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.

Association between the expression of epithelial-mesenchymal transition (EMT)-related markers and oncologic outcomes of colorectal cancer.

BACKGROUND: Epithelial-mesenchymal transition (EMT) is a key step in the development of colorectal cancer (CRC) that confers metastatic capabilities to cancer cells. The present study aimed to assess the immunohistochemical (IHC) expression and impact of EMT markers, including E-cadherin, Vimentin, ß-catenin, and SMAD4, on the oncologic outcomes of CRC. METHODS: This was a retrospective review of 118 CRC patients. Tissue slides were retrieved from the slide archive and five tissue microarray construction blocks were constructed. IHC for E-cadherin, Vimentin, ß-catenin, and SMAD4 was done. The main outcome was the association between abnormal marker expression and overall survival (OS), and disease-free survival (DFS). RESULTS: Adenocarcinomas accounted for 71.2% of tumors, whereas 25.4% and 3.4% were mucinous and signet ring cell carcinomas. The rates of lymphovascular invasion and perineural invasion were 72.9% and 20.3%, respectively. There was a positive, significant correlation, and association between the four markers. Abnormal expression of E-cadherin was associated with significantly lower OS (p < 0.0001) and similar DFS (p = 0.06). Abnormal Vimentin expression was associated with a significantly higher rate of distant metastasis (p = 0.005) and significantly lower OS and DFS (p < 0.0001). Abnormal expression of ß-catenin was associated with significantly lower OS (p < 0.0001) and similar DFS (p = 0.15). Abnormal expression of SMAD4 was associated with significantly lower OS and DFS (p < 0.0001). Abnormal expression of all four markers was associated with a higher disease recurrence, lower OS, and lower DFS. CONCLUSION: Abnormal expression of each marker was associated with lower OS, whereas abnormal expression of Vimentin and SMAD4 only was associated with lower DFS.

Obesity and overweight are associated with worse survival in early-onset colorectal cancer.

BACKGROUND: Obesity and its associated lifestyle are known risk factors for early-onset colorectal cancer and are associated with poor postoperative and survival outcomes in older patients. We aimed to investigate the impact of obesity on the outcomes of early-onset colorectal cancers. METHODS: Retrospective review of all patients undergoing primary resection of colon or rectal adenocarcinoma at our institution between 2015-2022. Patients who had palliative resections, resections performed at another institution, appendiceal tumors, and were underweight were excluded. The primary endpoint was survival according to the patient's body mass index: normal weight (18-24.9 kg/m2), overweight (25-29.9 kg/m2), and obesity (≥30 kg/m2). Patient and tumor characteristics and survival were compared between the three groups. RESULTS: A total of 279 patients aged <50 years with colorectal cancer were treated at our hospital; 120 were excluded from the analysis for the following reasons: main treatment or primary resection performed at another hospital (n = 97), no resection/palliative resection (n = 23), or body mass index <18 kg/m2 (n = 2). Of these, 157 patients were included in the analysis; 61 (38.9%) were overweight and 45 (28.7%) had obesity. Except for a higher frequency of hypertension in the overweight (P = .062) and obese (P = .001) groups, no differences in patient or tumor characteristics were observed. Mean overall survival was 89 months with normal weight, 92 months with overweight, and 65 months with obesity (P = .032). Mean cancer-specific survival was 95 months with normal weight, 94 months with overweight, and 68 months with obesity (P = .018). No statistically significant difference in disease-free survival (75 vs 70 vs 59 months, P = .844) was seen. CONCLUSION: Individuals with early-onset colorectal cancer who are overweight or obese present with similar tumor characteristics and postoperative morbidity to patients with normal weight. However, obesity may have a detrimental impact on their survival. Addressing obesity as a modifiable risk factor might improve early-onset colorectal cancer prognosis.

Propensity-score matched outcomes of resection of stage IV primary colon cancer with and without simultaneous resection of liver metastases.

