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ESCP Enhanced Recovery Collaborating Group. Colorectal Dis. 2021 Aug 8.

Aim: The Enhanced Recovery After Surgery (ERAS® ) Society guidelines aim to standardise perioperative care in colorectal surgery via 25 principles. We aimed to assess the variation in uptake of these principles across an international network of colorectal units.

Method: An online survey was circulated amongst European Society of Coloproctology members in 2019/20. For each ERAS® principle, respondents were asked to score how frequently the principle was implemented in their hospital, from 1 (‘rarely’) to 4 (‘always’). Respondents were also asked to recall whether practice had changed since 2017. Subgroup analyses based on hospital characteristics were conducted.

Results: Of hospitals approached, 58% responded to the survey (195/335), with 296 individual responses (multiple responses were received from some hospitals). The majority were European (163/195 [83.6%]). Overall, respondents indicated they ‘most often’ or ‘always’ adhered to most individual ERAS® principles (18/25 [72%]). Variability in uptake of principles was reported, with universal uptake of some principles (e.g., prophylactic antibiotics; early mobilisation) and inconsistency from ‘rarely’ to ‘always’ in others (e.g., no nasogastric intubation; no preoperative fasting and carbohydrate drinks). In alignment with 2018 ERAS® guideline updates, adherence to principles for prehabilitation, managing anaemia, and postoperative nutrition appears to have increased since 2017.

Conclusions: Uptake of ERAS® principles varied across hospitals, and not all 25 principles were equally adhered to. Whilst some principles exhibited a high level of acceptance, others had a wide variability in uptake indicative of controversy or barriers to uptake. Further research into specific principles is required to improve ERAS® implementation.



GlobalSurg Collaborative and National Institute for Health Research Global Health Research Unit on Global Surgery.
Lancet. 2021 Jan 30;397(10272):387-397.

Background: 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality.

Methods: This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494.

Findings: Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70-8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39-8·80) and upper-middle-income countries (2·06, 1·11-3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26-11·59) and upper-middle-income countries (3·89, 2·08-7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications.

Interpretation: Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications.



COVIDSurg Collaborative.
Colorectal Dis. 2020 Nov 15:10.1111/codi.15431.

Aim: This study aimed to describe the change in surgical practice and the impact of SARS-CoV-2 on mortality after surgical resection of colorectal cancer during the initial phases of the SARS-CoV-2 pandemic.

Method: This was an international cohort study of patients undergoing elective resection of colon or rectal cancer without preoperative suspicion of SARS-CoV-2. Centres entered data from their first recorded case of COVID-19 until 19 April 2020. The primary outcome was 30-day mortality. Secondary outcomes included anastomotic leak, postoperative SARS-CoV-2 and a comparison with prepandemic European Society of Coloproctology cohort data.

Results: From 2073 patients in 40 countries, 1.3% (27/2073) had a defunctioning stoma and 3.0% (63/2073) had an end stoma instead of an anastomosis only. Thirty-day mortality was 1.8% (38/2073), the incidence of postoperative SARS-CoV-2 was 3.8% (78/2073) and the anastomotic leak rate was 4.9% (86/1738). Mortality was lowest in patients without a leak or SARS-CoV-2 (14/1601, 0.9%) and highest in patients with both a leak and SARS-CoV-2 (5/13, 38.5%). Mortality was independently associated with anastomotic leak (adjusted odds ratio 6.01, 95% confidence interval 2.58-14.06), postoperative SARS-CoV-2 (16.90, 7.86-36.38), male sex (2.46, 1.01-5.93), age >70 years (2.87, 1.32-6.20) and advanced cancer stage (3.43, 1.16-10.21). Compared with prepandemic data, there were fewer anastomotic leaks (4.9% versus 7.7%) and an overall shorter length of stay (6 versus 7 days) but higher mortality (1.7% versus 1.1%).

Conclusion: Surgeons need to further mitigate against both SARS-CoV-2 and anastomotic leak when offering surgery during current and future COVID-19 waves based on patient, operative and organizational risks.



Essangri H, Majbar MA, Benkabbou A, Amrani L, Mohsine R, Souadka A.
Surgery. 2021 Jul;170(1):47-52.

Background: Bowel dysfunction symptoms such as stool clustering, urgency, incomplete voiding, and fecal incontinence are frequent after colorectal surgery and known as the low anterior resection syndrome. The Wexner score is the most widely used tool for fecal incontinence assessment. We aimed to translate and test the psychometric properties of the Moroccan Arabic dialect version of the Wexner questionnaire in patients with low anterior resection syndrome after rectal surgery.

