Background
Transanal total mesorectal excision (TaTME) appeared to be a challenging alternative to Laparoscopic Total Mesorectal Excision (LaTME) for low and middle rectal cancer. However, evidence ...remains low on the possible benefits of TaTME. The aim of this study was to perform a meta-analysis of comparative studies between TaTME and LaTME.
Methods
A systematic review and meta-analysis based on Preferred Reporting Items for Systematic reviews and Meta-analysis (PRISMA) guidelines was conducted on Medline, Embase, and Cochrane database. The following outcomes were assessed: conversion, operative time, morbidity, length of stay, readmission rate, and pathological and oncological results.
Results
After review of 756 identified records, 14 studies were included (case-matched control
n
= 10, prospective cohort
n
= 3, retrospective study
n
= 1) comparing 495 TaTME and 547 LaTME. No randomized trial was available. Following criteria were significantly improved after TaTME vs. LaTME: readmission’s rate (9% after TaTME vs. 18% after LaTME, OR 0.44, 95%CI 0.26–0.74,
p
= 0.002), length of stay (OR − 2.17, 95%CI − 3.68 to − 0.66,
p
= 0.005), overall morbidity (34 vs. 41%, OR 0.65, 95%CI 0.46-0.91,
p
= 0.001), major morbidity (8.7 vs. 14%, OR 0.53, 95%CI 0.34–0.83,
p
= 0.005), anastomotic leak (6.4 vs. 11.6%, OR 0.53, 95%CI 0.31–0.93,
p
= 0.03), and circumferential resection margin (CRM) involvement (4 vs. 8.8%, OR 0.48, 95%CI 0.27–0.86,
p
= 0.01). No significant differences were observed between TaTME and LaTME regarding conversion’s rate (3.2 vs. 8.8%,
p
= 0.09), operative time (OR − 10.73,
p
= 0.26), intraoperative complications (8.1 vs. 6.3%,
p
= 0.48), minor morbidity (27.9 vs. 29.6%,
p
= 0.27), positive distal resection margin (1.4 vs. 1.4%,
p
= 0.93), complete TME (75 vs. 75%,
p
= 0.74), harvested lymph nodes (OR 0.38,
p
= 0.44), and local recurrence rate (3.5 vs. 2.2%,
p
= 0.64).
Conclusion
This meta-analysis based on nonrandomized studies suggests that TaTME seems better than LaTME in terms of overall and major morbidities, anastomotic leak, readmission rate, CRM involvement, and length of stay. These results need to be confirmed by randomized controlled trial.
The optimal elective colectomy in patients with splenic flexure tumor is debated.
This study aimed to compare splenic flexure colectomy, left hemicolectomy, and subtotal colectomy for perioperative, ...histological, and survival outcomes in this setting.
This is a multicenter retrospective cohort study.
Patients diagnosed with nonmetastatic splenic flexure tumor who underwent elective colectomy were included.
Between 2006 and 2014, 313 consecutive patients were operated on in 15 French Research Group of Rectal Cancer Surgery centers.
Propensity score weighting was performed to compare short- and long-term outcomes.
The primary end point was disease-free survival. Secondary end points included overall survival, quality of surgical resection, overall postoperative morbidity, surgical postoperative morbidity, and rate of anastomotic leakage.
The most performed surgery was splenic flexure colectomy (59%), followed by subtotal colectomy (23%) and left hemicolectomy (18%). Subtotal colectomy was more often performed by laparotomy compared with splenic flexure colectomy and left hemicolectomy (93% vs 61% vs 56%, p < 0.0001), and was associated with a longer operative time (260 minutes (120-460) vs 180 minutes (68-440) vs 217 minutes (149-480), p < 0.0001). Postoperative morbidity was similar between the 3 groups, but the median length of hospital stay was significantly longer after subtotal colectomy (13 days (5-56) vs 10 (4-175) vs 9 (4-55), p = 0.0007). The median number of harvested lymph nodes was significantly higher after subtotal colectomy compared with splenic flexure colectomy and left hemicolectomy (24 (8-90) vs 15 (1-81) vs 16 (3-52), p < 0.0001). The rate of stage III disease and the number of patients treated by adjuvant chemotherapy were similar between the 3 groups. There was no difference in terms of disease-free survival and overall survival between the 3 procedures.
The study was limited by its retrospective design.
