The empty pelvis syndrome: a core data set from the PelvEx collaborative

BACKGROUND

Empty pelvis syndrome (EPS) is a significant source of morbidity following pelvic exenteration (PE), but is undefined. EPS outcome reporting and descriptors of radicality of PE are inconsistent; therefore, the best approaches for prevention are unknown. To facilitate future research into EPS, the aim of this study is to define a measurable core outcome set, core descriptor set and written definition for EPS. Consensus on strategies to mitigate EPS was also explored.

METHOD

Three-stage consensus methodology was used: longlisting with systematic review, healthcare professional event, patient engagement, and Delphi-piloting; shortlisting with two rounds of modified Delphi; and a confirmatory stage using a modified nominal group technique. This included a selection of measurement instruments, and iterative generation of a written EPS definition.

RESULTS

One hundred and three and 119 participants took part in the modified Delphi and consensus meetings, respectively. This encompassed international patient and healthcare professional representation with multidisciplinary input. Seventy statements were longlisted, seven core outcomes (bowel obstruction, enteroperineal fistula, chronic perineal sinus, infected pelvic collection, bowel obstruction, morbidity from reconstruction, re-intervention, and quality of life), and four core descriptors (magnitude of surgery, radiotherapy-induced damage, methods of reconstruction, and changes in volume of pelvic dead space) reached consensus-where applicable, measurement of these outcomes and descriptors was defined. A written definition for EPS was agreed.

CONCLUSIONS

EPS is an area of unmet research and clinical need. This study provides an agreed definition and core data set for EPS to facilitate further research.

Minimum standards of pelvic exenterative practice: PelvEx Collaborative guideline

This document outlines the important aspects of caring for patients who have been diagnosed with advanced pelvic cancer. It is primarily aimed at those who are establishing a service that adequately caters to this patient group. The relevant literature has been summarized and an attempt made to simplify the approach to management of these complex cases.

Simultaneous pelvic exenteration and liver resection for primary rectal cancer with synchronous liver metastases: results from the PelvEx Collaborative

AIM

At presentation, 15-20% of patients with rectal cancer already have synchronous liver metastases. The aim of this study was to determine the surgical and survival outcomes in patients with advanced rectal cancer who underwent combined pelvic exenteration and liver (oligometastatic) resection.

METHOD

Data from 20 international institutions that performed simultaneous pelvic exenteration and liver resection between 2007 and 2017 were accumulated. Primarily, we examined perioperative outcomes, morbidity and mortality. We also assessed the impact that margin status had on survival.

RESULTS

Of 128 patients, 72 (56.2%) were men with a median age of 60 years [interquartile range (IQR) 15 years]. The median size of the liver oligometastatic deposits was 2 cm (IQR 1.8 cm). The median duration of surgery was 406 min (IQR 240 min), with a median blood loss of 1090 ml (IQR 2010 ml). A negative resection margin (R0 resection) was achieved in 73.5% of pelvic exenterations and 66.4% of liver resections. The 30-day mortality rate was 1.6%, and 32% of patients had a major postoperative complication. The 5-year overall survival for patients in whom an R0 resection of both primary and metastatic disease was achieved was 54.6% compared with 20% for those with an R1/R2 resection (P = 0.006).

CONCLUSION

Simultaneous pelvic exenteration and liver resection is feasible, with acceptable morbidity and mortality. Simultaneous resection should only be performed where an R0 resection of both pelvic and hepatic disease is anticipated.

Small bowel adenocarcinoma in Crohn's disease: a rare but devastating complication

BACKGROUND

Small bowel adenocarcinoma (SBA) remains a rare entity but occurs at increased frequency in the setting of chronic Crohn's disease (CD). Our aim was to study the presentation, diagnosis and prognosis of SBA in patients undergoing surgery for CD at a single institution.

METHODS

We reviewed the medical records of all patients with CD complicated by adenocarcinoma of the small bowel from 2000 to 2017. Descriptive statistics and Kaplan-Meier overall survival estimates were calculated.

RESULTS

In total, 22 patients (14 males) with CD (median duration of Crohn's diagnosis 32 years) were diagnosed with SBA and underwent surgical resection (8 isolated small bowel resections, 12 ileocolic resections, and 2 total proctocolectomies). The median patient age at the time of diagnosis was 54 years (range 22-82 years). A total of 17 patients (77%) underwent cross-sectional CT imaging within 3 months of surgery, a cancer diagnosis was suggested in only one patient. In one other patient, SBA was diagnosed preoperatively on endoscopic biopsy of the terminal ileum. The remaining patients were operated on for obstruction (n = 17), abscess or fistulizing disease (n = 2), and sigmoid cancer (n = 1). For these 20 (90%) patients not suspected to have SBA on preoperative assessment, 5 (25%) were diagnosed intraoperatively on frozen section and 15 (75%) were unexpectedly diagnosed postoperatively on final pathology. T staging was characterized by more advanced tumors (T4: 59%, T3: 27%, T2: 9%, and T1: 5%). Nine patients (41%) had nodal involvement and five patients (23%) had hepatic and/or peritoneal carcinomatosis. The 1-, 3-, and 5-year survival estimates for our cohort were 84%, 30%, and 10%, respectively. Median survival was 30.5 months with median follow-up of 23 months (range 6-84 months).

CONCLUSIONS

SBA in the setting of CD is most commonly found incidentally after surgical resection for benign indications. As such, any suspicious finding at the time of surgery in a patient with chronic CD should warrant careful investigation with frozen section and/or resection. Prognosis for CD complicated by SBA remains poor even in the modern era.

Case-matched Comparison of Postoperative Outcomes Following Surgery for Inflammatory Bowel Disease After Exposure to Vedolizumab vs Other Biologics

BACKGROUND AND AIM

The effects of vedolizumab [VEDO] exposure on perioperative outcomes following surgery for inflammatory bowel disease [IBD] remain controversial. The aim of our study was to compare postoperative morbidity of IBD surgery following treatment with VEDO vs other biologics or no biologics.

