Stoma-free survival represents a key quality-of-life outcome following surgery for locally advanced rectal cancer. Despite advances in neoadjuvant and surgical management, up to 30% of patients ultimately require a permanent fecal diversion. To evaluate stoma-free survival and identify factors associated with permanent stoma formation in patients with locally advanced rectal cancer undergoing coloanal anastomosis. Retrospective cohort study. Single tertiary referral center, 2017-2021. A total of 126 patients with clinical stage II-III rectal adenocarcinoma who received neoadjuvant therapy and underwent curative-intent resection with coloanal anastomosis were included. Curative-intent resection with coloanal anastomosis. The primary outcome was stoma-free survival. Secondary analyses examined factors associated with permanent fecal diversion. One hundred twenty-six patients were analyzed, comprising 62.5% males, with a mean age of 54 ± 10 years and a median body mass index of 27.7 kg/m 2 (interquartile range: 24.5-31.4 kg/m 2). At a median follow-up of 53.0 months, the 5-year stoma-free survival rate was 88.9%. Univariate Cox-regression analysis showed that body mass index ≥ 35 kg/m 2 (Hazard Ratio=3.80, 95% confidence interval:1.04-13.91, p = 0.044) and handsewn coloanal anastomosis with mucosectomy compared to stapled coloanal anastomosis without mucosectomy (Hazard Ratio=5.58, 95% confidence interval:1.71-18.14, p = 0.004), as well as local recurrence (Hazard Ratio=6.51, 95% confidence interval:1.44-29.46) were associated with worse stoma-free survival. The 30-day major morbidity rate was 7.9% following the index surgery. Sixteen patients required permanent fecal diversion due to bowel dysfunction (n = 11), disease recurrence (n = 4), bowel obstruction (n = 1). Retrospective, single-institution design with limited generalizability. Coloanal anastomosis in the total neoadjuvant therapy era resulted in favorable 5-year stoma-free survival. Body mass index ≥ 35 kg/m2 handsewn coloanal anastomosis with mucosectomy, and local recurrence were associated with worse stoma-free survival. See Video Abstract.

Women with ulcerative colitis or IBD unclassified are often diagnosed during their reproductive years. After proctocolectomy and reconstructive surgery with IPAA, the mode of delivery when giving birth is subject to ongoing debate. To measure the amount of decreased pouch function and risk for pouch failure that women are willing to accept to deliver their child vaginally. Treatment tradeoff threshold study. Participants were identified in the institutional database at Mount Sinai Hospital in Toronto, Canada. Women aged between 18 to 49 years old who had previous surgery with IPAA for ulcerative colitis or IBD unclassified were asked to participate. All participants were subjected to a standardized interview. To measure the absolute increased risk for increased bowel frequency, urgency, incontinence, and pouch failure that participants were willing to accept to undergo vaginal delivery. A total of 49 participants (mean age, 36 [21-49] years) were included in the study. Twenty-five participants (51%) did not report any previous delivery. At baseline, 20% preferred cesarean section across all assessed outcomes. After vaginal delivery, a median increase of 2 bowel movements (baseline 5) per 24 hours was acceptable (median threshold: 8.0, interquartile range 6.0-9.0). For urgency, a 5-minute reduction from baseline 30 minutes was tolerated (median threshold: 20.0 minutes, interquartile range: 15.0-25.0). The median threshold for both liquid and solid fecal incontinence was 1 episode per month (baseline 0 episodes per month). The median risk threshold of pouch failure was 6.0% (interquartile range 6.0-9.5). Tolerance thresholds did not differ by delivery history. Selection bias and biases inherent to the interview are possible. Women with IBD and IPAA are willing to accept a slight increase in bowel frequency and urgency to have a vaginal delivery. See Video Abstract . ANTECEDENTES:Las mujeres con colitis ulcerosa o enfermedad inflamatoria intestinal no clasificada suelen ser diagnosticadas durante su edad fértil. Tras una proctocolectomía y una cirugía reconstructiva con anastomosis ileoanal, el modo de parto sigue siendo objeto de debate.OBJETIVO:Medir el grado de disminución de la función de la bolsa y el riesgo de fallo de la misma