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McNicholas DP, Parr NJ. Image intensifier-guided transperineal prostate biopsy for patients without a rectum: novel technique. BJU Int 2024; 133:487-490. [PMID: 38234225 DOI: 10.1111/bju.16279] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
INTRODUCTION It is challenging to perform prostate biopsy in men with suspicion of prostate malignancy without a rectum to facilitate prostate biopsy. Nevertheless, such patients are presenting at an earlier stage, due to increased PSA testing in association with improved MRI imaging. We describe a novel technique for prostate biopsy in two such cases. TECHNIQUE The patient is under General Anaesthesia and in lithotomy position. The patient is catheterised and a measured volume of contrast is inserted to the catheter balloon. By using anatomical surface landmarks, placing traction on the catheter to bring the balloon to the level of the bladder neck and using fluoroscopy, the distance to the apical prostate was estimated. This facilitates image intensifier guided trans-perineal prostate biopsy. OUTCOMES A 67-year-old patient, with a history of panproctocolectomy for ulcerative colitis, presented with increasing PSA and a suspicious prostate on MP-MRI. The prostate couldn't be visualised on transperineal ultrasound and the patient was offered transperineal biopsy using image intensifier guidance. Several biopsy cores were taken and prostate cancer was diagnosed. The second patient was a 68-year-old who presented similarly, but with a history of panproctocolectomy for Crohn's disease. Using the above technique, biopsies were taken with low-risk prostate cancer diagnosed. Subsequently, due to rising PSA levels, a repeat set of prostate biopsies was taken 13 months later in an identical manner, upstaging his disease. There were no post-operative complications after any of the procedures. CONCLUSION We review the literature and discuss several techniques available to sample the prostate in this patient cohort. We conclude that we have identified a safe and effective technique, which utilises commonly available equipment, to biopsy the prostate in the post proctectomy patient.
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Affiliation(s)
- Daniel P McNicholas
- Department of Urology, Wirral University Teaching Hospital, Birkenhead, Wirral, UK
| | - Nigel J Parr
- Department of Urology, Wirral University Teaching Hospital, Birkenhead, Wirral, UK
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Gillani M, Rupji M, Devin CL, Purvis LA, Paul Olson TJ, Jarc A, Shields MC, Liu Y, Rosen SA. Quantification of surgical workflow during robotic proctectomy. Int J Med Robot 2024; 20:e2625. [PMID: 38439215 DOI: 10.1002/rcs.2625] [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: 11/01/2023] [Revised: 02/15/2024] [Accepted: 02/22/2024] [Indexed: 03/06/2024]
Abstract
BACKGROUND Surgical workflow assessments offer insight regarding procedure variability. We utilised an objective method to evaluate workflow during robotic proctectomy (RP). METHODS We annotated 31 RPs and used Spearman's correlation to measure the correlation of step time and step visit frequency with console time (CT) and total operative time (TOT). RESULTS Strong correlations were seen with CT and step times for inferior mesenteric vein dissection and ligation (ρ = 0.60, ρ = 0.60), lateral-to-medial splenic flexure mobilisation (SFM) (ρ = 0.63), left rectal dissection (ρ = 0.64) and mesorectal division (ρ = 0.71). CT correlated strongly with medial-to-lateral (ρ = 0.75) and supracolic SFM visit frequency (ρ = 0.65). TOT correlated strongly with initial exposure time (ρ = 0.60), and medial-to-lateral (ρ = 0.67) and supracolic SFM visit frequency (ρ = 0.65). CONCLUSION This study correlates surgical steps with CT and TOT through standardised annotation, providing an objective approach to quantify workflow.
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Affiliation(s)
- Mishal Gillani
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Manali Rupji
- Biostatistics Shared Resource, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Courtney L Devin
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Lilia A Purvis
- Research Division, Intuitive Surgical, Norcross, Georgia, USA
| | - Terrah J Paul Olson
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Anthony Jarc
- Research Division, Intuitive Surgical, Norcross, Georgia, USA
| | | | - Yuan Liu
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Seth A Rosen
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
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Parnasa SY, Mizrahi I, Helou B, Cohen A, Abu Gazala M, Pikarsky AJ, Shussman N. Incidence and Risk Factors for Low Anterior Resection Syndrome following Trans-Anal Total Mesorectal Excision. J Clin Med 2024; 13:437. [PMID: 38256571 PMCID: PMC10816902 DOI: 10.3390/jcm13020437] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 12/31/2023] [Accepted: 01/10/2024] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND Trans-anal total mesorectal excision (Ta-TME) is a novel approach for the resection of rectal cancer. Low anterior resection syndrome (LARS) is a frequent functional disorder that might follow restorative proctectomy. Data regarding bowel function after Ta-TME are scarce. The aim of this study was to evaluate the incidence and risk factors for the development of LARS following Ta-TME. METHODS A prospectively maintained database of all patients who underwent Ta-TME for rectal cancer at our institution was reviewed. All patients who were operated on from January 2018 to December 2021 were evaluated. The LARS score questionnaire was used via telephone interviews. Incidence, severity and risk factors for LARS were evaluated. RESULTS Eighty-five patients underwent Ta-TME for rectal cancer between January 2018 and December 2021. Thirty-five patients were excluded due to ostomy status, death, local disease recurrence, ileal pouch or lack of compliance. Fifty patients were included in the analysis. LARS was diagnosed in 76% of patients. Anastomosis distance from dentate line was identified as a risk factor for LARS via multivariate analysis (p = 0.042). Neo-adjuvant therapy, hand sewn anastomosis and anastomotic leak did not increase the risk of LARS. CONCLUSION LARS is a frequent condition following ta-TME, as it is used for other approaches to low anterior resection. Anastomosis distance from dentate line is an independent risk factor for LARS. In this study neo-adjuvant therapy, hand sewn anastomosis and anastomotic leak did not increase the risk of LARS. Further studies with longer follow-up times are required to better understand the functional outcomes following Ta-TME.
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Affiliation(s)
| | | | | | | | | | | | - Noam Shussman
- Department of General Surgery, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91120, Israel; (S.Y.P.)
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Roskam JS, Pourghaderi P, Soliman SS, Chang GC, Rolandelli RH, Nemeth ZH. Assessment of Risk Factors for Iatrogenic Genitourinary Injuries During a Proctectomy. Am Surg 2023; 89:5927-5931. [PMID: 37260109 DOI: 10.1177/00031348231175450] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND It is critical to avoid iatrogenic injuries affecting genitourinary organs in order to prevent postoperative urinary or sexual dysfunction, which lead to lengthier recovery and possibly reoperation. METHODS Using the 2016-2019 American College of Surgeons National Quality Improvement Program (ACS NSQIP) Targeted Proctectomy Database, we collated 2577 patients with non-metastatic rectal cancer who underwent a laparoscopic or open proctectomy. Univariate analysis was used to identify differences in perioperative factors and genitourinary injuries (GUIs) between operative approaches, and multivariate logistic regression was used to identify independent risk factors for sustaining an intraoperative GUI. RESULTS The rates of preoperative comorbidities were significantly higher among patients who received an open operation. The proportion of GUIs was also significantly higher in this patient population. Multivariate logistic regression demonstrated that patients who underwent a laparoscopic proctectomy were associated with a 51.4% lower risk of sustaining a GUI. Furthermore, >10% body weight loss in the past 6 months and ASA class 3 status were independently associated with a higher risk of GUI regardless of operation type. CONCLUSION Patients who undergo a laparoscopic proctectomy are associated with a lower risk of GUI. On the other hand, patients with >10% body weight loss and ASA class 3: Severe Systemic Disease were associated with a higher risk of GUI.
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Affiliation(s)
- Justin S Roskam
- Department of Surgery, Morristown Medical Center, Morristown, NJ, USA
| | - Poya Pourghaderi
- Department of Surgery, Morristown Medical Center, Morristown, NJ, USA
| | - Sara S Soliman
- Department of Surgery, Morristown Medical Center, Morristown, NJ, USA
| | - Grace C Chang
- Department of Surgery, Morristown Medical Center, Morristown, NJ, USA
| | | | - Zoltan H Nemeth
- Department of Surgery, Morristown Medical Center, Morristown, NJ, USA
- Department of Anesthesiology, Columbia University, New York, NY, USA
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Gillani M, Rupji M, Devin C, Purvis L, Olson TP, Jarc A, Shields M, Liu Y, Rosen S. Quantification of Surgical Workflow during Robotic Proctectomy. Res Sq 2023:rs.3.rs-3462719. [PMID: 37886442 PMCID: PMC10602135 DOI: 10.21203/rs.3.rs-3462719/v1] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Abstract
Aim Assessments of surgical workflow offer insight regarding procedure variability, case complexity and surgeon proficiency. We utilize an objective method to evaluate step-by-step workflow and step transitions during robotic proctectomy (RP). Methods We annotated 31 RPs using a procedure-specific annotation card. Using Spearman's correlation, we measured strength of association of step time and step visit frequency with console time (CT) and total operative time (TOT). Results Across 31 RPs, a mean (± standard deviation) of 49.0 (± 20.3) steps occurred per procedure. Mean CT and TOT were 213 (± 90) and 283 (± 108) minutes. Posterior mesorectal dissection required most visits (8.7 ± 5.0), while anastomosis required most time (18.0 [± 8.5] minutes). Inferior mesenteric vein (IMV) ligation required least visits (1.0 ± 0.0) and lowest duration (0.9 [± 0.5] minutes). Strong correlations were seen with CT and step times for IMV dissection and ligation (ρ = 0.60 for both), lateral-to-medial splenic flexure mobilization (SFM) (ρ = 0.63), left rectal dissection (ρ = 0.64) and mesorectal division (ρ = 0.71). CT correlated strongly with medial-to-lateral and supracolic SFM visit frequency (ρ = 0.75 and ρ = 0.65). There were strong correlations with TOT and initial exposure time (ρ = 0.60), as well as visit frequency for medial-to-lateral (ρ = 0.67) and supracolic SFM (ρ = 0.65). Descending colon mobilization was nodal, rectal mobilization convergent and rectal transection divergent. Conclusion This study correlates individual surgical steps with CT and TOT through standardized annotation. It provides an objective approach to quantify workflow.
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Prathivadi Bhayankaram K, Meyer J, Sebastian B, Davies J, Wheeler J. Long-Term Surgical Outcomes and Pathological Analysis of Proctectomy Specimens after Subtotal Colectomy for Ulcerative Colitis: A Retrospective Cohort Study from a Tertiary Centre. J Clin Med 2023; 12:5729. [PMID: 37685796 PMCID: PMC10488829 DOI: 10.3390/jcm12175729] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 08/29/2023] [Accepted: 08/29/2023] [Indexed: 09/10/2023] Open
Abstract
Background: Reconstruction techniques after subtotal colectomy (STC) and end ileostomy for ulcerative colitis (UC), include ileal pouch-anal anastomosis (IPAA), ileorectal anastomosis (IRA) and continent ileostomy. Aim: To assess surgical strategies and outcomes after subtotal colectomy for UC by calculating the proportions of patients who had further surgery 10 years post-STC and those who did not undergo surgery but who were under surveillance, and histological analysis of pathology specimens from STC and proctectomy. Methods: Patients who had STC for UC from 2002 to 2018 were identified. Variables of interest were extracted from electronic records. Survival analysis on reconstruction surgery was performed using Kaplan-Meier curves. Curves were censored for loss from follow-up and death. Subtotal colectomy and proctectomy specimens were assessed by a pathologist for acute inflammation at the distal resection margin and within the resected bowel, and for dysplasia or cancer. Results: One hundred and ninety-two patients were included. Eighty-nine (46.3%) underwent proctectomy: eight had panproctocolectomy; thirty had completion proctectomy and the remaining fifty-one of the eighty-nine patients (27%) had IPAA. One patient who did not undergo a proctectomy had an ileorectal anastomosis. Sixty-one (69%) proctectomy specimens had active inflammation, with 29 (48%) including the resection margins. Of the 103 patients who did not have completion surgery, 72 (69%) were under surveillance as of August 2021. No patients in this non-operative group had developed cancer of the residual rectum at follow up. Conclusions: At 10 years after STC for UC, eighty-nine (46.4%) patients had proctectomy, of which fifty-two had IPAA (27%). However, no inflammation was found in the proctectomy specimen in one third of these patients. Therefore, it is possible that IRA may still have a role in the occasional patient with UC.
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Affiliation(s)
- Kethaki Prathivadi Bhayankaram
- Cambridge Colorectal Unit, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK; (K.P.B.)
- West Suffolk Hospital NHS Foundation Trust, Bury St Edmunds IP33 2QZ, UK
| | - Jeremy Meyer
- Cambridge Colorectal Unit, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK; (K.P.B.)