METHODS

An institutional review board-approved, prospectively collected database was queried to identify all patients undergoing abdominal surgery for IBD between August 2012 and May 2017. The impact of VEDO within 12 weeks preoperatively on postoperative morbidity was initially assessed with univariate and multivariable analyses on all patients. A case-matched analysis was then carried out comparing patients exposed to VEDO vs other biologic agents, based on gender, age ± 5 years, diagnosis, date of surgery ± 2 years, and surgical procedure.

RESULTS

Out of 980 patients, 141 received VEDO. The majority of patients [59%] underwent surgery involving end or diverting ostomy creation. The initial multivariate analysis conducted on all patients indicated that VEDO use was independently associated with increased overall morbidity [p <0.001], but not infectious morbidity [p = 0.30]. However, the case-matched comparison of 95 VEDO-treated patients vs 95 patients treated with adalimumab or infliximab did not indicate any difference in overall morbidity [p = 0.32], infectious complications [p = 0.15], or surgical site infections [p = 0.12].

CONCLUSIONS

In a study population having a high rate of surgery involving ostomy creation, the exposure to preoperative VEDO was not associated with an increased morbidity rate when compared with other biologics.

A high number of 'natural' mitochondrial DNA polymorphisms in a symptomatic Brugada syndrome type 1 patient

Brugada syndrome (BrS) is a rare genetic arrhythmic disorder with a complex model of transmission. At least 20 different genes have been identified as BrS-causal or susceptibility genes. Of these, SCN5A is the most frequently mutated. Coregulation of different mutations or genetic variants, including mitochondrial DNA (mtDNA), may contribute to the clinical phenotype of the disease. In thepresent study, we analysed the mitochondrial genome of a symptomatic BrS type 1 patient to investigate a possible mitochondrial involvement recently found in the arrhytmogenic diseases. No pathogenic mutation was identified; however, a high number of singlenucleotide polymorphisms were found (n=21) and some of them were already been reported in molecular autopsy case for sudden death.The results reported here further support our hypothesis on the potential role of mtDNA polymorphisms in mitochondrial dysfunction, which may represent a risk factor for arrhythmogenic disease.

Difference in the frequency of pouchitis between ulcerative colitis and familial adenomatous polyposis: is the explanation in peripouch fat?

AIM

Patients with ulcerative colitis (UC) have an unexplained higher incidence of pouchitis and a greater amount of peripouch fat compared with patients with familial adenomatous polyposis (FAP). The aims of this study were to compare the peripouch fat areas between patients with UC and patients with FAP, and to explore relationship between peripouch fat and pouchitis or chronic antibiotic-refractory pouchitis (CARP).

METHOD

Patients with an abdominal CT image from our prospectively maintained Pouch Database were included. Abdominal fat and peripouch fat were measured on CT images at different levels or planes. Comparisons of peripouch fat and CARP were performed before and after propensity score matching.

RESULTS

A total of 277 patients with UC and 40 patients with FAP were included. Compared with patients with FAP, patients with UC were found to have a higher incidence of pouchitis (58.5% vs 15.0%, P < 0.001) and CARP (24.5% vs 2.5%, P = 0.002) and a higher total peripouch fat area (P = 0.030) and mesenteric peripouch fat area (P = 0.022) at Level-3. Univariate and multivariate analyses showed that diagnosis (UC vs FAP) and peripouch fat areas at Level-3 and Level-5 were independent risk factors for CARP. With propensity score matching, 38 pairs of patients with UC and FAP were matched successfully. After matching, patients with UC were found to have higher total peripouch fat area and higher mesenteric peripouch fat area at Level-3, and a higher incidence of pouchitis (57.9% vs 13.2%, P < 0.001) and CARP (23.7% vs 2.6%, P = 0.007).

CONCLUSION

Our study demonstrates that patients with UC have more peripouch fat than those with FAP, which may explain the difference in the frequency of pouchitis and CARP between these groups of patients.

The relationship between mesorectal grading and oncological outcome in rectal adenocarcinoma

AIM

The prognostic association between mesorectal grading and oncological outcome in patients undergoing resection for rectal adenocarcinoma is controversial. The aim of this retrospective chart review was to determine the individual impact of mesorectal grading on rectal cancer outcomes.

METHOD

We compared oncological outcomes in patients with complete, near-complete and incomplete mesorectum who underwent rectal excision with curative intent from 2009 to 2014 for Stage cI-III rectal adenocarcinoma. We also assessed the independent association of mesorectal grading and oncological outcome using multivariate models including other relevant variables.

RESULTS

Out of 505 patients (339 men, median age of 60 years), 347 (69%) underwent a restorative procedure. There were 452 (89.5%), 33 (6.5%) and 20 (4%) patients with a complete, near-complete and incomplete mesorectum, respectively. Local recurrence was seen in 2.4% (n = 12) patients after a mean follow-up of 3.1 ± 1.7 years. Unadjusted 3-year Kaplan-Meier analysis by mesorectal grade showed decreased rates of overall, disease-free and cancer-specific survival and increased rates of overall and distant recurrence with a near-complete mesorectum, while local recurrence was increased in cases of an incomplete mesorectum (all P < 0.05). On multivariate analyses, a near-complete mesorectum was independently associated with decreased cancer-specific survival (hazard ratio 0.26, 95% CI 0.1-0.7; P = 0.007). There were no associations between mesorectal grading and overall survival, disease-free survival, overall recurrence or distant recurrence (all P > 0.05).

CONCLUSION

Mesorectal grading is independently associated with oncological outcome. It provides unique information for optimizing surgical quality in rectal cancer.

Ileal pouch revision vs excision: short-term (30-day) outcomes from the National Surgical Quality Improvement Program

AIM

Ileal pouch-anal anastomosis (IPAA) failure occurs in approximately 5%-10% of patients. We aimed to compare short-term (30-day) postoperative outcomes associated with pouch revision and pouch excision using a large international database. Our null hypothesis was that there is no statistically significant difference in overall postoperative complications between patients selected for pouch revision vs pouch excision.

