Aim Published outcomes following ligation of the intersphincteric fistula tract (LIFT) for high transsphincteric fistulas (HTFs) are equivocal probably because most trials are small and comprise mixed patient populations. The aim of this study was to highlight the long-term efficacy of LIFT for HTFs in a large homogeneous sample and to determine the risk factors that contribute to non-healing resulting in failure and recurrence. Method A retrospective study was performed which assessed patients with HTFs treated by LIFT without prior loose setons from September 2012 to December 2017. Continence function was evaluated by the Wexner incontinence scale and anal manometry. Quality of life was assessed by using the faecal incontinence quality of life (FIQL) scale with four domains: lifestyle, coping, depression and embarrassment. Results Seventy patients with HTFs underwent 71 LIFT procedures. The primary healing rate was 81.7% with a median follow-up duration of 16.5 (range 4.5-68) months. The healing rates of mature and immature fistulas were 83.7% and 77.3%, respectively. Two patients suffered failure with an unhealed intersphincteric wound. Recurrence occurred in 11 patients. Incontinence of flatus, present in four patients before surgery, improved postoperatively. Two patients undergoing LIFT combined with fistulotomy complained of flatus incontinence after surgery. No significant differences between preoperative and postoperative Wexner score, maximum resting pressure and maximum squeeze pressure were detected. The FIQL was improved in lifestyle, coping and depression. No risk factor for non-healing was found. Conclusion LIFT has a promising long-term outcome for HTFs, with negligible impairment on continence and improved quality of life.
Aim Total mesorectal excision (TME) for rectal cancer can be achieved by employing open (OpTME), laparoscopic (LaTME) and robotic (RoTME) approaches but which of these has the best outcome? The aim of present study is to identify the most effective technique for rectal cancer by comparing all outcomes. Methods Randomized controlled trials (RCTs) which compared at least two TME strategies were identified by literature search of electronic databases of articles published to June 2018. Network meta-analysis with trial sequential analysis was performed using a frequentist approach with random-effects meta-analysis. We conducted a systematic search of PubMed, EmBase, the Cochrane Library, CNKI, and Web of Science. Titles and abstracts of the retrieved publications were independently and blindly assessed by two authors. Data collection and analysisResults Twenty-two RCTs with 4882 rectal cancer patients were included in this analysis. The trial sequential analysis demonstrated that the cumulative Z-curve crossed either the traditional boundary or the trial sequential monitoring boundaries, suggesting that OpTME resulted in a more complete TME specimen than LaTME (relative risk 1.05, 95% confidence interval 1.01-1.08). Network meta-analysis showed there was no significant difference in the other comparisons. Based on the P score of completeness of the TME specimen and circumferential resection margin positivity, the best technique was OpTME, followed by RoTME and then LaTME. However, this order was reversed when complications and mortality were considered. RoTME led to better lymph node harvest. Conclusions Although OpTME may give better pathological specimens, minimally invasive techniques may have advantages when considering lymph node harvest, complications and mortality. More RCTs are needed to determine which technique actually gives the best chance of survival.
Aim Perineal wound complications after abdominoperineal resection (APR) have become a major clinical challenge. Myocutaneous flap closure has been proposed in place of primary closure to improve wound healing. We conducted this comprehensive meta-analysis to evaluate the current scientific evidence of primary closure vs myocutaneous flap closure of perineal defects following APR for colorectal disease. Methods We systematically searched the MEDLINE, Embase, PubMed, Web of Science and Cochrane Library databases to identify all relevant studies. After data extraction from the included studies, meta-analysis was performed to compare perioperative outcomes of primary closure and myocutaneous flap closure. Results Eighteen studies with a total of 17 913 patients (16 346 primary closure vs 1567 myocutaneous flap closure) were included. We found that primary closure was significantly associated with higher total perineal wound complications (P = 0.007), major perineal wound complications (P < 0.001) and perineal wound infection (P = 0.001). On the other hand, myocutaneous flap closure takes more operation time (P < 0.001) and increases the risk of perineal wound dehiscence (P = 0.01), deep surgical site infection (P < 0.001), enterocutaneous fistulas (P = 0.03) and return to the operating room (P = 0.0005). There were no significant differences between the two groups for other outcomes. Conclusions This is the first systematic review with meta-analysis comparing primary closure with myocutaneous flap closure of perineal defects after APR for colorectal disease. Although taking more operation time and an increased risk of specific complications, the pooled results have validated the use of myocutaneous flaps for reducing total/major perineal wound complications. More investigations are needed to draw definitive conclusions on this dilemma.
