North American multicentre evaluation of a same-day discharge protocol for minimally invasive colorectal surgery using mHealth or telephone remote post-discharge monitoring

BACKGROUND

Same-day discharge (SDD) after colectomy is feasible but requires effective post-discharge remote follow-up. Previous studies have used in-person home visits or a mobile health (mHealth) phone app, but the use of simple telephone calls for remote follow-up has not yet been studied. Therefore, the objective of this study was to compare outcomes after SDD for minimally invasive colectomy using mHealth or telephone remote post-discharge follow-up.

METHODS

A prospective cohort study was undertaken at two university-affiliated colorectal referral institutions from 02/2020 to 05/2021. Adult patients without significant comorbidities undergoing elective minimally invasive colectomy. Patients were discharged on the day of surgery based on set criteria. Post-discharge remote follow-up was performed using a mHealth app at site 1 and scheduled telephone calls at site 2 up to postoperative day (POD) 7. The main outcome for this study was the success rate of SDD, defined as discharge on POD0 without emergency department (ED) visit or readmission within the first 3 days.

RESULTS

A total of 105 patients were recruited (site 1, n = 70; site 2, n = 35). Overall, 75% of patients were discharged on POD0 (site 1 81% vs. site 2 63%, p = 0.038), of which only two patients required an ED visit within the first 3 days, leading to an overall success rate of 73% (site 1 80% vs. site 2 60%, p = 0.029). The incidence of 30-day complications (16% vs. 20%, p = 0.583), ED visits (11% vs. 11%, p = 1.00), and readmissions (9% vs. 14%, p = 0.367) were similar between the two sites. There was only one patient at each study site that went to the ED without instructions through remote follow-up.

CONCLUSIONS

A high proportion of patients planned for SDD were discharged on POD0 with few patients requiring an early unplanned ED visit. These results were similar with an mHealth app or telephone calls for post-discharge remote follow-ups, suggesting that SDD is feasible regardless of the method of post-discharge remote follow-up.

Same day discharge following elective, minimally invasive, colorectal surgery : A review of enhanced recovery protocols and early outcomes by the SAGES Colorectal Surgical Committee with recommendations regarding patient selection, remote monitoring, and successful implementation

BACKGROUND

As enhanced recovery programs (ERPs) have continued to evolve, the length of hospitalization (LOS) following elective minimally invasive colorectal surgery has continued to decline. Further refinements in multimodal perioperative pain management strategies have resulted in reduced opioid consumption. The interest in ambulatory colectomy has dramatically accelerated during the COVID-19 pandemic. Severe restrictions in hospital capacity and fear of COVID transmission forced surgical teams to rethink strategies to further reduce length of inpatient stay.

METHODS

Members of the SAGES Colorectal Surgery Committee began reviewing the emergence of SDD protocols and early publications for SDD in 2019. The authors met at regular intervals during 2020-2022 period reviewing SDD protocols, safe patient selection criteria, surrogates for postoperative monitoring, and early outcomes.

RESULTS

Early experience with SDD protocols for elective, minimally invasive colorectal surgery suggests that SDD is feasible and safe in well-selected patients and procedures. SDD protocols are associated with reduced opioid use and prescribing. Patient perception and experience with SDD is favourable. For early adopters, SDD has been the natural evolution of well-developed ERPs. Like all ERPs, SDD begins in the office setting, identifying the correct patient and procedure, aligning goals and objectives, and the perioperative education of the patient and their supporting significant others. A thorough discussion with the patient regarding expected activity levels, oral intake, and pain control post operatively lays the foundation for a successful application of SDD programs. These observations may not apply to all patient populations, institutions, practice types, or within the scope of an existing ERP. However, if the underlying principles of SDD can be incorporated into an existing institutional ERP, it may further reduce the incidence of post operative ileus, prolonged LOS, and improve the effectiveness of oral analgesia for postoperative pain management and reduced opioid use and prescribing.

CONCLUSIONS

The SAGES Colorectal Surgery Committee has performed a comprehensive review of the early experience with SDD. This manuscript summarizes SDD early results and considerations for safe and stepwise implementation of SDD with a specific focus on ERP evolution, patient selection, remote monitoring, and other relevant considerations based on hospital settings and surgical practices.

Reduced Opioid Use and Prescribing in a Same Day Discharge Pilot Enhanced Recovery Program for Elective Minimally Invasive Colorectal Surgical Procedures During the COVID-19 Pandemic

Purpose

Enhanced recovery pathways (ERPs) are associated with reduced complications and length of stay. The validation of the I-FEED scoring system, advances in perioperative anesthesia, multimodal analgesia, and telehealth remote monitoring have resulted in further evolution of ERPs setting the stage for same day discharge (SDD). Pioneers and early adopters have demonstrated the safety and feasibility of SDD programs. The aim of this study is to evaluate the impact of a pilot SDD ERP on patient self-reported pain scoring and narcotic usage.

Methods

A quality improvement pilot program was conducted to assess the impact of a SDD ERP on post-operative pain score reporting and opioid use in healthy patients undergoing elective colorectal surgery as an alternative to post-operative hospitalization during the COVID-19 pandemic (May 2020-December 2021). Patients were monitored remotely with daily telephone visits on POD 1-7 assessing the following variables: I-FEED score, pain score, pain management, bowel function, dietary advancement, any complications, and/or re-admissions.

Results

Thirty-seven patients met the highly selective eligibility criteria for “healthy patient, healthy anastomosis.” SDD occurred in 70%. The remaining 30% were discharged on POD 1. Mean total narcotic usage was 5.2 tablets of 5 mg oxycodone despite relatively high reported pain scores.