- Division of Digestive Surgery, University Hospitals of Geneva, 1205 Geneva, Switzerland
- Medical School, University of Geneva, 1206 Geneva, Switzerland
| | - Boby Sebastian
- West Suffolk Hospital NHS Foundation Trust, Bury St Edmunds IP33 2QZ, UK
| | - Justin Davies
- Cambridge Colorectal Unit, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK; (K.P.B.)
| | - James Wheeler
- Cambridge Colorectal Unit, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK; (K.P.B.)
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Fastner S, Hieken TJ, McWilliams RR, Hyngstrom J. Anorectal melanoma. J Surg Oncol 2023; 128:635-644. [PMID: 37395165 DOI: 10.1002/jso.27381] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 06/21/2023] [Indexed: 07/04/2023]
Abstract
Anorectal melanoma is an aggressive mucosal melanoma subtype with a poor prognosis. Although recent advancements have been seen for cutaneous melanoma, the optimal treatment paradigm for management of anorectal melanoma is evolving. In this review, we highlight differences in the pathogenesis of mucosal versus cutaneous melanoma, new concepts of staging for mucosal melanoma, updates to surgical management of anorectal melanoma, and current data for adjuvant radiation and systemic therapy in this unique patient population.
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Affiliation(s)
| | - Tina J Hieken
- Department of Surgery, Division of Breast and Melanoma Surgical Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - John Hyngstrom
- Huntsman Cancer Institute, Salt Lake City, Utah, USA
- Department of Surgery, Division of Surgical Oncology, University of Utah, Salt Lake City, Utah, USA
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Faier TAS, Queiroz FL, Lacerda-Filho A, Paiva RA, França Neto PR, Cortes MGW, Carvalho ARDE, Pereira BMT. Surgical treatment of rectal cancer: prospective cohort study about good oncologic results and low rates of abdominoperineal excision. Rev Col Bras Cir 2023; 50:e20233435. [PMID: 37531500 PMCID: PMC10508657 DOI: 10.1590/0100-6991e-20233435-en] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 03/28/2023] [Indexed: 08/04/2023] Open
Abstract
OBJECTIVES the purpose of this study was to evaluate the outcome of rectal cancer surgery, in a unit adopting the principles of total mesorectal excision (TME) with a high restorative procedure rate and with a low rate of abdominoperineal excision (APE). METHODS we enrolles patients with extraperitoneal rectal cancer undergoing TME or TME+APE. Patients with mid rectal tumors underwent TME, and patients with tumors of the lower rectum and no criteria for APE underwent TME and intersphincteric resection. Those in which the intersphincteric space was invaded and in those with a free distal margin less than 1cm or a tumor free radial margin were unattainable underwent APE or extralevator abdominoperineal excision (ELAPE). We assessed local recurrence rates, overall survival and involvement of the radial margin. RESULTS sixty (89.6%) patients underwent TME and seven (10.4%) TME + APE, of which five underwent ELAPE. The local recurrence, in pacientes undergoing TME+LAR, was 3.3% and in patients undergoing APE, 14.3%. The local recurrence rate (p=0.286) or the distant recurrence rate (p=1.000) was similar between groups. There was no involvement of radial margins. Survival after 120 months was similar (p=0.239). CONCLUSION rectal malignancies, including those located in the low rectum, may be surgically treated with a low rate of APE without compromising oncological principles and with a low local recurrence rates.
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Matsumoto R, Mori S, Nepal P, Kita Y, Tanabe K, Hokonohara K, Satake S, Hamada Y, Wada M, Arigami T, Sasaki K, Kurahara H, Ohtsuka T. Mucosectomy of the anal canal via transanal minimally invasive surgery combined with transanal total mesorectal excision for familial adenomatous polyposis: A technical note. Colorectal Dis 2023. [PMID: 37183353 DOI: 10.1111/codi.16595] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 04/11/2023] [Accepted: 04/12/2023] [Indexed: 05/16/2023]
Abstract
AIM Total proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the standard surgical treatment modality for familial adenomatous polyposis (FAP). It is challenging to perform proctectomy and preserve anal sphincter function. In this video, precise mucosectomy of the anal canal via transanal minimally invasive surgery (MAC-TAMIS) is reported. METHODS An asymptomatic 35-year-old man was found to have a positive faecal occult blood test in routine screening examination and was diagnosed with FAP on colonoscopic examination. The patient was scheduled for total proctocolectomy with IPAA using the TAMIS approach combined with transanal total mesorectal excision. MAC-TAMIS was performed to preserve the internal anal sphincter during laparoscopy. RESULTS The total duration of surgery was 543 min, blood loss was minimal, and the postoperative course was uneventful. The postoperative hospital stay was 12 days. The pathological findings demonstrated no evidence of malignancy. Gastrographic imaging from the ileostomy showed sufficient size of the J pouch and good tonus of the anus at 6 months after surgery. The Wexner scores at 1, 3 and 6 months after ileostomy closure were 5, 3 and 0, respectively. CONCLUSION The MAC-TAMIS technique is safe and feasible during total proctocolectomy with IPAA in patients with FAP. This technique allows us to precisely preserve the internal anal sphincter using a laparoscopic approach.
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Affiliation(s)
- Ryu Matsumoto
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima University, Kagoshima, Japan
| | - Shinichiro Mori
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima University, Kagoshima, Japan
| | - Pramod Nepal
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima University, Kagoshima, Japan
| | - Yoshiaki Kita
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima University, Kagoshima, Japan
| | - Kan Tanabe
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima University, Kagoshima, Japan
| | - Kentaro Hokonohara
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima University, Kagoshima, Japan
| | - Soichi Satake
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima University, Kagoshima, Japan
| | - Yuki Hamada
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima University, Kagoshima, Japan
| | - Masumi Wada
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima University, Kagoshima, Japan
| | - Takaaki Arigami
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima University, Kagoshima, Japan
| | - Ken Sasaki
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima University, Kagoshima, Japan
| | - Hiroshi Kurahara
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima University, Kagoshima, Japan
| | - Takao Ohtsuka
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima University, Kagoshima, Japan
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Devin CL, Gillani M, Shields MC, Eldredge K, Kucera W, Rupji M, Purvis LA, Paul Olson TJ, Liu Y, Jarc A, Rosen SA. Ratio of Economy of Motion: A New Objective Performance Indicator to Assign Consoles During Dual-Console Robotic Proctectomy. Am Surg 2023:31348231161767. [PMID: 36898676 DOI: 10.1177/00031348231161767] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023]
Abstract
BACKGROUND Our group investigates objective performance indicators (OPIs) to analyze robotic colorectal surgery. Analyses of OPI data are difficult in dual-console procedures (DCPs) as there is currently no reliable, efficient, or scalable technique to assign console-specific OPIs during a DCP. We developed and validated a novel metric to assign tasks to appropriate surgeons during DCPs. METHODS A colorectal surgeon and fellow reviewed 21 unedited, dual-console proctectomy videos with no information to identify the operating surgeons. The reviewers watched a small number of random tasks and assigned "attending" or "trainee" to each task. Based on this sampling, the remainder of task assignments for each procedure was extrapolated. In parallel, we applied our newly developed OPI, ratio of economy of motion (rEOM), to assign consoles. Results from the 2 methods were compared. RESULTS A total of 1811 individual surgical tasks were recorded during 21 proctectomy videos. A median of 6.5 random tasks (137 total) were reviewed during each video, and the remainder of task assignments were extrapolated based on the 7.6% of tasks audited. The task assignment agreement was 91.2% for video review vs rEOM, with rEOM providing ground truth. It took 2.5 hours to manually review video and assign tasks. Ratio of economy of motion task assignment was immediately available based on OPI recordings and automated calculation. DISCUSSION We developed and validated rEOM as an accurate, efficient, and scalable OPI to assign individual surgical tasks to appropriate surgeons during DCPs. This new resource will be useful to everyone involved in OPI research across all surgical specialties.
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Affiliation(s)
- Courtney L Devin
- Department of Surgery, 12239Emory University School of Medicine, Atlanta, GA, USA
| | - Mishal Gillani
- Department of Surgery, 12239Emory University School of Medicine, Atlanta, GA, USA
| | | | - Kyle Eldredge
- Department of Surgery, 12239Emory University School of Medicine, Atlanta, GA, USA
| | - Walter Kucera
- Department of Surgery, 12239Emory University School of Medicine, Atlanta, GA, USA
| | - Manali Rupji
- Biostatistics Shared Resource, Winship Cancer Institute, 1371Emory University, Atlanta, GA, USA
| | - Lilia A Purvis
- Research Division, 19727Intuitive Surgical, Norcross, GA, USA
| | | | - Yuan Liu
- Biostatistics Shared Resource, Winship Cancer Institute, 1371Emory University, Atlanta, GA, USA.,Department of Biostatistics and Bioinformatics, Rollins School of Public Health, 1371Emory University, Atlanta, GA, USA
| | - Anthony Jarc
- Research Division, 19727Intuitive Surgical, Norcross, GA, USA
| | - Seth A Rosen
- Department of Surgery, 12239Emory University School of Medicine, Atlanta, GA, USA
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Cheong JY, Connelly TM, Russell T, Valente M, Bhama A, Lightner A, Hull T, Steele SR, Holubar SD. Venous thromboembolism risk stratification for patients undergoing surgery for IBD using a novel six factor scoring system using NSQIP-IBD registry. ANZ J Surg 2023. [PMID: 36645783 DOI: 10.1111/ans.18242] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 12/06/2022] [Accepted: 12/17/2022] [Indexed: 01/17/2023]
Abstract
BACKGROUND Patients undergoing colorectal surgery for inflammatory bowel disease (IBD) are recognized to have an increased risk of venous thromboembolism (VTE). The aim of this study was to determine the perioperative risk factors for VTE and to create a predictive scoring system for VTE in the IBD cohort. METHODS The NSQIP-IBD Collaboration Registry from 2017 to 2020 was used to identify patients. Demographics, operative and outcomes data of IBD patients undergoing surgeries for IBD were analysed. A logistic multivariate regression model was performed using all significant variables to develop a predictive scoring system of VTE. RESULTS Five-thousand and three patients (51.9% male, mean age: 42.7, 42.7% ulcerative colitis) were included in the study. 125 (2.49%) developed VTE. On multivariate analysis ASA grade, ulcerative colitis, sepsis, serum sodium <139 mmol/L, an open abdomen and preoperative inter hospital transfer were associated with greater risk of VTE. Using these 6 significant factors, a risk model was constructed. The risk of VTE with one risk factor was 0.7% and 1.8% with two risk factors. The risk of VTE increased to 3.6% and 4.5% with three and four risk factors respectively. With five and six risk factors, the risk of VTE increased exponentially to 10.9% and 25% respectively. CONCLUSION This study shows that there are cumulative risk factors which increase the risk of VTE after surgery for IBD. The risk increases exponentially with more than five risk factors, and extended chemoprophylaxis may not be enough in reducing this risk.
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Affiliation(s)
- Ju Yong Cheong
- Department of Colon & Rectal Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Tara M Connelly
- Department of Colon & Rectal Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Tara Russell
- Department of Colon & Rectal Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Michael Valente
- Department of Colon & Rectal Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Anuradha Bhama
- Department of Colon & Rectal Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Amy Lightner
- Department of Colon & Rectal Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Tracy Hull
- Department of Colon & Rectal Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Scott R Steele
- Department of Colon & Rectal Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Stefan D Holubar
- Department of Colon & Rectal Surgery, Cleveland Clinic, Cleveland, Ohio, USA
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12
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Lee GC, Bhama AR. Minimally Invasive and Robotic Surgery for Ulcerative Colitis. Clin Colon Rectal Surg 2022; 35:463-468. [PMID: 36591398 PMCID: PMC9797258 DOI: 10.1055/s-0042-1758137] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Significant advancements have been made over the last 30 years in the use of minimally invasive techniques for curative and restorative operations in patients with ulcerative colitis (UC). Numerous studies have demonstrated the safety and feasibility of laparoscopic and robotic approaches to subtotal colectomy (including in the urgent setting), total proctocolectomy, completion proctectomy, and pelvic pouch creation. Data show equivalent or improved short-term postoperative outcomes with minimally invasive techniques compared to open surgery, and equivalent or improved long-term bowel function, sexual function, and fertility. Overall, while minimally invasive techniques are safe and feasible for properly selected UC patients, surgeons must remember to abide by the principles of high-quality proctectomy and pouch creation and convert to open if necessary.
