Jeremy Sugrue

No clinical benefit from routine histologic examination of stapler doughnuts at low anterior resection for rectal cancer

Background. The aim of this study was to evaluate the clinical utility and cost‐effectiveness of routine histologic examination of the doughnuts from stapled anastomoses in patients undergoing a low anterior resection for rectal cancer. Methods. We performed a retrospective review of 486 patients who underwent a low anterior resection with stapled anastomosis for rectal cancer between 2002 and 2015 at 3 institutions. Pathologic findings in the doughnuts and their impact on patient management were recorded. Tumor characteristics that may influence how often doughnuts were included in the pathology report were analyzed. An approximate cost of histologic examination of doughnuts was also calculated. Results. A total of 412 patients (85%) had doughnuts included in their pathology reports. Two patients had cancer cells in their doughnuts, and both patients had a positive distal margin in their primary tumor specimen; 33 patients had benign findings in their doughnuts. Pathologic examination of the doughnut did not change clinical management in any patient. Patients with rectosigmoid tumors were less likely to have their doughnuts included in the pathology report compared to patients with low tumors (P = .003). Doughnuts were not bundled with the primary tumor specimen in 374 (77%) of our patients; in these patients, pathologic analysis of the doughnut added an additional cost of approximately

Long-term Experience of Magnetic Anal Sphincter Augmentation in Patients with Fecal Incontinence

643 per specimen. Conclusion. This study demonstrates no clinical benefit in sending anastomotic doughnuts for histopathologic evaluation after performing a low anterior resection with a stapled anastomosis for rectal cancer. Overall cost may be decreased if doughnuts are not analyzed or if they are bundled with the primary tumor specimen.

Pathogenesis and persistence of cryptoglandular anal fistula: a systematic review

BACKGROUND: Magnetic anal sphincter augmentation is a novel technique for the treatment of patients with fecal incontinence. OBJECTIVE: The current study reports the long-term effectiveness and safety of this new treatment modality. DESIGN: This was a prospective multicenter pilot study. SETTINGS: The study was performed at 4 clinical sites in Europe and the United States. PATIENTS: The cohort included patients with severe fecal incontinence for ≥6 months who had previously failed conservative therapy and were implanted with a magnetic anal sphincter device between 2008 and 2011. MAIN OUTCOME MEASURES: Adverse events, symptom severity, quality of life, and bowel diary data were collected. RESULTS: A total of 35 patients (34 women) underwent magnetic anal sphincter augmentation. The median length of follow-up was 5.0 years (range, 0–5.6 years), with 23 patients completing assessment at 5 years. Eight patients underwent a subsequent operation (7 device explantations) because of device failure or complications, 7 of which occurred in the first year. Therapeutic success rates, with patients who underwent device explantation or stoma creation counted as treatment failures, were 63% at year 1, 66% at year 3 and 53% at year 5. In patients who retained their device, the number of incontinent episodes per week and Cleveland Clinic incontinence scores significantly decreased from baseline, and there were significant improvements in all 4 scales of the Fecal Incontinence Quality of Life instrument. There were 30 adverse events reported in 20 patients, most commonly defecatory dysfunction (20%), pain (14%), erosion (11%), and infection (11%). LIMITATIONS: This study does not allow for comparison between surgical treatments and involves a limited number of patients. CONCLUSIONS: Magnetic anal sphincter augmentation provided excellent outcomes in patients who retained a functioning device at long-term follow-up. Protocols to reduce early complications will be important to improve overall results.

Bio-Thiersch as an Adjunct to Perineal Proctectomy Reduces Rates of Recurrent Rectal Prolapse.

Anal fistulas continue to be a problem for patients and surgeons alike despite scientific advances. While patient and anatomical characteristics are important to surgeons who are evaluating patients with anal fistulas, their development and persistence likely involves a multifaceted interaction of histological, microbiological, and molecular factors. Histological studies have shown that anal fistulas are variably epithelialized and are surrounded by dense collagen tissue with pockets of inflammatory cells. Yet, it remains unknown if or how histological differences impact fistula healing. The presence of a perianal abscess that contains gut flora commonly leads to the development of anal fistula. This implies a microbiological component, but bacteria are infrequently found in chronic fistulas. Recent work has shown an increased expression of proinflammatory cytokines and epithelial to mesenchymal cell transition in both cryptoglandular and Crohn’s perianal fistulas. This suggests that molecular mechanisms may also play a role in both fistula development and persistence. The aim of this study was to examine the histological, microbiological, molecular, and host factors that contribute to the development and persistence of anal fistulas.

