BACKGROUND: Identifying patients with Crohn's disease with rapid disease progress or high risk of early surgery is crucial to clinical decision making. OBJECTIVE: The aim was to evaluate the correlation between the Lemann index at diagnosis and abdominal surgery in the first year after Crohn's disease diagnosis and to find the risk factors for early surgery. DESIGN: This was a retrospective cohort study. SETTINGS: The study was conducted at a single tertiary hospital. PATIENTS: Patients diagnosed with Crohn's disease between 2013 and 2015 in our center were included. MAIN OUTCOME MEASURES: The outcome of interest was the need for an abdominal surgery within 1 year after the Lemann index evaluation at diagnosis. RESULTS: Of 212 eligible patients, 48 patients underwent abdominal surgery during follow-up. Lemann index was much higher in the surgery group (5.3 vs 2.6; p < 0.001). On tertiles of the Lemann index, the frequency of surgery grew (2.8%, 9.9%, and 55.7%; p < 0.001) as the Lemann index increased. The receiver operating characteristic curve was constructed taking into account the Lemann index for selecting patients with a high risk of surgery. Specificity, sensitivity, and area under receiver operating characteristic curve were 84.8%, 81.3%, and 0.89 of the Lemann Index at a cutoff level of 3.7. Patients with Lemann index >= 3.7 carried a higher risk of abdominal surgery (OR = 18.6; p < 0.001). Stricturing and penetrating disease were predictors for abdominal surgery, whereas antitumor necrosis factor treatment was associated with a significant reduction of surgical requirements. LIMITATIONS: This study was limited by its retrospective design. The ability of the Lemann index to predict the long-term risk of surgery was unknown. CONCLUSIONS: Lemann index at diagnosis is a reliable index to predict the risk of abdominal surgery in the first year after diagnosis of Crohn's disease. Patients with a high Lemann index might need closer follow-up or aggressive medical therapy.
BACKGROUND: Visceral fat is the pathogenesis of Crohn's disease and is associated with disease status. OBJECTIVE: This study aimed to evaluate the effect of the visceral fat on mucosal healing in patients with Crohn's disease after infliximab induction therapy DESIGN: This was a retrospective study. SETTINGS: The study was conducted in a tertiary referral hospital. PATIENTS: Between 2011 and 2017, 97 patients with Crohn's disease with the presence of ulcers underwent infliximab therapy. MAIN OUTCOME MEASURES: We studied them retrospectively. Mucosal healing was the end point. Patients composed 2 groups: mucosal healing and no mucosal healing. Univariate, multivariate, and receiver operating characteristic curve analyses determined the predictive value of the visceral fat area. RESULTS: Univariate analysis showed a statistically significant difference in the smoking history between the groups. Mucosal healing rates after infliximab were lower among active smokers (p = 0.022). Healed patients had significantly less visceral fat area before therapy (47.76 +/- 4.94 vs 75.88 +/- 5.55; p = 0.000) and a lower mesenteric fat index (0.52 +/- 0.04 vs 0.89 +/- 0.07; p = 0.000). There was no significant difference in the subcutaneous fat area (87.39 +/- 5.01 vs 93.31 +/- 6.95; p = 0.500). Multivariate analysis showed that only visceral fat area (OR = 0.978 (95% CI, 0.964-0.992); p = 0.002) and smoking history (OR = 0.305 (95% CI, 0.089-0.996); p = 0.041) were independent factors for mucosal healing. Receiver operating characteristic curve analysis showed predictive cutoff values of 61.5 cm(2) and 0.62 for visceral fat area and mesenteric fat index. LIMITATIONS: This was a retrospective study. CONCLUSIONS: There was an association between increased visceral fat area and attenuated mucosal healing after infliximab therapy in biologically naive patients with Crohn's disease, indicating a need for earlier increased infliximab doses among patients with increased visceral fat. See Video Abstract at http://links.lww.com/DCR/A590.
