Techniques in Coloproctology最新文献

Introduction: Unhealed wounds and persistent perineal sinuses (PPS) may occur in as many as one third of patients after proctectomy for Crohn's disease. The management of these conditions remains a significant challenge, particularly in the context of inflammatory bowel disease (IBD), with existing therapies plagued by high failure rates. This systematic review of the literature assessed the efficacy of medical and surgical therapy for PPS closure in IBD. Secondary aims included review of classification systems used for PPS.

Methods: A literature search was conducted using Medline, Embase and Cochrane databases on 17 December 2024. The review was registered on PROSPERO (CRD42024622582). Inclusion criteria were adult patients with IBD and PPS or unhealed wounds following proctectomy. We excluded abstract-only publications, case reports, cancer and paediatric cohorts. Two reviewers independently screened abstracts and full texts and extracted data. The primary outcome was clinical healing rate. Secondary outcomes included classification systems used to describe PPS. Risk of bias was assessed.

Results: Of 496 records identified, following removal of duplicates, 489 abstracts were screened, and 60 full text articles assessed for eligibility. Of 25 articles included in the final analysis, 23 were case series or retrospective cohort studies, and all were at high risk of bias. No randomised controlled trials were identified. Five articles (including two of the case series) described classification systems for PPS. Interventions included hyperbaric oxygen therapy, Karydakis flap, cleft closure, omentoplasty, skin grafting, gracilis and rectus abdominis flap, platelet-derived growth factor, curettage, lay open and excision of sinuses. Reported healing rates ranged from 30% to 100%. Heterogeneity in the reporting of outcomes, as well as the interventions performed precluded meta-analysis.

Conclusion: The published evidence for treatment of PPS in IBD consists of low-quality evidence case series with high risk of bias. There is a need for standardised outcome reporting and high-quality, prospective studies to establish effective treatment algorithms.

Background: Transsphincteric anal fistula is a common and challenging diagnosis for patients and surgeons alike. Ligation of the intersphincteric fistula tract (LIFT) following non-cutting seton placement represents an established definitive treatment with many technical variations. Unfortunately, up to 53% of attempted LIFTs fail. We aim to describe a modified LIFT approach and evaluate outcomes at our institution.

Methods: Thirty-two patients from 2021 to 2024 underwent the modified LIFT approach which included the offsetting of the transected fistula ends with interposing muscle plication, along with closure of the internal opening, and wide excision of the external opening. Retrospective chart review was performed to assess rates of primary wound healing, complications, recurrence, and incontinence. Recurrences were grouped into three types: type I, sinus tract or recurrent abscess without an internal opening; type II, conversion to an intersphincteric fistula; and type III, transsphincteric recurrence.

Results: The majority of patients were male (69%) with a mean age of 44 years and mean BMI 31.6 kg/m². Median operative time was 88 min. Primary healing rate was 94%. Median healing period was 7 (range 4-16) weeks. Of the 10 recurrences, (5 type I, 5 type II, and 0 type III), median time to recurrence was 6 months after the primary wound healed. No patients experienced any postoperative incontinence or urinary retention.

Conclusions: In this cohort of patients with transsphincteric fistulas undergoing the LIFT procedure, the addition of offsetting muscle plication effectively limited transsphincteric recurrence. Further investigation is warranted to directly compare this LIFT adaptation to previously published literature.

Background and study aim: Endoscopic intermuscular dissection (EID) is an emerging technique for resecting early rectal cancer with deep submucosal infiltration. This study reports the short-term outcomes of EID for early rectal cancer from a single-center experience in China.

Patients and methods: Between January 2024 and March 2025, 12 patients diagnosed with rectal malignant tumors, with CT staging ≤ T2 and no lymph node metastasis underwent EID. For lesions staged as cT2, endoscopic ultrasound confirmation of no muscularis propria invasion was required prior to EID for therapeutic resection at our center. All patients were evaluated by a multidisciplinary team and provided informed consent. The primary outcomes included technical success (defined as macroscopic complete en bloc resection without major intraprocedural complications), postoperative complications, and tumor-free resection margins. Secondary outcomes included hospital stay duration, follow-up completion rates, and short-term oncological outcomes.

