Trends in management and outcomes of colon cancer in the United States over 15 years: Analysis of the National Cancer Database.

Management of colon cancer has changed over the last few decades. We assessed the trends in management and outcomes using the US National Cancer Database (NCDB). A retrospective analysis of all patients with colonic adenocarcinoma between 2005 and 2019 was conducted. The cohort was divided into three equal time periods: Period 1 (2005-2009), Period 2 (2010-2014), and Period 3 (2015-2019) to examine treatment and outcomes trends. The primary outcome was 5-year overall survival (OS). The study included 923,275 patients. A significant increase in patients with stage IV disease was noted in Period 3 compared to Period 1 (47.9% vs. 27.9%, respectively), whereas a reciprocal reduction was seen in patients with locally advanced disease (stage II: 20.8%-12%; stage III: 14.5%-7.7%). Use of immunotherapy significantly increased from 0.3% to 7.6%. Mean 5-year OS increased (43.6 vs. 42.1 months) despite the increase in metastatic disease and longer time from diagnosis to definitive surgery (7 vs. 14 days). A reduction in 30-day readmission (5.1%-4.2%), 30- (3.9%-2.8%), and 90-day mortality (7.1%-5%) was seen. Laparoscopic and robotic surgery increased from 45.8% to 53.1% and 2.9% to 12.7%, respectively. Median postoperative length of hospital stay decreased by 2 days. Rate of positive resection margins (7.2%-6%) and median number of examined lymph nodes (14-16) also improved. Minimally invasive surgery and immunotherapy for colon cancer significantly increased in recent years. Patient outcomes including OS improved over time.

Outcomes of Early Versus Standard Closure of Diverting Ileostomy After Proctectomy: Meta-analysis and Meta-regression Analysis of Randomized Controlled Trials.

OBJECTIVE: We aimed to compare outcomes of early and standard closure of diverting loop ileostomy (DLI) after proctectomy and determine risk factors for anastomotic leak (AL) and complications. BACKGROUND: Formation of DLI has been a routine practice after proctectomy to decrease the incidence and potential adverse sequela of AL. METHODS: PubMed, Scopus, and Web of Science were searched for randomized controlled trials (RCTs) that compared outcomes of early versus standard closure of DLI after proctectomy. Main outcome measures were postoperative complications, AL, ileus, surgical site infection, reoperation, readmission, and hospital stay following DLI closure. RESULTS: Eleven RCTs (932 patients; 57% male) were included. Early closure group included 474 patients and standard closure 458 patients. Early closure was associated with higher odds of AL [odds ratio (OR): 2.315, P =0.013] and similar odds of complications (OR: 1.103, P =0.667), ileus (OR: 1.307, P =0.438), surgical site infection (OR: 1.668, P =0.079), reoperation (OR: 1.896, P =0.062), and readmission (OR: 3.431, P =0.206). Hospital stay was similar (weighted mean difference: 1.054, P =0.237). Early closure had higher odds of AL than standard closure when early closure was done ≤2 weeks (OR: 2.12, P =0.047) but not within 3 to 4 weeks (OR: 2.98, P =0.107). Factors significantly associated with complications after early closure were diabetes mellitus, smoking, and closure of DLI ≤2 weeks, whereas factors associated with AL were ≥ American Society of Anesthesiologists II classification and diabetes mellitus. CONCLUSIONS: Early closure of DLI after proctectomy has a higher risk of AL, particularly within 2 weeks of DLI formation. On the basis of this study, routine early ileostomy closure cannot be recommended.

Functional Outcomes After Transanal Total Mesorectal Excision (taTME) for Rectal Cancer: Results From the Phase II North American Multicenter Prospective Observational Trial.

OBJECTIVE: To investigate fecal incontinence and defecatory, urinary, and sexual functional outcomes after transanal total mesorectal excision (taTME). BACKGROUND: Proctectomy for rectal cancer may result in alterations in defecatory, urinary, and sexual function that persist beyond 12 months. The recent multicenter phase II taTME trial demonstrated the safety of taTME in patients with stage I to III tumors. METHODS: Prospectively registered self-reported questionnaires were collected from 100 taTME patients. Fecal continence [Fecal Incontinence Quality of Life (FIQL), Wexner], defecatory function [Colorectal Functional Outcome (COREFO)], urinary function (International Prostate Symptom Score), and sexual function (Female Sexual Function Index-female, International Index of Erectile Function-male) were assessed preoperatively (PQ), 3 to 4 months postileostomy closure (FQ1), and 12 to 18 months post-taTME [postoperative questionnaire 2 (FQ2)]. RESULTS: Among 83 patients who responded at all 3 time points, FIQL, Wexner, and COREFO significantly worsened postileostomy closure. Between FQ1 and FQ2, FIQL lifestyle and coping, Wexner, and COREFO incontinence, social impact, frequency, and need for medication significantly improved, while FIQL depression and embarrassment did not change. International Prostate Symptom Score did not change relative to preoperative scores. For females, Female Sexual Function Index declined for desire, orgasm, and satisfaction between PQ and FQ1, and did not improve between FQ1 and FQ2. In males, International Index of Erectile Function declined with no change between FQ1 and FQ2. CONCLUSIONS: Although taTME resulted in initial decline in defecatory function and fecal continence, most functional domains improved by 12 months after ileostomy closure, without returning to preoperative status. Urinary function was preserved while sexual function declined without improvement by 18 months post-taTME. Our results address patient expectations and inform shared decision-making regarding taTME.

