The risk of long-term bowel dysfunction after resection for sigmoid adenocarcinoma: a cross-sectional survey comparing complete mesocolic excision with conventional surgery

The association between the cutaneous sensory block area, the surgical incision's location, and the block's analgesic efficacy: a post hoc sensitivity analysis of data from a controlled randomised multicentre trial

BACKGROUND

Transversus abdominis plane blocks are widely used, but the association between the cutaneous sensory block area and the analgesic effect is still debated. We aimed to determine the relationship between the cutaneous sensory block area, the surgical incision's location, and the block's analgesic efficacy.

METHODS

A sensitivity analysis of data from a multicentre, patient-, clinician-, investigator-blinded, placebo- and active-controlled, 3-arm randomised clinical trial. Patients undergoing minimally invasive colon surgery were included from four hospitals across Denmark between January 2021 and February 2024. In this sensitivity analysis, we used our previously collected data of the cutaneous sensory block area to examine the efficacy of two different approaches to the transversus abdominis plane block, as compared to each other and placebo based on incision location. The primary outcome was total morphine dose equivalents administered in the first 24 h after minimally invasive surgery in patients receiving either a Pfannenstiel or a supraumbilical transverse incision.

RESULTS

We found that the subcostal dual laparoscopic-assisted transversus abdominis plane block was superior to both the ultrasound-guided posterior transversus abdominis plane block and placebo in patients with a Pfannenstiel incision with an absolute difference of - 8.9 mg (95% CI, - 16.5 to - 1.3 mg; p = 0.02) and - 10.3 mg (95% CI, - 17.0 to - 3.6 mg; p < 0.01) morphine dose equivalents, respectively. No difference was found for the supraumbilical transverse incision. Patient-reported outcome measures favoured the laparoscopic-assisted block, with an absolute difference of 13 (95% CI, 1.7-24.3; p = 0.025) in the Quality of Recovery-15 score compared to placebo.

CONCLUSION

The effect of the transversus abdominis plane block seems to be independent of the distribution of the cutaneous sensory block area of the approach. The laparoscopic-assisted subcostal transversus abdominis plane block reduced postoperative pain with a high QoR-15 score.

Chronic pain after colorectal cancer treatment: A population-based cross-sectional study

AIMS

With the recently validated tool for estimating chronic pain after colorectal cancer surgery, the aims of this study were to calculate the prevalence and to identify predictive risk factors for chronic pain after colorectal cancer treatment.

METHOD

Clinical data from colorectal cancer patients treated between 2001 and 2014 were obtained from the Danish Colorectal Cancer Group database. In 2016, all survivors were invited to participate in a national cross-sectional questionnaire study on long-term functional outcomes, including the chronic pain questionnaire. The prevalence of chronic pain was analysed in groups based on demographic data and treatment-related factors. Multivariate logistic regression analysis was performed to determine significant predictors of chronic pain, displayed as odds ratios (OR) and 95% confidence intervals.

RESULTS

The response rate was 63.8%, representing 11 600 patients (7127 colon and 4473 rectal cancer patients). The overall prevalence of pain was 41.5%, with 15.4% having major pain. Major pain was more prevalent in rectal cancer patients than colon cancer patients (16.7% vs. 14.5%, p < 0.001). Predictors for major pain were: young age <60 years [OR 1.7 (95% CI 1.51-1.91)]; female sex [OR 1.63 (95% CI 1.46-1.82)]; an open surgical approach [OR 1.18 (95% CI 1.05-1.33)]; chemotherapy [OR 1.32 (95% CI 1.18-1.49)]; radiotherapy [OR 1.39 (95% CI 1.17-1.65)]; permanent stoma [1.56 (95% CI 1.31-1.86)]; comorbidity [OR 1.69 (95% CI 1.5-1.9)]; anastomotic leakage [OR 1.31 (95% CI 1.05-1.64)].

CONCLUSION

Chronic pain is prevalent after colorectal cancer surgery. All patients should be informed about the risks before cancer treatment, particularly those who are at an increased risk of developing major pain.

