The empty pelvis syndrome: a core data set from the PelvEx collaborative

BACKGROUND

Empty pelvis syndrome (EPS) is a significant source of morbidity following pelvic exenteration (PE), but is undefined. EPS outcome reporting and descriptors of radicality of PE are inconsistent; therefore, the best approaches for prevention are unknown. To facilitate future research into EPS, the aim of this study is to define a measurable core outcome set, core descriptor set and written definition for EPS. Consensus on strategies to mitigate EPS was also explored.

METHOD

Three-stage consensus methodology was used: longlisting with systematic review, healthcare professional event, patient engagement, and Delphi-piloting; shortlisting with two rounds of modified Delphi; and a confirmatory stage using a modified nominal group technique. This included a selection of measurement instruments, and iterative generation of a written EPS definition.

RESULTS

One hundred and three and 119 participants took part in the modified Delphi and consensus meetings, respectively. This encompassed international patient and healthcare professional representation with multidisciplinary input. Seventy statements were longlisted, seven core outcomes (bowel obstruction, enteroperineal fistula, chronic perineal sinus, infected pelvic collection, bowel obstruction, morbidity from reconstruction, re-intervention, and quality of life), and four core descriptors (magnitude of surgery, radiotherapy-induced damage, methods of reconstruction, and changes in volume of pelvic dead space) reached consensus-where applicable, measurement of these outcomes and descriptors was defined. A written definition for EPS was agreed.

CONCLUSIONS

EPS is an area of unmet research and clinical need. This study provides an agreed definition and core data set for EPS to facilitate further research.

Impact on defecatory, urinary and sexual function after high-tie sigmoidectomy: a post-hoc analysis of a multicenter randomized controlled trial comparing extended versus standard complete mesocolon excision

OBJECTIVE

To assess the effect of high inferior mesenteric artery tie on defecatory, urinary, and sexual function after surgery for sigmoid colon cancer. Performing a sigmoidectomy poses a notable risk of causing injury to the preaortic sympathetic nerves during the high ligation of the inferior mesenteric artery, as well as to the superior hypogastric plexus during dissection at the level of the sacral promontory. Postoperative defecatory and genitourinary dysfunction after sigmoid colon resection are often underestimated and underreported.

METHODS

This study is a secondary research of a multicenter, single-blind, randomized clinical trial. The trial involved patients with sigmoid cancer who underwent either extended complete mesocolic excision (e-CME) or standard CME (s-CME). Patients completed questionnaires to assess defecatory, urinary, and sexual function before, 1 month after surgery, and 1 year after surgery. Multivariate analysis was conducted to identify factors associated with functional dysfunction.

RESULTS

Seventy-nine patients completed functional assessments before and 1 year after surgery. One year after sigmoidectomy with a high tie of the inferior mesenteric artery, 15.2% of patients had minor low anterior resection syndrome (LARS) and 12.7% had major LARS; 22.2% of males and 29.4% of females had urinary dysfunction; and 43.8% of males and 27.3% of females had sexual dysfunction. After multivariate analysis, no significant associations were found between clinical and surgical factors and gastrointestinal or urinary dysfunction after 1 year of surgery. Age was identified as the only factor linked to sexual dysfunction in both sexes (women, β =  - 0.54, p = 0.002; men β =  - 0.38, p = 0.010). Regarding recovery outcomes, diabetes mellitus was identified as a contributing factor to suboptimal gastrointestinal recovery (p = 0.033) and urinary recovery in women (p = 0.039). Furthermore, the treatment arm was found to be significantly associated with the recovery of erectile function after 1 year of surgery (p = 0.046).

CONCLUSIONS

A high tie of the inferior mesenteric artery during sigmoidectomy is associated with a high incidence of defecatory and genitourinary dysfunction. Age was identified as a significant factor associated with sexual dysfunction 1 year after sigmoid colon resection in both sexes.

TRIAL REGISTRATION

Clinical trials NCT03083951 HIGHLIGHTS: • One year after high-tie sigmoidectomy, 27.9% of patients had LARS; 22.2% of the men and 29.4% of the women had urinary dysfunction; and 43.8% of the men and 27.3% of the women had sexual dysfunction. • e-CME is associated with a high rate of urinary dysfunction in men 1 year after surgery. However, after multivariate analysis, no association was found between e-CME and urinary dysfunction in men. • Age was correlated with the recovery of sexual function in both sexes 1 year after surgery. Furthermore, diabetes mellitus was identified as the factor associated with poorer recovery of urinary function in females.

Endoscopic treatment (endoscopic balloon dilation/self-expandable metal stent) vs surgical resection for the treatment of de novo stenosis in Crohn's disease (ENDOCIR study): an open-label, multicentre, randomized trial

BACKGROUND

Stenosis is one of the most common complications in patients with Crohn's disease (CD). Endoscopic balloon dilation (EBD) is the treatment of choice for a short stenosis adjacent to the anastomosis from previous surgery. Self-expandable metal stents (SEMS) may be a suitable treatment option for longer stenoses. To date, however, there is no scientific evidence as to whether endoscopic (EBD/SEMS) or surgical treatment is the best approach for de novo or primary stenoses that are less than 10 cm in length.