METHODS

Using the American College of Surgeons National Surgical Quality Improvement Program Participant User File from 2005 to 2016 we identified patients who underwent either IPAA revision via the combined abdominoperineal approach [Current Procedural Terminology (CPT) 46712] or IPAA excision (CPT 45136). Differences in baseline characteristics and short-term outcomes between groups were assessed with univariate and matched analyses.

RESULTS

We identified 593 reoperative IPAA procedures: revision group 78 (13%) and excision group 515 (86%). The groups had similar age and body mass index (kg/m² ), but the revision group had more women (65.4% vs 51.8%, P = 0.02) and fewer were on chronic steroids (3.9% vs 17.9%, P = 0.0008) relative to the excision group. Revision IPAA patients were more likely to have received a preoperative transfusion (5.1% vs 0.97%, P = 0.02). Revision and excision were associated with similar postoperative length of stay (9.3 vs 8.6 days, 0.44), mortality (nil vs 0.58%, respectively; P = 0.99) and short-term morbidity (34.6% vs 40.2%, respectively; P = 0.88) at 30 days.

CONCLUSIONS

Pouch revision and excision have comparable short-term postoperative outcomes, but pouch excision appears to be more commonly utilized. Increased awareness of the indications for pouch revision or referral to specialized centres may improve pouch revision rates.

Abstract P3-11-05: Everolimus-exemestane (EE) vs palbociclib-fulvestrant (PF) or abemaciclib-fulvestrant (AF) or everolimus-fulvestrant (EF) in the treatment of metastatic HR+, HER2- metastatic breast cancer and prior aromatase inhibitors treatment. An indirect comparison with network meta-analysis

Background. Treatment options for patients with hormone receptor positive metastatic breast cancer (MBC) and prior treatment with aromatase inhibitors (AIs) include EE or PF. To date no direct comparison has been presented between EE and Fulvestrant plus Cyclin-dependent Kinase 4/6 (CDK4/6) inhibitors in this setting. The objective of this study was to compare the efficacy of EE to PF or AF or EF in the treatment of metastatic HR+, HER2- breast cancer pre-treated with AIs.

Methods. An indirect comparison with a network meta-analysis comparing EE with PF or AF or EF in the treatment of metastatic HR+, HER2- breast cancer pre-treated with AIs was performed. The Progression-Free-Survival (PFS) was the primary end point of all our indirect comparisons. Efficacy data were expressed as Hazard Ratio (HR) and 95% Confidence Interval (95CI), assuming an α-error of 5% as index of statistical significance.

Results. All the data of the BOLERO-2 trial, the Bachelot et al network meta-analysis (Breast Cancer Treat Rep 2014), the Paloma-3, the Monarch-2, and the prECOG trials were analyzed and indirectly compared in a network meta-analysis. 6 orders of comparison were performed: AF vs PL, PF vs EE, AF vs EE, EF vs AF, EF vs PF and EF vs EE. The pooled HR and 95%CI are reported in table1.

Table 1: difference in PFS between comparatorsComparisonsHR (95% CI)AF vs PF1.202 (0.87-1.661) p = 0.265PF vs EE1.674 (0.995-2.818) p = 0.89AF vs EE2.012 (1.09-3.714) p = 0.025EF vs AF1.085 (0.681-1.728) p = 0.731EF vs PF1.304 (0.804-2.117) p = 0.283EF vs EE2.183 (1.072-4.444) p = 0.031Everolimus-exemestane (EE), palbociclib-fulvestrant (PF), abemaciclib-fulvestrant (AF), everolimus-fulvestrant (EF).

Conclusions. Till today EE and PF represent active and approved treatments for patients with metastatic HR+, HER2- breast cancer treated with AIs. The results of Monarch-2 study with AF vs Fulvestrant and prECOG study with FE vs Fulvestrant were recently presented and were included in this metaanalysis, while the results of Ribociclib and Fulvestrant vs Fulvestrant (Monaleesa-3 study) are not currently available.

These studies generally show that combination of hormone therapies with Everolimus or CDK4/6 inhibitors are better than hormone-therapy alone, however no direct comparisons between these treatment combinations exist in literature. The results of our indirect treatment comparisons suggests that EE is similar and, in some cases, it may be even better than other treatment options. The optimal treatment strategy and sequence for patient with MBC and prior treatment with AIs should be evaluated in clinical trials. Meanwhile these data could be considered together with safety and the economic profile to help physicians in daily clinical practice.

Citation Format: Gianni L, Arcangeli V, Gianni C, Stocchi L, Menghini L, Samorani D, Ridolfi C, Emiliano T, Tassinari D. Everolimus-exemestane (EE) vs palbociclib-fulvestrant (PF) or abemaciclib-fulvestrant (AF) or everolimus-fulvestrant (EF) in the treatment of metastatic HR+, HER2- metastatic breast cancer and prior aromatase inhibitors treatment. An indirect comparison with network meta-analysis [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P3-11-05.

Can Tangier disease cause male infertility? A case report and an overview on genetic causes of male infertility and hormonal axis involved

Tangier disease is an autosomal recessive disorder caused by mutations in the ABCA1 gene and characterized by the accumulation of cholesteryl ester in various tissues and a near absence of high-density lipoprotein. The subject in this investigation was a 36-year-old Italian man with Tangier disease. He and his wife had come to the In Vitro Fertilization Unit, Pesaro Hospital (Azienda Ospedaliera Ospedali Riuniti Marche Nord) seeking help regarding fertility issues. The man was diagnosed with severe oligoasthenoteratozoospermia. Testosterone is the sex hormone necessary for spermatogenesis and cholesterol is its precursor; hence, we hypothesized that the characteristic cholesterol deficiency in Tangier disease patients could compromise their fertility. The aim of the study was to therefore to determine if there is an association between Tangier disease and male infertility. After excluding viral, infectious, genetic and anatomical causes of the subject's oligoasthenoteratozoospermia, we performed a hormonal analysis to verify our hypothesis. The patient was found to be negative for frequent bacteria and viruses. The subject showed a normal male karyotype and tested negative for Yq microdeletions and Cystic Fibrosis Transmembrane Conductance Regulator gene mutations. A complete urological examination was performed, and primary hypogonadism was also excluded. Conversely, hormonal analyses showed that the subject had a high level of follicle stimulating hormone and luteinizing hormone, low total testosterone and a significant decline in inhibin B. We believe that the abnormally low cholesterol levels typically found in subjects with Tangier disease may result in a reduced testosterone production which in turn could affect the hormonal axis responsible for spermatogenesis leading to a defective maturation of spermatozoa.

