Development of a core descriptor set for Crohn's anal fistula

AIM

Crohn's anal fistula (CAF) is a complex condition, with no agreement on which patient characteristics should be routinely reported in studies. The aim of this study was to develop a core descriptor set of key patient characteristics for reporting in all CAF research.

METHOD

Candidate descriptors were generated from published literature and stakeholder suggestions. Colorectal surgeons, gastroenterologists and specialist nurses in inflammatory bowel disease took part in three rounds of an international modified Delphi process using nine-point Likert scales to rank the importance of descriptors. Feedback was provided between rounds to allow refinement of the next ratings. Patterns in descriptor voting were assessed using principal component analysis (PCA). Resulting PCA groups were used to organize items in rounds two and three. Consensus descriptors were submitted to a patient panel for feedback. Items meeting predetermined thresholds were included in the final set and ratified at the consensus meeting.

RESULTS

One hundred and thirty three respondents from 22 countries completed round one, of whom 67.0% completed round three. Ninety seven descriptors were rated across three rounds in 11 PCA-based groups. Forty descriptors were shortlisted. The consensus meeting ratified a core descriptor set of 37 descriptors within six domains: fistula anatomy, current disease activity and phenotype, risk factors, medical interventions for CAF, surgical interventions for CAF, and patient symptoms and impact on quality of life.

CONCLUSION

The core descriptor set proposed for all future CAF research reflects characteristics important to gastroenterologists and surgeons. This might aid transparent reporting in future studies.

Prevention and management of anastomotic leakage after colorectal surgery: A Swiss national consensus

Objective

Anastomotic leakage (AL) is one of the most feared complications of colorectal surgery. Despite surgical improvements, AL incidence remains significant and guidance on its prevention and management is lacking. The aim of the study was to achieve a Swiss nationwide consensus on clinical prevention and management of AL.

Methods

A three-step Delphi consensus meeting was performed in 2020 involving 78 Swiss surgeons from 40 centers. A steering-group drafted the questions, gathered best available evidence which was discussed in meetings prior answering the questions. Consensus was defined as ≥70% of agreement.

Results

The three consensus meetings were attended by 66, 57 and 37 surgeons, respectively. Surgeons’ median experience was 14 years, with 47% performing >50 colorectal resections yearly. Consensus was reached on routine use of preoperative nutritional screening (100%) using nutritional scores (88%) and >10% weight loss (95%). but not low BMI (63%) or low albumin (64%). Consensus was reached for no bowel preparation (BP) prior to right colectomy (RC) (76%) and for mechanical BP with oral antibiotics prior anterior resections (AR) (70%). No consensus was found on BP prior left colectomy (LC). Respondents favored a side-to-side anastomosis (76%) after RC, with extra-corporeal confection (70%), without consensus on the anastomosis being stapled or hand-sewn; an end-to-end (73%), stapled (80%) anastomosis after LC and a stapled anastomosis (86%) after AR, irrespective of the anastomosis configuration type. Anastomotic control with transanal leak-test was supported by 92%, while ICG control did not reached consensus (67%). After TME, routine diversion was favored (73%), irrespective of neoadjuvant therapy (94%) or not (70%). Consensus was reached on routine postoperative CRP monitoring (94%). CT-scan with rectal contrast enema was the preferred investigation for suspected AL after RC or LC (82%) and AR (76%). Conservative management of AL, provided appropriate clinical state, was an acceptable option after LC (72%), AR with stoma (95%), but not after RC (59%) or AR without stoma (53%).

Conclusion

Consensus was reached on several clinical aspects for prevention and management of AL among Swiss colorectal surgeons, providing national guidance. Further data is required on intraoperative aspects of anastomosis confection and control to ensure broader consensus.

Swiss consensus on the management of acute diverticulitis

Objective

Acute diverticulitis is a frequent clinical conditions encountered in emergency settings. Despite recent international guidelines, management of acute diverticulitis (AD) varies and is not standardized. The aim of the study was to achieve a Swiss nationwide consensus on clinical management of acute diverticulitis.

Methods

A three-staged consensus meeting according to the Delphi method was performed in 2020 involving 78 Swiss surgeons from 40 hospitals. A steering-group drafted the questionnaires, gathered best available evidence which was presented and discussed in meetings prior answering the questions. Consensus was defined as ≥70% of agreement.

Results

57 surgeons answered all the 3 rounds and 28 (53%) performed > 50 colorectal resections per year. On initial workup in the emergency setting, performing leucocytes count (87%), CRP (98%) and CT imaging (98%) reached consensus for the diagnosis, but no uniform classification system of AD was retained. Signs of generalized peritonitis (100%), requiring intravenous pain medication (98%), inability to tolerate oral intake (95%), lack of adequate social support (86%), immunosuppression (96%), and complicated AD on CT (84%) were criteria for hospitalization. Persisting symptoms (95%) and immunosuppression (89%) were criteria for elective colonic resection, while the number of AD episodes were not (27%). In case of abscess, a size ≥ 4 cm reached consensus for percutaneous drainage (88%). No consensus were reached for surgical approach and techniques in the emergency settings, apart from damage control surgery for instable patients (70%). In the follow-up, recommendation for dietary restrictions or lifestyle habits did not reach reach consensus.

Conclusion

Swiss colorectal surgeons reached consensus for several diagnostics, hospitalization, and elective surgery criterias. However, emergency surgical management and follow-up are less standardized. These variations should be further assessed, and particularly in the context the latest published recommendations.

Long-term outcome of surgery for perianal Crohn’s fistula

Objective

Perianal fistulizing disease is a problem in patients with Crohn’s disease (CD) because they often need repetitive surgeries. Among the various available procedures, none of them proves to be superior. In addition, the long-term outcome of fistula Seton drainage is not well described. The aims of this study were to analyze the long-term healing and recurrence rates of perianal fistulas in CD patients, stratified according to the first procedure performed.

Methods

Database analysis of a prospective Swiss cohort of patients with perianal CD.