Aim The aim was to examine the effect of activated carbon nanoparticles (ACNs) on lymph node retrieval in colorectal cancer (CRC) patients. Methods This prospective randomized study of 80 subjects was performed between March 2016 and December 2016. Eighty patients with CRC were randomly divided into two groups, the ACN group and a control group. The patients in the ACN group were subjected to 1 ml of ACN injection in the subserosa around the tumour before colectomy and D3 lymphadenectomy. The patients in the control group received the same procedure without the injection of ACNs. After surgery, lymph nodes were isolated, and the greatest dimensions were measured by the same pathologist. Results The average number of lymph nodes harvested from each patient was markedly more in the ACN group (31.3 +/- 8.1) than in the control group (21.9 +/- 5.3; P < 0.001), and the average number of lymph nodes less than 5 mm in greatest dimension was significantly more in the ACN group (11.9 +/- 4.9) than in the control group (4.1 +/- 2.4; P < 0.001). The ACN group (15/40) had a higher rate of Stage III patients compared to the control group (6/39; P = 0.026). Besides, the greatest dimension of 32.8% metastatic lymph nodes was less than 5 mm. Conclusion There is significant upstaging following the use of ACNs, which could find more involved nodes. Therefore, ACNs can be used as a tracer to harvest more lymph nodes in CRC patients, with improvement in the accuracy of pathological staging.
Aim We aimed to evaluate the association between selective COX-2 inhibitors (coxibs) and the risk of colorectal neoplasms and vascular events with and without low-dose aspirin. Method We searched for randomized controlled trials and comparative studies in PubMed, EMBASE and Cochrane Library databases using pertinent key terms. Risk ratios (RRs) were calculated for each study with a fixed- or random-effects model. Results Eight clinical studies with 44 566 subjects were eligible. The use of coxib significantly reduced the overall risk of colorectal neoplasms by 21% (RR = 0.79, 95% CI 0.70-0.89; P = 0.000). The chemopreventive effect of coxibs was beneficial in the first year (RR = 0.74, 95% CI 0.58-0.94; P = 0.013), marginal in the third year (RR = 0.79, 95% CI 0.63-1.01; P = 0.059) and counterproductive in the fifth year (RR = 1.65, 95% CI 1.23-2.21; P = 0.001). Compared with the use of aspirin alone, combined use of coxib and aspirin for 3 years increased the risk of a colorectal neoplasm by 80% in the fifth year (RR = 1.80, 95% CI 1.22-2.66; P = 0.003) but decreased by 79% and 30%, respectively, the risks of cardiovascular thromboembolic events (RR = 1.79, 95% CI 1.33-2.41; P = 0.0001) and renal impairment/hypertension (RR = 1.30, 95% CI 1.09-1.54; P = 0.003) caused by coxib use alone. Conclusion Coxibs may reduce the overall risk of colorectal neoplasms, but the chemopreventive effects are attenuated over time. When participants take low-dose aspirin simultaneously, coxibs may not be useful for chemoprevention of colorectal neoplasm.