Impact of a restrictive vs liberal transfusion strategy on anastomotic leakage and infectious complications after restorative surgery for rectal cancer

AIM

The aim of this study was to investigate the impact of a restrictive vs liberal transfusion strategy on anastomotic leakage and infectious complications after rectal cancer surgery.

METHODS

Patients undergoing restorative proctectomy for rectal cancer between January 2008 and December 2013 were divided into four groups according to the perioperative lowest haemoglobin (Hgb) level and transfusion status: group 1 with Hgb level ≥ 10 g/dl; group 2 with Hgb level ≥ 7 and < 10 g/dl who did not receive transfusion; and group 3 with Hgb level ≥ 7 and < 10 g/dl and group 4 with Hgb level < 7 g/dl, both of which received a transfusion. Clinical characteristics, anastomotic leakage and infectious complications within 30 days of surgery were compared.

RESULTS

There were 398 patients (66% men) with a mean age of 59.3 ± 11.9 years. Groups 1, 2, 3 and 4 included 162 (40.7%), 163 (41.0%), 47 (11.8%) and 26 (6.5%) patients, respectively. Perioperative characteristics were significantly different among groups regarding neoadjuvant chemo/radiotherapy use, preoperative albumin and Hgb levels, operative approach and blood loss, tumour size and stage, surgical margin involvement and histological differentiation. The unadjusted rates of overall infectious complications were 17.2%, 27.6%, 36.2% and 50% in groups 1, 2, 3 and 4, respectively (P = 0.001). In the multivariate analysis, compared to group 2, group 3 was associated with an increased likelihood of organ/space surgical site infections (SSIs) (OR 3.63, 95% CI 1.29-10.22, P = 0.01) with no significant differences in terms of anastomotic leakage, overall SSIs or overall infectious complications.

CONCLUSION

Blood transfusion of haemodynamically stable patients with Hgb level ≥ 7 g/dl is associated with increased organ/space SSIs in rectal cancer surgery.

Robotic versus conventional laparoscopic rectal cancer surgery in obese patients

AIM

Obesity adds to the technical difficulty of laparoscopic colorectal surgery. The robotic approach has the potential to overcome this limitation because of its proposed technical advantages over laparoscopy. The aim of this retrospective study was to compare the short-term outcomes of robotic surgery (RS) vs conventional laparoscopy surgery (LS) in this patient population.

METHOD

Patients with a body mass index ≥ 30 kg/m² undergoing RS or LS for rectal cancer between January 2011 and June 2014 were identified from an institutional database. Perioperative parameters, oncological findings and postoperative 30-day short-term outcomes were compared between the RS and LS groups.

RESULTS

The RS and LS groups included 29 and 27 patients, respectively. Groups were comparable in terms of patient demographics, body mass index (34.9 ± 7.2 vs 35.2 ± 5.0 kg/m² , P = 0.71), comorbidities, surgical and tumour characteristics. Comparison of the intra-operative findings revealed no significant differences between the groups including operative time (329.0 ± 102.2 vs 294.6 ± 81.1 min, P = 0.13), blood loss (434.0 ± 612.4 vs 339.4 ± 271.9 ml, P = 0.68), resection margin involvement (6.9% vs 7.4%, P = 0.99), conversions (3.4% vs 18.5%, P = 0.09) and complications (6.9% vs 0%, P = 0.49). Regarding postoperative outcomes, there were no significant differences in morbidity except that robotic surgery was associated with a quicker return of bowel function (median 3 vs 4 days, P = 0.01) and shorter hospital stay (median 6 vs 7 days, P = 0.02).

CONCLUSION

Robotic surgery for rectal cancer in obese patients has short-term outcomes similar to laparoscopy, but accelerated postoperative recovery.

Risk factors associated with portomesenteric venous thrombosis in patients undergoing restorative proctocolectomy for medically refractory ulcerative colitis

AIM

Data on risk factors for portomesenteric venous thrombosis (PMVT) following abdominal surgery for ulcerative colitis (UC) are limited. The aim of this study was to investigate factors associated with PMVT after surgical treatment for UC.

METHOD

Patients who underwent restorative proctocolectomy (RPC) and ileal pouch-anal anastomosis (IPAA) including diverting ileostomy closure for medically refractory UC were identified from a prospectively maintained database. Patient-related, disease-related and treatment-related variables were collected. Univariable and multivariable analyses were performed to assess factors associated with PMVT.

RESULTS

Of the 521 patients completing surgical treatment for UC between 2006 and 2012, symptomatic PMVT occurred in 36 (7%), which resulted in a significantly increased hospital stay (P < 0.001). Patients developing PMVT were younger (P = 0.014), had a lower preoperative albumin level (P = 0.037) and were more likely to have been taking steroids within 1 month before surgery (P = 0.006). The combined incidence of PMVT was comparable between patients having a three-stage and two-stage management (6% vs. 8%, P = 0.43), but the relative incidence of PMVT after RPC + IPAA was 8%, significantly higher than the 4% after total abdominal colectomy (TAC) (P = 0.005) and the 2% after subsequent completion proctectomy (CP) + IPAA (P = 0.038). Multivariate analysis confirmed that RPC + IPAA was associated with a significantly greater risk of PMVT than CP + IPAA (OR = 4.9, P = 0.003) or TAC (OR = 3.5, P = 0.011). Preoperative steroid use was an independent factor for PMVT (OR = 5.8, P = 0.006).

