Suprapubic versus transurethral catheterization for bladder drainage in male rectal cancer surgery (GRECCAR10), a randomized clinical trial.

BACKGROUND: Bladder drainage is systematically used in rectal cancer surgery; however, the optimal type of drainage, transurethral catheterization (TUC) or suprapubic catheterization (SPC), is still controversial. The aim was to compare the rates of urinary tract infection on the fourth postoperative day (POD4) between TUC and SPC, after rectal cancer surgery regardless of the day of removal of the urinary drain. METHODS: This randomized clinical trial in 19 expert colorectal surgery centers in France and Belgium was performed between October 2016 and October 2019 and included 240 men (with normal or subnormal voiding function) undergoing mesorectal excision with low anastomosis for rectal cancer. Patients were followed at postoperative days 4, 30, and 180. RESULTS: In 208 patients (median age 66 years [IQR 58-71]) randomized to TUC (n = 99) or SPC (n = 109), the rate of urinary infection at POD4 was not significantly different whatever the type of drainage (11/99 (11.1%) vs. 8/109 (7.3%), 95% CI, - 4.2% to 11.7%; p = 0.35). There was significantly more pyuria in the TUC group (79/99 (79.0%) vs. (60/109 (60.9%), 95% CI, 5.7-30.0%; p = 0.004). No difference in bacteriuria was observed between the groups. Patients in the TUC group had a shorter duration of catheterization (median 4 [2-5] vs. 4 [3-5] days; p = 0.002). Drainage complications were more frequent in the SPC group at all followup visits. CONCLUSIONS: TUC should be preferred over SPC in male patients undergoing surgery for mid and/or lower rectal cancers, owing to the lower rate of complications and shorter duration of catheterization. TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT02922647.

Good compliance to enhanced recovery program improves outcome after colorectal surgery.

AIM OF THE STUDY: The fast-track (FT) protocol consists of several measures to optimize physiologic response to the surgical stress and improve postoperative outcome. Our goal was to evaluate the compliance to our protocol and to analyze the effect of compliance to the FT protocol on postoperative outcome and postoperative hospital stay. We also aimed to identify isolated FT measures able to influence outcome. METHODS: This retrospective study involves a cohort of consecutive patients who underwent colorectal surgery within a FT protocol between 2007 and 2013. Beside basic demographics, adherence to protocol, postoperative complications, and postoperative hospital stay (POHS) were recorded. Both univariate and multivariate analyses were performed to determine the predictive value of the FT protocol compliance and of specific FT items on surgical outcome and POHS. RESULTS: There were 284 patients with a mean age of 58 years. Compliance to the FT protocol reached a median of 18 out of 19 items. The median hospital stay was 3 days (2-49). Overall complications rate was 34.9% and 7,4% when Dindo-Clavien classification > 2 was considered. Higher compliance to the FT protocol reduces the complication rate (p = 0.00004), severity of complication (p = 0.002), and POHS (p = < 0.00001). We have not been able to identify any specific isolated FT measure able to influence post-operative outcome. CONCLUSIONS: Greater adherence to the FT protocol decreases postoperative complications and POHS. Our data support a holistic effect of the FT protocol rather than specific isolated measures to improve the patient's postoperative outcome.

Lymph node ratio and surgical quality are strong prognostic factors of rectal cancer: results from a single referral centre.