Results

365 patients with 576 interventions and a median follow-up of 7.5 years (0 - 12.6) were analyzed. 39.7% of patients required more than one surgery. The first surgical interventions were fistulectomies (58.4%), Seton drainage (26.9%), fistula plugs (2.2%) and combined procedures (9.9%). Fistulectomy patients required no more surgery in 67.6%, one additional surgery in 25.4% and more than one additional surgery in 7.7%. In these 3 groups of patients, after a median follow-up of 12.1 years, perianal fistula closure was achieved in 77.1%, 74.1% and 66.7%, respectively. In patients with Seton drainage as index surgery, 50.3% required no more surgery and over 75% achieved fistula closure after 10 years. 49.7% of patients with Seton required one or more surgeries. At median follow up of 7.5 years, closure rates were 64.2% and 60.5% in patients with one and more than one surgeries, respectively. There was no difference in demographics in Seton patients with closed or not closed fistulas. Non-closure patients had a higher Crohn Disease Activity Index (33 vs. 6) and more frequent anti-TNF medication (57.4% vs. 48.1%).

Conclusion

First line fistulectomies achieved the highest healing rates in perianal CD but 1/3 of patients require additional surgeries and 1/4 patients will remain with a fistula at 10 years. Initial seton drainage and concurrent medical therapy can achieve fistula closure in 75%. However, in 50% of patients more surgeries are performed with a seton staying in place up to 5 years and fistula closure in only 2/3 patients.

Prospective surveillance after implementation of a colorectal surgical site infection prevention bundle

Objective

Surgical site infections (SSI) are the most frequent complications after colorectal surgery. The aim of the present study was to evaluate the impact of a standardized SSI prevention bundle.

Methods

The multimodal, evidence-based care bundle included 9 intraoperative items (antibiotic type, timing and re-dosing, desinfection, induction temperature control >36.5°, glove change, intracavity lavage, wound protection and closure strategy). The bundle was implemented in November 2018 and applied to all consecutive patients undergoing colonic resections. Demographics, surgical specifics and overall compliance to the care bundle were prospectively assessed until October 2020. The primary outcome SSI was defined according to the definition of the Center for Disease Control (CDC) and independently assessed by the National Infection Surveillance Committee (Swissnoso) up to 30 postoperative days. A historical, institutional pre-implementation control group (2012-2017, DOI: 10.1016/j.jhin.2018.09.011) with identical methodology was used for comparison.

Results

In total, 243 patients were included. The control group included 1’263 patients. Both groups were comparable regarding main demographics (age, sex, body mass index, American Society of Anaesthesiologists class) and surgical characteristics (type and duration of surgery). Overall compliance to the care bundle was 77% (IQR 77-88). Lowest compliance was observed for temperature control (48%), intracavity lavage (59%) and predefined wound closure strategy (74%). Surgical site infections were reported in 54 patients (22.2%) vs. 21.4% in the control group, p = 0.79. Infection rates were comparable throughout the CDC categories: superficial: 11 patients (4.5%) vs. 4.2%, p = 0.82, deep incisional: 9 patients (3.7%) vs. 5.1%, p = 0.34, organ space: 34 (14%) vs. 12.4%, p = 0.48.

Conclusion

Implementation of a standardized surgical care bundle had no impact on SSI rates according to these preliminary results. Improved compliance to individual measures may help to achieve a clinical benefit.

Sarcopenia and surgical outcomes in patients undergoing oncologic colonic surgery

Objective

Sarcopenia is a marker for malnutrition and frailty which could lead to higher complication rate and prolonged length of stay (LOS) after surgery. The study aim was to assess the correlation between sarcopenia and clinical outcomes in oncologic colonic surgery.

Methods

This retrospective study included consecutive patients operated between 2014 and 2019. Three radiological indices of sarcopenia were measured at the level of the third lumbar vertebra on preoperative CT scans: Skeletal Muscle Area (SMA), Skeletal Muscle Radiation Attenuation (SMRA), and Skeletal Muscle Index (SMI). Patients with major complications (> grade 3a) according to Clavien classification were compared to those without. Statistical correlation between sarcopenia indices, LOS and Comprehensive Complication Index (CCI) was tested by use of the Pearson correlation.

Results

A total of 325 patients were included, 50 (15.4%) with and 275 (84.6%) without major complications. SMA and SMI were comparable between both groups (respectively 126.0 vs 125.2 cm2, p = 0.974, and 43.4 vs 44.3 cm2/m2, p = 0.636), while SMRA was significantly lower in patients with major complications (33.6 vs 37.3 HU, p = 0.018). A lower SMRA was correlated with prolonged LOS (r=-0.207, p < 0.01) and higher CCI (r=-0.144, p < 0.01), while the other sarcopenia indices had no influence on surgical outcomes.

Conclusion

Preoperative SMRA or muscle quality appears to be a weak predictor for adverse outcomes after oncologic colectomy.

Obstructed defaecation syndrome: European consensus guidelines on the surgical management

Management of obstructed defaecation is challenging and remains controversial. No international guidelines have been published.

Gains and limitations of a connected tracking solution in the perioperative follow-up of colorectal surgery patients

AIM

The means to target shorter hospital stay include information technology strategies to improve communication between caregivers and patients in order to limit potentially avoidable readmissions. The aim of the present study was to analyse the benefits and limitations of a smartphone-based connected tracking solution in the perioperative follow-up of colorectal surgery patients.

METHOD

This was a retrospective monocentric cohort study of consecutive patients after colorectal surgery between February and December 2018. The mobile health application included information delivery and daily structured questionnaires on a personalized patient electronic profile, before the hospital stay and for 7 days post-discharge. The medical team answered automatic alerts in real time.

RESULTS

A total of 93 eligible patients were approached and 36 had to be excluded (26 no smartphone, five no email, five not French speaking). Among the potential users, 50 (88%) engaged in an mHealth app and seven refused. Of these 50 patients, seven dropped out. Of the remaining 43 patients, the app detected 12 adverse events, and 10 (83%) were handled through the app. Healthcare providers responded to patient-generated alerts after a median time of 90 min (range 9-448 min). Patients' mean satisfaction level was 4 ± 0.97 out of 5.

