0.17).

Conclusions: Botulinum toxin use for pain relief post-excisional haemorrhoidectomy is safe and effective in the initial peri-operative period; however, the results were short-lived. Further, more robust randomised controlled trials are needed to strengthen these findings and determine the utility of botulinum toxin in this setting.

Trial registration: PROSPERO Register for Systematic Reviews Registration Number - CRD42024541351 on April 29 2024.

Background: The management of obstetric rectovaginal fistula (RVF) is challenging for the surgeon. The best surgical procedure to repair RVFs, specifically after obstetric anal sphincter injury, has not been extensively studied. The objective was to compare the success of the different procedures performed to repair obstetric RVF.

Methods: The literature search was carried out on PubMed^® and Web of Science^® from database inception until 31 December 2022. Selection criteria were: (1) patients with a diagnosis of obstetric-related RVF; (2) patients treated surgically with no restriction concerning the considered surgery; (3) clinical trials or epidemiological studies. Meta-analysis was conducted considering the network meta-analysis framework to allow studying the relative value of each treatment mentioned in the selected articles.

Results: The quantitative synthesis included 32 studies (18 retrospective and 14 prospective) accounting for 595 patients. The quality of these studies was low because of the lack of prospective randomization. Nineteen procedure types were described and assessed. Most patients (n = 180) underwent endorectal advancement flap (ERAF) followed by excision and layered closure (ELC) (n = 213) and Musset procedure (n = 65). A diverting stoma was performed in 66/132 patients. Only 13 studies reported the functional results of the procedure. In the meta-analysis, the Musset procedure (OR = 4.29; 95% CI: 1.18-16.14), transvaginal ELC (OR = 11.84; 95% CI: 2.18-91.80) and transperineal ELC (OR = 3.56; 95% CI: 1.26-10) significantly improved the anatomical results compared to ERAF.

Conclusions: A further randomized controlled trial in the literature assessing ERAF and sphincteroplasty to compare the anatomical results, functional results and morbidity of this treatment is needed.

Registration: PROSPERO CRD42023447875.

Background: Minimally invasive surgery has become the gold standard for colorectal cancer treatment. Approximately 40% of patients undergoing elective colorectal resection develop postoperative complications. The median time to clinical diagnosis of a postoperative complication ranges between 5 and 8 days. Early detection of complications can reduce their morbidity and negative impact. This study aims to evaluate the effectiveness of routine postoperative inflammatory markers in predicting early postoperative complications in patients undergoing elective minimally invasive surgery for colorectal cancer.

Methods: This study was conducted at a single center and is a retrospective analysis of a prospectively mantained database. We included 397 consecutive patients who underwent elective minimally invasive surgery for colorectal cancer between May 2012 and September 2023. Routine inflammatory parameters, including C-reactive protein, Glasgow Prognostic Score, and neutrophil-lymphocyte ratio, were analyzed to identify those associated with postoperative complications. The cutoff values for these markers were determined using receiver-operating characteristic (ROC) curve analysis with the Youden index method.

Results: Of the patients, 29.2% experienced postoperative complications, with major complications (Clavien-Dindo ≥ III) occurring in 11.3%. On postoperative day 3, C-reactive protein level < 125 mg/L, Glasgow Prognostic Score < 2.12, and neutrophil-lymphocyte ratio < 5.26 were significantly associated with lower risk of postoperative complications (p < 0.0001). NLR was the best parameter to identify patients unlikely to experience a postoperative complication on day 3, with a cutoff value of 5.26 and a negative predictive value (NPV) of 83%.

Conclusions: Neutrophil-lymphocyte ratio, C-reactive protein, and Glasgow Prognostic Score on POD3 can predict postoperative complications in patients who undergoing minimally invasive surgery for colorectal cancer. These inflammatory markers demonstrated high negative predictive value, effectively identifying patients who are unlikely to develop complications and providing valuable information for safe early discharge.

Background: Surgical site infections (SSI) are the most common complication after stoma closure. Circular skin closure (CSC) has been proposed to reduce SSI with comparable or even better outcomes than conventional primary sutures (PS). The aim of this meta-analysis is to compare circular with primary skin closure in stoma closure.

Method: A systematic review of the literature was performed for articles published between January 2010 and June 2023, including all randomized control trials (RCT) on wound infection of adult patients following stoma reversal. The primary outcome was 30-day SSI; secondary outcomes were operative time, length of stay, and incisional hernia.

Results: Eight RCTs were identified that included a total of 606 patients undergoing stoma closure surgery. Four percent of patients in the CSC group developed SSI, compared to 27% of patients undergoing PS. The 30-day SSI rate was lower after the circular skin closure (OR 0.11, 95% CI 0.06-0.21; p < 0.00001, I² = 0%). There was no difference in the operative time (99.2 vs 103.5 min; MD - 0.17, 95% CI - 0.37, 0.03; p = 0.10), length of stay (7.1 vs 7.7 days; MD - 0.34, 95% CI - 0.55, - 0.12; p = 0.002), and incisional hernia rate (2% vs 4%; OR 0.61, 95% CI 0.23, 1.60; p = 0.31).