AIM: Nodal stage is a strong prognostic factor of oncological outcome of rectal cancer. To compensate for the variation in total number of harvested nodes, calculation of the lymph node ratio (LNR) has been advocated. The aim of the study was to compare the impact, on the long-term oncological outcome, of the LNR with other predictive factors, including the quality of total mesorectal excision (TME) and the state of the circumferential resection margin. METHOD: Consecutive patients having elective surgery for nonmetastatic rectal cancer were extracted from a prospectively maintained database. Retrospective uni- and multivariate analyses were performed based on patient-, surgical- and tumour-related factors. The prognostic value of the LNR on overall survival (OS) and on overall recurrence-free survival (ORFS) was assessed and a cut-off value was determined. RESULTS: From 1998 to 2013, out of 456 patients, 357 with nonmetastatic disease were operated on for rectal cancer. Neoadjuvant radiochemotherapy was administered to 66.7% of the patients. The mean number of lymph nodes retrieved was 12.8 ± 8.78 per surgical specimen. A lower lymph node yield was obtained in patients who received neoadjuvant chemoradiotherapy (11.8 vs 14.2; P = 0.014). The 5-year ORFS was 71.8% and the 5-year OS was 80.1%. Multivariate analysis confirmed LNR, the quality of TME and age to be independent prognostic factors of OS. LNR, age and perineural infiltration were independently associated with ORFS. Low- and high-risk patients could be discriminated using an LNR cut-off value of 0.2. CONCLUSION: LNR is an independent prognostic factor of OS and ORFS. In line with the principles of optimal surgical management, the quality of TME and lymph node yield are essential technical requirements.

Scoring the quality of total mesorectal excision for the prediction of cancer-specific outcome.

AIM: A three-grade system for macroscopic evaluation of the resection plane is used to describe the quality of total mesorectal excision (TME). In several studies, two of the three grades have been combined when analysing the outcome. The aim of our study was to compare the predictive value of the three-graded with that of a two-graded TME score. METHOD: The quality of TME in 1382 patients who underwent elective resection for mid or low rectal adenocarcinoma was registered by 65 hospitals in PROCARE, a Belgian multidisciplinary improvement project. Prediction of outcome based on the classic three-grade score was compared with a two-grade scoring system in which intramesorectal resection (IMR) was combined with mesorectal (MRR) or with muscularis propria resection (MPR). End-points included the local recurrence rate, distant metastasis rate (DMR), disease-free survival (DFS) and overall survival (OS). RESULTS: Among the 1382 resections, 63% were MRR, 27% IMR and 9% MPR. No significant differences were found in local recurrence between the different grades of TME. A two-grade score distinguishing MRR from the others was found to predict DMR, DFS and OS as well as the three-grade score. CONCLUSION: The discriminatory and predictive value of a two-grade score, differentiating MRR from the combined IMR and MPR, was as good as the classic three-grade score.

Effect of hospital volume on quality of care and outcome after rectal cancer surgery.

BACKGROUND: Research on the relationship between hospital volume and quality of care in the treatment of rectal cancer is limited. METHODS: Process and outcome indicators were assessed in patients with rectal adenocarcinoma who underwent total mesorectal excision, registered on a voluntary basis in the PROCARE clinical database. Volume was derived from an administrative database and analysed as a continuous variable. Sphincter preservation, 30-day mortality and survival rates were cross-checked against population-based data. RESULTS: A total of 1469 patients registered in PROCARE between 2006 and 2011 were included in this study. A volume effect was observed regarding neoadjuvant therapy for stage II-III disease, reporting of the circumferential resection margin, R0 resection rate, sphincter preservation rate, and number of nodes examined after chemoradiotherapy. The global estimate of quality of care was highly variable, but surgery was the single domain in which quality correlated with volume. No volume effect was observed for recurrence and overall survival rates. In the population-based data set (5869 patients), volume was associated with 30-day mortality adjusted for age (odds ratio 0·99, 95 per cent confidence interval (c.i.) 0·98 to 1·00; P = 0·014) and adjusted overall survival (HR 0·99 (95 per cent c.i. 0·99 to 1·00) per additional procedure; P = 0·001), but not with the sphincter preservation rate. Because of incomplete and biased registration on a voluntary basis, results from a clinical database could not be extrapolated to the population. CONCLUSION: Some volume effects were observed, but their effect size was limited.

Outcome following laparoscopic and open total mesorectal excision for rectal cancer.

