Techniques in Coloproctology最新文献

Aim: Despite the potential benefits of abdominoperineal pull-through with delayed coloanal anastomosis (DCAA), it is still infrequently performed as a salvage procedure for pelvic anastomotic failure. We aimed to perform a systematic review on the subject to guide practice.

Method: PubMed, Embase and Cochrane were used to identify studies evaluating DCAA for salvage after pelvic surgery from inception to August 2024. Risk of bias assessment was performed using the Newcastle-Ottawa scale. The primary outcome was overall stoma-free survival. Secondary outcomes included hospital length of stay, high-grade postoperative complication rates, 30-day postoperative mortality rates, incidence of redo surgical intervention after DCAA, and postoperative anorectal function.

Results: Five retrospective cohort studies evaluating a total of 97 patients who underwent salvage abdominoperineal pull-through and DCAA were included in this review. All patients had previous pelvic surgery, predominantly proctectomy (n = 84, 86.6%). The most common indication for redo surgery was chronic fistula (n = 62, 63.9%) followed by anastomotic leak or chronic pelvic sepsis (n = 34, 35.1%). The pooled overall stoma-free survival rate across all five studies was 81.4% over a mean 24-month postoperative follow-up duration. The overall incidence of high-grade complications after DCAA was 39.1% (n = 38). Pooled mean length of stay was 17 days. There were no cases of early postoperative death. Pooled rate of repeat surgery across four studies was 11.6% (n = 8). Pooled mean functional scores across three studies indicated minor low anterior resection syndrome at 26 months.

Conclusion: Abdominoperineal pull-through with delayed coloanal anastomosis is a viable option for salvage surgery following pelvic anastomotic complications, with low rates of permanent stoma and acceptable long-term anorectal function.

Background: Increasing participation in anal intercourse (AI) raises questions about its effects on the female anus. Societal change has moved faster than published literature.

Method: Online survey of Association of Coloproctology of Great Britian & Ireland (ACPGBI) and Association of Surgeons of Great Britain & Ireland (ASGBI) members to document clinical practice regarding female AI; opinion on female AI in causation of anal pathology; barriers to discussing AI; possible harms and harm reduction and public information.

Results: 91% of consultant colorectal surgeons (CCS) agree female AI causes anal fissures. Only 25% usually or always ask young women with fissures about AI and 31% never ask. Enquiry increases with refractory fissures (34%) and vulnerable patients (57%); 48% of CCS cite fear of patient discomfort, and 40% fear what the patient thinks of them as barriers to enquiry. Eighty per cent of CCS and 85% of pelvic floor specialists (PFS) agree AI can cause internal anal sphincter (IAS) damage and 72% and 78% faecal incontinence (FI) in women. Eleven per cent of CCS and no PFS agreed relaxation techniques, and 17% and 14% lubrication, protect the IAS; 97% of CCS think there should be increased public health awareness about female AI.

Conclusions: Experts think participation in AI can cause fissures, IAS damage and FI in women. They are sceptical about the protective value of lubrication and relaxation. Clinical conversations lag behind experts' opinions on the importance and possible consequences of female AI. Concern over patients' feelings are barriers to enquiry. Colorectal specialists think there should be more public health information about female AI.

Background: The therapeutic value of transanal irrigation (TAI) for low anterior resection syndrome (LARS) has not been fully confirmed. This study aims to evaluate the efficiency of TAI in improving bowel function and quality of life (QoL) following sphincter-preserving resections (SPRs) for rectal cancer through a systematic review and meta-analysis of randomized controlled trials (RCTs).

Methods: The protocol was registered in PROSPERO (CRD42024598219). PubMed, Embase, Web of Science, Cochrane Library, CNKI, and WanFang databases were systematically searched for RCTs comparing TAI with conservative treatments for LARS published before December 2024. Outcomes included pooled risk ratios (RRs) for dichotomous variables and weighted mean differences (WMDs) for continuous variables, calculated using Review Manager 5.4.1 with 95% confidence intervals (CIs). P < 0.05 was considered statistically significant. The I² test was used to assess heterogeneity.

