Department Of Colorectal Surgery Research Articles

Turnbull-Cutait Pull-Through Procedure Is an Alternative to Permanent Ostomy in Patients With Complex Pelvic Fistulas.

A permanent stoma is frequently recommended in the setting of complex or recurrent rectovaginal fistulas because of the high failure rate of reconstructive procedures. The Turnbull-Cutait pull-through procedure is a salvage operation for motivated patients desiring to avoid permanent fecal diversion. To analyze the cure rates of complex rectovaginal fistulas after the Turnbull-Cutait pull-through procedure based on cause. After the institutional review approval board, a retrospective review of women who underwent the procedure (1993-2018) for a rectovaginal fistula was conducted. Patients' demographics, cause, and postoperative outcomes were analyzed. Colorectal surgery department at a tertiary center in the United States. Adult women with a rectovaginal fistula who underwent a colonic pull-through procedure were included. Recurrence after the colonic pull-through procedure. There were 81 patients who underwent colonic pull-through; of those, 26 patients had a rectovaginal fistula, had a median age of 51 (43-57) years, and had a mean BMI of 28 ± 3.2 kg/m 2 . A total of 4 patients (15%) had a recurrence and 85% of the patients healed. Ninety-three percent of the patients healed after the prior anastomotic leak. Patients with a Crohn's disease-related fistula had a 75% cure rate. The Kaplan-Meier analysis showed a cumulative incidence of recurrence of 8% (95% CI, 0%-8%) within 6 months after surgery and 12% at 12 months. Retrospective design. The Turnbull-Cutait pull-through procedure may be the last option to preserve intestinal continuity and successfully treat rectovaginal fistulas in 85% of cases. ANTECEDENTES:Con frecuencia se recomienda un estoma permanente en el contexto de una fístula rectovaginal compleja o recurrente debido a la alta tasa de fracaso de los procedimientos reconstructivos. El procedimiento de extracción de Turnbull-Cutait es una operación de rescate para pacientes motivados que desean evitar la desviación fecal permanente.OBJETIVO:Analizar las tasas de curación de la fístula rectovaginal compleja después del procedimiento de extracción de Turnbull-Cutait según la etiología.DISEÑO:Después de la junta de aprobación de revisión institucional, se realizó una revisión retrospectiva de mujeres que se sometieron a un procedimiento (1993-2018) por fístula rectovaginal. Se analizaron los datos demográficos, la etiología y los resultados posoperatorios de los pacientes.AJUSTE:Departamento de cirugía colorrectal en un centro terciario en los Estados Unidos.PACIENTES:Mujeres adultas con fístula rectovaginal que se sometieron a extracción del colon.RESULTADO PRINCIPAL:recurrencia después de la extracción del colon.RESULTADOS:Hubo 81 pacientes que tenían extracción colónica, de esas 26 fístulas rectovaginales con una mediana de edad de 51 (43 - 57) años, y un índice de masa corporal promedio de 28 ± 3,2 kg/m2. Un total de 4 (15%) pacientes tuvieron una recurrencia y el 85% de los pacientes se curaron. El noventa y tres por ciento de los pacientes se curaron después de la fuga anastomótica previa. Los pacientes con fístula relacionada con EC tuvieron una tasa de curación del 75%. El análisis de Kaplan Meier mostró una incidencia acumulada de recurrencia del 8% [95% intervalo de confianza 0%-18%] dentro de los 6 meses posteriores a la cirugía y del 12% a los 12 meses.LIMITACIONES:Diseño retrospectivo.CONCLUSIONES:El procedimiento de extracción de Turnbull-Cutait puede ser la última opción que se puede ofrecer para preservar la continuidad intestinal y tratar la fístula rectovaginal con éxito en el 85% de los casos. (Traducción-Yesenia.Rojas-Khalil).

Bilaterally parallel elliptic flap versus Karydakis flap in primary pilonidal sinus disease: a randomized controlled trial.

