David W. Dietz

Fibrin glue treatment of complex anal fistulas has low success rate

Purpose: Fibrin glue has been used to treat anal fistulas in an attempt to avoid more radical surgical intervention. Reported success rates vary widely. The purpose of this study was to review the use of fibrin glue in the management of complex anal fistulas at a tertiary referral center. Methods: This study was designed as a retrospective review of all patients treated with fibrin glue injection for complex anal fistulas in the Section of Colon and Rectal Surgery, Washington University School of Medicine/Barnes-Jewish Hospital. Demographics, previous treatment, operative information, and early follow-up were obtained from the patients’ medical records. Phone interviews were conducted to determine successful healing or recurrence of fistulas requiring further treatment. Statistical analysis was by Fisher’s exact test. The institutional review board approved the study. Results: A total of 42 patients (19 males; median age, 44 (range, 20–76) years) were treated between 1999 and 2002. Three patients were lost to follow-up and were excluded from the study. Etiology of fistulas were cryptoglandular (n = 22), Crohn’s disease (n = 13), or coloanal and ileal pouch-anal anastomotic (n = 4). Fistulas were classified as deep transsphincteric (n = 33), superficial transsphincteric (n = 1), supralevator (n = 2), or rectovaginal (n = 3). Initially, most patients had “closure” of the fistula but recrudescence was common. Durable healing was only achieved in 31 percent (12/39). Healing rates by etiology were cryptoglandular 23 percent (5/22), Crohn’s disease 31 percent (4/13), and ileal pouch-anal anastomotic 75 percent (3/4; P = 0.14). Success rates by classification were deep transsphincteric 33 percent (11/33), superficial transsphincteric 0 percent (0/1), supralevator 0 percent (0/ 2), and rectovaginal 33 percent (1/3; P = 1). The success rate for patients with no previous treatment was 38 percent (8/21) vs. 22 percent (4/18) in those whose fistulas had been previously treated (P = 0.32). Eight patients underwent a second fibrin glue treatment and only one of them healed (12.5 percent). Median follow-up for successfully healed fistula was 26 months. Conclusions: Fibrin glue treatment for complex anal fistulas has a low success rate and most recrudescences occurred within three months. However, given the low morbidity and relative simplicity of the procedure, fibrin glue should still be considered as a first-line treatment for patients with complex anal fistulas.

Predictive factors of pathologic complete response after neoadjuvant chemoradiation for rectal cancer.

Objective:This study evaluates factors associated with a pathologic complete response (pCR) after neoadjuvant chemoradiation for rectal cancer. Summary Background Data:Approximately 20% of rectal cancer patients undergoing neoadjuvant chemoradiation achieve pCR, which has been associated with decreased local recurrence and improved recurrence-free survival. Means of predicting pCR remain incompletely defined. Methods:A total of 306 consecutive patients with stage II or stage III rectal cancer who underwent neoadjuvant chemoradiation then surgery between 1997 and 2007 were identified from a single-institution. Sixty-four patients with concurrent inflammatory bowel disease, hereditary colorectal cancer, other malignancy, urgent surgery, incomplete chemoradiation, or insufficient data were excluded. All patients received neoadjuvant 5-FU-based chemotherapy and external beam radiation. Histologic response was categorized as pCR or not-pCR, which defined the 2 study cohorts. Variables were analyzed by univariate and multivariate analysis with pCR as the dependent variable. Fisher exact test, &khgr;2, Wilcoxon rank-sum, and logistic regression were used for analysis. P < 0.05 was considered statistically significant. Results:Of the total patients, 242 were studied, including 58 (24%) that achieved pCR. The 2 groups were statistically similar in terms of age, gender, body mass index, tumor differentiation, radiation dose, and pretreatment stage. On multivariate analysis, an interval ≥8 weeks between treatment completion and surgical resection was significantly associated with a higher rate of pCR, which correlated with decreased local recurrence and improved overall survival. Conclusion:Despite traditional beliefs that certain patient and tumor factors influence pCR, an extended interval between completion of neoadjuvant therapy and surgery was the single most important determinant in achieving a pCR.

