Faculty Bibliography

BACKGROUND:Many surgeons prefer immediate diversion in patients with endoscopically obstructed rectal cancer before starting neoadjuvant chemotherapy. OBJECTIVE:The aim of this study was to compare immediate neoadjuvant chemoradiotherapy with diversion for endoscopically obstructed rectal cancer. DESIGN/METHODS:This study is a retrospective review of patients with rectal adenocarcinoma treated from January 2000 to December 2009. Demographic, tumor, treatment, and outcome data were obtained. Data were analyzed by the use of the Fisher exact probability test and the Student t test. SETTINGS/METHODS:This study was conducted at a tertiary care hospital/referral center. PATIENTS/METHODS:Included were patients with a rectal adenocarcinoma unable to be traversed endoscopically but without clinical evidence of obstruction before the initiation of neoadjuvant chemoradiotherapy. Patients with recurrent tumors or those who did not complete neoadjuvant chemoradiotherapy because of compliance were excluded. MAIN OUTCOME MEASURES/METHODS:The primary outcomes measured were the interval from diagnosis to neoadjuvant chemoradiotherapy initiation and resection and the incidence of complete obstruction. RESULTS:Eighty-five patients with endoscopically obstructed rectal cancer were identified; 16 underwent immediate diversion before neoadjuvant chemoradiotherapy (diverted group) and 69 were treated with immediate neoadjuvant chemoradiotherapy. Five patients undergoing immediate neoadjuvant chemoradiotherapy presented with bloating and distension; 2 were treated with dietary modification, and 3 (4.3%) progressed to complete obstruction following completion of neoadjuvant chemoradiotherapy and required diversion. Both groups were similar in age, tumor height, and surgical margin status. Patients undergoing diversion required a significantly greater number of permanent stomas and were associated with a higher rate of radical pelvic surgery. There was a significant delay in the initiation of neoadjuvant chemoradiotherapy (p < 0.05) and proctectomy (p < 0.001) from the time of diagnosis in the diverted group compared with the immediate neoadjuvant chemoradiotherapy group. The tumors of patients undergoing diversions were more likely to be unresectable following neoadjuvant chemoradiotherapy. LIMITATIONS/CONCLUSIONS:This study was limited by its retrospective design and possible selection bias. CONCLUSIONS:Immediate diversion is unnecessary in endoscopically obstructed rectal cancer without clinical signs of obstruction. There appears to be a relationship between immediate diversion and delay in initiation of neoadjuvant chemoradiotherapy and proctectomy. We conclude that immediate neoadjuvant chemoradiotherapy in patients with endoscopically obstructed rectal cancer is safe and feasible.

INTRODUCTION/BACKGROUND:The most feared complication of colorectal anastomoses is leaks resulting in severe morbidity. The concept of staple-line reinforcement is a growing area of interest. In this study, the authors evaluated the feasibility and effect of using 1.5:1 meshed AlloDerm to bolster end-to-end stapled rectal anastomoses in a porcine model. METHODS:A total of 30 female 45-kg domestic pigs were studied, and each served as its own control by creating a bolstered and unbolstered anastomosis in each animal. All anastomoses were created with a 29-mm end-to-end stapling device. Bolstered anastomoses were randomized to proximal and distal positions along the rectum, and each rectorectal anastomosis was separated by an average of 10 cm. The animals were survived to 3, 5, and 30 days. Barium enemas were then performed and the 2 anastomotic sites harvested. Each anastomosis underwent burst testing. The internal diameter of each anastomosis was measured, and a biochemical analysis was performed for elastin and collagen content. RESULTS:Bolstered anastomoses offered no strength advantage as burst pressures were no different when compared with unbolstered anastomoses. There was also no difference in anastomotic internal diameter, biochemical analysis of elastin or collagen, or presence of adhesions when comparing bolstered with unbolstered anastomoses. There were 4 subclinical leaks-1 in the unbolstered group and 3 in the bolstered group. CONCLUSIONS:The routine use of 1.5:1 meshed AlloDerm sandwich bolsters in stapled rectal anastomosis does not confer any detectable advantage in anastomotic strength. Further studies are needed to determine equivalence to traditional stapled anastomoses.