CONCLUSION

In total, 88% of smartphone-equipped patients showed a willingness to engage in mHealth. Reasons for exclusion were the absence of connection tools and a language barrier. Patients who responded to the survey were satisfied with the solution and 83% of post-discharge adverse events were solved through the app, avoiding emergency consultations.

Training in colorectal surgery in Europe and 20 years of the European Board of Surgical Qualification coloproctology examination

AIM

Training in colorectal surgery across Europe is not yet standardized. The European Board of Surgical Qualification (EBSQ) coloproctology examination has been held annually since 1998. The aims of this study were to illustrate the current situation of coloproctology specialization in Europe and to analyse the EBSQ examinations held over the last 20 years.

METHOD

A survey, focused on current training and education in colorectal surgery in Europe, was conducted among all national representatives of the European Society of Coloproctology (ESCP) in 2018. Candidate demographics (1998-2018) and the results of the EBSQ examination (2007-2018) were analysed.

RESULTS

In Europe, there are currently 26 national colorectal societies, 27 national annual colorectal meetings, 16 national specialized training programmes and 13 national colorectal fellowships. Six countries have board certification in colorectal surgery and five a dedicated examination. During the last 20 years, 475 candidates from 29 countries, of whom 88 (19%) were women, passed the EBSQ examination. The pass rate was higher in younger applicants (< 42 years, P = 0.01). The success rate was higher for candidates with academic experience (more than five publications or presentations) and with an academic title (thesis) (P = 0.01).

CONCLUSION

Colorectal surgical training is still not standardized in Europe, although efforts have been made to recognize colorectal surgery as an independent speciality. The number of holders of the EBSQ Diploma has increased over the years, demonstrating the acceptance of the examination among European surgeons. Young candidates with an academic profile are the most successful.

Identification of patients eligible for discharge within 48 h of colorectal resection

BACKGROUND

This study aimed to identify patients eligible for a 48-h stay after colorectal resection, to provide guidance for early discharge planning.

METHODS

A bi-institutional retrospective cohort study was undertaken of consecutive patients undergoing major elective colorectal resection for benign or malignant pathology within a comprehensive enhanced recovery pathway between 2011 and 2017. Overall and severe (Clavien-Dindo grade IIIb or above) postoperative complication and readmission rates were compared between patients who were discharged within 48 h and those who had hospital stay of 48 h or more. Multinominal logistic regression analysis was performed to ascertain significant factors associated with a short hospital stay (less than 48 h).

RESULTS

In total, 686 of 5122 patients (13·4 per cent) were discharged within 48 h. Independent factors favouring a short hospital stay were age below 60 years (odds ratio (OR) 1·34; P = 0·002), ASA grade less than III (OR 1·42; P = 0·003), restrictive fluid management (less than 3000 ml on day of surgery: OR 1·46; P < 0·001), duration of surgery less than 180 min (OR 1·89; P < 0·001), minimally invasive approach (OR 1·92; P < 0·001) and wound contamination grade below III (OR 4·50; P < 0·001), whereas cancer diagnosis (OR 0·55; P < 0·001) and malnutrition (BMI below 18 kg/m² : OR 0·42; P = 0·008) decreased the likelihood of early discharge. Patients with a 48-h stay had fewer overall (10·8 per cent versus 30·6 per cent in those with a longer stay; P < 0·001) and fewer severe (2·6 versus 10·2 per cent respectively; P < 0·001) complications, and a lower readmission rate (9·0 versus 11·8 per cent; P = 0·035).

CONCLUSION

Early discharge of selected patients is safe and does not increase postoperative morbidity or readmission rates. In these patients, outpatient colorectal surgery should be feasible on a large scale with logistical optimization.

Thresholds for optimal fluid administration and weight gain after laparoscopic colorectal surgery

Background

Perioperative fluid overload is an important modifiable risk factor for adverse outcomes after colorectal surgery. This study aimed to define critical thresholds for perioperative fluid management and postoperative weight gain for patients undergoing elective laparoscopic colorectal surgery.

Methods

This was an analysis of consecutive elective laparoscopic colorectal resections at Lausanne University Hospital from May 2011 to May 2017. Main outcomes were overall, major (Clavien–Dindo grade IIIb or above) and respiratory complications, and postoperative ileus. Thresholds regarding perioperative fluid management and postoperative weight gain were identified through receiver operating characteristic (ROC) analysis and clinical judgement. Independent risk factors for all four outcomes were assessed by multinominal logistic regression.

Results

Overall and major complications occurred in 210 (36·2 per cent) and 46 (7·9 per cent) of 580 patients respectively. Twenty‐three patients (4·0 per cent) had respiratory complications and 98 (16·9 per cent) had postoperative ileus. Median length of hospital stay was 5 (i.q.r. 3–9) days. Based on respiratory complications, thresholds for perioperative intravenous fluid administration (postoperative day (POD) 0) were set pragmatically at 3000 ml for colonic (calculated threshold 3120 ml (area under ROC curve (AUROC) 0·63)) and 4000 ml for rectal (AUROC 0·79) procedures. Postoperative weight gain of 2·5 kg at POD 2 was predictive of respiratory complications. Multivariable analysis retained perioperative intravenous fluid administration over the above thresholds as an independent risk factor for overall (odds ratio (OR) 2·25, 95 per cent c.i. 1·23 to 4·11), major (OR 2·49, 1·17 to 5·31) and respiratory (OR 4·71, 1·42 to 15·58) complications. Weight gain above 2·5 kg at POD 2 was identified as a risk factor for respiratory complications (OR 3·58, 1·10 to 11·70) and ileus (OR 1·82, 1·02 to 3·52).

Conclusion

Perioperative intravenous fluid and weight thresholds were associated with postoperative adverse outcomes. These thresholds need independent validation.

[Quality in coloproctology training : How is coloproctology training qualitatively integrated into the national training catalogue?]

