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Worldwide, the guaiac faecal occult blood test (gFOBT) is being replaced with the more accurate faecal immunochemical test (FIT) for colorectal cancer (CRC) screening. From January 2016, the National Screening Committee (NSC) in the UKhas recommended a change from the gFOBT to the FIT following a successful Bowel Cancer Screening Programme (BCSP) pilot study in over 40,000 participants. Although the test has shown improved uptake and the ability to detect significantly more colorectal cancers and advanced adenomas, the higher uptake and test positivity will challenge the capacity of colonoscopy services. One of the main advantages of the FIT is that it provides a quantitative haemoglobin concentration which has been shown to relate to the risk of CRC
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Colorectal resection is frequently performed during cytoreductive surgery for gynecological malignancy. The aim of the study was to assess the safety of colorectal anastomosis and especially low rectal anastomosis in the absence of a protective stoma in patients with gynecological cancer and peritoneal metastasis.
Patient data were retrospectively collected from a database for gynecological cancer procedures between January 2013 and July 2015. All patients who underwent a colorectal resection during cytoreduction were included in the study. The primary outcome was anastomotic leakage in the presence or absence of a diverting stoma. Secondary outcome parameters were complications and reoperations.
In the period of study, 43 major colorectal procedures had been performed on 37 women. The most common colorectal procedure was low rectal resection (n=22; 59%) followed by anterior rectal resection (n=7; 19%) and sigmoid resection (n=4; 11%). Five (14%) patients underwent Hartmann′s procedure. In 3 (8%) patients, a diverting loop-ileostomy wasow rectal resections during debulking procedures for gynaecological cancers with peritoneal carcinomatosis can safely be performed without a diverting stoma by an experienced surgeon.
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Nodal stage is a strong prognostic factor of oncological outcome of rectal cancer. To compensate for the variation in total number of harvested nodes calculation of the lymph node ratio (LNR) has been advocated. The aim of the study was to compare the impact on the long-term oncological outcome of the LNR with other predictive factors, including the quality of TME and the state of the circumferential resection margin.
Consecutive patients having elective surgery for non-metastatic rectal cancer were extracted from a prospectively maintained database. A retrospective uni- and multivariate analysis was performed based on patient-, surgical- and tumour-related factors. The prognostic value of the LNR on overall survival (OS) and overall recurrence-free survival (ORFS)was assessed and a cut-off value was determined.
From 1998 to 2013, out of 456 patients, 357 with non-metastatic disease were operated on for rectal cancer. Neoadjuvant radiochemotherapy was administered to 66.7% of the patients. The mean number of lymph nodes retrieved was 12.8 ± 8.78 per surgical specimen. A lower lymph node yield was obtained in patients who received neoadjuvant chemoradiotherapy (11.8 vs. 14.2, p=0.014). The overall 5-year recurrence-free survival (ORFS) was 71.8% and the 5-year overall survival (OS) was 80.1%. Multivariate analysis confirmed LNR, the quality of TME and age to be independent prognostic factors of OS. LNR, age and perineural infiltration were independently associated with ORFS. Low and high risk patients could be discriminated using an LNR cut-off value of 0.2.
LNR is an independent prognostic factor of OS and ORFS. In line with the principles of optimal surgical management, the quality of TME and lymph node yield are essential technical requirements.
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Rectal cancer surgery is currently going through considerable technological evolution. Surgeons now have the options of novel minimal access techniques or a traditional open approach to achieve total mesorectal excision (TME). But is there currently an optimal technique for TME? Recent evidence has failed to confirm significant advantages for laparoscopy and there remains an understandable reluctance to offer this approach to all patients. Robotic surgery and transanal total mesorectal excision (TME) have provided an alternative although longer-term results are still awaited and both techniques are in their infancy.
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The reasons for pre-hospital delay of the diagnosis of cancer are multifactorial, but include a physician-related component. Urgent cancer pathways and direct-to-test approaches have been implemented, but the emergency presentation of colorectal cancer (CRC) remains little changed over recent years. We examined the variability between primary care providers in referral patterns and its effect on outcome.
A retrospective analysis was performed of a prospectively maintained database for 2009-2014 in a UK district hospital providing bowel cancer screening and tertiary rectal cancer services.
Of 1,145 CRC patients, 937(81.8%) were diagnosed with a symptomatic cancer; 229/937(24.4%) initially presented as an emergency. Between 44 primary care providers, emergency presentation varied between 8.3% and 57.1%. Patients of providers with high levels of emergency presentations (HV) had more advanced cancers than those of providers with medium (MV) or low levels (LV) (103/253[40.7%], 154/461[33.4%], 65/223[29.1%] [p=0.025]) and a lower 3-year overall survival (50.2%, 57.8%, 65.6%, [p=0.013]), but with no difference in case-mix or deprivation levels. In adjusted analysis, this difference remained significant (advanced disease: OR 1.663, p=0.011, 3-year HR 1.479, p=0.010 compared with HV vs LV). Conversely, elective suspected cancer referrals were less often used (LV: 136/223 [61.0%], MV: 228/461 [49.5%], HV: 114/253 [45.1%], p<0.001) with limited evidence for a more selective approach in the use of the "2-week rule" (LV: 136/2,508 [5.4%], MV 228/4,239 [5.4%], HV: 115/1,526 [7.8%] positive cancer diagnosis, p=0.005).
Significant variability in emergency presentation of CRC requires local audit and examination of the reasons for delay in diagnosis and targeted measures to improve performance in non-emergency referral pathways.
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Laparoscopic surgery is well established for colon cancer with defined benefits. In performing restorative proctocolectomy (RPC) with ileoanal anastomosis it is more controversial. Technical aspects include difficult dissection of the distal rectum and a potentially increased risk of anastomotic leakage through multiple firings of the stapler. In an attempt to overcome these we have used the technique of transanal rectal excision to perform the proctectomy. This paper describes the technique which is combined with an abdominal approach using a single incision platform (SIP).
Data were collected prospectively for consecutive operations between May 2013 and October 2015, including all cases of restorative proctocolectomy with ileoanal pouch anastomosis performed laparoscopically. Only patients having a transanal total mesorectal excision (TaTME) assisted by SIP were included. The indication for RPC was ulcerative colitis (UC) refractory to medical treatment.
The procedure was performed on 16 patients of median age of 46 (26 – 70) years. The male:female ratio was 5:3 and the median hospital stay was 6 (3 – 20) days. The median operation time was 247 (185 – 470) minutes and the overall conversion rate to open surgery was 18.7%. The 30 day surgical complication rate was 37.5% (Clavien Dindo 1:4, 2:1, 3:1). One patient developed anastomotic leakage two weeks postoperatively.
This initial study has demonstrated the feasibility and safety of TaTME combined with SIP when performing RPC with ileal pouch-anal anastomosis (IPAA) for UC.
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Interest in transanal laparoscopy has increased in the last decade. This approach can allow primary procedures such as polypectomy and total mesorectal excision and the treatment of post-operative complications, like bleeding, leakage and fistula formation.
The authors report two patients treated by transanal repair for leakage of a colorectal anastomosis after laparoscopic anterior resection of the rectum. The first developed leakage immediately during the surgery and in the second leakage presented at four weeks. A new transanal platform according to DAPRI formed by a reusable port and reusable monocurved instruments was developed to permit manipulation of sutures introduced via the anus in a maximally ergonomic manner. Laparoscopic suturing was performed transanally and a protective ileostomy was added as well.
The transanal procedures took 60 and 45 minutes and the patients were discharged after five and two days. At two months both defects were found to be healed on contrast radiology and endoscopy, therefore the ileostomy was closed. Anal function was satisfactory with a frequency of two and one times /24 hours with no incontinence or evidence of sepsis.
Intraoperative or late leakage of coloanal anastomosis can be safely treated by transanal laparoscopy. This new transanal platform offers the surgeon the possibility to work in ergonomic positions, without increasing the cost of the procedure thanks to the reusable nature of the material used.
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The incidence of metastasis to the pelvic sidewall lymph nodes has been shown to be around 20% in locally advanced low rectal cancer [1, 2] and often lead to local recurrence, even after chemoradiotherapy [3]. Survival after recurrence of local nodal metastases in the lateral compartment is poor, especially in the case of a R+ resection, with a 5 year survival rate of approximately 10% [4].
The pelvic side wall,or pararectal space is an anatomical space not often dissected by the colorectal surgeon. In the case of locally advanced rectal cancer or involvement of the pelvic side wall lymph nodes, however, dissection is necessary.
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Enterocutaneous fistula (ECF) is considered to be one of the most challenging complications a general surgeon can encounter. The current mainstay of treatment is surgical closure, associated with significant morbidity and mortality. Vacuum assisted closure (VAC) has been successfully used for closure of persistent abdominal wounds for a number of years. This study aims to investigate whether current literature supports the use of VAC for ECF
A PubMed search of the search terms "enterocutaneous fistula" and "vacuum assisted closure/therapy" was performed in December 2014. Results were restricted to articles involving human subjects with an available abstracts and full text written between 1950-2014. The end points analysed included rate of fistula closure, duration of follow-up, and morbidity and mortality where available.
Ten studies (all level IV) including 151 patients were examined. In all except one, surgery was the underlying aetiology with median number of fistulae per patient of one. The median rate of closure with VAC was 64.6 (7.7-100) % with healing occurring within 58 (12-90) days. Follow-up was only mentioned in three of the ten studies, in which the patients were followed for 3, 20 and 28.5 months. No complications were reported in all but one of the studies, in which abdominal wall disruption and intestinal obstruction were identified in a minority of patients.
The included studies suggest that VAC therapy may be considered a safe treatment for ECF. The current evidence is generally of low level and characterised by heterogeneity. Definitive recommendations based on this information cannot therefore be made. Further studies are necessary to establish any proven benefit over standard surgical or conservative therapy.
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The study aimed to evaluate the implementation of non-antibiotic management of acute uncomplicated diverticulitis at a large university hospital in Norway with regard to management failure, disease recurrence and complications.
On January 1st 2013 we implemented a new policy for the management of acute uncomplicated diverticulitis without antibiotics. Antibiotic treatment was only provided in the case of defined criteria. All patients admitted from January 1st 2013 to June 30th 2014 with a computed tomography (CT)-verified left-sided, acute uncomplicated diverticulitis were included in the study and evaluated retrospectively, with 12 months follow-up.
Of 244 admissions with acute uncomplicated diverticulitis, 177 (73%) were managed without antibiotics. Among these there were seven (4%) management failures, including five patients in whom a deteriorating clinical picture prompted antibiotic treatment and two readmissions within one month due to persisting symptoms. The only complication in this group was one fistula (<1%). Eight (5%) patients had a recurrence of acute diverticulitis requiring hospital care and two (1%) underwent elective surgery within the first year. Twenty (8%) patients met predefined exemption criteria and received antibiotics from admission, six (30%) of whom developed complications. The recurrence rate in this group was 10% and none had surgery performed. The 47 (20%) policy violators treated with antibiotics from admission had no complications. Their recurrence rate was 11% and one (2%) patient underwent elective surgery.
The study confirms that non-antibiotic management of acute uncomplicated diverticulitis is safe and feasible. Most complications occurred in a small group of high-risk patients treated with antibiotics.
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Restorative proctocolectomy (RPC) with ileal pouch-anal anastomosis is the operation of choice for ulcerative colitis (UC) and some cases of familial adenomatous polyposis (FAP). Offering improvement in quality of life and high patient satisfaction, pouch surgery is also associated with significant morbidity. The aim of this study was to describe the management of patients referred to a tertiary centre with pouch dysfunction.
