Correspondence
is a continuously evolving process where novel treatments are evaluated and brought into practice to help improve the outcome. Smart and Daniels [1] cite the example of nonsteroidal anti-inflammatory drugs (NSAIDs) to illustrate this aspect. NSAIDs have a dual mechanism of action including an opioid-sparing effect and an anti-inflammatory effect that helps to reduce ileus. Cohort studies suggested an increased risk of anastomotic leakage associated with NSAID use, but this hypothesis has been challenged by a subsequent meta-analysis [3]. The debate is still ongoing and NSAIDs are not a cornerstone of the ERAS protocol; alternative methods of analgesia can be used. Another example showing that ERAS principles are not dogmatic is the use of chewing gum to enhance gut motility being included in ERAS programmes owing to evidence that this may promote return of physiological function when used with other measures such as early feeding [4]. This illustrates that ERAS is an evolving process. The ERAS Society (http:// www.erassociety.org) is working to assimilate the clinical research contributions in the field of peri-operative care and members of the network have contributed to more than 1500 papers in this field, leading to scientific advancement and further education in modern peri-operative care. Enhanced recovery is not limited to the reduction in the number and severity of postoperative complications. It also alludes to postoperative comfort, shorter hospital stay and faster return to normal activity. Morbidity after elective colonic surgery occurs in less than one-third of patients and re-operation is needed in under 10% [5]. Most patients therefore have an uneventful postoperative course and can benefit from evidence-based measures that enhance their recovery in terms of hospital stay or postoperative comfort. While all meta-analyses have shown that they reduce overall morbidity by half [6], ERAS protocols have not been demonstrated to reduce major complications. This should not be regarded as a failure of ERAS, since the protocol is effective for most patients. It is obvious that serious complications should be detected early in the postoperative course and managed according to rescue principles, which may involve suspension of ERAS pathways. We reiterate that ERAS is not dogmatic and that it is beneficial to the patient and to society and health care organizations through cost effectiveness and better resource utilization.
220
K. Slim*†, N. Demartines†‡, K. C. Fearon†§, D. N. Lobo†¶, J. Ramirez†**, M. Scott††† and O. Ljungqvist†‡‡ *Department of Digestive Surgery, CHU Estaing, Clermont-Ferrand, France, †ERAS Society, Kista, Sweden, ‡Department of Visceral Surgery, University Hospital of Lausanne, Lausanne, Switzerland, §Clinical and Surgical Sciences (Surgery), School of Clinical Sciences and Community Health, Royal Infirmary, Edinburgh, UK, ¶Biomedical Research Unit, Division of Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research, Nottingham University Hospitals, Queen’s Medical Centre, Nottingham, UK, **Department of Surgery, University Hospital, Zaragoza, Spain, ††Department of Anaesthesia, Royal Surrey County Hospital, Guildford, UK and ‡‡Department of Surgery, € € Orebro University Hospital and Karolinska Institutet, Orebro, Sweden E-mail: [email protected] Received 23 November 2013; accepted 29 November 2013; Accepted Article online 9 December 2013
References 1 Smart NJ, Daniels IR. Beyond enhanced recovery. Colorectal Dis 2013; 15: 1331–2. 2 Kehlet H, Slim K. The future of fast-track surgery. Br J Surg 2012; 99: 1025–6. 3 Burton TP, Mittal A, Soop M. Nonsteroidal anti-inflammatory drugs and anastomotic dehiscence in bowel surgery: systematic review and meta-analysis of randomized, controlled trials. Dis Colon Rectum 2013; 56: 126–34. 4 Lim P, Morris OJ, Nolan G, Moore S, Draganic B, Smith SR. Sham feeding with chewing gum after elective colorectal resectional surgery: a randomized clinical trial. Ann Surg 2013; 257: 1016–24. 5 Ricciardi R, Roberts PL, Read TE, Marcello PW, Hall JF, Schoetz DJ. How often do patients return to the operating room after colorectal resections? Colorectal Dis 2012; 14: 515–21. 6 Varadhan KK, Neal KR, Dejong CH, Fearon KC, Ljungqvist O, Lobo DN. The enhanced recovery after surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: a meta-analysis of randomized controlled trials. Clin Nutr 2010; 29: 434–40.
