Charles P. Heise

Adjuvant Chemotherapy for Stage II Colon Cancer With Poor Prognostic Features

PURPOSE Adjuvant chemotherapy is typically considered for patients with stage II colon cancer characterized by poor prognostic features, including obstruction, perforation, emergent admission, T4 stage, resection of fewer than 12 lymph nodes, and poor histology. Despite frequent use, the survival advantage conferred on patients with stage II disease by chemotherapy is yet unproven. We sought to determine the overall survival benefit of chemotherapy among patients with stage II colon cancer having poor prognostic features. PATIENTS AND METHODS A total of 43,032 Medicare beneficiaries who underwent colectomy for stage II and III primary colon adenocarcinoma diagnosed from 1992 to 2005 were identified from the Surveillance, Epidemiology, and End Results (SEER) -Medicare database. χ(2) and two-way analysis of variance were used to assess differences in patient- and disease-related characteristics. Five-year overall survival was examined using Kaplan-Meier survival analysis and Cox proportional hazards regression with propensity score weighting. RESULTS Of the 24,847 patients with stage II cancer, 75% had one or more poor prognostic features. Adjuvant chemotherapy was received by 20% of patients with stage II disease and 57% of patients with stage III disease. After adjustment, 5-year survival benefit from chemotherapy was observed only for patients with stage III disease (hazard ratio[HR], 0.64; 95% CI, 0.60 to 0.67). No survival benefit was observed for patients with stage II cancer with no poor prognostic features (HR, 1.02; 95% CI, 0.84 to 1.25) or stage II cancer with any poor prognostic features (HR, 1.03; 95% CI, 0.94 to 1.13). CONCLUSION Among Medicare patients identified with stage II colon cancer, either with or without poor prognostic features, adjuvant chemotherapy did not substantially improve overall survival. This lack of benefit must be considered in treatment decisions for similar older adults with colon cancer.

Short-Term Outcomes after Laparoscopic-Assisted Proctectomy for Rectal Cancer: Results from the ACS NSQIP

BACKGROUND Although numerous studies have demonstrated improved short-term outcomes after laparoscopic resection of colon cancer, the benefits of laparoscopic-assisted proctectomy (LAP) for rectal cancer are less clear. The current report addresses the need for a large multi-institutional study on early outcomes after proctectomy for cancer. STUDY DESIGN Patients who underwent elective LAP or open proctectomy for cancer during 2005 to 2009 were identified from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. The frequency of postoperative complications and other early outcomes was determined. Multivariate logistic regression identified predictors of 30-day morbidity. Propensity scores, stratified by quintiles, were included in all multivariable models to partially adjust for nonrandom assignment of treatment. RESULTS Of 5,420 patients who underwent surgery for rectal cancer, 4,380 underwent open proctectomy and 1,040 (19.2%) LAP. The LAP group had a lower frequency of blood transfusion (12.3% versus 4.3%; p < 0.0001) and a longer mean operative time (242 versus 219 minutes; p < 0.0001). Median length of stay was 5 days after LAP and 7 days after open resection (p < 0.0001). Although no difference in 30-day mortality was detected, the frequency of complications was less after LAP (20.5% versus 28.8%; p < 0.0001). Specifically, the frequencies of superficial surgical site infection, sepsis, respiratory complications, renal failure, and venous thromboembolism were each lower in the LAP group. After adjusting for potential confounders, the likelihood of 30-day morbidity was significantly greater in open versus laparoscopic proctectomy (odds ratio = 1.41; 95% CI, 1.19-1.68). CONCLUSIONS Compared with open proctectomy, LAP is associated with decreased length of stay and 30-day morbidity. If ongoing randomized clinical trials confirm oncologic equivalency, LAP might eventually replace open resection as the standard of care for the treatment of patients with resectable rectal cancer.

