A Propensity Score-Matched Analysis of the Impact of Neoadjuvant Radiation Therapy on the Outcomes of Stage II and III Mucinous Rectal Carcinoma

BACKGROUND

Patients with mucinous rectal carcinoma tend to present in advanced stage with a poor prognosis.

OBJECTIVE

This study aimed to assess the effect of neoadjuvant radiation therapy on outcomes of patients with stage II and III mucinous rectal carcinomas using data from the National Cancer Database.

DESIGN

Retrospective analysis of prospective national databases.

SETTING

National Cancer Database between 2004 and 2019.

PATIENTS

Patients with mucinous rectal carcinoma.

INTERVENTION

Patients who did or did not receive neoadjuvant radiation therapy were matched using the nearest-neighbor propensity score method for age, clinical stage, neoadjuvant systemic treatment, and surgery type.

MAIN OUTCOME MEASURES

Main outcomes of the study were numbers of total harvested and positive lymph nodes, disease downstaging after neoadjuvant radiation, and overall survival. Other outcomes were hospital stay, short-term mortality, and readmission.

RESULTS

A total of 3062 patients (63.5% men) with stage II and III mucinous rectal carcinoma were included, 2378 of whom (77.7%) received neoadjuvant radiation therapy. After 2:1 propensity score matching, 143 patients in the no neoadjuvant group were matched to 286 patients in the neoadjuvant group. The mean overall survival was similar (77.3 vs 81.9 months; p = 0.316). Patients who received neoadjuvant radiation therapy were less often diagnosed with pathologic T3 and 4 disease (72.3% vs 81.3%, p = 0.013) and more often had pathologic stage 0 and 1 disease (16.4% vs 11.2%, p = 0.001), yet with a higher stage III disease (49.7% vs 37.1%, p = 0.001). Neoadjuvant radiation was associated with fewer examined lymph nodes (median: 14 vs 16, p = 0.036) and positive lymph nodes than patients who did not receive neoadjuvant radiation. Short-term mortality, readmission, hospital stay, and positive surgical margins were similar.

LIMITATIONS

Retrospective study and missing data on disease recurrence.

CONCLUSIONS

Patients with mucinous rectal carcinoma who received neoadjuvant radiation therapy had marginal downstaging of disease, fewer examined and fewer positive lymph nodes, and similar overall survival to patients who did not receive neoadjuvant radiation. See Video Abstract .

UN ANLISIS EMPAREJADO POR PUNTUACIN DE PROPENSIN DEL IMPACTO DE LA RADIOTERAPIA NEOADYUVANTE EN LOS RESULTADOS DEL CARCINOMA MUCINOSO DE RECTO EN ESTADIO IIIII

ANTECEDENTES:Los pacientes con carcinoma mucinoso de recto tienden a presentarse en estadio avanzado con mal pronóstico.OBJETIVO:Este estudio tuvo como objetivo evaluar el efecto de la radioterapia neoadyuvante en los resultados de pacientes con carcinomas mucinosos de recto en estadio II-III utilizando datos de la Base de Datos Nacional del Cáncer.DISEÑO:Análisis retrospectivo de bases de datos nacionales prospectivas.PACIENTES:Pacientes con carcinoma mucinoso de recto.AJUSTE:Base de datos nacional sobre el cáncer entre 2004 y 2019.INTERVENCIÓN:Los pacientes que recibieron o no radioterapia neoadyuvante fueron emparejados utilizando el método de puntuación de propensión del vecino más cercano por edad, estadio clínico, tratamiento sistémico neoadyuvante y tipo de cirugía.PRINCIPALES MEDIDAS DE VALORACIÓN:Los principales resultados del estudio fueron el número total de ganglios linfáticos extraídos y positivos, la reducción del estadio de la enfermedad después de la radiación neoadyuvante y la supervivencia general. Otros resultados fueron la estancia hospitalaria, la mortalidad a corto plazo y el reingreso.RESULTADOS:Se incluyeron 3.062 pacientes (63,5% hombres) con carcinoma mucinoso de recto estadio II-III, de los cuales 2.378 (77,7%) recibieron radioterapia neoadyuvante. Después de un emparejamiento por puntuación de propensión 2:1, 143 pacientes del grupo sin neoadyuvancia fueron emparejados con 286 del grupo neoadyuvante. La supervivencia global media fue similar (77,3 vs 81,9 meses; p = 0,316). A los pacientes que recibieron radiación neoadyuvante se les diagnosticó con menos frecuencia enfermedad pT3-4 (72,3% frente a 81,3%, p = 0,013) y con mayor frecuencia tenían enfermedad en estadio patológico 0-1 (16,4% frente a 11,2%, p = 0,001), aunque con una enfermedad en estadio III superior (49,7% vs 37,1%, p = 0,001). La radiación neoadyuvante se asoció con menos ganglios linfáticos examinados (mediana: 14 frente a 16, p = 0,036) y ganglios linfáticos positivos que los pacientes que no recibieron radiación neoadyuvante. La mortalidad a corto plazo, el reingreso, la estancia hospitalaria y los márgenes quirúrgicos positivos fueron similares.LIMITACIONES:Estudio retrospectivo y datos faltantes sobre recurrencia de la enfermedad.CONCLUSIONES:Los pacientes con carcinoma mucinoso de recto que recibieron radioterapia neoadyuvante tuvieron una reducción marginal de la enfermedad, menos ganglios linfáticos examinados y positivos, y una supervivencia general similar a la de los pacientes que no recibieron radiación neoadyuvante. (Traducción- Dr Ingrid Melo ).

Surgical outcomes and predictors of overall survival of stage I-III appendiceal adenocarcinoma: Retrospective cohort analysis of the national cancer database

BACKGROUND

This study aimed to determine predictors of overall survival (OS) after surgical treatment of stage I-III appendiceal adenocarcinoma and compare the outcomes of partial colectomy and hemicolectomy.

METHODS

A retrospective analysis of the U.S. National Cancer Database (NCDB) including patients who underwent surgery for stage I-III appendiceal adenocarcinoma between 2005 and 2019 was conducted. A propensity-score matched analysis was undertaken to compare the outcomes of partial and hemicolectomy and multivariate analysis was performed to determine predictive factors of OS. The main outcome was OS and its independent predictors.

RESULTS

2607 patients (51.6 % male) with a mean age of 61.6 ± 13.9 years were included. 61.7 % of patients underwent hemicolectomy while 31.7 % underwent partial colectomy. After matching, partial colectomy, and hemicolectomy had similar OS (117.3 vs 117.2 months; p = 0.08), positive resection margins, short-term mortality, and 30-day readmission. The hemicolectomy group was associated with more examined lymph nodes and longer hospital stays. Older age (HR: 1.047, p < 0.0001), rural residence area (HR: 3.6, p = 0.025), higher Charlson score (HR: 1.6, p = 0.016), signet-ring cell carcinoma (HR: 2.37, p = 0.009), adjuvant systemic treatment (HR: 1.55, p = 0.015), positive surgical margins (HR: 1.83, p = 0.017), positive lymph nodes number (HR: 1.09, p < 0.0001), and examined lymph nodes number (HR: 0.962, p = 0.001) were independent predictors of OS.

CONCLUSIONS

Partial colectomy and hemicolectomy had similar OS and clinical outcomes. Older age, rural residence, higher Charlson score, signet-ring pathology, adjuvant systemic treatment, positive surgical margins, positive lymph node number, and examined lymph node number were independent predictors of OS.

Immunotherapy in rectal cancer patients-a propensity score matched analysis of the National Cancer Database

BACKGROUND

Rectal cancer patients with microsatellite instability (MSI-H) are candidates for immunotherapy. However, there is little evidence on its effect on overall survival (OS).

METHODS

Retrospective analysis of stage II-IV rectal adenocarcinoma patients in the National Cancer Database (NCDB) between 2010 and 2019. Propensity score matching was adjusted for baseline and treatment confounders. The cohort was divided into patients who received immunotherapy and matched controls. The primary outcome was OS.

RESULTS

5175/206,615 (2.5%) patients with rectal adenocarcinoma underwent immunotherapy. These patients were younger (58 vs 62 years; p < 0.001), more often male (64.4% vs 61.7%; p < 0.001), were more likely to have private insurance (50.8% vs 43.4%; p < 0.001), more metastatic disease at presentation (clinical TNM stage IV-80.8% vs 23.3%; p < 0.001), presented with larger tumors (median: 5 cm vs. 4.2 cm; p < 0.001) and less often underwent surgery (33.7% vs. 69.9%; p < 0.001), radiation therapy (21.5% vs 57.4%; p < 0.001), and standard chemotherapy (38.1% vs 61%; p < 0.001) than controls. After matching, 488 patients were in each group. OS was significantly shorter in the immunotherapy group (mean survival: 56.4 months (95% CI: -53.03-59.86)) compared to controls (mean survival: 70.5 months (95% CI: -66.15-74.92) (p = 0.004)). Cox regression analysis of factors associated with OS demonstrated that immunotherapy was associated with increased mortality (HR 2.16; 95% CI: 2.09-2.24; p < 0.001). After clinical staging stratification, immunotherapy was associated with improved OS in stage IV (HR 0.91, 95% CI: 0.88-0.95; p < 0.001) but lower survival in stage II (HR 2.38; 95% CI: 2.05-2.77; p < 0.001) and stage III (HR 2.43; 95% CI: 2.18-2.7; p < 0.001) patients.

