Sean C. Glasgow

Retrorectal Tumors: A Diagnostic and Therapeutic Challenge

PURPOSETumors occurring in the retrorectal space are heterogeneous and uncommon. The utility of newer imaging techniques has not been extensively described, and operative approach is variable. This study examined the diagnosis, treatment, and outcome of retrorectal tumors at a tertiary referral center.METHODSPatients with primary, extramucosal neoplasms occurring in the retrorectal space were identified using a prospectively maintained, procedural database of all adult colorectal surgical patients (1981–2003). Patients also were incorporated from the gynecologic oncology service. Exclusion criteria included inflammatory processes, locally advanced colorectal cancer, and metastatic malignancy. Medical records, radiology, and pathology reports were reviewed retrospectively.RESULTSThirty-four patients with retrorectal tumors were treated. Malignant tumors comprised 21 percent. Older age, male gender, and pain were predictive of malignancy (P < 0.05). Sensitivity of proctoscopy was 53 percent; this increased to 100 percent with the use of transrectal ultrasound. Accuracy of magnetic resonance vs. computed tomographic imaging for specific histologic tumor type was 28 vs. 18 percent, respectively. Surgical approach was anterior (n = 14), posterior (n = 11), and combined abdominoperineal (n = 9). Eleven patients required en bloc proctectomy. Patients undergoing posterior resection had lower blood loss and required fewer transfusions (P < 0.05). All benign tumors were resected with normal histologic margins and none recurred (median follow-up, 22 months). All patients with malignancy had recurrence/recrudescence of their disease. For these patients, median disease-free and overall survivals were 38 and 61 months, respectively.CONCLUSIONSRetrorectal tumors remain a diagnostic and therapeutic challenge. Pain, male gender, and advanced age increase the likelihood of malignancy. Various imaging modalities are useful for planning resection but cannot establish a definitive diagnosis. Whereas benign retrorectal tumors can be completely resected, curative resection of malignant retrorectal tumors remains difficult.

Long-term outcomes of anal sphincter repair for fecal incontinence: a systematic review.

BACKGROUND: Thorough and objective analysis of long-term results following anal sphincter repair for fecal incontinence will permit the correct application of this operation in the context of newer treatment methods. OBJECTIVE: This investigation aimed to comprehensively review outcomes beyond 5 years in patients undergoing anal sphincter repair for fecal incontinence. DATA SOURCES: A systematic review of Embase and MEDLINE articles published between January 1991 and December 2010 was conducted; additional studies were identified by hand-searching bibliographies. STUDY SELECTION: A 2-step process was used for screening articles examining sphincter repair or sphincteroplasty in adults with fecal incontinence, with a minimum follow-up of 60 months. MAIN OUTCOME MEASURES: Subjective or objective assessment of fecal incontinence in the postoperative period was completed. RESULTS: Data from 16 studies were examined, comprising nearly 900 repairs. There was significant heterogeneity in outcome measures, although most articles utilized at least one established incontinence instrument. In general, most series reported an initial subjectively “good” outcome in the majority of patients, with declines in this proportion over longer follow-up. There was poor correlation between quality of life and the severity of fecal incontinence, with all articles reporting high overall patient satisfaction even if continence declined with time or adaptive measures were needed. No consistent predictive factors for failure were identified. LIMITATIONS: This study was limited by the paucity of level I data with an adequate length of follow-up. CONCLUSION: Despite worsening results over time, most patients remain satisfied with their surgical outcome postsphincteroplasty. Efforts should be directed at identifying patients who may do poorly following sphincter repair, as well as establishing standardized long-term outcome benchmarks for comparing novel techniques for treating fecal incontinence.

Outcomes and costs associated with robotic colectomy in the minimally invasive era.

BACKGROUND: Robotic-assisted surgery has become increasingly common; however, it is unclear if its use for colectomy improves in-hospital outcomes compared with the laparoscopic approach. OBJECTIVE: The aim of the study is to compare in-hospital outcomes and costs between patients undergoing robotic or laparoscopic colectomy. DESIGN: This study is a retrospective review of the 2008 to 2009 Nationwide Inpatient Sample. SETTINGS, PATIENTS, INTERVENTIONS: All adult patients who underwent an elective robotic or laparoscopic colectomy in hospitals performing both procedures (N = 2583 representing an estimated 12,732 procedures) were included. MAIN OUTCOME MEASURES: Outcomes included intraoperative and postoperative complications, length of stay, and direct costs of care. Regression models were used to compare these outcomes between procedural approaches while controlling for baseline differences in patient characteristics. RESULTS: Overall, 6.1% of patients underwent a robotic procedure. Factors associated with robotic-assisted colectomy included younger age, benign diagnoses, and treatment at a lower-volume center. Patients undergoing robotic and laparoscopic procedures experienced similar rates of intraoperative (3.0% vs 3.3%; adjusted OR = 0.88 (0.35–2.22)) and postoperative (21.7% vs 21.6%; adjusted OR = 0.84 (0.54–1.30)) complications, as well as risk-adjusted average lengths of stay (5.4 vs 5.5 days, p = 0.66). However, robotic-assisted colectomy resulted in significantly higher costs of care (

Unfavourable expression of pharmacologic markers in mucinous colorectal cancer.