METHODS/DESIGN

Exploratory study as "proof-of-concept", multicentre, open-label, randomized trial of the treatment of de novo stenosis in the CD; endoscopic treatment (EBD/SEMS) vs surgical resection (SR). The type of endoscopic treatment will initially be with EDB; if a therapeutic failure occurs, then a SEMS will be placed. We estimate 2 years of recruitment and 1 year of follow-up for the assessment of quality of life, costs, complications, and clinical recurrence. After the end of the study, patients will be followed up for 3 years to re-evaluate the variables over the long term. Forty patients with de novo stenosis in CD will be recruited from 15 hospitals in Spain and will be randomly assigned to the endoscopic or surgical treatment groups. The primary aim will be the evaluation of the patient quality of life at 1 year follow-up (% of patients with an increase of 30 points in the 32-item Inflammatory Bowel Disease Questionnaire (IBDQ-32). The secondary aim will be evaluation of the clinical recurrence rate, complications, and costs of both treatments at 1-year follow-up.

DISCUSSION

The ENDOCIR trial has been designed to determine whether an endoscopic or surgical approach is therapeutically superior in the treatment of de novo stenosis in CD.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04330846. Registered on 1 April 1 2020. https://clinicaltrials.gov/ct2/home.

Short-term outcomes of chemoradiotherapy and local excision versus total mesorectal excision in T2-T3ab,N0,M0 rectal cancer: a multicentre randomised, controlled, phase III trial (the TAU-TEM study)

BACKGROUND

The standard treatment of T2-T3ab,N0,M0 rectal cancers is total mesorectal excision (TME) due to the high recurrence rates recorded with local excision. Initial reports of the combination of pre-operative chemoradiotherapy (CRT) and transanal endoscopic microsurgery (TEM) have shown reductions in local recurrence. The TAU-TEM study aims to demonstrate the non-inferiority of local recurrence and the improvement in morbidity achieved with CRT-TEM compared with TME. Here we describe morbidity rates and pathological outcomes.

PATIENTS AND METHODS

This was a prospective, multicentre, randomised controlled non-inferiority trial including patients with rectal adenocarcinoma staged as T2-T3ab,N0,M0. Patients were randomised to the CRT-TEM or the TME group. Patients included, tolerance of CRT and its adverse effects, surgical complications (Clavien-Dindo and Comprehensive Complication Index classifications) and pathological results (complete response in the CRT-TEM group) were recorded in both groups. Patients attended follow-up controls for local and systemic relapse.

TRIAL REGISTRATION

NCT01308190.

RESULTS

From July 2010 to October 2021, 173 patients from 17 Spanish hospitals were included (CRT-TEM: 86, TME: 87). Eleven were excluded after randomisation (CRT-TEM: 5, TME: 6). Modified intention-to-treat analysis thus included 81 patients in each group. There was no mortality after CRT. In the CRT-TEM group, one patient abandoned CRT, 1/81 (1.2%). The CRT-related morbidity rate was 29.6% (24/81). Post-operative morbidity was 17/82 (20.7%) in the CRT-TEM group and 41/81 (50.6%) in the TME group (P < 0.001, 95% confidence interval 42.9% to 16.7%). One patient died in each group (1.2%). Of the 81 patients in the CRT-TEM group who received the allocated treatment, 67 (82.7%) underwent organ preservation. Pathological complete response in the CRT-TEM group was 44.3% (35/79). In the TME group, pN1 were found in 17/81 (21%).

CONCLUSION

CRT-TEM treatment obtains high pathological complete response rates (44.3%) and a high CRT compliance rate (98.8%). Post-operative complications and hospitalisation rates were significantly lower than those in the TME group. We await the results of the follow-up regarding cancer outcomes and quality of life.

Minimum standards of pelvic exenterative practice: PelvEx Collaborative guideline

This document outlines the important aspects of caring for patients who have been diagnosed with advanced pelvic cancer. It is primarily aimed at those who are establishing a service that adequately caters to this patient group. The relevant literature has been summarized and an attempt made to simplify the approach to management of these complex cases.

Noninferiority multicenter prospective randomized controlled study of rectal cancer T2–T3s (superficial) N0, M0 (T2T3sN0M0) undergoing neoadjuvant treatment and local excision (TEM) versus total mesorectal excision (TME): Preoperative, surgical, and pathological outcomes—The TAUTEM-study

