Annals of Coloproctology

Optimizing postoperative pain management in minimally invasive colorectal surgery: Soo Young Lee; Received November 13, 2024 Accepted November 14, 2024 Published online December 3, 2024; DOI: https://doi.org/10.3393/ac.2024.00815.0116 [Epub ahead of print]

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Robotic abdominoperineal resection, bilateral robotic groin node dissection and simultaneous perineal gracilis flap reconstruction for locally advanced node-positive anal squamous cell carcinoma: Mohammed Ali, Melanie Holzgang, Vivekanandan Kumar, Dhalia Masud, Sandeep Kapur, Ahmed El-Hadi, Dolly Dowsett, Irshad Shaikh; Received January 2, 2024 Accepted May 1, 2024 Published online December 2, 2024; DOI: https://doi.org/10.3393/ac.2023.00801.0114 [Epub ahead of print]

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Botulinum injection technique to reduce spasms in refractory anal fissures and after anal fistula or hemorrhoid surgery: Pankaj Garg, Vipul D. Yagnik, Kaushik Bhattacharya; Received October 13, 2023 Accepted January 2, 2024 Published online December 2, 2024; DOI: https://doi.org/10.3393/ac.2023.00696.0099 [Epub ahead of print]

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Effect of continuous wound infiltration on patients using intravenous patient-controlled analgesia for pain management after reduced-port laparoscopic colorectal surgery: Hyeon Deok Choi, Sung Uk Bae; Received February 14, 2023 Accepted March 29, 2023 Published online November 22, 2024; DOI: https://doi.org/10.3393/ac.2023.00143.0020 [Epub ahead of print]

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Abstract PDF: Purpose
Continuous wound infiltration (CWI) has been introduced as a component of multimodal analgesia to counteract the adverse effects of the most frequently used opioids. Advantages of reduced-port laparoscopic surgery (RPLS) include cosmetic benefits and decreased postoperative pain. We aimed to investigate the effect of CWI in patients using intravenous (IV) patient-controlled analgesia (PCA) for pain management after RPLS for colorectal cancer.
Methods
This retrospective study included 25 patients who received both CWI (0.5% ropivacaine infused over 72 hours) and IV PCA (fentanyl citrate) and 52 patients who received IV PCA alone. The primary endpoint was pain scores on postoperative days (PODs) 0, 1, and 2. Univariate and multivariate analyses were conducted to determine the factors affecting the pain score on POD 0.
Results
On POD 0, the mean numeric rating scale score was significantly lower in the CWI group than in the control group (3.2±0.8 vs. 3.7±0.9, P=0.042). However, the scores were comparable between the groups during the rest of the period. Within 24 hours of surgery, the CWI group consumed fewer opioids (0.7±0.9 vs. 1.3±1.1, P=0.018) and more nonsteroidal anti-inflammatory drugs (2.0±1.4 vs. 1.3±1.4, P=0.046) than the control group. Time to removal of IV PCA was significantly longer in the CWI group than in the control group (4.4±1.6 days vs. 3.4±1.0 days, P=0.016).
Conclusion
CWI with ropivacaine and IV PCA was more effective than IV PCA alone in controlling postoperative pain within 24 hours of surgery, and opioid use could be reduced further.

New double-stapling technique without staple-crossing line in laparoscopic low anterior resection: effort to reduce anastomotic leakage: Nam Seok Kim, Ji Hoon Kim, Yoon Suk Lee, In Kyu Lee, Won Kyung Kang; Received June 8, 2022 Accepted November 21, 2023 Published online November 22, 2024; DOI: https://doi.org/10.3393/ac.2022.00409.0058 [Epub ahead of print]

