Pelvic exenteration for locally advanced rectal cancer and associated outcomes in England between 1995 and 2016: Analysis of a national database.

AIM: The clinical burden of pelvic exenteration (PE) for locally advanced rectal cancer (LARC) is nationally under-reported. The widespread use of pelvic MRI since 2005 has increased the accuracy of local staging and awareness of the need for 'beyond TME (total mesorectal excision)' surgery. The aim of this study was to assess the volume of patients undergoing PE within England, which factors affected survival outcomes and whether the use of MRI has influenced these outcomes. METHOD: The volume of patients undergoing PE and associated survival outcomes across England between 1995 and 2016 was evaluated from Public Health England Hospital Episode Statistics data. RESULTS: A total of 2996 patients were recorded as undergoing PE. The 5-year overall survival rate improved after 2005 compared with prior to 2005 (61.7% vs. 37%, p < 0.001), with no significant difference between cancer registries throughout England. After 2005, the volume of patients undergoing PE and undergoing preoperative MRI increased, as did the number of non-T4 cancers operated on. After 2005, age, preoperative MRI and preoperative radiotherapy were the significant factors influencing 5-year overall survival on multivariate analysis. CONCLUSION: This review of national data confirms that PE outcomes are under-reported. MRI staging aids with the identification of patients suitable for perioperative treatment, surgery or palliation and facilitates treatment planning. Since 2005, MRI, likely in combination with advances in surgery and perioperative treatment, has improved survival outcomes. It is imperative that detailed information from patients with LARC undergoing PE is captured and reported in order to optimize care and future service provision.

EAES/SAGES evidence-based recommendations and expert consensus on optimization of perioperative care in older adults.

BACKGROUND: As the population ages, more older adults are presenting for surgery. Age-related declines in physiological reserve and functional capacity can result in frailty and poor outcomes after surgery. Hence, optimizing perioperative care in older patients is imperative. Enhanced Recovery After Surgery (ERAS) pathways and Minimally Invasive Surgery (MIS) may influence surgical outcomes, but current use and impact on older adults patients is unknown. The aim of this study was to provide evidence-based recommendations on perioperative care of older adults undergoing major abdominal surgery. METHODS: Expert consensus determined working definitions for key terms and metrics related to perioperative care. A systematic literature review and meta-analysis was performed using the PubMed, Embase, Cochrane Library, and Clinicaltrials.gov databases for 24 pre-defined key questions in the topic areas of prehabilitation, MIS, and ERAS in major abdominal surgery (colorectal, upper gastrointestinal (UGI), Hernia, and hepatopancreatic biliary (HPB)) to generate evidence-based recommendations following the GRADE methodology. RESULT: Older adults were defined as 65 years and older. Over 20,000 articles were initially retrieved from search parameters. Evidence synthesis was performed across the three topic areas from 172 studies, with meta-analyses conducted for MIS and ERAS topics. The use of MIS and ERAS was recommended for older adult patients particularly when undergoing colorectal surgery. Expert opinion recommended prehabilitation, cessation of smoking and alcohol, and correction of anemia in all colorectal, UGI, Hernia, and HPB procedures in older adults. All recommendations were conditional, with low to very low certainty of evidence, with the exception of ERAS program in colorectal surgery. CONCLUSIONS: MIS and ERAS are recommended in older adults undergoing major abdominal surgery, with evidence supporting use in colorectal surgery. Though expert opinion supported prehabilitation, there is insufficient evidence supporting use. This work has identified evidence gaps for further studies to optimize older adults undergoing major abdominal surgery.

Demographics and incidence of anal squamous cell carcinoma in people living in high HIV prevalence geographical areas.

OBJECTIVES: Anal squamous cell carcinoma (ASCC) is an uncommon cancer that is rapidly increasing in incidence. HIV is a risk factor in the development of ASCC, and it is thought that the rapidly increasing incidence in men is related to increasing numbers of people living with HIV (PLWH). We undertook a population-based study comparing the demographics and incidence of ASCC in patients residing high HIV prevalence areas in England to patients living in average HIV prevalence areas in England. METHODS: This is a cross-sectional study following the 'Strengthening the Reporting of Observational Studies in Epidemiology' statement. Demographic data and incidence rates of ASCC within Clinical Commissioning Groups (CCGs) between 2013 and 2018 were extracted from the Cancer Outcomes and Services Dataset. CCGs were then stratified by HIV prevalence from data given by Public Health England, and high HIV prevalence geographical areas were compared with average HIV geographical areas. RESULTS: Patients in high HIV areas were more likely to be young and male with higher levels of social deprivation. Incidence rates in men between 2013 and 2017 were higher in high HIV areas than average HIV areas with a rapidly increasing incidence rates in early-stage disease and a 79.1% reduction in incidence of metastatic stage 4 disease.Whereas women in high HIV areas had lower ASCC incidence than the national average and a low incidence of early-stage disease; however, metastatic disease in women had quintupled in incidence in high HIV areas since 2013. CONCLUSIONS: Patients presenting with ASCC in high HIV geographical areas have different demographics to patients presenting in average HIV geographical areas. This may be related to screening programmes for PLWH in high HIV areas.