19,231 vs

Meta-analysis of Histopathological Features of Primary Colorectal Cancers that Predict Lymph Node Metastases

15,807, p < 0.001). Although the overall postoperative morbidity rate was similar between groups, the individual complications experienced by each group were different. LIMITATIONS: A limitation of this study is the potential miscoding of robotic cases in administrative data. CONCLUSIONS: Robotic-assisted colectomy significantly increases the costs of care without providing clear reductions in overall morbidity or length of stay. As the use of robotic technology in colon surgery continues to evolve, critical appraisal of the benefits offered in comparison with the resources consumed is required.

Ischemia–reperfusion injury in rat steatotic liver is dependent on NFκB P65 activation☆

Patients with mucinous colorectal cancer generally have worse prognoses than those with the nonmucinous variety. The reason for this disparity is unclear, but may result from a differential response to adjuvant chemotherapy. We examined known molecular markers for response to common chemotherapy in these two histological subtypes. In all, 21 patients with mucinous and 30 with nonmucinous Dukes C colorectal cancer were reviewed for demographic data and outcome. Total RNA from the tumours and adjacent normal mucosa was isolated and reverse transcribed. Quantitative expression levels of drug pathway genes were determined using TaqMan RT–PCR (5-fluorouracil (5-FU): TYMS, DPYD, ECGF1; oxaliplatin: GSTP1 (glutathione S-transferase pi), ERCC1 and 2; irinotecan: ABCB1, ABCG2, CYP3A4, UGT1A1, CES2, TOP1). Mucinous tumours significantly overexpressed both TYMS and GSTP1 relative to nonmucinous tumours and patient-matched normal mucosa. No significant differences in expression of the remaining markers were found. Mean follow-up was 20 months; 17 patients had recurrent disease. Among patients receiving 5-FU, those with mucinous tumours experienced shorter disease-free survival (DFS) than those with nonmucinous tumours (median DFS 13.8 vs 46.5 months, P=0.053). Mucinous colorectal cancer overexpresses markers of resistance to 5-FU and oxaliplatin. Likewise, DFS may be decreased in patients with mucinous tumours who receive 5-FU. The presence of mucin should be carefully evaluated in developmental trials of new agents for treating colorectal cancer.

Clinical practice guidelines for ostomy surgery.

BackgroundTreatment decisions for colorectal cancer vary based on lymph node status. While some histopathological features of the primary tumor correlate with lymph node spread, the relative influences of these risk factors are not well quantified.ObjectiveThis study aims to systematically review published studies relating histopathological features of primary colorectal cancer to the presence of lymph node metastases and to determine how reliable certain factors might be at predicting nodal metastasis when only the primary lesion is available for study.Data SourcesInclusive literature search using EMBASE and Ovid MEDLINE databases plus manual reference checks of all articles correlating lymphatic spread with colorectal cancer (any T stage) from 1984 to mid-2008 was performed.Study SelectionThis search generated two levels of screening utilized on 602 citations, yielding 123 articles for full review. Data reported from 76 articles were chosen.Main Outcome MeasuresThe relative influence of each histopathological feature on the likelihood of lymphatic metastases was determined. Fixed-effects meta-analysis was performed, and results were reported as Mantel–Haenszel odds ratios (OR).ResultsOf 42 histopathological features analyzed, only 40.4% were reported in >2 articles. The positive predictive values for the top quartile of most frequently reported risk factors were 25.5–86.4%. Among the commonly reported histopathological findings, lymphatic invasion (OR, 8.62) significantly outperformed tumor depth (T2 vs. T1; OR, 2.62) and overall differentiation (OR, 2.38) in predicting nodal spread. For the rectal cancer subset, risk factors differed from the overall colorectal group in predictive ability; poor differentiation at the invasive front (OR, 6.08) and tumor budding (OR, 5.82) were the most predictive.LimitationsThis literature search is limited by the small number of studies examining only rectal cancers and the potential changes in histological and/or surgical techniques over the study period.ConclusionsNo single histopathological feature of colorectal cancer reliably predicted lymph node metastases. Several risk factors that correlate highly with nodal disease are not routine components of standard pathology reports. Until further research establishes histopathological or molecular patterns for predicting lymph node spread, caution should be exercised when basing treatment decisions solely on these factors.