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Abstract PDF: Purpose
This study aimed to demonstrate the safety of new double-stapling technique (nDST), without a crossing line and dog ears, by comparing with conventional DST (cDST) in laparoscopic low anterior resection (LAR).
Methods
We retrospectively reviewed 98 consecutive patients who underwent laparoscopic LAR for rectal cancer from January 2018 to December 2020. The inclusion criterion was an anastomosis level below the peritoneal reflection and 4 cm above the anal verge. In the nDST group, the staple line of the linear cutter was sutured using barbed sutures to shorten the staple line before firing the circular stapler. Therefore, there were no crossing lines after firing the circular stapler. A 2:1 propensity score matching was performed between the cDST and nDST groups.
Results
After propensity score matching, 39 patients were in the cDST group and 20 were in the nDST group. There were no significant differences in patient demographics between the 2 groups. There was no difference in the total operation time between the cDST and nDST groups (124.0±26.2 minutes vs. 125.2±20.3 minutes, P=0.853). Morbidity rates were similar between the 2 groups (9 cases [23.1%] vs. 5 cases [25.0%], P=0.855). There was no significant difference in leakage rate (4 cases [10.3%] vs. 1 case [5.0%], P=0.847) and anastomotic bleeding rate (1 case [2.6%] vs. 3 cases [15.0%], P=0.211).
Conclusion
The nDST to eliminate the crossing line and dog ears in laparoscopic LAR is technically feasible and safe. However, more attention should be paid to anastomotic bleeding in such cases.

Achieving a high cure rate in complex anal fistulas: understanding the conceptual role of the Garg cardinal principles: Pankaj Garg, Nicola Clemente, James C. W. Khaw; Ann Coloproctol. 2024;40(5):521-523. Published online October 25, 2024; DOI: https://doi.org/10.3393/ac.2024.00430.0061

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Colorectal cancer

Preventive efficacy of hydrocortisone enema for radiation proctitis in rectal cancer patients undergoing short-course radiotherapy: a phase II randomized placebo-controlled clinical trial: Mohammad Mohammadianpanah, Maryam Tazang, Nam Phong Nguyen, Niloofar Ahmadloo, Shapour Omidvari, Ahmad Mosalaei, Mansour Ansari, Hamid Nasrollahi, Behnam Kadkhodaei, Nezhat Khanjani, Seyed Vahid Hosseini; Ann Coloproctol. 2024;40(5):506-514. Published online October 22, 2024; DOI: https://doi.org/10.3393/ac.2024.00192.0027

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Abstract PDF: Purpose
This study aimed to investigate the efficacy of hydrocortisone enema in preventing radiation proctitis in patients with rectal cancer undergoing short-course radiotherapy (SCRT).
Methods
This phase II randomized controlled trial enrolled patients with newly diagnosed locally advanced rectal cancer (clinically staged T3–4 and/or N1–2M0). Participants received a median of 4 cycles of neoadjuvant chemotherapy (capecitabine plus oxaliplatin) followed by 3-dimensional conformal SCRT (25 Gy in 5 fractions). Patients were randomly assigned to receive either a hydrocortisone enema (n=50) or a placebo (n=51) once daily for 5 consecutive days during SCRT. The primary endpoint was the incidence and severity of acute proctitis.
Results
Of the 111 eligible patients, 101 were included in the study. Baseline characteristics, including sex, age, performance status, and tumor location, were comparable across the treatment arms. None of the patients experienced grade 4 acute gastrointestinal toxicity or had to discontinue treatment due to treatment-related adverse effects. Patients in the hydrocortisone arm experienced significantly less severe proctitis (P<0.001), diarrhea (P=0.023), and rectal pain (P<0.001) than those in the placebo arm. Additionally, the duration of acute gastrointestinal toxicity following SCRT was significantly shorter in patients receiving hydrocortisone (P<0.001).
Conclusion
Hydrocortisone enema was associated with a significant reduction in the severity of proctitis, diarrhea, and rectal pain compared to placebo. Additionally, patients treated with hydrocortisone experienced shorter durations of gastrointestinal toxicity following SCRT. This study highlights the potential benefits of hydrocortisone enema in managing radiation-induced toxicity in rectal cancer patients undergoing radiotherapy.