Conclusions

In our initial experience, SDD is associated with significantly lower patient narcotic utilization for postoperative pain management than hypothesized. This pilot SDD program resulted in a change in clinical practice with reduction of prescribed discharge oxycodone 5 mg quantity from #40 to #10 tablets.

Robotic Versus Laparoscopic Surgery for Rectal Cancer: A Comprehensive Review of Oncological Outcomes

The treatment of rectal cancer is complex and involves specialized multidisciplinary care, although the tenet is still rooted in a high-quality total mesorectal excision. The robotic platform is one of many tools in the arsenal to assist dissection in the low pelvis. This article is a comprehensive review of the oncological outcome comparing robotic vs laparoscopic rectal cancer resection, with a particular focus on total mesorectal excision. There is no statistical difference in total mesorectal grade, circumferential margin, distal margin, and lymph node harvest. Survival data are less mature, but there is also no difference in disease-free or overall survival between the two techniques. Although additional randomized trials are still needed to validate these findings, both techniques are currently acceptable in the minimally invasive treatment of rectal cancer, and surgeon preference is paramount to safe and optimal resection.

Metabolic Risk Factors Associated with Early-Onset Colorectal Adenocarcinoma: A Case-Control Study at Kaiser Permanente Southern California

BACKGROUND

The incidence of early-onset colorectal cancer (eoCRC) diagnosed among individuals under age 50 has been rising. However, risk factors for eoCRC are unclear. We investigated whether metabolic abnormalities are risk factors for eoCRC adenocarcinoma.

METHODS

Invasive colorectal adenocarcinoma cases diagnosed between ages 15 and 49 from 2008 to 2018 at Kaiser Permanente Southern California (KPSC) were identified. Those with a history of inflammatory bowel disease were excluded. Noncancer controls were selected 5:1 for each case matched by age, sex, and length of membership prior to index date. Data were collected from KSPC's electronic medical records. The exposures of interest included obesity, type II diabetes, hypertension, and dyslipidemia, assessed from ≥1 year prior to eoCRC diagnosis/index date. Conditional logistic regressions were used to evaluate the associations between these metabolic risk factors and risk of eoCRC adenocarcinoma, adjusting for race/ethnicity, smoking, family history, neighborhood socioeconomic status, and health care utilization.

RESULTS

A total of 1,032 cases and 5,128 controls were included. Risk of colorectal adenocarcinoma was significantly associated with obesity [odds ratio (OR) = 1.41; 95% confidence interval (CI), 1.15-1.74], but not diabetes, hypertension or dyslipidemia. In analysis stratified by tumor location, obesity was significantly associated with risk of colon adenocarcinoma OR = 1.56 (1.17-2.07), but its association with rectal adenocarcinoma was less clear OR = 1.19 (0.85-1.68). No significant interaction was detected between obesity and age (≥40 vs. <40), and obesity and sex.

CONCLUSIONS

Obesity was associated with risk for eoCRC adenocarcinoma.

IMPACT

This finding could help inform early-onset colorectal adenocarcinoma screening and prevention recommendations.See related commentary by Hayes, p. xxx.

Watch-and-Wait Compared to Operation for Patients with Complete Response to Neoadjuvant Therapy for Rectal Cancer

BACKGROUND

Trimodality therapy with neoadjuvant chemoradiation (nCRT), surgery, and adjuvant chemotherapy is the standard treatment for locally advanced rectal cancer. There is evidence that surgery can be deferred in patients with complete response (CR) to nCRT, a strategy termed "watch-and-wait" (WW). We compare WW to surgery in patients with CR to nCRT.

STUDY DESIGN

We reviewed records of patients treated with nCRT for nonmetastatic rectal cancer at our institution. Complete endoscopic response (CER) was defined as negative digital rectal exam and negative endoscopy at the end of neoadjuvant therapy (NAT). Clinical complete response (cCR) was defined as CER with negative rectal MRI. Patients with CER refusing surgery were offered WW, which included strict surveillance with digital rectal exam and endoscopy.

RESULTS

From January 2015 through February 2019, 465 patients completed nCRT; 406 patients had response assessment, of which 95 (23%) had CER. Of these patients, 53 patients underwent WW and 42 patients had surgery. Median follow-up was 35 months. In the WW group, 3-year freedom from local regrowth was 85%. In the surgical and WW groups, 3-year overall survival, rectal cancer-specific survival, and freedom from nonregrowth recurrence were 100% vs 88% (p = 0.03), 100% vs 95% (p = 0.16), and 92% vs 85% (p = 0.36), respectively. Of the 6 WW patients with local regrowth, 5 (83%) eventually developed distant recurrence.

CONCLUSIONS

WW in lieu of surgery appears to be a safe and feasible treatment approach for patients achieving CR to nCRT. Careful evaluation to confirm cCR after nCRT is valuable in selecting patients for WW.

Incidence and Survival Patterns of Rare Anal Canal Neoplasms Using the Surveillance Epidemiology and End Results Registry

Small cell, neuroendocrine tumors, and melanoma of the anus are rare. Limited data exist on the incidence and management for these rare tumors. A large, prospective, population-based database was used to determine incidence and survival patterns of rare anal neoplasms. The Surveillance, Epidemiology and End Results registry was queried to identify patients diagnosed with anal canal neoplasms. Incidence and survival patterns were evaluated with respect to age, sex, race, histology, stage, and therapy. We identified 7078 cases of anal canal neoplasms: melanoma (n = 149), neuroendocrine (n = 61), and small cell neuroendocrine (n = 26). Squamous cell carcinoma (SCC) (n = 6842) served as the comparison group. Anal melanoma (AM) demonstrated the lowest survival rate at 2.5 per cent. Neuroendocrine tumors (NETs) demonstrated similar survival as SCC (10-year survival for regional disease of 25 and 22.3%, respectively). Ten-year survival of small cell NETs resembled AM (5.3 vs 2.5%). Age 60 years or older, sex, black race, stage, and surgery were independent predictors of survival. This study presents the largest patient series of rare anal neoplasms. NETs of the anal canal demonstrate similar survival patterns to SCC, whereas small cell NETs more closely resemble AM. Accurate histologic diagnosis is vital to determine treatment and surgical management because survival patterns can differ among rare anal neoplasms.