3501

Background: The standard surgical treatment of rectal adenocarcinoma above T1 is total mesorectal excision (TME), but it is associated with high morbidity and quality of life disorders. Transanal endoscopic microsurgery (TEM) achieves minimal postoperative morbidity rates. The treatment of T2, T3 superficial, N0, M0 rectal cancers is TME due to local excision achieving high recurrence rates. Initial reports of preoperative chemoradiotherapy (CRT) in association with TEM shows reduction in local recurrence. The TAU-TEM study aims to demonstrate the non-inferiority of the oncological outcomes and the improvement in morbidity and quality of life achieved with CRT-TEM compared with TME. Methods: Prospective, multicenter, randomized controlled non-inferiority trial including patients with rectal adenocarcinoma less than 10 cm from the anal verge and up to 4 cm in size, staged as T2T3sN0M0. Patients were randomized to: CRT-TEM (Arm A) or TME (Arm B). Postoperative morbidity and mortality were recorded and patients in both arms completed quality of life questionnaires when starting treatment and 6 months after surgery. Patients attended follow-up controls for local and systemic relapse. Trial registration: ClinicalTrials.gov Identifier: NCT01308190. Results: From July/2010 to October/2021, 173 patients from 17 Spanish hospitals were included (Arm A: 86, Arm B: 87). Ten were excluded after randomization (Arm A: 4, [3 re-staged > T2T3sN0M0, 1 refused follow-up study]; Arm B: 6 [4 refused the arm, 2 re-staged > T2T3sN0M0]). Therefore, the patients with modified intention to treat analysis were: TME, 81 and CRT-TEM, 82. There was no mortality after CRT. In this group, 2 patients abandoned neoadjuvant therapy; thus 80/82 (97.6%) completed CRT. The CRT-morbidity was low (25/82, 30%) and of low grade (95% G1-2). In the CRT-TEM group, MRI showed disease progression in 3 patients who were treated with TME. Finally, 77 patients underwent TEM surgery. One patient died in each arm (1.2%). Postoperative morbidity was 41/81 (50.6%) (Arm B) and 17/82 (20.7%) (Arm A) (p < 0.001, 95 CI% 43.9 to 15.9). Median Comprehensive Complication Index was 8.7 (IQR 20.9) Arm B and 0 (IQR 0) Arm A (p < 0.001). Median hospital stay was 7 days (IQR 7) Arm B and 2 days (IQR 2) Arm A (p < 0.001). Complete response in Arm A was 45.3% (34/75 patients) with 5.3% ypT3 (4/75 patients) and in Arm B: pT1 (12.3%; 10/81patients), deep-pT3 (4.95; 4/81patients), pN1 (21%; 17/81). Conclusions: CRT-TEM treatment obtains high pathological complete response rates (45.3%), with a high CRT compliance rate (97.6%) and low morbidity. Postoperative complications and hospitalization are significantly lower in the CRT-TEM group. We await the results of the follow-up. Clinical trial information: NCT01308190.

Combined endoscopic-laparoscopic surgery (CELS) can avoid segmental colectomy in endoscopically unremovable colonic polyps: a cohort study over 10 years

BACKGROUND

Combined-Endoscopic-Laparoscopic-Surgery (CELS) was developed for benign colonic polyps, endoscopically unresectable, to avoid segmental colectomy. This observational study aims to compare surgical outcomes of endoscopically unresectable colonic polyps treated laparoscopically before and since the institutional introduction of CELS. Primary endpoint was postoperative morbidity and mortality; secondary endpoints were time of hospitalization and histopathological findings.

METHODS

Charts of all patients with preoperative diagnosis of benign colonic tumors, treated laparoscopically at our institution from 1/2010 to 2/2020 were reviewed. Patients with polyps (1) affecting ileocecal valve, (2) occupying > 50% of the circumference, (3) ≥ 3 endoscopically unresectable polyps, (4) inflammatory bowel disease, (5) polyps within diverticular area post diverticulitis, (6) rectal polyps (7) foreseen impossibility of laparoscopy (8) preoperatively biopsy proven invasive adenocarcinoma were excluded. Group I consists of all patients potentially treatable by CELS but operated by laparoscopic colonic resection as CELS was not yet institutionally established. Group II includes all patients treated with CELS (since 11/2017).

RESULTS

One hundred-fifteen consecutive patients were reviewed. Applying exclusion criteria, twenty-three patients form group I and twenty-three group II (female 30.4%, median age 68 years). Groups distributed homogenously for age, BMI (body mass index) and polyps´ localization with most polyps (60.4%) localized in right colon; group II patients had significantly higher American Society of Anesthesiologists (ASA) score. Median operating time, hospital stay and morbidity were significantly less in group II. Postoperative morbidity occurred overall in 14 patients (30.4%), mostly Clavien-Dindo class I-II (26.1%) and significantly less in group II (p = 0.017), Clavien-Dindo III-IV distributed equally (one patient each group) without postoperative mortality. Definitive histopathology showed invasive adenocarcinoma in 8.3% without differences between groups. Two patients with invasive adenocarcinoma after CELS were advised for oncological resection.

CONCLUSION

CELS is safe and efficient to treat complex, benign colonic polyps by a complete minimal invasive laparoscopic approach. CELS showed better surgical outcomes with less morbidity, no mortality and appropriate pathological results avoiding unnecessary laparoscopic surgery with intestinal anastomosis.

Simultaneous pelvic exenteration and liver resection for primary rectal cancer with synchronous liver metastases: results from the PelvEx Collaborative

AIM

At presentation, 15-20% of patients with rectal cancer already have synchronous liver metastases. The aim of this study was to determine the surgical and survival outcomes in patients with advanced rectal cancer who underwent combined pelvic exenteration and liver (oligometastatic) resection.

METHOD

Data from 20 international institutions that performed simultaneous pelvic exenteration and liver resection between 2007 and 2017 were accumulated. Primarily, we examined perioperative outcomes, morbidity and mortality. We also assessed the impact that margin status had on survival.

RESULTS

Of 128 patients, 72 (56.2%) were men with a median age of 60 years [interquartile range (IQR) 15 years]. The median size of the liver oligometastatic deposits was 2 cm (IQR 1.8 cm). The median duration of surgery was 406 min (IQR 240 min), with a median blood loss of 1090 ml (IQR 2010 ml). A negative resection margin (R0 resection) was achieved in 73.5% of pelvic exenterations and 66.4% of liver resections. The 30-day mortality rate was 1.6%, and 32% of patients had a major postoperative complication. The 5-year overall survival for patients in whom an R0 resection of both primary and metastatic disease was achieved was 54.6% compared with 20% for those with an R1/R2 resection (P = 0.006).

