AIM:Reporting of colorectal anastomotic leakage (CAL) risk factors and outcomes is not standardized worldwide. This study searched a cohort of national surgical registries to assess the scope of CAL-related elements that are routinely reported. METHODS:This international audit was conducted between June 2025 and April 2026. Surgeons were contacted to determine whether their country maintained a national registry and to provide the list of CAL-related variables collected. Registry variables were compared to the 79 CoReAL (Consensus for Reporting of colorectal Anastomotic Leaks) variables, an evidence-based framework developed to standardize how key CAL-related variables are reported. The primary outcome was the proportion of countries with a national registry reporting CAL and CAL-associated variables. The secondary outcome was the proportion and type of CoReAL variables included across registries. RESULTS:Thirty-eight countries across all continents participated. Among these, seven countries (18.4%) maintain national registries that centrally capture post-operative outcomes. Across all registries, the median number of registered variables was 28 (range 18-37, IQR 4). Completeness differed significantly between countries, with 10 elements being captured by all (p = 0.003). Registries reported a median of 11/25 preoperative (8-19, 6), 6/16 intraoperative (3-8, 2), 8/16 early post-operative (5-12, 4) and 2/22 (0-13, 4) of the long-term post-operative elements. CONCLUSION:The majority of countries lack a national registry for systematic CAL reporting. Among existing registries, substantial heterogeneity in reported variables was observed, including CAL risk factors and outcomes, particularly beyond 30 days. We propose global adoption of the CoReAL reporting framework to fill this gap in quality reporting of CAL.
BACKGROUND:Over recent decades, there has been a more pronounced shift towards earlier therapeutic intervention in luminal Crohn's disease (CD). However, it remains unclear if similar strategies apply to active perianal fistulizing CD (pCD). This study explores the patient journey by assessing pCD management across diagnostic time periods in a large national cohort. METHODS:Patients with active pCD were included in a multicentre cohort across 41 Dutch academic and non-academic hospitals. Diagnostic modalities, medical and surgical treatments were evaluated over the pCD disease course, particularly within the first year after pCD diagnosis, and compared across four time periods: < 2010, 2010-2015, 2015-2020 and > 2020. RESULTS:Four hundred and forty patients were included (53.0% female; median pCD disease course 4.1 years). 12% were diagnosed before 2010, 11% in 2010-2015, 31% in 2015-2020, 46% after 2020. Over time, imaging (MRI or EUS) within the first year after pCD diagnosis was used in 37% of cases diagnosed before 2010 to 66%, 83% and 95% in subsequent periods. Endoscopic evaluation for proctitis was performed in 23%, 40%, 57% and 60%. First-line anti-TNF use was initiated in 27% followed by 58%, 68% and 69%. A seton was placed in 27% initially and in 42%, 51% and 52% in later years. Fistula surgery aimed at closure was performed in 14%, 4%, 8% and 19% over time. CONCLUSIONS:This national cohort illustrates substantial progress in early pCD management over time. These shifts likely reflect growing clinical awareness of the importance of early and multidisciplinary interventions. However, surgical procedures aimed at fistula closure remain infrequently performed in the early disease course, which may be related to the inclusion of a predominantly therapy-refractory patient group.
BACKGROUND AND AIMS:So far, there are no diagnostic tools to identify Crohn's disease (CD) patients at risk of failure or recurrence after perianal fistula closure surgery. This study aims to analyse if fistula scrapings calprotectin levels in CD patients undergoing surgical fistula closure can be predictive of postoperative outcomes. METHODS:In this prospective study, fistula scrapings were collected from 47 TOpCLASS 2a patients who underwent a surgical closure procedure with or without mesenchymal stem cell (MST) between November 2019 and February 2024. Scraping calprotectin was determined by ELISA. The primary outcome parameter was the correlation between scraping calprotectin levels and clinical fistula closure and radiological remission (MAGNIFI score ≤ 6). RESULTS:Eighteen patients underwent primary surgical closure and 29 patients underwent surgical closure with MST. Scraping calprotectin levels were significantly lower in the primary closure group when compared to MST (822 μg/g (IQR 134-3285) vs. 2698 μg/g (IQR 1042-6000), p = 0.041). After a median follow-up of 18 months (IQR 14-51), overall, 68% clinical closure with 40% radiological remission was seen. In the primary surgical closure group, scraping calprotectin levels were significantly lower in patients with clinical fistula closure (586 μg/g (IQR 84-1454) vs. 5855 μg/g (IQR 3291-6000), p = 0.003). In contrast, in the MST group no significant differences were found for clinical closure, whereas higher scraping calprotectin levels were found in patients who reached radiological remission (4827 μg/g(IQR 2698-6000) vs. 1967 μg/g (IQR 428-3937), p = 0.033). CONCLUSIONS:These results suggest that scraping calprotectin can be used to identify patients amenable for primary surgical closure and select patients most likely to need additional treatment like MST.
