Steven A. Lee-Kong

Pilot study of PET imaging of 124I-iodoazomycin galactopyranoside (IAZGP), a putative hypoxia imaging agent, in patients with colorectal cancer and head and neck cancer

BackgroundHypoxia within solid tumors confers radiation resistance and a poorer prognosis. 124I-iodoazomycin galactopyranoside (124I-IAZGP) has shown promise as a hypoxia radiotracer in animal models. We performed a clinical study to evaluate the safety, biodistribution, and imaging characteristics of 124I-IAZGP in patients with advanced colorectal cancer and head and neck cancer using serial positron emission tomography (PET) imaging.MethodsTen patients underwent serial whole-torso (head/neck to pelvis) PET imaging together with multiple whole-body counts and blood sampling. These data were used to generate absorbed dose estimates to normal tissues for 124I-IAZGP. Tumors were scored as either positive or negative for 124I-IAZGP uptake.ResultsThere were no clinical toxicities or adverse effects associated with 124I-IAZGP administration. Clearance from the whole body and blood was rapid, primarily via the urinary tract, with no focal uptake in any parenchymal organ. The tissues receiving the highest absorbed doses were the mucosal walls of the urinary bladder and the intestinal tract, in particular the lower large intestine. All 124I-IAZGP PET scans were interpreted as negative for tumor uptake.ConclusionsIt is safe to administer 124I-IAZGP to human subjects. However, there was insufficient tumor uptake to support a clinical role for 124I-IAZGP PET in colorectal cancer and head and neck cancer patients.Trial registrationClinicalTrials.gov NCT00588276

Management of iatrogenic perforation during colonoscopy in ulcerative colitis patients: a survey of gastroenterologists and colorectal surgeons

PurposePatients with ulcerative colitis, a high-risk group for the development of colon cancer, undergo colonoscopy more frequently than the general population. This increase in endoscopic evaluation also exposes these patients to an increased risk of complications, including iatrogenic perforation. Our survey study aims to determine factors that affect the management choices for iatrogenic perforations for ulcerative colitis patients in remission and identify areas of consensus among general gastroenterologists, inflammatory bowel disease specialists, and colorectal surgeons.MethodsAn anonymous, cross-sectional survey was performed using an online platform. A matrix questionnaire posed five clinical scenarios with six management options for an iatrogenic perforation in ulcerative colitis patients with varying disease distribution, disease activity, and maintenance regimens.ResultsOne hundred thirty-eight general gastroenterologists, 35 inflammatory bowel disease specialists, and 174 colorectal surgeons responded to the survey; 47, 41, and 23%, respectively, answered they did not feel comfortable managing perforations in ulcerative colitis patients in remission. We found the greatest concordance among gastroenterologists and colorectal surgeons in cases of perforation in ulcerative colitis with a history of dysplasia; the majority of respondents chose staged total proctocolectomy with ileal pouch anal anastomosis. We found discordance in decision making for ulcerative colitis in remission without dysplasia, with perforation occurring in colitis involved and uninvolved areas.ConclusionOur survey revealed that a significant fraction of gastroenterologists and colorectal surgeons are uncomfortable managing iatrogenic colonic perforations in ulcerative colitis patients. We have identified knowledge and practice gaps in defining the optimal management of iatrogenic perforations in ulcerative colitis patients.

Use of an ACE inhibitor or angiotensin receptor blocker is a major risk factor for dehydration requiring readmission in the setting of a new ileostomy

PurposeDiverting ileostomies help prevent major complications related to anastomoses after colorectal resection but can cause metabolic derangement and hypovolemia, leading to readmission. This paper aims to determine whether angiotensin-converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB) use increased the risk of readmission, or readmission specifically for dehydration after new ileostomy creation.MethodsRetrospective analysis of patients undergoing diverting ileostomy at a tertiary-care hospital, 2009–2015. Primary outcome was 60-day readmission for dehydration; secondary outcomes included 60-day readmission for any cause, or for infection obstruction.ResultsNinety-nine patients underwent diverting ileostomy creation, 59% with a primary diagnosis of colorectal cancer. The 60-day readmission rate was 36% (n = 36). Of readmitted patients, 39% (n = 14) were admitted for dehydration. Other readmission reasons were infection (33%) and obstruction (3%). The majority (64%, n = 9) of patients readmitted for dehydration were taking either an ACEi or an ARB. Compared to patients not readmitted for dehydration, those who were readmitted for dehydration were more likely to be on an ACEi or an ARB (11/85, 13% vs. 9/14, 64%). After controlling for covariates, ACEi or ARB use was significantly associated with risk of readmission (p < 0.0001, odds ratio = 13.56, 95% confidence interval 3.54–51.92,). No other diuretic agent was statistically associated with readmission for dehydration.ConclusionsACEi and ARB use is a significant risk factor for readmission for dehydration following diverting ileostomy creation. Consideration should be given to withholding these medications after ileostomy creation to reduce this risk.

Correction to: Anal canal squamous cell cancer: are surgical alternatives to chemoradiation just as effective?

One of the author’s middle name of this article was incorrectly published as “Emmanouil E. Pappou.” This is now presented correctly in this article as “Emmanouil P. Pappou.”