que las mujeres están dispuestas a aceptar para dar a luz por vía vaginal.DISEÑO:Estudio del umbral de compensación del tratamiento.ENTORNO:Las participantes fueron identificadas en la base de datos institucional del Hospital Mount Sinai de Toronto (Canadá).PACIENTES:Se pidió la participación de mujeres de entre 18 y 49 años que se habían sometido previamente a una cirugía con anastomosis ileoanal por colitis ulcerosa o enfermedad inflamatoria intestinal no clasificada.INTERVENCIONES:Todas las participantes fueron sometidas a una entrevista estandarizada.PRINCIPALES MEDIDAS DE RESULTADOS:Para medir el aumento absoluto del riesgo de aumento de la frecuencia intestinal, la urgencia, la incontinencia y el fallo de la bolsa, las participantes estaban dispuestas a aceptar someterse a un parto vaginal.RESULTADOS:Se incluyó en el estudio a un total de 49 participantes (edad media, 36 [21-49] años). Veinticinco (51 %) participantes no informaron de ningún parto anterior. Al inicio del estudio, el 20 % prefería la cesárea en todos los resultados evaluados. Tras el parto vaginal, se consideró aceptable un aumento medio de 2 deposiciones (valor inicial: 5) por cada 24 horas (umbral medio: 8,0, IQR 6,0-9,0). En cuanto a la urgencia, se toleró una reducción de 5 minutos con respecto a los 30 minutos iniciales (umbral medio: 20,0 minutos, IQR: 15,0-25,0). El umbral medio para la incontinencia fecal líquida y sólida fue de 1 episodio al mes (valor inicial: 0 episodios al mes). El umbral medio para el riesgo de fallo de la bolsa fue del 6,0 % (IQR: 6,0-9,5). Los umbrales de tolerancia no difirieron según el historial de partos.LIMITACIONES:Es posible que existan sesgos de selección y sesgos inherentes a la entrevista.CONCLUSIÓN:Las mujeres con enfermedad inflamatoria intestinal y anastomosis ileoanal están dispuestas a aceptar un ligero aumento de la frecuencia y la urgencia intestinal para tener un parto vaginal. ( AI-generated translation ).

The optimal time interval between the 2 surgical stages of a delayed coloanal anastomosis has not been investigated. Assess the influence of the time interval on anastomotic leakage occurrence. Retrospective cohort study. Multicentric study (30 colorectal centers). All patients who underwent delayed coloanal anastomosis (2010-2021). Anastomotic leakage in relation to the time interval between the 2 surgical stages. A total of 506 patients (women 42%, median age 62.1 years) underwent delayed coloanal anastomosis, 63% immediately after a low anterior resection (primary delayed coloanal anastomosis) and 37% after failure of primary pelvic surgery as a salvage procedure (salvage delayed coloanal anastomosis). The main reasons for salvage delayed coloanal anastomosis were chronic pelvic sepsis (42%) and rectovaginal fistula (38%). The mean time interval between 2 stages was 8.6 ± 3.8 days, ranging from 1 to 22 days. In the entire cohort, the incidence of anastomotic leakage was 18% (89/506; 95% CI, 14%-21%) and the time interval did not affect its occurrence ( p = 0.529). In subgroup analysis, anastomotic leakage risk was not associated with time interval among primary delayed coloanal anastomosis patients ( p = 0.579), whereas it was for salvage delayed coloanal anastomosis patients ( p = 0.013). In salvage delayed coloanal anastomosis patients, multivariate analysis showed that a longer time interval (adjusted OR 0.89; 95 CI, 0.81-0.98; p = 0.035) and surgery in centers performing 4 or more delayed coloanal anastomoses per year (adjusted OR 0.07; 95 CI, 0.01-0.36; p = 0.011) were significantly linked to a lower risk of anastomotic leakage. Each additional day between the 2 salvage delayed coloanal anastomosis procedures was estimated to reduce the risk of anastomotic leakage by 11%. The retrospective design. In the context of primary delayed coloanal anastomosis, increasing the time interval between the 2 stages of delayed coloanal anastomosis does not influence the risk of anastomotic leakage. For salvage delayed coloanal anastomosis, extending the time interval significantly reduces the risk of anastomotic leakage. See Video Abstract. ANTECEDENTES:No se ha investigado el intervalo de tiempo óptimo entre las dos etapas quirúrgicas de una anastomosis coloanal diferida.OBJETIVO:Evaluar la influencia del intervalo de tiempo en la aparición de fugas anastomóticas.DISEÑO:Estudio de cohorte retrospectivo.ENTORNOS:Estudio