Revisional ileoanal pouch surgery: a systematic literature review assessing outcomes over the last 40 years.

AIM: Failure of primary ileal pouch-anal anastomosis (IPAA) occurs in up to 15% of patients. Revision surgery may be offered to patients wishing to maintain gastrointestinal continuity. This paper explores the literature relating to IPAA revision surgery, focusing on pouch function after revision and factors associated with pouch failure. METHODS: Search of PubMed database was carried out for 'ileal pouch anal anastomoses', 'ileoanal pouch', 'restorative proctocolectomy', 'revision surgery', 'redo surgery', 'failure', 'refashion surgery', 'reconstruction surgery' and 'salvage surgery'. Papers were screened using the PRISMA literature review strategy. Studies of adults published after 1980 in English with an available abstract were included. Case reports and studies that were superseded using the same data were excluded. RESULTS: Nineteen papers (1424 patients) were identified. Bowel motion frequency doubled following revision surgery compared to primary IPAA although the increase was not always statistically significant. In patients failing primary IPAA, frequency of daytime bowel motions improved following revision in three studies but only reached significance in one (12.1 vs. 6.9, P = 0.021). Risk of pouch failure is increased in patients who develop pelvic sepsis after the primary procedure with the largest study demonstrating a four-fold increased risk (hazard ratio 3.691, P < 0.0001). A final diagnosis of Crohn's causes a four-fold increased risk of pouch failure (n = 81; OR 3.92, 95% CI 1.1-15.9, P = 0.04). CONCLUSIONS: In patients undergoing revisional surgery, improved outcomes are observed but are inferior compared to primary IPAA patients. Pelvic sepsis after primary IPAA and a final diagnosis of Crohn's are associated with increased risk of pouch failure.

Surgical Assessment Units: The Key to More Efficient Emergency Surgical Provision and Admissions?

BACKGROUND: Hospitals establish surgical assessment units to promote efficiency and improve patient experience. Surgical assessment units are believed to reduce unnecessary admissions. We evaluated a hospital's on-call surgery service without this facility to determine benefits of implementation. METHODS: All emergency surgery referrals made over a 3-month period were recorded, including whether the patient was immediately discharged directly from emergency surgery. Data collection was undertaken by each surgical firm on-call. Immediate discharges were classed as patients not admitted to the hospital overnight (regardless of whether the patient had outpatient follow-up planned). RESULTS: Nine hundred eighty-four referrals were identified. Seven hundred ninety-three referrals had complete data and therefore were included for analysis. Of these, 349 patients (44.0% of referrals) were immediately discharged from emergency surgery, thereby preventing unnecessary admissions (a high proportion of surgical referrals not requiring hospital admission). This improves hospital efficiency, cost savings, and patient experience. Immediate discharge was less frequent and more difficult to accomplish if patients were initially assessed on wards (instead of in the emergency department). This is likely due to patients' perceptions that admission was required when transferred from emergency department to a ward. CONCLUSIONS: Establishment of surgical assessment units has multiple potential benefits to patients, hospitals and clinicians. Appropriateness of surgical assessment unit implementation by every hospital ought to be evaluated.

Preoperative magnetic resonance imaging assessment of circumferential resection margin predicts disease-free survival and local recurrence: 5-year follow-up results of the MERCURY study.

PURPOSE: The prognostic relevance of preoperative high-resolution magnetic resonance imaging (MRI) assessment of circumferential resection margin (CRM) involvement is unknown. This follow-up study of 374 patients with rectal cancer reports the relationship between preoperative MRI assessment of CRM staging, American Joint Committee on Cancer (AJCC) TNM stage, and clinical variables with overall survival (OS), disease-free survival (DFS), and time to local recurrence (LR). PATIENTS AND METHODS: Patients underwent protocol high-resolution pelvic MRI. Tumor distance to the mesorectal fascia of ≤ 1 mm was recorded as an MRI-involved CRM. A Cox proportional hazards model was used in multivariate analysis to determine the relationship of MRI assessment of CRM to survivorship after adjusting for preoperative covariates. RESULTS: Surviving patients were followed for a median of 62 months. The 5-year OS was 62.2% in patients with MRI-clear CRM compared with 42.2% in patients with MRI-involved CRM with a hazard ratio (HR) of 1.97 (95% CI, 1.27 to 3.04; P < .01). The 5-year DFS was 67.2% (95% CI, 61.4% to 73%) for MRI-clear CRM compared with 47.3% (95% CI, 33.7% to 60.9%) for MRI-involved CRM with an HR of 1.65 (95% CI, 1.01 to 2.69; P < .05). Local recurrence HR for MRI-involved CRM was 3.50 (95% CI, 1.53 to 8.00; P < .05). MRI-involved CRM was the only preoperative staging parameter that remained significant for OS, DFS, and LR on multivariate analysis. CONCLUSION: High-resolution MRI preoperative assessment of CRM status is superior to AJCC TNM-based criteria for assessing risk of LR, DFS, and OS. Furthermore, MRI CRM involvement is significantly associated with distant metastatic disease; therefore, colorectal cancer teams could intensify treatment and follow-up accordingly to improve survival outcomes.