Response to Tsiamoulos et al. (2014): Does diverticular disease protect against sigmoid colon cancer? doi:10.1111/codi.12547
Dear Sir, We read with interest the article by Tsiamoulos et al. [1] and were surprised that the authors believed that an inverse relationship between colon cancer and sigmoid diverticular disease had not been previously reported. In
Colorectal Disease ª 2013 The Association of Coloproctology of Great Britain and Ireland. 16, 219–221
Correspondence
2006 Krones et al. [2] provided evidence of this relationship by retrospectively analysing the results of nearly 2000 patients operated on following complete colonoscopy. There is now a considerable body of research into the aetiology and pathophysiology of diverticulosis coli, in particular regarding its likely relationship with herniosis being coined in 2004 by Klinge et al., but as an idea first proposed in 1948 as an association known as Saint’s triad [3,4]. Subsequently, understanding of the responsible pathology increased and a reduction in the ratio of type I/III collagen as a consequence of damaged fibroblasts was reported [5]. Metalloproteinases have been implicated in a reduction in this ratio in the bowel wall affected by diverticulosis coli [6]. Genetics also play a role. Crucially, as our understanding of cancer cell biology has increased it has become clear that the extracellular matrix provided by diverticulosis coli is not conducive to colon cancer, which appears to favour an increase in the type I/III collagen ratio [7]. This is beautifully summarized by Read in a recent review article: ‘Whereas the degradation of connective tissue was thought to encourage invasion, eliciting concern for the herniated, now, investigators report the reverse, a reactive vascularized stroma resembling wound healing with an increase in fibroblasts and collagen I’ [8]. Rather than reporting a new relationship, the authors have simply provided further evidence of one that has been previously established, although the current literature would suggest that this has more to do with the
extracellular matrix than changes in bacterial flora as they propose.
H. J. Knight, I. R. Daniels and N. J. Smart Royal Devon and Exeter NHS Foundation Trust, Barrack Road, Exeter, EX2 5DW, UK E-mail: [email protected] Received 15 December 2013; accepted 17 December 2013; Accepted Article online 24 December 2013
References 1 Tsiamoulos ZP, Peake ST, Nickerson C, Rutter MD, Saunders BP. Does diverticular disease protect against sigmoid colon cancer? Colorectal Dis 2014; 16: 70–71. 2 Krones CJ, Kling U, Butz N et al. The rare epidemiologic coincidence of diverticular disease and advanced colonic neoplasia. Int J Colorectal Dis 2006; 21: 18–24. 3 Saint CFM. Saint’s triad: the origin and story of its recognition. Rev Surg 1966; 23: 1–4. 4 Klinge U, Junge K, Mertens PR. Herniosis: a biological approach. Hernia 2004; 8: 300–1. 5 Wagh PV, Leverich AP, Sun CN et al. Direct inguinal herniation in men: a disease of collagen. J Surg Res 1974; 17: 425–33. 6 Stumpf M, Cao W, Klinge U et al. Increased distribution of collagen type III and reduced expression of matrix metalloproteinase 1 in patients with diverticular disease. Int J Colorectal Dis 2001; 16: 271–5. 7 Barkan D, Green JE, Chambers AF. Extracellular matrix: a gatekeeper in the transition from dormancy to metastatic growth. Eur J Cancer 2010; 46: 1181–8. 8 Read RC. The Nyhus Wantz lectureship: etiology, herniosis, diverticulosis coli, and cancer. Hernia 2011; 15: 481–3.
