Faculty Bibliography

As TaTME is gaining popularity for the treatment of low rectal cancers, certain complications are becoming more prevalent. A unique complication is neo-rectal prolapse, which can lead to a significantly poor quality of life (1). We present the case of a 48 year-old male with invasive rectal adenocarcinoma (T3N0) who received neoadjuvant chemoradiation and subsequently underwent a robotic low anterior resection and transanal total mesorectal excision (TaTME) with a handsewn coloanal anastomosis and a diverting loop ileostomy.

PURPOSE/OBJECTIVE:The purpose of this study was to describe the effect of rigid or flexible stoma bridges used for loop ostomy diversions on peristomal skin integrity. Additional aims were to describe surgeon practices related to stoma bridges, and determine the availability of an ostomy nurse specialist. DESIGN/METHODS:Retrospective chart review and cross-sectional survey. SAMPLE AND SETTING/METHODS:The sample used to address the first aim (effect of stoma bridges) comprised 93 adult patients cared for at Morristown Medical Center, Atlantic Health System, Morristown, New Jersey, an acute care facility. Data provided by 355 colorectal surgeons from 30 countries were used to describe surgeon practice in this area and determine the availability of an ostomy nurse specialist. Respondents were invited from an international roster of colorectal surgeons obtained with permission from the American Society of Colon and Rectal Surgeons (ASCRS). METHODS:In order to accomplish the initial aim, we retrospectively reviewed medical records of patients who underwent ostomy surgery from 2008 to 2015 and met inclusion criteria. In order to meet our additional aims, analyzed data were obtained from a survey of colorectal surgeons that queried practices related to stoma bridges, and availability of an ostomy nurse specialist. RESULTS:Patients managed with a rigid bridge were significantly more likely to experience leakage beneath the pouching system faceplate than were patients managed by a flexible bridge (42% vs 11%, P < .001). Slightly less than one quarter of patients who developed leakage (n = 22, 24%) experienced pressure and moisture-related peristomal skin complications. Peristomal wounds, inflammation, and infection were significantly higher when a rigid bridge was used (χ test, P < .003). The surgeon's survey (N = 355) showed variability in the use of bridges. Ninety-three percent of all surgeons indicated an ostomy nurse specialist was part of their health care team. CONCLUSIONS:Rigid ostomy bridges were associated with a higher likelihood of leakage from underneath the faceplate of the pouching system and impaired peristomal skin integrity. Analysis of colorectal surgeon responses to a survey indicated no clear consensus related to bridge use in patients undergoing loop ostomies.

Introduction: Kaposi's sarcoma is a fatal disease that typically presents with cutaneous manifestations in immunocompromised individuals. There are a small number of documented cases where patients diagnosed with this disease present without cutaneous lesions. Case Presentation: 35 year-old male presented with two weeks of left buttock pain. A CT scan confirmed a 1.8 cm perianal abscess with linear stranding in the left ischioanal fossa concerning for perianal fistula. The patient was taken to the OR for drainage. Flexible sigmoidoscopy revealed rectal ulcers, with biopsies taken. The patient was discharged home on antibiotics. The patient returned with increasing pain. Physical exam revealed a new area of fluctuance, and the patient was taken back to the OR. A large abscess was encountered with a new perirectal tract. Copious pus was expressed and a seton was placed. Postoperatively the patient was treated with IV antibiotics. Increasing purulent drainage prompted re-exploration, and a new supragluteal abscess was discovered and drained. This unusual recurrence prompted workup for an underlying immunocompromised state. HIV testing was positive, with a CD4 count of 14. The patient was started on HAART therapy. Pathology from the rectal biopsies returned confirming Kaposi Sarcoma (KS). Metastatic workup revealed pulmonary and hepatic lesions. The patient adamantly refused chemotherapy and was subsequently lost to follow up.
Discussion(s): KS is an aggressive tumor that classically presents with cutaneous manifestations. Mild forms can present with involvement of lymph nodes, and lesions in skin and oropharyngeal mucosa. The multicentric nature of the tumor can result in a severe progression involving visceral organs, often including the pulmonary and gastrointestinal systems. The prevalence of KS in AIDS patients was 20,000 times that of immunocompetent individuals in the 1980s. HAART therapy allowed the incidence of KS in AIDS patients to decrease from approximately 14% to around 2% by the early 2000s. AIDS-associated KS accounts for an estimated 94% of all reported cases. Low CD4 counts in immunocompromised individuals increases the likelihood of disease onset. The ability of KS to metastasize proves to be fatal without prompt initiation of treatment. KS presenting without cutaneous lesions is an uncommon occurrence, and can prove problematic and delay diagnosis.
Conclusion(s): Prompt diagnosis of Kaposi's sarcoma and initiation of treatment is vital to decrease disease progression. A high index of suspicion should be present in immunocompromised patients, and clinicians must recognize atypical presentations in order to improve long term survival

