30-day Morbidity and Mortality after Cholecystectomy for Benign Gallbladder Disease (AMBROSE): A Prospective, International Collaborative Cohort Study.

OBJECTIVE: This study aimed to assess 30-day morbidity and mortality rates following cholecystectomy for benign gallbladder disease and identify the factors associated with complications. SUMMARY BACKGROUND DATA: Although cholecystectomy is common for benign gallbladder disease, there is a gap in the knowledge of the current practice and variations on a global level. METHODS: A prospective, international, observational collaborative cohort study of consecutive patients undergoing cholecystectomy for benign gallbladder disease from participating hospitals in 57 countries between January 1 and June 30, 2022, was performed. Univariate and multivariate logistic regression models were used to identify preoperative and operative variables associated with 30-day postoperative outcomes. RESULTS: Data of 21,706 surgical patients from 57 countries were included in the analysis. A total of 10,821 (49.9%), 4,263 (19.7%), and 6,622 (30.5%) cholecystectomies were performed in the elective, emergency, and delayed settings, respectively. Thirty-day postoperative complications were observed in 1,738 patients (8.0%), including mortality in 83 patients (0.4%). Bile leaks (Strasberg grade A) were reported in 278 (1.3%) patients and severe bile duct injuries (Strasberg grades B-E) were reported in 48 (0.2%) patients. Patient age, ASA physical status class, surgical setting, operative approach and Nassar operative difficulty grade were identified as the five predictors demonstrating the highest relative importance in predicting postoperative complications. CONCLUSION: This multinational observational collaborative cohort study presents a comprehensive report of the current practices and outcomes of cholecystectomy for benign gallbladder disease. Ongoing global collaborative evaluations and initiatives are needed to promote quality assurance and improvement in cholecystectomy.

European Society of Coloproctology: Guidelines for diagnosis and treatment of cryptoglandular anal fistula.

AIM: The primary aim of the European Society of Coloproctology (ESCP) Guideline Development Group (GDG) was to produce high-quality, evidence-based guidelines for the management of cryptoglandular anal fistula with input from a multidisciplinary group and using transparent, reproducible methodology. METHODS: Previously published methodology in guideline development by the ESCP has been replicated in this project. The guideline development process followed the requirements of the AGREE-S tool kit. Six phases can be identified in the methodology. Phase one sets the scope of the guideline, which addresses the diagnostic and therapeutic management of perianal abscess and cryptoglandular anal fistula in adult patients presenting to secondary care. The target population for this guideline are healthcare practitioners in secondary care and patients interested in understanding the clinical evidence available for various surgical interventions for anal fistula. Phase two involved formulation of the GDG. The GDG consisted of 21 coloproctologists, three research fellows, a radiologist and a methodologist. Stakeholders were chosen for their clinical and academic involvement in the management of anal fistula as well as being representative of the geographical variation among the ESCP membership. Five patients were recruited from patient groups to review the draft guideline. These patients attended two virtual meetings to discuss the evidence and suggest amendments. In phase three, patient/population, intervention, comparison and outcomes questions were formulated by the GDG. The GDG ratified 250 questions and chose 45 for inclusion in the guideline. In phase four, critical and important outcomes were confirmed for inclusion. Important outcomes were pain and wound healing. Critical outcomes were fistula healing, fistula recurrence and incontinence. These outcomes formed part of the inclusion criteria for the literature search. In phase five, a literature search was performed of MEDLINE (Ovid), PubMed, Embase (Ovid) and the Cochrane Database of Systematic Reviews by eight teams of the GDG. Data were extracted and submitted for review by the GDG in a draft guideline. The most recent systematic reviews were prioritized for inclusion. Studies published since the most recent systematic review were included in our analysis by conducting a new meta-analysis using Review manager. In phase six, recommendations were formulated, using grading of recommendations, assessment, development, and evaluations, in three virtual meetings of the GDG. RESULTS: In seven sections covering the diagnostic and therapeutic management of perianal abscess and cryptoglandular anal fistula, there are 42 recommendations. CONCLUSION: This is an up-to-date international guideline on the management of cryptoglandular anal fistula using methodology prescribed by the AGREE enterprise.

Chronic pain after colon cancer surgery: Translation and validation of a scoring system.

