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Aim: The choice of whether to perform protective ileostomy (PI) after anterior resection (AR) is mainly guided by risk factors (RFs) responsible for the development of anastomotic leakage (AL). However, clear guidelines about PI creation are still lacking in the literature and this is often decided according to the surgeon's preferences, experiences or feelings. This qualitative study aims to investigate, by an open-ended question survey, the individual surgeon's decision-making process regarding PI creation after elective AR. Method: Fifty four colorectal surgeons took part in an electronic survey to answer the questions and describe what usually led their decision to perform PI. A content analysis was used to code the answers. To classify answers, five dichotomous categories (In favour/Against PI, Listed/Unlisted RFs, Typical/Atypical, Emotions/Non-emotions, Personal experience/No personal experience) have been developed. Results: Overall, 76% of surgeons were in favour of PI creation and 88% considered listed RFs in the question of whether to perform PI. Atypical answers were reported in 10% of cases. Emotions and personal experience influenced surgeons' decision-making process in 22% and 49% of cases, respectively. The most frequently considered RFs were the distance of the anastomosis from the anal verge (96%), neoadjuvant chemoradiotherapy (88%), a positive intraoperative leak test (65%), blood loss (37%) and immunosuppression therapy (35%). Conclusion: The indications to perform PI following rectal cancer surgery lack standardization and evidence-based guidelines are required to inform practice. Until then, expert opinion can be helpful to assist the decision-making process in patients who have undergone AR for adenocarcinoma.

ObjectiveWhile appendectomy may reduce colorectal inflammation in patients with ulcerative colitis (UC), appendectomy has been suggested to be associated with an increased risk of colitis-associated cancer (CAC). The aim of this study was to explore the mechanism underlying the appendectomy-associated increased risk of CAC.DesignFive-week-old male BALB/c mice underwent appendectomy, appendicitis induction or sham laparotomy. They were then exposed to azoxymethane/dextran sodium sulfate (AOM/DSS) to induce CAC. Mice were sacrificed 12 weeks later, and colons were taken for pathological analysis and immunohistochemistry (CD3 and CD8 staining). Human colonic tumors from 21 UC patients who underwent surgical resection for CAC were immunophenotyped and stratified according to the appendectomy status.ResultsWhile appendectomy significantly reduced colitis severity and increased CAC number, appendicitis induction without appendectomy led to opposite results. Intra-tumor CD3+ and CD8+ T-cell densities were lower after appendectomy and higher after appendicitis induction compared to the sham laparotomy group. Blocking lymphocyte trafficking to the colon with the anti-α4β7 integrin antibody or a sphingosine-1-phosphate receptor agonist suppressed the inducing effect of the appendectomy on tumors’ number and on CD3+/CD8+ intra-tumoral density. CD8+ or CD3+ T cells isolated from inflammatory neo-appendix and intravenously injected into AOM/DSS-treated recipient mice increased CD3+/CD8+ T-cell tumor infiltration and decreased tumor number. In UC patients with a history of appendectomy, intra-tumor CD3+ and CD8+ T-cell densities were decreased compared to UC patients without history of appendectomy.ConclusionsIn UC, appendectomy could suppress a major site of T-cell priming resulting in a less efficient CAC immunosurveillance.Significance of this studyWhat is already known on this subject?The protective effect of preemptive appendectomy is currently investigated as a therapy for refractory ulcerative colitis (UC), with encouraging results.An increased risk of developing colitis-associated cancer (CAC) caused by this promising treatment has been identified.Since it is commonly accepted that CAC is related to colitis severity and extent, this finding is counterintuitive and the mechanisms of this paradoxical effect remain unknown.What are the new findings?In a mouse model of CAC, less extended colitis associated with an increased number of tumors was observed. Intra-tumor T-cell infiltration was significantly reduced after appendectomy. Blocking lymphocyte trafficking to the colon with current or experimental UC treatments mimicked the appendectomy-associated phenotype whereas neo-appendicitis or appendix-primed T-cell injection in recipient mice increased intra-tumor T-cell infiltration and strengthened protection against CAC.In UC patients with CAC, appendectomy was associated with a decreased intra-tumor T-cell infiltration.These findings suggest that, in UC, appendectomy could suppress a major site of T-cell priming in the colon, resulting in a reduced CAC immunosurveillance.How might it impact on clinical practice in the foreseeable future?This work emphasizes the fact that precautions will be necessary if appendectomy becomes an accepted therapeutic option for the treatment of refractory UC.Innovative cell-based therapies and immunotherapies, such as the administration of stimulated autologous appendicular T cells in patients with CAC are promising options.

Several papers have been published about the risk of recurrence after an attack of diverticulitis treated conservatively. However, very few papers have been devoted to the risk of postoperative recurrence of diverticulitis (PRD) after prophylactic sigmoidectomy (PS). The aim of this work was to report the rate of PRD after PS and to assess possible risk factors for recurrence after surgery.All consecutive patients who underwent elective laparoscopic PS for diverticulitis between 2005 and 2019 were retrospectively included. PRD was assessed.Three hundred and sixty four patients (199 men, mean age 54 ± 13 years) were included. Among these, 26 (7%) presented with 1.7 ± 1 (range 1-4) episodes of recurrence of diverticulitis after a mean delay of 44 ± 39 months (1 month-11 years) after surgery. Patients who presented with postoperative recurrence of diverticulitis were younger (46 ± 11 vs. 55 ± 13 years, p = 0.002) and more frequently had uncomplicated diverticulitis [15/26 (58%) vs. 97/338 (29%), p = 0.002] and more than two previous episodes before PS [17/26 (65%) vs. 132/338 (39%), p = 0.009] than patients without PRD. After multivariate analysis, two independent risk factors for PRD were identified: patients with more than two episodes before PS (OR = 3.3, 95% CI = 1.2-9, p = 0.005) and age 50 years (OR = 4.5, 95% CI = 2-11, p = 0.001). If both factors were present, recurrence reached 18% (9/51).Postoperative recurrence of diverticulitis is rare (7%) after PS for diverticulitis. Some patients (i.e. those with more than two episodes before PS and/or age50 years) could be exposed to a higher risk of recurrence (up to 18%), making prophylactic surgery questionable in these patients.

Supplementary Figure 2 from Controlling Tumor Growth by Modulating Endogenous Production of Reactive Oxygen Species

Paradoxically, reactive oxygen species (ROS) can promote normal cellular proliferation and carcinogenesis, and can also induce apoptosis of tumor cells. In this report, we study the contribution of ROS to various cellular signals depending on the nature and the level of ROS produced. In nontransformed NIH 3T3 cells, ROS are at low levels and originate from NADPH oxidase. Hydrogen peroxide (H2O2), controlled by the glutathione system, is pivotal for the modulation of normal cell proliferation. In CT26 (colon) and Hepa 1-6 (liver) tumor cells, high levels of ROS, close to the threshold of cytotoxicity, are produced by mitochondria and H2O2 is controlled by catalase. N-acetylcysteine, which decreases H2O2 levels, inhibits mitogen-activated protein kinase and normal cell proliferation but increases tumor cell proliferation as H2O2 concentration drops from the toxicity threshold. In contrast, antioxidant molecules, such as mimics of superoxide dismutase (SOD), increase H2O2 levels through superoxide anion dismutation, as well as in vitro proliferation of normal cells, but kill tumor cells. CT26 tumors were implanted in mice and treated by oxaliplatin in association with one of the three SOD mimics manganese(III)tetrakis(4-benzoic acid) porphyrin, copper(II)(3,5-diisopropylsalicylate)2, or manganese dipyridoxyl diphosphate. After 1 month, the volumes of tumors were respectively 35%, 31%, and 63% smaller than with oxaliplatin alone (P < 0.001). Similar data were gained with Hepa 1-6 tumors. In conclusion, antioxidant molecules may have opposite effects on tumor growth. SOD mimics can act in synergy with cytotoxic drugs to treat colon and liver cancers.

