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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 -
Techniques in Coloproctology Dec 2023To mitigate pelvic wound issues following perineal excision of rectal or anal cancer, a number of techniques have been suggested as an alternative to primary closure.... (Meta-Analysis)
Meta-Analysis
BACKGROUND
To mitigate pelvic wound issues following perineal excision of rectal or anal cancer, a number of techniques have been suggested as an alternative to primary closure. These methods include the use of a biological/dual mesh, omentoplasty, muscle flap, and/or pelvic peritoneum closure. The aim of this network analysis was to compare all the available surgical techniques used in the attempt to mitigate issues associated with an empty pelvis.
METHODS
An electronic systematic search using MEDLINE databases (PubMed), EMBASE, and Web of Science was performed (Last date of research was March 15th, 2023). Studies comparing at least two of the aforementioned surgical techniques for perineal wound reconstruction during abdominoperineal resection, pelvic exenteration, or extra levator abdominoperineal excision were included. The incidence of primary healing, complication, and/or reintervention for perineal wound were evaluated. In addition, the overall incidence of perineal hernia was assessed.
RESULTS
Forty-five observational studies and five randomized controlled trials were eligible for inclusion reporting on 146,398 patients. All the surgical techniques had a comparable risk ratio (RR) in terms of primary outcomes. The pooled network analysis showed a lower RR for perineal wound infection when comparing primary closure (RR 0.53; Crl 0.33, 0.89) to muscle flap. The perineal wound dehiscence RR was lower when comparing both omentoplasty (RR 0.59; Crl 0.38, 0.95) and primary closure (RR 0.58; Crl 0.46, 0.77) to muscle flap.
CONCLUSIONS
Surgical options for perineal wound closure have evolved significantly over the last few decades. There remains no clear consensus on the "best" option, and tailoring to the individual remains a critical factor.
Topics: Humans; Network Meta-Analysis; Perineum; Plastic Surgery Procedures; Postoperative Complications; Surgical Flaps
PubMed: 37843643
DOI: 10.1007/s10151-023-02868-1 -
Cancer Control : Journal of the Moffitt... 2024This systematic review and meta-analysis aimed to compare outcomes between stapled ileal pouch-anal anastomosis (IPAA) and hand-sewn IPAA with mucosectomy in cases of... (Meta-Analysis)
Meta-Analysis Review
Stapled Anastomosis Versus Hand-Sewn Anastomosis With Mucosectomy for Ileal Pouch-Anal Anastomosis: A Systematic Review and Meta-analysis of Postoperative Outcomes, Functional Outcomes, and Oncological Safety.
PURPOSE
This systematic review and meta-analysis aimed to compare outcomes between stapled ileal pouch-anal anastomosis (IPAA) and hand-sewn IPAA with mucosectomy in cases of ulcerative colitis and familial adenomatous polyposis.
METHODS
This systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Review and Meta-analysis) guidelines 2020 and AMSTAR 2 (Assessing the methodological quality of systematic reviews) guidelines. We included randomized clinical trials (RCTs) and controlled clinical trials (CCTs). Subgroup analysis was performed according to the indication for surgery.
RESULTS
The bibliographic research yielded 31 trials: 3 RCTs, 5 prospective clinical trials, and 24 CCTs including 8872 patients: 4871 patients in the stapled group and 4038 in the hand-sewn group. Regarding postoperative outcomes, the stapled group had a lower rate of anastomotic stricture, small bowel obstruction, and ileal pouch failure. There were no differences between the 2 groups in terms of operative time, anastomotic leak, pelvic sepsis, pouchitis, or hospital stay. For functional outcomes, the stapled group was associated with greater outcomes in terms of seepage per day and by night, pad use, night incontinence, resting pressure, and squeeze pressure. There were no differences in stool Frequency per 24h, stool frequency at night, antidiarrheal medication, sexual impotence, or length of the high-pressure zone. There was no difference between the 2 groups in terms of dysplasia and neoplasia.