Pilonidal sinus disease is a disease that especially affects the young population and causes loss of workforce. Although many treatment methods have been defined, there is still no "gold standard" treatment method. Our objective was to evaluate the postoperative results of bilateral parallel elliptical flap and Karydakis flap in the surgical treatment of pilonidal sinus. This study was conducted at the Colorectal Surgery Department of Ankara Numune Training and Research Hospital. It designed a prospective randomized controlled study. Patients that underwent surgery due to pilonidal sinus were included in the study. The patients were randomly divided into two groups. Surgery was performed with the bilateral parallel elliptical flap (BPEF) technique in one group and the Karydakis flap (KF) technique in the other group. Postoperative pain, length of hospital stay, wound complications, time taken to return to work/school, and recurrence incidence were evaluated. A total of 102 patients were included in the study, 49 in the BPEF group and 53 in the KF group. The length of hospital stay was similar in the BPEF and KF groups (1.41 ± 0.81 and 1.45 ± 0.84, respectively; p > 0.05). There was less postoperative pain in the BPEF group (2.47 ± 1.02 vs 3.57 ± 1.10, p < 0.05). Wound complications were observed in nine patients in the BPEF group (18.2%) and 14 patients in the KF group (26.2%). The time to return to work/school was shorter in the BPEF group (21.06 ± 6.37 vs 27.04 ± 7.45; p < 0.05). Recurrence developed in two (4%) patients in the BPEF group and three (5.6%) patients in the KF group (p > 0.05). The patients who underwent surgery with the bilateral parallel elliptical flap technique had less pain and a shorter time to return to work/school after the operation. The postoperative complication and recurrence rates were similar in both groups. clinicaltrials.gov identifier: NCT05851690. (5/11/2023) (retrospectively registered).

The short-term false positives after sacral neuromodulation therapy: Who, how many and why? A prospective descriptive single centre study

Aim:I. To describe the number of false positive cases (FP), their characteristics and reason of occurrence in sacral neuromodulation therapy (SNM). Methods:A multidisciplinary prospective single-centre study was conducted between March 2018 and December 2021 with a follow-up of 12 months. Patients with therapy-resistant pelvic organ dysfunctions, scheduled for a 2-staged SNM procedure at the Urology (UD) and Colorectal Surgery Department (CRD), were included. All patients completed bowel and bladder diaries at baseline and during the test phase. Patient global impression of change (PGIC) and satisfaction scores concerning urological (US) and bowel symptoms (BS) were surveyed at baseline, at 1, 6 and 12 months after implantation. Patient characteristics and diary outcomes between FP and true positive cases (TP) were compared using non-parametric statistical tests. SPSS 27.0 was used. Clinical trial registration: NCT05313984. Results:The FP ratio at one month follow-up was 16% (11/68), with a FP ratio of 13% (N=6/48) and 25% (N=5/20) for the urology patients and colorectal surgery patients, respectively. There were no significant differences in demographic characteristics between the FP and TP group (p > 0,05), however there is a trend towards FP having worse baseline symptoms than TP. The FP group had a significant lower baseline and test phase 24 h diuresis (p < 0,05), without having a significant different intake than the TP group. Conclusion:At one month after full implantation of a sacral neuromodulator, 16% of the patients showed loss of subjective success. These FP could not be predicted from demographic characteristics, most likely due to the small study population. Although not significant, FP seem to have worse symptoms at baseline than TP, with a significant lower diuresis regardless of fluid intake.

Limberg Flap for Recurrent Pilonidal Sinus.

Department of Colorectal Surgery, Shanghai East Hospital, School of Medicine, Tongji University, China Funding/Support: None reported. Financial Disclosures: None reported. Correspondence: Chuangang Fu, M.D., Department of Colorectal Surgery, Shanghai East Hospital, Tongji University, 200120, No. 150, Jimo Road, Pudong New Area, Shanghai, China. E-mail: [email protected] This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

Comparison of Outcome between Ostomy Closure with Permanent Synthetic Mesh and Conventional Technique without Mesh to Prevent Incisional Hernia

