A Randomized Controlled Clinical Trial of Transanal Irrigation Versus Conservative Treatment in Patients With Low Anterior Resection Syndrome After Rectal Cancer Surgery.

OBJECTIVE: The aim of the study was to evaluate transanal irrigation (TAI) as a treatment for low anterior resection syndrome (LARS). BACKGROUND: LARS is a bowel disorder that is common after sphincter preserving rectal cancer surgery. Despite symptomatic medical treatment of LARS many patients still experience bowel symptoms that may have a negative impact on quality of life (QoL). TAI is a treatment strategy, of which the clinical experience is promising but scientific evidence is limited. MATERIALS AND METHODS: A multicenter randomized trial comparing TAI (intervention) with conservative treatment (control) was performed. Inclusion criteria were major LARS, age above 18 years, low anterior resection with anastomosis and a defunctioning stoma as primary surgery, >6 months since stoma reversal, anastomosis without signs of leakage or stricture, and no signs of recurrence at 1-year follow-up. The primary endpoint was differences in bowel function at 12-month follow-up measured by LARS score, Cleveland Clinic Florida Fecal Incontinence Score, and 4 study-specific questions. The secondary outcome was QoL. RESULTS: A total of 45 patients were included, 22 in the TAI group and 23 in the control group. Follow-up was available for 16 and 22 patients, respectively. At 12 months, patients in the TAI group reported significantly lower LARS scores (22.9 vs 32.4; P =0.002) and Cleveland Clinic Florida Fecal Incontinence Score (6.4 vs 9.2; P =0.050). In addition, patients in the TAI group also scored significantly higher QoL [8 of 16 European Organisation for the Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30) QoL aspects] compared with the control group. CONCLUSIONS: The results confirm our clinical experience that TAI reduces symptoms included in LARS and improves QoL.

Restorative Surgery Is More Common in Ulcerative Colitis Patients With a High Income: A Population-Based Study.

BACKGROUND: To avoid a permanent stoma, restorative surgery is performed after the colectomy. Previous studies have shown that less than half of patients with ulcerative colitis undergo restorative surgery. OBJECTIVE: The primary aim was to explore the association between socioeconomic status and restorative surgery after colectomy. DESIGN: This was a nationwide register-based cohort study. SETTINGS: The study was conducted in Sweden. PATIENTS: All Swedish patients with ulcerative colitis who underwent colectomy between 1990 and 2017 at the age of 15 to 69 years were included. MAIN OUTCOME MEASURES: The main outcome was restorative surgery, and the secondary outcome was failure of the reconstruction (defined as the need for a new ileostomy after the reconstruction or nonreversal of a defunctioning stoma within 2 years of the reconstruction). To calculate HRs for restorative surgery after colectomy, as well as failure after restorative surgery, multivariable Cox regression models were performed (adjusted for sex, year of colectomy, colorectal cancer diagnosis, education, civil status, country of birth, income (quartiles 1 to 4, where Q4 represents highest income), hospital volume, and stratified by age). RESULTS: In all, 5969 patients with ulcerative colitis underwent colectomy, and of those, 2794 (46.8%) underwent restorative surgery. Restorative surgery was more common in patients with a high income at the time of colectomy (quartile 1, reference; quartile 2, 1.09 (0.98-1.21); quartile 3, 1.20 (1.07-1.34); quartile 4, 1.27 (1.13-1.43)) and less common in those born in a Nordic country than in immigrants born in a non-Nordic country (0.86 (0.74-0.99)), whereas no association was seen with educational level and civil status. There was no association between socioeconomic status and the risk of failure after restorative surgery. LIMITATIONS: The study was restricted to register data. CONCLUSIONS: Restorative surgery in ulcerative colitis appears to be more common in patients with a high income and patients born in a non-Nordic country, indicating inequality in the provided care. See Video Abstract at http://links.lww.com/DCR/B433. LA CIRUGA RESTAURADORA ES MS COMN EN PACIENTES CON COLITIS ULCEROSA CON INGRESOS ALTOS UN ESTUDIO POBLACIONAL: ANTECEDENTES:Para evitar un estoma permanente, se realiza una cirugía reparadora después de la colectomía. Estudios anteriores han demostrado que menos de la mitad de los pacientes con colitis ulcerosa se someten a cirugía reconstituyente.OBJETIVO:El objetivo principal fue explorar la asociación entre el nivel socioeconómico y la cirugía reconstituyente después de la colectomía.DISEÑO:Estudio de cohorte basado en registros a nivel nacional.MARCO:Suecia.PACIENTES:Todos los pacientes Suecos con colitis ulcerosa que se sometieron a colectomía desde el 1990 a 2017 a la edad de 15 a 69 años.MEDIDAS DE RESULTADOS PRINCIPALES:El resultado principal fue la cirugía restaurativa y el resultado secundario fue el fracaso de la reconstrucción (definida como la necesidad de una nueva ileostomía después de la reconstrucción o la no-reversión de un estoma disfuncional dentro de los dos años posteriores a la reconstrucción). Para calcular los cocientes de riesgo para la cirugía restauradora después de la colectomía, así como el fracaso después de la cirugía restauradora, se realizaron modelos de regresión de Cox multivariables (ajustados por sexo, año de colectomía, diagnóstico de cáncer colorrectal, educación, estado civil, país de nacimiento e ingresos (cuartiles 1- 4; donde Q4 representa los mayores ingresos), volumen de hospitales y estratificado por edad).RESULTADOS:En total 5969 pacientes con colitis ulcerosa se sometieron a colectomía, y de ellos 2794 (46,8%) se sometieron a cirugía restauradora. La cirugía restauradora fue más común en pacientes con altos ingresos en el momento de la colectomía (referencia del cuartil 1, cuartil 2: 1,09 (0,98-1,21), cuartil 3: 1,20 (1,07-1,34), cuartil 4: 1,27 (1,13-1,43)), y menos común en los nacidos en un país nórdico que en los inmigrantes nacidos en un país no-nórdico (0,86 (0,74-0,99)), mientras que no se observó asociación con el nivel educativo y el estado civil. No hubo asociación entre el nivel socioeconómico y el riesgo de fracaso después de la cirugía reparadora.LIMITACIONES:Restricción para registrar datos.CONCLUSIONES:La cirugía reparadora en colitis ulcerosa parece ser más común en pacientes con ingresos altos y en pacientes nacidos en un país no-nórdico, lo que indica desigualdad en la atención brindada. Consulte Video Resumen en http://links.lww.com/DCR/B433.

