IMPORTANCE: Bridge to elective surgery using self-expandable metal stent (SEMS) placement is a debated alternative to emergency resection for patients with left-sided obstructive colon cancer because ...of oncologic concerns. A decompressing stoma (DS) might be a valid alternative, but relevant studies are scarce. OBJECTIVE: To compare DS with SEMS as a bridge to surgery for nonlocally advanced left-sided obstructive colon cancer using propensity score matching. DESIGN, SETTING, AND PARTICIPANTS: This national, population-based cohort study was performed at 75 of 77 hospitals in the Netherlands. A total of 4216 patients with left-sided obstructive colon cancer treated from January 1, 2009, to December 31, 2016, were identified from the Dutch Colorectal Audit and 3153 patients were studied. Additional procedural and intermediate-term outcome data were retrospectively collected from individual patient files, resulting in a median follow-up of 32 months (interquartile range, 15-57 months). Data were analyzed from April 7 to October 28, 2019. EXPOSURES: Decompressing stoma vs SEMS as a bridge to surgery. MAIN OUTCOMES AND MEASURES: Primary anastomosis rate, postresection presence of a stoma, complications, additional interventions, permanent stoma, locoregional recurrence, disease-free survival, and overall survival. Propensity score matching was performed according to age, sex, body mass index, American Society of Anesthesiologists score, prior abdominal surgery, tumor location, pN stage, cM stage, length of stenosis, and year of resection. RESULTS: A total of 3153 of the eligible 4216 patients were included in the study (mean SD age, 69.7 11.8 years; 1741 55.2% male); after exclusions, 443 patients underwent bridge to surgery (240 undergoing DS and 203 undergoing SEMS). Propensity score matching led to 2 groups of 121 patients each. Patients undergoing SEMS had more primary anastomoses (104 of 121 86.0% vs 90 of 120 75.0%, P = .02), more postresection stomas (81 of 121 66.9% vs 34 of 117 29.1%, P < .001), fewer major complications (7 of 121 5.8% vs 18 of 118 15.3%, P = .02), and more subsequent interventions, including stoma reversal (65 of 113 57.5% vs 33 of 117 28.2%, P < .001). After DS and SEMS, the 3-year locoregional recurrence rates were 11.7% for DS and 18.8% for SEMS (hazard ratio HR, 0.62; 95% CI, 0.30-1.28; P = .20), the 3-year disease-free survival rates were 64.0% for DS and 56.9% for SEMS (HR, 0.90; 95% CI, 0.61-1.33; P = .60), and the 3-year overall survival rates were 78.0% for DS and 71.8% for SEMS (HR, 0.77; 95% CI, 0.48-1.22; P = .26). CONCLUSIONS AND RELEVANCE: The findings suggest that DS as bridge to resection of left-sided obstructive colon cancer is associated with advantages and disadvantages compared with SEMS, with similar intermediate-term oncologic outcomes. The existing equipoise indicates the need for a randomized clinical trial that compares the 2 bridging techniques.
Background
Completion total mesorectal excision (TME) is advised for high‐risk early (pT1/pT2) rectal cancer following transanal removal. The main objective of this meta‐analysis was to determine ...oncological outcomes of adjuvant (chemo)radiotherapy as a rectum‐preserving alternative to completion TME.
Methods
A literature search using PubMed, Embase and the Cochrane Library was performed in February 2015. Studies had to include at least ten patients with pT1/pT2 adenocarcinomas that were removed transanally and followed by either adjuvant chemoradiotherapy or completion surgery. A weighted average of the logit proportions was determined for the pooled analyses of subgroups according to treatment modality and pT category.
Results
In total, 14 studies comprising 405 patients treated with adjuvant (chemo)radiotherapy and seven studies comprising 130 patients treated with completion TME were included. Owing to heterogeneity it was not possible to compare the two strategies directly. However, the weighted average local recurrence rate for locally excised pT1/pT2 rectal cancer treated with adjuvant (chemo)radiotherapy was 14 (95 per cent c.i. 11 to 18) per cent, and 7 (4 to 14) per cent following completion TME. The weighted averages for distance recurrence were 9 (6 to 14) and 9 (5 to 16) per cent respectively. Weighted averages for local recurrence rate after adjuvant chemo(radiotherapy) and completion TME for pT1 were 10 (4 to 21) and 6 (3 to 15) per cent respectively. Corresponding averages for pT2 were 15 (11 to 21) and 10 (4 to 22) per cent respectively.
Conclusion
A higher recurrence rate after transanal excision and adjuvant (chemo)radiotherapy must be balanced against the morbidity and mortality associated with mesorectal excision. A reasonable approach is close follow‐up and salvage mesorectal surgery as needed.
Salvage surgery may be superior
The need for routine diverting ileostomy following restorative total mesorectal excision (TME) is increasingly debated as the benefits might not outweigh the disadvantages. This study evaluated an ...institutional shift from routine (RD) to highly selective diversion (HSD) after TME surgery for rectal cancer.