OBJECTIVE: The aim of this study was to translate and validate the chronic pain score (CP score) in a cohort of colon cancer patients. Chronic pain following colon cancer surgery is still poorly understood, in particular the lack of a validated tool for measuring chronic pain is a major issue as such an instrument is critical for evaluating the incidence and risk factors. The CP score was created using data from Danish rectal cancer patients. METHODS: Danish colorectal cancer survivors diagnosed between 2001 and 2014 completed the CP score and two quality of life (QoL) measures. Clinical data were obtained from a national database. Convergent validity was investigated by testing the association of the CP score with a single ad hoc QoL item and the EORTC QLQ-C30, and discriminative validity was tested as the score's ability to differentiate between gender and age groups. Sensitivity and specificity were evaluated by determining the ability of the score to identify patients with a major impact of pain on QoL. RESULTS: Responses from 7127 colon cancer were included. Convergent validity was confirmed, as the score was associated with both QoL measures (p < 0.001). Moreover, the score could differentiate between males/females and older/younger patients (p < 0.001, respectively), reflecting high discriminative validity. Finally, the score was able to identify patients with a major impact on QoL, with a sensitivity of 87% and specificity of 82%. CONCLUSION: The CP score is a valid tool for measuring chronic pain after colon cancer surgery and should be used to homogenize outcomes in future studies.

Surviving rectal cancer at the cost of a colostomy: global survey of long-term health-related quality of life in 10 countries.

BACKGROUND: Colorectal cancer management may require an ostomy formation; however, a stoma may negatively impact health-related quality of life (HRQoL). This study aimed to compare generic and stoma-specific HRQoL in patients with a permanent colostomy after rectal cancer across different countries. METHOD: A cross-sectional cohorts of patients with a colostomy after rectal cancer in Denmark, Sweden, Spain, the Netherlands, China, Portugal, Australia, Lithuania, Egypt, and Israel were invited to complete questionnaires regarding demographic and socioeconomic factors along with the Colostomy Impact (CI) score, European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ-C30) and five anchor questions assessing colostomy impact on HRQoL. The background characteristics of the cohorts from each country were compared and generic HRQoL was measured with the EORTC QLQ-C30 presented for the total cohort. Results were compared with normative data of reference European populations. The predictors of reduced HRQoL were investigated by multivariable logistic regression, including demographic and socioeconomic factors and stoma-related problems. RESULTS: A total of 2557 patients were included. Response rates varied between 51-93 per cent. Mean time from stoma creation was 2.5-6.2 (range 1.1-39.2) years. A total of 25.8 per cent of patients reported that their colostomy impairs their HRQoL 'some'/'a lot'. This group had significantly unfavourable scores across all EORTC subscales compared with patients reporting 'no'/'a little' impaired HRQoL. Generic HRQoL differed significantly between countries, but resembled the HRQoL of reference populations. Multivariable logistic regression showed that stoma dysfunction, including high CI score (OR 3.32), financial burden from the stoma (OR 1.98), unemployment (OR 2.74), being single/widowed (OR 1.35) and young age (OR 1.01 per year) predicted reduced stoma-related HRQoL. CONCLUSION: Overall HRQoL is preserved in patients with a colostomy after rectal cancer, but a quarter of the patients interviewed reported impaired HRQoL. Differences among several countries were reported and socioeconomic factors correlated with reduced quality of life.

Multicenter validation of the PREDICT score for prediction of local recurrence after total mesorectal excision of rectal cancer.

BACKGROUND: Total mesorectal excision (TME) is the gold standard treatment for rectal cancer. Although TME has managed to decrease the rates of local recurrence after rectal cancer resection, local recurrence is still recorded at varying rates. The present study aimed to validate the PREDICT score in the prediction of local recurrence of rectal cancer after TME with curative intent. METHODS: This was a retrospective multicenter study on patients with nonmetastatic low or middle rectal cancer who underwent TME. The total PREDICT score was calculated for every patient and related to the onset of local recurrence. According to the final score, patients were allocated to one of three risk groups: low, moderate, and high, and the rates of local recurrence in each group were calculated and compared. RESULTS: The present study included 262 patients (50.4% males) with a mean age of 47.1 years. The overall local recurrence rate was 12.6%. 29.4% of patients were in the low-risk group, 63.7% in the moderate-risk group, and 6.9% in the high-risk group. The local recurrence rate was 3.9% (95% confidence interval [CI]: 0.8-10.9) in the low-risk group, 13.2% (95% CI: 8.4-19.3) in the moderate risk group, and 44.4% (95% CI: 21.5-69.2) in the high-risk group (p < 0.0001). The sensitivity of the PREDICT score was 72.7%, the specificity was 88.1%, and the accuracy was 86.3%. CONCLUSIONS: The PREDICT score had good diagnostic accuracy in the prediction of local recurrence after TME and a good discriminatory ability in the differentiation between patients at different risks to develop local recurrence.

