Kelly A. Garrett

Dynamic article: long-term outcomes of patients undergoing combined endolaparoscopic surgery for benign colon polyps.

BACKGROUND: Patients with large benign colon polyps not amenable to endoscopic removal commonly undergo resections. Polyp removal using combined endolaparoscopic surgery may be an effective alternative to bowel resection in select patients. OBJECTIVE: The aim of this study was to evaluate short-term and long-term outcomes of patients who underwent endolaparoscopy at our institution. DATA SOURCES: Medical records and a prospectively maintained database were reviewed. STUDY SELECTION: This study constituted a retrospective review of consecutive patients who underwent endolaparoscopy for benign polyps from 2003 to 2012. INTERVENTIONS: Combined endolaparoscopic surgery was performed. MAIN OUTCOME MEASURES: The primary outcomes measured were success rate, rate of recurrence, rate of malignancy, length of stay, and complication rate. RESULTS: A total of 75 patients were taken to the operating room with the intention of endolaparoscopy. The most common indications were large polyp size and difficult location. Based on intraoperative findings, 10 patients were suspected of having cancer and underwent immediate laparoscopic colectomy. Of 65 attempted cases, 48 patients (74%) underwent successful combined endolaparoscopic surgery. Median follow-up time was 65 (8–87) months. Patients in whom combined endolaparoscopic surgery was unsuccessful were converted to colectomy (2 open, 15 laparoscopic). Two patients were converted because of concerns of cancer and 15 because of technical difficulties. Median operative time for successful endolaparoscopy was 145 (50–249) minutes. The complication rate was 4.4% (2/48). Median length of stay was 1 (0–6) day for endolaparoscopy vs 5 (3–19) days for those converted to colectomy. Median polyp size was 3 (1.0–7.0) cm. One patient was found to have cancer on final pathology, but refused to have further surgery. Sensitivity and specificity of predicting malignancy based on clinical findings were 33% (4/12) and 98.5% (64/65). Four of 5 patients who had recurrence (10%) after endolaparoscopy had complete endoscopic polypectomy. One patient required delayed laparoscopic colectomy for a second recurrence. LIMITATIONS: This study was limited by its retrospective nature. CONCLUSIONS: Combined endolaparoscopic surgery appears to be a safe and effective alternative to colectomy in all parts of the colon in patients who have benign polyps not removable with colonoscopy alone.

History of hysterectomy: a significant problem for colonoscopists that is not present in patients who have had sigmoid colectomy.

PURPOSE: During colonoscopy, it is often difficult to traverse the sigmoid colon in patients who have had a hysterectomy, presumably due to postsurgical pelvic adhesions. We performed this study to document this difficulty and to determine whether sigmoid colectomy prevents it. METHODS: Data were acquired from a single endoscopists prospective database. Colonoscopies performed in women were grouped according to history of hysterectomy and/or sigmoid colectomy. Groups were compared for colonoscopy completion rate, medication used, and time of examination. Participation of fellows and rate of complications were recorded. Patients with a history of abdominal-perineal resection of the rectum were excluded. RESULTS: From 1989 to 2006, a total of 4116 colonoscopies were performed in women: 993 had undergone hysterectomy (24.1%), of whom 108 (10.9%) had also undergone sigmoid colectomy. There were 3123 exams in woman who had their uterus (75.9%); 320 (10.2%) had undergone sigmoid colectomy. Patients who still had a sigmoid colon but had a history of hysterectomy had significantly lower colonoscopy completion rates (89.2%) and significantly longer mean examination time (28.9 ± 12.3 minutes), and more of them required sedation with benzodiazepines (88.7%) than the other groups (P < .05). Fellow participation increased time of colonoscopy and complications were more frequent in patients with hysterectomy. CONCLUSION: Posthysterectomy adhesions to the sigmoid colon make colonoscopy more difficult and more painful. These adverse effects are not present in hysterectomized women who have undergone sigmoid resection.