Methods: The Wexner questionnaire was translated to Moroccan Arabic and administered to a group of 158 patients, among which a subgroup of 43 patients took the test for a second time to examine test-retest reliability. Cronbach alpha coefficient was used to determine internal consistency and correlation, and the European Organisation for the Research and Treatment of Cancer Quality of Life C30 and the low anterior resection syndrome questionnaires were assessed for convergent validity. Discriminant validity was demonstrated through the Wexner score ability to detect differences based on the patients’ different clinical and pathological characteristics.

Results: One hundred and fifty-eight patients completed the Moroccan Arabic dialect version of the Wexner score, which showed an excellent internal consistency with a Cronbach alpha score of 0.91. Test-retest reliability was established by a Bland-Altman plot with 95% limits of agreement. The score showed positive correlation to the low anterior resection syndrome score (r = 0.748; P < .001) and the European Organisation for the Research and Treatment of Cancer Quality of Life C30 diarrhea symptom scale (r = 0.519; P < .001). A negative correlation was also demonstrated for each one of the 5 European Organisation for the Research and Treatment of Cancer quality of life C30 functional scales, namely physical functioning (r = -0.217 ; P = .006), role functioning (r = -0.267; P = .001), emotional functioning (r = -0.266; P = .001), cognitive functioning (r = -0.283; P < .001), and social functioning (r = -0,283; P < .001). The Wexner score differed between patients according to tumor location, chemoradiotherapy, type of mesorectal excision, and anastomosis.

Conclusion: The Moroccan Arabic dialect version of the Wexner score shows good psychometric properties and can be used for fecal incontinence assessment, particularly in colorectal cancer patients.



Ziati J, Souadka A, Benkabbou A, Boutayeb S, Ahmadi B, Amrani L, Mohsine R, Anass Majbar M.
Gulf J Oncolog. 2021 Jan;1(35):66-76

Background: Transanal total mesorectal excision (TaTME) is a new technique that is designed to overcome the limits encountered during laparoscopic total mesorectal excision (LaTME) for rectal cancer, especially in male, obese patients with a narrow pelvis and mid and low rectal tumours.

Aim: The objective of our meta-analysis is to evaluate short-term oncological and perioperative outcomes of transanal total mesorectal excision (TaTME) compared to laparoscopic total mesorectal excision (LaTME) for rectal cancer.

Methods: A meta-analysis based on Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines was conducted in MEDLINE (PubMed). All original studies published in English that compared TaTME with laTME were included. The quality of the included studies was assessed by the Newcastle- Ottawa Quality Assessment Scale (NOS) and Cochrane Library Handbook 5.1.0. Data analysis was conducted using the Review Manager 5.3 software.

Results: Twelve studies including 835 TaTME patients and 1707 LaTME patients with rectal cancer met the inclusion criteria in this meta-analysis. No statistical significant differences were observed in regard to positive circumferential resection margin (PCRM), positive distal resection margin (PDRM), macroscopic quality of mesorectum (MQM) and harvested lymph nodes (HLN). Concerning the perioperative outcomes, the results of conversion rates, operative time, hospital stay (HS), anastomotic leakage (AL) and postoperative complications were comparable between the two groups.

Conclusion: Our meta-analysis provides that TaTME may be a valid alternative approach for the treatment of rectal cancer in comparison with LaTME.



Majbar MA, Courtot L, Dahbi-Skali L, Rafik A, Jouppe PO, Moussata D, Benkabbou A, Mohsine R, Ouaissi M, Souadka A.

J Visc Surg. 2021 Jun 3:S1878-7886(21)00061-8.

Background: Delayed colo-anal anastomosis (DCA) is an underused technique rarely performed after resection of primary low rectal adenocarcinoma. The objective of this study was to compare the short-term outcomes of DCA and classical colo-anal anastomosis (CAA).

Methods: This is a retrospective comparative study carried out at two tertiary centres in Morocco and France. It included all patients who underwent colo-anal anastomosis after complete mesorectal excision for primary rectal adenocarcinoma between January 2018 and December 2019. The main outcomes were 90-day morbidity and rates completing the surgical steps of DCA and CAA.

Results: Among 215 rectal resections, 45 patients received colo-anal anastomosis, including 19 DCA and 26 CAA. Seventeen patients in the DCA group completed the two steps compared to 16 in the CAA group (89.5% vs. 61.5%, P=0.04). The rates of severe complications (26.9% vs. 26.3%, P=0.96) and anastomotic leakage (42.3% vs. 31.6%, P=0.46) were not different between the two groups.

Conclusion: This study showed that DCA was associated with a higher rate of completing the two surgical steps, with no difference in overall and severe morbidity. DCA may be a strong alternative to classical colo-anal anastomosis.



Bhangu A, Li E; COVIDSurg Collaborative, Fisher A, Manku B.

Aim: This study aimed to describe the change in surgical practice and the impact of SARS-CoV-2 on mortality after surgical resection of colorectal cancer during the initial phases of the SARS-CoV-2 pandemic.