There is controversy in the best management of colorectal cancer liver metastasis (CLM). This study aimed to compare short-term and survival outcomes of simultaneous resection of CLM and primary colon cancer compared to resection of only colon cancer. This retrospective matched cohort study included patients from the National Cancer Database (2015-2019) with stage IV colon adenocarcinoma and synchronous liver metastases who underwent colectomy. Patients were divided into two groups: colectomy-only (resection of primary colon cancer only) and colectomy-plus (simultaneous resection of primary colon cancer and liver metastases). The groups were matched using the propensity score method. The primary outcome was short-term mortality and readmission. Secondary outcomes were conversion, hospital stay, surgical margins, and overall survival. 4082 (37.6%) of 10,862 patients underwent simultaneous resection of primary colon cancer and liver metastases. After matching, 2038 patients were included in each group. There were no significant differences between the groups in 30-days mortality (3.1% vs 3.8%, p = 0.301), 90-days (6.6% vs 7.7%, p = 0.205) mortality, 30-days unplanned readmission (7.2% vs 5.3%, p = 0.020), or conversion to open surgery (15.5% vs. 13.8%, p = 0.298). Patients in the colectomy plus group had a higher rate of lower incidence of positive surgical margins (13.2% vs. 17.2%, p = 0.001) and longer overall survival (median: 41.5 vs 28.4 months, p < 0.001). Synchronous resection of CLM did not increase the rates of short-term mortality, readmission, conversion from minimally invasive to open surgery, or hospital stay and was associated with a lower incidence of positive surgical margins.

Upfront laparotomy versus conversion from minimally invasive surgery to open surgery in colon cancer: Is there a difference in outcomes?

BACKGROUND: It is unclear whether conversion from minimally invasive surgery to laparotomy in patients with colon cancer contributes to worse outcomes compared with those operated by laparotomy. In this study, we aimed to assess the implications of transitioning from minimally invasive surgery to laparotomy in patients with colon cancer compared with patients undergoing upfront laparotomy. METHODS: A retrospective analysis of the National Cancer Database, including patients with stages I to III colon cancer (2010-2019). Patients who underwent either upfront laparotomy (Open Surgery Group) or minimally invasive surgery converted to open surgery (Converted Surgery Group) were included. Groups were balanced using propensity-score matching. Primary outcome was overall survival, and secondary outcomes included 30- and 90-day mortality and 30-day readmission rates. RESULTS: The study included 65,083 operated patients with stage I to III colon cancer; 57,091 patients (87.7%) were included in the Open Surgery group and 7,992 (12.3%) in the Converted Surgery group. 93.5% were converted from laparoscopy, and 6.5% were converted from robotic surgery. After propensity-score matching, 7,058 patients were included in each group. Median overall survival was significantly higher in the Converted Surgery group (107.3 months) than in the Open Surgery group (101.5 months; P = .006). A survival benefit was seen in patients >65 years of age (79.5 vs 71.9 months; P = .001), left-sided disease (129.4 vs 114.5 months; P < .001), and with a high Charlson comorbidity index score (=3; 58.9 vs 42.3 months; P = .03). Positive margin rates were similar between the groups (6.3% vs 5.6%; P = .07). Converted patients had a higher 30-day readmission rate (6.7% vs 5.6%, P = .006) and shorter duration of stay (median, 5 vs 6 days, P < .001) than patients in the Open Surgery group. In addition, 30-day mortality was comparable between the groups (2.9% vs 3.5%; P = .07). CONCLUSION: Conversion to open surgery from minimally invasive surgery was associated with better overall survival compared with upfront open surgery. A survival benefit was mainly seen in patients >65 years of age, with significant comorbidities, and with left-sided tumors. We believe these data suggest that, in the absence of an absolute contraindication to minimally invasive surgery, it should be the preferred approach in patients with colon cancer.

Characteristics and outcomes of large (≥5 cm) colonic adenocarcinomas and comparing outcomes of minimally invasive and open surgery for stage I to III disease.