AIM:Early ileocaecal resection has recently emerged as a feasible alternative to biologics in patients with localized Crohn's disease unresponsive to standard therapy. However, early resection is not widely implemented in clinical settings, and data on its comparison to biologics therapy are limited. METHODS:We searched PubMed, Scopus and Cochrane for randomized clinical trials (RCTs) and observational studies comparing early ileocaecal resection to biologics therapy in patients with localized Crohn's disease. Risk ratio (RR) was calculated for pooled outcomes; a p-value of < 0.05 was considered statistically significant. RESULTS:We included 1,644 patients from one RCT and two cohort studies, where 799 patients were treated with a surgery-first approach (48.8%). In the biologics group, patients were mainly treated with infliximab or adalimumab. Fewer patients in the resection group required additional surgery beyond the allocated treatment compared to patients treated with biologics therapy (RR 0.09; 95% CI 0.03-0.24; p = 0.01). There was no statistically significant difference between groups regarding the need to escalate treatment to the other arm's therapy. In two studies, at final follow-up, nearly half of the resection group (315/650, 48%) were off medication without further treatment, whereas all patients treated with biologics first required ongoing medical therapy or surgery. CONCLUSION:In patients with localized predominantly inflammatory ileocaecal Crohn's disease, who are naïve to biologics therapy, early resection may reduce the need for subsequent treatment. These findings should be interpreted with caution due to the limited evidence base and the low to very low certainty of evidence highlighted by GRADE assessment.
BACKGROUND:Sexual dysfunction is a recognised adverse outcome after rectal cancer treatments, yet reporting is predominantly male-focused, with female sexual dysfunction less consistently assessed or reported. This systematic review aimed to assess sexual health domains studied, examine sex-based reporting disparities, and identify limitations in the current evidence. METHODS:A systematic review and narrative synthesis were conducted in accordance with PRISMA and registered with PROSPERO (CRD420251178502). PubMed/MEDLINE, EMBASE, Scopus, CINAHL Plus, PsycINFO, and Cochrane Library were searched from March 1995 to March 2025, with an updated search to March 2026. Eligible studies included adults treated for rectal cancer in whom sexual function outcomes were assessed using International Index of Erectile Function (IIEF) and/or Female Sexual Function Index (FSFI), with additional related patient-reported outcome measures (PROMs) accepted where relevant. Risk of bias was assessed using RoB 2 and MINORS. RESULTS:Twenty-five studies involving 4,071 patients were included. Participants were predominantly male (65.8%), while women comprised 34.2%. PROM reporting was inconsistent; only eight studies reported both total and domain-level results. Sexual outcomes were most consistently reported for men, particularly erectile and ejaculatory function, whereas female outcomes were often reduced to overall scores. Five studies restricted sexual outcome assessment and analysis to men. Only six reported response rates, and missing PROM data handling was not described. Key contextual variables, including sexual activity, sexual orientation, sexual practices, and menopausal status, were rarely captured. CONCLUSIONS:Sexual function outcomes after rectal cancer treatment are inconsistently reported, with low certainty. Female sexual dysfunction remains under-represented. Standardised, inclusive sex-specific reporting and development of a core outcome set are needed.
