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Journal of Gastrointestinal Surgery :... Nov 2023This systematic review explored different medications and methods for prevention and treatment of pouchitis after restorative proctocolectomy with ileal pouch-anal... (Meta-Analysis)
Meta-Analysis Review
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, I = 20%, p < 0.001) and similar odds of adverse effects to placebo (RR: 2.43, 95% CI: 0.11-55.9, I = 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.
Topics: Humans; Pouchitis; Metronidazole; Colitis, Ulcerative; Randomized Controlled Trials as Topic; Proctocolectomy, Restorative; Ciprofloxacin; Anastomosis, Surgical
PubMed: 37815701
DOI: 10.1007/s11605-023-05841-3 -
European Journal of Gastroenterology &... Nov 2023Restorative proctocolectomy (RPC) is the most common surgical procedure to restore gastrointestinal continuity after surgical resection of the colon and rectum.... (Meta-Analysis)
Meta-Analysis
Restorative proctocolectomy (RPC) is the most common surgical procedure to restore gastrointestinal continuity after surgical resection of the colon and rectum. Pouchitis is a common complication with several different modalities that can be used to aid diagnosis. This systematic review and meta-analysis aimed at exploring the sensitivity and specificity these diagnostic modalities. The medical literature was searched using MEDLINE, EMBASE and EMBASE classic and PubMed from 1978 to June 2022. We calculated descriptive statistics using sensitivity, specificity, and false-positive rate of the primary studies and also their positive and negative likelihood ratios, and their diagnostic odds ratios. The screen found 5477 records with 13 studies being included. Faecal lactoferrin was found to have the highest pooled sensitivity and specificity of 98% and 88% respectively with imaging modalities coming in second and faecal calprotectin third with pooled sensitivities and specificities of 87% and 79% and 74% and 81% respectively. Faecal biomarkers particularly lactoferrin and imaging modalities may have an important role to play in diagnosing pouchitis. Importantly due to delays in availability of pouchoscopy, our data supports early ordering of these tests to help delineate from other causes. Further studies are required with larger cohort sizes to further validate these tests.
Topics: Humans; Pouchitis; Lactoferrin; Proctocolectomy, Restorative; Sensitivity and Specificity; Feces
PubMed: 37695613
DOI: 10.1097/MEG.0000000000002638 -
International Journal of Surgery... Apr 2024The efficacy of intersphincteric resection (ISR) surgery for patients with lower rectal cancer remains unclear compared to abdominoperineal resection (APR). The aim of... (Meta-Analysis)
Meta-Analysis Comparative Study
BACKGROUND
The efficacy of intersphincteric resection (ISR) surgery for patients with lower rectal cancer remains unclear compared to abdominoperineal resection (APR). The aim of this study is to compare the oncologic outcomes for lower rectal cancer patients after ISR and APR through a systematic review and meta-analysis.
MATERIALS AND METHODS
A systematic electronic search of the Cochrane Library, PubMed, EMBASE, and MEDLINE was performed through January 12, 2022. The primary outcomes included 5-year disease-free survival (5y-DFS) and 5-year overall survival. Secondary outcomes included circumferential resection margin involvement, local recurrence, perioperative outcomes, and other long-term outcomes. The pooled odds ratios, mean difference, or hazard ratios (HRs) of each outcome measurement and their 95% CIs were calculated.
RESULTS
A total of 20 nonrandomized controlled studies were included in the qualitative analysis, with 1217 patients who underwent ISR and 1135 patients who underwent APR. There was no significant difference in 5y-DFS (HR: 0.84, 95% CI: 0.55-1.29; P =0.43) and 5-year overall survival (HR: 0.93, 95% CI: 0.60-1.46; P =0.76) between the two groups. Using the results of five studies that reported matched T stage and tumor distance, we performed another pooled analysis. Compared to APR, the ISR group had equal 5y-DFS (HR: 0.76, 95% CI: 0.45-1.30; P =0.31) and 5y-LRFS (local recurrence-free survival) (HR: 0.72, 95% CI: 0.29-1.78; P =0.48). Meanwhile, ISR had equivalent local control as well as perioperative outcomes while significantly reducing the operative time (mean difference: -24.89, 95% CI: -45.21 to -4.57; P =0.02) compared to APR.
CONCLUSIONS
Our results show that the long-term survival and safety of patients is not affected by ISR surgery, although this result needs to be carefully considered and requires further study due to the risk of bias and limited data.