Sphincter-Sparing Anal Fistula Repair: Are We Getting Better?

BACKGROUND: The rates of recurrent prolapse after perineal proctectomy vary widely in the literature, with incidences ranging between 0% and 50%. The Thiersch procedure, first described in 1891 for the treatment of rectal prolapse, involves encircling the anus with a foreign material with the goal of confining the prolapsing rectum above the anus. The Bio-Thiersch procedure uses biological mesh for anal encirclement and can be used as an adjunct to perineal proctectomy for rectal prolapse to reduce recurrence. OBJECTIVE: The aim of this study was to evaluate the Bio-Thiersch procedure as an adjunct to perineal proctectomy and its impact on recurrence compared with perineal proctectomy alone. DESIGN: A retrospective review of consecutive patients undergoing perineal proctectomy with and without Bio-Thiersch was performed. SETTINGS: Procedures took place in the Division of Colon and Rectal Surgery at a tertiary academic teaching hospital. PATIENTS: Patients who had undergone perineal proctectomy and those who received perineal proctectomy with Bio-Thiersch were evaluated and compared. INTERVENTIONS: All of the patients with rectal prolapse received perineal proctectomy with levatorplasty, and a proportion of those patients had a Bio-Thiersch placed as an adjunct. MAIN OUTCOME MEASURES: The incidence of recurrent rectal prolapse after perineal proctectomy alone or perineal proctectomy with Bio-Thiersch was documented. RESULTS: Sixty-two patients underwent perineal proctectomy (8 had a previous prolapse procedure), and 25 patients underwent perineal proctectomy with Bio-Thiersch (12 had a previous prolapse procedure). Patients who received perineal proctectomy with Bio-Thiersch had a lower rate of recurrent rectal prolapse (p < 0.05) despite a higher proportion of them having had a previous prolapse procedure (p < 0.01). Perineal proctectomy with Bio-Thiersch had a lower recurrence over time versus perineal proctectomy alone (p < 0.05). LIMITATIONS: This study was limited by nature of being a retrospective review. CONCLUSIONS: Bio-Thiersch as an adjunct to perineal proctectomy may reduce the risk for recurrent rectal prolapse and can be particularly effective in patients with a history of previous failed prolapse procedures.

Reply to: Unnecessary histologic examination of stapler doughnuts at low anterior resection for rectal cancer: Is it just a blame game?

BACKGROUND: Sphincter-sparing repairs are commonly used to treat anal fistulas with significant muscle involvement. OBJECTIVE: The current study evaluates the trends and efficacy of sphincter-sparing repairs and determines risk factors for fistula recurrence. DESIGN AND SETTINGS: A retrospective review was performed at 3 university-affiliated teaching hospitals. PATIENTS: All 462 patients with cryptoglandular anal fistulas who underwent 573 sphincter-sparing repairs between 2005 and 2015 were included. Patients with Crohn’s disease were excluded. MAIN OUTCOME MEASURES: The primary outcome was the rate of fistula healing defined as cessation of drainage with closure of the external opening. Risk factors for nonhealing were also analyzed. RESULTS: Five hundred three sphincter-sparing repairs were analyzed, whereas 70 were lost to follow-up. Two hundred twenty sphincter-sparing repairs (44%) resulted in healing, 283 (56%) resulted in nonhealing with a median follow-up of 9 (range, 1–125) months. The median time to fistula recurrence was 3 (range, 0–75) months with 79% and 91% of recurrences noted within 6 and 12 months. Patients treated with a dermal advancement flap, rectal advancement flap, or ligation of the intersphincteric tract procedure were less likely to have a recurrence than patients treated with a fistula plug or fibrin glue (p < 0.001). Over time, there was a significantly increased use of the ligation of the intersphincteric tract procedure (p < 0.001) and a significantly decreased use of fistula plugs and fibrin glue (p < 0.001); healing rates improved accordingly. There were no significant differences in healing rates with respect to patient demographics, comorbidities, or fistula characteristics. LIMITATIONS: This study was limited by its retrospective design. CONCLUSIONS: Healing rates following sphincter-sparing repairs of cryptoglandular anal fistulas are modest, but have improved over time with the use of better surgical techniques. In this study, ligation of the intersphincteric fistula tract and flaps were superior to fistula plugs and fibrin glue; the former procedures are therefore favored. See Video Abstract at http://links.lww.com/DCR/A391.