Patients and health professionals face difficult decisions every day when choosing between standard-of-care treatments for the same disease. In bowel disease, some treatments are used interchangeably, but a lack of evidence may exist as to whether one is more effective than another. Randomised controlled trials provide robust evidence in these settings, but they are expensive, time-consuming and disruptive to usual care. The introduction of electronic health records (EHR) has created unique opportunities to develop efficient trial designs, such as Decision Architecture Randomised Trials (DART). These implement unobtrusive and sometimes indiscernible EHR 'nudges', prompting clinicians towards one treatment or another. There is no obligation for clinicians to use the assigned intervention or for the patient to accept it. However, the association between the assignment and the actual treatment received can be used to estimate unbiased treatment effects. We discuss the key features of DART studies and outline the persisting uncertainties to operationalising this study design in clinical practice.
AIM:A prolonged time from diagnosis to start of radiotherapy (TTRT) for malignant disease may negatively influence survival, but studies in squamous cell carcinoma of the anus (SCCA) are largely lacking. The purpose of this study was to investigate the impact of TTRT on overall survival (OS) and anal cancer-specific survival (ACSS) in a nationwide population-based cohort from the Swedish Anal Cancer Registry. METHOD:Patients with non-metastatic SCCA treated with curative intent definitive radiotherapy (93.3% concomitant chemotherapy) during 2015-2023 were included (n = 958). According to national guidelines TTRT should be ≤ 46 days and this was used as a cut-off in the primary analyses. Cox proportional hazards models were used to estimate hazard ratios for OS and ACSS. Variables with p < 0.10 in univariable analyses were entered into multivariable models, with TTRT included in all models. RESULTS:The median TTRT was 48 days (range 17-350), and in 55% of the patients it exceeded 46 days. Old age, poor performance status, small tumour size, absence of lymph node metastasis and no concomitant chemotherapy were associated with TTRT >46 days. With a median follow-up of 43 months, TTRT > 46 days had no impact on OS or ACSS. Sensitivity analyses using alternative TTRT cut-offs and restricting the analysis to high-risk subgroups showed similar results. CONCLUSION:Moderate delays beyond 46 days from diagnosis to radiotherapy initiation did not adversely affect OS or ACSS in patients with SCCA.
BACKGROUND:Redo ileocolic resection (ICR) for Crohn's disease is technically challenging, and surgeons often debate whether a laparoscopic approach should be attempted given the risk of conversion. We evaluated predictors of conversion and postoperative outcomes following conversion to inform operative decision-making. METHODS:Patients undergoing redo ileocolic resection for Crohn's disease from 2009 to 2021 at a quaternary referral centre were identified from a prospectively maintained database. Cases were categorized as completed laparoscopically, converted or planned open. Predictors of conversion and perioperative outcomes were analysed. RESULTS:Among 436 redo ileocolic resections, 100 were attempted laparoscopically, with a 10% conversion rate. Penetrating disease was significantly associated with conversion. Postoperative outcomes after conversion were comparable to planned open surgery, including overall complications, readmission and reoperation. Length of stay was shorter after completed laparoscopy. CONCLUSIONS:Conversion during laparoscopic redo ileocolic resection is uncommon and primarily driven by penetrating disease. Importantly, outcomes after conversion approximate those of planned open surgery, supporting an initial laparoscopic approach in appropriately selected patients.
AIM:Literature comparing total proctocolectomy with permanent end ileostomy (TPC-EI) and IPAA in patients with UC is sparse. We aimed to (a) elucidate reasons for non-restorative surgery in ulcerative colitis (UC), (b) describe the incidence of perineal wound complications and (c) assess differences in short-term outcomes between groups. We hypothesized that non-restorative surgery was associated with a higher overall complication rate than ileoanal pouch (IPAA). METHODS:We identified a sample of patients with UC who underwent proctectomy (2005-2023) at our institution. The primary endpoint was the overall 30-day complication rate. Odds ratios (ORs) and 95% confidence intervals are presented. RESULTS:A total of 821 patients were included: 689 (83.9%) IPAA and 132 (16.1%) TPC-EI (80% and 52% staged proctectomy, respectively). The most common reasons for TPC-EI over IPAA were patient preference (53%), neoplasia (10.6%), incontinence (9.1%) and obesity (7.6%). Compared with IPAA patients, TPC-EI patients were older, had more comorbidities, and more were receiving biologics. Postoperatively, 18.2% of TPC-EI patients developed perineal wound complications, whereas 4.5% of IPAA patients experienced leaks. The overall 30-day complication rate was higher after TPC-EI (37.1% vs. 19.2%, p < 0.0001); however, after excluding these procedure-specific complications, rates were equivalent (22.7% vs. 17.9%, p = 0.23). In multivariable analysis after propensity score matching, TPC-EI remained a significant predictor of any complication (OR 2.84, 95% CI 1.37-6.08, p = 0.006). CONCLUSIONS:Patient preference was the most common reason for permanent ileostomy in UC. Although short-term complication rates were similar overall, perineal complications occurred in 18% after TPC-EI. These data may inform preoperative counselling when discussing surgical options for UC.
