Drs Julio Garcia-Aguilar and Emina Huang: Colorectal Surgeons Advancing the Science of Colorectal Diseases No abstract available |
Evaluation and Management of Enterocutaneous Fistula Case Summary: A 36-year-old woman presents with an abscess at her midline wound 4 weeks following an ileocecectomy for Crohn's disease. After the abscess is incised, there is purulent drainage followed by the drainage of enteric contents; the output is 750 mL per 24 hours. |
| Expert Commentary on the Management of Enterocutaneous Fistula No abstract available |
| Abstracts Featured in This Issue: August 2019 No abstract available |
Anatomic Distribution of Colorectal Adenocarcinoma in Young Patients BACKGROUND: The incidence of colorectal cancer has increased in the younger population. Studies show an increased prevalence of left-sided tumors in younger patients; however, exact anatomic distribution is not known. OBJECTIVE: We sought to determine the anatomic distribution of colorectal cancer in young patients and to calculate the proportion of tumors that would be within reach of a flexible sigmoidoscopy. DESIGN: The National Cancer Database (2004–2015) was used to identify patients with colorectal cancer. SETTINGS: This was a multicenter study using national data. PATIENTS: The study included 117,686 patients under the age of 50 years diagnosed with colorectal cancer and 1,331,048 patients over the age of 50 years diagnosed with colorectal cancer. MAIN OUTCOME MEASURES: The primary outcome was the proportion of left-sided tumors in patients under the age of 50 years. RESULTS: A total of 74.4% of patients under age 50 years and 56.1% of patients over age 50 years had left-sided colorectal cancer. LIMITATIONS: The study is a retrospective review and does not exclude young patients who developed colorectal cancer with familial syndromes with a colorectal cancer disposition. CONCLUSIONS: A total of 74.4% of colorectal cancers diagnosed before age 50 years are left sided. In light of recent changes to screening recommendations, distribution of disease in young patients is important to both provider and patient education and decision-making. See Video Abstract at http://links.lww.com/DCR/A966. |
Predictive Factors for Bowel Dysfunction After Sphincter-Preserving Surgery for Rectal Cancer: A Single-Center Cross-sectional Study BACKGROUND: With increasing rates of sphincter preservation because of advances in preoperative chemoradiation, restoration of bowel continuity has become a main goal of rectal cancer treatment. However, in many patients, postoperative bowel dysfunction negatively affects the quality of life. OBJECTIVE: This study aimed to analyze predictors of bowel dysfunction after sphincter-preserving surgery in patients with rectal cancer. DESIGN: This was a cross-sectional study. SETTINGS: Assessment of bowel dysfunction was conducted between November 2015 and June 2017 at our institution. PATIENTS: A total of 316 patients with rectal cancer who underwent sphincter-preserving surgery between February 2009 and April 2017 and agreed with an interview for assessing bowel dysfunction were included. MAIN OUTCOME MEASURES: Bowel dysfunction was assessed with the Memorial Sloan Kettering Cancer Center Bowel Function Instrument and Wexner score. All the assessments were conducted face-to-face by the same interviewer. RESULTS: The median time interval between the restoration of bowel continuity and assessment was 10 months (interquartile range, 3–37), and the median total Memorial Sloan Kettering Cancer Center and Wexner scores were 65 (interquartile range, 58–73) and 6 (interquartile range, 0–11). The time interval was correlated with the Memorial Sloan Kettering Cancer Center scores (rho, 0.279) and Wexner scores (rho, –0.306). In a multivariate analysis, handsewn anastomosis and short time interval (≤1 year) were independently associated with poor bowel function (Memorial Sloan Kettering Cancer Center score ≤65). A short time interval (≤1 year), preoperative chemoradiation, and ileostomy were independently associated with major fecal incontinence (Wexner ≥8). LIMITATIONS: Selection bias may be inherent. CONCLUSIONS: Bowel function recovers with time after the restoration of bowel continuity. A short time interval, handsewn anastomosis, preoperative chemoradiation, and ileostomy were significantly associated with poor bowel function or major fecal incontinence. Surgeons should discuss postoperative bowel dysfunction and its predictive factors with the patients. See Video Abstract at http://links.lww.com/DCR/A930. |
Risk of Invasive Anal Cancer in HIV-Infected Patients With High-Grade Anal Dysplasia: A Population-Based Cohort Study BACKGROUND: The progression rate and predictors of anal dysplastic lesions to squamous cell carcinoma of the anus remain unclear. Characterizing these parameters may help refine anal cancer screening guidelines. OBJECTIVE: This study aimed to determine the rate of progression of high-grade anal dysplasia to invasive carcinoma in HIV-infected persons. DESIGN: Using the Surveillance, Epidemiology, and End Results database linked to Medicare claims from 2000 to 2011, we identified HIV-infected subjects with incident anal intraepithelial neoplasia III. To estimate the rate of progression of anal intraepithelial neoplasia III to invasive cancer, we calculated the cumulative incidence of anal cancer in this cohort. We then fitted Poisson models to evaluate the potential risk factors for incident anal cancer. SETTINGS: This is a population-based study. PATIENTS: Included were 592 HIV-infected subjects with incident anal intraepithelial neoplasia III. MAIN OUTCOME MEASURES: The primary outcome measured was incident squamous cell carcinoma of the anus. RESULTS: Study subjects were largely male (95%) with a median age of 45.7 years. Within the median follow-up period of 69 months, 33 subjects progressed to anal cancer. The incidence of anal cancer was 1.2% (95% CI, 0.7%–2.5%) and 5.7% (95% CI, 4.0%–8.1%) at 1 and 5 years, following a diagnosis of anal intraepithelial neoplasia III. Risk of progression did not differ by anal intraepithelial neoplasia III treatment status. On unadjusted analysis, black race (p = 0.02) and a history of anogenital condylomata (p = 0.03) were associated with an increased risk of anal cancer incidence, whereas prior anal cytology screening was associated with a decreased risk (p = 0.04). LIMITATIONS: The identification of some incident cancer episodes used surrogate measures. CONCLUSIONS: In our population-based cohort of HIV-infected subjects with long-term follow-up, the risk of progression from anal intraepithelial neoplasia III to anal squamous cell carcinoma was higher than reported in other studies and was not associated with the receipt of anal intraepithelial neoplasia III treatment. See Video Abstract at http://links.lww.com/DCR/A933. |