The incorporation of coloproctology as a part of the surgical training and further education of assistant and specialist physicians shows great differences between Germany, Austria and Switzerland. In this article the international and national possibilities before and after specialist medical training are described in detail. In Austria, an optional coloproctology module can already be chosen in the third year of surgical training. Coloproctology is a compulsory component during the complete surgical training in Germany but a lower number of operations are required. In the basic module in Switzerland coloproctology is compulsory but contained in the operation catalogue to a lesser extent, although it has to be explicitly chosen in the further specialist training. The mandatory training in coloproctology in Germany enables all surgical assistants to undergo training, even if it is less intensive. As a result of partially compulsory and partially optional modules in Switzerland, a lower proportion of trainees receive specific training but it is more detailed. The number of trainees who are trained in coloproctology is even smaller in Austria due to the coloproctological training being optional. In the German-speaking regions a variety of specialized courses and further education are available for assistants and surgeons to further deepen their knowledge, no matter which form of training they had. At the international level the European Board of Surgical Qualification (EBSQ) for coloproctology has been available since 1998 and for many European specialists is the only possibility for formal specialization. The quality of a coloproctology training and further education curriculum may vary with national and international factors; however, it is a parameter for high standards in coloproctology in routine daily work, for the numbers of young coloproctology surgeons and is associated with a sufficient research performance in this discipline.

Receiver operating characteristic analysis to determine optimal fluid management during open colorectal surgery

AIM

The present study aimed to analyse fluid management and to define optimal fluid-related thresholds for elective open colorectal surgery.

METHOD

A retrospective analysis was made of all consecutive elective open colorectal resections performed in our tertiary centre between May 2011 and May 2017. The main outcomes were postoperative complications [overall (I-V) and severe (IIIB-V) according to the Clavien classification], respiratory complications and postoperative ileus (POI). Critical thresholds regarding perioperative fluid management and postoperative weight gain were identified by using receiver operator characteristic (ROC) analysis. Independent risk factors for overall complications were identified by multivariable logistic regression analysis.

RESULTS

Of 121 patients who had open operations, 84 (69%) had some complication and 26 (21%) had severe complications. Respiratory complications and POI occurred in 15 (12%) and 46 patients (38%), respectively. The thresholds for intravenous fluids were 3.5 l at postoperative day (POD) 0 [area under ROC curve (AUROC) 0.7 for any 0.69 for respiratory complications] and 3.5 kg weight gain at POD 2 (AUROC 0.82 for respiratory complications). Multivariable analysis revealed weight gain of > 3.5 kg at POD 2 (OR 5.9; 95% CI 1.3-16.6) as a significant risk factor for overall complications. Acute kidney injury was observed in five patients (4%), three (5%) in the group with > 3.5 l at POD 0 and two (3%) in the group with < 3.5 l at POD 0 (P = 0.64). Creatinine increase was transitory and all patients regained baseline levels before discharge.

CONCLUSION

A weight gain of > 3.5 kg at POD 2 has been identified as the critical threshold for overall and respiratory complications and prolonged length of stay after open elective colorectal surgery.

Resection with primary anastomosis vs nonrestorative resection for perforated diverticulitis with peritonitis: a systematic review and meta-analysis

AIM

It is still controversial whether the optimal operation for perforated diverticulitis with peritonitis is primary anastomosis (PRA) or nonrestorative resection (NRR). The aim of this systematic review and meta-analysis was to evaluate mortality and morbidity rates following emergency resection for perforated diverticulitis with peritonitis and ostomy reversal, as well as ostomy nonreversal rates.

METHOD

The Pubmed, EMBASE, Cochrane Library, MEDLINE via Ovid, CINAHL and Web of Science databases were systematically searched. Mortality was the primary end-point. A subgroup meta-analysis of randomized controlled trials was performed in addition to a meta-analysis of all eligible studies. Odds ratios (ORs) and mean difference (MD) were calculated for dichotomous and continuous outcomes, respectively.

RESULTS

Seventeen studies, including three randomized controlled trials (RCTs), involving 1016 patients (392 PRA vs 624 NRR) were included. Overall, mortality was significantly lower in patients with PRA compared with patients with NRR [OR (95% CI) = 0.38 (0.24, 0.60), P < 0.0001]. Organ/space surgical site infection (SSI) [OR (95% CI) = 0.25 (0.10, 0.63), P = 0.003], reoperation [OR (95% CI) = 0.48 (0.25, 0.91), P = 0.02] and ostomy nonreversal rates [OR (95% CI) = 0.27 (0.09, 0.84), P = 0.02] were significantly decreased in PRA. In the RCTs, the mortality rate did not differ [OR (95% CI) = 0.46 (0.15, 1.38), P = 0.17]. The mean operating time for PRA was significantly longer than for NRR [MD (95% CI) = 19.96 (7.40, 32.52), P = 0.002]. Organ/space SSI [OR (95% CI) = 0.28 (0.09, 0.82), P = 0.02] was lower after PRA. Ostomy nonreversal rates were lower after PRA. The difference was not statistically significant [OR (95% CI) = 0.26 (0.06, 1.11), P = 0.07]. However, it was clinically significant [number needed to treat/harm (95% CI) = 5 (3.1, 8.9)].

CONCLUSION

This meta-analysis found that organ/space SSI rates as well as ostomy nonreversal rates were decreased in PRA at the cost of prolonging the operating time.

Organ preservation in rectal cancer: a synopsis of current guidelines

BACKGROUND

The high morbidity associated with radical resection for rectal cancer is an incentive for surgeons to adopt strategies aimed at organ preservation, particularly for early disease. There are a number of different approaches to achieve this. In this study we have collated current national and international guidelines to produce a synopsis to support this changing practice.

METHODS

The databases PubMed, Embase, Trip database, national guideline clearinghouse, BMJ Best practice were interrogated. Guidelines published before 2010 were excluded. The AGREE-II tool was used for quality assessment.

