Giovanna DaSilva

Does Rectal Wall Tumor Eradication With Preoperative Chemoradiation Permit a Change in the Operative Strategy

PURPOSEPreoperative chemoradiation may downstage locally advanced rectal cancer and, in some cases, with no residual tumor. The management of complete response is controversial and recent data suggest that radical surgery may be avoided in selected cases. Transanal excision of the scar may determine the rectal wall response to chemoradiation. This study was designed to assess whether the absence of tumor in the bowel wall corresponds to the absence of tumor in the mesorectum, known as true complete response.METHODSA retrospective review of the medical records of patients who underwent preoperative chemoradiation for advanced mid (6–11 cm from the anal verge) and low (from the dentate line to 5 cm from the anal verge) rectal cancer (uT2–uT3) followed by radical surgery with total mesorectal excision was undertaken. Patients in whom the pathology specimen showed no residual tumor in the rectal wall (yT0, “y” signifies pathologic staging in postradiation patients) were assessed for tumoral involvement of the mesorectum.RESULTSA total of 109 patients underwent preoperative, high-dose radiation therapy (94 percent with 5-fluorouracil chemosensitization), followed by radical surgery for advanced rectal cancer. Preoperatively, 47 patients were clinically assessed to have potentially complete response. After radical rectal resection, pathology did not reveal any residual tumor within the rectal wall (yT0) in 17 patients. In two (12 percent) of these patients, the mesorectum was found to be positive for malignancy: one had positive lymph nodes that harbored cancer; one had tumor deposits in the mesorectal tissue.CONCLUSIONSCompete rectal wall tumor eradication does not necessarily imply complete response, because the mesorectum may harbor tumor cells. Thus, caution should be exercised when considering the avoidance of radical surgery. Reliable imaging methods and clinical predictors for favorable outcome are important to allow less radical approaches in the future.

Long-term outcomes of artificial bowel sphincter for fecal incontinence: a systematic review and meta-analysis.

Fecal incontinence (FI) is a symptom with considerable adverse impact on quality of life. It is estimated that FI affects up to 18% of the population. The treatment of medically refractory severe FI remains challenging. Christiansen and Lorentzen first reported successful perianal implantation of an artificial urinary sphincter (AMS 800; American Medical Systems) for FI in 1987. Subsequently, Lehur and colleagues started using Acticon Neosphincter (American Medical System), designed specifically for FI in 1996. Since that time, the artificial bowel sphincter (ABS) has produced good results. However, even with improved experience, the incidence of surgical revision and explantation remains high. Consequently, between technical challenges and high rates of additional surgery for complications, the device never became widely accepted. Possible indications include end-stage severe FI associated with extensive anal sphincter loss or congenital anorectal malformation, where the only other option is a stoma. Despite these problems, many authors reported considerable improvement in continence and quality of life. Recently, Wexner and colleagues found that the cumulative risk of device explant increases with time, but less dramatically in the longer follow-up. In addition, even after device explant due to infection, reimplantation has been done without difficulty. To assess the effectiveness of this device, we sought to examine the proportion of patients who have a functional device as well as the functional outcomes in this population during long-term follow-up. Most studies have had small number of patients, different lengths of follow-up, and often <5 years of follow-up. In this systematic review, we considered the changes in device-related outcomes and functional outcomes

Prophylactic ureteric catheters in laparoscopic colorectal surgery

BackgroundThe purpose of this study was to evaluate the use of ureteric catheter placement in laparoscopic colorectal surgery and to assess the morbidity related to this procedure.MethodsBetween 1994 and 2001, 313 elective laparoscopic colorectal surgeries were performed. Patients with and without ureteric catheters were retrospectively analyzed.ResultsCatheter placement was attempted in 149 patients (catheter group) and was not attempted in 164 (controls). There were no significant differences between groups in the number of patients with prior colorectal resection (p=0.286) or other abdominal surgery (p=0.074). Crohn’s disease and diverticulitis were more common in the catheter group than among controls (p<0.001). Concomitant intra-abdominal fistula or abscess was present in 29 patients (19.5%) in the catheter group vs. 14 (8.5%) in the control group (p=0.005). The duration of surgery was longer in the catheter group (p=0.001). There were no significant differences in conversion, duration of bladder catheter placement, or length of hospital stay. Urinary tract infection occurred in 3 patients (2.0%) in the catheter group and 7 (4.3%) in the control group (p=0.257) and urinary retention occurred in 3 patients (2.0%) and 11 patients (6.7%), respectively (p=0.045). No intraoperative ureteric injuries occurred in either group.ConclusionUreteric catheter placement was successful in most cases and was not associated with intraoperative injuries. The increased length of surgery in patients with ureteric catheter placement may attest to the increased severity of pathology in these patients.

Local excision of T1 and T2 rectal cancer: proceed with caution.

This study aimed to compare the clinical outcome between local excision (LE) and total mesorectal excision (TME) for early rectal cancer.