Learning Transanal Total Mesorectal Excision

A dynamic evolution is occurring in transanal surgery. Transanal techniques began with intraluminal surgical removal of rectal masses and have progressed to transanal total mesorectal excision (taTME) for rectal cancer. TaTME was first performed in 2009 by Sylla, Rattner, Delgado, and Lacy. This article documents the training pathway followed by pioneers in the taTME technique as well as consensus reports outlining the process of learning the taTME technique. A literature search was performed for taTME training, learning, and technique. Key elements in learning the taTME technique include appropriate indications, cadaver training, and outcomes reporting such as participating in a taTME registry. Consensus reports also agree on the following facets associated with improved outcomes: (1) appropriate case selection of mid and low rectal cancers, (2) prerequisite completion of an accredited training program in laparoscopic colorectal surgery and prior experience in transanal endoscopic surgery, (3) a two-team taTME approach from above and below is ideal, and (4) higher rectal cancer volume surgical practice. The unifying international recommendation for surgeons interested in learning the taTME technique conveys the following message: taTME is an advanced and complex technique that requires dedicated training and experience in TME surgery.

Transanal Total Mesorectal Excision (taTME) for Rectal Cancer: A Case Series Report of a Natural Orifice Surgical Technique

In the treatment of colorectal cancer, total mesorectal excision (TME) has risen as the gold standard in the surgical treatment of this disease in order to obtain negative distal and circumferential radial margins. Since introduction in 2010, transanal TME has aimed to decrease the rate of positive margins and improve the quality of the dissection while decreasing the complications associated with a transabdominal low pelvic dissection. We retrospectively reviewed 25 cases of transanal TME completed between December 2014 and August 2017. Most of the patients in our case series were male (60%) with an average age of 57.1 years, BMI of 28.4 kg/m², and with an American Society of Anesthesiologists score of II. The average tumor was midrectal (about 5.9 cm from the anal verge), clinically T3-T4 (92%), and had undergone neoadjuvant therapy (96%). The average operation was about six hours and 44 minutes with ileostomy placed most of the time (92%). In all the cases where the TME quality was graded, the specimens were reported to have been complete (grade I). There were no positive distal, radial, or proximal margins. The average hospital stay was about 5.9 days. The rate of minor complications was about 48 per cent and major complications occurred about 16 per cent of the time.

Racial and Socioeconomic Treatment Disparities in Adolescents and Young Adults with Stage II-III Rectal Cancer

INTRODUCTION

Stage II-III rectal cancer requires multidisciplinary cancer care, and adolescents and young adults (AYA, ages 15-39 years) often do not receive optimal cancer therapy.

METHODS

Overall, 3295 AYAs with clinical stage II-III rectal cancer were identified in the National Cancer Database. Factors associated with the receipt of adjuvant and surgical therapies, as well as overall survival (OS), were examined.

RESULTS

The majority of patients were non-Hispanic White (72.0 %), male (57.5 %), and without comorbidities (93.8 %). A greater proportion of Black and Hispanic patients did not receive radiation (24.5 and 27.1 %, respectively, vs. 16.5 % for non-Hispanic White patients), surgery (22.4 % and 21.6 vs. 12.3 %), or chemotherapy (21.5 % and 24.1 vs. 14.7 %) compared with non-Hispanic White patients (all p < 0.05). After controlling for competing factors, Black (odds ratio [OR] 0.7, 95 % confidence interval [CI] 0.5-0.9) and Hispanic patients (OR 0.6, 95 % CI 0.4-0.9) were less likely to receive neoadjuvant chemoradiation compared with non-Hispanic White patients. Females, the uninsured, and those treated at a community cancer center were also less likely to receive neoadjuvant therapy. Having government insurance (OR 0.22, 95 % CI 010-0.49) was a predictor for not receiving surgery. Although 5-year OS was lower (p < 0.05) in Black (59.8 %) and Hispanic patients (65.9 %) compared with non-Hispanic White patients (74.9 %), on multivariate analysis race did not impact mortality. Not having surgery (hazard ratio [HR] 7.1, 95 % CI 2.8-18.2) had the greatest influence on mortality, followed by poorly differentiated histology (HR 3.0, 95 % CI 1.3-6.5), nodal positivity (HR 2.6, 95 % CI 1.9-3.6), no chemotherapy (HR 1.9, 95 % CI 1.03-3.6), no insurance (HR 1.7, 95 % CI 1.1-2.7), and male sex (HR 1.5, 95 % CI 1.1-2.0).

CONCLUSION

There are racial and socioeconomic disparities in the treatment of stage II-III rectal cancer in AYAs, many of which impact OS. Interventions that can address and mitigate these differences may lead to improvements in OS for some patients.

