Editor's Choice
February 2024Incidence of adhesive small bowel obstruction after surgery for colorectal cancer in Sweden 2007–2016
Thorbjörn Sakari, Filip Sköldberg, Caroline E. Dietrich, Caroline Nordenvall, Urban Karlbom
January 2024
Mesh mediated fascial traction in the management of the open abdomen: A video vignette
Elena Schembari, Carl Richardson, Andrew T. King, David M. Layfield
The open abdomen (OA) can be life-saving in patients with severe injuries or surgical conditions which cause physiological instability (failure to control intrabdominal sepsis, vascular emergencies and severe pancreatitis). Different techniques have been described to manage an OA, the chief aims of which are to reduce risk of enteroatmospheric fistula formation whilst achieving fascial continuity and avoiding ventral herniation. Here, we present a video detailing the application of mesh mediated fascial traction in combination with a negative pressure wound management system.
December 2023
The Association of Coloproctology of Great Britain and Ireland guideline on the management of anal fissure
Katie L. R. Cross, Steven R. Brown, Jos Kleijnen, James Bunce, Melanie Paul, Sophie Pilkington, Oliver Warren, Oliver Jones, Jon Lund, Henry J. Goss, Michael Stanton, Tatenda Marunda, Artaza Gilani, L. Wee Sing Ngu, Philip Tozer
'The management of anal fissure: ACPGBI position statement' was written 15 years ago. [KLR Cross et al., Colorectal Dis, 2008]. Our aim was to update the guideline and provide recommendations on the most effective treatment for patients with anal fissures utilising a multidisciplinary, rigorous guideline methodology.
November 2023
Understanding patients' perspectives when unprepared for the emergence of a parastomal bulge—a qualitative study
Marianne Krogsgaard, Pia Dreyer, Thordis Thomsen
The aim was to investigate patients' experiences of being prepared for the development of a parastomal bulge in relation to a stoma.
October 2023
A survey of treatment preferences of UK surgeons in the treatment of pilonidal sinus disease
Matthew J. Lee, Emily B. Strong, Jon Lund, Dan Hind, Steven R. Brown, the PITSTOP Management Group
Pilonidal sinus is a common surgical condition which impacts a young and economically active population. There are limited data to guide treatment in this condition. The aim of this work was to assess current practice.
September 2023
Poor outcomes in patients with sepsis undergoing emergency laparotomy and laparoscopy are attenuated by faster time to care measures
Natthaya Eiamampai, Euan A. Ramsay, Roy L. Soiza, David A. McDonald, Susan J. Moug, Phyo K. Myint
Emergency laparotomy and laparoscopy (EmLap) are amongst the commonest surgical procedures, with high prevalence of sepsis and hence poorer outcomes. However, whether time taken to receive care influences outcomes in patients requiring antibiotics for suspected infection remains largely unexplored. The aim of this work was to determine whether (1) time to care contributes to outcome differences between patients with and without suspected infection and (2) its impact on outcomes only amongst those with suspected infection.
August 2023
An analysis of randomized controlled trials on anal fistula conducted between 2000 and 2020 based on the Fragility Index and Reverse Fragility Index
Carlos Placer-Galán, Jose María Enriquez-Navascués, Ane Etxart Lopetegui, Yolanda Saralegui Ansorena
An analysis of Randomized Controlled Trials on Anal Fistula conducted between 2000 and 2020 based of Fragility Index and Reverse Fragility Index. Placer Galan et al.
July 2023
Patient and multidisciplinary team perspectives on watch and wait in rectal cancer
Helen Mohan, Mohammed Rabie, Ciaran Walsh, Deena Harji, Paul Sutton, Ian Geh, Ian Jackson, Emma Helbren, Martyn Evans, John T. Jenkins
This article adopts a multidisciplinary approach, including surgery, oncology, radiology and patient perspectives, to discuss the key points of debate surrounding a watch and wait approach. In an era of shared decision-making, discussion of watch and wait as an option in the context of complete clinical response is appropriate, although it is not the gold standard treatment. Key challenges are the difficulty in assessing for a complete clinical response, prediction of recurrence and access to timely diagnostics for surveillance. Salvage surgery has good results if regrowth is detected early but does have imperfect outcomes, with only a 90% salvage rate. Good communication with patients about the risks and alternatives is essential. Patients undergoing watch and wait should ideally be enrolled in prospective registries or clinical trials.
June 2023
“Happy to close?” The relationship between surgical experience and incisional hernia rates following abdominal wall closure in colorectal surgery
Laurie Smith, Alexandra Coxon-Meggy, Michael Shinkwin, Julie Cornish, Alan Watkins, Greg Fegan, Jared Torkington, HART Trial Collaborators
Incisional hernia (IH) is a common complication of colorectal surgery, affecting up to 30% of patients at 2 years. Given the associated morbidity and high recurrence rates after attempted repair of IH, emphasis should be placed on prevention. There is an association between surgeon volume and outcomes in hernia surgery, yet there is little evidence regarding impact of the seniority of the surgeon performing abdominal wall closure on IH rate. The aim of our study was to assess the rates of IH at 1 year following abdominal wall closure between junior and senior surgeons in patients undergoing elective colorectal surgery.
May 2023
‘He's a surgeon, like I'm not going to waste his time’: interviews to determine healthcare needs of people with low anterior resection syndrome after rectal cancer surgery
Jennie Burch, Jeanee Wright, Claire Taylor, Ana Wilson, Christine Norton
The aim of this study was to determine the views of people on their healthcare needs when managing their bowel symptoms following an anterior resection.
April 2023
The incidence of extraction site incisional hernia after minimally invasive colorectal surgery: a systematic review and meta-analysis
Floris P. J. den Hartog, Sarah van Egmond, Marijn M. Poelman, Anand G. Menon, Gert-Jan Kleinrensink, Johan F. Lange, Pieter J. Tanis, Eva B. Deerenberg
Minimally invasive colorectal surgery reduces surgical trauma with better preservation of abdominal wall integrity, but the extraction site is still at risk of incisional hernia (IH). The aim of this study was to determine pooled incidence of IH for each type of extraction site and to compare rates of IH after midline, nonmidline and Pfannenstiel extraction.
March 2023
United Kingdom criteria for liver transplantation in the setting of isolated unresectable colorectal liver metastases
Jamie Murphy, Raj Prasad, Krishna Menon, the NHS Blood and Transplant Liver Transplantation for Colorectal Liver Metastases Fixed Term Working Unit
Studies have demonstrated that liver transplantation may be an effective treatment for isolated unresectable colorectal cancer liver metastases (CRCLM). Published data suggest that 5-year survival may be as high as 80%; however, recurrent disease is commonplace. Consequently, the Liver Transplantation for Unresectable Colorectal Liver Metastases Fixed Term Working Unit recommended to the NHS Blood and Transplant Liver Advisory Group that while CRCLM is an appropriate indication for transplantation, selection criteria should be conservative and that it should be undertaken within a clinical service evaluation programme. The aim of this work is to outline the proposed UK selection criteria and follow-up process for CRCLM transplantation.
February 2023
Impact of surgeon volume on 18-month unclosed ileostomy rate after restorative rectal cancer resection
Neil Smart
For some time, the impact of defunctioning loop ileostomy has been under scrutiny with rates of adverse health outcomes such as acute kidney injury, high output stomata and readmission rates being sobering to say the least. Longer term sequelae of delayed ileostomy closure such as poorer function from low anterior resection syndrome have also come to the fore. Many surgeons are now more questioning of the balance between risk and benefit of creating a loop ileostomy for patients undergoing low anterior resection and several studies have tried to identify risk factors for delayed closure in order to facilitate a more selective approach to loop ileostomy formation.
In this month's Editor's Choice paper by Tyler et al the authors have sought to investigate such risk factors further in a UK setting. The novelty of the paper lies in its examination of surgical volume and its relationship to outcomes. In a surprise to almost no one high volume surgeons performed better than low volume ones. But why? The cut off between high and low volumes of five cases per year is low by international standards and even their proposal for 10 cases per year doesn't match the volumes seen in many other countries. Surgical skill alone is unlikely to be sufficient to explain all the outcome differences in this study. What the paper doesn't explore is the improvements in decision making that comes with increased operative volume – both pre and intraoperatively.
January 2023
Acute PresentatiOn of coLorectaL cancer - an internatiOnal snapshot (APOLLO): Protocol for a prospective, multicentre cohort study
Eurosurg Collaborative
Before the Covid pandemic it seemed that acute presentation of colorectal cancer to the emergency general surgery service was a relative rarity despite some figures suggesting that it had stubbornly remained at approximately 20% of diagnoses, even with the advent of screening. Those patients that presented often had characteristic features concordant with the “inverse care law” – male, lower socioeconomic status etc. And yet even in those far off halcyon days of the 2010s there was no consensus within my own department, let alone nationally or internationally, on how best to manage the various subgroups (obstructed or not, metastatic disease or not, etc) who presented in this way. So many different factors seemed to come into play – local demographics (age / frailty / socioeconomic status etc), service provision (access to stenting facilities out of hours), tumour characteristics and individual surgeon philosophy (measured as propensity to operate in some studies of emergency laparotomy) – as much as any evidence-based practice. Not that the evidence base was clear about what to do. Randomised trials in the field were notoriously difficult to do, often with slow recruitment or with unexpectedly poor outcomes in the intervention arm. Only recently have we had any sort of clarity on the use of stents, but even then, there will inevitably be uncertainty arising from the health care system changes (that have prioritised emergency laparotomy patients within the NHS) widely adopted since the recruitment period ended and adoption of minimally invasive surgical techniques in emergency settings for colorectal surgery.
December 2022
Subcutaneous incision of the fistula tract and internal sphincterotomy: A novel surgical procedure for transsphincteric anal fistula
Albert M. Wolthuis
In December's edition of Colorectal Disease, Sahara et al. present a novel surgical procedure for the treatment of transsphincteric anal fistula, which they call subcutaneous incision of the fistula tract and internal sphincterotomy (SIFT-IS). The authors hypothesized that so-called deep crypts (primary anal fistula openings comprising wide and thick pockets) are responsible for non-healing of the fistula. The aim of the proposed technique is to eradicate these deep crypts. SIFT-IS flattens deep crypts by dissecting fistula tracts and fibrous subepithelial tissue. Basically, the external fistula opening was excised and drained optimally. Furthermore, an incision was made at the anoderm and meticulous dissection was performed in the submucosal layer. The internal anal sphincter was identified and sharp sphincterotomy was performed. Then, the fistula was identified and divided. It should be noted that the fistula was not ligated and that the internal opening was not closed. In this study, including 151 patients over a 2-year period, primary endpoint was healing rate at 16 weeks postoperatively, defined as complete epithelialization of the surgical wound. SIFT-IS had primary healing rate of 85%, at a median healing time of 6 weeks. After secondary surgery to treat recurrent and remnant fistulas, overall success rate was 98%.
November 2022
Mesh, flap or combined repair of perineal hernia after abdominoperineal resection – A systematic review and meta-analysis
Albert M. Wolthuis
In this month's issue of Colorectal Disease, the important issue, but rather less-frequently studied problem of perineal hernia after abdominoperineal resection (APR) is published. Sharabiany et al. performed a systematic review and meta-analysis of available studies on perineal hernia repair after APR. They included 19 studies describing the outcome of only 172 patients. Recurrence rate after repair with biological or synthetic mesh was 39% and 29%, respectively. Tissue flap reconstruction resulted in a recurrence rate of 37%, and it was 9% if a combination of tissue flap reconstruction and mesh was used. Professor Tanis and colleagues already have a long track record of investigating perineal wound problems after APR. The present systematic review could be seen as an update and extension of the pooled analysis and review already published in 2012 and 2017, respectively. What has been shown repeatedly is that there is a scarcity of data, lack of standardization and low-level evidence regarding any surgical approach and/or technique. This is remarkable, because one would estimate that there would be a considerable problem with a huge potential field of research. Indeed, about 20% of patients require an APR during rectal cancer treatment. Incidence of perineal hernia is estimated to be between 7% and 30%. With increased overall survival rates, perineal hernia should be considered as an important long-term complication of APR, significantly impacting patients' quality of life.
October 2022
Turnbull-Cutait abdominoperineal pull-through operation: The Cleveland Clinic experience in the 21st century
Albert M. Wolthuis
In October's edition of Colorectal Disease, the department of colorectal surgery from the Cleveland clinic Ohio (USA) presents their experience with the Turnbull-Cutait abdominoperineal pull-through operation (TCO). The eponym comes from 2 surgeons (Dr R. Turnbull and Dr D. Cutait) who simultaneously described the technique, in literature also referred to as delayed coloanal anastomosis (CAA). This is a retrospective study from a prospectively maintained database, and the authors acknowledge inherent types of bias as a limitation of their study. Overall, 81 patients with TCO and 129 patients with immediate coloanal anastomosis were included. The aim was to analyse outcomes of patients who underwent TCO for salvaging complicated anorectal and pelvic conditions with hand-sewn immediate CAA. Failure was defined as the creation of either permanent colostomy, permanent ileostomy, or if the diverting loop ileostomy was never reversed. The authors observed TCO success rate at 1, 3 and 5 years to be 79%, 60%, and 51%, respectively, compared to 91%, 81% and 73% after CAA. Although there was a significant difference in indications, there were no differences in postoperative complications. This has also been shown in a cohort of patients undergoing primary delayed CAA for rectal cancer. Moreover, a recent meta-analysis showed that there were no differences in postoperative complications when comparing delayed CAA with immediate CAA, but another meta-analysis showed that pelvic sepsis rate was significantly lower in the group of patients who underwent delayed CAA (7% vs. 14%, respectively). Regarding the present study, another point to be raised here is that the majority of CAA patients (75%) had a laparoscopic approach, whereas all TCO procedures were performed in an open fashion. There are more and more reports showing that TCO can also be performed in a minimally-invasive way.
September 2022
Will a better-informed patient take ‘the right’ decision?
Albert M. Wolthuis
Nowadays, treatment decisions for rectal cancer are complex, with many stakeholders involved. Multidisciplinary team meetings, mainly consisting of medical oncologists, radiotherapists, radiologists, pathologists, nurse specialists and surgeons, have the difficult task of deciding on a strategy to optimize oncological outcome. This decision, and potential outcome, is then communicated with the patient. Patients often have to choose between treatment options, with potential impact on oncological and functional outcome. In particular, in rectal cancer surgery a risk–benefit analysis regarding operative outcome and the need for temporary stomas but also the impact of surgical procedures on quality of life should be taken into account. More and more, health-related quality of life has become an important outcome parameter, because oncological outcome has improved during the last decades. Therefore, patients have become partners in decision making and should be well informed of surgical options and expected outcome. It has already been shown that patients' expectations may be different compared to preferences of healthcare professionals (surgeons, oncologists …), and this could become a barrier in shared decision making. Indeed, patients are willing to trade survival for quality of life when decisions about rectal cancer surgery should be made.
August 2022
Neoadjuvant chemotherapy in patients undergoing colonic resection for locally advanced nonmetastatic colon cancer: A nationwide propensity score matched cohort study
Albert M. Wolthuis
In August's edition of Colorectal Disease, Laursen et al. present the results of a nationwide propensity score matched cohort study on the use of neoadjuvant chemotherapy (NCT) in patients undergoing resection for locally advanced colon cancer (LACC). The authors used the Danish Colorectal Cancer Group Database and selected patients with LACC who underwent resection between 2015 and 2019. They performed propensity score matching in patients who had NCT and patients who were operated without receiving NCT. Short-term surgical and oncological outcomes were analysed. They found no differences in perioperative outcome, but significant differences regarding radicality and pathological N-stage were found in favour of the use of neoadjuvant chemotherapy.
July 2022
Pregnancy outcomes after stoma surgery for inflammatory bowel disease: The results of a retrospective multicentre audit, by the PAPooSE study group
Albert M. Wolthuis
In July's edition of Colorectal Disease, the ‘PregnAncy outcomes & experience in Patients with ileoStomiEs’ or PAPooSE study group present an infrequently studied issue on the difficult triangle of inflammatory bowel disease (IBD), stoma-, and pregnancy-related outcome. Indeed, this brings specific problems, questions, fear and anxiety when these patients, faced with IBD and a stoma at young age, will also have to deal with the effects of pregnancy.
June 2022
The prognostic value of extramural venous invasion in preoperative MRI of rectal cancer patients
Taru M. Lehtonen
This study aimed to examine the prognostic value of extramural venous invasion observed in preoperative MRI on survival and recurrences.
May 2022
Tumour genotypes account for survival differences in right- and left-sided colon cancers
Thomas M. Ward
Despite advances in screening and therapeutics, colorectal cancer remains the second leading cause of cancer mortality worldwide. Differences in survival between cancers of the right and left colon have long been reported, with the majority of studies, including multiple meta-analyses, demonstrating worse survival with right-sided tumours. Previous studies have hypothesized a variety of mechanisms through which tumour site could cause these survival differences.
April 2022
Standardized documentation and synoptic reporting of complex intestinal anatomy in enteric fistulation and intestinal failure
Katherine J. Williams
In intestinal failure, delineation of both structure and function are key to controlling symptoms and planning further intervention. We have developed a template for developing an ‘anatomy at a glance’ patient-specific map to aid decision making and counselling.
March 2022
Endoscopic management of colovesical and colovaginal fistulas with over-the-scope clips: A single-institution case series
Colin G. DeLong
Fistulous tracts between the colon and pelvic organs, including the bladder and vagina, are a difficult problem encountered by general and colorectal surgeons. Colovesical and colovaginal fistulas, although distinct clinical entities, have considerable overlap in aetiology, management options and therapeutic complexity. In both cases, the primary risk factor for development is diverticular disease followed by malignancy, inflammatory bowel disease and pelvic surgery. The incidence of such fistulas is not well characterized in the literature. However, colovesical fistulas have been estimated to complicate up to 20% of cases of severe diverticular disease, a disease characterized by an increasing global incidence.