Emergency Surgery for Obstructive Colon Cancer in Elderly Patients: Results of a Multicentric Cohort of the French National Surgical Association BACKGROUND: Although elderly patients constitute most of the patients undergoing surgery for obstructed colon cancer, available data in the literature are very limited. OBJECTIVE: The purpose of this study was to assess the management and outcomes of elderly patients treated for obstructed colon cancer. DESIGN: This was a multicenter, retrospective cohort study. SETTINGS: Between 2000 and 2015, 2325 patients managed for an obstructed colon cancer in member centers of the French National Surgical Association were identified. Data were collected by each center on a voluntary basis after institutional approval. Bowel obstruction was defined clinically and confirmed by imaging. PATIENTS: Three age groups were defined, including patients <75 years, 75 to 84 years, and ≥85 years. MAIN OUTCOME MEASURES: Postoperative and oncologic results in elderly patients with an obstructed colon cancer were measured. Relative survival was calculated as the ratio of the overall survival with the survival that would have been expected based on the corresponding general population. INTERVENTIONS: A total of 302 patients (13%) underwent colonic stent insertion, and 1992 (87%) underwent surgery as emergency procedure. RESULTS: A total of 2294 patients were analyzed (<75 y, n = 1200 (52%); 75–84 y, n = 650 (28%); and ≥85 y, n = 444 (20%)). Elderly patients were more likely to be women (p < 0.0001), to have proximal colon cancer (p < 0.0001), and to have a higher incidence of comorbidities (p < 0.0001). The use of colonic stent or the type of surgery was identical regardless of age. In patients with resected colon cancer, elderly patients had less stage IV disease (p < 0.0001). The absence of tumor resection (p < 0.0001) and definitive stoma rate increased with age (p < 0.0001). Postoperative mortality and morbidity were significantly higher in elderly patients (p < 0.0001), but surgical morbidity was similar across age groups (p = 0.60). Postoperative morbidity was correlated to the 6-month mortality rate in elderly (p < 0.0001). Overall and disease-free survivals were significantly lower in more elderly patients (p < 0.0001) but relative survival was not (p = 0.09). LIMITATIONS: It is quite difficult to know how to interpret these data as a whole, given the inherent bias in the study population, lack of ability to stratify by performance status, and long study period duration. CONCLUSIONS: Elderly patients have high morbidity with lower survival in the highest age ranges of elderly subgroups. These data should be considered when deciding on an operative approach. See Video Abstract at http://links.lww.com/DCR/A964. |
Propensity Score Adjusted Comparison of Pelviperineal Morbidity With and Without Omentoplasty Following Abdominoperineal Resection for Primary Rectal Cancer BACKGROUND: Abdominoperineal resection is associated with a high incidence of perineal complications, and whether this is reduced by an omentoplasty is still unclear. OBJECTIVE: This study aimed to investigate the impact of omentoplasty on pelviperineal morbidity in patients undergoing abdominoperineal resection for rectal cancer. DESIGN: This was a retrospective comparative cohort study using propensity score analyses to reduce potential confounding. SETTING: The study was undertaken in 2 teaching hospitals and 1 university hospital. PATIENTS: Patients who underwent abdominoperineal resection for primary rectal cancer between 2000 and 2017 were included. MAIN OUTCOME MEASURES: The main end points were primary perineal wound healing at 30 days and overall and specific pelviperineal morbidity until the end of the study period. RESULTS: Among 254 included patients, 106 had an omentoplasty. The primary perineal wound healing rate at 30 days was similar for omentoplasty and no omentoplasty (65% vs 60%; p = 0.422), also after adjusting for potential confounding by propensity score analysis (OR, 0.89; 95% CI, 0.45–1.75). Being free from any pelviperineal complication at 6 months (75% vs 79%; p = 0.492), absence of any pelviperineal morbidity until 1 year (54% vs 49%; p = 0.484), and incidence of persistent perineal sinus (6% vs 10%; p = 0.256) were also similar in both groups. The unadjusted higher perineal hernia rate after omentoplasty (18% vs 7%; p = 0.011) did not remain statistically significant after regression analysis including the propensity score (OR, 1.34; 95% CI, 0.46–3.88). Complications related to the omentoplasty itself were observed in 8 patients, of whom 6 required reoperation. LIMITATIONS: This study was limited by the retrospective and nonrandomized design causing some heterogeneity between the 2 cohorts. CONCLUSION: In this multicenter study using propensity score analyses, the use of omentoplasty did not lower the incidence or the duration of pelviperineal morbidity in patients undergoing abdominoperineal resection for rectal cancer, and omentoplasty itself was associated with a risk of reoperation. See Video Abstract at http://links.lww.com/DCR/A918. |
