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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 -
Irish Journal of Medical Science Mar 2024Perianal wound healing and/or complications are common following abdominoperineal resection (APR). Although primary closure is commonly undertaken, myocutaneous flap... (Review)
Review
Primary closure versus vertical rectus abdominis myocutaneous (VRAM) flap closure of perineal wound following abdominoperineal resection-a systematic review and meta-analysis.
PURPOSE/AIM
Perianal wound healing and/or complications are common following abdominoperineal resection (APR). Although primary closure is commonly undertaken, myocutaneous flap closure such as vertical rectus abdominis myocutaneous flap (VRAM) is thought to improve wound healing process and outcome. A comprehensive meta-analysis was performed to compare outcomes of primary closure versus VRAM flap closure of perineal wound following APR.
METHODS
PubMed, MEDLINE, EMBASE, and Cochrane Central Registry of Controlled Trials were comprehensively searched until the 8th of August 2023. Included studies underwent meta-analysis to compare outcomes of primary closure versus VRAM flap closure of perineal wound following APR. The primary outcome of interest was perineal wound complications, and the secondary outcomes were abdominal wound complications, dehiscence, wound healing time, length of hospital stay, and mortality.
RESULTS
Ten studies with 1141 patients were included. Overall, 853 patients underwent primary closure (74.8%) and 288 patients underwent VRAM (25.2%). Eight studies reported on perineal wound complications after APR: 38.2% (n = 263/688) in the primary closure group versus 32.8% (n = 80/244) in the VRAM group. Perineal complication rates were statistically significantly lower in the VRAM group versus primary closure ((M-H OR, 1.61; 95% CI 1.04-2.49;
CONCLUSION
We highlight the advantage of VRAM flap closure over primary closure for perineal wounds following APR. However, tailoring operative strategy based on patient and disease factors remains important in optimising outcomes.
PubMed: 38532236
DOI: 10.1007/s11845-024-03651-3 -
Medicine Mar 2024Locally advanced colon cancer is considered a relative contraindication for minimally invasive proctectomy (MIP), and minimally invasive versus conventional open... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Locally advanced colon cancer is considered a relative contraindication for minimally invasive proctectomy (MIP), and minimally invasive versus conventional open proctectomy (COP) for locally advanced colon cancer has not been studied.
METHODS
We have searched the Embase, Cochrane Library, PubMed, Medline, and Web of Science for articles on minimally invasive (robotic and laparoscopic) and COP. We calculated pooled standard mean difference (SMD), relative risk (RR), and 95% confidence intervals (CIs). The protocol for this review has been registered on PROSPERO (CRD42023407029).
RESULTS
There are 10132 participants including 21 articles. Compared with COP, patients who underwent MIP had less operation time (SMD 0.48; CI 0.32 to 0.65; I2 = 0%, P = .000), estimated blood loss (MD -1.23; CI -1.90 to -0.56; I2 = 95%, P < .0001), the median time to semi-liquid diet (SMD -0.43; CI -0.70 to -0.15; I2 = 0%, P = .002), time to the first flatus (SMD -0.97; CI -1.30 to -0.63; I2 = 7%, P < .0001), intraoperative blood transfusion (RR 0.33; CI 0.24 to 0.46; I2 = 0%, P < .0001) in perioperative outcomes. Compared with COP, patients who underwent MIP had fewer overall complications (RR 0.85; CI 0.73 to 0.98; I2 = 22.4%, P = .023), postoperative complications (RR 0.79; CI 0.69 to 0.90; I2 = 0%, P = .001), and urinary retention (RR 0.63; CI 0.44 to 0.90; I2 = 0%, P = .011) in perioperative outcomes.
CONCLUSION
This study comprehensively and systematically evaluated the difference between the safety and effectiveness of minimally invasive and open treatment of locally advanced colon cancer through meta-analysis. Minimally invasive proctectomy is better than COP in postoperative and perioperative outcomes. However, there is no difference in oncological outcomes. This also provides an evidence-based reference for clinical practice. Of course, multi-center RCT research is also needed to draw more scientific and rigorous conclusions in the future.
Topics: Humans; Colonic Neoplasms; Postoperative Complications; Robotics; Proctectomy; Laparoscopy
PubMed: 38489676
DOI: 10.1097/MD.0000000000037474 -
Diseases of the Colon and Rectum Jun 2024The IPAA is a boon to patients needing proctocolectomy but maintains per anal function through anatomic and physiologic compromises. The state of pouch function is hard...
BACKGROUND
The IPAA is a boon to patients needing proctocolectomy but maintains per anal function through anatomic and physiologic compromises. The state of pouch function is hard to define because pouch anatomy is not normal and pouch physiology is a distortion of normal defecation. Patients with pouches develop multiple symptoms: some are expected, some are disease related, and some are the result of surgical complications. It is important to understand the cause of pouch-related symptoms so that appropriate management is offered.
OBJECTIVES
The study aimed to review pouch symptoms and discuss their likely cause, review the literature on pouch function and dysfunction, and provide clarity to clear the confusion.
DATA SOURCES
PubMed and Cochrane databases were searched using the terms "ileoanal pouch function" and "ileoanal pouch dysfunction."
STUDY SELECTION
From 1983 to 2023, 553 articles related to "ileoanal pouch function" and 178 related to "ileoanal pouch dysfunction" were reviewed. Nine studies appeared under both headings. Case studies, duplicate publications, and articles concerning pouch diseases were excluded.
MAIN OUTCOME MEASURES
Definitions of pouch function and dysfunction, methods of describing and scoring symptoms, and understanding of expected changes in pouch function given the nature of the surgery.