CONCLUSIONS
Compared to hand-sewn anastomosis, stapled ileoanal anastomosis leads to a large reduction in anastomotic stricture, small bowel obstruction, ileal pouch failure, seepage by day and night, pad use, and night incontinence. This may ensure a higher resting pressure and squeeze pressure in manometry evaluation.
PROTOCOL REGISTRATION
The protocol was registered at PROSPERO under CRD 42022379880.
Topics: Male; Humans; Constriction, Pathologic; Surgical Stapling; Proctocolectomy, Restorative; Anastomosis, Surgical; Colonic Pouches; Postoperative Complications; Treatment Outcome
PubMed: 38410083
DOI: 10.1177/10732748241236338 -
PloS One 2023Minimally invasive total mesorectal excision is increasingly being used as an alternative to open surgery in the treatment of patients with rectal cancer. This...
OBJECTIVES
Minimally invasive total mesorectal excision is increasingly being used as an alternative to open surgery in the treatment of patients with rectal cancer. This systematic review aimed to compare the total, operative and hospitalization costs of open, laparoscopic, robot-assisted and transanal total mesorectal excision.
METHODS
This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement (PRISMA) (S1 File) A literature review was conducted (end-of-search date: January 1, 2023) and quality assessment performed using the Consensus Health Economic Criteria.
RESULTS
12 studies were included, reporting on 2542 patients (226 open, 1192 laparoscopic, 998 robot-assisted and 126 transanal total mesorectal excision). Total costs of minimally invasive total mesorectal excision were higher compared to the open technique in the majority of included studies. For robot-assisted total mesorectal excision, higher operative costs and lower hospitalization costs were reported compared to the open and laparoscopic technique. A meta-analysis could not be performed due to low study quality and a high level of heterogeneity. Heterogeneity was caused by differences in the learning curve and statistical methods used.
CONCLUSION
Literature regarding costs of total mesorectal excision techniques is limited in quality and number. Available evidence suggests minimally invasive techniques may be more expensive compared to open total mesorectal excision. High-quality economical evaluations, accounting for the learning curve, are needed to properly assess costs of the different techniques.
Topics: Humans; Robotics; Rectal Neoplasms; Proctectomy; Laparoscopy; Hospitalization; Transanal Endoscopic Surgery; Rectum; Treatment Outcome; Postoperative Complications
PubMed: 37506122
DOI: 10.1371/journal.pone.0289090 -
Techniques in Coloproctology Sep 2023The transanal approach to ileal pouch-anal anastomosis (Ta-IPAA) for ulcerative colitis was introduced in 2015 and has since been shown to be a safe and feasible... (Review)
Review
The transanal approach to ileal pouch-anal anastomosis (Ta-IPAA) for ulcerative colitis was introduced in 2015 and has since been shown to be a safe and feasible technique, although the impact of this approach on patient function remains unclear. A systematic literature review was performed to identify studies exploring functional outcomes and quality of life after Ta-IPAA. Seven papers were identified, which all demonstrated satisfactory functional outcomes after Ta-IPAA as measured by tools such as Cleveland Global Quality of Life (CGQOL), Oresland Score (OS), Pouch Functional Score (PFS), and Inflammatory Bowel Disease Questionnaire (IBDQ). Many gaps in the literature were identified including paucity of follow-up data beyond the 1-year mark, lack of fertility and fecundity assessment as functional outcomes, and limited evaluation of objective physiologic anal sphincter function. The Ta-IPAA therefore shows promise for good functional results in the short-term, although further research will be required to evaluate the stability of function over time as the technique becomes increasingly integrated into modern surgical practice.
Topics: Humans; Colitis, Ulcerative; Quality of Life; Treatment Outcome; Proctocolectomy, Restorative; Anastomosis, Surgical; Colonic Pouches; Postoperative Complications
PubMed: 37039927
DOI: 10.1007/s10151-023-02798-y -
Diseases of the Colon and Rectum Jun 2024Radiographic imaging of the abdomen and pelvis plays an important role in the diagnosis and management of ileal pouch disorders with modalities including CT, MRI,...