Topics: Humans; Rectal Neoplasms; Proctectomy; Anal Canal; Treatment Outcome; Disease-Free Survival; Neoplasm Recurrence, Local
PubMed: 36928167
DOI: 10.1097/JS9.0000000000000205 -
Journal of Clinical Imaging Science 2024Presacral/Retrorectal tumors (RRT) are rare lesions that comprise a multitude of histological types. Data on surgical management are limited to case reports and small... (Review)
Review
Presacral/Retrorectal tumors (RRT) are rare lesions that comprise a multitude of histological types. Data on surgical management are limited to case reports and small case series. The aim of the study was to provide a comprehensive review of the epidemiology, pathological subtypes, surgical approaches, and clinical outcomes. A PubMed search using terms "retrorectal tumor" and "presacral tumor" was used to identify articles reporting RRT of non-urological, non-gynecologic, and non-metastatic origin. Articles included were between 2015 and 2023. A total of 68 studies were included, comprising 570 patients. About 68.2% of patients were female, and the mean overall age of both sexes was 48.6 years. Based on histopathology, 466 patients (81.8%) had benign lesions, and 104 (18.2%) were malignant. In terms of surgical approach, 191 (33.5%) were treated anteriorly, 240 (42.1%) through a posterior approach, and 66 (11.6%) combined. The mean length of stay was 7.6 days. Patients treated using the posterior approach had a shorter length of stay (5.7 days) compared to the anterior and combined approaches. RRT are rare tumors of congenital nature with prevalence among the female sex. R0 resection is crucial in its management, and minimal access surgery appears to be a safer option in appropriate case selection.
PubMed: 38841312
DOI: 10.25259/JCIS_27_2024 -
Diseases of the Colon and Rectum Jun 2024Structural and inflammatory adverse sequelae are common after restorative proctocolectomy and IPAA. On rare occasions, neoplasia can occur in patients with ileal...
BACKGROUND
Structural and inflammatory adverse sequelae are common after restorative proctocolectomy and IPAA. On rare occasions, neoplasia can occur in patients with ileal pouches. Pouchoscopy plays a key role in the diagnosis, differential diagnosis, disease monitoring, assessment of treatment response, surveillance, and delivery of therapy.
OBJECTIVE
A systematic review of the literature was performed, and principles and techniques of pouchoscopy were described.
DATA SOURCES
PubMed, Google Scholar, and Cochrane databases.
STUDY SELECTION
Relevant articles on endoscopy in ileal pouches published between January 2000 and May 2023 were included based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.
INTERVENTION
Diagnostic, surveillance, and therapeutic endoscopy in ileal pouch disorders were included.
MAIN OUTCOME MEASURES
Accurate characterization of the ileal pouch in healthy or diseased states.
RESULTS
The main anatomic structures of a J- or S-pouch are the stoma closure site, prepouch ileum, inlet, tip of the "J," pouch body, anastomosis, cuff, and anal transition zone. Each anatomic location can be prone to the development of structural, inflammatory, or neoplastic disorders. For example, ulcers and strictures are common at the stoma closure site, inlet, and anastomosis. Leaks are commonly detected at the tip of the "J" and anastomosis. Characterization of the anastomotic distribution of inflammation is critical for the differential diagnosis of subtypes of pouchitis and other inflammatory disorders of the pouch. Neoplastic lesions, albeit rare, mainly occur at the cuff, anal transition zone, or anastomosis.
LIMITATIONS
This is a qualitative, not quantitative, review of mainly case series.
CONCLUSIONS
Most structural, inflammatory, and neoplastic disorders can be reliably diagnosed with a careful pouchoscopy. The endoscopist and other clinicians taking care of pouch patients should be familiar with the anatomy of the ileal pouch and be able to recognize common abnormalities. See video from symposium.
Topics: Humans; Colonic Pouches; Proctocolectomy, Restorative; Pouchitis; Postoperative Complications; Endoscopy, Gastrointestinal; Ileum
PubMed: 38276962
DOI: 10.1097/DCR.0000000000003269 -
Surgery Sep 2023Idiopathic myointimal hyperplasia of the mesenteric veins is an extremely rare non-thrombotic mesenteric veno-occlusive disease. The management of idiopathic myointimal... (Review)
Review
BACKGROUND
Idiopathic myointimal hyperplasia of the mesenteric veins is an extremely rare non-thrombotic mesenteric veno-occlusive disease. The management of idiopathic myointimal hyperplasia of the mesenteric veins is not well-established, and although surgery is the mainstay of treatment, the optimal operation remains unclear. Therefore, we aimed to perform a systematic review to assess the various surgical procedures and associated outcomes for patients with idiopathic myointimal hyperplasia of the mesenteric veins.