CONCLUSION

Simultaneous pelvic exenteration and liver resection is feasible, with acceptable morbidity and mortality. Simultaneous resection should only be performed where an R0 resection of both pelvic and hepatic disease is anticipated.

Non-inferiority multicenter prospective randomized controlled study of rectal cancer T2-T3s (superficial) N0, M0 undergoing neoadjuvant treatment and local excision (TEM) vs total mesorectal excision (TME)

PURPOSE

The standard treatment of rectal adenocarcinoma is total mesorectal excision (TME), in many cases requires a temporary or permanent stoma. TME is associated with high morbidity and genitourinary alterations. Transanal endoscopic microsurgery (TEM) allows access to tumors up to 20 cm from the anal verge, achieves minimal postoperative morbidity and mortality rates, and does not require an ostomy. The treatment of T2, N0, and M0 cancers remains controversial. Preoperative chemoradiotherapy (CRT) in association with TEM reduces local recurrence and increases survival. The TAU-TEM study aims to demonstrate the non-inferiority of the oncological outcomes and the improvement in morbidity and quality of life achieved with TEM compared with TME.

METHODS

Prospective, multicenter, randomized controlled non-inferiority trial includes patients with rectal adenocarcinoma less than 10 cm from the anal verge and up to 4 cm in size, staged as T2 or T3-superficial N0-M0. Patients will be randomized to two areas: CRT plus TEM or radical surgery (TME). Postoperative morbidity and mortality will be recorded and patients will complete the quality of life questionnaires before the start of treatment, after CRT in the CRT/TEM arm, and 6 months after surgery in both arms. The estimated sample size for the study is 173 patients. Patients will attend follow-up controls for local and systemic relapse.

CONCLUSIONS

This study aims to demonstrate the preservation of the rectum after preoperative CRT and TEM in rectal cancer stages T2-3s, N0, M0 and to determine the ability of this strategy to avoid the need for radical surgery (TME).

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01308190. Número de registro del Comité de Etica e Investigación Clínica (CEIC) del Hospital universitario Parc Taulí: TAU-TEM-2009-01.

A Double-Blinded Randomized Clinical Study on the Therapeutic Effect of Gastrografin in Prolonged Postoperative Ileus After Elective Colorectal Surgery

BACKGROUND

Postoperative ileus is a common problem with significant clinical and economic consequences. We hypothesized that Gastrografin may have therapeutic utility by accelerating the recovery of postoperative ileus after colorectal surgery. The aim of this trial was to study the impact of oral Gastrografin administration on postoperative prolonged ileus (PPI) after elective colorectal surgery.

METHODS

The main endpoint of this randomized, double-blinded, controlled trial was time of resolution of PPI. The secondary endpoints were overall hospital length of stay, time to start oral intake, time to first passage of flatus or stools, time of need of nasogastric tube, and need of parenteral nutrition. Included criteria were patients older than 18 years, operated for colonic neoplasia, inflammatory bowel disease, or diverticular disease. There were two treatments: Gastrografin administration and placebo. The sample size was calculated taking into account the average length of postoperative ileus after colorectal resection until tolerance to oral intake. Statistical analysis showed that 29 subjects in each group were needed.

RESULTS

Twenty-nine patients per group were randomized. Groups were comparable for age, gender, ASA Physical Status Classification System, stoma construction, and surgical technique. No statistical differences were observed in mean time to resolution between the two groups, 9.1 days (CI 95%, 6.51-11.68) in Gastrografin group versus 10.3 days (CI 6.96-10.29) in Placebo group (P = 0.878). Even if not statistically significant, time of resolution of PPI, overall length of stay, time of need of nasogastric tube, and time to tolerance of oral intake were shorter in the G group.

CONCLUSIONS

Gastrografin does not accelerate significantly the recovery of prolonged postoperative ileus after elective colorectal resection when compared with placebo. However, it seems to clinically improve all the analyzed variables.

Outcomes of colonic diverticulitis according to the reason of immunosuppression

BACKGROUND

The aims of this study were to analyze the relationship between the different causes of immunosuppression (IMS) and diverticulitis.

METHODS

IMS patients admitted for colonic diverticulitis were included in the study. Patients were divided in 5 groups according to the reasons of IMS: group I, chronic corticosteroid therapy; group II, transplant patients; group III, malignant neoplasm disease; group IV, chronic renal failure; group V, others immunosuppressant treatment. Rate of emergency surgery, outcomes in terms of postoperative mortality, and recurrence rate after nonoperative management were analyzed according to the reason of IMS.

RESULTS

Emergency surgery was performed in 76 patients (39.3%). It was needed more frequently in group I. Overall, postoperative mortality was of 31.6% and recurrence rate after successful nonoperative management occurred in 30 patients (27.8%). No differences were observed among the groups.

CONCLUSIONS

The rate of emergency surgery in IMS patients at the first episode of acute colonic diverticulitis is high. Elective surgery in IMS patients should be individually indicated according to persistence of symptoms or early recurrences.