BACKGROUND
Radiographic imaging of the abdomen and pelvis plays an important role in the diagnosis and management of ileal pouch disorders with modalities including CT, MRI, contrasted pouchography, and defecography.
OBJECTIVES
To perform a systematic review of the literature and describe applications of cross-sectional imaging, pouchography, defecography, and ultrasonography.
DATA SOURCES
PubMed, Google Scholar, and Cochrane database.
STUDY SELECTION
Relevant articles on endoscopy in ileal pouches published between January 2003 and June 2023 in English were included on the basis of Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.
INTERVENTION
Main abdominal and pelvic imaging modalities and their applications in the diagnosis of ileal pouch disorders were included.
MAIN OUTCOME MEASURES
Accuracy in characterization of ileal pouch disorders.
RESULTS
CT is the test of choice for the evaluation of acute anastomotic leaks, perforation, and abscess(es). MRI of the pelvis is suitable for the assessment of chronic anastomotic leaks and their associated fistulas and sinus tracts, as well as for the penetrating phenotype of Crohn's disease of the pouch. CT enterography and magnetic resonance enterography are useful in assessing intraluminal, intramural, and extraluminal disease processes of the pouch and prepouch ileum. Water-soluble contrast pouchography is particularly useful for evaluating acute or chronic anastomotic leaks and outlines the shape and configuration of the pouch. Defecography is the key modality to evaluate structural and functional pouch inlet and outlet obstructions. Ultrasonography can be performed to assess the pouch in experienced IBD centers.
LIMITATIONS
This is a qualitative, not quantitative, review of mainly case series and case reports.
CONCLUSIONS
Abdominopelvic imaging, along with clinical and endoscopic evaluation, is imperative for accurately assessing structural, inflammatory, functional, and neoplastic disorders. See video from symposium .
Topics: Humans; Colonic Pouches; Magnetic Resonance Imaging; Proctocolectomy, Restorative; Defecography; Ultrasonography; Tomography, X-Ray Computed; Pouchitis; Anastomotic Leak; Postoperative Complications; Crohn Disease
PubMed: 38441126
DOI: 10.1097/DCR.0000000000003181 -
Journal of Clinical Gastroenterology Feb 2024Patients with medically-refractory ulcerative colitis or advanced neoplasia are often offered an ileal-pouch-anal anastomosis to restore bowel continuity. However, up to... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Patients with medically-refractory ulcerative colitis or advanced neoplasia are often offered an ileal-pouch-anal anastomosis to restore bowel continuity. However, up to 50% of patients can suffer from inflammatory conditions of the pouch, some of which require biological therapy to treat. The aim of this study was to determine the efficacy of each biological agent for the treatment of inflammatory conditions of the pouch.
MATERIALS AND METHODS
A comprehensive literature search was performed in the major databases from inception through February 11, 2020, for studies assessing the efficacy of biologics in chronic antibiotic-refractory pouchitis (CARP) and Crohn's disease (CD) of the pouch. Both prospective and retrospective studies were included. The primary outcomes of interest were complete and partial responses were defined within each study. χ 2 test was used to compare variables.
RESULTS
Thirty-four studies were included in the systematic review and meta-analysis. Sixteen studies (N=247) evaluated the use of infliximab (IFX), showing complete response in 50.7% and partial response in 28.1% for CARP, and complete response in 66.7% and partial response in 20% for CD of the pouch. Seven studies (n=107) assessed the efficacy of adalimumab. For CARP, 33.3% of patients had a complete response, and 38.1% had a partial response, whereas for CD of the pouch, 47.7% experienced a complete response, and 24.6% had a partial response. Three studies (n=78) reported outcomes with the use of ustekinumab, showing 50% complete response and 3.8% partial response for CARP. For the CD of the pouch, 5.8% had a complete response and 78.8% had a partial response. Seven studies (n=151) reported the efficacy of vedolizumab, showing 28.4% complete response and 43.2% partial response in patients with CARP, whereas 63% of patients experienced partial response in CD of the pouch. IFX had higher rates of complete response in CARP compared with adalimumab ( P =0.04) and compared with vedolizumab ( P =0.005), but not compared with ustekinumab ( P =0.95). There were no new safety signals reported in any of the studies.