Development and Validation of an Artificial Intelligence-Based Model to Predict Gastroesophageal Reflux Disease After Sleeve Gastrectomy.

PURPOSE: Prediction of the onset of de novo gastroesophageal reflux disease (GERD) after sleeve gastrectomy (SG) would be helpful in decision-making and selection of the optimal bariatric procedure for every patient. The present study aimed to develop an artificial intelligence (AI)-based model to predict the onset of GERD after SG to help clinicians and surgeons in decision-making. MATERIALS AND METHODS: A prospectively maintained database of patients with severe obesity who underwent SG was used for the development of the AI model using all the available data points. The dataset was arbitrarily split into two parts: 70% for training and 30% for testing. Then ranking of the variables was performed in two steps. Different learning algorithms were used, and the best model that showed maximum performance was selected for the further steps of machine learning. A multitask AI platform was used to determine the cutoff points for the top numerical predictors of GERD. RESULTS: In total, 441 patients (76.2% female) of a mean age of 43.7 ± 10 years were included. The ensemble model outperformed the other models. The model achieved an AUC of 0.93 (95%CI 0.88-0.99), sensitivity of 79.2% (95% CI 57.9-92.9%), and specificity of 86.1% (95%CI 70.5-95.3%). The top five ranked predictors were age, weight, preoperative GERD, size of orogastric tube, and distance of first stapler firing from the pylorus. CONCLUSION: An AI-based model for the prediction of GERD after SG was developed. The model had excellent accuracy, yet a moderate sensitivity and specificity. Further prospective multicenter trials are needed to externally validate the model developed.

Ultrasound-guided versus laparoscopic-guided subcostal transversus abdominis plane (TAP) block versus No TAP block in laparoscopic cholecystectomy; a randomized double-blind controlled trial.

BACKGROUND: Transversus abdominis plane (TAP) block is an effective modality for the control of immediate postoperative pain. The present randomized trial aimed to assess the efficacy of ultrasound-guided subcostal TAP (USTAP) and laparoscopic subcostal TAP (LSTAP) block as compared to standard care without TAP block after laparoscopic cholecystectomy. METHODS: This was a prospective, randomized, controlled trial on patients who underwent laparoscopic cholecystectomy. Patients were equally randomized to one of three groups: USTAP, LSTAP, and control group (no TAP block). The main outcome measures were pain scores and analgesic consumption within the first 24 h postoperatively, postoperative nausea and vomiting (PONV), time to ambulation, time to first flatus, and adverse effects of TAP block. RESULTS: The trial included 110 patients (90% females) with a mean age of 40.9 ± 11.7 years. Both USTAP and LSTAP block groups were associated with significantly lower pain scores at 2, 6, 12, and 24 h postoperatively, lower cumulative dose of paracetamol, less PONV, and shorter time to flatus than the control group. USTAP and LSTAP block were associated with similar pain scores at all time points, similar analgesic requirements, a similar incidence of PONV, and comparable time to first ambulation and time to first flatus. No adverse effects related to TAP block were recorded. CONCLUSIONS: TAP block is a safe and effective method for pain control and improving recovery after laparoscopic cholecystectomy. Both USTAP and LSTAP blocks were equally effective in terms of pain relief, analgesic requirements, PONV, return of bowel function, and time to ambulation.

Transvenous Embolization of Brain Arteriovenous Malformations: Up-to-Date Meta-Analysis.

AIM: To conduct an up-to-date meta-analysis to assess the success and complication rates of transvenous embolization (TVE) of brain arteriovenous malformations (BAVMs), and to determine its efficacy and safety. MATERIAL AND METHODS: Relevant and potentially relevant studies from 1982 to February 2021 were searched; after which those that satisfied our eligibility criteria and reported the main outcomes (endovascular occlusion and complication rates) were included. RESULTS: Ultimately seven studies were selected. In total, 154 patients were comprehensively reviewed for BAVMs characteristics and endovascular TVE techniques. The weighted mean rate of immediate endovascular total occlusion, overall technical complication, and overall good functional outcome (mRs < 2) were 93% (95% confidence intervals (CI), 89.1%?96.9%, I2 = 0%, p=0.487), 10.5% (95% CI, 4.3%?16.6%, I2 = 30.8%, p=0.193), and 90.9% (95% CI, 85.3%?96.6%, I2 = 26.6%, p=0.241), respectively. CONCLUSION: TVE for BAVMs was found to be generally safe and effective in certain selected patients. However, the complementary role of TAE to TVE as a definitive endovascular treatment for BAVMs cannot be separated. More studies regarding this role need to be conducted.