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Affiliation(s)
- Grace C. Lee
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Anuradha R. Bhama
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio
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Abstract
BACKGROUND Recent series have raised concerns about the oncologic outcomes of transanal total mesorectal excision for mid and low rectal cancer. There is a paucity of large data sets from the United States to contribute to the ongoing international discourse. OBJECTIVE This study aimed to investigate the rate of local recurrence and other oncologic outcomes in patients undergoing transanal total mesorectal excision for rectal adenocarcinoma. DESIGN This study is a retrospective review of patients undergoing transanal total mesorectal excision for primary rectal cancer from January 2014 to December 2019. SETTINGS This study was conducted at a single academic tertiary care medical center in the United States. PATIENTS Consecutive patients aged ≥18 years undergoing surgical resection for primary rectal cancer were selected. INTERVENTION The transanal total mesorectal excision procedures were performed utilizing a 2-team approach. MAIN OUTCOME MEASURES Primary outcomes were pathologic quality, local and distant recurrence, treatment-related complications, and overall- and cancer-specific survival. RESULTS Seventy-nine consecutive patients were included. The median age was 58 years (interquartile range, 50-64), and median BMI was 28 kg/m2 (interquartile range, 24.6-32.4). The mesorectum was complete in 69 patients (87.3%), nearly complete in 9 (11.4%), and incomplete in 1 (1.3%). There was circumferential resection margin involvement (<1 mm) in 4 patients (5.1%), and no patients had a positive distal margin (<1 mm) or intraoperative rectal perforation. Composite optimal pathology was achieved in 94.9% of specimens. Median follow-up was 29 months (range, 6-68). There were no local recurrences. Distant metastases were found in 10 (13.5%) patients and diagnosed after a median of 14 months (range, 0.6-53). Disease-free survival was 91.2% at 2 years, and overall survival was 94.7% at 2 years. LIMITATIONS Retrospective design, a single center, and relatively short follow-up period were limitations of this study. CONCLUSION The oncologic outcomes of this cohort support the use of transanal total mesorectal excision in the surgical management of mid to low rectal cancer at centers with appropriate expertise. See Video Abstract at http://links.lww.com/DCR/B723. RESULTADOS ONCOLGICOS DESPUS DE LA EXCISIN TOTAL DEL MESORRECTO POR VA TRANSANAL EN CASOS DE CNCER RECTAL ANTECEDENTES:Estudios recientes han suscitado preocupación sobre los resultados oncológicos de la excisión total del mesorecto por vía transanal en casos de cáncer de recto medio y bajo. Existe una gran escasez de conjuntos de datos en los Estados Unidos, para contribuir en el actual discurso internacional sobre el tema.OBJETIVO:Investigar la tasa de recurrencia local y otros resultados oncológicos en pacientes sometidos a una excisión total del mesorrecto por vía transanal por adenocarcinomas de recto.DISEÑO:Revisión retrospectiva de pacientes sometidos a excisión total del mesorecto por vía transanal en casos de cáncer de recto primario desde enero de 2014 hasta diciembre de 2019.AJUSTE:Centro médico Universitario de atención terciaria único en los Estados Unidos.PACIENTES:Aquellos pacientes consecutivos de ≥ 18 años de edad, sometidos a resección quirúrgica por cáncer de recto primario.INTERVENCIÓN:Los procedimientos de excisión total del mesorecto por vía transanal se realizaron utilizando un enfoque de dos equipos.PRINCIPALES MEDIDAS DE RESULTADO:Los resultados primarios fueron la calidad anatomo-patológica de las piezas, la recidiva local y a distancia, las complicaciones relacionadas con el tratamiento y la sobrevida global específica para el cáncer.RESULTADOS:Se incluyeron 79 pacientes consecutivos. La mediana de edades fue de 58 años (IQR, 50-64) y la mediana del índice de masa corporal fue de 28 kg / m (IQR, 24,6-32,4). El mesorrecto se encontraba completo en 69 pacientes (87,3%), casi completo en 9 (11,4%) e incompleto en 1 (1,3%). Hubo afectación de CRM (<1 mm) en 4 pacientes (5,1%) y ningún paciente tuvo un margen distal positivo (<1 mm) o perforación rectal intraoperatoria. La histopatología óptima compuesta se logró en el 94,9% de las muestras. La mediana de seguimiento fue de 29 meses (rango 6-68). No se presentaron recurrencias locales. Se encontraron metástasis a distancia en 10 (13,5%) pacientes y se diagnosticaron después de una mediana de 14 meses (rango 0,6-53). La sobrevida libre de enfermedad fue del 91,2% a los 2 años y la sobrevida global fue del 94,7% a los 2 años.LIMITACIONES:Diseño retrospectivo, unicéntrico y período de seguimiento relativamente corto.CONCLUSIÓN:Los resultados oncológicos de este estudio de cohortes, apoyan la realización de excisión total del mesorecto por vía transanal para el tratamiento quirúrgico del cáncer de recto medio y bajo, en centros con la experiencia adecuada. Consulte Video Resumen en http://links.lww.com/DCR/B723. (Traducción-Dr. Xavier Delgadillo).
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Affiliation(s)
- Justin A. Maykel
- University of Massachusetts Memorial Medical Center, Worcester, Massachusetts
| | - Sue J. Hahn
- University of Massachusetts Memorial Medical Center, Worcester, Massachusetts
| | | | - David C. Meyer
- University of Massachusetts Memorial Medical Center, Worcester, Massachusetts
| | - Susanna S. Hill
- University of Massachusetts Memorial Medical Center, Worcester, Massachusetts
| | - Paul R. Sturrock
- University of Massachusetts Memorial Medical Center, Worcester, Massachusetts
| | - Jennifer S. Davids
- University of Massachusetts Memorial Medical Center, Worcester, Massachusetts
| | - Karim Alavi
- University of Massachusetts Memorial Medical Center, Worcester, Massachusetts
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Yuen A, Brar MS, de Buck van Overstraeten A. Indications and Surgical Technique for Transanal Proctectomy and Ileal Pouch-Anal Anastomosis for Inflammatory Bowel Disease. Clin Colon Rectal Surg 2022; 35:135-140. [PMID: 35237109 PMCID: PMC8885156 DOI: 10.1055/s-0041-1742114] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Surgical management of inflammatory bowel disease has advanced significantly over the years. One particular focus of its evolution has been to minimize invasiveness. Transanal surgery has given the contemporary surgeon an alternate approach to access the low rectum situated in the confines of the deep pelvis. In benign disease, combining transanal surgery with laparoscopy has allowed for the development of novel techniques to create ileal pouch-anal anastomoses, perform intersphincteric Crohn's proctectomies, manage complications from pelvic surgery, and facilitate redo pelvic surgery. We aim to review the indications for transanal surgery in benign disease, describe an approach to transanal pouch surgery in detail, and discuss the potential benefits, pitfalls, and contentious issues surrounding this approach.
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Affiliation(s)
- Andrew Yuen
- Department of Surgery, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Mantaj S. Brar
- Department of Surgery, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Anthony de Buck van Overstraeten
- Department of Surgery, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada,Address for correspondence Anthony de Buck van Overstraeten, MD, MSc 600 University Avenue Rm 455, Toronto, ON M5G1X5Canada
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McCurdy JD, Reid J, Yanofsky R, Sinnathamby V, Medawar E, Williams L, Bessissow T, Rosenfeld G. Fecal Diversion for Perianal Crohn Disease in the Era of Biologic Therapies: A Multicenter Study. Inflamm Bowel Dis 2022; 28:226-233. [PMID: 33988225 DOI: 10.1093/ibd/izab086] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 11/26/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND The natural history of perianal Crohn disease (PCD) after fecal diversion in the era of biologics is poorly understood. We assessed clinical and surgical outcomes after fecal diversion for medically refractory PCD and determined the impact of biologics. METHODS We performed a retrospective, multicenter study from 1999 to 2020. Patients who underwent fecal diversion for refractory PCD were stratified by diversion type (ostomy with or without proctectomy). Times to clinical and surgical outcomes were estimated using Kaplan-Meier methods, and the association with biologics was assessed using multivariable Cox proportional hazards models. RESULTS Eighty-two patients, from 3 academic institutions, underwent a total of 97 fecal diversions: 68 diversions without proctectomy and 29 diversions with proctectomy. Perianal healing occurred more commonly after diversion with proctectomy than after diversion without proctectomy (83% vs 53%; P = 0.021). Among the patients who had 68 diversions without proctectomy, with a median follow-up of 4.9 years post-diversion (interquartile range, 1.66-10.19), 37% had sustained healing, 31% underwent surgery to restore bowel continuity, and 22% underwent proctectomy. Ostomy-free survival occurred in 21% of patients. Biologics were independently associated with avoidance of proctectomy (hazard ratio, 0.32; 95% confidence interval, 0.11-0.98) and surgery to restore bowel continuity (hazard ratio, 3.10; 95% confidence interval, 1.02-9.37), but not fistula healing. CONCLUSIONS In this multicenter study, biologics were associated with bowel restoration and avoidance of proctectomy after fecal diversion without proctectomy for PCD; however, a minority of patients achieved sustained fistula healing after initial fecal diversion or after bowel restoration. These results highlight the refractory nature of PCD.
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Affiliation(s)
- Jeffrey D McCurdy
- Department of Medicine, University of Ottawa, Ottawa, Canada.,The Ottawa Hospital Research Institute, Ottawa, Canada
| | - Jacqueline Reid
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Russell Yanofsky
- Division of Gastroenterology, Department of Medicine, McGill University Health Center, Montreal, Canada
| | | | - Edgar Medawar
- Division of Gastroenterology, Department of Medicine, McGill University Health Center, Montreal, Canada
| | - Lara Williams
- Department of Surgery, University of Ottawa, Ottawa, Canada
| | - Talat Bessissow
- Division of Gastroenterology, Department of Medicine, McGill University Health Center, Montreal, Canada
| | - Greg Rosenfeld
- Department of Medicine, University of British Columbia, Vancouver, Canada
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16
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Yamamoto T, Shimoyama T. Fecal Diversion in Complex Perianal Fistulizing Crohn's Disease. Clin Colon Rectal Surg 2022; 35:5-9. [PMID: 35069025 PMCID: PMC8763458 DOI: 10.1055/s-0041-1740028] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Complex perianal Crohn's disease (CD) remains a challenging problem. Fecal stream is thought to be a trigger of disease progression in patients with CD. In patients with refractory perianal CD, diversion of fecal stream is sometimes required to alleviate clinical symptoms when medical and local surgical management are unsuccessful. Several studies evaluated the outcomes of fecal diversion for complex perianal CD. After fecal diversion, the majority of patients achieved early clinical response, but the prospect of restoring bowel continuity was low (approximately 20%). Nearly half of the patients eventually required proctectomy. A number of studies attempted to identify predictive factors for the outcomes of fecal diversion. Only rectal involvement was associated with unsuccessful restoration of bowel continuity. Biologic therapy did not seem to improve the efficacy of fecal diversion, although the evidence level was low because of insufficient data or methodological limitations. Based on these results, fecal diversion may be useful in alleviating clinical symptoms related to severe perianal CD and avoiding immediate proctectomy. The impact of biologic therapy on the outcomes of fecal diversion should be further investigated.
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Affiliation(s)
- Takayuki Yamamoto
- Inflammatory Bowel Disease Center, Department of Surgery, Yokkaichi Hazu Medical Center, Yokkaichi, Mie, Japan,Address for correspondence Takayuki Yamamoto, MD, PhD, FACG Inflammatory Bowel Disease Center, Department of Surgery, Yokkaichi Hazu Medical Center10-8 Hazuyamacho, Yokkaichi, Mie 510-0016Japan
| | - Takahiro Shimoyama
- Inflammatory Bowel Disease Center, Department of Surgery, Yokkaichi Hazu Medical Center, Yokkaichi, Mie, Japan
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17
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Lightner AL, Steele SR, Delaney CP, Lavryk O, Vaidya P, McMichael J, Jia X, de Buck van Overstraeten A, Brar MS. Colonic disease recurrence following proctectomy with end colostomy for anorectal Crohn's disease. Colorectal Dis 2021; 23:2425-2435. [PMID: 34157206 DOI: 10.1111/codi.15777] [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] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 05/17/2021] [Accepted: 05/18/2021] [Indexed: 12/13/2022]
Abstract
AIM In patients with anorectal Crohn's disease, it remains uncertain whether a total proctocolectomy with end ileostomy or proctectomy with end colostomy should be recommended due to the unknown rate of disease recurrence in the remaining colon. METHODS A retrospective review of all patients with a known diagnosis of Crohn's disease who underwent a proctectomy with end colostomy for distal Crohn's disease between January 1, 2010 and January 1, 2019 at two IBD referral centres was conducted. Data collected included patient demographics, surgical variables at the time of proctectomy, and postoperative clinical, endoscopic and surgical recurrence rates. RESULTS A total of 63 patients were included; mean age was 47 years (SD 15 years) and 32 (50.8%) were female. The majority of patients underwent a proctectomy with end colostomy (n = 56; 88.9%) while the remaining seven patients (11.1%) underwent a proctectomy with end colostomy and concurrent ileocectomy. A total of 55 patients (87.3%) had proctitis, 51 (81%) had perianal fistulating disease, and 34 (54%) had anal canal stenosis or ulceration. Most patients had medically refractory disease (n = 54; 85.7%) versus neoplasia (n = 9; 14.3%). The median length of long-term follow-up was 17.7 months (IQR: 4.72, 38.7 months). During that time, 14 (22.2%) experienced clinical recurrence, 10 of 34 evaluated (29.4%) had endoscopic recurrence, and 3 (4.76%) required a completion total abdominal colectomy for recurrent medically refractory disease in the colon. CONCLUSION Colonic recurrence remains low following proctectomy and descending colostomy suggesting this operative management strategy is reasonable in Crohn's patients with distal disease.
