Purpose
Transanal minimally invasive surgery (TAMIS) is gaining worldwide popularity as an alternative for the transanal endoscopic microsurgery (TEMS) method for the local excision of rectal polyps ...and selected neoplasms. Data on patient reported outcomes regarding short-term follow-up are scarce; data on functional outcomes for long-term follow-up is non-existent.
Methods
We used the fecal incontinence severity index (FISI) to prospectively assess the fecal continence on the intermediate-term follow-up after TAMIS. The primary outcome measure is postoperative fecal continence. Secondary outcome measures are as follows: perioperative and intermediate-term morbidity.
Results
Forty-two patients (m = 21:f = 21), median age 68.5 (range 34–94) years, were included in the analysis. In four patients (9.5%), postoperative complications occurred. The median follow-up was 36 months (range 24–48). Preoperative mean FISI score was 8.3 points. One year after TAMIS, mean FISI score was 5.4 points (
p
= 0.501). After 3 years of follow-up, mean FISI score was 10.1 points (
p
= 0.01). Fecal continence improved in 11 patients (26%). Continence decreased in 20 patients (47.6%) (mean FISI score 15.2 points, range 3–31).
Conclusions
This study found that the incidence of impaired fecal continence after TAMIS is substantial; however, the clinical significance of this deterioration seems minor. The present data is helpful in acquiring informed consent and emphasizes the need of proper patient information.
Functional results seem to be comparable to results after TEMS. Furthermore, we confirmed TAMIS is safe and associated with low morbidity.
•A significant hospital variation is present in neoadjuvant rectal cancer treatment.•Hospital of diagnosis influences overall survival in high-risk rectal cancer.•After a national guideline update, ...less overtreatment was present in low-risk rectal cancer.•Implementation of regionalized MDTs may be warranted.
The aim of this study was to examine the hospital variation in neoadjuvant treatment of rectal cancer according to the different risk groups (low-, intermediate- and high-risk) and evaluate the influence on survival.
Patients with non-metastasized rectal cancer diagnosed between 2009 and 2016 were selected from the Netherlands Cancer Registry. The observed and case-mix adjusted distribution of the different neoadjuvant treatment schemes (none, radiotherapy (RT), chemoradiotherapy (CRT)) by hospital of diagnosis were generated for each risk group in the cohorts before and after the national guideline update of 2014.
A total of 25,306 patients were included and after case-mix adjustment, hospital of diagnosis was found to have a significant impact on neoadjuvant treatment administration in each of the three risk groups (p < 0.001). Overall survival was however not influenced, except for the high-risk group where hospitals with highest rates of CRT were associated with a better 5-years overall survival (HR 0.79; p = 0.03). After guideline revision, the rate of patients in the low-risk group who did not undergo RT increased from a median of 30.8% to 90.5% (p < 0.001).
Although a significant change in treatment was observed after revision of the national guidelines, a wide range of hospital variation still exists in administered neoadjuvant treatment in rectal cancer patients. High-risk rectal cancer patients had a better survival when treated in hospitals with the highest rates of CRT provided. In order to minimize treatment differences, further research into the causes of this variation and implementation of regionalized MDTs may be warranted.
Background
Laparoscopic ventral mesh rectopexy (LVMR) is considered to be the gold standard for managing rectal prolapse. Nevertheless, concerns have been expressed about the use of this procedure in ...elderly patients. The aim of the current study was to examine the perioperative safety of primary LVMR operations in the oldest old in comparison to younger individuals and to assess our hospital policy of offering LVMR to all patients, regardless of age and morbidity.
Methods
A retrospective study analysed demographic information, operation notes, meshes utilised, operation times, lengths of hospital stay (LOS) and American Society of Anesthesiologists (ASA) scores of patients who underwent LVMR at Elisabeth-TweeSteden Hospital between 2012 and 2023.
Results
Eighty-seven female patients underwent LVMR. Nineteen patients were 80 years of age or older (OLD group); the remaining 65 patients were under the age of 80 (YOUNG group). The difference between the groups in terms of age was statistically significant. ASA scores were not significantly different. No mortality was observed. There was no statistically significant difference between the groups in terms of LOS, operation time or morbidity. Moreover, the postoperative morbidity profile was excellent in both groups.
Conclusion
LVMR seems to be a safe operation for the “oldest old” patients with comorbidity, despite a single-centre, retrospective trial with limited follow-up. The present study suggests abandoning the dogma that “frail patients with rectal prolapse are not suitable for laparoscopic ventral mesh rectopexy.”
The aim of the present study was to evaluate MRI response rate and clinical outcome of short-course radiotherapy (SCRT) on rectal cancer as an alternative to chemoradiotherapy in patients where ...downstaging is indicated.