RESULTS

24 guidelines were drawn from 2278 potential publications. A consensus exists for local excision for "low risk" T1 rectal cancer but there is no agreement how to stratify the risk of treatment failure. There is a low level of agreement for rectal preservation for more advanced disease but when mentioned is recommended for unfit patients or in th context of a clinical trial. Guidelines are inconsistent with respect to surveillance in node negative disease and after, complete response to chemoradiotherapy CONCLUSION: According to current guidelines and consensus statements organ preservation for rectal cancer beyond low risk T1, is still considered experimental and only indicated in patients unsuitable for radical surgery.. Follow up strategies and cN0 staging deserve attention and highlight the need for high quality clinical trials. This article is protected by copyright. All rights reserved.

Delaying surgery to perform CT scans for suspected appendicitis decreases the rate of negative appendectomies without increasing the rate of perforation nor postoperative complications

PURPOSE

Negative appendectomies are costly and are embedded with unnecessary risks for the patients. A careful indication for surgery seems mandatory even more so, since conservative therapy emerges as a potential alternative to surgery. The aims of this population-based study were to analyze whether radiological examinations for suspected appendicitis decreased the rate of negative appendectomies without increasing the rate of perforation or worsening postoperative outcomes.

METHOD

This study is a retrospective analysis of a prospective population-based database. The data collection included preoperative investigations and intraoperative and postoperative outcomes.

RESULTS

Based on 2559 patients, the rate of negative appendectomies decreased significantly with the use of CT scan as compared to clinical evaluation only (9.3 vs 5 %, p = 0.019), whereas ultrasonography alone was not able to decrease this rate (9.3 vs 6.2 %, p = 0.074). Delaying surgery for radiological investigation did not increase the rate of perforation (18.1 vs 19.2 %; adjusted odds ratio (OR) 1.01; 0.8-1.3; p = 0.899). Postoperative complications (surgical reintervention, postoperative wound infection, postoperative hematoma, postoperative intra-abdominal abscess, postoperative ileus) were all comparable.

CONCLUSION

In this population-based study, CT scan was the only radiological modality that significantly reduced the rate of negative appendectomy. The delay induced by such additional imaging did not increase perforation nor complication rates. Abdominal CT scans for suspected appendicitis should therefore be more frequently used if clinical findings are unconclusive.

Systematic review of evidence and consensus on perianal fistula: an analysis of national and international guidelines

AIM

Treatment of perianal fistula has evolved with the introduction of new techniques and biologicals in Crohn's disease (CD). Several guidelines are available worldwide, but many recommendations are controversial or lack high-quality evidence. The aim of this work was to provide an overview of the current available national and international guidelines for perianal fistula and to analyse areas of consensus and areas of conflicting recommendations, thereby identifying topics and questions for future research.

METHOD

MEDLINE, EMBASE and PubMed were systematically searched for guidelines on perianal fistula. Inclusion was limited to papers in English less than 10 years old. The included topics were classified as having consensus (unanimous recommendations in at least two-thirds of the guidelines) or controversy (fewer than three guidelines commenting on the topic or no consensus) between guidelines. The highest level of evidence was scored as sufficient (level 3a or higher of the Oxford Centre for Evidence-based Medicine Levels of Evidence 2009, http://www.cebm.net/oxford-centre-evidence-based-medicine-levels-evidence-march-2009/) or insufficient.

RESULTS

Twelve guidelines were included and topics with recommendations were compared. Overall, consensus was present in 15 topics, whereas six topics were rated as controversial. Evidence levels varied from strong to lack of evidence.

CONCLUSION

Evidence on the diagnosis and treatment of perianal fistulae (cryptoglandular or related to CD) ranged from nonexistent to strong, regardless of consensus. The most relevant research questions were identified and proposed as topics for future research.

Rectal enema is an alternative to full mechanical bowel preparation for primary rectal cancer surgery

AIM

According to the French GRECCAR III randomized trial, full mechanical bowel preparation (MBP) for rectal surgery decreases the rate of postoperative morbidity, in particular postoperative infectious complications, but MBP is not well tolerated by the patient. The aim of the present study was to determine whether a preoperative rectal enema (RE) might be an alternative to MBP.

METHODS

An analysis was performed of 96 matched cohort patients undergoing rectal resection with primary anastomosis and protective ileostomy at two different university teaching hospitals, whose rectal cancer management was comparable except for the choice of preoperative bowel preparation (MBP or RE). Prospective databases were retrospectively analysed.

RESULTS

Patients were well matched for age, gender, body mass index and Charlson index. The surgical approach and cancer characteristics (level above anal verge, stage and use of neoadjuvant therapy) were comparable between the two groups. Anastomotic leakage occurred in 10% of patients having MBP and in 8% having RE (P = 1.00). Pelvic abscess formation (6% vs 2%, P = 0.63) and wound infection (8% vs 15%, P = 0.55) were also comparable. Extra-abdominal infection (13% vs 13%, P = 1.00) and non-infectious abdominal complications such as ileus and bleeding (27% and 31%, P = 0.83) were not significantly different. Overall morbidity was comparable in the two groups (50% vs 54%, P = 0.83).

CONCLUSION

A simple RE before rectal surgery seems not to be associated with more postoperative infectious complications nor a higher overall morbidity than MBP.

[Acute sigmoid diverticulitis: toward a more and more conservative treatment]

Acute diverticulitis of the colon is a frequent pathology especially among elderly people and people of Caucasian origin. The prevalence is higher among sedentary people and in people with low-fiber diet. Its diagnosis is mainly based on computed tomography (CT) that allows guiding the therapeutic management. Over the last few years the treatment of acute diverticulitis has passably changed with in particular an evolution toward a restriction of the elective and emergency surgery indications and a reduction of the antiobiotherapy and hospitalization number. This article reviews the epidemiology, the diagnostic tools, and the management of this frequent digestive pathology.

An outcome and cost analysis of anal fistula plug insertion vs endorectal advancement flap for complex anal fistulae

AIM

The study aimed to compare the rate of success and cost of anal fistula plug (AFP) insertion and endorectal advancement flap (ERAF) for anal fistula.

METHOD

Patients receiving an AFP or ERAF for a complex single fistula tract, defined as involving more than a third of the longitudinal length of of the anal sphincter, were registered in a prospective database. A regression analysis was performed of factors predicting recurrence and contributing to cost.