CONCLUSION

Immunotherapy showed modest increase in OS in stage IV metastatic rectal cancer. OS was significantly lower in stage II-III disease treated with immunotherapy.

Distal Tumor Spread in Rectal Cancer-How Low Should We Go?

BACKGROUND

Distal tumor spread (DTS) is an adverse prognostic factor in rectal cancer correlating with advanced stage disease. We aimed to assess prevalence and location of distal tumor spread and impact of neoadjuvant chemoradiotherapy (NACRT) in patients who underwent proctectomy for rectal cancer.

METHODS

The pathology database at our institution was queried for all patients who underwent proctectomy with curative intent for rectal cancer from 1/2008 to 12/2016. Specimen slides were re-evaluated by a single expert rectal cancer pathologist to verify diagnosis and measure the distance to the distal resection margin. Main outcome measures were 3-year overall and disease-free survival.

RESULTS

275 consecutive patients were identified. 109/111 patients with clinical stage 3 disease received preoperative neoadjuvant chemoradiotherapy. DTS was found in 13 (4.7%) specimens, 6 with intra-mural and 7 with extra-mural distal tumor spread. DTS was found only in patients with clinical stage 3 disease. Length of DTS from the distal end of the tumor ranged from 0 to 30 mm; in only 4 specimens DTS was >10 mm. A positive distal resection margin was found in 5/275 (1.8%) specimens.

CONCLUSION

A macroscopically tumor-free margin may suffice in patients with pre-treatment stage 1 or 2 disease. Furthermore, a 1 cm margin is adequate in most patients with stage 3 disease.

Meta-analysis of Randomized Clinical Trials on Long-term Outcomes of Surgical Treatment of Perforated Diverticulitis

OBJECTIVE

To assess long-term outcomes of patients with perforated diverticulitis treated with resection or laparoscopic lavage (LL).

BACKGROUND

Surgical treatment of perforated diverticulitis has changed in the last few decades. LL and increasing evidence that primary anastomosis (PRA) is feasible in certain patients have broadened surgical options. However, debate about the optimal surgical strategy lingers.

METHODS

PubMed, Scopus, and Web of Science were searched for randomized clinical trials (RCT) on surgical treatment of perforated diverticulitis from inception to October 2022. Long-term reports of RCT comparing surgical interventions for the treatment of perforated diverticulitis were selected. The main outcome measures were long-term ostomy, long-term complications, recurrence, and reintervention rates.

RESULTS

After screening 2431 studies, 5 long-term follow-up studies of RCT comprising 499 patients were included. Three studies, excluding patients with fecal peritonitis, compared LL and colonic resection, and 2 compared PRA and Hartmann procedures. LL had lower odds of long-term ostomy [odds ratio (OR) = 0.133, 95% CI: 0.278-0.579; P < 0.001] and reoperation (OR = 0.585, 95% CI: 0.365-0.937; P = 0.02) compared with colonic resection but higher odds of diverticular disease recurrence (OR = 5.8, 95% CI: 2.33-14.42; P < 0.001). Colonic resection with PRA had lower odds of long-term ostomy (OR = 0.02, 95% CI: 0.003-0.195; P < 0.001), long-term complications (OR = 0.195, 95% CI: 0.113-0.335; P < 0.001), reoperation (OR = 0.2, 95% CI: 0.108-0.384; P < 0.001), and incisional hernia (OR = 0.184, 95% CI: 0.102-0.333; P < 0.001). There was no significant difference in odds of mortality among the procedures.

CONCLUSIONS

Long-term follow-up of patients who underwent emergency surgery for perforated diverticulitis showed that LL had lower odds of long-term ostomy and reoperation, but more risk for disease recurrence when compared with resection in purulent peritonitis. Colonic resection with PRA had better long-term outcomes than the Hartmann procedure for fecal peritonitis.

A Systematic Review and Meta-analysis of Randomized Clinical Trials on the Prevention and Treatment of Pouchitis after Ileoanal Pouch Anastomosis

BACKGROUND

This systematic review explored different medications and methods for prevention and treatment of pouchitis after restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA).

METHODS

PubMed, Scopus, and Web of Science were searched for randomized clinical trials that assessed prevention or treatment of pouchitis. The systematic review was reported in line with updated 2020 PRISMA guidelines. Risk of bias in the trials included was assessed using the ROB-2 tool and certainty of evidence was assessed using GRADE. The main outcomes were the incidence of new pouchitis episodes in the preventative studies and resolution or improvement of active pouchitis in the treatment studies.

RESULTS

Fifteen randomized trials were included. A meta-analysis of 7 trials on probiotics revealed significantly lower odds of pouchitis with the use of probiotics (RR: 0.26, 95% CI: 0.16-0.42, I2 = 20%, p < 0.001) and similar odds of adverse effects to placebo (RR: 2.43, 95% CI: 0.11-55.9, I2 = 0, p = 0.579). One trial investigated the prophylactic role of allopurinol in preventing pouchitis and found a comparable incidence of pouchitis in the two groups (31% vs 28%; p = 0.73). Seven trials assessed different treatments for active pouchitis. One recorded the resolution of pouchitis in all patients treated with ciprofloxacin versus 67% treated with metronidazole. Both budesonide enema and oral metronidazole were associated with similar significant improvement in pouchitis (58.3% vs 50%, p = 0.67). Rifaximin, adalimumab, fecal microbiota transplantation, and bismuth carbomer foam enema were not effective in treating pouchitis.

CONCLUSIONS

Probiotics are effective in preventing pouchitis after IPAA. Antibiotics, including ciprofloxacin and metronidazole, are likely effective in treating active pouchitis.

Segmental and extended resections provide comparable survival for clinically node-negative splenic flexure cancer: a propensity score-matched analysis of the National Cancer Database

PURPOSE

There is an ongoing debate regarding the extent of resection for splenic flexure tumors (SFT). The purpose of this study was to compare segmental and extended resections in terms of overall survival (OS) and pathologic outcomes.

METHODS

Retrospective analysis of all patients surgically treated for SFT in the National Cancer Database (NCDB) for the period 2010-2019. Outcomes of segmental and extended resections were compared and a 1:1 propensity score matching was used to match for confounders. Primary outcome was OS.

RESULTS

In total 3498/668,852 (0.5%) patients with clinical stage I-III splenic flexure adenocarcinoma in the NCDB were included. Of these, 1533 (43.8%) underwent segmental resection while 1965 (56.1%) underwent extended resection. After matching, mean OS was similar between the groups (92 vs 91 months; p = 0.94). When survival was stratified by clinical N stage, an 8-month survival benefit was shown in the extended resection group for clinical N-positive status (86 vs 78); however, this difference did not achieve statistical significance (p = 0.078). Median number of harvested lymph nodes was significantly lower in the segmental resection group (16 vs 17; p < 0.001) and the percentage of patients with  fewer than 12 harvested nodes was significantly higher (18.4% vs 11.6%; p < 0.001). Length of stay was significantly shorter in the segmental resection group (5 vs 6 days; p = 0.027). There were no significant differences between the groups in terms of 30-day readmission or 30- or 90-day mortality.

CONCLUSIONS

While segmental and extended resections were associated with similar OS for clinically node-negative SFT, there might be a survival benefit for extended resection in patients with clinical evidence of lymph node involvement.

A network meta-analysis of surgical treatments of complete rectal prolapse

PURPOSE

Surgical treatment of complete rectal prolapse can be undertaken via an abdominal or a perineal approach. The present network meta-analysis aimed to compare the outcomes of different abdominal and perineal procedures for rectal prolapse in terms of recurrence, complications, and improvement in fecal incontinence (FI).

METHODS

A PRISMA-compliant systematic review of PubMed, Scopus, and Web of Science was conducted. Randomized clinical trials comparing two or more procedures for the treatment of complete rectal prolapse were included. The risk of bias was assessed using the ROB-2 tool. The main outcomes were recurrence of full-thickness rectal prolapse, complications, operation time, and improvement in FI.

RESULTS

Nine randomized controlled trials with 728 patients were included. The follow-up ranged between 12 and 47 months. Posterior mesh rectopexy had significantly lower odds of recurrence than did the Altemeier procedure (logOR, - 12.75;  95% credible intervals, - 40.91, - 1.75), Delorme procedure (- 13.10; - 41.26, - 2.09), resection rectopexy (- 11.98; - 41.36, - 0.19), sponge rectopexy (- 13.19; - 42.87, - 0.54), and sutured rectopexy (- 13.12; - 42.58, - 1.50), but similar odds to ventral mesh rectopexy (- 12.09; - 41.7, 0.03). Differences among the procedures in complications, operation time, and improvement in FI were not significant.

CONCLUSIONS

Posterior mesh rectopexy ranked best with the lowest recurrence while perineal procedures ranked worst with the highest recurrence rates.

How reliable is restaging MRI after neoadjuvant therapy in rectal cancer?

BACKGROUND

Despite the pivotal role of magnetic resonance imaging (MRI) in rectal cancer staging and evaluation, the reliability of restaging MRI after neoadjuvant therapy is still debatable. This study aimed to assess the accuracy of restaging MRI by comparing post-neoadjuvant MRI findings with those of the final pathology.

METHODS

This study was a retrospective review of the medical records of adult rectal cancer patients who had restaging MRI following neoadjuvant therapy and prior to rectal cancer resection in a NAPRC-certified rectal cancer centre between 2016 and 2021. The study compared findings of preoperative, post-neoadjuvant MRI with final pathology relative to T stage, N stage, tumour size, and circumferential resection margin (CRM) status.

