Techniques in Coloproctology最新文献

Background: Pelvic anatomy is a complex network of organs that varies between individuals. Understanding the anatomy of individual patients is crucial for precise rectal cancer surgeries. Therefore, developing technology that can allow visualization of anatomy before surgery is necessary. This study aims to develop an auto-segmentation model of pelvic structures using AI technology and to evaluate the accuracy of the model toward preoperative anatomical understanding.

Methods: Data were collected from 63 male patients who underwent 3D MRI during a preoperative examination for colorectal and urogenital diseases between November 2015 and July 2019 and from 11 healthy male volunteers. Eleven organs and tissues were segmented. The model was developed using a threefold cross-validation process with a total of 59 cases as development data. The accuracy was evaluated with the separately prepared test data using dice similarity coefficient (DSC), true positive rate (TPR), and positive predictive value (PPV) by comparing AI-segmented data with manual-segmented data.

Results: The highest value of DSC, TPR, and PPV were 0.927, 0.909, and 0.948 for the internal anal sphincter (including the rectum), respectively. On the other hand, the lowest values were 0.384, 0.772, and 0.263 for the superficial transverse perineal muscle, respectively. While there were differences among organs, the overall quality of automatic segmentation was maintained in our model, suggesting that the morphological characteristics of the organs may influence the accuracy.

Conclusions: We developed an auto-segmentation model that can independently delineate soft-tissue structures in the male pelvis using 3D T2-weighted MRIs, providing valuable assistance to doctors in understanding pelvic anatomy.

Background: Endoscopic submucosal dissection (ESD) has emerged as an effective technique for the en bloc and curative removal of sizable colorectal tumors. Despite ESD's advantages over traditional surgery, its primary associated complications of perforation and hemorrhage pose significant challenges. Sedation-free ESD allows for real-time reporting of symptoms by patients, improving the identification and management of complications. This study aimed to evaluate the safety of sedation-free ESD.

Methods: A retrospective cohort study included patients undergoing sedation-free ESD for colorectal lesions at a tertiary center in Taiwan from 2018 to 2023. Patient demographics, lesion characteristics, procedure time, and clinical outcomes were collected. The primary outcome was safety as assessed via intraoperative complications (e.g., perforation or hemorrhage) and overall complication rates. Additional analyses included factors associated with perforation and management strategies (i.e., endoclips or surgical intervention) using univariate and multivariable logistic regression analyses.

Results: A total of 134 patients were included in the study. The mean patient age was 65.3 years, with an average lesion size of 3.6 ± 1.5 cm. ESD-associated perforation or hemorrhage occurred in 6.7% and 10.4% of cases, respectively, most of which were successfully managed with endoclips. Patients with hemorrhage-compared with those without-had significantly larger lesions (median: 4.7 cm versus 3 cm, p = 0.004). Multivariable analysis revealed no statistically significant associations between lesion characteristics and perforation. No delayed perforations were reported.

Conclusions: Sedation-free ESD is a safe alternative to traditional sedated ESD for colorectal lesions. Real-time symptom reporting by patients enhances management of complications. In addition, precision application of endoclips ensures optimal perforation and hemorrhage control, improving patient outcomes and safety.

Background: The aim of this study was to identify patients at risk of Crohn's disease (CD) when presenting with perianal disease and to prospectively identify clinical characteristics ('red flags') associated with CD.

Methods: All consecutive patients ≥ 16 years presenting with a perianal abscess (PAA)/fistula (PAF) between January and December 2022 were prospectively included. Faecal calprotectin (FCP) was measured in all patients, and patients were screened for potential red flags associated with CD by the use of a perianal red flags index (pRFI)-questionnaire. Colonoscopy was performed when FCP ≥ 150 mcg/g.

