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Sylla P, Sands D, Ricardo A, Bonaccorso A, Polydorides A, Berho M, Marks J, Maykel J, Alavi K, Zaghiyan K, Whiteford M, Mclemore E, Chadi S, Shawki SF, Steele S, Pigazzi A, Albert M, DeBeche-Adams T, Moshier E, Wexner SD. Multicenter phase II trial of transanal total mesorectal excision for rectal cancer: preliminary results. Surg Endosc 2023; 37:9483-9508. [PMID: 37700015 PMCID: PMC10709232 DOI: 10.1007/s00464-023-10266-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 06/27/2023] [Indexed: 09/14/2023]
Abstract
BACKGROUND Transanal TME (taTME) combines abdominal and transanal dissection to facilitate sphincter preservation in patients with low rectal tumors. Few phase II/III trials report long-term oncologic and functional results. We report early results from a North American prospective multicenter phase II trial of taTME (NCT03144765). METHODS 100 patients with stage I-III rectal adenocarcinoma located ≤ 10 cm from the anal verge (AV) were enrolled across 11 centers. Primary and secondary endpoints were TME quality, pathologic outcomes, 30-day and 90-day outcomes, and stoma closure rate. Univariable regression analysis was performed to assess risk factors for incomplete TME and anastomotic complications. RESULTS Between September 2017 and April 2022, 70 males and 30 females with median age of 58 (IQR 49-62) years and BMI 27.8 (IQR 23.9-31.8) kg/m2 underwent 2-team taTME for tumors located a median 5.8 (IQR 4.5-7.0) cm from the AV. Neoadjuvant radiotherapy was completed in 69%. Intersphincteric resection was performed in 36% and all patients were diverted. Intraoperative complications occurred in 8% including 3 organ injuries, 2 abdominal and 1 transanal conversion. The 30-day and 90-day morbidity rates were 49% (Clavien-Dindo (CD) ≥ 3 in 28.6%) and 56% (CD ≥ 3 in 30.4% including 1 mortality), respectively. Anastomotic complications were reported in 18% including 10% diagnosed within 30 days. Higher anastomotic risk was noted among males (p = 0.05). At a median follow-up of 5 (IQR 3.1-7.4) months, 98% of stomas were closed. TME grade was complete or near complete in 90%, with positive margins in 2 cases (3%). Risk factors for incomplete TME were ASA ≥ 3 (p = 0.01), increased time between NRT and surgery (p = 0.03), and higher operative blood loss (p = 0.003). CONCLUSION When performed at expert centers, 2-team taTME in patients with low rectal tumors is safe with low conversion rates and high stoma closure rate. Mid-term results will further evaluate oncologic and functional outcomes.
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Affiliation(s)
- Patricia Sylla
- Division of Colon and Rectal Surgery, Mount Sinai Hospital, New York, NY, USA.
- Division of Colon and Rectal Surgery, Mount Sinai Hospital, New York, NY, USA.
| | - Dana Sands
- Department of Colon and Rectal Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | - Alison Ricardo
- Division of Colon and Rectal Surgery, Mount Sinai Hospital, New York, NY, USA
| | | | | | - Mariana Berho
- Executive Administration Florida, Cleveland Clinic Florida, Weston, FL, USA
| | - John Marks
- Department of Colorectal Surgery, Lankenau Medical Center, Wynnewood, PA, USA
| | - Justin Maykel
- Division of Colon and Rectal Surgery, UMass Memorial Medical Center, Worcester, MA, USA
| | - Karim Alavi
- Division of Colon and Rectal Surgery, UMass Memorial Medical Center, Worcester, MA, USA
| | - Karen Zaghiyan
- Division of Colorectal Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Mark Whiteford
- Gastrointestinal and Minimally Invasive Surgical Division, The Oregon Clinic, Providence Cancer Center, Portland, OR, USA
| | - Elisabeth Mclemore
- Division of Colorectal Surgery, Department of Surgery, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, USA
| | - Sami Chadi
- Division of Surgical Oncology, Department of Surgery, Princess Margaret Cancer Centre and University Health Network, Toronto, ON, Canada
| | - Sherief F Shawki
- Department of Colorectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Scott Steele
- Department of Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Alessio Pigazzi
- Division of Colorectal Surgery, Department of Surgery, New York-Presbyterian Weill Cornell Medical Center, New York, NY, USA
| | - Matthew Albert
- Department of Colon and Rectal Surgery, Advent Health Orlando, Orlando, FL, USA
| | | | - Erin Moshier
- Department of Population Health Sciences and Policy, Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA
| | - Steven D Wexner
- Department of Colorectal Surgery, Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL, USA
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2
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Akhlaghpour M, Haritunians T, More SK, Thomas LS, Stamps DT, Dube S, Li D, Yang S, Landers CJ, Mengesha E, Hamade H, Murali R, Potdar AA, Wolf AJ, Botwin GJ, Khrom M, Ananthakrishnan AN, Faubion WA, Jabri B, Lira SA, Newberry RD, Sandler RS, Sartor RB, Xavier RJ, Brant SR, Cho JH, Duerr RH, Lazarev MG, Rioux JD, Schumm LP, Silverberg MS, Zaghiyan K, Fleshner P, Melmed GY, Vasiliauskas EA, Ha C, Rabizadeh S, Syal G, Bonthala NN, Ziring DA, Targan SR, Long MD, McGovern DPB, Michelsen KS. Genetic coding variant in complement factor B (CFB) is associated with increased risk for perianal Crohn's disease and leads to impaired CFB cleavage and phagocytosis. Gut 2023; 72:2068-2080. [PMID: 37080587 DOI: 10.1136/gutjnl-2023-329689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 03/09/2023] [Indexed: 04/22/2023]
Abstract
OBJECTIVE Perianal Crohn's disease (pCD) occurs in up to 40% of patients with CD and is associated with poor quality of life, limited treatment responses and poorly understood aetiology. We performed a genetic association study comparing CD subjects with and without perianal disease and subsequently performed functional follow-up studies for a pCD associated SNP in Complement Factor B (CFB). DESIGN Immunochip-based meta-analysis on 4056 pCD and 11 088 patients with CD from three independent cohorts was performed. Serological and clinical variables were analysed by regression analyses. Risk allele of rs4151651 was introduced into human CFB plasmid by site-directed mutagenesis. Binding of recombinant G252 or S252 CFB to C3b and its cleavage was determined in cell-free assays. Macrophage phagocytosis in presence of recombinant CFB or serum from CFB risk, or protective CD or healthy subjects was assessed by flow cytometry. RESULTS Perianal complications were associated with colonic involvement, OmpC and ASCA serology, and serology quartile sum score. We identified a genetic association for pCD (rs4151651), a non-synonymous SNP (G252S) in CFB, in all three cohorts. Recombinant S252 CFB had reduced binding to C3b, its cleavage was impaired, and complement-driven phagocytosis and cytokine secretion were reduced compared with G252 CFB. Serine 252 generates a de novo glycosylation site in CFB. Serum from homozygous risk patients displayed significantly decreased macrophage phagocytosis compared with non-risk serum. CONCLUSION pCD-associated rs4151651 in CFB is a loss-of-function mutation that impairs its cleavage, activation of alternative complement pathway, and pathogen phagocytosis thus implicating the alternative complement pathway and CFB in pCD aetiology.
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Affiliation(s)
- Marzieh Akhlaghpour
- F. Widjaja Inflammatory Bowel Disease Institute, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
- Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Talin Haritunians
- F. Widjaja Inflammatory Bowel Disease Institute, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Shyam K More
- F. Widjaja Inflammatory Bowel Disease Institute, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Lisa S Thomas
- F. Widjaja Inflammatory Bowel Disease Institute, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Dalton T Stamps
- F. Widjaja Inflammatory Bowel Disease Institute, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Shishir Dube
- F. Widjaja Inflammatory Bowel Disease Institute, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Dalin Li
- F. Widjaja Inflammatory Bowel Disease Institute, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Shaohong Yang
- F. Widjaja Inflammatory Bowel Disease Institute, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Carol J Landers
- F. Widjaja Inflammatory Bowel Disease Institute, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Emebet Mengesha
- F. Widjaja Inflammatory Bowel Disease Institute, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Hussein Hamade
- F. Widjaja Inflammatory Bowel Disease Institute, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Ramachandran Murali
- Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Alka A Potdar
- F. Widjaja Inflammatory Bowel Disease Institute, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Andrea J Wolf
- F. Widjaja Inflammatory Bowel Disease Institute, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
- Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Gregory J Botwin
- F. Widjaja Inflammatory Bowel Disease Institute, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Michelle Khrom
- F. Widjaja Inflammatory Bowel Disease Institute, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | | | | | - Bana Jabri
- Biological Sciences Division, University of Chicago, Pritzker School of Medicine, Chicago, Illinois, USA
| | - Sergio A Lira
- Immunology Institute, Mount Sinai Medical Center, New York, New York, USA
| | - Rodney D Newberry
- Division of Gastroenterology, Washington Univ. Sch. of Medicine, Saint Louis, Missouri, USA
| | - Robert S Sandler
- Center for Gastrointestinal Biology and Disease, University of North Carolina, Chapel Hill, North Carolina, USA
| | - R Balfour Sartor
- Center for Gastrointestinal Biology and Disease, University of North Carolina, Chapel Hill, North Carolina, USA
| | | | - Steven R Brant
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Judy H Cho
- Genetics and Genomics Sciences, Mt Sinai School of Medicine, New York, New York, USA
| | - Richard H Duerr
- Departments of Medicine and Human Genetics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Mark G Lazarev
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - John D Rioux
- Faculty of Medicine, Universite de Montreal, Montreal, Québec, Canada
| | - L Philip Schumm
- Dept of Health Studies, University of Chicago, Chicago, Illinois, USA
| | - Mark S Silverberg
- Division of Gastroenterology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Karen Zaghiyan
- Division of Colorectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Phillip Fleshner
- Division of Colorectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Gil Y Melmed
- F. Widjaja Inflammatory Bowel Disease Institute, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Eric A Vasiliauskas
- F. Widjaja Inflammatory Bowel Disease Institute, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Christina Ha
- F. Widjaja Inflammatory Bowel Disease Institute, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Shervin Rabizadeh
- Department of Pediatrics, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Gaurav Syal
- F. Widjaja Inflammatory Bowel Disease Institute, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Nirupama N Bonthala
- F. Widjaja Inflammatory Bowel Disease Institute, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - David A Ziring
- Department of Pediatrics, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Stephan R Targan
- F. Widjaja Inflammatory Bowel Disease Institute, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Millie D Long
- Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Dermot P B McGovern
- F. Widjaja Inflammatory Bowel Disease Institute, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
- Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Kathrin S Michelsen
- F. Widjaja Inflammatory Bowel Disease Institute, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
- Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California, USA
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Sylla P, Berho M, Sands D, Ricardo A, Bonaccorso A, Moshier E, Hain E, Letchinger R, Marks J, Whiteford M, Mclemore E, Maykel J, Alavi K, Zaghiyan K, Chadi S, Shawki SF, Steele S, Pigazzi A, Albert M, DeBeche-Adams T, Polydorides A, Wexner S. Discordance in Total Mesorectal Excision Specimen Grading in a Prospective Phase 2 Multicenter Rectal Cancer Trial: Are We Overestimating the Quality of Our Resections? Ann Surg 2023; 278:452-463. [PMID: 37450694 DOI: 10.1097/sla.0000000000005948] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
OBJECTIVES To report the results of a rigorous quality control (QC) process in the grading of total mesorectal excision (TME) specimens during a multicenter prospective phase 2 trial of transanal TME. BACKGROUND Grading of TME specimens is based on the macroscopic assessment of the mesorectum and standardized through synoptic pathology reporting. TME grade is a strong predictor of outcomes with incomplete (IC) TME associated with increased rates of local recurrence relative to complete or near complete (NC) TME. Although TME grade serves as an endpoint in most rectal cancer trials, in protocols incorporating centralized review of TME specimens for quality assurance, discordance in grading and the management thereof has not been previously described. METHODS A phase 2 prospective transanal TME trial was conducted from 2017 to 2022 across 11 North American centers with TME quality as the primary study endpoint. QC measures included (1) training of site pathologists in TME protocols, (2) blinded grading of de-identified TME specimen photographs by central pathologists, and (3) reconciliation of major discordance before trial reporting. Cohen Kappa statistic was used to assess agreement in grading. RESULTS Overall agreement in grading of 100 TME specimens between site and central reviewer was rated as fair, (κ = 0.35; 95% CI: 0.10-0.61; P < 0.0001). Concordance was noted in 54%, with minor and major discordance in 32% and 14% of cases, respectively. Upon reconciliation, 13/14 (93%) major discordances were resolved. Pre versus postreconciliation rates of complete or NC and IC TME are 77%/16% and 7% versus 69%/21% and 10%. Reconciliation resulted in a major upgrade (IC-NC; N = 1) or major downgrade (NC/C-IC, N = 4) in 5 cases overall (5%). CONCLUSIONS A 14% rate of major discordance was observed in TME grading between the site and central reviewers. The resolution resulted in a major change in final TME grade in 5% of cases, which suggests that reported rates or TME completeness are likely overestimated in trials. QC through a central review of TME photographs and reconciliation of major discordances is strongly recommended.
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Affiliation(s)
- Patricia Sylla
- Division of Colon and Rectal Surgery, Mount Sinai Hospital, New York, NY
| | - Mariana Berho
- Executive Administration Florida, Cleveland Clinic Florida, Weston, FL
| | - Dana Sands
- Department of Colon and Rectal Surgery, Cleveland Clinic Florida, Weston, FL
| | - Alison Ricardo
- Division of Colon and Rectal Surgery, Mount Sinai Hospital, New York, NY
| | | | - Erin Moshier
- Department of Population Health Sciences and Policy, Icahn School of Medicine at Mount Sinai Hospital, New York, NY
| | - Elisabeth Hain
- Department of Colon and Rectal Surgery, Mount Sinai Hospital, New York, NY
| | - Riva Letchinger
- Icahn School of Medicine at Mount Sinai Hospital, New York, NY
| | - John Marks
- Department of Colorectal Surgery, Lankenau Medical Center, Wynnewood, PA
| | - Mark Whiteford
- Gastrointestinal and Minimally Invasive Surgical Division, the Oregon Clinic Providence Cancer Center, Portland, OR
| | - Elisabeth Mclemore
- Department of Surgery, Division of Colorectal Surgery, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA
| | - Justin Maykel
- Division of Colon and Rectal Surgery, UMass Memorial Medical Center, Worcester, MA
| | - Karim Alavi
- Division of Colon and Rectal Surgery, UMass Memorial Medical Center, Worcester, MA
| | - Karen Zaghiyan
- Division of Colorectal Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Sami Chadi
- Department of Surgery, Division of Surgical Oncology, Princess Margaret Cancer Centre and University Health Network, Toronto, Ontario, Canada
| | | | - Scott Steele
- Department of Surgery, Cleveland Clinic, Cleveland, OH
| | - Alessio Pigazzi
- Department of Surgery, Division of Colorectal Surgery, New York-Presbyterian Weill Cornell Medical Center, New York, NY
| | - Matthew Albert
- Department of Colon and Rectal Surgery, Advent Health Orlando, Orlando, FL
| | | | | | - Steven Wexner
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL
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Bikhchandani M, Amersi F, Hendifar A, Gangi A, Osipov A, Zaghiyan K, Atkins K, Cho M, Aguirre F, Hazelett D, Alvarez R, Zhou L, Hitchins M, Gong J. POLE-Mutant Colon Cancer Treated with PD-1 Blockade Showing Clearance of Circulating Tumor DNA and Prolonged Disease-Free Interval. Genes (Basel) 2023; 14:genes14051054. [PMID: 37239414 DOI: 10.3390/genes14051054] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 04/28/2023] [Accepted: 05/04/2023] [Indexed: 05/28/2023] Open
Abstract
Colon cancer with high microsatellite instability is characterized by a high tumor mutational burden and responds well to immunotherapy. Mutations in polymerase ɛ, a DNA polymerase involved in DNA replication and repair, are also associated with an ultra-mutated phenotype. We describe a case where a patient with POLE-mutated and hypermutated recurrent colon cancer was treated with pembrolizumab. Treatment with immunotherapy in this patient also led to the clearance of circulating tumor DNA (ctDNA). ctDNA is beginning to emerge as a marker for minimal residual disease in many solid malignancies, including colon cancer. Its clearance with treatment suggests that the selection of pembrolizumab on the basis of identifying a POLE mutation on next-generation sequencing may increase disease-free survival in this patient.