BACKGROUND: Colon cancer prognosis is primarily dependent on the stage at diagnosis, but tumor size and location may also impact prognosis. This study aimed to assess the characteristics and outcomes of patients with ≥5 cm colonic adenocarcinomas and compare outcomes of open and minimally invasive surgery for stage I to III large colonic adenocarcinomas. METHODS: The National Cancer Database (2010-2019) was searched for patients with colonic adenocarcinomas ≥5 cm. Outcomes of patients who underwent minimally invasive surgery or open surgery were compared after propensity-score matching. The primary outcome was 5-year overall survival and, secondarily, hospital stay, surgical margins, and short-term mortality. RESULTS: A total of 126,959 patients were included (22.1% of all diagnosed adenocarcinomas). 56% of tumors were right-sided, 32.6% were left-sided, and 11.4% were in the transverse colon. Stage IV disease was recorded in 34.6% of patients. Lymphovascular invasion, perineural invasion, and Kirsten rat sarcoma viral oncogene homolog mutations were recorded in 35.7%, 14.9%, and 41.6% of patients. The rate of positive surgical margins was 9.8%. Median hospital stay was 6 (interquartile range: 4-8) days. 30- and 90-day mortality rates were 4.1% and 7.5%, respectively. After matching, 15,228 patients in the open surgery group were matched to a similar number in the minimally invasive surgery group. The minimally invasive surgery group was associated with significantly lower rates of 30- and 90-day mortality, positive surgical margins, shorter hospital stay, and longer median overall survival (110.6 vs 86.6 months, P < .001) than did open surgery. CONCLUSION: Large colonic adenocarcinomas are mostly right-sided or transverse and present at a more advanced stage with adverse pathologic features. Minimally invasive surgery was associated with better overall survival and short-term benefits when compared with open surgery.

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 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.

Toward less invasive coloproctology: The future is out there.

Medical care has undergone remarkable improvements over the past few decades. One of the most important innovative breakthroughs in modern medicine is the advent of minimally and less invasive treatments. The trend towards employing less invasive treatment has been vividly shown in the field of gastroenterology, particularly coloproctology. Parallel to foregut interventions, colorectal surgery has shifted towards a minimally invasive approach. Coloproctology, including both medical and surgical management of colorectal diseases, has undergone a remarkable paradigm shift. The treatment of both benign and malignant colorectal conditions has gradually transitioned towards more conservative and less invasive approaches. An interesting paradigm shift was the trend to avoid the need for radical resection of rectal cancer altogether in patients who showed complete response to neoadjuvant treatment. The trend of adopting less invasive approaches to treat various colorectal conditions does not seem to be stopping soon as further research on novel, more effective and safer methods is ongoing.

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.

Surgical outcomes and predictors of overall survival of stage I-III appendiceal adenocarcinoma: Retrospective cohort analysis of the national cancer database.

BACKGROUND: This study aimed to determine predictors of overall survival (OS) after surgical treatment of stage I-III appendiceal adenocarcinoma and compare the outcomes of partial colectomy and hemicolectomy. METHODS: A retrospective analysis of the U.S. National Cancer Database (NCDB) including patients who underwent surgery for stage I-III appendiceal adenocarcinoma between 2005 and 2019 was conducted. A propensity-score matched analysis was undertaken to compare the outcomes of partial and hemicolectomy and multivariate analysis was performed to determine predictive factors of OS. The main outcome was OS and its independent predictors. RESULTS: 2607 patients (51.6 % male) with a mean age of 61.6 ± 13.9 years were included. 61.7 % of patients underwent hemicolectomy while 31.7 % underwent partial colectomy. After matching, partial colectomy, and hemicolectomy had similar OS (117.3 vs 117.2 months; p = 0.08), positive resection margins, short-term mortality, and 30-day readmission. The hemicolectomy group was associated with more examined lymph nodes and longer hospital stays. Older age (HR: 1.047, p < 0.0001), rural residence area (HR: 3.6, p = 0.025), higher Charlson score (HR: 1.6, p = 0.016), signet-ring cell carcinoma (HR: 2.37, p = 0.009), adjuvant systemic treatment (HR: 1.55, p = 0.015), positive surgical margins (HR: 1.83, p = 0.017), positive lymph nodes number (HR: 1.09, p < 0.0001), and examined lymph nodes number (HR: 0.962, p = 0.001) were independent predictors of OS. CONCLUSIONS: Partial colectomy and hemicolectomy had similar OS and clinical outcomes. Older age, rural residence, higher Charlson score, signet-ring pathology, adjuvant systemic treatment, positive surgical margins, positive lymph node number, and examined lymph node number were independent predictors of OS.