Efficacy and Safety of Non-Operative Management of Uncomplicated Acute Appendicitis Compared to Appendectomy: An Umbrella Review of Systematic Reviews and Meta-Analyses.

BACKGROUND: Non-operative management (NOM) of uncomplicated acute appendicitis (AA) has been introduced as an alternative to appendectomy. This umbrella review aimed to provide an overview of the efficacy and safety of NOM of uncomplicated AA in the published systematic reviews. METHODS: This umbrella review has been reported in line with the PRISMA guidelines and umbrella review approach. Systematic reviews with and without meta-analyses on the efficacy of NOM of AA were analyzed. The quality of the reviews was assessed with the AMSTAR 2 tool. The main outcomes measures were the treatment failure and complication rates of NOM and hospital stay as compared to appendectomy. RESULTS: Eighteen systematic reviews were included to this umbrella review. Eight reviews documented higher odds of failure with NOM, whereas two reviews revealed similar odds of failure. Six reviews reported lower odds of complications with NOM, six reported similar odds, and one reported lower odds of complications with surgery. Eight reviews reported similar hospital stay between NOM and appendectomy, one reported longer stay with NOM and another reported shorter stay with NOM. Pooled analyses showed that NOM was associated with higher treatment failure overall, in children-only, adults only, and RCTs-only meta-analyses. NOM was associated with lower complications overall, yet children-only and RCTs-only analyses revealed similar complications to surgery. NOM was associated with shorter stay in the overall and adult-only analysis, but not in the children-only analysis. CONCLUSIONS: NOM of AA is associated with higher treatment failure, marginally lower rate of complications and shorter stay than appendectomy.

Functional Outcomes and Quality of Life after Redo Anastomosis in Patients With Rectal Cancer: An International Multicenter Comparative Cohort Study.