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Affiliation(s)
- Mihir Bikhchandani
- Department of Hematology and Oncology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA 90027, USA
| | - Farin Amersi
- Department of Surgery, Division of Surgical Oncology, Samuel Oschin Comprehensive Cancer Institute, Cedars Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Andrew Hendifar
- Department of Medicine, Division of Hematology and Oncology, Samuel Oschin Comprehensive Cancer Institute, Cedars Sinai Medical Center, 8700 Beverly Blvd, AC 1042B, Los Angeles, CA 90048, USA
| | - Alexandra Gangi
- Department of Surgery, Division of Surgical Oncology, Samuel Oschin Comprehensive Cancer Institute, Cedars Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Arsen Osipov
- Department of Medicine, Division of Hematology and Oncology, Samuel Oschin Comprehensive Cancer Institute, Cedars Sinai Medical Center, 8700 Beverly Blvd, AC 1042B, Los Angeles, CA 90048, USA
| | - Karen Zaghiyan
- Department of Surgery, Division of Surgical Oncology, Samuel Oschin Comprehensive Cancer Institute, Cedars Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Katelyn Atkins
- Department of Radiation Oncology, Samuel Oschin Comprehensive Cancer Institute, Cedars Sinai Medical Center, Los Angeles, CA 90048, USA
| | - May Cho
- Department of Medicine, Division of Hematology and Oncology, University of California Irvine, Irvine, CA 92868, USA
| | - Francesca Aguirre
- Department of Biomedical Sciences, Cedars-Sinai, Los Angeles, CA 90048, USA
| | - Dennis Hazelett
- Department of Biomedical Sciences, Cedars-Sinai, Los Angeles, CA 90048, USA
| | - Rocio Alvarez
- Department of Biomedical Sciences, Cedars-Sinai, Los Angeles, CA 90048, USA
| | - Lisa Zhou
- Department of Biomedical Sciences, Cedars-Sinai, Los Angeles, CA 90048, USA
| | - Megan Hitchins
- Department of Biomedical Sciences, Cedars-Sinai, Los Angeles, CA 90048, USA
| | - Jun Gong
- Department of Medicine, Division of Hematology and Oncology, Samuel Oschin Comprehensive Cancer Institute, Cedars Sinai Medical Center, 8700 Beverly Blvd, AC 1042B, Los Angeles, CA 90048, USA
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Aviran E, Assaf D, Zaghiyan K, Fleshner P. Long-term Outcomes and Factors Predicting Outcome of IPAA When Used Intentionally for Well-Defined Crohn's Disease. Dis Colon Rectum 2023; 66:700-706. [PMID: 36856670 DOI: 10.1097/dcr.0000000000002701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
BACKGROUND Crohn's disease is considered a contraindication for IPAA. In our prior study, when IPAA was used intentionally for well-defined Crohn's disease, we found a high incidence of recurrent disease with a low incidence of pouch failure. OBJECTIVE This study aimed to replicate these findings in a larger cohort over a longer period. DESIGN Retrospective review of a prospective IBD registry. SETTINGS Large IBD referral center. PATIENTS Patients with preoperative colorectal Crohn's disease requiring surgery were included in the study. INTERVENTION IPAA. MAIN OUTCOME MEASURES Long-term Crohn's disease recurrence, pouch failure, and pouch function. RESULTS Forty-six patients were identified. Crohn's disease was diagnosed on the basis of perianal disease (n = 18; 39%), small-bowel disease (n = 16; 35%), noncaseating granuloma (n = 10; 22%), and discontinuous inflammation (colorectal skip lesions) (n = 11; 24%). After a median follow-up of 93 (7-291) months, 22 patients (48%) developed recurrent Crohn's disease based on afferent limb disease (n = 14; 30%) or pouch fistulizing disease (n = 8; 18%). Only 4 patients (9%) developed pouch failure. No clinical factor was associated with Crohn's disease recurrence. Young age at the time of surgery and short duration of disease before IPAA were associated with pouch fistula recurrence ( p = 0.003 and p = 0.03, respectively). Most patients (86%) reported excellent continence, with no urgency (67%) and median stool frequency of 6 (range, 3-9) per day. LIMITATION Retrospective nature and relatively small sample size. CONCLUSION This largest reported series examining the intentional use of IPAA in Crohn's disease showed a high (48%) incidence of postoperative Crohn's disease with a low (9%) incidence of pouch failure. Young age and short disease course before surgery were risk factors for poor outcomes. Highly motivated patients with colorectal Crohn's disease may consider IPAA and avoid a definitive ileostomy. See Video Abstract at http://links.lww.com/DCR/C171 . RESULTADOS A LARGO PLAZO Y FACTORES PREDICTORES DE RESULTADOS DE LA ANASTOMOSIS ILEOANAL CON RESERVORIO CUANDO SE USA INTENCIONALMENTE PARA LA ENFERMEDAD DE CROHN BIEN DEFINIDA ANTECEDENTES: La enfermedad de Crohn (EC) se considera una contraindicación para la anastomosis ileoanal con reservorio (IPAA). Nuestro estudio previo de IPAA cuando fue usada intencionalmente para EC bien definida mostró una alta incidencia de enfermedad recurrente con una baja incidencia de falla del reservorio.OBJETIVO: Replicar estos hallazgos en una cohorte más grande durante un período más largo.DISEÑO: Revisión retrospectiva de una base de datos prospectiva de enfermedad inflamatoria intestinal.ESCENARIO: Un centro grande de referencia de EII.PACIENTES: EC colorrectal preoperatoria con necesidad de tratamiento quirúrgico.INTERVENCIÓN: Anastomosis ileoanal con reservorio.RESULTADOS PRINCIPALES: Recurrencia de EC a largo plazo, falla del reservorio y función del reservorio.RESULTADOS: Cuarenta y seis pacientes fueron identificados. El diagnóstico de EC se basó en enfermedad perianal (n = 18; 39%), enfermedad del intestino delgado (n = 16; 35%), granuloma no caseificante (n = 10; 22%) e inflamación discontinua (lesiones salteadas colorrectales) (n = 11; 24%). Después de una mediana de seguimiento de 93 (7-291) meses, 22 (48 %) pacientes desarrollaron EC recurrente debido a enfermedad del asa aferente (n = 14; 30%) o enfermedad fistulizante del reservorio (n = 8; 18%). Solo 4 (9%) pacientes desarrollaron falla del reservorio. Ningún factor clínico se asoció con la recurrencia de EC. La edad joven en el momento de la cirugía y la corta duración de la enfermedad antes de IPAA se asociaron con la recurrencia de la fístula del reservorio ( p = 0.003 y p = 0.03, respectivamente). El recuento de plaquetas preoperatorio más alto fue la única característica clínica significativamente asociada con el fracaso del reservorio ( p = 0.02). La mayoría de los pacientes (86%) reportaron una continencia excelente, sin urgencia (67%) y una mediana de frecuencia evacuatoria de 6 (rango, 3-9) por día.LIMITACIONES: Naturaleza retrospectiva y tamaño de muestra relativamente pequeño.CONCLUSIÓN: Esta serie, la más grande reportada que examina el uso intencional de IPAA en la EC mostró una incidencia alta (48Rectal Cancer: Clinical and Molecular Predictors of a Complete Response to Total Neoadjuvant Therapy%) de EC posoperatoria con una incidencia baja (9%) de falla del reservorio. La edad joven y el curso corto de la enfermedad antes de la cirugía fueron factores de riesgo para pobres resultados. Pacientes altamente motivados con EC colorrectal pueden considerar una IPAA y evitar una ileostomía permanente. Consulte Video Resumen en http://links.lww.com/DCR/C171 . (Traducción-Dr. Jorge Silva Velazco ).
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Affiliation(s)
- Eyal Aviran
- Division of Colon and Rectal Surgery, Cedars Sinai Medical Center, Los Angeles, California
- Department of General and Oncological Surgery- Surgery C, The Chaim Sheba Medical Center, Ramat Gan, Israel
| | - Dan Assaf
- Department of General and Oncological Surgery- Surgery C, The Chaim Sheba Medical Center, Ramat Gan, Israel
| | - Karen Zaghiyan
- Division of Colon and Rectal Surgery, Cedars Sinai Medical Center, Los Angeles, California
| | - Phillip Fleshner
- Division of Colon and Rectal Surgery, Cedars Sinai Medical Center, Los Angeles, California
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Sensi B, Khan J, Warusavitarne J, Nardi A, Spinelli A, Zaghiyan K, Panis Y, Sampietro G, Fichera A, Garcia-Granero E, Espin-Basany E, Konishi T, Siragusa L, Stefan S, Bellato V, Carvello M, Adams E, Frontali A, Artigue M, Frasson M, Marti-Gallostra M, Pellino G, Sica GS. Long-term Oncological Outcome of Segmental Versus Extended Colectomy for Colorectal Cancer in Crohn's Disease: Results from an International Multicentre Study. J Crohns Colitis 2022; 16:954-962. [PMID: 34897426 DOI: 10.1093/ecco-jcc/jjab215] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 10/11/2021] [Accepted: 11/22/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Crohn's disease increases colorectal cancer risk, with high prevalence of synchronous and metachronous cancers. Current guidelines for colorectal cancer in Crohn's disease recommend pan-proctocolectomy. The aim of this study was to evaluate oncological outcomes of a less invasive surgical approach. METHODS This was a retrospective database analysis of Crohn's disease patients with colorectal cancer undergoing surgery at selected European and US tertiary centres. Outcomes of segmental colectomy were compared with those of extended colectomy, total colectomy, and pan-proctocolectomy. Primary outcome was progression-free survival. Secondary outcomes included overall survival, synchronous and metachronous colorectal cancer, and major postoperative complications. RESULTS Ninety-nine patients were included: 66 patients underwent segmental colectomy and 33 extended colectomy. Segmental colectomy patients were older [p = 0.0429], had less extensive colitis [p = 0.0002] and no preoperatively identified synchronous lesions [p = 0.0109].Median follow-up was 43 [31-62] months. There was no difference in unadjusted progression-free survival [p = 0.2570] or in overall survival [p = 0.4191] between segmental and extended colectomy. Multivariate analysis adjusting for age, sex, ASA score, and AJCC staging, confirmed no difference for progression-free survival (hazard ratio [HR] 1.00, p = 0.9993) or overall survival [HR 0.77, p = 0.6654]. Synchronous and metachronous cancers incidence was 9% and 1.5%, respectively. Perioperative mortality was nil and major complications were comparable [7.58% vs 6.06%, p = 0.9998]. CONCLUSIONS Segmental colectomy seems to offer similar long-term outcomes to more extensive surgery. Incidence of synchronous and metachronous cancers appears much lower than previously described. Further prospective studies are warranted to confirm these results.
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Affiliation(s)
- Bruno Sensi
- University of Rome Tor Vergata, Department of Surgery, Rome, Italy
| | - Jim Khan
- Portsmouth Hospital, NHS trust, Surgery, Portsmouth, UK
| | | | - Alessandra Nardi
- University of Rome Tor Vergata, Department of Mathematics, Rome, Italy
| | | | | | - Yves Panis
- Beaujon Hospital, Colorectal Surgery, Paris, France
| | | | | | | | | | | | - Leandro Siragusa
- University of Rome Tor Vergata, Department of Surgery, Rome, Italy
| | - Samuel Stefan
- Portsmouth Hospital, NHS trust, Surgery, Portsmouth, UK
| | | | | | - Evan Adams
- Cedars Sinai Hospital, Surgery, Los Angeles, CA, USA
| | | | | | | | | | - Gianluca Pellino
- Hospital Universitario Val d'Hebron, Surgery, Barcelona, Spain.,Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli", Naples,Italy
| | - Giuseppe S Sica
- University of Rome Tor Vergata, Department of Surgery, Rome, Italy
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7
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Sensi B, Khan J, Warusavitarne J, Nardi A, Spinelli A, Zaghiyan K, Panis Y, Sampietro G, Fichera A, Garcia-Granero E, Espin-Basany E, Konishi T, Siragusa L, Stefan S, Bellato V, Carvello M, Adams E, Frontali A, Artigue M, Frasson M, Marti-Gallostra M, Pellino G, Sica GS. Corrigendum to: Long-term Oncological Outcome of Segmental Versus Extended Colectomy for Colorectal Cancer in Crohn's Disease: Results from an International Multicentre Study. J Crohns Colitis 2022; 16:1009. [PMID: 35171229 DOI: 10.1093/ecco-jcc/jjac022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Bruno Sensi
- University of Rome Tor Vergata, Department of Surgery, Rome, Italy
| | - Jim Khan
- Portsmouth Hospital, NHS trust, Surgery, Portsmouth, UK
| | | | - Alessandra Nardi
- University of Rome Tor Vergata, Department of Mathematics, Rome, Italy
| | | | | | - Yves Panis
- Beaujon Hospital, Colorectal Surgery, Paris, France
| | | | | | | | | | | | - Leandro Siragusa
- University of Rome Tor Vergata, Department of Surgery, Rome, Italy
| | - Samuel Stefan
- Portsmouth Hospital, NHS trust, Surgery, Portsmouth, UK
| | | | | | - Evan Adams
- Cedars Sinai Hospital, Surgery, Los Angeles, CA, USA
| | | | | | | | | | - Gianluca Pellino
- Hospital Universitario Val d'Hebron, Surgery, Barcelona, Spain.,Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy
| | - Giuseppe S Sica
- University of Rome Tor Vergata, Department of Surgery, Rome, Italy
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8
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Chung EM, Gong J, Zaghiyan K, Kamrava M, Atkins KM. Local Therapies for Colorectal Cancer Oligometastases to the Lung. Curr Colorectal Cancer Rep 2022. [DOI: 10.1007/s11888-022-00477-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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9
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Lightner AL, Buhulaigah H, Zaghiyan K, Holubar SD, Steele SR, Jia X, McMichael J, Vaidya P, Fleshner PR. Is Intestinal Diversion an Effective Treatment for Distal Crohn's Disease? Inflamm Bowel Dis 2022; 28:547-552. [PMID: 34076248 DOI: 10.1093/ibd/izab126] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Fecal diversion with an ileostomy is selectively used in cases of medically refractory Crohn's proctocolitis or advanced perianal disease. The aim of this study was to evaluate clinical improvement after fecal diversion in Crohn's disease (CD) and factors associated with clinical improvement. METHODS A retrospective chart review of adult CD patients undergoing ileostomy formation for distal disease between 2000 and 2019 at 2 CD referral centers was conducted. The primary outcome was the rate of clinical improvement with diversion that allowed for successful restoration of intestinal continuity. Secondary outcomes included the rate of clinical and endoscopic improvement after fecal diversion, ileostomy morbidity, need for subsequent total proctocolectomy and end ileostomy, and factors associated with a clinical response to fecal diversion. RESULTS A total of 132 patients with a median age of 36 years (interquartile range, 25-49) were included. Mean duration of disease was 16.2 years (10.4) years. Indication for surgery was medically refractory proctocolitis with perianal disease (n = 59; 45%), perianal disease alone (n = 24; 18%), colitis (n = 37; 28%), proctitis (n = 4; 3%), proctocolitis alone (n = 4; 3%), and ileitis with perianal disease (n = 4; 3%). Medications used before surgery included corticosteroids (n = 59; 45%), immunomodulators (n = 55; 42%) and biologics (n = 82; 62%). The clinical and endoscopic response to diversion was 43.2% (n = 57) and 23.9% (n = 16). At a median follow-up of 35.3 months (interquartile range, 10.6-74.5), 25 patients (19%) had improved and had ileostomy reversal, but 86 (65%) did not improve, with 50 (38%) undergoing total proctocolectomy for persistent symptoms. There were no significant predictors of clinical improvement. CONCLUSIONS The use of a "temporary" ileostomy is largely ineffective in achieving clinical response.
