Techniques in Coloproctology最新文献

Background: Indocyanine green (ICG) lymphangiography for colon cancer has been regarded as a sentinel lymph node (LN) detection tool, but its repeatedly reported suboptimal sensitivity rates suggest that approach aiming to define locoregional lymphatic collector margins might be more efficient in guiding surgeon's decision making. Thus, present study was designed to determine if sensitivity of the latter approach is sufficient to guide resection margins' selection in colon cancer surgery.

Methods: This is a prospective, single-centre, single-arm phase II interventional trial, including patients with histologically confirmed colon adenocarcinoma. ICG was injected subserosally in the beginning of operation, fluorescence was assessed 30 min after injection or later, when it became detectable. Primary endpoint was proportion of pN + patients in whom all metastatic lymph nodes were located within the area of fluorescence of lymphatics (AFL). Secondary endpoints included feasibility, safety, lymphatic spread patterns and proportion of resections modified based on ICG mapping.

Results: Between 26 July 2022 and 27 February 2024, 101 patients underwent colectomies with intraoperative ICG lymphatic mapping. AFL was registered in all cases. Average lateral spread was 5.87 ± 3.20 proximally and 5.89 ± 2.54 cm distally. In two of 46 pN + cases affected LNs were discovered beyond AFL. ICG lymphatic mapping sensitivity was found to be 95.6%, which was beyond 0.960-0.990 interval, so null hypothesis was retained.

Conclusions: In this trial, metastatic LNs were confined within ICG AFL in 95.6% of pN + cases. Although the predefined sensitivity threshold was not met, the result suggests potential for ICG mapping to guide resection margins in colon cancer surgery.

The accurate localization of lateral pelvic nodes is essential for staging and surgical planning in rectal cancer. The objective of this article is to review existing radiologic and surgical definitions of the boundaries of lateral pelvic lymph node compartments on cross-sectional CT/MR images. In addition, we propose a simplified approach to facilitate the application of these boundaries to CT/MR images. We also discuss a few pitfalls in the localization of pelvic nodes in rectal cancer.

Background: Limited data exist on hospital costs incurred by anastomotic leakage (AL), particularly in relation to specific treatment approaches. This study aimed to analyse the incremental hospital costs of AL after total mesorectal excision (TME), stratified by treatment strategy, over a 1-year time horizon.

Methods: Patients undergoing total mesorectal excision (TME) for rectal cancer (2020-2023), included in the control cohort of the IMARI-study at 15 Dutch centres, were analysed. A cost analysis was conducted according to Dutch National Healthcare Institute guidelines. The primary outcome was the incremental hospital costs incurred by patients with AL detected within 30 days postoperatively, stratified by treatment strategy.

Results: The analysis compared treatment costs in 32 patients with AL and 82 patients without AL. The average hospital costs per patient in the first postoperative year were €15.312. In patients with AL, the mean incremental costs were €24.333. Major cost drivers in the AL group were prolonged hospitalization (+€13.150) and (re)interventions (+€8.910). The treatment costs differed significantly between strategies: no faecal diversion (€10.062), faecal diversion with passive drainage (€23.903), faecal diversion with active drainage (€35.552), and salvage surgery (€38.793).

Conclusions: AL after TME resulted in a nearly fourfold increase in hospital costs compared with patients without AL. Salvage surgery was the most expensive treatment strategy, followed by faecal diversion with active drainage. Future studies should evaluate how these treatment costs relate to clinical success rates, including rates of chronic pelvic sepsis and permanent stomas.

Trial registration: This study used data from the IMARI-study. The IMARI-study is registered with the Dutch Central Committee on Research Involving Human Subjects (NL67600.018.18) and is submitted to the http://www.onderzoekmetmensen.nl/en database (NL-OMON26456 and NL-OMON55903).

Background: Sigmoid resection is the preferred treatment for diverticular colovesical fistula. To prevent postoperative intra-abdominal urine leakage, an indwelling urinary catheter (IUC) is placed, with cystography sometimes performed before IUC removal. Given the absence of well-defined postoperative guidelines, this study investigates diagnostic yield of cystography and IUC use.

Methods: We conducted a single-center retrospective cohort study of patients who underwent elective sigmoid resection for diverticulitis (2010-2023). Patients with colovesical fistula were identified. Data on patient characteristics, operative details, complications, postoperative IUC duration, and cystography use were analyzed.

Results: Sigmoid resection was performed in 204 patients, 55 (27.0%) of whom had a colovesical fistula. Simple bladder repair was performed in 18 (32.7%) patients, while four (7.3%) patients underwent complex repair. The remaining 33 (60%) patients did not undergo vesical closure. All 55 patients retained an IUC postoperatively, of whom 37 (67.3%) underwent cystography before IUC removal. Cystography was normal in 34 (91.9%) patients. In three patients, extravesical contrast was observed, resolving with extended IUC duration (7, 14, and 14 days, respectively). In two of three cases, extravesical contrast occurred following complex bladder repair. Median IUC duration did not differ significantly between those with and without cystography (7 versus 6 days, p = 0.104). However, median hospital stay was significantly longer in patients with fistula compared to patients without fistula (5 versus 4 days, p = 0.040).

Conclusions: Postoperative cystography may not be necessary in patients with diverticular colovesical fistula without or after simple bladder repair. However, cystography should be considered if complex repair has been performed.

Trial registration number: 20231001, 28 November 2023.

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.