BACKGROUND: Redo anastomosis can be considered in selected patients with persistent leakage, stenosis, or local recurrence. It is technically challenging, and little is known about the functional outcomes after this seldomly performed type of surgery. OBJECTIVE: The aim of this study was to compare functional outcomes and the quality of life between redo anastomosis and primary successful anastomosis following total mesorectal excision for rectal cancer. DESIGN: This study was designed as an international multicenter comparative cohort study. SETTINGS: The study was conducted in 3 tertiary referral centers in the Netherlands, Belgium, and France. PATIENTS: Patients undergoing redo anastomosis were compared with patients with a primary successful anastomosis after total mesorectal excision for rectal cancer. MAIN OUTCOME MEASURES: Low anterior resection syndrome score, European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ) C30, and EORTC QLQ-CR29 questionnaires were used to assess outcomes. RESULTS: In total, 170 patients were included; 52 underwent redo anastomosis and 118 were controls. Major low anterior resection syndrome occurred in 73% after redo anastomosis compared with 68% following primary successful anastomosis (p = 0.52). The redo group had worse EORTC QLQ-CR29 mean scores for fecal incontinence (p = 0.03) and flatulence (p = 0.008). There were no differences in urinary (p = 0.48) or sexual dysfunction, either in men (p = 0.83) or in women (p = 0.76). Significantly worse scores in the redo group were found for global health (p = 0.002), role (p = 0.049) and social function (p = 0.006), body image (p = 0.03), and anxiety (p = 0.02). LIMITATIONS: This study is limited by the possible response bias. CONCLUSIONS: Redo anastomosis is associated with significantly worse quality of life compared with primary successful anastomosis. However, major low anterior resection syndrome was comparable between groups and should not be a reason to preclude restoration of bowel continuity in highly motivated patients. See Video Abstract at http://links.lww.com/DCR/B565. RESULTADOS FUNCIONALES Y DE CALIDAD DE VIDA POSTERIOR A LA RECONSTRUCCIN DE LA ANASTOMOSIS EN PACIENTES CON CNCER DE RECTO ESTUDIO INTERNACIONAL MULTICNTRICO DE COHORTE COMPARATIVO: ANTECEDENTES:Se puede considerar reconstruir la anastomosis en pacientes seleccionados con fuga persistente, estenosis o recidiva local. Esto es técnicamente desafiante y poco se sabe sobre los resultados funcionales después de este tipo de cirugía que rara vez se realiza.OBJETIVO:El objetivo de este estudio fue comparar resultados funcionales y la calidad de vida entre reconstrucción de la anastomosis y la anastomosis primaria exitosa posterior de la escisión total de mesorrecto (TME) por cáncer de recto.DISEÑO:Este estudio fue diseñado como un estudio internacional multicéntrico de cohorte comparativo.ENTORNO CLINICO:El estudio se llevó a cabo en tres centros de referencia terciarios en Holanda, Bélgica y Francia.PACIENTES:Los pacientes sometidos a reconstrucción de anastomosis fueron comparados con pacientes con anastomosis primaria exitosa después de TME por cáncer de recto.PRINCIPALES MEDIDAS DE VALORACION:Los cuestionarios; Escala de Síndrome de Resección Anterior Baja (LARS), EORTC QLQ-C30, y QLQ-CR29, fueron utilizados para evaluar los resultados.RESULTADOS:En total, se incluyeron 170 pacientes; 52 reconstrucción de anastomosis y 118 controles. LARS ocurrió en el 73% posterior a la reconstrucción de la anastomosis en comparación con el 68% posterior a la anastomosis primaria exitosa (p = 0,52). El grupo de reconstrucción tuvo peores puntuaciones medias de EORTC QLQ-CR29 para incontinencia fecal (p = 0,03) y flatulencia (p = 0,008). No hubo diferencias en disfunción urinaria (p = 0,48) o sexual, ni en hombres (p = 0,83) ni en mujeres (p = 0,76). Se encontraron puntuaciones significativamente peores en el grupo de reconstrucción para salud global (p = 0,002), desempeño (p = 0,049) y función social (p = 0,006), imagen corporal (p = 0,03) y ansiedad (p = 0,02).LIMITACIONES:La limitación de este estudio es el posible sesgo de respuesta.CONCLUSIONES:La reconstrucción de la anastomosis se asocia con una calidad de vida significativamente peor en comparación con los pacientes con anastomosis primaria exitosa. Sin embargo, LARS fue comparable entre los grupos y no debería ser una razón para impedir la restauración de la continuidad intestinal en pacientes muy motivados. Consulte Video Resumen en http://links.lww.com/DCR/B565.

Urinary dysfunction after colorectal cancer treatment and impact on quality of life-a national cross-sectional study in males.

AIM: Despite advances in the treatment of colorectal cancer, postoperative urogenital dysfunction is still a problem although its exact extent remains unclear. The aim of this study was to identify the prevalence and patterns of urinary dysfunction in men following treatment for colorectal cancer and the impact of urinary dysfunction on quality of life. METHOD: A retrospective national Danish cross-sectional study was performed in patients treated for colorectal cancer between 2001 and 2014. Patients answered questionnaires on urinary function and quality of life including the International Consultation on Incontinence Modular Questionnaire-Male Lower Urinary Tract Symptoms measuring voiding and incontinence. Results were analysed based on data on demographics and treatment-related factors obtained from the Danish Colorectal Cancer Group database. RESULTS: A total of 5710 patients responded to the questionnaire (response rate 52.8%). In both crude analysis and after adjusting for patient-related factors (age, time since surgery and American Society of Anesthesiologists score), both voiding (P < 0.0001) and incontinence scores (P < 0.0001) were significantly higher after rectal cancer than after colon cancer. In the rectal cancer group, abdominoperineal excision was found to be a significant risk factor for both voiding (P < 0.0001) and incontinence (P = 0.011), while radiotherapy only impaired continence (P = 0.014). Significant correlations between high voiding and incontinence scores and impaired quality of life were found in both groups. CONCLUSION: We found a high prevalence of urinary dysfunction following treatment for colorectal cancer, especially in the rectal cancer group. Abdominoperineal excision was the most significant risk factor for both voiding and incontinence. Urinary dysfunction significantly impairs patients' quality of life.

Urinary dysfunction after colorectal cancer treatment and its impact on quality of life - a national cross-sectional study in women.

