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ObjectiveTo investigate the success rate of cold snare polypectomy (CSP) for complete resection of 4–9 mm colorectal adenomatous polyps compared with that of hot snare polypectomy (HSP).DesignA prospective, multicentre, randomised controlled, parallel, non-inferiority trial conducted in 12 Japanese endoscopy units. Endoscopically diagnosed sessile adenomatous polyps, 4–9 mm in size, were randomly assigned to the CSP or HSP group. After complete removal of the polyp using the allocated technique, biopsy specimens from the resection margin after polypectomy were obtained. The primary endpoint was the complete resection rate, defined as no evidence of adenomatous tissue in the biopsied specimens, among all pathologically confirmed adenomatous polyps.ResultsA total of 796 eligible polyps were detected in 538 of 912 patients screened for eligibility between September 2015 and August 2016. The complete resection rate for CSP was 98.2% compared with 97.4% for HSP. The non-inferiority of CSP for complete resection compared with HSP was confirmed by the +0.8% (90% CI −1.0 to 2.7) complete resection rate (non-inferiority p<0.0001). Postoperative bleeding requiring endoscopic haemostasis occurred only in the HSP group (0.5%, 2 of 402 polyps).ConclusionsThe complete resection rate for CSP is not inferior to that for HSP. CSP can be one of the standard techniques for 4–9 mm colorectal polyps. (Study registration: UMIN000018328)

Background The aim of colonic stenting with self-expandable metallic stents in neoplastic colon obstruction is to avoid emergency surgery and thus potentially reduce morbidity, mortality, and need for a stoma. Concern has been raised, however, about the effect of colonic stenting on short-term complications and long-term survival. We compared morbidity rates after colonic stenting as a bridge to surgery (SBTS) versus emergency surgery (ES) in the management of left-sided malignant large-bowel obstruction. Methods This multicentre randomised controlled trial was designed with the endorsement of the European Association for Endoscopic Surgery. The study population was consecutive patients with acute, symptomatic malignant left-sided large-bowel obstruction localised between the splenic flexure and 15 cm from the anal margin. The primary outcome was overall morbidity within 60 days after surgery. Results Between March 2008 and November 2015, 144 patients were randomly assigned to undergo either SBTS or ES; 29/144 (13.9%) were excluded post-randomisation mainly because of wrong diagnosis at computed tomography examination. The remaining 115 patients (SBTS n  = 56, ES n  = 59) were deemed eligible for analysis. The complications rate within 60 days was 51.8% in the SBTS group and 57.6% in the ES group ( p  = 0.529). Although long-term follow-up is still ongoing, no statistically significant difference in 3-year overall survival ( p  = 0.998) and progression-free survival rates between the groups has been observed ( p  = 0.893). Eleven patients in the SBTS group and 23 in the ES group received a stoma ( p  = 0.031), with a reversal rate of 30% so far. Conclusions Our findings indicate that the two treatment strategies are equivalent. No difference in oncologic outcome was found at a median follow-up of 36 months. The significantly lower stoma rate noted in the SBTS group argues in favour of the SBTS procedure when performed in expert hands.

The anatomy of the superior mesenteric vessels is complex, yet important, for right-sided colorectal surgery. The usefulness of three-dimensional (3D) printing of these vessels in right hemicolon cancer surgery has rarely been reported. In this prospective clinical study, 61 patients who received laparoscopic surgery for right hemicolon cancer were preoperatively randomized into 3 groups: 3D-printing (20 patients), 3D-image (19 patients), and control (22 patients) groups. Surgery duration, bleeding volume, and number of lymph node dissections were designed to be the primary end points, whereas postoperative complications, post-operative flatus recovery time, duration of hospitalization, patient satisfaction, and medical expenses were designed to be secondary end points. To reduce the influence of including different surgeons in the study, the surgical team was divided into 2 groups based on surgical experience. The duration of surgery for the 3D-printing and 3D-image groups was significantly reduced (138.4 ± 19.5 and 154.7 ± 25.9 min vs. 177.6 ± 24.4 min, P  = 0.000 and P  = 0.006), while the number of lymph node dissections for the these 2 groups was significantly increased (19.1 ± 3.8 and 17.6 ± 3.9 vs. 15.8 ± 3.0, P  = 0.001 and P  = 0.024) compared to the control group. Meanwhile, the bleeding volume for the 3D-printing group was significantly reduced compared to the control group (75.8 ± 30.4 mL vs. 120.9 ± 39.1 mL, P  = 0.000). Moreover, patients in the 3D-printing group reported increased satisfaction in terms of effective communication compared to those in the 3D-image and control groups. Medical expenses decreased by 6.74% after the use of 3D-printing technology. Our results show that 3D-printing technology could reduce the duration of surgery and total bleeding volume and increase the number of lymph node dissections. 3D-printing technology may be more helpful for novice surgeons. Trial registration : Chinese Clinical Trial Registry, ChiCTR1800017161. Registered on 15 July 2018.