Supplementary Figure 1 from Controlling Tumor Growth by Modulating Endogenous Production of Reactive Oxygen Species

Supplementary Figure 3 from Controlling Tumor Growth by Modulating Endogenous Production of Reactive Oxygen Species

This study aimed to investigate the prevalence, risk factors, and outcomes of colonic involvement in patients with acute mesenteric ischemia (AMI). CT scans from a prospective cohort of 114 AMI patients treated in an intestinal stroke center between 2009 and 2018 were blindly reviewed by two radiologists. Colon involvement was defined on CT scan by the presence of at least one of the following CT colonic features: wall thickening, pneumatosis, decreased wall enhancement, dilatation, or perforation. In addition, the clinical, biological, and radiological characteristics of patients with and without colonic involvement were compared to identify risk factors for colonic involvement on CT and its impact on morbidity and mortality. Colonic involvement was identified in 32/114 (28%) patients with AMI, the right colon being more frequently involved (n = 29/32, 91%). Wall thickening (n = 27/32) was the most common CT finding. Occlusion of the inferior mesenteric artery was the only statistically significant risk factor for colonic involvement (35% vs. 15%, p = 0.02). Patients with colonic involvement on CT vs. those without had more frequently transmural colonic necrosis (13% vs. 0%, p = 0.006), short bowel syndrome (16% vs. 4%, p = 0.04), need for long-term parenteral support (19% vs. 5%, p = 0.03), and death during follow-up (22% vs. 10%, p = 0.03). In patients with AMI, colonic involvement is associated with increased morbidity and mortality and should be carefully searched for during initial CT scan assessment. • In a prospective cohort of acute mesenteric ischemia patients from an intestinal stroke center, 28% had an associated colonic involvement on CT. • Colonic involvement on CT most commonly affected the right colon, and the occlusion of the inferior mesenteric artery was the only risk factor. • Colonic involvement on CT was associated with increased morbidity and mortality and should be carefully searched for during initial CT scan assessment.

Lay Summary Clinical decision-making in the treatment of patients with obstructed defaecation remains controversial and no international guidelines have been provided so far. This study reports a consensus among European opinion leaders on the management of obstructed defaecation in different possible clinical scenarios.Management of obstructed defaecation is challenging and remains controversial. No international guidelines have been published.

Objective To investigate whether oral antimicrobial prophylaxis as an adjunct to intravenous antibiotic prophylaxis reduces surgical site infections after elective colorectal surgery. Design Multicentre, randomised, double blind, placebo controlled trial. Setting 11 university and non-university hospitals in France between 25 May 2016 and 8 August 2019. Participants 926 adults scheduled for elective colorectal surgery. Intervention Patients were randomised to receive either a single 1 g dose of ornidazole (n=463) or placebo (n=463) orally 12 hours before surgery, in addition to intravenous antimicrobial prophylaxis before surgical incision. Main outcome measures The primary outcome was the proportion of patients with surgical site infection within 30 days after surgery. Secondary outcomes included individual types of surgical site infections and major postoperative complications (Clavien-Dindo classification grade 3 or higher) within 30 days after surgery. Results Of the 960 patients who were enrolled, 926 (96%) were included in the analysis. The mean age of participants was 63 years and 554 (60%) were men. Surgical site infection within 30 days after surgery occurred in 60 of 463 patients (13%) in the oral prophylaxis group and 100 of 463 (22%) in the placebo group (absolute difference −8.6%, 95% confidence interval −13.5% to −3.8%; relative risk 0.60, 95% confidence interval 0.45 to 0.80). The proportion of patients with deep infections was 4.8% in the oral prophylaxis group and 8.0% in the placebo group (absolute difference −3.2%, 95% confidence interval −6.4% to −0.1%). The proportion of patients with organ space infections was 5.0% in the oral prophylaxis group and 8.4% in the placebo group (absolute difference −3.4%, −6.7% to −0.2%). Major postoperative complications occurred in 9.1% patients in the oral prophylaxis group and 13.6% in the placebo group (absolute difference −4.5%, −8.6% to −0.5%). Conclusion Among adults undergoing elective colorectal surgery, the addition of a single 1 g dose of ornidazole compared with placebo before surgery significantly reduced surgical site infections. Trial registration ClinicalTrials.gov NCT02618720 .