Background: Stomal site incisional hernia is a common complication following ostomy closure. Prophylactic mesh reinforcement of the fascial defect is typically not considered due to the contaminated nature of the case. The effectiveness of prophylactic mesh placement at the time of stoma closure is unknown because of fear of mesh infection and subsequent wound complications. Purpose: To compare the results obtained by placing synthetic mesh in the stoma site during closure with conventional technique without mesh to prevent incisional. Patients and Methods: Prospective interventional study had been designed to compare the outcome of permanent synthetic mesh placement at the time of ostomy closure. Total 45 patients were selected purposively who were candidates for ostomy closure and presented at the Department of Colorectal Surgery, Bangabandhu Sheikh Mujib Medical University (BSMMU) from April 2019 to September 2020 and divided into two groups (no mesh and mesh). In the mesh group, permanent synthetic mesh (ProleneTM – Polypropylene) was placed. Primary outcome, incisional stomal hernia was assessed at regular follow-up for one year along with associated morbidities. Results: The primary outcome of this study i.e. incisional hernia (stomal site) was observed among 1 (4.8%) patients at 4th week, 3 (14.3%) at 3rd month, 7 (33.3%) at 6th month and 8 (38.1%) at 12th month follow-up in no mesh group. And, only 1 patient at 6th month and 12th month follow-up had hernia in the mesh group (Figure 3). There was no difference statistically between no mesh and mesh groups at 4th week and 3rd month but significant difference found at 6th and 12th month follow-up (p=0.280, p=0.344, p=0.033 and p=0.017, respectively). Conclusion: Prophylactic placement of permanent polypropylene mesh during ostomy closure placement significantly reduced the rate of incisional hernia without any additional morbidity. Placement of mesh was found to be both safe and effective.

Survival and Prognostic Factors Predicting Outcomes of Patients with Primary Non-Metastatic Colorectal Cancer who have not had Curative Intervention

Abstract Background: The natural progression and life expectancy of patients following a diagnosis of treatable colorectal cancer who receive only symptomatic treatment, nonoperative palliative therapy, or noncurative surgical interventions are relatively unknown. Objectives: The objective of this retrospective study was to examine the survival of patients following a diagnosis of primary nonmetastatic colorectal cancer who did not undergo major surgery for the purpose of curative treatment. Design: A retrospective observational study. Study Settings: Department of Colorectal Surgery, King’s College Hospital, London. Patient and Methods: A retrospective study of patients with stages I–III colorectal cancer who had not undergone noncurative surgery, palliative chemotherapy, or radiotherapy between 2012 and 2019 was conducted. Multivariate and univariate analyses were used to evaluate the prognostic factors associated with overall survival (OS). Main Outcome Measure: OS. Sample Size: A total of 78 patients. Results: A total of 78 patients were enrolled in this study. The median survival rate was 296 days or 9.7 months, and the mean survival rate was 385 days (15–1894 days). The 1- and 2-year OS rates were 37.2% and 3.8%, respectively. Univariate analysis revealed that three parameters were statistically significant for OS with a significant correlation with performance status (PS) (P = 0.004), tumor stage (pT) (P = 0.030), and lymph node metastasis (pN) (P = 0.001). Multivariate analysis revealed that pN2 (hazard ratio: 2.19, 95% confidence index: -1.1–4.4) and PS 3 and 4 (hazard ratio: 0.525, 95% confidence index: 0.3–1.0, P = 0.026) were prognostic factors associated with OS. Conclusion: Operable colorectal cancer patients without surgical resection have an OS rate of &lt;1 year; a higher T and N stage is associated with adverse prognosis. Limitations: Our study is limited by its retrospective nature and small sample size. In addition, patients underwent various palliative interventions based on their unique clinical, pathological, and social needs. Conflict of Interest: The authors have no conflict of interest to declare.

Design and application of a new transoral gastric tube for extraction and storage of gastric contents

