Bashar Safar

Anal fistula plug: Initial experience and outcomes

PURPOSE: This study was designed to analyze the efficacy of the Cook Surgisis® AFP™ anal fistula plug for the management of complex anal fistulas. METHODS: This was a retrospective review of all patients prospectively entered into a database at our institution who underwent treatment for complex anal fistulas using Cook Surgisis® AFP™ anal fistula plug between July 2005 and July 2006. Patients demographics, fistula etiology, and success rates were recorded. The plug was placed in accordance with the inventors guidelines. Success was defined as closure of all external openings, absence of drainage without further intervention, and absence of abscess formation. RESULTS: Thirty-five patients underwent 39 plug insertions (22 men; mean age, 46 (range, 15-79) years). Three patients were lost to follow-up, therefore, 36 procedures to be analyzed. The fistula etiology was cryptoglandular in 31 (88.6 percent) patients and Crohns disease associated in the other 4 (11.4 percent). There were 11 smokers and 3 patients with diabetes. The mean follow-up was 126 days (standard = 69.4). The overall success rate was 5 of 36 (13.9 percent). One of the four Crohns disease-associated fistulas healed (25 percent) and 4 of 32 (12.5 percent) procedures resulted in healing of cryptoglandular fistulas. In 17 patients, further procedures were necessary as a result of failure of treatment with the plug. The reasons for failure were infection requiring drainage and seton placement in 8 patients (25.8 percent), plug dislodgement in 3 (9.7 percent), persistent drainage/tract and need for other procedures in 20 patients (64.5 percent). CONCLUSIONS: The success rate for Surgisis® AFP™ anal fistula plug for the treatment of complex anal fistulas was (13.9 percent), which is much lower than previously described. Further analysis is needed to explain significant differences in outcomes.

The clinical significance of fat clearance lymph node harvest for invasive rectal adenocarcinoma following neoadjuvant therapy

PURPOSE: This study aimed to investigate the application of fat clearance in cases of rectal cancer after neoadjuvant chemoradiation. METHODS: All patients who underwent proctectomy (R0 resection) from 1998 to 2007 were included. N1 and N2 stages were regarded as N+ stage. RESULTS: Two hundred thirty-seven patients were identified, including 157 patients in the neoadjuvant group and 80 patients in the nonneoadjuvant group. In both groups, patients were assigned to receive the traditional method of harvesting lymph nodes, or the fat clearance method. Before July 2001, the patients received the traditional method, and after July 2001, they received exclusively the fat clearance method. In the nonneoadjuvant group, there was no significant difference in the number of positive lymph nodes (0.5 ± 0.2 vs. 1.0 ± 0.3, P = 0.235), N stage (P = 0.265), or patients with N+ stage (7/31 vs. 16/49, P = 0.332) between the two methods, even though the total lymph node harvest was significantly increased by use of the fat clearance method (9.6 ± 1.3 vs. 27.6 ± 2.5, P < 0.001). In contrast, the total lymph node retrieval (5.2 ± 0.6 vs. 20.4 ± 1.2, P < 0.001), number of positive lymph nodes (0.4 ± 0.2 vs. 1.2 ± 0.3, P = 0.007), N stage (P = 0.005), and patients with N+ stage (6/51 vs. 34/106, P = 0.006) were all increased by fat clearance in the neoadjuvant group. Moreover, the number of patients with N+ stage was stratified by T stage level (T0–T4) to eliminate the background bias, and the results were confirmed. CONCLUSIONS: The utilization of the fat clearance technique significantly influences lymph node staging in patients with rectal cancer following neoadjuvant chemoradiation. These findings suggest that fat clearance may represent a useful tool in all patients receiving neoadjuvant therapy; a more generalized application in colorectal carcinoma specimens remains controversial and warrants further investigation.

Conversion in laparoscopic surgery: does intraoperative complication influence outcome?