Management of obstructed colorectal carcinoma in an emergency setting: An update

Colorectal carcinoma is common, particularly on the left side. In 20% of patients, obstruction and ileus may be the first clinical manifestations of a carcinoma that has advanced (stage II, III or even IV). Diagnosis is based on clinical presentation, plain abdominal radiogram, computed tomography (CT), CT colonography and positron emission tomography/CT. The best management strategy in terms of short-term operative or interventional and long-term oncological outcomes remains unknown. For the most common left-sided obstruction, the first choice should be either emergency surgery or endoscopic decompression by self-expendable metal stents or tubes. The operative plan should be either one-stage or two-stage resection. One-stage resection with on-table bowel decompression and irrigation can be accompanied or not accompanied by proximal defunctioning stoma (colostomy or ileostomy). Primary anastomosis is more convenient but has increased risks of anastomotic leakage and morbidity. Two-stage resection (Hartmann's procedure) is safer and the most widely used despite temporally affecting quality of life. Damage control surgery in high-risk frail patients is less frequently performed since it can be successfully substituted with endoscopic stenting or tubing. For the less common right-sided obstruction, one-stage surgical resection is more beneficial than endoscopic decompression. The role of minimally invasive surgery (laparoscopic or robotic) is a subject of debate. Emergency laparoscopic-assisted management is advantageous to some extent but requires much expertise due to inherent difficulties in dissecting the distended colon and the risk of rupture and subsequent septic complications. The decompressing stent as a bridge to elective surgery more substantially decreases the risks of morbidity and mortality than emergency surgery for decompression and has equivalent medium-term overall survival and disease-free survival rates. Its combination with neoadjuvant chemotherapy or radiation may have a positive effect on long-term oncological outcomes. Management plans are crucial and must be individualized to better fit each case.

Functional outcome after Hartmann's reversal surgery using LARS, COREFO & QoL scores

BACKGROUND

Functional complaints after colorectal surgery have a profound effect on quality of life (QoL). Our goal was to investigate the prevalence of functional complaints and quality of life after Hartmann's reversal surgery.

METHOD

A cross-sectional study was performed where one hundred nineteen patients were included. All patients underwent Hartmann's reversal procedure between 2007 and 2019. All patients were asked to complete 3 validated questionnaires related to bowel function in benign and colorectal cancer surgery as well as general QoL.

RESULTS

The response rate was 67%. Among responders, 32.8% reported LARS-like symptoms whereas 25% had significant COREFO Scores (>15). Higher LARS and COREFO scores were significantly associated with worse global QoL and several QoL domain scores (p < 0.05).

CONCLUSION

This study highlights the prevalence of bowel dysfunction after Hartmann's reversal surgery. Patients undergoing this procedure show similar functional complaints compared to those in literature who had a resection without colostomy.

Long-term Bowel Dysfunction and Decline in Quality of Life Following Surgery for Colon Cancer: Call for Personalized Screening and Treatment

BACKGROUND

Differences in long-term outcomes regarding types of colon resections are inconclusive, precluding patient counseling, effective screening, and personalized treatment.

OBJECTIVE

This study aimed to compare long-term bowel function and quality of life in patients who underwent right or left hemicolectomy or sigmoid colon resection.

DESIGN

This was a multicenter cross-sectional study.

SETTINGS

Seven Dutch hospitals participated in this study.

PATIENTS

This study included patients who underwent right or left hemicolectomy or sigmoid colon resection without construction of a permanent stoma between 2009 and 2015. Patients who were deceased, mentally impaired, or living abroad were excluded. Eligible patients were sent the validated Defecation and Fecal Continence and Short-Form 36 questionnaires.

MAIN OUTCOME MEASURES

Constipation, fecal incontinence (both Rome IV criteria), separate bowel symptoms, and generic quality of life were the main outcomes assessed.

RESULTS

This study included 673 patients who underwent right hemicolectomy, 167 who underwent left hemicolectomy, and 284 who underwent sigmoid colon resection. The median follow-up was 56 months. Sigmoid colon resection increased the likelihood of constipation compared to right and left hemicolectomy (OR, 2.92; 95% CI, 1.80-4.75; p < 0.001 and OR, 1.93; 95% CI, 1.12-3.35; p = 0.019). Liquid incontinence and fecal urgency increased after right hemicolectomy compared to sigmoid colon resection (OR, 2.15; 95% CI, 1.47-3.16; p < 0.001 and OR, 2.01; 95% CI, 1.47-2.74; p < 0.001). Scores on quality-of-life domains were found to be significantly lower after right hemicolectomy.

LIMITATIONS

Because of the cross-sectional design, longitudinal data are still lacking.

CONCLUSIONS

Different long-term bowel function problems occur after right or left hemicolectomy or sigmoid colon resection. The latter seems to be associated with more constipation than right or left hemicolectomy. Liquid incontinence and fecal urgency seem to be associated with right hemicolectomy, which may explain the decline in physical and mental generic quality of life of these patients. See Video Abstract at http://links.lww.com/DCR/C13 .