Difficulty in swallowing is a common symptom in stroke patients, and nasogastric tubes are routinely used to solve the nutritional support problem of these patients. The existing nasogastric tube have the disadvantages of causing aspiration pneumonia and patient discomfort. The traditional transoral gastric tube has no one-way valve switch and gastric content storage device, and cannot be fixed in the stomach, resulting in reflux of gastric contents, inability to fully understand the digestion and absorption of gastric contents, and accidental dislocation of the gastric tube, affecting further feeding and gastric content detection. For these reasons, the medical staff of the department of gastroenterology and colorectal surgery of Jilin University China-Japan Union Hospital designed a new transoral gastric tube that can extract and store gastric contents, and was granted a national utility model patent of China (ZL 2020 2 1704393.1). The device consists of collection, cannula and fixation modules. The collection module includes three parts. Gastric contents storage capsule, which can clearly visualize the gastric contents; three-way switch, which can be controlled by rotating the pathway, makes the pathway exist in different states, which is convenient for medical personnel to extract gastric juice, as well as perform intermittent oral tube feeding on the patient or close the pipeline, and reduce contamination and prolong the service life of the gastric tube; one-way valve, which can effectively avoid the contents of the reflux back into the stomach. The tube insertion module includes three parts. A graduated tube, which can enable the medical staff to effectively identify the insertion depth; a solid guide head, which makes the insertion of the tube through the mouth more smoothly; the gourd-shaped passageway, which effectively avoids the blockage of the tube. The fixation module is a water-filled balloon, which is properly filled with water and air. After the pipe is inserted through the mouth, it can be injected with water and gas properly to avoid accidental withdrawal of the gastric tube. Intermittent oroesophageal tube feeding of patients with dysphagia after stroke through a transoral gastric tube that can extract and store gastric contents can not only accelerate the recovery process of patients and shorten the hospitalization time, but also transoral enteral nutrition can effectively promote the recovery of patients' systemic systems, which has certain clinical use value.

High serum riboflavin is associated with the risk of sporadic colorectal cancer

BackgroundExperimental results indicate that riboflavin is involved in tumorigenesis. Data regarding the relationship between riboflavin and colorectal cancer (CRC) are limited, and findings vary between observational studies. DesignThis was a case–control retrospective study. ObjectiveThis study aimed to evaluate the associations between serum riboflavin level and sporadic CRC risk. MethodsIn total, 389 participants were enrolled in this study – including 83 CRC patients without family history and 306 healthy controls – between January 2020 and March 2021 at the Department of Colorectal Surgery and Endoscope Center at Xinhua Hospital, Shanghai Jiao Tong University School of Medicine. Age, sex, body mass index, history of polyps, disease conditions (e.g., diabetes), medications, and eight other vitamins were used as confounding factors. Adjusted smoothing spline plots, subgroup analysis, and multivariate logistic regression analysis were conducted to estimate the relative risk between serum riboflavin levels and sporadic CRC risk. After fully adjusting for the confounding factors, an increased risk of colorectal cancer was suggested for individuals with higher levels of serum riboflavin (OR = 1.08 (1.01, 1.15), p = 0.03) in a dose–response relationship. ConclusionsOur results support the hypothesis that higher levels of riboflavin may play a role in facilitating colorectal carcinogenesis. The finding of high levels of circulating riboflavin in patients with CRC warrants further investigation.

Outcomes of gracilis muscle interposition for rectourethral fistulas caused by treatment of prostate cancer.

Gracilis muscle interposition (GMI) has been associated with favorable outcomes in treating complex perianal fistulas. Outcomes of GMI may vary according to the fistula etiology, particularly between rectovaginal fistulas in women and rectourethral fistulas (RUF) in men. The aim of this study was to assess the outcome of GMI to treat RUF acquired after prostate cancer treatment. This retrospective cohort study included male patients treated with GMI for RUF acquired after prostate cancer treatment between January 2000 and December 2018 in the Department of Colorectal Surgery, Cleveland Clinic Florida. The primary outcome was the success of GMI, defined as complete healing of RUF without recurrence. Secondary outcomes were length of hospital stay and postoperative complications. This study included 53 male patients with a median age of 68 (range, 46-85) years. Patients developed RUF after treatment of prostate cancer with radiation (52.8%), surgery (34%), or transurethral resection of the prostate (TURP) (13.2%). Median hospital stay was 5 (IQR, 4-7) days. Twenty (37.7%) patients experienced 25 complications, the most common being wound infection and dehiscence. Primary healing after GMI was achieved in 28 (52.8%) patients. Fifteen additional patients experienced successful healing of RUF after additional procedures, for a total success rate of 81.1%. Median time to complete healing was 8 (range, 4-56) weeks. The only significant factor associated with outcome of GMI was wound dehiscence (p = 0.008). Although the initial success rate of GMI was approximately 53%, it increased to 81% after additional procedures. Complications after GMI were mostly minor, with wound complications being the most common. Perianal wound dehiscence was significantly associated with failure of healing of RUF after GMI.