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Affiliation(s)
- Amy L Lightner
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland Ohio, USA
| | - Hassan Buhulaigah
- Division of Colon and Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Karen Zaghiyan
- Division of Colon and Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Stefan D Holubar
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland Ohio, USA
| | - Scott R Steele
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland Ohio, USA
| | - Xue Jia
- Department of Qualitative Health Science, Cleveland Clinic, Cleveland, Ohio, USA
| | - John McMichael
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland Ohio, USA
| | - Prashansha Vaidya
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland Ohio, USA
| | - Phillip R Fleshner
- Division of Colon and Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
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10
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Gong J, Aguirre F, Hazelett D, Alvarez R, Zhou L, Hendifar A, Osipov A, Zaghiyan K, Cho M, Gangi A, Hitchins M. Circulating tumor DNA dynamics and response to immunotherapy in colorectal cancer. Mol Clin Oncol 2022; 16:100. [PMID: 35463213 PMCID: PMC9022091 DOI: 10.3892/mco.2022.2533] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 02/24/2022] [Indexed: 11/06/2022] Open
Abstract
Circulating tumor DNA (ctDNA) is increasingly being investigated as a tool to detect minimal residual disease in resected, stage I-III colorectal cancer. Recent ctDNA studies have indicated that detection of ctDNA following surgery for resectable colorectal cancer confers a significantly higher risk of recurrence than those with negative ctDNA postoperatively. In those with postoperative ctDNA positivity, clearance of minimal residual disease with adjuvant chemotherapy is a positive prognostic indicator. Lastly, ctDNA has demonstrated superior sensitivity to the conventional blood tumor marker carcinoembryonic antigen (CEA) and can offer median lead times of up to 11 months for radiographic detection of recurrence during the surveillance of resected, stage I-III colorectal cancer. In metastatic colorectal cancer (mCRC), there is growing evidence to suggest that plasma ctDNA can be used to monitor tumor response to conventional chemotherapy as well. The present case series demonstrated that plasma ctDNA is a predictor of tumor response to immunotherapy in patients with mCRC that are microsatellite stable or microsatellite instability high. Plasma ctDNA could serve as a dynamic marker of immunotherapy response even in colorectal tumors that were CEA non-producers. Overall, these findings add to ongoing efforts to establish the role of plasma ctDNA in monitoring response to immunotherapy in CRC.
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Affiliation(s)
- Jun Gong
- Department of Medicine, Division of Hematology and Oncology, Samuel Oschin Comprehensive Cancer Institute, Cedars‑Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Francesca Aguirre
- Department of Biomedical Sciences, Cedars‑Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Dennis Hazelett
- Department of Biomedical Sciences, Cedars‑Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Rocio Alvarez
- Department of Biomedical Sciences, Cedars‑Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Lisa Zhou
- Department of Biomedical Sciences, Cedars‑Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Andrew Hendifar
- Department of Medicine, Division of Hematology and Oncology, Samuel Oschin Comprehensive Cancer Institute, Cedars‑Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Arsen Osipov
- Department of Medicine, Division of Hematology and Oncology, Samuel Oschin Comprehensive Cancer Institute, Cedars‑Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Karen Zaghiyan
- Department of Surgery, Samuel Oschin Comprehensive Cancer Institute, Cedars‑Sinai Medical Center, Los Angeles, CA 90048, USA
| | - May Cho
- Division of Hematology and Oncology, Department of Medicine, University of California, Irvine, CA 92697, USA
| | - Alexandra Gangi
- Department of Surgery, Samuel Oschin Comprehensive Cancer Institute, Cedars‑Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Megan Hitchins
- Department of Biomedical Sciences, Cedars‑Sinai Medical Center, Los Angeles, CA 90048, USA
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11
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Yao L, Zaghiyan K. When you think something is wrong – something IS wrong: timely diagnosis of anastomotic leak. Seminars in Colon and Rectal Surgery 2022. [DOI: 10.1016/j.scrs.2022.100882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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12
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Wood T, Truong A, Mujukian A, Zaghiyan K, Fleshner P. Increasing experience with the LIFT procedure in Crohn's disease patients with complex anal fistula. Tech Coloproctol 2022; 26:205-212. [PMID: 35103901 DOI: 10.1007/s10151-022-02582-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 01/21/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Surgical management of anal fistulas in Crohn's disease (CD) is associated with high failure rates, and treatment options are limited due to ongoing proctitis, multiple tracts, and concern for incontinence and non-healing wounds. The aim of this study was to investigate the healing rate of ligation of the inters-sphincteric fistula tract (LIFT) for anal fistulas in Crohn's disease and identify prognostic factors for healing. METHODS This prospective analysis compared long-term healing rates of CD patients undergoing LIFT for anal fistulas. Consecutive patients with CD who underwent LIFT procedure at our institution, in the period from March 2012 to September 2019 were included. The main outcome was anal fistula healing rate. RESULTS The study cohort of 46 patients (mean age of 34.2 ± 13.0 years, 18 (40%) males). After a mean follow-up time of 33 ± 28 months, fistula healing was seen in 30 (65%) patients. A total of 8 patients were noted to have inter-sphincteric recurrence and 8 patients had trans-sphincteric recurrence. Smoking at the time of surgery was significantly associated with LIFT failure (HR 3.18, 95% CI 1.18-8.61, p = 0.02). Other factors, such as age, sex, race, disease duration and location, type of fistula history of proctitis, preoperatively use of biologics or a seton, and previous repair attempts, did not appear to influence LIFT healing. Although not statistically significant, there was a trend toward increase in failure among patients with active proctitis at the time of surgery (HR 1.97, 95% CI 0.71-5.42, p = 0.19). CONCLUSION Our increasing experience with LIFT for anal fistula in CD demonstrates a higher rate of healing (65%) than previously reported (48%). Smoking appears to negatively influence healing of LIFT in CD.
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Affiliation(s)
- T Wood
- Department of Surgery, Cedars-Sinai Medical Center, 8737 Beverly Blvd, Suite 101, Los Angeles, CA, 90048, USA
| | - A Truong
- Department of Surgery, Cedars-Sinai Medical Center, 8737 Beverly Blvd, Suite 101, Los Angeles, CA, 90048, USA
| | - A Mujukian
- Department of Surgery, Cedars-Sinai Medical Center, 8737 Beverly Blvd, Suite 101, Los Angeles, CA, 90048, USA
| | - K Zaghiyan
- Department of Surgery, Cedars-Sinai Medical Center, 8737 Beverly Blvd, Suite 101, Los Angeles, CA, 90048, USA
| | - P Fleshner
- Department of Surgery, Cedars-Sinai Medical Center, 8737 Beverly Blvd, Suite 101, Los Angeles, CA, 90048, USA.
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13
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Mujukian A, Truong A, Steinhagen E, Prashansha V, Lightner AL, Morin F, Zaghiyan K, de Buck van Overstraeten A, Fleshner P. Is synoptic operative reporting necessary for Crohn's disease surgery? Variability in surgical reports across inflammatory bowel disease referral centres. Colorectal Dis 2021; 23:2955-2960. [PMID: 34464478 DOI: 10.1111/codi.15895] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 08/23/2021] [Accepted: 08/24/2021] [Indexed: 01/05/2023]
Abstract
AIM Ileocolic resection (ICR) is the most commonly performed operation in Crohn's disease (CD) patients. The surgical report is a vital tool for accessing information to gauge a patient's long-term prognosis and guide treatment decisions. Dictated narrative reports are the traditional method for surgical documentation but often lack essential information. The objective was to assess the quality of operation note in CD patients undergoing ICR. METHOD This was a multi-institutional retrospective cohort collaborative study involving four tertiary inflammatory bowel disease referral centres in the USA and Canada. The patients were consecutive CD patients undergoing ICR between 2014 and 2020. There were no interventions. The main outcome measures were the variability and frequency of 28 critical items in the operation note. RESULTS An analysis of 400 consecutive operation reports in four institutions (n = 100/institution) revealed significant variability in almost all variables. The initial surgical approach and wound protector use were the most consistently or frequently reported across all inflammatory bowel disease centres. The limitation was that this was a retrospective cohort study with inevitable selection bias. CONCLUSIONS This study highlights the need for synoptic reporting in CD patients undergoing ICR.
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Affiliation(s)
| | - Adam Truong
- Cedars Sinai Medical Center, Los Angeles, California, USA
| | - Emily Steinhagen
- University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | | | | | - Frédéric Morin
- Mt Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Karen Zaghiyan
- Cedars Sinai Medical Center, Los Angeles, California, USA
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14
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Kumar R, Zaghiyan K, Ha C. Lower Surgical Risks in "Contemporary" IBD Cohorts: A Reflection of Better Quality of Care or Statistics? Clin Gastroenterol Hepatol 2021; 19:2029-2030. [PMID: 33524597 DOI: 10.1016/j.cgh.2021.01.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 01/25/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Rashmi Kumar
- The F Widjaja Foundation Inflammatory Bowel, Immunology Research Institute at Cedars-Sinai, Cedars-Sinai, Los Angeles, California
| | - Karen Zaghiyan
- The F Widjaja Foundation Inflammatory Bowel, Immunology Research Institute at Cedars-Sinai, Cedars-Sinai, Division of Colorectal Surgery, Cedars-Sinai, Los Angeles, California
| | - Christina Ha
- The F Widjaja Foundation Inflammatory Bowel, Immunology Research Institute at Cedars-Sinai, Cedars-Sinai, Los Angeles, California
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15
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Parrish AB, Lopez NE, Truong A, Zaghiyan K, Melmed GY, McGovern DPB, Ha C, Syal G, Bonthala N, Jain A, Landers CJ, Targan SR, Fleshner P. Preoperative Serum Vedolizumab Levels Do Not Impact Postoperative Outcomes in Inflammatory Bowel Disease. Dis Colon Rectum 2021; 64:1259-1266. [PMID: 34516445 DOI: 10.1097/dcr.0000000000001920] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Vedolizumab has been proposed to lead to fewer postoperative complications because of its gut specificity. Studies, however, suggest an increased risk of surgical site infections, yet the data are conflicting. OBJECTIVE This study aimed to assess the effect of vedolizumab drug levels on postoperative outcomes in patients undergoing major abdominal surgery for IBD. DESIGN This was a retrospective study of a prospectively maintained database. SETTING Patients were operated on by a single surgeon at an academic medical center. PATIENTS A total of 72 patients with IBD undergoing major abdominal surgery were included. INTERVENTIONS Patients were exposed preoperatively to vedolizumab. MAIN OUTCOME MEASURES The primary outcome measured was the postoperative morbidity in patients who had IBD with detectable vs undetectable vedolizumab levels. RESULTS A total of 72 patients were included in the study. Thirty-eight patients had detectable vedolizumab levels (>1.6 μg/mL), and 34 had undetectable vedolizumab levels. The overall rate of complications was 39%, and ileus was the most common complication. There were no significant differences in clinical variables between the detectable and undetectable vedolizumab level patient groups except for the time between the last dose and surgery (p < 0.01). There were 42 patients in the ulcerative colitis cohort; 48% had an undetectable vedolizumab level and 52% had a detectable vedolizumab level. There were no differences in any postoperative morbidity between ulcerative colitis groups. The Crohn's cohort had 27 patients; 48% had an undetectable vedolizumab levels and 52% had a detectable vedolizumab level. There was a significantly lower incidence of postoperative ileus in patients who had Crohn's disease with detectable vedolizumab levels compared with patients with an undetectable vedolizumab level (p < 0.04). LIMITATIONS Limitations include a low overall patient population and a high rate of stoma formation. CONCLUSIONS Serum vedolizumab levels do not influence postoperative morbidity in IBD. Vedolizumab may reduce the incidence of postoperative ileus in patients with Crohn's disease. See Video Abstract at http://links.lww.com/DCR/B574. LOS NIVELES DE VEDOLIZUMAB EN SUERO PREOPERATORIO, NO AFECTAN LOS RESULTADOS POSTOPERATORIOS EN LA ENFERMEDAD INFLAMATORIA INTESTINAL ANTECEDENTES:Se ha propuesto que el vedolizumab presenta menos complicaciones postoperatorias debido a su especificidad intestinal. Sin embargo, estudios sugieren un mayor riesgo de infecciones en el sitio quirúrgico, aunque los datos son contradictorios.OBJETIVO:Evaluar el efecto en los niveles del fármaco vedolizumab, en resultados postoperatorios de pacientes sometidos a cirugía mayor abdominal, por enfermedad inflamatoria intestinal.DISEÑO:Estudio retrospectivo de una base de datos mantenida prospectivamente.ENTORNO CLÍNICO:Pacientes intervenidos por un solo cirujano en un centro médico académico.PACIENTES:Un total de 72 pacientes con enfermedad inflamatoria intestinal sometidos a cirugía mayor abdominal.INTERVENCIONES:Exposición preoperatoria a vedolizumab.PRINCIPALES MEDIDAS DE VALORACIÓN:Morbilidad postoperatoria en pacientes con enfermedad inflamatoria intestinal, con niveles detectables versus no detectables de vedolizumab.RESULTADOS:Se incluyó en el estudio a un total de 72 pacientes. Treinta y ocho pacientes tuvieron niveles detectables de vedolizumab (> 1,6 mcg / ml) y 34 con niveles no detectables de vedolizumab. La tasa global de complicaciones fue del 39% y el íleo fue la complicación más común. No hubo diferencias significativas en las variables clínicas entre los grupos de pacientes con niveles detectables y no detectables de vedolizumab, excepto por el intervalo de tiempo entre la última dosis y la cirugía (p <.01). La cohorte de colitis ulcerosa tuvo 42 pacientes, el 48% con un nivel no detectable de vedolizumab y el 52% un nivel detectable de vedolizumab. No hubo diferencias en ninguna morbilidad postoperatoria entre los grupos de colitis ulcerosa. La cohorte de Crohn tuvo 27 pacientes, 48% con niveles no detectables de vedolizumab y el 52% con niveles detectables de vedolizumab. Hubo una incidencia significativamente menor de íleo postoperatorio en pacientes de Crohn con niveles detectables de vedolizumab, comparados con los pacientes con un nivel no detectable de vedolizumab (p <0,04).LIMITACIONES:Las limitaciones incluyen una baja población general de pacientes y una alta tasa de formación de estomas.CONCLUSIONES:Los niveles séricos de vedolizumab no influyen en la morbilidad postoperatoria de la enfermedad inflamatoria intestinal. Vedolizumab puede reducir la incidencia de íleo postoperatorio en pacientes de Crohn. Consulte Video Resumen en http://links.lww.com/DCR/B574.
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MESH Headings
- Adult
- Antibodies, Monoclonal, Humanized/adverse effects
- Antibodies, Monoclonal, Humanized/metabolism
- Antibodies, Monoclonal, Humanized/therapeutic use
- Colitis, Ulcerative/blood
- Colitis, Ulcerative/epidemiology
- Colitis, Ulcerative/surgery
- Crohn Disease/blood
- Crohn Disease/epidemiology
- Crohn Disease/surgery
- Female
- Gastrointestinal Agents/adverse effects
- Gastrointestinal Agents/metabolism
- Gastrointestinal Agents/therapeutic use
- Humans
- Ileus/epidemiology
- Incidence
- Inflammatory Bowel Diseases/blood
- Inflammatory Bowel Diseases/surgery
- Male
- Middle Aged
- Morbidity
- Outcome Assessment, Health Care
- Postoperative Complications/epidemiology
- Postoperative Period
- Preoperative Period
- Retrospective Studies
- Surgical Stomas
- Surgical Wound Infection/chemically induced
- Surgical Wound Infection/epidemiology
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Affiliation(s)
- Aaron B Parrish
- Division of Colorectal Surgery, Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles California
| | - Nicole E Lopez
- Division of Colorectal Surgery, Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles California
| | - Adam Truong
- Division of Colorectal Surgery, Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles California
| | - Karen Zaghiyan
- Division of Colorectal Surgery, Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles California
| | - Gil Y Melmed
- Department of Gastroenterology, Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles California
| | - Dermot P B McGovern
- Department of Gastroenterology, Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles California
| | - Christina Ha
- Department of Gastroenterology, Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles California
| | - Gaurav Syal
- Department of Gastroenterology, Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles California
| | - Nirupama Bonthala
- Department of Gastroenterology, Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles California
| | - Anjali Jain
- Prometheus Laboratories, San Diego, California
| | - Carol J Landers
- Department of Gastroenterology, Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles California
| | - Stephan R Targan
- Department of Gastroenterology, Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles California
| | - Phillip Fleshner
- Division of Colorectal Surgery, Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles California
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Lightner AL, Vaidya P, Holubar S, Warusavitarne J, Sahnan K, Carrano FM, Spinelli A, Zaghiyan K, Fleshner PR. Perioperative safety of tofacitinib in surgical ulcerative colitis patients. Colorectal Dis 2021; 23:2085-2090. [PMID: 33942470 DOI: 10.1111/codi.15702] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 02/03/2021] [Accepted: 03/11/2021] [Indexed: 01/19/2023]
Abstract
AIM The literature regarding monoclonal antibodies and increased postoperative complications in inflammatory bowel disease remains controversial. There have been no studies investigating tofacitinib. The aim of this work was to determine preoperative exposure to the small-molecule inhibitor tofacitinib and postoperative outcomes. METHOD We conducted a retrospective review of all adult patients exposed to tofacitinib within 4 weeks of total abdominal colectomy for medically refractory ulcerative colitis between 1 January 2018 and 1 September 2020 at four inflammatory bowel disease referral centres. Data collected included patient demographics and 90-day postoperative morbidity, readmission and reoperation rates. RESULTS Fifty-three patients (32 men, 60%) with ulcerative colitis underwent a total abdominal colectomy (n = 50 laparoscopic, 94%) for medically refractory disease. Previous exposure to monoclonal antibodies included infliximab (n = 34), adalimumab (n = 35), certolizumab pegol (n = 5), vedolizumab (n = 33) and ustekinumab (n = 10). Twenty-seven (51%) patients were on concurrent prednisone at a median daily dose of 30 mg by mouth (range 5-60 mg). There were no postoperative deaths. Ninety-day postoperative complications included ileus (n = 7, 13.2%), superficial surgical site infection (n = 4, 7.5%), intra-abdominal abscess (n = 2, 3.8%) and venous thromboembolism (VTE) (n = 7, 13.2%). Locations of VTE included portomesenteric venous thrombus (n = 4), internal iliac vein (n = 2) and pulmonary embolism (n = 1). Nine (17%) patients were readmitted to hospital and five (9%) patients had a reoperation. CONCLUSION Mirroring the recently issued US Food and Drug Administration black box warning of an increased risk of VTE in medically treated ulcerative colitis patients taking tofacitinib, preoperative tofacitinib exposure may present an increased risk of postoperative VTE events. Consideration should be given for prolonged VTE prophylaxis on hospital discharge.
