Faculty Bibliography

BACKGROUND: Many rectal cancer patients experience tumor downstaging and some are found to achieve a pathologic complete response (pCR) after neoadjuvant chemoradiotherapy (nCRT). Previous data suggest that there is an association between the time interval from nCRT completion to surgery and tumor response rates, including pCR. However, these studies have been primarily from single institutions with small sample sizes. The aim of this study was to examine the relationship between a longer interval after nCRT and pCR in a nationally representative cohort of rectal cancer patients. STUDY DESIGN: Clinical stage II to III rectal cancer patients undergoing nCRT with a documented surgical resection were selected from the 2006 to 2011 National Cancer Data Base. Multivariable logistic regression analysis was used to assess the association between the nCRT-surgery interval time (<6 weeks, 6 to 8 weeks, >8 weeks) and the odds of pCR. The relationship between nCRT-surgery interval, surgical morbidity, and tumor downstaging was also examined. RESULTS: Overall, 17,255 patients met the inclusion criteria. An nCRT-surgery interval time >8 weeks was associated with higher odds of pCR (odds ratio [OR] 1.12, 95% CI 1.01 to 1.25) and tumor downstaging (OR 1.11, 95% CI 1.02 to 1.25). The longer time delay was also associated with lower odds of 30-day readmission (OR 0.82, 95% CI 0.70 to 0.92). CONCLUSIONS: An nCRT-surgery interval time >8 weeks results in increased odds of pCR, with no evidence of associated increased surgical complications compared with an interval of 6 to 8 weeks. These data support implementation of a lengthened interval after nCRT to optimize the chances of pCR and perhaps add to the possibility of ultimate organ preservation (nonoperative management).

BACKGROUND/OBJECTIVE: The Knowledge Program (TKP) allows prospective data collection during routine clinical practice. The aim of this study was to evaluate the efficacy and feasibility of TKP for capturing and monitoring health status measures in patients undergoing lateral internal sphincterotomy (LIS). METHODS: TKP data of patients undergoing LIS from December 2008 to May 2013 were retrieved. Health status measures including the Cleveland Global Quality of Life (CGQL), European Quality of Life Index (EQ-5D), Fecal Incontinence Severity Index (FISI), anorectal pain scores, and satisfaction questions were evaluated in the study. RESULTS: A total of 500 patients underwent LIS within the study period. Overall patient numbers responding to the health status measures in the pre- and postoperative period were as follows: CGQL: 112 preoperatively, 53 postoperatively; EQ-5D: 112 preoperatively, 55 postoperatively; FISI: 102 preoperatively, 30 postoperatively; and anorectal pain score: 107 preoperatively, 45 postoperatively. Among the responders, the number of patients who completed the health status measures both pre- and postoperatively was as follows: EQ-5D: 31, CGQL: 28, anorectal pain: 24, and FISI: 15. A total of 30 patients completed postoperative satisfaction and recommendation questions. Postoperative earliest (p = 0.02) and most recent (p = 0.01) anorectal pain visual analog scores were significantly lower than the preoperative measurements. The earliest postoperative EQ-5D scores were significantly higher than their preoperative values (p = 0.02). The majority of patients who completed the surveys said they were satisfied (70% and 67%) and would recommended (73% and 70%) LIS to others undergoing postoperative earliest and most recent follow up. CONCLUSION: LIS reduces anorectal pain without worsening quality of life. TKP captures information directly from patients and records it to a database which may reduce the risk of information loss or alteration.