Incidence and management of anastomotic bleeding after ileocolic anastomosis

AIM

Ileocolic anastomosis is performed using a stapled or manual technique, but with either there is a risk of bleeding from the suture line. The aim of this study was to analyse, retrospectively, bleeding after different anastomotic techniques.

METHOD

Patients having elective right colectomy were divided, according to the type of ileocolic anastomosis, into Group 1 (circular, double-stapled, end-to-side), Group 2 (linear-stapled, side-to-side) and Group 3 (handsewn, side-to-side). Postoperative lower gastrointestinal bleeding (LGIB) was studied in the three groups. Uni- and multivariate analysis was performed to study risk factors for LGIB and the need for postoperative allogeneic blood transfusion.

RESULTS

Three-hundred and fifty patients were included: 174 in Group 1, 59 in Group 2 and 117 in Group 3. The postoperative LGIB rate was 4.9% and occurred exclusively in Group 1. Five patients had severe anastomotic bleeding. Postoperative blood transfusion was indicated in Groups 1, 2 and 3 in 19.0%, 5.1% and 13.7% of patients. In the five patients with severe bleeding, four attempts of colonoscopic arrest were made, achieving bleeding control in one. Angiographic embolization was successful in one patient. There were no procedure-specific complications.

CONCLUSION

End-to-side, circular, double-stapling ileocolic anastomosis seems to be related to an increased incidence of anastomotic bleeding and of postoperative blood transfusion compared with patients having other techniques of ileocolic anastomosis.

Emergency surgery for perforated diverticulitis in the immunosuppressed patient

AIM

Immunosuppression is believed to worsen outcomes for patients who require surgery for perforated diverticulitis. The aim of this study was to compare surgical outcomes between immunocompromised and immunocompetent patients undergoing surgery for complicated diverticulitis.

METHOD

All patients who underwent emergency surgery for complicated diverticulitis between 2004 and 2012 in a single unit were studied. Patients were classified as immunosuppressed (group I) or immunocompetent (group II). Operation type and postoperative morbidity and mortality were compared between groups. The impact of operating surgeons' specialization and the Peritonitis Severity Score (PSS) were also evaluated to determine their impact on the restoration of gastrointestinal (GI) continuity.

RESULTS

One-hundred and sixteen patients (mean age: 63.7 years), 41.4% women, were included. Fifty-three (45.7%) patients were immunosuppressed (group I): 42 underwent Hartmann's procedure (HP) (79.2%), nine (17.0%) underwent resection and primary anastomosis (RPA) with ileostomy (IL) and two (3.8%) underwent RPA without IL. In group II, 15 HP (23.8%), nine RPA with IL (14.3%) and 39 RPA without IL (61.9%) were performed. Postoperative morbidity and mortality were 79.2% and 26.4%, respectively, in group I and 63.5% and 6.3%, respectively, in group II. The overall mean PSS was 9.5, with a mean PSS of 11.1 in group I and of 8.1 in group II. The decision to perform a primary anastomosis differed significantly between colorectal surgeons and general surgeons in the patients with a PSS of 9-10-11.

CONCLUSION

In immunocompromised patients, RPA with IL can be a safe surgical option, whereas HP should be reserved for patients with a PSS of > 11. Colorectal surgical specialization is associated with higher rates of restoration of GI continuity in patients with perforated diverticulitis, especially in patients with an intermediate PSS score. Evaluation of each patient's PSS facilitates decision making in surgery for perforated diverticulitis.

[Current status of elective surgical treatment of ulcerative colitis. A systematic review]

Despite recent advances in the medical treatment of ulcerative colitis (UC), approximately 25-40% of patients will need surgery during their disease. The aim of elective surgical treatment of UC is to remove the colon/and rectum with minimal postoperative morbidity, and to offer a good long-term quality of life. There are several technical options for the surgical treatment of UC; at present, the most frequently offered is restorative proctocolectomy and ileal pouch-anal anastomosis. Both the surgeon and patient should be aware of the risks associated with a technically demanding procedure and possible postoperative complications, including the possibility of infertility, permanent stoma, or several surgical procedures for pouch-related complications. A precise knowledge of each surgical technique, and its indications, complications, long-term risks and benefits is useful to offer the best surgical option tailored to each patient. We searched in PubMed, MEDLINE, and EMBASE for all kinds of articles (all the publications until April 2012). Papers on Crohn's disease, indeterminate colitis, or other forms of colitis were excluded from the review. We reviewed the abstracts and identified potentially relevant articles. MeSH words were used as search, "ulcerative colitis", "surgery", "indications", "elective surgery", "colectomy," "proctocolectomy," "laparoscopy", "Complications," "outcome", "results" "quality of life". One hundred and four articles were included in this review.

Risk factors for prolonged postoperative ileus after colorectal cancer surgery

BACKGROUND

The aim of this study was to analyze factors contributing to prolonged postoperative ileus (POI) after elective bowel resection in patients with colorectal cancer.

METHODS

This was a retrospective review of a prospectively maintained database of patients operated on for colorectal cancer during 2006-2009. Patients with abdominal procedures and bowel resection without anastomotic leakage were included. Prolonged POI was defined as no flatus by postoperative day (POD) 6, with or without intolerance to oral intake by POD 6. Variables studied included demographics, prior medical conditions, details of the surgical procedure, and hospital stay.

