The impact of transanal local excision of early rectal cancer on completion rectal resection without neoadjuvant chemoradiotherapy: a systematic review.

BACKGROUND: The impact of transanal local excision (TAE) of early rectal cancer (ERC) on subsequent completion rectal resection (CRR) for unfavorable histology or margin involvement is unclear. The aim of this study was to provide a comprehensive review of the literature on the impact of TAE on CRR in patients without neoadjuvant chemoradiotherapy (CRT). METHODS: We performed a systematic review of the literature up to March 2020. Medline and Cochrane libraries were searched for studies reporting outcomes of CRR after TAE for ERC. We excluded patients who had neoadjuvant CRT and endoscopic local excision. Surgical, functional, pathological and oncological outcomes were assessed. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed. RESULTS: Sixteen studies involving 353 patients were included. Pathology following TAE was as follows T0 = 2 (0.5%); T1 = 154 (44.7%); T2 = 142 (41.2%); T3 = 43 (12.5%); Tx = 3 (0.8%); T not reported = 9. Fifty-three percent were > T1. Abdominoperineal resection (APR) was performed in 80 (23.2%) patients. Postoperative major morbidity and mortality occurred in 22 (11.4%) and 3 (1.1%), patients, respectively. An incomplete mesorectal fascia resulting in defects of the mesorectum was reported in 30 (24.6%) cases. Thirteen (12%) patients developed recurrence: 8 (3.1%) local, 19 (7.3%) distant, 4 (1.5%) local and distant. The 5-year cancer-specific survival was 92%. Only 1 study assessed anal function reporting no continence disorders in 11 patients. In the meta-analysis, CRR after TAE showed an increased APR rate (OR 5.25; 95% CI 1.27-21.8; p 0.020) and incomplete mesorectum rate (OR 3.48; 95% CI 1.32-9.19; p 0.010) compared to primary total mesorectal excision (TME). Two case matched studies reported no difference in recurrence rate and disease free survival respectively. CONCLUSIONS: The data are incomplete and of low quality. There was a tendency towards an increased risk of APR and poor specimen quality. It is necessary to improve the accuracy of preoperative staging of malignant rectal tumors in patients scheduled for TAE.

Practice parameters for the diagnosis and treatment of anal intraepithelial neoplasia (AIN) on behalf of the Italian Society of Colorectal Surgery (SICCR).

Squamous cell carcinoma (SCC) of the anus is a human papilloma virus (HPV) related malignancy that is preceded by anal intraepithelial neoplasia (AIN) making this cancer, at least theoretically, a preventable disease. In the past 10 years the diagnosis, management and nomenclature of AIN has dramatically changed. Increased life expectancy in human immunodeficiency virus (HIV) positive patients due to highly active antiretroviral therapy (HAART) has caused an increase in the incidence of SCC of the anus. While many experts recommend screening and treatment of anal high-grade squamous intraepithelial lesion (HSIL), there is no consensus on the optimal management these lesions. Therefore, there is a need to review the current evidence on diagnosis and treatment of AIN and formulate recommendations to guide management. Surgeons who are members of the Italian Society of Colorectal Surgery (SICCR) with a recognized interest in AIN were invited to contribute on various topics after a comprehensive literature search. Levels of evidence were classified using the Oxford Centre for Evidence-based Medicine of 2009 and the strength of recommendation was graded according to the United States (US) preventive services task force. These recommendations are among the few entirely dedicated only to the precursors of SCC of the anus and provide an evidence-based summary of the current knowledge about the management of AIN that will serve as a reference for clinicians involved in the treatment of patients at risk for anal cancer.

In-hospital mortality, 30-day readmission, and length of hospital stay after surgery for primary colorectal cancer: A national population-based study.