Conclusion: CSC is associated with lower SSI rate and should be preferred to linear skin closure technique after stoma closure surgery.

Introduction: Preoperative anemia is an important target in preventing colorectal anastomotic leakage (CAL). However, it is not consistently detected and corrected in patients undergoing colorectal surgery. This study aimed to evaluate the impact of early detection and correction of preoperative anemia on perioperative outcomes and CAL.

Methods: This was a prospective subanalysis of an international open-labeled trial, which implemented an enhanced care bundle to prevent CAL after elective colorectal surgeries. It introduced interventions for early detection and correction of preoperative anemia. Primary outcome was the incidence of preoperative anemia and the effect of early correction. Secondary outcomes included the impact on CAL, postoperative course, and mortality.

Results: The study included 899 patients across eight European hospitals (September 2021-December 2023). Preoperative anemia was identified in 35.0% (n = 315) of participants, with 77.4% (n = 192) receiving iron therapy. Hemoglobin levels decreased in 4.2% (n = 13), remained stable in 45.8% (n = 143), and increased in 50.0% (n = 156) (p < 0.001). Perioperative hyperglycemia was more common among patients with anemia (7.8% versus 16.4%, p < 0.001). CAL occurred in 6.1% (n = 53) of patients. Anemia correction and changes in hemoglobin levels after iron treatment were not significantly associated with CAL, other complications, or mortality.

Conclusions: Early detection and correction of preoperative anemia is achievable. However, routine preoperative administration of iron alone, without concurrently optimizing other CAL risk factors, does not result in CAL prevention. Preoperative anemia indicates overall poor physiological fitness rather than being an isolated risk factor.

Trial number: NCT05250882 (20-01-2022).

Background: Complex anal fistulas, particularly those with intersphincteric extensions, pose significant challenges in surgical management due to their high recurrence rates. Often, recurrence is attributed to surgeons' inability to precisely identify the fistula tract in the intersphincteric plane and to achieve secure ligation.

Objective: This video aims to present a novel surgical technique derived from our experience to address the challenges and reduc recurrences in treating complex fistulas, especially those with intersphincteric extensions.

Materials and methods: A patient with a posterior complex anal fistula was examined. The external opening was situated at the 9 o'clock position, while proctoscopy revealed the internal opening at 6 o'clock. Our surgical strategy entailed the utilization of an arterial clamp to determine the fistula tract's orientation. Verification of the tract's connection was achieved by injecting water through the external opening. Subsequently, an intra-anal fistulotomy was executed using electrocauterization. A key aspect of this procedure was the continuous observation of the fistula tract's granulation tissue to prevent inaccurate dissection. This tissue was later eradicated with a curette. To further ascertain the internal opening's location at the external sphincter, another water injection was administered. The internal opening was then securely sealed using absorbable sutures employing the horizontal mattress technique. The success of this procedure was confirmed with a water injection post-tract ligation, which displayed no seepage. Additional curettage was conducted to eliminate granulation at the external tract, succeeded by the placement of a tube drain. Finally, sutures were used to overlay the internal opening, promoting optimal healing.

Results: The patient did not face any postoperative complications. The healing process of the wound was satisfactory, with no observed recurrence six months subsequent to the operation.

Conclusions: Our innovative surgical method demonstrates a promising alternative to conventional techniques. It bears significant potential in diminishing recurrence rates in intricate fistula situations that encompass intersphincteric extensions.

Background: Delay in diagnosing Crohn's disease (CD) in patients presenting with perianal abscess (PAA) and/or fistula (PAF) is common. The aim of this study was to identify red flags suggestive of CD.

Methods: A systematic literature review was conducted to identify symptoms associated with CD in patients presenting with PAA/PAF. A questionnaire including those symptoms, supplemented with items from the International Organization for the Study of Inflammatory Bowel Diseases (IO-IBD) red flags index for luminal CD, was administered to all adult patients presenting with a PAF and eventually diagnosed with CD and matched patients (1:3) from the same study period with a cryptoglandular PAF (2012-2023) at a single non-academic teaching hospital. All patients were asked to recall symptoms/signs experienced during their first PAF.

Results: The systematic review identified 8 articles reporting on 15 clinical characteristics in patients presenting with PAA (n = 2)/PAF (n = 6), supplemented with 13 items from the IO-IBD red flags index (28 items in total). A total of 25 patients with CD and 75 patients with PAF without CD answered the questionnaire. Univariate analysis identified seven items associated with CD (age, family history, > 2 perianal interventions, weight loss, abdominal pain, diarrhoea and fatigue), and four items remained significant in multivariate analysis: age (OR 3.4 [1.0-11.5]), > 2 previous perianal interventions (OR 3.4 [1.0-10.1]), weight loss (OR 14.4 [3.7-55.6]) and abdominal pain (OR 9.8 [1.9-49.8]). Receiver-operating characteristic curve (ROC) analysis showed that a combination of these red flags was associated with good discrimination of CD versus non-CD (AUC 0.83 [0.72-0.94]).

Conclusions: The perianal red flags index has a good predictive value for early identification of patients with PAF at risk for underlying CD.