BACKGROUND: Patients with locally advanced rectal cancer could be managed by a watch-and-wait approach if they achieve clinical complete response after preoperative chemoradiotherapy. Mucosal integrity, endorectal ultrasound, and rectal MRI are used to evaluate clinical complete response; however, the accuracy remains questionable. Clinical practice based on those assessment methods needs more data and discussion. OBJECTIVE: The aim of this prospective study was to evaluate the accuracy of mucosal integrity, endorectal ultrasound, and rectal MRI to predict clinical complete response after chemoradiotherapy. DESIGN: Endorectal ultrasound and rectal MRI were undertaken 6 to 7 weeks after preoperative chemoradiation therapy. Patients then received radical surgery based on the principles of total mesorectal excision. Preoperative tumor staging achieved by endorectal ultrasound and rectal MRI was compared with postoperative staging by pathologic examination. Sensitivity, specificity, and accuracy of each evaluation method were calculated. SETTINGS: The study was conducted at a single tertiary care center. PATIENTS: Patients diagnosed with mid-low rectal cancer by biopsy between May 2014 and December 2016 were enrolled in this study. RESULTS: A total of 124 patients were enrolled in this study, and postoperative pathology revealed that 20 patients (16.13%) achieved complete response (ypT(0)N(0)). The sensitivity of mucosal integrity, endorectal ultrasound, and MRI to predict clinical complete response was 25%. The specificity of mucosal integrity, endorectal ultrasound, and MRI was 94.23%, 93.90%, and 93.27%. The combination of each 2 or all 3 methods did not improve accuracy. Regression analysis showed that none of these methods could predict postoperative ypT(0). LIMITATIONS: The sample size is small, and we did not focus on the follow-up data and cannot compare prognosis data with previous research studies. CONCLUSIONS: Both single-method and combined mucosal integrity, endorectal ultrasound, and rectal MRI have poor correlation with postoperative pathologic examination. A watch-and-wait approach based on these methods might not be a proper strategy compared with radical surgery after neoadjuvant therapy. See Video Abstract at http://links.lww.com/DCR/A693.
BACKGROUND: Anastomotic leak is a life-threatening complication of colorectal surgery. Recent studies showed that indocyanine green fluorescence angiography might be a method to prevent anastomotic leak. OBJECTIVE: The purpose of this study was to investigate whether intraoperative indocyanine green fluorescence angiography can reduce the incidence of anastomotic leak. DATA SOURCES: Potential relevant studies were identified from the following databases: PubMed, Embase, Web of Science, Cochrane Library, and China National Knowledge Infrastructure. STUDY SELECTION: This meta-analysis included comparative studies investigating the association between indocyanine green fluorescence angiography and anastomotic leak in patients undergoing surgery for colorectal cancer where the diagnosis of anastomotic leak was confirmed by CT and the outcomes of the indocyanine green group were compared with a control group. INTERVENTION: Indocyanine green was injected intravenously after the division of the mesentery and colon but before anastomosis. MAIN OUTCOME MEASURES: The Newcastle-Ottawa Scale was used to assess methodologic quality of the studies. ORs and 95% CIs were used to assess the association between indocyanine green and anastomotic leak. RESULTS: In 4 studies with a total sample size of 1177, comparing the number of anastomotic leaks in the indocyanine green and control groups, the ORs were 0.45 (95% CI, 0.18-1.12), 0.30 (95% CI, 0.03-2.98), 0.17 (95% CI, 0.01-3.69), and 0.12 (95% CI, 0.03-0.52). The combined OR was 0.27 (95% CI, 0.13-0.53). The difference was statistically significant (p < 0.001), and there was no significant heterogeneity (p = 0.48; I-2 = 0). LIMITATIONS: Data could not be pooled because of the small number of studies; some differences between studies may influence the results. Also, the pooled data were not randomized. CONCLUSIONS: The result revealed that indocyanine green was associated with a lower anastomotic leakage rate after colorectal resection. However, larger, multicentered, high-quality randomized controlled trials are needed to confirm the benefit of indocyanine green fluorescence angiography.