How Reliable Is CT Scan in Staging Right Colon Cancer? BACKGROUND: The observation of inferior oncologic outcomes after surgery for proximal colon cancers has led to the investigation of alternative treatment strategies, including surgical procedures and neoadjuvant systemic chemotherapy in selected patients. OBJECTIVE: The purpose of this study was to determine the accuracy of CT staging in proximal colon cancer in detecting unfavorable pathologic features that may aid in the selection of ideal candidates alternative treatment strategies, including extended lymph node dissection and/or neoadjuvant chemotherapy. DESIGN: This was a retrospective consecutive series. SETTINGS: Trained abdominal radiologists from 2 centers performed a blinded review of CT scans obtained to locally stage proximal colon cancer according to previously defined prognostic groups, including T1/2, T3/4, N+, and extramural venous invasion. CT findings were compared with histopathologic results as a reference standard. Unfavorable pathologic findings included pT3/4, pN+, or extramural venous invasion. PATIENTS: Consecutive patients undergoing right colectomy in 2 institutions between 2011 and 2016 were retrospectively reviewed from a prospectively collected database. MAIN OUTCOME MEASURES: T status, nodal status, and extramural venous invasion status comparing CT with final histologic findings were measured. RESULTS: Of 150 CT scans reviewed, CT failed to identify primary cancer in 18%. Overall accuracy of CT to identify unfavorable pathologic features was 63% with sensitivity, specificity, positive predictive value, and negative predictive value of 63% (95% CI, 54%–71%), 63% (95% CI, 46%–81%), 87% (95% CI, 80%–94%) and 30% (95% CI, 18%–41%). Only cT3/4 (55% vs 45%; p = 0.001) and cN+ (42% vs 58%; p = 0.02) were significantly associated with correct identification of unfavorable features at final pathology. CT scans overstaged and understaged cT in 23.7% and 48.3% and cN in 28.7% and 53.0% of cases. LIMITATIONS: The study was limited by its retrospective design, relatively small sample size, and heterogeneity of CT images performed in different institutions with variable equipment and technical details. CONCLUSIONS: Accuracy of CT scan for identification of pT3/4, pN+, or extramural venous invasion was insufficient to allow for proper identification of patients at high risk for local recurrence and/or in whom to consider alternative treatment strategies. Locoregional overstaging and understaging resulted in inappropriate treatment strategies in <48%. See Video Abstract at http://links.lww.com/DCR/A935. |
Benign
Identification of Collagenolytic Bacteria in Human Samples Screening Methods and Clinical Implications for Resolving and Preventing Anastomotic Leaks and Wound Complications
Guyton, Kristina L.; Levine, Zoe C.; Lowry, Ann C.; More
Diseases of the Colon & Rectum. 62(8):972-979, August 2019.
Abstract
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BACKGROUND:
Bacteria that produce collagen-digesting enzymes (collagenolytic bacteria) have been shown to play a critical and previously unappreciated role in anastomotic leak pathogenesis by breaking down host tissue extracellular matrix proteins. Detection of these bacteria is labor intensive, and no screening method currently exists.
OBJECTIVES:
We evaluated a rapid screening method developed to detect the presence of these collagenolytic bacteria in clinical samples, such as drain fluid, anastomotic tissue, or feces.
DESIGN:
We compared a new method of detecting collagenolytic bacterial species with a previously used technique using samples from a murine experimental model and then demonstrated the utility of this screening method in samples from patients with anastomotic complications.
SETTINGS:
All of the laboratory work and previous murine experiments were performed in Dr Alverdy's laboratory at the University of Chicago under institutional review board–approved protocols.
PATIENTS:
Samples from patients with challenging wound complications were provided by participating clinicians with verbal patient consent. Given the small number of patients, this was determined to be institutional review board exempt.
MAIN OUTCOME MEASURES:
Whether this analysis can influence patient management and outcomes will require additional study.
RESULTS:
This screening method detects numerous strains of bacteria with collagenolytic properties, including the collagenolytic species that have been implicated previously in anastomotic leak. Once collagenolytic strains are identified, they can be speciated and tested for antibiotic resistance using standard laboratory techniques.
LIMITATIONS:
This study is limited by the small number of patient samples tested.
CONCLUSIONS:
We demonstrated the potential applicability of this assay to evaluate rare and complex anastomotic complications that often require analysis beyond standard culture and sensitivity assays. Future applications of this method may allow the development of strategies to prevent anastomotic leak related to collagenolytic bacteria. See Video Abstract at http://links.lww.com/DCR/A962 .
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Anorectal
Drainage Seton Versus External Anal Sphincter–Sparing Seton After Rerouting of the Fistula Tract in the Treatment of Complex Anal Fistula A Randomized Controlled Trial
Omar, Waleed; Alqasaby, Abdallah; Abdelnaby, Mahmoud; More
Diseases of the Colon & Rectum. 62(8):980-987, August 2019.
Abstract
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BACKGROUND:
Complex anal fistula is one of the challenging anorectal conditions. Several treatments have been proposed for complex anal fistula, yet none proved to be ideal.
OBJECTIVE:
This randomized trial aimed to assess the efficacy of external anal sphincter–sparing seton in comparison with the conventional drainage seton in the treatment of complex anal fistula.
DESIGN:
This was a prospective, randomized, single-blind controlled study.