RESULTS

Seventy-one patients (AFP 31, ERAF 40) were analysed. Twelve (39%) recurrences occurred in the AFP and 17 (43%) in the ERAF group (P = 1.00). The median length of stay was 1.23 and 2.0 days (P < 0.001), respectively, and the mean cost of treatment was €5439 ± €2629 and €7957 ± €5905 (P = 0.021), respectively. On multivariable analysis, postoperative complications, underlying inflammatory bowel disease and fistula recurring after previous treatment were independent predictors of de novo recurrence. It also showed that length of hospital stay ≤ 1 day to be the most significant independent contributor to lower cost (P = 0.023).

CONCLUSION

Anal fistula plug and ERAF were equally effective in treating fistula-in-ano, but AFP has a mean cost saving of €2518 per procedure compared with ERAF. The higher cost for ERAF is due to a longer median length of stay.

Transanal minimal invasive surgery for rectal lesions: should the defect be closed?

AIM

Transanal minimal invasive surgery (TAMIS) of rectal lesions is increasingly being used, but the technique is not yet standardized. The aims of this study were to evaluate peri-operative complications and long-term functional outcome of the technique and to analyse whether or not the rectal defect needs to be closed.

METHOD

Consecutive patients undergoing TAMIS using the SILS port (Covidien) and standard laparoscopic instruments were studied.

RESULTS

Seventy-five patients (68% male) of mean age 67 (± 15) years underwent single-port transanal surgery at three different centres for 37 benign lesions and 38 low-risk cancers located at a mean of 6.4 ± 2.3 cm from the anal verge. The median operating time was 77 (25-245) min including a median time for resection of 36 (15-75) min and for closure of the rectal defect of 38 (9-105) min. The defect was closed in 53% using interrupted (75%) or a running suture (25%). Intra-operative complications occurred in six (8%) patients and postoperative morbidity was 19% with only one patient requiring reoperation for Grade IIIb local infection. There was no difference in the incidence of complications whether the rectal defect was closed or left open. Patients were discharged after 3.4 (1-21) days. At a median follow-up of 12.8 (2-29) months, the continence was normal (Vaizey score of 1.5; 0-16).

CONCLUSION

Transanal rectal resection can be safely and efficiently performed by means of a SILS port and standard laparoscopic instruments. The rectal defect may be left open and at 1 year continence is not compromised.

Systematic review of evidence and consensus on diverticulitis: an analysis of national and international guidelines

AIM

The study aimed to analyse the currently available national and international guidelines for areas of consensus and contrasting recommendations in the treatment of diverticulitis and thereby to design questions for future research.

METHOD

MEDLINE, EMBASE and PubMed were systematically searched for guidelines on diverticular disease and diverticulitis. Inclusion was confined to papers in English and those < 10 years old. The included topics were classified as consensus or controversy between guidelines, and the highest level of evidence was scored as sufficient (Oxford Centre of Evidence-Based Medicine Level of Evidence of 3a or higher) or insufficient.

RESULTS

Six guidelines were included and all topics with recommendations were compared. Overall, in 13 topics consensus was reached and 10 topics were regarded as controversial. In five topics, consensus was reached without sufficient evidence and in three topics there was no evidence and no consensus. Clinical staging, the need for intraluminal imaging, dietary restriction, duration of antibiotic treatment, the protocol for abscess treatment, the need for elective surgery in subgroups of patients, the need for surgery after abscess treatment and the level of the proximal resection margin all lack consensus or evidence.

CONCLUSION

Evidence on the diagnosis and treatment of diverticular disease and diverticulitis ranged from nonexistent to strong, regardless of consensus. The most relevant research questions were identified and proposed as topics for future research.

[Acute anal pain]

Anal pain is a common reason for consultation, whose etiology is varied and should not be limited to the hemorrhoidal disease. The purpose of this article is to conduct a review of the literature on anorectal pathologies most frequently encountered and make recommendations regarding their management.

Anal mucosectomy for haemorrhoids: should we start to speak Chinese?

AIM

Circular stapled mucosectomy is the standard therapy for the treatment of symptomatic third-degree haemorrhoids and mucosal prolapse. Recently, new staplers made in China have entered the market offering an alternative to the PPH stapling devices. The aim of this prospective randomized study was to compare the safety and efficacy of these new devices.

METHODS

Fifty patients with symptomatic third-degree haemorrhoids were randomized to mucosectomy either by using stapler A (CPH32; Frankenman International Ltd, Hong Kong, China; n = 25) or stapler B (PPH03; Ethicon Endo-Surgery, Spreitenbach, Switzerland; n = 25). All procedures were performed by two experienced surgeons. After the stapler was fired by one surgeon, the other surgeon, who was blinded for stapler type, evaluated the stapler line. Postoperative outcome including pain, complications and patient satisfaction were analysed.

RESULTS

Demographic and clinical features were no different between the groups. There was no significant difference regarding venous bleeding (P = 0.55), but arterial bleeding was significantly more frequent when stapler B was used (P < 0.001). This led to significantly more suture ligations (P = 0.002). However, no differences regarding operation time (P = 0.99), weight of the resected mucosa (P = 0.81) and height of the stapler line (anterior, P = 0.18; posterior, P = 0.65) were detected. Postoperative pain scores (visual analogue scale) and patient satisfaction were no different either (P = 0.91 and P = 0.78, respectively). No recurrence or incontinence occurred during follow-up.

CONCLUSIONS

CPH32 required significantly fewer sutures for bleeding control along the stapler line after circular mucosectomy. However, operation time, rate of postoperative complications and patient satisfaction were similar in both groups.