All patients referred with pouch dysfunction from other institutions, between October 2006 and November 2014, were included in this retrospective study. Information regarding initial diagnosis before RPC, type of procedure, symptoms leading to referral, relation of the appearance of symptom to the ileostomy closure, investigations, final diagnosis, treatment and follow-up was reviewed.
One hundred and twenty one patients were included, having RPC mostly for UC (94%), and with diverting ileostomy (83%). The most frequent reasons for referral were high frequency of defaecation in 83 (69%) patients, abdominal pain and incontinence in 45 (37%) each and perianal pain in 44 (36%). The principal investigations performed were pouchoscopy in 97 (80%) patients, examination under anaesthesia (EUA) in 62 (51%), pelvic magnetic resonance imaging (MRI) in 56 (46%) and contrast radiology of the pouch (pouchogram) in 45 (35%). The commonest diagnoses were pouchitis (primary and secondary) in 24 (21%) patients and anastomotic leakage in 26 (22%). After full investigation a cause for the symptoms could not be found in 24 (20%) patients, resulting in the diagnosis of exclusion of 'irritable pouch syndrome' or functional disorder.
Treatments given were long term antibiotic therapy in 29 (25%) patients, ileostomy in 19 (16%), use of a Medena catheter to promote anal evacuation in 17 (15%) and dilatation of a stenosis under anaesthetic in12 (10%). Six (5%) patients underwent major revision surgery of the pouch with a defunctioning ileostomy and the pouch was excised in another 6 (5%).
Patients with ileoanal pouch dysfunction often have multiple symptoms. This study shows that a wide range of investigations and treatment modalities need to be available to manage such patients, with a specialised approach in a multidisciplinary setting.
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A 16-year-old male was operated for peritonitis from perforated appendicitis with the finding of a large abscess in the pelvic and right iliac fossa (RIF). He returned 12 days after discharge, complaining of fever and diffuse abdominal pain. An urgent abdominal ultrasound examination showed a large deep pelvic collection covered by the bladder and small bowel loops, with a further collection in the RIF. The white cell count (WCC) was 25,980 mm-3 and the C-reactive protein (CRP) 23.70 mg/dL.
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We read with interest the paper by Marinello et al relating individual surgeons and anastomotic leakage and congratulate them on their work [1] .The authors raise valid points in challenging topic regarding an individual surgeon to the anastomotic leak rate, but we feel there a few limitations of the study which warrant highlighting.
First, the authors have reported surgeons who chose their preferred technique of hand-sewn or stapled anastomosis, with neither anastomosis showing a statistically significant lower anastomotic leak rate. It is, however, difficult to determine whether each surgeon used the same type of anastomosis for each patient or whether they chose the type of anastomoses based on other clinical factors.
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An RCT was conducted to test the null hypothesis that there is no difference in complication rates and length of stay (LOS) between laparoscopic right colectomy (LRC) and laparoscopic-assisted colonoscopic polypectomy (LACP) for endoscopically unresectable polyps of the right colon.
A single-centre RCT (NCT01986699) was conducted on patients with polyps of the right colon deemed non-resectable by the gastroenterologist. They underwent a repeat colonoscopy with biopsy by an interventional endoscopist and were allocated to LRC or LACP. Patients with a non-lift sign, dysplasia, adenocarcinoma, IBD or FAP were excluded from the trial. The study was powered to detect a 73% difference in the LOS which required 17 patients in each arm with an α error of 0.05 and a power of 95%.
Thirty four patients were comparable for age (p=0.919), gender (p=0.364), BMI (p=0.634), ASA class (p=0.388) and previous abdominal surgery (p=0.366). There was no significant difference in the preoperative morphology (p=0.485), location (p=0.297), size (p=0.690) or histology of the polyps (p=0.779). LRC patients experienced a longer operating time (180 vs. 90 minutes [p=0.001]), required more IV infusion (3.1 vs. 2.0 litres [p=0.025]), took significantly longer to pass flatus (2.88 vs. 1.44 days [p<0.001]), resumed solid food (3.94 vs. 1.69 days [p<0.001]), and had a longer postoperative hospital stay (4.94 vs. 2.63 days [p<0.001]). Postoperative complications (p=0.656), readmissions (p=0.5), reoperations (p=0.5) did not differ. Final size (p=0.339) and histology (p=0.104) of the polyps did not differ. There were four cancers in the LRC arm. At follow-up colonoscopy with biopsy of the scar in 10 patients at 15.3 months, one patient had recurrence of the polyp at the site of the previous LACP.
LACP and LRC had similar complication rates, but LOS was shorter after LACP.
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Conventional laparoscopy of the rectum has shown advantages over laparotomy with equal oncologic results. Single-incision laparoscopy is worthy of consideration during up-to-down rectal resection because it allows single-access at the site of the temporary ileostomy placed at the end of the procedure.
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Confusion remains as to what is meant by Denonvilliers' fascia. This review searched the literature on pelvic surgical anatomy to determine whether there is agreement with Denonvilliers' original description and its implication in defining the correct anterior plane of dissection when mobilising the rectum.
The original French description of the fascia was translated into English and then compared both to French and English studies identified by searching Pubmed, Medline and Scopus from 1836 to June 2015. Special emphasis was given to the years between 1980 to 2015 in order to capture the literature pertinent to and following on from the description of total mesorectal excision for rectal cancer.
The final literature search revealed sixteen studies from the original 2,150 citations. Much of the debate was concerned with the origin and development of the fascia, arising from either the fusion or condensation of local primitive tissue into a mature "multilayered" structure.
Controversy as to the correct plane of rectal mobilisation is due to different interpretations understood by surgeons, anatomists and radiologists and bears little resemblance to Denonvilliers' original description. This may reflect wide anatomical variability in the adult pelvis or a form of dissection artefact. Further study is required to investigate this. Logically for both men and women the plane of rectal mobilisation should be behind Denonvilliers' fascia and between it and the fascia propria of the rectum.
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We read with interest the correspondence by Noone et al suggesting that pathologists are able to recognise good surgery and wondering whether they should inform the public. Completeness of total mesorectal excision (TME) as evaluated by pathologists indeed has prognostic value, as shown by several groups [1,2]. The contribution of good quality TME has, however, been put in perspective in a study by Leonard et al. Taking into account multiple variables, TME quality appeared to play an important though limited relative role in the prediction of outcome after rectal cancer resection [3]. We believe it is more pertinent to benchmark differences in quality of care at a hospital level, including all disciplines concerned [4].
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The study aimed to determine the current state of UK pelvic floor services and to discuss future strategies.
A questionnaire developed by The Pelvic Floor Society was sent in 2014 to the 175 colorectal units recognised by the Association of Coloproctology of Great Britain and Ireland. Questions included type of centre, frequency of pelvic floor clinics/ inter-disciplinary joint pelvic floor clinics/ multidisciplinary meeting (MDM) and workload.
sixty seven (38%) centres replied including 75% of units with a consultant who was as member of the Pelvic Floor Society. Of the 67 centres 39% were tertiary centres for pelvic floor surgery (Tertiary), 48% performed some pelvic floor surgery (Regional) and 13% did not perform any (Local). Ninety six per cent of tertiary referral centres served a population over 500,000. The mean number of whole time equivalent (WTE) consultants in Tertiary centres was 1.03 and 0.77 in Regional centres. Eighty per cent of Tertiary and 56% of Regional centres ran pelvic floor clinics. Eighty four per cent of tertiary referral and 75% of regional units held or attended a multidisciplinary meeting (MDM). Anal ultrasonography, anorectal physiology and proctography were performed in 96% of tertiary centres compared with 50% in non-Tertiary units.
The provision of pelvic floor services includes Local, Regional and Tertiary centres. The overall response rate was low (38%) and biased to centres with a consultant who was a member of The Pelvic Floor Society. Not all Regional or Tertiary centres held an MDM or a pelvic floor clinic. Given the nature of pelvic floor pathology an integrated service should be aimed for linking different centres and specialities.
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Previous literature has sought prognostic factors for survival of anal cancer patients. The present study aimed to determine prognostic factors for local disease recurrence, distant metastases and survival from patients treated with radical chemoradiotherapy (CRT) at the Rosemere Cancer Centre, Preston, UK.
Patients treated with CRT for non-metastatic squamous cell anal cancer between September 2000 and January 2013 were studied. Kaplan-Meier and Cox Regression analysis assessed the prognostic value of age, sex, tumour size, the proportion of the anal canal circumference involved (ACCI), nodal disease, tumour location and pre-treatment haemoglobin.
148 patients with a mean age of years were studied of whom 15% suffered local disease recurrence and 10% developed distant metastases. The five-year overall and cancer specific survivals were 84% and 86% respectively. Predictors of local recurrence were tumour size >5cm and over two-thirds ACCI (p<0.01). Predictors of distant metastases and poor survival were tumour size >5cm (p<0.01), node positive disease on imaging (p<0.05), over two-thirds ACCI (p<0.01) and a pre-treatment haemoglobin level below 130g/l (p<0.05). Multivariate analysis found large tumour size the most significant factor for local recurrence (p=0.002) and survival (p=0.02) whilst over two-thirds ACCI was most predictive of distant metastases (p<0.001). Age, gender, palpable lymph nodes and tumour location were not of prognostic value for local disease recurrence, distant metastases or survival.
Tumour size, nodal disease, over two thirds ACCI and low pre-treatment haemoglobin confer poorer prognostic and survival outcomes. Use of intensity modulated radiation therapy may allow greater radiation doses to be given for locally advanced tumours, thus improving local control and survival and reducing morbidity.
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The rate of ileostomy reversal was estimated in patients undergoing an elective anterior resection for rectal cancer and factors associated with reversal were identified.
The records of 4,879 rectal patients who had an ileostomy created during anterior resection between 2009 and 2012 were identified in the National Bowel Cancer Audit database and linked to administrative records of the Hospital Episode Statistics (HES). Patients were followed from surgery. Multivariable proportional hazards regression was used to estimate impact of patient and cancer characteristics on ileostomy reversal with death as the competing risk.
Within 18 months from anterior resection, 3,536 (72.5%) patients had undergone ileostomy reversal. The reversal rate was lower in the following circumstances: older patients (Hazard Ratio (HR) 0.90; 95% CI 0.84 to 0.96, aged 80 vs 70 years), male gender (HR 0.90; 0.84 to 0.97), higher ASA grade (HR 0.64; 0.56 to 0.74, ASA 3+ vs 1), more advanced cancer (HR 0.77; 0.69 to 0.87, T3 vs T1), socioeconomic deprivation (HR 0.83; 0.74 to 0.93, most vs least deprived quintile), comorbidity (HR 0.92; 0.84 to 1.00, one vs no comorbidity), and open surgical procedure (HR 0.90; 0.84 to 0.97, open vs laparoscopic).
Overall, two thirds of ileostomies were reversed within 18 months. Reversal rates were linked to patient and cancer characteristics (age, sex, fitness, and stage), mode of surgical access, and socioeconomic deprivation. Observed lower reversal rates in patients from poorer backgrounds may indicate inequity in access.
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We read the PATRASTOM pilot randomised controlled trial (RCT) paper (1) with great interest. Parastomal Hernia (PSH) prevention is an area needing high quality evidence. Good pre-trial work, such as pilot studies, has an important role in the design of definitive multi-centre trials. We have several methodological concerns, however, that limit the findings and interpretation of this study.
Pilot studies aim to test the feasibility, reliability and validity of the proposed design of a main RCT [2]. As such, pilot RCTs are designed to establish whether, for example, it is possible to recruit and randomise patients, and whether the preferred end points in a main trial can be collected with acceptable completeness [3].