Application of laparoscopic modified Bacon operation in patients with low rectal cancer and analysis of the changes in anal function: A retrospective single-center study.

To investigate the value of modified Bacon operation in patients with low rectal cancer. Retrospective analysis of 60 patients treated with laparoscopic surgery for low rectal cancer in the Department of Colorectal and Anal Surgery, Jingzhou Hospital affiliated to Yangtze University, from 2019 to 2022, divided into observation and control groups based on the method of the operation (laparoscopic modified Bacon operation group and laparoscopic Dixon operation with prophylactic ileostomy group). We compared the variations between the two groups. The length of the abdominal surgical incision was shorter in the observation group than in the control group(P<0.05). In the observation group, the length of hospital stay after the first operation was shorter(P<0.05), the both operations time and the second intraoperative bleeding were less(P<0.05), the DET score at one week after the first operation and the VAS after both operations were fewer than in the control group(P<0.05), the postoperative rate of ischemic necrosis of the exposed bowel was higher(P<0.05), and the anal function was poorer in the short term after the second operation compared with the control group(P<0.05), but there was no significant difference between the anal function at 6 months after the second operation compared with the control group(P>0.05).12 months after the second operation, the anal function has recovered to the preoperative level in the observation group(P>0.05). The laparoscopic modified Bacon operation has smaller abdominal wounds, which reduces postoperative pain; it does not require the use of staplers, which reduces the patient's financial burden; no postoperative anastomotic leakage occurs, and a more satisfactory anal function can be obtained.

Adequate vitamin D level associated with reduced risk of sporadic colorectal cancer.

The effect of vitamin D level pertinent to colorectal cancer incidence, progression, or mortality risk is complicated, and study findings are mixed. Therefore, we evaluated whether serum vitamin D [25-hydroxyvitamin D, 25(OH)D] is associated with the incidence of sporadic colorectal cancer (CRC). This study is a retrospective analysis of the relationship between serum 25(OH)D level and the risk of CRC. Age, sex, body mass index, history of polyp, disease conditions (i.e., diabetes), medications, and other eight vitamins were used as confounding factors. A total of 389 participants were enrolled in this study, including comprising 83 CRC patients without a family history and 306 healthy controls, between January 2020 and March 2021 at the Department of Colorectal Surgery and Endoscope Center at the Xinhua Hospital, Shanghai Jiao Tong University School of Medicine. Adjusted smoothing spline plots, subgroup analysis, and multivariate logistic regression analysis were conducted to estimate the relative risk between serum 25(OH)D and sporadic CRC risk. After fully adjusting the confounding factors, it was found that circulating 25(OH)D played a protective role in patients with CRC (OR = 0.76 [0.63, 0.92], p = 0.004) and that an adequate vitamin D level was significantly associated with a reduced CRC risk compared to vitamin D deficiency or sufficiency (OR = 0.31 [0.11, 0.9], p = 0.03). According to this study, statins did not affect the potential protective effects of vitamin D (OR = 1.02 [0.97, 1.08], p = 0.44) and may account for the inverse association between serum 25(OH)D and colorectal cancer. An adequate level of serum 25(OH)D was associated with a reduced CRC risk, especially for the elderly. The finding on the absence of protective effect of vitamin D in the statin use subgroup, suggests it may be one of the substantial contributing confounders, and warrants further investigation.

Role of C-Reactive Protein (CRP) as a Predictive Marker of Anastomotic Leak in Colorectal Surgery: Is it Still Reliable?

Introduction: Anastomotic leaks after colorectal surgery is associated with serious morbidity and early diagnosis is critical. C-reactive protein (CRP) on postoperative day (POD) 3 to 5 has been described as a good predictor of anastomotic leak. Therefore, this study aims to review if CRP level of greater than 150mg/l is a reliable predictor of anastomotic leak. 1.2. Methodology: The study was conducted using a prospectively held database from Department of Colorectal Surgery, Singapore General Hospital. From 1 January 2011 to 31 October 2017, all patients who had anastomotic leaks after colorectal resection surgery were analysed retrospectively. Patients without postoperative CRP levels were excluded.