The optimal elective colectomy in patients with splenic flexure tumor is debated.This study aimed to compare splenic flexure colectomy, left hemicolectomy, and subtotal colectomy for perioperative, histological, and survival outcomes in this setting.This is a multicenter retrospective cohort study.Patients diagnosed with nonmetastatic splenic flexure tumor who underwent elective colectomy were included.Between 2006 and 2014, 313 consecutive patients were operated on in 15 French Research Group of Rectal Cancer Surgery centers.Propensity score weighting was performed to compare short- and long-term outcomes.The primary end point was disease-free survival. Secondary end points included overall survival, quality of surgical resection, overall postoperative morbidity, surgical postoperative morbidity, and rate of anastomotic leakage.The most performed surgery was splenic flexure colectomy (59%), followed by subtotal colectomy (23%) and left hemicolectomy (18%). Subtotal colectomy was more often performed by laparotomy compared with splenic flexure colectomy and left hemicolectomy (93% vs 61% vs 56%, p0.0001), and was associated with a longer operative time (260 minutes (120-460) vs 180 minutes (68-440) vs 217 minutes (149-480), p0.0001). Postoperative morbidity was similar between the 3 groups, but the median length of hospital stay was significantly longer after subtotal colectomy (13 days (5-56) vs 10 (4-175) vs 9 (4-55), p = 0.0007). The median number of harvested lymph nodes was significantly higher after subtotal colectomy compared with splenic flexure colectomy and left hemicolectomy (24 (8-90) vs 15 (1-81) vs 16 (3-52), p0.0001). The rate of stage III disease and the number of patients treated by adjuvant chemotherapy were similar between the 3 groups. There was no difference in terms of disease-free survival and overall survival between the 3 procedures.The study was limited by its retrospective design.In the elective setting, splenic flexure colectomy is safe and oncologically adequate for patients with nonmetastatic splenic flexure tumor. However, given the oncological clearance after splenic flexure colectomy, it seems that the debate is not completely closed. See Video Abstract at http://links.lww.com/DCR/B703.ANTECEDENTES:La colectomía electiva óptima en pacientes con tumores del ángulo esplénico continua en debate.OBJETIVO:Comparar la colectomía de ángulo esplénico, hemicolectomía izquierda y colectomía subtotal para los resultados perioperatorios, histológicos y de supervivencia en este escenario.DISEÑO:Estudio de cohorte retrospectivo multicéntrico.ESCENARIO:Se incluyeron pacientes diagnosticados de tumores del ángulo esplénico no metastásicos que se sometieron a colectomía electiva.PACIENTES:Entre 2006 y 2014, 313 pacientes consecutivos fueron intervenidos en 15 centros GRECCAR.INTERVENCIONES:Se realizó una ponderación del puntaje de propensión para comparar los resultados a corto y largo plazo.PRINCIPALES MEDIDAS DE RESULTADO:El criterio de valoración principal fue la supervivencia libre de enfermedad. Los criterios de valoración secundarios incluyeron la supervivencia general, la calidad de la resección quirúrgica, la morbilidad posoperatoria general, la morbilidad posoperatoria quirúrgica y la tasa de fuga anastomótica.RESULTADOS:La cirugía más realizada fue la colectomía del ángulo esplénico (59%), seguida de la colectomía subtotal (23%) y la hemicolectomía izquierda (18%). La colectomía subtotal se realizó con mayor frecuencia mediante laparotomía en comparación con la colectomía de ángulo esplénico y la hemicolectomía izquierda (93% frente a 61% frente a 56%, p0.0001), y se asoció con un tiempo quirúrgico más prolongado (260 min [120-460] frente a 180 min [68-440] frente a 217 min [149-480], p0.0001). La morbilidad posoperatoria fue similar entre los tres grupos, pero la duración media de la estancia hospitalaria fue significativamente más prolongada después de la colectomía subtotal (13 días [5-56] frente a 10 [4-175] frente a 9 [4-55], p = 0.0007). La mediana del número de ganglios linfáticos extraídos fue significativamente mayor después de la colectomía subtotal en comparación con la colectomía del ángulo esplénico y la hemicolectomía izquierda (24 [8-90] frente a 15 [1-81] frente a 16 [3-52], p0.0001). La tasa de enfermedad en estadio III y el número de pacientes tratados con quimioterapia adyuvante fueron similares entre los 3 grupos. No hubo diferencias en términos de supervivencia libre de enfermedad y supervivencia general entre los 3 procedimientos.LIMITACIONES:El estudio estuvo limitado por su diseño retrospectivo.CONCLUSIONES:En un escenario electivo, la colectomía del ángulo esplénico es segura y oncológicamente adecuada para pacientes con tumores del ángulo esplénico no metastásicos. Sin embargo, dado el aclaramiento oncológico tras la colectomía del ángulo esplénico, parece que el debate no está completamente cerrado. Consulte Video Resumen en http://links.lww.com/DCR/B703.

Background and Aims Crohn’s disease increases colorectal cancer risk, with high prevalence of synchronous and metachronous cancers. Current guidelines for colorectal cancer in Crohn’s disease recommend pan-proctocolectomy. The aim of this study was to evaluate oncological outcomes of a less invasive surgical approach. Methods This was a retrospective database analysis of Crohn’s disease patients with colorectal cancer undergoing surgery at selected European and US tertiary centres. Outcomes of segmental colectomy were compared with those of extended colectomy, total colectomy, and pan-proctocolectomy. Primary outcome was progression-free survival. Secondary outcomes included overall survival, synchronous and metachronous colorectal cancer, and major postoperative complications. Results Ninety-nine patients were included: 66 patients underwent segmental colectomy and 33 extended colectomy. Segmental colectomy patients were older [p = 0.0429], had less extensive colitis [p = 0.0002] and no preoperatively identified synchronous lesions [p = 0.0109]. Median follow-up was 43 [31–62] months. There was no difference in unadjusted progression-free survival [p = 0.2570] or in overall survival [p = 0.4191] between segmental and extended colectomy. Multivariate analysis adjusting for age, sex, ASA score, and AJCC staging, confirmed no difference for progression-free survival (hazard ratio [HR] 1.00, p = 0.9993) or overall survival [HR 0.77, p = 0.6654]. Synchronous and metachronous cancers incidence was 9% and 1.5%, respectively. Perioperative mortality was nil and major complications were comparable [7.58% vs 6.06%, p = 0.9998]. Conclusions Segmental colectomy seems to offer similar long-term outcomes to more extensive surgery. Incidence of synchronous and metachronous cancers appears much lower than previously described. Further prospective studies are warranted to confirm these results.

Background The extent of resection in colonic Crohn’s disease [cCD] is still a topic of debate, depending on the number of locations, the risk of recurrence and permanent stoma, and the role of medical therapy. Methods The Segmental COlecTomy for CroHn’s disease [SCOTCH] international study is a retrospective analysis on six tertiary centre prospective databases, comprising all consecutive, unselected patients operated on between 2000 and 2019 with segmental colectomy [SC] or total colectomy [TC] for cCD. The primary aim was long-term surgical recurrence. Secondary aims were perioperative complications, stoma formation and predictors of recurrence. Results Among 687 patients, SC was performed in 285 [41.5%] and TC in 402 [58.5%]. Mean age at diagnosis and surgery, disease duration, and follow-up were 30 ± 15.8, 40.4 ± 15.4, 10.4 ± 8.6 and 7.1 ± 5.2 years respectively. Isolated cCD, inflammatory pattern, perianal CD, younger age, longer disease duration and preoperative maximal therapy were more frequent in TC, while SC presented more small bowel locations and perforating disease, required fewer 90-day re-admissions, and fewer temporary and definitive stomas. Morbidity and mortality were similar. The 15-year surgical recurrence was 44% in TC and 27% in SC [p = 0.006]. In patients with one to three diseased segments, recurrence risk was related to the omission of biological therapy (hazard ratio [HR] 5.6), the number of segments [HR 2.5], perianal disease [HR 1.9] and paediatric diagnosis [HR 2.8]. Conclusion When technically feasible, SC is safe and reduces temporary and permanent stoma. Young age, number of locations and perianal disease adversely affect, but postoperative biological therapy significantly reduces, the long-term surgical recurrence.

AIM Graciloplasty (GP) is indicated in the case of recurrent rectovaginal fistula (RVF) after failure of previous local treatments. The aim of this study was to assess risk factors for GP failure performed for RVF. METHODS This is a retrospective study based on a prospective database on GP, coming from two expert centres. RESULTS Sixty-one patients undergoing a first GP for RVF (n = 51) or ileal-vaginal fistula after ileal pouch anal anastomosis (n = 10), with a mean age of 42 years (range 24-72), were analysed. After a mean follow-up of 56 ± 48 months (range 1-183), failure of GP (considered as persistent stoma and/or clinical RVF) was noted in 24/61 patients (39%). The failure rate was 43% (13/30) in the case of Crohn's disease, 38% (3/8) in the case of ileal-vaginal fistula after ileal pouch anal anastomosis for ulcerative colitis, 30% (3/10) in the case of obstetrical RVF, 33% (1/3) in the case of post radiotherapy RVF and 40% (4/10) for other causes (not significant). Two risk factors for failure of GP were found on univariate analysis: (1) absence of postoperative antibiotic prophylaxis-only 3/24 (13%) patients with failure of GP received postoperative antibiotic prophylaxis versus 18/37 (49%) patients with success of GP (P = 0.0053); (2) postoperative perineal infection-11/23 (48%) with failure of GP developed postoperative perineal infection versus only 4/37 (10%) patients with success of GP (P = 0.0021). CONCLUSIONS Failure of GP for RVF is observed in approximately 40% of the patients whatever the aetiology of the fistula. A reduced failure rate was associated with systematic postoperative antibiotic prophylaxis.