A retrospective analysis was performed of a patient cohort with rectal carcinoma (cT1-4cN0-2 cM0-1) from a large teaching hospital receiving restaging MRI, deferred surgery or no surgery after SCRT between 2011 and 2017. Patients who received chemotherapy during the interval between SCRT and restaging MRI were excluded. The primary outcome measure was the magnetic resonance tumor regression grade (mrTRG) at restaging MRI after SCRT followed by a long interval. Secondary, pathological tumor stage, complete resection rate and 1-year overall survival were assessed.
A total of 47 patients (M:F = 27:20, median age 80 (range 53-88) years), were included. In 33 patients MRI was performed for response assessment 10 weeks after SCRT. A moderate or good response (mrTRG≤3) was observed in 24 of 33 patients (73%). While most patients (85%; n = 28) showed cT3 or cT4 stage on baseline MRI, a ypT3 or ypT4 stage was found in only 20 patients (61%) after SCRT (p < 0.01). A complete radiologic response (mrTRG 1) was seen in 4 patients (12%). Clinical N+ stage was diagnosed in n = 23 (70%) before SCRT compared to n = 8 (30%) post-treatment (p = 0.03). After SCRT, 39 patients underwent deferred surgery (after a median of 14 weeks after start of SCRT) and a resection with complete margins was achieved in 35 (90%) patients. One-year overall survival after surgery was 82%. Complete pathological response was found in 2 patients (5%).
The use of SCRT followed by a long interval to restaging showed a moderate to good response in 73% and therefore can be considered as an alternative to chemoradiotherapy in elderly comorbid patients.
Introduction
Visualising the course of a complex perianal fistula on imaging can be difficult. It has been postulated that three-dimensional (3D) models of perianal fistulas improve understanding of ...the perianal pathology, contribute to surgical decision-making and might even improve future outcomes of surgical treatment. The aim of the current study is to investigate the accuracy of 3D-printed models of perianal fistulas compared with magnetic resonance imaging (MRI).
Methods
MRI scans of 15 patients with transsphincteric and intersphincteric fistulas were selected and then assessed by an experienced abdominal and colorectal radiologist. A standardised method of creating a 3D-printed anatomical model of cryptoglandular perianal fistula was developed by a technical medical physicist and a surgeon in training with special interest in 3D printing. Manual segmentation of the fistula and external sphincter was performed by a trained technical medical physicist. The anatomical models were 3D printed in a 1:1 ratio and assessed by two colorectal surgeons. The 3D-printed models were then scanned with a 3D scanner. Volume of the 3D-printed model was compared with manual segmentation. Inter-rater reliability statistics were calculated for consistency between the radiologist who assessed the MRI scans and the surgeons who assessed the 3D-printed models. The assessment of the MRI was considered the ‘gold standard’. Agreement between the two surgeons who assessed the 3D printed models was also determined.
Results
Consistency between the radiologist and the surgeons was almost perfect for classification (
κ
= 0.87,
κ
= 0.87), substantial for complexity (
κ
= 0.73,
κ
= 0.74) and location of the internal orifice (
κ
= 0.73,
κ
= 0.73) and moderate for the percentage of involved external anal sphincter in transsphincteric fistulas (ICC 0.63, ICC 0.52). Agreement between the two surgeons was substantial for classification (
κ
= 0.73), complexity (
κ
= 0.74), location of the internal orifice (
κ
= 0.75) and percentage of involved external anal sphincter in transsphincteric fistulas (ICC 0.77).
Conclusions
Our 3D-printed anatomical models of perianal fistulas are an accurate reflection of the MRI. Further research is needed to determine the added value of 3D-printed anatomical models in preoperative planning and education.
Aim
Transanal minimally invasive surgery (TAMIS) is used increasingly often as an organ‐preserving treatment for early rectal cancer. If final pathology reveals unfavourable histological prognostic ...features, completion total mesorectal excision (cTME) is recommended. This study is the first to investigate the results of cTME after TAMIS.
Method
Data were retrieved from the prospective database of the Elisabeth‐TweeSteden Hospital. Completion TME patients were case matched with a control group of patients undergoing primary TME (pTME). Primary and secondary outcomes were surgical outcomes and oncological outcomes, respectively.
Results
From 2011 to 2017, 20 patients underwent cTME and were compared with 40 patients undergoing pTME. There were no significant differences in operating time (238 min vs 226 min, P = 0.53), blood loss (137 ml vs. 158 ml, P = 0.88) or complications (45% vs 55%, P = 0.07) between both groups. There was no 90‐day mortality in the cTME group. The mesorectal fascia was incomplete in three patients (15%) in the cTME group compared with no breaches in the pTME group (P = 0.083). There were no local recurrences in either group. In three patients (15%), distant metastases were detected after cTME compared with one patient (2.5%) in the pTME group (P = 0.069). After cTME patients had a 1‐ and 5‐year disease‐free survival of 85% compared with 97.5% for the pTME group (P = 0.062).