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Affiliation(s)
- Amy L Lightner
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Prashansha Vaidya
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Stefan Holubar
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH, USA
| | | | - Kapil Sahnan
- Division of Colon and Rectal Surgery, St Marks Hospital, London, UK
| | - Francesco Maria Carrano
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Center, Colon and Rectal Surgery Unit, Rozzano, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Rozzano, Milan, Italy
| | - Antonino Spinelli
- Department of Biomedical Sciences, Humanitas University, Rozzano, Milan, Italy
| | - Karen Zaghiyan
- Division of Colon and Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Phillip R Fleshner
- Division of Colon and Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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17
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Himbert C, Figueiredo JC, Shibata D, Ose J, Lin T, Huang LC, Peoples AR, Scaife CL, Pickron B, Lambert L, Cohan JN, Bronner M, Felder S, Sanchez J, Dessureault S, Coppola D, Hoffman DM, Nasseri YF, Decker RW, Zaghiyan K, Murrell ZA, Hendifar A, Gong J, Firoozmand E, Gangi A, Moore BA, Cologne KG, El-Masry MS, Hinkle N, Monroe J, Mutch M, Bernadt C, Chatterjee D, Sinanan M, Cohen SA, Wallin U, Grady WM, Lampe PD, Reddi D, Krane M, Fichera A, Moonka R, Herpel E, Schirmacher P, Kloor M, von Knebel-Doeberitz M, Nattenmueller J, Kauczor HU, Swanson E, Jedrzkiewicz J, Schmit SL, Gigic B, Ulrich AB, Toriola AT, Siegel EM, Li CI, Ulrich CM, Hardikar S. Clinical Characteristics and Outcomes of Colorectal Cancer in the ColoCare Study: Differences by Age of Onset. Cancers (Basel) 2021; 13:cancers13153817. [PMID: 34359718 PMCID: PMC8345133 DOI: 10.3390/cancers13153817] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 07/02/2021] [Accepted: 07/06/2021] [Indexed: 01/13/2023] Open
Abstract
Early-onset colorectal cancer has been on the rise in Western populations. Here, we compare patient characteristics between those with early- (<50 years) vs. late-onset (≥50 years) disease in a large multinational cohort of colorectal cancer patients (n = 2193). We calculated descriptive statistics and assessed associations of clinicodemographic factors with age of onset using mutually-adjusted logistic regression models. Patients were on average 60 years old, with BMI of 29 kg/m2, 52% colon cancers, 21% early-onset, and presented with stage II or III (60%) disease. Early-onset patients presented with more advanced disease (stages III-IV: 63% vs. 51%, respectively), and received more neo and adjuvant treatment compared to late-onset patients, after controlling for stage (odds ratio (OR) (95% confidence interval (CI)) = 2.30 (1.82-3.83) and 2.00 (1.43-2.81), respectively). Early-onset rectal cancer patients across all stages more commonly received neoadjuvant treatment, even when not indicated as the standard of care, e.g., during stage I disease. The odds of early-onset disease were higher among never smokers and lower among overweight patients (1.55 (1.21-1.98) and 0.56 (0.41-0.76), respectively). Patients with early-onset colorectal cancer were more likely to be diagnosed with advanced stage disease, to have received systemic treatments regardless of stage at diagnosis, and were less likely to be ever smokers or overweight.
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Affiliation(s)
- Caroline Himbert
- Huntsman Cancer Institute, Salt Lake City, UT 84112, USA; (C.H.); (J.O.); (T.L.); (L.C.H.); (A.R.P.); (C.L.S.); (B.P.); (L.L.); (J.N.C.); (M.B.); (E.S.); (J.J.); (C.M.U.)
- Department of Population Health Sciences, University of Utah, Salt Lake City, UT 84112, USA
| | - Jane C. Figueiredo
- Cedars-Sinai Center, Los Angeles, CA 90048, USA; (J.C.F.); (D.M.H.); (Y.F.N.); (R.W.D.); (K.Z.); (Z.A.M.); (A.H.); (J.G.); (E.F.); (A.G.); (B.A.M.); (K.G.C.); (M.S.E.-M.)
| | - David Shibata
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN 37996, USA; (D.S.); (N.H.); (J.M.)
| | - Jennifer Ose
- Huntsman Cancer Institute, Salt Lake City, UT 84112, USA; (C.H.); (J.O.); (T.L.); (L.C.H.); (A.R.P.); (C.L.S.); (B.P.); (L.L.); (J.N.C.); (M.B.); (E.S.); (J.J.); (C.M.U.)
- Department of Population Health Sciences, University of Utah, Salt Lake City, UT 84112, USA
| | - Tengda Lin
- Huntsman Cancer Institute, Salt Lake City, UT 84112, USA; (C.H.); (J.O.); (T.L.); (L.C.H.); (A.R.P.); (C.L.S.); (B.P.); (L.L.); (J.N.C.); (M.B.); (E.S.); (J.J.); (C.M.U.)
- Department of Population Health Sciences, University of Utah, Salt Lake City, UT 84112, USA
| | - Lyen C. Huang
- Huntsman Cancer Institute, Salt Lake City, UT 84112, USA; (C.H.); (J.O.); (T.L.); (L.C.H.); (A.R.P.); (C.L.S.); (B.P.); (L.L.); (J.N.C.); (M.B.); (E.S.); (J.J.); (C.M.U.)
- Department of Population Health Sciences, University of Utah, Salt Lake City, UT 84112, USA
| | - Anita R. Peoples
- Huntsman Cancer Institute, Salt Lake City, UT 84112, USA; (C.H.); (J.O.); (T.L.); (L.C.H.); (A.R.P.); (C.L.S.); (B.P.); (L.L.); (J.N.C.); (M.B.); (E.S.); (J.J.); (C.M.U.)
- Department of Population Health Sciences, University of Utah, Salt Lake City, UT 84112, USA
| | - Courtney L. Scaife
- Huntsman Cancer Institute, Salt Lake City, UT 84112, USA; (C.H.); (J.O.); (T.L.); (L.C.H.); (A.R.P.); (C.L.S.); (B.P.); (L.L.); (J.N.C.); (M.B.); (E.S.); (J.J.); (C.M.U.)
| | - Bartley Pickron
- Huntsman Cancer Institute, Salt Lake City, UT 84112, USA; (C.H.); (J.O.); (T.L.); (L.C.H.); (A.R.P.); (C.L.S.); (B.P.); (L.L.); (J.N.C.); (M.B.); (E.S.); (J.J.); (C.M.U.)
| | - Laura Lambert
- Huntsman Cancer Institute, Salt Lake City, UT 84112, USA; (C.H.); (J.O.); (T.L.); (L.C.H.); (A.R.P.); (C.L.S.); (B.P.); (L.L.); (J.N.C.); (M.B.); (E.S.); (J.J.); (C.M.U.)
| | - Jessica N. Cohan
- Huntsman Cancer Institute, Salt Lake City, UT 84112, USA; (C.H.); (J.O.); (T.L.); (L.C.H.); (A.R.P.); (C.L.S.); (B.P.); (L.L.); (J.N.C.); (M.B.); (E.S.); (J.J.); (C.M.U.)
| | - Mary Bronner
- Huntsman Cancer Institute, Salt Lake City, UT 84112, USA; (C.H.); (J.O.); (T.L.); (L.C.H.); (A.R.P.); (C.L.S.); (B.P.); (L.L.); (J.N.C.); (M.B.); (E.S.); (J.J.); (C.M.U.)
| | - Seth Felder
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA; (S.F.); (J.S.); (S.D.); (D.C.); (S.L.S.); (E.M.S.)
| | - Julian Sanchez
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA; (S.F.); (J.S.); (S.D.); (D.C.); (S.L.S.); (E.M.S.)
| | - Sophie Dessureault
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA; (S.F.); (J.S.); (S.D.); (D.C.); (S.L.S.); (E.M.S.)
| | - Domenico Coppola
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA; (S.F.); (J.S.); (S.D.); (D.C.); (S.L.S.); (E.M.S.)
| | - David M. Hoffman
- Cedars-Sinai Center, Los Angeles, CA 90048, USA; (J.C.F.); (D.M.H.); (Y.F.N.); (R.W.D.); (K.Z.); (Z.A.M.); (A.H.); (J.G.); (E.F.); (A.G.); (B.A.M.); (K.G.C.); (M.S.E.-M.)
| | - Yosef F. Nasseri
- Cedars-Sinai Center, Los Angeles, CA 90048, USA; (J.C.F.); (D.M.H.); (Y.F.N.); (R.W.D.); (K.Z.); (Z.A.M.); (A.H.); (J.G.); (E.F.); (A.G.); (B.A.M.); (K.G.C.); (M.S.E.-M.)
| | - Robert W. Decker
- Cedars-Sinai Center, Los Angeles, CA 90048, USA; (J.C.F.); (D.M.H.); (Y.F.N.); (R.W.D.); (K.Z.); (Z.A.M.); (A.H.); (J.G.); (E.F.); (A.G.); (B.A.M.); (K.G.C.); (M.S.E.-M.)
| | - Karen Zaghiyan
- Cedars-Sinai Center, Los Angeles, CA 90048, USA; (J.C.F.); (D.M.H.); (Y.F.N.); (R.W.D.); (K.Z.); (Z.A.M.); (A.H.); (J.G.); (E.F.); (A.G.); (B.A.M.); (K.G.C.); (M.S.E.-M.)
| | - Zuri A. Murrell
- Cedars-Sinai Center, Los Angeles, CA 90048, USA; (J.C.F.); (D.M.H.); (Y.F.N.); (R.W.D.); (K.Z.); (Z.A.M.); (A.H.); (J.G.); (E.F.); (A.G.); (B.A.M.); (K.G.C.); (M.S.E.-M.)
| | - Andrew Hendifar
- Cedars-Sinai Center, Los Angeles, CA 90048, USA; (J.C.F.); (D.M.H.); (Y.F.N.); (R.W.D.); (K.Z.); (Z.A.M.); (A.H.); (J.G.); (E.F.); (A.G.); (B.A.M.); (K.G.C.); (M.S.E.-M.)
| | - Jun Gong
- Cedars-Sinai Center, Los Angeles, CA 90048, USA; (J.C.F.); (D.M.H.); (Y.F.N.); (R.W.D.); (K.Z.); (Z.A.M.); (A.H.); (J.G.); (E.F.); (A.G.); (B.A.M.); (K.G.C.); (M.S.E.-M.)
| | - Eiman Firoozmand
- Cedars-Sinai Center, Los Angeles, CA 90048, USA; (J.C.F.); (D.M.H.); (Y.F.N.); (R.W.D.); (K.Z.); (Z.A.M.); (A.H.); (J.G.); (E.F.); (A.G.); (B.A.M.); (K.G.C.); (M.S.E.-M.)
| | - Alexandra Gangi
- Cedars-Sinai Center, Los Angeles, CA 90048, USA; (J.C.F.); (D.M.H.); (Y.F.N.); (R.W.D.); (K.Z.); (Z.A.M.); (A.H.); (J.G.); (E.F.); (A.G.); (B.A.M.); (K.G.C.); (M.S.E.-M.)
| | - Beth A. Moore
- Cedars-Sinai Center, Los Angeles, CA 90048, USA; (J.C.F.); (D.M.H.); (Y.F.N.); (R.W.D.); (K.Z.); (Z.A.M.); (A.H.); (J.G.); (E.F.); (A.G.); (B.A.M.); (K.G.C.); (M.S.E.-M.)
| | - Kyle G. Cologne
- Cedars-Sinai Center, Los Angeles, CA 90048, USA; (J.C.F.); (D.M.H.); (Y.F.N.); (R.W.D.); (K.Z.); (Z.A.M.); (A.H.); (J.G.); (E.F.); (A.G.); (B.A.M.); (K.G.C.); (M.S.E.-M.)
| | - Maryliza S. El-Masry
- Cedars-Sinai Center, Los Angeles, CA 90048, USA; (J.C.F.); (D.M.H.); (Y.F.N.); (R.W.D.); (K.Z.); (Z.A.M.); (A.H.); (J.G.); (E.F.); (A.G.); (B.A.M.); (K.G.C.); (M.S.E.-M.)
| | - Nathan Hinkle
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN 37996, USA; (D.S.); (N.H.); (J.M.)
| | - Justin Monroe
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN 37996, USA; (D.S.); (N.H.); (J.M.)
| | - Matthew Mutch
- Department of Surgery, Washington University St. Louis, St. Louis, MO 63130, USA; (M.M.); (C.B.); (D.C.); (A.T.T.)
| | - Cory Bernadt
- Department of Surgery, Washington University St. Louis, St. Louis, MO 63130, USA; (M.M.); (C.B.); (D.C.); (A.T.T.)
| | - Deyali Chatterjee
- Department of Surgery, Washington University St. Louis, St. Louis, MO 63130, USA; (M.M.); (C.B.); (D.C.); (A.T.T.)
| | - Mika Sinanan
- Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA; (M.S.); (S.A.C.); (U.W.); (W.M.G.); (P.D.L.); (D.R.); (M.K.); (R.M.); (C.I.L.)
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA 98195, USA
| | - Stacey A. Cohen
- Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA; (M.S.); (S.A.C.); (U.W.); (W.M.G.); (P.D.L.); (D.R.); (M.K.); (R.M.); (C.I.L.)
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA 98195, USA
| | - Ulrike Wallin
- Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA; (M.S.); (S.A.C.); (U.W.); (W.M.G.); (P.D.L.); (D.R.); (M.K.); (R.M.); (C.I.L.)
| | - William M. Grady
- Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA; (M.S.); (S.A.C.); (U.W.); (W.M.G.); (P.D.L.); (D.R.); (M.K.); (R.M.); (C.I.L.)
| | - Paul D. Lampe
- Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA; (M.S.); (S.A.C.); (U.W.); (W.M.G.); (P.D.L.); (D.R.); (M.K.); (R.M.); (C.I.L.)
| | - Deepti Reddi
- Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA; (M.S.); (S.A.C.); (U.W.); (W.M.G.); (P.D.L.); (D.R.); (M.K.); (R.M.); (C.I.L.)
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA 98195, USA
| | - Mukta Krane
- Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA; (M.S.); (S.A.C.); (U.W.); (W.M.G.); (P.D.L.); (D.R.); (M.K.); (R.M.); (C.I.L.)