The current and possible future role of 3D modelling within oesophagogastric surgery: a scoping review.

BACKGROUND: 3D reconstruction technology could revolutionise medicine. Within surgery, 3D reconstruction has a growing role in operative planning and procedures, surgical education and training as well as patient engagement. Whilst virtual and 3D printed models are already used in many surgical specialities, oesophagogastric surgery has been slow in their adoption. Therefore, the authors undertook a scoping review to clarify the current and future roles of 3D modelling in oesophagogastric surgery, highlighting gaps in the literature and implications for future research. METHODS: A scoping review protocol was developed using a comprehensive search strategy based on internationally accepted guidelines and tailored for key databases (MEDLINE, Embase, Elsevier Scopus and ISI Web of Science). This is available through the Open Science Framework (osf.io/ta789) and was published in a peer-reviewed journal. Included studies underwent screening and full text review before inclusion. A thematic analysis was performed using pre-determined overarching themes: (i) surgical training and education, (ii) patient education and engagement, and (iii) operative planning and surgical practice. Where applicable, subthemes were generated. RESULTS: A total of 56 papers were included. Most research was low-grade with 88% (n = 49) of publications at or below level III evidence. No randomised control trials or systematic reviews were found. Most literature (86%, n = 48) explored 3D reconstruction within operative planning. These were divided into subthemes of pre-operative (77%, n = 43) and intra-operative guidance (9%, n = 5). Few papers reported on surgical training and education (14%, n = 8), and were evenly subcategorised into virtual reality simulation (7%, n = 4) and anatomical teaching (7%, n = 4). No studies utilising 3D modelling for patient engagement and education were found. CONCLUSION: The use of 3D reconstruction is in its infancy in oesophagogastric surgery. The quality of evidence is low and key themes, such as patient engagement and education, remain unexplored. Without high quality research evaluating the application and benefits of 3D modelling, oesophagogastric surgery may be left behind.

Catheter-Directed Hemorrhoidal Dearterialization Technique for the Management of Hemorrhoids: A Meta-Analysis of the Clinical Evidence.

PURPOSE: To assess the efficacy and safety of a catheter-directed hemorrhoidal dearterialization technique for the management of hemorrhoidal bleeding. MATERIALS AND METHODS: A systematic review and meta-analysis of pubmed, cochrane, and scopus databases was conducted according to the preferred reporting items for systematic reviews and meta-Analysis (PRISMA) guidelines. Clinical studies reporting on catheter-directed hemorrhoidal dearterialization for rectal bleeding were analyzed. RESULTS: Fourteen studies (n = 362) were identified. The mean maximum follow-up duration was 12.1 months (SD, 7.31; range, 1-28; median, 12), and the mean length of hospital stay was 1.5 days (SD, 1.1; range, 0-2.5). The mean technical success was 97.8% (SD, 3.5), and the mean clinical success was 78.9% (SD, 10.5). A statistically significant reduction in the french bleeding score before and after embolization was noted (P = .004). In subgroup analysis, when the coils-only group was compared with the coils and particles group, the average rebleeding rate was 21.5% (n = 111; SD, 18.2; range, 0%-44%) versus 10.05% (N = 108; SD, 4.8; range, 5%-15.7%), respectively (P < .0001). No bowel ischemia/necrosis or anorectal complications were reported. CONCLUSIONS: The current preliminary clinical evidence suggests that catheter-directed hemorrhoidal dearterialization is an effective and safe procedure for the treatment of hemorrhoidal bleeding. The standardization of the technique and the generation of higher level evidence will be required to compare this minimally invasive procedure with more invasive surgical options for patients with grades I-III hemorrhoids and chronic bleeding.

Evaluating the efficacy of treatment options for anal intraepithelial neoplasia: a systematic review.