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 ).

Outcomes of transanal total mesorectal excision compared to laparoscopic total mesorectal excision: A meta-analysis of randomized controlled trials.

BACKGROUND: Transanal dissection is increasingly used in laparoscopic surgery for total mesorectal excision of lower rectal cancers. Several studies compared outcomes of laparoscopic total mesorectal excision with and without transanal dissection, yet there is a paucity of high-quality evidence. This meta-analysis aimed to provide a pooled comparative analysis of outcomes of laparoscopic total mesorectal excision with and without transanal dissection based on evidence from randomized controlled trials. METHODS: This Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2022-compliant systematic review of randomized controlled trials compared laparoscopic total mesorectal excision with and without transanal dissection. PubMed, Scopus, and Web of Science were searched through March 2023. The Medical Subject Headings terms used in the search were Rectal neoplasms, Proctectomy, Laparoscopy, and Transanal. The main outcomes included operative and pathologic outcomes. The risk of bias was assessed using the Risk of Bias version 2 tool, and certainty of the evidence was graded using the Grading of Recommendations Assessment, Development, and Evaluation approach. The primary study outcome was conversion to open surgery. RESULTS: Four randomized controlled trials (1,339 patients; median age 61.2 years) were included; 671 patients underwent laparoscopic total mesorectal excision with transanal dissection, and 668 underwent laparoscopic total mesorectal excision without transanal dissection. Both groups were similar in age, body mass index, and disease stage, but the laparoscopic total mesorectal excision with transanal dissection group had a higher male-to-female ratio, received neoadjuvant therapy and had a hand-sewn anastomosis more often. Patients who underwent laparoscopic total mesorectal excision with transanal dissection had lower conversion rates (odds ratio = 0.179; P = .001), a higher likelihood of achieving complete total mesorectal excision (odds ratio = 1.435; P = .025), and fewer harvested lymph nodes (weighted mean difference = -1.926; P = .035). The groups had similar operative times (weighted mean difference = -3.476; P = .398), total complications (odds ratio = 0.94; P = .665), major complications (odds ratio = 1.112; P = .66), anastomotic leak (odds ratio = 0.67; P = .432), positive circumferential resection margin (odds ratio = 0.549; P = .155), and positive distal margins (odds ratio = 0.559; P = .171). CONCLUSION: Laparoscopic total mesorectal excision with transanal dissection was associated with lower odds of conversion to open surgery, greater likelihood of achieving complete total mesorectal excision, and fewer harvested lymph nodes than laparoscopic total mesorectal excision without transanal dissection.

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.

Strategies to reduce ileus after colorectal surgery: A qualitative umbrella review of the collective evidence.

BACKGROUND: Various strategies were proposed to reduce postoperative ileus after colorectal surgery. This umbrella review aimed to provide a comprehensive overview of current evidence on measures to reduce the incidence and severity of postoperative ileus after colorectal surgery. METHODS: A Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant systematic search was conducted in PubMed and Scopus to identify systematic reviews that assessed the efficacy of interventions used to prevent postoperative ileus after colorectal surgery. Data on study characteristics, interventions, and outcomes were summarized in a narrative manner. RESULTS: A total of 26 systematic reviews incorporating various strategies like early oral feeding, gum chewing, coffee consumption, medications, and acupuncture were included. Early oral feeding reduced postoperative ileus and accelerated bowel function return. The most assessed intervention was chewing gum, which was associated with a median reduction of postoperative ileus by 45% (range, 11%-59%) and shortening of the time to first flatus and time to defecation by a median of 11.9 and 17.7 hours, respectively. Coffee intake showed inconsistent results, with a median shortening of time to flatus and time to defecation by 1.32 and 14.45 hours, respectively. CONCLUSION: Early oral feeding, chewing gum, and alvimopan were the most commonly assessed and effective strategies for reducing postoperative ileus after colorectal surgery. Medications used to reduce postoperative ileus included alvimopan, intravenous lidocaine, dexamethasone, probiotics, and oral antibiotics. Intravenous dexamethasone and lidocaine and oral probiotics helped hasten bowel function return. Acupuncture positively impacted the recovery of bowel function.