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA 98195, USA
| | | | - Ravi Moonka
- Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA; (M.S.); (S.A.C.); (U.W.); (W.M.G.); (P.D.L.); (D.R.); (M.K.); (R.M.); (C.I.L.)
| | - Esther Herpel
- Pathologisches Institut, University Hospital Heidelberg, 69120 Heidelberg, Germany; (E.H.); (P.S.); (M.K.); (M.v.K.-D.); (J.N.); (H.-U.K.); (B.G.); (A.B.U.)
| | - Peter Schirmacher
- Pathologisches Institut, University Hospital Heidelberg, 69120 Heidelberg, Germany; (E.H.); (P.S.); (M.K.); (M.v.K.-D.); (J.N.); (H.-U.K.); (B.G.); (A.B.U.)
| | - Matthias Kloor
- Pathologisches Institut, University Hospital Heidelberg, 69120 Heidelberg, Germany; (E.H.); (P.S.); (M.K.); (M.v.K.-D.); (J.N.); (H.-U.K.); (B.G.); (A.B.U.)
| | - Magnus von Knebel-Doeberitz
- Pathologisches Institut, University Hospital Heidelberg, 69120 Heidelberg, Germany; (E.H.); (P.S.); (M.K.); (M.v.K.-D.); (J.N.); (H.-U.K.); (B.G.); (A.B.U.)
| | - Johanna Nattenmueller
- Pathologisches Institut, University Hospital Heidelberg, 69120 Heidelberg, Germany; (E.H.); (P.S.); (M.K.); (M.v.K.-D.); (J.N.); (H.-U.K.); (B.G.); (A.B.U.)
| | - Hans-Ulrich Kauczor
- Pathologisches Institut, University Hospital Heidelberg, 69120 Heidelberg, Germany; (E.H.); (P.S.); (M.K.); (M.v.K.-D.); (J.N.); (H.-U.K.); (B.G.); (A.B.U.)
| | - Eric Swanson
- Huntsman Cancer Institute, Salt Lake City, UT 84112, USA; (C.H.); (J.O.); (T.L.); (L.C.H.); (A.R.P.); (C.L.S.); (B.P.); (L.L.); (J.N.C.); (M.B.); (E.S.); (J.J.); (C.M.U.)
| | - Jolanta Jedrzkiewicz
- Huntsman Cancer Institute, Salt Lake City, UT 84112, USA; (C.H.); (J.O.); (T.L.); (L.C.H.); (A.R.P.); (C.L.S.); (B.P.); (L.L.); (J.N.C.); (M.B.); (E.S.); (J.J.); (C.M.U.)
- Department of Population Health Sciences, University of Utah, Salt Lake City, UT 84112, USA
| | - Stephanie L. Schmit
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA; (S.F.); (J.S.); (S.D.); (D.C.); (S.L.S.); (E.M.S.)
| | - Biljana Gigic
- Pathologisches Institut, University Hospital Heidelberg, 69120 Heidelberg, Germany; (E.H.); (P.S.); (M.K.); (M.v.K.-D.); (J.N.); (H.-U.K.); (B.G.); (A.B.U.)
| | - Alexis B. Ulrich
- Pathologisches Institut, University Hospital Heidelberg, 69120 Heidelberg, Germany; (E.H.); (P.S.); (M.K.); (M.v.K.-D.); (J.N.); (H.-U.K.); (B.G.); (A.B.U.)
| | - Adetunji T. Toriola
- Department of Surgery, Washington University St. Louis, St. Louis, MO 63130, USA; (M.M.); (C.B.); (D.C.); (A.T.T.)
| | - Erin M. Siegel
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA; (S.F.); (J.S.); (S.D.); (D.C.); (S.L.S.); (E.M.S.)
| | - Christopher I. Li
- Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA; (M.S.); (S.A.C.); (U.W.); (W.M.G.); (P.D.L.); (D.R.); (M.K.); (R.M.); (C.I.L.)
| | - Cornelia M. Ulrich
- Huntsman Cancer Institute, Salt Lake City, UT 84112, USA; (C.H.); (J.O.); (T.L.); (L.C.H.); (A.R.P.); (C.L.S.); (B.P.); (L.L.); (J.N.C.); (M.B.); (E.S.); (J.J.); (C.M.U.)
- Department of Population Health Sciences, University of Utah, Salt Lake City, UT 84112, USA
| | - Sheetal Hardikar
- Huntsman Cancer Institute, Salt Lake City, UT 84112, USA; (C.H.); (J.O.); (T.L.); (L.C.H.); (A.R.P.); (C.L.S.); (B.P.); (L.L.); (J.N.C.); (M.B.); (E.S.); (J.J.); (C.M.U.)
- Department of Population Health Sciences, University of Utah, Salt Lake City, UT 84112, USA
- Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA; (M.S.); (S.A.C.); (U.W.); (W.M.G.); (P.D.L.); (D.R.); (M.K.); (R.M.); (C.I.L.)
- Correspondence: ; Tel.: +1-(801)-213-6238
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Cavallaro PM, Fearnhead NS, Bissett IP, Brar MS, Cataldo TE, Clarke R, Denoya P, Elder AL, Gecse KB, Hendren S, Holubar S, Jeganathan N, Myrelid P, Norton BA, Wexner SD, Wilson L, Zaghiyan K, Bordeianou L. Patients Undergoing Ileoanal Pouch Surgery Experience a Constellation of Symptoms and Consequences Representing a Unique Syndrome: A Report From the Patient-Reported Outcomes After Pouch Surgery (PROPS) Delphi Consensus Study. Ann Surg 2021; 274:138-145. [PMID: 33914449 PMCID: PMC8968673 DOI: 10.1097/sla.0000000000004829] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The primary aim was to create a patient-centered definition of core symptoms that should be included in future studies of pouch function. BACKGROUND Functional outcomes after ileoanal pouch creation have been studied; however, there is great variability in how relevant outcomes are defined and reported. More importantly, the perspective of patients has not been represented in deciding which outcomes should be the focus of research. METHODS Expert stakeholders were chosen to correlate with the clinical scenario of the multidisciplinary team that cares for pouch patients: patients, colorectal surgeons, gastroenterologists/other clinicians. Three rounds of surveys were employed to select high-priority items. Survey voting was followed by a series of online patient consultation meetings used to clarify voting trends. A final online consensus meeting with representation from all 3 expert panels was held to finalize a consensus statement. RESULTS One hundred ninety-five patients, 62 colorectal surgeons, and 48 gastroenterologists/nurse specialists completed all 3 Delphi rounds. Fifty-three patients participated in online focus groups. One hundred sixty-one stakeholders participated in the final consensus meeting. On conclusion of the consensus meeting, 7 bowel symptoms and 7 consequences of undergoing ileoanal pouch surgery were included in the final consensus statement. CONCLUSIONS This study is the first to identify key functional outcomes after pouch surgery with direct input from a large panel of ileoanal pouch patients. The inclusion of patients in all stages of the consensus process allowed for a true patient-centered approach in defining the core domains that should be focused on in future studies of pouch function.
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Affiliation(s)
- Paul M. Cavallaro
- Department of General Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Nicola S. Fearnhead
- Department of Colorectal Surgery, Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, United Kingdom
| | - Ian P. Bissett
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Mantaj S. Brar
- Division of General Surgery, Department of Surgery, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Thomas E. Cataldo
- Division of Colon and Rectum Surgery, Beth Israel-Deaconess Health Medical Center, Harvard Medical School, Boston, Massachusetts
| | | | - Paula Denoya
- Division of Colon and Rectal Surgery, Department of Surgery, Stony Brook University Hospital. Stony Brook, New York
| | | | - Krisztina B. Gecse
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Samantha Hendren
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Stefan Holubar
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Nimalan Jeganathan
- Department of Surgery, Division of Colon and Rectal Surgery, Pennsylvania State University College of Medicine, Hershey, Pennsylvania
| | - Pär Myrelid
- Department of Surgery, County Council of Östergötland, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Beth-Anne Norton
- Crohn’s and Colitis Center, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Steven D. Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida
| | - Lauren Wilson
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Karen Zaghiyan
- Division of Colorectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Liliana Bordeianou
- Massachusetts General Hospital Colorectal Surgery and Crohn’s Colitis Centers, Department of Gastrointestinal Surgery and Surgical Oncology, Boston, Massachusetts
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19
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Abstract
BACKGROUND Crohn's disease is a relative contraindication to IPAA due to perceived increased rates of pouch failure. OBJECTIVE This study aimed to determine pouch functional outcomes and failure rates in patients with a known preoperative diagnosis of Crohn's disease. DATA SOURCES A database search was performed in Ovid Medline In-Process & Other NonIndexed Citations, Ovid MEDLINE, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, and Ovid Cochrane Database of Systematic Reviews. STUDY SELECTION The published human studies that reported short-term postoperative outcomes and/or long-term outcomes following IPAA in adult (≥18 years of age) Crohn's disease populations were selected. INTERVENTION Ileal pouch anal anastomoses were constructed in patients who had Crohn's disease diagnosed preoperatively or through proctocolectomy pathology. MAIN OUTCOMES MEASURES The primary outcomes measured were long-term functional outcomes (to maximal date of follow-up) and the pouch failure rate. RESULTS Of 7019 records reviewed, 6 full articles were included in the analysis. Rates of pelvic sepsis, small-bowel obstruction, pouchitis, anal stricture, and chronic sinus tract were 13%, 3%, 31%, 18%, and 28%. Rates of incontinence, urgency, pad usage in the day, pad usage at night, and need for antidiarrheals were 24%, 21%, 19%, 20%, and 28%, and mean 24-hour stool frequency was 6.3 bowel movements at a mean 69 months of follow-up. The overall pouch failure rate was 15%; no risk factors for pouch failure were identified. LIMITATIONS This investigation was limited by the small number of studies with significant study heterogeneity. CONCLUSION In patients with known preoperative Crohn's disease, IPAA construction is feasible with functional outcomes equivalent to patients with ulcerative colitis, but, even in highly selected patients with Crohn's disease, pouch failure rates remain higher than in patients with ulcerative colitis.
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Affiliation(s)
- Amy L Lightner
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - Xue Jia
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - Karen Zaghiyan
- Division of Colon and Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Phillip R Fleshner
- Division of Colon and Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California
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20
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Syal G, Shemtov R, Bonthala N, Vasiliauskas EA, Feldman EJ, Zaghiyan K, Ha CY, McGovern DPB, Targan SR, Melmed GY, Fleshner PR. Pre-pouch Ileitis is Associated with Development of Crohn's Disease-like Complications and Pouch Failure. J Crohns Colitis 2020; 15:960-968. [PMID: 33300546 PMCID: PMC8218713 DOI: 10.1093/ecco-jcc/jjaa251] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS It is unclear whether pre-pouch ileitis heralds an aggressive inflammatory pouch disease in patients with ileal pouch-anal anastomosis [IPAA]. We compared outcomes of patients with pouchitis and concomitant pre-pouch ileitis with those with pouchitis alone. METHODS Patients undergoing IPAA surgery for inflammatory bowel disease, who subsequently developed pouchitis with concomitant pre-pouch ileitis [pre-pouch ileitis group], were matched by year of IPAA surgery and preoperative diagnosis [ulcerative colitis or inflammatory bowel disease-unclassified] with patients who developed pouchitis alone [pouchitis group]. Primary outcomes were development of Crohn's disease [CD]-like complications [non-anastomotic strictures or perianal disease >6 months after ileostomy closure] and pouch failure. Secondary outcomes were need for surgical/endoscopic interventions and immunosuppressive therapy. Log-rank testing was used to compare outcome-free survival, and Cox regression was performed to identify predictors of outcomes. RESULTS There were 66 patients in each group. CD-like complications and pouch failure developed in 36.4% and 7.6% patients in the pre-pouch ileitis group and 10.6% and 1.5% in pouchitis group, respectively. CD-like complications-free survival [log-rank p = 0.0002] and pouch failure-free survival [log-rank p = 0.046] were significantly lower in the pre-pouch ileitis group. The pre-pouch ileitis group had a higher risk of requiring surgical/endoscopic interventions [log-rank p = 0.0005] and immunosuppressive therapy [log-rank p <0.0001]. Pre-pouch ileitis was independently associated with an increased risk of CD-like complications (hazard ratio [HR] 3.8; p = 0.0007), need for surgical/endoscopic interventions [HR 4.1; p = 0.002], and immunosuppressive therapy [HR 5.0; p = 0.0002]. CONCLUSIONS Pre-pouch ileitis is associated with a higher risk of complicated disease and pouch failure than pouchitis. It should be considered a feature of CD.
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Affiliation(s)
- Gaurav Syal
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA,Division of Digestive and Liver Diseases, Cedars-Sinai Medical Center, Los Angeles, CA, USA,Corresponding author: Gaurav Syal, MD, 8730 Alden Drive, Second Floor East, Los Angeles, CA 90036, USA. Tel.: 310-423-4100; fax: 310-423-0146;
| | - Ron Shemtov
- Sackler School of Medicine, Tel Aviv, Israel
| | - Nirupama Bonthala
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA,Division of Digestive and Liver Diseases, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Eric A Vasiliauskas
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA,Division of Digestive and Liver Diseases, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Edward J Feldman
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA,Division of Digestive and Liver Diseases, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Karen Zaghiyan
- Division of Colorectal Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Christina Y Ha
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA,Division of Digestive and Liver Diseases, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Dermot P B McGovern
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA,Division of Digestive and Liver Diseases, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Stephan R Targan
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA,Division of Digestive and Liver Diseases, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Gil Y Melmed
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA,Division of Digestive and Liver Diseases, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Phillip R Fleshner
- F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA,Division of Colorectal Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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21
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Caycedo-Marulanda A, Nadeau K, Verschoor CP, Sands D, Spinelli A, Ashamalla S, Patel SV, Di Candido F, Mujukian A, Zaghiyan K, Stevenson G, Wolthuis A, Clark DA, D'Hoore A, Stevenson A, Wexner SD. Exploring the perioperative outcomes of a sample of successful adopters of transanal total mesorectal excision (taTME) during the learning phase. Surgery 2020; 169:774-781. [PMID: 33243484 DOI: 10.1016/j.surg.2020.10.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 10/06/2020] [Accepted: 10/19/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Transanal total mesorectal excision can be a technically challenging operation to master. While many early adopters have reported adequate outcomes, others have failed to reproduce these results. There are contradicting data on oncologic outcomes during the learning phase of this technique. Thus, our objective was to perform a multicentered assessment of oncological outcomes in patients undergoing transanal total mesorectal excision during the learning phase in a sample of successful adopting centers. METHODS Surgeons from 8 centers with experience in the management of rectal cancer were invited to participate. The initial 51 consecutive benign and malignant cases of the participating units were retrospectively reviewed, but only 366 cancer cases were included in the analysis. Procedures were divided into implementation (ie, the first 10 cases) and postimplementation (ie, case 11 on onwards) groups, and the main outcome was the incidence of local recurrence. RESULTS The overall prevalence of local recurrence was 4.1% at a median follow-up of 35 months (interquartile range 20.3-44.2); among implementation and postimplementation groups local recurrence was 7.5% and 3.1%, respectively, and the rate of local recurrence was observed to be nearly 60% lower in the postimplementation group (hazard ratio [95% confidence interval] = 0.43 [0.26-0.72]) Total mesorectal excision specimens were complete or nearly complete in 87.7% of cases, and the circumferential and distal margins were clear in 93.2% and 92.6%, respectively CONCLUSION: Local recurrence rate was low during the learning phase of the transanal total mesorectal excision in a sample of rectal cancer surgeons with acceptable surgical and oncologic outcomes. Both the prevalence and rate of local recurrence were markedly lower in the postimplementation phase, indicating improvement as experience accumulated.