Are postoperative complications more common following colon and rectal surgery in patients with chronic kidney disease

Aim  According to National Kidney Foundation guidelines, early stages of chronic kidney disease (CKD) can be detected through the estimated glomerular filtration rate (eGFR). We assessed complications following colorectal surgery (CRS) in patients with CKD Stages 3 and 4, as defined by the eGFR.

Inter-observer and intra-observer variability in the diagnosis of dysplasia in patients with inflammatory bowel disease: correlation of pathological and endoscopic findings

Colonic epithelial dysplasia is deemed the precursor lesion of cancer arising in inflammatory bowel disease (IBD). It has been suggested that many dysplastic lesions could be endoscopically detected to obtain target biopsies, leading to better yield. However, the clinical impact of a diagnosis of dysplasia may be hampered by a significant degree of histological and endoscopic intra‐observer and inter‐observer variability. This study aimed to evaluate intra‐observer and inter‐observer variability in the microscopic diagnosis of dysplasia in IBD and correlate endoscopic and histological findings.

IPAA-related sepsis significantly increases morbidity of ileoanal pouch excision.

BACKGROUND: Perineal wound complications after ileoanal pouch excision remain a significant cause of morbidity. OBJECTIVE: The purpose of this work was to describe the incidence, outcomes, and predictors of perineal wound complications after pouch excision. DESIGN: This was a retrospective medical chart review. SETTINGS: The study was conducted in a single clinical institution. PATIENTS: Patients who underwent pouch excision at our institution from July 1992 through July 2012 were identified. Patient and perioperative variables were reviewed. Multivariate and univariate analyses were undertaken. MAIN OUTCOME MEASURES: Perineal wound (including perineal wound infection and persistent perineal sinus [nonhealing by 6 months]) and perineal hernia were measured. RESULTS: A total of 47 patients (mean age, 46 years; 42.6% men) with familial adenomatous polyposis (10.6%), mucosal ulcerative colitis (61.7%), or Crohn’s disease (27.7%) underwent pouch excision, including 36.2% for IPAA-related sepsis (presacral abscess; perineal-, sacral-, or pouch-vaginal fistula; and anastomotic defect), 44.7% for pouch dysfunction, 10.6% for refractory pouchitis, and 8.5% for neoplasia. Fourteen (29.8%) developed perineal wound complications, including 100% perineal wound infection, 28.6% persistent perineal sinus, and 7.1% perineal hernia. Perineal wound infection was associated with delayed healing (>6 weeks; 71.4% vs 24.2%; p = 0.002) and IPAA-related sepsis (28.6% vs 0%; p = 0.001). Patients with and without perineal wound complications were similar in age, diagnoses, fecal diversion, immunosuppression, comorbid conditions, nutrition, and surgical variables. Most patients underwent intersphincteric dissection (87.2%) with primary perineal closure (97.0%). Perineal wound complications were significantly associated with IPAA-related sepsis as an indication for pouch excision (57.1% vs 27.2%; p = 0.05), intraoperative pouch perforation (35.7% vs 9.1%, p =0.03), and smoking (21.4% vs 3.0%; p = 0.04). IPAA-related sepsis and a current smoking status (OR, 19.3 [95% CI, 1.8 -488.1]) are significant independent predictors on multivariate logistic regression (OR, 6.4 [95% CI, 1.4–30.2]) of perineal wound complications. All of the patients with persistent perineal sinus achieved successful healing at a median of 734 days (range, 363–2182 days), requiring a median of 1.5 procedures. LIMITATIONS: This was a single-center retrospective review with a small sample size. CONCLUSIONS: Preoperative IPAA-related sepsis and current smoking are significant risk factors for perineal wound complications after pouch excision.

Outcomes of Sacral Neurostimulation Lead Reimplantation for Fecal Incontinence: A Cohort Study.

BACKGROUND: Adverse events and complications have been reported after sacral neurostimulation for fecal incontinence, which may result in surgical revision and device explantation. Lead reimplantation may be feasible; however, available data regarding outcomes are less robust. OBJECTIVE: The aim of this study was to determine the outcomes of sacral neurostimulation lead reimplantation for fecal incontinence. DESIGN: This was a retrospective review of prospectively collected data. SETTINGS: The study was conducted at 2 clinical sites from a single institution. PATIENTS: Patients with fecal incontinence who underwent sacral neurostimulation implantation or reimplantation between 2011 and 2014 were included in the study. INTERVENTIONS: Sacral neurostimulation reimplantation was the included intervention. MAIN OUTCOME MEASURES: Change in the Cleveland Clinic Florida Fecal Incontinence Score (0 best; 20 worst) in reimplantation as compared with index implantation controls was the main measure. Secondary outcomes included the frequency and type of adverse events and complications. RESULTS: A total of 112 patients underwent either sacral neurostimulation implantation or reimplantation between 2011 and 2014. Ninety-seven patients underwent an index percutaneous nerve stimulation trial, 93 of whom also underwent a stimulator implantation. Fifteen patients underwent lead reimplantation, with 5 performed before stimulator implantation and 10 after stimulator implantation. The index implanted and reimplanted groups had similar demographics, comorbidities, and complication profiles including explantation rates. The most common reason for reimplantation was lead related (6/15), including 4 lead migrations, 1 lead fracture, and 1 lead erosion. Significant decreases in the incontinence score were achieved in each group (index implantation: p < 0.001; reimplantation: p = 0.006). When comparing the efficacy of sacral neurostimulation therapy in decreasing the fecal incontinence score from baseline in each group, patients with an index implantation were found to have a more significant improvement in their incontinence score as compared with the reimplantation group (p = 0.047). LIMITATIONS: This was a retrospective study. A large number of patients with incomplete functional assessment data were excluded from analysis. CONCLUSIONS: The improvements in fecal incontinence are significantly better after index implantation than after reimplantation.