Results: Technical success was achieved in 11 of 12 patients (91.7%), with one patient experiencing an intraprocedural perforation. En bloc resection margins were confirmed histopathologically in all cases. One patient (8.3%) experienced delayed perforation requiring additional surgery. All lesions were confirmed as pT1b adenocarcinoma on final pathology. Among patients who reached follow-up timepoints, 6-month follow-up completion was 100% (9/9 eligible patients) and 12-month follow-up completion was 50.0% (2/4 eligible patients). No tumor recurrence was observed in patients with available follow-up data during a median follow-up of 9 months (range 3-16 months).

Conclusion: This preliminary single-center experience suggests that EID may be a feasible technique for carefully selected cases of resecting early rectal cancer with deep submucosal infiltration, demonstrating acceptable rates of complete resection and reasonable short-term safety profiles. However, the small sample size, staging limitations, and short follow-up period mean that these findings require cautious interpretation. Larger multicenter studies with extended follow-up periods are necessary to establish the role of EID in the treatment algorithm for early rectal cancer.

Background: In the Netherlands, approximately 15% of patients with rectal cancer undergo a low Hartmann's procedure (low-HP). This is often preoperatively planned to avoid poor functional outcome or complications, but might be unplanned as a result of intraoperative difficulties. Low-HPs seem to be associated with worse oncological outcomes.

Methods: All patients who underwent either restorative low anterior resection (rLAR), planned low-HP, or unplanned low-HP for primary rectal cancer in 2016 were included from a nationwide cohort. Main outcomes were 4-year local recurrence (LR) rate and disease-free survival (DFS).

Results: Of 2043 patients, 1704 underwent rLAR (83.4%), 253 planned low-HP (12.4%), and 86 unplanned low-HP (4.2%). Among intended rLAR patients (n = 1790), independent risk factors for unplanned low-HP were older age, higher body mass index (BMI), higher American Society of Anesthesiologists (ASA) score, and more distal tumor location. Oncological outcomes after low-HPs were worse than after rLARs (LR 13.7% vs 5.6%, DFS 54.7% vs 71.8%, both p < 0.001), but similar for unplanned and planned low-HP. In multivariable analysis, unplanned and planned low-HP were not associated with LR or DFS, but R1 resection was (HR 6.6 (4.1-10.6), HR 3.0 (2.2-4.0), respectively). In R1 resections, the distal margin was more often involved after low-HP (70.0% vs 28.6%, p = 0.013) compared to rLAR.

Conclusion: Poor outcomes in univariable analysis after low-HP appear to be associated with more challenging procedures and increased risk of involved resection margin rather than the low-HP itself. In case of expected difficulties, an extralevator abdominoperineal excision or referral to an expert center might be an alternative to improve resection margins.

Trial registration: ClinicalTrials.gov, identifier NCT05539417, retrospectively registered on September 16, 2022.

Background: Chronic anal fissures in patients with Crohn's disease (CD) remain a significant therapeutic challenge, particularly when linked to active perianal disease. Conventional treatments often fail, highlighting the need for alternative approaches. This study explores the efficacy and safety of freshly collected autologous adipose tissue injection (AATI) for treating chronic fissures in patients with CD.

Methods: Nine patients with CD with anal fissures were included. The primary outcome was complete healing (CH) at 3 months after last AATI, defined as full fissure re-epithelialization and complete pain relief. Secondary outcomes included changes in defecation pain (visual analog scale [VAS]), anal discomfort (VAS), Perianal Disease Activity Index (PDAI), and St. Mark's Incontinence Score (SMIS).

Results: Five patients (56%) achieved CH after one (n = 4) or two (n = 1) AATI. Partial healing was observed in four patients (44%). Defecation pain improved from a VAS score of 7.5 (IQR 5.0-8.5) to 2.75 (0.0-4.5; p = 0.009), anal discomfort from VAS score of median 5.0 (2.5-6.5) to 1.0 (0.0-2.5; p = 0.014), PDAI from 5.0 (3.0-6.0) to 1.0 (1.0-2.0; p = 0.022), and SMIS from 7.0 (4.0-9.0) to 4.0 (0.0-4.0; p = 0.041). No treatment-related complications occurred.