C-reactive protein (CRP) is a common biomarker of inflammation which has largely been used to predict the risk of postoperative septic complications after colorectal surgery. However, no data exist concerning its potential benefit after ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC). The aim of this study was to evaluate a CRP-driven monitoring discharge strategy after laparoscopic IPAA for UC.Since 2012, 158 patients undergoing a laparoscopic IPAA for UC have been included: 66 patients (CRP group) operated since 2016 had a CRP-driven monitoring discharge on postoperative day 5 (POD 5) and were discharged on POD 6 if CRP 100 mg/L; these patients were matched (according to age, gender, body mass index, IPAA in two or three steps) to 92 patients operated between 2012 and 2016 without any CRP monitoring (control group).Median length of hospital stay was shorter in the CRP than the control group (7 vs. 9 days; P 0.001) and discharge on POD 6 occurred more frequently in the CRP group (47% vs. 7%, P 0.001). No difference was observed between the two groups concerning overall morbidity (P = 0.980), surgical site infection (P = 0.554), Clavien-Dindo ≥ IIIa morbidity (P = 0.523), unplanned rehospitalization (P = 0.734) and 30-day reoperation (P = 0.240).CRP-driven monitoring discharge strategy after laparoscopic IPAA for UC is associated with a significant reduction in length of hospital stay, without increasing morbidity, reoperation or rehospitalization rates.

Aim Postoperative morbidity is high in patients operated on for Crohn's disease (CD) complicated by malnutrition. This study aimed to evaluate the impact of preoperative enteral nutritional support (PENS) on postoperative outcome in patients with CD complicated by malnutrition included in a prospective nationwide cohort. Method Malnutrition was defined as body mass index 10%. Failure of PENS was defined as the requirement for additional preoperative parenteral nutrition to PENS. Univariate analysis of the risk factors for PENS failure was performed. Propensity score matching (PSM) was used to compare the outcomes between 'upfront surgery' and 'PENS' groups. The primary endpoint was the rate of intra-abdominal septic morbidity and/or temporary defunctioning stoma. Results Among 592 patients included, 149 were selected. In the intention-to-treat population including 20 (13.4%) patients with PENS failure after PSM, 78 'upfront surgery' and 71 'PENS'-matched patients were compared, with no significant difference in the primary endpoint. Perforating CD and preoperative intra-abdominal fistula were associated with PENS failure [37.5 vs 16.1% (P = 0.047) and 41.2% vs 16.2% (P = 0.020), respectively]. After exclusion of these 20 patients, PSM was used to compare 45 'upfront surgery' and 51 'PENS'-matched patients, with a significantly decreased rate of intra-abdominal septic complications and/or temporary defunctioning stoma in the PENS group (19.6 vs 42.2%, P = 0.016). Conclusion Preoperative enteral nutritional support is associated with a trend but no conclusive evidence of a reduction in intra-abdominal septic complications and/or requirement for defunctioning stoma. Patients with perforating CD complicated with malnutrition are at risk of PENS failure.

Aim The treatment of perianal fistulas in Crohn's disease remains challenging. Fibrin glue injection has previously shown short-term efficacy in a randomized controlled trial. No long-term data are available to assess the benefit of this treatment. Methods This retrospective multicentre study included all patients with drained fistulas treated by at least one fibrin glue injection between January 2004 and June 2015 in three tertiary French centres. The primary end-point was the rate of complete clinical remission at 1 year after injection defined by the closure of all fistula tracts with no need for iterative anal surgery or for optimization of immunosuppressants and/or biologics. Results In all, 119 patients (median age 33 years, complex fistulas 65%, median previous anal surgery two, median Harvey Bradshaw score 3, immunosuppressants exposure 50%, anti-tumor necrosis factor exposure 60% with median time of administration of 1.1 year) were analysed with a median follow-up of 18.3 months. The complete clinical remission rate at 1 year was 45.4%. The primary end-point was achieved in 63% of the cases in the combination therapy group and 37% in other patients. The only predictor of complete clinical remission at 1 year was combination therapy at the time of injection (P = 0.01). The rate of early reintervention after glue injection was 2.5%. The cumulative incidence of iterative anal surgery and ostomy in the whole population was 54% and 5.6% respectively at 5 years. Conclusion An adjunct of fibrin glue to conventional medical therapy may be an effective and safe treatment for perianal fistulas in patients with Crohn's disease.

Resume Introduction L’enterite radio-induite chronique (ERC) resistante au traitement medical necessite une chirurgie. Notre etude visait a correler l’histologie des ERC a la presentation clinique et a la recidive postoperatoire. Patients et methodes Les donnees anatomopathologiques des patients operes d’une resection de l’intestin grele entre 2006 et 2017 ont ete correlees aux donnees cliniques initiales et a la recidive postoperatoire de l’ERC (occlusion, besoin de nutrition parenterale) lors d’un suivi median de 32 mois. Resultats Quarante-et-un ans patients ont ete etudies (39 femmes, âge median 62 ans lors de l’irradiation pour cancer pelvien gynecologique dans 80 % des cas). Le delai median de la chirurgie apres l’irradiation etait de 3 ans. Les resections ileo-caecales (80 %) ont retire 60 cm de grele (en mediane). Histologiquement, une arteriopathie obliterante diffuse etait presente chez 24 (59 %) patients, significativement associee a une amyotrophie, une atrophie villositaire ou des ulcerations observees chez 66, 63 et 34 % des patients respectivement (p Conclusion L’enterite radio-induite necessitant une chirurgie 13 ans en moyenne apres l’irradiation presentait une arteriopathie obliterante diffuse et des caracteristiques ischemiques en histologie. Dans notre centre, la moitie des patients ont ete gueris par la chirurgie. L’arteriopathie n’etait pas un facteur de risque de recidive postoperatoire.

Background and AimsFew prospective data exist on outcomes of surgery in Crohn’s disease [CD] complicated by an intra-abdominal abscess after resolution of this abscess by antibiotics optionally combined with drainage.MethodsFrom 2013 to 2015, all patients undergoing elective surgery for CD after successful non-operative management of an intra-abdominal abscess [Abscess-CD group] were selected from a nationwide multicentre prospective cohort. Resolution of the abscess had to be computed tomography/magnetic resonance-proven prior to surgery. Abscess-CD group patients were 1:1 matched to uncomplicated CD [Non-Penetrating-CD group] using a propensity score. Postoperative results and long-term outcomes were compared between the two groups.ResultsAmong 592 patients included in the registry, 63 [11%] fulfilled the inclusion criteria. The abscess measured 37 ± 20 mm and was primarily managed with antibiotics combined with drainage in 14 patients and nutritional support in 45 patients. At surgery, a residual fluid collection was found in 16 patients [25%]. Systemic steroids within 3 months before surgery [p = 0.013] and the absence of preoperative enteral support [p = 0.001] were identified as the two significant risk factors for the persistence of a fluid collection. After propensity score matching, there was no significant difference between the Abscess-CD and Non-Penetrating-CD groups in the rates of primary anastomosis [84% vs 90% respectively, p = 0.283], overall [28% vs 15% respectively, p = 0.077] and severe postoperative morbidity [7% vs 7% respectively, p = 1.000]. One-year recurrence rates for endoscopic recurrence were 41% in the Abscess-CD and 51% in the Non-Penetrating-CD group [p = 0.159].ConclusionsSurgery after successful non-operative management of intra-abdominal abscess complicating CD provides good early and long-term outcomes.

