Functional outcomes following ileal pouch-anal anastomosis (IPAA) in older patients: a systematic review

Aim Ileal pouch-anal anastomosis (IPAA) is performed in ulcerative colitis or familial adenomatous polyposis with a view to restoration of GI continuity and prevention of permanent faecal diversion. Debate exists as to its safety in older patients. This review aims to assess functional outcomes and safety of restorative proctocolectomy (RPC) in older compared to younger patients. Methods Literature search was performed for age-stratified studies which assessed functional outcomes of IPAA. Twelve papers were included overall. Patients were categorized into ‘older’ and ‘younger’ groups. Analysis was split into three separate parts: 1. Age cut-off of 50 ± 5 years (with sensitivity analysis); 2. Age cut-off of 65 ± years; 3. Long-term outcomes (>10 years). Results With an age cut-off of 50 years (4327 versus 513 patients), complication rates were comparable with the exception of an increased rate of small-bowel obstruction in the younger patients (p = 0.034). At 1 year, 24-h stool frequency was significantly higher in the older patient group (p < 0.0001). Daytime (p < 0.0001) and night-time (p < 0.0001) incontinence rates were also significantly higher in older patients. Overall, function deteriorated with time across all ages; however, after 10 years, there was no significant difference in incontinence rates between age groups. Dehydration and electrolyte loss was a significant problem in patients over 65 (p < 0.0001). Despite differences in postoperative function, quality of life was comparable between groups; however, only a few studies reported quality of life data. Conclusion IPAA is safe in older patients, although treating clinicians should bear in mind the increased risk of dehydration. Postoperative function is worse in older patients, but seems to level out with time and does not appear to significantly impact on overall quality of life and patient satisfaction. Assessment for suitability for RPC should not be based on chronological age in isolation. It is imperative that the correct support is given to older patients with worsened postoperative function in order to maintain patient satisfaction and adequate quality of life

Functional outcomes with handsewn versus stapled anastomoses in the treatment of ultralow rectal cancer

Adequate oncological outcomes have been demonstrated with rectal resection and handsewn coloanal anastomosis (CAA) in tumours in close proximity to the internal anal sphincter. Our aim was to assess functional differences between handsewn CAA and ultralow stapled anastomosis. Participants were identified from a single-surgeon series. Included participants underwent anorectal physiology testing of anal sphincter function, in addition to completion of several questionnaires: Wexner Incontinence Score (WIS); Birmingham Bowel, Bladder and Urinary Symptom Questionnaire (BBUSQ); Low Anterior Resection Syndrome (LARS) Score; SF36. Non-parametric data compared using the Mann-Whitney U test. 20 participants were included; 11 stapled and 9 handsewn. Mean follow-up was 2.95 ± 1.97 years. The mean LARS score was 21.9 ± 1.97 years in the stapled group versus 29.4 ± 9.57 in the handsewn group (p = 0.133). The Wexner incontinence score was significantly higher in the handsewn group (p = 0.0076), with a mean score of 4.6 ± 3.69 versus 10.9 ± 4.76. The incontinence domain of the BBUSQ was also significantly worse in patients with a handsewn anastomosis (p = 0.001). With the exception of general health (p = 0.035) and social functioning (p = 0.035), which were worse in the handsewn groups, the other six domains of the SF-36 showed no statistical difference between groups. Anorectal physiology scores were not significantly different. Handsewn CAA anastomosis is known to be safe and oncologically feasible. Patient selection should be vigorous, with preoperative counseling regarding the likelihood of incontinence to manage patients' expectations and promote comparable quality of life in the long-term

Predictors of short-term readmission after beyond total mesorectal excision for primary locally advanced and recurrent rectal cancer

Unplanned readmissions heavily affect the cost of health care and are used as an indicator of performance. No clear data are available regarding beyond-total mesorectal excision (bTME) procedure. Aim of the study is to identify patient-related and surgery-related factors influencing the 30-day readmissions after bTME. Retrospective data were collected from 220 patients who underwent bTME procedures at single centre between 2006 and 2016. Patient-related and operative factors were assessed, including body mass index (BMI), age, gender, American Society of Anaesthesiologists’ (ASA) score, preoperative stage, neo-adjuvant therapy, primary tumour vs recurrence, the extent of surgery. The readmission rate was 8.18%. No statistically significant association was found with BMI, ASA score, length of stay and stay in the intensive care unit, primary vs recurrent tumour or blood transfusions. Not quite statistically significant was the association with pelvic side wall dissection (OR 3.32, p = 0.054). Statistically significant factors included preoperative stage &gt; IIIb (OR: 4.77, p = 0.002), neo-adjuvant therapy (OR: 0.13, p = 0.0006), age over 65&nbsp;years (OR: 5.96, p = 0.0005), any re-intervention during the first admission (OR: 7.4, p = 0.0001), and any post-operative complication (OR: 9.01, p = 0.004). The readmission rate after beyond-TME procedure is influenced by patient-related factors as well as post-operative morbidity