Accuracy of Clinical Staging of Localized Colon Cancer: A National Cancer Database Cohort Analysis.

BACKGROUND: This study aimed to assess concordance between clinical and pathologic assessment of colon cancer. PATIENTS AND METHODS: A retrospective cohort analysis of patients with stage I-III colon cancer in the National Cancer Database (2010-2019) was conducted. Concordance between clinical and pathologic assessment of colon cancer was calculated using Kappa coefficients and 95% confidence intervals (CIs). RESULTS: A total of 125,473 patients (51.2% female; mean age 68.2 years) were included. There was moderate concordance between clinical and pathologic T stage (Kappa = 0.606, 95%CI: 0.602-0.609) and between clinical and pathologic N stage (Kappa = 0.506, 95%CI: 0.501-0.511). For right-sided colon cancer, there was moderate agreement between clinical and pathologic T stage (Kappa = 0.594, 95%CI: 0.589-0.599) and N stage (Kappa = 0.530, 95%CI: 0.523-0.537). For left-sided colon cancer, there was substantial agreement between clinical and pathologic T stage (Kappa = 0.624, 95%CI: 0.619-0.630) and moderate agreement between N stage (Kappa 0.472, 95%CI: 0.463-0.480). Sensitivity of clinical assessment of T and N stage ranged from 64.3% to 77.2% and 41.6% to 54.5%, respectively. Specificity ranged from 96.7% to 97.7% for T stage and 95.7% to 97.3% for N stage. CONCLUSIONS: Clinical assessment of T and N stages of colon cancer had good diagnostic accuracy with moderate concordance with the final pathologic stage. While clinical assessment was highly specific with < 3% of patients being over-staged, it had modest sensitivity, especially for detection of nodal involvement. Diagnostic accuracy of clinical assessment of right and left colon cancers was similar, except for higher sensitivity and accuracy of assessment of nodal involvement in right than left colon cancers.

A Propensity Score-Matched Analysis of the Impact of Neoadjuvant Radiation Therapy on the Outcomes of Stage II and III Mucinous Rectal Carcinoma.

BACKGROUND: Patients with mucinous rectal carcinoma tend to present in advanced stage with a poor prognosis. OBJECTIVE: This study aimed to assess the effect of neoadjuvant radiation therapy on outcomes of patients with stage II and III mucinous rectal carcinomas using data from the National Cancer Database. DESIGN: Retrospective analysis of prospective national databases. SETTING: National Cancer Database between 2004 and 2019. PATIENTS: Patients with mucinous rectal carcinoma. INTERVENTION: Patients who did or did not receive neoadjuvant radiation therapy were matched using the nearest-neighbor propensity score method for age, clinical stage, neoadjuvant systemic treatment, and surgery type. MAIN OUTCOME MEASURES: Main outcomes of the study were numbers of total harvested and positive lymph nodes, disease downstaging after neoadjuvant radiation, and overall survival. Other outcomes were hospital stay, short-term mortality, and readmission. RESULTS: A total of 3062 patients (63.5% men) with stage II and III mucinous rectal carcinoma were included, 2378 of whom (77.7%) received neoadjuvant radiation therapy. After 2:1 propensity score matching, 143 patients in the no neoadjuvant group were matched to 286 patients in the neoadjuvant group. The mean overall survival was similar (77.3 vs 81.9 months; p = 0.316). Patients who received neoadjuvant radiation therapy were less often diagnosed with pathologic T3 and 4 disease (72.3% vs 81.3%, p = 0.013) and more often had pathologic stage 0 and 1 disease (16.4% vs 11.2%, p = 0.001), yet with a higher stage III disease (49.7% vs 37.1%, p = 0.001). Neoadjuvant radiation was associated with fewer examined lymph nodes (median: 14 vs 16, p = 0.036) and positive lymph nodes than patients who did not receive neoadjuvant radiation. Short-term mortality, readmission, hospital stay, and positive surgical margins were similar. LIMITATIONS: Retrospective study and missing data on disease recurrence. CONCLUSIONS: Patients with mucinous rectal carcinoma who received neoadjuvant radiation therapy had marginal downstaging of disease, fewer examined and fewer positive lymph nodes, and similar overall survival to patients who did not receive neoadjuvant radiation. See Video Abstract . UN ANLISIS EMPAREJADO POR PUNTUACIN DE PROPENSIN DEL IMPACTO DE LA RADIOTERAPIA NEOADYUVANTE EN LOS RESULTADOS DEL CARCINOMA MUCINOSO DE RECTO EN ESTADIO IIIII: ANTECEDENTES:Los pacientes con carcinoma mucinoso de recto tienden a presentarse en estadio avanzado con mal pronóstico.OBJETIVO:Este estudio tuvo como objetivo evaluar el efecto de la radioterapia neoadyuvante en los resultados de pacientes con carcinomas mucinosos de recto en estadio II-III utilizando datos de la Base de Datos Nacional del Cáncer.DISEÑO:Análisis retrospectivo de bases de datos nacionales prospectivas.PACIENTES:Pacientes con carcinoma mucinoso de recto.AJUSTE:Base de datos nacional sobre el cáncer entre 2004 y 2019.INTERVENCIÓN:Los pacientes que recibieron o no radioterapia neoadyuvante fueron emparejados utilizando el método de puntuación de propensión del vecino más cercano por edad, estadio clínico, tratamiento sistémico neoadyuvante y tipo de cirugía.PRINCIPALES MEDIDAS DE VALORACIÓN:Los principales resultados del estudio fueron el número total de ganglios linfáticos extraídos y positivos, la reducción del estadio de la enfermedad después de la radiación neoadyuvante y la supervivencia general. Otros resultados fueron la estancia hospitalaria, la mortalidad a corto plazo y el reingreso.RESULTADOS:Se incluyeron 3.062 pacientes (63,5% hombres) con carcinoma mucinoso de recto estadio II-III, de los cuales 2.378 (77,7%) recibieron radioterapia neoadyuvante. Después de un emparejamiento por puntuación de propensión 2:1, 143 pacientes del grupo sin neoadyuvancia fueron emparejados con 286 del grupo neoadyuvante. La supervivencia global media fue similar (77,3 vs 81,9 meses; p = 0,316). A los pacientes que recibieron radiación neoadyuvante se les diagnosticó con menos frecuencia enfermedad pT3-4 (72,3% frente a 81,3%, p = 0,013) y con mayor frecuencia tenían enfermedad en estadio patológico 0-1 (16,4% frente a 11,2%, p = 0,001), aunque con una enfermedad en estadio III superior (49,7% vs 37,1%, p = 0,001). La radiación neoadyuvante se asoció con menos ganglios linfáticos examinados (mediana: 14 frente a 16, p = 0,036) y ganglios linfáticos positivos que los pacientes que no recibieron radiación neoadyuvante. La mortalidad a corto plazo, el reingreso, la estancia hospitalaria y los márgenes quirúrgicos positivos fueron similares.LIMITACIONES:Estudio retrospectivo y datos faltantes sobre recurrencia de la enfermedad.CONCLUSIONES:Los pacientes con carcinoma mucinoso de recto que recibieron radioterapia neoadyuvante tuvieron una reducción marginal de la enfermedad, menos ganglios linfáticos examinados y positivos, y una supervivencia general similar a la de los pacientes que no recibieron radiación neoadyuvante. (Traducción- Dr Ingrid Melo ).