3-Dimensional Laparoscopic Rectal Anterior Resection With Transanal Specimen Extraction For Rectal Prolapse.

Department of Colorectal Surgery, Shanghai East Hospital, School of Medicine, Tongji University, China Funding/Support: None reported Financial Disclosures: None reported Informed Consent: Informed consent was obtained from the patient. Correspondence: Chuangang Fu, M.D., Department of Colorectal Surgery, Shanghai East Hospital, Tongji University, 200120, No. 150 Jimo Road, Pudong District, Shanghai, China. E-mail: [email protected]

S72 Bibliometric Analysis of the Top Inflammatory Bowel Disease Citations From the Department of Colorectal Surgery at Cleveland Clinic

S72 Bibliometric Analysis of the Top Inflammatory Bowel Disease Citations From the Department of Colorectal Surgery at Cleveland Clinic

Challenges and Learning Curves in Adopting TaTME and Robotic Surgery for Rectal Cancer: A Cusum Analysis.

Simple SummaryRectal cancer surgery remains a challenge and information about the learning curve in adopting new techniques is lacking. This paper analyzes our experience in taTME (since 2015) and robotic surgery (since 2018) at a fully accredited referral center for the treatment of rectal cancer in Spain. In this retrospective study, we aim to analyze the learning curves for taTME and robot-assisted rectal procedures in the incorporation of these platforms into our practice. We sought to describe our team’s experience in incorporating these techniques and to analyze the difficulties that we have had. Hoping that sharing our experience can help other groups improve their results during the difficult initial phase of incorporating new techniques.New techniques are being developed to improve the results of laparoscopic surgery for rectal cancer. This paper analyzes the learning curves for transanal total mesorectal excision (taTME) and robot-assisted surgery in our colorectal surgery department. We analyzed retrospectively data from patients undergoing curative and elective surgery for rectal cancer ≤12 cm from the anal verge. We excluded extended surgeries. We used cumulative sum (CUSUM) curve analysis to identify inflection points. Between 2015 and 2021, 588 patients underwent surgery for rectal cancer at our center: 67 taTME and 79 robot-assisted surgeries. To overcome the operative time learning curve, 14 cases were needed for taTME and 53 for robot-assisted surgery. The morbidity rate started to decrease after the 17th case in taTME and after the 49th case in robot-assisted surgery, but it is much less abrupt in robot-assisted group. During the initial learning phase, the rate of anastomotic leakage was higher in taTME (35.7% vs. 5.7%). Two Urological lesions occurred in taTME but not in robot-assisted surgery. The conversion rate was higher in robot-assisted surgery (1.5% vs. 10.1%). Incorporating new techniques is complex and entails a transition period. In our experience, taTME involved a higher rate of serious complications than robot-assisted surgery during initial learning period but required a shorter learning curve.

Diagnosis of rectal cancer based on the Xception-MS network

Objective. Accurate T staging of rectal cancer based on ultrasound images is convenient for doctors to determine the appropriate treatment. To effectively solve the problems of low efficiency and accuracy of traditional methods for T staging diagnosis of rectal cancer, a deep-learning-based Xception-MS diagnostic model is proposed in this paper. Approach. The proposed diagnostic model consists of three steps. First, the model preprocesses rectal cancer images to solve the problem of data imbalance and deficiency of sample size, and reduces the risk of model overfitting. Second, a new Xception-MS network with stronger feature extraction capability, which is a combination of the Xception network and MS module, is proposed. The MS module is a new function module that can more effectively extract multi-scale information from rectal cancer images. In addition, to solve the deficiency of the small sample size of rectal cancer, the proposed network is combined with transfer learning technology. At last, the output layer of the network is modified, in which the global average pooling and a fully connected softmax layer are employed to replace the original ones, and then the rectal cancer 4 classification (T1, T2, T3, T4 staging) is output. Main results. Experiments of rectal cancer T staging are conducted on a dataset of 1078 rectal cancer images in 4 categories collected from the Department of Colorectal Surgery of the Third Affiliated Hospital of Kunming Medical University. The experimental results show that the accuracy, precision, recall and F1 values obtained by the model are 94.66%, 94.70%, 94.65%, and 94.67%, respectively. Significance. The experimental results show that our model is superior to the existing classification models, can effectively and automatically classify ultrasound images of rectal cancer, and can better assist doctors in the diagnosis of rectal cancer.