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Affiliation(s)
- Amy L Lightner
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Scott R Steele
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Conor P Delaney
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Olga Lavryk
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Prashansha Vaidya
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - John McMichael
- General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Xue Jia
- Department of Qualitative Health Science, Cleveland Clinic, Cleveland, OH, USA
| | | | - Mantaj S Brar
- Department of Surgery, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
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Grant RK, Elosua-González A, Bouri S, Sahnan K, Brindle WM, Dilke SM, Vincent MLM, Adegbola SOA, Warusavitarne JH, Tozer PJ, Arnott IDR, Hart AL. Prognostic factors associated with unhealed perineal wounds post- proctectomy for perianal Crohn's disease: a two-centre study. Colorectal Dis 2021; 23:2091-2099. [PMID: 34021522 DOI: 10.1111/codi.15744] [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] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 03/11/2021] [Accepted: 05/13/2021] [Indexed: 12/19/2022]
Abstract
AIM The aim of this work was to determine the factors associated with poor wound healing in patients with perianal Crohn's disease (pCD) who had undergone proctectomy in the era of biologic therapies. METHOD Case record review was performed on 103 patients with pCD who underwent proctectomy at St Mark's Hospital, Harrow and the Western General Hospital, Edinburgh between 2005 and 2017. Healing rates at 6 and 12 months post-proctectomy were considered; univariate analysis was performed. RESULTS Sixty out of 103 patients (58.3%) had failure of wound healing at 6 months and 41/103 (39.8%) at 12 months. In total, 63.1% (65/103) patients received biologic therapies prior to proctectomy; however, exposure to biologics was not a significant factor in predicting failure of wound healing at 12 months (infliximab p = 0.255; adalimumab p = 0.889; vedolizumab p = 0.153). Male gender was the only variable associated with poor wound healing at 12 months on univariate analysis (p = 0.017). A lower pre-operative C-reactive protein was associated with early wound healing at 6 months compared with at 12 months (p = 0.041) on univariate analysis. Other parameters not associated with rates of wound healing included smoking status, corticosteroid exposure, thiopurine exposure, number of previous biologics, perianal sepsis on MRI within the last 12 months, duration of CD prior to proctectomy and pre-operative albumin. CONCLUSION More than a third of patients had unhealed wounds 12 months after proctectomy. We report that unhealed wounds are more common in male patients. Importantly, our results also suggest that exposure to biologics does not affect rates of wound healing.
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Affiliation(s)
- Rebecca K Grant
- The Edinburgh IBD Unit, Western General Hospital, Edinburgh, UK
| | | | | | | | | | | | | | | | | | | | - Ian D R Arnott
- The Edinburgh IBD Unit, Western General Hospital, Edinburgh, UK
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Pedersen KE, Lightner AL. Managing Complex Perianal Fistulizing Disease. J Laparoendosc Adv Surg Tech A 2021; 31:890-897. [PMID: 34314631 DOI: 10.1089/lap.2021.0285] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Perianal disease is a particularly morbid phenotype of Crohn's disease, affecting up to one third of patients, with a significantly diminished quality of life. Conventional medical therapy and surgical interventions have limited efficacy. Medical treatment options achieve long-term durable remission in only a third of patients. Therefore, most patients undergo an operation, leaving them with a chronic seton or at risk of incontinence with multiple interventions. Mesenchymal stem cell therapy is an emerging therapy without risk of incontinence and improved efficacy as compared with conventional therapy. Laser therapy is another new intervention. Unfortunately, up to 40% of patients still require a stoma related to perianal fistulizing disease.
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Affiliation(s)
- Karina E Pedersen
- College of Medicine, Northeast Ohio Medical University, Rootstown, Ohio, USA
| | - Amy L Lightner
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland, Ohio, USA
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20
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Gilshtein H, Ghuman A, Dawoud M, Yellinek S, Kent I, Sharp SP, Nagarajan A, Wexner SD. Total Neoadjuvant Treatment for Rectal Cancer: Preliminary Experience. Am Surg 2020; 87:708-713. [PMID: 33169626 DOI: 10.1177/0003134820951499] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Administration of chemotherapeutic regimens such as FOLFOX or CAPEOX with chemoradiation in the neoadjuvant setting, termed total neoadjuvant treatment (TNT), was introduced in recent years. By increasing the complete pathologic and clinical responses, patients with locally advanced rectal cancer may have better oncologic outcomes and potentially abstain from undergoing a proctectomy. METHODS All patients who underwent TNT at a single National Accreditation Program for Rectal Cancer accredited referral center were included. A retrospective analysis was performed using a computerized Institutional Review Board-approved database. Patient demographics, diagnostic workup, treatment regimens, and surgical and pathological reports were reviewed. Complete pathological response was the primary outcome. Univariable and multivariable logistic regression analyses were performed to identify potential factors predisposing to complete pathological response. RESULTS Thirty patients met the inclusion criteria, 14(46.6%) of whom had complete pathologic response. There was no difference in baseline demographic characteristics between patients who achieved complete pathological response and those who did not. Pathology revealed a 92% intact mesorectum rate in the complete pathologic response group and a mean of 24 harvested lymph nodes in the entire study cohort. Both univariable and multivariable logistic regression analyses failed to demonstrate statistically significant factors predicting complete pathologic response, magnetic resonance imaging (MRI) tumor size, and posttreatment MRI lymph node positivity. CONCLUSION TNT is safe and efficient for patients with locally advanced rectal cancer. It increases complete pathological and clinical response rates and may more widely evolve to be the treatment of choice in this group of patients in the near future.
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Affiliation(s)
- Hayim Gilshtein
- Department of Colorectal Surgery, Cleveland Clinic Florida, FL, USA
| | - Amandeep Ghuman
- Department of Colorectal Surgery, Cleveland Clinic Florida, FL, USA
| | - Mirelle Dawoud
- Department of Colorectal Surgery, Cleveland Clinic Florida, FL, USA
| | - Shlomo Yellinek
- Department of Colorectal Surgery, Cleveland Clinic Florida, FL, USA
| | - Ilan Kent
- Department of Colorectal Surgery, Cleveland Clinic Florida, FL, USA
| | - Stephen P Sharp
- Department of Colorectal Surgery, Cleveland Clinic Florida, FL, USA
| | - Arun Nagarajan
- Department of Hematology and Medical Oncology, Cleveland Clinic Florida, FL, USA
| | - Steven D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, FL, USA
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21
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Lumpkin ST, Strassle PD, Fine JP, Carey TS, Stitzenberg KB. Early Follow-up After Colorectal Surgery Reduces Postdischarge Emergency Department Visits. Dis Colon Rectum 2020; 63:1550-8. [PMID: 33044296 DOI: 10.1097/DCR.0000000000001732] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Thirty-day readmissions, emergency department visits, and observation stays are common after colorectal surgery (9%-25%, 8%-12%, and 3%-5%), yet it is unknown to what extent planned postdischarge care can decrease the frequency of emergency department visits. OBJECTIVE This study's aim was to determine whether early follow-up with the surgical team reduces 30-day emergency department visits. DESIGN This retrospective cohort study used a central data repository of clinical and administrative data for 2013 through 2018. SETTING This study was conducted in a large statewide health care system (10 affiliated hospitals, >300 practices). PATIENTS All adult patients undergoing colorectal surgery were included unless they had a length of stay <1 day or died during the index hospitalization. INTERVENTION Early (<10 days after discharge) versus late (≥10 days) follow-up at the outpatient surgery clinic, or no outpatient surgery clinic follow-up, was assessed. MAIN OUTCOME MEASURES The primary outcome measured was the time to 30-day postdischarge emergency department visit. RESULTS Our cohort included 3442 patients undergoing colorectal surgery; 38% of patients had an early clinic visit. Overall, 11% had an emergency department encounter between 11 and 30 days after discharge. Those with early follow-up had decreased emergency department encounters (adjusted HR 0.13; 95% CI, 0.08-0.22). An early clinic visit within 10 days, compared to 14 days, prevented an additional 142 emergency department encounters. Nationwide, this could potentially prevent 8433 unplanned visits each year with an estimated cost savings of $49 million annually. LIMITATIONS We used retrospective data and were unable to assess for health care utilization outside our health system. CONCLUSIONS Early follow-up within 10 days of adult colorectal surgery is associated with decreased subsequent emergency department encounters. See Video Abstract at http://links.lww.com/DCR/B330. EL SEGUIMIENTO TEMPRANO DESPUÉS DE LA CIRUGÍA COLORRECTAL REDUCE LAS VISITAS AL SERVICIO DE URGENCIAS POSTERIOR AL ALTA: Los readmisión a los treinta días, las visitas al servicio de urgencias y las estancias de observación son comunes después de la cirugía colorrectal, 9-25%, 8-12% y 3-5%, respectivamente. Sin embargo, se desconoce en qué medida la atención planificada posterior al alta puede disminuir la frecuencia de las visitas al servicio de urgencias.Determinar si el seguimiento temprano con el equipo quirúrgico reduce las visitas a 30 días al servicio de urgencias.Este estudio de cohorte retrospectivo utilizó un depósito central de datos clínicos y administrativos para 2013-2018.Gran sistema de salud estatal (10 hospitales afiliados,> 300 consultorios).Se incluyeron todos los pacientes adultos de cirugía colorrectal a menos que tuvieran una estadía <1 día o murieran durante el índice de hospitalización.Temprano (<10 días después del alta) versus tardío (≥10 días) o sin seguimiento en la clínica de cirugía ambulatoria.Tiempo para la visita al servicio de urgencias a 30 días después del alta.Nuestra cohorte incluyó 3.442 pacientes de cirugía colorrectal; El 38% de los pacientes tuvieron una visita temprana a clínica. En total, el 11% tuvo un encuentro con el servicio de urgencias entre 11 y 30 días después de ser dado de alta. Aquellos con seguimiento temprano disminuyeron las visitas al servicio de urgencias (HR 0,13; IC del 95%: 0,08 a 0,22). Además, una visita temprana a la clínica en un plazo de 10 días, en comparación con 14 días, evitó 142 encuentros adicionales en el servicio de urgencias. A nivel nacional, esto podría prevenir 8.433 visitas no planificadas cada año con un ahorro estimado de $ 49 millones anuales.Utilizamos datos retrospectivos y no pudimos evaluar la utilización de la atención médica fuera de nuestro sistema de salud.El seguimiento temprano dentro de los 10 días de la cirugía colorrectal en adultos se asocia con una disminución de los encuentros posteriores en el servicio de urgencias. Consulte Video Resumen en http://links.lww.com/DCR/B330. (Traducción-Dr. Gonzalo Hagerman).
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McKenna NP, Bews KA, Colibaseanu DT, Mathis KL, Nelson H, Habermann EB. The intersection of tumor location and combined bowel preparation: Utilization differs but anastomotic leak risk reduction does not. J Surg Oncol 2020; 123:261-270. [PMID: 33002190 DOI: 10.1002/jso.26224] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 08/16/2020] [Accepted: 09/05/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND OBJECTIVE Whether bowel preparation utilization rates or effectiveness varies based on tumor location is unknown. METHODS The 2012-2016 American College of Surgeons National Surgical Quality Improvement Program Colectomy Targeted participant user file was queried for patients undergoing elective colorectal resection for cancer. Bowel preparation was classified as combined, mechanical bowel preparation alone, oral antibiotic alone, or none. Cochran-Armitage tests were used for trend analysis. Multivariable analyses stratified by tumor location were performed for the outcome of anastomotic leak. An additional multivariable model including all tumor locations assessed for interaction between bowel preparation and tumor location on an anastomotic leak. RESULTS A total of 29,739 operations were included and the anastomotic leak rate was 1.9% with combined preparation versus 4.0% without preparation. Combined bowel preparation utilization increased over time as tumor location became more distal (both p < .0001). However, the adjusted effect of combined bowel preparation on anastomotic leak risk reduction did not differ by individual tumor location or across all tumor locations (p = .43 for interaction). CONCLUSION Though the utilization rate of combined bowel preparation increased as tumor location became more distal, its risk-reducing effect remained similar. Quality improvement initiatives should focus on increased utilization of combined bowel preparation with an emphasis on tumors in the ascending colon.