Colorectal Disease ª 2013 The Association of Coloproctology of Great Britain and Ireland. 16, 219–221
221
Copyright of Colorectal Disease is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
is a continuously evolving process where novel treatments are evaluated and brought into practice to help improve the outcome. Smart and Daniels [1] cite the example of nonsteroidal anti-inflammatory drugs (NSAIDs) to illustrate this aspect. NSAIDs have a dual mechanism of action including an opioid-sparing effect and an anti-inflammatory effect that helps to reduce ileus. Cohort studies suggested an increased risk of anastomotic leakage associated with NSAID use, but this hypothesis has been challenged by a subsequent meta-analysis [3]. The debate is still ongoing and NSAIDs are not a cornerstone of the ERAS protocol; alternative methods of analgesia can be used. Another example showing that ERAS principles are not dogmatic is the use of chewing gum to enhance gut motility being included in ERAS programmes owing to evidence that this may promote return of physiological function when used with other measures such as early feeding [4]. This illustrates that ERAS is an evolving process. The ERAS Society (http:// www.erassociety.org) is working to assimilate the clinical research contributions in the field of peri-operative care and members of the network have contributed to more than 1500 papers in this field, leading to scientific advancement and further education in modern peri-operative care. Enhanced recovery is not limited to the reduction in the number and severity of postoperative complications. It also alludes to postoperative comfort, shorter hospital stay and faster return to normal activity. Morbidity after elective colonic surgery occurs in less than one-third of patients and re-operation is needed in under 10% [5]. Most patients therefore have an uneventful postoperative course and can benefit from evidence-based measures that enhance their recovery in terms of hospital stay or postoperative comfort. While all meta-analyses have shown that they reduce overall morbidity by half [6], ERAS protocols have not been demonstrated to reduce major complications. This should not be regarded as a failure of ERAS, since the protocol is effective for most patients. It is obvious that serious complications should be detected early in the postoperative course and managed according to rescue principles, which may involve suspension of ERAS pathways. We reiterate that ERAS is not dogmatic and that it is beneficial to the patient and to society and health care organizations through cost effectiveness and better resource utilization.
220
K. Slim*†, N. Demartines†‡, K. C. Fearon†§, D. N. Lobo†¶, J. Ramirez†**, M. Scott††† and O. Ljungqvist†‡‡ *Department of Digestive Surgery, CHU Estaing, Clermont-Ferrand, France, †ERAS Society, Kista, Sweden, ‡Department of Visceral Surgery, University Hospital of Lausanne, Lausanne, Switzerland, §Clinical and Surgical Sciences (Surgery), School of Clinical Sciences and Community Health, Royal Infirmary, Edinburgh, UK, ¶Biomedical Research Unit, Division of Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research, Nottingham University Hospitals, Queen’s Medical Centre, Nottingham, UK, **Department of Surgery, University Hospital, Zaragoza, Spain, ††Department of Anaesthesia, Royal Surrey County Hospital, Guildford, UK and ‡‡Department of Surgery, € € Orebro University Hospital and Karolinska Institutet, Orebro, Sweden E-mail: [email protected] Received 23 November 2013; accepted 29 November 2013; Accepted Article online 9 December 2013
References 1 Smart NJ, Daniels IR. Beyond enhanced recovery. Colorectal Dis 2013; 15: 1331–2. 2 Kehlet H, Slim K. The future of fast-track surgery. Br J Surg 2012; 99: 1025–6. 3 Burton TP, Mittal A, Soop M. Nonsteroidal anti-inflammatory drugs and anastomotic dehiscence in bowel surgery: systematic review and meta-analysis of randomized, controlled trials. Dis Colon Rectum 2013; 56: 126–34. 4 Lim P, Morris OJ, Nolan G, Moore S, Draganic B, Smith SR. Sham feeding with chewing gum after elective colorectal resectional surgery: a randomized clinical trial. Ann Surg 2013; 257: 1016–24. 5 Ricciardi R, Roberts PL, Read TE, Marcello PW, Hall JF, Schoetz DJ. How often do patients return to the operating room after colorectal resections? Colorectal Dis 2012; 14: 515–21. 6 Varadhan KK, Neal KR, Dejong CH, Fearon KC, Ljungqvist O, Lobo DN. The enhanced recovery after surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: a meta-analysis of randomized controlled trials. Clin Nutr 2010; 29: 434–40.