Conclusion: AATI may be a promising new treatment of chronic anal fissures in patients with CD. Effects of AATI should be explored further in controlled trials.

Background: The purpose of this study was to compare the perioperative efficacy and safety of neoadjuvant chemoradiotherapy (NCRT) alone versus short-course radiotherapy combined with immunochemotherapy (SCRT + ICT) in patients with proficient mismatch repair (pMMR) rectal cancer.

Methods: This study was designed as a single-center, retrospective, case-matched analysis conducted at a tertiary referral center. The patient cohort consisted of individuals diagnosed with pMMR rectal cancer between 2022 and 2024. The main outcome measures evaluated were pathological complete response (pCR) rate, anus preservation rate, neoadjuvant therapy-related adverse events, and surgery-related complications.

Results: In the final analysis, 46 pairs of patients were included. The SCRT + ICT group had a significantly higher pathological complete response (pCR) rate (47.8% versus 10.9%, P < 0.001) and anus preservation rate (84.8% versus 37.0%, P < 0.001), but also a higher temporary stoma rate (76.1% versus 21.7%, P < 0.001). Both groups achieved a 100% R0 resection rate. Regarding safety, the combined therapy group had lower intraoperative blood loss (20 ml versus 50 ml, P < 0.001) and shorter postoperative hospital stay (6 days versus 8 days, P < 0.001). Adverse events and postoperative complications were similar in both groups. Additionally, logistic regression analysis showed that SCRT + ICT is a protective factor for achieving postoperative pCR, while intraoperative blood loss ≥ 50 ml and elevated pretreatment carcinoembryonic antigen (CEA) levels are risk factors for postoperative pCR.

Conclusions: Short-course radiotherapy combined with immunochemotherapy is safe and effective for patients with pMMR rectal cancer.

Background: The incidence of acute appendicitis in older patients significantly varies from that in younger adults. The coronavirus disease 2019 (COVID-19) pandemic has increased the risk of early post-appendectomy complications (EPAC). This study aimed to investigate the incidence and risk factors associated with EPAC in older patients after appendectomy and to define active COVID-19 infection during surgery as an associated risk factor for EPAC.

Methods: We conducted a retrospective multicenter analysis of older patients aged ≥ 60 years who underwent appendectomy between April 2020 and December 2024. Logistic regression identified the risk factors associated with EPAC.

Results: A total of 585 patients aged ≥ 60 years were divided into the EPAC (n = 32) and no EPAC (n = 553) groups. The incidences of EPAC was 5.5% (32/585), including superficial incisional surgical site infections (SSI) (9/32, 28.1%), deep incisional SSI (2/32, 6.3%), organ/space infection (2/32, 6.3%), intra-abdominal abscess (9/32, 28.1%), ileus (2/32, 6.3%), pneumonia (3/32, 9.4%), acute myocardial infraction (MI) (2/32, 6.3%), fecal fistula (2/32, 6.3%), and acute adhesive intestinal obstruction (1/32, 3.1%). Multivariable analysis identified that active COVID-19 infection during surgery (odds ratio (OR) = 25.9; 95% confidence interval (CI) 4.8-139.1; p < 0.001), American Society of Anesthesiologists (ASA) score ≥ II (OR = 4.5; 95% CI 1.2-17.07; p = 0.02), open approach (OR = 30.6; 95% CI 8.1-115.3; p < 0.001), and high-grade appendicitis ≥ IV (OR = 63.06; 95% CI 7.5-526.4; p < 0.001) were significant associated risk factors for EPAC.

Conclusions: The incidence of EPAC in older patients after appendectomy is 5.5%. Active COVID-19 infection during surgery is strongly associated with an increased risk of EPAC. COVID-19 should be considered in perioperative risk assessment of EPAC.

Trial registration: This study was registered as a clinical trial (NCT06787573). Retrospectively registered.