Disparities in the Use of Sacral Neuromodulation among Medicare Beneficiaries

PURPOSE Sacral neuromodulation with the InterStim® has been done to treat urinary and bowel control. There are limited data in the literature on use trends of sacral neuromodulation. We explored disparities in use among Medicare beneficiaries. MATERIALS AND METHODS We queried a 5% national random sample of Medicare claims for 2001, 2004, 2007 and 2010. All patients with an ICD-9 diagnosis code representing a potential urological indication for sacral neuromodulation were included. Patients who underwent device implantation were identified using CPT-4 codes. Statistical analysis was done with the chi-square and Fisher tests, and multivariate logistic regression using software. RESULTS A total of 2,322,060 patients were identified with a diagnosis that could potentially be treated with sacral neuromodulation. During the 10-year study period the percent of these patients who ultimately underwent implantation increased from 0.03% to 0.91% (p <0.0001) for a total of 13,360 (0.58%). On logistic regression analysis women (OR 3.85, p <0.0001) and patients younger than 65 years (OR 1.00 vs 0.29 to 0.39, p <0.0001) were more likely to be treated. Minority patients (OR 0.38, p <0.0001) and those living in the western United States (OR 0.52, p <0.0001) were less likely to receive treatment. CONCLUSIONS Sacral neuromodulation use significantly increased among Medicare beneficiaries in a 10-year period. Patients were more likely to be treated with sacral neuromodulation if they were female, white, younger (younger than 65 years) and living outside the western United States.

Surveillance, Epidemiology, and End Results-based analysis of the impact of preoperative or postoperative radiotherapy on survival outcomes for T3N0 rectal cancer

PURPOSE Preoperative chemoradiation has been established as standard of care for T3/T4 node-positive rectal cancer. Recent work, however, has called into question the overall benefit of radiation for tumors with lower risk characteristics, particularly T3N0 rectal cancers. We retrospectively analyzed T3N0 rectal cancer patients and examined how outcomes differed according to the sequence of treatment received. METHODS The Surveillance, Epidemiology, and End Results (SEER) database was used to analyze T3N0 rectal cancer cases diagnosed between 1998 and 2008. Treatment consisted of surgery alone (No RT), preoperative radiation followed by surgery (Neo-Adjuvant RT), or surgery followed by postoperative radiation (Adjuvant RT). Demographic and tumor characteristics of the three groups were compared using t-tests for the comparison of means. Survival information from the SEER database was utilized to estimate cause-specific survival (CSS) and to generate Kaplan-Meier survival curves. Multivariate analysis (MVA) of features associated with outcomes was conducted using Cox proportional hazards regression models with Adjuvant RT, Neo-Adjuvant RT, No RT, histological grade, tumor size, year of diagnosis, and demographic characteristics as covariates. RESULTS 10-Year CSS estimates were 66.1% (95% CI 62.3-69.6%; P=0.02), 73.5% (95% CI 68.9-77.5%; P=0.02), and 76.1% (95% CI 72.4-79.4%; P=0.02), for No RT, Neo-Adjuvant RT, and Adjuvant RT, respectively. On MVA, Adjuvant RT (HR=0.688; 95% CI, 0.578-0.819; P<0.001) was associated with significantly decreased risk for cancer death. By contrast, Neo-Adjuvant RT was not significantly associated with improved cancer survival (HR=0.863; 95% CI, 0.715-1.043; P=0.127). CONCLUSION Adjuvant RT was associated with significantly higher CSS when compared with surgery alone, while the benefit of Neo-Adjuvant RT was not significant. This indicates that surgery followed by Adjuvant RT may still be an important treatment plan for T3N0 rectal cancer with potentially significant survival advantages over other treatment sequences.

Combined Endoscopic and Laparoscopic Surgery.

Benign colon polyps are best treated endoscopically. Colon polyps that are not amenable for endoscopic removals either because they are too large or situated in anatomically difficult locations can pose a clinical dilemma. Traditionally the most common recommendation for these patients has been to offer a colon resection. Although the laparoscopic approach has improved short-term outcomes, morbidities associated with bowel resection are still significant. We may be over treating majority of these patients because of the remote possibility that these polyps may be harboring a cancer. A combined approach using both laparoscopy and colonoscopy (combined endoscopic and laparoscopic surgery) has been described as an alternative to bowel resection in select patients with polyps that cannot be removed endoscopically. Polyp removal using this combined approach may be an effective alternative in select patients.