multicéntrico (30 centros colorrectales).PACIENTES:Todos los pacientes que se sometieron a una anastomosis coloanal diferida (2010-2021).PRINCIPALES MEDIDAS DE RESULTADO:Fuga anastomótica en relación con el intervalo de tiempo entre las dos etapas quirúrgicas.RESULTADOS:Un total de 506 pacientes (mujeres 42 %, mediana de edad 62,1 años) se sometieron a una anastomosis coloanal diferida, el 63 % inmediatamente después de una resección anterior baja (anastomosis coloanal diferida primaria) y el 37 % tras el fracaso de la cirugía pélvica primaria como procedimiento de rescate (anastomosis coloanal diferida de rescate). Las principales razones para la anastomosis coloanal tardía de rescate fueron la sepsis pélvica crónica (42 %) y la fístula rectovaginal (38 %). El intervalo medio de tiempo entre las dos etapas fue de 8,6 ± 3,8 días, con un rango de 1 a 22 días. En toda la cohorte, la incidencia de fuga anastomótica fue del 18 % (89/506; IC del 95 %, 14 %-21 %) y el intervalo de tiempo no afectó a su aparición ( p = 0,529). En el análisis de subgrupos, el riesgo de fuga anastomótica no se asoció con el intervalo de tiempo entre los pacientes con anastomosis coloanal primaria retrasada ( p = 0,579), mientras que sí lo hizo en los pacientes con anastomosis coloanal retrasada de rescate ( p = 0,013). En los pacientes con anastomosis coloanal tardía de rescate, el análisis multivariante mostró que un intervalo de tiempo más largo (OR ajustado 0,89; IC del 95 %, 0,81-0,98; p = 0,035) y la cirugía en centros que realizan 4 o más anastomosis coloanales tardías al año (OR ajustado 0,07; IC del 95 %, 0,01-0,36; p = 0,011) se asociaron significativamente con un menor riesgo de fuga anastomótica. Se estimó que cada día adicional entre las dos intervenciones de anastomosis coloanal diferida de rescate reducía el riesgo de fuga anastomótica en un 11 %.LIMITACIONES:El diseño retrospectivo.CONCLUSIONES:En el contexto de la anastomosis coloanal primaria diferida, aumentar el intervalo de tiempo entre las dos etapas de la anastomosis coloanal diferida no influye en el riesgo de fuga anastomótica. En el caso de la anastomosis coloanal diferida de rescate, prolongar el intervalo de tiempo reduce significativamente el riesgo de fuga anastomótica. (AI-generated translation).

Limited evidence is available on the effects of sacral neuromodulation on concomitant nondigestive symptoms of low anterior resection syndrome. To assess the impact of sacral neuromodulation on urinary and sexual dysfunction in patients with low anterior resection syndrome. Secondary analysis of a randomized, double-blinded, 2-phased, controlled, multicenter crossover trial (NCT02517853). Three tertiary hospitals. Patients with major low anterior resection syndrome 12 months after transit reconstruction after rectal resection who had failed conservative treatment. Patients underwent an advanced test phase of stimulation for 3 weeks and received a pulse generator implant if a 50% reduction in a low anterior resection syndrome score was achieved. These patients entered the randomized phase in which the generator was left active or inactive for 4 weeks. After a 2-week washout, the sequence was changed. After the crossover, all generators were left activated. Improvement of urinary and sexual dysfunction as assessed with validated questionnaires. Data for 35 patients were analyzed. The International Consultation on Incontinence Questionnaire-Short Form for urinary incontinence score at baseline (5.09 ± 6.48) decreased by 46% (p = 0.002) and 35% (p = 0.023) at 6- and 12-month follow-up. The proportion of patients with several urine leaks per day decreased from 17.1% to 5.7% (baseline vs 12-month follow-up, p = 0.001). High confidence in keeping an erection increased from 0 to 13.6% (baseline vs 12-month follow-up, p = 0.002). Improvement in sexual function in the 7 female patients who reported being sexually active was less apparent. The Female Sexual Function Index score at baseline, 6-, and 12-month follow-up were 15.84 ± 3.17, 18.03 ± 1.44 (p = 0.433), and 16.53 ± 2.61 (p = 0.7). This is a secondary analysis of a randomized trial, which could be underpowered for the current aim. Neuromodulation seemed to ameliorate urinary dysfunction associated with low anterior resection syndrome. See Video Abstract. ANTECEDENTES:Existen pocas pruebas disponibles sobre los efectos de la