A national database analysis of the evolution of outcomes of surgery for anal melanoma.

BACKGROUND: This study assessed trends in treatment and outcomes of anal melanomas over a 17-year period. METHODS: NCDB was searched for patients with anal melanoma (2004-2020). Receiver-operating characteristic curve analysis was used to determine cutoff year marking increased overall survival (OS) of anal melanoma. Characteristics, treatments, and outcomes in consecutive time periods were compared. RESULTS: A total of 815 patients (mean age: 67.2 years; 59.4% female) were included: 354 in Period 1 (2004-2012) and 461 in Period 2 (2013-2020). Period 2 included fewer abdominoperineal resections (18% vs. 28%, p = 0.002), more local tumor excisions (61.1% vs. 55%, p = 0.002), more often immunotherapy (odds ratio [OR]: 3.41, 95% confidence interval [CI]: 2.22-5.22, p < 0.001) and less often chemotherapy (OR: 0.516, 95% CI: 0.352-0.755, p < 0.001) administered and longer median OS (25.2 vs. 19.8 months, p = 0.006). Independent predictors of worse OS were older age (hazard ratio [HR]: 1.02, p = 0.012), higher Charlson score (HR: 2.32, p = 0.02), and greater number of positive lymph nodes (HR: 1.15, p < 0.001); conversely private insurance (HR: 0.385, p = 0.008) was predictive of increased OS. CONCLUSIONS: Anal melanoma patients diagnosed between 2013 and 2020 underwent fewer abdominoperineal resections and more local excisions than patients diagnosed between 2004 and 2013. Increased immunotherapy and longer median OS were noted in period two. Age and private insurance were significant predictors of OS, remaining constant across time periods.

Factors Associated With Prolonged Operative Times in Laparoscopic Right Hemicolectomy and Its Association With Short-Term Outcomes.

BACKGROUND: This study aimed to investigate factors associated with prolonged operative time in laparoscopic right hemicolectomy for colon cancer. METHODS: This was a retrospective review of patients with colon cancer who underwent laparoscopic right hemicolectomy between 2011 and 2021. Linear and binary logistic regression analyses were performed to determine factors associated with prolonged operative time. The association between longer operative times and complications and hospital stay was assessed. RESULTS: One hundred and ninety-seven patients (52.3% female; mean age: 68.8 ± 14.1 years) were included. Factors independently associated with operative time were male sex (ß = 17.3, 95% CI: 2, 32.5; p = 0.026) and extended hemicolectomy (ß = 67.7, 95% CI: 27.6, 107.9; p = 0.001). American Society of Anesthesiologists (ASA) IV classification had a borderline significant association with operative time (ß = 100.4, 95% CI: -2.05, 202.9; p = 0.055). Male sex (r = 0.158; p = 0.026), body mass index (r = 0.205; p = 0.004), ASA classification (r = 0.232; p = 0.001), extended hemicolectomy (r = 0.256; p < 0.001), and intracorporeal vessel control (r = 0.161; p = 0.025) had significant positive correlation with operative times. Patients with operative times ≥ 160 min had significantly longer hospital stays (5 vs. 4 days; p = 0.043) and similar complication rates to patients with shorter operative times. CONCLUSIONS: Male sex, advanced ASA classification, and extended hemicolectomy were independently and significantly associated with longer operative times in laparoscopic right hemicolectomy. Longer operative times were associated with longer hospital stays and similar complication rates.