RESULTS

A total of 126 patients were included in the study. We found fair concordance (kappa -0.316) for T stage between restaging MRI and pathology report, and slight concordance for N stage and CRM status (kappa -0.11, kappa = 0.089, respectively). Concordance rates were lower for patients following total neoadjuvant treatment (TNT) or with a low rectal tumour. In total, 73% of patients with positive N pathology status had negative N status in the restaging MRI. Sensitivity and specificity regarding positive CRM in post-neoadjuvant treatment MRI were 45.45% and 70.4%, respectively.

CONCLUSION

We found low concordance levels between restaging MRI and pathology regarding TN stage and CRM status. Concordance levels were even lower for patients after TNT regimen and with a low rectal tumour. In the era of TNT and watch-and-wait approach, we should not rely solely on restaging MRI to make post-neoadjuvant treatment decisions.

Does Completeness of the Mesorectal Excision Still Correlate With Local Recurrence?

BACKGROUND

Total mesorectal excision is the standard surgical procedure for rectal cancer treatment. Several studies have shown a close correlation between the prognosis of patients with rectal cancer and the completeness of the mesorectal specimen.

OBJECTIVE

To assess the correlation between macroscopic assessment of mesorectal excision and long-term oncological outcomes.

DESIGN

Retrospective analysis of an Institutional Review Board-approved database.

SETTINGS

Tertiary referral center.

PATIENTS

Patients with rectal cancer who were operated on between March 2016 and October 2019 were classified into 3 groups based on the mesorectal specimen quality: complete, near complete, and incomplete. Only patients with a follow-up of ≥2 years and without signs of preoperative distant disease were included.

MAIN OUTCOME MEASURES

Relationship between total mesorectal excision and local and distant recurrence rates in patients with rectal cancer.

RESULTS

A total of 124 patients (35.5% females) were included in the analysis, with a mean age of 58.1 (SD 12) years and a mean BMI of 26.4 (SD 4.59) kg/m². Neoadjuvant chemoradiation was administered to 71% of patients, whereas 13.7% received total neoadjuvant therapy. Restorative procedures were performed in 107 patients (86.3%), whereas 17 patients (13.7%) underwent abdominoperineal resection. The majority of mesorectal excision specimens (87.09%) were complete or near complete. Local recurrence rates were 6.3% (1/16) in the incomplete and 7.4% (8/108) in the complete/near complete group ( p = 0.86). Metachronous distant metastases occurred in 6 patients (37.5%) in the incomplete group and in 24 patients (22.2%) in the complete/near complete group (p = 0.18). Thus, specimen quality did not appear to impact disease-free survival.

LIMITATIONS

Retrospective, single-center study with relatively short follow-up.

CONCLUSIONS

In the era of a multidisciplinary approach and extensive use of neoadjuvant therapy, macroscopic completeness of total mesorectal excision may not be as valuable a prognosticator as in the past. Larger studies with longer follow-ups are needed to clarify these preliminary findings. See Video Abstract at http://links.lww.com/DCR/C129.

LA INTEGRIDAD DE LA ESCISIN MESORRECTAL TODAVA SE CORRELACIONA CON LA RECURRENCIA LOCAL

ANTECEDENTES:La escisión total desl mesorrecto es el estándar de oro para el tratamiento del cáncer de recto. Varios estudios han demostrado una estrecha correlación entre el pronóstico de los pacientes con cáncer de recto y la integridad espécimen mesorrectal.OBJETIVO:Evaluar la correlación entre la evaluación macroscópica de la escisión mesorrectal y los resultados oncológicos a largo plazo en pacientes con cáncer de recto.DISEÑO:Análisis retrospectivo de una base de datos aprobada por el IRB.ENTORNO CLINICO:El estudio se realizó en un centro de referencia terciario de una sola institución.PACIENTES:Todos los pacientes con cáncer de recto operados entre 3/2016-10/2019. Los pacientes se clasificaron en 3 grupos, según la calidad del espécimen mesorrectal: completo, casi completo e incompleto. Solo se incluyeron pacientes con seguimiento >2 años y sin signos de enfermedad a distancia preoperatoria.PRINCIPALES MEDIDAS DE RESULTADO:Identificar la relación entre la escisión mesorrectal total y las tasas de recurrencia local y a distancia en pacientes con cáncer de recto.RESULTADOS:Se incluyeron 124 pacientes (35,5% mujeres) con una edad media de 58,1 años (DE 12) y un índice de masa corporal medio de 26,4 (DE 4,59). Se administró quimiorradiación neoadyuvante al 71% de los pacientes, mientras que el 13,7% recibió terapia neoadyuvante total. Se realizaron procedimientos de restauración en 107 pacientes (86,3%), mientras que 17 pacientes (13,7%) se sometieron a resección abdominoperineal. La mayoría (87,09%) de los especímenes de escisión mesorrectal fueron completas o casi completas. Las tasas de recurrencia local fueron 1/16 (6,3%) en el grupo incompleto y 8/108 (7,4%) en el grupo completo/casi completo ( p = 0,86). Se produjeron metástasis a distancia metacrónicas en 6 pacientes (37,5%) en el grupo incompleto y 24 (22,2%) en el grupo completo/casi completo ( p = 0,18). Por lo tanto, la calidad del espécimen no pareció afectar la supervivencia libre de enfermedad.LIMITACIONES:Estudio retrospectivo de un solo centro con pequeño número de casos y seguimiento relativamente corto.CONCLUSIÓN:En la era de un enfoque multidisciplinario y el uso extensivo de la terapia neoadyuvante, la integridad macroscópica de la escisión total del mesorrecto, puede no ser un pronóstico tan valioso como en el pasado. Se necesitan estudios más amplios con períodos de seguimiento más prolongados para aclarar estos hallazgos preliminares. Consulte Video Resumen en http://links.lww.com/DCR/C129 . (Traducción-Dr. Fidel Ruiz Healy ).

Treatment and outcome trends and predictors of overall survival of rectal melanoma: Analysis of the National Cancer Database

BACKGROUND

We aimed to assess characteristics, treatment, and outcomes of rectal melanoma (RM).

METHODS

This retrospective cohort study looked at patients with RM from National Cancer Database (2004-2019) analyzed characteristics and outcomes of the entire cohort and across three time periods (2004-2009; 2010-2014; 2015-2019). Main outcome measures were change in treatment and survival trends across time periods and overall survival (OS).

RESULTS

641 patients (58.5% female; mean age: 68.2 ± 13.6 years) were included. OS rate was 26%; median survival duration was 17.9 (IQR: 15.93-20.67) months. There was a significant decrease in the use of chemotherapy (17.3%-6.6%; p = 0.001) and surgery (62.9%-41.8%; p = 0.00004) but increased use of immunotherapy (11.9%-52%; p < 0.001) across time periods. OS was longer in the last time period than in the first two (21.8 vs 16.8 vs 16.5 months; p = 0.09). Surgical excision was an independent predictor of improved OS (HR = 0.266, 95%CI: 0.089-0.789, p = 0.017) whereas older age (HR = 1.039, 95%CI: 1.007-1.072, p = 0.016), positive resection margins (HR = 5.06, 95%CI: 1.902-13.48, p = 0.001) and metastasis (HR = 34.62, 95%CI: 3.973-301.6, p = 0.001) were predictors of poor survival.

CONCLUSIONS

Over time, chemotherapy and surgery have been used less often in the treatment of RM while the use of immunotherapy increased by more than four-fold. Older age, surgical treatment, positive resection margins, and metastasis were predictive of survival of RM.

Outcomes of graciloplasty in the treatment of fecal incontinence: a systematic review and meta-analysis of the literature

BACKGROUND

Patients with refractory fecal incontinence symptoms can be treated with several surgical procedures including graciloplasty. Reported outcomes and morbidity rates of this procedure are highly variable. The aim of this study was to assess continence rate and safety of dynamic and adynamic graciloplasty.

METHODS

PubMed and Google Scholar databases were systematically searched from inception until January 2022 according to preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. Reviews, animal studies, studies with patients < 18 years or < 10 patients, with no success rate reported or non-English text, were excluded. Main outcome measures were overall continence and morbidity rates of each technique.

RESULTS

Fourteen studies were identified, incorporating a total of 450 patients (337 females), published between 1980 and 2021. Most common etiology of incontinence (35.5%-n = 160) was obstetric trauma followed by anorectal trauma (20%-n = 90). The weighted mean rate of continence after dynamic graciloplasty was 69.1% (95% CI 0.53-0.84%, I2 = 90%) compared to 71% (95% CI 0.54-0.87, I2 = 82.5%) after adynamic. Although the weighted mean short-term complication rate was lower in the dynamic group (26% versus 40%), when focusing on complications requiring intervention under general anesthesia, there was a much higher incidence (43.4% versus 10.5%) in the dynamic group. The weighted mean rate of long-term complications was 59.4% (95% CI 0.13-1.04%, I2 = 97.7%) in the dynamic group, almost twice higher than in the adynamic group [30% (95% CI - 0.03 to 0.63), I2 = 95.8%]. Median follow-up ranged from 1 to 13 years.

CONCLUSIONS

Our data suggest that graciloplasty may be considered for incontinent patients. Dynamic graciloplasty may harbor higher risk for reoperation and complications compared to adynamic. The fact that the functional results between adynamic and dynamic graciloplasty are equivalent and the morbidity rate of adynamic graciloplasty is significantly lower reinforce the graciloplasty as an option to treat appropriately selected patients with fecal incontinence.

