Patricia Sylla

Transanal colorectal resection using natural orifice translumenal endoscopic surgery (NOTES)

The surgical management of rectal cancer has evolved over the past century, with total mesorectal excision (TME) emerging as standard of care. As a result of the morbidity associated with open TME, minimally invasive techniques have become popular. Natural orifice translumenal endoscopic surgery (NOTES) has been held as the next revolution in surgical techniques, offering the possibility of ‘incisionless’ TME. Early clinical series of transanal TME with laparoscopic assistance (n = 72) are promising, with overall intraoperative and postoperative complication rates of 8.3% and 27.8%, respectively, similar to laparoscopic TME. The mesorectal specimen was intact in all patients, and 94.4% had negative margins. There was no oncological recurrence in average‐risk patients at short‐term follow up, and 2‐year survivalrates in high‐risk patients were comparable to that after laparoscopic TME. These preliminary studies demonstrate transanal NOTES TME with laparoscopic assistance to be clinically feasible and safe given careful patient selection, surgical expertise, and appropriate procedural training. We are hopeful that with optimization of transanal instruments and surgical techniques, pure transanal NOTES TME will become a viable alternative to open and laparoscopic TME in the future.

Impact of Screening Colonoscopy on Outcomes in Colon Cancer Surgery

IMPORTANCE Screening colonoscopy seemingly decreases colorectal cancer rates in the United States. In addition to removing benign lesions and preventing progression to malignancy, screening colonoscopy theoretically identifies asymptomatic patients with early-stage disease, potentially leading to higher survival rates. OBJECTIVES To assess the effect of screening colonoscopy on outcomes of colon cancer surgery by reviewing differences in staging, disease-free interval, risk of recurrence, and survival and to identify whether diagnosis through screening improves long-term outcomes independent of staging. DESIGN Retrospective review of prospectively maintained, institutional review board-approved database. SETTING Tertiary care center with high patient volume. PATIENTS All patients who underwent colon cancer surgery at Massachusetts General Hospital from January 1, 2004, through December 31, 2011. INTERVENTION Colon cancer surgery. MAIN OUTCOMES AND MEASURES Postoperative staging, death, and recurrence, measured as incidence and time to event. RESULTS A total of 1071 patients were included, with 217 diagnosed through screening. Patients not diagnosed through screening were at risk for a more invasive tumor (≥T3: relative risk [RR] = 1.96; P < .001), nodal disease (RR = 1.92; P < .001), and metastatic disease on presentation (RR = 3.37; P < .001). In follow-up, these patients had higher death rates (RR = 3.02; P < .001) and recurrence rates (RR = 2.19; P = .004) as well as shorter survival (P < .001) and disease-free intervals (P < .001). Cox and logistic regression controlling for staging and baseline characteristics revealed that death rate (P = .02) and survival duration (P = .01) were better stage for stage with diagnosis through screening. Death and metastasis rates also remained significantly lower in tumors without nodal or metastatic spread (all P < .001). CONCLUSIONS AND RELEVANCE Patients with colon cancer identified on screening colonoscopy not only have lower-stage disease on presentation but also have better outcomes independent of their staging. Compliance to screening colonoscopy guidelines can play an important role in prolonging longevity, improving quality of life, and reducing health care costs through early detection of colon cancer.

Obesity, outcomes and quality of care: body mass index increases the risk of wound-related complications in colon cancer surgery

BACKGROUND Obese patients may face higher complication rates during surgical treatment of colon cancer. The aim of this study was to measure this effect at a high-volume tertiary care center. METHODS All patients with colon cancer treated surgically at a single center from 2004 through 2011 were reviewed. Multivariate regression assessed relationships of complications and stay outcomes with body mass index (BMI) controlling for age, gender, comorbidity score, surgical approach, and history of smoking. RESULTS In 1,048 included patients, BMI was a predictor of several complications in both laparoscopic and open procedures. For every increase of BMI by one World Health Organization category, the odds ratios were 1.61 (P < .001) for wound infection and 1.54 (P < .001) for slow healing. Additionally, right colectomies had an odds ratio of 3.23 (P = .017) for wound dehiscence. No further associations with BMI were found. CONCLUSIONS BMI was incrementally associated with wound-related complications, illustrating how the proliferation of obesity relates to a growing risk for surgical complications. As the surgical community strives to improve the quality of care, patient-controllable factors will play an increasingly important role in cost containment and quality improvement.

