Minimally invasive colectomies can be performed with similar outcomes to open counterparts for colorectal cancer emergencies: a propensity score matching analysis utilizing ACS-NSQIP

PURPOSE

The safety and feasibility of minimally invasive surgery (MIS) in the setting of colorectal cancer emergencies have been debated. We sought to compare postoperative outcomes of MIS with open techniques in the setting of colorectal cancer emergencies from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database.

METHODS

We included patients undergoing colectomy for colorectal cancer emergency between 2012 and 2019 "2012-2019" from the ACS-NSQIP dataset. We compared short-term morbidity, mortality, short-term oncological outcomes, and secondary outcomes for MIS vs open colectomies using propensity score matching. We then evaluated the trends of MIS versus open colectomies using linear regression analysis.

RESULTS

We examined a total of 5544 patients (open n = 4070; MIS n = 1474) and included 1352 patients for our postoperative outcome analyses after propensity score matching 1:1 (open n = 676; MIS n = 676). Within the matched cohort, mortality was significantly higher in the open group (open 6.95% vs MIS 3.99%, OR 1.8, p = 0.023). Anastomotic leak rates were comparable between the  two groups (open 4.46% vs MIS 4.02%, OR 1.12, p = 0.787). Pulmonary complications were significantly higher after open surgery (open 10.06% vs MIS 4.73%, OR 2.25, p < 0.001). Rates of ileus were significantly higher amongst open patients (open 29.08% vs MIS 19.94%, p < 0.001). Patients stayed on average 1 day longer in the hospital after open surgery (p < 0.001). Rates of MIS for early tumors (N0 and T1/T2, n = 289) did not significantly change over 7 years (p = 0.597, rate = - 0.065%/year); however, utilization of MIS for late tumors (N1 or T3/T4, n = 4359) increased by 2.06% per year (p < 0.001).

CONCLUSIONS

This study demonstrates that MIS was associated with superior postoperative outcomes compared to open surgery without compromising oncological outcomes in patients undergoing emergency colectomy for colon cancer. Within the matched cohort, MIS was associated with lower rates of mortality, pulmonary complications, ileus, and shorter postoperative length of stay.

The usefulness of the H-pouch configuration in salvage surgery for failed ileal pouches

AIM

Abdominal salvage surgery for a failed ileal pouch-anal anastomosis (5) is safe and feasible in experienced hands. When salvaging an ileal pouch or creating a new J, S or W pouch may not be feasible, construction of an H-pouch may be the final option. This study reports a single colorectal surgeon's experience on H-pouch anal anastomosis in patients referred with a failed ileal pouch.

METHOD

Patients undergoing transabdominal salvage surgery with H-pouch formation for a failed pouch from February 2012 to May 2016 were evaluated.

RESULTS

Five patients were identified with a mean age of 46 (22-63) years. The pathological diagnosis was mucosal ulcerative colitis in all patients. Three patients had an initial traditional two-stage J-pouch creation and two patients had an initial three-stage approach. The median time to redo pouch surgery after the index IPAA creation was 99 (11-158) months. One patient required excision of the pouch and two patients had a complication within 30 days of surgery.

CONCLUSION

The H-pouch is a good alternative for a failed IPAA when another type of reservoir is not an option.

Robotic versus conventional laparoscopic rectal cancer surgery in obese patients

AIM

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

METHOD

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

RESULTS

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

CONCLUSION

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

Primacy of surgery for colorectal cancer

BACKGROUND

The optimal technique for curative resection of colonic cancer includes high ligation of the mesenteric vessels, wide excision of the colonic mesentery and prevention of tumour cell spillage. This article reports results from the authors' institution for patients in whom complete mesocolic excision was performed long before the term was coined.

METHODS

Patients operated on for cure for primary adenocarcinoma of the colon between January 1994 and December 2004 were identified from a prospectively maintained, institutional review board-approved, colorectal cancer registry. Medical records and operation notes were reviewed. The primary outcomes were recurrence (local and distal) and age-adjusted 5-year survival.