Evaluation of Trends in the Use of InterStim for Fecal Incontinence: The New York State Experience

Background: Fecal incontinence (FI) represents a large source of morbidity and is a challenging clinical problem to manage. InterStim was approved to treat FI in 2011. Little is known about its adoption. We sought to characterize patterns of use of Interstim since Food and Drug Administration approval for FI. Methods: The New York State SPARCS database was used to evaluate InterStim use for FI from 2011 to 2014. The primary endpoint was the number of successful implantations of InterStim. Secondary endpoints included device removal, median time to removal of device, 90-day infection rates, and percentage of procedures performed by surgeon specialty and geographic location. Results: A total of 369 patients with FI underwent “Stage 1” of InterStim from 2011 to 2014. A total of 302 patients underwent “Stage 2,” yielding a trial period failure rate of 18.2%. The majority of patients who underwent successful implantation were female (87.7%) and White (78.8%). Twenty-nine patients underwent device removal after a median duration of 147 days. Estimated risk of removal at median follow-up of 2 years was 11.8%. Colorectal surgeons comprised 51.1% of all providers followed by gynecologic (24.4%) and urologic surgeons (17.8%). A total of 71.7% of providers performed <5 procedures, while 3 of the highest volume providers performed 50.7% of all procedures. Conclusions: InterStim for FI has been used by a wide variety of providers in New York State although only a few high-volume providers have performed the majority of procedures. White, female patients with Medicare are the most common recipients of InterStim. Further work must be done to develop strategies for improving access to this technology and to determine whether volume relates to outcomes.

Changing trends in surgery for abdominal Crohn's disease

The introduction of biological agents and laparoscopy are, arguably, the most important developments for the treatment of Crohns disease (CD) in the last two decades. Due to the efficacy of biological agents in treating mild disease, it is likely that the percentage of surgery for complex cases may have increased. The objective of this study was to analyse the changing characteristics and results of the surgical treatment of patients with CD over the past 13 years.

Endoscopic Management of Polyps, Polypectomy, and Combined Endoscopic and Laparoscopic Surgery

Polypectomy is fundamental to the practice of colonoscopy. Polypectomy disrupts the adenoma to carcinoma sequence, thereby reducing colorectal cancer incidence and mortality. The goals of polypectomy are the effective, safe, and efficient removal of precancerous polyps while minimizing the risk of complications. Recent advances in endoscopic techniques such as endoscopic mucosal resection and endoscopic submucosal dissection can ensure complete and safe resection of lesions and evade surgery in some patients. Combined endo-laparoscopic surgery is an adjunct to endoscopic polypectomy that may help to avoid colectomy. Although polyp removal using these advanced techniques may be an effective alternative in select patients, they require both experience and expertise to become an available option in a surgeon’s armamentarium.

Surgical Therapy for Fecal Incontinence

Fecal incontinence is a common condition that is frequently underreported. Although the most common causative factor is obstetric injury, the origin can frequently be multifactorial. A thorough history and physical examination is necessary to determine the source of the problem. Physiologic and radiologic tests may be added to assist in diagnosis and also in directing treatment. First line treatment consists of medical management and in some cases physical therapy. If this fails then surgical intervention is considered. Surgery consists of overlapping sphincteroplasty, the injection of bulking agents, and sacral nerve stimulation and less frequently anal encirclement procedures, radiofrequency ablation, artificial bowel sphincter, and muscle transposition. A diverting stoma may be considered as a last resort.

Combined Endo-Laparoscopic Surgery (CELS)

Colonoscopic polypectomy is the treatment of choice for diagnosing and removing most colon polyps. Large polyps or those in an anatomically difficult location can be very challenging to remove by endoscopic techniques alone. Traditionally, the most common recommendation for these patients has been to undergo a subsequent colon resection. Although the laparoscopic approach has reduced the morbidity of an abdominal operation, it still poses potential morbidities related to bowel resection. A combined approach using both laparoscopy and colonoscopy (combined endo-laparoscopic surgery, CELS) has more recently been described as an alternative to bowel resection in select patients with polyps that cannot be removed endoscopically. This procedure allows laparoscopic manipulation of the colon wall adjacent to the polyp to facilitate polypectomy. Furthermore, it enables prompt diagnosis and treatment of full-thickness defects of the colon and provides an opportunity to proceed with a standard oncological resection in lesions that are not amenable or suitable for this CELS. In this chapter, we will review this technique including key points for success.