Adam Klipfel

Neoadjuvant Bevacizumab, Oxaliplatin, 5-Fluorouracil, and Radiation for Rectal Cancer

PURPOSE To evaluate the feasibility and pathologic complete response rate of induction bevacizumab + modified infusional fluorouracil, leucovorin, and oxaliplatin (FOLFOX) 6 regimen followed by concurrent bevacizumab, oxaliplatin, continuous infusion 5-fluorouracil (5-FU), and radiation for patients with rectal cancer. METHODS AND MATERIALS Eligible patients received 1 month of induction bevacizumab and mFOLFOX6. Patients then received 50.4 Gy of radiation and concurrent bevacizumab (5 mg/kg on Days 1, 15, and 29), oxaliplatin (50 mg/m(2)/week for 6 weeks), and continuous infusion 5-FU (200 mg/m(2)/day). Because of gastrointestinal toxicity, the oxaliplatin dose was reduced to 40 mg/m(2)/week. Resection was performed 4-8 weeks after the completion of chemoradiation. RESULTS The trial was terminated early because of toxicity after 26 eligible patients were treated. Only 1 patient had significant toxicity (arrhythmia) during induction treatment and was removed from the study. During chemoradiation, Grade 3/4 toxicity was experienced by 19 of 25 patients (76%). The most common Grade 3/4 toxicities were diarrhea, neutropenia, and pain. Five of 25 patients (20%) had a complete pathologic response. Nine of 25 patients (36%) developed postoperative complications including infection (n = 4), delayed healing (n = 3), leak/abscess (n = 2), sterile fluid collection (n = 2), ischemic colonic reservoir (n = 1), and fistula (n = 1). CONCLUSIONS Concurrent oxaliplatin, bevacizumab, continuous infusion 5-FU, and radiation causes significant gastrointestinal toxicity. The pathologic complete response rate of this regimen was similar to other fluorouracil chemoradiation regimens. The high incidence of postoperative wound complications is concerning and consistent with other reports utilizing bevacizumab with chemoradiation before major surgical resections.

Surgical approach to extensive hidradenitis suppurativa in the perineal/peri-anal and gluteal regions.

Background Verneuil’s disease, or hidradenitis suppurativa, is a chronic suppurative disease with a tendency to sinus formation, fibrosis, and sclerosis. It is a disease of the apocrine sweat glands and may arise from each of the localizations where apocrine glands are prominent: axilla, nipples, umbilicus, perineum, groin, and buttocks. Extensive hidradenitis suppurativa of the perineal/perianal and the gluteal regions constitute a serious social problem. In this study, we present our experience with stage III extensive hidradenitis suppurativa cases, including our treatment methods and patient outcomes.

Complete Neoadjuvant Treatment for Rectal Cancer: The Brown University Oncology Group CONTRE Study.

Purpose: Following preoperative chemoradiation and surgery, many patients with stage II to III rectal cancer are unable to tolerate full-dose adjuvant chemotherapy. BrUOG R-224 was designed to assess the impact of COmplete Neoadjuvant Treatment for REctal cancer (CONTRE), primary chemotherapy followed by chemoradiation and surgery, on treatment delivery, toxicities, and pathologic response at surgery. Methods: Patients with clinical stage II to III (T3 to T4 and/or N1 to N2) rectal cancer received 8 cycles of modified FOLFOX6 followed by capecitabine 825 mg/m2 bid concurrent with 50.4 Gy intensity-modulated radiation therapy. Surgery was performed 6 to 10 weeks after chemoradiation. Results: Thirty-nine patients were enrolled between August 2010 and June 2013. Median age was 61 years (30 to 79 y); 7 patients (18%) were clinical stage II and 32 (82%) stage III. Thirty-six patients (92%) received all 8 cycles of mFOLFOX6, of whom 35 completed subsequent chemoradiation; thus 89% of patients received CONTRE as planned. No unexpected toxicities were reported. All patients had resolution of bleeding and improvement of obstructive symptoms, with no complications requiring surgical intervention. Pathologic complete response (ypT0N0) was demonstrated in 13 patients (33%; 95% CI, 18.24%-47.76%). Conclusions: CONTRE seems to be a well-tolerated alternative to the current standard treatment sequence. Evaluating its impact on long-term outcomes would require a large randomized trial, but using pathologic response as an endpoint, it could serve as a platform for assessing the addition of novel agents to preoperative treatment in stage II to III rectal cancer.

Colon and rectal surgery surgical site infection reduction bundle: To improve is to change

BACKGROUND Despite the introduction of the Surgical Care Improvement Project, surgical site infections remain a source of morbidity. The aim of this study was to determine the value of implementing a colorectal bundle on SSI rates. METHODS Between 2011 and 2016 a total of 1351 patients underwent colorectal operations. Patients were grouped into pre-implementation (Group A, January 1, 2011-December 31, 2012), implementation (Group B, January 1, 2013-December 31, 2014) and post-implementation (Group C, January 1, 2015-December 31, 2016). Primary endpoints were superficial SSI, deep SSI, wound separation and total SSI. RESULTS After the bundle was implemented, there was a significant reduction in superficial (6.6%-4%, p < 0.05), deep (3.7%-1.1%, p < 0.05), and total SSI rates (10.9%-4.7%, p < 0.05). Comparing Group A to Group C there was a decrease in total SSI (9.4%-4.7%, p < 0.05). CONCLUSION Implementation of the bundle resulted in a reduction in overall SSI rates particularly as compliance increased. This study offers evidence that small changes can lead to significant decreases in surgical site infections.