DISFUNCIN INTESTINAL A LARGO PLAZO Y DISMINUCIN DE LA CALIDAD DE VIDA DESPUS DE LA CIRUGA DE CNCER DE COLON SOLICITUD DE DETECCIN Y TRATAMIENTO PERSONALIZADOS

ANTECEDENTES:Las diferencias en los resultados a largo plazo con respecto a los tipos de resecciones de colon no son concluyentes, lo que impide el asesoramiento preoperatorio del paciente y la detección eficaz y el tratamiento personalizado de la disfunción intestinal postoperatoria durante el seguimiento.OBJETIVO:Comparar la función intestinal a largo plazo y la calidad de vida en pacientes sometidos a hemicolectomía derecha o izquierda, o resección de colon sigmoide.DISEÑO:Estudio transversal multicéntrico.AJUSTES:Participaron siete hospitales holandeses.PACIENTES:Se incluyeron pacientes sometidos a hemicolectomía derecha o izquierda, o resección de colon sigmoide sin construcción de estoma permanente entre 2009 y 2015. Se excluyeron pacientes fallecidos, con discapacidad mental o residentes en el extranjero. A los pacientes elegibles se les enviaron los cuestionarios validados de Defecación y Continencia Fecal y Short-Form 36.PRINCIPALES MEDIDAS DE RESULTADO:Se evaluaron el estreñimiento, la incontinencia fecal (ambos criterios de Roma IV), los síntomas intestinales separados y la calidad de vida genérica.RESULTADOS:Se incluyeron 673 pacientes con hemicolectomía derecha, 167 con hemicolectomía izquierda y 284 con resección de colon sigmoide. La mediana de seguimiento fue de 56 meses (RIC 41-80). La resección del colon sigmoide aumentó la probabilidad de estreñimiento en comparación con la hemicolectomía derecha e izquierda (OR, 2,92, IC 95%, 1,80-4,75, p < 0,001 y OR 1,93, IC 95%, 1,12-3,35, p = 0,019). La incontinencia de líquidos y la urgencia fecal aumentaron después de la hemicolectomía derecha en comparación con la resección del colon sigmoide (OR, 2,15, IC 95%, 1,47-3,16, p < 0,001 y OR 2,01, IC 95%, 1,47-2,74, p < 0,001). Las puntuaciones en los dominios de calidad de vida fueron significativamente más bajas después de la hemicolectomía derecha.LIMITACIONES:Debido al diseño transversal, aún faltan datos longitudinales.CONCLUSIONES:Se producen diferentes problemas de función intestinal a largo plazo después de la hemicolectomía derecha o izquierda, o la resección del colon sigmoide. Este último parece estar asociado con más estreñimiento que la hemicolectomía derecha o izquierda. La incontinencia de líquidos y la urgencia fecal parecen estar asociadas a la hemicolectomía derecha, lo que puede explicar el deterioro de la calidad de vida física y mental en general de estos pacientes. Consulte Video Resumen en http://links.lww.com/DCR/C13 . (Traducción-Dr. Yolanda Colorado ).

The impact of three-dimensional reconstruction and standardised CT interpretation (AMIGO) on the anatomical understanding of mesenteric vascular anatomy for planning complete mesocolic excision surgery: A randomised crossover study

BACKGROUND

Preoperative planning is a crucial aspect of safe complete mesocolic excision (CME) surgery. 3D models derived from imaging may help improve anatomical understanding of the complex vascular anatomy. Here, we assessed the effect of 3D models on surgeons' anatomical understanding in comparison to a systematic approach for CT scan interpretation (AMIGO).

METHOD

Fifteen cases were included in the study. Two GI radiology consultants reviewed each scan to ascertain the vascular anatomy. Virtual 3D models were produced and displayed on a web-based platform (https://skfb.ly/6OZUZ). A total of 13 surgical trainees were recruited. Candidates were assessed after baseline anatomical training and subsequently using the AMIGO method and 3D models. Five cases were randomly allocated in each round of testing for each participant. The primary outcome measure was an objective vascular anatomy knowledge score. The secondary outcome measure was subjective feedback from participants.

RESULTS

Both 3D and AMIGO significantly improved anatomical understanding in comparison to baseline testing. However, 3D was superior to AMIGO (3D [n = 65; median score 8/14] vs. AMIGO [n = 65; median score 6/14; p < 0.0001]. For 13/15 patient cases examined, 3D was superior to the AMIGO method. Eleven participants demonstrated better anatomical understanding using 3D models versus AMIGO. Ten participants preferred 3D models in comparison to standard CT imaging.

CONCLUSIONS

3D models improve anatomical understanding of mesenteric vascular anatomy in a group of colorectal surgical trainees in comparison to a formal CT interpretation method. 3D models may be a useful planning adjunct to 2D imaging for CME surgery.