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In colorectal cancer (CRC), improved methods for early detection are essential for increasing survival. Hypermethylated DNA in blood or stool has been proposed as a biomarker for CRC. In recent years, biochemical methods have improved, and several hypermethylated genes that are sensitive and specific for CRC have been proposed. Articles describing the use of hypermethylated promoter regions in blood or stool as biomarkers for CRC were systematically reviewed.
The Medline, Web of Science, and Embase databases were used in a systematic literature search. Studies were included if they analysed hypermethylated genes from stool or blood samples in correlation with CRC. Non-English-language studies and studies based on animal models or cell lines were excluded.
The literature search yielded 72 articles, including 43 addressing blood samples and 29 addressing stool samples. In blood samples, hypermethylated P16, HLTF, TMEFF1, ALX4, VIM, and FBN2 were associated with poor prognosis, hypermethylated APC, TAC1, SEPT9, NEUROG1, RASSF1A, SDC2, and THBD were detected in early-stage CRC, and hypermethylated P16 and TFPI2 could detect CRC recurrence. In stool samples, hypermethylated BMP3, PHACTR3, SFRP2, SPG20, TFPI2, and TMEFF2 could detect CRC in the early stages.
Hypermethylation of the promoters of specific genes measured in blood or stool samples could be used to detect CRC and could provide prognostic information. The majority of studies include, however, only a few patients with poorly defined control groups. Further studies are therefore needed before hypermethylated DNA can be applied as a clinical biomarker for CRC detection and prognosis.
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The use of a loose seton for complex anal fistulae can cause perianal discomfort and reduced quality of life. The aim of this study was to assess the impact of the novel knot-free Comfort Drain on quality of life, perianal comfort and faecal continence compared to conventional loose setons.
Forty-four patients treated for complex anal fistula at a single institution between July 2013 and September 2014 were included in the study. A match-paired analysis was performed to compare patients with a knot-free Comfort Drain and controls, who were managed by conventional knotted setons. The 12-item short form survey (SF-12) questionnaire was used to assess quality of life. Additionally, patients reported perianal comfort and faecal incontinence using a Visual Analog Scale (VAS) and the St. Mark's incontinence score,.
The Comfort Drain was associated with improved quality of life with significant higher median physical (p=0.001) and mental (p=0.04) health scores compared with a conventional loose seton.
According to the VAS, patients with a Comfort Drain in situ reported greater perianal comfort with significantly less burning sensation (p<0.001) and pruritus (p<0.001). Faecal continence was similar in each group.
The Comfort Drain offers improved perianal comfort and better quality of life compared with a conventional loose seton and therefore facilitates long-term therapy in patients with complex fistula-in-ano.
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Colorectal cancer (CRC) is a major health problem worldwide accounting for over a million deaths annually. While many patients with stage II and III CRC can be cured with combinations of surgery, radiotherapy and chemotherapy, this is morbid costly treatment and a significant proportion will recur and eventually die of CRC. Increased understanding of the molecular pathogenesis of CRC has the potential to identify high risk patients and target therapy more appropriately.
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Despite transanal endoscopic microsurgery (TEM) being used for over 30 years, there has been slow adoption of this modality in many centers. There remains a paucity of research regarding the learning curve and early performance of surgeons who begin to offer TEM. We sought to determine predictors of longer rates of tumour excision and improvements in operative time in a newly established TEM program.
All patients who underwent TEM at the Ottawa Hospital, Ottawa, Canada, between October 2009 and September 2014 were included. Data were abstracted through a retrospective chart review. The Average Rate of Lesion Excision (ARE) was calculated to standardise the operation time by size of the pathological specimen (min/cm3), representing a measure of surgical efficiency. Surgical efficiency was plotted using restricted cubic splines. Predictors of higher ARE were determined using multivariable regression.
During the study period 108 patients underwent TEM. ARE was available for 95 patients of mean age of 67.2 years. The mean ARE was 18.6 min/cm3. While adjusting for important covariates, the ARE improved with each additional case until 16 cases were completed. Significant predictors of higher ARE on multivariable analysis were age < 50 years, experience of fewer than five cases, and carcinoid/GIST or scar histology.
Operative efficiency appears to improve as surgeons completed 16 TEM cases. We have identified important factors that result in longer operating time. The study has important implications with regard to surgical training and operative planning for new TEM programs.
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Many different surgical techniques have been reported for the surgical treatment of full thickness external rectal prolapse. Stapled Prolapse (PSP) Resection is a relatively newly reported technique for full thicjness external rectal prolapse. The aim of this prospective multicenter study was to evaluate the results of this procedure.
Consecutive patients who underwent a PSP resection for full thickness external rectal prolapse at 5 centres were recruited to the study. Median operating time, hospital stay complications, recurrences, and functional results according to the Wexner incontinence scale and obstructive defecation syndrome score were recorded.
There were 27 patients treated by PSP. Median Wexner incontinence score improved from 10 presurgery to 5 points after surgery (p<0.001); the median obstructed defecation syndrome score improved from 12 presurgery to 5 points (range, 4-10) after surgery (p<0.001). A laparoscopic-assisted procedure was performed in 3 patients (11.1%). The meandian number of cartridges used was 6 (range, 4-9). The median operating time was 48 minutes. Early complications occurred in 6 patients (22.2%) and late complications in 2 (7.4%). The median length of hospital stay was 5 days. The recurrence rate at a meandian follow-up of 30.3 months was 14.8%.
Perineal stapled prolapse resection appears to be an easy, fast and safe procedure. Early functional results are good. The recurrence rate compares favorably with other perineal procedures like the Delorme or the Altemeier operations. Long-term functional results need to be investigated further.
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Transanal Minimal Access Surgery (TAMIS), often in combination with trans-abdominal multiport laparoscopic assistance, is proposed to improve the operative visualization and access to the low rectum especially anteriorly, particularly in males with a narrow pelvis. Intra-abdominal extension of TAMIS has been described for mobilization of the proximal colon and rectum, but not to facilitate the treatment of synchronous pathology. When TAMIS is used for completion proctectomy following a previous subtotal colectomy with end ileostomy for severe ulcerative colitis, gas-sealed transperineal access provides excellent visualization of any concomitant parastomal hernia (which is often present) and allows the placement of tacks into a mesh placed around the distal ileum via the stoma site.
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Intestinal failure (IF) is a debilitating condition of inadequate nutrition due to an anatomical and/or physiological deficit of the intestine. Surgical management of patients with acute and chronic intestinal failure requires expertise to deal with technical challenges and make correct decisions. Dedicated intestinal failure units have expertise in patient selection, operative risk assessment, and multi-disciplinary support such as nutritional input and interventional radiology, which dramatically improve the morbidity and mortality of this complex condition and can beneficially affect the continuing dependence on parenteral nutritional support.
Currently there is little guidance to bridge the gap between general surgeons and specialist IF surgeons. Fifteen European experts took part in a consensus process to develop a guidance to support surgeons in the management of patients with intestinal failure. Based on a systematic literature review, statements were prepared for a modified Delphi process. The evidence for each statement was graded using Oxford Centre for Evidence-Based Medicine 'Level of Evidence'. The current article contains the statements reflecting the position and practice of leading European intestinal failure experts encompassing the general definition of intestinal failure surgery and organisation of an IF unit, strategies to prevent IF, management of acute IF, management of wound, fistula and stoma, rehabilitation, intestinal and abdominal reconstruction, criteria for referral to a specialist unit and intestinal transplantation.
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Full-thickness laparo-endoscopic excision (FLEX) is a new technique developed for the full thickness excision of colonic adenomas and, potentially, early cancer, avoiding the need for colectomy. FLEX requires accurate preoperative characterisation of three key morphological features of the tumour including its relation to the mesenteric border, the diameter and the circumferential extent of the bowel wall involved. The study evaluated the accuracy of CT colonography (CTC) for the assessment of these features in early colonic tumours.
Consecutive patients undergoing CTC prior to colonic resection for complex benign polyps or UICC stage 1 cancer were retrospectively analysed by two specialist gastrointestinal radiologists blinded to the subsequent histopathological findings. The location of the tumour in relation to the mesenteric border, its maximum diameter and the extent of involvment of the colonic wall circumference were correlated with the histopathological examination of the surgical resection specimen. Pearson's correlation coefficient (r) and Kappa agreement (κ) were used to compare the maximum diameter and the circumferential extent of involvement of the colonic wall.
28 patients with early colonic neoplasia were included. All had had a surgical segmental resection. Four had a benign adenoma and 24 had a TNM stage 1 cancer. Histopathological assessment of the resected surgical specimen showed that 21 of the 28 lesions were located on the mesenteric border. The median diameter was 35 (interquartile range [IQR] 28-42) mm and 13 lesions involved less than one third of the circumference, 11 between one and two thirds and four more than two thirds. CTC correctly identified the location of the lesion in relation to the mesenteric border in all 28 cases. Correlation between CTC and histopathology was good for the assessment of the circumferential extent of involvement of the colonic wall (κ: 0.76) and the maximum diameter of the lesion (k: 0.81).
CTC can accurately assess the key morphological features for the selection for full-thickness laparo-endoscopic excision of patients with early colonic neoplasia.
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The aim of the present study is to investigate the clinicopathological characteristics and prognostic factors of schistosomal colorectal cancer.
74 consecutive schistosomal colorectal cancer patients, who underwent curative surgery from July 2009 to July 2012, were included in this study. The clinical and pathological characteristics of all 74 patients were analysed and univariate and multivariate analyses were performed. This study demonstrated positive correlations between the site of deposition of schistosomal eggs and certain essential variables.
The site of deposition of schistosome eggs, the (CEA), and the pathologic N and T stages were statistically significantly correlated with the OS. The pathologic T stage and the CEA were independent prognostic factors for OS. The site of deposition of schistosome eggs was positively correlated with the T and N stages, tumour size, the CEA, and the resection margins.
Schistosome eggs might be associated with tumorigenesis. The site of deposition of schistosome eggs was statistically significantly correlated with the OS, but it was not an independent prognostic factor for OS. It was, however, correlated with the depth of the tumour. The presence of schistosoma eggs at the margin did not affect the patient's prognosis or anastomotic healing. The existing standard surgical approach was equally applicable to schistosomal colorectal cancer. It was not necessary to expand the scope of surgical resection.
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Hernia formation at closed stoma sites occurs in up to 30% of patients. The ROCSS randomised controlled trial is evaluating whether biologic mesh placement during stoma closure safely reduces hernia rates compared to closure without mesh, without increasing surgical or wound complications. This paper aims to report recruitment, deliverability and safety from the internal feasibility study.
Multicentre, patient and assessor blinded, randomised controlled trial, delivered though surgical trainee research networks. A 90 patient internal feasibility study assessed recruitment, randomisation, deliverability and early (30 day) safety of the novel surgical technique (ClinicalTrials. gov registration number: NCT02238964).
The feasibility study recruited 90 patients from 104 patients considered for entry (45 to mesh, 45 to no mesh). Seven of eight participating centres randomised patients within 30 days of opening. Overall, 41% of stomas were created for malignant disease and 73% were ileostomies. No mesh-specific complications occurred. Thirty-two post-operative adverse events were experienced by 31 patients, including surgical site infection (9%) and post-operative ileus (6%). One mesh was removed for re-access to the abdominal cavity, for reasons unrelated to the mesh. Independent Data Monitoring and Ethics Committee review of adverse event data by treatment allocation found no safety concerns.
Multicentre randomisation to this trial of biologic mesh is feasible with no early safety concerns. Progression to the full phase III trial has continued. ROCSS shows that trainee research networks can efficiently develop and deliver complex interventional surgical trials.
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The present study was designed to investigate the function and clinical implications of stool short-chain fatty acids (SCFAs) in patients with mixed refractory constipation.