February 2022
Editor's Choice – February 2022
Niel Smart
Ileostomy formation remains a common component of colorectal surgery whether for cancer, IBD or functional disorders. Balancing the risks of ileostomy formation and its sequelae against alternative management strategies remains a key judgement call for colorectal surgeons. The colorectal community has long known of the impact of dehydration that results from a high output stoma, but there are challenges with the subjective clinical assessment of dehydration for research purposes. The development of acute kidney injury (AKI) defined and by graded according to KDIGO criteria is more objective, however its development during index surgery and its relation to patient outcomes has not previously been studied. In this month's Colorectal Disease Loria et al. examine the relationship between index admission AKI development, complications and readmission, specifically dehydration related readmission. The results necessitate reflection about how we counsel patients as part of the informed consent process.
January 2022
Editor's Choice – January 2022
Niel Smart
Ileostomy formation remains a common component of colorectal surgery whether for cancer, IBD or functional disorders. Balancing the risks of ileostomy formation and its sequelae against alternative management strategies remains a key judgement call for colorectal surgeons. The colorectal community has long known of the impact of dehydration that results from a high output stoma, but there are challenges with the subjective clinical assessment of dehydration for research purposes. The development of acute kidney injury (AKI) defined and by graded according to KDIGO criteria is more objective, however its development during index surgery and its relation to patient outcomes has not previously been studied. In this month's Colorectal Disease Loria et al. examine the relationship between index admission AKI development, complications and readmission, specifically dehydration related readmission. The results necessitate reflection about how we counsel patients as part of the informed consent process.
December 2021
Training videos to optimize right hemicolectomy for colon cancer
Pieter J. Tanis
Colectomies have commonly been considered as belonging to high volume surgery with relatively low complexity. Almost all surgeons felt to have a sufficient level of competency to perform an open colectomy for benign or malignant indications. With the introduction of minimally invasive surgery, colonic surgery has become more and more the field of specialized (colorectal) surgeons, although still numerous general surgeons worldwide are performing open colectomy. This is in contrast to rectal resections. High local recurrence rates and poor survival in rectal cancer patients - as observed until the end of the 20th century - clearly indicated that there was room for improvement of surgical quality. This has led to worldwide initiatives to standardize the technique, to selection of a few specialized surgeons per centre to perform this type of surgery, and even centralization of rectal cancer care at a national level.
November 2021
The end of the era of routine diversion after rectal cancer resection?
Pieter J. Tanis
There are several examples of surgical interventions that are intuitively being performed under the assumption that it will benefit the patient. Constructing a diverting ileostomy after a (low) anterior resection for rectal cancer is such an intervention. But there is accumulating evidence that the benefits do not outweigh the short and long-term sequelae of routine diversion. The population based study of Holmgren and colleagues adds another piece to the puzzle [1]. A primary diverting ileostomy is intended to prevent anastomotic leakage and preserve the anastomosis in case of leakage, thereby striving for the highest chance of bowel continuity in the end. However, Holmgren et al. show that the defunctioning stoma itself increases the risk of a permanent stoma, which turns the principle of faecal diversion upside down.
October 2021
Minimally invasive surgery improves survival after colorectal cancer resection
Pieter J. Tanis
The first randomized trial comparing laparoscopic and open colon cancer resection reported a survival benefit for laparoscopy in 2008 [1]. None of the subsequent trials could confirm this finding. Nevertheless, Fahim et al. conclude that laparoscopy might improve long-term outcomes based on a multivariable analysis of a retrospective three-centre cohort study including 4531 colorectal cancer patients treated between 2009 and 2018 [2]. Strictly following the levels of evidence, this paper does not overrule the absence of any survival impact of laparoscopy in meta-analysis of randomized trials, but it is still worthwhile to elaborate further on this topic.
September 2021
Lymphatic dissemination of mid-transverse colon cancer
Pieter J. Tanis
Park and colleagues address an infrequently studied issue in the field of colon cancer surgery, which is the optimal type of colectomy for treatment of tumours of the transverse colon [1]. They performed a retrospective comparative cohort study with all the inherent types of bias, but otherwise the study is of good methodological quality with detailed pathological assessment of the specimens and propensity score matching as a statistical strategy to decrease confounding. The primary aim was to explore the distribution of lymph node metastases between extended and transverse colectomies. After matching, 74 patients remained for definitive analysis and only 36 patients had node-positive disease (18 patients per group). The authors adequately discuss the limitations of their study.
August 2021
Distribution of lymph node metastasis and oncological outcomes of mid-transverse colon cancer: Extended versus transverse colectomy, by Park et al
Elaine Burns
In this month's issue of Colorectal Disease, Park et al. [1] explore the optimal management of a transverse colonic tumour. Right sided tumours may be associated with a poorer prognosis than left sided disease [2]. The increasing popularity of Central Mesocolic Excision (CME) and the emerging data on the technique's efficacy has highlighted the need to standardise and improve resectional surgery for right sided tumours [3].
July 2021
The impact of the first peak of the COVID-19 pandemic on colorectal cancer services in England and Wales: A national survey, by Boyle et al
Elaine Burns
In this month's issue of Colorectal Disease, Boyle et al [1] report on the impact of COVID-19 on colorectal cancer care during the first wave of the pandemic and highlight the key lessons learnt by institutions in the United Kingdom (UK). Combining regional variation in COVID-19 rates and questionnaire data, the authors sought to explore the impact on units in terms of referrals, access to ‘cold’ sites, and changes to services. This study suggested that there were significant reductions in referrals during the first wave for colorectal cancer with significant departures from previous established management pathways. This led to delays in diagnostics, starting radiotherapy and delays or deferrals to surgery and management of distant disease.
June 2021
Redefining the collateral system between the superior mesenteric artery and inferior mesenteric artery: A novel classification
Kuzu et al
In this month's issue of Colorectal Disease, Professor Ayhan Kuzu and colleagues have published a fascinating exploration of the vascular anatomy of the left colon [1]. This study assesses the vasculature of 107 fresh cadavers. Many of us live in fear of inadvertently ligating the ‘Arc of Riolan’ and compromising the blood supply of the colonic conduit during an anterior resection. We balance the need for adequate length with a high tie of the inferior mesenteric vein (IMV) against the risk of devascularising the colon. Careful dissection reduces such risks. However, a more in depth understanding of this anatomy is useful.
May 2021
Stoma-related complications: A report from the Stoma-Const randomized controlled trial, Correa-Marinez et al.
Elaine Burns
In this month’s issue of Colorectal Disease, Correa-Marinez et al. report on the secondary end points of the Stoma-Const randomized controlled trial [1]. This trial randomised and analysed the parastomal hernia (PSH) and complication rates of 201 patients undergoing an end colostomy. These patients were randomised to have a sublay mesh or a cruciate or circular incision to the sheath to form their colostomy. The paper by Correa Marinez et al. highlights a significant issue impacting on the quality of life of many patients undergoing both emergency and elective colorectal resection [1]. Based on historic data, it has been suggested that up to 30% of rectal cancers are managed with either a Hartmann’s procedure or abdominoperineal resection [2]. David and colleagues demonstrated that less than a third of patients having a Hartmann’s procedure underwent reversal of their stoma [3]. Correa-Marinez and colleagues show that, with an intense follow-up strategy, a staggering 63% of patients experience a stoma related complication. Indeed, this trial suggested that between 38% and 51% of patients develop a parastomal hernia [4].
April 2021
The association of the neutrophil–lymphocyte ratio with the presence of minimal residual disease and outcome in patients with stage II colon cancer treated with surgery alone, by Murray et al
Frank D. McDermott
In the April Edition of Colorectal Disease, Murray et al. [1] present their paper on the impact of immune function on residual disease in stage 2 colorectal cancer. There is increasing interest in the use of biomarkers and tools to identify high-risk patients for recurrence. This follows the trend towards personalisation of medical care and risk stratification utilising, for example, biomarkers and genomic tests. Previous studies have assessed the effectiveness of neutrophil–lymphocyte ratio (NLR) as a marker for early recurrence but in a more heterogeneous group of stage 1–stage 4 colorectal cancers [2]. In this prospective study, consecutive patients with stage 2 colorectal cancer were recruited. Stage 2 disease itself encompasses a wide spectrum of disease including patients with T3 to T4b colorectal cancers and consequent differences in outcomes after surgery. There is a need to better stratify this group of patients who do not have lymph node or distant metastatic disease to tailor their treatment and surveillance pathways.
March 2021
A colorectal straight-to-test cancer pathway with general-practitioner-guided triage improves attainment of the 28-day diagnosis target and increases outpatient clinic capacity by Sagar et al
Frank D. McDermott
In the March edition of Colorectal Disease, Sagar et al. present their study on the use of a General practitioner triage/ ‘straight to test’ (STT) pathway for colorectal cancer [1]. There are 42 000 new diagnoses of colorectal cancer in the UK per year. With the implementation in 2020 of NHS England's 28-day cancer diagnosis target, there is a great need to streamline pathways. This has been compounded by the impact of COVID-19 on the provision of healthcare services and diagnostics that will delay management and cause harm [2]. NICE recommends better access for GPs to STT investigations, and this study reinforces previous work on the effectiveness of this approach in colorectal cancer [3]. I chose this paper as a timely example of how a relatively straightforward intervention can be implemented and assessed with this type of service evaluation study.
February 2021
Altered colonic motility is associated with low anterior resection syndrome, by Keane et al
Frank D. McDermott
In February's edition of Colorectal Disease, Keane et al present their paper on colonic motility and its association with low anterior resections syndrome (LARS) [1]. I chose this paper as we know the high prevalence (60–90%) and significant impact that LARS can have on our patients and that there is a need to better understand its likely multi-factorial aetiology. Although guidelines for the management of LARS exist without better understanding of the underlying pathophysiology, it is challenging to develop preventative and management strategies for the future. I would recommend reading the MANagement gUidelinEs for Low Anterior Resection Syndrome (MANUEL project) recently published open access in Colorectal Disease [2]. The authors use high resolution manometry (HRM) to produce detailed spatiotemporal data improving on previous low resolution studies. Previous studies using HRM have demonstrated a ‘rectosigmoid’ brake or cyclic motor pattern (CMP) [3] that is proposed as a mechanism to prevent rectal filling and might be disrupted in patients with LARS.
January 2021
Allogeneic expanded adipose-derived stem cells in the treatment of rectovaginal fistulas in Crohn’s disease, by Nikolic et al
Frank D. McDermott
In January's edition of Colorectal Disease, Nikolic et al. present their study on the use of allogeneic adipose-derived mesenchymal stem cells (ASC) to treat rectovaginal fistula (RVF) in Crohn’s disease [1]. I chose this paper as there is enormous interest in the use of ASCs in across surgical disciplines including colorectal surgery, for example in fistula in ano and more recently for faecal incontinence. This study used allogeneic ASCs (Alofisel®); which is a manufactured ASC product as compared autologous ASCs that are usually harvested and filtered during the same procedure before administration. Rectovaginal fistulas related to Crohn's are thankfully rare and account for only 5% of all rectovaginal fistulas, and only four women are presented in this case series. Despite being rare, RVFs are debilitating and due to high treatment failure, a high proportion of patients (40%) will opt for a permanent end colostomy. Patients had the fistula tract curetted, rectal and vaginal mucosal flaps raised to close the defects and a 6ml vial of allogeneic ASCs injected around the fistula tract. None of the patients had a diversionary stoma at the time of surgery and only 25% (1 out of 4) had successful closure of the fistula at 6 month follow up.
December 2020
Exploring shared surgical decision-making from the patient’s perspective: is the personality of the surgeon important?, Bisset et al
Gabrielle H. van Ramshorst
It is with great interest that I read the article by Bisset et al. in this month's issue of Colorectal Disease [1]. This study builds on previous work by Moug et al., which showed that colorectal surgeons are more likely to demonstrate high levels of emotional stability and conscientiousness in comparison with a non-clinical population [2].
The authors currently present a study on the perspective of patients on influence of the surgeon's personality on shared decision-making. Patients from various predominantly English-speaking countries, mostly from the United Kingdom, filled out online patient surveys distributed through X and Facebook. Within 72 h nearly 300 responses were recorded, illustrating the value of online platforms for scientific studies. Most of the patients had undergone surgery for colorectal cancer (40%) or inflammatory bowel disease (45%). In the second part of the study, a face-to-face patient and public involvement exercise was performed.
November 2020
Prognostic factors influencing survival in patients undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy for isolated colorectal peritoneal metastases: A systematic review and meta-analysis
Gabrielle van Ramshorst
This month's issue of Colorectal Disease features a systematic review and meta-analysis by Narasimhan et al. [1] This study focused on identifying prognostic factors influencing survival in patients undergoing cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). Twenty-five studies were included and worse survival was seen in patients undergoing incomplete cytoreduction, increasing peritoneal carcinoma index and lymph node involvement. Patients with rectal cancer and grade 3 or 4 morbidity had worse survival rates, whilst adjuvant systemic chemotherapy improved survival.
October 2020
Simultaneous pelvic exenteration and liver resection for primary rectal cancer with synchronous liver metastases: results from the PelvEx Collaborative
Gabrielle van Ramshorst
In this issue of Colorectal Disease [1], the PelvEx Collaborative present a series of 128 patients from 20 international institutions who underwent simultaneous pelvic exenteration and liver resection between 2007 and 2017. The median size of liver metastasis was 2 cm, which shows that this was a highly selected patient group.
The mortality rate of 1.6% after 30 days in this series is comparable to the literature, as well as a 32% rate of patients developing major postoperative complications. The 5-year overall survival for patients with R0 resections of the tumour and liver metastasis was 54.6%, reinforcing the goal of complete oncological resection [2]. These outcome data support the belief that responsible decisions were made by these surgeons and specialist multidisciplinary team meetings.
September 2020
Impact of surgical complications on the operating surgeon, Biggs et al
Gabrielle van Ramshorst
I felt one coming. Disbelief, guilt, self-doubt, shame and sadness were my companions. Amidst the turmoil, I tried to cope according to expectations: repeated updates with the intensive care unit specialist, lengthy empathic conversations with the wife and the rest of the family, a phone call to the general practitioner. Nothing I did would bring my patient back to life. Nothing helped me to understand why he aspirated, developed acute respiratory distress syndrome and died. Maybe I jinxed it.
Studies have shown that nearly 80% of healthcare personnel are emotionally affected by a near miss or adverse event at least once in their career [1, 2]. Regardless of a complaint or lawsuit, doctors show a higher prevalence of mental health sequelae compared to nurses [3]. The most common symptom is hypervigilance, which lasts longer than 6 months in 28% of doctors after a patient safety incident [4]
Biggs et al. [5] conducted an online survey using the X feed of the European Society of Coloproctology, the Association of Coloproctology of Great Britain and Ireland and the Association of Surgeons of Great Britain and Ireland. A total of 94% of 82 respondents reported personal involvement in a serious surgical complication in the previous 5 years. A negative impact on personal/family life was noted by 55% and over 25% reported a negative impact on interactions with colleagues. Stress was coped with through discussion with colleagues, ensuring optimal management of the complication, and involvement with patients and relatives.
August 2020
Video-assisted anal fistula treatment for complex anal fistula: a long-term follow-up study, Giarratano et al
S. K. Clark
In this month's issue, Giarratano et al [1] report the outcomes of a series of 72 patients with complex fistula-in-ano undergoing video-assisted anal fistula treatment (VAAFT). The results are promising, with a 79% healing rate, minor complications only, and no impairment of continence reported. Further strengths of the study are the use of clear definitions of fistula healing, persistence and recurrence, in addition to adequate length of follow-up, which studies in the past have failed to apply. Their findings are very much in line with those of recent meta-analyses of efficacy and safety of the technique [2, 3], but raise many more questions than answers.
So another dish has been added to the smorgasbord of potential treatments for anal fistula, which includes fistulotomy, seton (loose, snug or tight; of various materials), ligation of the intersphincteric fistula tract (LIFT), ablation (laser or photodynamic), use of clips, glues, inert plugs or biomaterials including stem cells and growth factors, and a dizzying array of modifications and combinations of these [4].
June 2020
Early clinical outcomes of a rapid colorectal cancer diagnosis pathway using faecal immunochemical testing in Nottingham
Chapman et al.
The paper by Chapman et al [1] in this issue could not be more timely. Every colorectal and gastroenterology unit globally has been impacted by at least partial shutdown of outpatient and diagnostic services, particularly endoscopy. Many patients with symptoms potentially due to colorectal cancer have been referred, but not seen or investigated; many more will be will join them once ‘lockdown’ is lifted and patients seek help. Over its 20‐year lifespan the ‘2‐week‐wait’ (2WW) pathway in the UK has ballooned, but the poor colorectal cancer detection rate (< 8%) and stage distribution at diagnosis have remained stubbornly unchanged [2].
Faecal immunochemical testing (FIT) is due to replace guaiac faecal occult blood testing (gFOBT) in the Bowel Cancer Screening programme, and both have been recommended in the assessment of low‐risk potential bowel cancer patients [3], though concern remains around false reassurance that a low faecal haemoglobin level might bring. Previous work by this group has addressed this, piloting a combination of FIT with clinical referral criteria which suggested that it might have a useful role in risk stratification within the 2WW pathway [4], as has that of others [5, 6].