The effect of mechanical bowel preparation on postoperative complications in laparoscopic right colectomy: a retrospective propensity score matching analysis

PURPOSE

To assess whether full bowel preparation affects 30-day surgical outcomes in laparoscopic right colectomy for colon cancer.

METHODS

A retrospective chart review of all elective laparoscopic right colectomies performed for colonic adenocarcinoma between Jan 2011 and Dec 2021. The cohort was divided into two groups-no bowel preparation (NP) group and patients who received full bowel preparation (FP), including oral and mechanical cathartic bowel preparation. All anastomoses were extracorporeal stapled side-to-side. The two groups were compared at baseline and then were matched using propensity score based on demographic and clinical parameters. The primary outcome was 30-day postoperative complication rate, mainly anastomotic leak (AL) and surgical site infection (SSI) rate.

RESULTS

The original cohort included 238 patients with a median age of 68 (SD 13) and equal M:F ratio. Following propensity score matching, 93 matched patients were included in each group. Analysis of the matched cohort showed a significantly higher overall complication rate in the FP group (28 vs 11.8%, p = 0.005) which was mostly due to minor type II complications. There were no differences in major complication rates, SSI, ileus, or AL rate. Although operative time was significantly longer in the FP group (119 vs 100 min, p ≤ 0.001), length of stay was significantly shorter in the FP group (5 vs 6 days, p = 0.001).

CONCLUSIONS

Aside from a shorter hospital stay, full mechanical bowel preparation for laparoscopic right colectomy does not seem to have any benefit and may be associated with a higher overall complication rate.

Can preoperative CT/MR enterography preclude the development of Crohn's disease-like pouch complications in ulcerative colitis patients undergoing J pouch surgery?

AIM

We aimed to determine whether ulcerative colitis patients with preoperative negative computed tomography or magnetic resonance enterography (CTE/MRE) were less likely to develop Crohn's disease-like pouch complications (CDLPC) and establish risk factors and predictors for developing CDLPC.

METHODS

This was a single centre retrospective analysis of patients with ulcerative colitis (UC) and inflammatory bowel disease unclassified (IBDU) who underwent total proctocolectomy with ileal J-pouch between January 2010 and December 2020. The study group comprised patients with negative preoperative CTE/MRE and the control group included patients operated without preoperative CTE/MRE.

RESULTS

A total of 131 patients were divided into the negative CTE/MRE study group (76 [58%] patients) and control group (55 [42%] patients). There were no significant differences in incidence rates (21% vs. 23.6%, p = 0.83), time to developing CDLPC from ileostomy closure (22.3 vs. 23.8 months; p = 0.81), pouchitis rates (23.6% vs. 27.2%; p = 0.68), or pouch failure rates (5.2 vs. 7.2; p = 0.71). Multivariate Cox regression analysis showed backwash ileitis (HR 4.1; p = 0.03, CI: 1.1-15.1), severe pouchitis (HR 3.4; p = 0.039, CI: 1.0-10.9), and history of perianal disease (HR 3.4; p = 0.017, CI: 1.4-39.6) were independent predictors for CDLPC.

CONCLUSIONS

Negative findings on MRE/CTE prior to J-pouch surgery in ulcerative colitis should be interpreted with caution as it is does not reliably exclude or predict development of CDLPC. These patients should be preoperatively counselled concerning the possibility of developing CDLPC regardless of lack of positive findings on preoperative CTE/MRE. Patients with backwash ileitis with a previous history of perianal disease should be informed of the potentially increased risk of developing such complications.

Surgical treatment of stomal prolapse: A systematic review and meta-analysis of the literature

AIM

This study aimed to assess success, recurrence, and overall complication rates among different surgical procedures for stomal prolapse.

METHODS

This study was a PRISMA-compliant systematic review. PubMed, Scopus, and Google Scholar were searched until March 2022. Studies that assessed surgical treatments of stomal prolapse in adults were included. The primary outcome was recurrence of stomal prolapse and the secondary outcome was 30-day complications. A random-effect meta-analysis was used to estimate the weighted mean rates of recurrence.

RESULTS

Six studies published (111 patients; 103 males) were included. 52 (46.8%) patients had end colostomies, 35 (31.5%) had loop colostomies. Seven procedures were assessed and included local stoma reconstruction (40%), stapled local repair (27%), modified Altemeier technique (10%), mesh strip repair (9%), stoma relocation (6%) redo laparotomy repair (5%), and colectomy and end ileostomy (3%). The weighted mean recurrence rate after local stoma reconstruction was 37.2% (95% CI: -1.8 to 76.3), higher than that after the stapled local repair technique (14.9%; 95% CI: 1.7-28.2). The crude recurrence rate of the modified Altemeier technique was 20%, and of stoma relocation was 66.6%. No recurrence was detected after the mesh strip technique (n = 10). The median follow-up ranged between 7 months and 2.5 years.

CONCLUSION

Several surgical techniques are available to treat stomal prolapse. Local stoma reconstruction may be associated with high rates of recurrence while the stapled local repair and modified Altemeier procedure has relatively low recurrence. Further larger studies are needed to compare the efficacy of these techniques.

Predictors and outcomes of positive surgical margins after local excision of clinical T1 rectal cancer: A National Cancer Database analysis

BACKGROUND

Transanal local excision and the use of specialized platforms has become increasingly popular for early-stage rectal cancer. Predictors and outcomes of positive resection margins following transanal local excision for early-stage rectal cancer have yet to be explored.

METHODS

This was a retrospective analysis of the National Cancer Database of all patients with clinical nonmetastatic node negative T1 rectal adenocarcinoma who underwent transanal local excision from 2004 to 2017. Patients with positive surgical margins were compared to those with negative resection margins to determine factors associated with predictors and outcomes of positive surgical margins after transanal local excision. The main outcome measure was overall survival.

RESULTS

Of 318,548 patients with rectal adenocarcinoma in the National Cancer Database, 9,078 (2.8%) met the inclusion criteria. The positive surgical margins rate was 7.4%. Predictors of positive surgical margins were older age (odds ratio, 1.03; P < .001), higher Charlson comorbidity index (odds ratio, 1.24; P = .004), poorly differentiated carcinomas (odds ratio, 1.89; P < .001), mucinous (odds ratio, 2.36; P = .003) and signet-ring cell carcinomas (odds ratio, 4.7; P = .048). Independent predictors of reduced survival were older age (hazard ratio, 1.062; P < .001), male sex (hazard ratio, 1.214; P = .011), Charlson comorbidity index 3 (hazard ratio, 1.94; P < .001), pathologic T2 (hazard ratio, 1.27; P = .036) and T3 stages (hazard ratio, 1.77; P = .006), poorly differentiated carcinomas (hazard ratio, 1.47; P = .008), and positive surgical margins (hazard ratio, 1.374; P = .018). The positive surgical margins group's median overall survival was significantly shorter (88 vs 159.3 months, P < .001).

CONCLUSION

Positive surgical margins after transanal local excision for early-stage node-negative rectal cancer adversely affects prognosis. Older male patients with higher Charlson comorbidity index scores and poorly differentiated mucinous or signet cell histology tumors are at risk for positive surgical margins. Patient selection according to these suggested criteria may help avoid positive surgical margins.

The importance of surgical resection in the management of rectal sarcoma: A national cancer database analysis of 133 cases

BACKGROUND AND PURPOSE

Rectal sarcomas (RS) are rare malignant tumors with a very poor prognosis. This study aimed to assess the characteristics, treatment, and outcomes of RS in the United States.

METHODS

This study was a retrospective analysis of the National Cancer Database (NCDB) from 2004 to 2019 of patients with a diagnosis of RS. The main outcome measures were overall survival (OS) and its predictors.

RESULTS

133 RS patients (39.1% female) with a mean age of 65.7 ± 15.6 years were included in the study. Mean tumor size was 6.1 ± 3 cm. The crude OS rate was 22.5% and median survival duration was 10.1 (IQR: 3.2-21) months. Factors associated with an improved OS on were private insurance (HR = 0.23, p = 0.001) and undergoing surgery (HR 0.23, p < 0.001), Factors associated with poor survival were age (HR 1.02, p = 0.005), male sex (HR 2.27, p = 0.001), Charlson score of 3 (HR 5.17, p = 0.003), and positive resection margins (HR: 2.64, p = 0.01). Multivariate Cox regression analysis revealed that male sex (HR 2.16, p = 0.04) and positive resection margins (HR 2.31, p = 0.03) were predictors of poor survival whereas surgery was an independent predictor of improved OS (HR 0.321, p < 0.001) CONCLUSIONS: RS is a very rare rectal malignancy with an even poorer prognosis than previously reported. However, undergoing surgery with curative intent while obtaining negative margins may confer better OS.

Trends in the Characteristics, Treatment, and Outcomes of Rectal Adenocarcinoma in the US From 2004 to 2019: A National Cancer Database Analysis

Importance

Rectal cancer management has significantly evolved over the last 2 decades.

Objective

This study aimed to evaluate trends in the characteristics, treatment, and outcomes of rectal adenocarcinoma across 16 years.

Design, Setting, and Participants

This retrospective, observational case series study used data from the National Cancer Database (NCDB) to evaluate patients diagnosed with rectal adenocarcinoma from 2004 through 2019. Data analysis was performed from March to May 2022.