Association between microsatellite status and characteristics and outcomes of early-onset compared to late-onset rectal cancer.

BACKGROUND: Microsatellite instability (MSI) is an important prognosticator for colorectal cancer (CRC). The present study aimed to assess the impact of MSI status on the characteristics and outcomes of early-onset compared to late-onset rectal cancer. METHODS: This retrospective cohort study used data from the US National Cancer Database (2004-2019) to assess the baseline characteristics, treatment patterns, short-term outcomes, and overall survival (OS) of early-onset rectal adenocarcinoma affecting patients < 50 years compared to late-onset rectal adenocarcinoma according to the MSI status. RESULTS: The present study included 48,407 patients (59.9% male) with rectal cancer, 17.3% of patients were < 50 years and 6.3% had MSI-H tumors. In the early-onset group, patients with MSI-H tumors had a lower mean age (41.5 vs 43 years, p < 0.001) and presented less often with stage IV disease (22.1% vs 17.7%, p = 0.03) and liver metastasis (9.1% vs 13.5%, p = 0.011) than patients with MSS tumors. In the late-onset group, patients with MSI-H and MSS tumors had similar demographics, disease stage, and metastatic pattern, yet MSI-H patients more often received neoadjuvant radiation therapy (58.9% vs 55.1%, p = 0.009) and neoadjuvant systemic therapy (40% vs 36.2%, p = 0.005). In both age groups, MSI-H tumors were associated with more pathologic T3-4 stage and were more likely mucinous and poorly differentiated carcinomas than MSS tumors. The median OS of MSI-H tumors was similar to MSS tumors (108.09 vs 102.31 months, p = 0.1), whether in the early-onset (139.5 vs 134.2 months, p = 0.821) or late-onset groups (106.1 vs 104.3 months, p = 0.236). CONCLUSIONS: In both age groups, MSI-H rectal cancers were more often mucinous and poorly differentiated carcinomas and had pT3-4 stage more often than MSS cancers. MSI-H rectal cancers tend to present less often with distant metastases and nodal involvement than MSS cancers only in early-onset, but not in late-onset rectal cancers. The association between MSI status and survival was not notable in this study, whether in the early-onset or late-onset groups.

Trends in surgical outcomes for Ileal pouch-anal anastomosis construction using a large nationwide database.

AIM: Ulcerative colitis (UC) affects over 3 million (1.3%) US adults, approximately 20% of whom will require surgery. Since it was first described in 1978, restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) has become the gold standard for patients requiring surgery, as well as for patients with familial adenomatous polyposis (FAP). In 1991 the laparoscopic approach to IPAA was introduced. The aim of this study was to evaluate the advances made in IPAA as minimally invasive surgery (MIS) has become more prevalent. METHOD: The American College of Surgeons NSQIP database from 2005 to 2019 was used. Laparoscopic (MIS) and open cases of IPAA construction for UC or FAP were used. These patients were subdivided into three time point cohorts: early (2005-2009), middle (2010-2014) and recent (2015-2019). Univariable and multivariable analyses were performed to evaluate morbidity, mortality and hospital length of stay. RESULTS: A total of 6184 patients were analysed, and 2555 underwent MIS while 3629 underwent open surgery. After multivariable analysis, the MIS approach was associated with a lower risk of morbidity compared with open procedures [relative risk (RR) = 0.86, p < 0.0001, 95% CI 0.78-0.94], both in the early and recent periods [early period = RR = 0.66 (p < 0.0001), recent period RR = 0.78 (p = 0.0029)]. Superficial surgical site infection (SSI) was consistently lower in the MIS cohort across all three time periods. After multivariable analysis, the overall RR of superficial SSI in the MIS cohort was 0.41 (p < 0.0001) [early period RR = 0.35 (p < 0.0001), middle period RR = 0.55 (p = 0.0007), recent period RR = 0.31 (p < 0.0001)]. The RR of deep space SSI was decreased overall (RR = 0.58, p = 0.013, 95% CI 0.62-0.93), with the most significant effect occurring during the early period (RR = 0.30, p = 0.0260, 95% CI 0.105-0.868). Sepsis related to any infective aetiology was also decreased in the MIS cohort (RR = 0.76, p = 0.0093, 95% CI 0.62-0.93), especially in the recent time period (RR = 0.63, p = 0.0344, 95% CI 0.41-0.97). Furthermore, hospital length of stay was decreased in the MIS cohort (-0.287 days, p = 0.0170), with a greater difference occurring in the more recent cohort (-0.375 days, p = 0.0418). CONCLUSION: With increasing utilization of minimally invasive techniques in IPAA creation there have been significant decreases in the rates of morbidity including decreasing rates of superficial and deep space SSI, as well as decreased hospital length of stay.

Splenic flexure mobilization in left-sided colonic and rectal resections: A meta-analysis and meta-regression of factors associated with anastomotic leak and complications.