hese recommendations summarise the current evidence on the medical management of adult patients with UC. Gaps were iden-tified during the analysis of the data, which should be addressed by further research. Where evidence is lacking or is very weak and evidence-based recommendations cannot be given, ECCO provides alternative tools, such as Topical Reviews28,95,153–158 or Position Papers.159–161 It is important that clinicians use these guidelines within the framework of local regulations, and seek to understand and address the individual needs and expectations of every patient. We recognise that constraints on health care resources are an im-portant factor in determining whether recommendations can be implemented for patients in many countries. The recommendations outlined here should be used to inform treatment decisions and form part of an overall multidisciplinary treatment plan for patients with UC, which may also encompass psychological, nutritional, and other non-pharmacological interventions.

This is the second of a series of two articles reporting the European Crohn’s and Colitis Organisation [ECCO] evidence-based consensus on the management of adult patients with ulcerative colitis [UC]. The first article is focused on medical management, and the present article addresses medical treatment of acute severe ulcerative colitis [ASUC] and surgical management of medically refractory UC patients, including preoperative optimisation, surgical strategies, and technical issues. The article provides advice for a variety of common clinical and surgical conditions. Together, the articles represent an update of the evidence-based recommendations of the ECCO for UC.

AIM The aim of this comparative study was to report a 10-year experience of an organ preservation strategy by local excision (LE) in selected high-risk patients (aged patients and/or patients with severe comorbidity and/or indication for abdominoperineal excision) versus total mesorectal excision (TME) after neoadjuvant radiochemotherapy (RCT) for patients with locally advanced (T3-T4 and/or N+) low and mid rectal cancer with suspicion of complete tumour response (CTR) or near-CTR. METHOD Thirty-nine patients with rectal cancer who underwent LE after RCT for suspicion of CTR were matched to 71 patients who underwent TME according to body mass index, gender, tumour location and ypTNM stage. Operative, oncological and functional results were compared between groups. RESULTS In the LE group, ypT0, ypTis or ypT1N0R0 were noted in 28/39 (72%). Overall morbidity was observed in 10/39 (26%) in LE vs 46/71 in the TME group (65%) (P = 0.001). Severe morbidity (Clavien-Dindo ≥ 3) was noted in 1/39 patients from the LE group (3%) vs 3/71 (4%) from the TME group (P = 1.000). After a mean follow-up of 63 ± 4 months (range 56-70 months), local recurrence was noted in 2/39 (5%) from the LE group vs 2/71 (3%) from the TME group (P = 0.601). Definitive stoma was noted in 2/39 (6%) from the LE group vs 8/71 (12%) from the TME group (P = 0.489). Major low anterior resection syndrome was noted in 5/23 (22%) from LE group vs 11/33 (33%) from the TME group (P = 0.042). CONCLUSION The accuracy of response prediction after RCT was 72% after LE. In high-risk patients, LE represents a safe alternative to TME with better functional results and the same long-term oncological outcome.

The aim of this study was to assess the effect of transanal drainage (TD) tube (a Foley catheter) on the anastomotic leak (AL) rate after laparoscopic sphincter-saving surgery for rectal cancer (SSS). A prospective study was conducted on, all consecutive patients undergoing SSS at our institution between June 2017 and October 2018. All patients had TD for at least 4 days after surgery and constituted the TD group. The patients from TD group were matched to patients who underwent SSS without TD between January 2015 and May 2017 (no-TD group) according to age, sex, body mass index, neoadjuvant radiochemotherapy, mesorectal excision (total vs partial), and type of anastomosis (stapled vs hand sewn and side-to-end versus end-to-end). The primary endpoint was the AL rate, including both clinical and radiological AL. A total of 258 patients were included. Eighty-nine patients (34%) had a TD tube. After matching, 72 patients were included in each group. Mean TD duration was 3.9 [2.0–5.9] days. No significant differences between groups were observed in the rates of overall AL: 25/72 (35%) (TD) vs 17/72 (22%) (no-TD), (p = 0.14), clinical AL: 13/72 (18%) (TD) vs 7/72 (10%) (no-TD), (p = 0.23), and asymptomatic radiological AL: 12/72 (17%) (TD) vs 9/72 (13%) (no-TD), (p = 0.64). Multivariate analysis showed that male sex (OR 2.92, 95% CI [1.04–8.24]) and preoperative radiochemotherapy (OR 5.66, 95% CI [1.36–23.53]) were associated with AL. Our case-matched study suggested that a TD tube does not reduce the AL rate after laparoscopic sphincter-saving surgery for rectal cancer.

Neoadjuvant chemoradiation/radiation therapy in locally advanced (LA) upper rectal adenocarcinoma management remains unclear. The aim of this study was to compare outcomes between neoadjuvant chemoradiation therapy (CRT) and upfront surgery (US).A total of 127 patients were retrospectively included from 5 centers (79 treated with US and 48 with CRT). CRT and US groups were compared in terms of postoperative complications and long-term oncological and functional results.Total mesorectal excision (TME) was more frequent in CRT (58% vs. 20% in US, p0.001). CRT was associated with more overall and severe postoperative complications (60% vs. 30%, p0.001 and 17% vs. 1%, p=0.002, respectively), and was the only risk factor [OR=18.8 (2.2-160.2), p=0.007]. Five-year overall survival and 5-year recurrence-free survival were similar between CRT and US (96% vs. 91% p=0.256 and 85.4% vs. 85%, p=0.495). The functional results were similar between the two groups.CRT did not improve long-term oncological outcomes in patients with LA upper rectal adenocarcinoma, but increased postoperative complications compared with US.

In an elective setting, there is no consensus regarding the type of colectomy that is best for patients with tumors of the splenic flexure: segmental left colectomy (or splenic flexure colectomy), left hemicolectomy or subtotal colectomy (or extended right hemicolectomy). In the United Kingdom, extended right hemicolectomy is preferred by surgeons. The aim of the present survey was to report on the practices in France for this particular tumor location. Between 15/07/17 and 15/10/17, members of two French surgical societies [the French Association of Surgery (AFC) and the French Society of Digestive Surgery (SFCD)] and two French surgical cooperative groups [the French Federation of Surgical Research (FRENCH) and the French Research Group of Rectal Cancer Surgery (GRECCAR)] were solicited by email to answer an online anonymous questionnaire. A total of 190 out of 420 surgeons participated in this study (response rate 45%). The preferred procedure was splenic flexure colectomy (70%), followed by left hemicolectomy (17%) and subtotal colectomy (13%). The most used surgical approach was laparoscopy (63%), followed by laparotomy (31%) and hand-assisted laparoscopy (6%). Lymph node dissection was extended to the middle colic artery in 29% of splenic flexure colectomies and in 33% of left hemicolectomies. Twenty-nine percent of responders thought that tumors of the splenic flexure had a worse prognosis in comparison with other colonic sites, because of insufficient lymph node dissection (73%) or a more advanced stage (50%) at diagnosis. However, this opinion did not change the type of colectomy performed. There is a strong consensus in France to operate tumors of the splenic flexure with a splenic flexure colectomy and lymph node dissection limited to the left colic artery.

