Mechanical and oral antibiotic bowel preparation versus no bowel preparation in right and left colectomy: subgroup analysis of MOBILE trial

BACKGROUND

In retrospective series, mechanical and oral antibiotic bowel preparation (MOABP) has been reported to reduce surgical-site infections (SSIs) after colectomy compared with no bowel preparation (NBP).

METHOD

This was a subgroup analysis of a multicentre randomized trial that included patients scheduled for elective colectomy. The MOABP group underwent mechanical bowel preparation, and took 2 g neomycin and 2 g metronidazole orally during the day before surgery. The NBP group did not undergo bowel preparation. Patients were categorized according to the side of resection (right versus left colectomy), and these subgroups compared for postoperative outcomes.

RESULTS

Among 217 patients undergoing right colectomy (106 in MOABP and 111 in NBP group), SSI was detected in seven (7 per cent) and 10 (9 per cent) patients (odds ratio (OR) 0.71, 95 per cent c.i. 0.26 to 1.95; P = 0.510), anastomotic dehiscence in two (2 per cent) and two (2 per cent) patients (OR 1.05, 0.15 to 7.58; P = 1.000), and the mean(s.d.) Comprehensive Complication Index (CCI) score was 9.4(12.9) and 10.5(18.0) (mean difference -1.09; 95 per cent c.i. -5.29 to 3.11; P = 0.608) in the MOABP and NBP groups respectively. Among 164 patients undergoing left colectomy (84 in MOABP and 80 in NBP group), SSI was detected in five (6 per cent) and eight (10 per cent) patients (OR 0.57, 0.18 to 1.82; P = 0.338), anastomotic dehiscence in four (5 per cent) and five (6 per cent) patients (OR 0.75, 0.19 to 2.90; P = 0.742), and the CCI score was 10.2(13.1) and 6.5(11.0) (mean difference 3.68, -0.06 to 7.42; P = 0.053) in the MOABP and NBP groups respectively.

CONCLUSIONS

MOABP did not decrease the rate of SSI or complications in patients undergoing either right or left colectomy compared with NBP.

Timing of prophylactic colectomy in familial adenomatous polyposis

AIM

The aim was to evaluate the timing of prophylactic colectomy in patients with familial adenomatous polyposis (FAP) in Finland.

METHOD

All Finnish FAP patients were included from the years 1963-2018. Among the 452 FAP patients studied, 252 were called up as relatives of the proband. Of these, 180 underwent prophylactic colectomy. Patient data including mutation characteristics and surgical technique were collected. We assessed the timing of prophylactic colectomy in relation to the time of diagnosis, time of decision for surgery and age.

RESULTS

There were 94 (52%) colectomies with ileorectal anastomosis, 79 (44%) proctocolectomies with ileal pouch-anal anastomosis and seven (4%) proctocolectomies with an ileostomy. Median age at diagnosis and at the time of surgery was 20.9 and 25.2 years, respectively. The median time from decision to operate to undergoing surgery was 4 months. There were eight (4%) cancers in the colectomy specimens, but none was found during the annual follow-ups after the first-round endoscopy. After genetic testing became available, the diagnosis was made primarily by either genetic testing in 52 (49%) or endoscopy in 54 (51%) patients at a median age of 17.8 and 19.3 years, respectively. Thirty-eight (21%) patients died during follow-up, 23 (61%) for FAP-related reasons and only six from rectal cancer. The relative survival of 30 years from diagnosis was 84% and 78% in men and women, respectively.

CONCLUSIONS

For those who underwent surgery, timing of prophylactic surgery was successful as there were no unexpected colorectal cancers found in colectomy specimens among the screened patients. Two major improvements over the study period have changed the treatment of FAP patients: one is the introduction of the ileal pouch-anal anastomosis procedure and the other is the availability of genetic testing. FAP-related extra-colonic malignancies affect the relative survival of these patients after prophylactic surgery.

Clinical management of 52 consecutive retro-rectal tumours treated at a tertiary referral centre

AIM

The aim of this single-institution study was to analyse the diagnostic methods, preoperative work-up and outcomes of 52 retro-rectal tumours.

METHOD

All patients treated for retro-rectal tumours from 2012 to 2017 were included.

RESULTS

Out of 52 patients, 40 (77%) were women. The median age of patients at the time of surgery was 43 (19-76) years, and 30 (58%) were asymptomatic at the time of diagnosis. All tumours were visible on magnetic resonance imaging (MRI) prior to surgery. The sensitivity and specificity for predicting malignancy on preoperative imaging for retro-rectal tumours were 25% and 98%, respectively. Forty-four procedures (85%) were performed using the perineal approach. The median hospital stay was 3 (1-18) days. There was no 30-day postoperative mortality. Eleven (21%) patients developed postoperative complications, mostly surgical site infections. Twenty-nine tumours (56%) were benign tailgut cysts. Four (8%) tumours were malignant and were considered to be removed with a tumour-free resection margin. Local recurrent disease was detected on MRI in 14 (27%) patients at a median of 1.05 (range 0.78-1.77) years after primary surgery. Only the multi-lobular shape of the tumour was found to be an independent risk factor for recurrence (P = 0.030).