Race-based socioeconomic and treatment disparities in adolescent and young adults with stage II-III rectal cancer

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Background: Stage II-III rectal cancer (CA) requires a multidisciplinary approach to optimize outcomes. This study explores whether treatment disparities account for racial differences in outcomes of AYA (ages 15-39) patients. Methods: AYAs with clinical stage II-III rectal CA were identified in the National Cancer Database. Demographic, clinical, and pathologic features predictive of receipt of adjuvant and surgical therapies were examined as well as factors associated with overall survival (OS). Results: Most of the 3,295 patients were white (72.0%), male (57.5%) and free of comorbidities (93.8%). Income, education levels, and rates of health insurance coverage were higher for whites than for blacks or Hispanics. Clinical stage was balanced by race, but more blacks and Hispanics did not receive radiation (24.5% and 27.1%, respectively, vs 16.5% for whites), surgery (22.4% and 15.3%, vs 12.3%), or chemotherapy (21.5% and 24.1%, vs 16.7%; p < 0.05). Additionally, the average number of days before treatment was 34.0 for blacks and 33.3 for Hispanics, versus 27.5 for whites (p < 0.05). Multivariate analysis showed that receipt of neoadjuvant chemoradiation was less likely when patients were black (OR 0.7, 95%CI 0.5-0.9, p = 0.014), Hispanic (OR 0.6, 95%CI 0.4-0.9, p = 0.012), female (OR 0.8, 95% CI 0.63-0.94, p = 0.011), without insurance (OR 0.5, 95%CI 0.36-0.69, p < 0.001), or treated at a community cancer center (OR 0.5, 95%CI 0.36- 0.74, p < 0.05). Race significantly influenced treatment, regardless of disease stage. Although 5-year OS was lower (p < 0.05) in blacks (59.8±3.3%) and Hispanics (65.9±3.5%) compared to whites (74.9±1.1%), race did not impact mortality on Cox regression. Instead, mortality was associated with male sex (HR 1.5, 95%CI 1.1-2.0, p = 0.009), nodal positivity (HR 2.6, 95%CI 1.9-3.6, p < 0.001), nonsurgical therapy (HR 7.1, 95%CI 2.8-18.2, p < 0.001), no chemotherapy (HR 1.9, 95%CI 1.03-3.6, p = 0.04), poorly differentiated histology (HR 3.0, 95%CI 1.3-6.5, p = 0.007), and no insurance (HR 1.7, 95%CI 1.1-2.7, p = 0.022). Conclusions: Race-based socioeconomic and treatment disparities may contribute to survival differences among AYAs with rectal cancer.

Significant reduction in the incidence of small bowel obstruction and ventral hernia after laparoscopic compared to open segmental colorectal resection

PURPOSE

The aim of this study is to assess the incidence of incisional ventral hernia and small bowel obstruction following laparoscopic and open colorectal resection.

METHODS

A retrospective review was performed of a large database comprising 13 hospitals, serving 3.6 million patients in Southern California. Patients 18 years and older undergoing elective colorectal resection over a 3-year period were included. The crude incidence rates were calculated, and relative risks of ventral hernia and small bowel obstruction were determined using multivariable proportional hazard modeling.

RESULTS

Four thousand six hundred and thirteen patients underwent 4765 colorectal resections between August 2008 and August 2011. Fifty-nine percent of the cases were performed laparoscopically; the median age was 63 years, and 49% were males. Colorectal carcinoma (45%) and diverticulitis (18%) were the most common indications for surgery. The median follow-up was 2.4 years. Kaplan-Meier estimates of ventral hernia at 1, 2, and 3 years among the open cohort were significantly higher at 10.1, 17.0, and 20.5%, compared to 5.7, 8.7, and 10.8% in the laparoscopic cohort (p < 0.001). Similarly, small bowel obstruction was higher in the open compared to the laparoscopic group (open 10.4, 15.0, and 18.3% vs. laparoscopic 2.7, 4.4, and 5.5%, p < 0.001). Patients undergoing laparoscopic colorectal resection were less likely to develop ventral hernia [adjusted hazard ratio (AHR) 0.64 (95% CI 0.52, 0.80); p < 0.0001] and small bowel obstruction [AHR 0.41 (95% CI 0.31, 0.54); p < 0.0001].

CONCLUSIONS

The incidence of incisional ventral hernia and small bowel obstruction is significantly reduced in patients who undergo laparoscopic compared to open colorectal resection.

Perfusion assessment in laparoscopic left-sided/anterior resection (PILLAR II): a multi-institutional study

BACKGROUND

Our primary objective was to demonstrate the utility and feasibility of the intraoperative assessment of colon and rectal perfusion using fluorescence angiography (FA) during left-sided colectomy and anterior resection. Anastomotic leak (AL) after colorectal resection increases morbidity, mortality, and, in cancer cases, recurrence rates. Inadequate perfusion may contribute to AL. The PINPOINT Endoscopic Fluorescence Imaging System allows for intraoperative assessment of anastomotic perfusion.

STUDY DESIGN

This is a prospective, multicenter, open-label, clinical trial that assessed the feasibility and utility of FA for intraoperative perfusion assessment during left-sided colectomy and anterior resection at 11 centers in the United States.

RESULTS

A total of 147 patients were enrolled, of whom 139 were eligible for analysis. Diverticulitis (44%), rectal cancer (25%), and colon cancer (21%) were the most prevalent indications for surgery. The mean level of anastomosis was 10 ± 4 cm from the anal verge. Splenic-flexure mobilization was performed in 81% and high ligation of the inferior mesenteric artery in 61.9% of patients. There was a 99% success rate for FA, and FA changed surgical plans in 11 (8%) patients, with the majority of changes occurring at the time of transection of the proximal margin (7%). Overall morbidity rates were 17%. The anastomotic leak rate was 1.4% (n = 2). There were no anastomotic leaks in the 11 patients who had a change in surgical plan based on intraoperative perfusion assessment with FA.

CONCLUSIONS

PINPOINT is a safe and feasible tool for intraoperative assessment of tissue perfusion during colorectal resection. There were no anastomotic leaks in patients in whom the anastomosis was revised based on inadequate perfusion with FA.