Background Factors associated with rectal NENs prognosis are poorly investigated. Aim To evaluate the prognostic role of the ENETs staging and grading systems in rectal NENs. Methods Tertiary referral, multicenter, retrospective study. Factors associated with OS and PFS were investigated by Cox-regression analysis, with best size cut-offs calculated by ROC analysis. Results Of 100 patients (mean age 55, 45% male, mean size 16.2 mm) 62, 5, 10 and 23 were TNM stage 1 to 4, and 63, 15 and 22 were G1, G2 and G3. Primary treatment was endoscopic snare resection in 62%, endoscopic mucosal resection/endoscopic submucosal dissection in 10%, surgery in 20% and medical treatment in 8%. The best size cut-offs to predict OS and PFS were 10 and 12 mm. During a mean follow-up of 40.7 months 12% died and 26% progressed. The 5-year OS and PFS were 79.5% and 65.2%. Stage IV and G3 were associated with worse OS (HR 8.16; p = 0.002; HR 15.57; p = 0.0004) and PFS (HR 14.26 p Conclusion Both staging and grading accurately predict rectal NENs prognosis. Size alone has limited accuracy as 26% of patients with stage IV and 16% with G3 have a primary tumour≤10 mm.

The aim of this study was to assess recurrence risk factors following ileocolonic resection (ICR) for Crohn disease (CD) in a nationwide cohort study SUMMARY BACKGROUND DATA:: Recurrence rate after ICR for CD can be up to 60%, but its predictive factors have never been evaluated in large prospective cohort studies.From 2013 to 2015, 346 consecutive patients undergoing ICR for CD and a postoperative ileocoloscopy within 6 to 12 months after surgery at 19 academic French centers were included prospectively.Twelve-month postoperative endoscopic (Rutgeerts score ≥i2) and clinical recurrence rates were 57.6% [95% confidence interval (CI), 54.2-61.0] and 11.3% (95% CI, 9-13.6), respectively. A total of 185 patients (54%) had a postoperative CD prophylaxis, comprising thiopurine in 69 (20%), or anti-tumor necrosis factor (TNF) therapy in 93 (27%). In multivariate Cox regression analysis, absence of postoperative smoking {odds ratio [OR] = 0.60 (95% CI, 0.40-0.91); P = 0.016}, postoperative prophylaxis [OR = 0.60 (95% CI, 0.41-0.88); P = 0.009], and penetrating disease behavior [OR = 0.58 (95% CI, 0.39-0.86); P = 0.007] were the only independent predictors of reduced endoscopic recurrence risk. Postoperative prophylaxis [OR 0.31 (95% CI, 0.15-0.66); P = 0.002), and penetrating behavior [OR = 00.36 (95% CI, 0.16-0.81); P = 0.013), were the only independent predictors of reduced clinical recurrence risk. Postoperative anti-TNF therapy was associated with a significant reduction of both 12-month risks of endoscopic (P0.001) and clinical (P = 0.019) recurrences.Absence of postoperative smoking, CD prophylaxis, and penetrating disease behavior could be independent predictors of reduced postoperative recurrence after ICR for CD. Prophylactic anti-TNF therapy reduces both endoscopic and clinical recurrence rates. It suggests that upfront surgery followed by postoperative anti-TNF therapy is probably the best therapeutic approach for complex CD (penetrating disease behavior).

AIM This study aimed to assess outcomes of Hartmann's reversal (HR) after failure of previous colorectal anastomosis (CRA) or coloanal anastomosis (CAA). METHODS All patients planned for HR from 1997 to 2018 following the failure of previous CRA or CAA were included. RESULTS From 1997 to 2018, 45 HRs were planned following failed CRA or CAA performed for rectal cancer (n = 19, 42%), diverticulitis (n = 16, 36%), colon cancer (n = 4, 9%), inflammatory bowel disease (n = 2, 4%) or other aetiologies (n = 4, 9%). In two (4%) patients, HR could not be performed. HR was performed in 43/45 (96%) patients with stapled CRA (n = 24, 53%), delayed handsewn CAA with colonic pull-through (n = 11, 24%), standard handsewn CAA (n = 6, 14%) or stapled ileal pouch-anal anastomosis (n = 2, 4%). One (2%) patient died postoperatively. Overall postoperative morbidity rate was 44%, including 27% of patients with severe postoperative complication (Clavien-Dindo ≥ 3). After a mean follow-up of 38 ± 30 months (range 1-109), 35/45 (78%) patients presented without stoma. Multivariate analysis identified a remnant rectal stump

International audience; To evaluate whether systematic mesh implantation upon primary colostomy creation was effective to prevent PSH.Summary of background data: Previous randomized trials on prevention of PSH by mesh placement have shown contradictory results.Methods: This was a prospective, randomized controlled trial in 18 hospitals in France on patients aged ≥18 receiving a first colostomy for an indication other than infection. Participants were randomized by blocks of random size, stratified by center in a 1:1 ratio to colostomy with or without a synthetic, lightweight monofilament mesh. Patients and outcome assessors were blinded to patient group. The primary endpoint was clinically diagnosed PSH rate at 24 months of the intention-to-treat population. This trial was registered at ClinicalTrials.gov, number NCT01380860.Results: From November 2012 to October 2016, 200 patients were enrolled. Finally, 65 patients remained in the no mesh group (Group A) and 70 in the mesh group (Group B) at 24 months with the most common reason for drop-out being death (n = 41). At 24 months, PSH was clinically detected in 28 patients (28%) in Group A and 30 (31%) in Group B [P = 0.77, odds ratio = 1.15 95% confidence interval = (0.62;2.13)]. Stoma-related complications were reported in 32 Group A patients and 37 Group B patients, but no mesh infections. There were no deaths related to mesh insertion.Conclusion: We failed to show efficiency of a prophylactic mesh on PSH rate. Placement of a mesh in a retro-muscular position with a central incision to allow colon passage cannot be recommended to prevent PSH. Optimization of mesh location and reinforcement material should be performed.

After total mesorectal excision (TME) for low rectal cancer, current guideline recommendations for sphincter-saving surgery are to perform a side-to-end manual coloanal anastomosis (CAA) (or with J-pouch) with a temporary stoma. Our study aimed to evaluate if delayed pull-through coloanal anastomosis (DCAA) without a temporary stoma could represent a safe alternative in low rectal cancer.From 2003 to 2020, 223 consecutive patients with low rectal cancer undergoing TME were compared: CAA and diverting stoma (n = 190) versus DCAA without stoma (n = 33).Overall 3-month and severe (Dindo ≥ IIIb) morbidity rates were similar in CAA versus DCAA groups: 34% (65/190) vs. 36% (12/33) and 2.6% (5/190) vs. 3% (1/33), respectively. In the DCAA group, only one patient (3%) underwent reoperation (Hartmann's procedure) at day 3 due to colon necrosis. The anastomotic leakage rate (both clinical and radiological) was significantly higher after CAA than DCAA: 28% (53/190) vs. 3% (1/33; p = 0.00138). Failure of the procedure (with return to stoma) was observed in 8% (15/190) vs. 6% (2/33) of patients after CAA and DCAA respectively (not significant).Our comparative study suggested that in patients with low rectal cancer, DCAA without a temporary stoma could represent an interesting alternative to the actual recommended CAA with a temporary ileostomy. DCAA could offer two major advantages over CAA: a significantly lower rate of anastomotic leakage and absence of a temporary stoma and its potential complications (rehospitalization, dehydration, wound hernia after stoma closure).

