Techniques in Coloproctology最新文献

Background: This study aims to evaluate the current rates and outcomes of minimally invasive versus open surgery for colonic diverticular disease in Germany, using a nationwide dataset.

Methods: We analyzed data from 36 hospitals, encompassing approximately 1.25 million hospitalizations from 1 January 2019 to 31 December 2023. Patients aged 18 years and older with colonic diverticular disease (International Classification of Diseases, Tenth Revision (ICD-10): K57.2 and K57.3) who underwent surgical treatment were included. Surgeries were classified as open or minimally invasive (laparoscopic or robotic). Outcomes such as in-hospital mortality, complications, and length of stay were assessed using multivariable logistic and linear regression models.

Results: Out of 1670 patients who underwent surgery for colonic diverticular disease, 63.2% had perforation and abscess. The rate of minimally invasive surgery increased from 34.6% in 2019 to 52.9% in 2023 for complicated cases and from 67.8% to 86.2% for uncomplicated cases. Open surgery was associated with higher in-hospital mortality (odds ratio (OR): 7.41; 95% CI: 2.86-19.21) and complications compared with minimally invasive surgery. The length of hospital stay was significantly longer for open surgery patients, with an increase of 4.6 days for those with perforation and abscess and 5.0 days for those without.

Conclusions: Minimally invasive surgery for colonic diverticular disease is increasingly preferred in Germany, especially for uncomplicated cases. However, open surgery remains common for complicated cases, but is associated with higher mortality, more complications, and longer hospital stays.

Background: Neoadjuvant combination immunotherapy is a potential treatment option for patients with proficient mismatch repair/microsatellite stable colorectal cancer. Preoperative screening via endoscopy and imaging examinations could help identify patients who may potentially achieve a complete response after neoadjuvant combination immunotherapy. This study aims to evaluate the diagnostic accuracy of endoscopic and imaging examinations in predicting pathological complete response after neoadjuvant combination immunotherapy.

Methods: This single-center, retrospective, observational study included patients diagnosed with colorectal cancer by biopsy between 2015 and 2023 at a tertiary referral center. The main outcome measures included endoscopic examination, imaging findings, and pathological results after neoadjuvant combination immunotherapy.

Results: This study included 36 patients with locally advanced proficient mismatch repair colorectal cancer. Postoperative pathology revealed that 17 patients (47.2%) achieved a complete response (ypT0N0). The sensitivity, specificity, and accuracy of the endoscopic ypT0N0 diagnosis were 62.5%, 80.0%, and 80.6%, respectively; those of imaging-based ypT0N0 diagnosis were 43.8%, 100%, and 75.0%, respectively; and those of the combined diagnosis were 37.5%, 100%, and 72.2%, respectively. The areas under the receiver-operating characteristic curve for the endoscopic and imaging ypT0N0 diagnoses were 0.768 and 0.706, respectively.

Conclusions: The specificities of endoscopy and imaging for diagnosing complete response after neoadjuvant combination immunotherapy for colorectal cancer were high; however, sensitivities were low. Therefore, radical surgery should still be recommended for patients with an incomplete response based on either examination. Larger scale studies are required to determine if a watch-and-wait strategy is suitable for patients with a complete response based on these two examinations.

Background: Inadequate bowel perfusion is among risk factors for colorectal anastomotic leaks. Perfusion can be assessed with indocyanine green fluorescence angiography (ICG) during colon resections. Possible benefits from its systematic use in high-risk patients with rectal cancer remain inconsistent. This study aimed to evaluate the surgical modifications induced by ICG assessment during rectal cancer surgery and associated anastomotic leaks.

Methods: This prospective before and after cohort study was conducted in a single Canadian high-volume colorectal surgery center. Eligible patients were undergoing a low anterior resection for rectal cancer below 15 cm from the anal margin. Stapled and handsewn coloanal anastomoses were included. The experimental group was recruited prospectively, undergoing surgery using fluorescence angiography with ICG. The control group was built retrospectively from consecutive patients who had been operated on without ICG, prior to its implementation.

Results: Each cohort included 113 patients. The use of ICG led to modifications from initial surgical plan in 10.6% of patients, with no occurrence of anastomotic leaks in this specific group. When comparing leak rates, using ICG seemed to be protective, but this could not be statistically proven, overall (13.3% vs. 6.2%, p = 0.07), nor for handsewn coloanal anastomoses (11.8% vs. 5.9%, p = 0.67). A lack of power could explain such non-significant results, especially with low overall anastomotic leak rates recorded.

Conclusion: ICG influenced ultimate proximal resection margin in a clinically relevant proportion of cases. It might be associated with reduced leak rates although not formally proven with this data. This technology is safe and easy to apply in high-volume colorectal centers.