Outcomes of Reimplantation of the Artificial Bowel Sphincter.

BACKGROUND: Outcomes of artificial bowel sphincter reimplantation for severe fecal incontinence remain unknown. OBJECTIVE: The purpose of this study was to evaluate the feasibility and outcomes of artificial bowel sphincter reimplantation versus implantation. DESIGN: This was a retrospective review study. SETTINGS: The study was conducted at a single institution. PATIENTS: Patients with severe incontinence who underwent de novo implantation and re-implantation between January 1998 and December 2012 were included. MAIN OUTCOME MEASURES: Complications, length of functional device time, success rates (functioning device at follow-up), patient demographics, comorbidities, etiology of incontinence, operative data, postoperative complications, and outcomes of initial implantation versus reimplantation were analyzed. RESULTS: A total of 57 patients (mean age, 49.3 ± 13.5 years; 44 women) underwent implantation. Sixteen (28%) succeeded and 41 (72%) failed, requiring explantation; 17 of 41 patients underwent reimplantation; 5 had 2 reimplantations. There were 79 implantations and 50 explantations (63.3%) in total. Implantation and reimplantation procedures had similar lengths of operation, hospital stay, postoperative complications, and explantation rate. Most common reasons for device explantation were infection/erosion (27/50 (54%)) and malfunction (19/50 (38%)). Reasons for reimplantation included device malfunction/migration (17/22 (77.3%)) and/or infection/erosion (5/22 (22.7%)). Seven (41.2%) of 17 patients for whom reimplantation was attributed to noninfectious reasons had a functioning device, whereas only 1 (20.0%) of 5 who had reimplantation because of infection/erosion had a working device. At a median follow-up of 29.5 months (range, 1.0–215.0 months), 24 patients (42%) retained a functioning device (implantation = 16; reimplantation = 8). Success rates were not significantly different between initial implantation and reimplantation procedures (p = 0.755). There were no differences in the length of functional device time between implanted and reimplanted devices (p = 0.439). LIMITATIONS: The study was limited by its retrospective nature and small sample size. CONCLUSIONS: Artificial bowel sphincter implantation has a high failure rate, requiring explantation in 72% of patients in this study. Reimplantation was often possible, with a success rate of 47%. Selected reimplantation for noninfectious complications had better outcomes than did reimplantation for septic causes. Short- and long-term outcomes are comparable to initial implantation.

Redo sphincteroplasty: are the results sustainable?

Objective: This study aimed to investigate the long-term outcomes of patients who undergo redo sphincteroplasty (RS). Methods: Patients with fecal incontinence (FI) who underwent RS between November 1988 and December 2011 were retrospectively identified from a prospective database. A questionnaire and telephone survey assessed current Cleveland Clinic Fecal Incontinence Score (CCFFIS; best 0, worst 20) and Fecal Incontinence Quality of Life (FIQoL; best 4.1, worst 1) scale. Success was defined as no further continence surgery, no stoma and CCFFIS <9 at completion of follow-up. The Wilcoxon and Mann-Whitney U tests were used for comparing quantitative variables. Bivariate logistic regression analysis was done to identify predictive factors for success. Results: Fifty-six (66.7%) of 84 patients who underwent RS were available for evaluation at a median follow-up of 74 (range: 12–283) months. The mean CCFFIS decreased from 16.5 ± 3.7 to 11.9 ± 6.6 (P < 0.001) at last follow-up. Twelve patients (21.4%) underwent further continence surgery for failed sphincteroplasty, three (5.4%) of whom had a permanent stoma. Eighteen patients (32.1%) had a CCFFIS <9 at the completion of follow-up, and 16 (28.6%) had long-term success. Twenty-four patients evaluated for FIQoL had a mean value of 2.6 (range: 1.0–4.1). Postoperative CCFFIS was correlated with FIQoL (Spearman’s correlation coefficient = −0.854, P < 0.001). Logistic regression analysis did not reveal any significant predictive variables for success of RS. Conclusion: Based on our criteria for success, the long-term success rate for RS over a median of 74 months is poor.