INTRODUCTION: Laparoscopy is accepted as a standard surgical approach for Crohn's disease. However, the rate of conversion is high, ranging from 15 to 70 % depending on the population. There are also concerns that conversion results in worsened outcomes versus an initial open procedure. METHODS: This study evaluated preoperative radiographic findings to determine who is at increased risk of conversion and may therefore benefit from an initial open approach. A case-matched study included patients from 2004 to 2013 with preoperative CTE/MRE who underwent laparoscopic surgery converted to an open approach, and compared them to laparoscopically completed controls with similar age, same surgeon, and number of previous abdominal operations. Studies were reviewed by two blinded radiologists. Variables included abdominal AP diameter, amount of subcutaneous fat, peritoneal versus pelvic location of disease (greater or lesser hemipelvis or abdomen), intestinal location of disease (colon, TI, ileum, jejunum), and presence, length, and location of strictures, simple or complex fistula, phlegmon, or abscess. Conditional logistic regression evaluated relationships between radiographic variables and conversion. Twenty-seven patients meeting study criteria were compared with 81 controls. RESULTS: A negative association between conversion and disease in the left lesser pelvis was found (p = 0.019) and neared significance for left abdomen (p = 0.08). Positive correlations were found with pelvic fistulas (p = 0.003), complex fistulas (p = 0.017), and pelvic abscesses (p = 0.009) and neared significance for Society of Abdominal Radiology classification (p = 0.058). CONCLUSION: Preoperative imaging in patients with Crohn's disease can help in selecting the most suitable cases to approach laparoscopically and reduce conversion rates and should be evaluated in conjunction with other preoperative factors.

BACKGROUND: Nearly half of all incidental splenectomies caused by iatrogenic splenic injury occur during colorectal surgery. This study evaluates factors associated with incidental splenic procedures during colorectal surgery and their impact on short-term outcomes using a nationwide database. METHODS: Patients who underwent colorectal resections between 2005 and 2012 were identified from the American College of Surgeons National Surgical Quality Improvement Program database according to Current Procedural Terminology codes. Patients were classified into two groups based on whether they underwent a concurrent incidental splenic procedure at the time of the colorectal procedure. All splenic procedures except a preoperatively intended splenectomy performed in conjunction with colon or rectal resections were considered as incidental. Perioperative and short-term (30 day) outcomes were compared between the groups. RESULTS: In total, 93633 patients who underwent colon and/or rectal resection were identified. Among these, 215 patients had incidental splenic procedures (153 open splenectomy, 17 laparoscopic splenectomy, 36 splenorraphy, and 9 partial splenectomy). Open colorectal resections were associated with a significantly increased likelihood of incidental splenic procedures (OR 6.58, p < 0.001) compared to laparoscopic surgery. Incidental splenic procedures were associated with increased length of total hospital stay (OR 1.25, p < 0.001), mechanical ventilation dependency (OR 1.62, p = 0.02), transfusion requirement (OR: 3.84, p < 0.001), re-operation requirement (OR 1.7, p = 0.005), and sepsis (OR: 2.03, p = 0.001). Short-term advantages of splenic salvage (splenorraphy or partial splenectomy) included shorter length of total hospital stay (p = 0.001) and decreased need for re-operation (p < 0.001). CONCLUSIONS: Incidental splenic procedures during colorectal resections are associated with worse short-term outcomes. Use of the laparoscopic technique decreases the need for incidental splenic procedures.

BACKGROUND: Several studies suggest that preoperative functional health status (FHS) affects postoperative outcomes after ventral hernia repair, hepatic resections, and infrainguinal by-pass surgery. However, little is known about the proficiency of FHS in terms of preoperative outcome prediction of patients who undergo elective resection for colorectal cancer. METHODS: All patients who underwent elective colorectal resections for malignancy between 2005 and 2009 were identified from the American College of Surgeons National Surgical Quality Improvement Program. We classified patients into three groups according to their preoperative FHS: independent (IND), partially dependent (PDN), and totally dependent (TDN). Multivariable techniques were used to evaluate the impact of FHS on postoperative outcomes. Outcomes of laparoscopic and open procedures in patients with dependent FHS were also compared. RESULTS: In total, 25,591 patients included (94.2% IND, 5.1% PDN, and 0.71% TDN). Surgical, infectious, pulmonary, cardiovascular, renal, neurological complications, and mortality rate showed a linear progression that paralleled a decline in preoperative FHS of the patients (p < 0.05). Laparoscopic technique was associated with better outcomes in terms of reduced length of total hospital stay, decreased infectious complication rate, and mortality with comparable operating time in patients with dependent (PDN and TDN) FHS (p < 0.05). CONCLUSIONS: Functional health status may predict postoperative outcomes after colorectal cancer surgery. A detailed preoperative evaluation, providing an optimization period before surgery if necessary, and increased utilization of laparoscopic technique may improve outcomes after elective colorectal resections for malignancy in patients who are partially or TDN.