May 2020
Quality of life and functional outcomes following pelvic exenteration and sacrectomy
McCarthy et al
Pelvic exenteration, sometimes combined with sacrectomy, is increasingly recognised as the cornerstone of treatment for advanced or recurrent pelvic tumours, many of which are rectal cancers [1]. The procedure was first described in the late 1940s as a palliative treatment for recurrent cervical cancer [2], and the first reported cases with additional bone excision (including sacrectomy) were published in the late 1960s [3]. A number of groups have documented outcomes, mostly focusing on perioperative mortality and morbidity, completeness of excision and longer‐term cancer‐related survival, all of which have improved markedly over the last 20 years; perioperative mortality is now under 5%, and up to 60% can be cured of their cancer [1]. This surgery is feasible and can cure advanced tumours – but at what cost?
It has been generally acknowledged that this destructive surgery has profound consequences: most patients have a colostomy or ileostomy, and many a urostomy as well; function of retained bowel or bladder is affected by sacrifice of sacral nerve roots; sexual function is impacted; lower limb motor function can be impaired. Little has been published on functional and quality of life outcomes, important information for patients weighing up whether to undergo this potentially life saving but very major surgery. It is intuitive that higher sacrectomy results in greater functional impairment and poorer quality of life, something that should be balanced careful with the need for clear excision margins, but there is little objective evidence.
The paper by McCarthy et al. [4] in this issue is one of the first to use patient reported outcome measures following pelvic exenteration, with and without high or low sacrectomy. While there are inevitable limitations, this study is from a group with a strong track record in this field and describes highly relevant quality of life and functional outcomes in what is large and mature cohort given the rarity of this surgery. This information will assist in informing patients, framing expectations and guiding decision making and is a step forward in the development of management of advanced pelvic tumours.
Quality of life and functional outcomes following pelvic exenteration and sacrectomy
En bloc
Sacrectomy for locally advanced cancer of the pelvis is a complex and morbid procedure. Sacrectomy has evolved to be recognized as the curative treatment of choice for pelvic cancers involving the sacrum but is not offered universally 1-5. Sacrectomy is performed as part of a pelvic exenteration involving radical multivisceral resection of locally advanced or recurrent tumours of the pelvis 5. Considerable long‐term functional complications can result depending on the number and level of sacral nerve roots that are sacrificed.
April 2020
International evaluation of circumferential resection margins after rectal cancer resection: insights from the Swedish and Dutch audits
R. Detering D. Saraste M. P. M. de Neree tot Babberich J. W. T. Dekker M. W. J. M. Wouters A. A. W. van Geloven W. A. Bemelman P. J. Tanis A. Martling M. Westerterp on behalf of the Swedish ColoRectal Cancer Registry and the Dutch ColoRectal Audit
Evaluation of rectal cancer care at regional, national and international level can provide relevant information regarding current quality, hospital variability, adherence to guidelines and potential areas for improvement 1. In 1995 Sweden was one of the first countries to start a rectal cancer registry 2. Several improvement projects have been launched since then, and these were evaluated using auditing 3. Furthermore, prospective trials were conducted (e.g. Stockholm I–III) that had an impact on the provision of care and guideline development 4. The Netherlands is another northern European country with a similar cultural background and similar developments in rectal cancer care, and there is a long tradition of cooperation between the two countries (e.g. the TME and RAPIDO trials) 5, 6. Colorectal auditing in the Netherlands started relatively late, in 2009, but rapidly evolved to become an important source of quality population‐based information 7.
International comparisons have shown significant differences in the outcomes of colorectal cancer care between countries 8-11. This would suggest a potential for improvement at a country‐specific level. Sweden is a country with a surface area that is 10.8 times larger than that of the Netherlands but has almost half the number of inhabitants (0.57 times). Recently, there has been a tendency towards reducing the number of hospitals treating rectal cancer. This will have a bigger impact in Sweden than in the Netherlands from a patient perspective due to the travel distance required to access care. Centralization of only complex subpopulations might be an alternative, thereby minimizing the effects on patient logistics. But first we have to analyse in more detail the current management of rectal cancer care in both countries and define potential areas for improvement.
Therefore, the purpose of this international population‐based study was to analyse the predictive factors for the circumferential resection margin (CRM) in the period 2011–2015 after resection of tumour node metastasis (TNM) Stage I–III rectal cancer, using data from the Swedish and Dutch national registries, in which cT1–3 and cT4 stage rectal cancers were separated.
International evaluation of circumferential resection margins after rectal cancer resection: insights from the Swedish and Dutch audits, Detering et al.
Samson Tou
Since the seminal paper published on the surgical volumes and outcomes four decades ago [1], we have witnessed the centralisation of complex surgical procedures including hepato‐pancreato‐biliary, oesophageal and gastric cancers. This centralisation of care is not limited to cancer services and it also applies to benign conditions such as bariatric surgery. The rationale for the concentration of patient care for rare diseases with specialist surgeons enables the accumulation of experience, with benefits including the improved quality of treatment and economic efficiency [2]. There has been an ongoing debate about the need for centralisation of rectal cancer given the complexity and evolving treatments of this condition.
In the UK, the National Institute for Health and Care Excellence (NICE) guideline for rectal cancer has appraised the volume‐outcome relationship. Their recommendations are hospitals performing major rectal cancer resection should perform at least ten and individual surgeons should perform at least five each year. [3]
In this issue, Detering et al. [4] used the colorectal cancer audits from Sweden and the Netherlands to examine factors associated with positive circumferential resection margins (CRM) over five years. CRM is chosen as a quality indicator; a negative margin indicates the achievement of curative resection, and it is associated with lower morbidity, mortality and improved post‐operative quality of life [4].
There are some interesting observations from this study. Laparoscopic surgery was less frequently performed in Sweden (20.9%) than in the Netherlands (69.7%), but this did not have an impact on the CRM positivity. This finding may contribute to the ongoing debates between open and laparoscopic rectal cancer surgery.
Low‐volume hospitals (< 20 rectal resections per year) were associated with positive CRM in the Dutch cT1‐3 population. In both countries with cT1‐3 stage disease, common independent risk factors for positive CRM were cT3, abdomino‐perineal resection and multi‐visceral resection. The authors proposed that for patients with locally advanced or distally located tumours, a certain degree of specialisation may help to concentrate volume and improve outcomes. These findings and suggestion have given us food for thought in the future provision of complex rectal cancer management.
March 2020
Randomized controlled trial of 8 weeks’ vs 12 weeks’ interval between neoadjuvant chemoradiotherapy and surgery for locally advanced rectal cancer
Terzi M. Bingul N. C. Arslan E. Ozturk A. E. Canda O. Isik T. Yilmazlar F. Obuz I. Birkay Gorken M. Kurt M. Unlu N. Ugras O. Kanat I. Oztop
Over 70% of patients with rectal cancer have locally advanced disease at presentation 1. Neoadjuvant chemoradiotherapy (CRT) is an essential part of the management in these patients, with superior outcomes in terms of surgical margins, sphincter preservation and long‐term recurrence‐free survival 2. The best timing of surgery after completion of long‐course CRT in rectal cancer is unclear, however. Consensus‐based guidelines have conflicting recommendations: the European Society of Medical Oncology suggests 6–8 weeks and the National Comprehensive Cancer Network suggests 5–12 weeks. A majority of surgeons prefer to carry out surgery at approximately 6 weeks after completion of CRT 3, 4. Recently, there has been an increasing tendency to extend the interval after completion of neoadjuvant CRT on the basis that this might increase tumour response and pathological complete response (pCR) rate. Longer waiting time is considered to enhance the killing effect of CRT on tumour cells. It was shown that tumour cell elimination was increased with longer intervals after radiotherapy 5.
An important manifestation of the biological aggressiveness of rectal cancers is the response to neoadjuvant CRT. There is clear evidence that the prognosis is much better in patients with a pCR 6. In a recent study, the response to CRT was found to be an independent prognostic factor on prognosis in Stage III rectal cancer 7. Thus, the efforts in rectal cancer management have been centred upon increasing pCR rates. Further, pCR may lend itself to an expectant watch and wait policy if this group can be identified before surgery 8.
The aim of the present study was to compare an 8‐week to a 12‐week interval between completion of CRT and surgery on the pCR rate. The primary end‐point was pCR rate. Secondary end‐points included the rate of sphincter preservation, operative mortality and morbidity.
February 2020
The ‘multilayer’ theory of Denonvilliers’ fascia: anatomical dissection of cadavers with the aim to improve neurovascular bundle preservation during rectal mobilization
W. M. Ghareeb et al.
Denonvilliers’ fascia, an important and yet, controversial structure, was first noted by a French Surgeon, Charles‐Pierre Denonvilliers after a series of anatomical dissections of the perineum in 1936 1, 2. This structure is vital for colorectal surgeons as the understanding of it would significantly improve the oncological and functional outcomes after rectal cancer surgery.
In the classical description of the total mesorectal excision (TME), Professor Heald advocated that the dissection plane should be in front of the Denonvilliers’ fascia during anterior mobilisation of the low rectum 3. Professor Bokey, amongst others, suggested this layer should be left intact, unless when dealing with locally advanced, anteriorly located tumours 4. A pragmatic approach was proposed by Professor Mortensen’s group in Oxford when performing anterior mobilisation of the low rectum 5.
In this issue, Ghareeb et al. 6, on reviewing their videos of low anterior resection, noted the presence of multiple fascial layers in the pre‐rectal space, went on to study 18 newly fixed male and female cadavers, with a binocular loupe for a more detailed dissection. They have confirmed the multi‐layered theory of Denonvilliers’ fascia, as opposed to ‘fusion’ or ‘condensation’ of embryonic connective tissues. The authors proposed their technique to initiate the anterior rectal mobilisation by making an incision a few millimetres posterior to the peritoneal reflection to minimise the injuries to the neurovascular bundles. The study also provided insight into the mysteries of the Denonvilliers’ fascia in females.
This cadaveric study has added further evidence and understanding of this important anatomical structure. With the advancement of surgical equipment, including ever‐improving higher resolution imaging with a magnified view; we are in a better position and equipped to provide a more precise surgical dissection.
January 2020
Selective central vascular ligation (D3 lymphadenectomy) in patients undergoing minimally invasive complete mesocolic excision for colon cancer: optimizing the risk–benefit equation
T. Sammour et al.
Complete mesocolic excision (CME) with central vascular ligation (CVL) for colonic cancer was described by Professor Hohenberger more than a decade ago. The principle that he described for CME/CVL mirrored the principle used in total mesorectal excision (TME), to remove colonic cancer by meticulous dissection in the mesocolic plane with central ligation of the tumour‐supplying arteries. Despite the potential oncological benefits for CME/CVL for right‐side colonic tumours, the uptake for this technique is variable amongst colorectal surgeons due to the risk of serious complications.
In this issue, Sammour and co‐workers present a series of 197 patients who underwent laparoscopic/robotic CME with high‐ligation (optimal D2 lymphadenectomy) or CVL (D3 lymphadenectomy). The level of lymphadenectomy was left to the discretion of the individual surgeon. CVL was employed when abnormal N3 nodes were identified in the pre‐operative imaging.
Their intra‐operative and post‐operative outcomes were impressive with conversion rate to open surgery was 4.6% overall, 13% morbidity rate, 1% leak rate, and zero 60‐day mortality.
The median lymph nodes yield was high in both groups (27 in optimal D2 lymphadenectomy vs 31 in D3 lymphadenectomy). There was no difference in overall survival and disease‐free survival between the two groups with a short follow‐up of 2 years.
This study showed, with their pragmatic approach, CME with selective D3 lymphadenectomy achieves an optimal balance between oncological benefits and operative risk for right colon cancer. However, the real benefits of D3 lymphadenectomy remained to be solved.
December 2019
Better survival for patients with colon cancer operated on by specialized colorectal surgeons – a nationwide population‐based study in Sweden 2007–2010
M. Bergvall et al.
Several studies suggest that surgeon subspecialisation and nature of surgery (emergency or elective) both impact outcomes of colon cancer surgery. It is not possible to realize a prospective randomized study on this issue, and therefore large well documented population‐based registers can be a possible source of information to shed light on this issue. This month’s Editor’s Choice by Bergvall et al. 1 studied 12 365 patients operated on for colon cancer in Sweden between 2007 and 2010. They used the Swedish Colorectal Cancer Registry to perform a retrospective analysis of the prospectively collected data on early and late outcomes of colon cancer operations done by colorectal specialists or general surgeons in the emergency or elective setting.
Postoperative complications occurred in 1 in 3 patients after acute operations (N = 2931) versus 1 in 4 patients after elective surgery (N = 10 434). Among acute patients with postoperative complications 3 in 4 died within 5 years. Adjusting for 31 other well‐known risk‐factors (e.g. curative resection, TNM stage, ASA classification, postoperative complications, etc.), Bergvall et al. found that patients who undergo surgery for colon cancer by colorectal surgeons have an improved 5‐years survival (60%) compared to patients who underwent surgery by general surgeons (48%). The significance of colorectal subspecialisation on short‐term and 5‐years survival was demonstrated after both elective and acute surgery. This article is yet another well‐constructed analysis proving the importance of specialized surgical training.
The remaining question is to construct a definition of the colorectal surgeon. In most of the European countries there is not a well‐defined colorectal surgery subspecialty. The accreditation and certification are based on self‐reporting or subjective credentials. Recently, the European Board of Surgery with its European Board of Surgical Qualification (EBSQ) has started offering the possibility to apply for a Fellowship of the European Board of Surgery – Coloproctology. There is no doubt that the ESBQ‐coloproctology examination will become the norm for colorectal surgeons in Europe. However, to display an ESBQ‐coloproctology certificate on the wall is not enough. An ongoing effort to read the professional literature and to attend the colorectal society meetings is necessary. Furthermore, it is important to be involved in the colorectal cancer/ IBD/ pelvic floor multidisciplinary meetings, and the development and maintenance of hospital protocols, data collection and complication registration. Yo‐Yo Ma said: “I think one of the great things about being a musician is that you never stop learning.” Hopefully, colorectal surgeons feel the same about their job.
Professor Mortensen, is an example of this attitude par excellence. Since his appointment in Oxford in 1987 he campaigned for the recognition of colorectal surgery as a specialty and created the now world‐renowned colorectal department. Even in the winter of his surgical career he continues developing his surgical skills and as an early adopter he lowers the threshold for others to hold up to develop their skills. His recent involvement in the introduction of robotic surgery and transanal total mesorectal excision in the department shows this extraordinary ability to learn. Furthermore, his highly influential research subjects varied from basic to functional science, from pelvic floor to oncology. This issue of Colorectal Disease will unfortunately be his last as Editor‐in‐Chief. It is the merit of Professor Mortensen’s leadership that Colorectal Disease achieved its highest impact factor. We thank him for his great contribution to the success of Colorectal Disease and we are excited about Neil Smart taking on the Editor‐in‐Chief position. We can rest assured that the journal will stay in the hands of one of the best colorectal surgeons of his generation.
November 2019
Reduction in surgical stoma rates in Crohn's disease: a population‐based time trend analysis
C. Ma et al.
Up to one‐third of patients with Crohn’s disease will require major abdominal surgery over the first 5 years of their disease and most Crohn’s patients will have a Crohn’s related operation at some time in their lifetime 1. Nonetheless, as surgeons we notice a trend towards less referrals for operations for Crohn’s disease, where the patients tend to present later and often in a poorer condition. It has been suggested that this change in surgical practice is due to the introduction of biologic medications for Crohn’s disease in the first half of the 2000s. However, despite the increasing use of novel biologic agents, counterintuitively the incidence of Crohn’s disease related surgery does not appear to be reducing 2. A recent large population based cohort study from Alberta, Canada, showed a decrease in emergency surgery but an increase in elective surgery 3. This might explain why surgeons get the sense that the burden for Crohn’s related surgery is less. One could expect that more elective surgery is related to earlier referral, a better condition of the patient at the time of surgery and therefore less stoma formation.
In this month’s Editor’s choice study, Ma et al., from the same Canadian group, are looking at trends in stoma formation after the introduction of biologics in management of Crohn’s disease 4. In order to assess the need for stoma creation in the biological era, the authors queried an administrative population database from their area, serving 1.4 million inhabitants. They identified 545 patients who underwent bowel resection and stoma formation for Crohn’s disease between 2002 and 2011. They found a time based reduction in stoma rates from 2.30 stomas per 100 person‐years to 1.51 stomas per 100 person‐years. The number of emergency and temporary stomas decreased over time, whereas the number of elective permanent stomas remained stable.
Except for severe perianal fistulising disease, elective stoma formation for Crohn’s disease becomes necessary where primary anastomosis is technically impossible or if there is a high risk for anastomotic breakdown. Unfortunately, this study was not able to identify the reason the stoma was indicated 4. Well‐known risk factors for anastomotic complications in Crohn’s patients include recurrent clinical episodes, steroid use, and malnutrition 5. Nowadays, gastroenterologists have a wide range of medical therapies available to avoid intestinal resection. This might cause a delay to progress to surgery, which may result in a progressively more complex disease phenotype at the time of surgery. If this delay occurs, the patient’s condition deteriorates, and this forces the surgeon to elect for a stoma to avoid an anastomotic complication. The study by Ma et al. reminds us of the importance of appropriate and timely surgery, especially in the biologic era. Therefore, the IBD surgeon should be involved in the management of the Crohn’s patient from the first onset of the disease, as a member of an IBD multidisciplinary team.