In the elective setting, splenic flexure colectomy is safe and oncologically adequate for patients with nonmetastatic splenic flexure tumor. However, given the oncological clearance after splenic flexure colectomy, it seems that the debate is not completely closed. See Video Abstract at http://links.lww.com/DCR/B703.
ANTECEDENTES:La colectomía electiva óptima en pacientes con tumores del ángulo esplénico continua en debate.OBJETIVO:Comparar la colectomía de ángulo esplénico, hemicolectomía izquierda y colectomía subtotal para los resultados perioperatorios, histológicos y de supervivencia en este escenario.DISEÑO:Estudio de cohorte retrospectivo multicéntrico.ESCENARIO:Se incluyeron pacientes diagnosticados de tumores del ángulo esplénico no metastásicos que se sometieron a colectomía electiva.PACIENTES:Entre 2006 y 2014, 313 pacientes consecutivos fueron intervenidos en 15 centros GRECCAR.INTERVENCIONES:Se realizó una ponderación del puntaje de propensión para comparar los resultados a corto y largo plazo.PRINCIPALES MEDIDAS DE RESULTADO:El criterio de valoración principal fue la supervivencia libre de enfermedad. Los criterios de valoración secundarios incluyeron la supervivencia general, la calidad de la resección quirúrgica, la morbilidad posoperatoria general, la morbilidad posoperatoria quirúrgica y la tasa de fuga anastomótica.RESULTADOS:La cirugía más realizada fue la colectomía del ángulo esplénico (59%), seguida de la colectomía subtotal (23%) y la hemicolectomía izquierda (18%). La colectomía subtotal se realizó con mayor frecuencia mediante laparotomía en comparación con la colectomía de ángulo esplénico y la hemicolectomía izquierda (93% frente a 61% frente a 56%, p <0.0001), y se asoció con un tiempo quirúrgico más prolongado (260 min 120-460 frente a 180 min 68-440 frente a 217 min 149-480, p <0.0001). La morbilidad posoperatoria fue similar entre los tres grupos, pero la duración media de la estancia hospitalaria fue significativamente más prolongada después de la colectomía subtotal (13 días 5-56 frente a 10 4-175 frente a 9 4-55, p = 0.0007). La mediana del número de ganglios linfáticos extraídos fue significativamente mayor después de la colectomía subtotal en comparación con la colectomía del ángulo esplénico y la hemicolectomía izquierda (24 8-90 frente a 15 1-81 frente a 16 3-52, p <0.0001). La tasa de enfermedad en estadio III y el número de pacientes tratados con quimioterapia adyuvante fueron similares entre los 3 grupos. No hubo diferencias en términos de supervivencia libre de enfermedad y supervivencia general entre los 3 procedimientos.LIMITACIONES:El estudio estuvo limitado por su diseño retrospectivo.CONCLUSIONES:En un escenario electivo, la colectomía del ángulo esplénico es segura y oncológicamente adecuada para pacientes con tumores del ángulo esplénico no metastásicos. Sin embargo, dado el aclaramiento oncológico tras la colectomía del ángulo esplénico, parece que el debate no está completamente cerrado. Consulte Video Resumen en http://links.lww.com/DCR/B703.
Background After sphincter-saving operation for rectal cancer, the impact of anastomotic leakage on function has been well studied. The purpose of the present work was to assess the influence of ...symptomatic and asymptomatic anastomotic leakage on bowel function and health-related quality of life using the Low Anterior Resection Syndrome score and the disease-specific questionnaire European Organization for Research and Treatment of Quality of Life Questionnaire for Colorectal Cancer. Methods The study was a case-matched study with multiple controls per case in a variable ratio from a prospectively maintained database conducted at a tertiary, colorectal operation referral center. A total of 46 patients with postoperative anastomotic leakage (symptomatic, n = 23, asymptomatic, n = 23) after laparoscopic, sphincter-saving operative intervention for rectal cancer were matched with all available patients without anastomotic leakage (control group, n = 89) using the following criteria: age, sex, type of neoadjuvant treatment, and type of anastomosis. The Low Anterior Resection Syndrome score and European Organization for Research and Treatment of Quality of Life Questionnaire for Colorectal Cancer were submitted to all included patients. The Low Anterior Resection Syndrome scores were categorized into 3 categories (no Low Anterior Resection Syndrome, minor Low Anterior Resection Syndrome, and major Low Anterior Resection Syndrome). Results Mean follow-up after stoma closure was 46 ± 26 months. Median (interquartile range) Low Anterior Resection Syndrome score for all included patients was 27 (16–36). Patients with symptomatic anastomotic leakage had impaired Low Anterior Resection Syndrome score: median 30 (23–39) vs 27 (15–34) in the control group ( P = .02), with no Low Anterior Resection Syndrome in 4% (vs 31%), minor Low Anterior Resection Syndrome in 52% (vs 52%), and major Low Anterior Resection Syndrome in 44% (vs 17%) ( P = .004). No difference was noted between the asymptomatic anastomotic leakage group and control group for median Low Anterior Resection Syndrome score ( P = .70) and Low Anterior Resection Syndrome categories (no Low Anterior Resection Syndrome, minor LARS, and major Low Anterior Resection Syndrome; P = .58). Patients with symptomatic anastomotic leakage had significantly more anorectal and urinary symptoms compared with patients with no or asymptomatic anastomotic leakage. Conclusion Symptomatic anastomotic leakage impairs function and quality of life after laparoscopic, sphincter-saving operative intervention for rectal cancer.