INTRODUCTION: The simultaneous assessment of multiple indicators for quality of care is essential for comparisons of performance between hospitals and health care systems. The aim of this study was to assess the rates of in-hospital mortality and 30-day readmission and length of hospital stay (LOS) in patients who underwent surgical procedures for colorectal cancer between 2005 and 2014 in Italy. METHODS: All patients in the National Italian Hospital Discharge Dataset who underwent a surgical procedure for colorectal cancer during the study period were included. The adjusted odd ratios for risk factors for in-hospital mortality, 30-day readmission, and LOS were calculated using multilevel multivariable logistic regression. RESULTS: Among the 353 941 patients, rates of in-hospital mortality and 30-day readmission were 2.5% and 6%, respectively, and the median LOS was 13 days. High comorbidity, emergent/urgent admission, male gender, creation of a stoma, and an open approach increased the risks of all the outcomes at multivariable analysis. Age, hospital volume, hospital geographic location, and discharge to home/non-home produced different effects depending on the outcome considered. The most frequent causes of readmission were infection (19%) and bowel obstruction (14.6%). CONCLUSIONS: We assessed national averages for mortality, LOS and readmission and related trends over a 10-year time. Laparoscopic surgery was the only one that could be modified by improving surgical education. Higher hospital volume was associated with a LOS reduction, but our findings only partially support a policy of centralization for colorectal cancer procedures. Surgical site infection was identified as the most preventable cause of readmission.

Body mass index and colorectal cancer prognosis: a systematic review and meta-analysis.

Colorectal cancer is one of the most common cancers worldwide. However, it is unclear what influence body mass index (BMI) has on colorectal cancer prognosis. We conducted a systematic review and meta-analysis of observational studies to examine the association of BMI with colorectal cancer outcomes. We searched MEDLINE and EMBASE databases from inception to February 2015 and references of identified articles. We selected observational studies that reported all-cause mortality, colorectal cancer-specific mortality, recurrence and disease-free survival according to BMI category. Random-effects meta-analyses were conducted to combine estimates. We included 18 observational studies. Obese patients had an increased risk of all-cause mortality [relative risk (RR) 1.14; 95 % confidence interval (CI) 1.07-1.21], cancer-specific mortality (RR 1.14; 95 % CI 1.05-1.24), recurrence (RR 1.07; 95 % CI 1.02-1.13) and worse disease-free survival (RR 1.07; 95 % CI 1.01-1.13). Underweight patients also had an increased risk of all-cause mortality (RR 1.43; 95 % CI 1.26-1.62), cancer-specific mortality (RR 1.50; 95 % CI 1.20-1.87), recurrence (RR 1.13; 95 % CI 1.05-1.21) and worse disease-free survival (RR 1.27; 95 % CI 1.13-1.43). Overweight patients had no increased risk for any of the outcomes studied. Both obese and underweight patients with colorectal cancer have an increased risk of all-cause mortality, cancer-specific mortality, disease recurrence and worse disease-free survival compared to normal weight patients.

Fiber Bragg grating laser sensor with direct radio-frequency readout.

A fiber Bragg grating (FBG)-coupled ring laser sensor is demonstrated. In the proposed configuration the interrogating source, the sensing head and the readout instrument are integrated in a single fiber-optic device. An FBG inserted within a bidirectional fiber ring couples the two counterpropagating modes of the cavity, generating a splitting of the resonant wavelengths proportional to the FBG reflectivity. When the cavity gain is brought beyond threshold, the two peaks of the split resonances simultaneously lase, leading to a beat note in the emission spectrum whose frequency tracks any small shift of the FBG reflectivity spectrum. Such a beat note can be simply monitored by a frequency counter, without the need for an optical spectrometer, allowing to significantly reduce size and costs of the sensor setup. The sensing performance compares well to the state-of-the-art thermo-mechanical fiber sensors.

Psychological stress in patients with anal fistula.

AIM: Psychological stress is known to affect the immunologic system and the inflammatory response. The aim of this study was to assess the presence of psychological stress, anxiety, and depression in patients with anal fistula. METHODS: Consecutive patients with anal fistula, hemorrhoids, and normal volunteers were studied prospectively. Stressful life events were recorded and subjects were asked to complete the state-trait anxiety inventory (STAI), a depression scale, and three different reactive graphic tests (RGT). RESULTS: Seventy-eight fistula patients, 73 patients with grade III-IV hemorrhoids, and 37 normal volunteers were enrolled. Of the fistula patients, 65 (83 %) reported one or more stressful events in the year prior to diagnosis, compared to 16 (22 %) of the hemorrhoid patients (P = 0.001). There were no significant differences in the percentage of subjects with abnormal trait anxiety (i.e., proneness for anxiety) and depression scores between fistula patients, hemorrhoid patients, and controls. Fistula patients had significantly higher (i.e., better) scores compared to hemorrhoid patients in two of three RGT and significantly lower (i.e., worse) scores in all three RGT compared to healthy volunteers. Of 37 patients followed up for a median of 28 months (range 19-41 months) after surgery, 8 (21.6 %) had persistent or recurrent sepsis. There was no significant difference in depression, STAI, and RGT scores between patients with sepsis and patients whose fistula healed. CONCLUSION: Our results suggest that an altered emotional state plays an important role in the pathogenesis of anal fistula and underline the importance of psychological screening in patients with anorectal disorders.