AIM: Splenic flexure mobilization (SFM) is commonly performed during left-sided colon and rectal resections. The aim of the present systematic review was to assess the outcomes of SFM in left-sided colon and rectal resections and the risk factors for complications and anastomotic leak (AL). METHOD: This study was a PRISMA-compliant systematic review. PubMed, Scopus and Web of Science were searched for studies that assessed the outcomes of sigmoid and rectal resections with or without SFM. The primary outcomes were AL and total complications, and the secondary outcomes were individual complications, operating time, conversion to open surgery, length of hospital stay (LOS) and pathological and oncological outcomes. RESULTS: Nineteen studies including data on 81 116 patients (49.1% male) were reviewed. SFM was undertaken in 40.7% of patients. SFM was associated with a longer operating time (weighted mean difference 24.50, 95% CI 14.47-34.52, p < 0.0001) and higher odds of AL (OR 1.19, 95% CI 1.06-1.33, p = 0.002). Both groups had similar odds of total complications, splenic injury, anastomotic stricture, conversion to open surgery, (LOS), local recurrence, and overall survival. A secondary analysis of rectal cancer cases only showed similar outcomes for SFM and the control group. CONCLUSIONS: SFM was associated with a longer operating time and higher odds of AL, yet a similar likelihood of total complications, splenic injury, anastomotic stricture, conversion to open surgery, LOS, local recurrence, and overall survival. These conclusions must be cautiously interpreted considering the numerous study limitations. SFM may have only been selectively undertaken in cases in which anastomotic tension was suspected. Therefore, the suboptimal anastomoses may have been the reason for SFM rather than the SFM being causative of the anastomotic insufficiencies.

Stapler size independently predicts postoperative complications following stapled ileocolic anastomosis: A retrospective cohort study.

AIM: Staplers used in ileocolic anastomosis construction differ in length and height. We assessed the impact of stapler type in creating ileocolic anastomoses on postoperative outcomes. METHODS: This retrospective cohort study of an Institutional Review Board approved database included patients who underwent laparoscopic right colectomy for cancer between January 2011 and August 2021. All patients had construction of extracorporeal antiperistaltic stapled ileocolic anastomosis using a linear cutting stapler. Main outcome measures were short-term (<30 day) morbidity and mortality. RESULTS: In all, 270 patients (136 men; median age 70.2 years) were included. A 75 mm stapler was used in 49 (18.1%) patients, 80 mm in 97 (35.9%) and 100 mm in 124 (45.9%). Blue cartridge (stapler height 3.5 mm) was used in 175 (64.5%) and green cartridge (4.8 mm) in 18 (7%) patients; this information was unavailable in 77 (28.5%) cases. Apical enterotomy closure was performed by linear stapler in 54% and linear cutting stapler in 46%. Apical staple line reinforcement or imbrication suturing was used in 26.3%. The overall postoperative complication rate was 28.9%. The anastomotic leak rate was 2.6%. Independent predictors of complications after laparoscopic right colectomy were older age (OR 1.03, 95%CI 1-1.06; P = 0.01), extended colectomy (OR 2.76, 95%CI 1.07-7.08; P = 0.035) and emergency surgery (OR 4.5, 95%CI 1.3-14.9; P = 0.014). A 100-mm linear cutting stapler was an independent protective factor against postoperative complications (OR 0.3, 95%CI 0.18-0.85; P = 0.019). Stapler height and closure technique of apical enterotomy did not affect postoperative complications. CONCLUSION: Independent predictors of complications after laparoscopic right colectomy were older age, extended colectomy and emergency surgery. Using a 100 mm stapler was an independent protective factor against postoperative complications.

Technical risk factors for benign anastomotic strictures in colorectal and/or coloanal anastomosis: A retrospective case-control study.

AIM: Anastomotic stricture occurs in up to 30% of colorectal resections; however, evidence on risk factors and preventive measures remains scarce. This study aimed to identify technical factors responsible for increasing the risk for colorectal and coloanal anastomotic strictures. METHOD: This was a retrospective cohort study of patients with anastomotic stricture who underwent resection and/or redo anastomosis between January 1, 2011 and August 1, 2021 in a tertiary referral centre. Patients with anastomotic stricture were compared with an equal number of randomly selected patients without anastomotic complications, who were operated on during the same time period. The main outcome measures were technical risk factors of anastomotic stricture. RESULTS: Each group included 50 patients who were similar for age, sex, American Society of Anesthesiologists score, distance of anastomosis to the dentate line and indication for surgery. Median follow-up was significantly longer in the non-stricture group (38.6 months vs. 12.6 months, p = 0.04). Splenic flexure mobilization [hazard ratio (HR) = 0.18 [2], 95% CI: 0.08-0.39, p < 0.001], high ligation of the inferior mesenteric artery (HR = 0.22, 95% CI: 0.09-0.5, p < 0.001) and high ligation of the inferior mesenteric vein (HR = 0.21, 95% CI: 0.09-0.50, p < 0.001) were associated with a lower likelihood of anastomotic stricture. Conversely, use of a 25-mm-diameter circular stapler (HR = 22.69, 95% CI: 2.69-191.10, p < 0.001), clinically significant anastomotic leak (HR = 3.94, 95% CI: 2.04-7.64, p < 0.001), firing the stapler more than once for rectal division (HR = 24.75, 95% CI: 6.85-89.38, p < 0.001) and diverting stoma (HR = 3.087, 95% CI: 1.736-5.491, p < 0.0001) were predictive of an anastomotic stricture. CONCLUSION: Failure to mobilize the splenic flexure and to perform high ligation of the inferior mesenteric vessels were associated with higher odds of anastomotic stricture. A small-diameter circular stapler and multiple distal stapler firings were also associated with anastomotic stricture. These data support routine splenic flexure ligation and high ligation of the inferior mesenteric vessels as well as avoidance of both multiple  stapler firings for rectal transection and a 25-mm circular stapler for anastomosis..

