Luca Stocchi

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.

Redo pouches: Salvaging of failed ileal pouch-anal anastomoses

From October 1, 1984 to December 31, 1991 at the Clinica Chirurgica II of the University of Bologna, 140 patients submitted to ileal pouch-anal anastomosis for ulcerative colitis (UC) and familial adenomatous polyposis (FAP). Nineteen patients (13.5 percent) developed septic complications. Of these, 11 patients (7.8 percent) had pelvic sepsis. Eight patients required further surgical intervention. Five patients underwent the redo pouch procedure. Another redo pouch was performed in a patient who had previously, in another hospital, had an ileal pouch-anal anastomosis placed and then removed because of ischemic necrosis of the reservoir. No deaths are reported in the reoperated patients. Currently, five of the six patients who underwent the redo pouch procedure have a well-functioning ileoanal anastomosis. The redo pouch procedure should always be attempted prior to the establishment of pelvic fibrosis.

Conservative surgical management of terminal ileitis : Side-to-side enterocolic anastomosis

PURPOSE: Terminal ileitis is the most frequent presentation of Crohns disease. Resection of the terminal ileum and cecum with ileocolic anastomosis has always been considered the “gold standard” in the surgical treatment of this condition. This study illustrates an alternative technique referred to as “side-to-side enterocolic anastomosis.” METHODS: It consists of a longitudinal section of the terminal ileum starting 1 to 2 cm away from the beginning of the stricture and continued for a similar length on the ascending colon. A side-to-side anastomosis is then fashioned, in a kind of Finney-shaped strictureplasty. A series of five patients is reported. RESULTS: Average length of the anastomosis was 18.4 (range, 12–25) cm. Postoperative course was uneventful. Colonoscopy and large-bowel enema performed on some patients six months after surgery revealed a complete morphologic regression of the disease. All patients are presently in good condition, with no evidence of recurrence after an average follow-up of 8.9 (range, 6–15) months. CONCLUSIONS: “Side-to-side enterocolic anastomosis” can be a possible alternative option for the surgical management of Crohns disease of the terminal ileum, providing at least regression of the morphologic aspects of the disease. Contraindications are presence of abscesses, fistulas, or rigid and fibrotic stricture. This technique can be considered a further example of nonresectional surgery such as strictureplasty. This makes it possible to conceive surgical treatment of Crohns disease without resection in selected cases for the whole length of the small bowel and suggests the introduction of the new definition of “conservative surgical management of small-bowel Crohns disease.”

Factors affecting recurrence in Crohn's disease Results of a prospective audit

Abstract. It has been suggested that certain clinical and morphological features can modify the outcome of Crohns disease, particularly regarding recurrence after surgery. A series of 233 patiens was followed prospectively. They underwent a resectional surgical procedure for both primary and recurrent Crohns disease during a fifteen-year period with a minimum follow-up of eighteen months. Possible risk factors for recurrence were studied. They included duration of disease before primary surgery, the type of clinical presentation at onset (whether ``Perforating or ``Non-perforating), the initial anatomical location, the presence of microscopic disease at the resection edges, the type of surgical procedure (anastomosis vs stoma), post-operative surgical complications and the age of the patient. The duration of the disease before the initial operation was the only significant factor related to the recurrence rate.Résumé. On a suggéré que certaines données cliniques et morphologiques étaient susceptibles de modifier lévolution de la maladie de Crohn, en particulier quant à lincidence des récidives après chirurgie. Une série de 233 patients ont été suivis prospectivement. Au cours dune période de 15 ans, ces patients ont subi deux interventions de résection soit, la résection du foyer primaire et la résection dune récidive de la maladie de Crohn. Le suivi minimum de ces patients est de 18 mois. Les facteurs de risque dune récidive ont étéétudiés. Parmi ceux-ci on note la durée de lévolution de la maladie avant la chirurgie primaire, le mode de présentation clinique au début (maladie transmurale ou non transmurale) le siège initial, la présence de lésions microscopiques sur les tranches de section, le type de geste chirurgical (anastomose versus stoma), la survenue de complications postopératoires et lâge du patient. Seule la durée dévolution avant le geste chirurgical initial a étéétablie comme représentant un facteur significatif en faveur dune récidive.

