Diseases of the Colon & Rectum最新文献

Background: Diabetes mellitus has been associated with poor outcomes following elective colorectal surgery. The use of preoperative glycated hemoglobin may provide a more precise estimate of glycemic control.

Objective: To determine whether glycemic control, using preoperative glycated hemoglobin values, could risk-stratify postoperative outcomes.

Design: Observational retrospective cohort study.

Settings: Multicenter study including North American centers that contribute towards the National Surgical Quality Improvement Program of the American College of Surgeons dataset.

Patients: Adult patients who underwent an elective colectomy or proctectomy for neoplasia or diverticular disease between 2021 and 2023.

Interventions: The primary exposure was glycemic control, categorized according to diabetes mellitus status and glycated hemoglobin as "no diabetes mellitus," "well-controlled diabetes mellitus," and "poorly controlled diabetes mellitus."

Main outcome measures: Ten 30-day postoperative outcomes were evaluated and were defined according to the online National Surgical Quality Improvement Program surgical risk calculator. The co-primary outcomes included serious complications, any complication, cardiac complications, and surgical site infection.

Results: In total, 32,578 patients were retained for analysis: 19,261 (59.1%) had no diabetes mellitus, 8,999 (27.6%) had well-controlled diabetes mellitus, and 4,318 (13.3%) had poorly controlled diabetes mellitus. On multivariable logistic regression, compared to those with no diabetes mellitus, those with well-controlled diabetes mellitus had a similar risk of any complication (OR 1.04; 95% CI: 0.96-1.12), serious complications (OR 1.03; 95% CI: 0.95-1.12), cardiac complications (OR 1.22; 95% CI: 0.93-1.59), and surgical site infection (OR 0.97; 95% CI: 0.87-1.07). In contrast, compared to patients with no diabetes mellitus, those with poorly-controlled diabetes mellitus had a higher odds of any complication (OR 1.23; 95% CI: 1.12-1.35), serious complications (OR 1.20; 95% CI: 1.08-1.33), and surgical site infection (OR 1.21; 95% CI: 1.06-1.37), but not cardiac complications (OR 1.27; 95% CI: 0.90-1.76).

Limitations: Observational study design, limited to covariates within the National Surgical Quality Improvement Program dataset.

Conclusions: In patients who underwent elective colorectal surgery, glycemic control based on preoperative glycated hemoglobin levels improved postoperative risk stratification compared to diabetes mellitus status alone. See Video Abstract.

Introduction: Achieving margin-negative complete resection in locally recurrent rectal cancer often requires en bloc resection involving adjacent structures such as the sacrum. However, sacrectomy is technically demanding and poses a high risk of significant intraoperative bleeding and postoperative pelvic sepsis due to the dead space created after resection. We developed a minimally invasive surgical technique to address these challenges.

Technique: We used a laparoscopic approach to sacrectomy as part of en bloc resection for posterior locally recurrent rectal cancer. In this technique, the anterior and lateral dissection of the sacrum was performed laparoscopically, whereas the final sacral transection was performed under direct vision in the prone position. Preoperative imaging was used to identify the planned sacral transection line, which was reproduced intraoperatively using a premeasured vascular tape. Anterior and lateral dissection of the sacrum was performed laparoscopically to allow secure vascular control. Final sacral transection was performed under direct vision in the prone position. A pedicled omental flap and a dead-space-filling nonfunctional anastomosis were used to fill the pelvic cavity and prevent postoperative sepsis. A double-barreled stoma was created to facilitate fecal diversion.

Results: Laparoscopic sacrectomy was successfully performed in 43 patients with locally recurrent rectal cancer. The margin-negative complete resection rate was 86%, which is notably high for this challenging population. The 5-year overall survival rate was approximately 59%. No cases of major intraoperative bleeding or early complications related to the dead-space-filling nonfunctional anastomosis were observed.

Conclusions: This laparoscopic technique offers a safe and feasible option for selected patients with posterior locally recurrent rectal cancer. Combined dead-space management may further help reduce postoperative complications while preserving oncological validity.