Biological materials in colorectal surgery: current applications and potential for the future

Biological materials are increasingly used in abdominal surgery for ventral, pelvic and perineal reconstructions, especially in contaminated fields. Future applications are multi-fold and include prevention and one-step closure of infected areas. This includes prevention of abdominal, parastomal and pelvic hernia, but could also include prevention of separation of multiple anastomoses, suture- or staple-lines. Further indications could be a containment of infected and/or inflammatory areas and protection of vital implants such as vascular grafts. Reinforcement patches of high-risk anastomoses or unresectable perforation sites are possibilities at least. Current applications are based mostly on case series and better data is urgently needed. Clinical benefits need to be assessed in prospective studies to provide reliable proof of efficacy with a sufficient follow-up. Only superior results compared with standard treatment will justify the higher costs of these materials. To date, the use of biological materials is not standard and applications should be limited to case-by-case decision.

A challenging hernia: primary venous aneurysm of the proximal saphenous vein

INTRODUCTION

Primary venous aneurysm is a rare, but essential consideration in the differential diagnosis of an inguinal and femoral hernia.

METHODS

We report a case of a 43-year-old man who was referred for evaluation and treatment of a femoral hernia.

RESULTS

The patient presented with a 3-month history of an asymptomatic tumor on his right upper inner thigh. Physical examination noted a non-tender, non-indurated tumor.

CONCLUSION

Surgical exploration demonstrated a primary venous aneurysm of the proximal saphenous vein.

What should we do about anal condyloma and anal intraepithelial neoplasia? Results of a survey

AIM

There is a lack of standardization regarding diagnosis, treatment and surveillance of patients with anal HPV infection.

METHOD

An Internet-based survey was sent to members of international, surgical and dermatological societies. Answers were obtained from 1017 dermatologists and 393 colorectal surgeons (n = 1410).

RESULTS

More dermatologists than surgeons provided noninvasive treatment of anal condyloma with 5% imiquimod (80.4 vs 28.2%; P < 0.001), whereas the situation was reversed for surgical excision (56.8 vs 91.3%; P < 0.001). To detect dysplastic lesions, 42.0% of surgeons used acetic acid only, 23.2% used this in combination with high-resolution anoscopy and 19.5% applied intra-anal cytological smears. Likewise, 64.6% of dermatologists applied acetic acid only, 16.5% combined acetic acid with high-resolution anoscopy and 30.2% performed intra-anal cytological smears (all P < 0.001 compared with surgeons). The therapy for anal intraepithelial lesions was not influenced by the grade of dysplasia, but it was by immune status.

CONCLUSION

There were significant differences in practice between colorectal surgeons and dermatologists. These findings highlight the need for international and cross-disciplinary clinical guidelines.

Parastomal hernia incarceration due to migrated intragastric balloon

The temporary placement of intragastric balloons is a common method to achieve rapid weight loss before planned metabolic surgery. We report the case of a 48-year-old morbidly obese patient. Ten years ago the patient underwent emergency sigmoidectomy with creation of a double-barreled ileostomy for perforated diverticulitis. Over time he developed a giant parastomal hernia. For preoperative weight reduction before planned restoration of intestinal continuity, an intragastric balloon was inserted 3 years ago. The patient was admitted to our emergency department with peritonism and a septic shock. After computed tomography showing small bowel ileus, laparotomy was performed, revealing marked ischemia of incarcerated small and large intestine. Only postoperatively was the intragastric balloon found in the resected small bowel, causing a mechanical ileus with consecutive incarceration of the bowel. We review the literature on complications due to the migration of intragastric balloons. This clinical case gives a fair warning of the possible deleterious outcome of intragastric balloons, especially in hernia patients.

Colonic transformation of ileal pouch-anal anastomosis and of the distal ileum: MRI findings

Colonic metaplasia of the ileal reservoir in patients after ileal pouch-anal anastomosis (IPAA) is described in pathological and histochemical studies. So far, there are no reports on the imaging presentation of colonic transformation. We describe the distinctive post-operative MRI features found in a 28-year-old patient with IPAA after failed conservative treatment of chronic ulcerative colitis. These distinct MRI features of colonic transformation of ileum mimicking normal colon are important to know for radiologists reading MR examinations of patients with IPAA.

Population-based trend analysis of 2813 patients undergoing laparoscopic sigmoid resection

BACKGROUND

The use of laparoscopic sigmoid resection for diverticular disease has become increasingly popular. The objective of this trend analysis was to assess whether clinical outcomes following laparoscopic sigmoid resection for diverticular disease have improved over the past 10 years.

METHODS

The analysis was based on the prospective database of the Swiss Association of Laparoscopic and Thoracoscopic Surgery. Some 2813 patients undergoing elective laparoscopic sigmoid resection for diverticular disease from 1995 to 2006 were included. Unadjusted and risk-adjusted analyses were performed.

RESULTS

Over time, there was a significant reduction in the conversion rate (from 27.3 to 8.6 per cent; P(trend) < 0.001), local postoperative complication rate (23.6 to 6.2 per cent; P(trend) = 0.004), general postoperative complication rate (14.6 to 4.9 per cent; P(trend) = 0.024) and reoperation rate (5.5 to 0.6 per cent; P(trend) = 0.015). Postoperative median length of hospital stay significantly decreased from 11 to 7 days (P(trend) < 0.001).

CONCLUSION

This first trend analysis in the literature of clinical outcomes after laparoscopic sigmoid resection, based on almost 3000 patients, has provided compelling evidence that rates of postoperative complications, conversion and reoperation, and length of hospital stay have decreased significantly over the past 10 years.

Prospective randomized study of monopolar scissors, bipolar vessel sealer and ultrasonic shears in laparoscopic colorectal surgery

Background

Many instruments are used for laparoscopic dissection, including monopolar electrosurgery scissors (MES), electrothermal bipolar vessel sealers (BVS) and ultrasonically coagulating shears (UCS). These three devices were compared with regard to dissection time, blood loss, safety and costs.

Methods

Sixty-one consecutive patients undergoing laparoscopic left-sided colectomy were randomized to MES, BVS or UCS. The primary endpoint was dissection time.