BackgroundConversion from laparoscopy to laparotomy can be expected in a variable percentage of surgeries. Patients who experience conversion to a laparotomy may have a worse outcome than those who have a successfully completed laparoscopic procedure. This study aimed to compare the outcomes of converted cases based on whether the case was a reactive conversion (RC, due to an intraoperative complication such as bleeding or bowel injury) or a preemptive conversion (PC, due to a lack of progression or unclear anatomy).MethodsAll laparoscopic colorectal procedures converted to a laparotomy were retrospectively reviewed from data prospectively entered into an institutional review board–approved database. Patients who underwent an RC were matched with patients who underwent a PC according to age, gender, body mass index (BMI), and diagnosis. Patients who underwent a laparoscopic colorectal resection (LCR) were taken as the control group. The incidence and nature of postoperative complications, the time to liquid or regular diet, and the length of hospital stay were recorded.ResultsOf 962 laparoscopic procedures performed between 2000 and 2007, 222 (23.1%) converted to a laparotomy were identified. The 30 patients who had undergone an RC were matched with 60 patients who had undergone a PC and 60 patients who had undergone an LCR. The reasons for RC were bleeding in 14 cases, bowel injury in 6 cases, ureteric damage in 3 cases, splenic injury in 3 cases, and other complications in 4 cases. The patients who had undergone RC were more likely to have experienced a postoperative complication (50% vs 27%; pxa0=xa00.028), required longer time to toleration of a regular diet (6 vs 5xa0days; pxa0=xa00.03), and stayed longer in the hospital (8.1 vs 7.1xa0days; pxa0=xa00.080).ConclusionPreemptive conversion is associated with a better outcome than reactive conversion. Based on this finding, it appears preferable for the surgeon to have a low threshold for performing PC rather than awaiting the need for an RC.

Five Fractions of Radiation Therapy Followed by 4 Cycles of FOLFOX Chemotherapy as Preoperative Treatment for Rectal Cancer

BACKGROUNDnPreoperative radiation therapy with 5-fluorouracil chemotherapy is a standard of care for cT3-4 rectal cancer. Studies incorporating additional cytotoxic agents demonstrate increased morbidity with little benefit. We evaluate a template that: (1) includes the benefits of preoperative radiation therapy on local response/control; (2) provides preoperative multidrug chemotherapy; and (3) avoids the morbidity of concurrent radiation therapy and multidrug chemotherapy.nnnMETHODS AND MATERIALSnPatients with cT3-4, any N, any M rectal cancer were eligible. Patients were confirmed to be candidates for pelvic surgery, provided response was sufficient. Preoperative treatment was 5 fractions radiation therapy (25 Gy to involved mesorectum, 20 Gy to elective nodes), followed by 4 cycles of FOLFOX [5-fluorouracil, oxaliplatin, leucovorin]. Extirpative surgery was performed 4 to 9 weeks after preoperative chemotherapy. Postoperative chemotherapy was at the discretion of the medical oncologist. The principal objectives were to achieve T stage downstaging (ypT < cT) and preoperative grade 3+ gastrointestinal morbidity equal to or better than that of historical controls.nnnRESULTSn76 evaluable cases included 7 cT4 and 69 cT3; 59 (78%) cN+, and 7 cM1. Grade 3 preoperative GI morbidity occurred in 7 cases (9%) (no grade 4 or 5). Sphincter-preserving surgery was performed on 57 (75%) patients. At surgery, 53 patients (70%) had ypT0-2 residual disease, including 21 (28%) ypT0 and 19 (25%) ypT0N0 (complete response); 24 (32%) were ypN+. At 30 months, local control for all evaluable cases and freedom from disease for M0 evaluable cases were, respectively, 95% (95% confidence interval [CI]: 89%-100%) and 87% (95% CI: 76%-98%). Cases were subanalyzed by whether disease met requirements for the recently activated PROSPECT trial for intermediate-risk rectal cancer. Thirty-eight patients met PROSPECT eligibility and achieved 16 ypT0 (42%), 15 ypT0N0 (39%), and 33 ypT0-2 (87%).nnnCONCLUSIONnThis regimen achieved response and morbidity rates that compare favorably with those of conventionally fractionated radiation therapy and concurrent chemotherapy.