RESULTS
Twenty-seven studies were reviewed from the ileoanal pouch dysfunction search and 38 from ileoanal pouch function. Three studies tried to define normal pouch function, 10 attempted to measure pouch function, and 4 aimed to score pouch function. Only 3 studies addressed pouch physiology.
LIMITATIONS
A full discussion of pouch dysfunction is limited by the lack of studies focussing on the anatomic and physiologic consequences of turning the terminal ileum into an organ of storage.
CONCLUSIONS
Most studies of pouch function and dysfunction do not consider expected changes in the physiology of defecation that follow restorative proctocolectomy. Thus, most studies of pouch function produce conclusions that lack an important dimension. See video from symposium.
Topics: Humans; Colonic Pouches; Proctocolectomy, Restorative; Postoperative Complications; Defecation; Anal Canal
PubMed: 38459724
DOI: 10.1097/DCR.0000000000003332 -
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 -
Diseases of the Colon and Rectum Jun 2024Restorative proctocolectomy and IPAA have become the surgical procedure of choice in pediatric patients with medically refractory colitis or familial adenomatous...
BACKGROUND
Restorative proctocolectomy and IPAA have become the surgical procedure of choice in pediatric patients with medically refractory colitis or familial adenomatous polyposis.
OBJECTIVE
This systematic review aims to assess the diagnosis and treatment of pouch disorders in pediatric patients who undergo IPAA.
DATA SOURCES
A literature search was performed using MEDLINE, Google Scholar, and Embase for all publications describing outcomes of pediatric IPAA.
STUDY SELECTION
Studies between January 1, 2000, and September 7, 2022, published in English were included. Studies were excluded on the basis of title, abstract, and full-length review.
INTERVENTIONS
IPAA.
MAIN OUTCOME MEASURES
Pouch disorders described include anastomotic leaks, pouch strictures, pouch failure, pouchitis, cuffitis, and de novo Crohn's disease of the pouch.
RESULTS
Thirty-three studies were included in this review, all of which were retrospective in nature. The outcomes of 2643 pediatric patients were included in the 33 studies.
LIMITATIONS
Management is largely informed by clinical practices in adult patients with scant data on treatment efficacy in children.
CONCLUSIONS
The reported incidence of disorders of the pouch in children varies widely and is likely attributable to differences in definitions and follow-up periods across studies. Pouchitis was the most frequently described outcome. The overall rate of pouch failure in children is relatively low, with de novo Crohn's disease of the pouch being the most significant risk factor. Multicenter prospective studies are needed in the pediatric population to accurately identify risk factors, standardize the assessment of pouch complications, and determine effective treatment strategies. See video from the symposium .
Topics: Humans; Proctocolectomy, Restorative; Child; Pouchitis; Postoperative Complications; Colonic Pouches; Colitis, Ulcerative; Adenomatous Polyposis Coli; Anastomotic Leak; Crohn Disease
PubMed: 38422401
DOI: 10.1097/DCR.0000000000003317 -
Diseases of the Colon and Rectum Jun 2024Restorative proctocolectomy with IPAA improves the quality of life in patients with ulcerative colitis by the removal of diseased large bowel and preservation of the...
BACKGROUND
Restorative proctocolectomy with IPAA improves the quality of life in patients with ulcerative colitis by the removal of diseased large bowel and preservation of the natural route of defecation. Although the surgery may improve preexisting extraintestinal manifestations in the joints, skin, and eyes, extraintestinal manifestations, particularly primary sclerosing cholangitis, can persist after colectomy.
OBJECTIVES
A systematic review of diagnosis and treatment of liver, joint, skin, and eye manifestations in patients with restorative proctocolectomy and IPAA for ulcerative colitis.
DATA SOURCES
PubMed, Google Scholar, and Cochrane database.
STUDY SELECTION
Relevant articles on primary sclerosing cholangitis and extraintestinal manifestations in ileal pouches published between January 2001 and July 2023 in English were included on the basis of Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.
INTERVENTION
Diagnosis and treatment of primary sclerosing cholangitis and extraintestinal manifestations in patients with restorative proctocolectomy and IPAA were included.
MAIN OUTCOME MEASURES
Association between primary sclerosing cholangitis, extraintestinal manifestations, and inflammatory disorders of the pouch and their management.
RESULTS
Primary sclerosing cholangitis and extraintestinal manifestations are associated with pouchitis, particularly chronic pouchitis. Primary sclerosing cholangitis is associated with chronic pouchitis, enteritis, and possible pouch neoplasia. However, the disease severity and course of primary sclerosing cholangitis and pouchitis do not appear to be parallel. Despite the fact that oral vancomycin or budesonide have been used to treat primary sclerosing cholangitis-associated pouchitis, their impact on the disease course of primary sclerosing cholangitis is not known. Biological therapy for chronic inflammatory disorders of the pouch may also be beneficial for the concurrent extraintestinal manifestations of the joints, skin, and eyes. However, studies on the correlation between the severity of inflammatory pouch disorders and the severity of joint, skin, and eye diseases are lacking.
LIMITATIONS
This is a qualitative, not quantitative, review of case series and case reports.
CONCLUSIONS
Primary sclerosing cholangitis and extraintestinal manifestations of the joints, skin, and eyes appear to be associated with inflammatory disorders of the ileal pouch. Although the treatment of pouchitis does not seem to affect the disease course of primary sclerosing cholangitis, effective therapy of inflammatory pouch disorders, particularly with biologics, likely benefits concurrent disorders of the joints, skin, and eyes. See video from the symposium .
Topics: Cholangitis, Sclerosing; Humans; Proctocolectomy, Restorative; Pouchitis; Colitis, Ulcerative; Colonic Pouches; Eye Diseases; Skin Diseases
PubMed: 38411984
DOI: 10.1097/DCR.0000000000003231 -
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 -
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 -
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