October 2019
Changes in the multidisciplinary management of rectal cancer from 2009 to 2015 and associated improvements in short‐term outcomes
C. S. D. Roxburgh et al.
The treatment of rectal cancer is rapidly evolving. We are gaining a better understanding of the molecular and cellular mechanisms that underlie the pathophysiology of the disease. Innovative tools and techniques have enabled us to operate within the confines of the pelvis. A multidisciplinary approach for planning the treatment of rectal cancer is now the standard. This month's Editor's Choice by Mege et al. describes the changes in the multidisciplinary management of locally advanced rectal cancer at Memorial Sloan Kettering Cancer Center (MSKCC) between 2009 and 2015 1.
In 1916, William J. Mayo advocated not to save the sphincters in rectal cancer surgery 2. He stated that a sphincter sparing operation would not be radical enough and he found anastomosis related sepsis in up to 40 percent of patients. However, he also realised that patients, as a rule, were willing to accept the possible decreased survival in order to maintain faecal continence.
The first step towards a multidisciplinary approach to rectal cancer started with the development of the modern systems of cancer grading by Albert C. Broders at the Mayo clinic in 1928 3. Cuthbert E. Dukes, at St Mark's Hospital, replicated Broders’ study in 1932 4. This paper starts with the first description of his famous rectal cancer staging classification using John P. Lockhart‐Mummery's earlier effort at categorization. As the trend has shifted away from adjuvant therapy to neoadjuvant therapy, staging information on the tumour is ideally needed at an early stage in the diagnosis. Magnetic resonance imaging (MRI) for local staging of rectal cancer was first investigated in 1999 and has become almost mandatory in planning rectal cancer treatment 5. Nowadays, a multidisciplinary team for the treatment of rectal cancer should include at least the following disciplines; surgery, pathology, medical oncology and radiology.
In the present era of neoadjuvant chemoradiotherapy and minimal invasive surgery, Roxburgh et al. evaluated how changes in assessment and treatment of locally advanced rectal cancer over time affect the short‐term outcome. Their results are impressive. The use of MRI increased from 57% to 98% between 2009 and 2015. All patients received neo‐adjuvant therapy resulting in a complete response in almost one in three patients and tumour down‐staging in 70 percent of patients. Sphincter saving surgery was possible in three quarters of the patients. The circumferential resection margin was negative in 94% of patients and the distal resection margin was negative in 98%. Anastomotic breakdown after low anterior resection decreased from 11% to 3% during this time period. The percentage patients managed non‐operatively increased from 10% to 22% of patients. Roxburgh et al. observed, that patients expressed a strong preference for a non‐operative watch‐and wait approach after complete response.
The MSKCC paper shows the enormous improvement in the treatment of locally advanced rectal cancer since William J. Mayo's concerns regarding the completeness of dissection and postoperative sepsis. Already in 1910, this pioneer in colorectal surgery famously stated: ‘The best interest of the patient is the only interest to be considered, and in order that the sick may have the benefit of advancing knowledge, union of forces is necessary 6.’ William J. Mayo recognized that the only way forward is a multidisciplinary approach. Now, more than a century later, we have come to that same conclusion.
September 2019
Sacral nerve modulation for faecal incontinence: influence of age on outcomes and complications. A multicentre study
D. Mege et al.
Surgery for defaecation disturbances is a growing field and maybe the most important recent development is sacral nerve modulation (SNM). Although its effectiveness is proven, its place in the treatment algorithm of faecal incontinence is still based on large patient series. This month's Editor's Choice by Mege et al. 1 evaluated 352 patients who underwent SNM for faecal incontinence, collected from seven French tertiary referral centres in the time period between 2010 and 2015. Fifty‐four percent of patients had a significant sphincter defect. The median follow‐up was 3.4 years. Their aim was to determine if patients older than 70 years of age had similar outcomes after SNM.
We know from colorectal cancer surgery that fitness, rather than age per se, is an important prognostic indicator for postoperative outcomes. One could argue that in surgical treatment of faecal incontinence, age is more relevant, as the pelvic floor function deteriorates with time. Comparing patients under the age of 70 years with those of 70 years or more, Mege et al. 1 found favourable outcome in 79% and 76% of patients, respectively. The reduction of the Cleveland Clinical Faecal Incontinence (CCFI) score was similar in both groups (42% and 35%, respectively).
Non‐controlled studies on SNM should be interpreted with caution. Firstly, the patient selection is based on a successful test stimulation. Secondly, the placebo effect following SNM contributes largely to the overall treatment response. In one of the few randomized double‐blinded trials on this topic, the median frequency of FI episodes decreased by 76% and the CCFI improved 38% during sham stimulation 2. Finally, the life expectancy of the battery necessitates an expensive replacement operation. In the study by Mege et al., 48% of all patients had revision surgery at 3 years after implantation. Fifty percent of them because of battery depletion.
Looking at the long‐term probability of success after SNM in the present study (figure 2), there is a striking similarity with the deteriorating success‐rate after anterior spincteroplasty (AS). Studies, conducted to assess the long‐term outcome after AS show acceptable to excellent outcomes in 60% of patients after an 8‐years follow‐up 3, 4. However, there is one important difference: the long‐term success rate after AS is age dependent. Comparing patients under the age of 50 years, with those of 50 years or more, acceptable outcomes were achieved in 71–75% and 27–47%, respectively 3, 4.
Despite the potential appeal of SNM, we need more evidence to show its cost‐effectiveness over other established treatments for faecal incontinence. There is already a paucity of trials comparing surgical and non‐surgical treatments for faecal incontinence, and studies comparing the different surgical techniques are almost non‐existent 5. Future research will hopefully provide more guidance to the surgeon in terms of patient selection. We can use the data from Mege et al. for the design of future clinical trials. Going forward, there is a need for a randomized trial comparing SNM and AS in younger patients with an external sphincter defect. To find alternatives for SNM in older patients with disabling faecal incontinence is more difficult, but it could be interesting to compare SNM with coping strategies, such as retrograde colonic irrigation or promising new treatment modalities such as for example intrasphincteric injection of autologous myoblasts.
August 2019
Sphincter‐sparing surgery for complex anal fistulas: radiofrequency thermocoagulation of the tract is of no help
A. Merlini l'Héritier et al.
Obliteration of the internal opening has long been held as the key resolution of high transsphincteric fistulae. This month's Editor's Choice by Merlini l'Héritier et al. evaluated ablation of the tract by applying radiofrequency thermocoagulation 1. They used a control group, selected from a prospective database consisting of patients who underwent occlusion of the fistula tract by a rectal advancement flap, paired‐matched for sex, age and the presence of Crohn's disease. The healing rate was only 26% at 5 months after radiofrequency thermocoagulation, vs 68% after flap repair, and dropped further to 10% after 21 months. These findings suggest that obliteration of the fistula tract is not enough to accomplish healing of perianal fistulae in most cases. The authors must be congratulated on publishing these findings. Negative findings provide much needed feedback on the effectiveness of treatment after introducing a new technique or pursuing new indications for a known technique.
July 2019
Evaluating unmet needs in patients undergoing surgery for colorectal cancer: a patient reported outcome measures study
P. A. Sutton et al.
The shift away from surgeon‐derived clinical outcomes towards patient‐centred outcome measures provides new insights into patients’ healing journeys. Patient‐Reported Outcome Measures (PROMs) represent a powerful tool to assess the patient's perception of their care. To develop and test PROMs, rigorous qualitative and quantitative methods need to be employed. The overwhelming majority of papers in Colorectal Disease are describing quantitative research. Our readers are less familiar with the methodological challenges which arise in qualitative research.
In this month's Editor's choice study, Sutton et al. try to set out the optimum content for a PROM regarding unmet needs arising after colorectal cancer surgery 1. First, they investigated unmet needs using six different validated questionnaires. These questionnaires were selected by a multidisciplinary team, including patients. Approximately, one in three patients were found to have ongoing physical symptoms and psychological needs as a result of the treatment. It is important to realize that these unmet postoperative needs may be difficult to pick up during normal counseling. Finally, they invited patients to attend a focus group, to identify and prioritize needs not met by the current treatment. During these group discussions, unexpected themes emerged, such as information provision and physiological coping mechanisms. This last part of the study is especially interesting because this kind of qualitative data is an important first step in establishing a correctly constructed PROM to use in clinical practice.
June 2019
Morbidity related to diverting ileostomy after restorative proctocolectomy in patients with ulcerative colitis
E.K. Karjalainen et al.
In the era of biologics, the majority of ileal pouch anal anastomoses, done as the restorative procedure of choice for ulcerative colitis, are being conducted in a three stage, or modified two stage fashion. This is to prevent the dreaded morbidity related to an anastomotic leak, and pelvic sepsis. This is known to be associated with increased pouch failure rates due to long‐term poor function. While there have been no randomized control trials to compare a three stage versus a modified two stage approach, Karjalainen et al. 1 nicely highlight the limitations of a stoma at the time of pouch formation, or utilizing a three stage approach. Whilst a diverting loop ileostomy does have a lower rate of anastomotic leak, and, theoretically then a lower rate of pelvic sepsis and pouch failure, it is often used as a means to protect the pouch anastomosis. However, in this study, while there was a higher rate of anastomotic leak, there was no difference in the pouch failure rate. And, interestingly the rate of readmission was higher in the ileostomy group. One third of patients had a postoperative complication following their ileostomy reversal, with three patients requiring a reoperation due to a leak at the ileostomy takedown site. In the modified two stage group, without a stoma, 23 patients (6%) required formation of a diverting ileostomy for their pouch‐anastomotic leak. Overall, the pouch failure rate was not different in the two groups. Therefore, the authors concluded that a diverting loop ileostomy should only be utilized in high risk patients with tension and obesity. In the future, it would be useful to have a randomized controlled trial comparing a three stage to a modified two stage ileal pouch anal anastomosis.
May 2019
Assessing the readability, quality and accuracy of online health information for patients with low anterior resection syndrome following surgery for rectal cancer
R. Garfinkle et al.
In the recent manuscript by Garfinkle et al. 1, the authors do a nice job highlighting the limitations of on‐line resources for an important topic – low anterior resection syndrome (LARS). LARS is a known complication following restorative rectal surgery defined by a constellation of bowel symptoms including frequency, urgency, clustering, and incontinence, all of which significantly affect patients’ quality of life. And, LARS is strikingly common, occurring in up to 90% of patients and causing major bowel dysfunction in 50%. Because many of our patients suffer from LARS postoperatively, it is important that relevant, accurate, and informative content be made available for those suffering from the symptoms. Unfortunately, what is highlighted in this manuscript is the lack of appropriate on line resources to help those with LARS. The information is often presented in a way that is not easily understood, and does not direct patients to treatment options and next steps of appropriate intervention. While not perfect, there are numerous options for LARS including dietary modification, physical therapy, and behavioral modification which can significantly improve the quality of life in these patients. However, without the appropriate direction and insight communicated, patients are left hopeless. With improved online resources, many patients may be exposed to treatment options. Future work should look to improve awareness and offer better on line resources for patients undergoing restorative operations. While this starts in the clinic with the treating physician, there is a great role for postoperative continuing education at home, on‐line.
April 2019
Synchronous colorectal carcinoma: predisposing factors and characteristics
C.‐C. Chin et al.
Synchronous colon cancer at initial index presentation is reported in at least 5% of patients. Risk factors for synchronous cancer include male sex, advanced age, and hereditary colorectal neoplastic conditions. However, the impact of synchronous cancers has yet to be determined. Chin et al. 1 herein report on over 17 000 colorectal cancer patients, of which 5.6% had a synchronous colorectal cancer, and describe synchronous lesions to be an independent risk factor for poor survival in stages I–III of colorectal cancer. While over half of patients had synchronous lesions found in the same segment of colon as the primary cancer, up to 45% were found in two to three segments. These findings, together, underscore the importance of completion colonoscopy prior to surgical intervention, when able to not miss undiagnosed lesions at the time of surgery.
Their study is particularly relevant in that only 0.2% of patients were lost to follow up, and the study spanned 1995–2016, encompassing years in which novel treatment modifications were introduced. There were no differences over time with respect to synchronous colon cancer continuing to be an independent risk factor for poor survival.
March 2019
Redo ileal pouch‐anal anastomosis: outcomes from a case–controlled study
C. Rossi, L. Beyer‐Berjot, L. Maggiori et al.
Rossi et al. 1 have put together a matched series of redo pouches as compared to primary pouch construction with regard to both short term morbidity and longer term functional results. Pouch revision or reconstruction is an important topic to highlight as up to 3–15% of pouches will fail, largely due to pelvic sepsis following the initial pouch construction. Without an option for pouch revision or reconstruction, these young patients would be subjected to a permanent stoma. In highly selected patients, treated at a high‐volume pouch center with reconstructive experience, patients may do very well following pouch reconstruction as has been previously reported 2, 3. Similar to these previous series, Rossi et al. underscored the finding that patients can do well after pouch construction, especially when performed in a trans‐abdominal fashion. In this series, the authors eloquently report that a trans‐abdominal pouch reconstruction proved superior to a transanal pouch reconstruction with less need for re‐intervention and superior long‐term functional results. In fact, bowel function, quality of life and sexual function not differ between a trans abdominal reconstructive pouch and primary pouch construction. And, 85% of patients had conservation of their pouch following trans‐abdominal reconstruction. These findings highlight that patients with pouch failure can be salvaged with a reconstruction pouch and expect good outcomes, when carefully selected and performed in high volume centers.
February 2019
Chronic immunosuppressant use in colorectal cancer patients worsens postoperative morbidity and mortality through septic complications in a propensity‐matched analysis
S. M. Sims, A. M. Kao, K. Spaniolas et al.
While the effect of immunosuppressive therapy on postoperative outcomes have been thoroughly evaluated in patients with inflammatory bowel disease, there are less outcome data in immunosuppressed patients undergoing surgery for colorectal cancer. Sims et al. 1 utilized the American College of Surgeons National Surgical Quality Improvement Program (ACS‐NSQIP) database to determine the effect of immunosuppression on 30‐day postoperative morbidity and mortality following surgery for colon and rectal cancer. As one might expect, the authors found an increased rate of 30‐day postoperative morbidity and mortality in the group receiving immunosuppression. While this is useful information and captures a large number of patients, there are important limitations to the ACS‐NSQIP database. First, the definition of ‘immunosuppression’ includes corticosteroids, immunomodulators and biologics. While we can assume that most of these patients are on corticosteroids, the database does not separate the patients into cohorts based on immunosuppressive type. From the literature in inflammatory bowel disease, we know that various immunosuppressives are more consistently shown to be higher risk for postoperative complications – corticosteroids are associated with increased postoperative morbidity 2, 3, immunomodulators do not appear to increase risk of postoperative morbidity 4, and biologic therapy remains controversial 3, 5, 6. Second, the definition of ‘immunosuppression’ does not, after 2011, include chemotherapeutic regimens which may contribute to perioperative complications. Third, there are no long term data to better understand if infectious complications or anastomotic leaks impact long term oncologic outcomes or stoma reversal rates. Despite these limitations, the authors point out that immunosuppression does increase morbidity, namely in the infectious complications as septic complications and surgical site infectious were increased while pulmonary, cardiovascular, renal, and neurologic complications remained unchanged. Therefore, holding immunosuppression, lowering doses, and having a lower threshold to divert low anastomoses may be warranted in patients undergoing abdominal surgery for colon and rectal cancer.
January 2019
Does transanal local resection increase morbidity for subsequent total mesorectal excision for early rectal cancer
C. Coton, J. H. Lefevre, C. Debove et al.
Coton C et al. 1 present a retrospective review on the morbidity following a total mesorectal excision (TME) performed after local excision of a T1 rectal cancer for adverse pathologic features. An increasing number of patients with a T1 mid to low rectal lesion are being offered transanal excision in order to prevent the functional morbidity of a transabdominal TME including low anterior resection syndrome or permanent stoma with an abdominoperineal resection 2. The unfortunate trade‐off is the increased rate of local recurrence with local excision as compared to radical resection, likely due to the undisturbed lymphatic system harboring positive lymph nodes in up to 10–20% of the cases 3. Unfortunately, it is difficult to predict who will have positive lymph nodes based on pathology at the time of local excision. In the study by Coton C, the histologic indications for TME following local excision included tumoral infiltration larger than T1sm2, R1 excision, lymphatic or vascular emboli and tumor budding. While the authors’ primary endpoint was 30‐day postoperative surgical morbidity among patients with TME following transanal excision vs initial TME, perhaps more interesting were the pathologic findings. At the time of TME following local excision for a. T1 rectal lesion, 32% had a T2 lesion and another 12% had a T3 lesion, and 34% had positive lymph nodes. This is strikingly high and supports the increased rates of local recurrence following transanal resection for a T1 lesion vs TME 2. Thus, the real question is: are we performing the safest operation, oncologically, for T1 rectal cancers? It is important to counsel patients about expected morbidity, and the potential for needing more radical resection following transanal excision which could result in additional postoperative morbidity. But, the more important counseling is the oncologic potential for understaging and having an increased risk of local recurrence in the pelvis. Yes, the authors suggest from the standpoint of short term postoperative morbidity, a TME following local excision is equivalent to TME at the initial operation even with regard to anastomotic leak (2.4% vs 2.4%) and permanent stoma (9.8% vs 4.9%). But, again, the high rate of lymph node positivity and 17% vs 5% defects in the mesorectum at the time of TME suggest that further investigation is needed about the long‐term oncologic implications of transanal resection for T1 rectal tumors. While salvage TME within 30 days may not result in worsened oncologic outcomes 4, overall transanal excision for T1 vs TME does result in significantly increased local recurrence 2. Without definitive predictors of high risk T1 lesions who need TME, we may be doing some of our patients is disservice by offering a transanal excision for a T1 lesion.