BackgroundThe aim of this study was to compare thoracic epidural analgesia (TEA) with transversus abdominis plane (TAP) block in post-operative pain management after laparoscopic colon surgery.MethodsOne hundred thirty-six patients undergoing laparoscopic colon resection randomly received either TEA or TAP with ropivacaine only. The primary endpoint was opioid requirement up to 48 h postoperatively. Intensity of pain, time to onset of bowel function, time to mobilization, postoperative complications, length of hospital stay, and patients’ satisfaction with pain management were also assessed.ResultsWe observed a significant decrease in opioid consumption on the day of surgery with TEA compared with TAP block (30 mg vs 14 mg, p < 0.001). On the first two postoperative days (POD), the balance shifted to opioid consumption being smaller in the TAP group: on POD 1 (15.2 mg vs 10.6 mg; p = 0.086) and on POD 2 (9.2 mg vs 4.6 mg; p = 0.021). There were no differences in postoperative nausea/vomiting or time to first postoperative bowel movement between the groups. No direct blockade-related complications were observed and the length of stay was similar between TEA and TAP groups.ConclusionTEA is more efficient for acute postoperative pain than TAP block on day of surgery, but not on the first two PODs. No differences in pain management-related complications were detected.

Purpose To assess the effect of computed tomography angiography (CTA) and three-dimensional (3D) reconstruction on laparoscopic colectomy in patients with colon cancer. Methods Patients with colon cancer who were treated at Zhejiang Cancer Hospital between August 2020 and December 2022 were included in this pilot, randomized controlled trial. The participants were randomly assigned to either the CTA group, in which patients underwent preoperative CTA and 3D reconstruction, or the control group, in which patients underwent preoperative enhanced abdominal and pelvic CT examinations. The primary outcome was the duration of the operation. The secondary outcomes included intraoperative blood loss, length of hospital stay, number of lymph node dissections, fasting duration, duration of tube drainage, overall survival (OS), and progression-free survival (PFS). To minimize statistical bias, patients were stratified into subgroups on the basis of tumor location (left colon or right colon). Additionally, variations in the middle colonic artery (MCA), inferior mesenteric artery (IMA), and colonic branches of superior mesenteric artery (cbSMA) classifications were documented. Results A total of 82 patients (41 in each group) were included in the analysis. The CTA group had significantly shorter operation durations (123.68 ± 26.09 vs. 154.12 ± 33.15 min, P  < 0.001) and fasting durations (median 4.00 vs. 5.00 days, P  < 0.001) as well as reduced intraoperative blood loss (median 50.00 vs. 100.00 mL, P  = 0.001) compared to the control group; these differences were observed in the overall colon cancer cohort and in the left and right colon subgroups. However, no significant differences were observed between the two groups in terms of lymph node dissection, tube drainage duration, hospitalization duration, OS or PFS. In the CTA group, the proportions of patients with different IMA types were as follows: Type A (60.97%), Type B (9.76%), Type C (17.07%), and Type D (12.20%); the proportions of patients with different MCA types were as follows: Type A (78.05%), Type B (12.20%), Type C (7.31%), and Type D (2.44%); and the proportions of patients with different cbSMA types were as follows: Type A (65.85%), Type B (7.32%), Type C (17.07%), and Type D (9.76%). Patients with a tumor size ≥ 5 cm, preoperative intestinal obstruction, postoperative pathological serosal invasion, lymph node metastasis, and stage III disease had significantly worse OS and PFS than those with a tumor size < 5 cm ( P  = 0.007, P  = 0.026), no preoperative intestinal obstruction ( P  = 0.015, P  = 0.019), no serosal invasion ( P  = 0.001, P  = 0.001), no lymph node metastasis ( P  = 0.016, P  = 0.001), and stage I–II disease ( P  = 0.013, P  = 0.001). However, no significant differences in OS or PFS were observed between patients who underwent preoperative CTA examination and the control group ( P  = 0.551, P  = 0.591), between male and female patients ( P  = 0.402, P  = 0.361), or between patients with and without postoperative complications ( P  = 0.561, P  = 0.520). Finally, multivariate Cox proportional hazards regression analysis revealed that serosal invasion ( P  = 0.013; P  = 0.009), lymph node metastasis ( P  = 0.029; P  = 0.043), and tumor stage ( P  = 0.002; P  = 0.001) were independent prognostic factors that affected the OS and PFS of patients with colon cancer. Conclusion Preoperative CTA and 3D reconstruction provide essential information for laparoscopic surgery, facilitate the optimization of surgical procedures, and support improved postoperative recovery for patients with colon cancer, suggesting promising clinical applications.