Patients having TME with primary anastomosis and HSD for low or mid rectal cancer between December 2014 and March 2017 were compared with a historical control group with RD in the preceding period since January 2011. HSD was introduced in conjunction with uptake of transanal TME.
In the RD group, 45/50 patients (90%) had a primary diverting stoma, and 3/40 patients (8%) in the HSD group. Anastomotic leakage occurred in 10 (20%) and three (8%) cases after a median follow-up of 36 and 19 months after RD and HSD, respectively. There was no postoperative mortality. An unintentional stoma beyond 1 year postoperative was present in six and two patients, respectively. One-year stoma-related readmission and reoperation rate (including reversal) after RD were 84% and 86%, respectively. Corresponding percentages were significantly lower after HSD (17% and 17%; P < 0.001). Total hospital stay within one year was median 11 days (IQR 8–19) versus 5 days (IQR 4–11), respectively (P < 0.001).
This single institutional comparative cohort study shows that highly selective defunctioning of a low anastomosis in rectal cancer patients did not adversely affect incidence or consequences of anastomotic leakage with a substantial decrease in 1-year readmission and reintervention rate, leading to an overall significantly reduced hospital stay.
Abstract This study investigated the diagnostic accuracy of cone beam computed tomography (CBCT) compared to panoramic radiography in determining the anatomical position of the impacted third molar ...in relation with the mandibular canal. The study sample comprised 53 third molars from 40 patients with an increased risk of inferior alveolar nerve (IAN) injury. The panoramic and CBCT features (predictive variables) were correlated with IAN exposure and injury (outcome variables). Sensitivity and specificity of modalities in predicting IAN exposure were compared. The IAN was exposed in 23 cases during third molar removal and injury occurred in 5 patients. No significant difference in sensitivity and specificity was found between both modalities in predicting IAN exposure. To date, lingual position of the mandibular canal was significantly associated with IAN injury. CBCT was not more accurate at predicting IAN exposure during third molar removal, however, did elucidate the 3D relationship of the third molar root to the mandibular canal; the coronal sections allowed a bucco-lingual appreciation of the mandibular canal to identify cases in which a lingually placed IAN is at risk during surgery. This observation dictates the surgical approach how to remove the third molar, so the IAN will not be subjected to pressure.
Aim
The aim of this study was to report on the feasibility of transanal minimally invasive surgery (TAMIS) as a novel approach to redo colorectal or ileoanal anastomoses.
Methods
From October 2014, a ...prospective institutional database was created for all consecutive patients who underwent redo surgery by TAMIS for presacral sinus or anastomotic stenosis after low anterior resection or pouch-related problems following restorative proctocolectomy. Intra-operative feasibility, 30-day postoperative outcomes, intestinal continuity and complications after 6-month follow-up were evaluated.
Results
Of 17 included patients, 14 underwent anastomotic reconstruction and three completion proctectomy. The median operation time was 265 min (range 201–413). A successful rendezvous with simultaneous transabdominal access was achieved in 15 patients, and the procedure was completed by TAMIS alone in two. Five patients were readmitted within 30 days (29 %). Two (14 %) patients developed an anastomotic leakage within 30 days and 4 (24 %) developed a pelvic abscess requiring reintervention. One patient developed an urethra stenosis and was managed with a suprapubic catheter. Median follow-up was 9 (6–15) months. Within 6-month follow-up, the redo-TAMIS 1 patient developed a delayed anastomotic leak and 1 patient had a recurrent presacral abscess after stoma closure. Intestinal continuity was reached in 71 % of the patients at 6-month follow-up.
Conclusion
TAMIS is a valuable approach in redo pelvic surgery, but is still associated with high complication rates related to the complexity of the underlying problem.
Abstract Craniosynostosis is a congenital defect which can result in abnormal cranial morphology. Three dimensional (3D) stereophotogrammetry is potentially an ideal technique for the evaluation of ...cranial morphology and diagnosis of craniosynostosis because it is fast and harmless. This study presents a new method for objective characterization of the morphological abnormalities of scaphocephaly and trigonocephaly patients using 3D photographs of patients and healthy controls. Sixty 3D photographs of healthy controls in the age range of 3–6 months were superimposed and scaled. Principal component analysis (PCA) was applied to find the mean cranial shape and the cranial shape variation in this normal population. 3D photographs of 20 scaphocephaly and 20 trigonocephaly patients were analysed by this PCA model to test whether cranial deformities of scaphocephaly and trigonocephaly patients could be objectively identified. PCA was used to find the mean cranial shape and the cranial shape variation in the normal population. The PCA model was able to significantly distinguish scaphocephaly and trigonocephaly patients from the normal population. 3D stereophotogrammetry in combination with the presented method can be used to objectively identify and classify the cranial shape of healthy newborns, scaphocephaly and trigonocephaly patients.
Introduction
Non-healing of anastomotic leakage can be observed in up to 50% after total mesorectal excision for rectal cancer. This study investigates the efficacy of early transanal closure of ...anastomotic leakage after pre-treatment with the Endosponge
®
therapy.