BACKGROUND: Endoscopic balloon dilation is used to treat ileocolic anastomotic stricture attributed to recurrent Crohn's disease. OBJECTIVE: The purpose of this work was to investigate long-term outcomes after dilation of ileocolic anastomotic stricture and to identify risk factors associated with the need for subsequent surgical intervention. DESIGN: This was a retrospective study based on chart review of an electronic medical chart system. SETTINGS: The study was conducted at a tertiary care center. PATIENTS: All of the eligible patients with ileocolic anastomotic stricture attributed to recurrent Crohn's disease treated with endoscopic dilation between December 1998 and May 2013 were evaluated. Patients with concurrent enterocutaneous fistula or abdominal or pelvic abscess were excluded. MAIN OUTCOME MEASURES: The main outcome measure was the need for subsequent salvage surgery because of stricture-related symptoms. RESULTS: A total of 185 patients with Crohn's disease (45.9% women; mean age, 43.1 years; symptomatic strictures in 80%) underwent 462 endoscopic dilations of ileocolic anastomosis (median per-patient dilations, 2; range, 1-3). During a mean follow-up of 3.9 years, 27 patients (14.6%) required hospitalization without surgery for stricture-related symptoms, and 66 patients (35.7%) required subsequent salvage surgery. Specific medical management, type of anastomosis, and endoscopic intralesional steroid injection had no impact on the risk of needing surgery. Significant factors associated with the need for surgery on multivariable analysis were symptomatic disease (HR, 3.54 [95% CI, 1.41-8.93]), longer time interval from last surgery (HR, 1.05 [95% CI, 1.01-1.10]), and radiographic proximal bowel dilation (HR, 2.36 [95% CI, 1.38-4.03]). A nomogram estimating the need for surgery was created with a concordance index of 0.67. LIMITATIONS: The study was limited by its retrospective design. CONCLUSIONS: Although endoscopic dilation is a valid option for ileocolic anastomotic stricture attributed to recurrent Crohn's disease, the need for surgery is common. The nomogram can identify patients who might benefit from upfront surgery.

The effectiveness of laparoscopic intestinal resection in patients with previous midline laparotomy (PML) is controversial. The aim of this study was to assess the feasibility of laparoscopic surgery and identify possible factors associated with postoperative outcomes in patients with PML. Patients with PML (at least an infraumbilical incision or longer) undergoing elective laparoscopic intestinal resection between 1997 and 2011 were case matched with patients without PML undergoing laparoscopic surgery based on age, gender, body mass index, ASA score, surgical procedure, and diagnosis. Fifty patients with PML undergoing laparoscopic intestinal resection were well matched to 50 counterparts. Conversion to open surgery (n = 8 vs. n = 4, p = 0.22), operating time (211 vs. 192 min, p = 0.22), and estimated blood loss (158 vs. 184 ml, p = 0.95) were similar between the groups. Intraabdominal adhesions (either disease related or from previous operations) were significantly more common in patients with PML (n = 24 vs. n = 11, p = 0.01). Intraoperative complications included inadvertent enterotomy and hemorrhage and were comparable between the groups (n = 1 vs. n = 0, p = 1 and n = 1 vs. n = 2, p = 1 for PML vs. no PML, respectively). One patient without PML died postoperatively from aspiration pneumonia. Overall morbidity (n = 26 vs. n = 10, p = 0.001) and particularly postoperative ileus (n = 10 vs. n = 3, p = 0.04) were significantly increased in the PML group when compared to laparoscopy without PML, unlike the respective differences in postoperative return of bowel function (4 vs. 3 days, p = 0.15), reoperations (n = 5 vs. n = 3, p = 0.72), length of hospital stay (9 vs. 6 days, p = 0.09), and readmissions (n = 5 vs. n = 4, p = 0.73). Intestinal resections in patients with PML can be frequently completed laparoscopically but are associated with worse postoperative outcomes when compared to laparoscopy on a virgin abdomen.