Lymph node harvest after proctectomy for invasive rectal adenocarcinoma following neoadjuvant therapy: does the same standard apply?

PURPOSE: Recent reports indicate that neoadjuvant therapy significantly reduces the lymph node harvest of rectal cancer. The aim of this study was to interpret the lymph node harvest in this setting based on the primary tumor response. METHODS: All patients undergoing proctectomy were included. Three variables were used as indicators of primary tumor response: ypT stage, tumor size, and tumor regression grade. RESULTS: From 1998 to 2007, 237 patients were identified: 157 in the neoadjuvant therapy group and 80 in the nonneoadjuvant therapy group. Neoadjuvant therapy significantly reduced the number of lymph nodes harvested (P = 0.011). Compared with the nonneoadjuvant group, there were significantly fewer lymph nodes in the neoadjuvant early T stage group (P = 0.001), small tumor size group (P = 0.003), and low tumor regression grade group (P < 0.001). However, there was no significant difference between the nonneoadjuvant group and the neoadjuvant advanced T stage (P = 0.664), large tumor (P = 0.815), and high tumor regression grade groups (P = 0.566). CONCLUSION: The current standard of lymph node harvest should be applied to patients with poorly responding primary tumors after neoadjuvant therapy. However, a new standard may be necessary to define the adequate number of lymph nodes for tumors that respond well to neoadjuvant therapy.

Perianal Crohn's Disease

Crohns disease is commonly complicated by perianal manifestations. The surgeon plays a pivotal role in caring for these patients; a detailed history along with a thorough clinical exam provides the treating physician with invaluable information upon which to base further investigations and management decisions. Other than abscess drainage, medical management to control proximal disease often precedes any surgical attempt to cure the disease. Surgical interventions are indicated in selective patients, but are often complicated by poor wound healing and recurrences. A sizable percentage of these patients may need a proctectomy.

Obesity Increases Risk for Pouch-Related Complications Following Restorative Proctocolectomy with Ileal Pouch–Anal anastomosis (IPAA)

PurposeRestorative proctocolectomy with ileal pouch–anal anastomosis (IPAA) is the preferred surgical treatment for patients with ulcerative colitis and familial adenomatous polyposis. As obesity is becoming more epidemic in surgical patients, the aim of this study was to investigate if obesity increases complication rates following IPAA.MethodsThis study was conducted as a retrospective review of patients undergoing IPAA between January 1990 and April 2011. Patients were categorized by body mass index (BMI): BMIu2009<u200930 (non-obese) and BMIu2009≥u200930 (obese). Preoperative patient demographics, operative variables, and postoperative complications were recorded through chart review. The primary outcome studied was cumulative complication rate.ResultsA total of 103 non-obese and 75 obese patients were identified who underwent IPAA. Obese patients had an increased rate of overall complications (80xa0% vs. 64xa0%, pu2009=u20090.03), primarily accounted for by increased pouch-related complications (61xa0% vs. 26xa0%, pu2009<u20090.01). In particular, obese patients had more anastomotic/pouch strictures (27xa0% vs. 6xa0%, pu2009<u20090.01), inflammatory pouch complications (17xa0% vs. 4xa0%, pu2009<u20090.01) and pouch fistulas (12xa0% vs. 3xa0%, pu2009=u20090.03). In a regression model, obesity remained a significant risk factor (odds ratio [OR]u2009=u20092.86, pu2009=u20090.01) for pouch-related complications.ConclusionsObesity is associated with an increased risk of overall and pouch-related complications following IPAA. Obese patients should be counseled preoperatively about these risks accordingly.