CONCLUSION

Steroid use 1 month before surgery is associated with an increased risk of PMVT. A staged restorative proctocolectomy does not increase the overall incidence of PMVT.

What are the consequences of enlarging the extraction site to exteriorize a large specimen during laparoscopic surgery for Crohn's enteritis?

AIM

The implications of extraction site enlargement for the removal of large specimens during laparoscopic surgery for Crohn's disease have not been clearly described; such a description is the aim of this study.

METHOD

An institutional database was queried to identify patients undergoing laparoscopic resection for Crohn's disease through midline incision between 1995 and 2013. Perioperative outcomes were compared among cases completed through their initial extraction site (L), completed after increasing the length of the initial extraction site (IL) for specimen exteriorization, and cases converted to open surgery (C). Univariate and multivariate statistical analyses were performed.

RESULTS

Out of 309 patients, 52 required IL and 36 required C. Heavier, older, male patients were more likely to require IL or C. There were no differences in disease behaviour (P = 0.260), procedures performed (P = 0.12) or postoperative morbidity (P = 0.33). IL and L groups had a comparable initial length of hospital stay (LOS), which was shorter than in the C group. While there were no significant differences in causes of readmission (P = 0.31), IL had increased readmission rates compared with L [odds ratio (OR) 2.80, P = 0.021] or C (OR 13.89, P = 0.015). When combining initial and readmission LOS, C and IL groups had comparable overall LOS [median ratio (MR) 1.09, P = 0.57], which was significantly longer than in the L group (MR 1.27, P = 0.02).

CONCLUSION

Extraction site enlargement during laparoscopic surgery for enteric Crohn's disease had no impact on primary LOS. However, the shorter initial LOS was offset by increased readmission rates when compared with formal conversion. The threshold to convert in case of anticipated difficulty due to a large specimen should be low.

Association between high visceral fat area and postoperative complications in patients with Crohn's disease following primary surgery

AIM

The aim of this study was to determine the association between visceral fat area (VFA) on CT and postoperative complications after primary surgery in patients with Crohn's disease (CD).

METHOD

Inclusion criteria were patients with a confirmed diagnosis of CD who had preoperative abdominal CT scan. The areas of total fat, subcutaneous fat and visceral fat were measured using an established image-analysis method at the lumbar 3 (L3) level on CT cross-sectional images. Visceral obesity was defined as a visceral fat area (VFA) of ≥ 130 cm(2) . Clinical variables, intra-operative outcomes and postoperative courses within 30 days were analysed.

RESULTS

A total of 164 patients met the inclusion criteria. Sixty-three (38.4%) patients had postoperative complications. The mean age of the patients with complications (the study group) was 40.4 ± 15.4 years and of those without complications (the control group) was 35.8 ± 12.9 years (P = 0.049). There were no differences in disease location and behaviour between patients with or without complications (P > 0.05). In multivariable analysis, VFA [odds ratio (OR) = 2.69; 95% confidence interval (CI): 1.09-6.62; P = 0.032] and corticosteroid use (OR = 2.86; 95% CI: 1.32-6.21; P = 0.008) were found to be associated with postoperative complications. Patients with visceral obesity had a significantly longer operative time (P = 0.012), more blood loss (P = 0.019), longer bowel resection length (P = 0.003), postoperative ileus (P = 0.039) and a greater number of complications overall (P < 0.001).

CONCLUSION

High VFA was found to be associated with an increased risk for 30-day postoperative complications in patients with CD undergoing primary surgery.

Mutational analysis of mitochondrial DNA in Brugada syndrome

BACKGROUND

Brugada syndrome (BrS) is a primary electrical disease associated with an increased risk of sudden cardiac death due to ventricular fibrillation. This pathology has nuclear heterogeneous genetic origins, and at present, molecular diagnostic tests on nuclear DNA cover only 30% of BrS patients. The aim of this study was to assess the possible involvement of mitochondrial (mt) DNA variants in BrS since their etiological role in several cardiomyopathies has already been described.

METHODS AND RESULTS

The whole mt genome of BrS patients was sequenced and analyzed. A specific mtDNA mutation responsible for BrS can be excluded, but BrS patient d-loop was found to be more polymorphic than that of control cases (P=0.003). Moreover, there appears to be an association between patients with the highest number of variants (n>20) and four mt Single Nucleotide Polymorphism (SNPs) (T4216C, A11251G, C15452A, T16126C) and the most severe BrS phenotype (P=0.002).

CONCLUSIONS

The high substitution rate found in BrS patient mtDNA is unlikely to be the primary cause of the disease, but it could represent an important cofactor in the manifestation of the BrS phenotype. Evidence suggesting that a specific mtDNA allelic combination and a high number of mtDNA SNPs may be associated with more severe cases of BrS represents the starting point for further cohort studies aiming to test whether this mt genetic condition could be a genetic modulator of the BrS clinical phenotype.

Salvage surgery after failure of endoscopic balloon dilatation versus surgery first for ileocolonic anastomotic stricture due to recurrent Crohn's disease

BACKGROUND

Both surgical resection and endoscopic balloon dilatation are treatment options for ileocolonic anastomotic stricture caused by recurrent Crohn's disease unresponsive to medications. Perioperative outcomes of salvage surgery owing to failed endoscopic balloon dilatation in comparison with performing surgery first for the same indication are unclear.

METHODS

An analysis of a prospectively maintained Crohn's disease database was carried out to compare perioperative outcomes of patients who had surgery for failure of endoscopic balloon dilatation with outcomes in patients who underwent resection first for ileocolonic anastomotic stricture caused by recurrent Crohn's disease between 1997 and 2013.