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Affiliation(s)
- Nicholas P McKenna
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA.,Division of Health Care Policy and Research, The Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Katherine A Bews
- Division of Health Care Policy and Research, The Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Dorin T Colibaseanu
- Division of Colon and Rectal Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Heidi Nelson
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Elizabeth B Habermann
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA.,Division of Health Care Policy and Research, The Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
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23
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Solomon MJ, Loizides S, Däster S, Austin KKS, Lee PJ. Prone en bloc sacrectomy with proctectomy: a surgical approach to the inaccessible and hostile pelvis. Colorectal Dis 2020; 22:1440-1444. [PMID: 32359204 DOI: 10.1111/codi.15106] [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: 03/28/2020] [Accepted: 04/18/2020] [Indexed: 12/12/2022]
Abstract
AIM Reoperative pelvic surgery is rarely hostile and unsafe. Kraske's procedure has historically been used to approach the mid-rectum and to resect retrorectal tumors. However, it provides limited access to the pelvis and is best in the 'virgin' pelvis. We have encountered a select group of patients who required completion proctectomy or resection of a disconnected ileoanal J-pouch where trans-abdominal access to the pelvis was not possible and access to the pelvis could only be safely gained by a prone en bloc sacrectomy. METHOD We describe a prone approach that provides an alternative route of access to the hostile pelvis. After exposure of the sacrum and coccyx and transection of the sacrum, access to the mesorectal plane is achieved and a proctectomy (or resection of an ileoanal J-pouch) can be completed. The procedure is similar to the Kraske approach but requires a higher and wider exposure similar to the extent of an abdominal resection; however, the operation is performed in 'reverse'. RESULTS We found that this approach was feasible and safe in the previously operated, hostile pelvis. We employed it in one patient to excise a disconnected J-pouch with chronic sepsis and in another patient for a completion proctectomy. Both patients had an uneventful recovery and clear margins were obtained with no complications. CONCLUSION The en bloc prone sacrectomy approach is a useful alternative in a very select group of patients with difficult trans-abdominal access to the pelvis. Experience in pelvic surgery and identification of clear anatomical landmarks is paramount to avoid catastrophic uncontrollable bleeding.
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Affiliation(s)
- M J Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Surgical Outcomes Research Centre (SOuRCe), Sydney Local Health District, University of Sydney, Sydney, New South Wales, Australia.,Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - S Loizides
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - S Däster
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - K K S Austin
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Surgical Outcomes Research Centre (SOuRCe), Sydney Local Health District, University of Sydney, Sydney, New South Wales, Australia
| | - P J Lee
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Surgical Outcomes Research Centre (SOuRCe), Sydney Local Health District, University of Sydney, Sydney, New South Wales, Australia
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24
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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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25
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Hung LY, Benlice C, Jia X, Steele SR, Valente MA, Holubar SD, Gorgun E. Outcomes after Early versus Delayed Urinary Bladder Catheter Removal after Proctectomy for Benign and Malignant Disease in 2,429 Patients: An Observational Cohort Study. Surg Infect (Larchmt) 2020; 22:310-317. [PMID: 32721201 DOI: 10.1089/sur.2020.159] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background: There currently is no standard practice for optimal urinary catheter removal after rectal resection (proctectomy). Delayed removal may increase urinary tract infection risk, an important hospital quality metric. This study aimed to assess the effect of catheter duration on urinary tract infection rate. We hypothesized that early removal would be associated with fewer infections. Methods: We performed a retrospective review of patients who underwent proctectomy from January 2007 to December 2017 with urinary catheter placement in our colorectal surgery department. The main outcome measures were urinary tract infection, post-operative urinary retention, and length of stay. Patients were divided into early (post-operative day one or two) and late (day three or later) removal groups. Results: A series of 2,429 patients were included; 1,176 in the early and 1,253 in the late group. The early group had a shorter median length of stay (5.26 versus 7 days). The urinary tract infection (n = 77) multivariable logistic regression model showed no association between timing of removal and infection; however, females had more infections (odds ratio [OR] 2.70, 95% confidence interval [CI] 1.65-4.41). The post-operative urinary retention model (n = 280) showed no association between the timing of removal and retention; however, patients who underwent pre-operative radiation (OR 1.55; 95% CI 1.15-2.09) or total proctocolectomy (OR 1.74; 95% CI 1.21-2.49) or were male (OR 1.35; 95% CI 1.02-1.78) were more likely to have retention. When analyzed by specific removal day, each one-day delay in removal increased the odds of infection by 21% (OR 1.21; 95% CI 1.09-1.35] and decreased the odds of retention by 12% (OR 0.88; 95% CI 0.80-0.97] with a cross-over at 9 days. Patients who experienced retention were not more likely to have infection. Conclusion: Early urinary catheter removal after proctectomy was associated with a lower urinary tract infection rate and a shorter hospital stay.
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Affiliation(s)
- Laurie Y Hung
- Colorectal Surgery Department, Cleveland Clinic, Cleveland, Ohio, USA
| | - Cigdem Benlice
- Colorectal Surgery Department, Cleveland Clinic, Cleveland, Ohio, USA
| | - Xue Jia
- Colorectal Surgery Department, Cleveland Clinic, Cleveland, Ohio, USA
| | - Scott R Steele
- Colorectal Surgery Department, Cleveland Clinic, Cleveland, Ohio, USA
| | - Michael A Valente
- Colorectal Surgery Department, Cleveland Clinic, Cleveland, Ohio, USA
| | - Stefan D Holubar
- Colorectal Surgery Department, Cleveland Clinic, Cleveland, Ohio, USA
| | - Emre Gorgun
- Colorectal Surgery Department, Cleveland Clinic, Cleveland, Ohio, USA
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26
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Dimov I, Sobczak S, Grabs D, Nayouf A. The median sacral artery in rectal blood supply: A cadaveric study. Clin Anat 2020; 34:342-347. [PMID: 32319711 DOI: 10.1002/ca.23611] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 04/07/2020] [Accepted: 04/18/2020] [Indexed: 11/12/2022]
Abstract
INTRODUCTION Insufficient blood supply to the posterior rectal remnant after proctectomy is a possible mechanism for anastomotic leakage. The median sacral artery (MSA) is not generally considered to participate in the rectal blood supply, although some case studies have reported the rectum being supplied by it. The aim of this study is to elucidate the anatomy of the MSA in relation to the posterior rectal wall. METHODS Nineteen embalmed cadavers (12 males, seven females; mean age: 76 ± 9 years) were injected with a colored radio-opaque mixture in the aortic bifurcation, radiographed and subsequently dissected along the sacrum. The relationship between the MSA and the rectum was observed and the diameter of the MSA was measured 2 cm below the aortic bifurcation. RESULTS MSAs were identified in 16 (84.2%) of the 19 cadavers. Nine MSAs (47.4%) reached the rectal wall and penetrated it. MSAs that reached the posterior rectum took two different routes in the presacral space. Dissection and radiography showed four penetrating MSAs (21.1%) ending in a branching pattern and five (26.3%) as a tapering vessel. Seven MSAs (36.8%) did not reach the rectal wall. The mean MSA diameter was 1.98 ± 0.12 mm. CONCLUSIONS Almost half the MSAs reached and penetrated the posterior rectal wall, suggesting possible participation in the rectal blood supply. A large portion of the MSAs that penetrate the rectal wall run outside surgical margins and could continue to provide blood supply to the rectal remnant, potentially preventing anastomotic leakage.
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Affiliation(s)
- Ivan Dimov
- Department of Anatomy, Université du Québec à Trois-Rivières, Trois-Rivières, Quebec, Canada
| | - Stéphane Sobczak
- Department of Anatomy, Université du Québec à Trois-Rivières, Trois-Rivières, Quebec, Canada.,Research Unit of Clinical and Functional Anatomy, Université du Québec à Trois-Rivières, Trois-Rivières, Quebec, Canada
| | - Detlev Grabs
- Department of Anatomy, Université du Québec à Trois-Rivières, Trois-Rivières, Quebec, Canada.,Research Unit of Clinical and Functional Anatomy, Université du Québec à Trois-Rivières, Trois-Rivières, Quebec, Canada
| | - Anna Nayouf
- Department of Anatomy, Université du Québec à Trois-Rivières, Trois-Rivières, Quebec, Canada.,Research Unit of Clinical and Functional Anatomy, Université du Québec à Trois-Rivières, Trois-Rivières, Quebec, Canada
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27
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Bednarski BK. Minimally invasive rectal surgery: Laparoscopy, robotics, and transanal approaches. J Surg Oncol 2020; 122:78-84. [PMID: 32291771 DOI: 10.1002/jso.25925] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 03/16/2020] [Indexed: 12/15/2022]
Affiliation(s)
- Brian K Bednarski
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
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28
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Ofshteyn A, Weaver AB, Brady JT, Idrees J, Coronado WM, Steele SR, Reynolds H, Steinhagen E, Stein SL. Institutional Outcomes Should Be a Determinant in Decision to Perform Laparoscopic Proctectomies for Rectal Cancer. Cureus 2020; 12:e7666. [PMID: 32419994 PMCID: PMC7226664 DOI: 10.7759/cureus.7666] [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] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Purpose Minimally invasive rectal cancer (RC) resection has become common, despite recent high-profile trials failing to show non-inferiority to open proctectomy. We hypothesized that at a high-volume center, laparoscopic resection may have superior outcomes compared to those seen in ALaCaRT and ACOSOG Z6051. Methods Retrospective review of patients undergoing laparoscopic proctectomy from 2007 to 2015 for RC was performed at a high-volume center. Primary outcome was successful resection defined by negative circumferential resection margin (CRM) and distal margin (DM), and complete total mesorectal excision (TME). Results A total of 89 patients were included. Of 33 patients with TME grading, 31 (93.9%) had complete/near complete TME, and 29 (87.9%) had a “successful resection” compared with 81.7% in ACOSOG and 82% in ALaCART trials using same criteria. CRM was ≥1 mm in 87 (97.8%) of patients. Mean DM was 3.8 cm; 97.8% of patients had negative DM. Conclusion High-volume centers can achieve similar high quality RC outcomes to those demonstrated in recent trials. Institutional outcomes should determine optimal surgical technique.
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Affiliation(s)
- Asya Ofshteyn
- Surgery, University Hospitals Cleveland Medical Center / University Hospitals Research in Surgical Outcomes & Effectiveness Center (UH-RISES), Cleveland, USA
| | - Allson B Weaver
- Surgery, University Hospitals Cleveland Medical Center / University Hospitals Research in Surgical Outcomes & Effectiveness Center (UH-RISES), Cleveland, USA
| | - Justin T Brady
- Surgery, University Hospitals Cleveland Medical Center / University Hospitals Research in Surgical Outcomes & Effectiveness Center (UH-RISES), Cleveland, USA
| | - Jay Idrees
- General Surgery, University Hospitals Cleveland Medical Center / University Hospitals Research in Surgical Outcomes & Effectiveness Center (UH-RISES), Cleveland, USA
| | - Wendy M Coronado
- Surgery, University Hospitals Cleveland Medical Center / University Hospitals Research in Surgical Outcomes & Effectiveness Center (UH-RISES), Cleveland, USA
| | | | - Harry Reynolds
- Surgery, Harney District Hospital, Burns, USA.,Surgery, University Hospitals Cleveland Medical Center / University Hospitals Research in Surgical Outcomes & Effectiveness Center (UH-RISES), Cleveland, USA
| | - Emily Steinhagen
- Surgery, University Hospitals Cleveland Medical Center / University Hospitals Research in Surgical Outcomes & Effectiveness Center (UH-RISES), Cleveland, USA
| | - Sharon L Stein
- Colorectal Surgery, University Hospitals Cleveland Medical Center / University Hospitals Research in Surgical Outcomes & Effectiveness Center (UH-RISES), Cleveland, USA
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29
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Johnston S, Louis M, Churilov L, Ma R, Christophi C, Weinberg L. Health costs of post-operative complications following rectal resection: a systematic review. ANZ J Surg 2020; 90:1270-1276. [PMID: 32053858 DOI: 10.1111/ans.15708] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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: 08/15/2019] [Revised: 01/03/2020] [Accepted: 01/04/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Post-operative complications following rectal resection pose significant health and cost implications for patients and health providers. The objective of this study is to review the associated cost of complications following rectal resection. This included reporting on the proportion and severity of these complications, associated length of stay and surgical technique used. Studies were sourced from Embase OVID, MEDLINE OVID (ALL) and Cochrane Library databases by utilizing a search strategy. METHODS This search contained studies from 1 January 2010 until 13 February 2019. Studies were included from the year 2010 to account for the implementation of enhanced recovery after surgery protocols. Studies that reported the financial cost associated with complications were included. Any indication for rectal resection was considered. Data was extracted into a formatted table and a narrative synthesis was performed. RESULTS We identified 13 eligible studies for inclusion. There was strong evidence to suggest that complications are associated with increased costs. There was considerable variation as to the costs attributable to complications ($1443 (P < 0.001) to $17 831 (P < 0.0012), n = 12). The presence of complications was associated with an increased length of stay (5.54 (P-value not given) to 21.04 (P < 0.0001) days, n = 7). There was significant variation in the proportion of complications (6.41 to 64.71%, n = 8). Weak evidence existed around surgical technique used and the associated cost of complications. There was considerable heterogeneity among included studies. CONCLUSIONS Complications following rectal resection increased health costs. Costs should be standardized and provide a clear methodology for their calculation. Complications should be standardized and include a grading of severity.