BACKGROUND: Recent studies have suggested that electrolyte disorders might be a negative prognostic factor for some diseases. OBJECTIVE: The purpose of this study was to systematically evaluate the prognostic role of electrolyte disorders in patients with stage I to III colorectal cancer who received radical surgical resection. DESIGN: This study was retrospectively performed. SETTINGS: The study was conducted at a single tertiary care center. PATIENTS: Patients with colorectal cancer who underwent radical resection in between April 2007 and April 2014 were included. MAIN OUTCOME MEASURES: The Kaplan-Meier method was adopted to estimate the overall and disease-free survival with and without propensity score matching. RESULTS: In total, our study recruited 5089 eligible patients. In prematching analysis, patients with hypochloremia showed both shorter overall survival (HR = 0.943 (95% CI, 0.908-0.980); p = 0.003) and disease-free survival (HR = 0.957 (95% CI, 0.933-0.981); p < 0.001) than those with normal serum chloride levels. In postmatching analysis, 770 patients from each group were compared, and the results further confirmed that hypochloremia was significantly associated with worse overall survival (HR = 0.646 (95% CI, 0.489-0.855); p = 0.002) and disease-free survival (HR = 0.782 (95% CI, 0.647-0.944); p = 0.01), with the hypochloremia group as a reference. LIMITATIONS: The study was limited by its retrospective nature. CONCLUSIONS: Hypochloremia diagnosed before treatment can independently prognosticate the overall and disease-free survival for patients with stage I to ? colorectal cancer after radical resection. Intensive surveillance and management might improve the survival outcome for patients with hypochloremia. See Video Abstract at http://links.lww.com/DCR/A727.
BACKGROUND: There is little information about the prognostic value of a microscopically positive distal margin in patients who have rectal cancer. OBJECTIVE: We aimed to investigate the influence of a distal margin of <= 1 mm on oncologic outcomes after sphincter-preserving resection for rectal cancer. DESIGN: This is a retrospective cohort study. SETTINGS: The study was conducted at 2 hospitals. PATIENTS: A total of 6574 patients underwent anterior resection for rectal cancer from January 1999 to December 2014; 97 (1.5%) patients with a distal margin of <= 1 mm were included in this study. For comparative analyses, patients were matched with 194 patients with a negative distal margin (>1 mm) according to sex, age, BMI, ASA score, neoadjuvant treatment, tumor location, and stage. MAIN OUTCOME MEASURES: The oncologic outcomes of the 2 groups were compared. RESULTS: Perineural and lymphovascular invasion rates were significantly higher in patients with a positive distal margin (54.6% vs 28.9%; 67.0% vs 42.8%; both p < 0.001) compared with to patients with negative distal margin. Comparison between microscopically positive and negative distal margin showed worse oncologic outcomes in patients with a microscopically positive distal margin, including 5-year local recurrence rate (24.1% vs 12.0%, p = 0.005); 5-year distant recurrence rate (35.5% vs 20.2%, p = 0.011); 5-year disease-free survival (45.5% vs 69.5%, p < 0.001); and 5-year OS (69.2% vs 79.7%, p = 0.004). Among the 97 patients with a microscopically positive distal margin, the 5-year disease-free survival rate was higher in patients who received adjuvant therapy (52.0% vs 30.7%, p = 0.089). LIMITATIONS: This is a retrospective study; bias may exist. CONCLUSIONS: A distal margin of 1 mm is associated with worse oncologic results. Our data indicate the importance of achieving a clear distal margin in the surgical treatment of rectal cancer. Adjuvant therapy should be used in these patients to reduce recurrence.
BACKGROUND: Double and triple stapling techniques to close the rectal stump in laparoscopic anterior resection are fraught with technical drawbacks that could possibly be avoided with the use of the single stapling technique. However, little is known of its safety in laparoscopic surgery or outcomes when combined with natural orifice specimen extraction. OBJECTIVE: This study aims to analyze the feasibility and the operative and immediate postoperative outcomes of single-stapled anastomosis and natural orifice specimen extraction with conventional techniques. It intends to evaluate technical variations related to colon, mesentery, and pelvic anatomy characteristics. DESIGN AND PATIENTS: A consecutive series of 188 patients underwent elective surgery for benign or malignant lesions between 10 and 40 cm from the anal verge, 5 cm or less in diameter on radiological examination, stage T1 to T3, Nx, M0, with 2 different methods of rectal stump closure (pursestring vs linear-stapled closure) associated with single or double stapling and per anus vs conventional specimen extraction. SETTING: This study was conducted at China Medical University Hospital, Taiwan, a tertiary referral center, between January 2012 and April 2015. MAIN OUTCOME MEASURES: The main outcomes measured are feasibility and operative and immediate postoperative outcomes. RESULTS: Single-stapled resection with natural orifice specimen extraction was feasible in 94% patients with an 11% perioperative morbidity rate. The patients required statistically significantly less analgesia, had earlier return of bowel movements, and shorter hospital stay, whereas there was no statistically significant difference in the overall readmission rate and overall morbidity, including anastomotic leakage. LIMITATIONS: This was a single-center, retrospective case-matched study. CONCLUSION: Anatomic variations (short colon and short mesentery) can be managed adequately with intracorporeal anvil head fixation. The single stapling technique is feasible and as safe as conventional double stapling techniques, although it is technically more demanding. The transanal endoscopic operation platform can be useful when the rectal stump is long.