Transanal minimally invasive surgery for benign and malignant rectal neoplasia

BACKGROUND

Transanal minimally invasive surgery (TAMIS), an alternative technique to transanal endoscopic microsurgery, was developed in 2009. Herein, we describe our initial experience using TAMIS for benign and malignant rectal neoplasia.

METHODS

This is an institutional review board approved, retrospective case series report.

RESULTS

TAMIS was performed in 32 patients for rectal adenoma (13), adenocarcinoma (16), and carcinoid (3). There were 14 women, with mean age 62 ± 15 years and body mass index 28 ± 5 kg/m(2). Lesion size ranged from .5 to 8.5 cm, distance from the dentate line 1 to 11 cm, and circumference of the lesion 10% to 100%. The mean operative time was 123 ± 62 minutes. Mean hospital length of stay was 2.5 ± 2 days. Complications included urinary tract infection (1), Clostridium difficile diarrhea (1), atrial fibrillation (1), rectal stenosis (1), and rectal bleeding (1).

CONCLUSION

TAMIS using a disposable transanal access platform is a safe and effective method to remove rectal lesions in this case series.

Incidence and survival patterns of rare anal canal neoplasms using the surveillance epidemiology and end results registry

Small cell, neuroendocrine tumors, and melanoma of the anus are rare. Limited data exist on the incidence and management for these rare tumors. A large, prospective, population-based database was used to determine incidence and survival patterns of rare anal neoplasms. The Surveillance, Epidemiology and End Results registry was queried to identify patients diagnosed with anal canal neoplasms. Incidence and survival patterns were evaluated with respect to age, sex, race, histology, stage, and therapy. We identified 7078 cases of anal canal neoplasms: melanoma (n = 149), neuroendocrine (n = 61), and small cell neuroendocrine (n = 26). Squamous cell carcinoma (SCC) (n = 6842) served as the comparison group. Anal melanoma (AM) demonstrated the lowest survival rate at 2.5 per cent. Neuroendocrine tumors (NETs) demonstrated similar survival as SCC (10-year survival for regional disease of 25 and 22.3%, respectively). Ten-year survival of small cell NETs resembled AM (5.3 vs 2.5%). Age 60 years or older, sex, black race, stage, and surgery were independent predictors of survival. This study presents the largest patient series of rare anal neoplasms. NETs of the anal canal demonstrate similar survival patterns to SCC, whereas small cell NETs more closely resemble AM. Accurate histologic diagnosis is vital to determine treatment and surgical management because survival patterns can differ among rare anal neoplasms.

eTAMIS: endoscopic visualization for transanal minimally invasive surgery

BACKGROUND

Transanal endoscopic microsurgical (TEM) resection is associated with improved outcomes compared to transanal excision of rectal lesions. However, TEM equipment requires additional operative setup time, and tumor location dictates patient positioning. In 2010, Drs. Attallah, Albert, and Larach developed an alternative technique, transanal minimally invasive surgery (TAMIS). Herein, we describe our novel experience using endoscopic visualization to perform TAMIS (eTAMIS) to remove a large rectal polyp.

METHODS

This is a technical note describing a new surgical technique, eTAMIS. The technique is performed with the Gelpoint Path TAMIS platform (Applied Medical, Rancho Santa Margarita, CA) and a standard single-channel endoscope for visualization. Patient demographics, operative data, and pathologic data were recorded.

RESULTS

eTAMIS was initially performed in a 50-year-old woman with an endoscopically defiant rectal mass discovered on routine screening colonoscopy. The lesion was a tubulovillous adenoma, 10 cm from the anal verge, anterior, and occupied 15-20 % of the circumference. The rectal mass was removed by eTAMIS. The operative time was 101 minutes, and the patient was discharged within 24 h without event. Final pathology revealed a focus of well-differentiated rectal adenocarcinoma with focal invasion into the muscularis mucosa (Haggit level 0, pTis) arising in the head of a pedunculated tubulovillous adenoma. At 1-year follow-up endoscopy, the patient had no evidence of recurrent mass or polyp.

CONCLUSIONS

This is the first technical report describing endoscopic visualization for TAMIS. Endoscopic visualization facilitates intraluminal articulation and lens cleaning while minimizing extraluminal instrument collisions. eTAMIS is a practical and logical evolution of the visual approach to natural orifice transluminal endoscopic surgery and laparoendoscopic surgery.

Molecular predictors of treatment response in colon and gastric cancer

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Background: With the exception of KRAS mutational status, there is limited use of tumor-derived biomarkers in the clinical management of GI malignancies. High ERCC1 expression is associated with inferior outcomes in platinum-exposed patients with non-small cell lung, esophageal, and head and neck cancers. Previous studies have concluded ERCC-1 gene expression levels may identify patients unlikely to benefit from oxaliplatin-based chemotherapy in metastatic colon cancer and in the adjuvant therapy of esophageal/gastric cancer. Methods: Biomarkers were obtained from formalin fixed paraffin embedded tumor samples from 69 colorectal and 22 gastric cancer subjects. Each tumor was dissected using laser-captured microdissection and analyzed mRNA expression using a quantitative RT-PCR. A retrospective chart review was performed to evaluate clinical response. The primary objective was todetermine the prevalence of select tumor biomarkers including ERCC1, TS, VEGFR2a, Her2, KRAS, BRAF, and EGFR mutation status and and correlate these with overall survival. Results: Colon: Subjects with high ERCC1 expression had significantly worse OS survival compared to those with lower ERCC1 expression (26.0 vs 71.1 mo, p=0.0077). There was a trend towards decreased OS with high TS expression, but this was not statistically significant (71 vs 56 mo, p=0.49). Subjects with the V600E BRAF mutation had significantly worse OS compared to wild-type tumors (48.5 vs 61.3 mo, p=0.03). Gastric: Median OS was not reached due to a limited number of gastric subjects and only 9 of 22 had died at time of analysis. Updated analysis is planned. Conclusions: Even in this small population it is possible to detect survival differences using biomarker analysis of biopsy and resection specimens. Virtually all tumor samples yielded sufficient material for analyses. We suspect that the decreased OS in high ERCC1 expressing tumors is a result of platinum resistance. These results suggest that the use of biomarkers may identify patients unlikely to respond to conventional therapy, and warrant further investigation in a prospective clinical trial.