Exposures

Trends in the treatment and outcomes of rectal adenocarcinoma in the US between 2004 and 2019 were explored. This period was subdivided into 4 equal periods: 2004-2007, 2008-2011, 2012-2015, and 2016-2019.

Main Outcomes and Measures

Patient and tumor characteristics, treatments, short-term outcomes, and overall survival.

Results

A total of 318 548 patients diagnosed with rectal adenocarcinoma were included in the analysis, 191 369 (60.1%) of whom were males and 127 179 (39.9%%) were females. The mean (SD) age of the patients was 63.5 (13.4) years, and 46 824 patients (14.8%) were younger than 50 years. Among the patients, 10 859 (3.4%) were of Asian race and ethnicity, 28 464 (8.9%) were Black, and 271 236 (85.1%) were White. The percentage of patients younger than 50 years who were diagnosed with rectal cancer increased by 1.5%, from 13.9% in period 1 to 15.4% in period 4. Patients in the last period (2016-2019) presented more often with stages III (36.2% vs 30.2% vs 25.0% vs 23.4%; P < .001) and IV (21.5% vs 19.3% vs 18.1% vs 18.6%; P < .001) disease compared with those in the remaining 3 periods. The use of chemotherapy (36.8% vs 48.1% vs 49.1% vs 47.0%; P < .001) and immunotherapy (0.4% vs 0.2% vs 3.5% vs 6.5%; P < .001) significantly increased across the 4 periods. Although neoadjuvant radiotherapy was used more often across the periods studied (28.6% in period 1 to 34.3% in period 4), the use of adjuvant radiotherapy was reduced by half (12.9% to 6.0%). The median (IQR) time from diagnosis to definitive surgery increased from 95 (15-126) days in period 1 to 128 (47-158) days in period 4. The rate of use of open surgery decreased by half (60.1% in period 2 to 30.1% in period 4), and the use of robotic surgery significantly increased (5.2% in period 2 to 28.4% in period 4). The conversion rate was significantly reduced (11.2% in period 2 to 7.3% in period 4) and the median (IQR) hospital stay decreased by 2 days, from 6 (3-9) days to 4 (2-7) days. The median (IQR) overall survival significantly increased across the periods (from 83.1 months [95% CI, 81.8-84.6 months] in period 1 to 92.1 months [95% CI, 90.2-93.6 months] in period 3; P < .001).

Conclusion and Relevance

The findings of this case series study suggest a treatment trend of increased use of chemotherapy, immunotherapy, sphincter-saving surgery, and minimally invasive surgery. In addition, the time between diagnosis and definitive surgery increased by a median of 33 days. This treatment trend was associated with a significant improvement in the overall survival, reduction in the conversion rate by 3.9%, and a 2-day shorter hospital stay. These findings have major clinical relevance to the management of rectal cancer. The improvements seen in short-term outcomes and survival of patients diagnosed with rectal cancer can probably be attributed to the treatment trends observed. Continued improvement in outcomes warrant further updates in treatments.

A National Cancer Database analysis of the predictors of unplanned 30-day readmission after proctectomy for rectal adenocarcinoma: The CCF RETURN-30 Score

BACKGROUND

Unplanned 30-day readmission is common after major surgery, including rectal cancer surgery. The present study aimed to assess the rate and predictors of unplanned 30-day readmission after proctectomy for rectal cancer.

METHODS

This was a retrospective case-control study using data from the National Cancer Database. Patients with non-metastatic rectal cancer who underwent proctectomy were included, and patients who required readmission within 30 days after discharge were compared to patients who were not readmitted in regard to patient and treatment baseline factors to determine the predictors of 30-day readmission after proctectomy. The main outcome measures were the rate and predictors of 30-day unplanned readmission and the impact of readmission on short-term mortality and overall survival.

RESULTS

A total of 55,181 patients (60.9% men) with a mean age of 61.2 years were included. The 30-day readmission rate was 7.07% (95% confidence interval: 6.9-7.3). A Charlson score of 0 (odds ratio: 0.75, P < .001), Medicare insurance (odds ratio: 0.836, P = .04), and private insurance (odds ratio: 0.73, P = .0003) were predictive of a lower likelihood of 30-day readmission, whereas urban living area (odds ratio: 1.18, P = .01), rural living area (odds ratio: 1.65%, P = .0004), neoadjuvant radiation therapy (odds ratio: 1.37, P = .001), pull-through coloanal anastomosis (odds ratio: 1.37, P = .0005), conversion to open surgery (odds ratio: 1.25, P = .001), and hospital stay ≥6 days (odds ratio: 1.02, P < .001) were predictive of a higher likelihood of 30-day readmission. Readmitted patients had a higher rate of 90-day mortality (3.1% vs 2.1%, P < .001) and a lower 5-year overall survival (67.0% vs 72.7%, P < .001) than non-readmitted patients. Using the weighted ORs of the significant predictors of 30-day readmission, a risk score, the Cleveland Clinic Florida REadmission afTer sUrgery for Rectal caNcer in 30 days (RETURN-30) score, was developed.

CONCLUSION

Comorbidities, residence in urban or rural areas, neoadjuvant radiation therapy, pull-through coloanal anastomosis, conversion to open surgery, and extended hospital stay were predictive of a higher risk of 30-day readmission. Patients who were readmitted had a higher rate of 90-day mortality and a lower 5-year overall survival.

Risk factors and predictors of 30-day complications and conversion to open surgery after repeat ileocolic resection of Crohn's disease

BACKGROUND

Repeat ileocolic resection of Crohn's disease (CD) is a challenging procedure that can be followed by a high rate of complications. The present study aimed to identify the factors associated with complications and conversion to open surgery in patients undergoing repeat ileocolic resection for CD.

METHODS

This was a retrospective review of an IRB-approved prospective database of CD patients who underwent elective repeat ileocolic resection between 2011 and 2021. Univariate and multivariate analyses were performed to determine the predictive factors of postoperative complications and conversion to open surgery.

RESULTS

The present study included 65 patients (47.7% male) with a mean age of 52.5 years. 43.1% of patients developed short-term complications, most of which were of Clavien-Dindo class I-II. Longer operative time was found to be an independent predictor of complications (OR 1.016, p = 0.014). The preoperative use of biological therapy was an independent protective factor from complications (OR 0.243, p = 0.016). The only significant risk factor of a longer operation time was higher BMI (OR 3.11, p = 0.044). Overall, 28.1% of laparoscopic procedures were converted to laparotomy. According to bivariate analysis, previous ileocolic open resection (OR 190, p < 0.0001), longer operation time (OR 1.01; p = 0.036), and takedown of incidental fistula of incidental fistula (OR 3.78, p = 0.04) were associated with higher odds of conversion to open surgery.

CONCLUSION

Longer operation time was significantly associated with and predictive of complications after repeat ileocolic resection of CD. Preoperative biological therapy was predictive of a lower rate of complications. Previous ileocolic resection by laparotomy, longer operation time, and takedown of fistula were associated with a higher likelihood of conversion to open surgery.

Concordance between clinical and pathologic assessment of T and N stages of rectal adenocarcinoma patients who underwent surgery without neoadjuvant therapy: A National Cancer Database analysis

BACKGROUND

Clinical assessment of T and N stages in rectal cancer is important to guide decision-making. The present study aimed to assess the accuracy of the clinical T and N staging of rectal cancer compared to the pathological staging and their overall agreement in a large cohort of patients.

METHODS

This retrospective study used data from the National Cancer Database (NCDB) between 2004 and 2017. Patients with non-metastatic rectal adenocarcinoma who did not receive neoadjuvant therapy were reviewed and the clinical T and N stages were compared to their pathologic counterparts. The overall concordance between clinical and pathologic assessments was calculated using Kappa coefficient.

RESULTS

The study included 8929 patients (57.3% male) with a mean age of 64 years. Clinical T stage and N stage were identical to pathologic stages in 70.3% and 77.6% of patients, respectively. Sensitivity and specificity of the clinical assessment of N stage was 35.2% and 95.5%, respectively. Concordance between the clinical and pathologic stages was moderate for the T stage (kappa = 0.575) and fair for the N stage (kappa = 0.346). Pathologic T4 stage (OR: 2.12, p < 0.0001), poorly differentiated adenocarcinoma (OR: 1.45, p = 0.026), lymphovascular invasion (OR: 4.5, p < 0.001), and longer time from diagnosis to first treatment (OR = 0.996, p = 0.046) were the independent predictors of N stage discrepancy.

CONCLUSIONS

There was a moderate agreement between the clinical and pathologic T stages and a fair agreement between the clinical and pathologic N stages. The clinical assessment of the N stage was highly specific yet had low sensitivity.

Outcomes of laparoscopic versus robotic-assisted resection of T4 rectal cancer: propensity score-matched analysis of a national cancer database

BACKGROUND

T4 rectal cancer is a challenging condition owing to the highly invasive nature of the tumour that may compromise R0 resection. The present study aimed to assess the outcomes of laparoscopic versus robotic-assisted resection of non-metastatic T4 rectal adenocarcinoma.

METHODS

This was a retrospective propensity score-matched analysis using the National Cancer Database between 2010 and 2019. Patients with pathological T4 non-metastatic rectal adenocarcinoma who underwent laparoscopic or robotic-assisted resection were compared and a propensity score-matched analysis was performed in a 1:1 manner. The main outcome measures were conversion to open surgery, mortality, readmission, resection margins, and overall survival.

