Techniques in Coloproctology最新文献

Background: The International Anorectal Physiology Working Group (IAPWG) suggests a standardized protocol to perform high-resolution anorectal manometry. The applicability and possible limitations of the IAPWG protocol in performing three-dimensional high-definition anorectal manometry (3D-ARM) have still to be extensively evaluated.

Methods: The IAPWG protocol was applied in performing 3D-ARM. Anorectal manometry (ARM) and a balloon expulsion test (BET) were performed according to IAPGW protocol in 290 patients.

Key results: A total of 84 males and 206 females (mean age 57.1 ± 15.7 years) were enrolled in six Italian centers. The reasons for which the patients were sent to perform 3D-ARM were: constipation (53.1%), fecal incontinence (26.9%), anal pain (3.1%), postsurgical (3.8%) and presurgical evaluation (4.8%), prolapse (3.4%), anal fissure (2.8%), and other (2.1%). Due to organic and functional conditions (low rectal anterior resections, rectal prolapses, and J-pouch after colectomy), we were unable to perform a complete 3D-ARM on six patients. Overall, a complete 3D-ARM and BET following IAPWG protocol was carried out in 284 patients (97.9%). The following were recorded: rest pressure (81.9 ± 32.0 mmHg) and length of the anal sphincter (37.0 ± 6.2 cm), maximum anal squeeze pressure (201.6 ± 81.3 mmHg), squeeze duration (22.0 ± 8.8 s), maximum rectal (48.7 ± 41.0 mmHg) and minimum anal pressure (73.3 ± 36.5 mmHg) during push, presence/absence of a dyssynergic pattern, cough reflex and rectal sensations (first constant sensation 48.4 ± 29.5 mL, desire to defecate 83.7 ± 52.1 mL, and maximum tolerated volume 149.5 ± 72.6 mL), and presence/absence of rectoanal inhibitory reflex. Mean 3D-ARM registration time was 14 min 7 s ± 3 min 12 s.

Conclusions: This is the first multicentric study that evaluates the applicability of the IAPWG protocol in 3D-ARM performed in different manometric laboratories (both gastroenterological and surgical). The IAPWG protocol was easy to perform and was not time consuming. A diagnosis according to the London Classification was easily obtained in most patients in which 3D-ARM was carried out. No clear limitations to the applicability of the IAPWG protocol were detected.

Background: This study aimed to compare clinical outcomes of patients with clinical stage III mucinous rectal adenocarcinoma (M) and non-mucinous rectal adenocarcinoma (NM) and evaluate the effectiveness of neoadjuvant chemoradiation. It was hypothesized that patients with M would fare worse with neoadjuvant chemoradiation than those with NM and that patients with M and NM not receiving chemoradiation would have similar outcomes. Moreover, it was hypothesized that patients with M would have similar outcomes regardless of chemoradiation.

Methods: This study compares eligible patients distributed in three cohorts: (cohort 1) M versus NM, including only patients treated with neoadjuvant chemoradiation; (cohort 2) M versus NM, including only patients treated without neoadjuvant chemoradiation; and (cohort 3) only M patients treated with versus without neoadjuvant chemoradiation.

Results: We identified 515 patients with an average age of 58.8 (SD 12.4) years, and 30% were female. Fifty-seven (11.1%) patients had M and 458 (88.9%) had NM. Neoadjuvant chemoradiation was administered to 382 (74%) patients, of whom 41 (10.7%) were M and 341 (89.3%) NM. In cohort 1, patients with M had advanced pathological staging (stage 3: M 68% vs. NM 42%; p < 0.001), worse pathological differentiation (poor: M, 37% vs. NM, 11%; p = 0.001), more involved lymph nodes (M 0 [0;7] vs. NM 0 [0;1]; p < 0.001) and a higher rate of local recurrence (M 22% vs. 3%; p < 0.001). Patients with M demonstrated worse 7-year cancer-specific (p = 0.007) and overall survival (p = 0.01). There were no significant differences in cohort 2 and 3.

Conclusion: Patients with clinical stage III mucinous adenocarcinomas may not benefit as much from standard neoadjuvant chemoradiation as their non-mucinous counterparts do.