Results

Patient and operation characteristics did not differ between the groups. Median dissection time was significantly shorter with BVS (105 min) and UCS (90 min) than with MES (137 min) (P &lt; 0·001). With BVS and UCS, significantly fewer additional clips were required (MES 9 versus BVS 0 versus UCS 3; P &lt; 0·001) and there was a trend towards lower blood loss (125 versus 50 versus 50 ml respectively; P = 0·223) and a reduced volume of suction fluid (425 versus 80 versus 110 ml; P = 0·058). Overall satisfaction was similar for the three instruments. Dissection with BVS and UCS was significantly cheaper than with MES, assuming a centre volume of 200 cases per year (P = 0·009).

Conclusion

BVS and UCS shorten dissection time in laparoscopic left-sided colectomy and are cost-effective compared with MES. Registration number: NCT00517608 (http://www.clinicaltrials.com).

High secondary failure rate of rebanding after failed gastric banding

BACKGROUND

Over the last decade, more than 130,000 laparoscopic adjustable gastric bandings (LAGB) have been performed for the treatment of morbid obesity. Nowadays, longer follow-up data are available in the literature and increasing numbers of late complications and treatment failures of gastric banding have been reported. The aim of the present study was the long-term evaluation of two different rescue operations after failed LAGB: conversion to laparoscopic Roux-en-Y bypass (LRYGB) versus laparoscopic gastric rebanding.

METHODS

Between January 1997 and November 2002, 74 consecutive patients underwent either laparoscopic gastric rebanding (n = 44) or LRYGB (n = 30) after failed LAGB. There were 14 men and 60 women, with a median age of 42 (23-60) years. The indication for reoperation was an increasing body mass index (BMI) and band-related complications such as pouch dilatation, band slippage, and penetration after LAGB. Rebandings were done by preference during the initial period of the study and LRYGB was the treatment of choice during the latter period. The success of the rescue operation was assessed by postoperative changes in the BMI, improvements of co-morbidities, and the need for further reoperations (secondary failure). The median follow-up was 36 months (range, 24-60 months).

RESULTS

Patients who underwent LRYGB had a significantly better weight loss than patients with a rebanding operation (mean -6.1 versus +1.5 BMI points). In addition, the LRYGB patients showed a significantly better control of serum cholesterol during the long term follow-up (-0.6 versus +0.1 mmol/l). Almost half of the patients (45%) in the rebanding group needed a further operative revision, whereas only 20% underwent reoperation after rescue LRYGB. Thus, the secondary failure rate in the rebanding group was significantly higher compared to the bypass group (p = 0.028).

CONCLUSIONS

The present long-term study confirms our previous finding that LRYGB is a better treatment than rebanding after failed laparoscopic gastric banding regarding weight loss and treatment of co-morbidities. During the long-term follow-up the reoperation rate due to secondary failure became significantly higher in the rebanding group. We therefore recommend that LRYGB should be preferred as rescue procedure after failed laparoscopic adjustable gastric banding.

Long-term follow-up after combined fissurectomy and Botox injection for chronic anal fissures

BACKGROUND AND AIMS

Chronic anal fissures are difficult to treat. The aim of this retrospective study was to determine the outcome of combined fissurectomy and injection of botulinum toxin Type A (BT).

MATERIALS AND METHODS

Between January 2001 and August 2004, 40 patients (21 women), median age 37 years (range 18 to 57), underwent fissurectomy and BT injection. Fissurectomy was performed followed by injection of 10 U of BT into the internal anal sphincter on both sides of the fissure. All patients were clinically checked 6 weeks after the operation. At 1 year, patients were sent a detailed questionnaire regarding symptoms, recurrence and further treatment for evaluation of long-term results.

RESULTS/FINDINGS

At 6 weeks, 38 patients (95%) were free of symptoms. No adverse effects were detected. The response rate of questionnaires was 93%; the median follow-up was 1 year (range 0.9 to 1.6). In the long-term, a recurrence was found in four patients. These patients were treated successfully with repeated fissurectomy and BT injections and salvage procedures, respectively. Overall, the success rate of combined fissurectomy and BT injection was 79%.

INTERPRETATION/CONCLUSION

Combined fissurectomy and Botox injection for chronic anal fissure is an excellent and safe procedure with low morbidity and a high healing rate.

[New concept in the treatment of the pilonidal sinus]

Symptomatic pilonidal sinus is characterized by an acute or a chronic inflammation. The surgical management of symptomatic pilonidal sinus is still a matter of discussion and no clear recommendations exists. On the basis of results from published studies and our own experience we developed a new two step therapy concept: Infected pilonidal were first drained by a small excision of the abscess (if possible in local anesthesia) followed by a close fistula excision. With this approach we were able to achieve a low morbidity and a high healing rate. In the case of extensive fistulating pilonidal sinus or recurrent disease we recommend radical excision and primary reconstructive flap what showed good aesthetic results.

Results at up to 20 years after ileal pouch-anal anastomosis for chronic ulcerative colitis

BACKGROUND

Ileal pouch-anal anastomosis (IPAA) is performed routinely for chronic ulcerative colitis.

METHODS

Using data from a prospective database and annual standardized questionnaires, functional outcome, complications and quality of life (QoL) after IPAA were assessed.

RESULTS

Some 1885 IPAA operations were performed for chronic ulcerative colitis over a 20-year period (mean follow-up 11 years). The mean age at the time of IPAA was 34.1 years, increasing from 31.2 years (1981-1985) to 36.3 years (1996-2000). The overall rate of pouch success at 5, 10, 15 and 20 years was 96.3, 93.3, 92.4 and 92.1 per cent respectively. Mean daytime stool frequency increased from 5.7 at 1 year to 6.4 at 20 years (P < 0.001), and also increased at night (from 1.5 to 2.0; P < 0.001). The incidence of frequent daytime faecal incontinence increased from 5 to 11 per cent during the day (P < 0.001) and from 12 to 21 per cent at night (P < 0.001). QoL remained unchanged and 92 per cent remained in the same employment. Seventy-six patients were eventually diagnosed with indeterminate colitis and 47 with Crohn's disease.

CONCLUSION

IPAA is a reliable surgical procedure for patients requiring proctocolectomy for chronic ulcerative colitis and indeterminate colitis. The clinical and functional outcomes are excellent and stable for 20 years after operation.