Robotic-assisted laparoscopic stage II restorative proctectomy for toxic ulcerative colitis

BACKGROUND

There is a paucity of literature reporting minimally invasive proctectomy for ulcerative colitis (UC). We report a novel application of a robotic system to perform restorative proctectomy in patients with toxic UC.

METHODS

Retrospective review, case series report.

RESULTS

Robotic-assisted laparoscopic proctectomy with ileal J-pouch anal anastomosis was performed in three patients with toxic UC. All patients previously underwent urgent laparoscopic total abdominal colectomy. One female and two male patients were aged 39, 24 and 43, respectively. The procedures were performed safely with minimal complications. The robotic proctectomy operative time was reduced from 134 to 106 min. None of the patients have experienced fecal incontinence, nocturnal seepage or sexual dysfunction.

CONCLUSIONS

This is a case series report of a robotic-assisted laparoscopic proctectomy with restorative ileal J-pouch in patients with toxic UC. This technique has been previously described for use in patients with medically refractory UC and neoplasia associated with chronic UC. This series exemplifies an ideal application of a robotic system with improved visibility, rotation and ergonomics.

Functional disorders: rectoanal intussusception

Rectoanal intussusception (RI) is a telescoping of the rectal wall during defecation. RI is an easily recognizable physiologic phenomenon on defecography. The management, however, is much more controversial. Two predominant hypotheses exist regarding the etiology of RI: RI as a primary disorder, and RI as a secondary phenomenon. The diagnosis may be suspected based on clinical symptoms of obstructive defecation. Diagnostic modalities include defecography as the gold standard. Dynamic pelvic magnetic resonance imaging (DPMRI) and transperineal ultrasound are attractive alternatives to defecography; however, their sensitivity is poor in comparison to the gold standard at this time. Management strategies including conservative measures such as biofeedback and surgical procedures including mucosal proctectomy (Delorme), rectopexy, and stapled transanal rectal resection (STARR) procedures have varied degrees of efficacy.

Parastomal hernia: short-term outcome after laparoscopic and conventional repairs

The purpose of this study was to evaluate the short-term outcomes after laparoscopic and conventional parastomal hernia repairs. A retrospective review of parastomal hernia repairs was performed. Conventional repairs included primary suture repair, stoma relocation, and mesh repair. Laparoscopic repairs included the Sugarbaker and keyhole techniques. Forty-nine patients underwent repair of symptomatic parastomal hernias: 19 ileostomies, 13 colostomies, and 17 urostomies. Thirty patients underwent 39 conventional repairs. Nineteen patients underwent laparoscopic surgical repairs. Operative times were longer for laparoscopic repair (208 +/- 58 vs 162 +/- 114 minutes, P = .06). The mean length of stay was 6 days for both groups (P = .74). The mean follow-up was shorter in the laparoscopic group (20 vs 65 months, P < or = .001). There were no significant differences in the incidence of surgical site infections (11% laparoscopic vs 5% conventional, P = .60) or complication rates (63% laparoscopic vs 36% conventional, P = .67). Laparoscopic parastomal hernia repair is a feasible operation with similar short-term outcomes to conventional repairs.

Cognitive Performance in Older Women Relative to ApoE-ε4 Genotype and Aerobic Fitness

INTRODUCTION

Apolipoprotein E (ApoE) genotype and aerobic fitness are each associated with cognitive performance in older adults. However, their potentially interactive effects on cognitive performance have not been examined.

PURPOSE

The primary purpose of this study was to determine whether ApoE genotype and aerobic fitness interact to uniquely impact memory performance and executive functioning. A secondary purpose was to examine the interactive effects on other measures of cognition to provide a more comprehensive assessment of cognitive abilities across a broad range of functions.

METHODS

Community-dwelling, cognitively normal older women (N = 90) provided blood samples to allow for assessment of ApoE genotype, completed cognitive tests, and performed a maximal aerobic fitness test. Primary outcome variables were the auditory verbal learning test (AVLT), the complex figures test (CFT), and the Wisconsin card-sorting task (WCST). Secondary outcome variables were the block design test and the paced auditory serial addition task (PASAT).

RESULTS

Regression analyses indicated that aerobic fitness was associated with significantly better performance on measures of the AVLT, the CFT, and the PASAT for the ApoE-epsilon4 homozygotes.

CONCLUSION

The preliminary findings from this study support the possibility that aerobic fitness is positively associated with the memory performance of those individuals at most genetic risk for Alzheimer disease.

The safety of open inguinal herniorraphy in patients on chronic warfarin therapy

BACKGROUND

The perioperative management of warfarin therapy increases the complexity of open inguinal herniorraphy.

METHODS

One thousand consecutive patients undergoing open inguinal herniorraphy were retrospectively reviewed. Patients on warfarin therapy were categorized into 3 groups: continued warfarin (CW), discontinued warfarin (DW), and discontinued warfarin with anticoagulation bridge (DWB).