BACKGROUND:Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is standard treatment for peritoneal metastases in Sweden. Prolonged postoperative ileus (PPOI) is a common complication following major abdominal surgery and is associated with increased morbidity and prolonged hospitalization. The aim of this study was to evaluate the incidence of PPOI following CRS-HIPEC and to identify factors associated with its development, including its relationship to postoperative complications. METHODS:This retrospective, bicentre cohort study included patients undergoing CRS-HIPEC for peritoneal metastases between January 2012 and 2024. Patients were identified through the Swedish HIPEC Registry, with supplementary data obtained from medical records. PPOI was defined as delayed defaecation beyond postoperative day 5 and/or prolonged use or reinsertion of a nasogastric tube. Clinical, surgical and postoperative outcomes were analysed and risk factors for PPOI were assessed using a multivariable logistic regression model. RESULTS:A total of 982 patients were included, of whom 443 (45%) developed PPOI. Patients with PPOI had significantly longer hospital stays (median 11 vs. 9; p < 0.001) and delayed return of bowel function compared with patients without PPOI (median 6 vs. 3 days; p < 0.001). Major complications were more frequently observed in patients with PPOI (36% vs. 16%, p < 0.001). Independent risk factors for PPOI were major postoperative complications (aOR 3.74, CI 2.55-5.48), blood transfusion (aOR 1.70, CI 1.08-2.70) and omentectomy below the gastroepiploic arcade (aOR 1.51, CI 1.01-2.26). This association remained even after excluding patients with major postoperative surgical complications. Ileostomy formation was associated with a reduced risk of PPOI (aOR 0.51, CI 0.33-0.77). CONCLUSIONS:PPOI is a frequent complication following CRS-HIPEC and is associated with increased postoperative morbidity and prolonged recovery. Strategies aimed to optimize perioperative care and enhanced recovery protocols may help to reduce the incidence and the adverse effects of PPOI.
AIM:The impact of different circular stapler platforms on the risk of anastomotic leakage following elective left colectomy and high anterior resection remains poorly defined. We compared the risk of anastomotic leakage across commonly used circular stapler platforms using advanced confounding control methods. METHODS:This pre-planned post hoc analysis pooled individual patient data from the published iCral-2 and iCral-3 studies and from the iCral-4 study, whose primary results are currently under peer review. Adults undergoing elective left colectomy or high anterior resection with standardized end-to-end circular stapled anastomosis were included. Five circular stapler platforms were compared. Confounding was addressed using generalized boosted model-based propensity score weighting targeting the average treatment effect on the treated, with doubly robust outcome modelling. The primary endpoint was overall anastomotic leakage at 60 days. RESULTS:Among 3,653 patients, overall anastomotic leakage occurred in 2.7% of patients receiving the reference 3-row platform. After weighting, Platforms 3 and 4 were associated with a significantly increased risk of overall anastomotic leakage (odds ratios >2), whereas no statistically significant differences were observed for Platforms 2 or 5. Because the effective sample size after weighting was substantially reduced for Platform 3 owing to limited covariate overlap, the corresponding effect estimate should be interpreted with appropriate caution. CONCLUSIONS:Selected circular stapler platforms were associated with an increased risk of overall anastomotic leakage. These findings suggest platform-specific rather than class-wide differences and warrant confirmation in prospective studies designed to identify the device-related and procedural factors underlying these associations. TRIAL REGISTRATION:NCT03771456 for iCral2, NCT04397627 for iCral3 and NCT05227014 for iCral4.