Primary Versus Staged Reconstruction and Risk of Surgical Failure in Patients With Ulcerative Colitis: a Nation-wide Cohort Study.

BACKGROUND: Restorative surgery after colectomy due to ulcerative colitis (UC) may be performed simultaneously with colectomy (primary) or as a staged procedure. Risk factors for failure after restorative surgery are not fully explored. This study aimed to compare the risk of failure after primary and staged reconstruction. METHODS: This is a national register-based cohort study of all patients 15 to 69 years old in Sweden treated with colectomy due to UC and who received an ileorectal anastomosis (IRA) or ileal pouch-anal anastomosis (IPAA) between 1997 and 2017. Failure was defined as a reoperation with new ileostomy after restorative surgery or a remaining defunctioning ileostomy after 2 years. Risk of failure was calculated using the Kaplan-Meier method and Cox regression adjusted for sex, age, calendar period, primary sclerosing cholangitis, and duration of UC. RESULTS: Of 2172 included patients, 843 (38.8%) underwent primary reconstruction, and 1329 (61.2%) staged reconstruction. Staged reconstruction was associated with a decreased risk of failure compared with primary reconstruction (hazard ratio, 0.73; 95% CI, 0.58-0.91). The 10-year cumulative risk of failure was 15% vs 20% after staged and primary reconstruction, respectively. In all, 1141 patients (52.5%) received an IPAA and 1031 (47.5%) an IRA. In stratified multivariable models, staged reconstruction was more successful than primary reconstruction in both IRA (hazard ratio, 0.75; 95% CI, 0.54-1.04) and IPAA (hazard ratio, 0.73; 95% CI, 0.52-1.01), although risk estimates failed to attain statistical significance. CONCLUSIONS: In UC patients undergoing colectomy, postponing restorative surgery may decrease the risk of failure.

This population-based study of 2172 patients treated with colectomy for ulcerative colitis shows that a colectomy and restorative IRA/IPAA surgery performed simultaneously entails a higher risk of failure than when reconstruction is performed later.

Stockholm score of lesion detection on computed tomography following mild traumatic brain injury (SELECT-TBI): study protocol for a multicentre, retrospective, observational cohort study.

INTRODUCTION: Mild traumatic brain injury (mTBI) is one of the most common reasons for emergency department (ED) visits. A portion of patients with mTBI will develop an intracranial lesion that might require medical or surgical intervention. In these patients, swift diagnosis and management is paramount. Several guidelines have been developed to help direct patients with mTBI for head CT scanning, but they lack specificity, do not consider the interactions between risk factors and do not provide an individualised estimate of intracranial lesion risk. The aim of this study is to create a model that estimates individualised intracranial lesion risks in patients with mTBI who present to the ED. METHODS AND ANALYSIS: This will be a retrospective cohort study conducted at ED hospitals in Stockholm, Sweden. Eligible patients are adults (≥15 years) with mTBI who presented to the ED within 24 hours of injury and performed a CT scan. The primary outcome will be a traumatic lesion on head CT. The secondary outcomes will be any clinically significant lesion, defined as an intracranial finding that led to neurosurgical intervention, hospital admission ≥48 hours due to TBI or death due to TBI. Machine-learning models will be applied to create scores predicting the primary and secondary outcomes. An estimated 20 000 patients will be included. ETHICS AND DISSEMINATION: The study has been approved by the Swedish Ethical Review Authority (Dnr: 2020-05728). The research findings will be disseminated through peer-reviewed scientific publications and presentations at international conferences. TRIAL REGISTRATION NUMBER: NCT04995068.