Results: Overall, 115 patients were included (median age 38 years; IQR 28-53), 55 with PAA (48%) and 60 with PAF (52%). In total, 19 patients had FCP levels ≥ 150 mcg/g (median 381 mcg/g; IQR 191-1040), and were referred for colonoscopy, of which 10 were diagnosed with CD (9% of all patients; 17% of patients with PAF). Of all patients with PAF < 40 years, 29% were diagnosed with CD (9/31). During a minimal follow-up of 2 years, two colonoscopies were performed in patients with clinical suspicion for CD, demonstrating CD in 1 patient, resulting in a total of 11/115 patients with CD (10%), all presenting with PAF (18% of all patients with PAF). Univariate analysis showed that young age (< 40 years; odds ratio [OR] 4.9; 95% confidence interval [CI] 1.0-23.6), abdominal pains (OR 4.8; 95% CI 1.2-19.1), rectal bleeding (OR 4.3; 95% CI 1.2-15.6), fatigue (OR 3.9; 95% CI 1.1-14.4), multiple external (OR 6.0; 95% CI 1.5-24.6)/internal fistula openings (OR 61.2; 95% CI 9.8-383.4), fissures (OR 4.4; 95% CI 1.1-17.2), and proctitis (OR 22.9; 95% CI 1.9-277.5) increased the likelihood of having CD.

Conclusion: With FCP-based screening for CD, approximately one in six patients with PAF, and even one in three patients with PAF < 40 years were diagnosed with CD. Therefore, FCP measurement is suggested in all patients with PAF, especially when they are < 40 years.

Background: The appendix, as a component of the digestive system, plays a role in intestinal immunity.

Objective: To investigate the association between appendectomy history and disease phenotype/progression in Crohn's disease patients.

Design: Two cohorts from a single center.

Patients: Patients with Crohn's disease diagnosed between 2011 and 2021, including those without surgery and those undergoing their first surgery for Crohn's disease.

Methods: Patients were divided into surgical and non-surgical cohorts, each further split into appendectomy and non-appendectomy groups.

Results: In the non-surgical cohort, significant phenotypic disparities were observed between appendectomy-only and non-appendectomy groups across Montreal classification parameters, including age (p < 0.001), location (p = 0.03), and behavior (p = 0.01), with reduced perianal lesion prevalence in appendectomy patients (15% (9/60) vs. 35.7% (162/454), p = 0.001). Appendectomy patients exhibited later disease onset (IQR36 vs. 24 years, p < 0.001) and diagnosis (IQR37 vs. 26 years, p < 0.001). In the surgical cohort, significant differences emerged among non-appendectomy, appendectomy-only, and ileocecal resection groups in Montreal classification parameters: age at diagnosis (p = 0.014), location (p < 0.001), and behavior (p = 0.003). Disease progression timelines differed markedly, with later onset (IQR 29 vs. 27 vs. 25 years, p < 0.001), diagnosis (IQR 31 vs. 30 vs. 27 years, p < 0.001), and surgery (IQR 35 vs. 33 vs. 31 years, p < 0.001) observed in appendectomy-only patients. Surgical management varied significantly, including diagnosis-to-surgery intervals (mean 3.4 vs. 2.6 vs. 3.7 years, p < 0.001), perianal lesion (29.3% (123/420) vs. 24.4% (39/160) vs. 35.3% (173/490), p = 0.02), and one-stage surgery (36.2% (152/420) vs. 75.6% (120/160) vs. 66.1% (324/490), p < 0.001).

Limitations: Retrospective analysis with potential data biases.

Conclusion: Despite notable differences in disease phenotype, appendectomy does not seem to influence the clinical course of Crohn's disease. However, it seems to be associated with the lower risk of perianal disease and alleviates the severity of their condition.

Background: Parastomal hernia (PSH), a common ostomy complication, significantly impairs patient quality of life. Various prophylactic strategies, including surgical (mesh reinforcement) and non-surgical (abdominal wall strengthening exercises, AWSE) interventions, have been proposed, but their comparative effectiveness is unclear. This network meta-analysis primarily assessed PSH incidence.

Methods: Following PRISMA guidelines, we conducted a systematic review and network meta-analysis. Searches in PubMed, Embase and Web of Science identified randomised controlled trials (RCTs) and observational studies comparing prophylactic PSH prevention strategies. Data on PSH incidence were extracted. Network meta-analysis estimated odds ratios (ORs) and 95% confidence intervals (CIs). Effectiveness was determined by PSH incidence reduction, comparing all prophylactic interventions against a transrectal colostomy control group. Interventions were ranked using surface under the cumulative ranking curve probabilities.