Acute diverticulitis in renal transplant patients: should we treat them differently?

Dear Editor, We have read with appreciation the correspondence from Spartalis et al about our recent article reporting no clinical benefit from routine histologic examination of stapler doughnuts at lower anterior resection for rectal cancer. In summary, we performed a retrospective multicenter review of 486 patients who underwent a low anterior resection with stapled anastomosis for rectal cancer and found no cases where doughnut pathology altered patient management. Doughnuts added an additional cost when processed by pathology as a unique specimen and this was practiced in 374 (77%) of our patients. Based on our data, we do not recommend routinely sending stapler doughnuts for histologic examination in patients with rectal cancer. The correspondence raises the question of since when have we been noticing these clinically insignificant results regarding histology of stapler doughnuts? In 2001, Pullyblank et al examined 100 doughnuts histologically at a single institution in the United Kingdom and found that none of the findings altered patient management. To our knowledge, this was the first published report on the topic. They suggested that pathologists should not process doughnuts unless the tumor is within 3 cm from the distal margin. Since then, several other retrospective, single-center series have reported similar findings and concluded that routine examination of stapler doughnuts in the setting of rectal cancer is not necessary. Although our findings are not novel, they substantiate the previously published conclusions by adding a large number of patients from an American multicenter experience. The other questions posed in the correspondence are why is the application of the recommended guidelines still inconsistent and who is to blame: the pathologist or the surgeon? These questions are difficult to answer. Part of the problem may be a lack of well-recognized guidelines, especially in the United States. Prior to our article, there was no published American experience on this topic. There is no mention of stapler doughnuts in the 2013 guidelines of the American Society of Colon and Rectal Surgeons for the management of rectal cancer or in the 2016 protocol of the College of American Pathologist (CAP) for the examination of specimens from patients with primary carcinoma of the colon and rectum. In January 2008, the CAP Today magazine published an article “CPT questions” recommending that stapler doughnuts should be bundled with the colon cancer specimen. However, the article did not cite any data to support this recommendation. Therefore, both surgeons and pathologists may be unaware of the aforementioned literature, which suggests that histologic examination of colorectal doughnuts is generally unnecessary. The correspondence reminds us that the situation in upper gastrointestinal cancer is indeed different. Our study only included patients with rectal cancer. Therefore, our data should not be generalized to patients undergoing operation for upper gastrointestinal cancer. We agree with the conclusion that doughnut involvement with cancer and its prognostic implications deserves further investigation with larger prospective studies. We also agree that it is safe to apply costefficient guidelines to colorectal doughnuts without detriment to patient care. We hope our study raises further awareness about these points.

Safety and efficacy of an electrothermal bipolar vessel sealing device in sealing and division of the inferior mesenteric vessels in minimally invasive colorectal surgery

Background. Current guidelines suggest that transplant patients with acute diverticulitis should be managed aggressively with early operative intervention to reduce morbidity and mortality. This study compared the treatment choices and clinical outcomes between renal transplant patients and immunocompetent patients with acute diverticulitis. Methods. A retrospective review was performed of all patients who were admitted with acute diverticulitis between 2002 and 2015 at a single academic institution. Patient demographics, comorbidities, physiologic and radiologic disease severity, management, and disease‐specific outcomes were recorded and compared between renal transplant patients and immunocompetent patients. Predictors of complications also were analyzed. Results. In the study, 20 renal transplant patients and 134 immunocompetent patients were admitted for acute diverticulitis and were followed for a median time of 36 and 40 months, respectively. Patient demographics were similar between the groups. Transplant patients had significantly more comorbidities. Overall, there were no differences in physiologic disease severity or rates of elective or urgent operation, ostomy, permanent ostomy, duration of stay, 30‐day readmission, disease recurrence or disease‐specific complications, organ failure, or death. Among patients with complicated disease, renal transplant patients were significantly more likely to undergo an urgent operation and had more complications. On multivariate analysis, undergoing operative therapy remained the sole predictor of complications. Conclusion. Nonoperative management of renal transplant patients who present with uncomplicated diverticulitis is safe as outcomes are similar to immunocompetent patients. However, the optimal management of renal transplant patients with complicated diverticulitis remains unclear as both treatment choices and complication rates differed from immunocompetent patients.