Safety and longterm efficacy of strictureplasty in 314 patients with obstructing small bowel Crohn’s Disease

BACKGROUND Since its introduction in the early 1980s, strictureplasty (SXP) has become a viable option in the surgical management of obstructing small bowel Crohns disease. Questions still remain regarding its safety and longterm durability in comparison to resection. Precise indications and contraindications to the procedure are also not well defined. STUDY DESIGN A retrospective review of all patients undergoing SXP for obstructing small bowel Crohns disease at the Cleveland Clinic between 1984 and 1999 was conducted. A total of 314 patients underwent a laparotomy that included the index SXP The total number of SXPs performed was 1,124, with a median of two (range 1 to 19) per patient. Sixty-six percent of patients underwent a synchronous bowel resection. Recurrence was defined as the need for reoperation. Followup information was determined by personal interviews, phone interviews, or both. RESULTS The overall morbidity rate was 18%, with septic complications occurring in 5% of patients. Preoperative weight loss (p = 0.004) and older age (p = 0.008) were found to be significant predictors of morbidity. The surgical recurrence rate was 34%, with a median followup period of 7.5 years (range 1 to 16 years). Age was found to be a significant predictor of recurrence (p = 0.02), with younger patients having a shorter time to reoperation. CONCLUSIONS This large series of patients with longterm followup confirms the safety and efficacy of strictureplasty in patients with obstructing small bowel Crohns disease. The 18% morbidity and 34% operative recurrence rates compare favorably with reported results of resective surgery. Caution should be used in patients with preoperative weight loss, because they experienced higher complication rates. Although young patients seem to follow an accelerated course, SXP remains indicated as part of an overall strategy to conserve intestinal length.

Neoadjuvant Therapy for Rectal Cancer: Histologic Response of the Primary Tumor Predicts Nodal Status

PURPOSE:This study was designed to compare histologic T and N stages in patients with rectal adenocarcinoma undergoing various neoadjuvant radiotherapy regimens and proctectomy, in an attempt to determine if final histologic stage of the mural tumor predicts nodal status.METHODS:Data were collected from computerized databases at two institutions on 649 consecutive patients who underwent neoadjuvant radiotherapy or chemoradiotherapy and proctectomy for primary adenocarcinoma of the rectum from 1990 to 2002.RESULTS:Five patients were excluded because of incomplete pathology data sets, leaving a study population of 644. Patients underwent neoadjuvant radiotherapy alone (2,000 cGy in 5 fractions, n = 191; or 4,500 cGy in 25 fractions, n = 259) or chemoradiation (4,500 cGy in 25 fractions with concurrent 5-fluorouracil, n = 194). Histologic stage of the remaining mural tumor (ypT) correlated with nodal status (ypN). Lymph nodes harboring metastatic tumor were found in 1 of 42 (2 percent) ypT0 patients, 2 of 45 (4 percent) ypT1 patients, 43 of 186 (23 percent) ypT2 patients, 158 of 338 (47 percent) ypT3 patients, and 16 of 33 (48 percent) ypT4 patients (P < 0.001, chi-squared test). The probability of finding ypN+ disease was 3 of 87 (3 percent) in patients with ypT0-1 residual primary tumors vs. 220 of 557 (39 percent) in patients with ypT2-4 residual primary tumors (P < 0.0001; Fisher’s exact test).CONCLUSIONS:Nodal metastases are rare in patients whose mural tumor burden shrinks to ypT0-1 after neoadjuvant radiotherapy. If transanal excision is offered to select patients with distal rectal cancer, it is reasonable to select those who have an excellent clinical response to neoadjuvant therapy for transanal excision, and then reserve proctectomy for patients proven to have residual ypT2-4 disease.

Retrorectal Tumors: A Diagnostic and Therapeutic Challenge

PURPOSETumors occurring in the retrorectal space are heterogeneous and uncommon. The utility of newer imaging techniques has not been extensively described, and operative approach is variable. This study examined the diagnosis, treatment, and outcome of retrorectal tumors at a tertiary referral center.METHODSPatients with primary, extramucosal neoplasms occurring in the retrorectal space were identified using a prospectively maintained, procedural database of all adult colorectal surgical patients (1981–2003). Patients also were incorporated from the gynecologic oncology service. Exclusion criteria included inflammatory processes, locally advanced colorectal cancer, and metastatic malignancy. Medical records, radiology, and pathology reports were reviewed retrospectively.RESULTSThirty-four patients with retrorectal tumors were treated. Malignant tumors comprised 21 percent. Older age, male gender, and pain were predictive of malignancy (P < 0.05). Sensitivity of proctoscopy was 53 percent; this increased to 100 percent with the use of transrectal ultrasound. Accuracy of magnetic resonance vs. computed tomographic imaging for specific histologic tumor type was 28 vs. 18 percent, respectively. Surgical approach was anterior (n = 14), posterior (n = 11), and combined abdominoperineal (n = 9). Eleven patients required en bloc proctectomy. Patients undergoing posterior resection had lower blood loss and required fewer transfusions (P < 0.05). All benign tumors were resected with normal histologic margins and none recurred (median follow-up, 22 months). All patients with malignancy had recurrence/recrudescence of their disease. For these patients, median disease-free and overall survivals were 38 and 61 months, respectively.CONCLUSIONSRetrorectal tumors remain a diagnostic and therapeutic challenge. Pain, male gender, and advanced age increase the likelihood of malignancy. Various imaging modalities are useful for planning resection but cannot establish a definitive diagnosis. Whereas benign retrorectal tumors can be completely resected, curative resection of malignant retrorectal tumors remains difficult.