RESULTS

Eighty-eight patients were on chronic warfarin therapy. Warfarin was continued in 19 patients, discontinued in 54, and discontinued with bridge in 15 patients. Operative times were similar between the 3 groups. Length of stay was longest in the discontinued warfarin with bridge group (CW 0.74, DW 0.54, and DWB 3.33 days; P < .0001). There was no significant difference in postoperative complications. The incidence of surgical site hematoma was higher in the continued warfarin and discontinued warfarin with bridge groups (CW 11%, DW 2%, and DWB 13%; P = .14).

CONCLUSIONS

Continuation of warfarin may be a safe alternative to discontinuation of warfarin therapy in select patients undergoing open inguinal herniorraphy.

Intraoperative Peripherally Inserted Central Venous Catheter Central Venous Pressure Monitoring in Abdominal Aortic Aneurysm Reconstruction

Numerous studies have found no clinically significant benefit to the perioperative use of pulmonary artery catheters (PACs), and peripherally inserted central venous catheters (PICCs) have been reported to measure central venous pressure (CVP) accurately. The objective of this study was to determine whether the dynamic shifts in preload associated with elective reconstruction of abdominal aortic aneurysms (AAAs) are accurately reflected by CVP measurements from open-ended PICCs compared to CVP measurements from concomitant indwelling PACs. This is a retrospective review of prospectively collected data. PICCs and PACs were placed preoperatively in five patients undergoing elective AAA reconstruction. CVP measurements were recorded every 15 min during the operation. Bland-Altman statistical analysis was used to determine the degree of agreement in data collected by the two measurement devices. Seventy-three paired measurements of CVP from concomitant indwelling PICCs and PACs obtained from five patients undergoing elective AAA reconstruction revealed PICC measurements to be higher than PAC measurements by 0.6 mm Hg (overall correlation coefficient 0.92). The difference between the two measurement devices was expected to be <3.4 mm Hg at least 95% of the time. The findings of this pilot study indicate that PICCs are an effective method for CVP monitoring in situations of dynamic systemic compliance and preload, such as those observed during elective AAA reconstruction.

Telepathy: maximizing resident exposure to surgical pathology decision making

BACKGROUND

General surgery residents are often not present for the critical intraoperative discussion between surgeon and pathologist regarding surgical pathology findings.

METHODS

A prospective pilot study analyzed general surgery resident exposure to surgical pathology. Thereafter, an operating room was equipped to view frozen section images in real time and verbally communicate with the pathologist (TelePATHy). Total operative cases, cases using frozen sections, and use of TelePATHy were recorded.

RESULTS

Most residents (78%) reported they were exposed to frozen-section surgical pathology < or =10% of the time. Overall, 202 operations were performed over the 123-day period. Forty-four cases had frozen-section specimens. General surgery residents were present for 40 cases. TelePATHy was successfully used in 32 cases (80%).

CONCLUSIONS

General surgery resident exposure to intraoperative pathology findings increased from a reported < or =10% to an observed 80%. TelePATHy is a novel intraoperative tool capable of maximizing the intraoperative experience of the surgical resident.

Short-term, moderate dosage Vitamin E supplementation may have no effect on platelet aggregation, coagulation profile, and bleeding time in healthy individuals

OBJECTIVE

To investigate the in vivo effect of short-term, moderate dosage synthetic dl-alpha-tocopherol acetate supplementation on platelet aggregation, coagulation profile, and simulated bleeding time in healthy individuals. alpha-tocopherol is the most biologically active isomer of Vitamin E, traditionally promoted as an antioxidant and therapeutic agent in cardiovascular disease. In vitro studies have suggested that alpha-tocopherol plays a role in the inhibition of platelet aggregation. However, further investigations into the effect of alpha-tocopherol on bleeding in vivo have not duplicated these findings.

MATERIALS AND METHODS

A total of 42 healthy volunteers complied with a 2-week abstinence period from the use of anti-platelet agents followed by determination of baseline platelet aggregation properties and coagulation studies using citrated whole blood. Moderate dosage Vitamin E (800 IU of dl-alpha-tocopherol acetate) was then self-administered for 14 days with reevaluation of platelet aggregation and coagulation profile, and simulated bleeding time after 14 days of Vitamin E supplementation.

RESULTS

Forty subjects completed the 4-week study period. All 40 subjects demonstrated normal baseline coagulation studies and all had collagen-stimulated platelet aggregation assessment performed in triplicate. After Vitamin E supplementation, no significant difference was demonstrated in any study parameter.

CONCLUSIONS

Dietary supplementation with moderate dosage synthetic dl-alpha-tocopherol acetate did not significantly prolong bleeding or platelet aggregation in vivo. The affect of Vitamin E on platelet aggregation in vitro does not appear to be reproducible in vivo. Therefore, peri-operative discontinuation of Vitamin E may not be necessary.

Breast cancer: presentation and intervention in women with gastrointestinal metastasis and carcinomatosis

BACKGROUND

Breast cancer metastatic to the gastrointestinal tract or peritoneum is rare. We reviewed the natural history of ductal and lobular carcinoma in women with breast cancer metastatic to the gastrointestinal tract, peritoneum, or both.

METHODS

We performed a retrospective review of all patients (1985-2000) with a pathologic diagnosis of breast cancer metastatic to the gastrointestinal tract or peritoneum. Patients were categorized into three groups: those with gastrointestinal metastasis, carcinomatosis, or both.