PURPOSE: Anal intraepithelial neoplasia (AIN) is the accepted precursor of anal squamous cell carcinoma (ASCC). There has long been a hypothesis that treating AIN may prevent ASCC. Many different treatment modalities have been suggested and studied. We conducted this systematic review to evaluate their efficacy and the evidence as to whether we can prevent ASCC by treating AIN. METHODS: MEDLINE and EMBASE were electronically searched using relevant search terms. All studies investigating the use of a single treatment for AIN that reported at least one end outcome such as partial or complete response to treatment, recurrence after treatment and/or ASCC diagnosis after treatment were included. RESULTS: Thirty studies were included in the systematic review investigating 10 treatment modalities: 5% imiquimod, 5-fluorouracil, cidofovir, trichloroacetic acid, electrocautery, surgical excision, infrared coagulation, radiofrequency ablation, photodynamic therapy and HPV vaccination. All treatment modalities demonstrated some initial regression of AIN after treatment; however, recurrence rates were high especially in HIV-positive patients. Many of the studies suffered from significant bias which prevented direct comparison. CONCLUSIONS: Although the theory persists that by inducing the regression of AIN, we may be able to reduce the risk of ASCC, there was no clinical evidence within the literature advocating that treating AIN does prevent ASCC.

The role of Neurotensin and its receptors in non-gastrointestinal cancers: a review.

BACKGROUND: Neurotensin, originally isolated in 1973 has both endocrine and neuromodulator activity and acts through its three main receptors. Their role in promoting tumour cell proliferation, migration, DNA synthesis has been studied in a wide range of cancers. Expression of Neurotensin and its receptors has also been correlated to prognosis and prediction to treatment. MAIN BODY: The effects of NT are mediated through mitogen-activated protein kinases, epidermal growth factor receptors and phosphatidylinositol-3 kinases amongst others. This review is a comprehensive summary of the molecular pathways by which Neurotensin and its receptors act in cancer cells. CONCLUSION: Identifying the role of Neurotensin in the underlying molecular mechanisms in various cancers can give way to developing new agnostic drugs and personalizing treatment according to the genomic structure of various cancers. Video abstract.

A Comparison of the Short-term Outcomes of Three Flap Reconstruction Techniques Used After Beyond Total Mesorectal Excision Surgery for Anorectal Cancer.

BACKGROUND: Surgery for advanced or recurrent pelvic malignancy can result in perineal defects that cannot be closed by wound edge approximation. Myocutaneous flaps can fill the defect and accelerate healing. No reconstruction has been proven to be superior to the others. OBJECTIVE: This study aimed to compare 3 flap procedures after beyond total mesorectal excision surgery. DESIGN: This is a retrospective analysis of a prospective database, according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement. SETTINGS: This study was performed at a tertiary hospital. PATIENTS: Consecutive series of patients who required flap reconstruction after beyond total mesorectal excision surgery between 2007 and 2016 were included. MAIN OUTCOME MEASURES: Short-term outcomes after oblique rectus abdominis flap vs vertical rectus abdominis flap vs inferior gluteal artery perforator flap reconstruction were evaluated. RESULTS: Included are 65 (59%) oblique rectus abdominis flap, 30 (27.3%) vertical rectus abdominis flap, and 15 (13.7%) inferior gluteal artery perforator flap outcomes. Sacrectomy was performed in 12 (18.5%), 10 (33.3%), and 8 (53.3%) patients (p = 0.016). Preoperative radiotherapy was used in 60 (92.3%), 26 (86.7%), and 11 (73.3%) patients (p = 0.11). Flap infection and dehiscence occurred in 7 (10.8%), 1 (3.3%), and 4 (26.7%) patients. There was an increased risk of flap complication with inferior gluteal artery perforator flap vs vertical rectus abdominis flap (p = 0.036). Inferior gluteal artery perforator flap (OR, 6.26; p = 0.02) and obesity (OR, 4.96; p = 0.02) were associated with flap complications. Only complications of the oblique rectus abdominis flap decreased significantly over time (p = 0.03). The length of stay and complete (R0) resection rate were not different between the groups. LIMITATIONS: This study was limited because of its retrospective nature and because it was conducted at a single center. CONCLUSIONS: The techniques appear comparable. The approaches should be considered complementary, and the choice should be individualized. See Video Abstract at http://links.lww.com/DCR/B141. COMPARACIÓN DE RESULTADOS A CORTO PLAZO DE TRES TÉCNICAS DE RECONSTRUCCIÓN CON COLGAJO UTILIZADAS DESPUÉS DE LA CIRUGÍA DE ESCISIÓN MESORRECTAL TOTAL EXTENDIDA PARA EL CÁNCER ANORRECTAL: La cirugía para malignidad pélvica avanzada o recurrente puede provocar defectos perineales, que no pueden cerrarse por aproximación de los bordes de la herida. Los colgajos miocutáneos pueden llenar el defecto y acelerar la curación. Ninguna reconstrucción ha demostrado ser superior a las demás.Comparar tres procedimientos de colgajo después de una cirugía de escisión mesorrectal total extendida.Análisis retrospectivo de una base de datos prospectiva, de acuerdo con la Declaración de Fortalecimiento de los informes de estudios observacionales en epidemiología.Hospital de tercer nivel.Series consecutivas de pacientes que requirieron reconstrucción con colgajo después de una cirugía de escisión mesorrectal total extendida entre 2007 y 2016.Resultados a corto plazo después del colgajo oblicuo recto abdominal versus colgajo vertical recto abdominal versus reconstrucción del colgajo perforador de la arteria glútea inferior.Se incluyen 65 (59%) colgajo oblicuo recto abdominal oblicuo, 30 (27.3%) colgajo vertical recto abdominal y 15 (13.7%) colgajo perforador de la arteria glútea inferior. Sacrectomía se realizó en 12 (18.5%), 10 (33.3%) y 8 (53.3%) pacientes respectivamente (p = 0.016). La radioterapia preoperatoria se utilizó en 60 (92.3%), 26 (86.7%) y 11 (73.3%) (p = 0,11). La infección del colgajo y la dehiscencia ocurrieron en 7 (10.8%), 1 (3.3%) y 4 (26.7%). Hubo un mayor riesgo de complicación con el colgajo perforador de la arteria glútea inferior en comparación al colgajo vertical del recto abdominal (p = 0.036). El colgajo perforador de la arteria glútea inferior (OR 6.26, p = 0.02) y la obesidad (OR 4.96, p = 0.02) se asociaron con complicaciones del colgajo. Solo las complicaciones del colgajo oblicuo recto abdominal disminuyeron significativamente con el tiempo (p = 0.03). La duración de la estancia hospitalaria y la tasa de resección completa (R0) no fue diferente entre los grupos.Estudio retrospectivo en centro único.Las técnicas parecen comparables. Los enfoques deben considerarse complementarios y la elección individualizada. Consulte Video Resumen en http://links.lww.com/DCR/B141.