BACKGROUND: There are few reports on the oncological quality of resection and outcome after laparoscopic versus open total mesorectal excision (TME) for rectal cancer in everyday surgical practice. METHODS: Between January 2006 and October 2011, data for patients with mid or low rectal adenocarcinoma who underwent elective TME were recorded in the PROCARE database. A multivariable model and the propensity score as a co-variable in Cox or logistic regression models were used for adjustment of differences in patient mix and non-random assignment of surgical approach. RESULTS: Data for 2660 patients from 82 hospitals were recorded. Implementation of laparoscopic TME was highly variable. The oncological quality of resection was similar in the laparoscopic and the open group: incomplete mesorectal excision in 13·2 and 11·4 per cent respectively, circumferential resection margin positivity in 18·1 per cent, and a median of 11 lymph nodes examined per specimen in both groups. The hazard ratio for survival after laparoscopic versus open TME was 1·05 (95 per cent confidence interval 0·88 to 1·24) after correction for differences in patient mix, and 1·06 (0·89 to 1·25) after correction for the propensity score. The definitive colostomy rate was similar in the two groups: 31·0 per cent after open and 31·4 per cent after laparoscopic TME. Postoperative morbidity was lower and length of stay was shorter after laparoscopic TME compared with open TME. Survival was not negatively affected by converted laparoscopic resection, whereas postoperative morbidity, mortality and length of stay after converted laparoscopy were comparable with those after open TME. CONCLUSION: Oncological outcome is comparable after laparoscopic and open TME in everyday surgical practice.

Insights into fast-track colon surgery: a plea for a tailored program.

BACKGROUND: This retrospective study compared the fast-track colon surgery program to conventional perioperative care and assessed factors that influence postoperative length of stay. DESIGN: This retrospective study included 124 fast-track and 119 conventional care colon surgical patients. Exclusion criteria were primary rectal disease, stoma, American Society of Anesthesiologists score IV, and Association Française de Chirurgie index 3 or 4. Laparoscopy was the preferred approach. Variables influencing length of stay were analyzed by multivariate linear and logistic regression. RESULTS: Overall mortality and complication rates were not significantly different between groups (fast-track vs. controls 0 vs. 0.8 %, 30.6 vs. 38.6 % respectively). As expected, median length of stay was significantly reduced in fast-track patients (3 vs. 6 days, p < 0.001), but emergency readmission rate was higher (16.9 vs. 7.6 %, p = 0.026), although rehospitalization rates were similar (8 vs. 4.2 %, not significant). Independent risk factors of increased length of stay were identified as age >69 years (p = 0.001), laparotomy (p = 0.011), and conventional perioperative care (p < 0.001). CONCLUSIONS: The introduction of a fast-track program reduced postoperative length of stay without increasing complication rate. This study proposes a modulation of the program according to patient age and surgical approach.

Altemeier's procedure for rectal prolapse: analysis of long-term outcome in 60 patients.

AIM: Altemeier's procedure (perineal rectosigmoidectomy) is the operation of choice for rectal prolapse in the elderly. The aims of this prospective observational study were to evaluate its long-term actuarial recurrence risk and the influence of the length of rectosigmoid resection and associated levatorplasty on recurrence rate and continence. METHOD: The perioperative and long-term data for all patients undergoing Altemeier's procedure since 1992 were analysed with regard to mortality, morbidity, continence, anorectal function and recurrence rate. RESULTS: Sixty patients [median age 77 years (35-98)] underwent rectosigmoid resection [median length of bowel 14 (6-60) cm] with associated levatorplasty in 21 (35%). Overall mortality and morbidity were 1.6 and 11.6%, respectively. Manometry showed increased anal sphincter basal pressure and maximal squeeze pressure. We observed a decrease in postoperative rectal compliance (P=0.002). Age, gender, prolapse duration before surgery, levatorplasty and length of resection had no statistically significant relationship with recurrence. Continence improved in 62% and was stable over a median follow-up of 48 (1-186) months. Continence was positively related to a short length of bowel resection, but not to decreased rectal compliance. Actuarial recurrence was 14% at 4 years. CONCLUSION: The long-term recurrence rate after the Altemeier procedure was low and not linked to resection length or to levatorplasty. Improvement in continence was stable over time.

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal carcinomatosis from colorectal cancer: a 13 years-retrospective monocentric study.

