Lymph node metastasis is regarded as an indubitable prognostic factor for predicting disease recurrence and survival in patients with colorectal cancer. Lymph node status based on examination of a resected specimen is a key element of the current staging system and is also a crucial factor to determine use of adjuvant chemotherapy after surgical resection. However, the current tumor-node-metastasis (TNM) staging system only incorporates the number of metastatic lymph nodes in the N category. Numerous attempts have been made to supplement this simplified N staging including lymph node ratio, distribution of metastatic lymph nodes, tumor deposits, or extracapsular invasion. In addition, several attempts have been made to identify more specific prognostic factors in resected colorectal specimens than lymph node status. In this review, we will discuss controversies in lymph node staging and factors that may influence survival beyond lymph node status.
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Purpose Despite the minimally invasive nature of transanal hemorrhoidal dearterialization (THD) with Doppler arterial identification procedures, hemorrhoidectomy is still considered the gold standard procedure for hemorrhoidal disease. However, the classical techniques of hemorrhoidectomy have a high rate of postoperative complications. The main purpose of this study is to demonstrate the efficacy and complications of these techniques used for grades II and III hemorrhoids.
Methods A retrospective (case-control) study was carried out from January 2009 to May 2014, and all patients undergoing surgical procedures for hemorrhoidal disease in two French clinics were considered. Application of inclusion and exclusion criteria identified 270 eligible patients (163 undergoing Doppler THD and 107 treated with Milligan Morgan hemorrhoidectomy). Statistical analysis was calculated considering immediate postoperative complications, functional results, chronic complications, and recurrences.
Results Analysis of primary outcomes showed a significant difference between the 2 groups concerning postoperative pain, which had a lower rate in THD (P = 0.0001) and in postoperative bleeding (P = 0.02) than hemorrhoidectomy. However, long-term follow-up at three years showed a superior rate of recurrence in the THD group (P = 0.009).
Conclusion The THD technique is a safe and effective procedure for grades II and III hemorrhoids, has lower rates of post-operative pain and bleeding, and allows faster hospital discharge; however, it also shows a higher rate of recurrence at three years of follow-up.
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Purpose Bioprosthetic plugs are appealing, allow simple, repeatable applications, preserve sphincter integrity, minimize patient discomfort, and allow subsequent surgical options when needed. However, success rates vary widely. This study assessed the healing rate in our department when both the Cook-Surgisis and the Gore fistula plugs were used and the long-term effectiveness of using anal plugs for managing anal fistulae.
Methods A chart review was performed for patients who had undergone plug insertion between January 2008 and December 2015 at Copenhagen University Hospital, Hvidovre. Data were collected through a prospectively collected database. Plugs were inserted according to guidance provided by 2 experienced surgeons. Long-term results were determined by clinical visits 3, 6, and 12 months after surgery and once yearly thereafter.
Results From 2008 to 2015, 36 fistula plugs were inserted. During the follow-up period with a median duration of 18 months (range, 7–60 months), the fistulae of 52.8% of the patients healed. The plug failure rate was 44.4%, and the fistula recurrence rate was 26.3%. The median time to recurrence was 12 months. The overall success rate for plug treatment in our department was 39% when adjusted for recurrence.
Conclusion The use of bioprosthetic plugs to treat patients with complex anal fistulae seems to be a safe, viable option for complex fistula repair when other surgical attempts have failed. However, it should not be the treatment of choice. Further prospective randomized studies with a sufficient sample-size and standardized measurements are necessary to evaluate the efficacy of fistula plugs fully.
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Purpose Inadequate bowel preparation (IBP) is commonly observed during surveillance colonoscopy after colorectal resection. We investigated potential risk factors affecting bowel preparation.
Methods We studied potential factors affecting bowel preparation quality. The Boston bowel preparation score was used to measure bowel preparation quality. Factors affecting IBP were analyzed, including age, body mass index, time elapsed between surgery and colonoscopy, and amount of bowel preparation drug consumed (conventional-volume vs. low-volume). Odds ratios were calculated for IBP.
Results This retrospective cohort study included 1,317 patients who underwent colorectal resection due to malignancy. Of these patients, 79% had adequate bowel preparation and 21% had IBP. In multivariate regression analysis, a surveillance colonoscopy within 1 year after surgery and age >80 were used as independent predictors of IBP. IBP rate of the low-volume group was significantly higher than that of the conventional-volume group among patients who underwent a surveillance colonoscopy within 1 year after surgery.
Conclusion For surveillance colonoscopy after colorectal resection, bowel preparation is affected by factors including colonoscopy timing after surgery and age. We recommend the use of conventional-volume 4-L polyethylene glycol solution when performing a surveillance colonoscopy, especially up to 1 year after surgery.
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Purpose The aim of this study was to assess oncological outcomes of postoperative radiotherapy plus chemotherapy (CRT) versus chemotherapy alone (CTx) in stage II or III upper rectal cancer patients who underwent curative surgery.
Methods We retrospectively reviewed 263 consecutive patients with pathologic stage II or III upper rectal cancer who underwent primary curative resection with postoperative CRT or CTx from January 2008 to December 2014 at Chonnam National University Hwasun Hospital. Multivariate and propensity score matching analyses were used to reduce selection bias.
Results Median follow-up was 48.1 months for the entire cohort and 53.5 months for the matched cohort. In subgroup analysis of the propensity score matched cohort, the 3-year local recurrence-free survival was 94.1% (95% confidence interval [CI], 87.8%–100%) in the CRT group and 90.1% (95% CI, 82.8%–97.9%) in the CTx group (P = 0.370). No significant difference in disease-free survival was observed according to treatment type. On multivariate analysis, circumferential resection margin involvement (hazard ratio [HR], 2.386; 95% CI, 1.190–7.599; P = 0.032), N stage (HR, 6.262; 95% CI, 1.843–21.278, P = 0.003), and T stage (HR, 5.896, 95% CI, 1.298–6.780, P = 0.021) were identified as independent risk factors for local recurrence of tumors of the upper rectum.
Conclusion Omission of radiotherapy in an adjuvant treatment setting may not jeopardize oncologic outcomes in stages II and III upper rectal cancer.
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Ann Coloproctol. 2019;35(3):144-151. Published online June 30, 2019
Purpose The most common risk factor for fecal incontinence (FI) is obstetric injury. FI affects 1.4%–18% of adults. Most patients are unaware when they are young, when symptoms appear suddenly and worsen with aging. Autologous fat graft is widely used in cosmetic surgical field and may substitute for injectable bulky agents in treating FI. Authors have done fat graft for past several years. This article reports the effectiveness of the fat graft in treating FI and discusses satisfaction with the procedure.
Methods Fat was harvested from both lateral thighs using 10-mL Luer-loc syringe. Pure fat was extracted from harvests and mixed with fat, oil, and tumescent through refinement. Fats were injected into upper border of posterior ano-rectal ring, submucosa of anal canal and intersphincteric space. Thirty-five patients with FI were treated with this method from July 2016 to February 2017 in Busan Hangun Hospital. They were 13 male (mean age, 60.8 years) and 22 female patients (mean age, 63.3 years). The Wexner score was checked before procedure. We evaluated outcome in outpatients by asking the patients. For 19 patients we checked the Wexner score after procedure.
Results Symptom improved in 29 (82.9%), and not improved in 6 (17.1%). In 2 of 6 patients, they felt better than before procedure, although not satisfied. No improvement in 4. Mean Wexner score was 9.7 before procedure. There were no serious complications such as inflammation or fat embolism.
Conclusion Autologous fat graft can be an effective alternative treatment for FI. It is safe and easy to perform, and cost effective.
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