Functional outcome in handsewn versus stapled ileal pouch-anal anastomosis

Eighty-eight of 119 patients who underwent ileal pouch-anal anastomosis for ulcerative colitis were evaluated. Forty patients had a handsewn anastomosis (Hs) with mucosectomy, and 48 had a stapled anastomosis (St). In each patient, we evaluated operative, morphologic, functional, and manometric features. The results in the Hs and St groups were similar when the anastomosis was within 1 cm of the dentate line. In particular, there was no correlation between the type of anastomosis and the number of bowel movements in a 24-hour period, the presence of the urge to defecate, and the use of antidiarrheal drugs. Leakage was significantly higher in the Hs group, even when the anastomosis was less than 1 cm from the dentate line. Pouchitis was more frequent in the Hs group, and, within this group, among those with a short distance between the anastomosis and the dentate line. No correlations were found between the presence of columnar epithelium or active colitis in the mucosa below the anastomosis, the functional outcomes, and the incidence of pouchitis.

Duodenal involvement of Crohn's disease : three different clinicopathologic patterns

PURPOSE: This study was designed to assess clinical and pathologic features of duodenal Crohns disease (CD) and address its management according to different patterns of disease. METHODS: Twelve cases of duodenal involvement in CD are reported out of 336 patients treated between 1978 and 1993. They represent 3.6 percent of all cases. Three patients had a duodenal fistula, and nine had an intrinsic duodenal lesion. The duodenal fistula was in all cases a manifestation of recurrent CD involving an ileocolic anastomosis and the third portion of the duodenum. RESULTS: Treatment consisted of resection of the fistulas source and primary closure of duodenal breach. Of nine patients with intrinsic CD, five had stenosis and the remaining four had peptic ulcer-like lesions. Duodenal stenosis was treated with strictureplasty in three cases and duodenojejunostomy in two. No patient with ulcer-like lesions underwent surgery. CONCLUSIONS: Differences encountered in intrinsic duodenal lesions apparently reflect two different clinical patterns. Stenosis is not usually associated with multifocal disease and is often the first evidence of disease. Ulcer-like lesions are not specific; they do not evolve into stenosis as do ulcers in other sites of the disease, spontaneously disappear and relapse, and do not require surgery, except for complications. They are always associated with other locations of the disease.

Outcomes of Crohn's disease presenting with abdominopelvic abscess.

PURPOSE: The aim of this study was to evaluate clinical outcomes, quality-adjusted life-years, and the cost-effectiveness gained from percutaneous drainage followed by elective surgery vs. initial surgery for abdominopelvic abscesses related to Crohns disease. METHODS: All consecutive patients with spontaneous Crohns disease-related abdominopelvic abscess from 1997 to 2007 were reviewed. The authors excluded postoperative and perirectal abscesses. Decision analysis during one year of patient life was used to calculate quality-adjusted life-years and the cost-effectiveness of each strategy. RESULTS: Of 94 patients, 48 (51 percent) were initially approached with percutaneous drainage. Thirty-one (65 percent) had successful percutaneous drainage and delayed elective surgery. The factors significantly associated with percutaneous drainage failure were steroid use, colonic phenotype, and multiple or multilocular abscesses. The initial treatment was surgery in the remaining 46 (49 percent) patients. The initial approach with percutaneous drainage gave higher quality-adjusted life-years and was more cost-effective than initial surgery. Percutaneous drainage was the optimal strategy in spite of the risk of failure and septic complications within the plausible range. CONCLUSIONS: Percutaneous drainage failure is associated with steroid use, colonic phenotype, and multiple or multilocular abscesses. When feasible, percutaneous drainage is the most effective strategy from the perspective of patients and third-party payers.

Outcomes of percutaneous drainage without surgery for patients with diverticular abscess.

BACKGROUND: Data on percutaneous drainage followed by observation for diverticular abscess is scant. OBJECTIVE: The aim of this study is to assess outcomes of percutaneous drainage alone in the management of peridiverticular abscess. DESIGN: This is a retrospective study from a prospectively collected database. SETTING: This study was conducted in a high-volume, specialized colorectal surgery unit. PATIENTS: All patients with a diverticular abscess of at least 3 cm in diameter, treated between 2001 and 2012, who had prohibitive comorbidities or refused surgery after percutaneous drainage were included. MAIN OUTCOME MEASURES: The primary outcome measured was the treatment of diverticular abscess with percutaneous drainage alone. RESULTS: A total of 18 patients (11 surgery refusal, 7 comorbidity) were followed up until death, surgery for recurrent diverticulitis, or for a median of 90 (17–139) months. The median abscess size was 5 (3.8–10) cm, and the location was pelvic in 8 cases and intra-abdominal in 10. The mean duration of drainage was 20 ± 1.3 days, with the exception of 2 patients who only had aspiration of the abscess because of technical difficulty in drain placement. Three patients died of preexisting comorbidities between 2 and 8 months after percutaneous drainage. Seven of the surviving patients (7/15) experienced recurrent diverticulitis; 3 of these patients underwent surgery between 7 months and 7 years after the index percutaneous drainage. Of the remaining 4 cases of recurrence, one abscess was treated with repeat percutaneous drainage alone and 3 patients had uncomplicated diverticulitis treated with antibiotics. There were no significant associations between long-term failure of percutaneous drainage and the location of the abscess (p = 0.54) or previous episodes of diverticulitis (p = 0.9). LIMITATIONS: This study was limited because of its retrospective nature, its nonrandomized design, and its small sample size. CONCLUSIONS: Percutaneous drainage alone was successful in avoiding surgery in the majority of this selected patient population with sigmoid diverticular abscess. Future studies should assess the appropriate indications for a more liberal use of percutaneous drainage not followed by elective surgery.

