Kellie L. Mathis

Frequency of Extrapancreatic Neoplasms in Intraductal Papillary Mucinous Neoplasm of the Pancreas: Implications for Management

Objective:To estimate the frequency of extrapancreatic neoplasms in patients with IPMN compared with those with ductal pancreatic cancer and a general referral population. Summary Background Data:Several studies have reported an increased risk of extrapancreatic neoplasms in patients with IPMN, but these studies focused only on those patients who underwent resection and excluded those patients treated nonoperatively. Methods:All patients diagnosed with IPMN at Mayo Clinic from 1994 to 2006 were identified. Two control groups consisting of Group 1–patients with a diagnosis of ductal pancreatic adenocarcinoma (1:1) and Group 2–a general referral population (3:1) were matched for gender and age at diagnosis, year of registration, and residence. Logistic regression was used to assess the risk of a diagnosis of extrapancreatic neoplasms among cases versus controls. Results:There were 471 cases, 471 patients in Group 1, and 1413 patients in Group 2. The proportion of IPMN patients having any extrapancreatic neoplasm diagnosed before or coincident to the index date was 52% (95% CI, 47%–56%), compared with 36% (95% CI, 32%–41%) in Group 1 (P < 0.001), and 43% (95% CI, 41%–46%) in Group 2 (P = 0.002). Benign neoplasms most frequent in the IPMN group were colonic polyps (n = 114) and Barretts neoplasia (n = 18). The most common malignant neoplasms were nonmelanoma skin (n = 35), breast (n = 24), prostate (n = 24), colorectal cancers (n = 19), and carcinoid neoplasms (n = 6). Conclusions:Patients with IPMN have increased risk of harboring extrapancreatic neoplasms. Based on the frequency of colonic polyps, screening colonoscopy should be considered in all patients with IPMN.

Outcomes following surgery without radiotherapy for rectal cancer

This study determined survival and recurrence rates following curative resection of rectal cancer without radiotherapy.

Unresectable Colorectal Cancer Can Be Cured With Multimodality Therapy

Objective:The aim of this study was to determine in what manner aggressive external beam radiotherapy (EBRT), chemotherapy, surgical resection, and intraoperative radiotherapy (IORT) impact relapse and survival in patients with locally unresectable primary colorectal cancer. Summary Background Data:Patients with colorectal cancer fixed to critical structures (eg, IVC and pelvic sidewall) are considered locally “unresectable” for cure and treated with palliative therapy. Methods:One hundred forty-six patients (65% males) with locally unresectable colon (40) and rectal (106) cancer were treated with EBRT, chemotherapy, surgical resection, and IORT. Final surgical margins were close, but negative in 100 patients (68%), microscopically positive in 28 (19%), and grossly positive in 18 (13%). Kaplan-Meier method was used to visualize survival and relapse curves; groups were compared using the log-rank test. Results:Median overall survival was 3.7 years. Median overall survival (years) favored patients with age <58 (7.6 vs. 3.6; P = 0.0012), those receiving adjuvant chemotherapy (9.4 versus 3.9; P = 0.0019), and those with negative or microscopic margins (6.3 vs. 1.9; P = 0.0006). There were no perioperative deaths. Fifteen complications occurred in 12 patients (8%) within 30 days of surgery/IORT. One hundred nineteen long-term complications occurred in 77 patients (53%), most commonly peripheral neuropathy (19%), bowel obstruction (14%), and ureteral obstruction (12%). Conclusions:Aggressive multimodality therapy for locally unresectable primary colorectal cancer results in excellent local disease control and a 5-year disease-free and overall survival rate of 43% and 52% respectively with no operative mortality and acceptable perioperative morbidities.

Malignant risk and surgical outcomes of presacral tailgut cysts

Presacral tailgut cysts are uncommon and few data exist on the outcomes following surgery.

Postoperative Outcomes in Vedolizumab-Treated Patients Undergoing Abdominal Operations for Inflammatory Bowel Disease

Introduction: Vedolizumab was recently approved by the Food and Drug Administration for the treatment of moderate to severe ulcerative colitis [UC] and Crohn’s disease [CD]. No study to date has examined the rate of postoperative infectious complications among patients who received vedolizumab in the perioperative period. We sought to determine the 30-day postoperative infectious complication rate among inflammatory bowel disease [IBD] patients who received vedolizumab within 12 weeks of an abdominal operation as compared to patients who received tumour necrosis factor &agr; [TNF&agr;] inhibitors or no biological therapy. Methods: A retrospective chart review between May 1, 2014 and December 31, 2015 of adult IBD patients who underwent an abdominal operation was performed. The study cohort comprised patients who received vedolizumab within 12 weeks of their abdominal operation and the control cohorts were patients who received TNF&agr; inhibitors or no biological therapy. Results: In total, 94 patients received vedolizumab within 12 weeks of an abdominal operation. Fifty experienced postoperative complications [53%], 35 of which were surgical site infections [SSIs] [36%]. The vedolizumab group experienced significantly higher rates of any postoperative infection [53% vs 33% anti-TNF and 28% non-biologics; p<0.001] and SSI [37% vs 10% and 13%; p<0.001]. On univariate and multivariate analysis, exposure to vedolizumab remained a significant predictor of postoperative SSI [p<0.001]. Conclusions: Thirty-seven per cent of IBD patients who received vedolizumab within 30 days of a major abdominal operation experienced a 30-day postoperative SSI, significantly higher than patients receiving TNF&agr; inhibitors or no biological therapy. Vedolizumab within 12 weeks of surgery remained the only predictor of 30-day postoperative SSI on multivariate analysis.