RESULTS

After propensity score matching, 235 patients were included in each group. There were 260 (55.3 per cent) men and 210 (44.7 per cent) women, with a mean (s.d.) age of 61 (13.2) years. Patients in the robotic group had a statistically significantly lower conversion rate (8.9 per cent versus 17.9 per cent; P = 0.006), shorter median duration of hospital stay (5 versus 6 days; P = 0.007), higher overall survival rate (56.2 per cent versus 43.4 per cent; P = 0.007), and a longer median survival (60.8 versus 43.2; P = 0.025). There were no significant differences between the two groups with regard to positive resection margins, examined lymph nodes, 30-day and 90-day mortality rates, and 30-day readmission rate.

CONCLUSIONS

Robotic resections of T4 rectal cancer were associated with a significantly lower conversion rate and shorter duration of hospital stay than laparoscopic resections. The two approaches were comparable with regard to positive resection margins, short-term mortality, and readmission.

Redo ileocolic resection for recurrent Crohn's disease: A review and meta-analysis of surgical outcomes

BACKGROUND

Recurrence of postoperative Crohn's disease neccesitating repeat ileocolic resection is a common problem. The aim of this meta-analysis was to present the collective evidence on the surgical outcomes of this procedure.

METHODS

PubMed, Scopus, and Google Scholar were searched for eligible studies that reported the surgical outcomes of redo ileocolic resection for Crohn's disease. The primary outcomes were overall and major complication rates. The secondary outcome was anastomotic leak and conversion rate. Risk of bias was assessed using the Risk of Bias in Non-Randomized Studies - of Interventions tool.

RESULTS

This meta-analysis included 12 studies comprising 1,203 patients (50% men). The weighted mean rate of overall complications was 31.8% (95% confidence interval, 25-38.6) and rate of major complications was 8% (95% confidence interval, 5.7-10.2). The weighted mean rate of conversion was 20.9%, and the weighted mean rate of anastomotic leak was 3% (95% confidence interval, 1.8%-4.3%; inconsistency = 0). Male sex (slope coefficient = 0.0001; P = .01), American Society of Anesthesiologists score >3 (slope coefficient = 0.001; P = .04), smoking (slope coefficient = 0.0001; P = .008), preoperative use of steroid therapy (slope coefficient = 0.0001; P = .009), open approach (slope coefficient = 0.0001; P = .005), and having ≥2 previous resections (slope coefficient = 0.0001; P = .02) were significant risk factors for major complications.

CONCLUSION

Although redo ileocolic resection for patients with recurrent Crohn disease has a relatively high overall complication rate, a majority of these complications are minor and anastomotic leak rate is relatively low. Further prospective multicenter trials are warranted to confirm the conclusions of this meta-analysis.

Gracilis muscle interposition for complex perineal fistulas: A systematic review and meta-analysis of the literature

AIM

Complex perineal fistulas (CPFs) are among the most challenging problems in colorectal practice. Various procedures have been used to treat CPFs, with none being a panacea. Our study aimed to assess the overall success and complication rates after gracilis muscle interposition in patients with CPF.

METHOD

PubMed, Scopus and Google Scholar databases were systematically searched until January 2022 according to PRISMA 2020 guidelines. Studies including children <18 years or <10 patients were excluded, as well as reviews, duplicate or animal studies, studies with poor documentation (no report of success rate) and non-English text. An open-source, cross-platform software for advanced meta-analysis openMeta [Analyst]™ version 12.11.14 and Cochrane Review Manager 5.4® were used to conduct the meta-analysis of data.

RESULTS

Twenty-five studies published between 2002 and 2021 were identified. The studies included 658 patients (409 women). Most patients had rectovaginal (50.7%) or rectourethral fistulas (33.7%). The most common causes of CPF were pelvic surgery (29.4%) and inflammatory bowel disease (25.2%). A history of radiotherapy was reported in approximately 18% of the patients. 498 (75.7%) patients with CPF achieved complete healing after gracilis muscle interposition. The weighted mean rate of success of the gracilis interposition procedure was 79.4% (95% CI 73.8%-85%, I²  = 75.3%), the weighted mean short-term complication rate was 25.7% (95% CI 18.1-33.2, I²  = 84.1%) and the weighted mean rate for 30-day reoperation was 3.6% (95% CI 1.6-5.6, I²  = 42%). The weighted mean rate of fistula recurrence was 16.7% (95% CI 11%-22.3%, I²  = 61%).

CONCLUSION

The gracilis muscle interposition technique is a viable treatment option for CPF. Surgeons should be familiar with indications and techniques to offer it as an option for patients. Given the relatively infrequent use of the operation, referral rather than performance of graciloplasty is an acceptable option.

Assessment of mesorectal fascia status in MRI compared with circumferential resection margin after total mesorectal excision and predictors of involved margins

BACKGROUND

Circumferential resection margin is an important prognosticator for total mesorectal excision outcome. We investigated the status of mesorectal fascia on magnetic resonance imaging compared with circumferential resection margin on pathology and factors associated with status change.

METHODS

This was a retrospective analysis of a prospective database of rectal cancer patients who underwent surgery. Mesorectal fascia status on magnetic resonance imaging done before neoadjuvant therapy and circumferential resection margin status on pathology were compared. The study outcomes were factors associated with a margin status conversion between magnetic resonance imaging and pathology, and predictors of involved circumferential resection margin.

RESULTS

In total, 244 patients (average follow-up of 25.4 months) were included. Eighty-one (33.2%) patients had potentially involved mesorectal fascia in magnetic resonance imaging and 12 (4.9%) had involved circumferential resection margin in pathology. A total of 2.8% of patients had a conversion of clear mesorectal fascia in magnetic resonance imaging to involved circumferential resection margin. Abdominoperineal resection was significantly associated with this status change (odds ratio: 25, 95% confidence interval: 2.4-255.8, P = .007). In total, 7.4% of patients with potentially involved mesorectal fascia had persistently involved circumferential resection margin. Lack of total neoadjuvant therapy was associated with higher, yet statistically insignificant, odds of persistently involved circumferential resection margin (odds ratio: 12, 95% confidence interval: 0.65-220.8, P = .09). The significant independent predictors of involved circumferential resection margin were body mass index (odds ratio: 1.2, P = .016) and abdominoperineal resection (odds ratio: 4.22, P = .04).

CONCLUSION

Change of clear mesorectal fascia in magnetic resonance imaging to an involved circumferential resection margin in pathology was recorded in 2.8% of patients; abdominoperineal resection might be associated with this change. Approximately 7% of patients had persistent involvement of circumferential resection margin as determined by pathology. Omission of total neoadjuvant therapy might be associated with persistent margin involvement.

Anorectal Malignancies Presenting as a Perianal Abscess or Fistula

BACKGROUND

Acute anorectal abscess and fistula are common conditions that usually presents as a painful lump close to the anal margin. Tumors in the distal rectum and in the perianal region may mimic the symptoms and signs of anorectal sepsis, thereby leading to a delay in diagnosis and management. The purpose of this study was to describe patients presenting with acute perianal abscess or fistula who were subsequently diagnosed with anorectal cancer.

METHODS

We performed a retrospective, review of all cases presenting with acute perianal abscess or fistula who were subsequently found to have anorectal carcinoma on biopsy in two tertiary centers. We analyzed the data focusing on the clinical features, laboratory values, clinical staging of the tumors, the subsequent management, the pathological staging, and the outcome of each patient.

RESULTS

Overall, 3219 patients presenting with anorectal abscess or fistula were reviewed. Cancer was diagnosed in 16 (.5%) patients, 12 with adenocarcinoma of the rectum and 4 with squamous cell carcinoma of the anus. In 5 patients (31.2%), cancer was diagnosed in the setting of chronic perianal fistula, 4 of them had Crohn's disease. In 10 patients (62.5%), cancer was not diagnosed during the initial evaluation of the acute symptoms.

CONCLUSIONS

A high index of suspicion is required to make the diagnosis of perianal tumors when assessing patients presenting with perianal sepsis, particularly those with Crohn's disease, a long history of persistent perianal disease, and an advanced age. In most cases, proper drainage followed by proximal diversion are the surgical treatment of choice in the acute setting.

Prevalence, diagnosis, and surgical management of complex ileocolic-duodenal fistulas in Crohn's disease

BACKGROUND

The aim of the present study was to review the prevalence and surgical management of patients with Crohn's disease (CD) complicated by ileocolic-duodenal fistulas (ICDF).

METHODS

We performed a retrospective chart review of CD patients who underwent surgical takedown and repair of ICDF during January 2011-December 2021 at two inflammatory bowel disease referral centers.

RESULTS

We identified 17 patients with ICDF (1.3%) out of 1283 CD patients who underwent abdominal surgery. Median age was 42 (20-71) years, 13 patients were male (76%) and median body mass index was 22.7 (18.4-30.3) kg/m². Four patients (24%) were diagnosed preoperatively and only 2 (12%) were operated on for ICDF-related symptoms. The most common procedure was ileocolic resection (13 patients, 76%) including 4 repeat ileocolic resections (24%). The duodenal defect was primarily repaired in all patients with no re-fistulization or duodenal stenosis, regardless of the repair technique. A laparoscopic approach was attempted in the majority of patients (14 patients, 82%); however, only 5 (30%) were laparoscopically completed. The overall postoperative complication rate was 65% including major complications in 3 patients (18%) and 2 patients (12%) who required surgical re-intervention for abdominal wall dehiscence and postoperative bleeding. Preoperative nutritional optimization was performed in 9 patients (53%) due to malnutrition. These patients had significantly less intra-operative blood loss (485 vs 183 ml, p = 0.05), and a significantly reduced length of stay (18 vs 8 days, p = 0.05).