Method: This was an international cohort study of patients undergoing elective colon or rectal cancer resection, without preoperative suspicion of SARS-CoV-2. Centres entered data from their first recorded case of COVID-19 until 19 April 2020. The primary outcome was 30-day mortality. Secondary outcomes included anastomotic leak, postoperative SARS-CoV-2, and a comparison with a pre-pandemic European Society of Coloproctology cohort data.

Results: From 2073 patients in 40 countries, 1.3% (27/2073) had a defunctioning stoma and 3.0% (63/2073) had an end stoma instead of an anastomosis only. 30-day mortality was 1.8% (38/2073), the incidence of postoperative SARS-CoV-2 was 3.8% (78/2073), and the anastomotic leak rate was 4.9% (86/1738). Mortality was lowest in patients without a leak or SARS-CoV2 (14/1601, 0.9%), and highest in patients with both a leak and SARS-CoV-2 (5/13, 38.5%). Mortality was independently associated with an anastomotic leak (adjusted odds ratio 6.01, 95% confidence interval 2.58-14.06), postoperative SARS-CoV-2 (16.90, 7.86-36.38), male sex (2.46, 1.01-5.93), age >70 years (2.87, 1.32-6.20), and advanced cancer stage (3.43, 1.16-10.21). Compared to pre-pandemic data, there were fewer anastomotic leaks (4.9% versus 7.7%), an overall shorter length of stay (6 versus 7 days), but higher mortality (1.7% versus 1.1%).

Conclusion: Surgeons need to further mitigate against both SARS-CoV-2 and anastomotic leak when offering surgery during current and future COVID-19 waves based on patient, operative, and organisational risks.



Essangri H, Majbar MA, Benkabbou A, Amrani L, Mohsine R, Souadka A.

Background: Sphincter sparing surgery is oftentimes associated with bowel dysfunction complaints, namely the low anterior resection syndrome (LARS). The LARS questionnaire is widely used to assess this syndrome. The aim of this observational study is to translate this tool into arabic and test its psychometric properties in rectal cancer patients, in order to ease its use in clinical practice and future research.

Methods: The LARS questionnaire was translated to arabic and administered to a total of 143 patients. A subgroup of 42 patients took the test twice for test-retest reliability. Internal consistency was examined through cronbach’s alpha. The score results were correlated to the EORTC QLQ-C30 questionnaire for convergent validity assessment, while discriminant validity was established through the ability of the LARS score to differentiate patients with different clinical and pathological criteria.

Results: The Moroccan Arabic version of the LARS score was completed by 143 patients. The internal consistency was demonstrated through a cronbach alpha score of 0.66. The agreement between the test and retest was established by a Bland Altman plot with 95% limits of agreement. 85.6% of patients remained in the same LARS category. The LARS score showed negative correlation with all five of the QLQ-C30 functional scales as well as positive correlation to the diarrhea symptom scale. The questionnaire score differed between patients according to their tumor location, chemoradiotherapy, type of mesorectal excision and anastomosis.

Conclusion: The Moroccan Arabic version of the LARS score shows good psychometric properties and can be used for bowel dysfunction assessment in clinical and research settings.



Souadka A, Majbar MA, Essangri H, Amrani L, Benkabbou A, Mohsine R, Souadka A.

J Surg Oncol. 2020 Jun 20. doi: 10.1002/jso.26074. Online ahead of print.

Abstract

Background and objectives: Pseudocontinent-perineal colostomy (PCPC) following abdominoperineal resection (APR) is a promising technique associated with good quality of life. This study evaluates over time the functional results after PCPC using the Kirwan score.

Methods: All PCPC patients operated on from January 2001 to January 2016 were followed with their functional results assessed at four checkpoints. A/B Kirwan scores and a 48 to 72 hours colonic irrigation rhythm were considered « good » and « convenient » and their overall variations over time were assessed by means of Cochran’s Q test corrected by Bonferroni post hoc test.

Results: Fifty-seven eligible patients were included in the study with 33 (58%) women. We noted a significant difference in both Kirwan score and colic irrigation rhythm during the four checkpoints in follow-up with Q(1) = 85.01 and Q(2) = 69. 86. By the fourth checkpoint, 86% of patients had a Kirwan score of A/B. Concerning the rhythm of colonic irrigation, there was a significant improvement between 6 months and other checkpoints. In the second year, 63% of patients reduced their colonic irrigation rhythm.

Conclusions: The functional results of PCPC after APR improve and stabilize from 6 months to 1 year after surgery thus making PCPC a good alternative that surgeons can present to their patients.

Keywords: Kirwan score; Schmidt’s technique; abdominoperineal resection; pseudocontinent-perineal colostomy; rectal adenocarcinoma.


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