A combination of transanal minimally invasive surgery and transanal technique to facilitate suturing during transanal minimally invasive surgery

The increasing use of minimally invasive techniques in colon and rectal surgery has led to widespread use of energy devices for tissue dissection and vessel sealing. Traditional devices for major vascular control, such as clips and vascular staplers, have been slowly replaced by energy devices due to their convenience and cost-effectiveness [1]. The use of electrothermal bipolar vessel sealing devices and ultrasonic energy devices has already been shown to be safe and effective in minimally invasive colon and rectal surgery [2]. Animal studies comparing EnSeal (ES) (Ethicon Inc., Cincinnati, OH) with other bipolar devices have shown favorable results with higher burst pressures, comparable sealing time, and less lateral thermal damage [3]. However, to date, there are no large studies reporting clinical effectiveness of ES on mesenteric vessels in humans. In our practice, ES is used for vascular control, tissue dissection, and splenic flexure mobilization when applicable. The inferior mesenteric artery (IMA) is isolated and transected close to its origin from the aorta in resections for cancer (Fig. 1). In benign cases, a small stump is preserved. In all cases, the hypogastric nerves are identified and preserved. Isolation of the inferior mesenteric vein (IMV) is undertaken below the lower border of the pancreas, and the main trunk is sealed and divided with the ES. We completely skeletonize the vessels before sealing and transection. During transection, care is taken to avoid tension and tenting of the vessel in order to avoid disruption and bleeding. In robotic-assisted resections, tissue dissection is carried out using a monopolar hook cautery and the bedside assistant transects the mesenteric vessels using the ES device through a 5-mm port. We reviewed a prospectively maintained database of patients in our practice to assess the safety and efficacy of the ES bipolar device in ligation of inferior mesenteric vessels. Four hundred consecutive laparoscopic and robotic left colon and rectal resections between August 2007 and October 2011 where the ES device was used for sealing of inferior mesenteric vessels were included. Institutional review board approval was obtained for this study. Intraoperatively, six patients (1.5 %) had bleeding following vascular control of the IMA by ES. None required conversion or a major change in operative approach. Endostitch (n = 1), endoloop (n = 3), and endoclips (n = 2) were successfully used to control the bleeding. Two of these patients were noted to have calcified vessels. One patient required 4 units of packed red blood cells postoperatively; however, this patient did not have ES failure intraoperatively and the blood loss was found to be unrelated to inadequate vessel sealing. Main branch IMV sealing and transection were uneventful in all cases. None of the patients had intraoperative thermal injuries to the bowel or ureteric injuries during colonic mobilization. No patient was returned to the operating room for hemorrhage, bowel perforation, ischemic bowel, or ureteral injuries. There are several limitations to our study. ES was not tried in patients with extensively scarred or thickened mesenteries, particularly in the initial stages of use. A & J. Sugrue jsugrue2@gmail.com

Wide local excision of perianal Paget’s disease with gluteal flap reconstruction: an interdisciplinary approach

Transanal minimally invasive surgery (TAMIS) is an effective option for the local excision of benign, non-invasive rectal lesions, or selected early stage rectal cancers. However, the suturing encountered in TAMIS remains technically challenging. A combination of TAMIS and transanal approach to suturing is demonstrated to address this challenge. A 64-year-old female with a T1N0 adenocarcinoma located in the anterior mid-rectum underwent TAMIS for resection of the lesion. Total operative time was 91 minutes. Free peritoneal defect was closed in two layers. The patient was discharged on postoperative day 1. Final pathology revealed a 0.7 cm T1 well-differentiated adenocarcinoma 0.8 cm from the closest resection margin. The patient remains free of systemic or local recurrence at 24 months. TAMIS is a safe and effective option for removal of benign rectal lesions or selected low grade T1 adenocarcinomas of the rectum. A hybrid TAMIS and transanal approach to suturing may often easily address the technical challenge of pure laparoscopic suturing in TAMIS.