AIM: The aim of this study was to investigate urinary dysfunction and its impact on the quality of life of colorectal cancer survivors. We also wanted to identify the risk factors for impaired urinary function. METHOD: A national cross-sectional study was performed including patients treated for colorectal cancer between 2001 and 2014. Patients answered questionnaires regarding urinary function and quality of life, including the International Consultation on Incontinence Questionnaire - Female Lower Urinary Tract Symptoms (ICIQ-FLUTS), measuring filling, voiding and incontinence. Data were compared with data on demographics and treatment-related factors from the Danish Colorectal Cancer Group (DCCG) database. RESULTS: We found that rectal cancer treatment significantly impaired urinary function compared with colon cancer treatment (filling score p = 0.003, voiding p < 0.0001, incontinence p = 0.0001). Radiotherapy was the single most influential risk factor for high filling (p = 0.0043), voiding (p < 0.0001) and incontinence (p < 0.0001) scores, whereas type of rectal resection was only significant in crude analysis. Urinary dysfunction was strongly associated with an impaired quality of life. CONCLUSION: Urinary dysfunction is common after treatment for colorectal cancer, particularly if the treatment includes radiotherapy. All patients must be informed of the risk before cancer treatment, and functional outcome should be routinely assessed at follow-up.

Modification of Parks Classification of Cryptoglandular Anal Fistula.

BACKGROUND: The Parks classification has been used for the classification of anal fistula for several years, but it does not allow for risk factors for failure after surgery. OBJECTIVE: This study aimed to describe a modification of the Parks classification of anal fistula and examine its predictive validity in the assessment of the outcome of anal fistula in terms of failure of healing and fecal incontinence. DESIGN: This is a retrospective review of a prospective database. SETTING: This study was conducted in the Colorectal Surgery Unit, Mansoura University Hospitals. PATIENTS: Adult patients with anal fistula who underwent surgery were included. INTERVENTIONS: Five risk factors for failure after fistula surgery were identified from the literature and were examined by multivariate analysis of our patients. Four risk factors proved to be significant independent predictors of failure: secondary extensions, horseshoe fistula, previous fistula surgery, and anterior anal fistula in women. We modified the Parks classification by dividing the transsphincteric type into high and low and by grouping supra- and extrasphincteric anal fistulas into 1 group. The first 3 stages were subdivided according to the absence or presence of predictors of failure. MAIN OUTCOME MEASURES: The primary outcome measured was the validity of the modified Parks classification with regard to the rates of failure and fecal incontinence after surgical treatment of each stage of anal fistula. RESULTS: A total of 665 patients with cryptoglandular anal fistula were included. Failure rates increased from 2.3% (95% CI, 0.9%-4.7%), to 17.4% (95% CI, 10.8%-25.9%), 19.5% (95% CI, 15%-24.6%), and 30.7% (95% CI, 9.1%-61.4%) across the 4 stages. The area under the receiver operating characteristic curve was 0.90 (95% CI, 0.85-0.94) indicating the strong discriminative ability of the final multivariable predictive model. The increase in failure and incontinence rates across the fistula stages was significant. LIMITATIONS: This is a retrospective, single-center study. CONCLUSION: Inclusion of predictors of poor outcome into the modified classification helped differentiate simple and complex fistulas within each stage and between the different stages, which can help in assessment and decision making for anal fistula. See Video Abstract at http://links.lww.com/DCR/B441. MODIFICACIN DE LA CLASIFICACIN DE PARKS DE LA FSTULA ANAL CRIPTOGLANDULAR: ANTECEDENTES:La clasificación de Parks se ha utilizado para la clasificación de la fístula anal durante varios años, sin embargo, no tuvo en cuenta los factores de riesgo de fracaso después de la cirugía.OBJETIVO:Describir una modificación de la clasificación de Parks de fístula anal y examinar su validez predictiva en la evaluación de los resultados de la fístula anal en términos de fracaso de la cicatrización e incontinencia fecal.DISEÑO:Revisión retrospectiva de la base de datos prospectiva.AJUSTE:Unidad de Cirugía Colorrectal, Hospital Universitario de Mansoura.PACIENTES:Pacientes adultos con fístula anal intervenidos quirúgicamente.INTERVENCIONES:Se identificaron cinco factores de riesgo de fracaso después de la cirugía de fístula de la literatura y se examinaron mediante análisis multivariante de nuestros pacientes. Cuatro factores de riesgo demostraron ser importantes predictores independientes de fracaso: extensiones secundarias, fístula en herradura, cirugía de fístula previa y fístula anal anterior en mujeres. Modificamos la clasificación de Parks dividiendo el tipo transesfinteriano en alto y bajo y agrupando la fístula anal supraesfinteriana y extraesfinteriana en un grupo. Las tres primeras etapas se subdividieron según la ausencia o presencia de predictores de fracaso.PRINCIPALES MEDIDAS DE RESULTADO:Validez de la clasificación de Parks modificada con respecto a las tasas de fracaso e incontinencia fecal después del tratamiento quirúrgico de cada etapa de la fístula anal.RESULTADOS:Se incluyeron 665 pacientes con fístula anal criptoglandular. Las tasas de fracaso aumentaron del 2,3% (IC del 95%: 0,9-4,7%), al 17,4% (IC del 95%: 10,8 al 25,9%), 19,5% (IC del 95%: 15-24,6%) y 30,7% (95% IC: 9,1- 61,4%) en las cuatro etapas. El área bajo la curva característica operativa del receptor fue 0,90 (IC del 95%: 0,85-0,94), lo que indica una fuerte capacidad discriminativa del modelo predictivo multivariable final. El aumento en las tasas de fracaso e incontinencia en las etapas de la fístula fue significativo.LIMITACIONES:Estudio retrospectivo, unicéntrico.CONCLUSIÓN:La inclusión de predictores de mal resultado en la clasificación modificada ayudó a diferenciar las fístulas simples y complejas dentro de cada etapa y entre las diferentes etapas, lo que puede ayudar en la evaluación y toma de decisiones para la fístula anal. Consulte Video Resumen en http://links.lww.com/DCR/B441.

