Annals of Coloproctology最新文献

Purpose: The role of antibiotics in preventing fistula formation following an initial abscess remains a subject of debate. This study compared the incidence of fistula in ano in patients experiencing their first episode of acute perianal sepsis, with and without antibiotic therapy, and evaluated the prevalence of fistula in ano necessitating surgical intervention at 1 year.

Methods: This retrospective cohort study was conducted at a tertiary care hospital with a dedicated proctology department. All patients who presented to the emergency proctology unit with a first episode of acute perianal sepsis were eligible for inclusion.

Results: This study included 276 patients. At 1 year, fistula formation was identified in 65.6% of all patients, 54.0% of those who had received antibiotics, and 75.0% of those who had not (P<0.001). This finding remained significant after weighted propensity analysis (odds ratio, 0.53; 95% confidence interval, 0.31-0.92; P=0.025).

Conclusions: The rate of fistula formation was relatively high in this study. However, it was lower among patients with perianal sepsis who were treated with antibiotics, although a causal relationship could not be established. Prolonged follow-up is needed to clarify the role of antibiotic therapy in preventing or delaying fistula development in patients with acute perianal sepsis.

The Korean Enhanced Recovery After Surgery (ERAS) Committee within the Korean Society of Surgical Metabolism and Nutrition was established to develop ERAS guidelines tailored to the Korean context. This guideline focuses on creating the most current evidence-based practice guidelines for ERAS purposes, based on systematic reviews. All key questions targeted randomized controlled trials exclusively, and if fewer than 2 were available, studies employing propensity score matching were also included. Recommendations for each key question were marked with strength of recommendation and level of evidence following internal and external review processes by the committee.

Purpose: This study aimed to evaluate the long-term efficacy of the ligation of the intersphincteric fistula tract (LIFT) procedure in treating high transsphincteric fistulas.

Methods: We conducted a retrospective study to evaluate the success rate of LIFT treatment in 82 patients with high transsphincteric fistulas involving at least one-third of the external sphincter. This study was carried out across 2 centers from November 2009 to February 2023.

Results: All patients underwent successful surgery with a median operative time of 48.9 minutes (range, 20-80 minutes), and no intraoperative or postoperative complications were reported. The median follow-up duration was 85.5 months (range, 4-120 months), with 5 patients (6.1%) lost to follow-up. Treatment was successful in 62 patients, whose symptoms disappeared and both the external opening and the intersphincteric incision completely healed, yielding an overall efficiency rate of 80.5%. There were 15 cases (19.5%) of treatment failure, including 6 (7.8%) that converted to intersphincteric anal fistula and 9 (11.7%) that experienced persistent or recurrent fistulas. Only 1 patient reported minor overflow during the postoperative follow-up, but no other patients reported any significant discomfort. There were no statistically significant differences between patients with surgical success and those with treatment failure in terms of fistula length, history of previous abscess or anal fistula surgery, number of external orifices or fistulas, and location of fistulas (all P>0.05).

Conclusions: LIFT is a safe and effective sphincter-preserving procedure that yields satisfactory healing outcomes and has minimal impact on anal function.

Purpose: Diagnosing sarcopenia necessitates the measurement of skeletal muscle mass. However, guidelines lack a standardized imaging modality with thresholds validated among Asians. This systematic review compared ultrasonography, computed tomography (CT), magnetic resonance imaging (MRI), and bioelectrical impedance analysis (BIA)/body composition monitoring in the detection of sarcopenia within Asian populations.

Methods: PubMed and Embase were systematically searched for studies analyzing ultrasonography, CT, MRI, and BIA in diagnosing sarcopenia among Asians. Study quality was assessed using the Newcastle-Ottawa scale.