Results: Among 123 initially identified studies, six RCTs involving 317 patients were included. Meta-analysis demonstrated that the TAI group exhibited significantly lower LARS scores (WMD = -10.35, 95% CI [-15.92, -4.78], P < 0.01). The TAI group demonstrated significantly better outcomes across all five LARS subscales compared to controls, including flatus incontinence (WMD = -0.92; 95% CI [-1.30, -0.54]; P < 0.01), liquid stool incontinence (WMD = -0.83; 95% CI [-1.07, -0.59]), frequency (WMD = -1.33; 95% CI [-1.95, -0.72]; P < 0.01), stool clustering (WMD = -4.89; 95% CI [-5.90, -3.88]), and urgency (WMD = -5.35; 95% CI [-7.12, -3.58]). There was also a significant difference in Wexner score (WMD = -2.78, 95% CI [-4.13, -1.42], P < 0.01). However, no significant differences were observed in SF-36 mental (WMD = 7.27, 95% CI [-1.61,16.15], P = 0.11) or physical component scores (WMD = 6.97, 95% CI [-1.26,15.19], P = 0.10). Heterogeneity was substantial for LARS score analysis (I² = 86%) but resolved in subgroup analyses.

Conclusion: TAI significantly improves bowel function in patients with LARS, as evidenced by reduced LARS and Wexner scores. However, its impact on QoL remains inconclusive. Large-scale RCTs with extended follow-up periods are warranted to validate long-term clinical benefits.

Background: Pelvic intraoperative neuromonitoring (pIONM) prevents functional disturbances after low anterior rectal resection. We investigated the workload of performing pIONM under telementoring conditions to catalyze translation into surgical practice.

Methods: Six patients with rectal cancer underwent nerve-sparing total mesorectal excision (TME) with laparoscopic or robot-guided pIONM. A telementoring system enables cross-reality interaction, with online communication between a briefed on-site surgeon at the operating room and a remote mentor at an external hospital. The validated NASA Task Load Index (NASA-TLX) was used to measure the workload for standardized pIONM.

Results: The pIONM was installed and performed without any problems. It required a median 7 min stimulation time (range 7-10 min) and confirmed nerve-sparing TME in all six patients. Remote and on-site telepresence required a median 31 min (range 24-44 min), enabling adequate application training for a first-time user. The overall NASA-TLX-based workload realizing pIONM was a median 8.7 (range 3.3-16.3) points. There was no significant difference in TLX between on-site and remote surgeons (p = 0.180). Overall workload was highest for the first-time user but decreased upon repetition. Significantly higher values were found in the following subscales for the surgeon performing pIONM: physical demand (p = 0.002) and temporal demand (p = 0.03).

Conclusion: Initiation of pIONM supported by teleconsulting is feasible and requires a low workload.

Background: Anastomotic leakage (AL) remains a challenging complication of rectal cancer surgery. In patients diagnosed with low risk of AL, low anterior resection (LAR) is often performed without creating a stoma. However, AL can still occur even in patients considered to be at low risk. This study assessed the effects of circumferential oversewing (CO) on AL in patients undergoing robotic LAR without fecal diversion.

Methods: We retrospectively reviewed data from 225 patients with rectal cancer who underwent robotic LAR without fecal diversion. They were divided into CO and non-CO groups. The CO group received oversewing along the circular staple line. The AL rate was assessed after the inverse probability of treatment weighting (IPTW) adjustments.

Results: After IPTW adjustment, no significant differences in baseline characteristics were observed between the two groups. Overall complication and AL rates were 12.0% and 4.5%, respectively. Although no difference in overall complications was observed between the two groups, patients in the CO group had a significantly lower AL rate than the non-CO group (1.7% vs. 10.3%, p = 0.010). Logistic regression analysis revealed that the CO procedure was a protective factor against AL (IPTW-adjusted OR 0.153, 95% CI 0.036-0.643, p = 0.010).

Conclusions: The application of the CO procedure in patients with LAR who were not indicated for stoma creation may contribute to reducing the risk of AL.