SETTINGS:
The study was conducted at the Colorectal Surgery Unit of Mansoura University Hospitals.
PATIENTS:
Adult patients of both sexes with complex anal fistula were recruited and evaluated with MRI before surgery.
INTERVENTIONS:
Patients were randomly divided into 2 groups; group 1 was treated with conventional drainage seton and group 2 was treated with external anal sphincter–sparing seton using a rerouting technique.
MAIN OUTCOME MEASURES:
The duration of healing, incidence of recurrence or persistence, postoperative pain, and complications including fecal incontinence were measured.
RESULTS:
Sixty patients (56 men) with a mean age of 43 years were included. Mean operation time in group 1 was significantly shorter than group 2 (29.8 ± 4.3 vs 43.8 ± 4.5 min; p < 0.0001). The mean pain score at 24 hours in group 1 was 8.1 ± 1.6 versus 5.3 ± 1.3 in group 2 ( p < 0.0001). Five patients (17%) in group 1 experienced complications versus 2 (7%) in group 2. All of the patients in group 1 required a second-stage fistulotomy versus 2 patients (7%) in group 2 ( p < 0.0001). Time to complete healing in group 1 was significantly ( p < 0.0001) longer than group 2 (103 ± 47 vs 46 ± 18 d). Four patients (13%) in group 1 and 1 patient (3%) in group 2 experienced persistence or recurrence of anal fistula ( p = 0.35).
LIMITATIONS:
This was a single-center study with relatively small numbers in each group.
CONCLUSIONS:
Patients treated with external anal sphincter–sparing seton after rerouting of the fistula tract achieved quicker healing and less postoperative pain than those with conventional drainage seton. Postoperative complication and recurrence rates were comparable in both groups. See Video Abstract at http://links.lww.com/DCR/A963 .
TRIAL REGISTRATION:
clinicaltrials.gov identifier: NCT03636997 ( https://clinicaltrials.gov/ct2/show/NCT03636997 ).
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Short-term Outcomes of Transanal Hemorrhoidal Dearterialization With Mucopexy Versus Vessel-Sealing Device Hemorrhoidectomy for Grade III to IV Hemorrhoids A Prospective Randomized Multicenter Trial
Trenti, Loris; Biondo, Sebastiano; Kreisler Moreno, Esther; More
Diseases of the Colon & Rectum. 62(8):988-996, August 2019.
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BACKGROUND:
Transanal hemorrhoidal dearterialization with mucopexy and vessel-sealing device hemorrhoidectomy seem to reduce postoperative pain compared with classic excisional hemorrhoidectomy, but whether one of them is superior remains unclear.
OBJECTIVE:
We compared transanal hemorrhoidal dearterialization with mucopexy and vessel-sealing device hemorrhoidectomy.
DESIGN:
This was a multicenter, randomized controlled trial.
SETTING:
The study was conducted at 6 Spanish centers.
PATIENTS:
Patients aged ≥18 years with grade III to IV hemorrhoids were included.
INTERVENTIONS:
Patients were randomly assigned to transanal hemorrhoidal dearterialization with mucopexy (n = 39) or vessel-sealing device hemorrhoidectomy (n = 41).
MAIN OUTCOME MEASURES:
Primary outcome was the mean postoperative number of days in which patients needed nonsteroidal anti-inflammatory drugs. Secondary outcomes were postoperative pain, 30-day morbidity, patient satisfaction, Vaizey score, hemorrhoid symptoms score, return to work, and quality of life.
RESULTS:
More patients were still taking analgesia in the vessel-sealing device hemorrhoidectomy group during the second postoperative week compared with the transanal hemorrhoidal dearterialization with mucopexy group (87.8% vs 53.8%; p = 0.002). For the transanal hemorrhoidal dearterialization with mucopexy group, analgesia consumption continued until day 10.1 (mean; SD = 7.22 d), whereas in the vessel-sealing device hemorrhoidectomy group it continued until day 15.2 (mean; SD = 8.70 d; p = 0.006). The mean daily average pain was similar during the first ( p = 0.900) and second postoperative weeks ( p = 0.265). Mean operative time was higher for the transanal hemorrhoidal dearterialization with mucopexy group versus the vessel-sealing device hemorrhoidectomy group (45 min; range, 40–60 vs 20 min; range, 15–41 min; p < 0.001). Postoperative complications rate, use of laxatives, patient satisfaction, Vaizey score, hemorrhoids symptoms score, return to work, and quality of life at 1 month after surgery were similar between groups.
LIMITATIONS:
The main limitation of this study was that the 2 groups did not contain equal numbers of grade III and IV hemorrhoids.
CONCLUSIONS:
Transanal hemorrhoidal dearterialization with mucopexy is associated with a shorter need for postoperative analgesia compared with vessel-sealing device hemorrhoidectomy. See Video Abstract at http://links.lww.com/DCR/A915 .
TRIAL REGISTRATION:
clinicaltrials.gov identifier: NCT02654249.
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Socioeconomic
Does Coffee Intake Reduce Postoperative Ileus After Laparoscopic Elective Colorectal Surgery? A Prospective, Randomized Controlled Study The Coffee Study
Hasler-Gehrer, Simone; Linecker, Michael; Keerl, Andreas; More
Diseases of the Colon & Rectum. 62(8):997-1004, August 2019.
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BACKGROUND:
Postoperative ileus after colorectal surgery is a frequent problem that significantly prolongs hospital stay and increases perioperative costs.