CONCLUSION

ICDF is a rare manifestation of CD which may go unrecognized despite the implementation of a comprehensive preoperative evaluation. Although laparoscopic management of ICDF may be technically feasible, it is associated with a high conversion rate. Preoperative nutritional optimization may be beneficial in improving surgical outcomes in this select group of patients.

Pancreatic injuries following laparoscopic splenic flexure mobilization

PURPOSE

To call awareness to pancreatic injury occurring following laparoscopic splenic flexure mobilization (LSFM) and to discuss the mechanisms which led to such an injury.

METHODS

Retrospective review of patients who underwent LSFM as part of their colectomy procedure and sustained pancreatic injuries at a colorectal surgery referral center during 2014-2021.

RESULTS

Of 1022 (0.6%) LSFM performed during the study period, six (0.6%) patients were identified in which clinically significant injuries to the pancreas occurred. Two patients had partial transection of the tail of the pancreas and underwent laparoscopic distal pancreatectomy during the index operation. Three patients developed a post-operative pancreatic fistula after their pancreatic injury went undiagnosed during surgery and required percutaneous drainage, one of whom eventually required a distal pancreatectomy for a persistent pancreatic fistula. Another patient developed a peripancreatic fluid collection which resolved with conservative treatment.

CONCLUSIONS

Pancreatic injury is rare and a potentially major complication of LSFM. Anatomical misperception, retroperitoneal bleeding, a large bulky splenic flexure tumor, and a "difficult flexure" were recognized as possible mechanisms of such injury.

Redo ileocolic resection in Crohn's disease - does time passed since previous surgery matter?

AIM

Surgical resection for Crohn's disease (CD) remains noncurative, therefore recurrence is a significant problem. Although numerous factors affecting surgical outcomes in redo ileocolic resection have been previously described, no study has considered the relation between the interval of time from initial ileocolic resection to the redo procedure and its effect on surgical outcomes. The aim of this study was to explore this relationship.

METHOD

A retrospective review of all adult patients undergoing redo ileocolic resection for CD between 2011 to 2020 was conducted. Patients were divided into two groups based on time from initial ileocolic resection. Patients operated within 10 years of their initial surgery (≤10 years) were assigned to the early group, while patients operated >10 years after initial surgery were allocated to the late group. Primary outcome was the 30-day postoperative major complication rate.

RESULTS

Fifty-eight patients underwent redo ileocolic resection, 24 in the early group and 34 in the late group. Apart from older median age in the late group (56 vs. 46.5 years, p = 0.026), the groups were similar for patient factors, disease site and behaviour, use of immune-suppressing medication and procedural factors. Significant differences in 30-day postoperative morbidity included longer length of stay (6 vs. 5 days, p = 0.035), a higher major complication rate (23.5% vs. 4.1%, p = 0.04) and higher readmission rate (26.4% vs. 4.1%, p = 0.035) in the late group. The overall complication rate remained nonsignificant (37.5% vs. 61.8%, p = 0.1).

CONCLUSIONS

Redo ileocolic resection, when performed >10 years from the initial ileocolic resection, may be associated with increased morbidity, specifically higher rates of major postoperative complications, a longer length of stay and more readmissions.

The effect of the first year of the COVID-19 pandemic on sphincter preserving surgery for rectal cancer: A single referral center experience

Background

COVID-19 has significantly impacted healthcare worldwide. Lack of screening and limited access to healthcare has delayed diagnosis and treatment of various malignancies. The purpose of this study was to determine the effect of the first year of the COVID-19 pandemic on sphincter-preserving surgery in patients with rectal cancer.

Methods

This was a single-center retrospective study of patients undergoing surgery for newly diagnosed rectal cancer. Patients operated on during the first year of the COVID-19 pandemic (March 2020–February 2021) comprised the study group (COVID-19 era), while patients operated on prior to the pandemic (March 2016–February 2020) served as the control group (pre–COVID-19).

Results

This study included 234 patients diagnosed with rectal cancer; 180 (77%) patients in the pre–COVID-19 group and 54 patients (23%) in the COVID-19–era group. There were no differences between the groups in terms of mean patient age, sex, or body mass index. The COVID-19–era group presented with a significantly higher rate of locally advanced disease (stage T3/T4 79% vs 58%; P = .02) and metastatic disease (9% vs 3%; P = .05). The COVID-19–era group also had a much higher percentage of patients treated with total neoadjuvant therapy (52% vs 15%; P = .001) and showed a significantly lower rate of sphincter-preserving surgery (73% vs 86%; P = .028). Time from diagnosis to surgery in this group was also significantly longer (median 272 vs 146 days; P < .0001).

Conclusion

Patients undergoing surgery for rectal cancer during the first year of the COVID-19 pandemic presented later and at a more advanced stage. They were more likely to be treated with total neoadjuvant therapy and were less likely candidates for sphincter-preserving surgery.

Use of indocyanine green fluorescence angiography during ileal J-pouch surgery requiring lengthening maneuvers

BACKGROUND

The purpose of this study was to review whether routine usage of indocyanine green (ICG) perfusion assessment during complex ileal J-pouch surgery requiring lengthening maneuvers reduces ischemic complications.

METHODS

Retrospective chart review of patients with ulcerative colitis (UC) or familial adenomatous polyposis (FAP) who underwent ileal pouch-anal anastomosis (IPAA) surgery with lengthening maneuvers and intraoperative ICG assessment between January 2015 and January 2021. All patients underwent a double stapled anastomosis and were temporarily diverted. All patients underwent laparoscopic and trans-anal ICG assessment of their J-pouch and anastomosis. All J-pouches were evaluated 6 weeks after surgery via contrast enema and pouchoscopy.

RESULTS

One hundred fifty eight patients underwent ileal J-pouch surgery during the study period. Sixteen patients (10%) underwent lengthening maneuvers and intra-operative ICG assessment. Twelve patients underwent surgery for UC and 4 for FAP. Median age was 40.3 years and average body mass index was 24.9 kg/m². Twelve patients underwent a two-stage procedure and the remaining underwent a three-stage procedure. 93.7% of cases were completed laparoscopically (15/16). All patients underwent scoring of the peritoneum and 43% (7/16) underwent division of the ileocolic or intermediate mesenteric vessels. There was no mortality or pouch ischemia and the leak rate was 12.5%. All patients underwent reversal after an average of 18 ± 7 weeks.

CONCLUSION

ICG perfusion assessment appears to be of utility in complex IPAA surgery requiring lengthening maneuvers. Its application may be associated with reduced J-pouch ischemia and leak rate in this unique setting.

Total Neoadjuvant Therapy Is a Predictor for Complete Pathological Response in Patients Undergoing Surgery for Rectal Cancer

INTRODUCTION

Total neoadjuvant therapy (TNT) is a new therapeutic strategy in patients with rectal cancer. We examined the role of TNT, in addition to other pre-operative factors, as a predictor for pathologic complete response (pCR).

METHODS

A retrospective analysis of all rectal cancer patients who underwent surgery between 2016 and 2021 was conducted. Patients were classified into two groups-pCR group and residual tumor group. Patient data were reviewed and entered into univariate and multivariate analyses to determine predictors of pCR.

RESULTS

A total of 172 patients were treated with neoadjuvant therapy and underwent surgery during the study period. Sixty patients (34.9%) were treated with TNT while 112 (65.1%) were treated with traditional neoadjuvant chemoradiation. The overall pCR rate was 25.6% (44 patients), with 31.6% (19 patients) in patients who received TNT compared to 22.3% (25 patients) in patients who received neoadjuvant chemoradiation (NCRT). Univariate analysis of clinical and radiological factors correlated with pCR demonstrated no significant differences between the two groups in cT stage (p = 0.46), cN stage (p = 0.52), positive circumferential resection margin (CRM) (p = 0.72), tumor location (p = 0.35), symptomatic presentation (p = 0.09), and anal sphincter involvement (p = 0.68). Multivariate logistic analysis demonstrated that only pre-operative TNT (OR:2.35; 95% CI 1.06-5.25; p = 0.03) was predictive of pCR, while extramural vascular invasion (EMVI) was a predictor for lower rates of pCR (OR: 0.28; 95% CI 0.09-0.9; p = 0.03).

CONCLUSION

Rectal cancer patients undergoing TNT prior to surgery have a higher chance of developing a complete pathologic response. Evaluation of this therapy should be continued and extended to larger numbers of patients to see if the differences we observed are real.

Use of indocyanine green fluorescence guidance in redo ileocolic resection for Crohn's disease

AIM

Redo ileocolic resection in patients with Crohn's disease (CD) is associated with significant technical challenges that may be associated with high complication rates. The aim of this study was to evaluate the feasibility of near-infrared fluorescence angiography with indocyanine green (ICG), often used to evaluate blood supply to the anastomosis in CD patients undergoing repeat ileocolic resection.

METHOD

This study was a retrospective analysis of patients who underwent redo ileocolic resection using ICG bowel perfusion assessment between 2015 and 2021. Patients were matched and compared on a 1:2 basis with a control group undergoing the same procedure without perfusion assessment.