Sporadic colorectal cancer in adolescents and young adults: a scoping review of a growing healthcare concern.

PURPOSE: Sporadic colorectal cancer (CRC) amongst adolescents and young adults (AYA) is increasing in incidence. The reasons for this trend are not well understood. Current guidelines do not specifically address this patient cohort. A scoping review was performed to summarise the range of available evidence and identify key areas that need to be addressed in current guidelines. METHODS: A systematic literature search was conducted adhering to the PRISMA statement. All potentially eligible studies were screened, and data extraction was performed by two reviewers independently. The studies were then divided into 5 broad subgroups: (1) risk factors, (2) screening, (3) clinicopathological and molecular features, (4) presentation and (5) management. Descriptive statistics were used for data analysis. RESULTS: A total of 17 studies were included from 2010 to 2019. Overall, young adults with CRC tend to present with non-specific symptoms. The majority of these patients have a delayed diagnosis and more advanced disease at presentation, with a rise in prevalence of distal colon and rectal cancers. AYAs tend to have poorly differentiated tumours and are managed more aggressively. Overall 5-year survival varies between studies. CONCLUSION: This is, to our knowledge, the first scoping review presenting the range of available evidence on CRC in AYAs. Although the rise in incidence is recognised by specialist bodies, recommendations are limited by the sparsity of available data. We seek to highlight the need for further research, define the role of earlier screening and raise awareness to promote thorough assessment of young patients.

Surgical challenges and research priorities in the era of the COVID-19 pandemic: EAES membership survey.