Anorectal benign disease

Proctitis distal to colorectal anastomosis: a retrospective cohort study of an underreported complication after sigmoidectomy: Ajmal Khan, Maziar Nikberg, Kenneth Smedh, Abbas Chabok; Ann Coloproctol. 2024;40(5):498-505. Published online October 22, 2024; DOI: https://doi.org/10.3393/ac.2023.00675.0096

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Abstract PDF: Purpose
Proctitis distal to colorectal anastomosis is rare and infrequently reported. We evaluated the incidence, symptoms, treatment, and potential risk factors associated with this condition.
Methods
We conducted a retrospective population-based cohort study in Västmanland County, Sweden. This investigation included all patients who underwent sigmoidectomy with colorectal anastomosis between 2008 and 2020. We excluded patients without an anastomosis and those with inflammatory bowel disease.
Results
Of the 546 patients identified, 233 fulfilled the inclusion criteria, of whom 26 (11.2%) developed proctitis distal to colorectal anastomosis. The most frequent symptoms included urgency (n=16, 61.5%), increased stool frequency (n=12, 46.2%), and anorectal pain (n=12, 46.2%). Endoscopic balloon dilation was performed in 20 cases (76.9%), with 10 requiring only a single therapeutic procedure. The median number of dilations was 3 (range, 1–8). Multivariable analysis revealed that surgery due to malignancy and emergency surgery were associated with elevated risk of proctitis. A subgroup analysis of patients who underwent surgery due to malignancy indicated that smoking (odds ratio, 3.9; 95% confidence interval, 1.1–14.0) and emergency surgery (odds ratio, 6.5; 95% confidence interval, 1.1–37.1) were also associated with increased proctitis risk.
Conclusion
Proctitis distal to colorectal anastomosis is not uncommon following sigmoidectomy. Patients undergoing emergency surgery or surgery due to malignancy and who had a history of smoking displayed an increased risk of developing proctitis. Due to the paucity of symptoms observed, particularly in patients with a diverting stoma, routine endoscopic rectal examination should be performed during follow-up after sigmoidectomy.

Technical tips

A unique surgical approach to the management of life-threatening, obscure lower gastrointestinal bleeding: Nelson Chen, Tessa Daly, Neil Strugnell, Russell Hodgson, David Bird; Ann Coloproctol. 2024;40(5):515-518. Published online October 17, 2024; DOI: https://doi.org/10.3393/ac.2024.00101.0014

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Early detection of anastomotic leakage in colon cancer surgery: the role of early warning score and C-reactive protein: Gyung Mo Son; Ann Coloproctol. 2024;40(5):415-416. Published online October 16, 2024; DOI: https://doi.org/10.3393/ac.2024.00661.0094

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Complication

Early warning model to detect anastomotic leakage following colon surgery: a clinical observational study: Pooya Rajabaleyan, Ravish Jootun, Sören Möller, Ulrik Deding, Mark Bremholm Ellebæk, Issam al-Najami, Ian Lindsey; Ann Coloproctol. 2024;40(5):431-439. Published online October 8, 2024; DOI: https://doi.org/10.3393/ac.2023.00745.0106

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Graphical Abstract Abstract PDF

Purpose
We aimed to develop a predictive tool for anastomotic leakage (AL) following colon cancer surgery by combining a clinical early warning score (EWS) with the C-reactive protein (CRP) level.
Methods
The records of 1,855 patients who underwent colon cancer surgery at the Oxford University Hospitals NHS Foundation Trust between January 2013 and December 2018, with or without AL, were retrospectively reviewed. EWS and CRP levels were assessed daily from the first postoperative day until discharge. AL was defined as an anastomotic defect observed at reoperation, the presence of feculent fluid in a pelvic drain, or evidence of AL on computed tomography. The tool incorporated postoperative EWS and CRP levels for the accurate early detection of AL.
Results
From postoperative days 3 to 7, the mean CRP level exceeded 200 mg/L in patients with AL and was under 200 mg/L in those without AL (P<0.05). From postoperative days 1 to 5, the mean EWS among patients with leakage exceeded 2, while scores were below 2 among those without leakage (P<0.05). Receiver operating characteristic curve analysis identified postoperative day 3 as the most predictive of early leakage, with cutoff values of 2.4 for EWS and 180 mg/L for CRP; this yielded an area under the curve of 0.87 (sensitivity, 90%; specificity, 70%).
Conclusion
We propose using an EWS of 2.4 and a CRP level of 180 mg/L on postoperative day 3 following colon surgery with anastomosis as threshold values to prompt investigation and treatment of AL.