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Affiliation(s)
- Samuel Johnston
- Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia.,Department of Anaesthesia, Austin Health, Melbourne, Victoria, Australia
| | - Maleck Louis
- Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia.,Department of Anaesthesia, Austin Health, Melbourne, Victoria, Australia
| | - Leonid Churilov
- Department of Medicine, Austin Health, Melbourne, Victoria, Australia.,Melbourne Brain Centre, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Ronald Ma
- Department of Finance, Austin Health, Melbourne, Victoria, Australia
| | | | - Laurence Weinberg
- Department of Anaesthesia, Austin Health, Melbourne, Victoria, Australia.,Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
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30
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Hong MKY, Yeung JMC, Watters DAK, Faragher IG. State-wide outcomes in elective rectal cancer resection: is there a case for centralization in Victoria? ANZ J Surg 2019; 89:1642-1646. [PMID: 31802618 DOI: 10.1111/ans.15546] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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: 07/29/2019] [Revised: 08/25/2019] [Accepted: 08/29/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND The role of service centralization in rectal cancer surgery is controversial. Recent studies suggest centralization to high-volume centres may improve postoperative mortality. We used a state-wide administrative data set to determine the inpatient mortality for patients undergoing elective rectal cancer surgery and to compare individual hospital volumes. METHODS The Victorian Admitted Episodes Dataset was explored using the Dr Foster Quality Investigator tool. The inpatient mortality rate, 30-day readmission rate and the proportion of patients with increased length of stay were measured for all elective admissions for rectal cancer resections between 2012 and 2016. A peer group of 14 hospitals were studied using funnel plots to determine inter-hospital variation in mortality. Procedure types were compared between the groups. RESULTS There were 2241 elective resections performed for rectal cancer in Victoria over 4 years. The crude inpatient mortality rate was 1.1%. There were no significant differences in mortality among 14 hospitals within the peer group. The number of elective resections over 4 years ranged from 14 to 136 (median 65) within these institutions. Ultralow anterior resection was the commonest procedure performed. CONCLUSION Inpatient mortality after elective rectal cancer surgery in Victoria is rare and compares favourably internationally. Based on inpatient mortality alone, there is no compelling evidence to further centralize elective rectal cancer surgery in Victoria. More work is needed to develop data sets with oncological information capable of providing accurate complete state-wide data which will be essential for future service planning, training and innovation.
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Affiliation(s)
- Michael K-Y Hong
- Colorectal Surgery Unit, Western Health, Melbourne, Victoria, Australia.,Department of Surgery (Western Health), The University of Melbourne, Melbourne, Victoria, Australia
| | - Justin M C Yeung
- Colorectal Surgery Unit, Western Health, Melbourne, Victoria, Australia.,Department of Surgery (Western Health), The University of Melbourne, Melbourne, Victoria, Australia
| | - David A K Watters
- Department of Surgery, Geelong Hospital, Deakin University, Geelong, Victoria, Australia
| | - Ian G Faragher
- Colorectal Surgery Unit, Western Health, Melbourne, Victoria, Australia.,Department of Surgery (Western Health), The University of Melbourne, Melbourne, Victoria, Australia
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31
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Nyangoh Timoh K, Deffon J, Moszkowicz D, Lebacle C, Creze M, Martinovic J, Zaitouna M, Diallo D, Lavoue V, Fautrel A, Benoit G, Bessede T. Smooth muscle of the male pelvic floor: An anatomic study. Clin Anat 2019; 33:810-822. [PMID: 31746012 DOI: 10.1002/ca.23515] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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: 06/29/2019] [Revised: 10/14/2019] [Accepted: 10/20/2019] [Indexed: 01/06/2023]
Abstract
Knowledge of the anatomy of the male pelvic floor is important to avoid damaging the pelvic floor muscles during surgery. We set out to explore the structure and innervation of the smooth muscle (SM) of the whole pelvic floor using male fetuses. We removed en-bloc the entire pelvis of three male fetuses. The specimens were serially sectioned before being stained with Masson's trichrome and hematoxylin and eosin, and immunostained for SMs, and somatic, adrenergic, sensory and nitrergic nerve fibers. Slides were digitized for three-dimensional reconstruction. We individualized a middle compartment that contains SM cells. This compartment is in close relation with the levator ani muscle (LAM), rectum, and urethra. We describe a posterior part of the middle compartment posterior to the rectal wall and an anterior part anterior to the rectal wall. The anterior part is split into (1) a centro-levator area of SM cells localized between the right and left LAM, (2) an endo-levator area that upholsters the internal aspect of the LAM, and (3) an infra-levator area below the LAM. All these areas are innervated by autonomic nerves coming from the inferior hypogastric plexus. The core and the infra-levator area receive the cavernous nerve and nerves supplying the urethra. We thus demonstrate that these muscular structures are smooth and under autonomic influence. These findings are relevant for the pelvic surgeon, and especially the urologist, during radical prostatectomy, abdominoperineal resection and intersphincteric resection. Clin. Anat., 2019. © 2019 Wiley Periodicals, Inc.
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Affiliation(s)
- Krystel Nyangoh Timoh
- UMR 1195, University Paris Sud, INSERM, Université Paris-Saclay, Le Kremlin-Bicetre, France.,Department of Obstetrics and Gynecology, Hopital Universitaire de Rennes, University Rennes 1, Rennes, France
| | - J Deffon
- UMR 1195, University Paris Sud, INSERM, Université Paris-Saclay, Le Kremlin-Bicetre, France
| | - D Moszkowicz
- UMR 1195, University Paris Sud, INSERM, Université Paris-Saclay, Le Kremlin-Bicetre, France
| | - C Lebacle
- UMR 1195, University Paris Sud, INSERM, Université Paris-Saclay, Le Kremlin-Bicetre, France.,Urology Department, Hopitaux Universitaires Paris-Sud, APHP, Le Kremlin-Bicetre, France
| | - M Creze
- UMR 1195, University Paris Sud, INSERM, Université Paris-Saclay, Le Kremlin-Bicetre, France
| | - J Martinovic
- Department of Fetal Pathology, Hopitaux Universitaires Paris-Sud, APHP, Clamart, France
| | - M Zaitouna
- UMR 1195, University Paris Sud, INSERM, Université Paris-Saclay, Le Kremlin-Bicetre, France
| | - D Diallo
- UMR 1195, University Paris Sud, INSERM, Université Paris-Saclay, Le Kremlin-Bicetre, France
| | - V Lavoue
- Department of Obstetrics and Gynecology, Hopital Universitaire de Rennes, University Rennes 1, Rennes, France
| | - A Fautrel
- Université de Rennes 1, Rennes, France.,INSERM, UMR991 Liver Metabolism and Cancer, Rennes, France
| | - G Benoit
- UMR 1195, University Paris Sud, INSERM, Université Paris-Saclay, Le Kremlin-Bicetre, France
| | - T Bessede
- UMR 1195, University Paris Sud, INSERM, Université Paris-Saclay, Le Kremlin-Bicetre, France.,Urology Department, Hopitaux Universitaires Paris-Sud, APHP, Le Kremlin-Bicetre, France
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32
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McGee MF, Kreutzer L, Quinn CM, Yang A, Shan Y, Halverson AL, Love R, Johnson JK, Prachand V, Bilimoria KY. Leveraging a Comprehensive Program to Implement a Colorectal Surgical Site Infection Reduction Bundle in a Statewide Quality Improvement Collaborative. Ann Surg 2019; 270:701-711. [PMID: 31503066 PMCID: PMC7775039 DOI: 10.1097/sla.0000000000003524] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [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: 12/13/2022]
Abstract
OBJECTIVES Our objective was to examine the implementation and associated clinical outcomes of a comprehensive surgical site infection (SSI) reduction bundle in a large statewide surgical quality improvement collaborative leveraging a multifaceted implementation strategy. SUMMARY BACKGROUND DATA Bundled perioperative interventions reduce colorectal SSI rates when enacted at individual hospitals, but the ability to implement comprehensive SSI bundles and to examine the resultant clinical effectiveness within a larger, diverse population of hospitals is unknown. METHODS A multifaceted SSI reduction bundle was developed and implemented in a large statewide surgical quality improvement collaborative through a novel implementation program consisting of guided implementation, data feedback, mentorship, process improvement training/coaching, and targeted-implementation toolkits. Bundle adherence and ACS NSQIP outcomes were examined preimplementation versus postimplementation. RESULTS Among 32 hospitals, there was a 2.5-fold relative increase in the proportion of patients completing at least 75% of bundle elements (preimplementation = 19.5% vs. postimplementation = 49.8%, P = 0.001). Largest adherence gains were seen in wound closure re-gowning/re-gloving (24.0% vs. 62.0%, P < 0.001), use of clean closing instruments (32.1% vs. 66.2%, P = 0.003), and preoperative chlorhexidine bathing (46.1% vs. 77.6%, P < 0.001). Multivariable analyses showed a trend toward lower risk of superficial incisional SSI in the postimplementation period compared to baseline (OR 0.70, 95% CI 0.49-10.2, P = 0.06). As the adherence in the number of bundle elements increased, there was a significant decrease in superficial SSI rates (lowest adherence quintile, 4.6% vs. highest, 1.5%, P < 0.001). CONCLUSIONS A comprehensive multifaceted SSI reduction bundle can be successfully implemented throughout a large quality improvement learning collaborative when coordinated quality improvement activities are leveraged, resulting in a 30% decline in SSI rates. Lower superficial SSI rates are associated with the number of adherent bundle elements a patient receives, rendering considerable benefits to institutions capable of implementing more components of the bundle.
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Affiliation(s)
- Michael F McGee
- Illinois Surgical Quality Improvement Collaborative (ISQIC), Chicago, IL
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Lindsey Kreutzer
- Illinois Surgical Quality Improvement Collaborative (ISQIC), Chicago, IL
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Christopher M Quinn
- Illinois Surgical Quality Improvement Collaborative (ISQIC), Chicago, IL
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Anthony Yang
- Illinois Surgical Quality Improvement Collaborative (ISQIC), Chicago, IL
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Ying Shan
- Illinois Surgical Quality Improvement Collaborative (ISQIC), Chicago, IL
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Amy L Halverson
- Illinois Surgical Quality Improvement Collaborative (ISQIC), Chicago, IL
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Remi Love
- Illinois Surgical Quality Improvement Collaborative (ISQIC), Chicago, IL
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Julie K Johnson
- Illinois Surgical Quality Improvement Collaborative (ISQIC), Chicago, IL
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
- Center for Healthcare Studies, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Vivek Prachand
- Illinois Surgical Quality Improvement Collaborative (ISQIC), Chicago, IL
- Department of Surgery, University of Chicago, Chicago, IL
| | - Karl Y Bilimoria
- Illinois Surgical Quality Improvement Collaborative (ISQIC), Chicago, IL
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
- Center for Healthcare Studies, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
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Bhama AR, Holubar SD, Delaney CP. Health Care Policy and Outcomes after Colon and Rectal Surgery: What Is the Bigger Picture?-Cost Containment, Incentivizing Value, Transparency, and Centers of Excellence. Clin Colon Rectal Surg 2019; 32:212-220. [PMID: 31061652 DOI: 10.1055/s-0038-1677028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Early in the 21st century, the costs of health care in the United States have spiraled out of control, where the per capita spending is $9,237 per person-the highest in the world. By 2020, an estimated 20% of GDP will be spent on health care. The issue of cost and quality is now becoming a national crisis, with ∼50% of hospitals losing money on clinical operations, forcing closure of essential critical access hospitals, and forcing health care workers to relocate or change professions. This crisis will only worsen with the graying of America, as an estimated 17% of Americans will be over the age of 65 years by the year 2020. The policy and financial structures on which these changes are based are important factors of which practicing surgeons should be aware. This review discusses recent national health care policy reform and specific topics including cost-containment legislation, value-based incentives and penalties, transparency, and centers of excellence in colorectal surgery.