To determine the safety of performing an anastomosis after rectal cancer (RC) resection in patients with a previously treated prostate cancer (PC).Patients with a previously treated PC who underwent rectal resection from 2008 to 2018 were retrospectively included. Outcomes were compared between patients who underwent rectal resection with anastomosis (restorative surgery, RS+ group) and those with a definitive stoma (RS- group). In the RS+ group, anastomotic leak (AL) rates were assessed according to the type of reconstruction.A total of 126 patients underwent rectal surgery for mid-low RC after a previous PC treated by radiotherapy (RT) and/or radical prostatectomy. Overall, 80 patients (63%) underwent a RS and 46 patients (37%) underwent rectal surgery with a definitive stoma. There was no statistical difference between the two groups in terms of intraoperative data, except for the type of resection with more multivisceral resection in the RS- group (p 0.01). In the RS+group, a diverting stoma was performed in 74% of cases. No difference between the two groups in terms of overall morbidity was found. In the RS+group (n = 80), 17 patients (21%) experienced AL. Of these, none was observed when delayed coloanal anastomosis was performed (p = 0.16). Long-term permanent stoma in the RS+ group was 16% (n = 13).Restorative surgery after resection for RC in patients with a previous history of RT and/or radical prostatectomy for PC is safe without additional morbidity. In selected patients for restorative surgery, performing delayed coloanal anastomosis may represent a promising option.

To report the 3-year experience of endovascular revascularization of acute arterial mesenteric ischemia (AMI) from an intestinal stroke center unit (ISCU).All data from patients admitted to the ISCU between January 2016 and January 2019 for arterial AMI who underwent endovascular recanalization were prospectively acquired and retrospectively analyzed. Patient demographics, clinical and laboratory characteristics at presentation, and CT scans were reviewed. The type (thrombolysis, thrombectomy, stenting) and the outcome of endovascular procedures (technical success or failure, complications) were noted. Care pathways were described focusing on post-procedural treatments (surgical revascularization, bowel resection) and the mortality rate was evaluated in subgroups.Fifty-eight patients (34 men [59%], mean 69 ± 29 years) were included. Endovascular revascularization was technically successful in 51/58 (88%) patients, and 10 (17%) patients had post-procedural complications. Stenting and in situ thrombolysis were performed in most patients (n = 33 and n = 19, respectively). Thirty-two patients (55%) were recurrence-free and required no further treatment after the procedure, while 9 (16%), 5 (9%), and 5 (9%) patients underwent 2nd-line bowel resection, surgical revascularization, or both. Overall, 46 (79%), 45 (78%), and 34 patients (63%) were alive at 3 months, 1 year, and 3 years. No significant difference in survival was found in care pathways or baseline characteristics.Endovascular revascularization is highly feasible for the treatment of arterial AMI, and is associated with an acceptable rate of complications. Results of endovascular revascularization shall only be interpreted as part of a multidisciplinary patient management strategy.• Endovascular revascularization is highly feasible for the treatment of arterial AMI, and is associated with an acceptable rate of complications. • Several techniques are available to perform endovascular revascularization, and their use depends on the cause, the location, and the quality of underlying arteries of patients. • Results of endovascular revascularization shall only be interpreted in relation to its role in an integrated multidisciplinary and patient management strategy.

The aim of this prospective multicentric study was to compare the accurate colonic lesion localization ratio between CT and colonoscopy in comparison with surgery. All consecutive patients from 1st January to 31st December 2019 with a histologically confirmed diagnosis of dysplastic adenoma or adenocarcinoma with planned elective, curative colonic resection who underwent both colonoscopy and CT scans were included. Each patient underwent conventional colonoscopy and CT to stage the tumour, and the localization results of each procedure were registered. CT and colonoscopic localization were compared with surgical localization, adopted as the reference. Our analysis included 745 patients from 23 centres. After comparing the accuracy of colonoscopy and CT (for visible lesions) in localizing colonic lesions, no significant differences were found between the two preoperative tools (510/661 vs 499/661 correctly localized lesions, p = 0.518). Furthermore, after analysing only the patients who underwent complete colonoscopy and had a visible lesion on CT, no significant difference was observed between conventional colonoscopy and CT (331/427 vs 340/427, p = 0.505). Considering the intraoperative localization results as a reference, a comparison between colonoscopy and CT showed that colonoscopy significantly failed to correctly locate the lesions localized in the descending colon (17/32 vs 26/32, p = 0.031). We did not identify an advantage in using CT to localize colonic tumours. In this setting, colonoscopy should be considered the reference to properly localize lesions; however, to better identify lesions in the descending colon, CT could be considered a valuable tool to improve the accuracy of lesion localization.

A better understanding of pathological features and oncological survival in ypT0 rectal cancer after neoadjuvant chemoradiotherapy is required to improve patient selection criteria for rectal-preserving approach by local excision. Our aim was to define risk of lymph node metastasis and oncological outcomes in ypT0 rectal cancer after chemoradiotherapy and total mesorectal excision.All consecutive patients who underwent total mesorectal excision for a nonmetastatic rectal adenocarcinoma classified ypT0 after neoadjuvant chemoradiotherapy, with or without locoregional lymph node involvement (ypN+ or ypN-), in 14 French academic centers between 2002 and 2015 were included. Data were collected retrospectively. Overall and disease-free survival were explored.Among the 383 ypT0 patients, 6% were ypN+ (23/283). Before chemoradiotherapy, 86% (327/380) were staged cT3-T4 and 41% (156/378) were staged cN+. The risk of ypN+ did not differ between cT3-T4 and cT1-T2 patients (P = .345) or between cN+ and cN- patients (P = .384). After a median follow-up of 61.1 months, we observed 95% confidence interval (92%-97%) of 5-year overall survival and 93% confidence interval (91%-96%) of 5-year disease-free survival. In Cox multivariate analysis, overall survival was altered by intra-abdominal septic complications (hazard ratio = 2.53, confidence interval [1.11-5.78], P = .028). Regarding disease-free survival, ypN+ status and administration of adjuvant chemotherapy were associated with a reduced disease-free survival (P = .001 for both). cT3/T4 staging and cN+ staging did not modify overall survival (P = .332 and P = .450) nor disease-free survival (P = .862 and P = .124).The risk of lymph node metastasis and the oncological survival do not depend on the initial cT or cN staging in cases of ypT0 complete rectal tumor regression.