Citations

Citations to this article as recorded by

Early detection of anastomotic leakage in colon cancer surgery: the role of early warning score and C-reactive protein
Gyung Mo Son
Annals of Coloproctology.2024; 40(5): 415. CrossRef
Predictive Biomarkers for the Early Detection of Anastomotic Leaks in Colorectal Surgeries: A Systematic Review
Wahidullah Dost, Mohammad Qaher Rasully , Mohammad Nazir Zaman, Wahida Dost, Wahida Ali, Sami A Ayobi, Raisa Dost, Jamaluddin Niazi, Kinza Bakht, Asma Iqbal, Syed Faqeer Hussain Bokhari
Cureus.2024;[Epub] CrossRef

ERAS

Impact of an Enhanced Recovery After Surgery (ERAS) program on the management of complications after laparoscopic or robotic colectomy for cancer: Victoria Weets, Hélène Meillat, Jacques Emmanuel Saadoun, Marie Dazza, Cécile de Chaisemartin, Bernard Lelong; Ann Coloproctol. 2024;40(5):440-450. Published online September 20, 2024; DOI: https://doi.org/10.3393/ac.2023.00850.0121

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Graphical Abstract Abstract PDF Supplementary Material: Purpose
Enhanced Recovery After Surgery (ERAS) reduces postoperative complications (POCs) after colorectal surgery; however, its impact on the management of POCs remains unclear. This study compared the diagnosis and management of POCs before and after implementing our ERAS protocol after laparoscopic or robotic colectomy for cancer and examined the short- and mid-term oncologic impacts.
Methods
This single-center, retrospective study evaluated all consecutive patients who underwent laparoscopic or robotic colectomy for cancer between 2012 and 2021, focusing on the incidence of POCs within 90 days. We compared outcomes before (standard group) and after (ERAS group) the implementation of our ERAS protocol in January 2016.
Results
Significantly fewer patients in the ERAS group developed POCs (standard vs. ERAS, 136 of 380 patients [35.8%] vs.136 of 660 patients [20.6%]; P<0.01). The ERAS group had a significantly shorter mean total length of stay after POCs (13.1 days vs. 11.4 days, P=0.04), and the rates of life-threatening complications (6.7% vs. 0.7%) and 1-year mortality (7.4% vs. 1.5%) were significantly lower in the ERAS group than in the standard group. Among patients with anastomotic complications, laparoscopic reoperation was significantly more common in the ERAS group than in the standard group (8.3% vs. 75.0%, P<0.01). Among patients with postoperative ileus, the diagnosis and recovery times were significantly shorter in the ERAS group than in the standard group, resulting in a shorter total length of stay (13.5 days vs. 10 days, P<0.01).
Conclusion
The implementation of an ERAS protocol did not eliminate all POCs, but it did accelerate their diagnosis and management and improved patient outcomes.

Colorectal cancer

The impact of short-course total neoadjuvant therapy, long-course chemoradiotherapy, and upfront surgery on the technical difficulty of total mesorectal excision: an observational study with an intraoperative perspective: Cheryl Xi-Zi Chong, Frederick H. Koh, Hui-Lin Tan, Sharmini Su Sivarajah, Jia-Lin Ng, Leonard Ming-Li Ho, Darius Kang-Lie Aw, Wen-Hsin Koo, Shuting Han, Si-Lin Koo, Connie Siew-Poh Yip, Fu-Qiang Wang, Fung-Joon Foo, Winson Jianhong Tan; Ann Coloproctol. 2024;40(5):451-458. Published online September 19, 2024; DOI: https://doi.org/10.3393/ac.2023.00899.0128