Closure of an abdominal stoma, a common elective operation, is associated with frequent complications; one of the commonest and impactful is incisional hernia formation. We aimed to investigate whether biological mesh (collagen tissue matrix) can safely reduce the incidence of incisional hernias at the stoma closure site. In this randomised controlled trial (ROCSS) done in 37 hospitals across three European countries (35 UK, one Denmark, one Netherlands), patients aged 18 years or older undergoing elective ileostomy or colostomy closure were randomly assigned using a computer-based algorithm in a 1:1 ratio to either biological mesh reinforcement or closure with sutures alone (control). Training in the novel technique was standardised across hospitals. Patients and outcome assessors were masked to treatment allocation. The primary outcome measure was occurrence of clinically detectable hernia 2 years after randomisation (intention to treat). A sample size of 790 patients was required to identify a 40% reduction (25% to 15%), with 90% power (15% drop-out rate). This study is registered with ClinicalTrials.gov, NCT02238964. Between Nov 28, 2012, and Nov 11, 2015, of 1286 screened patients, 790 were randomly assigned. 394 (50%) patients were randomly assigned to mesh closure and 396 (50%) to standard closure. In the mesh group, 373 (95%) of 394 patients successfully received mesh and in the control group, three patients received mesh. The clinically detectable hernia rate, the primary outcome, at 2 years was 12% (39 of 323) in the mesh group and 20% (64 of 327) in the control group (adjusted relative risk [RR] 0·62, 95% CI 0·43–0·90; p=0·012). In 455 patients for whom 1 year postoperative CT scans were available, there was a lower radiologically defined hernia rate in mesh versus control groups (20 [9%] of 229 vs 47 [21%] of 226, adjusted RR 0·42, 95% CI 0·26–0·69; p<0·001). There was also a reduction in symptomatic hernia (16%, 52 of 329 vs 19%, 64 of 331; adjusted relative risk 0·83, 0·60–1·16; p=0·29) and surgical reintervention (12%, 42 of 344 vs 16%, 54 of 346: adjusted relative risk 0·78, 0·54–1·13; p=0·19) at 2 years, but this result did not reach statistical significance. No significant differences were seen in wound infection rate, seroma rate, quality of life, pain scores, or serious adverse events. Reinforcement of the abdominal wall with a biological mesh at the time of stoma closure reduced clinically detectable incisional hernia within 24 months of surgery and with an acceptable safety profile. The results of this study support the use of biological mesh in stoma closure site reinforcement to reduce the early formation of incisional hernias. National Institute for Health Research Research for Patient Benefit and Allergan.

BackgroundIn the field of rectal cancer surgery, there remains ongoing debate on the merits of high ligation (HL) and low ligation (LL) of the inferior mesenteric artery (IMA) in terms of perfusion and anastomosis leakage. Recently, infrared fluorescence of indocyanine green (ICG) imaging has been used to evaluate perfusion status during colorectal surgery.ObjectiveThe purpose of this study is to compare the changes in perfusion status between HL and LL through quantitative evaluation of ICG.MethodsPatients with rectosigmoid or rectal cancer were randomized into a high or LL group. ICG was injected before and after IMA ligation, and region of interest (ROI) values were measured by an image analysis program (HSL video©).ResultsFrom February to July 2020, 22 patients were enrolled, and 11 patients were assigned to each group. Basic demographics were similar between the two groups, except for albumin level and cardiac ejection fraction. There were no significant differences in F_max between the two groups, but T_max was significantly higher and Slope_max was significantly lower in the HL group than in the LL group. Anastomosis leakage was significantly associated with neoadjuvant chemoradiation and F_max.ConclusionAfter IMA ligation, T_max increased and Slope_max decreased significantly in the HL group. However, the intensity of perfusion status (F_max) did not change according to the level of IMA ligation.

Background Laparoscopic surgery has been widely accepted for the treatment of colorectal cancer; however, long-term outcomes in elderly patients remain controversial. The midterm results of a randomized trial comparing open surgery with laparoscopic surgery in elderly patients with colorectal cancer are presented. Methods This was a randomized trial comparing open surgery with laparoscopic surgery in elderly patients with colorectal cancer. The primary outcome was complication rate, and secondary outcomes included 3-year recurrence-free survival and overall survival. A total of 200 patients were randomly assigned to open surgery or laparoscopic surgery between 2008 and 2012. The main study objective was to compare the midterm outcomes of open surgery with those of laparoscopic surgery in elderly patients with colorectal cancer. This trial is registered with Clinical Trials.gov (NCT01862562). Results There were no differences between the laparoscopic surgery group and open surgery group in the 3-year overall survival rate (91.5% for laparoscopic surgery vs. 90.6% for open surgery, p  = 0.638) or the 3-year recurrence-free survival rate (84.8% for laparoscopic surgery vs. 88.2% for open surgery, p  = 0.324). The local recurrence rate was significantly higher in the laparoscopic surgery group than in the open surgery group in rectal cancer (13.8% for laparoscopic surgery vs. 0% for open surgery, p  = 0.038). In subgroup analysis according to tumor location, there were no significant differences in the 3-year overall survival rate or 3-year recurrence-free survival rate between the two treatment groups. Conclusion The midterm outcomes of laparoscopic surgery are similar to those of open surgery in elderly patients with colorectal cancer.