BACKGROUND: Healthcare systems and general surgeons are being challenged by the current pandemic. The European Association for Endoscopic Surgery (EAES) aimed to evaluate surgeons' experiences and perspectives, to identify gaps in knowledge, to record shortcomings in resources and to register research priorities. METHODS: An ad hoc web-based survey of EAES members and affiliates was developed by the EAES Research Committee. The questionnaire consisted of 69 items divided into the following sections: (Ι) demographics, (II) institutional burdens and management strategies, and (III) analysis of resource, knowledge, and evidence gaps. Descriptive statistics were summarized as frequencies, medians, ranges,, and interquartile ranges, as appropriate. RESULTS: The survey took place between March 25th and April 16th with a total of 550 surgeons from 79 countries. Eighty-one percent had to postpone elective cases or suspend their practice and 35% assumed roles not related to their primary expertise. One-fourth of respondents reported having encountered abdominal pathologies in COVID-19-positive patients, most frequently acute appendicitis (47% of respondents). The effect of protective measures in surgical or endoscopic procedures on infected patients, the effect of endoscopic surgery on infected patients, and the infectivity of positive patients undergoing laparoscopic surgery were prioritized as knowledge gaps and research priorities. CONCLUSIONS: Perspectives and priorities of EAES members in the era of the pandemic are hereto summarized. Research evidence is urgently needed to effectively respond to challenges arisen from the pandemic.

Augmented Reality System for Digital Rectal Examination Training and Assessment: System Validation.

BACKGROUND: Digital rectal examination is a difficult examination to learn and teach because of limited opportunities for practice; however, the main challenge is that students and tutors cannot see the finger when it is palpating the anal canal and prostate gland inside the patients. OBJECTIVE: This paper presents an augmented reality system to be used with benchtop models commonly available in medical schools with the aim of addressing the problem of lack of visualization. The system enables visualization of the examining finger, as well as of the internal organs when performing digital rectal examinations. Magnetic tracking sensors are used to track the movement of the finger, and a pressure sensor is used to monitor the applied pressure. By overlaying a virtual finger on the real finger and a virtual model on the benchtop model, students can see through the examination and finger maneuvers. METHODS: The system was implemented in the Unity game engine (Unity Technologies) and uses a first-generation HoloLens (Microsoft Inc) as an augmented reality device. To evaluate the system, 19 participants (9 clinicians who routinely performed digital rectal examinations and 10 medical students) were asked to use the system and answer 12 questions regarding the usefulness of the system. RESULTS: The system showed the movement of an examining finger in real time with a frame rate of 60 fps on the HoloLens and accurately aligned the virtual and real models with a mean error of 3.9 mm. Users found the movement of the finger was realistic (mean 3.9, SD 1.2); moreover, they found the visualization of the finger and internal organs were useful for teaching, learning, and assessment of digital rectal examinations (finger: mean 4.1, SD 1.1; organs: mean 4.6, SD 0.8), mainly targeting a novice group. CONCLUSIONS: The proposed augmented reality system was designed to improve teaching and learning of digital rectal examination skills by providing visualization of the finger and internal organs. The initial user study proved its applicability and usefulness.

Open Versus Laparoscopic Versus Robotic Versus Transanal Mesorectal Excision for Rectal Cancer: A Systematic Review and Network Meta-analysis.

OBJECTIVE: To compare techniques for rectal cancer resection. SUMMARY BACKGROUND DATA: Different surgical approaches exist for mesorectal excision. METHODS: Systematic literature review and Bayesian network meta-analysis performed. RESULTS: Twenty-nine randomized controlled trials included, reporting on 6237 participants, comparing: open versus laparoscopic versus robotic versus transanal mesorectal excision. No significant differences identified between treatments in intraoperative morbidity, conversion rate, grade III/IV morbidity, reoperation, anastomotic leak, nodes retrieved, involved distal margin, 5-year overall survival, and locoregional recurrence. Operative blood loss was less with laparoscopic surgery compared with open, and with robotic surgery compared with open and laparoscopic. Robotic operative time was longer compared with open, laparoscopic, and transanal. Laparoscopic operative time was longer compared with open. Laparoscopic surgery resulted in lower overall postoperative morbidity and fewer wound infections compared with open. Robotic surgery had fewer wound infections compared with open. Time to defecation was longer with open surgery compared with laparoscopic and robotic. Hospital stay was longer after open surgery compared with laparoscopic and robotic, and after laparoscopic surgery compared with robotic. Laparoscopic surgery resulted in more incomplete or nearly complete mesorectal excisions compared with open, and in more involved circumferential resection margins compared with transanal. Robotic surgery resulted in longer distal resection margins compared with open, laparoscopic, and transanal. CONCLUSIONS: The different techniques result in comparable perioperative morbidity and long-term survival. The laparoscopic and robotic approaches may improve postoperative recovery, and the open and transanal approaches may improve oncological resection. Technique selection should be based on expected benefits by individual patient.

The prognostic and therapeutic role of hormones in colorectal cancer: a review.