CONCLUSIONS
Biologics are safe and efficacious in the treatment of chronic, refractory inflammatory conditions of the pouch. IFX seems to be more efficacious than adalimumab and vedolizumab for CARP. Further prospective, head-to-head evaluations are needed to compare biological therapies in the treatment of CARP and CD of the pouch.
Topics: Humans; Adalimumab; Biological Products; Colitis, Ulcerative; Crohn Disease; Infliximab; Pathologic Complete Response; Pouchitis; Proctocolectomy, Restorative; Retrospective Studies; Ustekinumab; Antibodies, Monoclonal
PubMed: 36753457
DOI: 10.1097/MCG.0000000000001828 -
Techniques in Coloproctology Jun 2024Anastomotic leakage (AL) represents a major complication after rectal low anterior resection (LAR). Transanal drainage tube (TDT) placement offers a potential strategy... (Meta-Analysis)
Meta-Analysis
Updated evidence of the effectiveness and safety of transanal drainage tube for the prevention of anastomotic leakage after rectal low anterior resection: a systematic review and meta-analysis.
BACKGROUNDS
Anastomotic leakage (AL) represents a major complication after rectal low anterior resection (LAR). Transanal drainage tube (TDT) placement offers a potential strategy for AL prevention; however, its efficacy and safety remain contentious.
METHODS
A systematic review and meta-analysis were used to evaluate the influence of TDT subsequent to LAR as part of the revision of the surgical site infection prevention guidelines of the Japanese Society of Surgical Infectious Diseases (PROSPERO registration; CRD42023476655). We searched each database, and included randomized controlled trials (RCTs) and observational studies (OBSs) comparing TDT and non-TDT outcomes. The main outcome was AL. Data were independently extracted by three authors and random-effects models were implemented.
RESULTS
A total of three RCTs and 18 OBSs were included. RCTs reported no significant difference in AL rate between the TDT and non-TDT groups [relative risk (RR): 0.69, 95% confidence interval (CI) 0.42-1.15]. OBSs reported that TDT reduced AL risk [odds ratio (OR): 0.45, 95% CI 0.31-0.64]. In the subgroup excluding diverting stoma (DS), TDT significantly lowered the AL rate in RCTs (RR: 0.57, 95% CI 0.33-0.99) and OBSs (OR: 0.41, 95% CI 0.27-0.62). Reoperation rates were significantly lower in the TDT without DS groups in both RCTs (RR: 0.26, 95% CI 0.07-0.94) and OBSs (OR: 0.40, 95% CI 0.24-0.66). TDT groups exhibited a higher anastomotic bleeding rate only in RCTs (RR: 4.28, 95% CI 2.14-8.54), while shorter hospital stays were observed in RCTs [standard mean difference (SMD): -0.44, 95% CI -0.65 to -0.23] and OBSs (SMD: -0.54, 95% CI -0.97 to -0.11) compared with the non-TDT group.
CONCLUSIONS
A universal TDT placement cannot be recommended for all rectal LAR patients. Some patients may benefit from TDT, such as patients without DS creation. Further investigation is necessary to identify the specific beneficiaries.
Topics: Humans; Anastomotic Leak; Drainage; Proctectomy; Randomized Controlled Trials as Topic; Rectum; Anal Canal; Rectal Neoplasms; Treatment Outcome; Female; Male; Observational Studies as Topic; Middle Aged
PubMed: 38916755
DOI: 10.1007/s10151-024-02942-2 -
The American Surgeon Jan 2024The aim of this systematic review and meta-analysis is to evaluate clinical, functional, and anorectal physiology outcomes of the side-to-end vs colonic J-pouch (CJP)... (Comparative Study)
Comparative Study Meta-Analysis
BACKGROUND
The aim of this systematic review and meta-analysis is to evaluate clinical, functional, and anorectal physiology outcomes of the side-to-end vs colonic J-pouch (CJP) anastomosis following anterior resection for rectal cancer.