Background and study aim: Over the last 20 years, cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) has progressively become a therapeutic option for peritoneal carcinomatosis thanks to its favourable oncologic results. The aim of this study is to analyse the overall survival and recurrence-free survival, after complete CRS and closed abdomen technique HIPEC for peritoneal carcinomatosis from colorectal cancer. Patients and methods: This retrospective study collected the data from all patients who underwent a CRS with HIPEC for colorectal cancer at "Cliniques universitaires Saint Luc" from October 2007 to December 2020. Ninety-nine patients were included. Results: The median follow-up was 34 months. Post-operative mortality and Clavien-Dindo grade III/IV morbidity rates were 2.0% and 28.3%. The overall 2-year and 5-year survival rates were 80.1% and 54.4%. Using the multivariate analysis, age at surgery, liver metastases and PCI score >13 showed a statistically significant negative impact on overall survival. The 2-year and 5-year recurrence-free survival rates were 33.9% and 22%. Using the multivariate analysis, it was found that liver metastases, the extent of carcinomatosis with PCI>7 have a statistically significant negative impact on recurrence-free survival. Conclusions: Despite a high recurrence rate, CRS followed by HIPEC to treat peritoneal carcinomatosis from colorectal origin offer encouraging oncologic results with a satisfying survival rate. When PCI>13, CRS and HIPEC does not seem to offer any survival benefit and to efficiently limit recurrence, our data are in favor of a maximum PCI of 7.

Total perineal reconstruction after abdominoperineal excision for rectal cancer: long-term results of dynamic graciloplasty with Malone appendicostomy.

AIM: This study aimed to assess long-term function after total perineal reconstruction (TPR) with dynamic graciloplasty (DG) and systematic Malone appendicostomy (MA) adjunction after abdominoperineal excision (APR) for rectal cancer. METHOD: From 1999 to 2004, TPR using DG and MA was performed in 10 patients [seven women; median age 40 (range 28-55) years] after APR for rectal cancer (cT2 in one patient, cT3 in six patients and cT4 in three patients). We prospectively recorded early and late morbidity, mortality, oncological outcome, functional results (using the modified Working Party on Anal Sphincter Replacement 'WPASR' scoring system) and quality of life (QoL; using the European Organisation for Research and Treatment of Cancer 'EORTC' QLQ-C30 and QLQ-CR38 questionnaires). RESULTS: There was no procedure-related mortality. One patient required intra-abdominal re-operation. Nine patients required local and multiple revisions [there was one coloperineal anastomosis (CPA) stenosis, five CPA mucosal prolapse, three stenosis related to graciloplasty, two MA stenosis and one MA reflux]. After a median follow up of 78 months, there was no local recurrence and six patients were alive and disease-free. Regarding the functional results, the median modified WPASR score, of 8, after a follow up of 78 months, was good. The overall QoL scores remained stable over time. CONCLUSION: In carefully selected patients who want to avoid definitive abdominal colostomy after APR for rectal cancer, reconstruction involving MA and DG after APR for low rectal cancer is followed by good long-term function and QoL.

Malone appendicostomy: an unexpected complication.

The Malone appendicostomy is a novel option for surgical management of faecal incontinence and chronic constipation, by permitting the administration of antegrade colonic enemas for colonic evacuation. We report the case of a 54-year-old female who had undergone abdomino perineal resection for low rectal cancer followed by total perineal reconstruction with perineal colostomy, dynamic double graciloplasty and Malone appendicostomy. After 7-year follow-up, functional results and quality of life scores were satisfactory. Suddenly the patient described increasing difficulty with intubation of her appendicostomy and complete reflux of the enema liquid, which radiology referred to a calcified body of 35 mm within the Malone appendicostomy causing nearly complete obstruction of the conduit. A surgical exploration was necessary to extract the fecolith allowing full recovery with return to satisfactory Malone appendicostomy function. To our knowledge, this is the first report of a fecolith causing obstruction within a Malone appendicostomy.

Single-incision laparoscopic surgery for locally advanced colorectal cancer : feasibility, short-term and oncologic outcomes.

