Long-term outcomes of an acellular dermal matrix for the treatment of complex cryptoglandular anal fistula: a pilot study

Backgound Effective, standardized treatments for complex anal fistula (CAF) still represent a clinical challenge. Emerging procedures attempted to achieve the healing rates of fistulotomy whilst preserving sphincter function. Acellular dermal matrix (ADM) used as a plug inserted through the fistulous tract is among newer treatment options. Varying success rates have been reported, most with short-term follow-up. The aim of this study was to report the long-term results of ADM-plug for CAF. Methods Retrospective analysis of a prospective database of patients treated with CAF. All consecutive patients presenting at two tertiary centers (Vall d'Hebron University Hospital and Bellvitge University Hospital, Barcelona, Spain) between November 2015 and March 2019 with a single, cryptoglandular CAF were evaluated for treatment with an ADM-plug were included. The primary endpoint was absence of discharge at clinical examination at 12 month follow-up. Results Twenty-two patients were included [7 women and 15 men, median age 56 (33-74) years]. Most patients had high transsphincteric fistulas (63.6%). The median follow-up was 42 (21-53) months. The 12 month success rate was 68.2%, with an overall healing rate of 59.1%. 77.8% of recurrences occurred within 12 months from surgery. One plug extrusion was observed. No major complications or mortality occurred during the follow-up. Patients did not report any worsening of fecal continence. Conclusions This pilot study showed that more than half of patients with CAF could benefit from ADM-plug placement, preserving continence. A minimum follow-up of 12 months is recommended, because most recurrences occur during the first year

Percutaneous tibial nerve stimulation in patients with severe low anterior resection syndrome: randomized clinical trial

Treatment of low anterior resection syndrome (LARS) is challenging. Percutaneous tibial nerve stimulation (PTNS) can improve select bowel disorders. An RCT was conducted to assess the efficacy of PTNS compared with sham stimulation in patients with severe LARS

Trends and outcome of neoadjuvant treatment for rectal cancer: A retrospective analysis and critical assessment of a 10-year prospective national registry on behalf of the Spanish Rectal Cancer Project

Introduction: Preoperative treatment and adequate surgery increase local control in rectal cancer. However, modalities and indications for neoadjuvant treatment may be controversial. Aim of this study was to assess the trends of preoperative treatment and outcomes in patients with rectal cancer included in the Rectal Cancer Registry of the Spanish Associations of Surgeons. Method: This is a STROBE-compliant retrospective analysis of a prospective database. All patients operated on with curative intention included in the Rectal Cancer Registry were included. Analyses were performed to compare the use of neoadjuvant/adjuvant treatment in three timeframes: I)2006–2009; II)2010–2013; III)2014–2017. Survival analyses were run for 3-year survival in timeframes I-II. Results: Out of 14, 391 patients, 8871 (61.6%) received neoadjuvant treatment. Long-course chemo/radiotherapy was the most used approach (79.9%), followed by short-course radiotherapy ± chemotherapy (7.6%). The use of neoadjuvant treatment for cancer of the upper third (15-11 cm) increased over time (31.5%vs 34.5%vs 38.6%, p = 0.0018). The complete regression rate slightly increased over time (15.6% vs 16% vs 18.5%; p = 0.0093); the proportion of patients with involved circumferential resection margins (CRM) went down from 8.2% to 7.3%and 5.5% (p = 0.0004). Neoadjuvant treatment significantly decreased positive CRM in lower third tumors (OR 0.71, 0.59–0.87, Cochrane-Mantel-Haenszel P = 0.0008). Most ypN0 patients also received adjuvant therapy. In MR-defined stage III patients, preoperative treatment was associated with significantly longer local-recurrence-free survival (p < 0.0001), and cancer-specific survival (p < 0.0001). The survival benefit was smaller in upper third cancers. Conclusion: There was an increasing trend and a potential overuse of neoadjuvant treatment in cancer of the upper rectum. Most ypN0 patients received postoperative treatment. Involvement of CRM in lower third tumors was reduced after neoadjuvant treatment. Stage III and MRcN + benefited the most

Contemporary Management of Locally Advanced and Recurrent Rectal Cancer: Views from the PelvEx Collaborative

Pelvic exenteration is a complex operation performed for locally advanced and recurrent pelvic cancers. The goal of surgery is to achieve clear margins, therefore identifying adjacent or involved organs, bone, muscle, nerves and/or vascular structures that may need resection. While these extensive resections are potentially curative, they can be associated with substantial morbidity. Recently, there has been a move to centralize care to specialized units, as this facilitates better multi-disciplinary care input. Advancements in pelvic oncology and surgical innovation have redefined the boundaries of pelvic exenterative surgery. Combined with improved neoadjuvant therapies, advances in diagnostics, and better reconstructive techniques have provided quicker recovery and better quality of life outcomes, with improved survival This article provides highlights of the current management of advanced pelvic cancers in terms of surgical strategy and potential future developments

Intraperitoneal drain placement and outcomes after elective colorectal surgery: international matched, prospective, cohort study