Results: The analysis included 73 studies (30 RCTs, 44 observational; 7473 patients). Funnel mesh was the most effective intervention (OR 0.09, 95% CI 0.05-0.17), followed by Stapled Mesh stomA Reinforcement Technique (SMART) (OR 0.16, 95% CI 0.05-0.48) and AWSE (OR 0.18, 95% CI 0.08-0.39). Subgroup analyses confirmed consistency in findings across study designs but highlighted variability in ileal conduits due to limited data. Heterogeneity was moderate (τ² = 0.21, I² = 36.1%).

Conclusions: Funnel mesh could be the most effective measure for high-risk patients, while extraperitoneal colostomy (ES) and AWSE may be a practical and scalable alternative. Further high-quality RCTs are needed to validate these findings and refine clinical guidelines for PSH prevention.

Background: Perineal wound complications after abdominoperineal resection (APR) for anal or low rectal cancer remain a significant clinical concern, frequently leading to surgical site infections (SSIs), wound dehiscence, and delayed healing. These complications contribute to increased patient morbidity, prolonged hospitalization, and higher healthcare costs. Prophylactic negative pressure wound therapy (pNPWT) has been proposed to improve wound outcomes in this context, but evidence regarding its effectiveness remains inconclusive.

Objective: This systematic review evaluates the clinical outcomes and technical application of pNPWT in closed perineal wounds following APR, with a focus on its potential impact on SSIs, wound dehiscence, and healing time.

Methods: A systematic literature search was conducted in MEDLINE, Embase, and the Cochrane Library in accordance with PRISMA guidelines. Eligible studies included randomized controlled trials and observational studies assessing pNPWT after APR. Key outcomes of interest were SSI rates, wound dehiscence, healing time, and length of hospital stay. Due to clinical and methodological heterogeneity, a narrative synthesis was performed.

Results: In total, eight studies met the inclusion criteria. The results were heterogeneous: while three studies reported reduced SSI rates with pNPWT compared with conventional wound management, two studies observed higher SSI rates in the pNPWT groups. Variability in device type (canister-based versus portable systems), negative pressure settings, application duration, and patient selection limited the comparability across studies. The risk of bias was moderate to high in several studies, and outcome reporting was inconsistent.

Conclusions: Current evidence does not allow for definitive conclusions regarding the clinical benefit of pNPWT after APR. While some studies suggest potential advantages, particularly in terms of SSI reduction, results remain inconsistent and device-dependent. Further high-quality randomized trials are required to clarify the role of pNPWT and to define optimal application protocols in this challenging surgical context.

Background: Lymphadenectomy in right-sided colon cancer lacks standardized reporting. The aim was to develop a visual analogue scale (VAS) based on mesenteric vessels to describe the extent of lymphadenectomy.

Methods: We included patients undergoing surgery for right-sided colon cancer from January 2021 to September 2024. Data were collected via a web-based database. Immediately after surgery, surgeons recorded the VAS score, vascular visualization, and specimen quality.

Results: Data from 155 patients were analyzed. Median age was 74 (IQR: 68-80), with 53% female. The median VAS score was 8.2 (IQR: 7.8-8.9). The superior mesenteric vein (SMV) was visualized in 84% of cases, with a median VAS score of 8.4 (IQR: 8.0-9.2) for visualized and 7.0 (IQR: 6.8-7.5) for non-visualized (p < 0.001). The gastrocolic trunk of Henle (GTH) was visualized in 51%, with a median VAS score of 8.7 (IQR: 8.3-9.7) for visualized and 7.9 (IQR: 7.3-8.0) for non-visualized (p < 0.001). Specimen quality was Type 0 (best) in 54% (VAS score 8.6, IQR: 8.2-9.5), Type I in 37% (VAS score 7.9, IQR: 7.3-8.0), and Type II in 6% (VAS score 6.9, IQR: 6.5-7.9; p < 0.001). A positive correlation between VAS score and lymph node count was found (r = 0.43, p < 0.001).