RESULTS

A total of 773 patients met the inclusion criteria. POI occurred in 15.9%. The mean hospital stay was 11 days without POI and 20 days for POI patients (P < 0.001). Factors associated with POI in the univariate analysis were ASA III-IV (P < 0.005), male sex (P < 0.004), smoking (P < 0.015), chronic pulmonary disease (COPD) (P < 0.002), rectal cancer (P < 0.02), and ileostomy (P < 0.001). Multivariate logistic regression analysis showed male sex [odds ratio (OR) 1.6, 95% confidence interval (CI) 1.04-3.5]; COPD (OR 1.9, 95% CI 1.25-31.0), and ileostomy (OR 1.9; 95% CI 1.23-3.07) as risk factors for POI.

CONCLUSIONS

The risk of POI seems increased in patients with preoperative COPD and patients with an ileostomy, especially in men. Consideration of these factors could be important for the prevention and treatment of POI.

Recurrence and virulence of colonic diverticulitis in immunocompromised patients

BACKGROUND

To evaluate the probability of recurrence and the virulence of colonic diverticulitis correlated with immunocompromised status.

METHODS

Nine hundred thirty-one patients admitted in a single tertiary referral university hospital over a 14-year period were included. Patients were divided into 2 groups: group 1, 166 immunosuppressed patients, and group 2, 765 nonimmunosuppressed patients. The variables studied were sex, age, American Society of Anesthesiologist status, reasons of immunosuppression (eg, chronic use of corticosteroids, transplant recipients, and diseases affecting the immune system), severity of the diverticulitis episode, recurrence, emergency and elective surgery, and morbidity and mortality rates.

RESULTS

Two hundred thirteen patients underwent an emergency operation during the first hospitalization and 26 patients in further episodes. One hundred thirty-six patients developed 1 or more recurrent episodes of diverticulitis. The overall recurrence rate was similar in both groups. Patients in group 1 with a severe first episode presented significantly higher rates of recurrence and severity without needing more emergency surgery. Mortality after emergency surgery was 33.3% in group 1 and 15.9% in group 2 (P = .004).

CONCLUSIONS

After successful medical treatment of acute diverticulitis, patients with immunosuppression need not be advised to have an elective sigmoidectomy.

Long-term results of surgery plus fibrin sealant for anal fistula

AIM

The long-term recurrence rate of fibrin glue treatment was analysed in patients with trans-sphincteric cryptoglandular fistula operated by a two-phase procedure: (i) fistulectomy with seton placement; (ii) fibrin sealant (Tissucol Duo®, Baxter) insertion in the track.

METHOD

Clinical data were collected prospectively for all patients operated between 2004 and 2010. The statistical association of clinical variables and recurrence was analysed and a disease-free curve was constructed using the Kaplan-Meier method.

RESULTS

Twenty-eight consecutive patients (mean age 48.3 ± 13.3 years; 22 men) were enrolled in the study. Middle and high trans-sphincteric fistulae were diagnosed in 20 (71.4%) and eight (28.6%) patients. Seven (25%) had secondary track formation. The mean interval between the first operation and the fibrin sealant treatment was 12.5 ± 7.6 months. There were no complications related to the procedure. Nine (32.1%, 95% CI 17.9-50.7%) patients developed recurrence between 3 and 27 months after fibrin sealant treatment. Disease-free curves showed that the highest probability of recurrence occurred in the first 2 years. No incontinence was found at a mean follow-up of 20.6 (3-60) months among the 67.8% patients with no evidence of recurrence.

CONCLUSION

Fibrin sealant is safe and simple. The healing rate is satisfactory without the risk of incontinence.

Differences between proximal and distal obstructing colonic cancer after curative surgery

AIM

To study any possible differences in morbidity, mortality and overall survival rate after curative surgery for obstructive colon cancer according to tumour location.

METHOD

From January 1994 to December 2006, patients with colonic cancer presenting as obstruction were analysed. The two groups were defined as proximal and distal according to the tumour location with respect to the splenic flexure. In relation to the surgeon specialization, patients were operated on by a colorectal surgeon and by a general surgeon. Postoperative morbidity and mortality and cancer-related survival at 3 years were analysed.

RESULTS

Of the 377 patients included in the study, there were 173 patients (45.9%) in the proximal group and 204 patients (54.1%) in the distal group. The global morbidity was 54.9% without differences in postoperative morbidity except for anastomotic leakage, which was higher in the proximal group (P < 0.014). No differences in postoperative mortality were observed. After patients were stratified by the tumour node metastasis system, the differences between the groups, with respect to 3-year overall survival, cancer-related survival and probability of being free from recurrence, did not reach statistical significance. The overall survival after radical surgery for colonic obstruction was 57.6%.

CONCLUSION

Mortality and morbidity after emergency surgery for obstructing colon cancer are high. Specialization in colorectal surgery influences postoperative results in terms of lower anastomotic dehiscence rate after emergency proximal colon resection. After radical surgery, tumour location does not appear to influence the prognosis of obstructive colon cancer.

Follow-up of double-barreled wet colostomy after pelvic exenteration at a single institution

PURPOSE

Double-barreled wet colostomy consists of simultaneous urinary and fecal diversions into a lateral colostomy and is indicated after pelvic exenteration or in palliative operations, when complete intestinal and urinary reconstruction is not possible. We report experience at our institution with Double-barreled wet colostomy regarding postoperative and long-term morbidity and mortality.