CONCLUSION

A preoperative MRI is mandatory in order to plan the surgical strategy for retro-rectal tumours. Symptomatic, solid, large tumours should be removed because of the risk of malignancy. Minor cystic lesions with thin walls as well as asymptomatic recurrences of benign tumours are suitable to be followed conservatively.

Sex differences in faecal occult blood test screening for colorectal cancer

Background

This analysis of patients in a randomized population‐based health services study was done to determine the effects of faecal occult blood test (FOBT) screening of colorectal cancer (CRC) in outcomes beyond mortality, and to obtain explanations for potential sex differences in screening effectiveness.

Methods

In the Finnish FOBT screening programme (2004–2011), people aged 60–69 years were randomized into the screening and control arms. Differences in incidence, symptoms, tumour location, TNM categories, non‐vital outcomes and survival in the screening and control arms were analysed.

Results

From 321 311 individuals randomized, 743 patients with screening‐detected tumours and 617 control patients with CRC were analysed. CRC was less common in women than in men (0·34 versus 0·50 per cent; risk ratio (RR) 0·82, 95 per cent c.i. 0·74 to 0·91) and women were less often asymptomatic (16·7 versus 22·0 per cent; RR 0·76, 0·61 to 0·93). Women more often had right‐sided tumours (32·0 versus 21·3 per cent; RR 1·51, 1·26 to 1·80). Among men with left‐sided tumours, those in the screening arm had lower N (RR 1·23, 1·02 to 1·48) and M (RR 1·57, 1·14 to 2·17) categories, as well as a higher overall survival rate than those in the control arm. Furthermore among men with left‐sided tumours, non‐radical resections (26·2 versus 15·7 per cent; RR 1·67, 1·22 to 2·30) and postoperative chemotherapy sessions (61·6 versus 48·2 per cent; RR 1·28, 1·10 to 1·48) were more frequent in the control arm. Similar benefits of screening were not detected in men with right‐sided tumours or in women.

Conclusion

Biennial FOBT screening seems to be effective in terms of improving several different outcomes in men, but not in women. Differences in incidence, symptoms and tumour location may explain the differences in screening efficacy between sexes.

Only of benefit in men

Comparison of proctocolectomy and ileal pouch-anal anastomosis to colectomy and ileorectal anastomosis in familial adenomatous polyposis

Prophylactic surgical options for familial adenomatous polyposis (FAP) are either colectomy and ileorectal anastomosis (IRA) or proctocolectomy and ileal pouch-anal anastomosis (IPAA). The aim of this study was to analyse the short-term and long-term outcomes of these two operative techniques. All patients with FAP in Finland have been prospectively recorded in a database since 1963 were retrospectively reviewed in this analysis. Altogether 140 (61%) colectomies with IRA and 88 (39%) proctocolectomies with IPAA have been performed. Complications occurred in 28 (21%) patients after IRA and in 26 (30%) patients after IPAA. There were 15 (11%) severe complications for IRA and 5 (6%) for IPAA. Twenty-one (15%) patients of the IRA group ended up in conventional ileostomy whereas 3 (3.4%) patients of the IPAA group had their ileal reservoir converted to an ileostomy (p = 0.01). Cumulative survival for IRA was lower than for the IPAA (p = 0.03), but if accounting only for operations made after the IPAA era had commenced, there was no significant difference. IPAA was associated with improved long-term survival without an increase in postoperative complications. The risk of death after colectomy and IRA seemed to be predominantly related to the remaining risk of rectal cancer. Therefore, we favour proctocolectomy with IPAA as the prophylactic surgical procedure for FAP with intermediate or severe polyposis.

The frequency and outcome of breast cancer risk-reducing surgery in Finnish BRCA1 and BRCA2 mutation carriers

BACKGROUND AND AIMS

Risk-reducing mastectomy of BRCA1 and BRCA2 gene mutation carriers is known to significantly reduce lifetime risk of breast cancer. Our aim was to study the frequency and outcome of risk-reducing mastectomies performed in Helsinki University Central Hospital during 1997-2010.

MATERIAL AND METHODS

In testing for mutations in BRCA1 and BRCA2, 136 female carriers had been identified and followed up in Helsinki University Central Hospital.

RESULTS

A total of 69 breasts in 52 women were operated on for risk-reduction, including 28 (54%) bilateral mastectomies at mean age of 43 years. Autologous tissue was used for reconstruction in 40 (50%) and implants in 31 (39%) of the breasts, respectively. In all, 8 patients (15%) chose to have no reconstruction. Minor or major complications were recorded in 21 (40%) patients. Five reconstructions failed and were corrected with re-reconstruction.

CONCLUSIONS

In this series of Finnish BRCA1 and BRCA2 mutation carriers, a high percentage 52 (41%) chose risk-reducing breast surgery. Autologous tissue was favored in breast reconstructions. Immediate breast reconstructions were associated with a relatively high risk of complications in free flaps and in implant reconstructions, but not in latissimus dorsi reconstructions. It is mandatory that patients are informed about the risks associated with risk-reducing operations.