BACKGROUND: A simple and accurate predictor of postoperative complications is needed for early and safe discharge after surgery. A decrease in serum albumin is commonly observed early after surgery, even in patients with normal preoperative levels. However, whether it predicts patient postoperative outcome is unknown. OBJECTIVE: The purpose of this study was to evaluate whether the reduction in serum albumin within 2 postoperative days compared with the preoperative level could serve as an independent predictor of postoperative complications after colorectal surgery. DESIGN: This was a retrospective study from a single institution. SETTINGS: The study was conducted in a tertiary referral hospital. PATIENTS: A total of 626 patients undergoing major colorectal surgery between December 2012 and January 2016 were eligible for this study. MAIN OUTCOME MEASURES: Univariate and multivariate analyses were performed to identify risk factors for postoperative complications and to identify the factors associated with Delta albumin. Receiver operating characteristic curves were developed to examine the cutoff value of the change in albumin in predicting postoperative complications. RESULTS: Among all of the patients, the median Delta albumin after surgery was 15% Delta albumin was an independent risk factor for overall complications ( p < 0.01). The cutoff value was 15%, and an increased area under the curve compared with C-reactive protein occurred on postoperative day 3 or 4. Patients with Delta albumin >= 15% experienced more postoperative major complications, a higher comprehensive complication index, a longer postoperative stay, and increased surgical site infections ( p < 0.05) than those < 15% Delta albumin correlated with sex, type of surgery, stoma creation, C-reactive protein on postoperative day 3 or 4, and intraoperative blood transfusion. Postoperative C-reactive protein remained independently associated with.albumin ( p < 0.01). LIMITATIONS: The study was limited by its retrospective nature. CONCLUSIONS: A cutoff value of a 15% reduction in serum albumin within 2 postoperative days could help to identify patients with a high probability of postoperative complications and permit safe and early discharge after colorectal surgery.
Complete mesenteric excision (CME) is a novel concept for right colon cancer surgery. It derives from an embryological concept that the enveloped planes of viscera and fascia cover the lymphatic drainage and the mesentery. Research1-5 has shown that CME is a feasible and safe procedure and can reduce the rate of local recurrence and improve long-term survival in open surgeries. Recently, a consensus statement6 has stated that CME is as equally well suited for an open right colectomy as a laparoscopic right colectomy. However, laparoscopic right radical colectomy with CME is technically challenging because the procedure involves many organs and complex anatomical structures. 7 Therefore, it is necessary to develop an approach to reduce the procedural complexity and difficulty for advanced right colon cancer. Based on our more than 2000 previous laparoscopic surgeries for colon cancer and our understanding of surgical oncol-ogy and the anatomical structures of the right mesocolon, we present a caudal-to-cranial approach for laparoscopic right colectomy with CME.