RESULTS

Some 1013 patients (560 men and 453 women) were identified, with a median age of 69 (range 21-96) years. The most common location of the cancer was the sigmoid colon (32·9 per cent), followed by the caecum (26·7 per cent) and ascending colon (17·0 per cent). Operations were performed laparoscopically in 134 patients (13·2 per cent). Median duration of hospital stay was 7 (range 1-64, mean 8·2) days. Overall morbidity and mortality rates were 13·5 and 2·2 per cent respectively; there were 20 anastomotic leaks (2·0 per cent). Some 282 patients (27·8 per cent) had stage I, 386 (38·1 per cent) stage II and 345 (34·1 per cent) stage III disease. Median lymph node yield was 28·3 (range 0-241, mean 28·3), and 12 or more nodes were examined in 88·1 per cent of patients. Adjuvant chemotherapy was administered to 277 patients (80·3 per cent) with stage III disease. Overall local and distant recurrence rates at 5 years were 5·1 and 17·1 per cent respectively. The 5-year local recurrence rate was 2·2, 5·3 and 7·7 per cent for American Joint Committee on Cancer stages I, II and III respectively. Corresponding distant recurrence rates were 4·0, 14·7 and 30·5 per cent. The 5-year overall cancer-free age-standardized survival rate was 85·3 per cent. Five-year age standardized survival rates for patients with disease stages I, II and III were 97·7, 90·8 and 69·8 per cent respectively.

CONCLUSION

These data define modern results of surgery for colonic cancer with conservative use of chemotherapy.

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

AIM

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

METHOD

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

RESULTS

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

CONCLUSION

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

Minimally invasive surgical wound infections: laparoscopic surgery decreases morbidity of surgical site infections and decreases the cost of wound care

AIM

The morbidity of surgical site infections (SSIs) were compared in patients who underwent open (OS) vs laparoscopic (LS) colorectal surgery.

METHOD

Data from 603 consecutive LS patients and 2246 consecutive OS patients were prospectively recorded. Morbidity of SSIs was assessed by the need for emergency department (ED) evaluation, subsequent hospital re-admission and re-operation. The cost of wound care was measured by the need for home healthcare, wound vacuum assisted closure (VAC) or independent patient wound care.

RESULTS

SSIs were identified in 5.8% (n = 25) of LS patients and 4.8% (n = 65) of OS patients. ED evaluation for the infection was needed in 24% of the LS group and 42% of the OS group. Hospital re-admission was needed in one LS patient and in 52% OS patients. No LS patient needed re-operation compared with 12% of OS patients. HHC ($162/dressing change) was required in 63% of the OS group compared with 8% of LS group. A home wound VAC system ($107/day) was utilized in 12% of the OS patients but in none of the LS patients. Dressing changes were managed independently by the patient in 92% of the LS compared with 37% of the OS patients.

CONCLUSION

Laparoscopic colorectal surgery patients experience less morbidity when they develop SSIs incurring less cost compared with open colorectal surgery patients.

Hand-assisted laparoscopic surgery may be a useful tool for surgeons early in the learning curve performing total abdominal colectomy

OBJECTIVE

We evaluated outcomes after hand-assisted (HALC) and straight laparoscopic (LC) techniques for the initial laparoscopic total abdominal colectomy (TAC) procedures performed by surgeons starting their laparoscopic careers.

METHOD

The first eight HALC cases of two surgeons performing TAC by this technique (Group A) were compared with the first (Group B) and last eight (Group C) TAC cases of three surgeons performing LC. Groups A and B were compared with a matched group of open total colectomy cases (Group D) and to the eight cases performed by an experienced surgeon (Group E). Demographics, intra-operative and postoperative outcomes including operation time, morbidity, conversion and readmission rates and length of hospital stay (LOS) were compared using Wilcoxon or Chi-squared tests.

RESULTS

Demographics of the patients were similar. Groups A, B C and E had similar operating time (P = 0.10) which was significantly longer than Group D (P < 0.0001). Morbidity (P = 0.75) and readmission rates were similar (P = 0.89). Conversion rate was significantly higher for Group B (Group B: 41.7%vs Group A: 0%, P = 0.008), in the early period. LOS was comparable between minimally invasive groups but significantly shorter than open surgery group (P = 0.0005). For Groups A and C, operating time (P = 0.55), conversion rate (P = 0.11), morbidity (P = 0.83) and LOS (P = 0.12) were similar.

CONCLUSIONS

Hand-assisted laparoscopic colectomy may be associated with a significantly shorter learning curve for TAC as results are better than early LC and comparable with LC performed by experienced laparoscopic surgeons. It may be a better option for surgeons early in their laparoscopic career.

Portal vein thrombi after restorative proctocolectomy: serious complication without long-term sequelae

PURPOSE

Portal vein thrombi have been observed after restorative proctocolectomy and ileal pouch-anal anastomosis, and present as a clinical spectrum of abdominal pain, fever, and leukocytosis. Anticoagulation treatment is usually associated with resolution of symptoms. However, the long-term consequences and effect on pouch function are not known. The purpose of this study was to analyze the long-term functional outcome of patients with confirmed portal vein thrombi after restorative proctocolectomy.