BACKGROUND Redo anastomosis can be considered in selected patients with persistent leakage, stenosis, or local recurrence. It is technically challenging, and little is known about the functional outcomes after this seldomly performed type of surgery. OBJECTIVE The aim of this study was to compare functional outcomes and the quality of life between redo anastomosis and primary successful anastomosis following total mesorectal excision for rectal cancer. DESIGN This study was designed as an international multicenter comparative cohort study. SETTINGS The study was conducted in 3 tertiary referral centers in the Netherlands, Belgium, and France. PATIENTS Patients undergoing redo anastomosis were compared with patients with a primary successful anastomosis after total mesorectal excision for rectal cancer. MAIN OUTCOME MEASURES Low anterior resection syndrome score, European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ) C30, and EORTC QLQ-CR29 questionnaires were used to assess outcomes. RESULTS In total, 170 patients were included; 52 underwent redo anastomosis and 118 were controls. Major low anterior resection syndrome occurred in 73% after redo anastomosis compared with 68% following primary successful anastomosis (p = 0.52). The redo group had worse EORTC QLQ-CR29 mean scores for fecal incontinence (p = 0.03) and flatulence (p = 0.008). There were no differences in urinary (p = 0.48) or sexual dysfunction, either in men (p = 0.83) or in women (p = 0.76). Significantly worse scores in the redo group were found for global health (p = 0.002), role (p = 0.049) and social function (p = 0.006), body image (p = 0.03), and anxiety (p = 0.02). LIMITATIONS This study is limited by the possible response bias. CONCLUSIONS Redo anastomosis is associated with significantly worse quality of life compared with primary successful anastomosis. However, major low anterior resection syndrome was comparable between groups and should not be a reason to preclude restoration of bowel continuity in highly motivated patients. See Video Abstract at http://links.lww.com/DCR/B565. RESULTADOS FUNCIONALES Y DE CALIDAD DE VIDA POSTERIOR A LA RECONSTRUCCIN DE LA ANASTOMOSIS EN PACIENTES CON CNCER DE RECTO ESTUDIO INTERNACIONAL MULTICNTRICO DE COHORTE COMPARATIVO ANTECEDENTES:Se puede considerar reconstruir la anastomosis en pacientes seleccionados con fuga persistente, estenosis o recidiva local. Esto es tecnicamente desafiante y poco se sabe sobre los resultados funcionales despues de este tipo de cirugia que rara vez se realiza.OBJETIVO:El objetivo de este estudio fue comparar resultados funcionales y la calidad de vida entre reconstruccion de la anastomosis y la anastomosis primaria exitosa posterior de la escision total de mesorrecto (TME) por cancer de recto.DISENO:Este estudio fue disenado como un estudio internacional multicentrico de cohorte comparativo.ENTORNO CLINICO:El estudio se llevo a cabo en tres centros de referencia terciarios en Holanda, Belgica y Francia.PACIENTES:Los pacientes sometidos a reconstruccion de anastomosis fueron comparados con pacientes con anastomosis primaria exitosa despues de TME por cancer de recto.PRINCIPALES MEDIDAS DE VALORACION:Los cuestionarios; Escala de Sindrome de Reseccion Anterior Baja (LARS), EORTC QLQ-C30, y QLQ-CR29, fueron utilizados para evaluar los resultados.RESULTADOS:En total, se incluyeron 170 pacientes; 52 reconstruccion de anastomosis y 118 controles. LARS ocurrio en el 73% posterior a la reconstruccion de la anastomosis en comparacion con el 68% posterior a la anastomosis primaria exitosa (p = 0,52). El grupo de reconstruccion tuvo peores puntuaciones medias de EORTC QLQ-CR29 para incontinencia fecal (p = 0,03) y flatulencia (p = 0,008). No hubo diferencias en disfuncion urinaria (p = 0,48) o sexual, ni en hombres (p = 0,83) ni en mujeres (p = 0,76). Se encontraron puntuaciones significativamente peores en el grupo de reconstruccion para salud global (p = 0,002), desempeno (p = 0,049) y funcion social (p = 0,006), imagen corporal (p = 0,03) y ansiedad (p = 0,02).LIMITACIONES:La limitacion de este estudio es el posible sesgo de respuesta.CONCLUSIONES:La reconstruccion de la anastomosis se asocia con una calidad de vida significativamente peor en comparacion con los pacientes con anastomosis primaria exitosa. Sin embargo, LARS fue comparable entre los grupos y no deberia ser una razon para impedir la restauracion de la continuidad intestinal en pacientes muy motivados. Consulte Video Resumen en http://links.lww.com/DCR/B565.

The aim of this study was to assess if to prolong follow-up (FU) more than 5 years after surgery for colorectal cancer (CRC) is justified or not. Patients who underwent surgery for a CRC before 2013 and without any tumor recurrence (or synchronous metastases) during the first 5 years after surgery were identified from our database and included. Between 1996 and 2012, 121 patients operated for rectal (RC) (median of FU of 84 months; range 60–211) and 97 with colonic cancer (CC) (median of FU of 78 months; range 60–139), without any tumor recurrence (or synchronous metastases) during the first 5 years after surgery, presented a late tumor recurrence: 13/121 RC (10.7%) versus 2/97 CC (2.1%) (p = 0.014); 8/13 recurrences in RC (61.5%) were observed after neoadjuvant radiochemotherapy, and 9/13 (69.2%) in pN0 tumors. Among the 13 recurrences, 3 had both local and metastatic recurrences (23%), 5 an isolated local recurrence (38.5%) and 5 an isolated metastatic recurrence (38.5%). After surgery for CC, the 2 recurrences were observed in patients with T3N0 tumors. After surgery for a CRC, in patients without tumor recurrence during the first 5 years after surgery, follow-up after 5 years must be continued in rectal cancer patients because of a 10.7% rate of late recurrence. On the opposite, after surgery for colon cancer the 2% rate of late recurrence after 5 years suggested that only patients with pT3–T4 colonic cancer could probably be followed more than 5 years after surgery.

Background Specific surgical and oncological outcomes in patients with rectal cancer surgery after a previous diagnosis of prostate cancer have not been well described. The aim of this study was to compare surgical outcomes in patients with rectal cancer with or without a history of prostate cancer. Methods Patients who had surgery for rectal cancer with (PC group) or without (no-PC group) previous curative treatment for prostate cancer were enrolled between January 2001 and December 2015. Comparisons between the two groups were performed by multivariable Cox analysis, and after propensity score matching in a 3 : 1 ratio for demographic and tumour characteristics, and surgical and oncological outcomes. Results A total of 944 patients with rectal cancer were enrolled, of whom 10·8 per cent had a history of prostate cancer. After matching, 83 patients who had received treatment for prostate cancer were compared with 249 who had not. The PC and no-PC groups were similar regarding patient characteristics. Extended total mesorectal excision, conversion to open surgery, transfusion and tumour perforation were more frequent in the PC group than in the no-PC group. Major surgical morbidity (28 versus 17·2 per cent; P = 0·036), anastomotic leakage (25 versus 13·7 per cent; P = 0·019) and permanent stoma (41 versus 12·4 per cent; P < 0·001) occurred more frequently in the PC group. Local recurrence was increased significantly in the PC group (17 versus 8·0 per cent; P = 0·019), and resulted in a significant decrease in disease-free and overall survival. Conclusion Prostate cancer treatment increases short- and long-term surgical morbidity in patients with rectal cancer, and impairs oncological outcomes.