Repeat Transanal Advancement Flap Repair: Impact on the Overall Healing Rate of High Transsphincteric Fistulas and on Fecal Continence

PURPOSE: Transanal advancement flap repair (TAFR) has been advocated as the treatment of choice for transsphincteric fistulas passing through the upper or middle third of the external anal sphincter. It is not clear whether previous attempts at repair adversely affect the outcome of TAFR. The purpose of the present study was to evaluate the success rate of a repeat TAFR and to assess the impact of such a second procedure on the overall healing rate of high transsphincteric fistulas and on fecal continence. METHODS: Between January 2001 and January 2005, a consecutive series of 87 patients (62 males; median age, 49 (range, 27-73) years) underwent TAFR. Median follow-up was 15 (range, 2-50) months. Patients in whom the initial operation failed were offered two further treatment options: a second flap repair or a long-term indwelling seton drainage. Twenty-six patients (male:female ratio, 5:2; median age, 51 (range, 31-72) years) preferred a repeat repair. Continence status was evaluated before and after the procedures by using the Rockwood Faecal Incontinence Severity Index (RFISI). RESULTS: The healing rate after the first TAFR was 67 percent. Of the 29 patients in whom the initial procedure failed, 26 underwent a repeat TAFR. The healing rate after this second procedure was 69 percent, resulting in an overall success rate of 90 percent. Both before and after the first attempt of TAFR, the median RFISI was 7 (range, 0-34). In patients who underwent a second TAFR, the median RFISI before and after this procedure was 9 (range, 0-34) and 8 (range, 0-34), respectively. None of these changes were statistically significant. CONCLUSIONS: Repeat TAFR increases the overall healing rate of high transsphincteric fistulas from 67 percent after one attempt to 90 percent after two attempts without a deteriorating effect on fecal continence

After-hours colorectal surgery: a risk factor for anastomotic leakage

__Purpose:__ This study aims to increase knowledge of colorectal anastomotic leakage by performing an incidence study and risk factor analysis with new potential risk factors in a Dutch tertiary referral center. __Methods:__ All patients whom received a primary colorectal anastomosis between 1997 and 2007 were selected by means of operation codes. Patient records were studied for population description and risk factor analysis. __Results:__ In total 739 patients were included. Anastomotic leakage (AL) occurred in 64 (8.7%) patients of whom nine (14.1%) died. Median interval between operation and diagnosis was 8 days. The risk for AL was higher as the anastomoses were constructed more distally (p = 0.019). Univariate analysis showed duration of surgery (p = 0.038), BMI (p = 0.001), time of surgery (p = 0.029), prophylactic drainage (p = 0.006) and time under anesthesia (p = 0.012) to be associated to AL. Multivariate analysis showed BMI greater than 30 kg/m2(p = 0.006; OR 2.6 CI 1.3-5.2) and "after hours" construction of an anastomosis (p = 0.030; OR 2.2 CI 1.1-4.5) to be independent risk factors. __Conclusion:__ BMI greater than 30 kg/m2and "after hours" construction of an anastomosis were independent risk factors for colorectal anastomotic leakage

The Prospective Dutch Colorectal Cancer (PLCRC) cohort: real-world data facilitating research and clinical care