RESULTS

Of 73 patients, 23 (32%) had gastrointestinal metastasis only, 32 (44%) had carcinomatosis only, and 18 (25%) had both. The median age at initial breast cancer diagnosis was 55 years. The mean interval between the primary diagnosis and metastatic presentation was 7 years. Sites of gastrointestinal metastases included the esophagus (8%), stomach (28%), small intestine (19%), and colon and rectum (45%). Infiltrating lobular carcinoma represented 34 (64%) of the 53 gastrointestinal metastases. The median overall survival after diagnosis was 28 months. Palliative surgical intervention in 47 patients (64%) did not affect overall survival. Some survival benefit may have accrued to select patients with gastrointestinal metastasis who underwent surgical palliation (44 vs. 9 months). Advanced age at diagnosis and gastric metastases had a negative effect on survival, whereas treatment with systemic chemotherapy or tamoxifen had a positive effect on survival.

CONCLUSIONS

Gastrointestinal metastasis occurred more often in patients with invasive lobular carcinoma. Surgical intervention did not significantly extend overall survival but may be considered in a select group of patients.

Role of the small heat shock proteins in regulating vascular smooth muscle tone

BACKGROUND

Vasospasm occurs in conduits used for vascular reconstructions. The small heat shock proteins, HSP20 and HSP27, coordinately regulate vascular smooth muscle tone. Phosphorylated HSP20 is associated with vasorelaxation, and phosphorylated HSP27 inhibits the phosphorylation of HSP20 and relaxation. We hypothesized that the relationship between the phosphorylated states of these two proteins might dictate the tone of a vessel and may contribute to vasospasm.

STUDY DESIGN

Sodium nitroprusside relaxation of vascular smooth muscle was recorded using pig coronary artery and human saphenous vein. Segments were frozen and homogenized, and extracted proteins were separated by one- and two-dimensional gel electrophoresis, transferred to Immobilon (Millipore), and probed with anti-cGMP-dependent protein kinase (anti-PKG), -HSP20, -HSP27, and -phosphoHSP27 antibodies. Band intensity was estimated using densitometry.

RESULTS

Pig coronary artery completely relaxed (100%) with SNP (10(-7)M), but human saphenous vein only partially relaxed (20%). The levels of cGMP-dependent protein kinase and HSP20 were similar in the two tissue types. Human saphenous vein had significantly higher levels of HSP27 versus pig coronary artery (30.14 +/- 0.8 versus 6.62 +/- 0.2 pixels/mg; p < or = 0.001) and phosphoHSP27 (8.29 +/- 3.43 versus 0.012 +/- 0.008 pixels/mg; p < or = 0.001).

CONCLUSIONS

Human saphenous vein contained significantly higher levels of HSP27 and pHSP27. Increased levels of phosphorylated HSP27 might contribute to vasospasm in human saphenous vein.

Depletion of activated Vbeta8+ T cells disrupts bispecific antibody directed antitumor immunity

INTRODUCTION

Activation of Vbeta8+ T cells with superantigen staphylococcal enterotoxin B (SEB) and use of an antitumor, anti-CD3 bispecific antibody (BsAb) leads to tumor protective immunity. We hypothesize that Vbeta8+ T-cell activation in combination with BsAb is crucial for tumor protective immunity in this model.

METHODS

Adolescent C3H/HeN mice were intravenously injected with syngeneic CL62 melanoma to establish pulmonary metastasis. Three days after establishing pulmonary metastasis, predominantly Vbeta8+ T cells are activated with 50 mug of intraperitoneal superantigen SEB. T cells were depleted at different time points in relation to SEB administration to assess the effect on protective immunity against a second tumor challenge.

RESULTS

Protective immunity is significantly (P < 0.008) decreased when Vbeta8+ depletion occurs 6 h after SEB injection, as growth of rechallenged CL62 melanoma occurred in 43%. Protective immunity is present at all other time points when mice survive Vbeta8+ T-cell depletion. Survival of animals treated with SEB/BsAb (82%) is significantly better (P < 0.002) than with SEB alone (60%) or nontreated control (0%). Survival when Vbeta8+ T-cell depletion occurred at 6 h and 48 h post-SEB is 72% and 77%, respectfully, and is statistically indistinguishable (P < 0.232 and P < 0.602). If T-cell depletion was conducted before SEB administration, however, the combination of SEB and BsAb did not result in significant protective immunity. T-cell depletion before the use of SEB alone, without BsAb, failed to result in significant protective immunity.

CONCLUSIONS

Depletion of Vbeta8+ T cells 6 h after activation disrupts the development of protective immunity.

Transducible recombinant small heat shock-related protein, HSP20, inhibits vasospasm and platelet aggregation

BACKGROUND

Human saphenous vein (HSV) is the autologous conduit of choice for peripheral vascular reconstruction. Injury during harvest leads to vasospasm and a thrombogenic endoluminal surface. A proteomic transduction approach was developed to prevent vein graft vasospasm and thrombosis.

METHODS

Recombinant HSP20 protein linked to the TAT protein transduction domain was generated in a bacterial expression system (TAT-HSP20). The effect of this protein on the inhibition of smooth muscle contraction was determined using rings of rabbit aorta and HSV in a muscle bath. In addition, the effects of TAT-HSP20 on platelet aggregation were determined in vitro using human citrated whole blood.

RESULTS

Recombinant TAT-HSP20 inhibited norepinephrine-induced contraction of rabbit aortic and HSV segments. Similarly, TAT-HSP20 induced smooth muscle relaxation in HSV segments precontracted with norepinephrine. In human-citrated whole blood, platelet aggregation was significantly inhibited by TAT-HSP20 in a dose-dependent manner.

CONCLUSIONS

The results of this study demonstrate that recombinant TAT-HSP20 inhibits vascular smooth muscle contraction and platelet aggregation. This suggests that HSP20 may be an ideal effector molecule to target as a proteomic approach to enhance early vein graft patency rates by preventing acute vasospasm and thrombosis.