Ostomy continence devices: a systematic review of the literature and meta-analysis.

AIM: Colostomy complication rates range widely from 10% to 70%. The psychological burden on patients, leading to lifestyle changes and decreased quality of life (QoL), is one of the largest factors. The aim of this work was to assess the history and efficacy of ostomy continence devices in improving continence and QoL. METHOD: In this PRISMA-compliant systematic review and meta-analysis, we searched PubMed, Scopus, Google Scholar and clinicaltrials.gov for studies on continence devices for all ostomies up to April 2023. Primary outcomes were continence and improvement in QoL. Secondary outcomes were leakage, patient's device preference and complications. Risk of Bias 2 and the revised tool to assess risk of bias in non-randomized studies of interventions (ROBINS-1) were used to assess risk of bias. Certainty of evidence was graded using GRADE. RESULTS: Twenty-two studies assessed devices from 1978 to 2022. The two main types identified were ball-valve devices and plug systems. Conseal and Vitala were the two main devices with significant evidence allowing for pooled analyses. Conseal, the only currently marketed device, had a pooled rate of continence of 67.4%, QoL improvement was 74.9%, patient preference over a traditional appliance was 69.1%, leakage was 10.1% and complications was 13.7%. Since 2011, five studies have investigated experimental devices on both human and animal models. CONCLUSION: Ostomy continence has been a long-standing goal without a consistently reliable solution. We propose that selective and short-term usage of continence devices may lead to improved continence and QoL in ostomy patients. Further research is needed to develop a reliable daily device for ostomy continence. Future investigation should include the needs of ileostomates.

Short-term outcomes of surgical treatment for primary ileocaecal Crohn's disease: Results of the Crohn's(urg) study, a multicentre, retrospective, comparative analysis between inflammatory and complicated phenotypes.

AIM: Recent evidence challenges the current standard of offering surgery to patients with ileocaecal Crohn's disease (CD) only when they present complications of the disease. The aim of this study was to compare short-term results of patients who underwent primary ileocaecal resection for either inflammatory (luminal disease, earlier in the disease course) or complicated phenotypes, hypothesizing that the latter would be associated with worse postoperative outcomes. METHOD: A retrospective, multicentre comparative analysis was performed including patients operated on for primary ileocaecal CD at 12 referral centres. Patients were divided into two groups according to indication of surgery for inflammatory (ICD) or complicated (CCD) phenotype. Short-term results were compared. RESULTS: A total of 2013 patients were included, with 291 (14.5%) in the ICD group. No differences were found between the groups in time from diagnosis to surgery. CCD patients had higher rates of low body mass index, anaemia (40.9% vs. 27%, p < 0.001) and low albumin (11.3% vs. 2.6%, p < 0.001). CCD patients had longer operations, lower rates of laparoscopic approach (84.3% vs. 93.1%, p = 0.001) and higher conversion rates (9.3% vs. 1.9%, p < 0.001). CCD patients had a longer hospital stay and higher postoperative complication rates (26.1% vs. 21.3%, p = 0.083). Anastomotic leakage and reoperations were also more frequent in this group. More patients in the CCD group required an extended bowel resection (14.1% vs. 8.3%, p: 0.017). In multivariate analysis, CCD was associated with prolonged surgery (OR 3.44, p = 0.001) and the requirement for multiple intraoperative procedures (OR 8.39, p = 0.030). CONCLUSION: Indication for surgery in patients who present with an inflammatory phenotype of CD was associated with better outcomes compared with patients operated on for complications of the disease. There was no difference between groups in time from diagnosis to surgery.

The impact of facility type on surgical outcomes in colon cancer patients: analysis of the national cancer database.