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Affiliation(s)
- Anuradha R Bhama
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Stefan D Holubar
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Conor P Delaney
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio
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de Groof EJ, van der Meer JHM, Tanis PJ, de Bruyn JR, van Ruler O, D'Haens GRAM, van den Brink GR, Bemelman WA, Wildenberg ME, Buskens CJ. Persistent Mesorectal Inflammatory Activity is Associated With Complications After Proctectomy in Crohn's Disease. J Crohns Colitis 2019; 13:285-293. [PMID: 30203027 DOI: 10.1093/ecco-jcc/jjy131] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [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] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Rectal resection in inflammatory bowel disease [IBD] is frequently complicated by disturbed perineal wound healing. Close rectal dissection, where the mesorectum remains in situ, is hypothesized to reduce complications by minimizing dead space, compared to total mesorectal excision. The aim of this study was to analyse post-operative outcomes of both techniques. In addition, immune activity in mesorectal tissue was assessed. METHODS Perineal complications and healing were retrospectively assessed in a series of 74 IBD patients undergoing proctectomy using close rectal dissection or total mesorectal excision. The mesorectums of 15 patients were analysed by fluorescence-activated cell sorting, immunofluorescence and in situ hybridization. Based on the clinical and in vitro findings, a novel surgical approach for Crohn's disease patients with disturbed perineal healing after proctectomy was developed. RESULTS In Crohn's disease, perineal complications were more frequent after close rectal dissection than after total mesorectal excision [59.5% vs 17.6%; p = 0.007] with lower healing rates [51.4% vs 88.2%; p = 0.014]. No differences were observed in ulcerative colitis. The mesorectal tissue in Crohn's disease contained enhanced numbers of tumour necrosis factor α-producing CD14+ macrophages, with less expression of the wound-healing marker CD206. Based on these findings, mesorectal excision with omentoplasty was performed in eight patients with perineal complications after close rectal dissection, resulting in complete perineal wound closure in six. Pro-inflammatory characteristics remained present in the mesorectum after close rectal dissection in these patients. CONCLUSIONS In Crohn's disease, close rectal dissection resulted in more perineal complications, associated with a pro-inflammatory immune status of the mesorectal tissue. Excision of this pro-inflammatory mesenteric tissue resulted in improved perineal healing rates.
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Affiliation(s)
- E Joline de Groof
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands.,Department of Gastroenterology & Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Jonathan H M van der Meer
- Department of Gastroenterology & Hepatology, Academic Medical Center, Amsterdam, The Netherlands.,Tytgat Institute for Liver and Intestinal Research, Academic Medical Center, Amsterdam, The Netherlands
| | - Pieter J Tanis
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Jessica R de Bruyn
- Department of Gastroenterology & Hepatology, Academic Medical Center, Amsterdam, The Netherlands.,Tytgat Institute for Liver and Intestinal Research, Academic Medical Center, Amsterdam, The Netherlands
| | - Oddeke van Ruler
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Geert R A M D'Haens
- Department of Gastroenterology & Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Gijs R van den Brink
- Department of Gastroenterology & Hepatology, Academic Medical Center, Amsterdam, The Netherlands.,Tytgat Institute for Liver and Intestinal Research, Academic Medical Center, Amsterdam, The Netherlands.,GlaxoSmithKline, Medicines Research Center, Stevenage, UK
| | - Willem A Bemelman
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Manon E Wildenberg
- Department of Gastroenterology & Hepatology, Academic Medical Center, Amsterdam, The Netherlands.,Tytgat Institute for Liver and Intestinal Research, Academic Medical Center, Amsterdam, The Netherlands
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Eisenstein S, Stringfield S, Holubar SD. Using the National Surgical Quality Improvement Project (NSQIP) to Perform Clinical Research in Colon and Rectal Surgery. Clin Colon Rectal Surg 2019; 32:41-53. [PMID: 30647545 DOI: 10.1055/s-0038-1673353] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The American College of Surgeons' National Surgical Quality Improvement Project (ACS-NSQIP) is probably the most well-known surgical database in North American and worldwide. This clinical database was first proposed by Dr. Clifford Ko, a colorectal surgeon, to the ACS, and NSQIP first started collecting data ca. 2005 with the intent of comparing hospitals (benchmarking) and for hospital-level quality improvement projects. Since then, its popularity has grown from just a few participating hospitals in the United States to more than 708 participating hospitals worldwide, and collaboration allows regional or disease-specific data sharing. Importantly, from a methodological perspective, as the number of hospitals has grown so has the hospital heterogeneity and thus generalizability of the results and conclusions of the individual studies. In this article, we will first briefly present the structure of the database (aka the Participant User File) and other important methodological considerations specific to performing clinical research. We will then briefly review and summarize the approximately 60 published colectomy articles and 30 published articles on proctectomy. We will conclude with future directions relevant to colorectal clinical research.
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Affiliation(s)
- Samuel Eisenstein
- Section of Colon and Rectal Surgery, Rebecca and John Moores Cancer Center, University of California San Diego Health, La Jolla, California
| | - Sarah Stringfield
- Section of Colon and Rectal Surgery, Rebecca and John Moores Cancer Center, University of California San Diego Health, La Jolla, California
| | - Stefan D Holubar
- Department of Colon & Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
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Spanheimer PM, Armstrong JG, Fu S, Liao J, Regenbogen SE, Byrn JC. Robotic proctectomy for rectal cancer: analysis of 71 patients from a single institution. Int J Med Robot 2017; 13. [PMID: 28568650 DOI: 10.1002/rcs.1841] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [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: 08/25/2016] [Revised: 04/07/2017] [Accepted: 04/24/2017] [Indexed: 11/06/2022]
Abstract
BACKGROUND Despite increasing use of robotic surgery for rectal cancer, few series have been published from the practice of generalizable US surgeons. METHODS A retrospective chart review was performed for 71 consecutive patients who underwent robotic low anterior resection (LAR) or abdominoperineal resection (APR) for rectal adenocarcinoma between 2010 and 2014. RESULTS 46 LARs (65%) and 25 APRs (35%) were identified. Median procedure time was 219 minutes (IQR 184-275) and mean blood loss 164.9 cc (SD 155.9 cc). Radial margin was negative in 70/71 (99%) patients. Total mesorectal excision integrity was complete/near complete in 38/39 (97%) of graded specimens. A mean of 16.8 (SD+/- 8.9) lymph nodes were retrieved. At median follow-up of 21.9 months, there were no local recurrences. CONCLUSIONS Robotic proctectomy for rectal cancer was introduced into typical colorectal surgery practice by a single surgeon, with a low conversion rate, low complication rate, and satisfactory oncologic outcomes.
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Affiliation(s)
| | | | - Sunyang Fu
- Department of Surgery, University of Iowa, Iowa City, IA, USA
| | - Junlin Liao
- Department of Surgery, University of Iowa, Iowa City, IA, USA
| | | | - John C Byrn
- Department of Surgery, University of Iowa, Iowa City, IA, USA
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Mizrahi I, Chadi SA, Haim N, Sands DR, Gurland B, Zutshi M, Wexner SD, da Silva G. Sacral neuromodulation for the treatment of faecal incontinence following proctectomy. Colorectal Dis 2017; 19:O145-O152. [PMID: 27885800 DOI: 10.1111/codi.13570] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [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: 07/14/2016] [Accepted: 09/20/2016] [Indexed: 02/08/2023]
Abstract
AIM This study assessed the effectiveness of sacral neuromodulation (SNM) for faecal incontinence (FI) following proctectomy with colorectal or coloanal anastomosis. METHODS An Institutional Review Board (IRB)-approved database identified patients treated for FI following proctectomy (SNM-P) for benign or malignant disease, who were matched 1:1 according to preoperative Cleveland Clinic Florida Faecal Incontinence Scores (CCF-FIS) with patients without proctectomy (SNM-NP). Primary outcome was change in CCF-FIS. RESULTS Twelve patients (seven women) were in the SNM-P group and 12 (all women) were in the SNM-NP group. In the SNM-P group, six patients underwent proctectomy for low rectal cancer and five received neoadjuvant chemoradiation. Five patients had handsewn anastomosis, and one had stapled coloanal anastomosis. One lead explantation occurred after a failed 2-week SNM percutaneous trial. Six patients underwent proctectomy for benign conditions. Within-group analyses revealed significant improvement in CCF-FIS in the SNM-P group (reduction from a score of 18 to a score of 14; P = 0.02), which was more profound for benign disease (reduction from 14.5 to 8.5) than for rectal cancer (reduction from 19.5 to 15). SNM was explanted in 66% and 33% of patients after proctectomy for malignant and benign conditions, respectively. In the SNM-NP group, 41% underwent overlapping sphincteroplasty. One patient received chemoradiation for anal cancer. Within-group analysis for the SNM-NP group showed significant improvement in CCF-FIS (a reduction from 17.5 to 4.0; P = 0.003). There was significant improvement in CCF-FIS in patients without previous proctectomy (mean delta CCF-FIS: 11.1 vs 4.7; P = 0.011). Analysis of covariance (ANCOVA) reaffirmed that controls outperformed proctectomy patients (P = 0.006). CONCLUSION SNM for FI after proctectomy appears less effective than SNM in patients without proctectomy, with high device explantation rates, particularly after neoadjuvant chemoradiation and proctectomy for low rectal cancer.
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Affiliation(s)
- I Mizrahi
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA
| | - S A Chadi
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA
| | - N Haim
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA
| | - D R Sands
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA
| | - B Gurland
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - M Zutshi
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - S D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA
| | - G da Silva
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA
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Abstract
It is evident that the use of laparoscopy in the management of rectal cancer has gained popularity in the last few years. It is still, however, not widely accepted as the standard of care. Multiple randomized trials have shown that short-term outcomes and perioperative morbidity and mortality of laparoscopic proctectomy are equivalent to open surgery. However, data regarding long-term oncologic outcomes are still scarce, with only a few randomized trials reporting similar outcomes in both laparoscopic and open group. A more recent trial failed to replicate those results in patients with locally advanced rectal cancer. In this article, we will look at the most recent evidence regarding the use of laparoscopy for patients with rectal cancer. We will also briefly discuss the different approaches and new minimally invasive techniques used in this field, and we will talk about the challenges facing the widespread adoption of laparoscopic surgery in the management of rectal cancer.
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Affiliation(s)
- Chady Atallah
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jonathan E Efron
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Massarotti H, Rodrigues F, O'Rourke C, Chadi SA, Wexner S. Impact of surgeon laparoscopic training and case volume of laparoscopic surgery on conversion during elective laparoscopic colorectal surgery. Colorectal Dis 2017; 19:76-85. [PMID: 27234928 DOI: 10.1111/codi.13402] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [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: 12/10/2015] [Accepted: 04/16/2016] [Indexed: 12/19/2022]
Abstract
AIM The study aimed to determine whether laparoscopic volume and type of training influence conversion during elective laparoscopic colorectal surgery. METHOD An Institutional Review Board-approved prospective database was reviewed for patients who underwent colorectal resection, performed by six colorectal surgeons, for all diagnoses from 2009 to 2014. Surgeons were designated as laparoscopic- or open-trained based on formal laparoscopic colorectal surgery training, and were classified as low laparoscopic volume (LLV) (i.e. had performed < 100 laparoscopic procedures) or high laparoscopic volume (HLV) (i.e. had performed ≥ 100 laparoscopic procedures). Technique was laparoscopic, open or converted (pre-emptive or reactive). Conversion was compared among three groups: LLV, laparoscopic trained (group A); LLV, open trained (group B); and HLV, open trained (group C). RESULTS In total, 159/567 procedures were open and 408 laparoscopic procedures were attempted. Of the 408 laparoscopic procedures, 73 were converted. Among the 567 patients [mean age: 56 ± 17 years (44% male)], the overall conversion rate was 13% (73/567), including 75% pre-emptive and 25% reactive. Conversion rates for groups A, B and C were 17.9%, 42.6% and 14.3%, respectively. Significantly higher conversion was seen in group B compared with group C (P = 0.01), but not between group A and group C (P = 0.85) or between group B and group A (P = 0.11). Converted patients were older (P < 0.001), with lower rates of proctectomy (P = 0.007), higher rates of anastomosis (P < 0.001) and higher body mass index (BMI) (P < 0.001). After adjusting for patient and surgeon factors, training type was not associated with conversion (P = 0.15). Compared with successful laparoscopy, converted patients had a significantly higher incidence of ileus (P < 0.001), length of stay (P = 0.002), time to flatus (OR = 3.21, P < 0.001) and time to solids (P < 0.001). Converted patients experienced increased morbidity. CONCLUSION Training is not associated with conversion. Rather, HLV surgeons, regardless of training, convert less frequently than do LLV surgeons.
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Affiliation(s)
- H Massarotti
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA
| | - F Rodrigues
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA
| | - C O'Rourke
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA
| | - S A Chadi
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA
| | - S Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA
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Connolly TM, Foppa C, Kazi E, Denoya PI, Bergamaschi R. Impact of a surgical site infection reduction strategy after colorectal resection. Colorectal Dis 2016; 18:910-8. [PMID: 26456021 DOI: 10.1111/codi.13145] [Citation(s) in RCA: 24] [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: 02/01/2015] [Accepted: 08/12/2015] [Indexed: 12/30/2022]
Abstract
AIM This study was performed to determine the impact of a surgical site infection (SSI) reduction strategy on SSI rates following colorectal resection. METHOD American College of Surgeons National Surgical Quality Improvement Program (NSQIP) data from 2006-14 were utilized and supplemented by institutional review board-approved chart review. The primary end-point was superficial and deep incisional SSI. The inclusion criterion was colorectal resection. The SSI reduction strategy consisted of preoperative (blood glucose, bowel preparation, shower, hair removal), intra-operative (prophylactic antibiotics, antimicrobial incisional drape, wound protector, wound closure technique) and postoperative (wound dressing technique) components. The SSI reduction strategy was prospectively implemented and compared with historical controls (pre-SSI strategy arm). Statistical analysis included Pearson's chi-square test, and Student's t-test performed with spss software. RESULTS Of 1018 patients, 379 were in the pre-SSI strategy arm, 311 in the SSI strategy arm and 328 were included to test durability. The study arms were comparable for all measured parameters. Preoperative wound class, operation time, resection type and stoma creation did not differ significantly. The SSI strategy arm demonstrated a significant decrease in overall SSI rates (32.19% vs 18.97%) and superficial SSI rates (23.48% vs 8.04%). Deep SSI and organ space rates did not differ. A review of patients testing durability demonstrated continued improvement in overall SSI rates (8.23%). CONCLUSION The implementation of an SSI reduction strategy resulted in a 41% decrease in SSI rates following colorectal resection over its initial 3 years, and its durability as demonstrated by continuing improvement was seen over an additional 2 years.