Magnetic resonance imaging as a predictor of surgical outcome in patients with local pelvic recurrence of colorectal cancer.

INTRODUCTION: Pelvic local recurrence of colorectal cancer (PRCRC) may be cured if radical surgery is performed. Preoperative assessment normally includes magnetic resonance imaging (MRI). The aim of this study was to evaluate the influence of specific MRI-related findings on outcome of surgery of PRCRC. MATERIALS AND METHODS: Clinical data from 95 consecutive patients, operated with a curative intent for PRCRC at Karolinska University Hospital during 2003-2013, were collected from medical records. Preoperative MRI examinations of the PRCRC were re-evaluated. The potential influence of clinical factors and specific MRI-findings (location, solid/mucinous, size, volume and border) on surgical resection margins (R0-R1) and survival were calculated with logistic and cox regression. RESULTS: Eighty-seven patients had available MRI scans and were included in the study. Sixty-five patients (75%) had a R0 resection and 22 patients (25%) had a R1 resection of their PRCRC. In all, 47 patients (54%) had an involved lateral compartment. Lateral location was the only MRI finding associated with both an increased risk of R1 resection (OR 3.97, 95%CI: 1.31-12.04) and death (HR 1.94, 95%CI: 1.07-3.51). Lateral location entailed an increased risk of death also after R0 resection (HR2.09, 95%CI: 1.07-4.10). Five-year survival was 35% for all patients, 44% after R0 resection and 7% after R1 resection. CONCLUSION: Tumour involvement of the lateral and posterior compartments on MRI was a predictor for R1 resection, but only lateral involvement was associated with an increased risk of death. An increased risk of death associated with lateral involvement was still present after R0 resection.

Women's Earnings are more Affected by Inflammatory Bowel Disease than Men's: A Register-Based Swedish Cohort Study.

BACKGROUND AND AIMS: Patients with inflammatory bowel disease [IBD] are subject to more work disability than the general population. We aimed to estimate the monetary cost of IBD for the individual through assessment of earnings in relation to diagnosis. METHODS: Through linkage of national registers, we identified patients aged 30-55 years at first IBD diagnosis in Sweden in 2002-2011, and same-sex IBD-free siblings. We estimated taxable earnings and disposable income from 5 years before to 5 years after diagnosis. RESULTS: The 5961 patients [27% Crohn's disease, 68% ulcerative colitis, 4.3% IBD unclassified] had similar taxable earnings to their 7810 siblings until the year of diagnosis, when earnings decreased and remained lower than for siblings during follow-up. The adjusted difference in earnings over the entire 5-year period after diagnosis was -5% [-8212€; 95% confidence interval: -11 458 to -4967€]. The difference was greater in women than in men, and greater in Crohn's disease than in ulcerative colitis. When stratifying for sex and IBD subtype and comparing earnings during each year of follow-up, median annual earnings were lower in women with Crohn's disease and ulcerative colitis than in their sisters during all years of follow-up, whereas the men had similar annual taxable earnings to their brothers. Disposable income was similar between patients and siblings during the investigated time period. CONCLUSION: From the year of diagnosis and at least 5 years onwards, patients with IBD had 5% lower earnings than siblings, mainly explained by differences between women with IBD and their sisters. However, there were no differences in disposable income.

Management and prognosis of locally recurrent rectal cancer - A national population-based study.

BACKGROUND: The rate of local recurrence of rectal cancer (LRRC) has decreased but the condition remains a therapeutic challenge. This study aimed to examine treatment and prognosis in patients with LRRC in Sweden. Special focus was directed towards potential differences between geographical regions and time periods. METHOD: All patients with LRRC as first event, following primary surgery for rectal cancer performed during the period 1995-2002, were included in this national population-based cohort-study. Data were collected from the Swedish Colorectal Cancer Registry and from medical records. The cohort was divided into three time periods, based on the date of diagnosis of the LRRC. RESULTS: In total, 426 patients fulfilled the inclusion criteria. Treatment with curative intent was performed in 149 patients (35%), including 121 patients who had a surgical resection of the LRRC. R0-resection was achieved in 64 patients (53%). Patients with a non-centrally located tumour were more likely to have positive resection margins (R1/R2) (OR 5.02, 95% CI:2.25-11.21). Five-year survival for patients resected with curative intent was 43% after R0-resection and 14% after R1-resection. There were no significant differences in treatment intention or R0-resection rate between time periods or regions. The risk of any failure was significantly higher in R1-resected patients compared with R0-resected patients (HR 2.04, 95% CI:1.22-3.40). CONCLUSION: A complete resection of the LRRC is essential for potentially curative treatment. Time period and region had no influence on either margin status or prognosis.