Local excision of rectal cancer followed by radical surgery because of poor prognostic features does not compromise the long term oncologic outcome.

AIM: The outcome of patients undergoing full-thickness local excision (LE) of rectal cancers may be compromised if poor prognostic features are found in the LE specimen. Our aim was to evaluate the long-term results of radical surgery performed after LE because poor prognostic factors are identified. METHOD: Patients with biopsy-proven rectal cancer who had undergone full-thickness LE followed by radical surgery because of a positive margin, T stage ≥3, lymphovascular invasion, poor differentiation or mucinous histology were identified from a prospective database. Their records were retrospectively reviewed and follow up was updated. RESULTS: Between 1995 and 2003, 17 patients underwent LE followed by radical surgery because of poor prognostic features. Combined chemotherapy and radiotherapy was given to 11 (65%) patients before radical surgery. Patients underwent radical surgery after a median of 14 (range: 0-40) weeks from LE. Nine underwent a low anterior resection and eight an abdominoperineal resection. At the time of radical surgery, residual disease was found in six (35%) patients (in lymph nodes in three; intramural in two; and both lymph nodes and intramural in one). Four of the patients with residual disease had undergone neoadjuvant therapy before radical surgery. The mean follow up was 110 (95% CI: 92-129) months. Recurrence-free survival at 10 years was 88%. There was no case of local recurrence, and two patients died of metastatic disease. CONCLUSION: In this series patients who underwent early radical surgery because of poor prognostic features found at LE had good overall and cancer-specific long-term survival. Even after neoadjuvant therapy, more than a third of patients had residual disease at the time of radical surgery. We therefore recommend radical surgery with neoadjuvant therapy when poor prognostic features are found at LE.

Combination of oral non-absorbable and intravenous antibiotics versus intravenous antibiotics alone in the prevention of surgical site infections after colorectal surgery: a meta-analysis of randomized controlled trials.

BACKGROUND: Oral non-absorbable antibiotics work by decreasing intraluminal bacterial content after mechanical bowel preparation. The advantage of adding oral non-absorbable antibiotics to intravenous antibiotics to decrease surgical site infection (SSI) after colorectal surgery is not well known. We conducted a meta-analysis of randomized controlled trials (RCT) comparing the effectiveness of combined oral non-absorbable and intravenous antibiotics versus intravenous antibiotics alone in reducing the incidence of SSI following colorectal surgery. METHOD: We included RCT comparing a combination of oral non-absorbable antibiotics and intravenous antibiotics to intravenous antibiotics alone in order to prevent SSI after colorectal surgery. Outcomes assessed included postoperative infectious complications, such as surgical wound infections (SWI) defined as a combination of superficial and deep SSI, organ-space infections and anastomotic dehiscence. RESULTS: Sixteen RCT published between 1979 and 2007 were included in the meta-analysis. The overall analyses indicated that patients randomly assigned to an oral non-absorbable antibiotic in addition to an intravenous antibiotic had a reduced risk of SWI (RR: 0.57 [95% CI: 0.43-0.76], p = 0.0002) compared with participants receiving only intravenous antibiotics. The use of oral non-absorbable antibiotics in addition to intravenous antibiotics had no significant effect on organ-space infections (RR: 0.71 [95% CI: 0.43-1.16], p = 0.2) or the risk of anastomotic leak (RR: 0.63 [95% CI: 0.28-1.41], p = 0.3). CONCLUSION: Our meta-analysis shows that a combination of oral non-absorbable antibiotics and intravenous antibiotics significantly lowers the incidence of SWI compared with intravenous antibiotics alone. In light of our results, the use of oral non-absorbable antibiotics in colorectal surgery should be encouraged.

A nationwide audit of the use of radiotherapy for rectal cancer in Italy.