neuromodulación sacra en los síntomas no digestivos concomitantes del síndrome de resección anterior baja.OBJETIVO:Evaluar el impacto de la neuromodulación sacra en la disfunción urinaria y sexual en pacientes con síndrome de resección anterior baja.DISEÑO:Análisis secundario de un ensayo cruzado aleatorizado, doble ciego, en dos fases, controlado y multicéntrico (NCT02517853).ENTORNO:Tres hospitales terciarios.PACIENTES:Pacientes con una puntuación alta en el síndrome de resección anterior baja 12 meses después de la reconstrucción del tránsito tras una resección rectal en los que había fracasado el tratamiento conservador.INTERVENCIONES:Los pacientes se sometieron a una fase de prueba avanzada mediante estimulación durante 3 semanas y recibieron el implante de un generador de impulsos si se lograba una reducción del 50% en la puntuación del síndrome de resección anterior baja. Estos pacientes entraron en la fase aleatoria en la que el generador se dejó activo o inactivo durante 4 semanas. Tras un lavado de 2 semanas, se cambió la secuencia. Tras el cruce, todos los generadores se dejaron activados.PRINCIPALES MEDIDAS DE RESULTADO:Mejora de la disfunción urinaria y sexual evaluada con cuestionarios validados.RESULTADOS:Se analizaron los datos de 35 pacientes. El cuestionario internacional de consulta sobre incontinencia (ICIN) en su versión abreviada para la incontinencia urinaria (5,09 ± 6,48) disminuyó en un 46% (p = 0,002) y un 35% (p = 0,023) en el seguimiento a los 6 y 12 meses. Los pacientes con varias pérdidas de orina al día disminuyeron del 17,1% al 5,71% (valor inicial frente al seguimiento a los 12 meses, p = 0,001). La confianza en mantener una erección aumentó del 0 al 13,64% (valor inicial frente a seguimiento a los 12 meses, p = 0,002). La mejora de la función sexual en las 7 pacientes que declararon ser sexualmente activas fue menos evidente. La puntuación del Índice de Función Sexual Femenina al inicio del estudio, a los 6 y a los 12 meses de seguimiento fue de 15,84 ± 3,17, 18,03 ± 1,44 (p = 0,433) y 16,53 ± 2,61 (p = 0,7), respectivamente.LIMITACIONES:Se trata de un análisis secundario de un ensayo aleatorizado que podría carecer de la potencia estadística necesaria para el objetivo actual.CONCLUSIONES:La neuromodulación pareció mejorar la disfunción urinaria asociada al síndrome de resección anterior baja. (AI-generated translation).

Despite generally favorable outcomes of ligation of intersphincteric fistula tract for anal fistula, several patients experience persistent or recurrent disease. This study aimed to identify patterns of treatment failure after ligation of intersphincteric fistula tract and evaluate their outcomes. Multicenter retrospective study. Five university hospitals in Thailand. Those diagnosed with persistent or recurrent cryptoglandular anal fistula after ligation of intersphincteric fistula tract between 2012 and 2020. Fistula characteristics, patterns of treatment failure and outcomes of subsequent management were analyzed. A total of 200 patients were included, of whom 12.5% had persistent fistulas and 87.5% had recurrence. Median time to recurrence was 6 months (range, 1-48). Most treatment failures (n = 186, 93%) occurred within one year after surgery. Six distinct patterns of treatment failure were identified. The most common was type 1 (I-E, tract running from the previous internal opening (I) to an external opening (E) - known as an original fistula: n=116, 58%), followed by type 2 (I-L, tract running from the previous internal opening (I) to an unhealed intersphincteric wound - known as an intersphincteric fistula: n = 56, 28%). Type 1 failure was effectively treated by redo- ligation of intersphincteric fistula tract with an 87% success rate. Overall, the healing rate was 90.5% - with a median follow-up period of 18 months (range, 12-38). Exclusion of non-cryptoglandular fistulas may limit generalizability. The retrospective multicenter design and surgeon-dependent decision-making may have introduced selection bias and heterogeneity in surgical technique. Most treatment failures occurred within one year after ligation of intersphincteric fistula tract. Understanding the six distinct failure patterns enables more appropriate surgical decision-making. The majority represented either recurrence of the original tract or persistence within the intersphincteric space. See Video Abstract.