Ascending colon specimens obtained from thirty patients with ascending colon cancer were regarded as the control group. Ascending colon specimens obtained from patients with mixed refractory constipation were regarded as the experimental group and were divided into three groups according to Wexner scores1 of 16-20, 21-25, and 26-30, respectively, with 30 cases in each group. The stool SCFAs were extracted and quantitatively analysed by gas chromatography-mass spectrometry (GC-MS). The expressions of G protein-coupled receptor 43 (GPR43) and choline acetyltransferase (ChAT) were detected by immunofluorescence, real-time polymerase chain reaction (RT-PCR), and Western blotting of colon samples.
The levels of acetate, propionate, and butyrate in the experimental group were all significantly decreased compared with those of the control group (P<0.05). Compared to the control group, the densitometric quantification, mean density, and gene expression of GPR43 and ChAT were significantly decreased in the patients with mixed refractory constipation (P<0.05).
In the patients with mixed refractory constipation, the levels of stool SCFAs, including acetate, propionate, and butyrate, as well as the expression levels of GPR43 and ChAT in the colon, which were all negatively correlated with the Wexner score, were decreased and may be associated with the pathogenesis of mixed refractory constipation
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Surgery aims to prevent cancer-related morbidity for patients with ulcerative colitis (UC)-associated dysplasia. The literature varies widely regarding the likelihood of dysplastic progression to higher grades of dysplasia or cancer. The aim of this study was to characterise the likelihood of the development of colorectal cancer (CRC) of patients with UC-associated dysplasia who chose to defer surgery.
A retrospective review was carried out of patients undergoing surgery for UC at the Mayo Clinic, who were diagnosed to have dysplasia between August 1993 and July 2012. The relationships between grade of dysplasia, time to surgery and the detection of unsuspected carcinoma were investigated.
175 patients underwent surgery at a median of 4.9 DEAR AUTHOR PLEASE BE HAPPY WITH THIS [IQR:2.5-8.9] months) after a diagnosis of dysplasia. Their median age was 52 (IQR:43-59) years. An initial diagnosis of indeterminate dysplasia was not associated with CRC (0/23; 17.7[8.1-29.6] months). Thirty six patients who had an initial diagnosis of dysplasia progressed from indeterminate to low-grade dysplasia (24.2[11.0-30.4] months). Low-grade dysplasia was associated with a 2% (1/56; T2N0M0) risk of CRC when present in random surveillance biopsies and a 3% (2/61; T1N0M0, T4N0M0) risk if detected in endoscopically visible lesions (7.4[5.2-33.3] months). Eighteen patients progressed from indeterminate to high-grade dysplasia (19.1 [9.2-133.9] months). Seventeen patients progressed from low- to high-grade dysplasia (11.0[5.8-30.1] months). None of the patients with high-grade dysplasia (0/35) progressed to CRC (4.5[1.7-9.9] months).
Dysplasia was associated with a low incidence of node negative CRC if surgery was deferred for up to five years. These findings may help inform the decision-making process for asymptomatic patients who are having to decide between intensive surveillance or surgery for UC associated-dysplasia.
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The introduction of anti-TNF (infliximab and adalimumab) has changed the management of Crohn's perianal fistula from almost exclusively surgical treatment to one with a much larger emphasis on medical therapy. The aim of this systematic review was to provide an overview of the success rates of setons and anti-TNF for Crohn's perianal fistulas.
Studies evaluating the effect of setons and anti-TNF on Crohn's perianal fistulas were included. Studies assessing perianal fistulas in children, rectovaginal and rectourinary fistulas were excluded. The primary endpoint was fistula closure rate. Partial closure and recurrence rates were secondary endpoints.
Ten studies on seton drainage were included (n=305). Complete closure varied from 13.6%-100% and recurrence from 0-83.3%. In 34 anti-TNF studies (n=1.449), complete closure varied between 16.7%-93% (partial closure: 8.0%-91.2%) and recurrence from 8.0%-40.9%. Four randomized controlled trials (n=1.028) comparing anti-TNF with placebo, showed no significant difference in complete or partial closure in meta-analysis (risk difference 0.12, -0.06-0.30 and 0.09, -0.23-0.41, respectively). Subgroup analysis (n=241) showed significant advantage for complete fistula closure with anti-TNF in two trials with follow-up >4 weeks (46% versus 13%, p=0.003 and 30% versus 13%, p=0.03). Of four included cohort studies, two revealed a significant difference in response in favour of combined treatment (p=0.001 and p=0.014).
Closure and recurrence rates after seton drainage as well as anti-TNF vary widely. Despite a large number of studies, no conclusion can be drawn regarding the preferred strategy. However, combination therapy with (temporary) seton drainage, immunomodulators and anti-TNF may be beneficial in achieving perianal fistula closure.
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Reoperation after elective colorectal resection may delay the start of adjuvant chemotherapy. The study investigated the dual impact of a reoperation and adjuvant chemotherapy (AC) delay on overall survival (OS).
The Hospital Episode Statistics (HES) database was analysed between 1997 and 2012. Patients were divided into colon and rectal cancer cohorts and data were analysed based on whether there was delay in receiving AC delay beyond eight weeks, and whether a patient suffered reoperation within 30 days. Multivariate regression analysis was undertaken to investigate the relationship between delay in givng AC and reoperation and their combined effect on OS.
Logistic regression showed reoperation, amongst others, to be an independent predictor of AC delay, in both colon and rectal cancer [colon: Odds Ratio (OR) 2.31, p<0.001; rectal: OR 2.19, p<0.001]. There was no significant difference in OS, between patients who had no AC delay but suffered a reoperation, and patients who had no AC delay and no reoperation. Patients who had AC delay but no reoperation, however, had significantly worse OS compared to those who had no AC delay and no reoperation [colon: Hazard Ratio (HR) 1.16, p<0.001); rectal: HR 1.17, p<0.001]. Individuals who had both AC delay and a reoperation also had worse overall survival compared with patients who had neither (colon: HR 1.33, p=0.037; rectal: HR1.38, p<0.001).
Delayed receipt of adjuvant chemotherapy beyond eight weeks after surgery is associated with significantly reduced overall survival regardless of reoperation status in both colon and rectal cancer patients.
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The purpose of this prospective randomised study was to compare the robot-assisted and laparoscopic ventral rectopexy procedures for posterior compartment procidentia in terms of restoration of the anatomy using MR-defecography.
Sixteen female patients (four total prolapse, 12 intussusception) underwent robot-assisted (RVMR) and 14 female patients (two prolapse, 12 intussusception) laparoscopic ventral mesh rectopexy (LVMR). Primary outcome measures were perioperative parameters, complications and restoration of anatomy as assessed by magnetic resonance (MR) defecography, which was performed preoperatively and three months after surgery.
Patient demographics, operation length, operating theatre times and length of in-hospital stay were similar between the groups. The anatomic defects of rectal prolapse, intussusception, and rectocele and enterocele were similarly corrected after rectopexy in either technique as confirmed at dynamic MR defecography. A slight residual intussusception was observed in three patients with primary total prolapse (two RVMR vs. one LVMR) and in one patient with primary intussusception (RVMR) (p=0.60). Rectocele was reduced from a mean of 33.0±14.9 mm to 5.5±8.4 mm after RVMR (p<0.001) and from 24.7±17.5 mm to 7.2±3.2 mm after LVMR (p<0.001) (RVMR vs. LVMR, p=0.10).
Robot-assisted laparoscopic ventral rectopexy can be performed safely and within the same operative time as conventional laparoscopy. Minimally invasive ventral rectopexy allows good anatomic correction as assessed by MR defecography, with no differences between the techniques.
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Delay in commencing adjuvant therapy for colorectal cancer seems to impair survival in some retrospective studies. This study was planned to evaluate its impact on survival.
This was a retrospective study enrolling patients registered from 2000 to 2012 in two large cancer-dedicated institutions in Brazil. The primary outcome was overall survival according to early versus late chemotherapy initiation. The interval between the primary surgery and the start of adjuvant chemotherapy was calculated. Survival was estimated using the Kaplan-Meier method and the impact of multiple prognostic factors on survival by Cox Regression analysis.
By the end of 2012, a total of 1963 stage II and III colorectal patients were found and 1318 patients received adjuvant chemotherapy, with 22% and 46% of those starting adjuvant chemotherapy within 6 weeks and 8 weeks of surgery. The median period of follow up was 41 months. Patients starting chemotherapy within 6-8 weeks of surgery had longer overall survival compared with those started after (6 weeks versus later HR 0.76; 95%CI 0.57-0.99, p=0.046; 8 weeks versus later HR 0.74; 95%CI 0.59-0.93, p=0.011). In the multivariate analysis, age, stage, histological grade, angiolymphatic invasion, emergency surgery and pre-operative therapy were independent prognostic factors, but the interval between surgery and start of adjuvant therapy was not.
In this large retrospective study, the standard prognostic factors impacted on survival whereas the timing of adjuvant therapy did not. Patients with delayed adjuvant chemotherapy may have worse prognostic factors which could play a major role in their poor outcome.
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The optimal extent of mesenteric resection in colon cancer surgery is not known. We have previously shown an increased mortality associated with wider mesenteric resection in right hemicolectomy. This study compares the short and long-term outcome in three variations of right hemicolectomy based on the position of the vascular ligature in the mesentery.
2084 cases of cancer in the caecum or ascending colon were identified in the Swedish ColoRectal Cancer Registry and categorized according to the position of the vascular ligature.: central ligation of ileocolic vessels (ICV) +/- right colic vessels (n=390); central ligation of ICV + right branch of middle colic vessels (MCV) (n=1360) and central ligation of ICV + central ligation of MCV (n=334).
Neither three-year overall survival, three-year disease-free survival nor local recurrence rate differed between the groups (p = 0.604; p = 0.247; p = 0.237). There was still no difference after multivariate analysis adjusted for age, sex, ASA-classification, TNM-stage and adjuvant therapy. An increased perioperative mortality was, however, observed in extended mesenteric resections, increasing from 0.8 in non-extended to 3.6% in more extended resection, p = 0.025.
The study showed no survival benefit by more extended mesenteric resection, indicating that there is no need to extend the mesenteric resection to involve the middle colic vessels in cancer of the caecum or ascending colon. On the contrary, increased perioperative mortality by more extensive mesenteric resection was noted suggesting that a more conservative approach may be favourable.
This study indicates that extensive mesenteric resection in right-sided colon cancer does not increase overall survival or produce better oncological results. These results will add new information to the existing knowledge in the field and contribute towards shaping a standardized surgery for colonic cancer.
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We were impressed by the paper of Demetter et al, which reports the accuracy of local pathologists' assessment of the grade of a rectal cancer specimen compared with a central panel of experts [1]. In the UK, the outcome measure for colorectal cancer used in the public domain is the 30-day and 90-day mortality rate. These figures represent the outcome of the patient following surgery, yet are influenced by the efforts of many members of the multi-disciplinary team and beyond, but identify only the operating surgeon [2]. Over the last decade several pathologists have reported the value of the specimen grade following rectal cancer surgery and this paper confirms the accuracy of the histopathologist in assessing the surgical ability to perform a total mesorectal excision [3]. Yet, this paper reminds us that pathologists have always been able to recognise good surgery as exemplified by the wise words of Cuthbert Dukes who in answer to a question posed at a meeting in New York in 1957 said "I should not chose the operation, but I should choose the surgeon who was to do it, and I should choose him with very great care. Then I should say to him, 'Do the operation just when and where you think is best, but please promise to go to bed the night before and get up in good time and have a good breakfast!' It would be a relief also to be assured that the operation would not be filmed or televised!" [4]. This leads us to the question, whether pathologists have always known who were the best surgeons and if so should they be informing the public?