Results: Pooled findings from 21,598 patients across 25 studies were examined. In receiver operating characteristic analysis, ultrasound displayed a pooled mean area under the curve (AUC) of 0.767 (95% confidence interval [CI], 0.709-0.806), with mean sensitivity of 81.1% (95% CI, 0.744-0.846) and specificity of 73.1% (95% CI, 0.648-0.774), for detecting sarcopenia in Asian populations. CT exhibited an AUC of 0.720 (sensitivity, 54.0%; specificity, 92.0%). MRI demonstrated an AUC of 0.839 (sensitivity, 67.0%; specificity, 66.0%). BIA displayed an AUC of 0.905 (95% CI, 0.842-0.968), 80.7% sensitivity (95% CI, 0.129-0.679), and 82.4% specificity (95% CI, 0.191-0.633).

Conclusions: Various modalities aid in diagnosing sarcopenia, and selection should be individualized. Although only BIA and dual-energy x-ray absorptiometry are recommended by the Asian Working Group for Sarcopenia and the European Working Group on Sarcopenia in Older People, ultrasound imaging may hold diagnostic value for sarcopenia in the Asian population. In certain groups, diagnostic use of CT and MRI is warranted. Future research can standardize and validate modality-specific thresholds and protocols within Asian populations.

Purpose: Advancements in gastrointestinal surgery have directed attention toward optimizing recovery, including through the use of feeding methods that reduce prolonged postoperative hospital stays, complications, and mortality, among other undesirable outcomes. This study's primary goals were to identify current peer-reviewed literature reporting the postoperative outcomes of elective bowel surgery and to evaluate the clinical evidence of patients' tolerance to oral feeding following elective bowel surgery.

Methods: An exhaustive literature search was conducted via PubMed and Scopus. The search results were screened for potential articles, and articles were assessed for eligibility based on prespecified eligibility criteria. The data were synthesized, and the results were reported and discussed thematically.

Results: The database search yielded 1,667 articles, from which 18 randomized controlled trials were chosen for inclusion in this study. This study included 874 early oral feeding (EOF) patients, 865 traditional oral feeding patients, and 91 patients whose postoperative care was unspecified. Data synthesis was done, and meta-analyses were conducted. The results showed that EOF patients required a significantly shorter time to tolerate a solid diet and had shorter hospital stays. In addition, bowel function was restored earlier in EOF groups.

Conclusion: The results show good tolerance to EOF, shorter hospitalizations, and faster restoration of bowel function, suggesting that EOF after elective bowel surgery is relatively safe. However, further studies with similar baseline conditions should be conducted to verify these results.

Purpose: To analyze adenoma detection rate (ADR) and related quality indicators of colonoscopy among trainees and make recommendations for appropriate colonoscopy training.

Methods: ADR and related indicators of colonoscopies performed by 3 trainees and 5 colonoscopy experts between March and November 2022 were analyzed. These indicators were analyzed in both the entire patients and the screening/surveillance group. In addition, the training period of the 3 trainees was divided into 3 sections, and the changes in these indicators were examined.

Results: The mean ADR of the 3 trainees was 50.6%. In the screening/surveillance group, the mean ADR of the 3 trainees was 51.8%, showing no significant difference from the experts' ADR (53.4%). When the training period was divided into 3 sections and analyzed in the screening/surveillance group, the mean ADR of the trainees gradually increased to 49.4%, 52.6%, and 53.6%, respectively; however, the difference was insignificant. Analyzing each trainee's ADR, there was a significant difference among the 3 trainees (58.5% vs. 44.7% vs. 50.2%, P=0.008). However, in the third section of the training period, the 3 trainees' ADRs were 53.0%, 49.2%, and 57.3%, respectively, showing no significant difference (P=0.606).

Conclusion: In the early stages of training, the ADR was higher than recommended; however, there were variances in ADR between individuals. As the training period passed, the ADR became similar at the expert level, whereas the difference in ADR between trainees decreased. Therefore, efforts to increase ADR should be made actively from the beginning of training and continued during the training period.

Purpose: Robot-assisted surgery is readily applied to every type of colorectal surgeries. However, studies showing the safety and feasibility of robotic surgery (RS) have dealt with rectal cancer more than colon cancer. This study aimed to investigate how technical advantages of RS can translate into actual clinical outcomes that represent postoperative systemic response.