Laparoscopy Decreases Anastomotic Leak Rate in Sigmoid Colectomy for Diverticulitis

BACKGROUND Early studies comparing laparoscopic and open operations for diverticulitis failed to show any advantages of the laparoscopic approach. Our study compared the 30-day postoperative outcomes of laparoscopic and open sigmoid colectomy for diverticulitis by surgeons who had performed 20 or more laparoscopic colectomies before the study period. HYPOTHESIS Patients who undergo an elective laparoscopic operation for diverticulitis have reduced postoperative complications compared with patients who have a traditional open operation. DESIGN Retrospective analysis. SETTING Academic medical center. PATIENTS A total of 249 patients who underwent elective open (n = 127) or laparoscopic (n = 122) sigmoid colectomy with primary anastomosis for diverticulitis between July 1, 2001, and February 1, 2008. MAIN OUTCOME MEASURES Combined rates of free and contained anastomotic leaks. A logistic regression model was used to determine predictors of anastomotic leaks while controlling for significant differences between study groups. RESULTS Patients who underwent laparoscopic or open operations were similar in age, sex, history of diagnosed intraabdominal abscess (9.4% vs 12.3%), and history of preoperative percutaneous abscess drainage (3.9% vs 4.9%). Patients who underwent the open procedure had a higher Charlson comorbidity index (1.6 vs 1.2; P = .04), and those who underwent laparoscopy more frequently underwent splenic flexure mobilization (82.8% vs 26.7%; P < .001). Patients who underwent a laparoscopy had lower rates of anastomotic leaks (2.4% vs 8.2%; P = .04). This finding held true on logistic regression analysis (odds ratio, 0.67; 95% confidence interval, 0.008-0.567; P = .01), even when controlling for age, Charlson comorbidity index, splenic flexure mobilization, and length of resected bowel. CONCLUSION Anastomotic leaks occurred less frequently after laparoscopic sigmoid colectomy performed by experienced laparoscopic colorectal surgeons.

Cavernous, arteriovenous, and mixed hemangioma–lymphangioma of the rectosigmoid: rare causes of rectal bleeding—case series and review of the literature

IntroductionCavernous hemangiomas of the sigmoid colon and rectum are uncommon vascular malformations usually found in young adults with a long history of episodic and painless rectal bleeding. Alternatively, they may present with massive life-threatening hemorrhage.DiscussionWe report three cases of hemangioma of the rectosigmoid including one case of cavernous hemangioma, one case of arteriovenous hemangioma, and one case of hemangiolymphangiomatosis with emphasis on clinical presentation, radiologic, operative, and pathologic findings. Definitive treatment consists of complete resection with a sphincter-preserving procedure or abdominoperineal resection, based on extent of disease.ConclusionTherapy is typically delayed by several years in these patients due to erroneous diagnosis and failed treatment of hemorrhoids and inflammatory bowel disease. Relative to hemangiomas, lymphangiomas of the rectosigmoid are even more rare and when symptomatic, present with rectal bleeding and pelvic pain.

The prognostic value of lymph node ratio after neoadjuvant chemoradiation and rectal cancer surgery.

