Delayed coloanal anastomosis as a stoma-sparing alternative to immediate coloanal anastomosis: A systematic review and meta-analysis.

BACKGROUND: Recent clinical trials have demonstrated favorable outcomes associated with trans-anal colonic pull-through for rectal resection followed by delayed coloanal anastomoses (DCA), resulting in a resurgence in popularity of the technique. This meta-analysis aims to review existing literature to evaluate the postoperative complications associated with DCA, and to make comparisons with immediate coloanal anastomoses (ICA) after colorectal resection to assess the suitability of DCA as an alternative form of surgical treatment. METHODS: Medline and Embase databases were reviewed from inception until 31 July 2020 in accordance with PRISMA guidelines. Single-arm studies that involved patients undergoing DCA for benign or malignant causes were selected, and meta-analysis of proportions was conducted to determine the prevalence of postoperative complications following DCA. Comparative studies comparing postoperative outcomes between DCA and ICA were also included for comparative meta-analysis. RESULTS: Patients undergoing DCA were significantly less likely to require diverting stoma construction as compared to ICA (odds ratio [OR] = 0.04; confidence interval [CI]: 0.02-0.07; P < 0.001). Overall postoperative morbidity (OR = 0.50; 95% CI: 0.23-1.12; P = 0.09) and mortality (OR = 0.49, 95% CI: 0.12-1.98; P = 0.32) was comparable between DCA and ICA groups. No significant differences in perioperative complications, such as anastomotic leakage (OR = 0.42; 95% CI: 0.11-1.64; P = 0.21), postoperative ileus, pelvic abscesses, or sepsis, were noted between DCA and ICA. CONCLUSION: Our study shows no differences in complications or functional outcomes between DCA and ICA. Pooled analysis expectedly revealed a lower rate of diverting stoma in patients undergoing DCA. DCA is thus a safe alternative to current surgical practices where avoidance of a stoma is desired.

Quantifying the rate of recurrence of postoperative Crohn's disease with biological therapy. A meta-analysis.

OBJECTIVE: Preventing the postoperative recurrence (POR) of Crohn's disease (CD) poses a significant challenge to clinicians. With the advent of biologics, various studies have observed a reduction of recurrence after surgery. Hence, we performed a systematic review and meta-analysis to identify the rate of POR at different time points in the era of biologic use. METHODS: We performed a literature search using Medline and Embase databases for studies investigating biologics in preventing the POR of CD. Data were extracted, and a single-arm meta-analysis with generalized linear mixed model and Clopper-Pearson method for confidence interval (CI) was performed to identify endoscopic, clinical and surgical recurrence rates at 6 months and 1, 2 and 5 years postoperatively. RESULTS: Altogether 24 studies were included in the meta-analysis. The endoscopic, clinical and surgical POR rate with the use of anti-tumor necrosis factor (TNF)-α agents at 1 year was 21.72% (95% CI 16.28%-28.37%), 13.06% (95% CI 8.18%-18.92%) and 3.76% (95% CI 1.37%-9.91%), respectively. The 5-year recurrence rate was 84.21% (95% CI 72.35%-91.57%) and 17.49% (95% CI 9.17%-30.80%) for endoscopic and surgical recurrence, respectively. Subgroup analyses at 1 year for the type of anti-TNF-α agent or the timing of initiation after surgery showed no significant difference in endoscopic, clinical and surgical recurrence rates. CONCLUSIONS: Anti-TNF-α agents are effective at preventing clinical, endoscopic and surgical POR of CD. The timing of initiating biological therapy after surgery has no significant effect on the rate of POR. The efficacy of infliximab and adalimumab for postoperative recurrence prevention is similar.

Moving beyond the initial colonoscopy: a call for action.