Propensity-Score Matched Analysis of Survival Outcomes of Adjuvant Therapy in Stage II-III Signet-Ring Cell Carcinoma of the Colon.

BACKGROUND: Colonic signet ring cell carcinoma (SRCC) is a mucinous adenocarcinoma subtype often associated with poor prognosis. This study assessed the survival benefits of adjuvant therapy after curative resection of stage II-III colonic SRCC. METHODS: This was a retrospective analysis of outcomes of adjuvant therapy in colonic SRCC using National Cancer Database (2010-2019) data. Patients who received adjuvant therapy were matched to those who did not use the nearest neighbor propensity-score matching. The primary outcome was 5-year overall survival (OS). RESULTS: The unmatched cohort included 3530 patients. Patients who received adjuvant therapy were significantly younger, more often male, and more often had Charlson scores 0-1, left-sided cancers, stage III disease, lymphovascular invasion, and perineural invasion. The matched cohort included 958 patients (53.6% female); 479 received adjuvant therapy and 479 did not. Adjuvant therapy was associated with longer mean OS (39.9 vs. 29.2 months; P < .001). Survival benefit of adjuvant therapy was evident in stage III disease (37.5 vs. 24.7 months; P < .001), right-sided colon cancer (40.2 vs. 27.7 months; P < .001), and transverse colon cancer (40.6 vs. 31.1 months; P = .002), but not stage II disease (52.1 vs. 53.1 months; P = .694) or left-sided colon cancer (35.8 vs. 32.6 months; P = .417). Independent predictors of improved OS were adjuvant therapy (HR: 0.539; P < .001), laparoscopic surgery (HR: 0.829; P = .001), robotic-assisted surgery (HR: 0.63; P = .007), and number of harvested lymph nodes (HR: 0.976; P < .001). CONCLUSIONS: Adjuvant therapy was associated with improved OS in stage III, right-sided, and transverse colon SRCC. The survival benefit of adjuvant therapy in stage II and left-sided colon SRCC was limited.

Characteristics and outcomes of rectal cancer in patients with inflammatory bowel disease: a single-center experience.

The increased risk of colorectal cancer (CRC) in patients with inflammatory bowel disease (IBD) has been well documented in the literature. The present study aimed to assess the characteristics and outcomes of rectal cancer in patients with IBD. This study was a retrospective review of a prospectively maintained IRB-approved database at Cleveland Clinic Florida. Rectal cancer patients with or without IBD treated with curative surgery between 2016 and 2020 were compared for demographics, disease characteristics, and pathologic and oncologic outcomes. The primary outcomes were 3-year overall survival (OS) and disease-free survival (DFS). Secondary outcomes were clinicopathologic outcomes including disease stage, tumor histology and histologic features, and treatments received. 238 patients with rectal cancer were included, 15 (6.3%) of whom had IBD. IBD patients were significantly younger (52.9 vs 60.3 years, p = 0.033), presented more often with cT1-2 tumors (64.3% vs 30.4%, p = 0.008), and signet-ring cell pathology (14.3% vs 2%, p = 0.02). IBD patients received neoadjuvant chemoradiation less often (40% vs 72.6%, p = 0.029) and had shorter time between diagnosis and surgery (7.5 vs 25 weeks, p = 0.013) than did non-IBD patients. Both groups had similar OS (36 vs 34.7 months, p = 0.431) and DFS (36 vs 32.9 months, p = 0.121). IBD patients with rectal cancer tend to present at a younger age, with a less invasive disease, and signet-ring carcinomas, and receive neoadjuvant treatment less often than non-IBD patients. Based on low level of evidence, IBD and non-IBD rectal cancer patients might have similar survival.