December 2018
Surgical management of haemorrhoids: an Italian survey of over 32 000 patients over 17 years
D. F. Altomare, A. Picciariello, G. Pecorella et al.
The authors present one of the largest series of prospectively maintained data from 32 458 patients treated for haemorrhoids during a 17‐year period (2000–2016) in several Italian referral centers. It included the era of PPH at the beginning of the 2000's and the rise of the novel non‐resection haemorrhoidal treatments at the turn of the 2010′s. The Doppler‐guided haemorrhoidal artery ligation alone procedure had unacceptably high recurrence rates for high grade haemorrhoids of up to 30% 2. With the addition of the mucopexy component (rectoanal repair) it replaced stapled haemorrhoidopexy as the number two technique in the treatment of grade III haemorrhoids. The authors report that non DG‐HAL techniques have gained in popularity which make the procedure less costly. Abandoning the Doppler proctoscope which had a questionable benefit for the success of this technique was already demonstrated by our own group and others 3.
The return to a conventional haemorrhoidectomy technique confirmed in the eTHOS trial for higher grade haemorrhoids (grade III and IV) parallels European strategies in the treatment of the most common proctological disorder in our daily practices and fits into recent guideline developments by the ESCP (https://www.escp.eu.com/guidelines#haemorrhoids).
November 2018
Predictors of complications and mortality following left colectomy with primary stapled anastomosis for cancer: results of a multicentric study with 1111 patients
G. Pellino, M. Frasson, A. García‐Granero et al.
Preoperative assessment and detection of risk factors for perioperative complications in colorectal surgery have gained increasing importance recently. Risk calculators for postoperative functional disorders are already in clinical use (e.g. POLARS Score, 2 and now Pellino et al. identify predictors of 60‐day anastomotic leakage (AL), complications and mortality after left colectomy using a mixed effects logistic regression model. Highlighting the shortcomings of prospectively collected registry data, the authors performed a multicentre snapshot audit of 1111 patients recruited within 1 year. Inclusion criteria were highly selective and excluded diverting stoma, rectosigmoid resections and benign resection. They show the usefulness of snapshot audits like these performed on behalf of the ESCP Cohort Studies and Audits Committee which facilitate a deeper insight into every day colorectal practice 3. They found that total parenteral nutrition (TPN) body mass index and non‐teaching hospital treatment are independent predictors of AL. Morbidity and mortality predictors were TPN, intake of corticoids, oral anticoagulants and urgent surgery. In IBD surgery, the dose of corticosteroids, and more information about early or late AL, unclear in this 60‐day observational cohort would have been useful to the reader.
Preconditioning and prehabilitation of our colorectal cancer patients using ERAS principles the use of malnutrition assessment tools in order to identify patients at risk, and the, need for different clinical management and preoperative strategies are highlighted in this article and push forward the limits of individualized surgery.
October 2018
Management of patients with incurable colorectal cancer: a retrospective audit
N. Thavanesan, M. Abdalkoddus, C. Yao et al.
Thavanesan et al. give a useful overview of the management and aftercare of incurable colorectal cancer. After discussions and decisions in the multidisciplinary team (MDT), however, they suggest that incurable cancer is re‐evaluated at follow‐up, especially after palliative chemotherapy. Incurable colorectal cancer and especially the management of side effects during follow‐up give colorectal surgeons inevitable problems and challenges 2. In their single‐centre study, the authors distinguish between patient and disease related reasons for the non‐curative first‐line treatment of colorectal cancer. They identified the extent of metastatic disease, frailty, patient choice, and locally advanced disease as the major contributors precluding curative surgery.
Patient‐related reasons like patient choice and frailty were significantly associated with longer median survival compared to disease‐related reasons such as metastatic or non‐resectable disease (277 days vs 179 days; P < 0.02). The disease‐related group underwent additional follow‐up interventions compared with the patient‐related group adding the valuable observation that our patients and their relatives must be well informed prior to making treatment decisions. Newer individualized treatment options, however, even in the initially non‐curative setting need to be re‐evaluated in the MDT and help to increase both quality of life and life expectancy.
September 2018
Resection with primary anastomosis vs nonrestorative resection for perforated diverticulitis with peritonitis: a systematic review and meta‐analysis
M. Gachabayov, C. E. Oberkofler, J. J. Tuech et al.
Gachabayov M et al. 1 present a systematic review on the ongoing hot topic–how to operate on perforated diverticulitis? The primary endpoint of this systematic review was postoperative mortality including overall mortality, mortality after emergency surgery and mortality after ostomy reversal. The overall mortality rate was 7.9% (29/366) in the primary anastomosis (PRA) group vs 19.5% (103/529) in the non‐restorative resection (NRR) group of patients [OR (95% CI) = 0.38 (0.24, 0.6); P < 0.0001]. However, a selection bias was highly evident in the majority of the investigated studies (14/17) with higher ASA score, Mannheim peritonitis index and higher proportion of faecal peritonitis in the NRR group. Clinical significance was further found in the secondary endpoints, morbidity after ostomy reversal, organ/space surgical site infection after emergency surgery, reoperation and non‐reversal of the ostomy. The latter showed a 31.8% stoma rate at the end of the observational period in the NRR group compared to 13.6% in the PRA group, which is comparable to the stoma rate of 17% in our small multicenter series of the damage control concept (DC) with delayed anastomosis with or without defunction 2.
The Hinchey classification was widely used and defined the inclusion criteria in this review. However, this encompasses only the different degrees of diverticulitis in a category of mild clinical diverticulitis, while the modified Hansen and Stock classification differentiates further between the perforated processes (micro‐/macroperforation, abscess size and localization) 3.
Unfortunately, too little attention has been paid so far to alternative interventions with delayed reconstruction like damage control surgery 2.
DC meets all the requirements for an emergency situation: short operating time, clearance of the septic focus, and better patient selection for definite reconstruction in a second operation. Moreover, this limited emergency procedure can be performed by a general surgeon not specialized in colorectal surgery. The estimated risk of overtreatment seems to be tolerably low if DC is used only in patients with generalized peritonitis.
To summarise, a strong recommendation for clinical practice in perforated diverticulitis cannot be given due to the high risk for performance and detection bias, short‐term follow‐up duration and a substantial heterogeneity in the definition of the study intervention. A closer look to alternative strategies like damage control are mandatory, and further randomized controlled trials including the damage control concept are required. Laparoscopic lavage, however, is controversial and is discussed regarding reoperation rates 4 and is thus poorly compared to the favoured strategy here of PRA.
August 2018
A systematic review and meta‐analysis comparing adverse events and functional outcomes of different pouch designs after restorative proctocolectomy
C. Simillis, T. Afxentiou, G. Pellino et al.
Technical developments in ileal pouch surgery for restorative proctocolectomy (RPC) over the last 20 years have led to a significant decrease in the rates of permanent end‐ileostomies and an increase in the use of the J‐pouch design. First described by Utsunomiya et al. in 1980 2 and popular due to its greater ease of construction by stapling in preference to other pouch styles (S‐, W‐, K‐pouches). The authors of this systematic review and meta‐analysis of thirty comparative studies include six randomized controlled trials with a total of 4098 patients analyzed. They conclude that although W‐, S‐ and K‐pouches show better functional results in the short‐term due to larger pouch volumes, the J‐pouch is still the most widely used in common clinical practice.
The problem with such analyses is the statistical shortcoming due to centre bias. This is also demonstrated in ‘Lessons learned from the Ileoanal Pouch Registry and the 2017 Ileoanal Pouch Report’ by Worley et al. 3 showing that the J‐pouch configuration was used in 99% of cases in the ACPGBI Ileoanal Pouch Registry which included 5352 pouch operations.
Pouch function settles down in a similar way to the function following colorectal reconstruction after low anterior resection, and in the long run with maturing pouches there is no disparity in function between pouch designs.
Still debateable are the potential pouch types used as salvage options after pouch failure and pouch excision Lightner AL et al. These are required in up to 10% of patients due to sepsis, poor function and pouchitis in the present review. Re‐do pouches are limited to reports from small series in specialized centres. And last but not least we should also take continent ileostomy creation (Kock pouch) into account. All these salvage strategies need further elucidation with demanding training courses and proctorships increasingly offered by national and international coloproctological societies.
July 2018
Full‐thickness neorectal prolapse after transanal transabdominal proctosigmoidectomy for low rectal cancer: a cohort study
M. Guraieb‐Trueba, A.R. Helber & J.H. Marks
Is functional deterioration really the prize for ultimate sphincter‐preserving surgery in low rectal cancer? Guraieb‐Trueba et al. highlight this question, and it is no longer academic when pushing the limits in rectal cancer surgery so far. Minimally‐invasive techniques including robotic surgery and transanal combined with abdominal approaches follow the classical TATA pathway with intersphincteric resection (ISR) or newer transanal TME (TaTME) techniques. These are likely to facilitate more distal resection margins with acceptable and non‐inferior oncological outcomes compared to abdomino‐perineal excision (APE). However, there is much concern about the functional outcome such as anal function and quality‐of‐life (QoL). They seem to deteriorate the more distal the resection is performed, with significant differences between the conventional laparoscopic and the open approach. Innovations in the transanal approach like TaTME claim to have a more nerve‐preserving and nerve-oriented focus due to a better overview, but long‐term data are still not yet available.
Guraieb‐Trueba et al. describe neorectal prolapse as a debilitating condition after restorative sphincter‐preserving low rectal resection and provide data on surgical management strategies for solving this problem.
Because of such admittedly rare complications of these techniques, both the need for an ISR and the likelehood of QoL impairment as a result of a functional disorder must be fully discussed with our patients before surgery.
June 2018
The timing of liver resection in patients with colorectal cancer and synchronous liver metastases: a population‐based study of current practice and survival
A.E. Vallance, J. van der Meulen, A. Kuryba et al.
When patients present with synchronous colorectal liver metastasis there are three main routes to choose; start with the bowel resection, start with the liver resection or do both at the same time. Either can of course be done with or without neoadjuvant chemotherapy. In this issue, Vallance et al. studied 1830 patients diagnosed with colorectal cancer in the UK 2010‐15 and going through bowel and liver resection. The differences between units were dramatic as some (13.6%) always did the bowel resection primarily while a similar number (14.4%) in more than half of the patients did the liver resection first or did a synchronous resection. Nationally there was also a time trend towards more patients having a synchronous resection or liver first, going from every fourth in the beginning to about every third at the end of the study period. The primary outcome was 4‐year survival and no differences were found between the three different strategies, not in general and nor in a propensity‐scored matched cohort. Of course there might be bias as to why patients are selected to the different treatment arms, and the use of adjuvant chemotherapy may of course also have an influence, both on the selection process and the outcome. As it seems from this study there is comfort in the finding that there is no truly inferior method. However, in order to really push our knowledge further more studies are needed in order to find which patients gain the most from which modality. An international randomized controlled study will be hard to complete, but in the field of colorectal cancer this must be one of the most prioritized questions in need of an answer.
May 2018
Anti‐TNF therapy is not associated with an increased risk of post‐colectomy complications, a population‐based study
S.T. Ward, J. Mytton, L. Henderson et al.
The possible adverse effect of different biologicals on post‐operative outcome have been evaluated in numerous publications regarding both ulcerative colitis (UC) and Crohn's disease. In the view of many colorectal surgeons the question is still unanswered. In this issue Ward et al. have made a large register based study of 6 225 patients with UC going through colectomy, comparing those with biologicals pre‐operatively (12%) with those not. No data regarding mortality is presented but biologicals were not found to be associated with an increased risk of post‐operative complications. The two factors found to be associated with such an increased risk were smoking and colectomy performed during an unplanned admission. Interestingly patients having a colectomy during the same hospital episode as their diagnosis with UC had a lower risk of post‐operative complications. This points towards an increased risk in patients with a long‐standing severe disease, and makes close collaboration between gastroenterologists and colorectal surgeons essential in making sure there are no unnecessary delays prior to surgery.
April 2018
Incidence and risk factors for parastomal bulging in patients with ileostomy or colostomy: a register‐based study using data from the Danish Stoma Database Capital Region
R.M. Andersen, T.W. Klausen, A.K. Danielsen et al.
In this issue, Andersen et al. 1, performed a one year follow up of all patients receiving a stoma at time of surgery. They could show that a peristomal bulging is a major problem, with a cumulative incidence of more than every third patient 400 days after surgery. Some previous risk factors of developing peristomal hernias could be shown, but also some more surprising ones as well as protective factors. In most cases inflammatory bowel disease (IBD) is associated with a worse outcome in surgery but regarding this issue it was found to be protective compared with cancer and diverticulitis. On the other hand laparoscopy and colostomy rather than ileostomy was found to have an increased risk. One of the advantages with laparoscopic procedures is the decreased risk of formation of adhesions and possibly could this rather be a disadvantage when a stoma is created. Speaking in favor of this possible correlation is the protective effect of IBD as especially Crohn's disease most often is associated with severe adhesions but at the same time surgery due to diverticulitis, another inflammatory condition, had an increased risk of peristomal bulging. Colostomies were far more often the cause of peristomal bulging compared to ileostomies. This is known from before but we still have not found the reason for this difference. Is it only the difference in the bowel lumen or could it be connected to the peristalsis of the bowel? Andersen et al. found placement of a peristomal mesh to be protective but we know from this and previous studies that this is not the perfect solution 2. For sure we need to understand the pathogenesis of peristomal bulging and herniation in more depth in order to improve the outcome.
March 2018
Risk factors for unfavourable postoperative outcome in patients with Crohn's disease undergoing right hemicolectomy or ileocaecal resection. An international audit by ESCP and S-ECCO. 2015 European Society of Coloproctology collaborating group
2015 European Society of Coloproctology collaborating group
Surgical research has often been accused of being very poor and of no or limited value in improving surgical care [1]. Historically we have published small or large series from single centres but more recently more high quality randomized controlled trials as well as prospectively collected register data. There has also been a more open approach to collaboration and a good example is the report on ileocolic resections for Crohn's disease, a subset from the 2015 European Society of Coloproctology collaborating group [2]. Together we can improve our knowledge and the surgical care of patients. The report raises a lot of interesting questions on how we treat our patients prior to surgery. Eighty-nine percent of the 375 patients received a primary anastomosis, despite 30% having hypo-albuminemia, 18% having an abdominal abscess pre-operatively (whereof only 26% were drained prior to surgery), 14% had urgent surgery (within 24 h), and 18% were on high dose steroids (= 20 mg) at time of surgery - all of these well known risk factors for post-operative septic complications [3]. The 30-day mortality was zero in this study but we need to watch out and work in close collaboration with our gastroenterologists. We do not want results like those in the recent publication on non-elective surgery in IBD from the state of New York with a 30-day mortality of 2.7% in Crohn's disease and 12.9% in ulcerative colitis [4].
February 2018
Reduced risk of emergency admission for colorectal cancer associated with the introduction of bowel cancer screening across England: a retrospective national cohort study
J. Geraghty, M. Shawihdi, E. Devonport, S. Sarkar et al.
The effects of screening programmes have often been questioned; do patients attend, will it make us detect cancers earlier or even prevent cancer, will it prevent cancer specific deaths, and most of all will it also improve the overall mortality? [1]. In this issue, Geraghty et al., [2] performed an analysis of a national bowel cancer screening programme and looked to see if it could have an influence on the frequency of emergency admissions due to colorectal cancer. Taking all patients with a new diagnosis of colorectal cancer in England during 1 year (n = 27 640) they could show that the risk of being admitted as an emergency had decreased from 6 months after the start-up of screening compared with patients not in a screening programme, adjusted odds ratio 0.83 (CI: 0.76-0.90). For comparison they also looked into the emergency admission rates for oesophageal and gastric cancers, not being included in a screening programme, where no decreased risk was seen during the same time frame. We know from previous studies that emergency procedures in colon cancer has a worse outcome [3] and now we have further evidence for the value of colorectal cancer screening.
January 2018
Pouch failures following ileal pouch–anal anastomosis for ulcerative colitis
A. Mark-Christensen, R. Erichsen, S. Brandsborg et al.
Mark-Christensen et al. perform a national cohort analysis on the long term outcome of restorative proctocolectomy in ulcerative colitis. Previous similar reports have found a number of factors associated with an increased risk of failure, e.g. pelvic sepsis, poor function, and pouchitis. Most of these are factors evident when they have already occurred and preferably one would like to have factors possible to improve or alter prior to the procedure itself. The authors evaluated 1991 ulcerative colitis patients restored with ileal pouch-anal anastomosis in Denmark during the period 1980–2013. Over a median follow up of 11.4 years 295 failures occurred with an annual failure rate of approximately 1% per year (18.2% at 20 years). Female gender, pouch creation without diversion and low hospital volume were all found to be associated with an increased failure rate. Denmark is an interesting country to follow regarding their national policy advocating centralization of less common surgical procedures like the pelvic pouch. Since there are only four centers doing pelvic pouches since 2010, taking these results into account, they seem to be doing the right things in Denmark.
December 2017
Doppler-guided goal-directed fluid therapy does not affect intestinal cell damage but increases global gastrointestinal perfusion in colorectal surgery: a randomized controlled trial
K.W. Reisinger, H.M. Willigers, J. Jansen et al.