Background: Anal fissure is one of the most painful anal conditions. Various management options are available, including topical nitrites, calcium channel blockers, botulinum toxin injection, and lateral internal sphincterotomy. This study aimed to assess the efficacy and safety of botulinum toxin A (BT) injection for the management of symptomatic chronic anal fissures by conducting a systematic review of the literature and meta-analysis of published randomized controlled trials (RCTs).

Methods: A systematic search was conducted using the Embase and Medline search platforms. The search identified 264 papers published from January 1974 to December 2023, 35 of which were RCTs. Meta-analysis was performed on the collected data with a random effects model using Freeman-Tukey arcsine-transformed proportions. A p value less than 0.05 was considered to indicate statistical significance. The I² test was used to assess heterogeneity.

Results: A total of 1532 patients were included. After data were pooled, 1117 patients out of 1532 (72.7%) demonstrated healing of the fissure after the first injection of BT (P < 0.001, I² = 86.6%). Subgroup analysis was performed on the basis of the follow-up period in months. Nine studies reported that a second BT injection was needed for patients who did not respond after the initial injection. Twenty-nine out of 38 patients (78.5%) responded to the second injection (p < 0.001, I² = 50.6%). Complications were observed in 88 out of 1532 patients (4.02%) (p < 0.001, I² = 60.2%).

Conclusion: BT injection is a safe treatment approach for chronic symptomatic anal fissures, typically associated with only minor, temporary complications. Evidence also supports the use of repeat injections for managing recurrent or persistent symptoms.

Background: Trends of stoma creation at index surgery for Crohn's disease (CD) in the biologics era has not been thoroughly investigated. This study aimed to assess the impact of increasing biologics use on stoma rates at index surgery of CD, as well as identifying risk factors for the creation and nonreversal of CD-related stoma.

Methods: In this single-center retrospective analysis, consecutive CD patients who underwent index bowel surgery from 2007 to 2021 were reviewed. The rates of diverting stoma formation and reversal were compared across different time periods, delineated by January 2019, as biologics [anti-tumor necrosis factor (anti-TNF)] were included in national health insurance coverage in China. Logistic regression models and Cox proportional hazards models were utilized to assess factors influencing stoma creation and its reversal, respectively.

Results: Among 1022 CD patients, 27.9% received a diverting stoma during index surgery. Despite increasing preoperative use of biologics, the incidence of stoma creation remained statistically unchanged pre- and post-2019 (29.5% versus 25.2%; P = 0.14). Factors contributing to stoma creation included colonic and perianal involvement, penetrating CD, poorer preoperative conditions, and preoperative steroid usage, but not preoperative biologics. Among diverted patients, 68.8% underwent successful bowel restoration, with the reversal rate significantly increasing from 63.0% before 2019 to 80.2% after 2019 (P < 0.01). Patients with postoperative use of immunomodulators and biologics were more likely to have the stoma closed, with a reversal rate of 90.0% for those receiving biologics compared with 64.0% for those not.

Conclusions: Increasing prevalence of biologics did not alter the stoma rates in CD patients. Additionally, postoperative biologics were independently associated with a higher probability of stoma reversal.

Background: Irritable bowel syndrome (IBS) is a very common condition worldwide. Treatment options for severe IBS are few. Sacral neuromodulation (SNM) for patients with IBS has been shown to reduce symptoms and improve quality of life in the medium term. This study aimed to evaluate the long-term effectiveness and safety of SNM in diarrhoea-predominant and mixed IBS.

Methods: A prospective cohort of patients with IBS treated with SNM were evaluated 1, 3, 5, and 10 years after implantation. The primary end-point was a change in the Gastrointestinal Symptom Rating Scale-Irritable Bowel Syndrome version questionnaire (GSRS-IBS) from baseline to 10-year follow-up (FU). Secondary end-points were change in the GSRS-IBS score from baseline to 5-year FU and change in the Irritable Bowel Syndrome-Impact Scale questionnaire (IBS-IS) from baseline to 5- and 10-year FU. Adverse events following SNM were observed.

Results: Of 36 patients treated with SNM, 23 were eligible for 5-year FU and 13 for 10-year FU. The GSRS-IBS score was significantly reduced at both 5-year (p < 0.0001) and 10-year (p = 0.0007) FU. The IBS-IS score was also significantly improved at both 5 years (p < 0.0001) and 10 years (p = 0.0002). Fifty-six adverse events were registered. Five patients were explanted because of adverse events.

Conclusion: SNM seems to offer an effective and safe treatment option for highly selected patients with diarrhoea-predominant and mixed IBS.

Clinical trial registration: The present study has not been registered. The latest founding study was registered at ClinicalTrials.gov, NCT01948973.