BACKGROUND: There is good evidence that radiotherapy is beneficial in advanced rectal cancer, but its application in Italy has not been investigated. METHODS: We conducted a nationwide survey among members of the Italian Society of Colo-Rectal Surgery (SICCR) on the use of radiation therapy for rectal cancer in the year 2005. Demographic, clinical and pathologic data were retrospectively collected with an online database. Italy was geographically divided into 3 regions: north, center and south which included the islands. Hospitals performing 30 or more surgeries per year were considered high volume. Factors related to radiotherapy delivery were identified with multivariate analysis. RESULTS: Of 108 centers, 44 (41%) responded to the audit. We collected data on 682 rectal cancer patients corresponding to 58% of rectal cancers operated by SICCR members in 2005. Radiotherapy was used in 307/682 (45.0%) patients. Preoperative radiotherapy was used in 236/682 (34.6%), postoperative radiotherapy in 71/682 (10.4%) cases and no radiotherapy in 375 (55.0%) cases. Of the 236 patients who underwent preoperative radiotherapy, only 24 (10.2%) received short-course radiotherapy, while 212 (89.8%) received long-course radiotherapy. Of the 339 stage II-III patients, 159 (47%) did not receive any radiotherapy. Radiotherapy was more frequently used in younger patients (P < 0.0001), in patients undergoing abdominoperineal resection (APR) (P < 0.01) and in the north and center of Italy (P < 0.001). Preoperative radiotherapy was more frequently used in younger patients (P < 0.001), in large volume centers (P < 0.05), in patients undergoing APR (P < 0.005) and in the north-center of Italy (P < 0.05). CONCLUSION: Our study first identified a treatment disparity among different geographic Italian regions. A more systematic audit is needed to confirm these results and plan adequate interventions.

The 'Draw-the-Family Test' in the preoperative assessment of patients with anorectal diseases and psychological distress: a prospective controlled study.

AIM: Some benign anorectal diseases may have psychosomatic aetiology, but patients often refuse direct psychological counselling. The Draw-the-Family Test (DFT) is a simple indirect investigation. The aim of this study was to evaluate the DFT in patients with psychological problems undergoing surgery for benign anorectal disease and to correlate the results with surgical outcome. METHOD: DFT was administered prior to surgery to 62 patients with benign anorectal disease who admitted psychological problems at the time of the outpatient visit. Of these 18 (29%) had functional disease, mainly obstructed defecation (OD) while 44 (71%) had organic disease (haemorrhoids, fissures, pilonidal sinus or fistula). DFT was also administered to 40 healthy control subjects. Each DFT was judged as normal or pathological according to 10 parameters. Patients were followed up for a median of 12 months (range 3-64) and divided into two outcome groups, success (n = 58) and failure (n = 12) according to the results of a questionnaire. The DFT of all patients was then correlated with the outcome. RESULTS: None of the patients refused DFT. All DFT parameters but one (animal/things instead of human beings) were more frequent in patients compared with controls (P < 0.05). When comparing separately organic or functional disease patients with controls, one parameter (absence of patient in the drawing) was only pathological in the organic disease group (P < 0.05). Another parameter (schematic figures) was more frequently altered in the organic disease group compared with the functional disease group (P = 0.01). Eight out of 10 parameters were more frequently pathological in patients who failed after treatment, but none reached statistical significance. CONCLUSION: Results of DFT in patients with anorectal disease admitting to psychological problems are markedly different from healthy controls. Patients with organic disease and those with functional bowel disease have different DFT profiles. In our study group, DFT had an excellent compliance but could not predict the outcome of surgery.

Our experience with endoscopic repair of large colonoscopic perforations and review of the literature.