BACKGROUND: There has been a long-lasting controversy about whether higher BMI is associated with worse perioperative outcomes of laparoscopic colorectal surgery. Recently, a number of newly published investigations have made it possible to draw a quantitative conclusion. OBJECTIVE: We conducted this comprehensive metaanalysis to clarify the exact effect that BMI imposes on perioperative outcome of laparoscopic colorectal surgery. DATA SOURCES: We systematically searched MEDLINE, Embase, and Cochrane Library databases to identify all relevant studies. STUDY SELECTION: Comparative studies in English that investigated perioperative outcome of laparoscopic colorectal surgery for patients with different BMIs were included. Quality of studies was evaluated by using the Newcastle-Ottawa Scale. INTERVENTION: The risk factor of interest was BMI. MAIN OUTCOME MEASURES: Effective sizes were pooled under a random-effects model to evaluate preoperative, intraoperative, and postoperative outcomes. RESULTS: A total of 43 studies were included. We found that higher BMI was associated with significantly longer operative time (p < 0.001), greater blood loss (p = 0.01), and higher incidence of conversion to open surgery (p < 0.001). Moreover, BMI was a risk factor for overall complication rates (p < 0.001), especially for ileus (p = 0.02) and events of the urinary system (p = 0.03). Significant association was identified between higher BMI and risk of surgical site infection (p < 0.001) and anastomotic leakage (p = 0.02). Higher BMI might also led to a reduced number of harvest lymph nodes for patients with colorectal cancer (p = 0.02). The heterogeneity test identified no significant cross-study heterogeneity, and the results of cumulative metaanalysis, sensitivity analysis, and the publication bias test verified the reliability of our study. LIMITATIONS: Most studies included were retrospectively designed. CONCLUSIONS: Body mass index is a practical and valuable measurement for the prediction of the perioperative outcome of laparoscopic colorectal surgery. Higher BMI is associated with worse perioperative outcome. More accurate conclusions, with more precise cutoff values, can be achieved by future well-designed prospective investigations.
BACKGROUND: Some patients receiving defunctioning stomas will never undergo stoma reversal, but it is difficult to preoperatively predict which patients will be affected. OBJECTIVE: The aim of this meta-analysis was to identify the risk factors associated with nonclosure of temporary stomas after sphincter-preserving low anterior resection for rectal cancer. DATA SOURCES: We performed a comprehensive search of the PubMed, Embase, and Cochrane Central Library databases for all of the studies analyzing risk factors for nonclosure of defunctioning stomas. STUDY SELECTION: We only included articles published in English in this meta-analysis. The inclusion criteria were as follows: 1) original article with extractable data, 2) studies including only defunctioning stomas created after low anterior resection for rectal cancer, 3) studies with nonclosure rather than delayed closure as the main end point, and 4) studies analyzing risk factors for nonclosure. INTERVENTION: Defunctioning stomas were created after low anterior resection for rectal cancer. MAIN OUTCOME MEASURES: Stoma nonclosure was the only end point, and it included nonclosure and permanent stoma creation after primary stoma closure. The Newcastle-Ottawa Scale was used to assess methodologic quality of the studies, and risk ratios and 95% CIs were used to assess risk factors. RESULTS: Ten studies with 8568 patients were included. The nonclosure rate was 19% (95% CI, 13%-24%; p < 0.001; I-2=96.2%). Three demographic factors were significantly associated with nonclosure: older age (risk ratio= 1.50 (95% CI, 1.12-2.02); p = 0.007; I-2= 39.3%), ASA score >2 (risk ratio = 1.66 (95% CI, 1.51-1.83); p < 0.001; I-2= 0%), and comorbidities (risk ratio = 1.58 (95% CI, 1.29-1.95); p < 0.001; I-2= 52.6%). Surgical complications (risk ratio = 1.89 (95% CI, 1.48-2.41); p < 0.001; I-2= 29.7%), postoperative anastomotic leakage (risk ratio = 3.39 (95% CI, 2.41-4.75); p < 0.001; I-2= 53.0%), stage IV tumor (risk ratio = 2.96 (95% CI, 1.73-5.09); p < 0.001; I-2= 88.1%), and local recurrence (risk ratio = 2.84 (95% CI, 2.11-3.83); p < 0.001; I-2= 6.8%) were strong clinical risk factors for nonclosure. Open surgery (risk ratio = 1.47 (95% CI, 1.01-2.15); p = 0.044; I-2= 63.6%) showed a borderline significant association with nonclosure. LIMITATIONS: Data on some risk factors could not be pooled because of the low number of studies. There was conspicuous heterogeneity between the included studies, so the pooled data were not absolutely free of exaggeration or influence. CONCLUSIONS: Older age, ASA score >2, comorbidities, open surgery, surgical complications, anastomotic leakage, stage IV tumor, and local recurrence are risk factors for nonclosure of defunctioning stomas after low anterior resection in patients with rectal cancer, whereas tumor height, radiotherapy, and chemotherapy are not. Patients with these risk factors should be informed preoperatively of the possibility of nonreversal, and joint decision-making is preferred.