Is There Any Difference in Recurrence Rates in Laparoscopic Ileocolic Resection for Crohn's Disease Compared With Conventional Surgery? A Long-Term, Follow-Up Study

PurposeThe long-term outcome of laparoscopic ileocolic resection in patients with Crohns disease is not well defined. This study was designed to define the surgical recurrence rate after laparoscopic ileocolic resection for Crohns disease and to compare it with that seen after open ileocolic resection.MethodsA retrospective review of 113 records of patients who underwent index ileocolic resection for terminal ileal Crohns disease was performed (1987–2003). Recurrence was defined as development of new preanastomotic Crohns disease requiring surgical intervention. Details of recurrence and use of chemoprophylaxis was determined by phone interview andchart review.ResultsSixty-three patients (26 males; mean age, 35.2 years) underwent laparoscopic ileocolic resection and 50 had open ileocolic resection (17 males; mean age, 37.1 years). Surgical recurrence developed in 6of 63 patients (9.5 percent) in the laparoscopic ileocolic resection group (mean follow-up, 62.9 months) and in 12of 50 patients (24 percent) in the open ileocolic resection group (mean follow-up, 81.8 months). Rates of chemoprophylaxis were similar between groups (laparoscopic ileocolic resection, 39 percent; open ileocolic resection, 54 percent; P = not significant). Median times to recurrence after laparoscopic ileocolic resection and open ileocolic resection were 60 (range, 36–72) months and 62 (range, 12–180) months, respectively. Fifty percent of the recurrences in the laparoscopic ileocolic resection group and 4 of 12 in the open ileocolic resection group were able to be retreated laparoscopically. Re-recurrence occurred in 4 of 12 open ileocolic resection patients (33 percent) at a mean of 63.6 months, and one patient had a third recurrence at 28 months.ConclusionsIn this study, the long-term outcome after laparoscopic ileocolic resection was not shown to be statistically different from that of open ileocolic resection. The relatively low recurrence rates in both groups may be explained by our aggressive use of chemoprophylaxis.

Downstaging after chemoradiotherapy for locally advanced rectal cancer: is there more (tumor) than meets the eye?

PURPOSE: Preoperative chemoradiotherapy can lead to pathologic complete response of rectal cancer. This study was designed to determine the relationship between postchemoradiotherapy pathologic T stage (ypT stage) and nodal metastases and to evaluate whether pathologic complete response of the primary tumor results in sterilization of mesorectal lymph nodes. METHODS: Clinicopathological data from 1997 to 2007 of a prospectively maintained colorectal cancer database were examined. Inclusion criteria were patients with extraperitoneal rectal cancer who underwent preoperative chemoradiotherapy and subsequent radical resection. Statistical analysis was performed by use of Kruskall-Wallis and Wilcoxon rank-sum tests. RESULTS: Two hundred forty-two patients were identified (73.1% male, median age, 57 y (range, 36–85 y)). Data regarding preoperative chemoradiotherapy were available for 177 patients (73.1%). The median dose of radiotherapy was 5040 cGy (3060–6100 cGy). The mean preoperative radiotherapy dose and interval between chemoradiotherapy and surgery are similar when stratified by ypT stage (P = .55 and P = .72, respectively). Low anterior resection was performed in 174 patients (71.6%), and the remainder underwent abdominoperineal resection. A mural pathologic complete response was achieved in 62 patients (25.6%). In this pathologic complete-response group, positive lymph nodes were found in 2 patients (3.2%). The rate of metastatic lymph nodes increased as ypT stage increased (ypT1 = 11.1%, ypT2 = 29.2%, ypT3 = 37.3%). CONCLUSION: Patients with a mural pathologic complete response have a low rate of positive lymph nodes. These findings may have implications for the management strategies of these patients, including the use of local resection or a watch-and-wait policy. When the response to chemoradiotherapy is not complete, radical surgery should remain the treatment based on high rates of lymph node involvement.