METHODS

All patients who underwent double-barreled wet colostomy construction at our institution from 1980 through 2008 were included in the study. Medical records were reviewed for type and history of the malignant tumor, previous treatments, comorbidity according to the American Society of Anesthesiologists' score, type and length of surgery, length of hospital stay, and postoperative (within 30 days after the operation) and long-term morbidity and mortality.

RESULTS

The study comprised 41 patients. The underlying disease was a malignant pelvic tumor in 30 patients (primary in 6 and recurrent in 24 patients) and a nonmalignant disease in 11 patients. Surgical mortality was 2.4%, and the postoperative morbidity rate was 65.9%. Double-barreled wet colostomy-related morbidity observed during follow-up included pyelonephritis (9.8%, with renal deterioration due to chronic pyelonephritis in 2.4%), stenosis of the uretero-colonic anastomosis (2.4%), and lithiasis in the urine reservoir (7.3%). Follow-up was discontinued after a mean of 18.6 (SD, 19.9) months in 14 patients who had been referred from other centers. A total of 27 patients were followed in our center for a mean of 32.2 (range, 1-156) months. Of these, 7 patients are currently alive, 1 with recurrent disease; 14 patients died from local or distant recurrence; and 6 patients died of causes other than malignancy.

CONCLUSION

Double-barreled wet colostomy is a safe alternative for patients who need simultaneous urinary and fecal diversion, although the risk of ascending urinary infection must be taken into consideration.

Impact of surgical specialization on emergency colorectal surgery outcomes

OBJECTIVE

To evaluate the impact of surgeon specialization on emergency colorectal resection in terms of mortality, morbidity, and type of operation performed.

DESIGN

Observational study from January 1, 1993, through December 31, 2006.

SETTING

Bellvitge University Hospital, Barcelona, Spain.

PATIENTS

A total of 1046 patients underwent emergency colorectal resection. Patients were classified into 2 groups: those operated on by a colorectal surgeon (CS) and those operated on by a general surgeon (GS).

MAIN OUTCOME MEASURES

Preoperative variables studied were sex, age, American Society of Anesthesiologists grade, associated medical disease, presentation, reason for surgery, and type of operation. Univariate relations between predictors and outcomes were estimated, and multivariate logistic regression analysis was used to assess the prognostic effect of the combination of the variables.

RESULTS

Patients in the CS group underwent a significantly higher percentage of resection and primary anastomosis. The postoperative morbidity rate was 52.2% in the CS group and 60.5% in the GS group (P = .01). The anastomotic dehiscence rate was lower in the CS group (6.2%) than in the GS group (12.1%) (P = .01). Postoperative mortality decreased among patients in the CS group (17.9%) with respect to the patients in the GS group (28.3%) (P < .001). Being operated on by a CS was predictive in both the univariate and multivariate analyses for postoperative complications and mortality, and it was the only variable with predictive value for anastomotic dehiscence.

CONCLUSIONS

Specialization in colorectal surgery has a significant influence on morbidity, mortality, and anastomotic dehiscence after emergency operations.

Soluble total human leukocyte antigen class I and human leukocyte antigen-G molecules in kidney and kidney/pancreas transplantation

The expression of human leukocyte antigen (HLA)-G, a nonclassical HLA class I molecule, and its soluble forms (sHLA-G) are found to improve graft acceptance. In this study we investigated whether sHLA-G is the most biologically relevant molecule among all types of soluble HLA class I molecules for graft acceptance. We addressed this question in kidney-transplanted (n = 32) and kidney/pancreas-transplanted patients (n = 29). To this end we analyzed the levels of total soluble HLA class I (sHLA-I) in comparison to sHLA-G in 488 plasma samples procured before and serial after transplantation by specific enzyme-linked immunoabsorbent assay. Samples from 126 healthy individuals served as controls. Pretransplantation sHLA-I levels were significantly increased in patients (p < 0.001), whereas sHLA-G levels were in the range of those of healthy controls. Importantly, pretransplantation sHLA-I and sHLA-G levels did not differ between the two groups. Patients with biopsy-proven rejection (n = 15) revealed significantly lower sHLA-G levels before transplantation (mean +/- standard error of the mean, 12.9 +/- 1.8 vs. 20.1 +/- 1.9, p = 0.013) and after transplantation (p = 0.006, two-way analysis of variance) than patients without rejection (n = 46). In contrast, sHLA-I was slightly increased after but not before transplantation in patients with rejection (p < 0.05, two-way analysis of variance). Nonparametric determination analysis showed that pretransplantation levels of sHLA-G < 11.5 ng/ml (sensitivity, 60%; specificity, 80.4%) were related to rejection. Regarding antibody status, retransplantation, number of HLA mismatches, recipient age, and recipient body mass index, multivariate analysis showed that sHLA-G but not sHLA-I is an independent risk factor for graft rejection. Thus high levels of sHLA-G but not of sHLA-I seem to contribute to better graft acceptance after kidney or kidney/pancreas transplantation.

Differences in patient postoperative and long-term outcomes between obstructive and perforated colonic cancer

BACKGROUND

The aim of this observational study was to analyze the differences between patients with obstructive and perforated colonic cancer who managed with emergency curative surgery.