Preoperative high-resolution magnetic resonance imaging can identify good prognosis stage I, II, and III rectal cancer best managed by surgery alone: a prospective, multicenter, European study.

OBJECTIVE: To assess local recurrence, disease-free survival, and overall survival in magnetic resonance imaging (MRI)-predicted good prognosis tumors treated by surgery alone. BACKGROUND: The MERCURY study reported that high-resolution MRI can accurately stage rectal cancer. The routine policy in most centers involved in the MERCURY study was primary surgery alone in MRI-predicted stage II or less and in MRI "good prognosis" stage III with selective avoidance of neoadjuvant therapy. PATIENTS AND METHODS: Data were collected prospectively on all patients included in the MERCURY study who were staged as MRI-defined "good" prognosis tumors. "Good" prognosis included MRI-predicted safe circumferential resection margins, with MRI-predicted T2/T3a/T3b (less than 5 mm spread from muscularis propria), regardless of MRI N stage. None received preoperative or postoperative radiotherapy. Overall survival, disease-free survival, and local recurrence were calculated. RESULTS: Of 374 patients followed up in the MERCURY study, 122 (33%) were defined as "good prognosis" stage III or less on MRI. Overall and disease-free survival for all patients with MRI "good prognosis" stage I, II and III disease at 5 years was 68% and 85%, respectively. The local recurrence rate for this series of patients predicted to have a good prognosis tumor on MRI was 3%. CONCLUSIONS: The preoperative identification of good prognosis tumors using MRI will allow stratification of patients and better targeting of preoperative therapy. This study confirms the ability of MRI to select patients who are likely to have a good outcome with primary surgery alone.

A systematic approach to the interpretation of preoperative staging MRI for rectal cancer.

OBJECTIVE: The purpose of this article is to provide an aid to the systematic evaluation of MRI in staging rectal cancer. CONCLUSION: MRI has been shown to be an effective tool for the accurate preoperative staging of rectal cancer. In the Magnetic Resonance Imaging and Rectal Cancer European Equivalence Study (MERCURY), imaging workshops were held for participating radiologists to ensure standardization of scan acquisition techniques and interpretation of the images. In this article, we report how the information was obtained and give examples of the images and how they are interpreted, with the aim of providing a systematic approach to the reporting process.

Female urogenital dysfunction following total mesorectal excision for rectal cancer.

BACKGROUND: The effect of Total Mesorectal Excision (TME) on sexual function in the male is well documented. However, there is little literature in female patients. The aim of this study was to review the pelvic autonomic nervous anatomy in the female and to perform a retrospective audit of urinary and sexual function in women following surgery for rectal cancer where TME had been performed. Urogenital dysfunction was assessed through interview and questionnaire. METHOD: Twenty-three questionnaires, eighteen returned, were sent to women with a mean age 65.5 yrs (range 34-86). All had undergone total mesorectal excision for rectal cancer between 1998-2001. Mean follow-up was 18.8 months (range 3-35). RESULTS: Preoperatively 5/18 (28%) were sexually active, 3/18 (17%) of patients described urinary frequency and nocturia and 7/18 (39%) described symptoms of stress incontinence prior to surgery. Postoperatively all sexually active patients remained active although all described some discomfort with penetration. Two of the patients sexually active described reduced libido secondary to the stoma. Postoperative urinary symptoms developed with 59% reporting the development of nocturia, 18% developed stress incontinence and one patient required a permanent catheter. Of those with symptoms, 80% persisted longer than three months from surgery. Symptoms were predominant in those patients with low rectal cancers, particularly those undergoing abdomino-perineal excision and in those who had previously undergone abdominal hysterectomy. CONCLUSION: The treatment of rectal cancer involves surgery to the pelvic floor. Despite nerve preservation this is associated with the development of worsening nocturia and stress incontinence. This is most marked in those patients who had previously undergone a hysterectomy. Further studies are warranted to assess the interaction with previous gynaecological surgery.