METHODS

A retrospective study of all patients undergoing restorative proctocolectomy from January 1997 to 2000 was performed. A case-control study was designed that matched 37 patients with confirmed portal vein thrombi in this period with 133 patients without portal vein thrombi; the groups were compared with respect to pouch function and quality of life by using the Global Cleveland Clinic Quality of Life Questionnaire for pelvic pouch patients.

RESULTS

The mean follow-up was 4.73 (range, 4.21-7.28) years. The percentage of male patients was 58.8. The most common diagnosis was ulcerative colitis (62.4 percent). There were no significant differences between portal vein thrombi patients and controls with respect to pouch function (number of bowel movements, urgency, incontinence), episodes of pouchitis, or quality of life.

CONCLUSIONS

Portal vein thrombi can be a serious complication after restorative proctocolectomy that usually resolves with anticoagulation therapy. Long-term pouch function and quality of life are not affected.

Risk factors associated with ileal pouch-related fistula following restorative proctocolectomy

Introduction

Pouch-related fistula occurs in 5–10 per cent of patients after restorative proctocolectomy. The present study identified risk factors associated with the development of such fistulas.

Methods

Data on preoperative and postoperative risk factors were recorded from 1965 patients who underwent restorative proctocolectomy in a single tertiary centre between 1983 and 2001. Cox regression analysis was used to identify independent predictors of pouch–perineal, pouch–abdominal wall and pouch–vaginal fistula during follow-up.

Results

Median patient follow-up was 4·1 (range 0–19) years. By 15 years' follow-up, pouch–vaginal fistulas had occurred in 44 women (5·2 per cent). The prevalence of ileal pouch–perineal and pouch–abdominal wall fistula was 3·6 per cent (70 patients) and 1·5 per cent (30 patients) respectively. Independent predictors of pouch-related fistula identified by multivariate analysis were diagnosis of indeterminate colitis or Crohn's disease (hazard ratio (HR) 1·28 (95 per cent confidence interval (c.i.) 1·00 to 1·65) and 1·73 (95 per cent c.i. 1·07 to 3·48) respectively versus ulcerative colitis or familial adenomatous polyposis), previous anal pathology (HR 3·43 (95 per cent c.i. 2·43 to 4·84) and 4·02 (95 per cent c.i. 1·27 to 12·77) respectively for perineal abscess and fistula in ano versus no previous anal pathology), abnormal anal manometry (HR 4·29 (95 per cent c.i. 2·33 to 7·91)), patient sex (HR 0·74 (95 per cent c.i. 0·58 to 0·95) for men versus women) and pelvic sepsis (HR 3·79 (95 per cent c.i. 2·48 to 5·79)).

Conclusion

This study suggests that Crohn's disease and the clinical signs that favour the diagnosis of Crohn's disease may contribute to the development of pouch-related fistula.

Incidence and natural history of dysplasia of the anal transitional zone after ileal pouch-anal anastomosis: results of a five-year to ten-year follow-up

PURPOSE

Preservation of the anal transitional zone during ileal pouch-anal anastomosis is still controversial because of the risk of dysplasia and the theoretical risk of associated cancer. Without long-term follow-up data, the natural history and optimal treatment of anal transitional zone dysplasia are unknown. The aim of this study was to determine the long-term risk of dysplasia in the anal transitional zone and to evaluate the outcome of a conservative management policy for anal transitional zone dysplasia.

METHODS

Two hundred ten patients undergoing anal transitional zone-sparing ileal pouch-anal anastomosis for ulcerative or indeterminate colitis between 1987 and 1992 and who were studied with serial anal transitional zone biopsies for at least five years postoperatively were included. Median follow up was 77 (range, 60-124) months.

RESULTS

Anal transitional zone dysplasia developed in seven patients 4 to 51 (median, 11) months postoperatively. There was no association with gender, age, preoperative disease duration or extent of colitis, but the risk of anal transitional zone dysplasia was significantly increased in patients with prior cancer or dysplasia in the colon or rectum. Dysplasia was high grade in one and low grade in six. Two patients each with low-grade dysplasia detected on three separate occasions underwent mucosectomy 29 and 38 months after detection of low-grade dysplasia, but no cancer was found. The five other patients with dysplasia on one or two occasions were treated expectantly and were apparently dysplasia-free for a median of 72 (range, 48-100) months.

CONCLUSIONS

Anal transitional zone dysplasia after ileal pouch-anal anastomosis is infrequent, is most common in the first two to three years postoperatively and may apparently disappear on repeated biopsy. Anal transitional zone preservation did not lead to the development of cancer in the anal transitional zone after five to ten years of follow-up. Long-term surveillance is recommended to monitor dysplasia. If repeat biopsy confirms persistent dysplasia, anal transitional zone excision with neoileal pouch-anal anastomosis is recommended.