Purpose A pathologic complete response (pCR; ypT0N0) of a rectal tumor after neoadjuvant radiochemotherapy (RCT) is associated with an excellent prognosis. Several retrospective studies have ...investigated the effect of increasing the delay after RCT. The aim of this study was to evaluate the effect of increasing the interval between the end of RCT and surgery on the pCR rate. Methods GRECCAR6 was a phase III, multicenter, randomized, open-label, parallel-group controlled trial. Patients with cT3/T4 or Tx N+ tumors of the mid or lower rectum who had received RCT (45 to 50 Gy with fluorouracil or capecitabine) were included. Patients were randomly included in the 7-week or the 11-week (11w) group. Primary end point was the pCR rate defined as a ypT0N0 specimen (NCT01648894). Results A total of 265 patients from 24 centers were enrolled between October 2012 and February 2015. The majority of the tumors were cT3 (82%). After RCT, surgery was not performed in nine patients (3.4%) because of the occurrence of distant metastasis (n = 5) or other reasons. Two patients underwent local resection of the tumor scar. A total of 47 (18.6%) specimens were classified as ypT0 (four had invaded lymph nodes 8.5%). The primary end point (ypT0N0) was not different (7 weeks: 20 of 133, 15.0% v 11w: 23 of 132, 17.4%; P = .5983). Morbidity was significantly increased in the 11w group (44.5% v 32%; P = .0404) as a result of increased medical complications (32.8% v 19.2%; P = .0137). The 11w group had a worse quality of mesorectal resection (complete mesorectum I 78.7% v 90%; P = .0156). Conclusion Waiting 11 weeks after RCT did not increase the rate of pCR after surgical resection. A longer waiting period may be associated with higher morbidity and more difficult surgical resection.
Surgery is a key feature of IBD management. Up to 70% of patients with Crohn's disease and 35% of patients with ulcerative colitis will require surgery during the course of their disease. This Review ...provides an overview of IBD surgical management, focusing on the potential benefits and drawbacks of laparoscopy compared with open surgery. Emergency and elective indications for both laparoscopic and open surgery are detailed for patients with ulcerative colitis and Crohn's disease. Evidence-based comparative results of these surgical approaches are discussed, along with factors that influence patient outcomes. Upcoming new techniques for IBD surgical management, including single-port surgery, are also presented.
To identify predictive factors for irreversible transmural intestinal necrosis (ITIN) in acute mesenteric ischemia (AMI) and establish a risk score for ITIN.
This single-center prospective cohort ...study was performed between 2009 and 2015 in patients with AMI. The primary outcome was the occurrence of ITIN, confirmed by specimen analysis in patients who underwent surgery. Patients who recovered from AMI with no need for intestinal resection were considered not to have ITIN. Clinical, biological and radiological data were compared in a Cox regression model.
A total of 67 patients were included. The origin of AMI was arterial, venous, or non-occlusive in 61%, 37%, 2% of cases, respectively. Intestinal resection and ITIN concerned 42% and 34% of patients, respectively. Factors associated with ITIN in multivariate analysis were: organ failure (hazard ratio (HR): 3.1 (95% confidence interval (CI): 1.1-8.5); P=0.03), serum lactate levels >2 mmol/l (HR: 4.1 (95% CI: 1.4-11.5); P=0.01), and bowel loop dilation on computerized tomography scan (HR: 2.6 (95% CI: 1.2-5.7); P=0.02). ITIN rate increased from 3% to 38%, 89%, and 100% in patients with 0, 1, 2, and 3 factors, respectively. Area under the receiver operating characteristics curve for the diagnosis of ITIN was 0.936 (95% CI: 0.866-0.997) depending on the number of predictive factors.