Objectives: Rectal prolapse is a serious but not life-threatening condition. It can involve many complications, including quality-of-life changes. Surgical intervention is the standard medical treatment for these patients. In this article, we aim to investigate the quality-of-life outcomes in patients undergoing rectal prolapse surgery, compare different surgical methods, and assess different quality-of-life questionnaires to study these patients.

Data sources: We conducted a systematic literature search on PubMed, Scopus, ScienceDirect, and Embase.

Study selection: A total of 4916 studies were screened, resulting in a final 34 included studies, and 20 were included in the meta-analysis.

Interventions: Data were extracted from studies comparing the quality of life in rectal prolapse patients before and after surgery.

Main outcome measures: Except for one, all included studies reported improved quality-of-life scores. Different instruments were used to examine these patients' quality of life, but SF-36 was implemented most frequently. It comprises eight different domains, and these domains were reported in six different studies.

Results: All eight domains showed better outcomes after surgery. The final analysis was based on the surgical approach (perineal or abdominal) and showed no statistically significant superiority of any of the approaches.

Limitations: The high heterogeneity of the included studies.

Conclusion: Surgical intervention can improve the quality of life of rectal prolapse patients. However, there is no consensus on which surgical approach achieves the best outcomes. Different instruments are used to evaluate the quality of life in these patients, but there is no specific questionnaire to assess this.

Objective: The objective of this study was to evaluate the efficacy and safety of a novel, simple internal traction method using a hemoclip, suture, and rubber band during endoscopic submucosal dissection (ESD) for colonic lesions.

Methods: A total of 96 patients undergoing ESD at Jiangyin Hospital Affiliated with Nantong University between January 2021 and December 2024 were randomized into two groups: Group A (n = 48) underwent conventional ESD, while Group B (n = 48) underwent ESD with hemoclip-suture-rubber band traction. The study included patients with early stage colon cancer, precancerous lesions (e.g., adenomas with high-grade dysplasia), and neuroendocrine tumors. Outcome measures included total procedure time, mucosal dissection time, number of submucosal injections, en bloc resection rate, adverse events, and the size of lesion area.

Results: The hemoclip-suture-rubber band traction group (Group B) demonstrated significantly shorter total procedure time (72.63 ± 34.14 min versus 85.13 ± 38.18 min, P < 0.05) and mucosal dissection time (53.56 ± 29.03 min versus 71.63 ± 39.18 min, P < 0.001) compared with the conventional ESD group (Group A). Group B also required significantly fewer submucosal injections (1.63 ± 1.23 versus 4.75 ± 1.62, P < 0.001). Lesions in Group B were significantly larger (7.650 [2.857, 10.386] cm² versus 4.895 [2.062, 6.774] cm², P < 0.05). There were no statistically significant differences in en bloc resection rate or adverse events between the two groups (P > 0.05). However, in Group B, two patients experienced intraoperative muscularis propria injury (2/48, 4.2%) and presented with postoperative abdominal pain.

Conclusions: The hemoclip-suture-rubber band traction technique facilitates colonic ESD by reducing procedure time and the need for submucosal injections, especially in larger lesions.While overall safety is comparable to conventional ESD, the potential for muscularis propria injury warrants further study in larger, multicenter trials.This simple and effective method holds promise for improving the efficiency and potentially the safety of colonic ESD.

Background: Endoscopic pilonidal sinus treatment (EPSiT) is a novel, minimally invasive surgical technique that has shown promise in the treatment of pilonidal sinus disease. Despite the apparent benefits and call for increased use, widespread uptake has been slow. This study aims to gather and understand expert international opinions on EPSiT and develop recommendations for its application in the surgical community.

Methods: Expert international panellists were identified and recruited to participate. A three-round modified Delphi consensus consisting of 43 questions regarding the application of EPSiT was posed. A combination of a five-point Likert scale, binary 'yes/no' scale and multiple-choice questions was used. The consensus threshold was set at 70% agreement. When consensus was not achieved or further insight was required, statement questions were posed. The study has been performed in accordance with ACcurate COnsensus Reporting Document (ACCORD) explanation and elaboration guidelines.