Methods: This study retrospectively reviewed consecutive cases in a single tertiary medical center in Korea. Patients with primary colon cancer who underwent curative resection between 2006 and 2012 were included. Propensity score matching was done to adjust baseline patient characteristics (age, sex, body mass index, American Society of Anesthesiologists physical status, tumor profile, pathologic stage, operating surgeon, surgery extent) between open surgery (OS), laparoscopic surgery (LS), and RS groups.

Results: After propensity score matching, there were 66 patients in each group for analysis, and there was no significant differences in baseline patient characteristics. Maximal postoperative leukocyte count was lowest in the RS group and highest in the OS group (P=0.021). Similar results were observed for postoperative neutrophil count (P=0.024). Postoperative prognostic nutritional index was highest in the RS group and lowest in the OS group (P<0.001). The time taken to first flatus and soft diet resumption was longest in the OS group and shortest in the RS group (P=0.001 and P<0.001, respectively). Among all groups, other short-term postoperative outcomes such as hospital stay and complications did not show significant difference, and oncological survival results were similar.

Conclusion: Better postoperative inflammatory indices in the RS group may correlate with their faster recovery of bowel motility and diet resumption compared to LS and OS groups.

Purpose: This study aimed to demonstrate the safety of new double-stapling technique (nDST), without a crossing line and dog ears, by comparing with conventional DST (cDST) in laparoscopic low anterior resection (LAR).

Methods: We retrospectively reviewed 98 consecutive patients who underwent laparoscopic LAR for rectal cancer from January 2018 to December 2020. The inclusion criterion was an anastomosis level below the peritoneal reflection and 4 cm above the anal verge. In the nDST group, the staple line of the linear cutter was sutured using barbed sutures to shorten the staple line before firing the circular stapler. Therefore, there were no crossing lines after firing the circular stapler. A 2:1 propensity score matching was performed between the cDST and nDST groups.

Results: After propensity score matching, 39 patients were in the cDST group and 20 were in the nDST group. There were no significant differences in patient demographics between the 2 groups. There was no difference in the total operation time between the cDST and nDST groups (124.0±26.2 minutes vs. 125.2±20.3 minutes, P=0.853). Morbidity rates were similar between the 2 groups (9 cases [23.1%] vs. 5 cases [25.0%], P=0.855). There was no significant difference in leakage rate (4 cases [10.3%] vs. 1 case [5.0%], P=0.847) and anastomotic bleeding rate (1 case [2.6%] vs. 3 cases [15.0%], P=0.211).

Conclusion: The nDST to eliminate the crossing line and dog ears in laparoscopic LAR is technically feasible and safe. However, more attention should be paid to anastomotic bleeding in such cases.

Purpose: In patients with acute left-sided colonic obstruction, stenting can convert an emergency operation into a semi-elective procedure. However, its use continues to be debated. We performed a cost-effective analysis using our institution's experiences.

Methods: Endoscopic, surgical, and financial details were prospectively collected for patients who presented with acute colonic obstruction and underwent stenting between 2019 and 2022. Outcomes were defined as technical/clinical success and successful surgical resection. The financial cost of stenting was compared with the expected cost without stenting.

Results: Forty patients were included, with 29 undergoing definitive resection. The most common pathology was primary colon cancer (27 patients, 93%). Endoscopic stenting had high technical (90%) and clinical (83%) success rates, with low rates of complications such as perforation (2 patients, 7%) and migration (0 patients, 0%). As a bridge to surgery, the median procedure time was 226 minutes and the surgical outcomes also showed a low rate of complications (3 patients, 11%), such as anastomotic leakage (0 patients, 0%), intraabdominal abscesses (2 patients, 7%), and 30-day postoperative mortality (0 patients, 0%). The cumulative costs with colonic stenting were $32,900, while the expected costs with emergency surgery, including stoma reversal, were $40,700 (healthcare cost-savings of $7,800 per person). The difference was mainly due to the avoidance of upfront emergency surgery. The incremental cost-effectiveness ratio was 0.81, favoring colonic stenting over upfront emergency surgery.

Conclusion: Colonic stenting as a bridge to surgery is safe and cost-effective for treating left-sided colonic obstruction with high success rates and low complication rates.