Ileal pouch–anal anastomosis and liver transplantation for ulcerative colitis complicated by primary sclerosing cholangitis

The aim was to evaluate outcomes in patients with ulcerative colitis complicated by primary sclerosing cholangitis (PSC) who required ileal pouch–anal anastomosis (IPAA) and orthotopic liver transplantation (OLT).

Systematic review with meta-analysis: faecal diversion for management of perianal Crohn's disease

Temporary faecal diversion is sometimes used for management of refractory perianal Crohns disease (CD) with variable success.

Outcomes in Patients with Ulcerative Colitis Undergoing Partial or Complete Reconstructive Surgery for Failing Ileal Pouch-anal Anastomosis

Objective:Evaluate outcomes of patients with an original diagnosis of ulcerative colitis (UC) who required partial or complete ileal pouch reconstruction due to poor function or infectious complications. Methods:A prospectively collected ileal pouch-anal anastomosis (IPAA) database was reviewed retrospectively to identify UC patients undergoing major reconstructive revisions of their IPAA at our institution between 1981 and 2005. Functional results were derived from continued surveys of patients. Results:Fifty-one UC patients were identified but 22 subsequently proved to have Crohns disease (CD). The initial IPAA was constructed at our institution in 32 patients and elsewhere in 19 patients. Indications for revision included infectious/inflammatory complications (65%) and mechanical difficulties (35%). Pouch revision was partial in 57% of patients and complete in 43%. There were no postoperative deaths. Following reconstruction, patients reported on average 5 daytime and 1 nighttime bowel movements. Daytime incontinence was occasional in 43% and frequent in 4%. Nighttime incontinence was occasional in 54% and frequent in 7%. The probability of pouch survival after reconstruction was 93% at 1 year and 89% at 5 years. Of the pouches that subsequently failed, 75% occurred in patients with a later diagnosis of CD. Postreconstruction abscess was a significant risk factor for ultimate pouch failure. Conclusions:In UC patients with failing IPAA, partial or complete pouch reconstruction can be done safely with good functional results, and may avoid pouch excision and permanent ileostomy in carefully selected patients, especially those with definite UC.

Surgical treatment for constipation in children and adults

Functional constipation is one of the most common gastrointestinal disorders. In both children and adults, most patients are managed conservatively with good results. In this review, we focus on the surgical approach to constipation. Patients who lack the capacity to consistently have voluntary bowel movements may need mechanical emptying of the colon through an enema program; for them, surgery to allow for antegrade enemas, (via the appendix or using a button device) is useful. Those patients with severe constipation not responsive to intense medical treatment may be candidates for other surgical interventions, such as resection of the dysfunctional colonic segment (rectosigmoid or whole colon), or plication, -pexy, and STARR techniques for evacuatory disorders secondary to obstructive anatomical features. Permanent stomas are an option of last resort.

Surgery for locally advanced recurrent colorectal cancer involving the aortoiliac axis: can we achieve R0 resection and long-term survival?

BACKGROUND: Locally advanced, recurrent colorectal cancer involving the aortoiliac axis may be considered a contraindication for curative surgery because of the technical challenges of achieving a negative margin resection and an assumed poor prognosis. OBJECTIVE: The aim of this study was to assess oncologic outcomes and the ability to achieve an R0 resection in these patients. DESIGN: A retrospective review of a prospectively maintained colorectal cancer database identified 406 consecutive patients who underwent surgery for locally recurrent colorectal cancer between 1997 and 2007. SETTING: This study was conducted at an academic multidisciplinary tertiary center. PATIENTS: The demographic and clinicopathological features of patients undergoing resection for locally advanced disease involving the aortoiliac axis at our institution were reviewed. RESULTS: Twelve patients (7 women, median age 51 years) were identified. Major vessel involvement included internal iliac artery (n = 7), common iliac artery (n = 5), external iliac artery (n = 3), aorta (n = 3), internal iliac vein (n = 2), and external iliac vein (n = 1). R0 resection was achieved in 7 patients, and R1 resection in 5. Eleven patients received intraoperative radiation therapy. Vascular reconstruction (3 aorta, 5 common iliac, 3 external iliac) included synthetic interposition grafts, femoral-femoral bypasses, or primary anastomosis. One patient underwent venous reconstruction of the external iliac vein. No graft complications were encountered, and graft patency at 4 years was 100%. Thirty-day morbidity was seen in 9 patients, 8 of whom had Clavien grade <3. Thirty-day mortality was nil. Overall and disease-free survival at 4 years was 55% and 45%. LIMITATIONS: This study was limited by its sample size, retrospective design, and the number of outcome events. CONCLUSION: R0 resection of locally advanced recurrent colorectal cancer involving the aortoiliac axis was achieved in over 50% of patients. Overall and disease-free survival was comparable to outcomes seen with locally advanced disease to nonvascular structures.