OBJECTIVE:
The aim was to evaluate the effect of standardized coffee intake on postoperative bowel movement after elective laparoscopic colorectal resection.
DESIGN:
This is a prospective randomized controlled trial that was conducted between September 2014 and December 2016.
SETTINGS:
This study was performed in a public cantonal hospital in Switzerland with accreditation for colon and rectum cancer surgery.
PATIENTS:
Patients who underwent elective colorectal surgery were included.
INTERVENTIONS:
Patients were randomly assigned either to the intervention group receiving coffee or the control group receiving tea. A total of 150 mL of the respective beverage was drunk 3 times per day every postoperative day until discharge.
MAIN OUTCOME MEASURES:
The primary end point was time to first bowel movement. Secondary end points included the use of laxative, insertion of a nasogastric tube, length of hospital stay, and postoperative complications.
RESULTS:
A total of 115 patients were randomly assigned: 56 were allocated to the coffee group and 59 to the tea group. After coffee intake, the first bowel movement occurred after a median of 65.2 hours versus 74.1 hours in the control group (intention-to-treat analysis; p = 0.008). The HR for earlier first bowel movement after coffee intake was 1.67 ( p = 0.009). In the per-protocol analysis, hospital stay was shorter in the coffee group (6 d in the coffee group vs 7 d in the tea group; p = 0.043).
LIMITATIONS:
The rate of protocol violation, mostly coffee consumption in the tea arm, was relatively high, even if patients were clearly instructed not to consume coffee if they were in the tea arm.
CONCLUSIONS:
Coffee intake after elective laparoscopic colorectal resection leads to faster recovery of bowel function. Therefore, coffee intake represents a simple and effective strategy to prevent postoperative ileus. See Video Abstract at http://links.lww.com/DCR/A955 .
TRIAL REGISTRATION:
clinicaltrials.gov identifier: NCT02469441.
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Antibiotics Versus No Antibiotics for Acute Uncomplicated Diverticulitis A Systematic Review and Meta-analysis
Desai, Madhav; Fathallah, Jihan; Nutalapati, Venkat; Saligram, Shreyas Less
Diseases of the Colon & Rectum. 62(8):1005-1012, August 2019.
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BACKGROUND:
Antibiotics are routinely used for diverticulitis irrespective of severity. Current practice guidelines favor against the use of antibiotics for acute uncomplicated diverticulitis.
OBJECTIVE:
We performed a systematic review and meta-analysis to examine the role of antibiotic use in an episode of uncomplicated diverticulitis.
DATA SOURCES:
PubMed/Medline, Embase, Scopus, and Cochrane were used.
STUDY SELECTION:
Eligible studies included those with patients with uncomplicated diverticulitis receiving any antibiotics compared with patients not receiving any antibiotics (or observed alone).
MAIN OUTCOME MEASURES:
Pooled odds rate of total complications, treatment failure, recurrent diverticulitis, readmission rate, sigmoid resection, mortality rate, and length of stay were measured.
RESULTS:
Of 1050 citations reviewed, 7 studies were eligible for the analysis. There were total of 2241 patients: 895 received antibiotics (mean age = 59.1 y; 38% men) and 1346 did not receive antibiotics (mean age = 59.4 y; 37% men). Antibiotics were later added in 2.7% patients who initially were observed off antibiotics. Length of hospital stay was not significantly different among either group (no antibiotics = 3.1 d vs antibiotics = 4.5 d; p = 0.20). Pooled rate of recurrent diverticulitis was not significantly different among both groups (pooled OR = 1.27 (95%, CI 0.90–1.79); p = 0.18). Rate of total complications (pooled OR = 1.99 (95% CI, 0.66–6.01); p = 0.22), treatment failure (pooled OR = 0.68 (95% CI, 0.42–1.09); p = 0.11), readmissions (pooled OR = 0.75 (95% CI, 0.44–1.30); p = 0.31). and patients who required sigmoid resection (pooled OR = 3.37 (95% CI, 0.65–17.34); p = 0.15) were not significantly different among patients who received antibiotics and those who did not. Mortality rates were 4 of 1310 (no-antibiotic group) versus 4 of 863 (antibiotic group).
LIMITATIONS:
Only 2 randomized controlled studies were available and there was high heterogeneity in existing data.
CONCLUSIONS:
This meta-analysis of current literature shows that patients with uncomplicated diverticulitis can be monitored off antibiotics.
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Perineal Hernia Repair With Mesh After Robotic Abdominoperineal Resection
Sapci, Ipek; Tiernan, Jim P.; Gorgun, Emre
Diseases of the Colon & Rectum. 62(8):1013, August 2019.
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Surgical Management of an Ileal J-Pouch-Anal Anastomosis Volvulus
Geers, Joachim; Bislenghi, Gabriele; D'Hoore, André; More
Diseases of the Colon & Rectum. 62(8):1014-1019, August 2019.
Abstract
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BACKGROUND:
A restorative proctocolectomy with an IPAA is the surgical treatment of choice for medically refractory ulcerative colitis. Until now, a pouch volvulus has been considered a rare complication, only described in case reports and small case series. The aim of this technical note was to develop a standardized approach to allow a minimally invasive treatment.
TECHNIQUE:
First, an endoscopic decompression of the pouch is attempted. Subsequently, an exploratory laparoscopy is performed. If the endoscopic decompression was successful, a complete laparoscopic reduction is feasible. Once the integrity of the pouch is confirmed, a bilateral pouchopexy is performed, using multifilament interrupted sutures. Finally, the pouch patency is tested by pouchoscopy.