BACKGROUND: The type of facility where patients with colon cancer are treated may play a significant role in their outcomes. We aimed to investigate the influence of facility types included in the National Cancer Database (NCDB) on surgical outcomes of colon cancer. METHODS: Retrospective cohort analysis of all patients with stage I-III colon cancer included in the NCDB database between 2010 and 2019 was performed. Patients were grouped based on facility type: Academic/Research Programs (ARP), Community Cancer Programs (CCP), Comprehensive Community Cancer Programs (CCCP), and Integrated Network Cancer Programs (INCP). Study outcomes included overall survival, 30- and 90-day mortality, 30-day readmission and conversion to open surgery. RESULTS: 125,935 patients were included with a median age of 68.7 years (50.5% females). Most tumors were in the right colon (50.6%). Patient were distributed among facility types as ARP (n = 34,321, 27%), CCP (n = 12,692, 10%), CCCP (n = 54,356, 43%), and INCP (n = 24,566, 19%). In terms of surgical approach, laparoscopy was more commonly used in ARP (46%) (p < 0.001). Laparotomy was more common in CCP (58.7%) (p < 0.001), and conversely, CCP had the least amount of robotic surgery (3.9%) (p < 0.001). Median overall survival was highest in ARP (129 months, 95% CI 127.4-134.1) and lowest in CCP (103.7 months, 95% CI 100.1-106.7) (p < 0.001). Conversion rates were comparable between ARP (12%), CCCP (12%) and INCP (11.8%) but were higher in CCP (15.5%) (p < 0.001). 30-day readmission rates and 30-day mortality rates were significantly lower in ARP compared to other facility types (p < 0.001). CONCLUSION: Our findings display differences in surgical outcomes of colon cancer patients among facility types. The findings suggest better outcomes in terms of operative access and survival at ARP as compared to other facilities. These findings underscore the importance of understanding facility-specific factors that may influence patient outcomes and can guide resource allocation and targeted interventions for improving colon cancer care.

Trans­anal minimally invasive surgery (TAMIS) versus rigid platforms for local excision of early rectal cancer: a systematic review and meta-analysis of the literature.

BACKGROUND: Available platforms for local excision (LE) of early rectal cancer are rigid or flexible [trans­anal minimally invasive surgery (TAMIS)]. We systematically searched the literature to compare outcomes between platforms. METHODS: PRISMA-compliant search of PubMed and Scopus databases until September 2022 was undertaken in this random-effect meta-analysis. Statistical heterogeneity was assessed using I2 statistic. Studies comparing TAMIS versus rigid platforms for LE for early rectal cancer were included. Main outcome measures were intraoperative and short-term postoperative outcomes and specimen quality. RESULTS: 7 studies were published between 2015 and 2022, including 931 patients (423 females); 402 underwent TAMIS and 529 underwent LE with rigid platforms. Techniques were similar for operative time (WMD 11.1, 95%CI - 2.6 to 25, p = 0.11), percentage of defect closure (OR 0.7, 95%CI 0.06-8.22, p = 0.78), and peritoneal violation (OR 0.41, 95%CI 0.12-1.43, p = 0.16). Rigid platforms had higher rates of short-term complications (19.1% vs 14.2, OR 1.6, 95%CI 1.07-2.4, p = 0.02), although no significant differences were seen for major complications (OR 1.41, 95%CI 0.61-3.23, p = 0.41). Patients in the rigid platforms group were 3-times more likely to be re-admitted within 30 days compared to the TAMIS group (OR 3.1, 95%CI 1.07-9.4, p = 0.03). Rates of positive resection margins (rigid platforms: 7.6% vs TAMIS: 9.34%, OR 0.81, 95%CI 0.42-1.55, p = 0.53) and specimen fragmentation (rigid platforms: 3.3% vs TAMIS: 4.4%, OR 0.74, 95%CI 0.33-1.64, p = 0.46) were similar between the groups. Salvage surgery was required in 5.5% of rigid platform patients and 6.2% of TAMIS patients (OR 0.8, 95%CI 0.4-1.8, p = 0.7). CONCLUSION: TAMIS or rigid platforms for LE seem to have similar operative outcomes and specimen quality. The TAMIS group demonstrated lower readmission and overall complication rates but did not significantly differ for major complications. The choice of platform should be based on availability, cost, and surgeon's preference.

Oncologic outcomes following transanal total mesorectal excision: the United States experience.

AIM: The benefits and short-term outcomes of transanal total mesorectal excision (taTME) for rectal cancer have been demonstrated previously, but questions remain regarding the oncologic outcomes following this challenging procedure. The purpose of this study was to analyze the oncologic outcomes following taTME at high-volume centers in the USA. METHODS: This was a multicenter, retrospective observational study of 8 tertiary care centers. All consecutive taTME cases for primary rectal cancer performed between 2011 and 2020 were included. Clinical, histopathologic, and oncologic data were analyzed. Primary endpoints were rate of local recurrence, distal recurrence, 3-year disease recurrence, and 3-year overall survival. Secondary endpoints included perioperative complications and TME specimen quality. RESULTS: A total of 391 patients were included in the study. The median age was 57 years (IQR: 49, 66), 68% of patients were male, and the median BMI was 27.4 (IQR: 24.1, 31.0). TME specimen was complete or near complete in 94.5% of cases and the rates of positive circumferential radial margin and distal resection margin were 2.0% and 0.3%, respectively. Median follow-up time was 30.7 months as calculated using reverse-KM estimator (CI 28.1-33.8) and there were 9 cases (2.5%) of local recurrence not accounting for competing risk. The 3-year estimated rate of disease recurrence was 19% (CI 15-25%) and the 3-year estimated overall survival was 90% (CI 87-94%). CONCLUSION: This large multicenter study confirms the oncologic safety and perioperative benefits of taTME for rectal cancer when performed by experienced surgeons at experienced referral centers.

Pathologic Outcomes and Survival in Patients with Rectal Cancer and Increased Body Mass Index.