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Affiliation(s)
- Antonio Caycedo-Marulanda
- Department of Surgery, Queen's University, Kingston, Canada; Health Sciences North Research Institute, Sudbury, Canada.
| | - Kara Nadeau
- Department of Surgery, Northern Ontario School of Medicine, Health Sciences North, Sudbury, Canada
| | | | - Dana Sands
- Department of Surgery, Cleveland Clinic, Weston, FL
| | - Antonino Spinelli
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Center, IRCCS, Rozzano-Milano, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milano, Italy
| | - Shady Ashamalla
- Department of Surgery, University Health Network, Toronto, Canada
| | - Sunil V Patel
- Department of Surgery, Queen's University, Kingston, Canada
| | - Francesca Di Candido
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Center, IRCCS, Rozzano-Milano, Italy
| | - Angela Mujukian
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Karen Zaghiyan
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Grant Stevenson
- School of Public Health, Faculty of Medicine, University of Queensland, Brisbane, Australia; Department of Surgery, University of Queensland, Brisbane, Australia
| | | | - David A Clark
- Department of Surgery, University of Queensland, Brisbane, Australia; Department of Surgery, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Andre D'Hoore
- Department of Surgery, University Hospital Leuven, Belgium
| | - Andrew Stevenson
- Department of Surgery, University of Queensland, Brisbane, Australia; Department of Surgery, Royal Brisbane and Women's Hospital, Brisbane, Australia
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22
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Abstract
Up to 80% of Crohn's disease (CD) patients require surgery. Fecal diversion is used selectively in CD proctocolitis refractory to medical treatment or advanced perianal disease. This study examines associations between clinical features in predicting clinical response (CR) to fecal diversion in CD. Charts of CD patients undergoing fecal diversion for medically refractory disease or perianal disease were reviewed. Clinical response was assessed focusing on improvements in urgency, abdominal and perineal pain, decreased anal fistula drainage, and weight gain. Univariate binary logistic regression and multivariate forward-stepwise modeling analysis were used to determine associations with CR. The study cohort comprised 79 patients. After a median follow-up of 36 (3-192) months, 40 (51%) patients achieved a CR. Binary logistic regression analysis revealed both age at diagnosis (hazard ratio [HR] 1.05; confidence interval [CI] 1.01-1.09; P = .007) and disease duration (HR .91; CI .86-.96; P = .001) to be significantly associated with CR. Later age of onset (HR 1.05; CI 1.01-1.10; P = .002) and shorter disease duration (HR .91; CI .86-.97; P = .02) remained significant on multivariate analysis. This largest reported series of fecal diversion for refractory CD in the biologic drug era revealed that young age at diagnosis and long disease duration are associated with a lower CR.
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Affiliation(s)
- Hassan Buhulaigah
- Division of Colon and Rectal Surgery, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Adam Truong
- Division of Colon and Rectal Surgery, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Karen Zaghiyan
- Division of Colon and Rectal Surgery, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Phillip Fleshner
- Division of Colon and Rectal Surgery, Cedars Sinai Medical Center, Los Angeles, CA, USA
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23
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Lightner AL, Ashburn JH, Brar MS, Carvello M, Chandrasinghe P, van Overstraeten ADB, Fleshner PR, Gallo G, Kotze PG, Holubar SD, Reza LM, Spinelli A, Strong SA, Tozer PJ, Truong A, Warusavitarne J, Yamamoto T, Zaghiyan K. Fistulizing Crohn's disease. Curr Probl Surg 2020; 57:100808. [PMID: 33187597 DOI: 10.1016/j.cpsurg.2020.100808] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 04/22/2020] [Indexed: 02/06/2023]
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24
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Lightner AL, Ashburn JH, Brar MS, Carvello M, Fleshner PR, Gallo G, Kotze PG, Holubar SD, Reza LM, Spinelli A, Strong SA, Tozer PJ, Truong A, Warusavitarne J, Yamamoto T, Zaghiyan K. In brief. Curr Probl Surg 2020. [PMID: 33187595 DOI: 10.1016/j.cpsurg.2020.100811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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25
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Hawkins AT, Wise PE, Chan T, Lee JT, Glyn T, Wood V, Eglinton T, Frizelle F, Khan A, Hall J, Ilyas MIM, Michailidou M, Nfonsam VN, Cowan ML, Williams J, Steele SR, Alavi K, Ellis CT, Collins D, Winter DC, Zaghiyan K, Gallo G, Carvello M, Spinelli A, Lightner AL. Diverticulitis: An update from the age old Paradigm. Curr Probl Surg 2020; 57:100863. [PMID: 33077029 DOI: 10.1016/j.cpsurg.2020.100863] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Alexander T Hawkins
- Section of Colon & Rectal Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN.
| | - Paul E Wise
- Section of Colon and Rectal Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Tiffany Chan
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Janet T Lee
- Division of Colon and Rectal Surgery, Department of Surgery, University of Minnesota, Saint Paul, MN
| | - Tamara Glyn
- Department of Surgery, University of Otago, Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Verity Wood
- Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Timothy Eglinton
- Department of Surgery, University of Otago, Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Frank Frizelle
- Department of Surgery, University of Otago, Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Adil Khan
- Raleigh General Hospital, Beckley, WV
| | - Jason Hall
- Department of Surgery, Boston Medical Center, Boston, MA
| | | | | | | | | | | | - Scott R Steele
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - Karim Alavi
- Division of Colorectal Surgery, University of Massachusetts Memorial Medical Center, Worcester, MA
| | - C Tyler Ellis
- Section of Colon & Rectal Surgery, Hiram C. Polk, Jr., MD Department of Surgery, University of Louisville, Louisville, KY
| | | | - Des C Winter
- St. Vincent's University Hospital, Dublin, Ireland
| | | | - Gaetano Gallo
- Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
| | - Michele Carvello
- Colon and Rectal Surgery Unit, Humanitas Clinical and Research Center IRCCS, Department of Biomedical Sciences, Humanitas University, Milano, Italy
| | - Antonino Spinelli
- Colon and Rectal Surgery Unit, Humanitas Clinical and Research Center IRCCS, Department of Biomedical Sciences, Humanitas University, Milano, Italy
| | - Amy L Lightner
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
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26
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Mujukian A, Zaghiyan K, Banayan E, Fleshner P. Outcomes of Definitive Draining Seton Placement for Complex Anal Fistula in Crohn’s Disease. Am Surg 2020; 86:1368-1372. [DOI: 10.1177/0003134820964462] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Definitive draining seton (DDS) alone is an accepted treatment for complex refractory anal fistulas in Crohn’s disease (CD). We evaluated the long-term success of DDS in CD patients. DDS was defined as draining seton placed definitively for at least 12 months. Primary end point was clinical response (CR) defined as a lack of induration, pain, swelling, abscess recurrence, or unintended dislodgement. The study cohort of 23 patients had a median age of 29 (range; 9-61) years and included 14 males (61%). Reasons for DDS included anal stenosis (n = 9; 39%), active proctitis (n = 9; 39%), and/or anal canal ulceration (n = 9; 39%). Median number of setons was 2 (range; 1-6) and 65% had multiple fistula tracts. Almost all patients (n = 22; 96%) were on a biologic postoperatively. At 12-month follow-up, only 39% (n = 9) had a CR. The remaining 14 patients failed due to new abscess formation (n = 6; 26%), new fistula formation (n = 6; 26%), and seton dislodgement (n = 2; 9%). Six (26%) patients required fecal diversion. No patients required proctectomy. DDS for complex CD fistula results in a mediocre CR with many patients developing recurrent abscess/fistula or requiring diversion despite biologic therapy.
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Affiliation(s)
- Angela Mujukian
- Division of Colon & Rectal Surgery, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Karen Zaghiyan
- Division of Colon & Rectal Surgery, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Elliot Banayan
- Division of Colon & Rectal Surgery, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Phillip Fleshner
- Division of Colon & Rectal Surgery, Cedars Sinai Medical Center, Los Angeles, CA, USA
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Mujukian A, Truong A, Tran H, Shane R, Fleshner P, Zaghiyan K. A Standardized Multimodal Analgesia Protocol Reduces Perioperative Opioid Use in Minimally Invasive Colorectal Surgery. J Gastrointest Surg 2020; 24:2286-2294. [PMID: 31515761 DOI: 10.1007/s11605-019-04385-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 08/27/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Multimodal analgesia protocols are becoming a common part of enhanced recovery pathways after colorectal surgery. However, few protocols include a robust intraoperative component in addition to pre-operative and post-operative analgesics. METHOD A prospective cohort study was performed in an urban teaching hospital in patients undergoing minimally invasive colorectal surgery before and after implementation of a multimodal analgesia protocol consisting of pre-operative (gabapentin, acetaminophen, celecoxib), intraoperative (lidocaine and magnesium infusions, ketorolac, transversus abdominis plane block), and post-operative (gabapentin, acetaminophen, celecoxib) opioid-sparing elements. The main outcome measure was use of morphine equivalents in the first 24-h post-operative period. RESULTS The study cohort (n = 71) included 41 patients before and 30 patients after implementation of a multimodal analgesia protocol. Mean age of the entire study cohort was 47 ± 19.7 years and 46% were male. Patients undergoing surgery post-multimodal analgesia vs. pre-multimodal analgesia had significantly lower use of IV morphine equivalents in first 24-h post-operative period (5.8 ± 6.4 mg vs. 22.8 ± 21.3 mg; p = 0.005) and first 48-h post-operative period (7.6 ± 9.4 mg vs. 42 ± 52.9 mg; p = 0.0008). This reduction in IV morphine equivalent use post-multimodal analgesia was coupled with improved pain scores in the post-operative period. Post-operative hospital length of stay, post-operative ileus, and overall complications were not significantly different between groups. CONCLUSIONS Multimodal analgesia incorporating pre-operative, intraoperative, and post-operative opioid-sparing agents is an effective method for reducing perioperative opioid utilization and pain after minimally invasive colorectal surgery.
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Affiliation(s)
- Angela Mujukian
- Division of Colon & Rectal Surgery, Cedars Sinai Medical Center, 8737 Beverly Blvd., Suite 101, Los Angeles, CA, 90048, USA
| | - Adam Truong
- Division of Colon & Rectal Surgery, Cedars Sinai Medical Center, 8737 Beverly Blvd., Suite 101, Los Angeles, CA, 90048, USA
| | - Hai Tran
- Department of Pharmacy, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Rita Shane
- Department of Pharmacy, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Phillip Fleshner
- Division of Colon & Rectal Surgery, Cedars Sinai Medical Center, 8737 Beverly Blvd., Suite 101, Los Angeles, CA, 90048, USA
| | - Karen Zaghiyan
- Division of Colon & Rectal Surgery, Cedars Sinai Medical Center, 8737 Beverly Blvd., Suite 101, Los Angeles, CA, 90048, USA.
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Lightner AL, Kearney D, Giugliano D, Hull T, Holubar SD, Koh S, Zaghiyan K, Fleshner PR. Excisional Hemorrhoidectomy: Safe in Patients With Crohn's Disease? Inflamm Bowel Dis 2020; 26:1390-1393. [PMID: 31633186 DOI: 10.1093/ibd/izz255] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Indexed: 12/09/2022]
Abstract
INTRODUCTION Due to concerns over wound healing, hemorrhoidectomy in patients with Crohn's disease (CD) remains controversial. We sought to ascertain safety and efficacy of excisional hemorrhoidectomy in CD. METHODS A retrospective review of all adult CD patients undergoing excisional hemorrhoidectomy between January 1, 1995, and January 1, 2019, at 2 IBD referral centers was performed. Data collected included patient demographics, clinical characteristics of CD (anorectal symptoms; prior nonoperative hemorrhoidal therapy; presence of other perianal disease; and activity, duration, and anatomic location of CD), and postoperative complications including bleeding, wound healing, and need for further therapy or surgical intervention after surgery. RESULTS A total of 36 adult patients with Crohn's disease with symptomatic hemorrhoidal disease were included. The study cohort included 16 males (44%), and median age was 49 (range, 21 to 77) years. Predominant symptoms included pain (n = 16; 44%), prolapse (n = 8; 22%), and bleeding (n = 12; 33%). Sixteen patients (44%) had nonoperative therapy before surgery. Twenty-four patients (67%) had other perianal disease. At the time of hemorrhoidectomy, 9 patients (25%) were exposed to corticosteroids, 8 patients (25%) to immunomodulators, and 9 patients (25%) to biologics. During a median follow-up time of 31.5 (range, 1 to 255) months after hemorrhoidectomy, 4 patients (11%) had complications (1 developed a stricture, 1 developed a perianal abscess/fistula, 1 had a nonhealing wound, and 1 had hemorrhoidal recurrence). CONCLUSION Our data suggest that excisional hemorrhoidectomy may be performed safely in CD patients who have failed nonoperative hemorrhoidal therapy without concern for de novo perianal disease or need for proctectomy.Hemorrhoidal disease is common in patients with Crohn's disease. This study sought to understand the outcomes of surgically treating hemorrhoids in patients with Crohn's disease.
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Affiliation(s)
- Amy L Lightner
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland, OH
| | - David Kearney
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland, OH
| | - Danica Giugliano
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland, OH
| | - Tracy Hull
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland, OH
| | - Stefan D Holubar
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland, OH
| | - Sharon Koh
- Division of Colon and Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Karen Zaghiyan
- Division of Colon and Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Phillip R Fleshner
- Division of Colon and Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
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29
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Hawkins AT, Wise PE, Chan T, Lee JT, Glyn T, Wood V, Eglinton T, Frizelle F, Khan A, Hall J, Ilyas MIM, Michailidou M, Nfonsam VN, Cowan ML, Williams J, Steele SR, Alavi K, Ellis CT, Collins D, Winter DC, Zaghiyan K, Gallo G, Carvello M, Spinelli A, Lightner AL. Diverticulitis: An Update From the Age Old Paradigm. Curr Probl Surg 2020; 57:100862. [PMID: 33077029 DOI: 10.1016/j.cpsurg.2020.100862] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 07/10/2020] [Indexed: 02/07/2023]
Affiliation(s)
- Alexander T Hawkins
- Section of Colon & Rectal Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN.
| | - Paul E Wise
- Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Tiffany Chan
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Janet T Lee
- Department of Surgery, University of Minnesota, Saint Paul, MN
| | - Tamara Glyn
- University of Otago, Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Verity Wood
- Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Timothy Eglinton
- Department of Surgery, University of Otago, Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Frank Frizelle
- Department of Surgery, University of Otago, Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Adil Khan
- Raleigh General Hospital, Beckley, WV
| | - Jason Hall
- Dempsey Center for Digestive Disorders, Department of Surgery, Boston Medical Center, Boston, MA
| | | | | | | | | | | | - Scott R Steele
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Oh
| | - Karim Alavi
- Division of Colorectal Surgery, University of Massachusetts Memorial Medical Center, Worcester, MA
| | - C Tyler Ellis
- Department of Surgery, University of Louisville, Louisville, KY
| | | | - Des C Winter
- St. Vincent's University Hospital, Dublin, Ireland
| | | | - Gaetano Gallo
- Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
| | - Michele Carvello
- Colon and Rectal Surgery Unit, Humanitas Clinical and Research Center IRCCS, Department of Biomedical Sciences, Humanitas University, Milano, Italy
| | - Antonino Spinelli
- Colon and Rectal Surgery Unit, Humanitas Clinical and Research Center IRCCS, Department of Biomedical Sciences, Humanitas University, Milano, Italy
| | - Amy L Lightner
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
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Truong A, Mujukian A, Fleshner P, Zaghiyan K. No Pain, More Gain: Reduced Postoperative Opioid Consumption with a Standardized Opioid-Sparing Multimodal Analgesia Protocol in Opioid-Tolerant Patients Undergoing Colorectal Surgery. Am Surg 2020. [DOI: 10.1177/000313481908501017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The utility of opioid-sparing multimodal analgesia protocols (OSMMAPs) in opioid-tolerant (OT) patients is unknown. We sought to determine the impact of a standardized OSMMAP in OT versus opioid-naïve (ON) patients after major colorectal surgery. Consecutive patients undergoing surgery before (January 2015–March 2017) and after OSMMAP implementation (April 2017–March 2018) were identified from a single-institution prospective colorectal surgery registry. OT was defined by the presence of an opioid on the preadmission medication record. Opioid use (measured in oral morphine equivalents (OMEs)) and surgical outcomes were compared between OT and ON patients pre- and post-OSMMAP. The study cohort of 201 patients included 59 OT patients (25 pre- and 34 post-OSMMAP) and 142 ON controls (34 pre- and 108 post-OSMMAP). The median age was 47.5 years (IQR 32), and 50% were male. 185 patients (92%) had a laparoscopic/ robotic resection and 16 (8%) open. There were statistically significant reductions in OME required post-OSMMAP on each postoperative day (days 1 to 4) and cumulative OME for both OT and ON patients. The reduction in opioid requirements was significantly larger in OT than ON patients. We present the first study highlighting a larger opioid usage reduction in OT than in ON patients after OSMMAP implementation.