Colorectal cancer (CRC) is one of the commonest cancers in Western society with a poor prognosis in patients with advanced disease. Targeted therapy is of increasing interest and already, targeted hormone treatment for breast and prostate cancer has improved survival. The aim of this literature review is to summarise the role of hormones in CRC prognosis and treatment. A literature review of all human and animal in vivo and in vitro studies in the last 20 years, which assessed the role of hormones in CRC treatment or prognosis, was carried out. The hormones described in this review have been subdivided according to their secretion origin. Most of the studies are based on in vitro or animal models. The main findings point to adipokines, insulin and the insulin growth factor axis as key players in the link between obesity, type 2 diabetes mellitus and a subset of CRC. Gut-derived hormones, especially uroguanylin and guanylin are being increasingly investigated as therapeutic targets, with promising results. Using hormones as prognostic and therapeutic markers in CRC is still in the preliminary stages for only a fraction of the hormones affecting the GIT. In light of the increasing interest in tailoring treatment strategies, hormones are an important area of focus in the future of CRC management.

Primary Tumor Resection in Patients with Incurable Localized or Metastatic Colorectal Cancer: A Systematic Review and Meta-analysis.

BACKGROUND: To assess the impact of primary tumor resection (PTR) on survival and morbidity in incurable colorectal cancer. METHODS: Systematic literature review and meta-analysis to compare PTR versus primary tumor intact (PTI). RESULTS: Seventy-seven studies were included, reporting on 159,991 participants (94,745 PTR; 65,246 PTI). PTR improved overall survival (hazard ratio [HR] 0.59, P < 0.0001; mean difference [MD] 7.27 months, P < 0.0001), cancer-specific survival (HR 0.47, MD 10.80), and progression-free survival (HR 0.76, MD 1.67). Overall survival remained significantly improved during subgroup analysis of asymptomatic patients (HR 0.69, MD 3.86), elderly patients (HR 0.46, MD 7.71), patients diagnosed after 2000 (HR 0.62, MD 7.29), patients with colon (HR 0.58, MD 6.31) or rectal (HR 0.54, MD 6.88) primary tumor, patients undergoing resection of primary tumor versus non-resectional surgery (NRS) to treat primary tumor complications (HR 0.56, MD 8.72), and of studies with propensity score analysis (HR 0.65, MD 5.68). Overall survival per treatment strategy was: [PTI/chemotherapy] 14.30 months, [PTI/bevacizumab] 17.27 months, [PTR/chemotherapy] 21.52 months, [PTR/bevacizumab] 27.52 months. PTR resulted in 4.5% perioperative mortality and 22.4% morbidity (major adverse events 10.2%, minor 18.5%, reoperation 2.5%, intraabdominal collection/sepsis 2.2%). PTI had 21.7% morbidity (obstruction 14.4%, anemia 11.0%, hemorrhage 1.5%, perforation 0.6%, adverse events requiring surgery 15.8%). NRS resulted in 10.6% perioperative mortality and 21.7% morbidity (major 7.9%, minor 21.7%, reoperation 0.1%). CONCLUSIONS: PTR in patients with incurable colorectal cancer results in a limited improvement of survival without a significant increase in morbidity. PTR should be considered by the multidisciplinary team on an individual patient basis.

A systematic review of the literature reporting on randomised controlled trials comparing treatments for faecal incontinence in adults.

AIM: To perform a review of the literature reporting on randomised controlled trials (RCTs) comparing treatments for faecal incontinence (FI) in adults. METHODS: A literature search of MEDLINE, Embase, Science Citation Index Expanded and Cochrane was performed in order to identify RCTs reporting on treatments for FI. RESULTS: The review included 60 RCTs reporting on 4838 patients with a mean age ranging from 36.8 to 88 years. From the included RCTs, 32 did not identify a significant difference between the treatments compared. Contradictory results were identified in RCTs comparing percutaneous posterior tibial nerve stimulation and transcutaneous tibial nerve stimulation versus sham stimulation, biofeedback-pelvic floor muscle training (BF-PFMT) versus PFMT, and between bulking agents such as PTQTM versus Durasphere®. In two separate RCTs, combination treatment of amplitude-modulated medium frequency stimulation and electromyography-biofeedback (EMG-BF), was noted to be superior to EMG-BF and low-frequency electrical stimulation alone. Combination of non-surgical treatments such as BF with sphincteroplasty significantly improved continence scores compared to sphincteroplasty alone. Surgical treatments were associated with higher rates of serious adverse events compared to non-surgical interventions. CONCLUSIONS: The current evidence has not identified significant differences between treatments for FI, and where differences were identified, the results were contradictory between RCTs.

Comparison of Western and Asian Guidelines Concerning the Management of Colon Cancer.