Difficult Colonoscopy: Tricks and New Techniques for Getting to the Cecum

Maximizing cecal intubation rates during screening colonoscopy is an important part of delivering high-quality care. In the setting of a difficult colonoscopy, there are a number of maneuvers and procedural considerations that can increase the likelihood of performing a complete colonoscopy.

Basic Colonoscopic Interventions: Cold, Hot Biopsy Techniques, Submucosal Injection, Clip Application, Snare Biopsy

Colonoscopy for the early detection of premalignant lesions of the colon and rectum has changed the natural history of colorectal cancer since its inception in the mid 1900s. The prevention of colorectal cancer by removal of adenomatous polyps (polypectomy) via colonoscopy is one of the greatest public health innovations in recent history. Programs such as the “80% by 2018” initiative have been successful in promoting age-appropriate colorectal cancer screening across the United States, and worldwide. Advances in flexible endoscopes and devices used for polypectomy have allowed for improvement in the sensitivity of colonoscopy in the detection of adenomatous polyps as well as improved safety. In this chapter, we will discuss various basic colonoscopic interventions, including hot and cold biopsy techniques, submucosal injection of substances (for tattooing and for facilitating polypectomy), clip application, and snare polypectomy.

Robotic right hemicolectomy with intracorporeal anastomosis using V-Loc™ - a video vignette

The incorporation of unidirectional, knotless and self-absorbable V-Loc™ device in minimally invasive intra-abdominal procedures has been reported to be safe and effective [1] [2]. Performance of enterotomy closure using V-Loc™ suture has been shown to be faster than nonbarbed closure [3]. This article is protected by copyright. All rights reserved.

Ongoing challenges and controversies in ulcerative colitis surgery.

ABSTRACT For patients with ulcerative colitis requiring surgery, surgical options include a total proctocolectomy with an end ileostomy and ileal pouch-anal anastomosis or a continent reservoir, or instead, a subtotal colectomy with an ileorectal anastomosis. The ileal pouch-anal anastomosis is currently considered the gold standard procedure that is employed in the majority of patients. Despite strong data supporting the feasibility, durability and the maintenance of long term functional outcomes and quality of life, certain controversies pertaining to its relative role, method of creation and effects on related pelvic structures remain a matter of debate.

Su1740 30-Day Mortality After Emergency Surgery for Colorectal Cancer: Who Is At Risk?

Introduction: Peritoneal carcinomatosis denotes extensive tumour involvement of the peritoneum, and is often regarded as terminal. There has been a paradigm shift in treatment, with the application of cytoreductive surgery combined with intra-peritoneal chemotherapy. The extensive nature of the surgery and malignancy-associated hypercoagulable state should increase the risk of PE, which can further increase morbidity and/or mortality. Incidence and risk factors for pulmonary embolism (PE) in this population have not been investigated in detail. Aims: To establish the incidence and specific operative risk factors for developing PE in patients with peritoneal carcinomatosis post peritonectomy and peri-operative intraperitoneal chemotherapy. Methods: A cohort of 596 patients that underwent cytoreductive surgery (peritonectomy) over a 12-year period was identified using the prospective database from St George Hospital Peritonectomy Unit. A case-control study was undertaken whereby cases were defined by the development of PE within 60 days of peritonectomy. A diagnosis of PE was based on computed tomography pulmonary angiography confirmation. The prospective database was reviewed to obtain the following clinical information for both cases (with PE) and controls (without PE): length of surgery, use of hyperthermic intraperitoneal chemotherapy (HIPEC) and early postoperative intraperitoneal chemotherapy (EPIC), peritoneal carcinomatosis index (PCI) and number of intraoperative blood transfusions. Results: The mean age of the cohort was 52.7 ± 13.1 years, with no significant difference in the ages of cases or controls; 43.3% were male and 56.7% were female. Primary malignancies in these patients were pseudomyxoma peritonei, appendiceal, ovarian or colorectal cancer, and mesothelioma. Out of the 596 patient cohort, 34 were identified as having PE post cytoreductive surgery (5.7%). When compared to controls, the PE group had longer mean operative time of 10.4 ± 2.8 hours vs 8.9 ± 3.1 hours (p=0.01) and higher mean PCI values at 23 ± 12 vs 18 ± 11 (p=0.02). An operative time of more >9 hours increased the risk of developing PE (OR 3.3, 95% CI 1.41-7.72, p=0.006) as did having a PCI of >20 (OR 2.4, 95% CI 1.18-4.9, p=0.02). There was no difference in mean transfusion requirements (6.6 vs 6.0; p=0.67). No significant association was found between HIPEC and development of PE (x2=2.87, 1 df, P=0.9) or EPIC and subsequent PE (x2=0.001, 1 df, P=1). Conclusions: There is a relatively high incidence of pulmonary embolism in patients following cytoreductive surgery for peritoneal carcinomatosis. Patients at highest risk of developing PE postoperatively are those with PCI of more than 20 and those who have operations lasting more than 9 hours. Peri-operative chemotherapy and blood transfusions are not risk factors for PE.