BACKGROUND: Colonic perforation is the most severe complication of lower gastrointestinal endoscopy. Recently successful closure with endoscopic clips has been reported. However large (>10 mm) perforations and perforations occurring during diagnostic colonoscopy are considered a contraindication to endoscopic closure. METHODS: We retrospectively reviewed our own experience with endoscopic closure of colonoscopic perforations. The size of the perforations was determined by comparison with the maximal opening of the clipping device. In addition we reviewed all cases of colonoscopic perforation published in the English language literature. RESULTS: From January 2006 we performed closure of three large colonoscopic perforations in three patients. One perforation occurred after en-bloc endoscopic mucosal resection of two polyps in the descending colon. The other two perforations occurred during diagnostic colonoscopy. All three cases were promptly diagnosed and successfully repaired with TriClips. Patients were kept on intravenous antibiotics and a clear liquid diet until bowel movement and were discharged between the 2nd and the 8th day after the procedure. A review of the literature, including our series, revealed 75 reported cases of colonoscopic perforations repaired with endoclips. Of these, four perforations were larger then 10 mm and four occurred during diagnostic colonoscopy. Of the perforations occurring during therapeutic colonoscopy, clip closure was carried out in 55-96% of the immediate perforations and was successful in 69-93% of cases. CONCLUSIONS: Nonsurgical management of colonoscopic perforations with endoclips is a highly feasible option. From our initial experience large perforations and perforations occurring during diagnostic colonoscopy are not a contraindication to endoscopic repair, but due to the small number of patients these data must be interpreted with caution.

Anastomotic leaks after anterior resection for mid and low rectal cancer: survey of the Italian Society of Colorectal Surgery.

BACKGROUND: The aim of the survey was to assess the incidence of anastomotic leaks (AL) and to identify risk factors predicting incidence and gravity of AL after low anterior resection (LAR) for rectal cancer performed by colorectal surgeons of the Italian Society of Colorectal Surgery (SICCR). METHODS: Information about patients with rectal cancers less than 12 cm from the anal verge who underwent LAR during 2005 was collected retrospectively. AL was classified as grade I to IV according to gravity. Fifteen clinical variables were examined by univariate and multivariate analyses. Further analysis was conducted on patients with AL to identify factors correlated with gravity. RESULTS: There were 520 patients representing 64% of LAR for rectal cancer performed by SICCR members. The overall rate of AL was 15.2%. Mortality was 2.7% including 0.6% from AL. The incidence of AL was correlated with higher age (p<0.05), lower (<20 per year) centre case volume (p<0.05), obesity (p<0.05), malnutrition (p<0.01) and intraoperative contamination (p<0.05), and was lower in patients with a colonic J-pouch reservoir (p<0.05). In the multivariate analysis age, malnutrition and intraoperative contamination were independent predictors. The only predictor of severe (grade III/IV) AL was alcohol/smoking habits (p<0.05) while the absence of a diverting stoma was borderline significant (p<0.07). CONCLUSION: Our retrospective survey identified several risk factors for AL. This survey was a necessary step to construct prospective interventional studies and to establish benchmark standards for outcome studies.

Postoperative complications after procedure for prolapsed hemorrhoids (PPH) and stapled transanal rectal resection (STARR) procedures.

Procedure for prolapsing hemorrhoids (PPH) and stapled transanal rectal resection for obstructed defecation (STARR) carry low postoperative pain, but may be followed by unusual and severe postoperative complications. This review deals with the pathogenesis, prevention and treatment of adverse events that may occasionally be life threatening. PPH and STARR carry the expected morbidity following anorectal surgery, such as bleeding, strictures and fecal incontinence. Complications that are particular to these stapled procedures are rectovaginal fistula, chronic proctalgia, total rectal obliteration, rectal wall hematoma and perforation with pelvic sepsis often requiring a diverting stoma. A higher complication rate and worse results are expected after PPH for fourth-degree piles. Enterocele and anismus are contraindications to PPH and STARR and both operations should be used with caution in patients with weak sphincters. In conclusion, complications after PPH and STARR are not infrequent and may be difficult to manage. However, if performed in selected cases by skilled specialists aware of the risks and associated diseases, some complications may be prevented.

Combining a difference-frequency source with an off-axis high-finesse cavity for trace-gas monitoring around 3 microm.

High-sensitivity spectroscopy of methane around 3 microm was carried out by means of a 5.5-mW cw difference-frequency generator in conjunction with a high finesse cavity in off-axis alignment. By cavity-output integration a minimum detectable absorption coefficient of 5.7*10-9 cm-1Hz-1/2 was achieved, which compares well with results already reported in the literature. Detection of methane in natural abundance was also performed in ambient air, for different values of total pressure, allowing direct concentration measurements via evaluation of the integrated absorbance of the spectra. In particular, at atmospheric pressure, a minimum detectable concentration of 850 parts per trillion by volume (pptv)*Hz-1/2 was demonstrated.