BACKGROUND: Neoadjuvant chemotherapy decreases total lymph nodes harvested and possibly affects lymph node staging after total mesorectal excision in patients with rectal cancer. OBJECTIVE: This study aimed to compare staging by lymph node ratio with staging by absolute number of positive lymph nodes. DESIGN: This study is a retrospective cohort review. SETTING: A tertiary care referral center was the setting for this investigation. PATIENTS: A total of 281 consecutive patients who underwent neoadjuvant chemoradiation and total mesorectal excision after histologically confirmed rectal cancer between January 1, 1998 and December 31, 2008 were included in this study. MAIN OUTCOME MEASURES: Lymph node ratio is the number of positive lymph nodes divided by the total number of lymph nodes within one sample. Risk categories of low (0 to <0.09); medium (0.09 to <0.36); and high (≥0.36) for lymph node ratio were chosen by significance with the use of Cox proportional hazards models. These categories were then used in a reclassification table and compared with positive lymph node stage: low (0 positive nodes), medium (1–3 nodes), and high (>3) by 5-year mortality rates. RESULTS: The majority (87%) of patients were concordant in risk assessment. Thirty patients were downstaged to lower risk lymph node ratio categories without showing actual lower mortality rates. Seven patients were upstaged to a high-risk lymph node ratio category with a supporting higher 5-year mortality rate. When limiting the analysis to those with fewer than 12 nodes, 136 (95%) patients were concordant in risk assessment; all 30 incorrectly downstaged patients were removed, but the 7 correctly upstaged patients remained. CONCLUSIONS: Patients who undergo neoadjuvant chemoradiation before rectal cancer surgery frequently have fewer than 12 lymph nodes harvested despite maintaining vigorous surgical standards. Lymph node ratios may provide excellent prognostic value and are possibly a better independent staging method than absolute positive lymph node counts when less than 12 lymph nodes are harvested after neoadjuvant treatment.

Current experience and future directions of completely NOTES colorectal resection

Clinical implementation and widespread application of natural orifice translumenal surgery (NOTES) has been limited by the lack of specialized endoscopic equipment, which has prevented the ability to perform complex procedures including colorectal resections. Relative to other types of translumenal access, transanal NOTES using transanal endoscopic microsurgery (TEM) provides a stable platform for endolumenal and direct translumenal access to the peritoneal cavity, and specifically to the colon and rectum. Completely NOTES transanal rectosigmoid resection using TEM, with or without transgastric endoscopic assistance, was demonstrated to be feasible and safe in a swine survival model. The same technique was successfully replicated in human cadavers using commercially available TEM, with endoscopic and laparoscopic instrumentation. This approach also permitted complete rectal mobilization with total mesorectal excision to be performed completely transanally. As in the swine model, transgastric and/or transanal endoscopic assistance extended the length of proximal colon mobilized and overcame some of the difficulties with TEM dissection including limited endoscopic visualization and maladapted instrumentation. This extensive laboratory experience with NOTES transanal rectosigmoid resection served as the basis for the first human NOTES transanal rectal cancer excision using TEM and laparoscopic assistance. Based on this early clinical experience, NOTES transanal approach using TEM holds significant promise as a safe and substantially less morbid alternative to conventional colorectal resection in the management of benign and malignant colorectal diseases. Careful patient selection and substantial improvement in NOTES instrumentation are critical to optimize this approach prior to widespread clinical application, and may ultimately permit completely NOTES transanal colorectal resection.

Preoperative carcinoembryonic antigen as an outcome predictor in colon cancer

Several reports have shown that certain pre‐operative CEA intervals can be predictive of long‐term outcomes and have subsequently implied that preoperative CEA may be useful to assess the risk of recurrence or death as a continuous number for individual cases. This analysis assesses if this hypothesis is valid after correction for confounders.