RESULTS:
Between December 2010 and December 2018, 151 minimally invasive restorative proctocolectomies with an IPAA were performed. Eighty-nine IPAAs were constructed with the mesentery positioned anteriorly, 35 posteriorly, and 27 on the right side. Three patients were diagnosed with an IPAA volvulus. All 3 of the patients were in the anterior group (3.4%) compared with 0 patients in the nonanterior group. One patient (33%) was treated laparoscopically, after a successful endoscopic reduction. In the other 2 cases, conversion to a laparotomy was needed because an endoscopic decompression could not be achieved.
CONCLUSION:
An endoscopic decompression was required to allow a laparoscopic treatment, and a bilateral pouchopexy was needed to avoid recurrence. This standardized approach might be a good treatment option, and we are awaiting additional follow-up to determine its long-term durability. In addition to the already described risk factors (minimally invasive technique, female sex, and low BMI), an anterior positioning of the pouch mesentery might be a potential risk factor as well for pouch volvulus. However, these observations should be carefully interpreted, considering the small number of cases.
Identification of Collagenolytic Bacteria in Human Samples Screening Methods and Clinical Implications for Resolving and Preventing Anastomotic Leaks and Wound Complications
Guyton, Kristina L.; Levine, Zoe C.; Lowry, Ann C.; More
Diseases of the Colon & Rectum. 62(8):972-979, August 2019.
Abstract
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BACKGROUND:
Bacteria that produce collagen-digesting enzymes (collagenolytic bacteria) have been shown to play a critical and previously unappreciated role in anastomotic leak pathogenesis by breaking down host tissue extracellular matrix proteins. Detection of these bacteria is labor intensive, and no screening method currently exists.
OBJECTIVES:
We evaluated a rapid screening method developed to detect the presence of these collagenolytic bacteria in clinical samples, such as drain fluid, anastomotic tissue, or feces.
DESIGN:
We compared a new method of detecting collagenolytic bacterial species with a previously used technique using samples from a murine experimental model and then demonstrated the utility of this screening method in samples from patients with anastomotic complications.
SETTINGS:
All of the laboratory work and previous murine experiments were performed in Dr Alverdy's laboratory at the University of Chicago under institutional review board–approved protocols.
PATIENTS:
Samples from patients with challenging wound complications were provided by participating clinicians with verbal patient consent. Given the small number of patients, this was determined to be institutional review board exempt.
MAIN OUTCOME MEASURES:
Whether this analysis can influence patient management and outcomes will require additional study.
RESULTS:
This screening method detects numerous strains of bacteria with collagenolytic properties, including the collagenolytic species that have been implicated previously in anastomotic leak. Once collagenolytic strains are identified, they can be speciated and tested for antibiotic resistance using standard laboratory techniques.
LIMITATIONS:
This study is limited by the small number of patient samples tested.
CONCLUSIONS:
We demonstrated the potential applicability of this assay to evaluate rare and complex anastomotic complications that often require analysis beyond standard culture and sensitivity assays. Future applications of this method may allow the development of strategies to prevent anastomotic leak related to collagenolytic bacteria. See Video Abstract at http://links.lww.com/DCR/A962 .
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Anorectal
Drainage Seton Versus External Anal Sphincter–Sparing Seton After Rerouting of the Fistula Tract in the Treatment of Complex Anal Fistula A Randomized Controlled Trial
Omar, Waleed; Alqasaby, Abdallah; Abdelnaby, Mahmoud; More
Diseases of the Colon & Rectum. 62(8):980-987, August 2019.
Abstract
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BACKGROUND:
Complex anal fistula is one of the challenging anorectal conditions. Several treatments have been proposed for complex anal fistula, yet none proved to be ideal.
OBJECTIVE:
This randomized trial aimed to assess the efficacy of external anal sphincter–sparing seton in comparison with the conventional drainage seton in the treatment of complex anal fistula.
DESIGN:
This was a prospective, randomized, single-blind controlled study.
SETTINGS:
The study was conducted at the Colorectal Surgery Unit of Mansoura University Hospitals.
PATIENTS:
Adult patients of both sexes with complex anal fistula were recruited and evaluated with MRI before surgery.
INTERVENTIONS:
Patients were randomly divided into 2 groups; group 1 was treated with conventional drainage seton and group 2 was treated with external anal sphincter–sparing seton using a rerouting technique.
MAIN OUTCOME MEASURES:
The duration of healing, incidence of recurrence or persistence, postoperative pain, and complications including fecal incontinence were measured.
RESULTS:
Sixty patients (56 men) with a mean age of 43 years were included. Mean operation time in group 1 was significantly shorter than group 2 (29.8 ± 4.3 vs 43.8 ± 4.5 min; p < 0.0001). The mean pain score at 24 hours in group 1 was 8.1 ± 1.6 versus 5.3 ± 1.3 in group 2 ( p < 0.0001). Five patients (17%) in group 1 experienced complications versus 2 (7%) in group 2. All of the patients in group 1 required a second-stage fistulotomy versus 2 patients (7%) in group 2 ( p < 0.0001). Time to complete healing in group 1 was significantly ( p < 0.0001) longer than group 2 (103 ± 47 vs 46 ± 18 d). Four patients (13%) in group 1 and 1 patient (3%) in group 2 experienced persistence or recurrence of anal fistula ( p = 0.35).