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Anal screening is recommended in HIV-positive patients, especially men who have sex with men (MSM) due to the increasing incidence in anal cancer. The optimal screening methods are not generally agreed.
Anal lesion screening by anorectal examination including anoscopy was offered to HIV-positive outpatients in a tertiary care university hospital regardless of gender and sexual orientation.
Among the 1206 screened patients (701 MSM, 247 heterosexual men, 258 women), 311 (26%) had histologically proven HPV-related lesions (34% MSM, 14% heterosexual men, 14% women); 123 (10%) had low-grade dysplasia and 70 (6%) high-grade dysplasia. Seven anal cancers were also diagnosed. Determinants of any lesion were age < 45 years (OR= 1.56 (1.16-2.11)); a CD4 count of < 200/mm3 (OR= 2.54 [1.71-3.78]); receptive anal intercourse (OR=3.03 [2.06-4.47], Sub-Saharan African origin (OR = 0.53 [0.33-0.85]), history of HPV-related lesion (OR = 1.84 [1.35-2.51]). These determinants were similar for all different grades of dysplasia. In patient subgroup analysis, receptive anal intercourse, the CD4 cell count and a history of HPV lesions were determinants of HPV-positivity in all patients, whereas age was determinant only in men.
Anoscopy is an alternative method for anal screening in an HIV-positive population. This screening has to be compared with other tools in high risk anal cancer populations.
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Local excision or wait-and-see policy may offer the possibility of organ preservation for locally advanced rectal cancer (LARC) after preoperative chemoradiotherapy (CRT). Identifying associated factors of good responders (GR) with stage ypT0-1N0 would likely influence the selection of potential candidates that were theoretically eligible for organ-sparing management. This study was to establish a scoring system to select stage ypT0-1N0 for LARC following preoperative CRT.
Between 2009 and 2014, 262 patients with middle and low LARC were treated with CRT and radical surgery. Clinicopathological data which were found to be significantly associated with GR were incorporated into a scoring system.
Fifty seven (21.8%) patients were GR with stage ypT0-1N0 in the operative specimen. Multivariate analyses indicated that low level of pretreatment CEA and post-treatment CEA less than 2.55ng/ml (p=0.008 and p=0.009 respectively), and long-axis diameter of residual tumors (p=0.006) were independently associated with stage ypT0-1N0. The three factors were incorporated into a scoring system. Using receiver operating characteristic curve analysis, we determined a cutoff value of -0.3 for scores, at which the system's sensitivity was 71.9% and specificity 73.1%. When applied to testing sample, the sensitivity was 74.1% and specificity 76.2%.
We demonstrated that low levels of pretreatment and post-treatment CEA and the long axis diameter of residual tumors were associated with stage ypT0-1N0 for locally advanced rectal cancer after CRT. Therefore, the three-factor scoring system may be used to select potential candidates for organ-sparing management.
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It is controversial whether a high or low ligation of the inferior mesenteric artery (IMA) is superior1,2. The former allows an extended lymph node clearance whereas the latter preserves the distal vascular supply via the left colic artery (LCA). Apical lymph node dissection of the IMA (ALMA) harvests nodal tissue along the IMA proximal to the LCA whilst performing a low ligation. This anatomically replicates the oncological benefit of high ligation and vascular preservation of low ligation. Our study evaluates the nodal yield of ALMA and the short-term outcome of this technique.
We retrospectively studied 19 patients with sigmoid or rectal cancer who underwent curative surgical resection with ALMA. All ALMAs were performed with a standard technique previously described3,4. Lymph node yield from the dissection (the ALMA specimen) was compared with the total lymph node yield. Data on the LCA anatomy, time required to perform ALMA, complications and postoperative recovery were evaluated.
ALMA was successful in 18 patients. Median postoperative hospitalization was 5 (2-26) days without ALMA-related morbidity or mortality. The median lymph node yield was 20 (9-41) and a median of 14.3(0-80)% was harvested with ALMA. Two patients not having neoadjuvant chemoradiotherapy had less than 12 lymph nodes excluding nodes harvested from ALMA. The average time required for ALMA was 18 minutes.
ALMA is a safe and feasible technique allowing extended lymphadenectomy without sacrificing the LCA. In this small group of patients, none was upstaged due to cancer involvement of the proximal nodes.
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Recent data highlight the potential of more intensive neoadjuvant protocols to increase and sustain the rate of complete response in rectal cancer managed non-operatively. The study aimed to review the outcome of all patients from our district general hospitals network who had received standard neoadjuvant therapy and were additionally referred to a centre of excellence for contact X-ray brachytherapy (CXB) or HDR brachytherapy boost.
A retrospective, chart-based review of all patients co-managed in this manner was performed. Patient details were retrieved from a prospectively maintained departmental database. Indications for treatment, patient outcome and serial data from follow-up clinical and radiological assessment were analysed.
Seventeen patients treated over a six-year period were identified. Median follow up was 20 (5-54) months. Fourteen patients were clinically staged as T2 or T3 and eight were clinically node positive. Three patients died of whom only one was initially a surgical candidate but refused an exenteration. Of the 14 patients who remain alive, 11 (79%) have a sustained complete (n=8) or partial (n=3) response. Two patients had an incomplete response, one is being palliated and the other awaits salvage surgery. One patient underwent abdominoperineal resection for suspected local recurrence. Currently 13 (93%) surviving patients are stoma free.
This series shows that the addition of a radiotherapy boost offered sustained responses and stoma free survival even in advanced disease and adverse patient populations whilst providing the majority of care closer to home.
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In addition to TNM stage, there are adverse tumour and host factors, such as venous invasion and the presence of an elevated systemic inflammatory response (SIR) that influence the outcome in colorectal cancer. The present study aimed to examine how these factors varied in screen detected (SD) and non-screen detected tumours (NSD).
Prospectively maintained databases of the prevalence round of a biennial population FOBt screening programme and a regional cancer audit database were analysed. Interval cancers (INT) were defined as cancers identified within two years of a negative screening test.
Of the 395 097 invited, 204 535 (52%) responded, 6159 (3%) tested positive, and 421 (9%) had cancer detected. From this cohort, a further 708 (63%) NSD patients were identified (468 (65%) non-responders, 182 (25%) INT cancers and 58 (10%) did not attend or did not have cancer diagnosed at colonoscopy). Comparing SD and NSD patients, SD patients were more likely to be male, and have a tumour with a lower Dukes stage (both p<0.05). On stage-by-stage analysis, SD patients had less evidence of an elevated SIR (p<0.05). Both the presence of venous invasion (p=0.761) and an elevated SIR (p=0.059) were similar between those with INT cancers and in those that arose in non-responders.
Independent of TNM stage, SD tumours have more favourable host prognostic factors than NSD tumours. There is no evidence that INT cancers are biologically more aggressive than those that develop in the rest of the population and hence are likely to be due to limitations of screening in its current format.
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Colonoscopy performed as part of the NHS Bowel Cancer Screening Programme (BCSP) is of high standard as measured using Global Rating Scale (GRS) criteria. Screening practitioners also provide a non-screening colonoscopy service. The current study compares colonoscopy quality indicators between screening and non-screening groups performed by a single practitioner using the GRS.
Patient details were obtained for all consecutive colonoscopies between 2007 and 2014 performed by a single screening practitioner. Data were collected retrospectively from electronic patient records; BCSP Exeter database and non-screening colonoscopies were compared. Data included patient demographics (age, gender), sedation, and the GRS data including caecal intubation, adenoma and neoplasia detection rates.
1961 colonoscopy procedures (1067 screening and 894 non-screening) were identified; 57% were male. Mean (SD) age for all patients was 64 (±10.4) years. Non-screening patients were younger (62 (±14) versus 66 (±4.8) years; p<0.05), and were less likely to be male (51.5% vs 61.9%; p<0.05) than their screening counterparts. Caecal intubation was more successful in screening patients (1027/1067 (96.3%)) than non-screening patients (805/894 (90%)); p<0.05. Adenoma detection rate was higher in the screening (46.8 ±4.4) than non-screening (26.3 ±11.8) group; p<0.05. There were no differences in neoplasia detection. Polypectomy was more likely (55.5% vs 30.2%), and polyp retrieval more successful (97.5% vs 86.7%) in the screening group.
Screening and non-screening colonoscopy differ in the GRS domains of completion and pathology detection. These differences need to be acknowledged when comparing screeners and non-screeners using GRS within units.
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This study aimed to investigate the results of salvage abdominoperineal resection (APR) in patients with persistent or recurrent squamous cell carcinoma of the anus (SCCA).
Patients with anal neoplasia were identified from a prospective database. Patients with invasive SCCA with demonstrated failure of chemoradiation therapy (CRT) who underwent salvage APR for one of three disease categories (persistent: <6 months post-CRT; early recurrent: 6-24 months; late recurrent: >24 months) were included. The primary outcome was overall survival after salvage APR. Tumour size, metastatic lymph nodes (LN), circumferential-resection margin positivity (CRM), and neurolymphovascular invasion (NLVI) were correlated with the outcome.
Thirty-six patients with a median 3-year overall survival of 46% (median follow-up: 24 months) underwent salvage APR due to persistent or recurrent SCCA (14 male, mean age 59 years). Eleven (31%) patients were diagnosed with persistent disease, 17 (47%) with early and 8 (22%) with late recurrence. Two-year overall survival of stage 0/I/II and III/IV disease was 81.5% and 33.74% (p=0.022). Overall disease stage was associated with disease categorization (p=0.009): patients with persistent disease or early recurrence had a significantly higher disease stage than patients with late recurrence (OR = 20.9 and 17.2). Despite apparently improved survival in patients with late disease recurrence on live table analysis, no significant difference was identified in overall survival when stratified by disease category on log-rank test analysis.
Persistent and recurrent disease does not show any significant difference in survival, but patients with late recurrence may have a better prognosis.
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The study used a national registry to compare the outcome after a low Hartmann's procedure (LHP), defined as removal of most of the rectum to leave a short anorectal stump and an end colostomy and low anterior resection (LA) with or without a diverting ileostomy (DI) in rectal cancer patients all of whom had received preoperative neoadjuvant radiotherapy (RT).
Patients who underwent LHP or LA with or without DI for rectal cancer after RT between 2009 and 2013 were identified from the Dutch Surgical Colorectal Audit. The postoperative outcome was compared between the three groups and risk of complications, reoperation and mortality were analysed in a multivariable model.
4288 patients were included, of whom 27.8% underwent LHP, 20.2% LA, and 52.0% LA with DI. Thirty-day mortality was higher after LHP (3.2% vs. 1.3% and 1.3% for LA with or without DI, p<0.001), but LHP was not an independent predictor of mortality in multivariable analysis. LHP and LA with DI were associated with a lower rate of abdominal infective complications (6.5% and 10.1% vs.16.2%, p<0.001) and reoperation (7.3% and 8.1% vs.16.5%, p<0.001). In multivariable analysis, LHP (OR 0.35, 95%CI 0.26-0.47) and LA with DI (OR 0.43, 95%CI 0.33-0.54) were associated with a lower risk of reoperation than LA alone. LHP was associated with a lower risk of any postoperative complication than LA with or without DI (OR 0.81, 95%CI 0.66-0.98).
LHP and LA with DI were associated with fewer infective complications and reoperations than LA alone. The thirty day mortality and the rate of any complication were less after LHR than LA with or without DI.
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Transanal endoscopic microsurgery (TEM) was originally invented by Buess (1) for the treatment of infraperitoneal rectal adenomas. Its indications have progressively expanded to include larger and more advanced lesions. The aim of the study was to report the results of TEM used for the treatment of circumferential rectal lesions.