Determining the Need for Radical Surgery in Patients With T1 Rectal Cancer

HYPOTHESIS In the era of modern preoperative staging of patients with rectal cancer, lymph node metastases can be reliably predicted by the histological features of the tumor and preoperative imaging. Local resection can then be safely offered to the patients who are at low risk of having malignant lymph nodes. DESIGN We reviewed the records of 109 consecutive patients with preoperative imaging results suggestive of T1N0 or T2N0 disease who underwent total mesorectal excision. All patients underwent preoperative endorectal ultrasonography or magnetic resonance imaging and computed tomography, with or without positron emission tomography. Final pathologic investigation identified T3 disease in 27 patients. History, physical examination results, and radiologic and pathologic data were evaluated for predictors of positive nodes in the remaining 82 patients. SETTING Tertiary care referral center. PATIENTS Patients with preoperative imaging suggestive of T1N0 or T2N0 rectal cancer. MAIN OUTCOME MEASURES To evaluate different clinical and pathologic tumor features as predictors of positive lymph nodes in T1 and T2 rectal cancers with negative radiographic nodes. BACKGROUND Local resection of T1 and T2 rectal cancer results in lower morbidity compared with radical resection. However, recurrence rates after local resection are higher, likely owing to unresected nodal metastasis. Reports on predictors of lymph node metastasis remain inconsistent in the literature. Although local resection may be appropriate for some rectal cancers, selection criteria remain unclear. RESULTS Despite indications of negative nodes on radiographic examination, 4 of 35 patients with T1 disease (11%) and 13 of 47 with T2 disease (28%) had positive nodes. On univariate analysis, the only significant predictor was depth of invasion: 24 of 65 patients with negative nodes (37%) vs 13 of 17 patients with positive nodes (76%) had tumors invading the lower third of the submucosa and beyond (P = .02). On logistic regression analysis accounting for depth of invasion (lower third of the submucosa and beyond), size, distance from anal verge, differentiation, and lymphovascular and small-vessel invasion, only depth of invasion remained a significant predictor. CONCLUSIONS In all, 89% of patients with T1 disease (31 of 35) and 72% of those with T2 disease (34 of 47) underwent unnecessary radical resection. Endorectal ultrasonography or magnetic resonance imaging and computed tomography, with or without positron emission tomography, for preoperative staging could not identify these patients reliably. In addition, histologic markers of aggressive disease were not helpful. Thus, local resection for T2 rectal cancer is not justified. Local resection should be offered only to patients with superficial T1 tumors who will adhere to aggressive postoperative surveillance.

Natural orifice versus conventional laparoscopic distal pancreatectomy in a porcine model: a randomized, controlled trial

BACKGROUND Natural orifice transluminal endoscopic surgery (NOTES) research has primarily involved case series reports of low-risk procedures. Distal pancreatectomy has significant postoperative morbidity and would permit rigorous examination in a controlled trial setting. OBJECTIVE To compare endoscopic transgastric distal pancreatectomy (ETDP) and laparoscopic distal pancreatectomy (LDP). DESIGN Prospective, randomized, controlled trial. SETTING Academic hospital. SUBJECTS Forty-one swine, 28 block randomized. INTERVENTIONS LDP was performed with 3 trocars and stapled transection of the pancreas. ETDP was performed via a gastrotomy, with 1 trocar for visualization, by using endoloop placement, snare transection, and purse-string gastrotomy closure. MAIN OUTCOME MEASUREMENTS Clinical examination, CT, serum chemistries, necropsy, peritoneal fluid analysis, and histologic examination. RESULTS Swine were survived for 8 days. The procedure time for ETDP was significantly greater than for LDP (1:52 vs 0:33 [hours:minutes]; P = .00). Pancreatic specimen weight was similar (4.1 g vs 5.5 g; P = .108). Postoperatively, 26 of 28 animals thrived. In the LDP group, 1 death caused by pancreatic leak and renal failure occurred on day 1. In the ETDP group, 1 death caused by pneumothorax occurred intraoperatively. The necropsy, CT, and histologic examinations revealed focal resection-margin necrosis in 3 to 7 swine in the ETDP group with no proximal necrosis or pancreatitis. The groups were equivalent clinically, by survival, and by serum and peritoneal fluid analysis. The gastrotomy closure was associated with small serosal adhesions, but no gross abscess or necrosis. LIMITATION Animal study. CONCLUSIONS In the largest controlled trial of NOTES orifice surgery to date, there was no clinical or survival difference between NOTES and laparoscopic approaches.