RESULTS

Twelve patients underwent redo ileocolic resection with ICG perfusion assessment (ICG group). These were compared with 24 patients who underwent the procedure without ICG (control group). Both groups were similar in demographics and operative characteristics including median operating time (255 vs. 255.5 min, p = 0.39) and conversion rate (22% vs. 36.8%, p = 0.68). Median estimated blood loss was significantly higher in the ICG group [150 (50-400) vs. 100 ml (20-125)]. Successful ICG perfusion assessment was seen in all patients in the ICG group and did not change management in any case. Overall postoperative complication rates were comparable between the groups (58.3% vs. 54.1%, p = 0.72). No anastomotic leaks occurred in the ICG group compared with one (1/24, 4.2%) in the control group (p = 0.99).

CONCLUSION

Fluorescence ICG perfusion assessment is feasible and safe in redo ileocolic resection in patients with CD. Larger studies are needed to evaluate whether this technique should be routinely used in these complex surgical interventions.

High Failure Rate Following Restorative Surgery for Rectal Prolapse in Systemic Sclerosis Patients

INTRODUCTION

Systemic sclerosis (SSc) is a rare autoimmune connective tissue disorder. Colonic disorders are reported in 70% of patients. Only a few cases of rectal prolapse surgical repair in SSc patients were published, demonstrating high recurrence rate following any restorative surgery. The aim of this study is to present our surgical experience combined with the reported cases of SSc patients who underwent surgical interventions for rectal prolapse.

METHODS

We reviewed our data and the published reports in the English literature of patients with SSc who underwent surgery for rectal prolapse. We located 6 case reports, in addition to 3 patients who were operated in our center.

RESULTS

A total of 19 procedures (9 patients) were included, among them 17 restorative surgeries and 2 low anterior resections (LAR) with end-colostomy. All patients were female (mean age 70.3). Index surgery was perineal rectosigmoidectomy in 5, abdominal resection rectopexy in 3, and LAR with colostomy in 1 patient. All patients following restorative surgery suffered from fecal incontinence. 5 patients (62.5%) who underwent restorative surgery required at least 1 re-operation. The 2 patients who underwent LAR and colostomy reported a complete resolution of anorectal symptoms with a major improvement in their quality of life.

CONCLUSION

High recurrence rate is expected in SSc patients with rectal prolapse who undergo a restorative procedure. Low anterior resection and permanent colostomy provide an alternative surgical option to patients with SSc and prolapse in contrast to restorative surgery. We believe that this surgical approach should be offered for these patients.

The application of regenerative medicine in colorectal surgery

Tissue reconstruction and regeneration represent one of the greatest challenges in any surgical field. Regenerative medicine combined with stem cell-based therapy is a novel and promising field of medicine. Stem cells possess the ability to differentiate into specialized cells and to decrease inflammation and therefore can play a role in repair or regeneration of damaged tissues. Colorectal surgery often deals with infected, poorly vascularized, radiated, and inflamed tissue, as well as instances where imperfect healing might have grave implications. This problem has led researchers to study utilizing stem cells in many colorectal conditions, such as anastomotic healing, perianal fistulae, rectovaginal fistulae, anal fissure, and fecal incontinence. The purpose of this review was to discuss prominent studies that explored stem cells utilization in treating different colorectal pathologies.

Platelet Activation and Reactivity in a Large Cohort of Patients with Gaucher Disease

OBJECTIVES

 Patients with Gaucher disease (GD) are at increased risk of bleeding and have varying degrees of thrombocytopenia, making the analysis of platelet function difficult. This study aimed to provide a clinically relevant quantitative assessment of platelet function and determine its relationship with bleeding and GD-related data.

METHODS

 Unstimulated and stimulated platelet function was measured by whole blood flow cytometry of platelet surface-activated αIIbβ3 integrin (detected with monoclonal antibody PAC1), P-selectin (CD62P), and lysosomal-associated membrane protein (LAMP3/CD63) in 149 GD patients.

RESULTS

 GD patients had a higher level of unstimulated CD63 expression than healthy subjects, which was mildly correlated with glucosylsphingosine (lyso-Gb1) levels (r = 0.17, p-value = 0.042). Splenectomized GD patients had a higher level of unstimulated αIIbβ3 integrin and P-selectin expression. Reduced platelet reactivity (-2 standard deviation of reference range) was found in 79 (53%, 95% confidence interval [CI]: 44-61%) patients, of whom 10 (6.7%, 95% CI: 3.3-12%) had more severe platelet dysfunction. In a multivariate model, only lyso-Gb1 levels were associated with the more severe platelet dysfunction. Fifty-four (49%) of 128 adult patients who completed the bleeding tendency questionnaire reported positive bleeding history. In a multivariate logistic model, older age (odds ratio [OR]: 1.05, 95% CI: 1.01-1.1) and low P-selectin reactivity (OR: 2.03, 95% CI: 1.25-3.35) were associated with more than one bleeding manifestation.

CONCLUSION

 Flow cytometry enables the study of platelet function in thrombocytopenic GD patients. A platelet degranulation defect, but not αIIbβ3 integrin activation defect, is associated with clinical bleeding. In vivo increased CD63 expression may be related to GD-related inflammation.

Perineal reconstruction after extralevator abdominoperineal resection: Differences among minimally invasive, open, or open with a vertical rectus abdominis myocutaneous flap approaches

BACKGROUND

Perineal wound complications after extralevator abdominoperineal resection for cancer are common with no consensus on optimal reconstructive technique. We compared short- and long-term results of laparoscopic abdominoperineal resection with open surgery ± vertical rectus abdominis myocutaneous flap.

METHODS

This is a single-institution retrospective observational study of 204 consecutive patients with advanced low rectal cancer who underwent extralevator abdominoperineal resection from January 2010 to August 2020. Main outcome measures were short-term results, wound complications, and incisional, parastomal, and perineal hernia rates.

RESULTS

Fifty-five (27%) patients had a laparoscopic approach, 80 (39%) open, and 69 (33%) open + vertical rectus abdominis myocutaneous flap. The groups had similar median length of follow up (P = .75). Patients' age and radiation, intraoperative and postoperative complications, mortality, and readmission rates were similar among the 3 groups. Perineal wound infection and dehiscence rates were not influenced by surgical approach. Laparoscopy resulted in higher perineal (7.3 vs 2.5 vs 0%; P = .047) and parastomal (23.6 vs 13.8 vs 5.8%; P = .016) hernia rates than did open or open + vertical rectus abdominis myocutaneous flap. Patients who underwent an open approach had a higher body mass index and rate of prior surgeries and preoperative ostomies. Laparoscopic and open approaches had significantly shorter operative times (300 vs 303 vs 404 minutes, respectively; P < .001) and shorter length of stay (7.6 vs 10.8 vs 11.12, respectively; P = .006) compared to open with a flap approach.

CONCLUSION

Open and open + vertical rectus abdominis myocutaneous flap approaches for reconstruction after abdominoperineal resection had lower parastomal and perineal hernias rates but similar postoperative morbidity as did the laparoscopic approach.

Superior Mesenteric Vein Injury During Oncologic Right Colectomy: Current Vascular Repair Modalities

Purpose:

To review the different vascular repair options of superior mesenteric vein (SMV) damage during oncologic right colectomy.

Methods:

This is a retrospective chart review of 5 cases in which severe damage to the SMV occurred during oncological right colectomy in an academic medical center.

Results:

During a 10-year study period, we encountered 5 cases in which severe damage to the SMV and its tributaries occurred. Two of the patients underwent primary venous repair for partial lacerations. The other 3 underwent interposition graft repair using a great saphenous vein (GSV) graft. Two of the grafts remained patent, while the third required replacement with a bovine pericardial patch.

Conclusions:

The SMV injury during oncologic right colectomy is a technically challenging injury. Based on our own experience and review of the literature, we formulated the following set of recommendations: (1) Venous ligation should be avoided, and revascularization should be attempted whenever feasible. (2) Primary venorrhaphy in cases of partial lacerations is the preferred treatment option. (3) End-to-end anastomosis is an efficient but seldom available repair option in the setting of complete SMV transection without segmental loss. (4) Autologous vein graft using the GSV is the preferred mode of repair during SMV injury with tissue loss. (5) Use of polytetrafluoroethylene (PTFE) graft should be avoided if possible due to greater risk of graft contamination. (6) A low threshold for reexploration depending on laboratory and imaging findings is advisable.

Iatrogenic superior mesenteric vein injury: the perils of high ligation

PURPOSE

The purpose of this review is to highlight the perils and pitfalls associated with high vascular ligation during right colectomies for adenocarcinoma and to identify the various mechanisms of injury to the superior mesenteric vein (SMV) and its tributaries.

METHODS

This is a retrospective chart review of 304 right colectomies (159 open and 145 laparoscopic) performed over a period of 10 years (1 June 2006-31 May 2016) for right-sided colonic adenocarcinoma in an academic medical center.

RESULTS

During a 10-year study period, we encountered five cases in which significant damage to the SMV and its tributaries occurred. This accounts for a total of 1.6 % of all right colectomies performed for colonic adenocarcinoma.

CONCLUSIONS

Iatrogenic superior mesenteric vein injury is a rare, severe, and underreported complication of both open and laparoscopic right colectomy for colonic adenocarcinoma. We identified several mechanisms of injury such as anatomic misperception, excessive traction and pulling on the venous system, extensive tumor involvement of the mesentery, and uncontrolled suturing attempts at hemostasis. We believe that increased awareness of this complication with profound understanding of vascular anatomy and the different mechanisms of injury will allow surgeons to avoid this often devastating complication.