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.

Immunotherapy in rectal cancer patients-a propensity score matched analysis of the National Cancer Database.

BACKGROUND: Rectal cancer patients with microsatellite instability (MSI-H) are candidates for immunotherapy. However, there is little evidence on its effect on overall survival (OS). METHODS: Retrospective analysis of stage II-IV rectal adenocarcinoma patients in the National Cancer Database (NCDB) between 2010 and 2019. Propensity score matching was adjusted for baseline and treatment confounders. The cohort was divided into patients who received immunotherapy and matched controls. The primary outcome was OS. RESULTS: 5175/206,615 (2.5%) patients with rectal adenocarcinoma underwent immunotherapy. These patients were younger (58 vs 62 years; p < 0.001), more often male (64.4% vs 61.7%; p < 0.001), were more likely to have private insurance (50.8% vs 43.4%; p < 0.001), more metastatic disease at presentation (clinical TNM stage IV-80.8% vs 23.3%; p < 0.001), presented with larger tumors (median: 5 cm vs. 4.2 cm; p < 0.001) and less often underwent surgery (33.7% vs. 69.9%; p < 0.001), radiation therapy (21.5% vs 57.4%; p < 0.001), and standard chemotherapy (38.1% vs 61%; p < 0.001) than controls. After matching, 488 patients were in each group. OS was significantly shorter in the immunotherapy group (mean survival: 56.4 months (95% CI: -53.03-59.86)) compared to controls (mean survival: 70.5 months (95% CI: -66.15-74.92) (p = 0.004)). Cox regression analysis of factors associated with OS demonstrated that immunotherapy was associated with increased mortality (HR 2.16; 95% CI: 2.09-2.24; p < 0.001). After clinical staging stratification, immunotherapy was associated with improved OS in stage IV (HR 0.91, 95% CI: 0.88-0.95; p < 0.001) but lower survival in stage II (HR 2.38; 95% CI: 2.05-2.77; p < 0.001) and stage III (HR 2.43; 95% CI: 2.18-2.7; p < 0.001) patients. CONCLUSION: Immunotherapy showed modest increase in OS in stage IV metastatic rectal cancer. OS was significantly lower in stage II-III disease treated with immunotherapy.

A Systematic Review and Meta-analysis of Randomized Clinical Trials on the Prevention and Treatment of Pouchitis after Ileoanal Pouch Anastomosis.

BACKGROUND: This systematic review explored different medications and methods for prevention and treatment of pouchitis after restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA). METHODS: PubMed, Scopus, and Web of Science were searched for randomized clinical trials that assessed prevention or treatment of pouchitis. The systematic review was reported in line with updated 2020 PRISMA guidelines. Risk of bias in the trials included was assessed using the ROB-2 tool and certainty of evidence was assessed using GRADE. The main outcomes were the incidence of new pouchitis episodes in the preventative studies and resolution or improvement of active pouchitis in the treatment studies. RESULTS: Fifteen randomized trials were included. A meta-analysis of 7 trials on probiotics revealed significantly lower odds of pouchitis with the use of probiotics (RR: 0.26, 95% CI: 0.16-0.42, I2 = 20%, p < 0.001) and similar odds of adverse effects to placebo (RR: 2.43, 95% CI: 0.11-55.9, I2 = 0, p = 0.579). One trial investigated the prophylactic role of allopurinol in preventing pouchitis and found a comparable incidence of pouchitis in the two groups (31% vs 28%; p = 0.73). Seven trials assessed different treatments for active pouchitis. One recorded the resolution of pouchitis in all patients treated with ciprofloxacin versus 67% treated with metronidazole. Both budesonide enema and oral metronidazole were associated with similar significant improvement in pouchitis (58.3% vs 50%, p = 0.67). Rifaximin, adalimumab, fecal microbiota transplantation, and bismuth carbomer foam enema were not effective in treating pouchitis. CONCLUSIONS: Probiotics are effective in preventing pouchitis after IPAA. Antibiotics, including ciprofloxacin and metronidazole, are likely effective in treating active pouchitis.