Conclusion
Completion TME surgery after TAMIS is not associated with increased peri‐ or postoperative morbidity or mortality compared with pTME surgery. After cTME surgery patients have a similar disease‐free and overall survival when compared with patients undergoing pTME.
Aim
New stoma patients often rely heavily on the assistance of the ward nursing staff during the hospital stay and on the availability of home nursing care services (HNCS) after discharge. An easily ...executable 4‐day in‐hospital educational stoma pathway was developed and implemented. The aim was to increase their level of independence (LOI) in order to reduce the need for HNCS after discharge.
Method
All new stoma patients on the gastrointestinal surgery ward, physically and psychologically capable of performing independent stoma care (SC), were enrolled in this pathway. They were compared to a retrospective control group of new stoma patients before the onset of the stoma pathway. The primary outcome is the need and frequency of HNCS for SC at the moment of discharge. Secondary outcome is the LOI in SC at discharge.
Results
A total of 145 patients m:f = 102:43, median age 67 (range 27–90) years were included in the present study. Patients requiring daily HNCS for SC decreased from 80% to 50%, P < 0.001; patients discharged without HNCS for SC increased from 5% to 27%. Patients’ independence in SC at discharge increased from 8% to 68%, P < 0.001.
Conclusion
This study shows that a clinical 4‐day in‐hospital educational stoma pathway is feasible and effective in increasing the LOI in SC of new stoma patients and significantly reducing their need for HNCS. Cost–benefit analysis and applicability of this pathway in multicentre settings are currently being investigated.
Background
Laser Ablation of Fistula Tract (LAFT) is a novel technique for the treatment of perianal fistulas. Initial reports have shown moderate-to-good results. The aim of this study was to ...evaluate this implementation and the effectiveness of this technique. Patients were offered LAFT as a treatment option for their perianal fistulas at the outpatient clinic between November 2016 and April 2018. Inclusion criteria were intersphincteric and transsphincteric fistula of cryptoglandular origin
10
. Exclusion criteria were supra- or extrasphincteric fistula, Crohn’s disease, presence of undrained collections or side tracts and malignancy-related fistula. The primary outcome was fistula healing rate, the main secondary outcome incidence of postoperative fecal incontinence. Healing and postoperative FISI were evaluated at our outpatient clinic during follow-up at 6 and 12 weeks. A questionnaire was sent to all patients to evaluate the long-term postoperative FISI and patient satisfaction after 3 months.
Results
Between November 2016 and April 2018, 20 patients m:f = 4:16, median age 45 (27–78) years underwent LAFT. Median follow-up was 10 months (IQR 7.3 months). A draining seton was placed in 15 (75%) of all patients with a median time of 12 weeks (IQR 14 weeks) prior to LAFT. Five intersphincteric and 13 transsphincteric fistulas were treated. Overall healing rate was 20% (4/20). The median postoperative fecal incontinence severity index (FISI) score was 0 (range 0–38); however, we found a change in continence in 39% of the patients.
Conclusions
LAFT has now been discontinued as a treatment of cryptoglandular perianal fistulas in our centre, because of its disappointing results. Further detailed research seems to be warranted to investigate its exact indication and limitations.
Background
Many surgeons believe that the distance from the external opening to the anal verge (DEOAV) predicts the complexity of a cryptoglandular fistulas-in-ano and, therefore, predicts the need ...for additional imaging. However, there is no evidence to support this.
The primary aim of this study was to determine if DEOAV can predict the complexity of a fistula. Secondary aims were clinical outcome and identification of those patients that might not benefit from preoperative imaging.
Methods
All patients having surgery for cryptoglandular fistula-in-ano between January 2014 and December 2016 were evaluated. Preoperative imaging was used to classify fistulas as simple or complex. The DEAOV was measured preoperatively and was divided into categories ≤ 1 cm, 1–2 cm, or > 2 cm. The relationship between the DEOAV and complexity of the fistula was investigated. Clinical outcome was recorded and a group of patients that might not benefit from preoperative imaging was identified.
Results
A total of 103 patients m:f = 65:38, median age 47 (range 19–79) years were included. Magnetic resonance imaging identified 39 simple and 64 complex fistulas. The percentage of simple fistula was 88% in fistulas with DEAOV ≤ 1 cm, 48% in DEAOV 1–2 cm and 38% in > 2 cm. There was a significant difference between the complexity of the fistula and the distance to the anal verge (
p
< 0.001). The overall healing rate was 88%.
Conclusions
The complexity of perianal fistula depends on the DEAOV. We propose that preoperative imaging should be performed in fistulas with external opening > 1 cm from the anal verge.
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