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Affiliation(s)
- Adam Truong
- Cedars-Sinai Medical Center, Los Angeles, California
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Chough I, Zaghiyan K, Ovsepyan G, Fleshner P. It is Not Just Cosmesis: Straight Laparoscopy with Stoma Site Extraction Improves Outcomes in Ulcerative Colitis Patients Undergoing Total Colectomy. Am Surg 2020. [DOI: 10.1177/000313481908501026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Minimally invasive approaches to total abdominal colectomy (TAC) in ulcerative colitis (UC) patients include straight laparoscopy (SL), hand-assisted laparoscopic surgery (HALS), and robotics. In this study, short-term outcomes of patients undergoing SL and HALS TAC were compared. Prospectively collected data on UC patients undergoing TAC were tabulated. The study cohort included 36 (27%) patients in the SL group and 95 (73%) patients in the HALS group. The groups were comparable in terms of preoperative characteristics and demographics. The mean operative time was 151 (range, 73–225) minutes in the SL group versus 164 (range, 103–295) minutes in the HALS group ( P = 0.09). Total 48-hour IV morphine use was 30 (range, 0–186) mg in the SL group compared with 56 (0–275) mg in the HALS group ( P < 0.01). Although overall morbidity was comparable between the groups, Clavien-Dindo Class III complications did not occur in any of the SL group patients versus 11 (11%) of the HALS group patients ( P = 0.03). The postoperative length of stay was 3 (3–21) days in the SL group versus 5 (3–15) days in the HALS group ( P < 0.01). Compared with HALS, SL is associated with lower postoperative narcotic use and hospital length of stay in UC patients undergoing TAC.
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Affiliation(s)
- Ino Chough
- Division of Colorectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Karen Zaghiyan
- Division of Colorectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Gayane Ovsepyan
- Division of Colorectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Phillip Fleshner
- Division of Colorectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California
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Kim JY, Zaghiyan K, Lightner A, Fleshner P. Risk of postoperative complications among ulcerative colitis patients treated preoperatively with vedolizumab: a matched case-control study. BMC Surg 2020; 20:46. [PMID: 32138717 PMCID: PMC7059353 DOI: 10.1186/s12893-020-00698-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 02/14/2020] [Indexed: 12/11/2022] Open
Abstract
Background Although biologic agents have revolutionized the medical management of severe ulcerative colitis (UC), there is considerable controversy regarding adverse effects of vedolizumab on surgical outcomes. We evaluated 30-day postoperative morbidity in UC patients undergoing abdominal colectomy (AC) treated with vedolizumab before surgery. Methods From 2007 to 2017, 285 patients were enrolled in prospectively maintained database evaluating the role of clinical, serologic markers with clinical phenotypes in UC. The patients treated with vedolizumab within 12 weeks of AC was queried, then matched 1:3:3 into 3 preoperative treatment groups based on age, gender and surgical treatment of UC; ileal pouch-anal anastomosis (IPAA) with ileostomy vs total colectomy with end stoma: a) vedolizumab (n = 25); b) anti-tumor necrosis factor (anti-TNF) (n = 74); and c) no biologics (n = 54). Thirty-day postoperative complications among patient groups were compared. Results The 3 patient groups were well-matched in other characteristics including disease duration, disease extent, medication history and preoperative serological data. There were no significant differences in the overall incidence of postoperative complications among patients treated preoperatively with vedolizumab, anti-TNFs, or no biologics (44% vs. 45% vs. 37%; p = 0.67). Although there was no significant difference between patient cohorts in infectious complications (p = 0.20), postoperative ileus (POI) was significantly more common among the vedolizumab group (n = 9; 36%) compared to anti-TNF (n = 12; 16%) or no biologics (n = 5; 9%) (p = 0.01). Multivariable analysis showed that vedolizumab treatment prior to surgery was an independent risk factor for POI (OR: 5.16, 95% CI; 1.71–15.52; p = .004). Conclusion Although preoperative vedolizumab exposure did not influence the rate of overall 30-day postoperative complications, vedolizumab tends to increase incidence of POI.
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Affiliation(s)
- Jeong Yeon Kim
- Department of Surgery, Hallym University College of Medicine, Dongtan, South Korea
| | - Karen Zaghiyan
- Division of Colorectal Surgery, Cedars-Sinai Medical Center, 7 Beverly Blvd., Suite 101, Los Angeles, California, 90048, USA
| | - Amy Lightner
- Department of Colon and Rectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Phillip Fleshner
- Division of Colorectal Surgery, Cedars-Sinai Medical Center, 7 Beverly Blvd., Suite 101, Los Angeles, California, 90048, USA.
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Chough I, Zaghiyan K, Ovsepyan G, Fleshner P. It Is Not Just Cosmesis: Straight Laparoscopy with Stoma Site Extraction Improves Outcomes in Ulcerative Colitis Patients Undergoing Total Colectomy. Am Surg 2019; 85:1194-1197. [PMID: 31657323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Minimally invasive approaches to total abdominal colectomy (TAC) in ulcerative colitis (UC) patients include straight laparoscopy (SL), hand-assisted laparoscopic surgery (HALS), and robotics. In this study, short-term outcomes of patients undergoing SL and HALS TAC were compared. Prospectively collected data on UC patients undergoing TAC were tabulated. The study cohort included 36 (27%) patients in the SL group and 95 (73%) patients in the HALS group. The groups were comparable in terms of preoperative characteristics and demographics. The mean operative time was 151 (range, 73-225) minutes in the SL group versus 164 (range, 103-295) minutes in the HALS group (P = 0.09). Total 48-hour IV morphine use was 30 (range, 0-186) mg in the SL group compared with 56 (0-275) mg in the HALS group (P < 0.01). Although overall morbidity was comparable between the groups, Clavien-Dindo Class III complications did not occur in any of the SL group patients versus 11 (11%) of the HALS group patients (P = 0.03). The postoperative length of stay was 3 (3-21) days in the SL group versus 5 (3-15) days in the HALS group (P < 0.01). Compared with HALS, SL is associated with lower postoperative narcotic use and hospital length of stay in UC patients undergoing TAC.
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Truong A, Mujukian A, Fleshner P, Zaghiyan K. No Pain, More Gain: Reduced Postoperative Opioid Consumption with a Standardized Opioid-Sparing Multimodal Analgesia Protocol in Opioid-Tolerant Patients Undergoing Colorectal Surgery. Am Surg 2019; 85:1155-1158. [PMID: 31657314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
The utility of opioid-sparing multimodal analgesia protocols (OSMMAPs) in opioid-tolerant (OT) patients is unknown. We sought to determine the impact of a standardized OSMMAP in OT versus opioid-naïve (ON) patients after major colorectal surgery. Consecutive patients undergoing surgery before (January 2015-March 2017) and after OSMMAP implementation (April 2017-March 2018) were identified from a single-institution prospective colorectal surgery registry. OT was defined by the presence of an opioid on the preadmission medication record. Opioid use (measured in oral morphine equivalents (OMEs)) and surgical outcomes were compared between OT and ON patients pre- and post-OSMMAP. The study cohort of 201 patients included 59 OT patients (25 pre- and 34 post-OSMMAP) and 142 ON controls (34 pre- and 108 post-OSMMAP). The median age was 47.5 years (IQR 32), and 50% were male. 185 patients (92%) had a laparoscopic/robotic resection and 16 (8%) open. There were statistically significant reductions in OME required post-OSMMAP on each postoperative day (days 1 to 4) and cumulative OME for both OT and ON patients. The reduction in opioid requirements was significantly larger in OT than ON patients. We present the first study highlighting a larger opioid usage reduction in OT than in ON patients after OSMMAP implementation.
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Abstract
Medical treatment remains the mainstay of perianal disease management for CD; however, aggressive surgical management should be considered for severe or recurrent disease. In all cases of perianal CD, medical and surgical treatments should be used in tandem by a multidisciplinary team. Significant development has been made in the treatment of Crohn's-related fistulas, particularly minimally invasive options with recent clinical trials showing success with mesenchymal stem cell applications. Inevitably, some patients with severe refractory disease may require fecal diversion or proctectomy. When considering reversal of a diverting or end ileostomy, cessation of proctitis is the most important factor.
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Affiliation(s)
- Adam Truong
- Division of Colorectal Surgery, Cedars-Sinai Medical Center, 8737 Beverly Blvd., Suite 101, Los Angeles, CA 90048, USA
| | - Karen Zaghiyan
- Division of Colorectal Surgery, Cedars-Sinai Medical Center, 8737 Beverly Blvd., Suite 101, Los Angeles, CA 90048, USA
| | - Phillip Fleshner
- Division of Colorectal Surgery, Cedars-Sinai Medical Center, 8737 Beverly Blvd., Suite 101, Los Angeles, CA 90048, USA.
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Daskivich TJ, Houman J, Lopez M, Luu M, Fleshner P, Zaghiyan K, Cunneen S, Burch M, Walsh C, Paiement G, Kremen T, Soukiasian H, Spitzer A, Jackson T, Kim HL, Li A, Spiegel B. Association of Wearable Activity Monitors With Assessment of Daily Ambulation and Length of Stay Among Patients Undergoing Major Surgery. JAMA Netw Open 2019; 2:e187673. [PMID: 30707226 PMCID: PMC6484591 DOI: 10.1001/jamanetworkopen.2018.7673] [Citation(s) in RCA: 81] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
IMPORTANCE Early postoperative ambulation is vital to minimizing length of stay (LOS), but few hospitals objectively measure ambulation to predict outcomes. Wearable activity monitors have the potential to transform assessment of postoperative ambulation, but key implementation data, including whether digitally monitored step count can identify patients at risk for poor efficiency outcomes, are lacking. OBJECTIVES To define the distribution of digitally measured daily step counts after major inpatient surgical procedures, to assess the accuracy of physician assessment and ordering of ambulation, and to quantify the association of digitally measured step count with LOS. DESIGN, SETTING, AND PARTICIPANTS Prospective cohort study at Cedars-Sinai Medical Center, an urban tertiary referral center. Participants were patients undergoing 8 inpatient operations (lung lobectomy, gastric bypass, hip replacement, robotic cystectomy, open colectomy, abdominal hysterectomy, sleeve gastrectomy, and laparoscopic colectomy) from July 11, 2016, to August 30, 2017. INTERVENTIONS Use of activity monitors to measure daily postoperative step count. MAIN OUTCOMES AND MEASURES Operation-specific daily step count, daily step count by physician orders and assessment, and a prolonged LOS (>70th percentile for each operation). RESULTS Among 100 patients (53% female), the mean (SD) age was 53 (18) years, and the median LOS was 4 days (interquartile range, 3-6 days). There was a statistically significant increase in daily step count with successive postoperative days in aggregate (r = 0.55; 95% bootstrapped CI, 0.47-0.62; P < .001) and across individual operations. Ninety-five percent (356 of 373) of daily ambulation orders were "ambulate with assistance," although daily step counts ranged from 0 to 7698 steps (0-5.5 km) under this order. Physician estimation of ambulation was predictive of the median step count (r = 0.66; 95% bootstrapped CI, 0.59-0.72; P < .001), although there was substantial variation within each assessment category. For example, daily step counts ranged from 0 to 1803 steps (0-1.3 km) in the "out of bed to chair" category. Higher step count on postoperative day 1 was associated with lower odds of prolonged LOS from 0 to 1000 steps (odds ratio [OR], 0.63; 95% CI, 0.45-0.84; P = .003), with no further decrease in odds after 1000 steps (OR, 0.99; 95% CI, 0.75-1.30; P = .80). CONCLUSIONS AND RELEVANCE In this study, digitally measured step count up to 1000 steps on postoperative day 1 was associated with lower probability of a prolonged LOS. Wearable activity monitors improved the accuracy of assessment of daily step count over the current standard of care, providing an opportunity to identify patients at risk for poor efficiency outcomes.
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Affiliation(s)
- Timothy J. Daskivich
- Division of Urology, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Cedars-Sinai Medical Center, Los Angeles, California
| | - Justin Houman
- Division of Urology, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Mayra Lopez
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Cedars-Sinai Medical Center, Los Angeles, California
| | - Michael Luu
- Division of Urology, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Philip Fleshner
- Division of Colorectal Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Karen Zaghiyan
- Division of Colorectal Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Scott Cunneen
- Division of Minimally Invasive Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Miguel Burch
- Division of Minimally Invasive Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Christine Walsh
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Guy Paiement
- Department of Orthopedic Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Thomas Kremen
- Department of Orthopedic Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Harmik Soukiasian
- Division of Thoracic Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Andrew Spitzer
- Department of Orthopedic Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Titus Jackson
- Department of Orthopedic Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Hyung L. Kim
- Division of Urology, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Andrew Li
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Brennan Spiegel
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Cedars-Sinai Medical Center, Los Angeles, California
- Division of Health Services Research, Department of Medicine, Cedars-Sinai Health System, Los Angeles, California
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles
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Rabbany J, Kim T, Koh S, Zaghiyan K, Fleshner P. Cosmesis in Patients after Multiport Laparoscopic Colorectal Surgery: Does the Extraction Incision Matter? Am Surg 2019; 85:162-166. [PMID: 30819292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
The ideal incision for specimen extraction during laparoscopic colorectal surgery is controversial. The objective of this study was to compare incision types (Pfannenstiel, periumbilical, lower midline, and right upper quadrant transverse) with regard to postoperative scar appearance, symptoms, preference, and satisfaction. This study is a retrospective survey review performed in an urban teaching hospital. The study participants were patients undergoing multiport laparoscopic colorectal surgery. Two web-based questionnaires, the Patient Scar Assessment Questionnaire and Photo-Series Questionnaire, were used to assess study parameters. The main outcome measures were incision symptoms and cosmetic satisfaction. The 112 study patients included 54 patients with a Pfannenstiel incision (Group P) and 58 patients with an alternate incision (Group A). Of the 58 patients in Group A, 19 (33%) had a periumbilical incision, 10 (17%) a lower midline incision, and 29 (50%) a right upper quadrant transverse incision. Although Groups P and A were comparable in all five subscales of the Patient Scar Assessment Questionnaire, more Group P participants (n = 12; 22%) said their incision felt "fairly numb" than Group A participants (n = 2; 3%) (P = 0.008). There was no significant difference between study groups in all Photo-Series Questionnaire domains; however, after comparing patients' own incisions with photographs of various alternative incisions, 36 (62%) Group A patients would choose an alternative incision compared with only 11 (19%) Group P patients (P = 0.001). Selection bias, recall bias, external validity, and variability of scar lengths were the limitations of the study. It was concluded that although a Pfannenstiel incision seems to be the optimal cosmetic choice, it is associated with a higher incidence of wound numbness than alternate extraction incisions.
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Rabbany J, Kim T, Koh S, Zaghiyan K, Fleshner P. Cosmesis in Patients after Multiport Laparoscopic Colorectal Surgery: Does the Extraction Incision Matter? Am Surg 2019. [DOI: 10.1177/000313481908500222] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The ideal incision for specimen extraction during laparoscopic colorectal surgery is controversial. The objective of this study was to compare incision types (Pfannenstiel, periumbilical, lower midline, and right upper quadrant transverse) with regard to postoperative scar appearance, symptoms, preference, and satisfaction. This study is a retrospective survey review performed in an urban teaching hospital. The study participants were patients undergoing multiport laparoscopic colorectal surgery. Two web-based questionnaires, the Patient Scar Assessment Questionnaire and Photo-Series Questionnaire, were used to assess study parameters. The main outcome measures were incision symptoms and cosmetic satisfaction. The 112 study patients included 54 patients with a Pfannenstiel incision (Group P) and 58 patients with an alternate incision (Group A). Of the 58 patients in Group A, 19 (33%) had a periumbilical incision, 10 (17%) a lower midline incision, and 29 (50%) a right upper quadrant transverse incision. Although Groups P and Awere comparable in all five subscales of the Patient Scar Assessment Questionnaire, more Group P participants (n = 12; 22%) said their incision felt “fairly numb” than Group A participants (n = 2; 3%) (P = 0.008). There was no significant difference between study groups in all Photo-Series Questionnaire domains; however, after comparing patients’ own incisions with photographs of various alternative incisions, 36 (62%) Group A patients would choose an alternative incision compared with only 11 (19%) Group P patients (P = 0.001). Selection bias, recall bias, external validity, and variability of scar lengths were the limitations of the study. It was concluded that although a Pfannenstiel incision seems to be the optimal cosmetic choice, it is associated with a higher incidence of wound numbness than alternate extraction incisions.