Goal-directed fluid therapy (GDFT) is one of the central components of enhanced recovery after surgery (ERAS) programs. Early studies found a significant reduction in length of stay and also decreased morbidity and mortality associated with the use of GDFT in the setting of traditional care pathways. However, more recent trials have shown no significant benefit, particularly when an ERAS program is fully implemented, reflecting the difficulty in estimating the contribution of each specific component of the bundle of interventions. Moreover, there is also great controversy over the value that the different methodologies used for GDFT, such as Doppler, hemodynamic parameters from an arterial line or noninvasive cardiac output monitoring devices, can provide. In this issue, Reisinger et al. have performed a randomized controlled trial (RCT) with the aim of investigating the effect of Doppler guided GDFT on intestinal damage and gastrointestinal perfusion during colorectal surgery as compared with standard post-operative fluid replacement. It is important to emphasize that unlike previous studies, the authors do not only analyse clinical outcomes but also try to uncover the mechanisms responsible for these results. This RCT shows that Doppler guided GDFT during and after surgery for colorectal cancer increases global gastrointestinal perfusion but no differences were observed in length of stay or postoperative complications. The authors hypothesize that the benefits of fluid optimization might be clinically evident only in high-risk patients. Although the observed changes in gastrointestinal perfusion did not translate into lower morbidity, we must highlight the need for studies such as this in which not only clinical outcomes are investigated but also the mechanisms responsible for them. That is the only way to advance in the knowledge of surgery and provide better care to our patients.
November 2017
The effect of adjuvant chemotherapy on survival and recurrence after curative rectal cancer surgery in patients who are histologically node negative after neoadjuvant chemoradiotherapy
D. L. H. Baird, Q. Denost, C. Simillis, G. Pellino, S. Rasheed, C. Kontovounisios, P. P. Tekkis and E. Rullier
Despite several randomized controlled trials, the use of adjuvant chemotherapy in patients with rectal cancer after preoperative chemoradiation and total mesorectal excision is still controversial. In this issue, Baird et al. have performed a propensity-score-matched cohort study aimed to assess the benefits of adjuvant chemotherapy on the oncological outcome in rectal cancer patients who were staged with MRI node positive disease and their pathological staging was N0 after neoadjuvant treatment.
Although this is a retrospective study with a limited number of patients, propensity 2 to 1 matching between patients who did and did not receive adjuvant chemotherapy yielded two similar groups for most of the variables analyzed. After a mean follow-up of more than 3 years, the authors found no statistically significant differences in recurrence, disease-free and overall survival.
It is important to note that during the second half of the study period all patients received induction chemotherapy with 5-FU and oxaliplatin, and in some cases irinotecan, in addition to the long course chemoradiotherapy. In this regard, neoadjuvant chemotherapy first, followed by chemoradiation and surgery has been proposed to both target micrometastasis and increase tumor regression. This modification in their strategy may be responsible, at least in part, for the absence of differences between the two groups.
These results do not support giving adjuvant chemotherapy in patients with rectal cancer who are histologically node negative after neoadjuvant chemoradiation. However, I agree with the authors that a randomized controlled trial is required to be definitive about the benefits of adjuvant treatment in this setting.
October 2017
Lymph node yield in right colectomy for cancer: a comparison of open, laparoscopic and robotic approaches
M. Widmar, M. Keskin, P. Strombom, P. Beltran, O.S. Chow, J.J. Smith, G.M. Nash, J. Shia, D. Russell and J. García-Aguilar
The association between the number of lymph nodes retrieved during colectomy in non-metastatic colorectal cancer and survival has been demonstrated in multiple studies. In this issue, Widmar et al. hypothesized that, with its increased dexterity and visualization, robotic right colectomy would lead to higher lymph node yield and improved mesocolic excision. The authors performed a retrospective study comparing open, laparoscopic and robotic colectomy for cancer. The two primary endpoints for this study were total lymph node yield and the lymph node to length of surgical especimen, the latter as an indirect marker of the completeness of the mesocolic excision. Pathologic examination showed that the lymph node yield was highest among patients undergoing robotic colectomy compared to the other groups. In multivariable analysis, robotic right colectomy was associated with higher lymph node yield and lower lymph node to length of surgical specimen. Although the present analysis has several confounding factors which are difficult to eliminate, these results suggest that robotic surgery might facilitate a more complete mesocolic excision with low morbidity. Before this approach can be recommended, these findings should be validated in a prospective study with a more complete pathologic evaluation investigating also its influence on tumor recurrence and survival.
September 2017
C-reactive protein as a predictor of anastomotic leak in the first week after anterior resection for rectal cancer
I.S. Reynolds, M.R. Boland, F. Reilly, A. Deasy, M.H. Majeed, J. Deasy, J.P Burke and D.A. McNamara
In this issue, Reynolds et al., perform a retrospective study aimed to assess the ability of C-reactive protein (CRP) to predict anastomotic leakage in the first week post-anterior resection and to determine an optimal cut-off point for below which a leak was improbable. The authors analysed a cohort of 221 patients and found significant differences in mean CRP between patients with and without a leak in postoperative days 5, 6 and 7. Moreover, a CRP value of 132 mg/dl on postoperative day 5 had an area under the roc curve of 0.75. Although the positive predictive value was only 16.3%, the negative predictive value was 97.5% meaning that patients with a CRP below the cutoff point are unlikey to have an anastomotic leak, which facilitates an early and safe discharge. Although the usefulness of CRP as a negative predictive test for the development of anastomotic leakage after colorectal surgery has been demonstrated in previous investigations, the present study is particulary interesting because it focuses only in patients undergoing anterior resection for rectal cancer. Despite the defunctioning loop ileostomy performed in the majority of these patients minimizing the anastomic leak-induced systemic inflammation, postoperative serum CRP is still a useful biomarker in this group of patients.
August 2017
Resection of synchronous liver metastases between radiotherapy and definitive surgery for locally advanced rectal cancer: short-term surgical outcomes, overall survival and recurrence-free survival
K. J. Labori, M. G. Guren, K. W. Brudvik, B. I. Røsok, A. Waage, A. Nesbakken, S. Larsen, S. Dueland, B. Edwin and B. A. Bjørnbeth
The optimal therapeutic strategy in patients with locally advanced rectal cancer and synchronous resectable liver metastases is controversial. This is a particularly complex clinical scenario in which the multidisciplinary team must combine different treatments: neoadjuvant radiotherapy, total mesorectal excision, resection of liver metastases and systemic chemotherapy. The order in which these treatments are combined is very important since the prioritization of one location (e.g. surgical excision of the rectum) may impair an effective treatment of the other (the liver). In this issue, Labori et al., perform a retrospective analysis of a cohort of 45 patients with rectal cancer and synchronous liver metastases who underwent a modified liver-first approach. In this series, the majority of patients received upfront systemic chemotherapy with 5-FU combined with oxaliplatin or irinotecan followed by, in all cases, either short-course or long-course radiotherapy. The particularity of the therapeutic strategy presented in this study is that resection of liver metastases was performed in the interval between radiotherapy and surgery of the rectum. The main advantage of this combination is that it shortens the overall treatment time and there are no delays in the treatment of the primary tumor or metastasis. It is also safe and feasible because overall morbidity was low and 89% of patients completed the treatment-sequence. This modified liver-first approach should be considered as a therapeutic strategy in patients with locally advanced rectal cancer and synchronous resectable liver metastases.
July 2017
Relation between postoperative ileus and anastomotic leakage after colorectal resection: a post hoc analysis of a prospective randomized controlled trial.
Peters EG, Dekkers M, van Leeuwen-Hilbers FW, Daams F, Hulsewé KWE, de Jonge WJ, Buurman WA, Luyer MDP.
In this issue, Peters et al., perform a post-hoc analysis of a previous prospective RCT comparing specific measures to prevent postoperative ileus (POI) in patients undergoing open colorectal resection. The aim of this analysis was to investigate the relation of POI with inflammation and anastomotic leakage (AL). Markers of tissue damage and inflammatory response were determined in plasma before and after surgery. POI was diagnosed in 43 (38%) out of 112 patients included. AL was diagnosed in 9 of 43 patients with POI compared with only 1 of 65 patients in patients without POI (P <0.001). Postoperative plasma levels of inflammatory markers were significantly higher in patients with POI. The authors conclude that POI is associated with an increased inflammatory response and a higher prevalence of AL. It is well known that POI is often the first clinical expression of an AL. However, the present study suggests that, in some cases, the same inflammatory response that causes POI may be involved in the pathogenesis of AL. Although the inflammatory response to surgical trauma is part of the wound healing process, a magnified and persistent inflammation in the early postoperative course could have a detrimental effect on anastomotic healing. In fact, some of the measures aimed at decreasing POI also decrease the percentage of anastomotic leakage. Even though the present study has several limitations acknowledged by the authors, it provides new insights into the association between POI and AL.
June 2017
The association between intensified medical treatment, time to surgery and ileocolic specimen length in Crohn's disease
de Groof EJ, Gardenbroek TJ, Buskens CJ, Tanis PJ, Ponsioen CY, D'Haens GRAM, Bemelman WA
The article by de Groof et al. in this issue demonstrates that over time the interval between diagnosis and surgery in patients with ileocecal Crohn's increased and more patients had anti-TNF therapy. This raises the important question of whether patients are operated on too late and whether surgery is still ‘only’ a second, third or fourth line therapy? We are eagerly awaiting the results of the LIR!C-trial (NTR1150) comparing surgery and anti-TNF therapy in ileocecal Crohn's. Oral presentations of the results are promising.
May 2017
Developing and assessing a cadaveric training model for transanal total mesorectal excision: initial experience in the UK and USA
Penna M, Whiteford M, Hompes R, Sylla P
Ta-TME (Transanal Total Mesorectal Excision) is the new kid on the cancer block amoungst surgical techniques for patients with rectal cancer. Insufflation and transanal dissection of the mesorectal plane from below aim to improve margins, to increase pelvic nerve preservation and facilitate anastomosis in the lower pelvis. However, a new and unfamiliar view of the pelvic anatomy, with new surgical complications like urethral damage are just some of the rising challenges. The article by Penna et al. highlights the need for proper standardized training, courses, curricula, mentoring and outcome measurements.
April 2017
Magnetic resonance-based texture parameters as potential imaging biomarkers for predicting long term survival in locally advanced rectal cancer treated by chemoradiotherapy
Jalil O, Afaq A, Ganeshan B, Patel UB, Boone D, Endozo R, Groves A, Sizer B, Arulampalam T
MRI has become the corner stone in the treatment of patients with rectal cancer. It is essential for locoregional staging, determining the need for and the response to neo-adjuvant treatment. Furthermore, MRI features such as extramural venous infiltration can predict long-term outcome and MRI is used for surveillance in organ sparing strategies. In this issue, Jalil et al. describe new MRI-based texture parameters as potential imaging biomarkers predicting outcome. To be honest, I had to read the manuscript several times and still do not completely understand it. However, it is fascinating that different areas of the tumour pre- and post treatment analysed by software can predict survival. This might become another piece in the puzzle for personalized and tailored treatment of patients with rectal cancer.
March 2017
Anastomotic leaks can be detected within 5 days following ileorectal anastomosis: a case-controlled study in patients with familial adenomatous polyposis
Aziz O, Albeyati A, Derias M, Varsani N, Ashrafian H, Athanasiou T, Clark SK, Jenkins JT, Kennedy RH
Nobody likes anastomotic leaks, but unfortunately, they happen. While many studies exist on risk factors and preventive measurements (decontamination of the bowel by oral antibiotics being currently one of the most discussed), not much literature exists on early detection of a leak after the anastomosis has been performed. CRP has a high negative predictive value of 97% (< 124 mg/l at POD#4) [2] and some authors suggest measuring it routinely [3]. However, in a study by Aziz et al. in this issue, inflammation parameters such as CRP and others had no influence on detection of an anastomotic leak after ileorectal anastomosis for FAP. They found several other changes in physiological, blood tests and observational parameters that allowed early detection of an anastomotic leakage within 4.5 days after surgery. Such parameters could be helpful for early, proactive search and treatment of anastomotic insufficiencies. Further studies are needed to determine whether these parameters are also valid for other colon anastomoses in a less young and less healthy patient population.
February 2017
Symptom load and individual symptoms before and after repair of parastomal hernia: a prospective single centre study
Krogsgaard M, Pilsgaard B, Borglit TB, Bentzen J, Balleby L, Krarup PM
Although parastomal hernia is a frequent problem after placement of an ostomy, it is still not well defined, indications for surgical repair are not always clear, and its impact on quality of life is poorly studied. In this issue, Krogsgaard et al. analysed symptoms before and after parastomal hernia surgery. Pain, difficulties in wearing clothing and stoma appliance problems are the most commonly reported and also corrected symptoms, whereas social restrictions, leakage and skin problems do not seem to disturb many patients and are influenced little by surgical repair. This article highlights the patient's perspective and might guide us in selecting patients for parastomal hernia repair.
January 2017
Laparoscopic ventral mesh rectopexy vs Delorme's operation in management of complete rectal prolapse: a prospective randomized study
Emile SH, Elbanna H, Youssef M, Thabet W, Omar W, Elshobaky A, Abd El-Hamed TM, Farid M
In this issue, Emile et al., prospectively randomized ventral mesh rectopexy vs Delorme's procedure for full thickness rectal prolapse. Patients were younger (mean 39.7 years) than usual with nearly 40% being men. The authors attributed this to Schistosomal pelvic floor myopathy affecting mainly young males in Egypt predisposing to rectal prolapse. Both procedures were performed with a low morbidity and similarly improved preoperative symptoms as well as manometric measurements. There were also no significant differences in recurrence rates at 18 month, although Delorme's procedure had twice as many recurrences as ventral mesh rectopexy (16% vs 8%). Only longer follow-up will demonstrate if this difference remains non-significant. In ventral rectopexy, the mesh should be placed and fixed as close as possible to the pelvic floor. Due to the prostate and the erectile nerves in men this is more challenging than dissecting the recto-vaginal septum in female patients. This could explain some of the recurrences. Nevertheless, the study again demonstrates that we still not have found the perfect standard procedure for rectal prolapse as results were comparable. Rectal prolapse remains a challenging problem and the procedure, although I do not like this term as it gives no guidance especially for younger surgeons, should be tailored to the patient.
December 2016
Initial experience of restorative proctocolectomy for ulcerative colitis by transanal total mesorectal rectal excision and single-incision abdominal laparoscopic surgery
Leo CA, Samaranayake S, Perry-Woodford ZL, Vitone L, Faiz O, Hodgkinson JD, Shaikh I, Warusavitarne J
Transanal minimally invasive surgery (TAMIS) is ‘hot and happening’. The procedure was first described only 7 years ago by Lacy et al., and is becoming the most rapidly adapted technical development in colorectal surgery. The improved visibility and working space associated with this technique is intriguing, resulting in a more controlled and safe distal rectal dissection with minimal surgical trauma.
So, it is no surprise that the indications for this procedure are expanding and novel approaches are emerging. The current paper by Leo et al., reports for the first time a combination of transanal rectal excision with single incision surgery for restorative proctocolectomy in ulcerative colitis patients. The manuscript describes a prospective cohort study of 16 patients with a low complication rate (31% Clavien-Dindo 1–2), and only one anastomotic leakage. As this is a small series, no firm conclusions could be drawn, and the authors only conclude that it is a feasible alternative to open or multiport laparoscopic surgery. However, reading between the lines, one can appreciate the potential promises this procedure has to offer for pouch surgery: ‘easier dissection of the distal 5 cm of rectum while avoiding the use of multiple applications of the stapler’. Just think about the implication for daily practice. I can't help speculating about less anastomotic leakage, with a reduced need for defunctioning ileostomies, and less retained rectum with less cuffitis?
Obviously, the procedure requires further evaluation, especially regarding functional results. I am really looking forward to subsequent publications describing larger comparative series with long-term functional outcome.
November 2016
Initiation of adjuvant chemotherapy within 8 weeks of elective colorectal resection improves overall survival regardless of reoperation
Nachiappan S, Askari A, Mamidanna R, Munasinghe A, Currie A, Stebbing J, Faiz O
There is a wealth of literature analyzing the effect of delay in adjuvant chemotherapy for colorectal carcinoma. Most studies suggest that starting earlier rather than later is beneficial, and two meta-analyses show that delayed adjuvant chemotherapy significantly decreases overall survival. In the Netherlands, these results have led to an interesting discussion around the start of the COLOPEC study (adjuvant HIPEC in patients with colon cancer at high risk of peritoneal carcinomatosis), as some considered it unethical to possibly delay adjuvant chemotherapy for this additional intervention. Obviously, all series analyzing the optimal timing for adjuvant chemotherapy have been biased by the effect of a patient's postoperative performance on time to adjuvant chemotherapy, and most criticasters suggest that the demonstrated association is predominantly due to confounding factors (e.g. extensive surgery because of large tumors, postoperative complications, comorbid conditions, etc.). So far, no one knows…
But now there is the paper by Nachiappan et al. which clearly demonstrates that early adjuvant chemotherapy significantly increases overall survival, regardless of reoperative status in both colon and rectal cancer.
This interesting finding in 192 706 patients not only calls for speculation about the pathological mechanisms explaining this finding, but emphasizes that it is of crucial importance that patients will commence on adjuvant chemotherapy as soon as possible after their operation. As the authors discuss: ‘It is our responsibility to ensure prompt delivery and reduce delay’. Point well taken: I will share these results with my team, and incorporate it in our patient counseling, so that the whole team will do their utmost to prevent delay.
October 2016
A comparison of tumour and host prognostic factors in screen-detected vs non screen-detected colorectal cancer: a contemporaneous study
Mansouri D, McMillan DC, McIlveen E, Crighton EM, Morrison DS, Horgan PG
Current guidelines generally recommend screening for colorectal cancer from the age of 50, as there is compelling evidence that the benefits outweigh the risks. Screening can either prevent cancer by early polyp removal or improve disease-specific survival due to detection of early tumours.
As prognosis in colorectal cancer is directly related to stage, the beneficiary effect of screening is by no means a surprise. I have been wondering for a long time, however, whether improved survival is also related to a different biological entity of screen-detected (SD) tumours, with better prognosis than non-screen-detected (NSD) cancer. After all, it might be possible that we are (also) looking at the effect of length-time bias (i.e. artificially improved cancer outcome due to the identification of indolent slow growing tumours).