BACKGROUND: Neoadjuvant therapy plays a vital role in the treatment of locally advanced rectal cancer but impairs bowel function after restorative surgery. Optimal decision making requires adequate information of functional outcomes. OBJECTIVE: This study aimed to assess postoperative bowel function and to identify predictors for severe dysfunction. DESIGN: The study included a cross-sectional cohort and retrospective assessments of pelvic anatomic features. SETTINGS: The study was conducted at a tertiary GI hospital in China. PATIENTS: Included patients underwent neoadjuvant chemoradiotherapy or chemotherapy without radiation and curative low anterior resection for rectal cancer between 2012 and 2014. MAIN OUTCOME MEASURES: Bowel function was assessed using the validated low anterior resection syndrome score. The thicknesses of the rectal wall, obturator internus, and levator ani were measured by preoperative MRI. RESULTS: A total of 151 eligible patients were identified, and 142 patients (94.0%) participated after a median of 19 months from surgery. Bowel dysfunction was observed in 71.1% (101/142) of patients, with 44.4% (63/142) reporting severe dysfunction. Symptoms of urgency and clustering were found to be major disturbances. Regression analysis identified preoperative long-course radiotherapy (p < 0.001) and a lower-third tumor (p = 0.002) independently associated with severe bowel dysfunction. Irradiated patients with a lower-third tumor (OR = 14.06; p < 0.001) or thickening of the rectal wall (OR = 11.09; p < 0.001) had a markedly increased risk of developing severe dysfunction. LIMITATIONS: The study was based on a limited cohort of patients and moderate follow-up after the primary surgery. CONCLUSIONS: Bowel function deteriorates frequently after low anterior resection for rectal cancer. Severe bowel dysfunction is significantly associated with preoperative long-course radiotherapy and a lower-third tumor, and the thickening of rectal wall after radiation is a strong predictor. Treatment decisions and patient consent should be implemented with raising awareness of bowel symptom burdens. See Video Abstract at http://links.lww.com/DCR/A317.
BACKGROUND: Although endoscopic submucosal tunnel dissection has been used for the resection of esophageal and stomach neoplastic lesions, there are still no reports about large superficial rectal neoplastic lesions. Compared with esophageal and stomach endoscopic submucosal dissection, the dissection of large superficial rectal neoplastic lesions is more difficult because of the flimsy bowel wall with abundant vasculature in the submucosal region, which results in poor endoscopic maneuverability and serious complications, such as bleeding and perforation. OBJECTIVE: The study aimed to assess the efficacy and safety of endoscopic submucosal tunnel dissection for large superficial rectal neoplastic lesions over 5 to 24 months in selected patients. DESIGN: This was a prospective, single-center evaluation. SETTINGS: The study was conducted at a digestive endoscopic center. PATIENTS: Patients with large superficial rectal neoplastic lesions were included. INTERVENTIONS: Endoscopic submucosal tunnel dissection was performed in all of the patients with large, superficial rectal neoplastic lesions. The submucosal tunnel was created via a submucosal incision from the anal incision to the oral incision. Next, tunnel wall resection was performed to completely remove the lesion. MAIN OUTCOME MEASURES: Dissection speed, complications, and recurrence rate were measured. RESULTS: A total of 19 patients, including 13 men and 6 women, with an average age of 60.1 +/- 12.2 years (range, 34.0-75.0 y) underwent endoscopic submucosal tunnel dissection. The average size of lesions was 17.54 +/- 13.47 cm(2). The mean operative time was 84.84 +/- 53.49 minutes, and the operating speed was 21.01 +/- 9.00 mm(2)/min. En bloc resections with negative basal margins were achieved in all cases without serious intraoperative complications. No recurrence was observed in any patient within 5 to 24 months after the operations. LIMITATIONS: This was a single-center study. CONCLUSIONS: Endoscopic submucosal tunnel dissection is feasible, safe, and effective for the treatment of large, superficial rectal neoplastic lesions in selected patients.