Despite current guidelines, intraperitoneal drain placement after elective colorectal surgery remains widespread. Drains were not associated with earlier detection of intraperitoneal collections, but were associated with prolonged hospital stay and increased risk of surgical-site infections.Background Many surgeons routinely place intraperitoneal drains after elective colorectal surgery. However, enhanced recovery after surgery guidelines recommend against their routine use owing to a lack of clear clinical benefit. This study aimed to describe international variation in intraperitoneal drain placement and the safety of this practice. Methods COMPASS (COMPlicAted intra-abdominal collectionS after colorectal Surgery) was a prospective, international, cohort study which enrolled consecutive adults undergoing elective colorectal surgery (February to March 2020). The primary outcome was the rate of intraperitoneal drain placement. Secondary outcomes included: rate and time to diagnosis of postoperative intraperitoneal collections; rate of surgical site infections (SSIs); time to discharge; and 30-day major postoperative complications (Clavien-Dindo grade at least III). After propensity score matching, multivariable logistic regression and Cox proportional hazards regression were used to estimate the independent association of the secondary outcomes with drain placement. Results Overall, 1805 patients from 22 countries were included (798 women, 44.2 per cent; median age 67.0 years). The drain insertion rate was 51.9 per cent (937 patients). After matching, drains were not associated with reduced rates (odds ratio (OR) 1.33, 95 per cent c.i. 0.79 to 2.23; P = 0.287) or earlier detection (hazard ratio (HR) 0.87, 0.33 to 2.31; P = 0.780) of collections. Although not associated with worse major postoperative complications (OR 1.09, 0.68 to 1.75; P = 0.709), drains were associated with delayed hospital discharge (HR 0.58, 0.52 to 0.66; P &lt; 0.001) and an increased risk of SSIs (OR 2.47, 1.50 to 4.05; P &lt; 0.001). Conclusion Intraperitoneal drain placement after elective colorectal surgery is not associated with earlier detection of postoperative collections, but prolongs hospital stay and increases SSI risk

Carcinomas neuroendocrinos de colon y recto: Experiencia de una unidad en seis años Neuroendocrine carcinomas of the colon and rectum: A unit's experience over six years

Introducción: los tumores neuroendocrinos de colon y recto son poco frecuentes. Suelen ser tumores poco diferenciados, diagnosticados por el patólogo y de especial agresividad en su comportamiento clínico. El pronóstico suele ser malo, con tendencia a la rápida metastatización. Material y métodos: se ha revisado la experiencia de una Unidad de Coloproctología durante un periodo de seis años. Se han revisado de manera retrospectiva los pacientes con un tumor de estirpe neuroendocrina. Se han excluido los tumores carcinoides. Resultados: durante este periodo, se han intervenido 2.155 pacientes por cáncer de colon y recto y se han hallado cinco pacientes con tumores neuroendocrinos. La edad media fue de 66 años, tres varones y dos hembras. Se localizaron uno en ciego, dos en recto y dos en sigma. Dos pacientes presentaban diseminación del tumor a distancia. Se realizó cirugía en todos los pacientes con quimioterapia posterior en dos de ellos. Un paciente falleció por insuficiencia hepática postoperatoria, otro a los dos meses y otro al año. Dos pacientes siguen vivos con un seguimiento medio de ocho meses. Conclusiones: los tumores neuroendocrinos son unos tumores de aparición rara en el colon y recto. La clínica de presentación no difiere de la que podrían tener los adenocarcinomas. En el momento del diagnóstico estos tumores suelen presentar enfermedad a distancia, como en dos de los cinco casos presentados, relacionándose con un mal pronóstico para el enfermo. El tratamiento quirúrgico y quimioterápico combinado es el que puede alargar más la supervivencia de los pacientes.<br>Introduction: neuroendocrine tumours of the colon and rectum are infrequent. They are usually undifferentiated, easy to diagnose for the pathologist and are especially aggressive in their clinical behaviour. Prognosis is usually poor and they have a high tendency to metastase early. Material and methods: we have reviewed our experience in a Colorectal Unit during a period of six years. Patients with neuroendocrine tumours have been reviewed retrospectively. Carcinoid tumours have not been included in this study. Results: during this period, 2,155 patients have been operated for colorectal cancer and in five patients a neuroendocrine tumour has been found in the specimen. Mean age was 66 years, three male and two female. One tumour was located in the caecum, two in the rectum and two in the sigmoid colon. Two patients had hepatic metastasis at diagnosis. Surgery was performed in all patients and two patients received adjuvant quimiotherapy. A patient died because of post-operative hepatic insufficiency, another at 2 months and another after one year. Two patients are still alive after eight months' follow-up. Conclusions: neuroendocrine tumours appear to be rare in the colon and rectum. Clinical manifestations are not different from standard adenocarcinoma. When these tumours are diagnosed, they have distance disease, as in two of the five cases, related to a poor prognosis for the patient. Surgery is the treatment that can offer a greater chance of survival to these patients