The ileal pouch anal anastomosis: past, present, and future

The modern era of ileal pouch anal anastomosis began just over 20 years ago. Several areas remain controversial, including patient selection, surgical technique, use of a temporary diverting ileostomy, aging sphincters, complications, and postoperative management. This article reviews current controversies concerning ileal pouch anal anastomoses and our approach to managing patients who undergo this complicated procedure.

Incidence and natural history of dysplasia of the anal transitional zone after ileal pouch-anal anastomosis: results of a five-year to ten-year follow-up

PURPOSE

Preservation of the anal transitional zone during ileal pouch-anal anastomosis is still controversial because of the risk of dysplasia and the theoretical risk of associated cancer. Without long-term follow-up data, the natural history and optimal treatment of anal transitional zone dysplasia are unknown. The aim of this study was to determine the long-term risk of dysplasia in the anal transitional zone and to evaluate the outcome of a conservative management policy for anal transitional zone dysplasia.

METHODS

Two hundred ten patients undergoing anal transitional zone-sparing ileal pouch-anal anastomosis for ulcerative or indeterminate colitis between 1987 and 1992 and who were studied with serial anal transitional zone biopsies for at least five years postoperatively were included. Median follow up was 77 (range, 60-124) months.

RESULTS

Anal transitional zone dysplasia developed in seven patients 4 to 51 (median, 11) months postoperatively. There was no association with gender, age, preoperative disease duration or extent of colitis, but the risk of anal transitional zone dysplasia was significantly increased in patients with prior cancer or dysplasia in the colon or rectum. Dysplasia was high grade in one and low grade in six. Two patients each with low-grade dysplasia detected on three separate occasions underwent mucosectomy 29 and 38 months after detection of low-grade dysplasia, but no cancer was found. The five other patients with dysplasia on one or two occasions were treated expectantly and were apparently dysplasia-free for a median of 72 (range, 48-100) months.

CONCLUSIONS

Anal transitional zone dysplasia after ileal pouch-anal anastomosis is infrequent, is most common in the first two to three years postoperatively and may apparently disappear on repeated biopsy. Anal transitional zone preservation did not lead to the development of cancer in the anal transitional zone after five to ten years of follow-up. Long-term surveillance is recommended to monitor dysplasia. If repeat biopsy confirms persistent dysplasia, anal transitional zone excision with neoileal pouch-anal anastomosis is recommended.

Serum ferritin: a tumor marker for renal cell carcinoma

Serum ferritin levels in 32 patients with renal cell carcinoma were evaluated preoperatively and postoperatively. Serum ferritin concentration was significantly higher in renal cell carcinoma patients compared to controls (259.10 versus 61.30 ng./ml., p less than 0.001). Furthermore, there was a steady and statistically significant increase in serum ferritin levels with advancing disease stage, as well as a significant decrease in serum ferritin levels after nephrectomy for stages 1 and 2 disease. The intracellular content of ferritin as estimated by polyclonal antibody was dramatically increased in renal cancer tissue compared to normal parenchyma. Although serum ferritin regulation is complex and only partly understood, the present study suggests that serum ferritin may be a useful tumor marker for renal cell carcinoma.

The effect of post-pubertal varicocele on testicular volume

Paediatric varicocele is a well known entity but its effect on adult infertility has not been adequately clarified. Since measurement of testicular volume is currently the best method of estimating the male reproductive potential, 945 boys aged between 13 and 18 years were examined with regard to testicular volume and the incidence of varicocele. The average volumes for right and left testes were 15.087 +/- 0.237 and 14.514 +/- 0.347 ml respectively, and the incidence of varicocele was 16.7%. The incidence increased from 14.5 to 21.7% as the ages increased from 14 to 18. The differences in volume of the 2 testes in boys with varicocele were statistically significant when compared with the normal group, but this significance failed to become more pronounced when the slight varicocele group (grade I) was included with the normal group and compared with the severe varicocele group (grades II and III). There may be no significant differences between the volumes of the 2 testes in boys with varicocele when careful measurement and strict statistical analyses are applied. However, some boys in the varicocele group were found to have testicular volumes below the confidence interval (mean - SE) or under 1 SD, and the 2 testicular volumes differed in certain age groups. This group requires further follow-up. The results of this study have added further contradictory findings to the issue of paediatric varicocele in terms of testicular atrophy, estimation of potential fertility and the indications for immediate surgery. There is a need for further prospective controlled trials.