Impact of the Specific Extraction-Site Location on the Risk of Incisional Hernia After Laparoscopic Colorectal Resection.

BACKGROUND: The impact of the specific incision used for specimen extraction during laparoscopic colorectal surgery on incisional hernia rates relative to other contributing factors remains unclear. OBJECTIVE: This study aimed to assess the relationship between extraction-site location and incisional hernia after laparoscopic colorectal surgery. DESIGN: This was a retrospective cohort study (January 2000 through December 2011). SETTINGS: The study was conducted at a high-volume, specialized colorectal surgery department. PATIENTS: All of the patients undergoing elective laparoscopic colorectal resection were identified from our prospectively maintained institutional database. MAIN OUTCOME MEASURES: Extraction-site and port-site incisional hernias clinically detected by physician or detected on CT scan were collected. Converted cases, defined as the use of a midline incision to perform the operation, were kept in the intent-to-treat analysis. Specific extraction-site groups were compared, and other relevant factors associated with incisional hernia rates were also evaluated with univariate and multivariate analyses. RESULTS: A total of 2148 patients (54.0% with abdominal and 46.0% with pelvic operations) with a mean age of 51.7u2009±u200918.2 years (52% women) were reviewed. Used extraction sites were infraumbilical midline (23.7%), stoma site/right or left lower quadrant (15%), periumbilical midline (22.5%), and Pfannenstiel (29.6%) and midline converted (9.2%). Overall crude extraction site incisional hernia rate during a mean follow-up of 5.9u2009±u20093.0 years was 7.2% (n = 155). Extraction-site incisional hernia crude rates were highest after periumbilical midline (12.6%) and a midline incision used for conversion to open surgery (12.0%). Independent factors associated with extraction-site incisional hernia were any extraction sites compared with Pfannenstiel (periumbilical midline HR = 12.7; midline converted HR = 13.1; stoma site HR = 28.4; p < 0.001 for each), increased BMI (HR = 1.23; p = 0.002), synchronous port-site hernias (HR = 3.66; p < 0.001), and postoperative superficial surgical-site infection (HR = 2.11; p < 0.001). LIMITATIONS: This study was limited by its retrospective nature, incisional hernia diagnoses based on clinical examination, and heterogeneous surgical population. CONCLUSIONS: Preferential extraction sites to minimize incisional hernia rates should be Pfannenstiel or incisions off the midline. Midline incisions should be avoided when possible.

Considering Value in Rectal Cancer Surgery: An Analysis of Costs and Outcomes Based on the Open, Laparoscopic, and Robotic Approach for Proctectomy

Objective: The aim of the study was to compare value (outcomes/costs) of proctectomy in patients with rectal cancer by 3 approaches: open, laparoscopic, and robotic. Background: The role of minimally invasive proctectomy in rectal cancer is controversial. In the era of value-based medicine, costs must be considered along with outcomes. Methods: Primary rectal cancer patients undergoing curative intent proctectomy at our institution between 2010 and 2014 were included. Patients were grouped by approach [open surgery, laparoscopic surgery, and robotic surgery (RS)] on an intent-to-treat basis. Groups were compared by direct costs of hospitalization for the primary resection, 30-day readmissions, and ileostomy closure and for short-term outcomes. Results: A total of 488 patients were evaluated; 327 were men (67%), median age was 59 (27–93) years, and restorative procedures were performed in 333 (68.2%). Groups were similar in demographics, tumor characteristics, and treatment details. Significant outcome differences between groups were found in operative and anesthesia times (longer in the RS group), and in estimated blood loss, intraoperative transfusion, length of stay, and postoperative complications (all higher in the open surgery group). No significant differences were found in short-term oncologic outcomes. Direct cost of the hospitalization for primary resection and total direct cost (including readmission/ileostomy closure hospitalizations) were significantly greater in the RS group. Conclusions: The laparoscopic and open approaches to proctectomy in patients with rectal cancer provide similar value. If robotic proctectomy is to be widely applied in the future, the costs of the procedure must be reduced.