LIMITATIONS:
This was a single-center study with relatively small numbers in each group.
CONCLUSIONS:
Patients treated with external anal sphincter–sparing seton after rerouting of the fistula tract achieved quicker healing and less postoperative pain than those with conventional drainage seton. Postoperative complication and recurrence rates were comparable in both groups. See Video Abstract at http://links.lww.com/DCR/A963 .
TRIAL REGISTRATION:
clinicaltrials.gov identifier: NCT03636997 ( https://clinicaltrials.gov/ct2/show/NCT03636997 ).
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Short-term Outcomes of Transanal Hemorrhoidal Dearterialization With Mucopexy Versus Vessel-Sealing Device Hemorrhoidectomy for Grade III to IV Hemorrhoids A Prospective Randomized Multicenter Trial
Trenti, Loris; Biondo, Sebastiano; Kreisler Moreno, Esther; More
Diseases of the Colon & Rectum. 62(8):988-996, August 2019.
Abstract
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BACKGROUND:
Transanal hemorrhoidal dearterialization with mucopexy and vessel-sealing device hemorrhoidectomy seem to reduce postoperative pain compared with classic excisional hemorrhoidectomy, but whether one of them is superior remains unclear.
OBJECTIVE:
We compared transanal hemorrhoidal dearterialization with mucopexy and vessel-sealing device hemorrhoidectomy.
DESIGN:
This was a multicenter, randomized controlled trial.
SETTING:
The study was conducted at 6 Spanish centers.
PATIENTS:
Patients aged ≥18 years with grade III to IV hemorrhoids were included.
INTERVENTIONS:
Patients were randomly assigned to transanal hemorrhoidal dearterialization with mucopexy (n = 39) or vessel-sealing device hemorrhoidectomy (n = 41).
MAIN OUTCOME MEASURES:
Primary outcome was the mean postoperative number of days in which patients needed nonsteroidal anti-inflammatory drugs. Secondary outcomes were postoperative pain, 30-day morbidity, patient satisfaction, Vaizey score, hemorrhoid symptoms score, return to work, and quality of life.
RESULTS:
More patients were still taking analgesia in the vessel-sealing device hemorrhoidectomy group during the second postoperative week compared with the transanal hemorrhoidal dearterialization with mucopexy group (87.8% vs 53.8%; p = 0.002). For the transanal hemorrhoidal dearterialization with mucopexy group, analgesia consumption continued until day 10.1 (mean; SD = 7.22 d), whereas in the vessel-sealing device hemorrhoidectomy group it continued until day 15.2 (mean; SD = 8.70 d; p = 0.006). The mean daily average pain was similar during the first ( p = 0.900) and second postoperative weeks ( p = 0.265). Mean operative time was higher for the transanal hemorrhoidal dearterialization with mucopexy group versus the vessel-sealing device hemorrhoidectomy group (45 min; range, 40–60 vs 20 min; range, 15–41 min; p < 0.001). Postoperative complications rate, use of laxatives, patient satisfaction, Vaizey score, hemorrhoids symptoms score, return to work, and quality of life at 1 month after surgery were similar between groups.
LIMITATIONS:
The main limitation of this study was that the 2 groups did not contain equal numbers of grade III and IV hemorrhoids.
CONCLUSIONS:
Transanal hemorrhoidal dearterialization with mucopexy is associated with a shorter need for postoperative analgesia compared with vessel-sealing device hemorrhoidectomy. See Video Abstract at http://links.lww.com/DCR/A915 .
TRIAL REGISTRATION:
clinicaltrials.gov identifier: NCT02654249.
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Does Coffee Intake Reduce Postoperative Ileus After Laparoscopic Elective Colorectal Surgery? A Prospective, Randomized Controlled Study The Coffee Study
Hasler-Gehrer, Simone; Linecker, Michael; Keerl, Andreas; More
Diseases of the Colon & Rectum. 62(8):997-1004, August 2019.
Abstract
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BACKGROUND:
Postoperative ileus after colorectal surgery is a frequent problem that significantly prolongs hospital stay and increases perioperative costs.
OBJECTIVE:
The aim was to evaluate the effect of standardized coffee intake on postoperative bowel movement after elective laparoscopic colorectal resection.
DESIGN:
This is a prospective randomized controlled trial that was conducted between September 2014 and December 2016.
SETTINGS:
This study was performed in a public cantonal hospital in Switzerland with accreditation for colon and rectum cancer surgery.
PATIENTS:
Patients who underwent elective colorectal surgery were included.
INTERVENTIONS:
Patients were randomly assigned either to the intervention group receiving coffee or the control group receiving tea. A total of 150 mL of the respective beverage was drunk 3 times per day every postoperative day until discharge.
MAIN OUTCOME MEASURES:
The primary end point was time to first bowel movement. Secondary end points included the use of laxative, insertion of a nasogastric tube, length of hospital stay, and postoperative complications.
RESULTS:
A total of 115 patients were randomly assigned: 56 were allocated to the coffee group and 59 to the tea group. After coffee intake, the first bowel movement occurred after a median of 65.2 hours versus 74.1 hours in the control group (intention-to-treat analysis; p = 0.008). The HR for earlier first bowel movement after coffee intake was 1.67 ( p = 0.009). In the per-protocol analysis, hospital stay was shorter in the coffee group (6 d in the coffee group vs 7 d in the tea group; p = 0.043).