Real-world data (RWD) sources are important to advance clinical oncology research and evaluate treatments in daily practice. Since 2013, the Prospective Dutch Colorectal Cancer (PLCRC) cohort, linked to the Netherlands Cancer Registry, serves as an infrastructure for scientific research collecting additional patient-reported outcomes (PRO) and biospecimens. Here we report on cohort developments and investigate to what extent PLCRC reflects the “real-world”. Clinical and demographic characteristics of PLCRC participants were compared with the general Dutch CRC population (n = 74,692, Dutch-ref). To study representativeness, standardized differences between PLCRC and Dutch-ref were calculated, and logistic regression models were evaluated on their ability to distinguish cohort participants from the Dutch-ref (AU-ROC 0.5 = preferred, implying participation independent of patient characteristics). Stratified analyses by stage and time-period (2013–2016 and 2017–Aug 2019) were performed to study the evolution towards RWD. In August 2019, 5744 patients were enrolled. Enrollment increased steeply, from 129 participants (1 hospital) in 2013 to 2136 (50 of 75 Dutch hospitals) in 2018. Low AU-ROC (0.65, 95% CI: 0.64–0.65) indicates limited ability to distinguish cohort participants from the Dutch-ref. Characteristics that remained imbalanced in the period 2017–Aug’19 compared with the Dutch-ref were age (65.0 years in PLCRC, 69.3 in the Dutch-ref) and tumor stage (40% stage-III in PLCRC, 30% in the Dutch-ref). PLCRC approaches to represent the Dutch CRC population and will ultimately meet the current demand for high-quality RWD. Efforts are ongoing to improve multidisciplinary recruitment which will further enhance PLCRC’s representativeness and its contribution to a learning healthcare system

Anovaginal and rectovaginal fistulas: Endoluminal sonography versus endoluminal MR imaging

OBJECTIVE. The exact location of anovaginal and rectovaginal fistulas cannot be determined by physical examination and conventional techniques. The objective of our study was to compare the accuracy of endoluminal sonography and endoluminal MR imaging in revealing the location of anovaginal and rectovaginal fistulas. MATERIALS AND METHODS. Nineteen consecutive patients (age range, 28-56 years; median age, 39 years) with clinical indications of an anovaginal or rectovaginal fistula were included in our retrospective study. Endoluminal sonography was performed using a 7.5-MHz transducer. Endoluminal MR imaging was performed at 0.5 T for 10 patients and 1.5 T for nine patients, axial T2-weighted gradient-echo, coronal and sagittal T2-weighted turbo spin-echo (0.5 T), or axial and radial T2-weighted turbo spin-echo and axial T2-weighted fat-saturated turbo spin-echo (1.5 T) images were obtained. For a variety of reasons, surgery of the fistula was not attempted in six of these 19 patients. The imaging findings were compared with the findings obtained during surgery in the remaining 13 patients. RESULTS. In 12 of the 13 patients, the fistula was found during surgery: seven of the fistulas were anovaginal, and five were rectovaginal. Findings of endoluminal sonography were true-positive in 11 patients, true-negative in one, and false-negative in one. Findings of endoluminal MR imaging were true-positive in 11 patients, false-negative in one, and false-positive in one. Positive predictive value for endoluminal sonography and endoluminal MR imaging were 100% and 92%, respectively. Imaging findings for anal sphincter defects were comparable. CONCLUSION. Endoluminal sonography and endoluminal MR imaging have comparable positive predictive values in revealing the location of anovaginal and rectovaginal fistula

Fitness effects of

In a field experiment with a susceptible population of annual wild carrot (Daucus carota) from Iran, artificial inoculations with the fungal pathogen A. dauci led to a strong and very significant increase of the diseased leaf area. The pathogen caused a very significant decrease in fecundity and seed survival of the host. This considerable fitness reduction by A. dauci would suggest that introgression of disease resistance from cultivated (transgenic) carrot cultivars into wild carrot populations could strongly increase the fitness of wild carrot. In spite of the potential ability of A. dauci to lower the fitness of the host considerably, wild carrot is very common in The Netherlands. Disease levels of wild carrot were estimated in 26 natural populations in 1998. No A. dauci could be detected on the leaves, and only 0.4% of the seeds were contaminated with A. dauci, in spite of the conducive weather for A. dauci. Resistance tests showed that all 26 monitored populations were highly resistant to A. dauci strains from The Netherlands. It is probable that the strong potential fitness reduction by A. dauci led to a high selection pressure towards resistance in The Netherlands. In conclusion, our results suggest that transgenic resistance to A. dauci would not be beneficial to wild carrot populations in The Netherlands because they are already resistant to this pathogen