Patients with Crohn's disease are prone to the development of pyogenic complications. These complications are most commonly in the form of perianal or intraabdominal abscesses and/or fistulas. Complications in these 2 distinct areas are managed differently; however, they are similar in the fact that initial treatment relies on medical or minimally invasive management to achieve a nonacute condition prior to definitive surgical procedure. This article reviews the current surgical management of obtaining pyogenic control in both anorectal and intraabdominal Crohn's disease.

BACKGROUND:Conversion from laparoscopy to laparotomy can be expected in a variable percentage of surgeries. Patients who experience conversion to a laparotomy may have a worse outcome than those who have a successfully completed laparoscopic procedure. This study aimed to compare the outcomes of converted cases based on whether the case was a reactive conversion (RC, due to an intraoperative complication such as bleeding or bowel injury) or a preemptive conversion (PC, due to a lack of progression or unclear anatomy). METHODS:All laparoscopic colorectal procedures converted to a laparotomy were retrospectively reviewed from data prospectively entered into an institutional review board-approved database. Patients who underwent an RC were matched with patients who underwent a PC according to age, gender, body mass index (BMI), and diagnosis. Patients who underwent a laparoscopic colorectal resection (LCR) were taken as the control group. The incidence and nature of postoperative complications, the time to liquid or regular diet, and the length of hospital stay were recorded. RESULTS:Of 962 laparoscopic procedures performed between 2000 and 2007, 222 (23.1%) converted to a laparotomy were identified. The 30 patients who had undergone an RC were matched with 60 patients who had undergone a PC and 60 patients who had undergone an LCR. The reasons for RC were bleeding in 14 cases, bowel injury in 6 cases, ureteric damage in 3 cases, splenic injury in 3 cases, and other complications in 4 cases. The patients who had undergone RC were more likely to have experienced a postoperative complication (50% vs 27%; p = 0.028), required longer time to toleration of a regular diet (6 vs 5 days; p = 0.03), and stayed longer in the hospital (8.1 vs 7.1 days; p = 0.080). CONCLUSION/CONCLUSIONS:Preemptive conversion is associated with a better outcome than reactive conversion. Based on this finding, it appears preferable for the surgeon to have a low threshold for performing PC rather than awaiting the need for an RC.

PURPOSE/OBJECTIVE:This study aimed to investigate the application of fat clearance in cases of rectal cancer after neoadjuvant chemoradiation. METHODS:All patients who underwent proctectomy (R0 resection) from 1998 to 2007 were included. N1 and N2 stages were regarded as N+ stage. RESULTS:Two hundred thirty-seven patients were identified, including 157 patients in the neoadjuvant group and 80 patients in the nonneoadjuvant group. In both groups, patients were assigned to receive the traditional method of harvesting lymph nodes, or the fat clearance method. Before July 2001, the patients received the traditional method, and after July 2001, they received exclusively the fat clearance method. In the nonneoadjuvant group, there was no significant difference in the number of positive lymph nodes (0.5 +/- 0.2 vs. 1.0 +/- 0.3, P = 0.235), N stage (P = 0.265), or patients with N+ stage (7/31 vs. 16/49, P = 0.332) between the two methods, even though the total lymph node harvest was significantly increased by use of the fat clearance method (9.6 +/- 1.3 vs. 27.6 +/- 2.5, P < 0.001). In contrast, the total lymph node retrieval (5.2 +/- 0.6 vs. 20.4 +/- 1.2, P < 0.001), number of positive lymph nodes (0.4 +/- 0.2 vs. 1.2 +/- 0.3, P = 0.007), N stage (P = 0.005), and patients with N+ stage (6/51 vs. 34/106, P = 0.006) were all increased by fat clearance in the neoadjuvant group. Moreover, the number of patients with N+ stage was stratified by T stage level (T0-T4) to eliminate the background bias, and the results were confirmed. CONCLUSIONS:The utilization of the fat clearance technique significantly influences lymph node staging in patients with rectal cancer following neoadjuvant chemoradiation. These findings suggest that fat clearance may represent a useful tool in all patients receiving neoadjuvant therapy; a more generalized application in colorectal carcinoma specimens remains controversial and warrants further investigation.