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Abstract PDF Supplementary Material: Purpose
Total neoadjuvant therapy (TNT) is becoming the standard of care for locally advanced rectal cancer. However, surgery is deferred for months after completion, which may lead to fibrosis and increased surgical difficulty. The aim of this study was to assess whether TNT (TNT-RAPIDO) is associated with increased difficulty of total mesorectal excision (TME) compared with long-course chemoradiotherapy (LCRT) and upfront surgery.
Methods
Twelve laparoscopic videos of low anterior resection with TME for rectal cancer were prospectively collected from January 2020 to October 2021, with 4 videos in each arm. Seven colorectal surgeons assessed the videos independently, graded the difficulty of TME using a visual analog scale and attempted to identify which category the videos belonged to.
Results
The median age was 67 years, and 10 patients were male. The median interval to surgery from radiotherapy was 13 weeks in the LCRT group and 24 weeks in the TNT-RAPIDO group. There was no significant difference in the visual analog scale for difficulty in TME between the 3 groups (LCRT, 3.2; TNT-RAPIDO, 4.6; upfront, 4.1; P=0.12). A subgroup analysis showed similar difficulty between groups (LCRT 3.2 vs. TNT-RAPIDO 4.6, P=0.05; TNT-RAPIDO 4.6 vs. upfront 4.1, P=0.54). During video assessments, surgeons correctly identified the prior treatment modality in 42% of the cases. TNT-RAPIDO videos had the highest recognition rate (71%), significantly outperforming both LCRT (29%) and upfront surgery (25%, P=0.01).
Conclusion
TNT does not appear to increase the surgical difficulty of TME.

Colorectal cancer

The role of lateral pelvic lymph node dissection in advanced rectal cancer: a review of current evidence and outcomes: Gyu-Seog Choi, Hye Jin Kim; Ann Coloproctol. 2024;40(4):363-374. Published online August 30, 2024; DOI: https://doi.org/10.3393/ac.2024.00521.0074

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Abstract PDF

Metastatic lateral pelvic lymph nodes (LPNs) in rectal cancer significantly impact the prognosis and treatment strategies. Western practices emphasize neoadjuvant chemoradiotherapy (CRT), whereas Eastern approaches often rely on LPN dissection (LPND). This review examines the evolving role of LPND in the context of modern treatments, including total neoadjuvant therapy (TNT), and the impact of CRT on the management of clinically suspicious LPNs. We comprehensively reviewed the key literature comparing the outcomes of LPND versus preoperative CRT for rectal cancer, focusing on recent advancements and ongoing debates. Key studies, including the JCOG0212 trial and recent multicenter trials, were analyzed to assess the efficacy of LPND, particularly in conjunction with preoperative CRT or TNT. Current evidence indicates that LPND can reduce local recurrence rates compared to total mesorectal excision alone in patients not receiving radiation therapy. However, the benefit of LPND in the context of neoadjuvant CRT is influenced by the size and pretreatment characteristics of LPNs. While CRT can effectively control smaller metastatic LPNs, larger or clinically suspicious LPNs may require LPND for optimal outcomes. Advances in surgical techniques, such as robotic-assisted LPND, offer potential benefits but also present challenges and complications. The role of TNT in controlling metastatic LPNs and improving patient outcomes is emerging but remains underexplored. The decision to perform LPND should be individualized based on patient-specific factors, including LPN size, response to neoadjuvant treatment, and surgeon expertise. Future research should focus on optimizing treatment protocols and further evaluating the role of TNT in managing metastatic LPNs.

Citations

Citations to this article as recorded by

From the Editor: Uniting expertise, a new era of global collaboration in coloproctology
In Ja Park
Annals of Coloproctology.2024; 40(4): 285. CrossRef

From the Editor: Uniting expertise, a new era of global collaboration in coloproctology: In Ja Park; Ann Coloproctol. 2024;40(4):285-286. Published online August 30, 2024; DOI: https://doi.org/10.3393/ac.2024.00514.0073

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