METHODS
A PRISMA-compliant systematic review and meta-analysis was conducted using multiple electronic databases and clinical trial registers and all studies comparing side-to-end vs CJP anastomosis were included. Peri-operative complications, mortality rate, functional bowel, and anorectal outcomes were evaluated.
RESULTS
Eight randomized controlled trials (RCTs) and two observational studies with 1125 patients (side-to-end: n = 557; CJP: n = 568) were included. Of the entire functional bowel outcome parameters analyzed, only the sensation of incomplete bowel evacuation was significant in the CJP group at 6 months [OR: 2.07; 95% CI 1.06 - 4.02, = .03]. Peri- and post-operative clinical parameters were comparable in both groups (total operative time, intra-operative blood loss, anastomotic leak rate, return to theater, anastomotic stricture formation and mortality). Equally, most of the analyzed anorectal physiology parameters (anorectal volume, anal squeeze pressure, maximum anal volume) were not significantly different between the two groups. However, anal resting pressure (mmHg) 2 years post-operatively was noted to be significantly higher in the side-to-end group than that of the CJP configuration [MD: -8.76; 95% CI - 15.91 - 1.61, = .02].
DISCUSSION
Clinical and functional outcomes following CJP surgery and side-to-end coloanal anastomosis are comparable. Neither technique appears to proffer solution to low anterior resection syndrome in the short term but future well-designed; high-quality RCTs with long term follow-up are required.
Topics: Humans; Anal Canal; Anastomosis, Surgical; Colon; Colonic Pouches; Proctectomy; Proctocolectomy, Restorative; Rectal Neoplasms; Rectum; Treatment Outcome
PubMed: 37507144
DOI: 10.1177/00031348231191769 -
Diseases of the Colon and Rectum Jun 2024Patients with familial adenomatous polyposis often require prophylactic colectomy with IPAA to treat or reduce the risk of colorectal neoplasia. However, after surgery,...
BACKGROUND
Patients with familial adenomatous polyposis often require prophylactic colectomy with IPAA to treat or reduce the risk of colorectal neoplasia. However, after surgery, patients are still at some risk of developing pouch polyps and even cancer in both handsewn and stapled anastomoses. Management relies mainly on endoscopic or surgical interventions, whereas chemopreventive agents have a limited role in the management and prevention of pouch neoplasia. Novel endoscopic techniques are evolving and may gradually overtake surgical intervention in selected cases. Because familial adenomatous polyposis is relatively rare, there is a scarcity of data regarding the natural history of pouch polyps and cancer in this population.
OBJECTIVE
This systematic literature review aims to describe the evolution, characteristics, various treatment modalities and their outcomes, and recommended surveillance strategies of pouch neoplasia.
DATA SOURCES
PubMed and Cochrane databases and the International Ileal Pouch Consortium (for expert opinion).
STUDY SELECTION
Studies published between 1990 and 2023 in English were included. Studies reporting neoplastic outcomes of only patients with IBD-related pouch neoplasia were excluded.
MAIN OUTCOME MEASURES
Incidence of pouch neoplasia and its outcomes (successful resections, surgical complications, and mortality).
RESULTS
Thirty-five studies were included.
LIMITATIONS
Most studies focused on patients with IBD-related pouch neoplasia; there were scarce data regarding polyposis patients only. Most cohorts were small and retrospective. Data on interventions were mainly descriptive, and no randomized controlled trials were available.
CONCLUSIONS
Pouch adenomas are common and well managed by endoscopic resections because advanced endoscopic techniques are becoming more available. Additional data are required for defining updated recommendations for either endoscopic or surgical intervention. Pouch cancer is a very rare event and may arise despite surveillance. Continued endoscopic surveillance is key in cancer prevention and early detection. The outcome of cancer cases is poor, and management in a referral center should be advised with tumor board discussions. See video from symposium .
Topics: Humans; Adenomatous Polyposis Coli; Proctocolectomy, Restorative; Colonic Pouches; Colectomy
PubMed: 37878460
DOI: 10.1097/DCR.0000000000003122