AimSarcopenia is a robust prognostic indicator of outcomes after surgery for colorectal cancer (CRC). However, there are no serum markers routinely available for estimating skeletal muscle mass (SMM). The present study aimed to describe a new sarcopenia index (SI), serum creatinine (Scr)xcystatin C-based glomerular filtration rate, and investigate its association with short-term complications after curative resection of CRC. MethodConsecutive patients who underwent curative resection of CRC from December 2011 to January 2017 were retrospectively identified. Skeletal muscle cross-sectional area was analysed on L3 computed tomographic images. Receiver operating characteristic curve analysis showed that the cutoff points of SI for sarcopenia were below 56.1 in men and below 43.7 in women. Patients were classified into low and high SI groups in accordance with these cutoff values. The association between SI and body composition and the impact of preoperative SI on postoperative outcomes were analysed. ResultsAmong 417 patients, SI showed a stronger correlation with skeletal muscle area (SMA) (r=0.537, P<0.001) than with the Scr/cystatin C ratio (r=0.469, P<0.001) and Scr (r=0.447, P<0.001). The low SI group had a lower SMA, lower preoperative haemoglobin, a higher prevalence of sarcopenia and experienced more postoperative complications compared with the high SI group (all P<0.001). Multivariate logistic regression analysis showed that the independent risk factors for overall complications were low preoperative haemoglobin, low SI, sarcopenia and American Society of Anesthesiologists grade 3. ConclusionThis new SI is a simple and useful surrogate marker for estimating SMM, and is associated with outcomes after CRC surgery.
AimThe aim was to compare the effectiveness of the anal fistula plug (AFP) with the rectal advancement flap (RAF) for complex cryptoglandular anal fistulas. MethodsWe conducted a literature search to identify relevant available articles published without language restriction from Embase and PubMed databases and the Cochrane Library. Studies comparing outcomes with the AFP vs RAF for complex cryptoglandular anal fistulas were eligible for inclusion. ResultsA total of 11 articles with 810 patients were included in this meta-analysis. Four RCTs and one observational clinical study provided long-term follow-up. The pooled analysis of all 11 studies indicated that there was no significant difference between the AFP and RAF in terms of healing rate, recurrence rate and incidence of fistula complications. However, the pooled results of studies with long-term follow-up revealed that the RAF group had a significantly higher healing rate (OR 0.32, 95% CI 0.13, 0.78, P=0.01) and lower recurrence rate (OR 4.45, 95% CI 1.45, 13.65, P=0.009) than the AFP group. ConclusionsFor the treatment of complex cryptoglandular anal fistulas, the RAF was superior to the AFP in terms of healing and recurrence rate after pooling of randomized controlled trials with long-term follow-up, even though a comparison based on the pooling of all studies showed no significant difference.
Aim Patients with ulcerative colitis (UC) have an unexplained higher incidence of pouchitis and a greater amount of peripouch fat compared with patients with familial adenomatous polyposis (FAP). The aims of this study were to compare the peripouch fat areas between patients with UC and patients with FAP, and to explore relationship between peripouch fat and pouchitis or chronic antibiotic-refractory pouchitis (CARP). Method Patients with an abdominal CT image from our prospectively maintained Pouch Database were included. Abdominal fat and peripouch fat were measured on CT images at different levels or planes. Comparisons of peripouch fat and CARP were performed before and after propensity score matching. Results A total of 277 patients with UC and 40 patients with FAP were included. Compared with patients with FAP, patients with UC were found to have a higher incidence of pouchitis (58.5% vs 15.0%, P < 0.001) and CARP (24.5% vs 2.5%, P = 0.002) and a higher total peripouch fat area (P = 0.030) and mesenteric peripouch fat area (P = 0.022) at Level-3. Univariate and multivariate analyses showed that diagnosis (UC vs FAP) and peripouch fat areas at Level-3 and Level-5 were independent risk factors for CARP. With propensity score matching, 38 pairs of patients with UC and FAP were matched successfully. After matching, patients with UC were found to have higher total peripouch fat area and higher mesenteric peripouch fat area at Level-3, and a higher incidence of pouchitis (57.9% vs 13.2%, P < 0.001) and CARP (23.7% vs 2.6%, P = 0.007). Conclusion Our study demonstrates that patients with UC have more peripouch fat than those with FAP, which may explain the difference in the frequency of pouchitis and CARP between these groups of patients.
