Association of mechanical bowel preparation with oral antibiotics and anastomotic leak following left sided colorectal resection:an international, multi-centre, prospective audit

Introduction: The optimal bowel preparation strategy to minimise the risk of anastomotic leak is yet to be determined. This study aimed to determine whether oral antibiotics combined with mechanical bowel preparation (MBP+Abx) was associated with a reduced risk of anastomotic leak when compared to mechanical bowel preparation alone (MBP) or no bowel preparation (NBP). Methods: A pre-planned analysis of the European Society of Coloproctology (ESCP) 2017 Left Sided Colorectal Resection audit was performed. Patients undergoing elective left sided colonic or rectal resection with primary anastomosis between 1 January 2017 and 15 March 2017 by any operative approach were included. The primary outcome measure was anastomotic leak. Results: Of 3676 patients across 343 centres in 47 countries, 618 (16.8%) received MBP+ABx, 1945 MBP (52.9%) and 1099 patients NBP (29.9%). Patients undergoing MBP+ABx had the lowest overall rate of anastomotic leak (6.1%, 9.2%, 8.7% respectively) in unadjusted analysis. After case-mix adjustment using a mixed-effects multivariable regression model, MBP+Abx was associated with a lower risk of anastomotic leak (OR 0.52, 0.30–0.92, P = 0.02) but MBP was not (OR 0.92, 0.63–1.36, P = 0.69) compared to NBP. Conclusion: This non-randomised study adds ‘real-world’, contemporaneous, and prospective evidence of the beneficial effects of combined mechanical bowel preparation and oral antibiotics in the prevention of anastomotic leak following left sided colorectal resection across diverse settings. We have also demonstrated limited uptake of this strategy in current international colorectal practice

Evaluating the incidence of pathological complete response in current international rectal cancer practice

The mainstay of management for locally advanced rectal cancer is chemoradiotherapy followed by surgical resection. Following chemoradiotherapy, a complete response may be detected clinically and radiologically (cCR) prior to surgery or pathologically after surgery (pCR). We aim to report the overall complete pathological response (pCR) rate and the reliability of detecting a cCR by conventional pre-operative imaging.A pre-planned analysis of the European Society of Coloproctology (ESCP) 2017 audit was performed. Patients treated by elective rectal resection were included. A pCR was defined as a ypT0 N0 EMVI negative primary tumour; a partial response represented any regression from baseline staging following chemoradiotherapy. The primary endpoint was the pCR rate. The secondary endpoint was agreement between post-treatment MRI restaging (yMRI) and final pathological staging.Of 2572 patients undergoing rectal cancer surgery in 277 participating centres across 44 countries, 673 (26.2%) underwent chemoradiotherapy and surgery. The pCR rate was 10.3% (67/649), with a partial response in 35.9% (233/649) patients. Comparison of AJCC stage determined by post-treatment yMRI with final pathology showed understaging in 13% (55/429) and overstaging in 34% (148/429). Agreement between yMRI and final pathology for T-stage, N-stage, or AJCC status were each graded as 'fair' only (n = 429, Kappa 0.25, 0.26 and 0.35 respectively).The reported pCR rate of 10% highlights the potential for non-operative management in selected cases. The limited strength of agreement between basic conventional post-chemoradiotherapy imaging assessment techniques and pathology suggest alternative markers of response should be considered, in the context of controlled clinical trials

How do social status and tree architecture influence radial growth, wood density and drought response in spontaneously established oak forests?

AbstractKey messageDuring the past decades, a multitude of oak stands have spontaneously established across the pine-dominated landscapes of the French Landes de Gascogne. Yet their future performance under modern climate change is unknown. We show that coppiced, dominant trees are most prepared to cope with drought episodes, displaying higher basal area increment and lower sensitivity to extreme events.ContextForest stands dominated by pedunculate oak (Quercus robur L.) have spontaneously established across the pine-dominated landscapes of the French Landes de Gascogne. These oak stands are typically unmanaged and unsystematically coppiced, resulting in mixtures of single- and multi-stemmed (coppiced) trees.AimsTo determine the ability of spontaneous oak forest stands to face climate change–related hazards, by analysing differences in growth (tree-ring width and basal area increment—BAI), wood density and climate sensitivity depending on their tree architecture (single- vs multi-stemmed trees) and their social status in the forest.MethodsWe exhaustively cored 15 oak stands (n = 657 trees). We compared stand characteristics and climate sensitivity between tree architectures considering two sampling designs, either all sampled trees (the exhaustive sampling) or those with a dominant status (dominant sampling). At the tree level, we used linear mixed effects models to compare wood density and growth between tree architectures and the trees’ social status within the canopy layer (dominant- vs non-dominant trees).ResultsMulti-stemmed trees exhibited higher wood density than single-stemmed trees for diameters > 30 cm. Dominant multi-stemmed trees showed lower sensitivity to extreme events (pointer years), higher BAI but lower annual growth rates than dominant single-stemmed trees.ConclusionDominant multi-stemmed trees are potentially the most prepared ones to cope with increasing soil water deficit following drought episodes, at least during the first 60 years of the life of the tree. The vulnerability to face harsher climate conditions for Q. robur stands can be misled when using a dominant sampling design