Background: In patients with high BMI and cardiopulmonary disease, the specificity of the laparoscopic approach may be an obstacle to the use of minimally invasive surgery. The primary retroperitoneal approach may overcome some of the unfavorable aspects of laparoscopic surgery and provide new possibilities for minimally invasive treatments. In this report, we present right colon resection using a primary retroperitoneal approach, in a patient with adhesions caused by previous surgical interventions.

Methods: A single-port single-access system is placed in the right lateral region of the abdomen. Dissection was performed between Toldt's fascia and Gerota's fascia. Medial to the head of the pancreas, the posterior layer of the mesentery was dissected along the course of the superior mesenteric artery and the dissection continues caudally. The roots of the ileocolic vessels were identified, clipped and cut at their origin while the dissection of the D3 lymph node was carried out along the trunk of Gillot up to the origin of the middle colic artery.

Results: The right colonic resection with D3 lymph node dissection was performed with primary retroperitoneal approach. The duration of the surgery was 240 min, with blood loss up to 100 ml. The incidence of pain syndrome in the early postoperative period was low and the hospital stay lasted 7 days.

Conclusion: The primary retroperitoneal approach appears to be safe for the treatment of cecal colon cancer. The anatomical structures are accessible and easy to visualize, allowing for safe resection of the right colon with extended D3 lymph node dissection.

Introduction: Despite advantages for patients with ulcerative colitis, Crohn's disease, and familial adenomatous polyposis, restorative proctocolectomy with ileal pouch-anal anastomosis carries a risk of pouch failure, necessitating pouch excision. The traditional open approach is associated with potential complications. Robotic and laparoscopic techniques are emerging, but comparative outcome data are limited.

Methods: We conducted a retrospective study of consecutive adult patients undergoing robotic, laparoscopic, and open ileal pouch excision at Mayo Clinic, Rochester, MN, between January 2015 and December 2023. We analyzed data on patient characteristics, perioperative variables, and postoperative outcomes, focusing on short-term complications. Statistical analysis included appropriate tests.

Results: The study included 123 patients: 23 underwent robotic-assisted pouch excision, 12 laparoscopic, and 82 open. The robotic approach had the longest median operative time (334 ± 170 min, p = 0.03). However, it demonstrated significantly lower estimated blood loss than open (150 ± 200 ml vs. 350 ± 300 ml, p = 0.002) and laparoscopic surgery (250 ± 250 ml, p = 0.005). Robotic and laparoscopic groups required fewer preoperative ureteral stents than the open group (p = 0.001). Additionally, the robotic approach utilized fewer pelvic drainages (p < 0.0001) and had a lower rate of lysis of adhesions > 60 min compared to open surgery (p = 0.003). Robotic procedures had significantly lower 30-day postoperative complications than the open approach (30.4% vs. 65.9%, p = 0.002) while also demonstrating fewer 30-day reoperations than the laparoscopic group (p = 0.04).

Conclusions: Robotic-assisted pouch excision offered significant benefits, including decreased EBL, reduced need for preoperative ureteral stents, and significantly fewer 30-day postoperative complications compared to open surgery.

Background: Pelvic floor rehabilitation is common in patients with colorectal cancer, the purpose of this study is to analyze the role of pelvic floor rehabilitation in patients with colorectal cancer and to understand the specific details of pelvic floor rehabilitation intervention in patients with colorectal cancer.

Methods: Six databases were searched for this scoping review and reported according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for scoping reviews.

Results: A total of 1014 studies were searched, and 12 studies were finally included for analysis. The study found that pelvic floor rehabilitation for colorectal cancer patients can help improve bowel symptoms, quality of life, and psychological status of colorectal cancer patients after surgery, but details of the interventions for pelvic floor rehabilitation for colorectal cancer patients are not standardized.

Conclusions: Pelvic floor rehabilitation has shown positive significance in patients with colorectal cancer, but there is a lack of uniform standards in the process of pelvic floor rehabilitation intervention in patients with colorectal cancer.

Introduction: Anal fissure (AF) poses a common challenge in clinical practice, prompting various treatment approaches. This multicenter study, conducted by the Italian Society of Colorectal Surgery, aimed to assess treatment trends in AF over a 10 year period.

Methods: A survey of proctologists and retrospective analysis of patient records were conducted to evaluate treatment modalities and outcomes across six different clinical scenarios based on AF presentation (acute/chronic) stratified by sphincter function (normal/hypertonic/hypotonic).