BACKGROUND: Guidelines are important to standardize treatments and optimize outcomes. Several societies have published authoritative guidelines for patients with colon cancer, and a certain degree of variation can be predicted. OBJECTIVE: This study aims to compare Western and Asian guidelines for the management of colon cancer. DATA SOURCES: A literature review was performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for studies published between 2010 and 2017 by the online resources from the official Web sites of the societies/panels. Sources included guidelines by European Society of Medical Oncology, the Japanese Society for Cancer of the Colon and Rectum, and the National Comprehensive Cancer Network. STUDY SELECTION: Only full-text studies and the latest guidelines dealing with colon cancer were included. Studies and guidelines were separately assessed by 2 authors, who independently identified discrepancies and areas for further research. These were discussed and agreed with by all the authors. MAIN OUTCOME MEASURES: The recommendations of the guidelines of each society were compared, seeking discrepancies and potential areas for improvement. RESULTS: Endoscopic techniques for the management of early colon cancer are discussed in detail in the Asian guidelines. Asian guidelines advocate extended (D3) lymphadenectomy on a routine basis in T3/T4 and in selected T2 patients, whereas such an approach is still under investigation in Western countries. Only US guidelines describe neoadjuvant chemotherapy and radiotherapy. All the guidelines recommend adjuvant treatment in selected stage II patients, but agreement exists that this is performed without solid evidence, because better outcomes are hypothesized based on studies including stage III or stage II/III patients. The role of cytoreductive surgery with intra-abdominal chemotherapy is dubious, and European guidelines only recommend it in the setting of trials. Asian guidelines endorse an aggressive surgical approach to peritoneal disease. Only US guidelines include a patient advocate in the drafting panel. LIMITATIONS: Bias may have arisen from country-specific socioeconomic and cultural issues, and from the latest available updates. CONCLUSIONS: Surgical approaches to colon cancer differ significantly among Western and Asian guidelines, reflecting different concepts of treatment. The role of adjuvant treatment in node-negative disease and quality-of-life assessment need further research.

Sacral nerve stimulation versus percutaneous tibial nerve stimulation for faecal incontinence: a systematic review and meta-analysis.

AIMS: Percutaneous tibial nerve stimulation (PTNS) and sacral nerve stimulation (SNS) are both second-line treatments for faecal incontinence (FI). To compare the clinical outcomes and effectiveness of SNS versus PTNS for treating FI in adults. METHOD: A literature search of MEDLINE, Embase, Science Citation Index Expanded and Cochrane was performed in order to identify studies comparing SNS and PTNS for treating FI. A risk of bias assessment was performed using The Cochrane Collaboration's risk of bias tool. A random effects model was used for the meta-analysis. RESULTS: Four studies (one randomised controlled trial and three nonrandomised prospective studies) reported on 302 patients: 109 underwent SNS and 193 underwent PTNS. All included studies noted an improvement in symptoms after treatment, without any significant difference in efficacy between SNS and PTNS. Meta-analysis demonstrated that the Wexner score improved significantly with SNS compared to PTNS (weighted mean difference 2.27; 95% confidence interval 3.42, 1.12; P < 0.01). Moreover, SNS was also associated with a significant reduction in FI episodes per week and a greater improvement in the Fecal Incontinence Quality of Life coping and depression domains, compared to PTNS on short-term follow-up. Only two studies reported on adverse events, reporting no serious adverse events with neither SNS nor PTNS. CONCLUSION: Current evidence suggests that SNS results in significantly improved functional outcomes and quality of life compared to PTNS. No serious adverse events were identified with either treatment. Further, high-quality, multi-centre randomised controlled trials with standardised outcome measures and long-term follow-up are required in this field.

Systematic review of blood diagnostic markers in colorectal cancer.