Comparative analysis of the Memorial Sloan Kettering Bowel Function Instrument and the Low Anterior Resection Syndrome Questionnaire for assessment of bowel dysfunction in rectal cancer patients after low anterior resection.

AIM: Neoadjuvant therapy and total mesorectal excision (TME) for rectal cancer are associated with bowel dysfunction symptoms known as low anterior resection syndrome (LARS). Our study compared the only two validated instruments-the LARS Questionnaire (LARS-Q) and the Memorial Sloan Kettering Bowel Function Instrument (MSK-BFI)-in rectal cancer patients undergoing sphincter-preserving TME. METHODS: One hundred and ninety patients undergoing sphincter-preserving TME for Stage I-III rectal cancer completed the MSK-BFI and LARS-Q simultaneously at a median time of 12 (range 1-43) months after restoration of bowel continuity. Associations between the MSK-BFI total/subscale scores and the LARS-Q score were investigated using Spearman rank correlation (r s ). Discriminant validity for the two questionnaires was assessed, and the questionnaires were compared with the European Quality of Life Instrument. RESULTS: Major LARS was identified in 62% of patients. The median MSK-BFI scores for no LARS, minor LARS and major LARS were 76.5, 70 and 57, respectively. We found a strong association between MSK-BFI and LARS-Q (r s -0.79). The urgency/soilage subscale (r s -0.7) and the frequency subscale (rs -0.68) of MSK-BFI strongly correlated with LARS-Q. Low correlation was observed between the MSK-BFI diet subscale and LARS-Q (r s -0.39). On multivariate analysis, both questionnaires showed worse bowel function in patients with distal tumours. A low to moderate correlation with the European Quality of Life Instrument was observed for both questionnaires. CONCLUSIONS: The MSK-BFI and LARS-Q showed good correlation and similar discriminant validity. As the LARS-Q is easier to complete, it may be considered the preferred tool to screen for bowel dysfunction.

Male erectile function after treatment for colorectal cancer: a population-based cross-sectional study.

AIM: The aim of this work was to determine the knowledge gap in the field of erectile function (EF) after colorectal cancer surgery and investigate and compare long-term male EF in colon and rectal cancer survivors in a national population. METHOD: Danish male patients alive without evidence of recurrence who were treated for colon or rectal cancer between May 2001 and December 2014 were invited to participate. Using the International Index of Erectile Function (IIEF) score the derived dichotomized erectile dysfunction (ED) was defined as moderate/severe or no/mild. Patients were grouped based on type of surgery [colon resection, rectal resection (RR) or local resection] and stratified for stoma, preoperative radiotherapy (RT), age and American Society of Anesthesiologists (ASA) score. RESULTS: Of 10 037 eligible patients, 4334 responded (43.18%). The EF score was significantly lower for RR (mean 12.14) compared with both colon resection (mean 15.82) and local resection (mean 14.81) (p < 0.0001). No significant difference between colon resection and local resection was found (p = 0.29). Both a stoma and the use of RT were independent risk factors for ED. After excluding patients with stoma and RT and adjusting for age and ASA score, RR still had a higher risk of ED (OR 1.42, CI 1.20-1.67) compared with colon resection. CONCLUSION: RR has a negative affect on EF. No difference between patients who underwent colon resection and local resection was found. RT and stoma were independent risk factors for ED.