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Affiliation(s)
- Jessica Rabbany
- From the Division of Colon and Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Teresa Kim
- From the Division of Colon and Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Sharon Koh
- From the Division of Colon and Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Karen Zaghiyan
- From the Division of Colon and Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Phillip Fleshner
- From the Division of Colon and Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California
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Parrish AB, Zaghiyan K, Fleshner P. Laparoscopic colectomy in inflammatory bowel disease: indications and special considerations. Ann Laparosc Endosc Surg 2019. [DOI: 10.21037/ales.2019.01.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Zaghiyan K, Warusavitarne J, Spinelli A, Chandrasinghe P, Di Candido F, Fleshner P. Technical variations and feasibility of transanal ileal pouch-anal anastomosis for ulcerative colitis and inflammatory bowel disease unclassified across continents. Tech Coloproctol 2018; 22:867-873. [DOI: 10.1007/s10151-018-1889-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 11/19/2018] [Indexed: 02/06/2023]
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Truong A, Lopez N, Fleshner P, Zaghiyan K. Preservation of Pathologic Outcomes in Robotic versus Open Resection for Rectal Cancer: Can the Robot Fill the Minimally Invasive Gap? Am Surg 2018. [DOI: 10.1177/000313481808401231] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Open resection remains the standard of care in the surgical management of rectal cancer with recent studies unable to prove noninferiority of laparoscopic resection. Few studies directly compare robotic versus open techniques. This is a retrospective chart review of all consecutive patients undergoing robotic or open rectal cancer resection during a three-year period. The primary endpoint was a composite of complete mesorectal excision, circumferential resection margin <1 mm, and distal resection margin <1 mm. The study cohort included 64 patients undergoing robotic (n = 28) or open (n = 36) resection. Successful surgical resection was similar between the robotic (75%) and open (76%) approaches. Robotic resection was associated with significantly lower blood loss ( P = 0.02) and significantly longer operative times ( P = 0.009) compared with open resection. Length of hospital stay and complications were similar between groups. Both male gender ( P = 0.03) and shorter tumor distance from the anal verge ( P = 0.01) were predictors for unsuccessful surgical resection in open, but not robotic, surgery. Pathologic outcomes are similar between robotic and open rectal cancer resection, even early in the learning curve. Tumor distance from the anal verge complicates open total mesorectal excision; however, robotic surgery is less impacted. Robotic resection may be a promising minimally invasive approach for rectal cancer resection.
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Affiliation(s)
- Adam Truong
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Nicole Lopez
- Division of Colon and Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Phillip Fleshner
- Division of Colon and Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Karen Zaghiyan
- Division of Colon and Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California
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Truong A, Lopez N, Fleshner P, Zaghiyan K. Preservation of Pathologic Outcomes in Robotic versus Open Resection for Rectal Cancer: Can the Robot Fill the Minimally Invasive Gap? Am Surg 2018; 84:1876-1881. [PMID: 30606342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Open resection remains the standard of care in the surgical management of rectal cancer with recent studies unable to prove noninferiority of laparoscopic resection. Few studies directly compare robotic versus open techniques. This is a retrospective chart review of all consecutive patients undergoing robotic or open rectal cancer resection during a three-year period. The primary endpoint was a composite of complete mesorectal excision, circumferential resection margin <1 mm, and distal resection margin <1 mm. The study cohort included 64 patients undergoing robotic (n = 28) or open (n = 36) resection. Successful surgical resection was similar between the robotic (75%) and open (76%) approaches. Robotic resection was associated with significantly lower blood loss (P = 0.02) and significantly longer operative times (P = 0.009) compared with open resection. Length of hospital stay and complications were similar between groups. Both male gender (P = 0.03) and shorter tumor distance from the anal verge (P = 0.01) were predictors for unsuccessful surgical resection in open, but not robotic, surgery. Pathologic outcomes are similar between robotic and open rectal cancer resection, even early in the learning curve. Tumor distance from the anal verge complicates open total mesorectal excision; however, robotic surgery is less impacted. Robotic resection may be a promising minimally invasive approach for rectal cancer resection.
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Chough I, Zaghiyan K, Ovsepyan G, Fleshner P. Practice Changes in Postoperative Feeding after Elective Colorectal Surgery: From Prospective Randomized Study to Everyday Practice. Am Surg 2018; 84:1675-1678. [PMID: 30747693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Early postoperative feeding is the standard of care after colorectal surgery and is associated with improved outcomes. A controlled study performed at our center demonstrated faster bowel function recovery and shorter hospital stay without an increase in postoperative morbidity for a solid versus clear-liquid diet on postoperative day (POD) 1 after colorectal surgery. The present study aims to evaluate the impact of these findings on the practice of diet advancement by board-certified general surgeons (GS) and colorectal surgeons (CRS) at an urban teaching hospital. Patients undergoing elective colorectal surgery were prospectively evaluated. Data were compared with that of a study cohort that underwent elective colorectal surgery reported in 2012. Early postoperative feeding in the more recent cohort statistically increased for all cases on POD 0 and POD 1. Diet advancement over time revealed significant changes in early feeding on POD 0 for patients operated on by CRS (0% vs 83%; P < 0.0001) but not GS (13% vs 13%; P = 1). Patients operated on by either CRS or GS and offered early feeding on POD 1 did not significantly differ between time periods. Despite well-documented evidence of the advantages of early feeding, GS, but not CRS, remain reluctant to administer early diets to patients after colorectal surgery.
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Affiliation(s)
- Ino Chough
- Division of Colorectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
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Chough I, Zaghiyan K, Ovsepyan G, Fleshner P. Practice Changes in Postoperative Feeding after Elective Colorectal Surgery: From Prospective Randomized Study to Everyday Practice. Am Surg 2018. [DOI: 10.1177/000313481808401028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Early postoperative feeding is the standard of care after colorectal surgery and is associated with improved outcomes. A controlled study performed at our center demonstrated faster bowel function recovery and shorter hospital stay without an increase in postoperative morbidity for a solid versus clear-liquid diet on postoperative day (POD) 1 after colorectal surgery. The present study aims to evaluate the impact of these findings on the practice of diet advancement by board-certified general surgeons (GS) and colorectal surgeons (CRS) at an urban teaching hospital. Patients undergoing elective colorectal surgery were prospectively evaluated. Data were compared with that of a study cohort that underwent elective colorectal surgery reported in 2012. Early postoperative feeding in the more recent cohort statistically increased for all cases on POD 0 and POD 1. Diet advancement over time revealed significant changes in early feeding on POD 0 for patients operated on by CRS (0% vs 83%; P < 0.0001) but not GS (13% vs 13%; P = 1). Patients operated on by either CRS or GS and offered early feeding on POD 1 did not significantly differ between time periods. Despite well-documented evidence of the advantages of early feeding, GS, but not CRS, remain reluctant to administer early diets to patients after colorectal surgery.
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Affiliation(s)
- Ino Chough
- Division of Colorectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Karen Zaghiyan
- Division of Colorectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Gayane Ovsepyan
- Division of Colorectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Phillip Fleshner
- Division of Colorectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California
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Rezaie A, Fleshner P, Pimentel M, Zaghiyan K. Response to 'Ultrasound anal sphincter defects and 3D anal pressure defects'. Colorectal Dis 2017; 19:1031-1032. [PMID: 28980428 DOI: 10.1111/codi.13908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 08/14/2017] [Indexed: 02/08/2023]
Affiliation(s)
- A Rezaie
- Division of Gastroenterology, Cedars Sinai Medical Center, Los Angeles, California, USA
| | - P Fleshner
- Division of Colorectal Surgery, Cedars Sinai Medical Center, Los Angeles, California, USA
| | - M Pimentel
- Division of Gastroenterology, Cedars Sinai Medical Center, Los Angeles, California, USA
| | - K Zaghiyan
- Division of Colorectal Surgery, Cedars Sinai Medical Center, Los Angeles, California, USA
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Pandrangi V, Mandel D, Gellada N, Mieses D, Kallman C, Zaghiyan K, Fleshner P. Abdominal Visceral Fat Area and Chronic Pouchitis after Ileal Pouch-Anal Anastomosis. Am Surg 2017; 83:1029-1032. [PMID: 29391089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Chronic pouchitis (CP) after ileal pouch-anal anastomosis is a significant clinical problem. Adipose tissues produce antiinflammatory cytokines and chemokines. We evaluated the association between abdominal visceral fat area (VFA) and CP. Patients with a preoperative CT evaluation were included. The diagnosis of CP was confirmed in all cases by endoscopy with afferent ileal limb intubation. Patients were allocated into groups of high VFA and low VFA. The study cohort of 52 patients had a median body mass index of 22 (range, 14-32). Indications for surgery were medically refractory disease in 46 (88%) patients and cancer/dysplasia in six (12%) patients. Median VFA was 27.1 (range, 1-144). Six (12%) patients developed CP. Low VFA patients were significantly younger (29 vs 45 years; P < 0.0001), had lower body mass index (20.4 vs 24.7; P < 0.0001), had surgery more commonly for medically refractory disease than for cancer or dysplasia (100 vs 77%; P = 0.02), and had a higher incidence of CP than high VFA patients (23 vs 0%; P = 0.02). Multiple linear regression analysis demonstrated that only low VFA was associated with CP (P = 0.009). An association is present between VFA and CP after ileal pouch-anal anastomosis, implicating adipocytes in the pathogenesis of inflammatory bowel disease.
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Affiliation(s)
- Vivek Pandrangi
- Divisions of Colon and Rectal Surgery and Diagnostic Radiology, Cedars-Sinai Medical Center, Los Angeles, California, USA
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Pandrangi V, Mandel D, Gellada N, Kallman C, Zaghiyan K, Fleshner P. Abdominal Visceral Fat Area and Chronic Pouchitis after Ileal Pouch-Anal Anastomosis. Am Surg 2017. [DOI: 10.1177/000313481708301003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Chronic pouchitis (CP) after ileal pouch-anal anastomosis is a significant clinical problem. Adipose tissues produce antiinflammatory cytokines and chemokines. We evaluated the association between abdominal visceral fat area (VFA) and CP. Patients with a preoperative CT evaluation were included. The diagnosis of CP was confirmed in all cases by endoscopy with afferent ileal limb intubation. Patients were allocated into groups of high VFA and low VFA. The study cohort of 52 patients had a median body mass index of 22 (range, 14–32). Indications for surgery were medically refractory disease in 46 (88%) patients and cancer/dysplasia in six (12%) patients. Median VFA was 27.1 (range, 1–144). Six (12%) patients developed CP. Low VFA patients were significantly younger (29 vs 45 years; P < 0.0001), had lower body mass index (20.4 vs 24.7; P < 0.0001), had surgery more commonly for medically refractory disease than for cancer or dysplasia (100 vs 77%; P = 0.02), and had a higher incidence of CP than high VFA patients (23 vs 0%; P = 0.02). Multiple linear regression analysis demonstrated that only low VFA was associated with CP (P = 0.009). An association is present between VFA and CP after ileal pouch-anal anastomosis, implicating adipocytes in the pathogenesis of inflammatory bowel disease.
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Affiliation(s)
- Vivek Pandrangi
- Divisions of Colon and Rectal Surgery and Diagnostic Radiology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Daniel Mandel
- Divisions of Colon and Rectal Surgery and Diagnostic Radiology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Norman Gellada
- Divisions of Colon and Rectal Surgery and Diagnostic Radiology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Cindy Kallman
- Divisions of Colon and Rectal Surgery and Diagnostic Radiology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Karen Zaghiyan
- Divisions of Colon and Rectal Surgery and Diagnostic Radiology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Phillip Fleshner
- Divisions of Colon and Rectal Surgery and Diagnostic Radiology, Cedars-Sinai Medical Center, Los Angeles, California
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Kamiński JP, Zaghiyan K, Fleshner P. Increasing experience of ligation of the intersphincteric fistula tract for patients with Crohn's disease: what have we learned? Colorectal Dis 2017; 19:750-755. [PMID: 28371062 DOI: 10.1111/codi.13668] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 12/20/2016] [Indexed: 12/13/2022]
Abstract
AIM Ligation of the intersphincteric fistula tract (LIFT) has been proposed as a treatment of trans-sphincteric fistula in perianal Crohn's disease (CD). The aim of this study was to look at our experience of the LIFT procedure in CD patients on long-term follow-up. Specifically, we aimed to determine the fistula healing rate after the LIFT procedure after more than 12 months follow-up and to identify any prognostic factors. METHOD Retrospective study of patients with trans-sphincteric Crohn's fistula tracts treated with the LIFT procedure between January 2011 and October 2015. Complete fistula healing as well as clinical outcomes were analysed. RESULTS Data were available for 23 patients. After a median follow-up of 23 months, LIFT site healing was 48%. Patients with healed LIFT had a median follow-up time of 10.5 months, while patients with failed LIFT had a median follow-up time of 31 months (P = 0.04). Median time to failure was 9 months for patients with follow-up > 1 year. Most patients failed within 1 year (9/12; 75%) of the procedure. In multi-site CD, the LIFT procedure was more likely to be successful in those with small bowel disease (P = 0.04) compared with colonic disease (P = 0.02). Other factors such as preoperative use of biological therapies, presence of a seton, previous repair attempts, fistula position, type or number of fistulas, multiple fistula tracts, smoking status and other associated perianal disease did not appear to influence LIFT healing rates. CONCLUSION The LIFT procedure offers reasonable long-term success in the treatment of perianal trans-sphincteric fistulas associated with CD. LIFT is more likely to fail in patients with concurrent colonic CD than in patients with small bowel CD.
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Affiliation(s)
- J P Kamiński
- Division of Colon and Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - K Zaghiyan
- Division of Colon and Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - P Fleshner
- Division of Colon and Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
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Rezaie A, Iriana S, Pimentel M, Murrell Z, Fleshner P, Zaghiyan K. Can three-dimensional high-resolution anorectal manometry detect anal sphincter defects in patients with faecal incontinence? Colorectal Dis 2017; 19:468-475. [PMID: 27657739 DOI: 10.1111/codi.13530] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Accepted: 07/25/2016] [Indexed: 12/21/2022]
Abstract
AIM Endoanal ultrasound (EAUS) is the gold standard for detecting anal sphincter defects in patients with faecal incontinence (FI), while anorectal manometry evaluates sphincter function. Three-dimensional high-resolution anorectal manometry (3D HRAM) is a newer modality with the potential to assess both sphincter function and anatomy. The purpose of the present study was to compare 3D HRAM with 3D EAUS for the detection of anal sphincter defects in patients with FI. METHOD A linkage analysis was performed between the 3D HRAM and 3D EAUS databases of a tertiary referral centre to identify patients with FI who underwent both 3D EAUS and 3D HRAM. With 3D HRAM, a defect was defined as any pressure measurement below 25 mmHg at rest with at least 18° of continuous expansion. The 3D HRAM findings were compared with those of 3D EAUS. RESULTS The study cohort included 39 patients with a mean age of 64.7 ± 15.2 years (SD); and 31 (79%) were female. Eight (21%) patients had an anal sphincter defect on EAUS with a median size of 93° (range 40°-136°). Fourteen (36%) had a defect shown by 3D HRAM with a median size of 144° (36°-180°). The sensitivity, specificity and positive and negative predictive values of 3D HRAM in detecting a sphincter defect were 75%, 74%, 43% and 92%, respectively. CONCLUSION With a negative predictive value of 92%, 3D HRAM may be a useful screening method for ruling out a sphincter defect in patients with FI, thereby avoiding both EAUS and manometry in selected patients.
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Affiliation(s)
- A Rezaie
- Division of Gastroenterology, Cedars Sinai Medical Center, Los Angeles, California, USA
| | - S Iriana
- Department of Internal Medicine, Cedars Sinai Medical Center, Los Angeles, California, USA
| | - M Pimentel
- Division of Gastroenterology, Cedars Sinai Medical Center, Los Angeles, California, USA
| | - Z Murrell
- Division of Colorectal Surgery, Cedars Sinai Medical Center, Los Angeles, California, USA
| | - P Fleshner
- Division of Colorectal Surgery, Cedars Sinai Medical Center, Los Angeles, California, USA
| | - K Zaghiyan
- Division of Colorectal Surgery, Cedars Sinai Medical Center, Los Angeles, California, USA
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Mahmoud NN, Halwani Y, Montbrun SD, Shah PM, Hedrick TL, Rashid F, Schwartz DA, Dalal RL, Kamiński JP, Zaghiyan K, Fleshner PR, Weissler JM, Fischer JP. Current management of perianal Crohn’s disease. Curr Probl Surg 2017; 54:262-298. [DOI: 10.1067/j.cpsurg.2017.02.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Accepted: 02/04/2017] [Indexed: 12/11/2022]
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