Methods
In this prospective, multicentre, feasibility study, transanal suturing of the anastomotic defect was performed after vacuum-assisted cleaning of the presacral cavity. Primary outcome was the proportion of patients with a healed anastomosis at 6 months after transanal closure. Secondary, healing at last follow-up, continuity, direct medical costs, functionality and quality of life were analysed.
Results
Between July 2013 and July 2015, 30 rectal cancer patients with a leaking low colorectal anastomosis were included, of whom 22 underwent neoadjuvant radiotherapy. Median follow-up was 14 (7–29) months. At 6 months, the anastomosis had healed in 16 (53%) patients. At last follow-up, anastomotic integrity was found in 21 (70%) and continuity was restored in 20 (67%) patients. Non-healing at 12 months was observed in 10/29 (34%) patients overall, and in 3/14 (21%) when therapy started within three weeks following the index operation. Major LARS was reported in 12/15 (80%) patients. The direct medical costs were €8933 (95% CI 7268–10,707) per patient.
Conclusion
Vacuum-assisted early transanal closure of a leaking anastomosis after total mesorectal excision with 73% preoperative radiotherapy showed that acceptable anastomotic healing rates and stoma reversal rates can be achieved. Early diagnosis and start of treatment seems crucial.
Abstract In cleft lip and palate patients the shape of the nose invariably changes in three dimensions (3D) due to rhinoplastic surgery. The purpose of this study was to evaluate stereophotogrammetry ...as a 3D method to document volumetric changes of the nose in patients with a cleft lip (CL) or cleft lip and palate (CLP) after secondary open rhinoplasty. 12 patients with unilateral CL or CLP were enrolled in the study prospectively. 3D facial images were acquired using 3D stereophotogrammetry preoperatively and 3 months postoperatively. A 3D cephalometric analysis of the nose was performed and volumetric data were acquired. The reliability of the method was tested by performing an intra- and inter-observer analysis. Left, right and total nasal volumes and symmetry were compared. No statistically significant differences ( p < 0.05) were found within and between observers for the measured volumes and symmetry. Postoperatively, the total volume of the nose increased significantly, especially the volume at the cleft side. No significant volume difference pre- and postoperatively was found for the non-cleft side. The symmetry of the nose improved significantly. 3D stereophotogrammetry is a sensitive, quick, non-invasive method for evaluating volumetric changes of the nose in patients with cleft lip or cleft lip and palate.
Abstract This prospective study evaluated the role of cone beam computed tomography (CBCT) in the treatment of patients with impacted mandibular third molars at increased risk of inferior alveolar ...nerve (IAN) injury. Subjects with an increased risk of IAN injury, as diagnosed on panoramic radiographs, were enrolled in this study and underwent additional CBCT imaging. Two oral maxillofacial surgeons independently planned the surgical technique and estimated the risk of IAN injury on panoramic radiographs and on CBCT images. A test of symmetry and the McNemar test were executed to calculate the differences between the two imaging modalities. The study sample comprised 40 patients (mean age 27.6 years) presenting 53 mandibular third molars. Risk assessment for IAN injury based on panoramic radiography compared with CBCT imaging differed significantly ( P < 0.005). After reviewing the CBCT images, significantly more subjects were reclassified to a lower risk for IAN injury compared with the panoramic radiograph assessments. This change in risk assessment also resulted in a significantly different surgical approach ( P < 0.03). The results of this study show that CBCT contributes to optimal risk assessment and, as a consequence, to more adequate surgical planning, compared with panoramic radiography.
OBJECTIVE:The purpose of this population-based study was to compare decompressing stoma (DS) as bridge to surgery (BTS) with emergency resection (ER) for left-sided obstructive colon cancer (LSOCC) ...using propensity-score matching.
SUMMARY BACKGROUND DATA:Recently, an increased use of DS as BTS for LSOCC has been observed in the Netherlands. Unfortunately, good quality comparative analyses with ER are scarce.
METHODS:Patients diagnosed with nonlocally advanced LSOCC between 2009 and 2016 in 75 Dutch hospitals, who underwent DS or ER in the curative setting, were propensity-score matched in a 1:2 ratio. The primary outcome measure was 90-day mortality, and main secondary outcomes were 3-year overall survival and permanent stoma rate.
RESULTS:Of 2048 eligible patients, 236 patients who underwent DS were matched with 472 patients undergoing ER. After DS, more laparoscopic resections were performed (56.8% vs 9.2%, P < 0.001) and more primary anastomoses were constructed (88.5% vs 40.7%, P < 0.001). DS resulted in significantly lower 90-day mortality compared to ER (1.7% vs 7.2%, P = 0.006), and this effect could be mainly attributed to the subgroup of patients over 70 years (3.5% vs 13.7%, P = 0.027). Patients treated with DS as BTS had better 3-year overall survival (79.4% vs 73.3%, hazard ratio 0.36, 95% confidence interval 0.20-0.65) and fewer permanent stomas (23.4% vs 42.4%, P < 0.001).
CONCLUSIONS:In this nationwide propensity-score matched study, DS as a BTS for LSOCC was associated with lower 90-day mortality and better 3-year overall survival compared to ER, especially in patients over 70 years of age.
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