A 25-Year Single Institution Analysis of Health, Practice, and Fate of General Surgeons

Objective:The objective of this study was to analyze nearly 3 decades of surgical residents from an established training program to carefully define individual outcomes on personal and professional health and practice satisfaction. Summary Background Data:A paucity of data exists regarding the health and related practice issues of surgeons postresidency training. Despite several studies examining surgeon burnout and alcohol dependency problems, there have been no detailed reports defining health problems in practicing surgeons or preventive health patterns in this physician population. Important practice factors, including family and practice stress, that may impact on surgical career longevity and satisfaction have similarly received minimal focused examination. Methods:All former surgery residents at the University of Wisconsin from 1978 to 2002 were contacted. Detailed direct interview or phone contact was made to ensure confidentiality and to obtain reliable data. Interviews concentrated on serious health and practice issues since residency completion. Results:One hundred ten of 114 (97%) former residents were contacted. There were 100 males and 14 females with 2 deaths (accident, suicide). Including deaths and those lost to follow up, 15 (13.2%) were nonpracticing; 5 voluntarily (3 planned, 1 accident, 1 arthritis) and 4 involuntarily (alcohol/substance dependency). Eighty-nine percent were married or remarried with a 21.4% divorce rate postresidency. Major health issues occurred in 32% of all surveyed and in 50% of those ages ≥50. Only 10% reported complete lack of weekly exercise activity with 62% exercising at least 3 times per week. Body mass index increased from 23.9 ± 1.5 kg/m2 (age <40) to 26.6 ± 3.0 kg/m2 (P = 0.009) by age ≥50. Alcohol dependency was confirmed in 7.3%. Overall, 75% of surgeons surveyed were satisfied with their practice/career. Conclusion:Despite a high job satisfaction rate, surgeon health may be compromised in up to 50% by age ≥50, with a 20% voluntary or involuntary retirement rate. Alcohol dependency occurred in up to 7.3% of surgeons, which contributed to the practice attrition rate. The success and length of a career in surgery is defined by postresidency factors rarely examined during training and include major and minor health issues, preventive health patterns/exercise, alcohol use or dependency, family life, and practice satisfaction. Surgeons mentoring during the course of surgical training should be improved to inform of important health and practice issues and consequences.

Epidemiology and Pathogenesis of Diverticular Disease

Diverticular disease is a common entity in the USA with an apparent increasing incidence worldwide. The pathogenesis of this disease process is likely multifactorial involving dietary habits, changes in colonic pressures and motility, and colon wall structural changes associated with aging. The following review addresses our current limited knowledge regarding the epidemiology and pathogenesis of diverticulosis and diverticulitis.

Postoperative complications in patients with rectal cancer are associated with delays in chemotherapy that lead to worse disease-free and overall survival.

OBJECTIVE: The objective of this study was to identify the risk factors for delays in chemotherapy after rectal cancer surgery and evaluate the effects of delayed therapy on long-term outcomes. We also sought to clarify what time frame should be used to define delayed adjuvant chemotherapy. BACKGROUND: Postoperative complications have been found to influence the timing of chemotherapy in patients with colon cancer. Delays in chemotherapy have been shown to be associated with worse overall and disease-free survival in patients with colorectal cancer, although the timing of delay has not been agreed upon in the literature. STUDY DESIGN: We performed a retrospective review of a prospectively maintained rectal cancer database. Univariate analysis was used to identify risk factors for delayed chemotherapy. Kaplan-Meier curves were generated to compare overall and disease-free survival in patients based on complications and timing of chemotherapy. SETTINGS: This study was performed at the University of Wisconsin Hospital, Madison, Wisconsin, between 1995 and 2012. PATIENTS: Patients with rectal cancer who underwent proctectomy with curative intent were included in this study. OUTCOME MEASURES: Timing of chemotherapy, 30-day complications, and 30-day readmissions were the main outcome measures. RESULTS: Postoperative complications and 30-day readmissions were associated with delays in chemotherapy ≥8 weeks after surgery. Patients who received chemotherapy ≥8 weeks postoperatively were found to have worse local and distant recurrence rates and worse overall survival in comparison with patients who received chemotherapy within 8 weeks of surgery. LIMITATIONS: The limitations of this study include its retrospective nature and that it was performed at a single institution. CONCLUSIONS: We found complications and readmissions to be risk factors for delayed chemotherapy. Patients who received therapy ≥8 weeks postoperatively had worse disease-free and overall survival.

Visceral obesity is associated with outcomes of total mesorectal excision for rectal adenocarcinoma

General obesity, measured by the body mass index (BMI), increases the technical difficulty of total mesorectal excision (TME) but does not affect oncologic outcomes. The purpose of this study is to compare visceral and general obesity as predictors of outcomes of TME for rectal adenocarcinoma.