INTRODUCTION: We assessed the association between increased body mass index (BMI) and rectal cancer outcomes. METHODS: We included patients who underwent surgery for stage I-III rectal adenocarcinoma who were divided according to BMI at diagnosis: ideal BMI (18.5-24.9 kg/m2) and increased BMI (≥25 kg/m2). Groups were compared using univariate association analyses relative to baseline characteristics, pathologic outcomes, overall survival (OS), and disease-free survival (DFS). Main outcome measures involved circumferential resection margin (CRM), pathologic TNM stage, total mesorectal incision (TME) grade, OS, and DFS. RESULTS: 243 patients (64.6% male; median age 59 years) with a median BMI of 26.3 kg/m2 were included. 62.1% had BMI ≥25 kg/m2. Increased BMI patients had similar proportions of males (66.9% vs. 60.9%; p = 0.407) and comorbidities (ASA III: 47% vs. 37.4%; p = 0.24) to ideal BMI patients. There were no significant differences in cN1-2 stage (p = 0.279) or positive CRM (p = 0.062) rates. The groups had similar complete/near-complete TME, pathologic TN stage, and survival rates. Pathologic and survival outcomes were also similar with a BMI cutoff of 30. CONCLUSIONS: There was a trend toward more nodal involvement in preoperative assessment and less CRM involvement in the final pathology of patients with increased BMI. Complete/near-complete TME and survival rates were comparable between the groups.

Colonic Diverticulosis at Colonoscopy in Africa: A Systematic Review and Meta-Analysis of Pooled Estimates.

INTRODUCTION: There is need to ascertain any epidemiologic shift of diverticulosis among Africans with traditionally high fiber diet consumption patterns and rare diverticulosis prevalence. METHODS: We systematically searched PubMed, Scopus, Cochrane Library, African Journal Online (AJOL), and Google Scholar. Eligibility criteria included full-text observational and experimental human colonoscopy studies on asymptomatic and symptomatic African population from 1985 to 2022. Case reports, conference abstracts, dissertations, systematic reviews, and studies lacking colonoscopy findings were excluded. NIH quality assessment tool for observational cohort and cross-sectional studies was used to assess risk of bias. Meta-analysis was performed using the random-effect model. Heterogeneity was assessed using inconsistency (I2) statistics. RESULTS: Thirty studies were included. Pooled prevalence rate of colonic diverticulosis in the last decade (2012-2022) has increased to 9.7% (95% CI 6.5-13.4; I2 = 97.3%) from 3.5% (95% CI 1.4-6.4; I2 = 62.7%). The highest regional prevalence rate was in West African studies at 11.3% (95% CI 7.6-14.9; I2 = 96.2%). Proportion of individuals with diverticulosis ≥50 years and male sex were 86.9% (95% CI 80.5-92.1) and 65.2% (95% CI 55.0-74.8), respectively. The left colon had the highest diverticulosis frequency (37% [148/400]). Bleeding/inflammation complications were sparingly detected (OR 0.2 [95% CI 0.03-0.75; p < 0.0001]). CONCLUSION: An increasing utilization of colonoscopy revealed approximately a threefold increase in the prevalence rate of colonic diverticulosis in Africa. This pathology was most common in males aged >50. Left colon was predominantly affected. Further studies are needed to demonstrate the effect of westernization of diet.

Meta-analysis of Randomized Clinical Trials on Long-term Outcomes of Surgical Treatment of Perforated Diverticulitis.

OBJECTIVE: To assess long-term outcomes of patients with perforated diverticulitis treated with resection or laparoscopic lavage (LL). BACKGROUND: Surgical treatment of perforated diverticulitis has changed in the last few decades. LL and increasing evidence that primary anastomosis (PRA) is feasible in certain patients have broadened surgical options. However, debate about the optimal surgical strategy lingers. METHODS: PubMed, Scopus, and Web of Science were searched for randomized clinical trials (RCT) on surgical treatment of perforated diverticulitis from inception to October 2022. Long-term reports of RCT comparing surgical interventions for the treatment of perforated diverticulitis were selected. The main outcome measures were long-term ostomy, long-term complications, recurrence, and reintervention rates. RESULTS: After screening 2431 studies, 5 long-term follow-up studies of RCT comprising 499 patients were included. Three studies, excluding patients with fecal peritonitis, compared LL and colonic resection, and 2 compared PRA and Hartmann procedures. LL had lower odds of long-term ostomy [odds ratio (OR) = 0.133, 95% CI: 0.278-0.579; P < 0.001] and reoperation (OR = 0.585, 95% CI: 0.365-0.937; P = 0.02) compared with colonic resection but higher odds of diverticular disease recurrence (OR = 5.8, 95% CI: 2.33-14.42; P < 0.001). Colonic resection with PRA had lower odds of long-term ostomy (OR = 0.02, 95% CI: 0.003-0.195; P < 0.001), long-term complications (OR = 0.195, 95% CI: 0.113-0.335; P < 0.001), reoperation (OR = 0.2, 95% CI: 0.108-0.384; P < 0.001), and incisional hernia (OR = 0.184, 95% CI: 0.102-0.333; P < 0.001). There was no significant difference in odds of mortality among the procedures. CONCLUSIONS: Long-term follow-up of patients who underwent emergency surgery for perforated diverticulitis showed that LL had lower odds of long-term ostomy and reoperation, but more risk for disease recurrence when compared with resection in purulent peritonitis. Colonic resection with PRA had better long-term outcomes than the Hartmann procedure for fecal peritonitis.