Port site hernias are a rare complication following robotic surgery that can result in disastrous outcomes. We describe incarcerated port site hernias in two patients with obesity. Both patients required laparoscopic reduction. Following laparoscopic reduction, one patient's postoperative course was complicated by pneumatosis intestinalis, requiring exploratory laparotomy and subsequent small bowel resection. It is standard practice to not close the fascia of port sites less than 12 mm in robotic surgery. However, this allows for the rare possibility of small bowel herniation through the port site. We suggest that our patients' history of obesity and metabolic dysfunction contributed to difficult port retention during the case, and longer operating times which caused an increased amount of torque at the port site. Additionally, compared with laparoscopic surgery, robotic surgery is associated with increased torque at port sites. The combination of these risk factors extended the fascial defect, ultimately leading to the incarceration of small bowel in the port site.

Kaposi's sarcoma is a fatal disease that typically presents with cutaneous manifestations in immunocompromised individuals. There are a small number of documented cases where patients diagnosed with this disease present without cutaneous lesions. We present a 35-year-old man with recurrent rectal abscesses and fistula-in-ano, which required multiple drainage procedures. Further investigation revealed a diagnosis of HIV-AIDS, and biopsy of a rectal mass confirmed the diagnosis of visceral Kaposi's sarcoma, despite the absence of cutaneous involvement. Workup revealed hepatic metastasis and a second pulmonary primary malignancy. The patient denied chemotherapy or further intervention and was subsequently lost to follow-up. Prompt diagnosis of Kaposi's sarcoma and initiation of treatment is vital to decrease disease progression. A high index of suspicion should be present in immunocompromised patients, and clinicians must recognise atypical presentations in order to improve long-term survival.

Background: Mucosal inflammation isolated to a segment of colon affected by diverticular disease with relative sparing of the rectum refers to Segmental Colitis Associated with Diverticulosis (SCAD, also known as Diverticular Disease-Associated Colitis (DDAC). Although SCAD is relatively rare, its clinical and pathologic resemblance to inflammatory bowel disease (IBD) represents a diagnostic challenge for clinicians and misdiagnosis can lead to its mismanagement. Objective: This study aimed to demonstrate that early elective colonic resection for symptomatic SCAD should be the treatment following a short course of conservative management with mesalamine derivatives. Design: This was a single-institution, retrospective observational study combined with a systematic review of the literature. Data Sources: Morristown Medical Center institutional database. Medline. EMBASE. Cochrane. Interventions: Medical therapy included anti-inflammatory and immunosuppressive agents currently used for IBD. Surgical therapy included segmental colonic or more extensive resections with or without primary anastomosis. Outcome Measures: Symptomatic or endoscopic recurrences at follow up Results: Our literature review yielded seventeen studies with two hundred-forty patients. Of these, 169 patients were managed medically. Eighty-five patients either initially or eventually required surgery. Study duration ranged from 0 to 15 years. Recurrence rate in the medically managed cohort was 26.0% (44/169) compared to the surgical cohort 10.5% (9/85). In our database, we found a total of seven patients (5 males and 2 females; mean age 62.9) all with endoscopically diagnosed acute-on-chronic colitis associated with diverticular disease. Two patients underwent Hartmann’s procedure, and five underwent segmental colectomy with primary anastomosis. Follow up ranged from 0-5 years, and four patients had surveillance colonoscopies that were negative for recurrence. Limitations: The study was limited by its retrospective nature and small sample size. Conclusions: Medical treatment does not alter the natural history of SCAD, and more aggressive subtypes will chronically recur or develop complications. In our experience, surgical intervention following a short treatment course of Mesalamine treatment will afford patients treatment with low morbidity and improved quality of life

Obtaining a reliable distal margin during anterior colorectal resection can be difficult. In this study, endoscopic transmural tattoos were placed to mark the distal transection point in patients with distal colorectal neoplasms who undergo bowel resection. In the operating room, before surgery, sigmoidoscopy is performed with a 2-channel scope using CO2 insufflation. Through channel 1, a biopsy forceps, marked 5 cm from its end, is inserted to the tumor's distal edge; in channel 2, a sclerotherapy catheter is placed. The scope is then withdrawn and forceps inserted at the same rate until the mark is seen, next, via the needle catheter, 4 tattoos are placed at that level circumferentially. After rectal mobilization, visible external tattoos guide stapler placement. If no tattoo is seen, sigmoidoscopy is done and the tattoos used to guide stapler placement. In all 27 patients, the tattoos guided stapler placement; tattoos were seen via the abdomen in 26 and the stapler placed as per tattoos in 25. In 2 patients, repeat endoscopy was done and tattoos used to guide or confirm stapler placement. The margin was