METHODS

Between January 1994 and December 2000, patients deemed to have undergone curative resection for complicated colonic cancer were considered for inclusion in the study. They were classified into 2 groups: patients with obstructive cancer (OC) and patients with perforated cancer (PC). The main end points were postsurgical outcomes and long-term overall survival, cancer-related survival, and tumor recurrence.

RESULTS

Of the 236 patients, surgery was deemed to be radical and performed with intent to cure in 155 patients (65.7%): 117 patients in the OC group and 38 patients in the PC group. No statistical differences were observed between the percentage of radical surgery between the 2 groups (P = .63). The overall postsurgical mortality rate was 12.2%: 14 patients in the OC group and 5 patients in the PC group (P = .839). Overall survival, probability of being free of recurrence, and cancer-related survival of the entire series were 64.57%, 67.72% and 73.03%, respectively. There were no differences between the 2 groups with respect to tumor recurrence, type of recurrence, overall survival, probability of being free of recurrence, and cancer-related survival at 5 years.

CONCLUSIONS

In our experience, patients with perforated colonic cancer do not seem to show worse long-term outcomes than those with OC. Studies with larger series are needed for further investigations.

Resultados a largo plazo de la cirugía urgente y electiva del cáncer de colon. Estudio comparativo

INTRODUCTION

Currently, the mechanisms that worsen the prognosis of complicated colon cancers are still not well known. Moreover, the possible effect of using sound oncological principles in emergency surgery on long-term prognosis has not been studied in detail.

AIMS

The aim of the present study was to analyze the 5-year efficacy of curative oncological surgery for complicated colon cancer performed in an emergency setting in terms of tumor recurrence and survival compared with elective surgery of uncomplicated tumors.

PATIENTS AND METHOD

We performed a prospective observational cohort study in patients who underwent emergency surgery for complicated colon cancer (group 1) and patients who underwent elective surgery (group 2). Exclusion criteria were tumors of less than 15 cm from the anal verge, palliative surgery, and distant metastases.

RESULTS

During the study period, 646 patients underwent surgery: there were 165 (25.5%) emergency surgeries and 481 (74.5%) elective interventions. Surgery was considered curative in 456 (70.6%) patients: 102 (22.4%) emergency and 354 (77.6%) elective surgeries. Significant differences were found in disease stage between the 2 groups (P = 0.003). The postoperative mortality rate was 12.7% in group 1 and 3.4% in group 2 (P = 0.001). When patients were stratified by TNM stage, worse 5-year cancer-related and disease-free survival rates were observed in group 1 patients with stage II tumors. No differences were found in cancer-related survival rates in stage III patients (P = 0.178). There were no significant differences in overall survival, cancer-related survival or tumor recurrence rates when group 1 was compared with a subgroup of patients in group 2 with factors of poor prognosis.

CONCLUSIONS

Complicated colon cancer presents in more advanced stages and had a worse overall long-term prognosis than uncomplicated tumour. These differences decrease when patients are subclassified by tumoral stage. Overall survival and cancer-related survival rates similar to those of elective surgery can be achieved in emergency surgery when curative oncological resection is performed.

The ability of biofilm formation does not influence virulence of Staphylococcus aureus and host response in a mouse tissue cage infection model

The virulence of Staphylococcus aureus Sa113 (SA113) and an isogenic ica deletion mutant (ica-), deficient in the production of polysaccharide intercellular adhesin (PIA), which is crucial for biofilm formation, was compared in a mouse tissue cage infection model. The minimal infective doses for the induction of persistent tissue infections in C57BL/6 mice were 10(3) CFU for both SA113 and the ica- mutant. Bacterial growth, initial adherence to surfaces within the implants and the course of inflammation including growth-dependent host TNF and MIP-2 release, influx of phagocytes and an accumulation of dead leukocytes were similar as well. Since SA113 expressed PIA in vivo, we could demonstrate that PIA and the lack of biofilm formation did not influence the capacity of S. aureus to induce persistent infections and did not modulate host responses in the mouse tissue cage model.

Novel mutants of NAB corepressors enhance activation by Egr transactivators

The NGFI-A binding corepressors NAB1 and NAB2 interact with a conserved domain (R1 domain) within the Egr1/NGFI-A and Egr2/Krox20 transactivators, and repress the transcription of Egr target promoters. Using a novel adaptation of the yeast two-hybrid screen, we have identified several point mutations in NAB corepressors that interfere with their ability to bind to the Egr1 R1 domain. Surprisingly, NAB proteins bearing some of these mutations increased Egr1 activity dramatically. The mechanism underlying the unexpected behavior of these mutants was elucidated by the discovery that NAB conserved domain 1 (NCD1) not only binds to Egr proteins but also mediates multimerization of NAB molecules. The activating mutants exert a dominant negative effect on NAB repression by multimerizing with native NAB proteins and preventing binding of endogenous NAB proteins with Egr transactivators. To examine NAB repression of a native Egr target gene, we show that NAB2 represses Egr2/Krox20-mediated activation of the bFGF/FGF-2 promoter, and that repression is reversed by coexpression of dominant negative NAB2. Because of their specific ability to alleviate NAB repression of Egr target genes, the dominant negative NAB mutants will be useful in elucidating the mechanism and function of NAB corepressors.