RESULTS

Of 194 patients, 114 (58·8 per cent) underwent surgery without previous endoscopic balloon dilatation. The remaining 80 patients had salvage surgery after one or more endoscopic balloon dilatations during a median treatment span of 14·5 months. Patients in the salvage surgery group had a significantly shorter length of anastomotic stricture (P < 0·001). Salvage surgery was associated with increased rates of stoma formation (P = 0·030), overall surgical-site infection (SSI) (P = 0·025) and organ/space SSI (P = 0·030). In multivariable analysis, preoperative endoscopic balloon dilatation was independently associated with both postoperative SSI (odds ratio 3·16, 95 per cent c.i. 1·01 to 9·84; P = 0·048) and stoma diversion (odds ratio 3·33, 1·14 to 9·78; P = 0·028).

CONCLUSION

Salvage surgery after failure of endoscopic balloon dilatation is associated with increased adverse outcomes in comparison with surgery first. This should be discussed with patients being considered for endoscopic balloon dilatation for ileocolonic anastomotic stricture due to recurrent Crohn's disease.

Comparative analysis between saliva and buccal swabs as source of DNA: lesson from HLA-B*57:01 testing

AIM

Our work aimed to designate the optimal DNA source for pharmacogenetic assays, such as the screening for HLA-B*57:01 allele.

MATERIALS & METHODS

A saliva and four buccal swab samples were taken from 104 patients. All the samples were stored at different time and temperature conditions and then genotyped for the HLA-B*57:01 allele by SSP-PCR and classical/capillary electrophoresis.

RESULTS

The genotyping analysis reported different performance rates depending on the storage conditions of the samples. Given our results, the buccal swab demonstrated to be more resistant and stable in time with respect to the saliva.

CONCLUSION

Our investigation designates the buccal swab as the optimal DNA source for pharmacogenetic assays in terms of resistance, low infectivity, low-invasiveness and easy sampling, and safe transport in centralized medical centers providing specialized pharmacogenetic tests.

Factors affecting the fate of faecal diversion in patients with perianal Crohn's disease

AIM

A study was carried out with the aim of identifying potential factors which might influence the fate of patients undergoing faecal diversion by stoma in perianal Crohn's disease.

METHOD

Patients with severe perianal Crohn's disease undergoing faecal diversion between 1994 and 2012 were identified and the factors associated with stoma closure were assessed using univariate and multivariate analysis.

RESULTS

Of 138 diverted patients, 30 (22%) achieved stoma closure, 45 (33%) had a stoma with the rectum left in situ and 63 (45%) underwent proctectomy with permanent stoma formation after a mean follow-up of 5.7 years. Univariate analysis demonstrated that synchronous colonic (P = 0.004) or rectal (P = 0.021) disease involvement and an increased frequency of loose seton placement (P = 0.001) adversely affected successful stoma closure rates. Multivariate analysis indicated a significant association between the inability to achieve stoma closure and persisting rectal involvement (OR 7.5, 95% CI 2.4-33.4), one or two placements of a loose seton (OR 3.3, 95% CI 1.4-8.8) and more than two placements (OR 6.9, 95% CI 1.2-132.5). No specific medical management was associated with an improved stoma closure rate, including biological agents when these were available (P = 0.25).

CONCLUSION

The fate of temporary faecal diversion in patients with perianal Crohn's disease is adversely affected by aggressive disease characteristics. No particular treatment, including biological therapy, was associated with an improved outcome.

Antibiotics alone instead of percutaneous drainage as initial treatment of large diverticular abscess

BACKGROUND

There are limited data assessing the effectiveness of antibiotics as sole initial therapy in patients with large diverticular abscess. The aim of our study was to compare outcomes of selected patients treated with initial antibiotics alone versus percutaneous drainage.

METHODS

All patients with diverticular abscess ≥3 cm in diameter treated in our institution in 1994-2012 with percutaneous drainage or antibiotics alone followed by surgery were identified from an institutional diverticular disease database. Groups were compared based on patient and disease characteristics, treatment failures and postoperative outcomes.

RESULTS

Thirty-two patients were treated with antibiotics alone because of either technically impossible percutaneous drainage (n = 15) or surgeon preference (n = 17) while 114 underwent percutaneous drainage. Failure of initial treatment required urgent surgery in 8 patients with persistent symptoms during treatment with antibiotics alone (25 %) and in 21 patients (18 %) after initial percutaneous drainage (p = 0.21). Reasons for urgent surgery after percutaneous drainage were persistent symptoms (n = 16), technical failure of percutaneous drainage (n = 4) and small bowel injury (n = 1). Patients treated with antibiotics had a significantly smaller abscess diameter (5.9 vs. 7.1 cm, p = 0.001) and shorter interval from initial treatment to sigmoidectomy (mean 50 vs. 80 days, p = 0.02). The Charlson comorbidity index, initial treatment failure rates, postoperative mortality, overall morbidity, length of hospital stay during treatments, and overall and permanent stoma rates were comparable in the two groups. Postoperative complications following antibiotics alone were significantly less severe than after percutaneous drainage based on the Clavien-Dindo classification (p = 0.04).

CONCLUSIONS

Selected patients with diverticular abscess can be initially treated with antibiotics without adverse consequences on their outcomes.

Factors affecting morbidity after conversion of laparoscopic colorectal resections

BACKGROUND

The impact of conversion on postoperative outcomes of laparoscopic colorectal surgery remains controversial. The purpose of this study was to assess whether a conversion results in increased postoperative morbidity and mortality, and to evaluate whether any specific factors affect the outcomes of converted procedures.

METHODS

Outcomes of procedures requiring conversion among patients undergoing elective laparoscopic colorectal resection between 1992 and 2011 were compared with those for operations completed laparoscopically. Subset analyses were also performed to evaluate the selective impact of patient-, disease- and treatment-related factors and the timing of conversion during surgery on outcomes. Primary endpoints were postoperative mortality and morbidity.