Conclusions: The VAS score is a reliable and feasible method to describe lymphadenectomy in right-sided colon cancer. Unlike categorical classifications, the VAS score is based on anatomical landmarks and does not depend on consensus definitions. It reflects the visualization of vascular structures and correlates with specimen quality and lymph node yield.

Clinical trial: ClinicalTrials.gov Identifier NCT06329102 (registered on March 24, 2024).

Article type: Prospective observational study.

Background: Neoadjuvant chemoradiotherapy (nCRT) is key for low rectal cancer but raises the risk of anastomotic leakage (AL). This study examines how fluorescence laparoscopic (FL) surgery reduces AL after intersphincteric resection (ISR), especially in nCRT patients.

Methods: This real-world multicenter cohort study included 533 patients undergoing laparoscopic ISR for ultra-low rectal adenocarcinoma from January 2012 to July 2023. Patients were categorized into FL and non-FL groups. Propensity score matching (PSM) was used at a 1:2 ratio to adjust for baseline differences. The primary endpoint was the incidence of AL within 6 months postoperatively. Secondary endpoints included anastomotic site perfusion, intraoperative blood loss, lymph node retrieval, perioperative complications, and postoperative recovery metrics. Subgroup analyses were conducted on the basis of nCRT status.

Results: After PSM, 393 patients were analyzed (131 FL versus 262 non-FL). The FL group showed a significantly lower AL incidence (3.1% versus 11.5%, P = 0.005), with fewer severe symptomatic AL cases (0.8% versus 6.1%, P = 0.014). Intraoperative blood loss was reduced (45.2 ± 58.9 mL versus 65.3 ± 73.1 mL, P = 0.004), and lymph node yield was higher (21.2 ± 11.4 versus 16.6 ± 7.3, P < 0.001) in the FL group. Postoperative recovery was accelerated, with earlier return of bowel function and shorter hospital stays (9.5 ± 3.1 versus 10.7 ± 3.8 days, P = 0.012). In subgroup analyses, FL significantly reduced AL rates in patients without nCRT (1.9% versus 7.2%, P = 0.045) and demonstrated a strong trend toward reduction in AL for patients receiving nCRT (13.0% versus 35.9%, P = 0.051). FL also increased the proportion of patients achieving benchmark lymph node retrieval, including those post-nCRT.

Conclusions: Fluorescence-guided laparoscopic surgery reduces anastomotic leakage and improves outcomes in low rectal cancer, especially after chemoradiotherapy, by enhancing surgical precision and recovery.

Background: Total mesorectal excision (TME) remains the oncologic standard for rectal cancer surgery; however, technical challenges persist in the minimally invasive treatment of low rectal cancer. Transanal TME (TaTME) and robotic TME were developed to overcome the limitations of laparoscopic TME in confined pelvic spaces. Despite promising results, comparative evidence among these approaches remains limited and heterogeneous. To address this gap, we conducted a propensity score-matched analysis to evaluate and compare the clinical and oncologic outcomes of TaTME, robotic TME, and laparoscopic TME in patients with rectal cancer treated at a high-volume tertiary center.

Methods: This retrospective study included patients with rectal cancer who underwent restorative proctectomy between 2015 and 2021. Propensity score matching was used to balance demographic, clinical, and treatment variables across the three groups. Outcomes were analyzed using standard statistical methods.

Results: After matching, 240 patients were included (40 TaTME, 40 robotic TME, and 160 laparoscopic TME). TaTME and robotic TME demonstrated significantly lower overall complication rates than laparoscopic TME (27.5% versus 20.0% versus 39.4%, p = 0.033). The circumferential resection margin positivity rate was highest in the laparoscopic group (10.6% versus 0% versus 2.5%, p = 0.031). However, 5-year overall survival (82.5% versus 85.0% versus 88.1%, p = 0.251), disease-free survival (75.0% versus 72.5% versus 73.8%, p = 0.772), local recurrence (17.5% versus 12.5% versus 24.7%, p = 0.488), and distal metastasis (17.5% versus 22.5% versus 25.2%, p = 0.694) did not significantly differ among groups.

Conclusions: All three minimally invasive TME techniques achieved comparable long-term oncologic outcomes. Surgical approach should be tailored on the basis of surgeon expertise and patient-specific factors.