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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, 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.

Njoumi N(1), Tarchouli M(1), Ratbi MB(1), Elochi MR(2), Yamoul R(1), Hachi H(1),  Bougtab A(1).


Author information:

(1)Service de chirurgie II, Institut National d’Oncologie, CHU Ibn Sina, Faculté  de Medecine et de Pharmacie de Rabat, Maroc.

(2)Service d’anatomie pathologique, HMIMV, Rabat, Maroc.


DOI: 10.11604/pamj.2013.16.131.2864

PMCID: PMC4024435

PMID: 24847393  [Indexed for MEDLINE]


Pan Afr Med J. 2013 Dec 8;16:131. doi: 10.11604/pamj.2013.16.131.2864. eCollection 2013.

Souadka A(1), Majbar MA, Bougutab A, El Othmany A, Jalil A, Ahyoud FZ, El Malki HO, Souadka A.


Author information:

(1)1 University Mohammed Vth Souissi, Rabat, Medical School, Surgical Department,

National Institute of Oncology, Rabat, Morocco 2 University Mohammed Vth Souissi,

Rabat, Medical School, Department of General Surgery, Rabat, Morocco 3 University

Mohammed Vth Souissi, Rabat, Medical School, Medical Center of Clinical Trials and Epidemiological Study (CRECET), Rabat, Morocco 4 Cheikh Zaid Ibn Soltan

Foundation, Cheikh Zaid International University Hospital, Rabat, Morocco 5 Surgical Department, Al Azhar Oncological Center, Rabat, Morocco.


BACKGROUND: Pseudocontinent perineal colostomy is one of the techniques that helps recover the body image of patients undergoing abdominoperineal resection. This technique is rarely used internationally given its unknown functional results.

OBJECTIVE: The study aimed to evaluate 1-year functional outcomes of perineal pseudocontinent colostomy and to determine the risk factors for “poor” functional results.

DESIGN: This study is a retrospective interventional case series.

SETTINGS: This study was conducted at a tertiary care university hospital and oncological center in Morocco.

PATIENTS: From January 1993 to December 2007, 149 patients underwent pseudocontinent perineal colostomy after abdominoperineal resection for low rectal adenocarcinoma.

INTERVENTION: Pseudocontinent perineal colostomy was performed with the use of the Schmidt technique after abdominoperineal resection.

MAIN OUTCOME MEASURES: One-year functional results were assessed according to the Kirwan classification system. Functional results were considered “poor” when the  Kirwan score was C, D, or E. Univariable and multivariable analyses were used to  evaluate the impact of age, sex, type of surgery, irrigation frequency, palpable  muscular ring, concomitant chemoradiotherapy, stage, and perineal complications on functional results.

RESULTS: One hundred forty-six patients were analyzed. According to the Kirwan system, the scores showed that 100 (68.5%) patients had “good” continence results (stage A-B) and 46 (31.5%) patients had altered functional results (stage C-D-E). With the exception of pelvic recurrences, no conversions from a perineal colostomy to an abdominal colostomy were performed for dissatisfactory functional results. In multivariate analysis, the only independent predictive factors of poor functional results were the occurrence of perineal complications (OR, 3.923; 95% CI, 1.461-10.35; p = 0.007) and extended resection (OR, 3.03; 95% CI, 1.183-7.750; p = 0.021) LIMITATION OF THE STUDY:: This study is an observational  retrospective study on selected patients (mainly a young population).

CONCLUSIONS: This study showed that perineal complications and extended resection are associated with poor functional results after pseudocontinent perineal colostomy. These data can help clinicians to better inform patients about the outcomes of this technique and to assist them in choosing the right reconstruction technique after abdominoperineal resection.


DOI: 10.1097/DCR.0b013e31829f8cd5

PMID: 24022531  [Indexed for MEDLINE]


Dis Colon Rectum. 2013 Oct;56(10):1143-8. doi: 10.1097/DCR.0b013e31829f8cd5.

Majbar MA, Elmalki Hadj O, Souadka A, El Alaoui M, Sabbah F, Raiss M, Hrora A, Ahallat M.


BACKGROUND: Anastomotic leakage (AL) is an important cause of morbidity after surgery for rectal cancer.

AIM: to analyze the risk factors associated with anastomotic leakage after anterior resection for rectal adenocarcinoma.

METHODS: We collected data from all the patients who had surgical resection with  an anastomosis, for rectal adenocarcinoma at the Surgical Clinic C (Ibn Sina Hospital, Rabat, Morocco), between January 2001 and December 2010. The associations between variables and anastomotic leakage were studied using univariate and multivariate analysis.

RESULTS: Our study included 130 patients. Anastomotic leakage occurred in 28 patients (21.5%). Univariate and multivariate analysis showed that the rate of anastomotic leakage was significantly higher in patients who received preoperative radiotherapy (34.2% vs. 12 %, p = 0.002 – OR 3.8 – CI 95%: 1.5 – 9.4). There was no significant difference in the rate of AL between patients with or without a protective stoma. In the group of patients with AL, the rate of reoperation was significantly lower in patients with a stoma protection (31.8% vs 83.3%, p = 0.04).

CONCLUSION: Radiotherapy is a risk factor for anastomotic leakage. The systematic design of a protective stoma in patients receiving neoadjuvant radiotherapy is advisable to reduce the rate of reoperations associated with AL.


PMID: 25775290  [Indexed for MEDLINE]


Tunis Med. 2014 Jul;92(7):493-6.

Dahiri M, Salmi N, Ahallat A, El Bahaoui N, Belkouchi O, Souadka A, Majbar A, Benkabbou A, Bougtab A, Mohsine R.

AME Case Rep. 2018 Jun 14;2:31. doi: 10.21037/acr.2018.06.01. eCollection 2018.


Cervical cancer is the second most common cancer and the third cause of cancer death in women. Radiotherapy occupies a prominent place in the therapeutic arsenal of cervical cancer in localized stages. Radiation induced secondary cancer is an entity that has been well described in the literature. We report a case of a rectal adenocarcinoma occurring in a woman previously treated by radiotherapy and brachytherapy for a squamous cell carcinoma of the cervix.


Rectal cancer; cervical cancer; radiation induced cancer; secondary cancer

PMID: 30264027 / PMCID: PMC6155695.

DOI: 10.21037/acr.2018.06.01

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