RESULTS

Of 2483 patients undergoing laparoscopic colorectal resection, 270 (10.9 per cent) required conversion to open surgery. The 30-day postoperative mortality rate was comparable after laparoscopically completed and converted procedures (0.4 versus 0 per cent respectively; P = 0.610). Factors significantly associated with morbidity after conversion were smoking, cardiovascular co-morbidity, previous abdominal operations (particularly colectomy or hysterectomy) and adhesions. Overall morbidity was not affected by conversion (27.0 per cent at 30 days in both groups; P > 0.999). However, patients experiencing morbidity tended to have had earlier conversions: median (range) 40 (15-90) min into surgery versus 50 (15-240) min for those who did not develop morbidity (P = 0.006). The risk of reoperation for postoperative morbidity was higher following conversion because of complications (13 versus 2.9 per cent; P = 0.024).

CONCLUSION

Conversions of laparoscopic colorectal resection are not associated with increased overall morbidity, regardless of the timing of conversion.

Factors associated with postoperative morbidity, reoperation and readmission rates after laparoscopic total abdominal colectomy for ulcerative colitis

AIM

The aim of this study was to evaluate factors affecting postoperative outcomes after laparoscopic total abdominal colectomy (TAC) with end ileostomy (EI) for ulcerative colitis (UC).

METHOD

Patients undergoing laparoscopic TAC/EI for severe UC/indeterminate colitis in our institution between 1998 and 2010 were retrospectively identified from a prospectively established database. Demographics, disease characteristics and perioperative outcomes were recorded. Associations between the 30-day postoperative outcome and patient-, disease- and treatment-related variables were assessed using univariate and multivariate logistic regression models.

RESULTS

Two hundred and four patients (105 men, median age 35.5 years) were identified. The conversion rate was 4.4%. Median blood loss and operation time were 100 ml and 185 min. Length of hospital stay was 5.8 ± 4.4 days. Overall postoperative morbidity, reoperation and readmission rates were 40, 7 and 17%, respectively Preoperative treatment with high steroid doses was significantly associated with postoperative morbidity on multivariate analysis (P = 0.011). Univariate analysis showed that lower preoperative body mass index (BMI), haemoglobin, serum albumin level and pancolitis were associated with reoperation, of which a lower BMI (P = 0.043) was also independently significant on multivariate analysis. No specific factor was significantly associated with readmission.

CONCLUSION

Preoperative clinical deterioration is associated with an adverse outcome after laparoscopic TAC for UC.

The Pharmacogenomic HLA Biomarker Associated to Adverse Abacavir Reactions: Comparative Analysis of Different Genotyping Methods

Many pharmacogenomic biomarkers (PGBM) were identified and translated into clinical practice, affecting the usage of drugs via label updates. In this context, abacavir is one of the most brilliant examples of pharmacogenetic studies translated into clinical practice. Pharmacogenetic studies have revealed that abacavir HSRs are highly associated with the major histocompatibility complex class I. Large studies established the effectiveness of prospective HLA-B*57:01 screening to prevent HSRs to abacavir. Accordingly to these results the abacavir label has been modified: the European Medicines Agency (EMA) and the FDA recommend/suggested that the administration of abacavir must be preceded by a specific genotyping test. The HLA locus is extremely polymorphic, exhibiting many closely related alleles, making it difficult to discriminate HLA-B*57:01 from other related alleles, and a number of different molecular techniques have been developed recently to detect the presence of HLA-B*57:01. In this review, we provide a summary of the available techniques used by laboratories to genotype HLA-B*57:01, outlining the scientific and pharmacoeconomics pros and cons.

Case-matched comparison of perioperative outcomes after surgical treatment of sigmoid diverticulitis in solid organ transplant recipients versus immunocompetent patients

AIM

To compare the perioperative outcomes following surgery for sigmoid diverticulitis in transplant recipients and immunocompetent patients.

METHOD

Solid organ transplant recipients operated on for sigmoid diverticulitis from 1995 to 2010 were case-matched to immunocompetent patients based on surgical procedure, American Society of Anesthesiologists classification, Hinchey score, elective vs urgent surgery, age ± 10 years and year of surgery ± 5 years. Demographics, clinical presentation and perioperative outcomes were assessed.

RESULTS

Of 5329 consecutive patients undergoing heart, lung, kidney and liver transplantation since 1995, 51 (0.6%) underwent surgery for diverticulitis between 1995 and 2010 with 14% mortality and 45% morbidity. Urgent surgery in 37/51 patients [Hartmann's procedure 28, sigmoidectomy with diverting ileostomy 8, loop ileostomy 1 (9 cases within 2 months after transplantation)] was associated with significantly increased postoperative mortality (19%vs 0%, P = 0.01), increased morbidity (51%vs 24%, P = 0.03) and longer mean hospital stay (19 vs 13 days, P = 0.1) when compared with immunocompetent patients. Four patients undergoing urgent surgery had suffered previous episodes of diverticulitis treated nonoperatively. Elective surgery was associated with no mortality in 14 transplant recipients (nine sigmoidectomy with diverting ileostomy, five sigmoidectomy without diversion) or in immunocompetent controls. Following elective procedures, transplant recipients had similar morbidity and increased hospital stay (29% and 9.6 vs 6.5 days, P = 0.2, respectively). Permanent stoma rates and postoperative morbidity after stoma takedown were comparable in the two groups. All living patients except one (kidney) retained their graft function.

CONCLUSIONS

Urgent surgery for sigmoid diverticulitis in transplant recipients is associated with worse postoperative outcomes when compared with immunocompetent patients, unlike elective surgery. Future studies will need to clarify the role of early surgery after the first diverticulitis episode.

Risk of infection and hernia recurrence for patients undergoing ventral hernia repair with non-absorbable or biological mesh during open bowel procedures

BACKGROUND

Ventral hernia repair (VHR) with mesh performed concurrently with colorectal surgery is presumably associated with significant risks of infection and recurrence. The purpose of this study is to evaluate the outcomes of patients undergoing VHR with non-absorbable mesh (NAM) or biological mesh (BM) at the same time as open colorectal surgery.