BACKGROUND AND STUDY AIMS: Data about single-incision laparoscopic surgery (SILS) in locally advanced colorectal cancers are scarce. This study aimed to evaluate perioperative and shortterm oncologic outcomes of SILS in pT3-T4 colorectal cancer. PATIENTS AND METHODS: From 2011 to 2015 data from 249 SILS performed in our Colorectal Unit were entered into a prospective database. Data regarding patients with a pT3-T4 colorectal adenocarcinoma were compared to those with pTis-pT2. Factors influencing conversion were assessed by multivariate analysis. RESULTS: There were 100 consecutive patients (T3-T4 = 70, Tis-T2 = 30). Demographics were similar. Tumor size was significantly larger in the T3-T4 group [3.9cm vs 2cm; p<0.001]. In T3-T4 patients we found a significant higher number of lymph nodes harvested [20 vs 13 ; p<0.001]. Early (<30 days) severe (Clavien-Dindo classification>2) postoperative complication rate was similar between groups (8.6% vs 10% ; p = 0.999), as well as conversion rate (18.6% vs 6.7% ; p = 0.220). Finally, there were no differences in terms of hospital stay and mortality rate. On multivariate analysis, age (OR = 1.06, 95%CI: 1.012-1.113 ; p = 0.015] and stage IV (OR = 5.372, 95%CI: 1.320-21.862, p = 0.019) were independently associated with conversion. CONCLUSIONS: SILS for locally advanced colorectal cancer did not affect the short-term outcomes in this series and oncological clearance remained satisfactory. Age and stage IV disease are independent risk factors for conversion.

Comparison between abdominal fat measured by CT and anthropometric indices as prediction factors for mortality and morbidity after colorectal surgery.

AIM: This study aims to determine which anthropometric (body mass index (BMI), waist-hip-ratio (WHR) and waist-to-height ratio (WHtR)) and radiological (visceral fat area (VFA) measured by CT scan) measurements of adiposity correlated better with postoperative outcome of colorectal cancer (CRC) surgery. We also assessed which of these measurements best predicted overall survival (OS) and disease-free survival (DFS). METHODS: Data from 90 consecutive Caucasian CRC patients who underwent surgery for colorectal cancer between 2010 and 2011 with a median follow-up of 53.25 months were analysed. The correlations of different adiposity measurements and postoperative outcomes were determined using logistic regression models and multivariate analyses. RESULTS: Higher WHtR (p = 0.007) and VFA (p = 0.01) significantly increased the risk of overall morbidity, especially of Clavien-Dindo III or IV. The WHtR correlated best with VFA (p <0.0001), which is considered the gold standard for measuring visceral fat, whereas BMI (p = 0.15) was not a good predictor of postoperative morbidity. Multivariate analyses showed consistently significant results for postoperative complications for VFA in combination with all of the other variables analysed and for WHtR, confirming that VFA and WHtR were reliable independent prognostic factors of morbidity. VFA had a significant effect on OS (p = 0.012) but did not correlate with DFS (p = 0.51). CONCLUSIONS: Both VFA and WHtR independently provided predictive data for potential postoperative complications after CRC surgery. In case CT scan was used for diagnostic purposes, VFA should be used in routine clinical practice.

Survival of rectal cancer patients in Belgium 1997-98 and the potential benefit of a national project.

BACKGROUND: PROCARE, a Belgian multidisciplinary project on rectal cancer (RC), will be launched in 2006. Guidelines have been developed, but remain to be implemented. AIM: A population-based study on RC treatment and outcome in Belgium and comparison with recent international benchmarks in order to better define targets that should be reached. PATIENTS AND METHODS: Anonymous data of 3079 patients with rectal cancer registered in the National Cancer Registry in 1997 and 1998 were analysed. Observed (OS) and relative survival (RS) were compared with figures from nationwide projects and multi-centre studies. RESULTS: The 5-yr OS and RS were 46.6% and 58.5%, respectively. For patients with stage I-III tumours 5-yr OS was 57.1% and 5-yr RS 70.1%. Adjuvant or neo-adjuvant treatment was given in 54.8% stage II-III patients who were < 70 years old. There were marked differences between the provinces in the use of radiotherapy for stage II-III patients and in 5-yr RS for all stages. In stage IV, the median OS was 13 months and the 2-yr OS was 28%. Comparison with recent multi-centre trials indicates significant potential benefits from the PROCARE project: an absolute increase of the 5-yr OS by 10 to 20% after chemoradiotherapy and TME in stage II-III patients 75 years old or less, a 7-month increase of the median OS and an absolute 15% increase of the 2-yr OS in unresectable stage IV patients with combined chemotherapy. CONCLUSION: Significant improvement seems to be achievable. Implementation of the PROCARE guidelines with quality assurance through prospective registration in a specific database, however, is a crucial prerequisite for credible audit of performance and feedback to individual teams.