We retrospectively reviewed the medical records of 17 consecutive patients (median age 69 (32-89) years; 9 male) who underwent TEM for a circumferential rectal lesion in our department between September 2010 and January 2015.
The median distance from the anal verge was 4 (3-11) cm, the median longitudinal extent was 7 (3-10) cm and the median surface area was 75 (40-255) cm2. An end-to-end anastomosis without proximal bowel mobilization was completed endoscopically in all cases. The median operating time was 120 (40-240) min. Persistent, endoscopically uncontrollable endoluminal bleeding in one patient was successfully treated with a second TEM procedure. One patient underwent preoperative radiotherapy for adenocarcinoma detected at the preoperative assessment. Surgical histology showed a pT3 cancer in one patient who refused further surgery, a pT2 cancer in two who subsequently underwent abdominoperineal resection, a pT1 cancer in four and a ypT0 in one patient. All are presently free of disease. No patients developed faecal incontinence or urinary or sexual dysfunction was observed. Four patients required endoscopic balloon dilatation for stenosis.
TEM is a feasible and safe technique for large circumferential lesions with a satisfactory outcome. Preoperative staging may be inaccurate.
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Novel minimally invasive techniques aimed to reposition the haemorrhoidal zone have been established for prolapsing haemorrhoids. We present a prospective randomised controlled trial to evaluate the efficacy of additional Doppler-guided ligation of submucosal haemorrhoidal arteries in patients with symptomatic grade III haemorrhoids. The trial was registered as ClinicalTrials. gov Identifier: NCT02372981.
All consecutive patients with symptomatic grade III haemorrhoids were randomly allocated to one of the two study arms: (Group A) DG-HAL with mucopexy or (Group B) mucopexy alone. End points were postoperative pain, faecal incontinence, bleeding, residual prolapse and alterations of vascularisation of the anorectal vascular plexus. Vascularisation of the anorectal vascular plexus was assessed by transperineal contrast enhanced ultrasound. Patients recorded their symptoms in a diary maintained for a month.
Forty patients were recruited and randomised to the two study groups. Patients in Group A had less pain in the first two postoperative weeks. At the 12-month follow-up, two patients in Group A (10%) and one in Group B (5%) showed recurrent grade III haemorrhoids (p=0.274). No significant morphological changes were observed in the transperineal ultrasound findings between the preoperative assessment and the assessment at 1 and 6-months in either group (p>0.05).
Mucopexy techniques for treating prolapsing haemorrhoids are effective, but Doppler-guided HAL does not add significantly to the results achieved by mucopexy Repositioning the haemorrhoidal zone is the key to success, and mucopexy should be placed at the sites of the largest visible prolapse.
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Sessile serrated adenomas/polyps (SSA/Ps) have been proposed as precursors of colorectal cancer. The aims of this investigation were to compare the endoscopic findings of SSA/Ps with those of other serrated lesions and to compare the histologic findings of SSA/Ps with those of conventional adenomas.
We retrospectively reviewed colonoscopy records from 1984 to 2013 at our institution and identified cases of endoscopically or surgically resected conventional adenomas and serrated lesions, including SSA/Ps, hyperplastic polyps (HPs) and traditional serrated adenomas (TSAs). The colonoscopic findings of SSA/Ps were compared with those of the other two serrated lesions and histologic findings were compared among all groups of lesions.
There were 79 HPs in 68 patients, 77 SSA/Ps in 63 patients, 167 TSAs in 145 patients and 6324 conventional adenomas in 4129 patients. The inverted type and flat-elevated type were more frequent among SSA/Ps than among the other two types of serrated lesions. Magnifying colonoscopy revealed that a round and open pit pattern, expanded crypt openings, and varicose microvascular vessels were more frequently observed among SSA/Ps than among the other types. The incidence of high-grade dysplasia or carcinoma among SSA/Ps (13.0%) was significantly higher than that among HPs (0%, p<0.001) and equivalent to that among conventional adenomas (12.3%).
SSA/Ps have colonoscopic features distinct from HPs and TSAs. The malignant potential of SSA/Ps seems to be equal to that of conventional adenomas.
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Pelvic exenteration is an aggressive operation for locally advanced rectal cancer. Social deprivation has been shown to reduce life expectancy and has been linked to a poorer outcome in patients with colorectal cancer. The aim of this study was to analyse the effect of social deprivation scores on the outcome in these complex patients.
A retrospective review of all patients undergoing pelvic exenteration for primary rectal cancer between 2006 and 2014 was performed. Deprivation scores were calculated for all patients using the Welsh Index of Multiple Deprivation (WIMD). Patients were then grouped into quartiles, form Q1 (most deprived) to Q4 (least deprived). The primary outcome measure was 5 year survival.
120 patients were included (65 female) with a median age of 64 (31-90) years. No differences between quartiles were identified for neoadjuvant therapy (p=0.687) or type of exenteration (p=0.690). The median length of stay was significantly higher in the most deprived groups (Q1-Q2; p=0.023). There was a significant difference in survival between the groups, with lowest five year survival rates (53%) in the most deprived quartile (Q1) (p=0.015).
Social deprivation is significantly associated with postoperative length of stay and survival in patients undergoing pelvic exenteration for primary rectal cancer.
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The analysis of the volatile part of the metabolome (Volatile Organic Compounds (VOC)) present in the gas phase of excreted materials is a promising new research field for the identification of screening tools for several cancers, including colorectal cancer (CRC). The VOC signature can reflect the health status as a 'fingerprint', which can be modified in several diseases. Technical difficulties still limit the widespread use of VOC analysis in the clinical setting, but this approach has already been applied successfully in the diagnosis of CRC. The present study reviews the available data on VOC present in DEAR AUITHOR THE WORD 'HEADSPACE' IS NOT ENGLISH AS FAR AS I KNOW. IF YOU WANT TO INCLUDE A WORD THAT IS RECOGNISED THEN PLEASE LET ME KNOW. OTHERWISE I WILL REMOVE IT FROM THE TEXT. Headspace is the word used to identify "the gaseous constituents of a closed space above liquids or solid emitting and vapors measured using headspace gas chromatography" the headspace (the gaseous constituents of a closed space above a liquid or solid) of blood, urine, faeces and breath as a potential screening tool for CRC.
A systematic electronic literature search was conducted in PubMed, Scirus and Google using the keywords Metabolomic, Volatile Organic Compounds (VOC), Electronic-nose and Colorectal Cancer. Only articles published in English between 2000-2015 were selected and independently checked by two of the authors.
Ten papers describing the reliability of VOC analysis in breath and faeces, blood and urine were selected, all indicating good reliability in detecting colorectal cancer. The use of different substrates and different analytical platforms has led to the identification of different patterns of VOC.
The reliability of a metabolomic approach in CRC screening as a non-invasive biomarker is supported by this review despite several limitation due to the number of patients included in each study, the different analytical platforms and the biological material used and different VOCs identified
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Minimally invasive approaches to proctectomy for rectal cancer have not been widely adopted due to inherent technical challenges. A modification of traditional trans-abdominal mobilization termed transanal total mesorectal excision (TaTME) has the potential to improve access to the distal rectum. The aim of the current study is to assess outcomes following TaTME for rectal cancer.
This is a retrospective analysis of a prospectively maintained database of consecutive patients who underwent TaTME for rectal cancer at a single institution. The study period was from March 1, 2012 to July 31, 2015.
During the study period 50 patients underwent TaTME. The median tumour distance from the anal verge was 4.4 (3.0-5.5) cm. The rate of conversion from a planned minimally invasive approach was 2.2%. The median operative time was 267.0 (227.0-331.0) minutes. The median lymph node yield was 18.0 (12.0-23.8), the macroscopic quality assessment of the resected specimen was incomplete in 2% and the circumferential resection margin positivity rate was 4%. Intra-operative morbidity occurred in 6% and the thirty-day morbidity rate was 36%. The median length of stay was 4.5 (4.0-8.0) days. The median follow-up was 15.1 (7.0-23.2) months, 2 patients have developed a local recurrence and 8 patients have developed distant recurrence.
These data suggest TaTME for rectal cancer is feasible with acceptable pathological outcomes and morbidity profile. Further data on functional and long-term survival outcomes are required.
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Colon cancer resection in a non-elective setting is associated with high rates of morbidity and mortality. The aim of this retrospective study is to identify risk factors for overall mortality after colon cancer resection with a special focus on non-elective resection.
Data were obtained from the Dutch Surgical Colorectal Audit. Patients undergoing colon cancer resection in the Netherlands between January 2009 and December 2013 were included. Patient, treatment and tumour factors were analyzed in relation to the urgency of surgery. The primary outcome was the thirty day postoperative mortality.
The study included 30,907 patients. In 5934 (19.2%) of patients, a non-elective colon cancer resection was performed. There was a 4.4% overall mortality rate, with significantly more deaths after non-elective surgery (8.5% vs 3.4%, P<0.001). Patients of older age and male gender, and with high comorbidity, advanced tumours, perforated tumours, a tumour in the right or transverse colon and postoperative anastomotic leakage were at risk of postoperative death. In non-elective resections, a right-sided tumour and postoperative anastomotic leakage were associated with high mortality.
Non-elective colon cancer resection is associated with high mortality. In particular, right-sided resections and patients with tumour perforation are at particularly high risk. The optimization of patients prior to surgery and expeditious operation after diagnosis might prevent the need for a non-elective resection.
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The study investigated the value of faecal lactoferrin as a follow-up biomarker for mucosal healing of ulcerative colitis during granulocyte and monocyte adsorptive apheresis (GMA) therapy.
Patients with ulcerative colitis exhibiting a moderate or severe disease activity with a partial Mayo Score (pMS) of over 4 were enrolled in this study. The patients received ten courses of GMA therapy. The pMS value and faecal lactoferrin level were monitored and compared with the findings of endoscopy until 12 months after the last dose of GMA therapy.
Twenty patients (male: female 11: 9) were enrolled in this study. Twelve had total colitis, while six had left-sided involvement and two had distal proctitis. Thirteen (65.0%) responded to GMA therapy. The faecal lactoferrin levels were significantly decreased in patients who responsed to GMA therapy (P<0.05), whereas the levels did not change in non-responders. Moreover, the faecal lactoferrin levels correlated with the endoscopic findings (r=0.792, P<0.01) and pMS scores (r=0.529, P<0.01). The correlation coefficients between the faecal lactoferrin levels and mucosal findings were higher than those observed between the pMS score and mucosal findings.
The faecal lactoferrin level is a useful biomarker of the mucosal findings in ulcerative colitis. Although endoscopy is the gold standard, the faecal lactoferrin level can be used as a biomarker during GMA therapy in patients with ulcerative colitis.
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The aim of this randomized clinical trial was to compare patients treated using a multimodal approach (enhanced recovery after surgery [ERAS]) with a special focus on counselling, to patients treated in a standard conventional care pathway, who underwent elective colorectal resection.
In a single-centre trial, adult patients eligible for open or laparoscopic colorectal resection were randomized to an ERAS programme or standard care. The primary end point was postoperative total hospital stay (THS). Identical discharge criteria were defined for both treatment groups. Secondary end points included postoperative complications, postoperative C-reactive protein levels, postoperative hospital stay (PHS), readmission rate, and mortality. All parameters were recorded before operation, on the day of surgery and daily thereafter until discharge.
Total hospital stay was significantly shorter among patients randomized to the ERAS than among the standard group (median, 5 days [range, 2-50 days] vs. median, 8 days [range, 2-48 days]; p=0.001). The two treatment groups exhibited similar outcomes regarding overall major and minor morbidity, reoperation rate, readmission rate and 30-day mortality. There were also no differences in tolerance of enteral nutrition or in the inflammatory response, as reflected by postoperative C-reactive protein levels.