The purpose of this systematic review was to compare the diagnostic ability of blood markers for colorectal cancer (CRC). A systematic review of the literature for diagnostic blood markers for primary human colorectal cancer over the last 5 years was performed. The primary outcome was to assess the diagnostic ability of these markers in diagnosing colorectal cancer. The secondary outcome was to see whether the marker was compared to other markers. The tertiary outcome was to assess diagnostic ability in early versus late CRC, including stage IV disease. We identified 51 studies (29 prospective, 14 retrospective, and 8 meta-analyses). The markers were divided in broadly four groups: nucleic acids (RNA/DNA/messenger RNA/microRNAs), cytokines, antibodies, and proteins. The most promising circulating markers identified among the nucleid acids were NEAT_v2 non-coding RNA, SDC2 methylated DNA, and SEPT9 methylated DNA. The most promising cytokine to detect CRC was interleukin 8, and the most promising circulating proteins were CA11-19 glycoprotein and DC-SIGN/DC-SIGNR. Sensitivities of these markers for detecting primary colorectal carcinoma ranged from 70 to 98% and specificities from 84 to 98.7%. The best studied blood marker was SEPT9 methylated DNA, which showed great variability with sensitivities ranging from 48.2 to 95.6% and specificities from 80 to 98.9%, making its clinical applicability challenging. If combined with fecal immunochemical test (FIT), the sensitivity improved from 78 to 94% in detecting CRC. Methylated SEPT9, methylated SDC2, and -SIGN/DC-SIGNR protein had better sensitivity and specificity than CEA or CA 19-9. With the exception of SEPT9 which is currently being implemented as a screening test for CRC all other markers lacked reproducibility and standardization and were studied in relatively small population samples.

A Systematic Review to Assess Resection Margin Status After Abdominoperineal Excision and Pelvic Exenteration for Rectal Cancer.

OBJECTIVE: The aim of this study was to assess resection margin status and its impact on survival after abdominoperineal excision and pelvic exenteration for primary or recurrent rectal cancer. SUMMARY OF BACKGROUND DATA: Resection margin is important to guide therapy and to evaluate patient prognosis. METHODS: A meta-analysis was performed to assess the impact of resection margin status on survival, and a regression analysis to analyze positive resection margin rates reported in the literature. RESULTS: The analysis included 111 studies reporting on 19,607 participants after abdominoperineal excision, and 30 studies reporting on 1326 participants after pelvic exenteration. The positive resection margin rates for abdominoperineal excision were 14.7% and 24.0% for pelvic exenteration. The overall survival and disease-free survival rates were significantly worse for patients with positive compared with negative resection margins after abdominoperineal excision [hazard ratio (HR) 2.64, P < 0.01; HR 3.70, P < 0.01, respectively] and after pelvic exenteration (HR 2.23, P < 0.01; HR 2.93, P < 0.01, respectively). For patients undergoing abdominoperineal excision with positive resection margins, the reported tumor sites were 57% anterior, 15% posterior, 10% left or right lateral, 8% circumferential, 10% unspecified. A significant decrease in positive resection margin rates was identified over time for abdominoperineal excision. Although positive resection margin rates did not significantly change with the size of the study, some small size studies reported higher than expected positive resection margin rates. CONCLUSIONS: Resection margin status influences survival and a multidisciplinary approach in experienced centers may result in reduced positive resection margins. For advanced anterior rectal cancer, posterior pelvic exenteration instead of abdominoperineal excision may improve resection margins.

Evaluation of sexual dysfunction in female patients presenting with faecal incontinence or defecation disorder.

PURPOSE: Female patients with pelvic floor diseases may suffer from several sexual disorders and sexual life impairments. The aim of this manuscript was to evaluate sexual dysfunction in female patients presenting with faecal incontinence (FI) and defecation disorder (DD). METHODS: A retrospective review was performed of a prospectively collected database of sexually active women referred to the pelvic floor clinic, who completed the Pelvic Organ Prolapse/Incontinence Sexual Questionnaire-12 (PISQ-12) at first visit. Statistical analysis was performed to evaluate and compare sexual dysfunction between patients with FI and DD and with published data on the general population. Regression analysis was used to identify predictors of sexual dysfunction and surgery. RESULTS: Three hundred thirteen patients were included, 192 (61%) with FI and 121 (39%) with DD. The patients with DD received more non-gynaecological surgical procedures (p = 0.023). More patients with DD received surgery for their current pelvic floor disease (p < 0.001). Major sexual impairment (PISQ-12 < 30) was found in 100 patients (31.9%). The mean PISQ-12 (33.2 ± 7.2) score was by 5 points lower than those reported in the general population from PISQ-validating studies. Prior anorectal surgery (odds ratio (OR) = 15.4), partner ejaculation problems (PISQ item 11, OR = 2.5), reduced sexual arousal (item 2, OR = 2.1), and orgasm perception (item 13, OR = 2.1) were the strongest predictors of worse sexual function in patients with FI. Patients with DD were almost 15 times more likely to receive subsequent surgery (OR = 14.6, p < 0.001), whereas fear of urine leakage almost doubled the risk. CONCLUSIONS: Sexual dysfunction is prevalent among patients suffering from FI and DD, and questionnaires are useful in recognizing these patients. Subsequent surgery is more common for patients with DD compared to those with FI.