METHODS

A retrospective review of short- and long-term outcomes for 25 patients undergoing repair of VHR with NAM or BM at the same time as an open colorectal procedure from 1991 to 2007 was performed.

RESULTS

The mean age of the patients was 50.8 ± 12.7 years. Fifteen patients (60 %) underwent VHR with NAM versus 10 (40 %) with BM at the time of colorectal surgery. Mean follow-up after surgery was 32.9 ± 38.2 months. Overall wound infection, mesh infection and hernia recurrence rates were 44, 36 and 36 %, respectively. There was no difference between the NAM and BM mesh repair groups in terms of operative indications (p = 0.23) and operations performed (p = 0.47). Both groups had similar gender, ASA score, age, BMI, operating time, hernia recurrence rate, wound infection and follow-up.

CONCLUSIONS

Although a proportion of patients who undergo concomitant use of mesh for VHR during colorectal resection has reasonable outcomes, there is a high associated risk of wound and mesh infection. Thus, a judicious decision regarding the use of mesh for hernia repair needs to be made on a case-by-case basis for patients undergoing open bowel surgery at the same time.

Morbidity and mortality of the Hartmann procedure for diverticular disease over 18 years in a single institution

AIM

Hartmann's procedure for perforated diverticulitis is associated with substantial morbidity and mortality. This study analyses factors associated with morbidity/mortality and possible changes over time.

METHOD

Patients treated by urgent Hartmann's procedure for perforated diverticulitis between 1992 and 2010 were studied, and information was collected on age, sex, perioperative details, 30-day morbidity and mortality recorded in an institutional review board approved database supplemented by chart review. Patients were divided into four groups based on the year of surgery. Univariate and multivariate logistic regression analysis was performed to identify risk factors associated with morbidity and mortality.

RESULTS

In all, 199 patients (51% female, mean age 65 years, mean body mass index 28 kg/m(2)) were identified. The American Society of Anesthesiologists (ASA) score was 4 in 30% of patients and Hinchey Stage IV in 16%. The mean length of stay was 12.5 ± 10 days. Mortality was 15% and did not change significantly over time. Overall morbidity was 52% and significantly increased over time on univariate analysis (P = 0.007) but not on multivariate analysis (P = 0.11). Independent predictors of morbidity on multivariate analysis were Hinchey IV (P < 0.001) and hypoproteinaemia (P = 0.001). Independent predictors for mortality were ASA > 3 (P = 0.01), abnormal creatinine (P = 0.007), steroid use (P = 0.007), Hinchey IV (P = 0.032), low albumin (P < 0.001) and low body mass index (P = 0.001).

CONCLUSION

Mortality after Hartmann's procedure for perforated diverticulitis has not decreased during the last 18 years. Morbidity has actually increased over time although this is related to increased disease severity and comorbidity. Future efforts should focus on the identification of patient subgroups benefiting from earlier elective surgery and alternative surgical approaches when perforated diverticulitis does occur.

Clinical implications of acellular mucin pools in resected rectal cancer with pathological complete response to neoadjuvant chemoradiation

AIM

Approximately 20% of rectal cancers treated with neoadjuvant chemoradiation achieve a pathological complete response (pCR), which is associated with an improved oncological outcome. However, in a proportion of patients with a pCR, acellular pools of mucin are present in the surgical specimen. The aim of this study was to evaluate the clinical implications of acellular mucin pools in patients with rectal adenocarcinoma achieving a pCR after neoadjuvant chemoradiation followed by proctectomy.

METHOD

A single-centre colorectal cancer database was searched for patients with clinical Stage II and Stage III rectal adenocarcinoma who achieved a pCR (i.e. ypT0N0M0) after neoadjuvant chemoradiation followed by proctectomy between 1997 and 2007. Patients were categorized according to the presence or absence of acellular mucin pools in the resected specimen, and groups were compared. Patient demographics, tumour and treatment characteristics, and oncological outcomes were recorded. Primary outcomes were 3-year local and distant recurrences, and disease-free and overall survivals.

RESULTS

Two hundred and fifty-eight patients with clinical Stage II or Stage III rectal adenocarcinoma were treated by neoadjuvant chemoradiation. Fifty-eight of these patients had a 58 pCR. Eleven of the 58 patients with a pCR had acellular mucin pools in the surgical specimen. The median follow up was 40 months. The groups were statistically similar with respect to demographics, chemoradiation regimens, distance of tumour from the anal verge, clinical stage and surgical procedure. No patient had local recurrence. Patients with acellular mucin pools had increased distant recurrence (21%vs 5%), decreased disease-free survival (79%vs 95%) and decreased overall survival (83%vs 95%) rates, although none of these differences was statistically significant.

CONCLUSION

The presence of acellular mucin pools in a proctectomy specimen with a pCR does not affect local recurrence, but may suggest a more aggressive tumour biology.

Effects of a 300 mT static magnetic field on human umbilical vein endothelial cells

This study describes the effects of a static magnetic field (SMF) on cell growth and DNA integrity of human umbilical vein endothelial cells (HUVECs). Fast halo assay was used to investigate nuclear damage; quantitative polymerase chain reaction (QPCR), standard PCR, and real-time PCR were used to evaluate mitochondrial DNA integrity, content, and gene expression. HUVECs were continually exposed to a 300 mT SMF for 4, 24, 48, and 72 h. Compared to control samples (unexposed cultures) the SMF-exposed cells did not show a statistically significant change in their viability. Conversely, the static field was shown to be significant after 4 h of exposure, inducing damage on both the nuclear and mitochondrial levels, reducing mitochondrial content and increasing reactive oxygen species. Twenty-four hours of exposure increased mitochondrial DNA content as well as expression of one of the main genes related to mitochondrial biogenesis. No significant differences between exposed and sham cultures were found after 48 and 72 h of exposure. The results suggest that a 300 mT SMF does not cause permanent DNA damage in HUVECs and stimulates a transient mitochondrial biogenesis.