ERAS care was associated with a significantly shorter length of hospital stay. Without any difference in surgical or general complications, tolerance of enteral nutrition or postoperative C-reactive protein levels, perioperative information and guidance for ensuring that patients comply with the ERAS approach appear to be important factors to reduce the length of hospital stay.
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A fair to moderate concordance in grading the total mesorectal excision (TME) surgical specimen by local pathologists and a central review panel has been observed in the PROCARE (Project on Cancer of the Rectum) project. In the present study the difference in the accuracy of prediction of oncological outcome through TME grading by local pathologists or by the review panel has been evaluated.
The quality of TME specimen was reviewed in 482 surgical specimens registered on a prospective database between 2006 and 2011. Patients with a stage IV tumour, with unknown incidence date or without follow-up information were excluded, resulting in a study population of 383 patients. Quality assessment of the specimen was based on three grades including mesorectal (MRR), intramesorectal (IMR) and muscularis propria resection (MPR). Using univariable Cox regression models local and review panel histopathological gradings of the quality of TME were assessed as predictors of local recurrence, distant metastasis and disease-free and overall survival. Differences in the predictions between local and review grading were determined.
Resection planes were concordant in 215 (56.1%) specimens. Downgrading from MRR to MPR was noted in 23 (6.0%). There were no significant differences in the prediction error between the two models; local and central review TME grading predicted the outcome equally well.
Any difference in grading of the TME specimen between local histopathologists and the review panel had no significant impact on the prediction of oncological outcome for this patient cohort. Grading of the quality of TME as reported by local histopathologists can therefore be used for outcome analysis. Quality control of TME grading is not warranted provided the histopathologist is adequately trained.
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A questionnaire completed by members of the ACPGBI in 1997 was a precursor to the PROSPER trial. It showed a significant variation in favoured practice for the surgical treatment of external rectal prolapse. We repeated the same questionnaire to assess how practice has changed since the completion of the trial and its publication.
An online survey was circulated to all members of the ACPGBI with identical questions to those used in the original in 1997.
Similar numbers of recipients responded (122/791 (15.4%) in 2014;153/600 (25.5%) in 1997). The median number of operations per surgeon per year was unchanged (6 [0-30] vs 6 [0-25]). The percentage of surgeons who favoured and abdominal approach in fit patients in 1997, rose significantly from 63.5% to 81.7% in 2014 (p<0.01)). erineal procedure (78.5% vs 93.3%), but the Altemeier procedure increased from 14.9% to 39.3%. Ventral rectopexy was the preferred abdominal approach in 2014 (48.6% vs 5.9% (p<0.01)), with 96.3% of these being performed laparoscopically. The number of surgeons carrying out posterior rectopexy decreased from 92.6% to 45.9% (p<0.01)). Only 9.9% of surgeons still undertook resection rectopexy compared with 39.7% in 1997 (p<0.01)). The numbers of surgeons favouring a perineal approach decreased (18.3% vs 36.5%) although the use of a perineal procedure in elderly or unfit patients was unchanged (38.5% vs 37.9%).Delorme's operation remained the most popular p
The surgical management of external rectal prolapse had changed. More surgeons favoured a laparoscopic abdominal approach in 2014 than in 1997 and the use of perineal approaches had decreased. Of these Delorme's operation remained the most popular but the incidence of the use of Altmeier's procedure had increased.
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This study evaluated continence, constipation, and quality of life (QOL) before and after laparoscopic ventral rectopexy (LVR)
Between February 2012 and July 2014, patients who underwent LVR for external rectal prolapse (ERP) and/or rectoanal intussusception (RAI) were prospectively included. A standard questionnaire including the Faecal Incontinence Severity Index (FISI), the Constipation Scoring System (CSS) and QOL instruments (Short-Forum 36 Health Survey (SF36), Faecal Incontinence QOL scale (FIQL), Patient Assessment of Constipation-QOL (PAC-QOL)) were administered before and after operation. Psychiatric patients and those with dementia were excluded from the study. Defaecography was performed 6 months postoperatively.
Fifty-nine patients were included in the study period and 44 (19 with ERP, 25 with RAI) completed the follow-up questionnaire and were reviewed after a median of 26 (range 12-42) months. There was no recurrent ERP. Postoperative defaecography showed new-onset RAI in 6 and persistent RAI in 1. One year after surgery, incontinence was improved in 30/39 patients (77%) and constipation in 19/32 (59%). The FISI scores reduced between preoperative status and 1 year after surgery (32 (13-61) vs. 11 (0-33), P<0.0001). The CSS scores also reduced (preoperative 12 (5-18) vs. 1 year 5 (1-12), P<0.0001). Compared to the preoperative scores, almost all of the scale scores on the three kinds of QOL instruments significantly improved overtime. The presence of new-onset or persistent RAI did not have an adverse effect on the improvement of QOL.
LVR improves both generic and symptom specific QOL with good functional results.
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This prospective cohort study was performed to evaluate the impact of complications on Quality of life (QoL) in colorectal surgery. The Clavien-Dindo complication classification (CDCC) is promising, but has not been evaluated by relating the classification to patient-reported outcome measures.
Patients undergoing colorectal surgery were evaluated prospectively 12 months postoperatively using the WHOQOL-Bref questionnaire. Patient data were prospectively recorded and complications were classified using the CDCC. Postoperative QoL in patients with minor and severe complications and patients without complications was compared using a general linear model. Relationships between CDCC and QoL were examined using correlations and multivariate regression.
Of 218 patients, 130 (59.6%) had complications. In patients with severe complications there was a greater decrease in overall QoL (p=0.043), QoL-physical (p<0.001) and QoL-psychological domain (p=0.013) in the first six postoperative weeks, whereas patients with minor complications had QoL scores comparable to patients without complications. QoL recovered to preoperative levels in all groups at 12 months. Change in QoL at six weeks significantly correlated with CDCC grade, especially in the physical domain (Spearman's rho -0.287, p<0.001). The presence of severe complications was an independent predictor of Overall QoL, QoL-physical domain and QoL-psychological domain at six weeks.
Severe complications are associated with reduced postoperative QoL at 6 weeks, but QoL recovers after 12 months. CDCC grade negatively correlates with change in QoL in the early postoperative period. These findings support the theoretical framework of the CDCC.
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Several sphincter-preserving techniques have been described with extremely encouraging initial reports. However, more recent studies have failed to confirm the positive early results. We evaluate the adoption and success rates of advancement flap procedures (AFP), fibrin glue sealant (FGS), anal collagen plug (ACP) and ligation of intersphincteric fistula tract (LIFT) procedures based on their evolution in time for the management of anal fistula.
A PubMed search from 1992 to 2015. An assessment of adoption, duration of study and success rate was undertaken.
We found 133 studies (5604 patients): AFP (40 studies, 2333 patients), FGS (31 studies, 871 patients), LIFT (19 studies, 759 patients), ACP (43 studies, 1641 patients). Success rates ranged from 0% to 100%. Study duration was significantly associated with success rates in AFP (P = 0.01) and FGS (P = 0.02) but not in LIFT or ACP. The duration of use of individual procedures since first publication was associated with success rate only in AFP (P = 0.027). There were no statistically significant differences in success rates relative to the number of the patients included in each study.
Success and adoption rates tend to decrease with time. Differences in patient selection, duration of follow-up, length of availability of the individual procedure and heterogeneity of treatment protocols contribute to the diverse results in the literature. Differences in success rates over time were evident, suggesting that both international trials and global best practice consensus are desirable. Further prospective randomized controlled trials with homogeneity and clear objective parameters would be needed to substantiate these findings.
Although the oncological adequacy of laparoscopic rectal resection (LR) appears equivalent to open resection (OR), its benefit is controversial in the elderly. The aim of this study was to investigate the influence of LR on morbidity and mortality in octogenarians.
This was a retrospective analysis of all patients who underwent rectal surgery for cancer between 2003 and 2013 in a teaching hospital. The primary aim of the study was to assess the influence of surgical approach on mortality and morbidity of rectal resection in patients ≥ 80 years old. Regression analysis was performed to control the effect of covariables on the clinical outcome.
Of 408 patients 203 were in the LR group and 205 in the OR group including 303 (74.3%) less than 80 years and 105 (25.7%) over 80 years. The mortality was lower in the LR group compared with the OR group for patients under 80 years (0% vs 4.6%; P = 0.049) and no different in the over 80 group (11.5% vs 9.4%; P = 0.859). In younger patients, the OR group showed longer hospital stay (9 vs 7 days; P < 0.001) and more complications (44.1% vs 29.8%; P = 0.042). Medical complications were more frequent in LR group than OR group octogenarians (40.4% vs 20.8%; P = 0.009) as well as grade C anastomotic leakage (13.8 vs 10.7; P = 0.041).
LR for rectal cancer showed clinical advantages in patients under 80 years and was as safe as OR in patients over 80 years, although the advantages of laparoscopic surgery were lost in the elderly group due to a higher rate of medical complications. OR may be an option in elderly patients with important comorbidities.
Many perianal fistulae in Crohn's disease do not respond to conventional surgical and medical management and recurrence rates are high. The study evaluated the safety and feasibility of allogeneic adipose-derived stem cells for the treatment of perianal fistula in Crohn's disease.
A multicentre, open-label, dose escalation pilot study was performed. The first three patients (group 1) were administered 1 × 107 cells/ml based on the size of the fistula tract. Four weeks later, after which time this dose had been confirmed to be safe, the next three patients (group 2) were administered 3 × 107 cells/ml. The end-point was complete closure at 8 weeks after the injection. Patients who attended for the 8 week assessment were followed for an additional 6 months.
There were no adverse events of Grade 3 or 4 severity and no adverse events related to the treatment with allogeneic adipose-derived stem cells. Two patients in group 1 achieved complete closure of the fistula at month 4 and month 6, and one patient in group 2 achieved complete closure at 8 weeks. The closure was sustained up to month 8 in all three of those patients.
These data suggest that allogeneic adipose-derived stem cells may be a feasible treatment option for perianal fistula in Crohn's disease.
Lipomodelling has been successfully used in reconstructive breast surgery but not yet in patients with permanent stomas.
A feasibility study of six patients with permanent stomas was undertaken. Patients underwent lipomodelling of the peristomal area. The number of leakages and quality of life were measured before and for 6 months after the procedure.
All patients reported an improvement in their stoma-related quality of life and a reduction in the number of leakages experienced (mean: 2.25 leakages/24 h before lipomodelling and 0.5 leakages/24 h after lipomodelling).
Lipomodelling appears to be an effective method to reduce stoma leakages caused by peristomal skin contour abnormalities.
Colovaginal fistula (CVF) has a negative impact on quality of life. Identifying the fistula track is a critical step in its management. In a subset of patients, localizing the fistula preoperatively can be difficult. The purpose of this report is to describe the technique and results of tandem vaginoscopy with colonoscopy (TVC).
A retrospective analysis was conducted of all patients referred to a tertiary centre with symptoms suggestive of CVF but no prior successful localization of a fistula. TVC was performed by one colorectal surgeon in the endoscopy suite under intravenous sedation.
Between 2003 and 2013, 18 patients (median age 58 years) underwent TVC. CVF was ruled out in three patients. In the remaining 15 patients, TVC documented the fistula in 13. In eight cases a wire was passed through the fistulous track from the vagina to the colon, in three the track was large enough to be traversed with the endoscope and in two a fistulous opening was noted on the vaginal side but passage of a wire to localize the opening on the colonic side was not possible due to extensive scarring. No TVC-related complications were recorded. The sensitivity, specificity, positive predictive value and negative predictive value for TVC in detecting CVF were 86.7%, 100%, 100% and 60%, respectively.