La risa de Quevedo

Background Rectal duplication cysts are rare gastrointestinal congenital duplicate cysts with various clinical presentations that require different management. Case presentation We present a case of a lady with a double rectal duplicate cyst which was found incidentally on a follow-up CT abdomen and pelvis scan. The patient initially had a mucocele excision, and following that, she had a non-contrast CT abdomen and pelvis to investigate post-operative pain. The CT scan revealed a single rectal duplicate cyst. She had a posterior approach excision to have it removed, and only intra-operatively, she was found to have a double rectal duplicate cyst. She had them both removed via a midline incision running from the perineal pigmentation and extending until the coccyx. She had another follow-up CT which showed complete excision of the cysts. Conclusions After a thorough review of the literature regarding rectal cysts, there was no mention of a double rectal duplicate cyst. The purpose of this paper is to point out the various potential presentations of a rectal cyst as well as the idea that a double cyst is managed effectively in a similar way as the single one

A review of the role of Neurotensin and its receptors in colorectal cancer

Neurotensin (NTS) is a physiologically occurring hormone which affects the function of the gastrointestinal (GI) tract. In recent years, NTS, acting through its cellular receptors (NTSR), has been implicated in the carcinogenesis of several cancers. In colorectal cancer (CRC), a significant body of evidence, from in vitro and in vivo studies, is available which elucidates the molecular biology of NTS/NTSR signalling and the resultant growth of CRC cells. There is growing clinical data from human studies which corroborate the role NTS/NTSR plays in the development of human CRC. Furthermore, blockade and modulation of the NTS/NTSR signalling pathways appears to reduce CRC growth in cell cultures and animal studies. Lastly, NTS/NTSR also shows potential of being utilized as a diagnostic biomarker for cancers as well as targets for functional imaging. We summarize the existing evidence and understanding of the role of NTS and its receptors in CRC

Assessment of a staging system for sigmoid colon cancer based on tumor deposits and extramural venous invasion on computed tomography

Importance: Pre-operative TNM stratification of colon cancer on computed tomography (CT) at present does not identify patients at high risk of recurrence that could be selected for pre-operative treatment. Objective: To evaluate the prognostic importance of CT imaging features of sigmoid colon cancer. Design: Retrospective database analysis performed April 2019. Setting Tertiary centre receiving international and national referrals for colorectal cancer. Participants: Patients undergoing bowel resection for sigmoid colon cancer between 2006 and 2015. Main Outcome and Measures: Cox regression analysis was performed to investigate CT risk factors associated with recurrence. Kaplan Meier survival plots were calculated for disease free survival (DFS) using CT staging systems. Results: Among the 414 patients included with sigmoid cancer with a median follow up of 61 months, 122 patients developed recurrence (29.5%). On multivariate analysis, nodal disease was not prognostic and only TDs (HR 1.90) and EMVI (HR 1.97) on CT were associated with recurrence. Significant differences in DFS were found by CT-T3 substage classification (HR 1.88, 95% CI(1.32-2.68)) but not CT-TNM (HR 1.55, 95% CI(0.94-255)). The presence of EMVI or TDs on CT (HR 2.45, 95% CI(1.68-3.56)) best identified poor outcome. Conclusions and Relevance: T3 substaging and detection of TDs or EMVI on CT were prognostic factors for DFS, whereas TNM and nodal staging on CT held no prognostic value. TDV staging of sigmoid colon cancer is superior to TNM on CT and could be used to pre-operatively identify patients at high risk of recurrence

Evaluation of POSSUM scoring system in patients with gastric cancer undergoing D2-gastrectomy

BACKGROUND: Risk adjustment and stratification play an important role in quality assurance and in clinical research. The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) is a patient risk prediction model based on 12 patient characteristics and 6 characteristics of the surgery performed. However, because the POSSUM was developed for quality assessment in general surgical units, its performance within specific subgroups still requires evaluation. The aim of the present study was to assess the accuracy of POSSUM in predicting mortality and morbidity in patients with gastric cancer undergoing D2-gastrectomy. METHODS: 137 patients with gastric cancer undergoing gastrectomy were included in this study. Detailed, standardized risk assessments and thorough documentation of the post-operative courses were performed prospectively, and the POSSUM scores were then calculated. RESULTS: The 30- and 90- day mortality rates were 3.6% (n = 5) and 5.8% (n = 8), respectively. 65.7% (n = 90) of patients had normal postoperative courses without major complications, 14.6% (n = 20) had moderate and 13.9% (n = 19) had severe complications. The number of mortalities predicted by the POSSUM-Mortality Risk Score (R1) was double the actual number of mortalities occurring in the median and high-risk groups, and was more than eight times the actual number of mortalities occurring in the low-risk group (R1 < 20%). However, the calculated R1 predicted rather well in terms of severe morbidity or post-operative death in each risk group: in predicted low risk patients the actual occurrence rate (AR) of severe morbidity or post-operative death was 14%, for predicted medium risk patients the AR was 23%, and for predicted high risk patients the AR was 50% (p < 0.05). The POSSUM-Morbidity Risk Score (R2) overestimated the risk of morbidity. CONCLUSION: The POSSUM Score may be beneficial and can be used for assessment of the peri- and post-operative courses of patients with gastric carcinoma undergoing D2-gastrectomy. However, none of the scores examined here are useful for preoperative prediction of postoperative course