Abstract Background We compared the Simple Endoscopic Score for Crohn’s Disease (SES-CD) and Modified Multiplied SES-CD (MM-SES-CD) scores with the Rutgeerts score for predicting clinical recurrence (CR) of postoperative Crohn’s disease (CD). Methods This post hoc analysis of the prospective, multicenter, randomized, double-blind, placebo-controlled trial comparing remicade and placebo in the prevention of recurrence in Crohn’s disease patients undergoing surgical resection who are at an increased risk of recurrence (PREVENT) study used receiver operating characteristic curve analyses to compare the Rutgeerts, SES-CD, and MM-SES-CD scores at week 76 for subsequent CR by week 104 in 208 participants. Multivariate logistic regression models evaluated cutoffs for the odds of experiencing CR by week 104, after adjustment for confounders. CR was defined as Crohn’s Disease Activity Index score ≥200 and ≥70-point increase from baseline (or development of fistulas, abscesses, or treatment failure) and endoscopic recurrence by week 104, defined as Rutgeerts score ≥i2. Results The week 76 Rutgeerts score predicted CR by week 104 with fair accuracy (area under the receiver-operating characteristic curve [AUC], 0.74; 95% confidence interval [CI], 0.65-0.83), which was similar to the SES-CD ileum score (AUC, 0.72; 95% CI, 0.64-0.80) and the MM-SES-CD ileum score (AUC, 0.72; 95% CI, 0.63-0.80). Compared with cutoffs by the other scores, the MM-SES-CD total score ≥26 at week 76 had the highest odds ratio to predict CR by week 104. Patients with a week 76 MM-SES-CD total score ≥26 were 4.41 times (95% CI, 2.06-9.43, P < .001) more likely to have CR by week 104 compared with those with an MM-SES-CD total score <26. Conclusions The SES-CD and MM-SES-CD perform similarly to the Rutgeerts score for predicting subsequent CR of postoperative CD. The MM-SES-CD threshold of ≥26 was predictive of postoperative CR. Clinicians and trialists could consider using the SES-CD or MM-SES-CD to assess postoperative CD given their ability to capture colonic disease recurrence and predict CR. Lay Summary This post hoc analysis of clinical trial data demonstrated that the Simple Endoscopic Score for Crohn’s Disease (SES-CD) and Modified Multiplied SES-CD (MM-SES-CD) perform similarly to the Rutgeerts score for predicting subsequent recurrence of postoperative Crohn’s disease (CD). Clinicians and trialists could consider using the SES-CD or MM-SES-CD to assess postoperative CD.

Introduction Right-sided colon cancer is a prevalent malignancy. The standard surgical treatment for this condition is laparoscopic right hemicolectomy, with ileocolic anastomosis being a crucial step in the procedure. Recently, intracorporeal ileocolic anastomosis has garnered attention for its minimally invasive benefits. However, there remains a paucity of rigorously designed, large-scale, international multicenter randomized controlled trials to definitively assess the safety and efficacy of intracorporeal ileocolic anastomosis in laparoscopic right hemicolectomy for right-sided colon cancer. Methods This study is an international, multicenter, randomized, controlled, open-label, non-inferiority trial designed to compare the safety and efficacy of intracorporeal versus extracorporeal ileocolic anastomosis in patients with right-sided colon cancer undergoing right hemicolectomy. The primary endpoint is the anastomotic leakage rate within 30 days post-surgery. The main secondary endpoint is the 3-year disease-free survival rate post-surgery. A comprehensive quality assurance protocol will be established before the trial begins, including CT review, pathological evaluation, and the standardization and assessment of surgical techniques. Discussion This study aims to evaluate the safety and efficacy of intracorporeal ileocolic anastomosis following right hemicolectomy in patients with right-sided colon cancer. The anticipated outcome is that intracorporeal ileocolic anastomosis will show an anastomotic leakage rate and a 3-year disease-free survival rate comparable to those of extracorporeal anastomosis, while offering the added benefit of faster postoperative recovery. Graphical abstract