Complete Mesocolic Excision and D3 Lymphadenectomy versus Conventional Colectomy for Colon Cancer: A Systematic Review and Meta-Analysis

BACKGROUNDS

Previous systematic reviews suggest that the implementation of 'complete mesocolon excision' (CME) for colon tumors entails better specimen quality but with limited long-term outcomes. We performed a meta-analysis to compare the pathological, perioperative, and oncological results of CME with conventional surgery (CS) in primary colon cancer.

METHODS

Embase, MEDLINE and CENTRAL databases were searched using Medical Subject Headings for CME and D3 lymphadenectomy. The systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

A total of 18,989 patients from 27 studies were included. Postoperative complications were higher in the CME group (relative risk [RR] 1.13, 95% confidence interval [CI] 1.04-1.22, I² = 0%), while no differences were observed in terms of anastomotic leak (I² = 0%) or perioperative mortality (I² = 49%). CME was associated with a higher number of lymph nodes harvested (I² = 95%), distance to high tie (I² = 65%), bowel length (I² = 0%), and mesentery area (I² = 95%). CME also had positive effects on 3- and 5-year overall survival (RR 1.09, 95% CI 1.04-1.15, I² = 88%; and RR 1.05, 95% CI 1.02-1.08, I² = 62%, respectively) and 3-year disease-free survival (RR 1.10, 95% CI 1.04-1.17, I² = 22%), as well as decreased local (RR 0.35, 95% CI 0.24-0.51, I² = 51%) and distant recurrences (RR 0.71, 95% CI 0.60-0.85, I² = 34%).

CONCLUSIONS

Limited evidence suggests that CME improves oncological outcomes with a higher postoperative adverse events rate but no increase in anastomotic leak rate or perioperative mortality, compared with CS.

A systematic review of quantitative bias analysis applied to epidemiological research

BACKGROUND

Quantitative bias analysis (QBA) measures study errors in terms of direction, magnitude and uncertainty. This systematic review aimed to describe how QBA has been applied in epidemiological research in 2006-19.

METHODS

We searched PubMed for English peer-reviewed studies applying QBA to real-data applications. We also included studies citing selected sources or which were identified in a previous QBA review in pharmacoepidemiology. For each study, we extracted the rationale, methodology, bias-adjusted results and interpretation and assessed factors associated with reproducibility.

RESULTS

Of the 238 studies, the majority were embedded within papers whose main inferences were drawn from conventional approaches as secondary (sensitivity) analyses to quantity-specific biases (52%) or to assess the extent of bias required to shift the point estimate to the null (25%); 10% were standalone papers. The most common approach was probabilistic (57%). Misclassification was modelled in 57%, uncontrolled confounder(s) in 40% and selection bias in 17%. Most did not consider multiple biases or correlations between errors. When specified, bias parameters came from the literature (48%) more often than internal validation studies (29%). The majority (60%) of analyses resulted in >10% change from the conventional point estimate; however, most investigators (63%) did not alter their original interpretation. Degree of reproducibility related to inclusion of code, formulas, sensitivity analyses and supplementary materials, as well as the QBA rationale.

CONCLUSIONS

QBA applications were rare though increased over time. Future investigators should reference good practices and include details to promote transparency and to serve as a reference for other researchers.

[Functional Results after Laparoscopic versus Robot-assisted Sigmoid Resection in Diverticulitis]

BACKGROUND

Sigmoid resection in diverticulitis is one of the most frequently performed colonic operations. A minimally invasive approach by laparoscopy is the surgical gold standard. For a few years now, sigmoid resections have also been performed robotically (da Vinci^® System). It is unclear whether there are relevant differences between the two procedures in terms of functional outcome.

METHODS

A postoperative follow-up was performed on all patients who underwent laparoscopic or robotic sigmoid resection for diverticulitis between November 2013 and November 2018, with a minimum interval of 6 months between surgery. Continence disorders, the development of symptoms compared to preoperative, changes in bowel movement (constipation, diarrhoea), impairment in daily life and pain were recorded. Differences between the groups were checked for statistical significance using the chi-square test.

RESULTS

During the study period, a total of 106 minimally invasive sigmoid resections for diverticulitis were performed (laparoscopic: n = 46, robot-assisted: n = 60). Of these, 74 patients (70%; laparoscopic: n = 28, robot-assisted: n = 46) answered the questionnaire and were included in the evaluation. Continence disorders were reported in a total of 22% of cases. There was no statistically significant difference between the groups in any of the variables surveyed.

CONCLUSION

With regard to functional results after minimally invasive sigmoid resection for diverticulitis, laparoscopic and robot-assisted sigmoid resection can be considered equivalent procedures.