PURPOSE/OBJECTIVE:Recent reports indicate that neoadjuvant therapy significantly reduces the lymph node harvest of rectal cancer. The aim of this study was to interpret the lymph node harvest in this setting based on the primary tumor response. METHODS:All patients undergoing proctectomy were included. Three variables were used as indicators of primary tumor response: ypT stage, tumor size, and tumor regression grade. RESULTS:From 1998 to 2007, 237 patients were identified: 157 in the neoadjuvant therapy group and 80 in the nonneoadjuvant therapy group. Neoadjuvant therapy significantly reduced the number of lymph nodes harvested (P = 0.011). Compared with the nonneoadjuvant group, there were significantly fewer lymph nodes in the neoadjuvant early T stage group (P = 0.001), small tumor size group (P = 0.003), and low tumor regression grade group (P < 0.001). However, there was no significant difference between the nonneoadjuvant group and the neoadjuvant advanced T stage (P = 0.664), large tumor (P = 0.815), and high tumor regression grade groups (P = 0.566). CONCLUSION/CONCLUSIONS:The current standard of lymph node harvest should be applied to patients with poorly responding primary tumors after neoadjuvant therapy. However, a new standard may be necessary to define the adequate number of lymph nodes for tumors that respond well to neoadjuvant therapy.

PURPOSE/OBJECTIVE:This study was designed to analyze the efficacy of the Cook Surgisis AFP anal fistula plug for the management of complex anal fistulas. METHODS:This was a retrospective review of all patients prospectively entered into a database at our institution who underwent treatment for complex anal fistulas using Cook Surgisis AFP anal fistula plug between July 2005 and July 2006. Patient's demographics, fistula etiology, and success rates were recorded. The plug was placed in accordance with the inventor's guidelines. Success was defined as closure of all external openings, absence of drainage without further intervention, and absence of abscess formation. RESULTS:Thirty-five patients underwent 39 plug insertions (22 men; mean age, 46 (range, 15-79) years). Three patients were lost to follow-up, therefore, 36 procedures to be analyzed. The fistula etiology was cryptoglandular in 31 (88.6 percent) patients and Crohn's disease associated in the other 4 (11.4 percent). There were 11 smokers and 3 patients with diabetes. The mean follow-up was 126 days (standard = 69.4). The overall success rate was 5 of 36 (13.9 percent). One of the four Crohn's disease-associated fistulas healed (25 percent) and 4 of 32 (12.5 percent) procedures resulted in healing of cryptoglandular fistulas. In 17 patients, further procedures were necessary as a result of failure of treatment with the plug. The reasons for failure were infection requiring drainage and seton placement in 8 patients (25.8 percent), plug dislodgement in 3 (9.7 percent), persistent drainage/tract and need for other procedures in 20 patients (64.5 percent). CONCLUSIONS:The success rate for Surgisis AFP anal fistula plug for the treatment of complex anal fistulas was (13.9 percent), which is much lower than previously described. Further analysis is needed to explain significant differences in outcomes.

The management of full-thickness rectal prolapse involves surgical intervention in the majority of cases. Many procedures have been described employing both perineal and abdominal approaches. Abdominal procedures result in more durable repair of the prolapse; however, the procedures require general anesthesia and are reserved for younger healthier patients. Laparoscopy has been utilized in the treatment of rectal prolapse since its introduction for colorectal procedures; recent studies have found equivalent long-term results and short-term outcomes.