METHODS
A systematic search for articles published from 1946 to April 2022 in MEDLINE, EMBASE, Cinahl, Scopus, Web of Science, and Cochrane Library databases is reported. In addition, we report 4 cases of idiopathic myointimal hyperplasia of the mesenteric veins managed at our institution until March 2023.
RESULTS
A total of 53 studies and 88 patients with idiopathic myointimal hyperplasia of the mesenteric veins were included. Most (82%) were male patients, with a mean age of 56.6 years old. The majority (99%) of patients required surgery. Most reports described the involvement of the rectum and sigmoid colon (81%). The most common surgical procedures were Hartmann's procedure (24%) and segmental colectomy (19%); completion proctectomy with ileal pouch-anal anastomosis was performed in 3 (3.4%) cases. In 6 (6.8%) cases, idiopathic myointimal hyperplasia of the mesenteric veins was suspected preoperatively and managed with elective surgery. Four (4.5%) complications were reported. Nearly all (99%) patients achieved remission with surgical intervention.
CONCLUSION
Idiopathic myointimal hyperplasia of the mesenteric veins is a rare pathologic entity infrequently suspected preoperatively and typically diagnosed after surgical resection. Surgical resection with Hartmann's procedure or segmental colectomy was most commonly performed, with completion proctectomy and ileal pouch-anal anastomosis reserved for cases of extensive rectal involvement. Surgical resection was safe and effective, with a low risk of complications and recurrence. Surgical decision-making should be based on the extent of the disease at the time of presentation.
Topics: Humans; Male; Middle Aged; Female; Hyperplasia; Mesenteric Veins; Colon, Sigmoid; Vascular Diseases; Colectomy
PubMed: 37301609
DOI: 10.1016/j.surg.2023.04.014 -
Surgery Feb 2024Transanal dissection is increasingly used in laparoscopic surgery for total mesorectal excision of lower rectal cancers. Several studies compared outcomes of... (Meta-Analysis)
Meta-Analysis Review
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.
Topics: Humans; Male; Female; Middle Aged; Randomized Controlled Trials as Topic; Rectal Neoplasms; Proctectomy; Laparoscopy; Anastomotic Leak; Margins of Excision; Postoperative Complications; Rectum; Treatment Outcome
PubMed: 38001011
DOI: 10.1016/j.surg.2023.10.006 -
International Journal of Colorectal... Dec 2023The management of early-stage rectal cancer in clinical practice is controversial. The aim of this network meta-analysis was to compare oncological and postoperative... (Meta-Analysis)
Meta-Analysis
PURPOSE
The management of early-stage rectal cancer in clinical practice is controversial. The aim of this network meta-analysis was to compare oncological and postoperative outcomes for T1T2N0M0 rectal cancers managed with local excision in comparison to conventional radical resection.
METHODS
A systematic review of Medline, Embase and Cochrane electronic databases was performed. Relevant studies were selected using PRISMA guidelines. The primary outcomes measured were 5-year local recurrence and overall survival. Secondary outcomes included rates of postoperative complication, 30-day mortality, positive margin and permanent stoma formation.
RESULTS
Three randomized controlled trials and 27 observational studies contributed 8570 patients for analysis. Radical resection was associated with reduced 5-year local recurrence in comparison to local excision. This was statistically significant in comparison to trans-anal local excision (odds ratio (OR) 0.23; 95% confidence interval 0.16-0.30) and favourable in comparison to endoscopic techniques (OR 0.40; 95% confidence interval 0.13-1.23) although this did not reach clinical significance. Positive margin rates were lowest for radical resection. However, 30-day mortality rates, perioperative complications and permanent stoma rates all favoured local excision with no statistically significant difference between endoscopic and trans-anal techniques.
CONCLUSION
Radical resection of early rectal cancer is associated with the lowest 5-year local recurrence rates and the lowest rate of positive margins. However, this must be balanced with its higher 30-day mortality and complication rates as well as the increased risk of permanent stoma. The emerging potential role of neoadjuvant therapy prior to local resection, and the heterogeneity of its use, as an alternative treatment for early rectal cancer further complicates the treatment paradigm and adds to controversy in this field.