Response to Tsiamoulos et al. (2014): Does diverticular disease protect against sigmoid colon cancer? doi:10.1111/codi.12547
Dear Sir, We read with interest the article by Tsiamoulos et al. [1] and were surprised that the authors believed that an inverse relationship between colon cancer and sigmoid diverticular disease had not been previously reported. In
Colorectal Disease ª 2013 The Association of Coloproctology of Great Britain and Ireland. 16, 219–221
Correspondence
2006 Krones et al. [2] provided evidence of this relationship by retrospectively analysing the results of nearly 2000 patients operated on following complete colonoscopy. There is now a considerable body of research into the aetiology and pathophysiology of diverticulosis coli, in particular regarding its likely relationship with herniosis being coined in 2004 by Klinge et al., but as an idea first proposed in 1948 as an association known as Saint’s triad [3,4]. Subsequently, understanding of the responsible pathology increased and a reduction in the ratio of type I/III collagen as a consequence of damaged fibroblasts was reported [5]. Metalloproteinases have been implicated in a reduction in this ratio in the bowel wall affected by diverticulosis coli [6]. Genetics also play a role. Crucially, as our understanding of cancer cell biology has increased it has become clear that the extracellular matrix provided by diverticulosis coli is not conducive to colon cancer, which appears to favour an increase in the type I/III collagen ratio [7]. This is beautifully summarized by Read in a recent review article: ‘Whereas the degradation of connective tissue was thought to encourage invasion, eliciting concern for the herniated, now, investigators report the reverse, a reactive vascularized stroma resembling wound healing with an increase in fibroblasts and collagen I’ [8]. Rather than reporting a new relationship, the authors have simply provided further evidence of one that has been previously established, although the current literature would suggest that this has more to do with the
extracellular matrix than changes in bacterial flora as they propose.
H. J. Knight, I. R. Daniels and N. J. Smart Royal Devon and Exeter NHS Foundation Trust, Barrack Road, Exeter, EX2 5DW, UK E-mail: [email protected] Received 15 December 2013; accepted 17 December 2013; Accepted Article online 24 December 2013
References 1 Tsiamoulos ZP, Peake ST, Nickerson C, Rutter MD, Saunders BP. Does diverticular disease protect against sigmoid colon cancer? Colorectal Dis 2014; 16: 70–71. 2 Krones CJ, Kling U, Butz N et al. The rare epidemiologic coincidence of diverticular disease and advanced colonic neoplasia. Int J Colorectal Dis 2006; 21: 18–24. 3 Saint CFM. Saint’s triad: the origin and story of its recognition. Rev Surg 1966; 23: 1–4. 4 Klinge U, Junge K, Mertens PR. Herniosis: a biological approach. Hernia 2004; 8: 300–1. 5 Wagh PV, Leverich AP, Sun CN et al. Direct inguinal herniation in men: a disease of collagen. J Surg Res 1974; 17: 425–33. 6 Stumpf M, Cao W, Klinge U et al. Increased distribution of collagen type III and reduced expression of matrix metalloproteinase 1 in patients with diverticular disease. Int J Colorectal Dis 2001; 16: 271–5. 7 Barkan D, Green JE, Chambers AF. Extracellular matrix: a gatekeeper in the transition from dormancy to metastatic growth. Eur J Cancer 2010; 46: 1181–8. 8 Read RC. The Nyhus Wantz lectureship: etiology, herniosis, diverticulosis coli, and cancer. Hernia 2011; 15: 481–3.
Colorectal Disease ª 2013 The Association of Coloproctology of Great Britain and Ireland. 16, 219–221
221
Copyright of Colorectal Disease is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