Application of the natural orifice specimen extraction surgery I-type E method combined with 3D laparoscopy in sphincter-preserving surgery of low rectal cancer

PurposeAnalysis of the clinical efficacy of the application of the NOSES I-type E method combined with 3D laparoscopy in sphincter-preserving surgery of low rectal cancer.MethodA retrospective analysis of 109 patients who underwent laparoscopic low rectal cancer surgery for anus preservation without preventive stoma admitted to the Department of Colorectal Surgery in Shanxi Provincial Cancer Hospital between January 2017 and May 2019. The 109 cases comprised 52 cases treated with the NOSES I-type E method (NOSES I-type E group) and 57 cases treated with the Dixon method (Dixon group). In the NOSES I-type E group, 25cases underwent 3D laparoscopic surgery (group A) and 27 cases underwent 2D laparoscopic surgery (group B). The general clinical data, perioperative indicators, three-day postoperative pain score, postoperative pathological conditions, complications, return visit to assess the 1-year postoperative anal function, 3-year local recurrence and distant metastasis, and survival were compared among the groups.ResultThe distance between the tumor and the anal verge was significantly different between NOSES I-type E group and the Dixon group (P < 0.05), while there was no significant difference between group A and group B (P > 0.05). The exhaust time, eating time, drainage tube removal time, hospitalization costs, hospitalization time, and the number of days of analgesic administration were significantly different between NOSES I-type E group and the Dixon group (P < 0.05), while group A had no significant difference compared to group B (P > 0.05). There were significant differences in difficulty urinating between group A and B (P < 0.05), while there was no significant difference between NOSES I-type E group and the Dixon group (P > 0.05). Anastomotic leakage in NOSES I-type E group were significantly lower than those in the Dixon group (P < 0.05), while there was no significant difference between group A compared to group B (P > 0.05). Anal stenosis, rectal Prolapse and colon retraction in NOSES I-type E group were significantly higher than those in Dixon group (P < 0.05), there was no significant difference between group A compared to group B (P > 0.05). Anastomotic bleeding in Dixon group occurred in higher frequency than in NOSES I-type E group (P < 0.05). The pain scores of patients in NOSES I-type E group in the first three days after operation were significantly lower than those in Dixon group (P < 0.05),while there was no significant difference between group A and group B (P > 0.05). There were no significant differences in postoperative pathology, 1-year postoperative anal function score, 3-year recurrence rate and overall survival rate among the groups (P > 0.05).ConclusionThe NOSES I-type E method is a safe and effective sphincter-preserving operation for low rectal cancer and its combination with 3D laparoscopy may have better neurological protection which is worth of clinical application.

EP-180 Analysis of two-week wait referrals to a colorectal surgery department for iron deficiency anaemia in a rural DGH

Abstract Iron deficiency anaemia (IDA), defined as low haemoglobin and ferritin levels, affects 2–5% of adults in the developed world. Asymptomatic malignant gastrointestinal pathology must be excluded in all patients. Patients referred on a two-week wait Colorectal pathway with IDA between 4/1/2018–28/2/2021 were recruited (n=566). 92.4% of patients were investigated, only 45.2% had true IDA. Although screening for coeliac disease was a prerequisite in the referral pro forma, 63.2% were referred without. NICE guidance recommends upper and lower gastrointestinal investigations in all patients with confirmed IDA. 61.6% of patients had both investigations performed. 65.1% patients were diagnosed with benign conditions- diverticular disease (37.6%), polyp (31%) and hiatus hernia (28.5%). Age was the strongest predictor for pathology in patients with IDA (p=0.001), not specifically for cancer (p=0.111). 4.4% (n=23) patients were diagnosed with colorectal cancer. Low haemoglobin was significantly correlated with cancer (p=0.002), however only 60.9% had low ferritin. Guidelines suggest that only post-menopausal women should be investigated for IDA unless symptomatic or risk factors. Although only 80% had symptoms; the entire cohort had investigations and only 60% returned a positive test. This study highlighted variability in investigations in addition to lack of adherence by primary care physicians to referral guidelines resulting in avoidable referrals and potentially inappropriate investigations in pre-menopausal women by secondary care physicians, thus overwhelming an exceedingly burdened two- week wait pathway.