Risk Factors for Surgical Recurrence after Ileocolic Resection of Crohn's Disease

PurposeWe evaluated the effect of potential clinical factors on surgical recurrence of ileal Crohn’s disease after initial ileocolic resection.MethodsOne hundred seventy-six patients with ileal Crohn’s disease who underwent an ileocolic resection with anastomosis were identified from our database. The outcome of interest was time from first to second ileocolic resection. Survival analysis was used to assess the significance of the Montreal phenotype classification, smoking habit, a family history of inflammatory bowel disease and other clinical variables.ResultsIn our final Cox model, a family history of inflammatory bowel disease (hazard ratio 2.24, 95 percent confidence interval 1.16–4.30, P = 0.016), smoking at time of initial ileocolic resection (hazard ratio 2.08, 95 percent confidence interval 1.11–3.91, P = 0.023) was associated with an increased risk of a second ileocolic resection while postoperative prescription of immunomodulators (hazard ratio 0.40, 95 percent confidence interval 0.18–0.88, P = 0.022) was associated with a decreased risk of a second ileocolic resection.ConclusionsBoth a family history of inflammatory bowel disease and smoking at the time of the initial ileocolic resection are associated with an increased risk of a second ileocolic resection. Postoperative prescription of immunomodulators is associated with a reduced risk of surgical recurrence. This study supports the concept that both genetic and environmental factors influence the risk of surgical recurrence of ileal Crohn’s disease.

Intestinal malrotation : a rare but important cause of bowel obstruction in adults

AbstractPURPOSE: Complications of intestinal malrotation are familiar to pediatric surgeons but are rarely encountered by those caring strictly for adults. The aim of this study was to review our experience with disorders of intestinal rotation in adult patients and to emphasize the clinical presentation, radiographic features, and results of surgical treatment. METHODS: Ten adult patients (mean age, 42 (range, 22–73) years) with complications of intestinal malrotation were identified by review of department records. Clinical presentation, operative treatment, and outcome were recorded. RESULTS: Nine patients presented with obstructive symptoms (five chronic and four acute). A diagnosis of malrotation was made preoperatively in all cases by a small-bowel contrast study or CT scan. Patients were treated by laparotomy with adhesiolysis (4 cases including one paraduodenal hernia and two midgut volvuli), Ladd’s procedure (4 cases), or duodenopexy and cecopexy (1 case). One patient presented with an acute abdomen and was found to have appendicitis. There was no mortality. Two patients developed complications (wound infection and ileus). Two patients had recurrent episodes of small-bowel obstruction with a mean follow-up of 30 (range, 2–69) months and one required reoperation. CONCLUSIONS: Complications of intestinal rotation can occur in adult patients and may present with chronic or acute symptoms. Prompt recognition and surgical treatment usually lead to a successful outcome. The diagnosis of intestinal malrotation should be considered in any adult patient with signs and symptoms of small-bowel obstruction.

Strictureplasty in diffuse Crohn's jejunoileitis: safe and durable.

AbstractPURPOSE: As an alternative to resection, strictureplasty may allow for preservation of intestinal length and avoidance of short-bowel syndrome in patients with diffuse Crohn’s jejunoileitis. However, the long-term durability of the procedure and its safety have not been confirmed. The purpose of this study was to report our experience with strictureplasty for diffuse Crohn’s jejunoileitis. METHODS: Between 1984 and 1999, 123 patients underwent a laparotomy that included an index strictureplasty for diffuse jejunoileitis. Patient history, operative details, and postoperative morbidities were obtained by chart review. Nineteen patients (15 percent) were receiving total parenteral nutrition for short-bowel syndrome, and 81 (66 percent) were taking chronic steroids. Total number of strictureplasties performed was 701 (median, 5/patient). Seventy percent of patients underwent a synchronous bowel resection. Follow-up information was determined by personal or phone interviews. Recurrence was defined as the need for reoperation, and risk was calculated by the Kaplan-Meier method. Patients with diffuse jejunoileitis were also compared with 219 patients with limited small-bowel Crohn’s disease undergoing strictureplasty. RESULTS: The overall morbidity rate was 20 percent, with septic complications occurring in 6 percent. The surgical recurrence rate was 29 percent with a median follow-up period of 6.7 (range, 1–16) years. The recurrence rate in diffuse jejunoileitis patients did not differ from that seen in patients with limited small-bowel Crohn’s disease (P = 0.38). Short duration of disease and short interval since last surgery were significant predictors of accelerated recurrence (P = 0.008 and 0.04, respectively). CONCLUSIONS: Strictureplasty is a safe and durable alternative to resection in diffuse Crohn’s jejunoileitis. Patients with a short duration of disease and short interval since last surgery are at higher risk for accelerated recurrence. Patients with diffuse jejunoileitis do not appear to be at higher risk for recurrence than patients with more limited Crohn’s disease.