Results: Twenty experts from six countries participated in all rounds, with a 100% response rate. Our experts agreed on 28 statements including: the absence of absolute contraindications to EPSiT; administering intravenous induction antibiotics routinely but not post-operative oral antibiotics; recommending laser epilation; offering re-EPSiT to the informed patient after first and second procedure failures; and that EPSiT should be incorporated into surgical training programmes.

Conclusions: This is the first study to provide an international expert consensus on the specific application of EPSiT in primary and recurrent adult and paediatric patients with pilonidal sinus disease. The findings of this study contribute to the development of protocols for EPSiT in pilonidal sinus disease management, addressing key areas of consensus and controversy and promoting procedure uptake.

Purpose: For treating complex transsphincteric fistula, a two-stage approach is usually administered: an initial seton placement followed by a sphincter-sparing procedure. However, success rates are not optimal. This study aimS to describe the modified transanal opening of the intersphincteric space (TROPIS), a single-staged procedure for managing transsphincteric fistula with or without concurrent anorectal abscess, and to compare its efficacy with the LIFT.

Methods: Thirty-six patients who presented with mid-high transsphincteric fistula with or without associated anorectal abscess and consented to the procedure from 2020 to 2023 were managed with modified TROPIS. The primary outcome measures were recurrent fistulas and fecal continence. These results were compared with our previous study data of 24 patients who underwent LIFT procedure from 2011 to 2013.

Results: Thirty-six patients received modified TROPIS; nine (25.0%) had an associated ischiorectal abscess. At the 8-month and 14-month follow-up, zero patients experienced fistula recurrence or fecal incontinence. In comparison with our previous study, 24 patients with transsphincteric fistula with or without associated abscess were treated with initial seton placement, then LIFT. With a follow-up range of 14-36 months, five (20.8%) patients presented with recurrent fistulas; no patients experienced fecal incontinence. These results were statistically significant.

Conclusions: Our results reflect that modified TROPIS is a safe, simple, and effective procedure for treating patients with transsphincteric fistula with or without associated abscess. Patients healed with no fistula recurrence, which is significant in comparison with previous patients treated with LIFT. Modified TROPIS does not require an initial seton placement for managing transsphincteric fistula with associated abscess.

Aim: This study aimed to assess whether early closure of loop ileostomy reduces the rate of postoperative complications related to ileostomy closure and improves patients' quality of life, as measured by the Low Anterior Resection Syndrome (LARS) and Wexner questionnaires.

Methods: All patients who underwent low anterior resection + ileostomy with subsequent reversal between January 2019 and May 2023 were included in the study. Patients were divided into two groups: early (< 3 months) and late closure (> 3 months). There were 46 (43%) patients in the early closure group and 61 (57%) in late closure. In this study, patients' demographics and complication rate (categorised by severity using the Clavien-Dindo scale) were assessed.

Results: We assessed and contacted 180 patients. Of these, 107 (59%) completed the LARS and Wexner questionnaires. Of the 107 patients, 51 were male (47.7%) and 56 female (52.3%). The time to ileostomy closure ranged between 0.5 and 28 months, with a median of 5. In the early and late closure groups, postoperative complications were observed in 4.3% vs. 14.8% (p = 0.08) of patients and postoperative ileus occurred in 6.5% vs. 4.9% (p = 0.72) of patients respectively. Median LARS score was 25 vs. 20 (p = 0.99) and Wexner's 2.5 vs. 2 (p = 0.82), respectively. The previously discussed indicators (postoperative ileostomy complications, postoperative ileus rate, LARS and Wexner scores) were not statistically significantly different.

Conclusion: In our small retrospective study, early ileostomy closure did not affect postoperative complications related to ileostomy closure and bowel dysfunction rates compared to late closure.

Trial registration: This study was a secondary analysis of the prospective trial registered at ClinicalTrials.gov no. NCT03607370, 01.07.2017.