Background: Patients with rectal cancer often experience adverse effects on urinary, sexual, and digestive functions. Despite recognised impacts and available treatments, they are not fully integrated into follow-up protocols, thereby hindering appropriate interventions. The aim of the study was to discern the activities conducted in our routine clinical practice outside of clinical trials.

Methods: This multicentre, retrospective cohort study included consecutive patients undergoing rectal cancer surgery between January 2016 and January 2020 at six tertiary Spanish hospitals.

Results: A total of 787 patients were included. Two years post surgery, gastrointestinal evaluation was performed in 86% of patients. However, bowel movements per day were only recorded in 242 patients (46.4%), and the values of the Low Anterior Resection Syndrome (LARS) questionnaire were recorded in 106 patients (20.3%); 146 patients received a diagnosis of fecal incontinence (28.2%), while 124 patients were diagnosed with low anterior resection syndrome (23.8%). Urogenital evaluation was recorded in 21.1% of patients. Thirty-seven patients (5.1%) were detected to have urinary dysfunction, while 40 patients (5.5%) were detected to have sexual dysfunction. A total of 320 patients (43.9%) had their quality of life evaluated 2 years after surgery, and only 0.8% completed the Quality of Life questionnaire. Medication was the most used treatment for sequelae (26.9%) followed by referral to other specialists (15.1%).

Conclusions: There is a significant deficit in clinical follow-ups regarding the functional assessment of patients undergoing rectal cancer surgery. It is crucial to implement a postoperative functional follow-up protocol and to utilize technologies such as Patient-Reported Outcome Measures (PROMs) to enhance the evaluation and treatment of these sequelae, thereby ensuring an improved quality of life for patients.

Introduction: Anorectal melanoma (ARM) is rare and highly lethal neoplasm. It has a poorer prognosis compared with cutaneous ones. Sentinel lymph node biopsy (SLNB) has become the preferred method of nodal staging method for cutaneous melanoma. The role of SLNB for staging of anal melanoma remains unclear. This study investigates SLN identification and biopsy in patients with ARM.

Methods and patients: We present our experience of patients affected by ARM who underwent to SLNB. Clinical workup included digital rectal examination, anoscopy, rigid proctoscopy, total body (computed tomography) CT scan, pelvic magnetic resonance imaging (MRI), and fludeoxyglucose-18-positron emission tomography-CT (FDG-PET-CT) to obtain an adequate pretreatment staging of the patients. Wide local excision and contemporary SLNB were performed to remove primary neoplasm and detect inguinal lymph node metastases.

Results: In total, five female patients, median age 68 years, were included. All were affected by anal melanoma. Detection rate of SLNB was 100% and scintigraphic migration was unilateral in three patients and bilateral in the other two. Definitive inguinal histological exam revealed unilateral metastases in three patients, bilateral metastases in one case, and the presence of isolated neoplastic cells in the remaining case. SLNB allowed a diagnostic upgrading of inguinal metastases in three of five patients (60%), permitting better staging and further appropriate treatment.

Conclusions: Our experience demonstrates SLN biopsy is a minimally invasive, cost-effective, and rapid procedure for accurately staging patients with clinically occult disease. In fact, SLNB emerges as an appropriate procedural tool to identify patients with occult lymph node metastases who could undergo immune or target therapy, as well as to avoid unnecessary inguinal lymph node dissection for patients who would not benefit.

Background: Chronic anal fissures (CAFs) are the second most common anorectal disease. Non-surgical treatment includes several options with controversial efficacy. The aim of this study was to evaluate the efficacy and safety of a new ointment based on methylene blue in addition to glyceryl trinitrate.

Methods: A phase II randomized single-centre triple-blinded study was carried out in a tertiary proctology unit on patients with CAF. The enrollment started after local ethics committee approval (study n. 6461, protocol approval n. 0045085). Eligible consecutive patients were randomized to one of three different groups, each receiving a different ointment. The efficacy of the treatment was evaluated with the REALISE score.

Results: Nine patients were treated with cream A (median age 47 years, IQR 40-56, 22% female), nine with cream B (median age 52 years, IQR 49-57, 33% female), and nine with cream C (median age 58 years, IQR 46-62, 55% female). In group A, REALISE scores decreased significantly from a median of 22 (IQR 12-25) to 6 (IQR 4-8) (p < 0.05) after 40 days. In group B, REALISE scores improved significantly from a median of 20 (IQR 17-22) to 5 (IQR 4-9) (p < 0.05). In group C, REALISE scores decreased significantly from a median of 19 (IQR 19-20) to 4 (4-5) (p < 0.05). No statistically differences were recorded. The healing rate was 77% with creams A and C, while it was 44% with cream B.

Conclusion: Methylene blue-based ointments could be a new and innovative treatment for the non-operative management and healing of CAFs.