Laparoscopic and Minimally Invasive Resection of Malignant Colorectal Disease

Minimally invasive surgery for colorectal cancer is a burgeoning field of general surgery. Randomized controlled trials have assessed short-term patient-oriented and long-term oncologic outcomes for laparoscopic resection. These trials have demonstrated that the laparoscopic approach is equivalent to open surgery with a shorter hospital stay. Laparoscopic resection also may result in improved short-term patient-oriented outcomes and equivalent oncologic resections versus the open approach. Transanal excision of select rectal cancer using endoscopic microsurgery is promising and robotic-assisted laparoscopic surgery is an emerging modality. The efficacy of minimally invasive treatment for rectal cancer compared with conventional approaches will be clarified further in randomized controlled trials.

Radiation Colitis and Proctitis

Radiation therapy is commonly utilized as a major component in the treatment of pelvic malignancy. Unfortunately, secondary toxicity to the lower gastrointestinal tract can occur. This most commonly affects the rectum, although injuries to the colon and small intestine are not uncommon. The presentation can be acute or chronic, and different mechanisms are responsible for each. Symptomatology is quite variable but can result in significant compromise for the patient. Numerous preventive and treatment strategies have been applied to this disease process. This article presents a summary of the current knowledge regarding radiation injury to the lower gastrointestinal tract with special emphasis on treatment options for radiation proctitis.

Peritoneography (Herniography) for Detecting Occult Inguinal Hernia in Patients with Inguinodynia

ObjectiveTo evaluate the usefulness of peritoneography in patients referred with inguinal pain (inguinodynia) and clinically absent inguinal hernia on physical examination. Summary Background DataIn patients with chronic groin pain, peritoneography is a seldom-used yet available technique that can detect an occult inguinal hernia. The value of peritoneography in the diagnosis of occult inguinal hernia has been previously shown. MethodsDuring a 60-month period, 80 consecutive patients with complaints of persistent inguinal pain (inguinodynia) without evidence of hernia on clinical examination were referred for outpatient evaluation by peritoneography. Twenty-nine patients had prior inguinal surgery in the region of their current pain. Peritoneography was performed using a midline or paraumbilical approach. Radiographs were obtained with patients in prone and prone oblique positions with the head elevated 20° to 25°, both with and without provocative maneuvers. All available records were retrospectively reviewed for radiographic findings and outcome. ResultsOf the 80 patients undergoing peritoneography, 36 (45%) were diagnosed radiographically to have inguinal hernias that were not detectable clinically. Twenty-seven of these patients subsequently underwent inguinal exploration, and a hernia was confirmed in 24 (89%). Of the patients having prior inguinal surgery in the region of their pain, 12/29 (41%) were diagnosed by peritoneography with a hernia. Two complications (2.5%), both colon perforations that did not require significant intervention, occurred as a result of peritoneography. ConclusionsPeritoneography is highly reliable for detecting clinically occult inguinal hernia and has a low complication rate. Its usefulness is shown in a prospective consecutive series for detection of occult hernias in patients with chronic inguinal pain. The authors conclude that peritoneography is a safe and useful diagnostic test in the setting of persistent inguinal pain and a negative clinical examination.

Fiber Endoscopes Utilizing Liquid Tunable-Focus Microlenses Actuated Through Infrared Light

We report on prototype fiber endoscopes with tunable-focus liquid microlenses integrated at their distal ends and actuated through infrared (IR) light. Tunable-focus microlenses allow minimal back-and-forth movements of the scopes themselves and different depths of focus (DOFs), thus having spatial depth perception in the obtained images. The liquid microlens was formed by a water-oil meniscus pinned at a hydrophobic-hydrophilic boundary at an aperture. IR light-responsive hydrogel microstructures were formed by photopatterning thermo-responsive N-isopropylacrylamide hydrogel with entrapped IR light absorbing gold nanoparticles. The volumetric change in the hydrogel microstructures regulated the pressure difference across the water-oil interface and thus varied its focal length. The operations of the microlenses were realized through light transmitted via optical fibers. The images obtained from the microlenses were transferred via image fiber bundles. For two alignments between the hydrogel structures and the fibers, the response times of the microlenses are 65 and 20 s, respectively. Images of the simulated polyps in simulated colons were obtained. The range of focal length of a typical microlens was from 52 to 8 mm. The angle of view of an endoscope was from 77° to 128°. A microlens array could potentially be utilized to simultaneously obtain different DOFs and to increase the field of view.