The study in this issue by Mansouri et al. assesses for the first time both host-factors and tumour-phenotype, in addition to tumour stage and site, within the context of a colorectal cancer screening programme. Compared to NSD tumours (both non-responders to screening and patients with interval tumours), patients with SD tumours had less advanced T-stage and less evidence of venous invasion. They had also less evidence of an elevated preoperative systemic inflammatory response. When adjustment was made for stage, however, the two key features representing phenotypically more aggressive tumours (i.e. venous invasion and poor differentiation) did not achieve statistical significance. Subgroup analysis comparing SD tumours with (more aggressive) interval tumours also did not show difference in prognostic factors when adjusted for stage.
The conclusion was therefore drawn that the inherent biological characteristics of SD tumours do not differ from those of NSD disease. I agree, although it should be realized that the present study represents a population setting where compliance to the screening programme was just over 50%, and only a minority of interval tumours was detected, which might have influenced the results.
So, although slightly reassured, I am still hoping for more studies which address this fascinating subject.
September 2016
Feasibility study from a randomized controlled trial of standard closure stoma site vs biological mesh reinforcement
On behalf of the Reinforcement of Closure of Stoma Site (ROCSS) Collaborative and the West Midlands Research Collaborative
I have enjoyed reading the feasibility study from the ROCCS trial (‘randomised controlled trial of standard closure of stoma site vs biologic mesh reinforcement’). Although the results are interesting, these are not the best part of the paper. It is above all an inspiring example of how surgical research can be, and should be performed. All involved in multicenter trials know the difficulty of fulfilling predicted accrual rates. Disturbing reports are emerging demonstrating that up to 50% of initiated trials is stopped prematurely, most often due to disappointing recruitment [2]. The majority of studies that have been published took much longer than anticipated, and include only a fraction of eligible patients. This results in questionable outcomes with reduced validity and limited generalizability.
The current feasibility study, led by a trainee research group, evaluated recruitment, percentage of eligible patients randomized, and safety of the surgical technique for mesh placement in different hospitals, before continuation to the main phase III trial. It was demonstrated that actual accrual rates exceeded anticipated rates. Within 12 months, > 90 patients were randomized in five centers (87% of eligible patients), and short-term results demonstrated safe incorporation of a biologic mesh into contaminated abdominal wound closure.
This report shows that ‘IDEAL’ preparation and good research infrastructure can improve trial delivery. It also emphasizes the value of engaging trainee research networks, facilitating recruitment and assuring rapid site set up. The successful model has been embraced by various European centers, leading to a multi-country phase III trial, recruiting 790 patients from 30 centers within 2,5 years! Hopefully, this inspiring initiative will lead to a culture of international surgical research practice.
August 2016
Appendiceal orifice inflammation is associated with proximal extension of disease in patients with ulcerative colitis
Anzai H, Hata K, Kishikawa J, Ishii H, Yasuda K, Otani K, Nishikawa T, Tanaka T, Kiyomatsu T, Kawai K, Nozawa H, Kazama S, Yamaguchi H, Ishihara S, Sunami E, Watanabe T
This interesting study demonstrates an increased incidence of appendiceal orifice inflammation (AOI) in patients with proctitis when compared to left-sided UC or pancolitis This finding had prognostic significance as subsequent proximal extension was seen in all patients with AOI.
In the literature AOI, or peri-appendiceal red patch (PARP), in UC is a frequently described phenomenon, but so far no clinical relevance has been attributed to the finding. There is increasing attention to the role of the little vermiform organ in UC, which has long been considered as ‘just an evolutionary redundancy’. Large epidemiological cohort studies have demonstrated the preventive effect of appendectomy during childhood on the development of UC. In addition, case series have suggested the improvement of UC after appendectomy, especially in young patients with PARP. Studies in UC-mouse models confirm that the appendix is involved in various immunological functions, although the molecular mechanism of the link between appendectomy and UC has not been resolved. Theories have been proposed that involve both an influence on the composition of the microbiota and homing of different immune cell populations.
Currently, two Randomised Controlled Trials in the UK and The Netherlands are being carried out to analyze the effect of appendectomy on the clinical course of UC (ACCURE 1 and 2). For everyone, like me, who is anxiously awaiting these results, this manuscript is a little appetizer suggesting that the appendix does have an intriguing role in UC, and that the idea of the appendix as a vestigial remnant should be discarded.
July 2016
Long-term results following an anatomically based surgical technique for resection of colon cancer: a comparison with results from complete mesocolic excision
Bokey L, Chapuis PH, Chan C, Stewart P, Rickard MJFX, Keshava A, Dent OF
The term ‘complete mesocolic excision’ (CME) for colon cancer was first introduced in 2009 by Hohenberger et al. [2]. It involves sharp separation of visceral and parietal fascia based on embryonic anatomy, and ligation at the root of central supply vessels leading to a more radical lymph node dissection.
This technique, it is suggested, improves the oncologic outcome of colon cancer patients, just like total mesorectum excision for rectal cancer. So far there are only a few studies reporting long-term results, and none that directly compares them to ‘non-anatomical dissection’. Although the term is relatively new, obviously ‘radical surgery’ has been performed for decades by many surgeons under different names (D3 resection, anatomical plane dissection, and so on). Various studies show an improved prognosis by more extensive resection, which is mostly attributed to the increased lymph node harvest leading to improved nodal staging accuracy [3, 4]. Nevertheless, the surgical technique itself probably also contributes, as Parson et al. [5] demonstrated - the percentage of stage 3 colorectal cancer remained the same with increasing lymph node yield.
In this study, Bokey et al. assess the long-term results of a standardized dissection technique based on anatomical planes with high vascular ligation for colon cancer. Included are 779 patients before the CME-era, and they compare these results to the only two studies presenting long-term CME outcome. The results are impressive. Although the median node count of 15 is only half that of Hohenberger et al., a lower 5-year local recurrence rate is seen (2.1% vs 4.9%), with an associated higher 5-year cancer-specific survival rate (89.8% vs 85%).
All high vascular ligation techniques emphasize the need to remove more lymph nodes. The results of this study suggest that there is at least a plateau phase in optimal harvest. Besides, the operation time is longer as the procedure is technically more challenging and complex, which may lead to more complications that could outweigh the oncological benefits. To gain insight into the additional value for daily clinical practice, an RCT might seem the optimal design at first sight. However, randomizing patients to non-anatomical dissection is unethical. Therefore a population based study would be preferable. This design always suffers from methodological problems like bias and confounding by indication, which is normally outweighed by the great advantage that it reflects current practice with large numbers of patients. However, that is only true when uniform terminology can be adopted. Bokey et al., discuss why ‘CME’ would not be the most appropriate term. Their suggestion of ‘anatomical dissection of the colon’ (ADC) is worth considering, and I recommend all colorectal surgeons and pathologists to read this manuscript. Although we should not end up in any name-discussion (after all, what's in the name?), this manuscript revives the awareness for the need of uniform quality parameters and terminology for mesocolic excision, so that we can start collecting and comparing data!
June 2016
The impact of complications on quality of life following colorectal surgery: a prospective cohort study to evaluate the Clavien-Dindo classification system
Bosma E, Pullens MJJ, de Vries J, Roukema JA.
Complications after colorectal surgery are unfortunately inevitable. Whilst we all recognize that a complication will have a detrimental effect on a patient's quality of life (QOL), it is can be difficult to counsel a patient about how long this impairment may last. In this months Colorectal Disease, the prospective cohort study by Bosma et al. has quantified the length of QOL impairment after complicated colorectal surgery in 218 patients. The study has also correlated the impaired QOL to the Clavien-Dindo classification and provides evidence that the conceptual framework of the Clavien-Dindo system is valid.
May 2016
Ligation of the intersphincteric fistula tract (LIFT) for the treatment of fistula-in-ano: tertiary care centre experience from South India
R. Parthasarathi, R. M. Gomes, S. Rajapandian, R. Sathiamurthy, P. Praveenraj, P. Senthilnathan and C. Palanivelu
The assessment and management of fistula-in-ano is something that coloproctologists perform on a frequent basis. For low simple fistulae the accepted and proven treatment is almost always fistulotomy. However, the management of more complex and high fistulae is more challenging with an ever expanding number of potential surgical options. The fact that so many techniques are described reflects the challenge of balancing the chance of cure against preservation of sphincter function. In this months Editor's choice study Parthasarthi et al. report their experience of the LIFT procedure in 167 patients with complex fistula. They report healing in 94% of patients at 12 months follow up. This study provides further evidence of the potential promise of the LIFT procedure to treat this challenging condition.
April 2016
Palliative surgical intervention in metastatic colorectal carcinoma a prospective analysis of quality life
Tan WJ, Chew MH, Tan IBH, Law JH, Zhao R, Acharyya S, Mao YL, Fernandez, LG, Loi CT, Tang CL.
Unfortunately around a fifth of patients diagnosed with colorectal cancer present with metastatic disease that is beyond cure. How to optimally manage a patient in this situation is an all too familiar scenario faced by the colorectal MDT. The aims of treatment are to optimize both the quantity and quality of that patient's remaining life. In the elective setting there is debate over whether to offer surgical resection of the primary tumour, with the evidence of the impact upon survival contradictory. Proponents of offering resection argue that it may improve survival and prevents primary tumour related complications and morbidity at a later date. Antagonists argue that primary resection does not improve survival and that the morbidity associated with surgery detracts from the patient's quality of life. This months Editor's Choice by Tan et al. reports the first prospective study of quality of life (QOL) in patients undergoing surgery for the primary tumour with unresectable metastatic disease. Their finding that QOL is improved at 3 and 6 months after surgery suggests concerns that surgery in this setting may have a deleterious impact on QOL are not supported by scientific data. Whilst the results of the SYNCHRONOUS trial are awaited the present study supports a decision to operate on the primary tumour in patient's with incurable distant disease.
March 2016
The outcome of fistulotomy for anal fistula at 1 year: a prospective multicentre French study
Abramowitz L, Soudan D, Souffran M, Bouchard D, Castinel A, Suduca JM, Staumont G, Devulder F, Pigot F, Ganansia R, Varastet M and for the Groupe de Recherche en Proctologie de la Société Nationale Francaise de Colo-Proctologie and the Club de Réflexion des Cabinets et Groupe d'Hépato-Gastroentérologie
In this study abramowitz et al. have evaluated the outcomes of one stage for low transphincteric and two high fistulotomy a year after surgery. they found that was associated with recurrence rates an improved quality life compared to fistula. in patients who required mild continence disturbance found. note nearly all would choose undergo surgery again. these results demonstrate again from patient s="s" perspective eradication sepsis discomfort is more important than small continence. lesson we sometimes forget when perusing sphincter saving techniques modest long term healing rates.
February 2016
Intersphincteric completion proctectomy with omentoplasty for chronic presacral sinus after low anterior resection for rectal cancer
G. D. Musters, W. A. Borstlap, W. A. Bemelman, C. J. Buskens and P. J. Tanis
Unfortunately, most colorectal surgeons will have experience of patients who have suffered an anastomotic leak after low anterior resection. Consequently many surgeons routinely defunction a low pelvic anastomosis. However, even with a diverting stoma in place a few patients will develop a chronic anastomotic sinus. Fortunately the incidence of this problem is low and therefore most individual surgeons have limited experience of managing this problem.
The paper in this issue by Musters et al. highlights some important aspects of managing the chronic pre-sacral anastomotic sinus in a reasonably large number of patients. Their experience underlines the need for definitive surgical treatment of this problem, without which the patient will endure the misery of chronic pelvic sepsis and be at potential risk of necrotizing fasciitis. Their finding that 96% of patients had received adjuvant radiotherapy suggests that the chance of spontaneous healing in the irradiated patient appears to be reduced. Improved outcomes were observed later in their series, when all rather than selected patients received an omentoplasty to fill the pelvic dead space. Whilst the importance and usefulness of an omentoplasty is not new, it is a lesson that should not be forgotten by the coloproctologist when faced with a patient with chronic pelvic sepsis, whatever the aetiology.
January 2016
The risk of definitive stoma formation at 10 years after low and ultralow anterior resection for rectal cancer
B. Celerier, Q. Denost, B. Van Geluwe, A. Pontallier and E. Rullier
Better understanding of the technical and oncological validity of restorative surgery for mid and low rectal cancer has increased the number of patients who could be considered potentially suitable for ultra low colorectal or coloanal anastomosis. However, most colorectal surgeons will be aware of patients whose bowel function and quality of life are poor following low anastomosis. With the benefit of hindsight these patients may have been better served by definitive end colostomy after total rectal excision. When patients are counseled for surgery it is our duty to explain the risks associated with and likely subsequent quality of life after the treatment. For a patient contemplating ultra low anastomosis after rectal excision we have reasonable data on the peri-operative risks of surgery and subsequent risk of not closing their defunctioning stoma. However, little has been known about the longer term rates of return to life with a stoma. In the present series Celerier et al. provide 10 year longitudinal follow up data on a series of nearly 300 patients treated by low colorectal or coloanal anastomosis, 60% had partial or total intersphincteric resection. They found the risk of definitive stoma rose from 11% at one year to 22% at 10 years with the risk greatest in patients over the age of 65 and in patients who had suffered peri-operative surgical morbidity. Interestingly, they found that intersphincteric resection was not associated with an increased risk of definitive stoma. These data should be helpful when counseling patients for low rectal cancer surgery.
October 2014
The influence of laparoscopy on incisional hernia rates: a retrospective analysis of 1057 colorectal cancer resections
A. Mishra, B. D. Keeler, C. Maxwell-Armstrong, J. A. Simpson and A. G. Acheson
The improvement in short term outcomes has validated the laparoscopic approach to colorectal surgery. Laparoscopic training has become well established and equipment and techniques have shown constant progression and development. Oncological outcome is essentially equal but late results in terms of hernia rate and adhesion related morbidity are still eagerly awaited. The present study addresses the hernia rate issue. In a retrospective study of well over a 1000 resections (28% laparoscopic) the authors found a hernia rate of just under 15%, most were confirmed by follow up CT scan, 1 in 4 patients needed surgery and more commonly after laparoscopic surgery, hernia rate was particularly high in laparoscopic to open converted patients and the parastomal hernia rate was double after laparoscopic procedures. In essence any breach of the abdominal wall may lead to a herniation and laparoscopic and open techniques lead to equal numbers of hernia, albeit of different type. It is of interest that when conversion is needed the hernia rate doubles and that parastomal hernia is twice as frequent after laparoscopic surgery. Good data always spawn new areas of research and the present paper is no exception.
July 2014
Not all patients need to be discussed in a colorectal cancer MDT meeting
J. Ryan and I. Faragher
The one commodity oncological specialists seem to lack is time and this may be partially caused by ever increasing, central, demands on multidisciplinary team (MDT) management of cancer patients. There is some evidence, but certainly not level I, that the introduction of MDTs has had a beneficial effect on outcome of rectal cancer patients (1). Some would argue that the management of colorectal cancer has become largely protocol based obviating the need for MDTs. The present paper argues that routine colorectal cancer patients should still be put on the MDT list but not be discussed because this would hardly ever change management. Only a minority of patients that fall outside predefined pathways should be discussed. This strategy would be time efficient. Because repetition is a powerful didactic tool it is questionable whether it would also be efficient in teaching junior medical and other staff. Coincident with the introduction of breast MDTs the complexity of breast cancer management has increased. It may well be that we find ourselves at the dawn of a similar development in colorectal cancer. This would almost certainly necessitate a re-definition of routine care-pathways and to my mind the logical place to do this is at the MDT meeting.
January 2014
First report: robotic pelvic exenteration for locally advanced rectal cancer
J. W. Shin et al.
The technical abilities of the surgical teams performing the pelvic exenterations described in the present series are such that they are capable of executing robotic exenteration safely. Obviously more expertise than just surgical is required, and the quality of the involved peri-operative teams must be excellent because not only did the patients survive the procedure they did so with minimal complications. Robotic exenteration is feasible in the hands of those that have become proficient at robotic rectal and/ or pelvic surgery.
The fact that only patients with primary T4 rectal cancer were included diminishes the generalizability of the study. One wonders what the advantages of a robotic approach would be when a partial or complete sacrectomy is part of planned radical surgery for local recurrence of rectal cancer. The face of rectal cancer surgery is changing rapidly and we are in dire need of patient specific, evidence based, treatment options and some standardization. It seems that we have just entered this era and it may well be that high tech, such as described in the present series, will become an integral part of the surgical management of rectal cancer. When that will happen is unclear but it is a sobering thought that open rectal cancer surgery is still the preferred option of many colorectal surgeons.
December 2013
Optimal plane for nerve sparing total mesorectal excision, immunohistological study and 3D reconstruction: an embryological study
M. M. Bertrand, B. Alsaid, S. Droupy, G. Benoit, M. Prudhomme
Rectal cancer surgery is challenging especially when it needs to be taught, be it in-vitro or in-vivo. A working knowledge of the pelvic planes has been established and is well recognised amongst colorectal surgeons. This has optimised the quality of our oncological resections and has reduced local recurrence rates to acceptable levels. We may have tamed the local recurrence issue but the problems of impaired post-operative urogenital function remain largely unchanged. Despite all the anatomical studies, surgeons still need better anatomical definitions and landmarks. The present anatomical study by Bertrand et al is a very fine example of one such study. The clarity of description, the anatomical detail and beautiful illustrations are all exemplary and serve to drive home a very important message on the anatomy of the inferior hypogastric plexus, Denonvilliers’ fascia, and the fascia propria of the rectum. This paper is a must read for those involved in rectal cancer surgery and a reference point for researchers of rectal anatomy.