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Affiliation(s)
- T M Connolly
- Division of Colon and Rectal Surgery, State University of New York, Stony Brook, NY, USA
| | - C Foppa
- Division of Colon and Rectal Surgery, State University of New York, Stony Brook, NY, USA
| | - E Kazi
- Division of Colon and Rectal Surgery, State University of New York, Stony Brook, NY, USA
| | - P I Denoya
- Division of Colon and Rectal Surgery, State University of New York, Stony Brook, NY, USA
| | - R Bergamaschi
- Division of Colon and Rectal Surgery, State University of New York, Stony Brook, NY, USA
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Holubar SD, Holder-Murray J, Flasar M, Lazarev M. Anti-Tumor Necrosis Factor-α Antibody Therapy Management Before and After Intestinal Surgery for Inflammatory Bowel Disease: A CCFA Position Paper. Inflamm Bowel Dis 2015; 21:2658-72. [PMID: 26422516 DOI: 10.1097/MIB.0000000000000603] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Biologic therapy with anti-tumor necrosis factor (TNF)-α antibody medications has become part of the standard of care for medical therapy for patients with inflammatory bowel disease and may help to avoid surgery in some. However, many of these patients will still require surgical intervention in the form of bowel resection and anastomosis or ostomy formation for the treatment of their disease. Postsurgical studies suggest up to 30% of patients with inflammatory bowel disease may be on or have used anti-TNF-α antibody medications for disease management preoperatively. Significant controversy exists regarding the potential deleterious impact of these medications on the outcomes of surgery, specifically overall and/or infectious complications. In this position statement, we systematically reviewed the literature regarding the potential risk of anti-TNF-α antibody use in the perioperative period, offer recommendations based both on the best-available evidence and expert opinion on the use and timing of anti-TNF-α antibody therapy in the perioperative period, and discuss whether or not the presence of these medications should lead to an alteration in surgical technique such as temporary stoma formation.
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Lee GC, Sylla P. Shifting Paradigms in Minimally Invasive Surgery: Applications of Transanal Natural Orifice Transluminal Endoscopic Surgery in Colorectal Surgery. Clin Colon Rectal Surg 2015; 28:181-93. [PMID: 26491411 DOI: 10.1055/s-0035-1555009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Since the advent of laparoscopy, minimally invasive techniques such as single port laparoscopy, robotics, endoscopically assisted laparoscopy, and transanal endoscopic surgery continue to revolutionize the field of colorectal surgery. Transanal natural orifice transluminal endoscopic surgery (NOTES) represents a further paradigm shift by combining the advantages of these earlier techniques to reduce the size and number of abdominal incisions and potentially optimize rectal dissection, especially with respect to performance of an oncologically adequate total mesorectal excision (TME) for rectal cancer. Since the first experimental report of transanal rectosigmoid resection in 2007, the potential impact of transanal NOTES in colorectal surgery has been extensively investigated in experimental models and recently transitioned to clinical application. There have been 14 clinical trials of transanal TME (taTME) for rectal cancer that have demonstrated the feasibility and preliminary oncologic safety of this approach in carefully selected patients, with results comparable to outcomes after laparoscopic and open TME, including cumulative intraoperative and postoperative complication rates of 5.5 and 35.5%, respectively, 97.3% rate of complete or near-complete specimens, and 93.6% rate of negative margins. Transanal NOTES has also been safely applied to proctectomy and colectomy for benign indications. The consensus among published series suggests that taTME is most safely performed with transabdominal assistance by surgeons experienced with laparoscopic TME, transanal endoscopic surgery, and sphincter-preserving techniques including intersphincteric resection. Future applications of transanal NOTES may include evolution to a pure endoscopic transanal approach for TME, colectomy, and sentinel lymph node biopsy for rectal cancer, with a potential role for robotic assistance.
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Affiliation(s)
- Grace Clara Lee
- Division of Gastrointestinal Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Patricia Sylla
- Division of Gastrointestinal Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
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Wilson TR, Welbourn H, Stanley P, Hartley JE. The success of rectus and gracilis muscle flaps in the treatment of chronic pelvic sepsis and persistent perineal sinus: a systematic review. Colorectal Dis 2014; 16:751-9. [PMID: 24831668 DOI: 10.1111/codi.12663] [Citation(s) in RCA: 10] [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: 11/03/2013] [Accepted: 02/03/2014] [Indexed: 02/08/2023]
Abstract
AIM Chronic pelvic sepsis is a challenging problem, which may require muscle flaps to fill the pelvic cavity. The aim of this systematic review was to determine the relative success of rectus and gracilis flaps used for this purpose. METHOD A systematic review was conducted to identify papers that reported the outcome of rectus or gracilis myocutaneous flaps in the treatment of persistent perineal sinuses or chronic pelvic sepsis. Reports of muscle flaps used for reconstruction or treatment of fistula in the absence of chronic sepsis were excluded. A successful outcome was defined as complete perineal healing within 12 months of surgery. RESULTS The review identified 19 studies reporting the outcome of 73 rectus and 87 gracilis flaps. Their respective success was 84% and 64%. Heterogeneity of the underlying cases did not allow for direct comparison of the flaps. Full healing of the flaps was generally achieved within 3 months. Donor site morbidity was minimal. CONCLUSION The surgical treatment of chronic pelvic sepsis should be tailored to the individual, but the rectus flap has a reasonable success rate with little morbidity.
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Affiliation(s)
- T R Wilson
- Academic Surgical Unit, Castle Hill Hospital, Hull, UK
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Cracco N, Zinicola R. Is haemorrhoidectomy in inflammatory bowel disease harmful? An old dogma re-examined. Colorectal Dis 2014; 16:516-9. [PMID: 24422778 DOI: 10.1111/codi.12555] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [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: 09/01/2013] [Accepted: 11/20/2013] [Indexed: 01/11/2023]
Abstract
AIM Haemorrhoidectomy and removal of anal skin tags in inflammatory bowel disease (IBD) have been considered to be potentially harmful, but the evidence for this is poor. A review of the literature was undertaken to determine the complications rate after haemorrhoidectomy in patients with IBD. METHOD A Medline, PubMed and Cochrane Library search was performed to retrieve studies reporting the surgical treatment of haemorrhoids in patients with IBD. All studies that investigated the complications of haemorrhoidectomy and skin tag removal in patients with IBD were included. Complications included local sepsis, fissure, ulcer, stenosis, faecal incontinence and the direct need for proctectomy or a stoma. RESULTS Eleven retrospective studies including 135 patients were identified. Most series were small and lacked information on the interval between surgery and the onset of complications. The range of complications ranged from 0% to 100%. Taking the studies together, complications occurred more frequently in Crohn's disease (CD) (17.1%) than in ulcerative colitis (UC) (5.5%). The risk of complication was much higher in patients with unknown than in those with known diagnosis of IBD (50% vs 9.8% in CD; 9.1% vs 4% in UC). CONCLUSION There is great variation in the incidence of complications reported after haemorrhoidectomy or removal of skin tags in patients with IBD and it is not possible to draw a firm conclusion. Nevertheless the incidence of complications is high in patients with CD.
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Affiliation(s)
- N Cracco
- Department of General Surgery, Sacro Cuore Don Calabria Hospital, Negrar, Verona
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Abstract
Complex perineal wounds are at risk for nonhealing. High-risk procedures include proctectomy for Crohn disease, anal cancer and radiated distal rectal cancers. A basic understanding of both patient and procedural risk factors is helpful in planning and executing operative procedures for these conditions and to minimize associated wound complications. Diabetes, obesity, and malnutrition may contribute to wound breakdown and failure to heal. Delaying operative intervention, adding nutritional supplementation, and employing intestinal diversion as well as myocutaneous flaps may help optimize conditions for wound healing.
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Affiliation(s)
- Allen Kamrava
- LA Colon and Rectal Surgical Associates, Beverly Hills, California
| | - Najjia N Mahmoud
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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Klos CL, Montenegro G, Jamal N, Wise PE, Fleshman JW, Safar B, Dharmarajan S. Segmental versus extended resection for sporadic colorectal cancer in young patients. J Surg Oncol 2014; 110:328-32. [PMID: 24888987 DOI: 10.1002/jso.23649] [Citation(s) in RCA: 7] [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] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Accepted: 04/17/2014] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND OBJECTIVES Guidelines on the management of colon cancer state that extensive colectomy should be "considered" for patients of young age (<50). This study aimed to compare the risk of metachronous cancer, overall recurrence and mortality between segmental and extended colon resections in patients under the age of 50 with sporadic CRC. METHODS We performed a retrospective review of patients age <50 undergoing surgery for CRC from 1991 to 2009. Patients were divided into two groups based on extent of resection: segmental versus extended. The primary outcomes analyzed were metachronous tumors, disease recurrence, and overall survival. RESULTS Two hundred seventy one patients underwent segmental resection and 30 underwent extended resection. 3.3% in the segmental resection group developed metachronous CRC versus 0% in the extended resection group (P = 0.61). There was no significant difference in the risk of recurrence or mortality for those who underwent a segmental resection compared to those with an extended resection. In a regression model, type of surgery was not an independent risk factor for recurrence or mortality. CONCLUSIONS Extended colectomy for sporadic CRC in patients younger than 50 does not improve disease-free or overall survival. Further study to determine if segmental resection is appropriate oncologic treatment is warranted.
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Affiliation(s)
- Coen L Klos
- Section of Colon and Rectal Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
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Abstract
BACKGROUND The unique surgical challenges of proctectomy may be amplified in obese patients. We examined surgical outcomes of a large, diverse sample of obese patients undergoing proctectomy. OBJECTIVE The purpose of this work was to determine whether increased BMI is associated with increased complications in proctectomy. DESIGN This was a retrospective review. SETTINGS The study uses the American College of Surgeons National Surgical Quality Improvement Program database (2010 and 2011). PATIENTS Patients included were those undergoing nonemergent proctectomy, excluding rectal prolapse cases. Patients were grouped by BMI using the World Health Organization classifications of underweight (BMI <18.5); normal (18.5-24.9); overweight (25.0-29.9); and class I (30.0-34.9), class II (35.0-39.9), and class III (≥40.0) obesity. MAIN OUTCOME MEASURES We analyzed the effect of preoperative and intraoperative factors on 30-day outcomes. Continuous variables were compared with Wilcoxon rank-sum tests and proportions with the Fisher exact or χ tests. Logistic regression controlled for the effects of multiple risk factors. RESULTS Among 5570 patients, class I, II, and III obesity were significantly associated with higher rates of overall complications (44.0%, 50.8%, and 46.6% vs 38.1% for normal-weight patients; p < 0.05). Superficial wound infection was significantly higher in classes I, II, and III (11.6%, 17.8%, and 13.0% vs 8.0% for normal-weight patients; p < 0.05). Operative times for patients in all obesity classes were significantly longer than for normal-weight patients. On multivariate analysis, an obese BMI independently predicted complications; ORs (95% CIs) were 1.36 (1.14-1.62) for class I obesity, 1.99 (1.54-2.54) for class II, and 1.42 (1.02-1.96) for class III. LIMITATIONS This study was a retrospective design with limited follow-up. CONCLUSIONS Class I, II, and III obese patients were at significantly increased risk for morbidity compared with normal BMI patients. Class II obese patients had the highest rate of complications, a finding that deserves further investigation.
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Abstract
The adoption of laparoscopic proctectomy for rectal cancer has been relatively slow, primarily because of the technical difficulty of the procedure. The wide surgeon-to-surgeon variability in disease-free survival and local pelvic recurrence noted after open proctectomy is probably due to differences in surgical technique, and these differences are likely to be magnified when the additional challenge of laparoscopy is added to the procedure. At present, oncologic and functional outcomes data are limited. Although the adoption of laparoscopic techniques to perform curative proctectomy is likely to expand as technical challenges are overcome and experience and training improve, the results of prospective multicenter trials are necessary to ensure that the procedures provide an oncologic and functional outcome equivalent to that of conventional surgery.
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Affiliation(s)
- Thomas E Read
- Division of Colon and Rectal Surgery, Western Pennsylvania Hospital, Temple University School of Medicine, Pittsburgh, PA 15224, USA.
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