Epidemiology of modern battlefield colorectal trauma: A review of 977 coalition casualties

BACKGROUND Steatotic liver grafts tolerate ischemia-reperfusion (I/R) injury poorly, contributing to increased primary graft nonfunction following transplantation. Activation of nuclear factor kappa-B (NFκB) following I/R injury plays a crucial role in activation of pro-inflammatory responses leading to injury. METHODS We evaluated the role of NFκB in steatotic liver injury by using an orthotopic liver transplant (OLT) model in Zucker rats (lean to lean or obese to lean) to define the mechanisms of steatotic liver injury. Obese donors were treated with bortezomib to assess the role of NF-κB in steatotic liver I/R injury. Hepatic levels of NF-κB and pro-inflammatory cytokines were analyzed by ELISA. Serum transaminase levels and histopathological analysis were performed to assess associated graft injury. RESULTS I/R injury in steatotic liver results in significant increases in activation of NF-κB (40%, p<0.003), specifically the p65 subunit following transplantation. Steatotic donor pretreatment with proteasome inhibitor bortezomib (0.1mg/kg) resulted in significant reduction in levels of activated NF-κB (0.58±0.18 vs. 1.37±0.06O.D./min/10 μg protein, p<0.003). Bortezomib treatment also reduced expression of pro-inflammatory cytokines MIP-2 compared with control treated steatotic and lean liver transplants respectively (106±17.5 vs. 443.3±49.9 vs. 176±10.6 pg/mL, p=0.02), TNF-α (223.8±29.9 vs. 518.5±66.5 vs. 264.5±30.1 pg/2 μg protein, p=0.003) and IL-1β (6.0±0.91 vs. 19.8±5.2 vs. 5±1.7 pg/10 μg protein, p=0.02) along with a significant reduction in ALT levels (715±71 vs. 3712.5±437.5 vs. 606±286 U/L, p=0.01). CONCLUSION These results suggest that I/R injury in steatotic liver transplantation are associated with exaggerated activation of NFκB subunit p65, leading to an inflammatory mechanism of reperfusion injury and necrosis. Proteasome inhibition in steatotic liver donor reduces NFκB p65 activation and inflammatory I/R injury, improving transplant outcomes of steatotic grafts in a rat model.

Dismounted Complex Blast Injuries: A Comprehensive Review of the Modern Combat Experience.

Diseases of the Colon & ReCtum Volume 58: 4 (2015) the american society of Colon and Rectal surgeons is dedicated to ensuring high-quality patient care by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus. the Clinical Practice Guidelines Committee is charged with leading international efforts in defining quality care for conditions related to the colon, rectum, and anus by developing Clinical Practice Guidelines based on the best available evidence. these guidelines are inclusive, not prescriptive, and are intended for the use of all practitioners, health care workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. their purpose is to provide information based on which decisions can be made, rather than to dictate a specific form of treatment. it should be recognized that these guidelines should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed to obtaining the same results. the ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all the circumstances presented by the individual patient.

Clinical Practice Guideline for the Management of Anal Fissures

BACKGROUND Traumatic injuries to the lower gastrointestinal tract occur in up to 15% of all injured combatants, with significant morbidity (up to 75%) and mortality. The incidence, etiology, associated injuries, and overall mortality related to modern battlefield colorectal trauma are poorly characterized. METHODS Using data from the Joint Theater Trauma Registry and other Department of Defense electronic health records, the ongoing Joint Surgical Transcolonic Injury or Ostomy Multi-theater Assessment project quantifies epidemiologic trends in colon injury, risk factors for prolonged or perhaps unnecessary fecal diversion, and quality of life in US military personnel requiring colostomies. In the current study, all coalition troops with colon or rectal injuries as classified by DRG International Classification of Diseases—9th Rev. diagnosis and Abbreviated Injury Scale (AIS) codes in the Joint Theater Trauma Registry were included. RESULTS During 8 years, 977 coalition military personnel with colorectal injury were identified, with a mean (SD) Injury Severity Score (ISS) of 22.2 (13.2). Gunshot wounds remain the primary mechanism of injury (57.6%). Compared with personnel with colon injuries, those with rectal trauma sustained greater injury to face and extremities but fewer severe thoracic and abdominal injuries (p < 0.005). Overall fecal diversion rates were significantly higher in Iraq than in Afghanistan (38.7% vs. 31.6%, respectively; p = 0.03), predominantly owing to greater use of diversion for colon trauma. There was little difference in diversion rates between theaters for rectal injuries (59.6% vs. 50%, p < 0.15). The overall mortality rate was 8.2%. Notably, the mortality rate for patients with no fecal diversion (10.8%) was significantly greater than those with fecal diversion (3.7%, p < 0.0001). CONCLUSION Military personnel sustaining colon or rectal trauma continue to have elevated mortality rates, even after reaching surgical treatment facilities. Furthermore, associated serious injuries are commonly encountered. Fecal diversion in these patients may lead to reduced mortality, although prospective selection criteria for diversion do not currently exist. Future research into risk factors for colostomy creation, timing of diversion in relation to damage-control laparotomy, and quality of life in veterans with stomas will produce useful insights and help guide therapy. LEVEL OF EVIDENCE Epidemiologic study, level III.