Mutational profile of KRAS, NRAS, BRAF, PIK3CA, and AKT1 genes in colorectal cancer patients in a tertiary care hospital, Dhaka

BackgroundColorectal carcinoma (CRC) is the third most common cancer in the world and incidences are on the rise in Bangladesh. KRAS, NRAS, BRAF, PIK3CA, and AKTI gene mutations are predictive markers of biological therapies, monoclonal antibodies targeting EGFR. The purpose of this study was to detect KRAS, NRAS, BRAF, PIK3CA, and AKT1 genes mutation in CRC patients by multiplex real-time Polymerase Chain Reaction (PCR) and evaluate the association of the mutations with clinicopathological features. MethodologyThis cross-sectional study was carried out in the Department of Microbiology & Immunology, Bangabandhu Sheikh Mujib Medical University (BSMMU) from March 2019 to January 2020. Tissues from surgically resected colorectal tumors were collected from 44 histopathologically confirmed adult colorectal cancer patients, who were admitted in the Department of Colorectal Surgery, BSMMU. ResultsAmong 44 histopathologically diagnosed colorectal cancer patients, KRAS, BRAF, and PIK3CA gene mutations were identified in 31.5%, 4.85%, and 4.85% tumors, respectively. In this study, no mutation was detected in NRAS and AKT1 genes. Concurrent mutation in KRAS and PIK3CA genes were found in one patient. Among the 14 KRAS mutant cases, most (92.85%) were in exon 2 (codon 12/13) and only 7.15% of the mutations were in exon 3 (codon 61). No mutation was detected in codon 59, 117, and 146. Among the two PIK3CA mutations, one was present in exon 9 and another was in exon 20. KRAS mutations were significantly associated with well and moderately differentiated tumors than poorly differentiated tumors (p < 0.05). Histopathologically there was no significant association of KRAS mutations with age, sex, tumor location, TNM staging, and other parameters. ConclusionA combined evaluation of genetic biomarkers can classify about one-third of colorectal cancer patients as mutant for any one of these KRAS, BRAF, and PIK3CA genes.

Ileo-rectal anastomosis in ulcerative colitis-Long-term outcome, failure and risk of cancer at a tertiary centre.

Ileo-rectal anastomosis (IRA) is an option to restore bowel continuity after colectomy in patients with ulcerative colitis (UC). Concerns that the remaining rectum may serve as a site for continuing proctitis with subsequent poor function and IRA failure and the fear of development of dysplasia and cancer have led to the abandonment of IRA in large parts of the world. This study investigated the outcome of IRA in a large patient cohort with UC and IRA with regard to failure of IRA and development of dysplasia and cancer. This was a retrospective data gathering of patients with UC and IRA enrolled at the Department of Colorectal Surgery, Surgical Clinic, Sahlgrenska University Hospital/Östra, Gothenburg, 1972-2019. End-points were IRA failure, rectal dysplasia and cancer. IRA survival analysis and the cumulative probability of rectal cancer were calculated. In total, 183 patients (121 men) were included in the study. The IRA failure rate was 34% and the estimated cumulative IRA failure rates were 25% and 35% at 5 and 10 years respectively. Four patients developed rectal cancer and the estimated cumulative probability of rectal cancer was 3% and 6% at 10 and 15 years respectively. Ileo-rectal anastomosis remains a restorative option after colectomy for UC, even if the failure rate raises some concern. Further knowledge is needed for optimal patient selection to avoid early IRA failures. With increasing probability of rectal cancer over time a vigilant surveillance protocol is mandatory.