[Traumatic perforation of the sigmoid colon: role of computed tomography]. / Perforation sigmoïdienne traumatique: intérêt du bilan tomodensitométrique.

The authors report a case of a delayed traumatic perforation of the sigmoid colon, presenting three days after a motor vehicle accident. A review of the literature is presented.

Comparison of surgical treatment of ulcerative colitis associated with primary sclerosing cholangitis: ileal pouch-anal anastomosis versus Brooke ileostomy.

OBJECTIVE: To compare the operative risks, operative complications, and late outcome of two homogeneous groups of patients with chronic ulcerative colitis (CUC) and primary sclerosing cholangitis (PSC) who underwent either Brooke ileostomy or ileal pouch-anal anastomosis (IPAA). MATERIAL AND METHODS: Between 1970 and 1990, 72 patients with CUC and PSC underwent proctocolectomy with either Brooke ileostomy (group I; N = 32) or IPAA (group II; N = 40). Postoperative data included operative mortality, need for blood transfusion, general postoperative complications, liver-related complications, and proctocolectomy-related complications. RESULTS: Eight group I patients and nine group II patients had a total of 12 and 11 general complications, respectively. Liver-related complications were diagnosed in 16% and 10% of group I and group II patients, respectively. Proctocolectomy-specific complications occurred in 34% of group I and 20% of group II patients. The overall need for blood transfusion was 94% in group I and 47% in group II (P < 0.001). The cumulative probability of proctocolectomy-related complications at 5 years was 23% for group I and 64% for group II patients (P < 0.002). The difference, however, was primarily due to the high frequency of pouchitis after IPAA, estimated at 57% at 4 years. The cumulative 5-year risk of liver-related complications was 37% and 28% for group I and group II, respectively. Peristomal varices and bleeding occurred in eight group I patients but in none of group II. CONCLUSION: Because IPAA avoids bleeding problems, it is the surgical treatment of choice in patients with PSC and CUC.

Use of the circular stapler in 1000 consecutive colorectal anastomoses: experience of one surgical team.

BACKGROUND: This study was performed to assess the exact performance of the conventional way of stapling colorectal anastomoses. Information collected from 1000 consecutive anastomoses performed by one surgical team could be considered as reliable reference with which results obtained by new approaches could be compared. METHODS: One thousand consecutive anastomoses were performed from 1979 to 1992. Characteristics of the procedure, intraoperative events, mortality rate, complications, and clinical outcome were detailed. RESULTS: There were 528 men and 472 women (age range, 20 to 90 years; average age, 63 years). Anastomoses were constructed by means of a circular stapler loaded with the largest cartridge in 82.3% of the cases. Imperfections were identified during operation in 124 cases. A diverting colostomy was performed in 127 cases. Postoperative mortality rate averaged 2.2%. Clinical anastomotic leaks developed in 35 patients: in 11.4% after low stapling (less than 5 cm from the dentate line) and in 2.2% after high stapling. The presence of a diverting colostomy influenced the leakage rate in patients with very low anastomoses. Total failure rate (death, definitive colostomy) as a result of anastomotic leak was 1.6%. Among the 933 survivors who had follow-up examination, the incidence of bad functional results decreased from 10% at the first attendance to 4.3% at the last one. Transanal dilatation and restapling were required for symptomatic narrowing in three and one patients, respectively. CONCLUSIONS: The conventional way of stapling colorectal anastomoses in reliable, but it requires strict observance of the rules for anastomosing intestine and a careful check of the stapled sutures. Results obtained by new approaches could be compared with these data.