LIMITATIONS:
The rate of protocol violation, mostly coffee consumption in the tea arm, was relatively high, even if patients were clearly instructed not to consume coffee if they were in the tea arm.
CONCLUSIONS:
Coffee intake after elective laparoscopic colorectal resection leads to faster recovery of bowel function. Therefore, coffee intake represents a simple and effective strategy to prevent postoperative ileus. See Video Abstract at http://links.lww.com/DCR/A955 .
TRIAL REGISTRATION:
clinicaltrials.gov identifier: NCT02469441.
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Antibiotics Versus No Antibiotics for Acute Uncomplicated Diverticulitis A Systematic Review and Meta-analysis
Desai, Madhav; Fathallah, Jihan; Nutalapati, Venkat; Saligram, Shreyas Less
Diseases of the Colon & Rectum. 62(8):1005-1012, August 2019.
Abstract
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BACKGROUND:
Antibiotics are routinely used for diverticulitis irrespective of severity. Current practice guidelines favor against the use of antibiotics for acute uncomplicated diverticulitis.
OBJECTIVE:
We performed a systematic review and meta-analysis to examine the role of antibiotic use in an episode of uncomplicated diverticulitis.
DATA SOURCES:
PubMed/Medline, Embase, Scopus, and Cochrane were used.
STUDY SELECTION:
Eligible studies included those with patients with uncomplicated diverticulitis receiving any antibiotics compared with patients not receiving any antibiotics (or observed alone).
MAIN OUTCOME MEASURES:
Pooled odds rate of total complications, treatment failure, recurrent diverticulitis, readmission rate, sigmoid resection, mortality rate, and length of stay were measured.
RESULTS:
Of 1050 citations reviewed, 7 studies were eligible for the analysis. There were total of 2241 patients: 895 received antibiotics (mean age = 59.1 y; 38% men) and 1346 did not receive antibiotics (mean age = 59.4 y; 37% men). Antibiotics were later added in 2.7% patients who initially were observed off antibiotics. Length of hospital stay was not significantly different among either group (no antibiotics = 3.1 d vs antibiotics = 4.5 d; p = 0.20). Pooled rate of recurrent diverticulitis was not significantly different among both groups (pooled OR = 1.27 (95%, CI 0.90–1.79); p = 0.18). Rate of total complications (pooled OR = 1.99 (95% CI, 0.66–6.01); p = 0.22), treatment failure (pooled OR = 0.68 (95% CI, 0.42–1.09); p = 0.11), readmissions (pooled OR = 0.75 (95% CI, 0.44–1.30); p = 0.31). and patients who required sigmoid resection (pooled OR = 3.37 (95% CI, 0.65–17.34); p = 0.15) were not significantly different among patients who received antibiotics and those who did not. Mortality rates were 4 of 1310 (no-antibiotic group) versus 4 of 863 (antibiotic group).
LIMITATIONS:
Only 2 randomized controlled studies were available and there was high heterogeneity in existing data.
CONCLUSIONS:
This meta-analysis of current literature shows that patients with uncomplicated diverticulitis can be monitored off antibiotics.
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Perineal Hernia Repair With Mesh After Robotic Abdominoperineal Resection
Sapci, Ipek; Tiernan, Jim P.; Gorgun, Emre
Diseases of the Colon & Rectum. 62(8):1013, August 2019.
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Surgical Management of an Ileal J-Pouch-Anal Anastomosis Volvulus
Geers, Joachim; Bislenghi, Gabriele; D'Hoore, André; More
Diseases of the Colon & Rectum. 62(8):1014-1019, August 2019.
Abstract
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BACKGROUND:
A restorative proctocolectomy with an IPAA is the surgical treatment of choice for medically refractory ulcerative colitis. Until now, a pouch volvulus has been considered a rare complication, only described in case reports and small case series. The aim of this technical note was to develop a standardized approach to allow a minimally invasive treatment.
TECHNIQUE:
First, an endoscopic decompression of the pouch is attempted. Subsequently, an exploratory laparoscopy is performed. If the endoscopic decompression was successful, a complete laparoscopic reduction is feasible. Once the integrity of the pouch is confirmed, a bilateral pouchopexy is performed, using multifilament interrupted sutures. Finally, the pouch patency is tested by pouchoscopy.
RESULTS:
Between December 2010 and December 2018, 151 minimally invasive restorative proctocolectomies with an IPAA were performed. Eighty-nine IPAAs were constructed with the mesentery positioned anteriorly, 35 posteriorly, and 27 on the right side. Three patients were diagnosed with an IPAA volvulus. All 3 of the patients were in the anterior group (3.4%) compared with 0 patients in the nonanterior group. One patient (33%) was treated laparoscopically, after a successful endoscopic reduction. In the other 2 cases, conversion to a laparotomy was needed because an endoscopic decompression could not be achieved.
CONCLUSION:
An endoscopic decompression was required to allow a laparoscopic treatment, and a bilateral pouchopexy was needed to avoid recurrence. This standardized approach might be a good treatment option, and we are awaiting additional follow-up to determine its long-term durability. In addition to the already described risk factors (minimally invasive technique, female sex, and low BMI), an anterior positioning of the pouch mesentery might be a potential risk factor as well for pouch volvulus. However, these observations should be carefully interpreted, considering the small number of cases.
Selected Abstracts
Abridged Abstracts From the Medical Literature
Lee, Lawrence; Raman, Shankar; Keller, Deborah S.; More
Diseases of the Colon & Rectum. 62(8):1020-1023, August 2019.
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