Results: Analysis of data from 17 principal investigators and 22,016 patients revealed significant variability in treatment approaches, influenced by factors such as symptom duration, anal tone, and surgeon preference. Conservative treatments were commonly utilized, while surgical interventions were reserved for refractory cases. Specifically, pharmaceutical treatment was administered to 66-75% of patients in cases of acute AF and 63-67% for chronic AF, while 10-15% underwent anal dilation, and < 2% received botulinum toxin injection. Among medical treatments, nifedipine with lidocaine and glycerin film-forming ointments were the most utilized. The most performed surgical techniques were fissurectomy and anoplasty, except for patients with chronic AF and hypertonic sphincter where sphincterotomy prevailed. Trends in treatment utilization varied depending on the clinical scenario, with notable shifts observed over time.

Conclusions: This study provides insights into the evolving landscape of AF management, highlighting the need for further research to elucidate optimal treatment strategies and improve patient outcomes.

Background: Iatrogenic urinary injury (IUI) can lead to significant complications after colorectal surgery, especially when diagnosis is delayed. This study analyzes risk factors associated with IUI and delayed IUI among patients undergoing colorectal procedures.

Methods: Adults undergoing colorectal surgery between 2012 and 2021 were identified in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP^®) database. Multivariable regression analysis was used to determine risk factors and outcomes associated with IUI and delayed IUI.

Results: Among 566,036 patients, 5836 patients (1.0%) had IUI after colorectal surgery, of whom 236 (4.0%) had delayed IUI. Multiple preoperative risk factors for IUI and delayed IUI were identified, with disseminated cancer [adjusted odds ratio (aOR) 1.4, 95% confidence interval (CI) 1.2-1.5; p < 0.001] and diverticular disease [aOR 1.1, 95% CI 1.0-1.2; p = 0.009] correlated with IUI and increased body mass index [aOR 1.6, 95% CI 1.2-2.1; p = 0.003] and ascites [aOR 5.6, 95% CI 2.1-15.4; p = 0.001] associated with delayed IUI. Laparoscopic approach was associated with decreased risk of IUI [aOR 0.4, 95% CI 0.4-0.5; p < 0.001] and increased risk of delayed IUI [aOR 1.8, 95% CI 1.4-2.5; p < 0.001]. Both IUI and delayed IUI were associated with significant postoperative morbidity, with severe multiorgan complications seen in delayed IUI.

Conclusions: While IUI occurs infrequently in colorectal surgery, unrecognized injuries can complicate repair and cause other negative postoperative outcomes. Patients with complex intra-abdominal pathology are at increased risk of IUI, and patients with large body habitus undergoing laparoscopic procedures are at increased risk of delayed IUI.

Background: Diverticulitis is experiencing a significant increase in prevalence and its widespread in-hospital management results in a high burden on healthcare systems worldwide. This study compared inpatient and outpatient approach of acute non-complicated diverticulitis using a non-selected population in a real-world setting.

Methods: This observational retrospective study included all consecutive patients from two Portuguese institutions diagnosed between January 2017 and December 2021 with non-complicated diverticulitis according to the modified Hinchey Classification. The primary endpoints were to identify criteria for inpatient treatment and compare the outcomes on the basis of the treatment regimen. The secondary endpoints were to determine the predictive factors for clinical outcomes, focusing on treatment failure, pain recurrence, and the need for elective surgery following the initial episode.

Results: A total of 688 patients were included in this study, 437 treated as outpatients and 251 hospitalized. Inpatient management was significantly associated with higher preadmission American society of anesthesiologists (ASA) score (p = 0.004), fever (p = 0.030), leukocytosis (p < 0.001), and elevated C-reactive protein (CRP) (p < 0.001). No significant association was found between failure of conservative treatment and patient's age, ASA score, baseline CRP, presence of systemic inflammatory response syndrome (SIRS), and inpatient or outpatient treatment regimen. Pain recurrence was significantly associated with higher CRP levels (p = 0.049), inpatient treatment regime (p = 0.009) and post index episode mesalazine prescription (p = 0.006). Moreover, the need for elective surgery was significantly associated with the presence of previous episodes (p = 0.004) and pain recurrence (p < 0.001).

Conclusions: The majority of patients with uncomplicated diverticulitis of the left colon experience successful conservative approach and can be safely managed in an ambulatory setting. Neither treatment failure, recurrence of pain, or need for posterior elective surgery are associated with outpatient treatment regimen.