We identified three predictive factors for irreversible intestinal ischemic injury requiring resection in the setting of AMI. Close monitoring of these factors could help avoid unnecessary laparotomy, prevent resection, as well as complications due to unresected necrosis, and possibly lower the overall mortality.
We sought to determine the frequency of and risk factors for early (30-day) postoperative complications after ileocecal resection in a well-characterized, prospective cohort of Crohn's disease ...patients.
The REMIND group performed a nationwide study in 9 French university medical centers. Clinical-, biological-, surgical-, and treatment-related data on the 3 months before surgery were collected prospectively. Patients operated on between 1 September 2010 and 30 August 2014 were included.
A total of 209 patients were included. The indication for ileocecal resection was stricturing disease in 109 (52%) cases, penetrating complications in 88 (42%), and medication-refractory inflammatory disease in 12 (6%). A two-stage procedure was performed in 33 (16%) patients. There were no postoperative deaths. Forty-three (21%) patients (23% of the patients with a one-stage procedure vs. 9% of those with a two-stage procedure, P=0.28) experienced a total of 54 early postoperative complications after a median time interval of 5 days (interquartile range, 4-12): intra-abdominal septic complications (n=38), extra-intestinal infections (n=10), and hemorrhage (n=6). Eighteen complications (33%) were severe (Dindo-Clavien III-IV). Reoperation was necessary in 14 (7%) patients, and secondary stomy was performed in 8 (4.5%). In a multivariate analysis, corticosteroid treatment in the 4 weeks before surgery was significantly associated with an elevated postoperative complication rate (odds ratio (95% confidence interval)=2.69 (1.15-6.29); P=0.022). Neither preoperative exposure to anti-tumor necrosis factor (TNF) agents (n=93, 44%) nor trough serum anti-TNF levels were significant risk factors for postoperative complications.
In this large, nationwide, prospective cohort, postoperative complications were observed after 21% of the ileocecal resections. Corticosteroid treatment in the 4 weeks before surgery was significantly associated with an elevated postoperative complication rate. In contrast, preoperative anti-TNF therapy (regardless of the serum level or the time interval between last administration and surgery) was not associated with an elevated risk of postoperative complications.
To investigate the factors associated with a delayed diagnosis (DD) of acute mesenteric ischemia (AMI).
An observational cohort study from an intestinal failure center. The primary outcome was DD >24 ...hours.
Between 2006 and 2015, 74 patients with AMI were included and 39 (53%) had a DD. Plasma lactate <2 mmol/L (odd ratio: 3.2; 95% confidence interval: 1.1-9.1; P = 0.03) and unenhanced computed tomography scan (odds ratio: 5.9; 95% confidence interval: 1.4-25.8; P = 0.01) were independently associated with DD.
Suspicion of AMI should no longer be affected by normal plasma lactate levels and should prompt evaluation by a contrast-enhanced computed tomography-scan.
Purpose
Colorectal redo surgery is well known to be a difficult procedure, associated with a high risk of failure. The aim of this study was to look into patients presenting two consecutive failed ...colorectal (CRA) or coloanal (CAA) anastomosis who underwent a second redo surgery (i.e., third anastomosis).
Methods
A retrospective study based on a prospective database of second redo surgeries of CRA or CAA, in an expert center. Sixteen patients between 2005 and 2020 were analyzed.
Results
After a mean follow-up of 28 ± 26 months, success of surgery (defined as no stoma at the end of follow-up) was reported in 10/16 patients (63%). One patient with chronic anastomotic leakage and another with early colonic ischemia had no defunctioning stoma reversal. In the remaining four patients with a failed second redo surgery, a definitive stoma was ultimately created for fistula recurrence (
n
= 1), poor functional results (
n
= 2), or local cancer recurrence (
n
= 1). Two risk factors for failure of this second redo surgery were significantly found in a univariate analysis: (1) nature of the primary anastomosis: 3/13 s redo surgeries failed (23%) if a CRA was first made and 3/3 (100%) if it was a CAA (
p
= 0.036); (2) age: patients with a failed second redo surgery were older (
p
= 0.04).
Conclusion
A 63% rate of success of second redo surgery was observed after two failed CRA or CAA. Although a demanding procedure, it can be proposed to carefully selected and motivated patients.
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