Optimizing rectal cancer management: Analysis of current evidence

Diseases of the Colon & ReCtum Volume 57: 2 (2014) Colorectal carcinoma remains the second leading cause of cancer-related deaths in Western countries, with rectal carcinoma accounting for ≈25% of cases arising from the large bowel. Rectal cancer affects more than 40,000 patients annually in the united states, and a majority of these patients undergo surgery, with approximately half dying as a consequence of their disease. therefore, rectal cancer represents a significant healthcare problem in terms of incidence, seriousness, and use of resources. historically a huge variation among surgeons has been described in results of colorectal cancer surgery, with statistically significant differences in curative resection, postoperative morbidity and mortality, and long-term survival. Rectal cancer surgery is considered more technically challenging compared with colon cancer surgery, mainly because of the anatomy of the pelvis and the resulting challenge that a surgeon faces in achieving good resection margins in a confined, fixed bony space in close proximity to vital structures. historically these challenges have been reflected in poorer oncologic results, with local recurrence rates approaching 30% and worse overall survival in comparison with that of colon cancer. in the united states, the majority of rectal cancer surgeries have traditionally been performed by trained general surgeons, who may or may not have a colorectal subspecialty interest. studies indicate that there is significant room for improvement in the outcomes of rectal cancer surgery, with significant variation in results including rates of margin positivity, local recurrence, use of neoadjuvant and adjuvant therapy, and permanent stomas. some reports indicate variations in local recurrence rates of between 0% and 13% for colorectal surgeons and between 21% and 37% for general surgeons. Differences in mortality also exist, with rates of 1.4% for colorectal surgeons and >7.0% for general surgeons being reported. in a recent study of proctectomies, restorative techniques were used in 50% of patients, with abdominoperineal resection rates as high as 60% in some regions. in addition, approximately one fifth of proctectomies were performed by a specialist colorectal surgeon, and ≈40% of the surgeons only performed nonrestorative surgery. the management of rectal cancer has fundamentally changed in the last 3 decades with the introduction of staging, total mesorectal excision (tme), chemoradiotherapy (CRt), and multidisciplinary management. since the 1980s, 5 main principles have been developed that, when combined, have led to significant reductions in rates of local recurrence, increases in disease-free and overall survival, and reduction in permanent stoma rates. in countries and centers that have implemented such programs, the cancer-specific outcomes from rectal cancer now match those of colon cancer for the first time. the principles include the following: 1) rectal surgery according to the principles of tme, 2) measurement of quality of surgery and accurate staging by specific techniques of pathology assessment, 3) specialist imaging techniques identifying Optimizing Rectal Cancer Management: Analysis of Current Evidence

Surgical management of pyogenic complications of Crohn's disease

&NA; Patients with Crohns disease are prone to the development of pyogenic complications. These complications are most commonly in the form of perianal or intraabdominal abscesses and/or fistulas. Complications in these 2 distinct areas are managed differently; however, they are similar in the fact that initial treatment relies on medical or minimally invasive management to achieve a nonacute condition prior to definitive surgical procedure. This article reviews the current surgical management of obtaining pyogenic control in both anorectal and intraabdominal Crohns disease. (Inflamm Bowel Dis 2010)

Laparoscopic Diverticular Resection With Situs Inversus Totalis (SIT): Report of a Case

Situs inversus totalis (SIT) is a rare condition where the abdominal and thoracic cavity structures are opposite of their usual position. Laparoscopic colonic surgery for this patient population is not well described, with only 2 reported cases. Our patient was a 62-year-old female with a history of SIT who underwent a laparoscopic sigmoid colectomy for recurrent diverticulitis. The procedure included the use of 4 ports. The sigmoid colon was noted on the right side. Laparoscopic resection with stapled anastomosis was performed. The patient tolerated the procedure well and was discharged home on postoperative day 5 without complications. We present a third case of laparoscopic colectomy for diverticulitis in a patient with SIT and a description of the operative procedure.