Outcome of lateral pelvic lymph node dissection with total mesorectal excision in treatment of rectal cancer: A systematic review and meta-analysis.

BACKGROUND: Total mesorectal excision is the gold standard treatment of mid- and low-lying rectal cancer. Lateral pelvic lymph node dissection has been suggested as an approach to decrease recurrence and improve survival. Our meta-analysis presented here aimed to review the current outcomes of lateral pelvic lymph node dissection and total mesorectal excision in comparison with total mesorectal excision alone. METHODS: A systematic literature search querying electronic databases was conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. We reviewed articles that reported the outcomes of lateral pelvic lymph node dissection combined with total mesorectal excision in comparison with total mesorectal excision alone. The main outcome measures were local recurrence, distant metastasis, overall and disease free-survival, and complications. RESULTS: This systematic review included 29 studies of 10,646 patients. Of those patients, 39.4% underwent total mesorectal excision with lateral pelvic lymph node dissection. The median operation time for the lateral pelvic lymph node dissection + total mesorectal excision was significantly longer than total mesorectal excision alone (360 minutes versus 294.7 minutes, P = .02). Lateral pelvic lymph node dissection + total mesorectal excision was associated with higher odds of overall complications (odds ratio = 1.48, 95% confidence interval: 1.18-1.87, P < .001) and urinary dysfunction (odds ratio = 2.1, 95% confidence interval: 1.21-3.67, P = .008) than total mesorectal excision alone. Both groups had similar rates of male sexual dysfunction (odds ratio = 1.62, 95% confidence interval: 0.94-2.79, P = .08), anastomotic leakage (odds ratio = 1.15, 95% confidence interval: 0.69-1.93, P = .59), local recurrence (hazard ratio = 0.96, 95% confidence interval: 0.75-1.25, P = .79), distant metastasis (hazard ratio = 0.96, 95% confidence interval: 0.76-1.2, P = .72), overall survival (hazard ratio = 1.056, 95% confidence interval: 0.98-1.13, P = .13), and disease-free survival (hazard ratio = 1.02, 95% confidence interval: 0.97-1.07, P = .37). CONCLUSION: Lateral pelvic lymph node dissection was not associated with a significant reduction of recurrence rates or improvement in survival as compared with total mesorectal excision alone; however, LPLND was associated with longer operation time and increased complication rate.

Patients with early-onset rectal cancer aged 40 year or less have similar oncologic outcomes to older patients despite presenting in more advanced stage; A retrospective cohort study.

BACKGROUND: Early-onset colon and rectal cancer has increased in alarming rates. The present study reviewed the characteristics and outcome of early-onset rectal cancer in patients aged ≤40 years. METHODS: This was a retrospective cohort study on rectal cancer patients who were treated in a tertiary center in the Middle East. Baseline characteristics and outcomes of patients ≤40 years were compared with patients >40 years. Main outcome measures were patients' and tumor characteristics, local recurrence, distance metastasis, overall survival (OS), and disease-free survival (DFS). RESULTS: Among 244 patients with rectal cancer, 81 (33.2%) aged 40 years or less. 56.8% of patients ≤40 years and 49.7% of patients >40 years presented with stage III/IV disease (p = 0.36). Local recurrence and distant metastasis were detected in 10.3% and 13.2% of patients ≤40 years and in 16.9% and 13.9% of patients >40 years (p = 0.29 and 0.88). The 3-year OS and DFS rates of patients ≤40 years were 75% and 80.9% versus 74.2% and 76.5% in patients >40 years (p = 0.9 and 0.59). Patients ≤40 years presented with ulcerative carcinoma (38.3% vs 21.5%, p = 0.01) and signet-ring carcinoma (12.3% vs 2.5%, p = 0.008) more than patients > 40 years. CONCLUSION: Early-onset rectal cancer accounted for one-third of all patients presenting with rectal cancer. Patients younger than 40 years had higher incidence of mucinous and signet-ring rectal carcinoma, and presented more with advanced stage. The age of patients did not have a significant impact on the oncologic outcome of rectal cancer.