BACKGROUND: There are scant data on the presumed reduction of small-bowel obstruction and incisional hernia rates associated with laparoscopic IPAA. OBJECTIVE: The aim of this study was to compare long-term outcomes after open vs laparoscopic IPAA based on a previous study from our institution. DESIGN: This was a retrospective cohort study (from January 1992 through December 2007). SETTINGS: The study was conducted in a high-volume, specialized colorectal surgery department. PATIENTS: Patients included those who were enrolled in a previous institutional case-matched (2:1) study that examined 238 open and 119 laparoscopic IPAAs. MAIN OUTCOME MEASURES: Long-term complications, including incisional hernia clinically detected by physician, adhesive small-bowel obstruction requiring hospital admission and surgery, pouch excision, and pouchitis rates, were collected. Laparoscopic abdominal colectomy followed by rectal dissection under direct vision (lower midline or Pfannenstiel incision) and converted cases were analyzed within the laparoscopic group. RESULTS: Groups were comparable with respect to age, sex, BMI, and extent of resection (completion proctectomy vs proctocolectomy), consistent with the original case matching. Mean follow-up was significantly longer in the open group (9.6 vs 8.1 years; p = 0.008). Open and laparoscopic operations were associated with similar incidences of incisional hernia (8.4% vs 5.9%; p = 0.40), small-bowel obstruction requiring hospital admission (26.1% vs 29.4%; p = 0.50), and small-bowel obstruction requiring surgery (8.4% vs 11.8%; p = 0.31). A subgroup analysis comparing 50 patients with laparoscopic rectal dissection versus 69 patients with rectal dissection under direct vision confirmed statistically similar incidences of incisional hernia, hospital admission, and surgery for small-bowel obstruction. LIMITATIONS: This study was limited by its retrospective nature. CONCLUSIONS: Some of the anticipated long-term benefits of laparoscopic IPAA could not be demonstrated in this cohort. The lack of such long-term benefits should be discussed with patients when proposing a laparoscopic approach.

BACKGROUND: De novo Crohn's disease (CD) of the neo-small intestine in ulcerative colitis (UC) patients after total proctocolectomy (TPC) is a new disease entity, which may persist even after a secondary diverting permanent ileostomy for pouch failure. We sought to compare outcomes of primary ileostomy (PI, i.e., stoma created after colectomy without trying of ileal pouch) and secondary ileostomy (SI, i.e., stoma created after pouch failure) and to evaluate factors associated with the development of CD of the neo-small intestine proximal to ileostomy. METHODS: A total of 123 eligible patients were identified from our Pouch Center Registry (PI group, n = 57 and SI group, n = 66). Demographics, clinical features and outcomes (CD of theneo-small intestine, non-CD related strictures, requirement of CD-related medications use, ileostomy-associated hospitalization, ileostomy failure with stoma revision/relocation, and shortgut syndrome) were compared. Step-wise logistic regression models were performed. RESULTS: The median follow-up for the whole cohort was 5.0 (2.0-12.0) years. Younger age at diagnosis and surgery, family history of IBD, toxic megacolon/fulminant colitis, pre-diversion severe diarrhea, prediversion anti-TNF biological therapy, arthralgia/arthropathy and staged surgery were more common in the SI group (p < 0.05). In multivariate analysis, the presence of SI [odds ratio (OR), 8.23; 95% confidence interval (CI), 2.43-27.85], family history of IBD (OR, 9.14; 95% CI, 3.13-26.69), and pre-diversion of weight loss (OR, 3.72; 95% CI, 1.23-11.21) were contributing factors for developing CD of the neo-small intestine. CONCLUSIONS: CD of the neo-small intestine in stoma patients was associated with the presence of SI, family history of IBD, and pre-diversion poor nutrition status. Patients with secondary ileostomy due to pouch failure should be carefully monitored. Aggressive medical, endoscopic or surgical therapy may be needed in patients at risk, before permanent diversion.