INTRODUCTION: The evolution of colorectal screening has made headway with continual efforts globally to increase screening rates for colonoscopy-naïve patients. However, little has been done to encourage repeat colonoscopies after the initial scope despite recommendations to repeat colonoscopy every 10 years, with the uptake rates of repeat colonoscopy remaining abysmal at 22%. METHODS: Previously, a qualitative systematic review evaluated the barriers and facilitators patients faced in their decisions to undergo colonoscopy, analyzing articles from Medline, Embase, CINAHL, PsycINFO and Web of Science. Key findings from articles which highlighted factors influencing patients' decisions to return for repeat colonoscopies were summarized. RESULTS: Three articles were identified in the search. Facilitators for repeat colonoscopy included patients' assurance garnered from fostered trust in the patient-provider relationship, their intrinsic motivations from fear of cancer and an innate appreciation for the significance of obtaining repeated colonoscopies. Procedural factors such as the option for procedural visualization, its comprehensiveness and the utilization of anesthesia were also crucial motivators. Barriers that patients highlighted comprised of cumbersome bowel preparation and potential complications. DISCUSSION: Recently, minimal research has been conducted on the sentiments of healthcare providers and patients regarding repeat colonoscopy. The lack of emphasis from healthcare institutions on encouraging patients to repeat colonoscopy after 10 years prevents effective colorectal cancer screening. To proficiently alleviate the burden of colorectal cancer, patient counseling has to shift beyond explaining colonoscopy risks and complications to promoting regular follow-up scopes. This article thus calls for more studies to focus on evaluating the uptake of repeat colonoscopies.

Afterthoughts on colonoscopy. Was it that bad?

OBJECTIVES: Colorectal cancer is among the top three most common cancers globally. In order to reduce the health burden, it is important to improve the uptake of colorectal cancer screening by understanding the barriers and facilitators encountered. There are numerous reports in the literature on the views of the general public on cancer screening. However, the experiences of colonoscopy patients are not as well studied. This paper maps their perceptions. METHODS: Keyword searches for terms such as 'colorectal', 'colonoscopy' and 'qualitative' were conducted on 3 December 2019 in five databases: Medline, Embase, CINAHL, PsycINFO and Web of Science Core Collection. Qualitative articles that quoted colonoscopy-experienced patients with no prior history of colorectal cancer were included for the thematic analysis. The systematic review was then synthesized according to PRISMA guidelines. RESULTS: The major themes were distilled into three categories: pre-procedure, during and post-procedure. The factors identified in the pre-procedure phase include the troublesome bowel preparation, poor quality of information provided and the dynamics within a support network. Perceptions of pain, emotional discomfort and the role of providers mark the experience during the procedure. The receipt of results, opportunities given for discussion and finances relating to colonoscopy are important post-procedure events. CONCLUSION: Understanding colorectal cancer screening behaviour is fundamental for healthcare providers and authorities to develop system and personal level changes for the improvement of colorectal cancer screening services. The key areas include patient comfort, the use of clearer instructional aids and graphics, establishing good patient rapport, and the availability of individualized options for sedation and the procedure.

Survival outcomes following primary tumor resection for patients with incurable metastatic colorectal carcinoma: Experience from a single institution.

OBJECTIVE: Palliative primary tumor resection (PTR) has been used for preventing and treating tumor-related complications. We aimed to determine whether PTR can increase overall survival (OS) in patients with unresectable metastatic colorectal cancer (CRC). METHODS: A retrospective review of a prospectively collected database in a single center was performed. Patients diagnosed with metastatic CRC from January 2004 to December 2014 were included. Patients who had attained curative resection or had disease recurrence were excluded. All patients were discussed at a multidisciplinary tumor board where subsequent treatment decisions were made. RESULTS: Altogether 408 patients were analyzed. Of these 145 received PTR with palliative chemotherapy (PC; group A), 110 received PC only (group B), 52 received PTR only (group C), while 101 received neither PTR nor PC (group D). Undergoing PTR led to statistically significant improvement in OS (22.7 months vs 12.1 months vs 6.9 months vs 2.7 months, P < 0.001). We performed subgroup analyses to control for potential confounders and found that the influence of PTR on OS persisted. With multivariate analysis, the predictors of poor OS were no PTR (hazards ratio [HR] 2.32, 95% confidence interval [CI] 1.82-2.96, P < 0.001), no PC (HR 4.25, 95% CI 3.27-5.33, P < 0.001) and the presence of peritoneal metastases (HR 1.37, 95% CI 1.06-1.78, P = 0.018). Diversion surgery did not lead to a statistical difference in OS. CONCLUSIONS: The absences of PTR and PC, and peritoneal metastases are independently associated with decreased OS in patients with unresectable metastatic CRC. Randomized controlled trials are needed to verify this observation.