Topics: Humans; Digestive System Surgical Procedures; Neoplasm Recurrence, Local; Neoplasm Staging; Network Meta-Analysis; Rectal Neoplasms; Treatment Outcome; Proctectomy; Observational Studies as Topic
PubMed: 38157077
DOI: 10.1007/s00384-023-04584-6 -
European Journal of Surgical Oncology :... Jun 2024There has been a lack of research comparing the efficacy of various treatments for low anterior resection syndrome (LARS). (Meta-Analysis)
Meta-Analysis Review
INTRODUCTION
There has been a lack of research comparing the efficacy of various treatments for low anterior resection syndrome (LARS).
METHODS
We conducted a comprehensive search across six electronic databases and a paired meta-analysis was undertaken to assess the effectiveness of the interventions. Furthermore, a network meta-analysis was utilized to compare the efficacy of different treatments for LARS.
RESULTS
This study encompassed nine randomized controlled trials, involving a total of 450 patients. Compared to routine care, 5-HT3 receptor antagonists (follow-up<3 months) and percutaneous tibial nerve stimulation (3 months ≤ follow-up <6 months) were effective in reducing the LARS score. Pelvic floor rehabilitation (follow-up≤3 months) was effective in decreasing daily number of bowel movements when compared to routine care. The network meta-analysis indicated that 5-HT3 receptor antagonists (follow-up<3 months) were the most effective in reducing both the LARS score and the daily number of bowel movements. Transanal irrigation (3 months ≤ follow-up ≤ 12 months) was most effective in reducing the LARS score. Additionally, 5-HT3 receptor antagonists demonstrated relative efficacy in improving patients' quality of life (follow-up ≤ 1 month).
CONCLUSIONS
This review indicates that 5-HT3 receptor antagonists and anal irrigation show significant promise in the treatment of LARS. Nevertheless, the contributions of percutaneous tibial nerve stimulation and pelvic floor rehabilitation to LARS treatment should not be overlooked. Given the clinical heterogeneity observed among the studies, the results should be interpreted with caution.
Topics: Humans; Network Meta-Analysis; Pelvic Floor; Postoperative Complications; Proctectomy; Randomized Controlled Trials as Topic; Rectal Neoplasms; Serotonin 5-HT3 Receptor Antagonists; Tibial Nerve; Transcutaneous Electric Nerve Stimulation
PubMed: 38626589
DOI: 10.1016/j.ejso.2024.108336 -
Colorectal Disease : the Official... May 2024Transanal total mesorectal (taTME) excision is a method used to assist in the radical removal of the rectum. By adopting the concept of natural orifice surgery, it... (Meta-Analysis)
Meta-Analysis Review
AIM
Transanal total mesorectal (taTME) excision is a method used to assist in the radical removal of the rectum. By adopting the concept of natural orifice surgery, it offers potential benefits over conventional techniques. Early enthusiasm for this strategy led to its rapid and widespread adoption. The imposing of a local moratorium was precipitated by the discovery in Norway of an uncommon multifocal pattern of locoregional recurrence. The aim of this systematic review and meta-analysis was to determine the incidence of local recurrence after taTME for rectal cancer.
METHOD
Conforming to the Cochrane Handbook for Systematic Reviews of Interventions and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines checklist, a systematic review and meta-analysis was conducted. This included case series and comparative studies between taTME and preferentially laparoscopic procedures published between 2010 and 2021.
RESULTS
There were a total of 1175 studies retrieved. After removal and screening for quality and relevance, the final analysis contained 40 studies. The local recurrence rate following taTME was 3.4% (95% CI 2.9%-3.9%, I = 0%) in 4987 patients with follow-up durations ranging from 0.7 to 5.5 years. Compared with laparoscopic TME, local recurrence was not statistically different for the taTME group (p = 0.076); however, it was less probable (OR = 0.51, 95% CI 0.24-1.09, I = 0%). Systemic recurrence and circumferential resection margin status were secondary outcomes; however, the differences were not statistically significant.
CONCLUSION
Our data suggest that the local recurrence for regular laparoscopic and transanal TME surgeries may be comparable, suggesting that taTME can be performed without influencing locoregional oncological outcomes in patients treated at specialized institutions and who have been cautiously selected.
Topics: Humans; Rectal Neoplasms; Transanal Endoscopic Surgery; Neoplasm Recurrence, Local; Proctectomy; Laparoscopy; Female; Treatment Outcome; Male; Middle Aged; Aged; Rectum; Incidence
PubMed: 38590019
DOI: 10.1111/codi.16982