Aim A modified repair technique for traumatic cloaca caused by obstetric anal sphincter injury was evaluated, and its feasibility and functional outcome were investigated. Methods A retrospective review of 23 consecutively enrolled patients diagnosed with traumatic cloaca who underwent the modified repair technique between September 2010 and August 2018 was performed. Demographic, clinical feature, operative and follow-up data were recorded. Results The patients diagnosed with traumatic cloaca who underwent surgical repair after obstetric anal sphincter injury had a median time from obstetric injury of 24 (12-35) years. The median preoperative Wexner faecal incontinence score was 16 (14-17). The postoperative hospital stay was 6 (6-7) days. The median postoperative Wexner faecal incontinence score decreased to 2 (2-3). The anal resting pressure increased from 9.00 (5.25-11.50) mmHg to 56.00 (55.00-65.75) mmHg (P < 0.01) and the anal squeeze pressure increased from 29.00 (22.50-33.20) mmHg to 110.00 (96.20-121.50) mmHg (P < 0.01) at 2 months after the repair. Sixteen patients completed the Faecal Incontinence Quality of Life Scale questionnaire, and there were significant improvements 1 year after surgical repair in lifestyle (3.10 [2.60-3.70] vs 2.60 [1.90-3.00], P < 0.01), coping/behaviour (3.38 [2.57-3.44] vs 2.33 [1.89-3.00], P < 0.01), depression/self-perception (3.11 [2.27-3.44] vs 2.33 [1.89-3.00], P < 0.01) and embarrassment (3.33 [2.75-3.67] vs 2.33 [2.33-3.00], P < 0.01). No patient presented rectovaginal fistula postoperatively within the median follow-up period of 24 (12-48) months. Conclusions The modified repair technique for traumatic cloaca is feasible and achieves good functional outcomes and improved life quality.
Aim Denonvilliers' fascia is thought to be a multilayered fascial structure, based on its embryological development with the neurovascular bundle embedded within it. Recently, this theory had been proven histologically and by confocal microscopy in many published articles. However, the literature does not report on how surgeons can identify these structures. We aimed to determine the optimal surgical approach for preserving these critical structures. Method Eighteen cadavers (13 male/five female) were included and treated according to the ethical considerations stated in the donation consent of our institution. Dissection was performed with the assistance of binocular loupes for better anatomical detail. The compositions of the prerectal fascia and the neurovascular bundle were observed and recorded at different levels of dissection using a high-definition camera. Results The theoretical multilayered fascia was found in male specimens as three fascial layers originating from the perineal body, seminal vesicles and posterior bladder neck. The first layer merged posterolaterally and fused with the rectosacral fascia (Waldeyer's fascia). The neurovascular bundle in male specimens was observed piercing the second and third layers, while the first layer acted as a protective cover. Dissection of female specimens demonstrated only one layer in the prerectal space. Conclusion Intiating anterior rectal mobilization by incising the peritoneum posterior to its reflection seems to be anatomically correct to preserve DVF. However, its applicability may be difficult in a narrow chanllenging pelvis. The lateral rectal ligaments and Waldeyer's fascia should be dissected from their attachments to the proper fascia of the rectum.
Aim Anastomotic leakage (AL) is one of the most feared postoperative complications after anterior resection (AR) of rectal cancer. An adequate blood supply at the anastomotic site is regarded as a prerequisite for healing. We hypothesize that the Aortic Calcification Index (ACI) might reflect the severity of atherosclerosis in patients, and thereby be a risk factor for AL. Method AL was investigated retrospectively according to the definition of the International Study Group of Rectal Cancer in 423 rectal cancer patients who underwent anterior rectal resection. The ACI was measured by preoperative abdominal CT scan. The cross-section of the aorta was evenly divided into 12 sectors, the number of calcified sectors was counted as the calcification score of each slice. Lasso logistic regression and multivariate regression analysis were used to identify risk factors for AL. Results The percentage of AL after AR was 7.8% (33/423); the mortality of patients who sustained a leak was 3.0% (1/33). Patients with a high ACI had a significantly higher percentage of AL than patients with low ACI (11.2% vs 5.6%, P = 0.04). Among patients with AL, a higher ACI was associated with greater severity of AL (the ACI of patients with grade A leakage, grade B leakage and grade C leakage was 0.5% +/- 0.2%, 11.5% +/- 9.2% and 24.2% +/- 21.7%, respectively; P = 0.008). After risk adjustment, multivariate regression analysis showed that a higher ACI was an independent risk factor for AL (OR 2.391, P = 0.04). Conclusion A high ACI might be an important prognostic factor for AL after AR for rectal cancer. Confirmatory studies are required.