TVC is a useful technique that can localize the fistulous track in most patients with CVF.
The treatment of transsphincteric anal fistula requires a balance between eradication of the disease and preservation of faecal control. A cutting seton is an old tool that is now out of vogue for many surgeons. We hypothesized that the concept remains reliable and safe with results that exceed those reported for many of the more recently described methods.
A retrospective review was conducted of real-time electronic health records (single institution, single surgeon) of patients presenting during the 14 years between 2001 and 2014 with a transsphincteric anal fistula who were treated with a cutting seton. Excluded were patients with Crohn's disease, fistulae related to malignancy or a previous anastomosis and patients whose fistula was treated by another method including a loose draining seton. Data collection included demographics, duration of the disease, duration of the treatment, outcome and continence.
In all, 121 patients (80 men) of mean age 40.2 ± 12.2 years (range 18–76) with a mean follow-up of 5.1 ± 3.3 (1–24) months were included in the analysis. The median duration of symptoms was 6 (1–84) months; 36% had failed other fistula surgery, 12% had a complex fistula with more than one track and 35% had some form of comorbidity. The median time to healing was 3 (1–18) months; 7.4% required further surgery, but eventually 98% had complete fistula healing. The incontinence rate decreased postoperatively to 11.6% from 19% before treatment with 17/121 with pre-existing incontinence resolved and 8/107 new cases developing.
Despite its retrospective non-comparative design, the study has demonstrated that a cutting seton is a safe, well tolerated and highly successful treatment for transsphincteric anal fistula and is followed overall by improved continence. The results compare very favourably with other techniques.
Ligation of the intersphincteric fistula tract (LIFT) is a new sphincter-sparing surgical technique increasingly used to treat fistulae-in-ano yielding good results. The aim of this study was to evaluate its effectiveness in the treatment of complex fistulae-in-ano and to determine factors associated with recurrence and its subsequent management.
A prospective observational study was performed of 167 patients with complex fistula-in-ano treated by LIFT from June 2013 to January 2014. In all patients a LIFT with partial core-out of the fistula tract was performed.
There were 167 patients of mean age 43.6 ± 12.8 years. Thirty-three fistulae were recurrent. 150 were trans-sphincteric, 16 were intersphincteric and one was a suprasphincteric fistula. The median postoperative stay was 2 (range: 1–14) days (mean = 2.4 days). At follow up there was no change in continence. The median healing time was 4 (range: 1–8) weeks. Two patients developed an intersphincteric abscess needing surgical drainage healing uneventfully. The mean follow up was 12.8 [median = 12 (range: 4–22)] months. The healing rate was 94.1%. Ten (5.9%) patients developed a recurrent fistula that was managed by a second LIFT procedure in seven, a sinus tract excision with curettage in two and seton placement in one. Recurrence was significantly associated with diabetes mellitus and perianal collections and showed an increased incidence with tract abscesses and multiple tracts.
LIFT has a high success rate in complex fistulae-in-ano. Recurrence is related to diabetes mellitus, perianal collections, tract abscesses and multiple tracts and a second LIFT procedure may be feasible and efficient.
Precise information regarding the location of an anal fistula and its relationship to adjacent structures is necessary for selecting the best surgical strategy. Retrospective and cross-sectional studies were performed to determine predictive factors for recurrence of anal fistula from preoperative examination by three-dimensional endoanal ultrasound (3D-EAUS).
Patients in our tertiary centre and in a private centre specialized in proctology undergoing preoperative 3D-EAUS for cryptoglandular anal fistulae between 2002 and 2012 were included. A questionnaire was sent in September 2013 to assess the patient's condition with regard to recurrence. Variables checked for association with recurrence were gender, type of centre, previous fistula surgery, secondary track formation and classification of the fistula.
There were 143 patients of whom 96 had a low fistula treated by fistulotomy, 28 a high fistula treated by fistulectomy and 19 a high fistula treated by fistulectomy combined with a mucosal advancement flap. The median duration of follow-up was 26 (2–118) months. The fistula recurred in 40 (27%) patients. Independent risk factors included the presence of secondary track formation [hazard ratio 2.4 (95% CI 1.2–51), P = 0.016] and previous fistula surgery [hazard ratio 1.2 (95% CI 1.0–4.6), P = 0.041]. Agreement between the 3D-EAUS examination and the evaluation under anaesthesia regarding the site of the internal opening, classification of the fistula and the presence of secondary tracks was 97%, 98% and 78%.
The identification of secondary tracks by preoperative 3D-EAUS examination was the strongest independent risk factor for recurrence. This stresses the importance of preoperative 3D-EAUS in mapping the pathological anatomy of the fistula and a thorough search for secondary track formation during surgery.
This study compared the efficacy of topical captopril with topical diltiazem in the treatment of chronic anal fissure (CAF).
Fifty patients aged between 15 and 75 years with CAF were included in a prospective randomized, double-blind clinical trial. They were randomly allocated to either captopril (0.5%) cream or diltiazem (2%) cream in a dose of 2 cm of cream on the perianal skin every 12 h for 8 weeks. The intensity of pain upon defaecation was evaluated every 10 days using a visual analogue scale. Bleeding on defaecation, pruritus and the presence of perianal irritation were also recorded before and during the trial.
The average pain scores were lower in the diltiazem group on the 20th and 30th days. From day 40 to the end of the trial the average pain scores of the two groups did not differ significantly. There were no significant differences in bleeding or perianal irritation between the groups, but the incidence of pruritus was considerably higher in the captopril group, and at the end of the trial 45.8% of the patients in this group still suffered from pruritus.
Topical captopril and diltiazem were found to be equally effective in the management of pain, bleeding and perianal irritation due to CAF, but due to the high incidence of pruritus observed with topical captopril this medication is not recommended for the treatment of CAF.
The pathogenesis of inflammatory bowel diseases remains unclear. Genetic and environmental factors are involved. Studies of the association between tonsillectomy and inflammatory bowel disease have yielded conflicting results.
PubMed and EMBASE were searched to identify studies evaluating the association between tonsillectomy and inflammatory bowel disease [Crohn's disease (CD) and ulcerative colitis (UC)]. Odds ratios with 95% CI were calculated using a random- or fixed-effects model. The χ2 test and I2 test were used to assess homogeneity. Egger's test was used to evaluate publication bias.
Thirteen observational case–control studies including 4122 patients (3035 UC/1087 CD) and 5103 controls were analysed. The summary odds ratio estimated for UC following a tonsillectomy was 0.932, 95% CI 0.819–1.062. The odds ratio for CD following a tonsillectomy was 1.194, 95% CI 0.992–1.437. Publication bias was not detected (Egger's test coefficient −3.50 to 1.55; P = 0.39).
No obvious association between tonsillectomy and inflammatory bowel disease was identified in our meta-analysis.
Clostridium difficile infection (CDI) of the ileal pouch following restorative proctocolectomy (RPC) is becoming increasingly recognized. We aimed to understand better (i) the associated risk factors, (ii) treatment practices and (iii) the pouch diversion and failure rate in patients who developed CDI of the pouch after RPC for ulcerative colitis (UC).
Patients who tested positive for C. difficile of the pouch between 2007 and 2010 were included in the analysis. Data collected included patient demographics, time from RPC to documented CDI, the treatment of CDI and rate of excision of the pouch.
Of 2785 patients recorded in the hospital CDI database, 15 had had an RPC with ileal pouch anal anastomosis. The median age was 44 years and the median interval from RPC to first documented episode of CDI was 3 years. Thirteen (81%) patients had had multiple episodes of pouchitis before and after CDI infection, and all were symptomatic at the time of testing for CDI. Within 30 days of the diagnosis of CDI, six (40%) patients were taking immunosuppressive medication, seven (47%) were taking a proton pump inhibitor and 12 (80%) had received antibiotics. Five patients required hospitalization for CDI and four had severe infections characterized by a serum creatinine more than 1.5 times baseline (n = 3) and a white cell count above 15 000 (n = 1). Six patients who underwent endoscopy had severe inflammation of the pouch including the presence of a pseudomembrane in one case. Ten patients were treated with metronidazole alone and five with vancomycin. Two patients had recurrent CDI of the pouch during a median follow-up period of 2.9 years and one had CDI refractory to medical management. This patient required diversion of the pouch with an ileostomy for refractory CDI but no patient required excision of the pouch.
All 15 patients developing CDI of the pouch were successfully treated with antibiotics and only one required surgery in the form of an ileostomy.
Percutaneous tibial nerve stimulation (PTNS) is a minimally invasive treatment for faecal incontinence. Many patients with faecal incontinence have coexisting pelvic floor disorders such as urinary incontinence and vaginal symptoms. We utilized a pelvic floor assessment tool to analyse any effect of PTNS on global pelvic floor function.
Patients with faecal incontinence attending our institution who had failed to respond sufficiently to biofeedback were offered a course of PTNS. Patients underwent pre- and post-stimulation assessment with a validated electronic Personal Assessment Questionnaire – Pelvic Floor (ePAQ-PF) for pelvic floor disorders. Scores were compared to assess the effect of treatment on global pelvic floor function.
During the study period pre- and post-stimulation ePAQ-PF data were available for 60 patients (55% of all patients starting PTNS). In this cohort there was a significant improvement in bowel continence, bowel related quality of life, irritable bowel syndrome and bowel evacuation with a large effect size for continence and bowel related quality of life. There was also a significant improvement in non-bowel related symptoms, including urinary pain and stress incontinence, urinary related quality of life and bowel related sexual function. Sixty-five per cent of those who answered the question reported improvement in global health after stimulation.
For patients presenting with faecal incontinence, PTNS appears to have a positive effect on bowel related function in approximately two-thirds of patients. However, for treatment responders, improvement appears to relate mainly to improvement in bowel related function rather than a global pelvic floor effect.
Pilonidal disease (PD) is a common inflammatory disease of the gluteal fold, resulting in recurrent acute/chronic infection at the level of the natal cleft. In this study, endoscopic pilonidal sinus treatment (EPSiT), a new endoscopic minimally invasive procedure, was evaluated for its effectiveness in treating PD.
Two hundred and fifty prospective patients with chronic PD were enrolled in a prospective multicentre study conducted at a secondary and tertiary colorectal surgery centre. The primary end-point of this study was wound healing, and the short-/long-term outcomes such as healing time, morbidity rate and recurrence rate were analysed. The secondary end-point of this study was quality of life (QoL).
The complete wound healing rate was 94.8%, and the mean complete wound healing time was 26.7 ± 10.4 days. The incomplete healing rate (5.2%) was significantly related to the number of external openings (P = 0.01). There was no difference in the failure rate when EPSiT was performed as the first-line treatment for PD or when it was used after unsuccessful procedures (P = n.s.). Recurrence occurred in 12 cases (5%). The QoL significantly increased from preoperative levels 15 days after the EPSiT procedure (45.3 vs 7.9; P < 0.0001).
The EPSiT procedure is a safe and effective technique for treating PD. It provides better short- and long-term outcomes than various other techniques that are more invasive. EPSiT is a minimally invasive outpatient procedure, which is associated with a quick recovery and a good QoL outcome.
The aim of this technical note is to describe a three-step technique for expeditious and complete mobilization of the splenic flexure (CMSF) during single docking totally robotic rectal cancer surgery.
A prospectively maintained database was searched for all patients who underwent single docking totally robotic rectal cancer surgery with CMSF through a stepwise technique.
We studied 89 patients underwent CMSF during single docking totally robotic lower anterior resection for rectal cancer.
The technique demonstrates that CMSF can be performed with a standardized approach using the natural embryological planes of surgery. Moreover, this technique does not involve any change in patient's position on the operating table or undocking the robotic system. We have included an intra-operative video recording to demonstrate the technique.