Abstract Aim In the era of multidisciplinary cancer care, proctectomy remains an essential procedure in treating rectal cancer. However, the current rates of optimal surgical resection in the US are unknown. This study examined the rates, hospital variation and factors associated with optimal surgical resection. Methods Patients with clinically locally advanced (cT3‐T4 and/or cN1‐2) rectal adenocarcinoma who underwent proctectomy between 2021 and 2023 were identified within the National Cancer Database (NCDB). Optimal surgical resection was a composite metric defined as complete total mesorectal excision (TME), negative surgical margins and adequate lymph node yield (LNY) ≥12. Mixed‐effects multivariable analyses were performed to assess the association between optimal surgical resection and overall survival, identify factors associated with optimal surgical resection and assess hospital variation. Results Among 6,183 patients, the optimal surgical resection rate was 59.2% (complete TME = 78.6%, negative surgical margins = 85.4%, adequate LNY = 83.7%). Optimal surgical resection was independently associated with longer overall survival (HR = 0.62, 95%CI = 0.48–0.80). Older age ( p < 0.001) and Black race ( p = 0.02) were independently associated with lower odds of achieving optimal surgical resection. There was wide variation in adjusted optimal surgical resection rates across hospitals (range = 30%–82%), and higher hospital volume was associated with optimal surgical resection ( p < 0.001). Conclusions Possible disparities in achieving optimal surgical resection were identified among older and Black patients. In addition, there is wide hospital variation in achieving optimal surgical resection along with a direct correlation between higher hospital volume and optimal surgical resection. These findings support selective referral to medium‐to‐high volume centres to achieve better outcomes and future research into the aetiology of these possible disparities.
Abstract Aim To evaluate the impact of lateral internal sphincterotomy on symptom resolution and quality of life, overall and related to faecal incontinence, in patients with chronic anal fissure. Methods An analytical observational before‐ and after study was conducted in adults with chronic anal fissure who underwent lateral internal sphincterotomy between 2020 and 2024. Quality of life changes were assessed using the EQ‐5D‐5L and VAS Score. In patients with preoperative faecal incontinence, changes were evaluated using the Faecal Incontinence Quality of Life Scale (FIQLS). FIQLS and VAS scores were compared using the Wilcoxon signed‐rank test, and EQ‐5D‐5L changes were analysed using the Paretian Classification of Health Change,Probability of Superiority and Health Profile Matrix. Results A total of 332 patients were analysed, 52.1% male (173/332), with a median age of 43 years (IQR 34–55). According to the Paretian Classification of Health Change, 85.6% (279/326) showed an overall improvement in quality of life. All EQ‐5D‐5L domains demonstrated improvement after the procedure, with the greatest impact observed in the pain/discomfort domain (96.9%, 281/290). These findings were supported by probability of superiority values (mobility = 0.53; self‐care = 0.54; usual activities = 0.64; pain/discomfort = 0.92; anxiety/depression = 0.58) and were reflected in the Health Profile Matrix. Preoperative faecal incontinence was present in 7.8% (26/332), with no significant changes in quality of life according to FIQLS. Conclusion Lateral internal sphincterotomy improved overall quality of life in patients with chronic anal fissure without worsening faecal incontinence related quality of life and was associated with symptom resolution.
Abstract Background The Crohn's Anal Fistula Quality of Life (CAF‐QoL) questionnaire is the first disease‐specific patient‐reported outcome measure (PROM) for perianal fistulising Crohn's disease (pfCD). However, validation against objective measures of disease burden is limited. We evaluated the relationship between CAF‐QoL and quantitative MRI fistula volume to determine whether MRI‐derived disease burden supports the construct validity of this PROM. Methods Adults with pfCD were prospectively recruited from a tertiary referral centre. Patients underwent pelvic MRI and completed CAF‐QoL within 3 months of imaging. MRI fistula volume was independently quantified by two radiologists using ITK‐SNAP, with concurrent scoring of the Van Assche Index (VAI). Clinical disease activity was assessed using the Perianal Disease Activity Index (PDAI). Associations between MRI measures, CAF‐QoL and PDAI were evaluated cross‐sectionally and longitudinally. Results Thirty‐eight patients were included. MRI fistula volume correlated with both CAF‐QoL ( ρ = 0.40, p = 0.03) and PDAI ( ρ = 0.59, p < 0.001). Patients achieving CAF‐QoL remission had significantly smaller fistula volumes than those with active disease (279 vs. 965 mm 3 , p = 0.04). Longitudinal changes in fistula volume correlated with changes in CAF‐QoL ( ρ = 0.61, p = 0.02) and PDAI ( ρ = 0.74, p ≤ 0.01). There was no significant association between the VAI and either CAF‐QoL or PDAI. Inter‐observer agreement for MRI volume measurement was excellent (ICC = 0.995). Conclusion Quantitative MRI fistula volume provides objective construct validation of the CAF‐QoL questionnaire and captures clinically meaningful disease burden in pfCD. Combined assessment of MRI fistula volume and CAF‐QoL may provide complementary imaging and patient‐reported endpoints for clinical practice and future therapeutic trials. Larger prospective multicentre studies are warranted.
Abstract Aim The concept of ‘early surgery’ for ileocaecal Crohn's disease (CD) has gained traction since the LIR!C trial demonstrated that laparoscopic ileocaecal resection is a cost‐effective alternative to infliximab for uncomplicated terminal ileitis. However, the term ‘early’ is imprecisely defined, temporally misleading and difficult to operationalise in clinical practice. This article aims to propose a more useful clinical framework for the timing of ileocaecal resection in CD. Method We critically appraised the 10‐year follow‐up of the LIR!C trial, together with population‐based and pooled observational data comparing ileocaecal resection with continued medical therapy. Results Current evidence suggests that resection may be superior to continued medical therapy in selected patients. It is associated with higher rates of therapy‐free remission and less need for subsequent surgery. Operating before complications develop is also associated with better perioperative outcomes. We propose distinguishing between reactive surgery, meaning operating in response to complications that have already developed, and strategic surgery. Strategic surgery is a proactive, multidisciplinary decision to offer ileocaecal resection at the optimal point in the disease course. It is based on phenotype, patient condition and shared decision‐making, rather than on elapsed time or biological exposure alone. Conclusion The evidence underpinning this position is largely retrospective and subject to selection bias. Substantial clinician, patient and health‐system barriers stand in the way of implementation. Prospective data are needed before guideline revision is warranted.