November 2013
Application of a modified Neff classification to patients with uncomplicated diverticulitis
L. Mora Lopez, S. Serra Pla, X. Serra-Aracil, E. Ballesteros, S. Navarro
The management of sigmoid diverticulitis is clearly evolving towards a more conservative approach. It is remarkable that this change has not been driven by large RCTs but rather by audit driven surgical awareness of weighing operative risk and outcome against the long term risks of recurrent diverticulitis and associated diminished quality of life. New questions arise and whether it is safe to treat patients with uncomplicated sigmoid diverticulitis in an out-patient setting is one of them. The present article attempts to answer this question and in doing so also addresses the associated problem of identifying patients with uncomplicated diverticulitis. Using CT scanning in all patients the authors have modified the Neff score. Patients with signs of microperforation, localised free air but no abscess or free fluid, have been classified 1a and deemed suitable for out-patient management. Patients with significant co-morbidity and recurrent diverticulitis were excluded leaving 1 in 3 patients for out-patient management which was successful in well over 90% of these cases. This paper is interesting because it offers us a modified way of classifying patients with uncomplicated diverticulitis as well as excellent data on outpatient management in a well-defined and stratified group of patients.
October 2013
Stapled vs hand suture closure of loop ileostomy: a meta-analysis
J. Gong, Z. Guo, Y. Li, L. Gu, W. Zhu, J. Li, N. Li
Surgical meta-analyses may be confusing because often, due to poor quality of raw data, no firm conclusions can be drawn. Yet meta-analyses are here to stay and are considered to be at the highest levels of evidence. In this respect the paper by Gong et al. is reassuring because their meta-analysis on outcome of stapled vs hand-sewn ileostomy closure clearly favours the stapled technique. Major complications did not differ between the techniques but there was a very significant drop in early small bowel obstruction occurrence in favour of the stapled anastomosis. All other things being equal the authors clearly state that stapled ileostomy closure should be the procedure of choice. Interestingly there was no difference in outcome between randomized vs non-randomized studies which strengthens the conclusion. Yet confounding issues remain and the authors correctly address these. Hand-sewn anastomosis must, however, remain in the armamentarium of colorectal surgeons because every so often a technical problem forces our hand. For example the intestinal limbs may not be long enough for a side-to-side stapled anastomosis and in such cases a hand-sewn anastomosis may obviate the need for a re-laparotomy.
September 2013
Phase II study of concomitant chemoradiotherapy with local hyperthermia and metronidazole for locally advanced fixed rectal cancer
Yu. A. Barsukov, S. S. Gordeyev, S. I. Tkachev, M. Yu. Fedyanin, A. G. Perevoshikov
One of the aims of Colorectal Disease is to be the pan-European forum for the dissemination of colorectal research. In the past it has been difficult, for obvious reasons, to attract papers from Eastern Europe but this has changed in recent years.
The present paper from Russia is an excellent example of great research that is timely and clinically relevant. In a Phase II trial the authors set out to analyse the effect of adding localhyperthermia to neo-adjuvant chemoradiotherapy in patients with true T4 rectal cancer.
August 2013
Randomized controlled trial: comparison of two surgical techniques for closing the wound following ileostomy closure: purse string vs direct suture
N. Dusch, D. Goranova, F. Herrle, M. Niedergethmann, P. Kienle
Sometimes we need a clinical illustration of a much used surgical adage – better is the enemy of good – to bring us back to the normal messy life of colorectal surgery. This is exactly what Dusch et al. are offering us in their analysis of a randomized trial comparing two different techniques of ileostomy wound closure. They have shown that it is better to leave the skin partially open to heal by secondary intention than to try to close the wound under tension to heal primarily. At a minimal cost of some 4 weeks prolonged healing time the semi-open approach prevented a surgical site infection in 1 of 4 patients, treated with skin closure, without negative effects on cosmetic appearance. This RCT elegantly brings us back the surgical principles of wound management which seem not to have lost any of their significance
July 2013
Is colectomy for fulminant Clostridium difficile colitis life saving? A systematic review
D. B. Stewart, C. S. Hollenbeak, M. Z. Wilson
From a hospital, insurer and societal perspective, Clostridium difficile (C. difficile) infection poses a major financial strain on the health system. From the patient's perspective, hospital-acquired C. difficile infection may run the gamut from diarrhoea causing minor discomfort to prolonged hospital stay and on to life-threatening enterocolitis associated with mortality rates exceeding 50%. Adult C. difficile fulminant colitis is on the rise and treatment standards, be they medical or surgical, have not been set. This is discussed in the present systematic review with a view to determine whether emergent colectomy has a role to play, or may even be preferable to medical management, in fulminant C. difficile colitis. The systematic review assessed six papers that compared the outcome of medical versus surgical treatment in just over 500 patients. The authors duly acknowledge the limitations of the review but conclude firmly that colectomy has its role in the management of fulminant C. difficile colitis refractory to medical management. The management of fulminant C. difficile is certainly not set in stone and is in need of further research. Awareness of the condition and early recognition of patients failing medical management, probably before patients go to the intensive care unit, is essential. This requires a multidisciplinary approach as with any patient with acute fulminant ulcerative colitis. The issues of exact timing of surgery and whether we should do a colectomy, loop ileostomy and colonic lavage or other procedures need clarification and this will no doubt spawn future research.
June 2013
A randomized placebo controlled trial of preoperative carbohydrate drinks and early postoperative nutritional supplement drinks in colorectal surgery
P. Lidder, S. Thomas, S. Fleming, K. Hosie, S. Shaw, S. Lewis
Despite all efforts to improve the technical aspects of colorectal surgery, a significant number of patients still face the consequences of major and minor postoperative complications. In recent years we have come to understand that a number of general factors may negatively influence the outcome of colorectal resection.
Insulin resistance plays a pivotal role and its prevention or early reversal is central to enhanced recovery programmes. Whether or not this should be done through preoperative carbohydrate loading, postoperative nutritional supplements or both is unclear. The present randomized controlled trial set out to answer this issue.
In a remarkable trial the authors have recruited almost 50% of eligible patients, have secured complete follow-up and have been brutally honest about their results. Their primary end-point was reduction of insulin resistance, and this was achieved best in the combined preoperative carbohydrate/postoperative nutritional supplements group. Hand grip strength improved and complications were down in this group, although the authors downplay this because it was not a primary end-point of the study.
The authors have reported complications in 40% of the patients, anastomotic leakage in 7.5% of the patients, and planned discharge at seven days. These may seem unfavourable results, but to me they point to the honesty and scrupulous reporting by this group and lend credibility to the data. The bitter pill of colorectal surgery may be sweetened by combining preoperative carbohydrate loading with postoperative nutritional supplements in a fast track setting.
May 2013
Preliminary outcome of a treatment strategy based on perioperative chemotherapy and surgery in patients with locally advanced colon cancer
J. Arredondo, C. Pastor, J. Baixauli, J. Rodríguez, I. González, C. Vigil, A. Chopitea, J. L. Hernández-Lizoáin
Neo-adjuvant chemotherapy has claimed its place in the treatment of a number of locally advanced solid tumours. Current RCTs like the Foxtrot trial are examining its role in locally advanced, but operable colon cancer.
The results are eagerly awaited but in the meantime results from well executed studies may be of help in further delineating the clinical use of neo-adjuvant chemotherapy in patients with locally advanced colon cancer.
The study by Arredondo et al. is a good example of a well designed study protocol. Careful patient inclusion and sensible exclusion criteria led to a homogenous study-group. Significant down-grading, perfect radical resection, and impressive short-term survival rates were shown. As stated by the authors, the effect may have been partially caused by treatment of over-staged tumours, which should have been treated by primary resection and adjuvant chemotherapy if indicated.
A case of short-term local recurrence was observed but one wonders whether the denominator, to put this into perspective, should have included all patients or just those who really had Stage III disease.
Other questions include the 9% leak rate possibly associated with early surgery following chemotherapy. Despite these issues, neo-adjuvant therapy may well be the answer to improving local control of locally advanced colon cancer, provided we get our preoperative staging right.
April 2013
Familial colorectal cancer risk assessment needs improvement for more effective cancer prevention in relatives
N. Dekker, R. P. M. G. Hermens, F. M. Nagengast, W. A. G. van Zelst-Stams and N. Hoogerbrugge on behalf of the RISCO study group
In the past two decades major advances in colorectal cancer treatment have improved the outlook for numerous patients suffering from this disease. Their lease on life has been prolonged and this has, most fortunately, been paralleled by an increase in quality of life. We are getting better at treating colorectal cancer and it is therefore timely to focus on prevention.
Although not supported by scientific data, one of the most frequently asked questions in outpatients is: what about my children, do they need screening? To assist in answering this question many guidelines have been developed. The present study set out to determine if clinical practice adhered to these guidelines.
The end points of the study were assessment of and correct interpretation of familial risk, and determination of and correct recommendation of preventive measures. The authors also present a theoretical knowledge survey among 312 clinicians. The good news is that in the majority of patients a family history was obtained. The bad news is that the family risk was interpreted incorrectly or not communicated to the patients, two thirds of whom were deemed to be at high familial risk.
Had they been advised by a clinician the vast majority of these patients would have sought genetic counselling. Surveillance colonoscopy for relatives of moderate risk patients was recommended in only half. Clearly there is room for improvement. The knowledge survey, included in this paper, may provide answers. Family risk was assessed and acted upon following guidelines in only two thirds of patients. It would seem that clinical genetics has not yet claimed its proper place in the multi-disciplinary treatment of patients with colorectal cancer and their relatives. The present paper clearly suggests that the time has come.
March 2013
Clinicopathological characteristics of T1 colorectal cancer without background adenoma
K. S. Han, S. W. Lim, D. K. Sohn, et al.
We have all been in the uncomfortable situation of deciding on major salvage surgery after minimal resection of a T1 colorectal adenocarcinoma. We worry about local recurrence and under-staging of involved lymph nodes. Some progress has been made to identify histopathological criteria indicative of lymph node involvement.
Some of these are flat or depressed tumour type, tumour size, SM 2/3 depth, tumour budding and tumour grade. Han et al. have looked at this issue from a different perspective and have analysed whether tumour pathways are in any way related to tumour behaviour.
The well-known adenoma–carcinoma pathway most likely driven by K-ras mutations and a de novo pathway, without background adenoma (BGA), probably driven by BRAF mutations were analysed. In a large group of 590 T1 colorectal cancer patients it was shown that de novo T1 tumours without BGA were smaller and more of a flat/depressed type, showed deeper SM involvement, had increased tumour budding and lymph node involvement than T1 tumours with BGA.
The authors concluded that de novo carcinomas may be more invasive than tumours arising through the adenoma–carcinoma pathway. This is of great interest to TEM surgeons but it may also assist surgeons and gastroenterologists to decide whether or not to pursue colonic salvage surgery.
February 2013
The WIMAT colonoscopy suitcase model: a novel porcine polypectomy trainer
J. Ansell, K. Arnaoutakis, S. Goddard, N. Hawkes, R. Leicester, S. Dolwani, J. Torkington and N. Warren
Surgeons are, by nature, eager to try new procedures and tools to improve patient care. This has not always been preceded by adequate training in properly validated teaching models. Ansell et al. address some of these issues in a paper on a new training model for interventional colonoscopy. In an ex vivo porcine model this group has elegantly shown that polypectomy may be taught efficiently because of the model's superior mucosal realism, endoscopic snare control and polyp handling. It may therefore be a more effective training model than virtual reality models. The paper also describes how teaching models should be validated and is a must-read if only for this reason.
January 2013
Diagnostic accuracy of narrow-band imaging for the differentiation of neoplastic from non-neoplastic colorectal polyps: a meta-analysis
L. Wu, Y. Li, Z. Li, Y. Cao, F. Gao
The field of endoscopy has evolved in recent years to become almost self-contained in terms of diagnosis, treatment and even microscopic assessment of colorectal polyps. Technical development of endoscopic equipment, making endoscopic mucosal and sub-mucosal dissection possible, has been phenomenal. But all new toys need to be assessed in light of their clinical, and ultimately health-economical, value. In this meta-analysis Wu et al. studied the accuracy of NBI to differentiate neoplastic from non-neoplastic disease. Some 11 studies that analysed 1351 polyps were included and it was found that NBI, with or without magnification, had a sensitivity of 0.92, a specificity of 0.83 and an area under the curve of 0.95. We have entered the era of colorectal screening and we will be picking up a significant number of non-neoplastic polyps. The present findings may help endoscopists to select polyps for excision and histological examination. This would reduce cost and, more importantly, polypectomy associated morbidity.
December 2012
Laparoscopy in the surgical treatment of rectal cancer in Germany 2000–2009
P. Mroczkowski, S. Hac, B. Smith, U. Schmidt, H. Lippert, R. Kube
Results from randomized studies may differ from those obtained from large prospective multi-centre databases. The study by Mroczkowski et.al. is a case in point. A large rectal cancer resection database containing almost 18,000 patients, operated in 345 hospitals, was analysed. Open resections were compared to laparoscopic resections that were done in just under 10% of the total. Not surprisingly patients did better after completed laparascopic resection, confirming data form randomised studies, but fared much worse after conversion to open resection. The authors make a bold, but probably justified, statement that at least in Germany the surgical community is not ready to accept and introduce laparoscopy as the new gold standard in rectal cancer treatment. Is this to do with laparoscopy per se or is this mainly to do with an inadequate number of training facilities and maintaining adequate hospital volume levels. This paper, like so many good papers, raises more questions than it provides answers.
November 2012
Perceived information after surgery for colorectal cancer – an explorative study
M. Lithner, J. Johansson, E. Andersson, U. Jakobsson, I. Palmquist, R. Klefsgard
We live in an information era. We may be quite good at gathering information but in this issue Lithner et.al. have shown that there is room for improvement in sharing our information. They have shown that almost 50% of patients did not recall, or were not given, specific information regarding the peri-operative process of their colon cancer surgery. Patients could not recall that specific information was given about the possible results of surgery, how to handle symptoms when at home and prognostic information about their future. These are important findings that should encourage us to adept our information programs and tailor them to the needs of the patient at specific and pre-defined moments in their treatment process.
October 2012
Functional disorders after rectal cancer resection: does a rehabilitation programme improve anal continence and quality of life?
A. Laforest, F. Bretagnol, A. S. Mouazan, L. Maggiori, M. Ferron, Y. Panis
In this controlled study, functional outcome and quality of life are compared in patients undegoing laparascopic TME with and without post-operative anal sphincter training. Weekly one-hour sessions with a specialised physiotherapist consisted of pelvic floor excercises, and biofeedback. Trained patients showed better functional outcome, especially reduced urgency, and subsequent improvement in quality of life. TME, laparoscopic or open, remains one of the most challenging procedures for colorectal surgeons. We tend to focus on controlling the technical aspects of TME to minimize postoperative complications and reduce the number of local recurrences. Oncological outcome has improved but from a patient’s perspective quality of life may be equally important. Technically demanding procedures, like TME, are by necessity multi-disciplinary and all disciplines, including specialised physiotherapists, need to work in unison to secure the best outcome.
September 2012
Short-term outcome following percutaneous tibial nerve stimulation for faecal incontinence: a single-centre prospective study
A. Hotouras, M. A. Thaha, D. J. Boyle, M. E. Allison, A. Currie, C. H. Knowles, C. L. H. Chan
In this prospective series the short-term results of Tibial Nerve Stimulation (TNS) are promising . In 85 patients with urge or mixed type fecal incontinence the Cleveland score improved significantly by about 30%, and 15 patients with passive incontinence did not benefit from TNS. Improved control, although it may appear to be only modest, did lead to a better quality of life in this series. Long-term results are eagerly awaited and TNS should be pitched against other invasive procedures in randomised studies. TNS is a rather straighforward minimal-invasive procedure that, after exhausting conservative options, may become a procedure of choice in patients with urge and mixed type fecal incontinence.
August 2012
Learning the hard way: the importance of accurate data
R. S. Lewis, D. G. Graham, J. D. Watson, P. J. Lunniss
This paper is about a rather small colorectal unit trying to come to grips with the frustration produced by the discrepancy between their perceived performance and NBOCAP performance. This is a sentiment that is most likely shared by many of us. After pulling all the records the authors noted large differences between data recorded by clinicians or administrative staff. The authors concluded that clinical and administrative staff need to work in close co-operation to ensure accurate and complete recording of patient data. If all centres that contribute to NBOCAP would record data in exactly the same way, Figures 1 and 2 of this paper could have true meaning. However, administrative data cannot represent the continuous time series of data points of a patient's treatment . The sad message is that although we might perhaps know what is happening we would still be left in the dark as to why it is that centres, surgeons or patients perform better.
July 2012
Thrombo-prophylaxis in colorectal surgery: a National Questionnaire Survey of the members of the Association of Coloproctology of Great Britain and Ireland
N. Srinivasaiah, R. Arsalani-Zadeh, J. R. Monson
This UK based Questionnaire Survey by Srinivasaiah et.al., is timely and shows us that peri-operative, in-hospital, use of thrombo-prophylaxis (medical and mechanical) is used nationwide in accordance with departmental guidelines by ACPGBI members who are inclined to fill in questionnaires. That was the good news. The bad news is that large variation exists in start-date of prophylaxis and that the stop-date, usually the date of discharge, is nowhere near the recent recommendation to prolong thrombo-profylaxis for at least 4 weeks after discharge, certainly in those patients who are at increased risk of developing DVT. This paper should act as a national, and international, wake-up call to continue thrombo-prophylaxis after colorectal surgery, especially for malignant disease, for a minimum of 28 days.