Operative Anatomy, Third Edition, Carol E. H. Scott-Conner and David L. Dawson

This text, like the two previous editions, provides the reader with relevant, procedure-specific, operative anatomy, including potential complications and safety elements. It includes more than 110 procedures, both open and laparoscopic, from all areas of the body. This text will be useful for surgeons from all specialty areas but especially for the general surgeon with a comprehensive and inclusive practice and for residents and fellows in surgery. The content and organization of this third edition has been improved by the addition of a section of highlights with two new key elements at the beginning of each chapter. The first edition had a ‘‘List of Structures,’’ which was interesting in terms of the anatomy, but the two new elements at the beginning of each chapter—‘‘Steps in Procedure’’ and ‘‘Hallmark Anatomic Complications’’— provide orientation and focus on the most important aspects of each chapter and thus each surgical procedure. This is a unique feature, one that I wish had appeared in textbooks when I was a resident reading for operative cases, or for the Medical Boards. The introduction to each chapter highlights the most relevant aspects of the procedures being presented, making reading more efficient and productive. This focus contrasts with many major textbooks in general surgery, most of which are so comprehensive that they are not useful for a quick read or review before an operation. In addition, the major texts do not contain sections that detail the specific steps relevant to an operation. Because of its special features, this text is useful for a preoperative review or just general learning about operative surgery. Each chapter is organized by procedures for a specific area of the body. The chapter then presents the details of the procedure, including the step-by-step description, as well as various pitfalls that may be encountered. Another very useful aspect of this text is the on-line access to the entire text and images. This is especially useful for a resident or attending surgeon who is in the hospital and has time between cases to refresh and review the anatomy and the surgical approach prior to a procedure. The majority of the images in the book are relevant and easy to understand; however, there are some in which the details are difficult to see. They could be improved, specifically those in the laparoscopy section, which could also benefit from additional photographs, and even videos. Because of costs, the publisher might resist the addition of videos, but these could be available on-line to purchasers of the text. Another area that I believe could be improved is the section on instruments. The addition of this chapter was a great idea, but the text needs more information and expansion. For the resident especially to be able to learn the names and uses of the various instruments could be helpful in preparation for the operating room. Overall, this is a well conceived and useful textbook. It helps fill a void in surgical educational by combining the factual information of a traditional surgical textbook with the descriptive anatomy and visual aids of a surgical atlas. I highly recommend this text to practicing general surgeons in any area of the world. It will be particularly useful for residents and fellows. I look forward to the authors’ continuing to expand and enhance further editions of this valuable book. A. Klipfel (&) RI Colorectal Clinic, Brown Medical School, 334 East Avenue, Pawtucket, RI 02860, USA e-mail: aaklipfel@yahoo.com

Neoplasms of the Colon, Rectum, and Anus, Second Edition, by Philip H. Gordon and Santhat Nivatvongs, Informa Healthcare, 2007, 3.6 pounds,

Neoplasms of the Colon, Rectum, and Anus in its second edition is nicely updated, including new data on current trends in the epidemiology and treatment of colorectal cancer. The authors are Phillip H. Gordon from McGill University in Montreal, and Santhat Nivatvongs from The Mayo Clinic, Rochester, Minnesota. In addition there is a special contribution from Lee Smith of the Washington Hospital Center, Washington, DC. All three of these authors are leaders in the field of colorectal surgery and are well known and respected by their peers. Drs. Gordon and Nivatvongs are authors of one of the Major Textbooks in Colorectal Surgery titled Principles and Practice of Surgery for the Colon, Rectum, and Anus, which is used by colorectal trainees and surgeons around the world. Many of the tables, pictures, and illustrations are the same for the two textbooks which are written by the same two lead authors; however the Neoplasms of the Colon, Rectum, and Anus has additional information focusing on the topic of neoplasms, both benign and malignant. This text goes into extra detail concerning the complicated topics of genetics and the mechanism of generation of colorectal and anorectal neoplasia. The book is divided into three main sections: colorectal disorders, anorectal disorders, and minimally invasive surgery. Most of the book— 300 of the 391 pages—is devoted to colorectal disorders. The minimally invasive section provides a comprehensive review of techniques and procedures of this rapidly advancing area of surgery as they relate to the treatment of colorectal surgery. The anorectal disorder section is comprehensive for malignant neoplasia, but the controversial area of anal intraepithelial neoplasia (AIN) should have received more detail. The relationship of AIN to the human papilloma virus (HPV) is an interesting field, and one of the areas in colorectal surgery that is seeing more attention, especially in high-risk immunocomprimised patients. This area of study is also highly controversial and with limited data, so definitive recommendations are difficult; thus future editions will likely have more inclusive data. I think this is an excellent text and a good resource that physicians specializing in or practicing colorectal surgery should have in their library. I believe that it has pertinent information for both U.S. and international surgeons. It is a book that I certainly will put in our library for our Colorectal Surgery fellowship program.